The recent "dip" in the influenza vaccine supply roller coaster resurrected a key practical and ethical issue with which many public health officials had previously struggled, but never fully resolved. When faced with the directive from the Centers for Disease Control and Prevention (CDC) to develop the capability to vaccinate every individual in their jurisdiction against smallpox, difficult questions such as "who goes first" and "who goes last" arose. The latter question was especially troubling since one could also interpret it to mean "who may not get vaccinated should the vaccine supply run out" or "who may not get vaccinated before the individual succumbs to the disease." It seems likely that the public at large will be reluctant to wait patiently at the end of the line, especially if they perceive a threat to their health or to that of their family. The long lines of elderly individuals vying for what appeared to be limited flu vaccine seem to substantiate this supposition.
Clearly, the best time to address these challenges would be prior to actually facing them. However, resolution of these troubling questions was deferred by many public health officials perhaps because of the distraction from numerous other competing emergency preparedness and public health tasks; reluctance to deal with the overwhelming ethical, legal, and practical aspects of this subject matter; and difficulty thinking through somewhat surreal situations that many have never faced and find hard to conceptualize.
While the CDC established eight high-risk categories of equivalent stature for flu vaccine distribution, some local public health officials who were in control of limited vaccine supplies felt the need for overlapping guiding principles to help further subprioritize at the grassroots level. Simply opening vaccination clinics simultaneously to individuals from all eight groups on a first come, first serve basis would allow Darwin's theory to prevail. Those who could figuratively (and sometimes literally) push to the front of the line would be vaccinated and stand the best chance for survival.
The Western New York Public Health Alliance took the opportunity created by this real-world challenge to adopt regional generic guiding principles (Figure 1) for use during significant public health emergencies requiring phased responses. Although this flu vaccine shortage would not likely be as cataclysmic as some potential public health emergencies, these guidelines allowed each of the eight-member county health departments to further prioritize flu vaccine according to their local circumstances and needs. Subgroups within the high-risk categories were either vaccinated by health department staff or by provision of vaccine to community health care providers serving those subgroups (eg, geriatricians caring for nursing home patients).
A reasonable alternative approach to vaccine distribution would have been to distribute vaccine to all requesting community health care providers according to some strategy (eg, first request, first provide; proportionate distribution to all requestors) and allow those providers to subprioritize within their patient population as they saw fit. However, it is important to acknowledge the difference by which health care providers and public health officials might approach prioritization.
Health care providers have an obligation to each and every one of their patients to minimize that individual patient's risk of mortality and morbidity regardless of the needs of that provider's other patients or the public at large. For example, individual providers may find it very difficult, or even impossible, to refuse to vaccinate a younger patient with a relatively mild chronic disease simply because an elderly patient with severe chronic disease may subsequently present. Only in limited situations are health care providers expected to ration or prioritize health care. Distribution of limited cadaveric organs for transplantation and triage of emergent and nonurgent patients in emergency departments are two examples, and our society has established standards on which to base these decisions.
On the other hand, public health officials must take a more global approach to protect the population at large. For example, public health officials could choose to provide vaccine to those same health care providers with the directive to only vaccinate elderly patients with chronic disease until further notice. These directives could later be expanded to include younger patients with mild disease if vaccine supplies remain adequate.
While the potential worst case outcome from the flu vaccine shortage may not have risen to the level of other possible extraordinary public health emergencies (eg, widespread severe acute respiratory syndrome outbreak), public health officials may be forced to approach these situations as a military leader or emergency manager would approach combat or a disaster, respectively-do the most good for the greatest number of individuals. In events that threaten society as a whole, an argument could be made that, above all, public health officials must first attempt to preserve critical societal infrastructure for without it the entire population is threatened.
While the definition of critical societal infrastructure will vary depending on the event itself, local circumstances, etc, it could be defined as anything or anyone necessary to contain or control the event and maintain vital community services such as public safety and utilities. For example, the inability to protect the well-being of key health care providers, public health staff, law enforcement, and officers of the court (if quarantine and isolation become necessary) during a widespread deadly avian influenza outbreak could result in the inability to limit the spread of the epidemic and place the entire community at increased risk. Should this event become prolonged, individuals necessary for food and pharmaceutical distribution and sales, as well as others might need to be added to this priority list. From a practical matter, provision of prophylaxis to the families of these individuals may also be necessary to ensure that these workers report for duty.
Following the preservation of critical societal infrastructure, public health actions can then focus on containment of the outbreak itself, utilizing the protected critical infrastructure. For example, rapid case finding, ring vaccination, and quarantine and isolation to the extent that it is practical during a smallpox outbreak may prove to be the best protection of the public at large. Shifting limited public health and health care resources from these activities to laborious and time-consuming actions that protect individual mortality and morbidity (eg, prophylaxis of every citizen within a jurisdiction regardless of their exposure or risk) before containment activities have been exhausted may ultimately prove unwise. However, protective measures may eventually need to be offered to every individual depending on the nature of the event.
It goes without saying that no public health official relishes the thought of facing these life and death choices. However, development of a generic consensus scheme on which to base overarching situational decisions is best done while the scenario is still a virtual one.