Pandemic Flu Work Group Outlines Vaccine Rationing Strategy for Minnesota

By Molly D’Esopo August 22, 2007

Vaccine recently published the findings of a work group charged with developing recommendations for rationing limited supplies of vaccine during a worst-case (1918-like) flu pandemic. First convened in December 2005 by the Minnesota Center for Health Care Ethics, the multidisciplinary work group was comprised of approximately 35 individuals with a wide range of professional expertise including public health; healthcare and public health ethics; infectious disease; spiritual health and faith-health collaborations; health law; community service; healthcare economics; health system, health plan, and academic administration; and health journalism.

In developing their recommendations, the work group made numerous assumptions about both the pandemic and the availability of vaccine. For example, they assumed that the pandemic would last two years, "with three waves of disease during the pandemic's course, each wave lasting two to three months" and that vaccine would not become available for at least six months. Additionally, the assumption was made that mortality would be highest and vaccine most efficacious among previously healthy individuals aged 15 to 40. The work group also assumed that when pandemic vaccines begin arriving in Minnesota, there will be sufficient data to help guide specific decisions about priority groups who will ultimately receive vaccine.

With these assumptions in mind, the work group developed an ethical framework comprised of "principles, goals and strategies" to help guide decisions about who in the state will receive vaccine during a pandemic. The primary goal of the framework is to "maximize Minnesotans' chances of surviving" flu and flu-related complications and to prevent “significant disruption of the basic healthcare, public health and public safety during the pandemic and the years immediately following." The secondary goal is to “promote social cohesiveness and collaboration” and "protect against the loss of any single generation." With those high-level goals in mind, the ethical framework is predicated on the following ethical principles:

Contain and limit serious harm to Minnesota’s public health
Respect the moral equality of all Minnesotans
Reduce significant differences in influenza-related mortality
Steward scarce pandemic vaccines efficiently and effectively
Treat equally those who are similarly situated with respect to their priority to receive vaccine
Use fair procedures to implement the vaccine rationing plan

The work group devised a six-tiered sample rationing strategy that attempts to limit the breakdown of infrastructure, as well as social disparities. Populations eligible for receiving the first vaccines are determined by various combinations of characteristics including:

high risk of influenza-related mortality;
high vaccine response;
perform basic healthcare, public health, or public safety functions;
high risk of transmitting influenza to groups served that are at a high risk of influenza-related mortality; and
lack of satisfactory alternative protections.

The framework also clearly identifies criteria that would exclude individuals from receiving vaccine while it is in limited supply. These are:

confirmation of natural immunity, i.e., have contracted and survived influenza;
low risk of influenza-related mortality;
low vaccine response; or
availability of satisfactory alternative protections

The rationing plan does not assign vaccine priority to all essential workers. Rather, the work group recommends that priority be assigned to those essential workers who are in contact with or serve, and thus have the potential to transmit influenza to, high-risk populations and who have high vaccine response. The work group maintains that in a worst-case scenario, it is "ethically preferable to redirect a portion of the vaccine supply away from essential workers who have lesser vaccine responses and mortality risks to the large cohort of healthy adolescents and young adults who are at higher risk of mortality and are best protected by direct vaccination."

The work group acknowledged that public trust is needed for the success of any vaccine rationing strategy. The report notes that “public acceptance of vaccine rationing will be fragile” and that the recommendations will need refining based on "informed public input."

- Center for Biosecurity

Contingency Planning