Thursday, May 25, 2006

health magazine:

As government plans for a possible global flu pandemic, it's ducking one of the hardest questions: Who gets vaccinated first?

The federal plan, released in November and updated earlier this month, painted a worst-case scenario of 2 million deaths, 90 million sick and 10 million hospitalized if a new flu virus emerges and begins spreading human-to-human.

The plan depends on vaccination as the ultimate solution. But it is also honest in acknowledging the likelihood of a four- to six-month lag between when the exact virus is identified and when vaccines can be manufactured and distributed.

It notes that only a few factories produce flu vaccine worldwide. Manufacturing capacity is weak.

Within the first year of a pandemic, chances are that only 10 percent of the U.S. population would be vaccinated. America needs frank talk about who should receive those early shots. Nearly everyone ranks frontline health-care workers, emergency responders and vaccine manufacturers first. After that, sorting becomes complicated.

Bioethicists Ezekiel Emanuel and Alan Wertheimer debate ethical principles in a provocative May 12 Science magazine article that should spur national discussion, not just on pandemic priorities but also on America's general approach to rationing health care.

Should America focus on saving the most lives? Or on "those instrumental in making society function"? Or those with the prospect of the "most quality years"? Or those most likely to recover?

Emanuel and Wertheimer favor "life-cycle" pandemic flu vaccination allocation based on the idea that each person be given the opportunity to experience all stages of life.

"Death seems more tragic when a child or young adult dies than an elderly person - not because the lives of older people are less valuable, but because the younger person has not had the opportunity to live and develop through all stages of life," they write.

Emanuel and Wertheimer would give people between 13 and 40 years old priority, in part, because of that age group's ability to ensure safety and provide necessities, such as food and fuel, during a pandemic. They reason that young children and the elderly can be more easily quarantined at home.

Other experts disagree. Paul Offit, director of Children's Hospital's vaccine education center, thinks young children are a "reservoir" for flu epidemics, and vaccination should start there.

Indeed, recognition of children's role in spreading seasonal flu led the Centers for Disease Control and Prevention in February to recommend annual flu vaccination for all children 6 months to 5 years old, and their caregivers. Previously, vaccination was recommended only for toddlers and children with medical conditions, such as asthma or kidney disease.

Also, emotionally, few parents would be able to vaccinate themselves ahead of their children, even if that did make the most sense.

Ultimately, the country will need one set of priorities, designed federally, implemented locally. The discussion needs to happen now, long before a crisis arrives.