For flu vaccine shortage, CDC priorities apply

What ethical considerations do you, as a family physician, consider when deciding whom to vaccinate?

Reply:

Influenza is a potentially lethal infection that can spread rapidly from person to person. With the exception of recent concerns about an impending avian flu pandemic, the public and most health care professionals have become largely complacent about the flu's potential health and societal impacts. There were three worldwide influenza pandemics in the 20th century, the most deadly of which in 1918 claimed the lives of millions. Many of the 1918 victims were young and healthy before infection; nevertheless, death often occurred within days of the initial symptoms.

Today, annual influenza vaccination is an effective means for controlling the spread of the virus. There are now two forms of influenza vaccine: deactivated, which has been used for many years and is administered by intramuscular injection, and live attenuated influenza vaccine (LAIV), which is administered nasally.

Influenza vaccine distribution delays or supply shortages have occurred in the United States in three of the last five influenza seasons. Last year the nation experienced a major shortage that left many physicians with limited or no doses. Last year's shortage highlighted communication and preparedness problems in the U.S. public health system. Local public health authorities found themselves without vaccine. In a display of distribution inefficiency, large business vendors had the vaccine when hospitals and doctors did not; low-risk patients were being vaccinated while high-risk patients went without; and the elderly and infirm had to stand in line for hours. Federal, state and local health authorities have worked hard to correct these deficiencies.

With the knowledge that health care is a limited resource, society seeks to satisfy each citizen's needs, while promoting the public interest through cost-containment programs. But we should strive wherever possible not to leave the allocation of a limited resource to the discretion of front-line care providers. National and local public health authorities who have the benefit of seeing the big picture should determine allocation priorities and coordinate distribution of the influenza vaccine. The Centers for Disease Control and Prevention has developed priority groups for getting flu shots. Physicians should be familiar with and use those guidelines if necessary. I believe I have little choice but to vaccinate patients according to these priorities and will do so with the vaccine I have available. If deactivated vaccine is in short supply, physicians are advised to extend the use of LAIV to cover groups for whom that form is not routinely recommended, such as health care workers.

The CDC and the Advisory Committee on Immunization Practices recommend vaccinating according to the priority schedule only in the event of shortages. At press time, the CDC and ACIP did not recommend prioritization. If the CDC announces the need for prioritization, people in tier 1 should be vaccinated first, followed by people in tier 2, then those in tier 3. If vaccine supply is extremely limited, state and local health officials and other vaccination providers should vaccinate those in group 1A before other groups.

Rationing is not a term that sits well with the public or health care professionals, but prioritization of care and triage -- the politically correct terms for rationing -- are routinely used in medical practice, though the principles are applied implicitly rather than explicitly. Health care is a limited commodity. This is especially true in an emergency where on-site medical personnel may be unable to cope with the unforeseen volume of sick or injured patients. In such an event, triage principles are applied. Much credit for modern-day triage is attributed to Dominique Jean Larrey, a famous French surgeon who devised a method to evaluate quickly and categorize the wounded in battle and then evacuate those requiring the most urgent medical attention.

Medical utility satisfies the ethical demand that benefits, risks and costs be distributed rationally and fairly. Distributive justice is employed at many different levels in the health care system. The federal government applies this principle to determine which services Medicare pays for, and states use a similar process for Medicaid. Organ transplantation boards depend upon the principle of distributive justice to decide how the limited resource of donated organs can be allocated to specific patients. They avoid the pressure of political agendas and decisions based on social utility; for example, saving the life of someone who is thought to have a higher social value than someone else. Unfortunately, medical care decisions are not always made solely on the basis of medical utility but are frequently influenced by politics.

Although most medical allocation decisions are made on the basis of medical utility, social utility could impact vaccination allocation in the event of a flu pandemic.

Health care personnel might assume a top priority based on the benefit of protecting them from the disease so that they could care for the sick. Public safety personnel and other public servants also might have a high priority. If these decisions are needed, they should be decided at a health policy level rather than being left to the discretion of the individual physician.

Patrick P. Coll, MD, professor of family medicine and associate director of the Center On Aging at the University of Connecticut Health Center