Copyright 2006 Toronto Star Newspapers, Ltd.
By RITA DALY
Toronto Star
The sick and elderly should be the last to be given a flu vaccine in a pandemic, according to a controversial paper published today in the journal Science.
Healthy teens and young productive adults aged 13 to 40 should get the vaccine ahead of the old and sick, states the commentary, which calls for a radical rethinking of how countries ought to ration the short supply of vaccine in the months after a pandemic breaks out.
The proposal runs contrary to American and Canadian vaccine advisory committees and pandemic plans that recommend people 65 and older be given priority due to their increased risk of dying, while healthy children and adults from the ages of 2 to 64 be vaccinated last.
“My first reaction is it doesn’t make sense and runs counter to everything we stand for in society,” said a horrified Judith Wahl, executive director of the Advocacy Centre for the Elderly. “We’re not just here for survival of the fittest.”
Dr. Ezekiel Emanuel, a National Institutes of Health ethicist who co-authored the paper, said no one disputes that health, vaccine and emergency workers should be vaccinated first, followed by firefighters, police, utility workers and key government leaders.
But the crucial question public health officials and ethicists are grappling with is, who gets saved next?
“Why should we value someone who’s 65 and going to live 15 more years compared to a 20-year-old who’s going to live 60 more years?” he asked.
It is expected to take at least four months for a vaccine once a pandemic breaks out but there won’t be enough for everyone at once, so public health officials have devised priority lists for rationing vaccine supplies.
Flu pandemics in 1957 and 1968 saw the very young and old at highest risk, similar to a seasonal flu. But the lethal 1918 flu pandemic, which killed 20 to 50 million people worldwide, targeted young and healthy adults. Some experts fear the H5N1 bird flu, which has killed millions of chickens in Asia and Europe, could spark a 1918-style pandemic. It has killed 115 people, mostly under age 40, although nearly all came in direct contact with infected birds.
Dr. Arlene King, Canada’s director-general for pandemic preparedness, said the country’s pandemic vaccine priority list is based on a two-pronged goal of saving the most lives and minimizing social disruption.
That list could change after the government puts it to public debate or once a pandemic strikes.
“When the pandemic occurs, we will be looking hard at how it rolls out and who is most likely to get infected and die. That will be considered in our decision-making at the time,” she said.
Emanuel said the “save the most lives” approach is not ethically justifiable in a pandemic. Priority should be given instead to three life principles: saving those who still have a life span ahead of them, whose lives have already been invested in and who can maintain public order in a pandemic.
So while a 4-year-old boy may have more life to live, he has not had the same emotional energy and education invested as a 20-year-old woman embarking on a life of independence and high productivity. Likewise, the 20-year-old has more life to live and productivity to give than a 70-year-old.
“I think even the elderly would say, yes, we’ve had a good life and children should have a chance to have as good a life as we’ve had. Most of us as parents would say that,” Emanuel said.
As an advocate of the elderly, Wahl said many seniors are more productive in their later years.
“I’m 53 and when have I been most productive? It’s actually been post-40.”
Emanuel criticized the University of Toronto’s Joint Centre for Bioethics for failing to propose vaccine priorities in its paper on pandemic ethics, but the centre’s Dr. Peter Singer said it’s up to the public to debate vaccine rationing.
“We certainly did not come up with a criteria like, if you’re 12 you don’t get it, if you’re 13 you do. Our key message is ... let’s have a public debate.”
“I say let’s take that paper, engage the public and see what the 12- and 41-year-olds think.”