Ethicists raise questions about how to ration vaccines in a flu pandemic

WASHINGTON -- Who should get the first flu vaccine during a worldwide outbreak -- the 60-year-old grandmother with a weak heart and lungs or the healthy 4-year-old with decades ahead of her?

Government guidelines put the ill grandmother at the head of that line, for now.

Younger, healthier people should be moved ahead, argue bioethicists at the National Institutes of Health, raising new issues to consider as federal officials review the nation's pandemic guidelines.

"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," Drs. Ezekiel Emanuel and Alan Wertheimer wrote for today's edition of the journal Science.

It's a different way of weighing the decision of how to ration scarce vaccine if a strain of influenza sparks a worldwide epidemic. If that flu arises, it will take manufacturers months to brew inoculations for everyone.

First doses will go to workers in vaccine factories and to people caring for the ill, a Bush administration decision widely shared by health specialists.

The question is who's next.

Federal health advisers have recommended that people up to age 64 who have at least two high-risk health conditions -- such as asthma, heart disease, emphysema -- be first in line. Next would come pregnant women and people who come in contact with people who have poor immune systems. They're followed by key government leaders and healthy people over age 65.

At the end of the list, after funeral directors, come healthy people ages 2 to 64.

The list is under discussion and not final.

It rests on a long-used public health principle, that the people most vulnerable to dying from a disease should be vaccinated first. In an average winter, flu mostly kills the elderly. No one knows if that will hold true during a pandemic; in 1918, history's worst pandemic, young adults were the chief victims.

To the average person, protect-the-young is an equally powerful principle, argues Emanuel, who also treats cancer and notes that the 65-year-old who succumbs is often mourned with the "but he had a good life" comfort that's missing when a child dies.

But youngest-first is too simple, Emanuel concluded. So he also considered how much has been invested in a young person's future, plus a "public order" principle that gives priorities to providers of necessities like food and fuel.

Combining those ideas, he wants healthy 13-to-40-year-olds to get scarce flu inoculations right after the vaccine makers and health workers -- especially those who are police officers, utility workers or in other professions important to societal order. They would be followed by younger children and the middle-aged, with the sick elderly last in line.

"We need principles people share (such as) this protective instinct for young people to allow them to lead a full life," said Emanuel, whose paper doesn't reflect NIH policy but his own opinion.

Other alternatives already are being debated, such as whether preschoolers and schoolchildren should be among the first vaccinated during a pandemic because they are the main spreaders of influenza.

And the government advisers who recommended the current guidelines first strongly considered putting police officers and truck drivers at the head of the line. Then, "not only can the truck driver keep delivering goods, he or she will be protected and cannot give it to others," said Dr. William Schaffner, a Vanderbilt University flu specialist who was part of those debates.

"There is no single right answer," said Schaffner, who praised the new article's call for wide public discussion about the hard choices that would have to be made. "These are prioritizations that should be transparent."

The government wants public input, said Dr. Bruce Gellin, who heads the federal vaccine policy office.

"There should be vigorous public discussion about this," Gellin said. "It's important that people know what's in the plan and begin to think what it may mean for them."