Bird Flu Shots Should Go to Elderly, Kids Last, Experts Say

Brian Handwerk
for National Geographic News

May 11, 2006

If a bird flu pandemic occurs, only 1 in 10 Americans is likely to be vaccinated within the first year given the current level of vaccine production.

So who should get the goods?

The existing U.S. Department of Health and Human Services Pandemic Influenza Plan prioritizes those at highest risk of hospitalization and dying—such as the elderly, very young, and chronically ill.

But a new paper flips the existing distribution model on its head and makes an ethical case for prioritizing those between early adolescence and middle age.

The study, appearing in tomorrow's issue of the journal Science, is sure to raise eyebrows. That's why experts stress that the time to tackle such a potentially explosive issue is now, before a pandemic occurs.

"One of the things that I keep saying is that we haven't had enough public debate and discussion about what the rules should be," said Arthur Caplan, director of the University of Pennsylvania's Center for Bioethics.

Caplan, who is not involved in the study, recalled that distribution rules during recent seasonal vaccine shortages were often disregarded.

"The only way that you can have buy-in is if people both understand what the rule is and what the rationale is," he said. "That's absolutely critical if we're going to have any kind of orderly distribution of scarce resources."

Medical Ethics

There are many different ethical principles that can be used to ration scarce and vital commodities.

"Women and children first" was a system most famously used (though not universally practiced) to allocate lifeboat space on ocean liners.

The "first come, first served" ethic is commonly employed in hospitals—admitted patients aren't kicked out to make room for those in worse condition.

"Save those most likely to recover" is a triage ethic that has often been employed in wartime.

Under the current plan, the ill elderly top the list, while healthy people age 2 to 64 are last in line.

This plan was based on recommendations from the National Vaccine Advisory Committee and the Advisory Committee on Immunization Policy.

It operates under several assumptions, including a prediction of how the virus will kill.

"The greatest risk of hospitalization and death—as during the 1957 and 1968 pandemics and annual influenza—will be in infants, the elderly, and those with underlying health conditions," the authors write.

Save Those With More to Live For?

Now Ezekiel Emanuel and Alan Wertheimer of the National Institutes of Health's Department of Clinical Bioethics in Bethesda, Maryland, have proposed an alternative scheme.

The pair would give priority to healthy individuals age 13 to 40, because of a "life-cycle allocation principle" that suggests that each person should have an opportunity to live through the various stages of life.

The theory considers the amount of time that a person has invested in their life and the amount of time that they likely have left to live.

Both approaches recognize that top priority must go to vaccine workers and front-line medical staff, because keeping these people healthy is the only way to save lives.

Some 1.5 million doses will also be required by the military—a number that will rise if soldiers are needed to support local authorities with pandemic-related missions.

"The question is really, Who's third?" Emanuel noted. "In general that's where we disagree with the government analysis."

Emanuel believes that the "save-the-most-lives" ethic initially sounds plausible but may not stand up to scrutiny.

"When you really begin to think about it, this means saving the elderly who are at the greatest risk. But if you ask people, what you end up hearing is that [they would prefer] to save the young people."

"If you ask most people, Between you or your children who should get the vaccine?, they'd say the children, who are just about to go out and begin to live their life. That's who many people want to save."

The authors also employ an ethical principle of public order. This would further prioritize police, firefighters, utility and telecommunications workers, and others essential to providing society's basic needs.

More Than Vaccine Must Be Rationed

Unlike the Health and Human Services report, Emanuel and Wertheimer's recommendations target groups that were at highest risk during the devastating 1918 "Spanish flu" epidemic: those between 20 and 40 years old.

The two approaches' differing assumptions about who the virus might kill highlight the fact that any resource distribution plan must be flexible.

As a pandemic develops, incoming medical data will likely reveal that certain groups are more badly affected. Young children may frequently become ill but rarely die, for example.

That kind of feedback would necessitate on-the-fly changes to any preconceived structure of distribution.

The Health and Human Services plan recognizes this need as well.

"In the 1918 pandemic, most deaths occurred in young adults, highlighting the need to reconsider the recommendations at the time of the pandemic based on the epidemiology of disease," the authors write.

The University of Pennsylvania's Caplan notes that in the event of a pandemic such ethical dilemmas are likely to arise long before a vaccine even becomes available.

"The first ration crunch will not be about vaccines. It will take a while to make them if we're lucky enough to get them," he explained.

"The first issue will be, Who gets into the hospital? Maybe, Who gets an antiviral? Who gets a ventilator?"

"It turns out that we have about 100,000 [intensive care units] and ventilators, but the CDC estimates that [victims of a significant epidemic] may need 500,000," he continued.

"Of course, most of the 100,000 that we do have are being used—someone's on the other end of them right now."

The consequences of a pandemic are likely to be dire. But their extent may be defined, at least in part, by the ethical choices we make, experts say.

"If you guess wrong you'll want to know what the consequences are," Emanuel, of the National Institutes of Health, said.

"If you immunize young people and it turns out that it's the old who get sick, the consequences are not as severe, because the elderly are not at a dramatically increased risk of dying. They already have a shorter life span."

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