As sales of pharmaceuticals and the supply of medical information on the Internet have increased substantially, so too have reports of suspected illegal advertising and other complaints from consumers.

How safe is it to seek medical advice or buy pharmaceutical products online? How can the Internet user know if the information offered is reliable? Is there any guarantee that medical products bought online will be safe or effective? And what sanctions exist to prevent improper use of the Internet?

To guide consumers through these relatively uncharted waters, WHO has produced a guide to obtaining reliable, independent and comparable information on medical products on the World-Wide-Web.¹

The guide - Medical Products and the Internet -has been developed in consultation with drug regulatory authorities, drug information experts, consumer organizations and the pharmaceutical industry. An edited version of the guide appears below.

POINT I The Internet is a valuable source of information - provided the source is known and trusted

The Internet is a valuable source of information on topics such as diseases, conditions, therapies, medical products, and health and medical organizations. When used properly, it allows quick and easy access to such information from on-line medical libraries, universities, health associations and government agencies. However, the quality of health and medical product information on the Internet varies, and it is often difficult for the Internet user to identify the true source of the information, and to determine whether it is reliable, complete and up-to-date.

POINT II Finding reliable health and medical information on the Internet

In order to evaluate the reliability and quality of the web site information, it is advisable to consult health care professionals or reliable organizations. Box 2 outlines the minimum information that a web site should contain.

Many health and medical sites on the Internet provide good information -aimed at health professionals or consumers - that may not be easily available from other media. However, even where information is from a reliable source, special training may be needed to evaluate it properly and to determine whether the information is applicable to the disease or condition of an individual patient. The information provided by these web sites covers topics such as:

- Ongoing research on a particular disease or condition - including rare diseases - and related clinical trials;

- New product approvals by health authorities for a specific disease or condition;

- General information about specific diseases or conditions, such as high blood pressure, arthritis or obesity;

- Support groups for people with certain diseases and conditions, such as HIV/AIDS or cancer;

- Lists of international, national and local organizations that provide support and information about a disease or condition.

Health authorities and organizations in each country can provide a list of sites with links to reliable sources of health and medical information. In addition, several private organizations are investigating ways of assuring the quality of information on the Internet. They include Health on the Net Foundation <http://www.hon.ch> and Internet Healthcare Coalition <http://www.ihealthcoalition.org>. National authorities should identify and list additional organizations and reliable web sites known to them.

POINT III Finding reliable medical product information on the Internet

The Internet also offers information on medical products. However, not all product information may be truthful. If information sounds too good to be true, it probably is. Warning signs include:

- Advertisements or information that use phrases such as “scientific breakthrough”, “miraculous cure”, “exclusive product”, “secret formula”, “ancient ingredient”, “without risk”, “anti-ageing”, “improve sexual performance” and “all natural”;

- Case histories from “cured” customers claiming amazing results;

- A list of symptoms and diseases it is claimed the product cures - for example, claims that one product can cure or treat HIV/AIDS or cancer, arthritis, Alzheimer’s disease, wrinkles, weight problems, or memory loss;

- Advertisements for the latest fashionable product featured in the media;

- Claims that a product is available from one source only and for a limited time;

- Testimonials from “famous” medical experts;

- Claims of “no risk” or failure to include information about risk. No product or treatment is completely risk-free;

- Claims that a product is “scientifically proven”.

Since products with the same name may contain different ingredients in different countries, it is essential to look at the International Nonproprietary Name (INN) of the active ingredients and not just the product name (brand name, trade name). Product information should be as complete as possible, and include at least the elements outlined in Box 3.

POINT IV Be cautious about buying medical products on the Internet

In some countries, advertising, selling or buying medical products from another country via the Internet is illegal. Caution should be the keyword when considering buying medical products through the Internet. Otherwise, users may place both their health and money at risk. Health care professionals should be consulted before embarking on self-treatment. And checks are needed to determine the legality of buying a medical product through the Internet. Potential risks include:

1. Safety and efficacy assurance may be lacking

In many countries, before medical products are approved, licensed or authorised for sale, the companies that develop and market them must conduct research and demonstrate to a drug regulatory authority that the products are safe, effective and of good quality for human use. Although these authorised medical products may be available through the Internet, there may also be unregulated products for sale. It may be difficult for the Internet user to distinguish between products that have met government requirements and those that have not.

Information about medical products being developed and tested in humans is available on the Internet. People suffering from a disease or condition for which there is currently no treatment or cure often search for information and read about these new products on the Internet. Although new products are often not available for prescription, a health care professional may prescribe one before approval, or discuss enrolment in a clinical trial to study the product. However, there may be additional risks in using such a product before approval, because the possible adverse effects (which may be serious or life-threatening) and the effectiveness and proper dosage schedule may not be known. In cases where a prescription product is unavailable in one country but approved for use in another, the country involved may have special legal procedures allowing the import of prescribed medicines from abroad. This could be done with the help of a health care professional, through legitimate distribution channels.

2. Instructions for use may be inadequate

To ensure that medical products are used properly and safely, they need to be accompanied by precise instructions. However, there is no assurance that a product obtained via the Internet will have the correct instructions for use, dosage and precautions. To make matters worse, instructions may be printed in a foreign language, be unreliable, out of date or otherwise unusable.

3. Quality may not be assured

When medical products are bought through the appropriate channels, such as a pharmacy, the product can usually be relied on to meet manufacturing requirements and to be of good quality. The product is likely to contain the right active ingredients and to have been manufactured, packaged, transported and properly stored prior to purchase. However, buying medical products through the Internet may deny consumers the quality assurance offered by authorised channels of medical product manufacturing, distribution and sales.

4. Products may circumvent regulatory protection

Medical products sold through the Internet may circumvent the regulatory protection provided by health authorities and governments. And it may be impossible to obtain compensation from the manufacturer or distributor for any damage resulting from the use of these products. The identity and location of the source of products may be disguised - a common ploy in the case of fraudulent medical products.

5. Products may be fraudulent and harmful to health

Products promoted and offered for sale on the Internet may be fraudulent if they do not meet the standards required for approval in the country where they are being purchased and if they are not sold by licensed or authorised health organizations. The use of such products for self-treatment may be harmful to health or provide no benefit at all - both of which can be dangerous. In the meantime, the opportunity to be properly treated by health care professionals may be lost.

6. Reimbursement may not be possible

In many countries, health insurance programmes may not agree to reimburse the cost of medical products bought through the Internet. Before buying medical products in this way, it is advisable to find out whether the cost is reimbursable and whether the Internet medical product provider is recognised by the health insurance programme.

7. Products may waste valuable resources

Seeking medical treatment through the Internet instead of through a health care professional could involve a waste of valuable resources. Money may be wasted on useless products and time lost in obtaining proper treatment.

8. Products bought across borders may be prohibited in some countries

Countries have different laws about what medical products can be sold and shipped across national borders. Products that have been identified as a hazard to public health or which are not approved for sale in a particular country may not be allowed in if they are identified at entry. And if the product has already been paid for, it may be impossible to get reimbursement. An additional constraint on the import of medical products is the prescription status of medical products, which varies from one country to another. Products that may be sold without prescription, or are even unregulated, in one country may only be available on prescription in another.

9. Products with the same name may be different in different countries

Internet users need to be aware that products with the same name may contain different ingredients in different countries. As a result, the wrong medical product may be selected. In addition, countries may have different standards for the quality of medical products and their manufacture. Products purchased across borders might not be exactly the same product or quality as in the Internet user’s own country.

10. Personal information may not remain confidential

Many web sites require the disclosure of personal medical data. However, there is no guarantee that this information will be kept confidential. To avoid this risk, medical products should be purchased through conventional, legitimate distribution channels.

POINT V Consult a health care professional before embarking on self-treatment or changing medication

Even after finding reliable health or medical information on the Internet, it is important to consult a health care provider to discuss the specific disease or condition and the information found on the Internet before embarking on self-treatment. This is important because:

- Not all diseases and symptoms need medical treatment. Medicines or medical products may be used unnecessarily - exposing the individual to unnecessary risk.

- Many medications or other medical products may cause harm if used improperly. It is important to be under the care of a health care professional when using such products.

- Not every medication is appropriate for everyone. For example, some individuals may be allergic to certain medications. A health care professional can help in determining the best medicine or treatment tailored to individual needs.

- A health care professional can provide guidance on the safe use of medication. For example, the effectiveness of some medications may be influenced by other products, such as other medicines, alcohol or certain foods. Mixing medication with these other products could strengthen or weaken the effect of the medication or cause an adverse reaction. This could be dangerous to health or delay recovery.

- Patients such as pregnant or breast-feeding women, the elderly and children, have special requirements when taking medication or using medical products. For example, some medications can harm an unborn child and pregnant women are advised to consult a health care professional before self-treatment.

- Whenever a patient takes medication or uses a medical product, it is important to inform a health care professional of any side-effects experienced. In this way, the health care professional is better prepared to offer advice or change the treatment in the event of an adverse reaction.

- By ordering medical products through the Internet patients may deprive themselves of the opportunity for personal, professional care and advice from a doctor, pharmacist or other health care professional.

Medical products and the Internet: a guide to finding reliable information is available at http://www.who.int/medicines/library/qsm/who-edm-qsm-99-4/medicines-on-internet-guide.html

In Portuguese: http://www.cvs.saude.sp.gov.br/medical.html

In Italian: http://www.edifolini.com/farmaci_txt.html

For those without web access a limited number of hard copies of the booklet in English are available from: Department of Essential Drugs and Medicines Policy, World Health Organization, 1211 Geneva 27, Switzerland. Reference: WHO/EDM/QSM/99.4.