Wisconsin DHS Health Alert #53: Interim Guidance for Clinicians to Prioritize Antiviral Treatment of Influenza in the Setting of Reduced Availability of Oseltamivir

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DHS Health Alert Network

Interim Guidance for Clinicians to Prioritize Antiviral Treatment of Influenza in the Setting of Reduced Availability of Oseltamivir

Bureau of Communicable Diseases

December 20, 2022

Key Points

  • The Centers for Disease Control and Prevention (CDC) has received numerous anecdotal reports of limited availability for generic oseltamivir in some locations. While oseltamivir may be difficult to obtain in some areas, the FDA has not determined that national shortages exist for oseltamivir (generic or Tamiflu) in any of its forms (capsules, oral suspension). 
  • Seasonal influenza activity remains high across the United States, and Influenza A activity is increasing throughout Wisconsin. To date, one pediatric death has been reported in Wisconsin during the 2022-2023 influenza season. 
  • A December 14, 2022, CDC Health Advisory provided clinicians and public health officials with guidance for prioritizing oseltamivir for treatment and information on other influenza antivirals that are recommended in areas where oseltamivir is temporarily unavailable.  


On December 14, 2022, the CDC issued a health advisory with Interim Guidance for Clinicians to Prioritize Antiviral Treatment of Influenza in the Setting of Reduced Availability of Oseltamivir. The advisory outlines general recommendations and considerations for prioritizing oseltamivir treatment for patients in a variety of settings. DHS has reviewed this interim guidance and encourages Wisconsin clinicians and public health practitioners to review the information summarized below.  

Recommendations for clinicians and public health practitioners when oseltamivir or other antivirals are limited: 

Clinicians, hospitals, health care systems, nursing homes, and public health officials are encouraged to use all available information and their best judgment to prioritize oseltamivir and other antivirals for treating patients with influenza, depending upon their local situation. The following are considerations for antiviral treatment prioritization when antivirals, such as oseltamivir, are in short supply. 

  • If oseltamivir is unavailable, oral baloxavir, inhaled zanamivir, or intravenous peramivir can be used for early treatment of outpatients at increased risk for complications who present with uncomplicated influenza, depending upon age and contraindications.  
  • When there is limited availability of oseltamivir or other antivirals, antiviral treatment should target patients with influenza who are at the highest risk of severe disease and those who are hospitalized.  
  • Patients with clinically mild influenza who are not at increased risk of influenza complications should not be prioritized to receive oseltamivir when supply is limited. 

The following individuals should be prioritized for treatment with oseltamivir except where specifically noted below. 

  • Hospitalized patients: Prioritize oseltamivir treatment as soon as possible for hospitalized patients with suspected or laboratory-confirmed influenza.  
    • Oseltamivir is the only antiviral that is recommended for treating influenza in hospitalized patients. 
  • Outpatients:  Prioritize oseltamivir treatment for patients with health conditions that put them at higher risk for influenza including those aged 65 and older and patients who test positive for influenza within 2 days of illness onset. 
    • Consider use of oral baloxavir, inhaled zanamivir or intravenous peramivir for those at increased risk of influenza in appropriate age ranges who are not contraindicated. 
    • Influenza testing for patients with suspected influenza is highly recommended to guide antiviral treatment in the outpatient setting when antivirals are limited. 
  • Patients who have progressive or severe influenza not requiring hospitalization, even if they test positive for influenza more than 2 days from illness onset.
  • Patients who are pregnant, less than 2 weeks postpartum, or immunocompromised. 
    • There are no data on the safety or efficacy of baloxavir in pregnancy and baloxavir is not recommended for pregnant people or those less than 2 weeks postpartum 
  • Children under the age of 5. 
    • Oseltamivir is the only recommended oral antiviral for treatment of influenza in children less than 5 years of age. 

Guidance for long-term care facilities (LTCFs): 

  • When an influenza outbreak is not occurring, prioritize oseltamivir for early treatment of influenza in residents who test positive. 
  • When there is a laboratory-confirmed influenza outbreak: 
    • Oseltamivir treatment of suspected influenza is recommended. Once an influenza diagnosis is confirmed through testing, post-exposure antiviral chemoprophylaxis of exposed residents is recommended.  
      • If oseltamivir is not available, baloxavir, zanamivir, or peramivir may be used for treatment of influenza.  
    • Consider using a limited duration treatment dosage (twice daily for five days) for post-exposure oseltamivir instead of extended use of oseltamivir chemoprophylaxis (once daily), with ongoing active daily monitoring and influenza testing for all residents with new illness signs and symptoms during a prolonged outbreak.  

Other considerations for administering influenza treatment: 

  • In hospitalized patients, oseltamivir can be administered orally or enterically via orogastric or nasogastric tube. For hospitalized patients who cannot absorb enterically-administered oseltamivir (e.g., due to gastric stasis, malabsorption, or gastrointestinal bleeding), or when oseltamivir is not available, intravenous peramivir is an option.  
  • For children who are not able to swallow prescribed oseltamivir capsules, the prescribed capsules may be opened and mixed with a thick sweetened liquid, such as chocolate syrup, prior to administration.  
  • When local generic oseltamivir availability issues are resolved, CDC recommends reverting back to original antiviral recommendations that include clinical diagnosis and empiric antiviral treatment of influenza in outpatients.  
  • Health care providers should use clinical judgement and all available data when making decisions about prescribing antibiotics to patients presenting with acute respiratory illness. 



Ryan Westergaard, MD, PhD, MPH
Chief Medical Officer and State Epidemiologist
Bureau of Communicable Diseases
Division of Public Health
Wisconsin Department of Health Services