An influenza pandemic strikes the United States. Tens of thousands of people have died, hundreds of thousands of people are sick, and the pandemic shows no signs of abating. The first pandemic flu vaccines are finally coming out and several of your neighbors have been vaccinated by the county health department, namely the police officer, the guardswoman, the paramedic, and the pregnant woman, along with several children, all of whom are younger than three years old. But there’s not enough vaccine yet for your three children, ages 3 1/2, 6, and 10, or for you and your spouse. The health department is saying that there will be enough vaccine for all kids up to 18 years old in another few weeks, but they don’t know exactly when it’ll come because there’s 50 million people at higher risk and “more important” than your family is, and they don’t know how many doses of vaccine can be produced weekly.

Not only do you have to wait, but there’s a few cases of pandemic flu in the neighborhood (and the houses have been quarantined) and you know that the last time you got a bad chest cold, your asthma flared up and you had to be hospitalized. So even though you’re further up the rationing list than your spouse, it may be weeks after your kids get vaccinated before you get similarly vaccinated, and your spouse may never be vaccinated at all – he/she’s healthy and between 19 and 64, the ages least likely to contract the flu and most likely to survive it. Small consolation that is if your spouse catches pandemic flu and is one of the unlucky ones.

What do you do? Do you wait for the vaccine and pray that your family avoids catching pandemic flu while you’re waiting? Do you try to ransack the national guard protected health department vaccination vans in order to get your family the shots they need? Do you lie about your youngest child’s age so at least someone in the family will be vaccinated and will survive the pandemic?

These sound like academic questions, but they’re not – they’re questions that we have to ask ourselves that will define who we are when, not if, the next pandemic flu strikes the planet.

It’s only a matter of time before pandemic flu of some variety rears its deadly head again, and when it does, it’s a matter of fact that vaccines will not be available in sufficient quantities to vaccinate everyone at the same time. So the government will have to ration the vaccines, vaccinating people most at risk and most necessary to the continuing operation and future recovery of the country. Yesterday, the U.S. Department of Health and Human Services (DHHS) pandemic flu website released their “Draft Guidance on Allocating and Targeting Pandemic Influenza Vaccine”, and it outlines the basic process I described above. It divides the entire country up into five tiers of people, as shown in the image to the right (click for a larger version), with Tier 1 people being vaccinated before Tier 2 and so on. Which fundamentally means that if you’re healthy and between the ages of 19 and 64 (Tier 5), there’s a very good chance that the pandemic will have run its course before you get vaccinated.

The reason for this is simple – the world presently lacks the production facilities required to produce flu vaccines on the scale required by a pandemic. The World Health Organization (WHO) is responsible for organizing the global response to a future flu pandemic and is developing the medical resources required to produce flu vaccines on a massive scale. The problem is that the current global production of flu vaccine is only 300 million doses per year, and even optimized production can increase production to only ~780 million per year. In addition, 780 million doses per year assumes that only a single dose of 15 micrograms of inactivated virus is required – if more virus or additional doses are required, or if the egg-based production process yields less virus for the hypothetical pandemic flu strain, the number of available doses drops significantly. With modern transportation and trade, pandemic flu would almost certainly be global in scope, and so up to 6 billion doses of vaccine would be required. If a new pandemic lasted two years (as the 1918-1919 flu pandemic did), a new pandemic would have burned itself out before even a quarter of the planet’s population could be vaccinated. If we assume a 50% infection rate and 2.5% mortality (the mortality of the 1918 flu), that’s between 56 and 75 million people dead worldwide.

And this is just the impact of pandemic flu on you and your family via vaccine rationing. Here in the U.S., if you or someone in your family is unlucky enough to catch pandemic flu, you’ll likely be checked by a doctor working with the health department at a public triage location before you’re even permitted to go to the hospital for treatment. Because of our recent health care cost cutting national mania, hospital beds, quarantine tents, and the link are at a premium – major health disasters that affect a significant proportion of the population are beyond the scope of the U.S.’ to cope. And because of limited “surge” capacity in beds, ventilators, drugs, etc., the entire health care system will be set up to perform “palliative care,” where the health department doctors will be required to decide whether to treat you or not, based on symptoms, patient’s age and general health level. Any patient deemed “too far gone” will not be treated and will either die or recover without any medical assistance from the health care system. There will be no comfort I can think of if its your child, spouse, sibling, parent, or friend who ends up being denied care because they can’t be saved.

Thinking about what pandemic flu might do to your family and friends, your community, your state, even the country is entirely unpleasant, but we must discuss how we will react when the next flu pandemic strikes. And as someone with a family, I understand that talking about this isn’t exactly relaxed dinnertime conversation. But the discussions need to happen before a pandemic hits, because once that happens, you may not have the time to think carefully or the ability to discuss your response rationally.

I strongly urge everyone to make time to sit down and discuss how you’ll respond to a pandemic. Talk about it with your children if they’re old enough to understand. Read the draft pandemic vaccine response, help your community organize for its pandemic flu response, and feedback any and all comments and discussion back to the DHHS. And use the DHHS’ individual planning guide to pull together emergency supplies in advance of a pandemic striking. If you’re already in a natural disaster-prone region of the world, you probably already have everything you need pulled together, but if you don’t, take some time, spend a little money, and prepare yourselves.

And hope you’ll never need those emergency supplies.

Thanks to NPR’s Morning Edition for putting me onto this story and to my sister for regularly annoying me with emails about how important it is to have boxes with emergency supplies stocked up.