Rapid testing, antivirals win gold for reducing flu at last Olympics
Studies show intense influenza-control measures can work in a
specialized setting, but can the model be applied more broadly?
By
Victoria Stagg Elliott, AMNews staff. Nov. 11, 2002.
Additional information
There was more happening at last winter's Salt Lake City Olympic Games
than the television coverage of sporting events and athletes revealed.
Behind the scenes, a group of physicians was researching whether
influenza outbreaks could be contained by combining aggressive
surveillance with prescriptions for antivirals for those who developed
influenza as well as for their close contacts.
The findings: the approach may have reduced antibiotic use and
prevented a large influenza outbreak at the winter games, according to a
series of studies presented at the Infectious Disease Society of America
annual meeting in Chicago last month.
"It was a beautiful example of really modern medicine -- we were able
to diagnose and treat athletes and Olympic workers promptly, as well as
prevent flu from infecting lots of folks who certainly would have gotten
it," said Merle Sande, MD, an infectious disease specialist and one of the
authors of the studies. He is also a professor of medicine at the
University of Utah Health Sciences Center in Salt Lake City. "I'm
absolutely sure we salvaged some medals with this approach, and we kept
antibiotic use to a minimum."
The researchers suggest their strategies may be successfully applied to
other situations where people are living in close proximity during the flu
season and have ready access to medical care, although further research is
needed to determine if they will be cost effective.
Antivirals are only effective early in the course of influenza
infection.
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"This is the wave of the future," said Dr. Sande. "The drugs are
relatively nontoxic. If you're not vaccinated, living in close quarters
and there's a lot of flu, taking these drugs probably makes sense."
The Centers for Disease Control and Prevention's Advisory Committee on
Immunization Practice has long recommended the use of antivirals to
control outbreaks in nursing homes and chronic care facilities. The use in
other closed situations such as cruise ships or schools should also be
considered.
As for the rapid tests, the ACIP says they can be useful, but
recommends that they be followed up with viral cultures because of their
low sensitivity.
A success story with drawbacks
Dr. Sande and several other researchers who were volunteering at the
polyclinic in the Olympic Village kept track of flu incidence by using
rapid antigen detection, direct fluorescent antibody and the more
traditional viral culture.
Antivirals were on hand for those showing symptoms of the flu as well
as their teammates and coaches who weren't. Antibiotics were available,
although inappropriate use was actively discouraged. Researchers believe
that these actions reduced antibiotic use, and stopped the flu from
crippling four teams.
The researchers concede, however, that their studies were far from
conclusive because they were observational, and there was no control
group.
Immunization remains the most effective approach to the flu.
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"We're happy to say that we stopped the flu definitely in four teams,
but I don't want to imply that we eliminated the flu," said Adi
Gundlapalli, MD, PhD, principal investigator and adjunct assistant
professor of infectious diseases at the University of Utah School of
Medicine, Salt Lake City. "What if we hadn't treated with antivirals?
Maybe it would have died down by itself."
The Olympics is also a very specialized situation -- team members have
constant access to a medical clinic -- and what works there may not work
elsewhere.
"This was a very idealized setting," said Dr. Gundlapalli.
Cost also may be a significant issue in other settings. Antivirals are
expensive, and not every physician may have access to the facilities
needed to make the rapid diagnoses. This is vital because antivirals are
only effective if given very early in the course of infection, although
they may still prevent contacts from developing symptoms. Experts did say,
however, that a study like this provides the groundwork to possibly design
studies for more common situations.
"It would be very worthwhile for people who are concerned about
efficient medical care delivery to look and see whether some of these
things can be used on a wide-scale basis," said Marvin Bittner, MD, an
infectious disease specialist and associate professor of medical
microbiology and immunology and internal medicine at Creighton University
in Omaha, Neb.
Infectious disease experts said the most exciting aspect of the study
was the reduction in antibiotic use.
But many experts also said that while these studies were interesting,
they did not point to the need for increased use of antivirals or rapid
testing when dealing with the flu; instead the studies pointed to the need
for increasing immunization rates.
According to the studies, only 20% of athletes had received the vaccine
before the games began.
"Why was the rate of vaccination so low?" asked Mark Russi, MD, MPH,
associate professor of medicine and public health at Yale University, New
Haven, Conn.
"I think this argues strongly that when you have events like this with
a bunch of athletes coming from all over the world who are going to be
living and working together for a period of many weeks during the flu
season, vaccinate them before they get there
"From a public health standpoint," Dr. Russi noted, "you'd rather
vaccinate than chase down little outbreaks using antivirals."
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ADDITIONAL INFORMATION:
Everyone's a winner when antibiotic use goes downhill
Objective: To reduce inappropriate use of antibiotics for upper
respiratory infections during the 2002 Olympic and Paralympic Games in
Salt Lake City
Method: Researchers, who were also volunteers at the Olympic
Village's polyclinic, ensured the availability of several rapid diagnostic
tests for the flu and strep. Guidelines for antibiotic use were displayed
prominently. Both antivirals and antibacterials were available as needed.
Results: Of the 2,635 visits to the polyclinic, 312 were for upper
respiratory symptoms. Forty-three (22%) received an antiviral for
treatment or prophylaxis for the flu and 26 (13%) received antibiotics. A
total of 121 (61%) had symptoms treated, but did not receive
antibacterials or antivirals.
Conclusion: Antibiotic use in the clinic was less than expected.
Symptomatic treatment or antivirals replaced antibiotic use for upper
respiratory symptoms.
Source: Infectious Disease Society of America
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Weblink
Abstracts from the 2002 annual meeting of the Infectious Disease
Society of America (http://www.journals.uchicago.edu/CID/2002Abstracts.html)
Utah Dept. of Health plan
for the 2002 Olympic Winter Games (http://health.utah.gov/olympic/)
Salt Lake 2002, official
site of 2002 Olympic Winter Games (http://www.saltlake2002.com/)
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Copyright 2002 American Medical Association. All
rights reserved.
