Who should MDs let die in a pandemic?

[Fusaki]

For those who may be interested in how Canada is approaching a potential problem with pandemic influenza they can read The Canadian Pandemic Influenza Plan for the Health Sector.

And more specifically, ANNEX D

http://www.phac-aspc.gc.ca/cpip-pclcpi/ann-d-eng.php

Annex D
Recommendations for the Prioritized Use of Pandemic Vaccine...

...3. Recommended Priority Groups for Pandemic Vaccination Program Implementation

Group 1: Health Care Workers, Public Health Responders and Key Health Decision Makers

Rationale: The health care and public health sectors will be the first line of defence in a pandemic. Maintaining the health service response and the vaccine program is central to the implementation of the response plan in order to reduce morbidity and mortality. Members of this group may be considered in the following work settings for vaccine program planning:

acute care hospitals
long-term care facilities and nursing homes
private physician offices
home care and other community care facilities
public health offices
ambulance and paramedic services
pharmacies
laboratories
government offices


Group 2: Pandemic Societal Responders and Key Societal Decision Makers

Rationale: The ability to mount an effective pandemic response may be highly dependent on persons, within the groups listed below, being in place to maintain key community services. Those individuals that are essential to the response or to maintaining key community services may vary among jurisdictions. Local plans will likely reflect these differences, however they are likely to include:

police
fire fighters
armed forces
key emergency response decision makers (e.g. elected officials, essential government workers, disaster services personnel)
utility workers (e.g. water, gas, electricity, nuclear power, essential communications systems)
funeral service and mortuary personnel
people who work with institutionalized populations (e.g. corrections)
persons who are employed in public transportation and the transportation of essential goods (e.g. food)
key government employees/elected officials (e.g. ministers, mayors)


Group 3: Persons at High Risk of Severe or Fatal Outcomes Following Influenza Infection

Rationale: To meet the goal of reducing morbidity and mortality, persons most likely to experience severe outcomes should be vaccinated. For planning purposes, this priority group has been based on the high-risk groups identified by the National Advisory Committee on Immunization (NACI) for annual vaccine recommendations. Additional groups have also been included based on evidence indicating an elevated risk (e.g. during the annual epidemics, young infants experiencing rates of hospitalization similar to the elderly).

If necessary, prioritization of the following subgroups within Group 3 would depend on the epidemiology of influenza disease at the time of a pandemic.

A: Persons living in nursing homes, long-term care facilities, homes for the elderly (e.g. lodges)
B: Persons with high-risk medical conditions living independently in the community
C: Persons over 65 years of age living independently and not included in 3A and 3B
D: Children, 6 to 23 months of age (current vaccines are not recommended for children under 6 months of age)
E: pregnant women

Currently, NACI does not consider pregnant women as a high-risk group in its recommendations for annual influenza vaccination. However, pregnant women have been at elevated risk during past pandemics.


Group 4: Healthy Adults (i.e., all individuals, 18-64 years of age, who do not have a medical condition that would qualify them for inclusion in the "high risk"; group and who do not fall into one of the other occupation-based priority groups)

Rationale: This group is at lower risk of developing severe outcomes from influenza during annual epidemics, but this group comprises the major work force and represents the most significant segment of the population from an economic impact perspective. Vaccination of healthy adults would reduce the demand for medical services and allow individuals to continue normal daily activities. Simultaneous absence of large numbers of individuals from their places of employment, even for non-essential personnel, could produce major societal disruption. Medical facilities could also be overwhelmed by health care demands, even for outpatient services. This might compromise the care of those with complications.


Group 5: Children, 24 Months to 18 Years of Age

Rationale: This group is at the lowest risk of developing severe outcomes from influenza during annual epidemics, but this group plays a major role in the spread of the disease. While children's absence from school might not have the direct economic and disruptive impact of illness in adults, it could have an indirect effect because of adults having to care for ill children.


Consideration was given to prioritizing the family members of health care workers, however it was decided that singling out these individuals would not be logistically feasible or ethically justifiable.

High Five for Group 2!! Yipee!!

 

[Blackadder1916]

And more specifically, ANNEX D

http://www.phac-aspc.gc.ca/cpip-pclcpi/ann-d-eng.php

High Five for Group 2!! Yipee!!

You may have misconceptions about the course that an influenza pandemic may take and the availability and efficacy of a vaccine.  Influenza currently strikes the population every year.  Sometimes the vaccine developed for a particular year helped in ameliorating the effects of the disease and sometimes it made no difference because the disease was of a different influenza strain than the ones in the vaccine. Amazingly, just because the vaccine had been of a different strain did not necessarily translate into the morbidity and mortality rates being excessive that year. 

The planning for a flu pandemic is based on an expectation that a "novel" (and thus more virulent) strain of flu virus will show up eventually, because , well, it's been a while since we had one.  Such a pandemic will probably not suddenly pop up, it may be a relatively gradual process.  Your glee about vaccine for the military may be somewhat premature.  Some of the "planning assumptions" from Annex H.

For the purposes of resource planning for pandemic influenza the following assumptions have been made.

a) It is unlikely that there will be a “Declaration of Emergency”.

Regional Pandemic Plans should not assume that a National or Provincial Emergency will be “declared”, as this is unlikely to occur in the event of a pandemic.

d) There will be limited transfer of resources.

The global nature of the crisis will mean that resources from other jurisdictions cannot be depended upon for meeting additional requirements during a pandemic.

f) A pandemic vaccine may be unavailable.

There will likely be no vaccine available until well into the first wave of a pandemic or later, depending on the time necessary to find a suitable vaccine seed strain, and for development, testing and production. When a vaccine does become available, immunization clinics targeting health care workers may need to be established inside health care facilities.

g) Anti-influenza drugs will be in short supply.

Currently no raw materials for anti-influenza drugs are produced in Canada. Existing supplies are very limited and insufficient to form the basis for an effective antiviral response strategy. Stockpiling of these medications is being considered.

When and if antivirals drugs are made available, treatment and prophylaxis for people seeking health care services at health care facilities will need to be prioritised according to national recommendations.

Planning for a vaccine is discussed more in the Preparedness section of the plan.

2.2.2 Planning Principles and Assumptions
The vaccines currently available in Canada are inactivated vaccines that are manufactured in fertilized hens' eggs. This production depends on egg availability, and it is characterized by stringent time requirements for the identification of vaccine candidate strains, the preparation of seed lots, testing and licensing, and manufacturing and distribution. Manufacturers typically require a minimum of 48 days from the availability of the seed strain to the production of the first lot of vaccine for testing.  Delays in the production of pandemic vaccine seed strains may occur as highlighted by the difficulties encountered in trying to produce a vaccine against the H5N1 virus that was involved during the 1997 Hong Kong outbreak. Consequently, vaccine may not be available when the first wave of the pandemic strikes Canada.

The figure of a minimum of 48 days for availability of first lot (through to availablility of internal quality control tests) assumes delivery of seed virus on day 0 and receipt of the ncessary reagent on later than 13 days after the seed strain has been provided.

At the time of a pandemic, it is assumed that monovalent vaccines containing only the pandemic strain will be used. The dosage and schedule of the pandemic vaccine needed to induce immunity in different populations must be determined through clinical testing. Where possible, clinical testing with vaccines for novel virus subtypes should be performed during the Interpandemic Period and confirmatory trial for the specific pandemic vaccine should be carried out at the time of a pandemic.

It is assumed all persons who lack previous exposure to the pandemic virus subtype will likely require two doses of vaccine, but the dosage is unknown (e.g. two 15-microgram doses or higher). It may be possible to give in advance an initial immunization with a generic vaccine of the correct H type and then give a second dose with the specific antigen. If that is possible, domestic vaccine production and immunization could begin before Canada has the required specific strain. Strategies to enhance the immunogenicity of influenza vaccines and reduce the amount of antigen required (e.g. use of adjuvants, whole-cell vaccines, intradermal route of injection) require further research.

Most countries will probably view a pandemic as a national health emergency or a threat to national security, therefore embargos on vaccines must be anticipated by countries with capacity for influenza vaccine production. Canada has invested in a domestic supplier to offset this possibility.

When vaccines become available, initial supplies may not be sufficient to immunize the whole population and prioritization of vaccine administration will be necessary. The F/P/T governments will control the allocation and distribution of influenza vaccine during a pandemic and will implement specific recommendations with regard to priority groups for immunization. Priority groups, based on the overall pandemic preparedness goal of minimizing serious illness, overall deaths and societal disruption, have been proposed in Annex D, Recommendations for the Prioritized Use of Pandemic Vaccine. However these priority groups may change when more is known about the epidemiology of the pandemic. It is assumed that for a two-dose program, completion of the second dose should be carried out as soon as possible to effect immunity; administration of the second dose should not wait until after every priority group has received a first dose. This strategy will require extensive planning that involves tracking and recall mechanisms.

The aim during a pandemic is to vaccinate the whole Canadian population on a continuous prioritized basis as quickly as possible. The current domestic pandemic vaccine production capacity is 8 million 15 microgram (ug) doses per month as specified in the current contract with this supplier. The possibility of increasing this capacity is currently being explored. Knowledge regarding anticipated schedules (i.e., antigen per dose, number of doses, and interval between doses) to optimize immunity may be derived from prototype vaccine clinical trails before a pandemic. Further clinical trails may be needed at the time of the pandemic. Vaccine recommendations may not be finalized until pandemic activity has commenced. These recommendations will be distributed as national guidelines as soon as possible, to facilitate a consistent and equitable approach.

 

[Gunner98]

There is an entire sub-culture industry and academia built on Pandemic planning.  I don't think MDs will be making the decisions on who lives/dies, it will be a bureaucratic decision process that will result in an escalating death toll, anarchy and create chaos. Just like in the movies. :'(

 

[mariomike]

During the SARS crisis in Toronto health care workers and their families were concerned about what might be brought home from the hospital.

With the Moderators permission, I would like to add to this topic.
During the outbreak, of Toronto EMS's 850 paramedics, over 600 were placed in a 10-day home quarantine, which meant being isolated from those persons within the home, continuously wearing an N95 respirator, and taking their temperature twice a day. SARS-like illnesses developed in 62 paramedics, and suspected or probable SARS requiring hospitalization developed in 5 others. That was a "working quarantine". ie: they had to isolate themselves in their homes after each shift. Not eat within nine metres of another human being, and use a separate bathroom.
I should like to add, after the official quarantine ended, Dr. Gerry Goldberg, the Toronto EMS staff psychologist, reported TEMS Paramedics were avoided by the public because of their contact with sick people.
He said Paramedics experienced and continue to experience the "Tim Hortons effect."
"They would go into a Tim Hortons and see the line parting in front of them because they were definitely being avoided by the public."
http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/1060289763522_30//

AMEMSO ( Association of Municipal EMS in Ontario ) wrote that consideration will be given for Paramedics to complete the Medical Certificates of Death under the 2008 Ontario Health Plan for an Influenza Epidemic. Plans involve moving the deceased to ice rinks where bodies may have to be stacked. Mass graves may become a reality.

 

[ModlrMike]

Who should MDs let die in a pandemic?

Lawyers. Well, personal injury lawyers anyways.

Then all those with bad piercings, followed closely by those old farts with fedoras driving in front of me at 5 mph, rude people in customer service roles, the crack head that broke into my truck and stole my DVD player (and all his crack head friends) and - of course - everyone who sports those sappy, motivational bumper stickers preaching idiotic 'isms' of one kind or another.

There, got the triage list going for you.

You forgot the guy with 20 items standing in front of me in the 10 item express line at the grocery.

 

[Kat Stevens]

You forgot the guy with 20 items standing in front of me in the 10 item express line at the grocery.

...and all the Manchester United players, management, fans, and all the people in Singapore sweat shops producing their jerseys.

 

[old medic]

Read this article yesterday and found it interesting.
In this case, faulty flu vaccine was released containing live avian flu virus.
The few bold highlights are my own.

http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20090227/Bird_Flu_090227/20090227?hub=Health

Baxter admits flu product contained live bird flu virus
Fri. Feb. 27 2009
The Canadian Press

TORONTO -- The company that released contaminated flu virus material from a plant in Austria confirmed Friday that the experimental product contained live H5N1 avian flu viruses.

And an official of the World Health Organization's European operation said the body is closely monitoring the investigation into the events that took place at Baxter International's research facility in Orth-Donau, Austria.

"At this juncture we are confident in saying that public health and occupational risk is minimal at present," medical officer Roberta Andraghetti said from Copenhagen, Denmark.

"But what remains unanswered are the circumstances surrounding the incident in the Baxter facility in Orth-Donau."

The contaminated product, a mix of H3N2 seasonal flu viruses and unlabelled H5N1 viruses, was supplied to an Austrian research company. The Austrian firm, Avir Green Hills Biotechnology, then sent portions of it to sub-contractors in the Czech Republic, Slovenia and Germany.

The contamination incident, which is being investigated by the four European countries, came to light when the subcontractor in the Czech Republic inoculated ferrets with the product and they died. Ferrets shouldn't die from exposure to human H3N2 flu viruses.

Public health authorities concerned about what has been described as a "serious error" on Baxter's part have assumed the death of the ferrets meant the H5N1 virus in the product was live. But the company, Baxter International Inc., has been parsimonious about the amount of information it has released about the event.

On Friday, the company's director of global bioscience communications confirmed what scientists have suspected.

"It was live," Christopher Bona said in an email.

The contaminated product, which Baxter calls "experimental virus material," was made at the Orth-Donau research facility. Baxter makes its flu vaccine -- including a human H5N1 vaccine for which a licence is expected shortly -- at a facility in the Czech Republic.

People familiar with biosecurity rules are dismayed by evidence that human H3N2 and avian H5N1 viruses somehow co-mingled in the Orth-Donau facility. That is a dangerous practice that should not be allowed to happen, a number of experts insisted.

Accidental release of a mixture of live H5N1 and H3N2 viruses could have resulted in dire consequences.

While H5N1 doesn't easily infect people, H3N2 viruses do. If someone exposed to a mixture of the two had been simultaneously infected with both strains, he or she could have served as an incubator for a hybrid virus able to transmit easily to and among people.

That mixing process, called reassortment, is one of two ways pandemic viruses are created.

There is no suggestion that happened because of this accident, however.

"We have no evidence of any reassortment, that any reassortment may have occurred," said Andraghetti.

"And we have no evidence of any increased transmissibility of the viruses that were involved in the experiment with the ferrets in the Czech Republic."

Baxter hasn't shed much light -- at least not publicly -- on how the accident happened. Earlier this week Bona called the mistake the result of a combination of "just the process itself, (and) technical and human error in this procedure."

He said he couldn't reveal more information because it would give away proprietary information about Baxter's production process.

Andraghetti said Friday the four investigating governments are co-operating closely with the WHO and the European Centre for Disease Control in Stockholm, Sweden.

"We are in very close contact with Austrian authorities to understand what the circumstances of the incident in their laboratory were," she said.

"And the reason for us wishing to know what has happened is to prevent similar events in the future and to share lessons that can be learned from this event with others to prevent similar events. ... This is very important."

 

[mariomike]

A friend of mine was quarantined at Etobicoke General Hospital during the Toronto Lassa Fever scare in 1976. He was working the night shift on our isolation ambulance at the time and had this to say:
"By the eighth morning, our arms were getting sore from the daily blood tests. It was at this point that the hospital officials made a diagnosis that I may have also contracted LASSA FEVER. 
I was immediately masked, the clinic was cleared, two fully isolated nurses then escourted me from the basement clinic to the 9th floor isolation area. 
As I was being escorted through the halls, the few people remaining in the hospital were warned to stand clear, because a "Lassa Fever" patient was coming through. I now know what a condemned prisoner feels when going to the gallows. I was escourted to a room adjacent to the infected patient I had brought in three weeks earlier.  In the background, I could hear her respirator working as I was given strict orders that I was not permitted to leave the room under any circumstances.
What started out as a routine call had now turned out to be my death sentence.
Later that morning, the specialists deemed me not to be infected and permitted me to leave. I think I was out of there before they finished their sentence."
Sorry if this doesn't answer the big subject question.