A tough call awaits if a killer flu breaks out

10/24/2006

Knowing there won’t be enough for all, a group of Minnesota experts dealt with who should get flu vaccines in the event of a pandemic.

Maura Lerner,
Star Tribune
Last update: October 23, 2006 – 10:23 PM

What would happen if a deadly flu pandemic hit today and, as expected, there wasn’t enough vaccine to go around?
A Minnesota panel of experts says the first flu shots should go to the healthiest among us—not the sick and elderly, as the federal government has advised.

In fact, the oldest and weakest Minnesotans could be at the bottom of the priority list, under a set of recommendations released by the Minnesota Center for Health Care Ethics.

The plan envisions that healthy people in critical jobs—such as delivering and administering vaccines—would get top priority. Kids with asthma, meanwhile, might have to wait their turn behind millions of healthy teenagers and young adults.

“Our society doesn’t like rationing,” said Dr. James Nordin, a St. Paul pediatrician and member of the panel that proposed the plan. “This will be an extreme form of rationing when it happens. The situation will force that on us.”

Published last week, the proposal is advisory only. But it was designed to “shine a light on a situation that we need to prepare for,” said Ellie Garrett, assistant director of the ethics center, an independent think tank in Minneapolis.

“We know that pandemic influenza is inevitable,” she said. “We think there’s an ethical obligation to think through the tough issues and to prepare as best we can.”

In this case, the center’s panel of experts assumed a “worst-case” scenario: that the next pandemic would resemble the horrific Spanish flu of 1918-1919. It killed tens of millions worldwide—most notably young adults.

If it happens again, the panel assumed:

• A third of Minnesota’s population, currently 4.9 million, would fall ill. Perhaps 2 to 3 percent would die.

• The pandemic would last for two years, coming in several waves of two to three months each.

• Life as we know it would be disrupted as people fall ill or stay home to take care of the sick.

• It will take six months to produce a vaccine. And then supplies will trickle slowly across the country. Minnesota would get about 35,000 doses a week.

An ‘ethical framework’

“Frankly, it could very easily be that ... we only get 10,000 doses a week,” said Aggie Leitheiser, director of emergency preparedness for the Minnesota Department of Health. “So who gets the first 10,000?”

That, she said, was the challenge before the ethics panel, which included doctors, nurses, ministers, lawyers and representatives of the health department. Only the governor, however, would have the power to impose such a plan in an emergency.

“We want to try to avoid the kind of situation we saw with [Hurricane] Katrina, where people could have done some planning and had some things in place and they weren’t there,” Leitheiser said.

The goal, said Garrett, was to come up with an “ethical framework” to “maximize Minnesotans’ chances of surviving” both the flu and its aftermath.

“We think this is an ethical way to distribute vaccines under the assumptions that we made,” she said.

First, the group agreed that the vaccine should be free, and that “the rich and privileged should not have an inside track,” Nordin said. The members also agreed to give top priority to people handling the vaccine itself. “If that person is ill and the vaccine doesn’t get delivered, then we’re in trouble,” he said.

After that, the choices got tougher.

The state panel ranked people on several factors: Are they at high risk? Do they have strong immune systems? Are they in critical jobs?

Low priorities were assigned to older people and babies younger than 6 months because they generally have weaker immune systems, which makes vaccines less effective.

“It’s not that we’re saying they’re not valuable,” said Garrett, adding that if the vaccine isn’t likely to help them, they may be better off if those around them are vaccinated instead.

‘Uphill battle’ ahead

Until now, federal guidelines have given preference to the elderly and the sick in the event of a pandemic.

But Dr. John Agwunobi, assistant U.S. secretary of health and human services, welcomed the Minnesota report, noting that groups all over the country are struggling with this issue.

“There are a number of different camps on how limited resources, vaccine being one, should be distributed,” he said. “We truly believe that our role today should be to encourage the debate.”

The big question, of course, is whether any rationing plan would work in a pandemic.

“It’s going to be an uphill battle if anything approaching the worst-case scenarios come to be,” said Jason L. Schwartz, of the Vaccine Ethics Program at the University of Pennsylvania’s Center for Bioethics.

He noted that a recent TV movie about a fictional pandemic “had tanks carrying vaccine down the street as people attacked the convoy. I don’t think it will come to that,” he said, adding that “the potential exists here for any plan to crumble in the worst of a crisis.”

Agwunobi, the assistant health secretary, agrees. “For any prioritization system to work in an emergency, there needs to be widespread acceptance,” he said. “You don’t want [people] stopping the trucks on the road and ripping the boxes off the back because they don’t trust in the system that was designed to protect the nation.”

In Minnesota, panel members agree it won’t be easy, but they think it’s important to try to engage people now.

“If we get in a situation like this envisions, there’s going to be a lot of irrational thinking going on,” Nordin said. “A rational discussion beforehand, I think, is our only real chance at preventing chaos.”