Roundtable I: Who Receives Limited Doses of Pandemic Flu Vaccine? Summary

Roundtable I: Who Receives Limited Doses of Pandemic Flu Vaccine?
An Exercise in Shared Decision-Making

Summary
Moderator: Peter A. Singer, Director, University of Toronto Joint Centre for Bioethics (UTJCB); Member, Pandemic Influenza Working Group of the UTJCB

The purpose of this roundtable discussion was to explore the feasibility and benefits of actively engaging citizens in pandemic influenza planning, in anticipation of the ethical dilemmas posed by a scarcity of life-saving medical resources such as vaccines, antivirals, antiibiotics, and hospital beds. Moderator Dr. Peter Singer led participants in a role-playing exercise in which health officials receive only a portion of pandemic flu vaccine needed to cover priority groups. Members were then asked to consider the implications of public involvement in vaccine distribution policy.

In the scenario before the roundtable participants, 6 months pass before a vaccine effective against an emerging strain of pandemic flu becomes available. The initial production batch available to each state contains only enough doses to vaccinate 20% of its population. More batches will be available later in increments. Broad federal guidelines outline priority recipients of the vaccine, but the number of people in the priority groups far exceeds the first allotment of the vaccine. State and local officials are left wondering how to fairly distribute the limited available vaccine and how those who are unable to receive a vaccine will react upon learning of the shortage and the designated priority groups.

Many ethical considerations remain unresolved. Participants generally agreed that despite a committee's efforts to develop a federal guideline for vaccine distribution, many ethical questions remain unconsidered and problematic. Questions about the "value of life" remain as children are not currently considered a priority while the elderly are afforded greater importance. Moreover, different cultural and faith traditions may hold differing notions about "valued" categories of people. While authorities largely agree that healthcare workers should be among the first vaccinated, deliberations regarding other priority groups remain contentious.
Pre-event plans and priorities may not match the requirements of a real pandemic. Participants concurred that no one can predict with certainty how an actual pandemic strain of influenza will ultimately affect different populations or how well a vaccine may actually work. Prioritization frameworks derived prior to an actual event may prove irrelevant or in need of significant revision. That said, participants agreed that public discussions of priorities and uncertainties, as well as pre-planning, are still warranted.
Public acceptance of final and/or evolving plans requires engagement and dialogue. Participants agreed that providing the public with an opportunity to engage in the dialogue of establishing the guidelines was crucial to public acceptance. Current guidelines were developed with strong participation by public health experts, but priorities may evolve as other stakeholders with varying perspectives become involved. The needs of the underserved and other special populations have yet to be addressed in current planning.
Policies about pandemic flu vaccine production and distribution have an international dimension. Some participants questioned whether it was feasible for the U.S. to produce vaccine without providing a portion to countries where outbreaks arise or to nations who are unable to produce their own vaccine.
Alternatives to care should be presented to the public. Participants expressed the desire to provide alternatives to care for citizens who are unlikely to receive initial doses of vaccine. The public needs to 1) know that it is not completely helpless, and 2) be informed about practices of self-care and protection. Teaching people how to care for themselves is important as efforts to empower individuals are critical for building the public's trust.
Additional studies are needed before informed decisions can be made. Important scientific unknowns have yet to be fully examined. Vaccines might be distributed to people not yet exposed, as it takes time after vaccination for individuals to build immunity; this would permit the limited vaccines to be used in the most immunologically effective manner. Furthermore, there was contention that the vaccine will likely display differing efficacy in different age populations. Greater study and modeling was suggested to better understand these concerns.