Colorized transmission electron micrograph of Avian influenza A H5N1 viruses (seen in gold). Image provided by CDC/C. Goldsmith, J. Katz, and S. Zaki.

Revisiting the CDCs Priority Rationing Plan

By Grattan Woodson, MD, FACP

U.S. Department of Health and Human Services
Room 434E
200 Independence Avenue, S.W
Washington, D.C. 20201

Attention: Pandemic Influenza Vaccine Prioritization RFI

Dear Sir or Madam:

An analysis of the US CDC’s current ration plan for scarce antiviral drugs and vaccines used for treatment of pandemic influenza raises important questions about the logic and appropriateness underlying the assumptions used to develop the policy. The CDC’s priority list is very similar to the one they recommend for use during seasonal influenza, a tame and very different beast by comparison to pandemic flu. Its use for seasonal flu is well thought out and entirely appropriate because it targets those at greatest risk and with the most to gain from influenza vaccination. During normal times, the influenza vaccine stocks are sufficient for everyone on their recommended list to receive inoculation with usually enough left over each year for healthy adults and children who want one. The list used for seasonal flu is not designed for rationing \ scarce resources during an emergency. It is a recommendation issued by the CDC to consumers and doctors about who should be vaccinated against influenza each year. When these recommendations are followed, there is good medical evidence that this policy provides the most benefit to the greatest number of people, a goal that is in everyone’s best interest. A major problem with the current plan is that it fails to protect those at greatest risk from pandemic influenza and therefore is an inappropriate use of limited resources.

Revisiting the CDC⁏s Priority Rationing Plan

During the 1918 Spanish Flu data clearly shows that deaths from influenza and post-influenza pneumonia skyrocketed in the 15-45 age groups while remaining about the same in the age 45+ groups. The children in the <1-14 age groups also suffered disproportionately compared to those 45+.

Age related death rates per 100,000 from influenza and pneumonia.
	<1	1 - 4	5 - 14	15 - 24	25 - 34	35 - 44	45 - 54	55 - 64	65 - 74	75 - 84	86+
1916	1474	211	24	38	59	98	148	281	614	1503	3187
1918	2273	718	176	580	992	554	347	381	646	1179	2230
1919	1594	293	63	141	235	181	163	233	450	913	1842
1920	1495	283	45	101	180	164	164	255	545	1191	2379

Under the present CDC plan, these groups of healthy people are given the lowest priority for access to antivirals and vaccine. In effect, the inadequate supply of these products means the people in these groups have very little chance of gaining access to them.

At this point, the CDC’s policy has been adopted and codified nationwide. The advisability of the current plan is being quietly discussed but not in public. If there is to be any change to the plan, it must be done before the beginning of the pandemic. Because opinions differ about who should be given priority to scare resources, it would be useful for the public to be brought into the discussion now.

The CDC Ration Plan is Too Limited

An even bigger problem with the CDC rationing plan is that it is limited to antiviral drugs and vaccines. This narrow focus is inadequate to address the needs of doctors and nurses faced with the difficult choice of who to admit to the hospital and treat when two people present with equally severe influenza complications but only one bed is available. The process of deciding whom will be given access to limited medical resources and who will not is called triage. This is a medical art that requires a grasp of what resources are available, the condition of the patient, what would be required to treat them, and their chances of survival if provided access to the available resources.

Triage is used most often in crisis situations when an unexpectedly large number of patients present at the same time with severe life threatening injuries. Rarely do we use this art these days as our hospital facilities are usually adequate to accommodate all who need care, even those with little hope of survival under the best of circumstances.

During the pandemic, most hospitals will become full very quickly, supplies and drugs will be heavily taxed and shortages will inevitably develop. Under these conditions, there will be very few beds or supplies available to treat the chronically ill or previously healthy person presenting with a critical influenza complication. Under the present circumstances, it will be first come first serve without any rational guidance of how limited resources can best be allocated for the benefit of all.

In the US all hospitals follow a standard admitting policy. Any critically ill person that presents to the emergency room requiring hospitalization is admitted and provided virtually unlimited access to the available resources even when their chances of survival is very low. Our society has decided to utilize its health resources in this way and as long as we can afford to do so, we can expect that this practice will continue.

During the pandemic, we will not have the resources available to support this luxury. Doing so will not result in the best outcome for the greatest number of people. It will have the exactly opposite effect. Currently our customs, laws, and tort system does not support the ruthless application of triage needed to get the best outcomes for the most people during the conditions likely to prevail during the pandemic. Without guidance to the contrary, healthcare providers and hospital administrators will follow the standard policy used during normal conditions or will introduce inadequately modified triage rules that fail to truly address the issue. Relying on the conventional approach to managing limited resources will have a disastrous impact on society for many years into the future.

What is needed is Priority Guidelines for All Medical Treatment

Instead of limiting priority guidelines to just the use of antivirals and vaccines, what makes better sense is to define ahead of time who will have priority access to hospital admission, advanced treatments, and all drugs including antivirals and vaccines. It makes no sense to give someone critically ill with influenza Tamiflu but then tell them, “sorry, while you will probably die without admission to the hospital, there are no beds available”. Without priority guidelines, in many instances, those without access to Tamiflu will be the ones occupying the hospital’s beds. So, we will be faced with the absurd predicament of giving a lifesaving drug to one person with a high priority under the CDC antiviral ration plan but not access to the hospital bed and advanced treatment they really need to survive because it is occupied by someone in a low priority tier to whom we cannot give Tamiflu. The result, both die! This is shear foolishness.

Triage Decisions are a Medical Responsibility

Doctors and nurses are already aware of the burden they will face standing in the hospital doorway deciding by triage who will live and who will die. This is a burden we are trained to perform and while it will be a gut wrenching one, we understand that it is for the good of all and is a necessary exercise of the medical arts during an emergency. What would help practitioners greatly would be for the CDC to issue priority treatment guidelines that are comprehensive in nature rather than simply applicable to antivirals and vaccines. These guidelines would help those tasked with carrying out triage to make decisions that were in the best interests of the society. They would still be required to apply their art because just because someone presented for treatment with a high priority but was unlikely to survive, he would not be admitted over someone with a lower priority but with a good chance of survival if admitted. Where it would help most is in deciding who got the only available bed when two people presented with an equal chance of survival if they were admitted. In this instance, their relative predetermined CDC treatment priority would be the deciding factor

Ideally, treatment group priorities should be proposed and discussed broadly before they are implemented and before the beginning of the pandemic when cool heads prevail. Forming them now and discussing them widely in the media and before the public is a good way to explain the rationale for each priority group clearly and dispassionately. Objections and suggestions by various interest groups can heard and weighed. In the end though, the Secretary of Health and Human Services will have to sign-off on the priority treatment list and whoever does so will be ending their political career forever as no choice will please everyone. As President Bush said in November 2006 in defense of his Iraq policy, “This is what it means to lead, making hard decisions.”

Medical Treatment Access Priorities Appropriate for Pandemic Influenza

It is my view that the survival of the nation will be threatened by the coming pandemic if it turns out to be as severe as I think. While all nations worldwide with be terribly affected as well, US moral, economic, and political leadership in the world post-pandemic could be lost if make the wrong policy decisions for coping with the emergency. The choices we make now will have a tremendous influence on how our nation fares during the pandemic. Given these stakes, the most rational and humane approach is to give priority treatment access not just to specific individuals but also to their spouses and dependent children. A strategy focusing upon the individual providing critical medical, infrastructure, security, and political services to the nation alone is not practical in my judgment. Most people owe their first allegiance to their loved ones, not their job. It will be difficult to keep anyone at work when they have a sick or dying children or spouse at home.

Having healthy families with dependent children survive intact has important societal and economic benefits for the nation during and after the pandemic. Giving this group priority access to medical treatment during the pandemic also has the virtue of including young health adults in the 15-40 year old age group who in studies of the 1918 Spanish flu were at the greatest risk of dying from influenza. It is likely that the average family with dependent children will have at least one person who will contract influenza during the coming pandemic. In some, there will be several. The case fatality rates among them will be high. Our society is based upon the family unit and a loss of even one member of any family can result in catastrophic and long lasting emotional and economic consequences for the survivors.

Since families with dependent children represent a large number of people, I suggest we use a lottery based upon the head of household’s Social Security number. This method would be fair to all and make it reasonably easy for those tasked with distributing the resources to properly identify those on the priority list.

By protecting the integrity of current families with dependent children, we can better ensure the foundation of our society and its economic system will remain intact. This is a critical need as it is these people who we will be relying upon the most for restoring our nation after the pandemic. Their children are our society’s “seed corn” upon whose shoulders rests our future prosperity. In my view, keeping them safe from harm should be our highest priority.

Proposed Alternative Guidelines for Priority Medical Treatment

A Revised Healthcare Access Plan During the Pandemic

Priority 1

All vaccine and antiviral manufacturers and others essential to manufacturing and critical support, their spouses and dependent children (120,000)
Half of Medical workers and public health workers who are involved in direct patient care, other support services essential for direct patient care, and vaccinators, their spouse and dependent children (13,500,000)
All Emergency response personnel (First Responders), police and firefighters, their spouses and dependent children (11,500,000 million)
Key federal, state, and local government officials chosen by lottery (limited to the US President, VP, the cabinet, the US Congress, Justices of the Supreme Court and their staffs, and 10,000 state and local key officials apportioned by state population together with their spouses and dependent children (70,000)
Active duty US regular armed forces personnel, activated US Reserves and National Guard troops stationed within the continental US together with their spouses and dependent children. (6,000,000)
25% of all heads of household, their spouse and dependent children (25,000,000)

Sub-total 56,178,500

Priority 2

Utility workers essential for maintenance of power, water, and sewage system functioning their spouses and dependent children (1,050,000)
Agricultural workers essential for the production, harvest, processing, transportation, and distribution of food, their spouses and dependent children (17,000,000)
Transportation workers transporting fuel, water, and medical supplies, their spouses and dependent children (3,000,000)
Half of all telecommunications/IT for essential network operations and maintenance chosen by lottery, their spouses and dependent children (1,500,000)
All funeral directors/embalmers, their spouses and dependent children (180,000)
25% of all heads of household, their spouse and dependent children (25,000,000)

Priority 3

The medical workers and public health workers not included in priority 1 who are involved in direct patient contact, other support services essential for direct patient care, and vaccinators together with their spouses and dependent children (13,500,000 million)
25% of all heads of household, their spouse and dependent children (25,000,000)

Sub-total 38,500,000

Priority 4

25% of all heads of household, their spouse and dependent children (25,000,000)

Sub-total 25,000,000

Priority 5

All other healthy children and adults through age 2-45 years not already selected

Priority 6

Healthy adults aged 46-70 years of age
Healthy children 6-23 months old, not already selected.

Priority 7

All persons not already selected.

Through Priority 4, the total included would be 167,378,500 persons. The actual number would be lower because of people being double eligible for one of the first 4 priority groups. This would leave about 150 million in the last 3 priority groups.

What Becomes of Those with Low Priority for Advanced Care?

An analysis of those that will make up the roughly 150 million Americans composing the last three tiers of the proposed plan finds that they include healthy adults over age 45, elderly, chronically ill and disabled adults, and sick children. These groups are the usual focus of our societies compassion and upon which we spend the lion’s share of the healthcare dollar in the US today. They are the recipients of most of the social security payments made annually, consume most of the drugs sold, and occupy virtually all the nursing home and most of the hospital beds day in and day out. Obviously this is a needy group deserving of our help and support. Without it, some of them would surely perish, starve to death, or die from their underlying illness. This is why the only sensible priority plan for access to limited health resources during the pandemic is one that ensures that our present and future work force remains as healthy as possible during the pandemic, for if their numbers are significantly reduced by influenza, who will provide for these legions of deserving people?

Studies of the Spanish flu show that the death rates of the elderly during 1918 was not much different than the years preceding or following the pandemic. The reason for this observation is not known and it would be unwise to extrapolate those outcomes to the coming pandemic for this group, but one can hope. The same relatively low pandemic death rates were also observed in the adults aged 45 to 65 years, which might also be a harbinger of good tidings for people in this group too without priority access.

The fact remains; up to half of the 150 million with low priority access to advanced medical treatment in the proposed plan will contract influenza during the pandemic. Since it is unlikely that under this alternative proposal they will gain access to the hospital during the pandemic, they will need to depend upon their families and friends for care in the home setting. Home care can be very effective if the caregivers are provided with basic guidelines to follow like those provided in The Bird Flu Manual and the free booklet, Good Home Influenza Treatment. While the outcomes expected with home care of severely ill patients will never be as good as hospital care, it can be expected to be a whole lot better than no care or care given in a haphazard manner.

Most of the drugs disabled and chronically ill adults, the elderly, and sick children take on a daily basis will not be the same ones used for advanced medical care of critically ill influenza patients. So having a low medical treatment priority will not mean going without regular medications. There is a chance that production and distribution of drugs will be interrupted during the pandemic, a possibility that becomes distinctly less likely under the proposed plan than otherwise. The reason for this is that protecting those in the proposal’s priority groups is the best way I can think of to prevent a collapse of our economy, social infrastructure, and civil order. Nonetheless, it is prudent for those with significant chronic disorders on key medications to prepare for the possibility of an interrupted drug supply. In this regard, I suggest that patients obtain a 6-month stockpile of their regular medications for use during the emergency. Having a secure stockpile on hand is one way to prevent complications of the patient’s chronic medical conditions occurring that might happen should the patient be forced to go without their medication for an extended time.

Those with a low priority for access to advanced medical care will still be cared for. They will not be abandoned by their friends, family or by society. Religious organizations and non-profit groups together with government healthcare agencies will all be making an effort to do what they can to provide for the needs of those being cared for in the home. This would include home or group hospice care where appropriate. On the other hand, should our economic and social structure collapse under the pandemic due to a loss of critical workers, it would be unlikely that any of these outside services would be available to anyone.

One of the biggest potential threats to the health and safety of everyone during a severe pandemic is a breakdown in law and order. Under the CDC’s present plan the police and firefighters are given such a low priority (Tier 2, Group B) that is unlikely that they will have access to antivirals or vaccines during the pandemic. The US armed forces, National Guard, and Ready Reserves are granted the lowest priority (Tier 4). These groups are composed of those at highest risk from pandemic flu. Who will protect the elderly, disabled, and sick children from civil strife if our law enforcement officers, firefighters, and armed forces become unable to respond?

There are many other examples that can be given for why the health and safety of those in the lowest priority groups in the proposed plan have much to gain from its adoption and yes, they will be making a sacrifice as well. During times like these, hard choices are going to be necessary to protect the future of our nation and its ability to support those most in need. Unless we make the right ones now, the prosperity and livelihoods of all could be placed in jeopardy.

A Families First Policy Makes Sense

Placing our nation’s families with dependent children first is in societies best interest. This policy would mean people with critical skills and services essential to the survival of our nation during and after the pandemic disaster would be more likely to remain at their posts in the knowledge that their families will have access to advanced treatment should the need arise. The inclusion of young families with dependent children in the top four tiers of the proposed priority rankings targets those most at risk from pandemic influenza rather than those most at risk from seasonal influenza, a glaring deficiency in the current CDC’s limited plan. By providing priority access to advanced medical treatment and drugs rather than just antiviral drugs and vaccine is a comprehensive approach that offers those selected a real chance of survival if they become critically ill rather than just a Tamiflu tablet or shot at vaccination. These half measures will not be very effective for critically ill patients requiring hospitalization. From the societal prospective, it makes little sense to vaccinate the children only to lose the family’s breadwinner. This definition must include both single parent families as well the traditionally structured unit given that in the US today, slight fewer than half of families have two parents present in the home. To be fair to all, selection for inclusion in the high priority groups must not be based on any discriminator other than being a family with dependent children, defined for the purposes of this essay as those 18 years of age and younger.

The key to recovery after the pandemic long emergency will be having intact healthy families. These folks are the seed corn from which every nation will sprout. Keeping them safe and healthy from illness and death during the pandemic is the best way for society to ensure its continuance.

The Unintended Consequences of the Current CDC Plan

Consider for a moment what the outcome would be if public health authorities keep to the CDC’s current limited ration plan. The result could be catastrophic for those dying from the flu as well as those who survived. The number of orphans would skyrocket. The old and infirm would survive in disproportionate numbers while the young healthy working aged population would experience a devastating decrease in their numbers. The loss of societies most productive workers would not be something that could be remedied for generations. Who would take care of the orphaned children, the disabled, and the elderly? Where would the taxes come from to pay for their social support? Who would do the work?

This is a difficult issue to contemplate. If asked who should get priority access to medical care most folks would say “women and children first, then the elderly and infirm”. These are almost exactly the groups chosen to receive priority in the CDC’s plan. In this case though it is necessary to ask how will the members of these groups do during or after the pandemic in the absence of their spouse, one or more of their children or both parents? Obviously, not particularly well. The psychological loss from the deaths of these key family members will be compounded by the loss of the economic support their deceased family members and society provided ante-pandemic. The chances that the children of these fragmented families have of achieving the same heights that were expected before the pandemic is very low. This is why fragmentation of the family unit is so destructive to society as a whole and explains why recovery from widespread family disruption requires generations to repair.

A Sensible Course Correction

The sensible course is to take a broader and more realistic view of the risk our society faces from a severe influenza pandemic. We need to reconsider what our priorities should be based upon the lessons learned from the last major pandemic in 1918 rather than basing them on what happens during the seasonal flu. What is needed is a more comprehensive approach that provides those selected with priority access to advanced medical care and all pharmaceuticals not just antivirals and influenza vaccine. Providing these guidelines before the start of the pandemic will give those health professionals charged with triaging acutely ill patients a logical and solid framework to act upon. This will help prevent egregious inequities or irrational decisions during triage as well as make the best use of our scarce resources during the pandemic.

Sincerely,

Grattan Woodson, MD, FACP