The CDC Must Do Better

cdcThe USPTF got schooled in 2009 when they released their guidelines for breast cancer screening.  They did not prepare for the backlash nor did they have media personnel or training to deal with the public’s ire.  The task force learned a lesson, and guideline release and dissemination has changed as a result.  The USPTF has become less forthcoming with information related to pending reviews–mostly due to politics.

Last year, the CDC had its own imbroglio over Ebola:

The Centers for Disease Control and Prevention (CDC) has been widely criticized for projecting overconfidence in U.S. hospitals’ capacity to manage Ebola. When two nurses at Texas Health Presbyterian Hospital Dallas became infected after caring for Thomas Duncan, critics cited the CDC’s assurance that “U.S. hospitals can safely manage patients with Ebola disease.”2 When the CDC said the nurses probably became infected because of a protocol breach and it turned out there was no protocol, things got worse. We seemed to hit rock bottom when it was revealed that the CDC had given the second infected nurse permission to fly from Dallas to Cleveland.

The miscue of Thomas Frieden, the agency’s director, for the above event was well documented.  He likewise presented a mea culpa post hoc most folks seemed to accept.  I include myself in that lot. In NYC, we have high esteem for Frieden, as his time here prior to moving to the CDC marked a high point for our public health department.  We knew him as a man of integrity and an honest broker.

However, with the recent uptick in influenza cases, I am teetering on my judgment.  My lack of surety stems from the treatment recommendations stemming from the agency.

You may be aware the use of oseltamivir (Tamiflu) has its detractors.  Those who question the efficacy of the drug don’t peddle snake oil or live under a rock.  In fact, I am told some even hold an esteemed place in the literature appraisal trade.  I am speaking of course, of the Cochrane Collaboration.

But then there is this:

Frieden acknowledged that some doctors in the United States may not be prescribing Tamiflu because they believe the drugs do not work.

The effectiveness of such antivirals has been the subject of fierce debate, with some researchers from the Cochrane Collaboration, a non-profit group, claiming there is little evidence Tamiflu works.

Frieden, however, defended the drugs. He said CDC scientists have combed through studies on Tamiflu, including observational studies published after the treatments were approved, and found “compelling evidence” that when used early, the drugs help.

“What we see is quite consistent. Particularly when given in the first 48 hours, there is an impact in reducing how long people are sick and how sick they get,” Frieden said.*

I am one of those physicians to which Frieden refers.  I am dubious of claims made by Roche and the veracity of the data.  Of course, many providers feel otherwise.  However, his proclamation will only confuse practitioners—including me.

If he wishes to instill confidence in the healthcare workforce, he cannot disregard what many still consider uncertain.  I and others have legitimate concerns over the efficacy of the drug.  When two heavyweights, Cochrane and the CDC, have a discrepancy, don’t expect a public proclamation of, “don’t believe the other guy,” to make things right and sway the skeptics.

CDC, you need to do better.  When you send a mixed message, you make the next oversight harder to reverse and create a cynical audience.  Unlike a board game, in public health do overs don’t come cheap.

Bonus: For a recent and succinct review of the subject, see here.  Also, Frieden on the PBS’s NewsHour defending the CDC’s position.  And another describing a new Lancet paper (2015) contradicting the Cochrane findings.

*Updated for clarity

 

Brad Flansbaum

Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.

Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.

He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

2 Comments

  1. James O'Callaghan, MD FAAP SFHM on January 13, 2015 at 11:07 pm

    Brad, you will find that many pediatric hospitalists across the country, active and vocal on the AAP Section of Hospital Medicine listserv, are equally doubting the efficacy and use of oseltamivir. Count us as unimpressed on oseltamivir.

  2. James O'Callaghan, MD FAAP SFHM on January 13, 2015 at 11:10 pm

    Brad, there are many pediatric hospitalists across this country, active and vocal on the AAP Section of Hospital Medicine, who are also quite skeptical of the efficacy and therefore need for oseltamivir. You can count us among those who are not impressed.

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