Pandemic flu vaccine will be rationed – and you may never get vaccinated

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.

9 replies »

  1. I have a close friend who runs a CDC research lab, Brian. He tells me that Avian flu is now mutating into a form that may, by flu season of ’09, be pandemic ready (air borne, easily contracted human to human). That should scare hell out of all of us.

    This heads up may be more apropos than you want it to be, Brian.

  2. Great. Just great.

    At least the H5N1 (avian) flu scared enough people that the WHO and DHHS are ahead of this one. Not far enough ahead, perhaps, but anything helps.

    I’m in Tier 5 (I doubt that my job is important enough to move me up the tiers), my wife in Tier 4, my daughter’s in Tier 2, and my son’s in Tier 1. And if it was me who knew that there was pandemic flu in the neighborhood that my kids could catch, I’d either be scared out of my mind and unable to function or I’d be hyper able to function because I’d have hit my “shut down the emotions and deal later” threshold.

    In either case, though, it’s better to have this particular conversation before it hits the proverbial fan.

  3. Optimistically, let’s assume that the infection rate of an H5N1 flu is about 20% (like the Spanish flu of 1918-1919) and that the mortality rate is somewhat lower than the 61% measured to date, say only 12%. That’s still almost 5x the mortality rate of the Spanish flu that killed between 50 and 100 million people in two years. Let’s also assume, optimistically again, that we can vaccinate 780 million people a year (or 65 million people per month), and that the disease runs its course over 24 months.

    To a first order, that’s 1.56 billion people vaccinated (~24%), 1.32 billion people infected (20% infection rate), and 158 million people dead (12% of the infected people die). If the mortality rate is 61%, though, the number dead is 805.2 million people.

    Doing math like this is enough to make you depressed.

  4. I can’t say what I’d do for sure. But I’m like a lot of people in that, if put in desperate straits, I’m probably capable of desperate action, especially if it would do something like save the lives of my family.

  5. Right – but the vaccines you could claim for your family might mean death for someone else. Would that be worth it? If you’re caught stealing vaccine doses, would the likely jail term and still no vaccine be worth it?

    I don’t expect answers, really – my point is to raise this issue in the minds of people a little more and hopefully to get people to realize that its something they should think about before the next pandemic hits.

  6. While I understand that vaccinating vital personnel is important, I do not understand why the population that will get nailed by this sort of flu- people who are in ‘tier 5’ are not actually in tier 2.

    The Spanish Flu wiped out the ‘healthy’ population between ages 19 and 64. That was also the most productive part of the population. Gone. That population is called the ‘Lost Generation’ for a reason.

    And they say that this new strain would be even more lethal. What is a squalling baby good for? Will that kid keep the power and the water on?

    No. And if the experienced workers are taken out, it will be hell for everyone, including the babies. Those people should get vaccinated first.

    Whatever happens will be really nasty, I fear. I plan to hole up in my home with plenty of food, water, and N95 masks and ride it out.

  7. One thing that’s clear from the website is that they’ve developed these tiers with input from state, local, and federal governments as well as representatives of different groups (like the AARP). And the NPR story specifically says that the DHHS wants public input before rolling these guidelines out officially. So the idea at this point is to make sure that as much of the country as possible agrees with these.

    In addition, there’s plans on the website to adjust the tiers some if a particular plan is more dangerous to a different age group. For example, the H5N1 virus affects youths and young adults more than anyone else, so maybe the most affected age groups get moved up a tier or two while less affected age groups get moved back down.

    Finally, if you’re part of the “general population,” by definition you’re not in a “critical occupation” like national defense, health care, utilities, or communications.

    Some kind of rationing will be necessary, and if pandemic flu is from a new strain of virus, we’ve got at least six months of absolute hell before any vaccine will be available – it takes that long to create doses once the virus is isolated for vaccine use, and who knows how long the isolation process will take first.

    If you think there should be changes, contact the DHHS via and/or contact your local state or local heath department. The feds claim to want our input – I say we give it to them.