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.

"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.

"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."

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

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/)

HEALTH & SCIENCE