Oseltamivir for flu prophylaxis in health care personnel comes with challenges

Trish M. Perl, MD, MSc, FIDSA, FSHEA

First, the article provides minimal data. But what the article does demonstrate, and the authors fairly point out, is there are two important considerations with the administration of oseltamivir to health care providers during an influenza season. One is that there are certain expectations that institutions must assume with the decision to use oseltamivir widely as prophylaxis. While we use it for treatment of influenza, it also has been shown to prevent acquisition of influenza in high-risk populations.

So when you give a healthy population oseltamivir, you may prevent influenza, but the authors demonstrate that these healthy residents did report some side effects from the drug. If they were not well-counseled about the potential side effects, this may have led some residents to stop treatment, especially if the risk for acquiring influenza was perceived to be lower than the risk for side effects. Hence, you are going to have some challenges if you try to implement this strategy in the setting of an epidemic or pandemic.

Abdominal side effects are well-reported with this medication. It is not surprising that these authors report up to 27% of residents with abdominal complaints. Whether this proportion of side effects is higher because it is a group that is primarily healthy, they are more sensitized to symptoms such as abdominal pain, or if they were all chatting among themselves and then they enhanced the importance and frequency of symptoms, is something that we cannot tell from the data presented. Sometimes, group behavior influences what others report. What I found most interesting is that the frequency of symptoms seems to be much higher in days 1 to 9 compared with those people who took medication for more than 10 days. The nausea persisted but the abdominal pain went down, cough went down, a lot of other symptoms decreased.

I am a firm believer in health care workers protecting themselves but also protecting other patients and colleagues, visitors and individuals they are exposed to. I think we should be vaccinating all health care providers. The challenge is that the influenza vaccine is not a perfect vaccine. Its efficacy can be anywhere from 40% to 60% depending on the population studied.

Because the vaccine is currently imperfect, we must have other strategies that we can effectively deploy in epidemic situations such as the one described by the authors. I have been personally involved in a very similar situation where influenza was circulating in the community and among the residents. We had no more residents we could use for emergency coverage of critical services. What people do not really appreciate is that residents or any critical personnel are an important backbone of the health care system. If you do not have residents or nurses, you commonly will not be able to provide care or the quality of care that you could provide with those individuals present. For example, if you ask me to order a critical test or who to call to facilitate a discharge, an attending physician, I will not be as efficient as somebody who does it every day.

These situations to beg important questions such as do we (collective — institutions) need to have to have the discussion about what we are going to do to protect the health care workforce? We do. I think these discussions are long overdue. The public expects health care facilities to be able to care for them, and we must have some of those discussions about how we care for health care workers so that they can meet this public expectation. This discussion has occurred in other industries and health care is overdue. You would never go into a coal mine without wearing whatever protective paraphernalia is needed and required and those standards are laid out.

The missing information that would have been nice for these authors to present, and I am guessing they just did not have the data or enough data, would have been to show if this strategy of mass prophylaxis of residents does reduce transmission or influenza. What was the impact over time? Nonetheless, this is important information to emerge because it tells us that we need to educate people (ie residents and health care providers) if we are going to implement such strategies and that we have an option in our back pocket with some data should we end up in a similar situation.