Bird Flu Alarm

2006-05-11-Experts Argue Over Allocation of Bird Flu Vaccine

Understanding Avian Influenza

2006-05-11-Experts Argue Over Allocation of Bird Flu Vaccine

If and when a bird flu pandemic occurs, experts estimate there will be only enough vaccine to protect one in every 10 Americans.

Now, an essay in the May 12 issue of Science is heating up the debate on who that lucky 10 percent should be.

Countering the federal government's policy of placing the elderly near the top of the list, two medical ethicists from the National Institutes of Health (NIH) say that after doling out the vaccine to essential health workers, people between 13 and 40 years of age should be next in line to receive the shot.

"What we are arguing is that younger people have more of their life to lead, and they ought to get higher priority," explained Dr. Ezekiel Emanuel, chairman of the department of bioethics at The Clinical Center, which is part of the NIH.

He and co-author Dr. Alan Wertheimer stress that their opinion piece does not represent any official stance on the issue by the NIH, but they do hope it widens the debate on what could one day prove to be a very divisive issue.

The H5N1 avian flu virus continues to spread worldwide, infecting more than 200 people so far in bird-to-human transmissions and killing half that number, mostly in Asia. The big fear for health officials everywhere is that the virus could someday mutate so it passes easily from human to human. Just such an event sparked the 1918 flu pandemic, which killed more than 50 million people worldwide.

Two U.S. bodies -- the National Vaccine Advisory Committee (NVAC) and the Advisory Committee on Immunization Policy (ACIP) -- have helped craft the nation's flu vaccine allocation strategy in the event of a pandemic. Everyone on the panels agreed that vaccine production staff and health-care workers should get top priority for any vaccine. Then were people at high risk for death or hospitalization due to preexisting health conditions, as well as pregnant women, and a few key government leaders.

The question of who should be next was tougher.

"You have to decide what the number one priority is, and we felt that that priority was saving lives and decreasing hospitalizations," said ACIP chairman Dr. Jon Abramson, who is also chairman of the department of pediatrics at Wake Forest University Baptist Medical Center, in Winston-Salem, N.C.

According to Abramson, that means doling out vaccine to those people deemed at highest risk of dying should they become infected. With the lone exception of the 1918 pandemic -- in which young adults were most at risk -- "it is mainly the elderly and those with underlying cardiopulmonary and other chronic conditions that are most at risk" in flu pandemics, he said.

With that in mind, NVAC/ACIP submitted their allocation plan prioritizing the elderly to the White House, which accepted it. "We've never been asked to come back and rethink it," Abramson said.

But Emanuel hopes that might change. In their essay, he and Wertheimer say that while the focus on "saving the most lives" does have merit, other considerations come into play. "On reflection, most people have the intuition that you should save children and young adults," Emanuel noted.

This reasoning is based, in part, on something called the "life-cycle principle." That states that people in late middle- and old-age have already had the opportunity to live through most of life's stages of growth and experience, while adolescents and young adults are only beginning to do so.

Then there's a concept the ethicists call "investment."

"People in their late teens/early 20s should get priority because [society] has already invested a lot in them, and they are just on the cusp of leading their lives," Emanuel said. "It's precisely for these reasons that the death of a young person always seems more tragic to us vs. the death of someone much older."

In their essay, Emanuel and Wertheimer posit a new set of priorities for the flu vaccine: health workers first, then Americans aged 13-40, based on the principles outlined above.

Emanuel pointed out that "saving the most lives" hasn't always been paramount when it came to allocating scarce, potentially lifesaving resources. In the Titanic's lifeboats, it was "women and children first," he said, and transplanted organs usually go to the sickest patients first, not those who are most likely to survive after transplant.

He said both he and Wertheimer are older than the 40-year-old cut-off, and he understands that many older people would want the vaccine, too.

"It's not as if I feel my life is over," he said, "but we have to give priority. If you ask me if I would take the vaccine or give it to my 16-year-old kid, it doesn't take me a millisecond for me to say 'Oh, my kid's first.' "

But another ethicist said Emanuel and Wertheimer's position has flaws.

"Part of the dilemma in developing vaccine-rationing policy is that we just don't know who's likely to be the most vulnerable -- the young, the old or the in-between," said Dr. G. Caleb Alexander, an assistant professor of medicine at the University of Chicago's MacLean Center for Medical Ethics.

He said that "support for their argument has to hinge to some degree, on how vulnerable different populations of individuals are to the pandemic. The less vulnerable this young and middle-aged group are, the less sense the proposed policy makes."

For example, what if a virulent flu virus was killing 80 percent of infected elderly, but just 20 percent of infected 13-to-40-year-olds? "Would they still really hold that we should be allocating these precious vaccines to people who have just one-fourth the likelihood of dying?" Alexander said.

Abramson said the official U.S. allocation policy does contain built-in flexibility. "If you're basing it on lives saved and hospitalizations, then as you get into the epidemic and you find that 20-year-olds are the ones dying, then absolutely you change [the policy] -- that's already in our recommendation," he said. "You adjust, you reprioritize."

But he said the policy as it stands now is based on a sense of "equity": Outside of health-care workers, no one group should get priority because of age or any other factor, other than their vulnerability to the virus. He said ethicists were included on the NVAC/ACIP panels and were familiar with Emanuel and Wertheimer's position, but "none of them bought that argument."

Still, the University of Chicago's Alexander said raising the public's awareness of the complexities of vaccine-distribution policies is important. For that reason, he said, the two NIH ethicists "deserve high praise for helping to move the debate about pandemic preparation and vaccine allocation to the public arena, highlighting the tough calls that may have to be made in the event of a flu pandemic."

Understanding Avian Influenza