Bird Flu Alarm

Understanding Avian Influenza

U.S. pandemic flu plan includes rationing of medicines

Sabin Russell, Chronicle Staff Writer, San Francisco Chronicle

Thursday, November 3, 2005

President Bush's pandemic flu response plan is a menu of hard choices the country will have to make in the event of an outbreak, setting out who will get scarce vaccines and influenza drugs first and laying the groundwork for curbs on civil liberties.

The plan assumes a worst-case scenario -- that a pandemic flu strain evolves and rapidly sickens 1 in 3 Americans, a bug capable of killing nearly 2 million people in the United States.

Driving the concern is the spread of the H5N1 strain of avian influenza. Scientists fear the bird illness -- carried by migratory fowl from Asia -- could mutate into the pandemic strain, spreading readily among people.

"The reality is that if the H5N1 virus does not trigger a pandemic flu, there will be another virus at a later time," Secretary of Health and Human Services Michael Leavitt said at a Washington, D.C., news conference Wednesday as details of the $7.1 billion proposal were released.

The Bush administration's 396-page pandemic preparedness plan includes recommendations on how to ration flu drugs and vaccines in the likely event there won't be enough to go around.

It also offers guidelines on travel bans, quarantines and involuntary isolation of patients, actions that are drawn from the international experience in containing the SARS outbreak in 2003.

Leavitt said Wednesday that enough antiviral drugs to treat 81 million people could be readied as early as the summer of 2007 -- much sooner than any previous predictions -- but in the event of a deadly pandemic even that amount would be divvied out to priority groups first, leaving millions of others without the means to fight the illness.

Hospitalized flu patients would be at the top of the list for Tamiflu and Relenza, which are the only medications thought to be effective against the H5N1 strain.

Planners anticipate there could be 7.5 million such patients in a pandemic. If the outbreak happened tomorrow, two-thirds of them would go without.

Next in line for treatment would be health care workers and ambulance crews who come down with the flu while caring for others, followed by flu-stricken pregnant women and people at high risk of hospitalization or death, such as those with compromised immune systems.

The queue for flu drugs would wind down through vaccinators, police and firefighters and employees of the plants that make the drugs and vaccine.

Only then would the elderly and small children -- typically the first to be rationed flu vaccine when in short supply -- be allotted their share of the flu drugs.

Americans, unaccustomed to rationing, would have to wait their turn for these drugs, which the Bush administration now proposes to buy in vast quantities, for more than $1 billion, over the next two years.

The priority lists were drawn up by doctors, academic researchers, flu experts and medical ethicists.

"This was a painful and very difficult process. Docs don't even like to use the word 'rationing,' " said Dr. Andrew Pavia, a University of Utah pediatrician who served as chairman of the committee that drew up the priority list for the flu drugs.

A separate committee developed a rationing scheme for scarce flu vaccine, which is less likely to be available in large quantities than the antiviral drugs.

At the top of the list to receive vaccine are some 40,000 employees of vaccine and antiviral drug makers -- the assumption being that their health is essential to producing enough of those products.

Next on the list for vaccines are 9 million health care workers. Eighteen million elderly with moderate health problems would be next, followed by younger people with medical conditions that put them at high risk for influenza.

Nursing home residents -- among the first to be vaccinated against seasonal flu -- are far down the list for the pandemic vaccine. Planners concluded that the immune systems of these frail patients would not respond well to the vaccine.

Scarce flu vaccine supplies are certain to be allocated early on to military personnel, who are not included in the priority lists that considered civilians only. The plan notes that the Department of Defense requires 1.5 million doses of vaccine to maintain current combat operations. The plan specifies that $81 million be spent on H5N1 vaccine for the military, and a separate stockpile of antiviral drugs is also being procured.

Larger amounts of vaccine would be needed for the military, the plan notes, if "the military should be called upon to support civil authorities" in a pandemic emergency.

Details of the rationing plans can be found in the 396-page document at

Priority groups for antiviral drugs

The Bush administration's plan includes the following list of groups ranked by their priority to receive antiviral drugs - not flu vaccine - if stricken by pandemic flu.

Group / Number of treatments allocated Group

1. Hospitalized patients: 7.5 million

2. Health care workers and ambulance crews: 2.4 million

3. Pregnant women and the immune-compromised: 700,000

4. Police, firefighters, vaccinators, key decision-makers: 900,000

5. Seniors and children under 2: 22.4 million

6. Nursing home residents at outbreak sites*: 2 million

7. Health care workers in emergency rooms and ICUs*: 4.8 million

8. Support personnel in health facilities, utility workers, trash collectors: 2.7 million

9. Citizens sick at home not needing hospitalization: 47.3 million

* Provided drug to prevent infection

Source: U.S. Department of Health and Human Services

Understanding Avian Influenza