DISCUSSION: How Will Vaccine Be Used Against Pandemic Influenza?

COMMENT THREAD

• Clarification: 1st Reduce Deaths, then Protect Infrastructure?
  

  Submitted by Nicholas Dewar   on 12/4/07 06:18 AM

  So, it looks like you'd prioritize the reduction of death ahead of the protection of infrastructure. You add that susceptible age-groups that are involved in economic activity should also be prioritized. But you raise another point: "collateral damage of the Just In Time economy collapsing would dwarf the damage caused by the virus". Do you believe that the collapse of the economy would cause more death than the virus? If so, is the protection of the economic infrastructure a priority path to reducing death? I'm just trying to clarify this.

  • Who is critical
    

    Submitted by Roy Kamen on 12/4/07 06:30 AM

    The ages most likely to die from H5N1 are also the most important critical workers.
    Military, Power, Delivery.
    
    These are the people we need to keep alive and functioning. As an age group, they fall into priority cat 5 - last in line. As workers, they fall into the cats developed already. What I am saying is that I believe that we should vax the critical workers within the ages most affected first.
    
    and yes, i believe the collapse of the JIT is more dangerous than the virus itself.
    
    People must be supplied at home to weather the storm that will last 6-8 weeks.

    • Could US vaccines be used overseas?
      

      Submitted by Nick Kelley on 12/4/07 11:53 AM

      I think both of you raise important points...given our global economy and global production of products. Do either of you think that their could be value in providing vaccines overseas to ensure the supply chains stay up?

      • Insulin: could more die from the lack of insulin than influenza
        

        Submitted by Nick Kelley on 12/4/07 12:07 PM

        The CDC estimates that there are 20.8 million Americans with Diabetes (2005 data). 5-10% of these Americans have Type 1 (insulin dependent diabetes). They face serious medical problems if they dont get insulin or advanced medical treatment and possibly death. A large proportion of (over 70%) originates outside of the US and is supplied just in time to the US. I think one could argue that ensuring the insulin supply chain does not fail could save lots of lives, but that would require sending vaccines offshore.
        
        This is just one of hundreds of examples one can looks at for who should get vaccines.

        • Insulin need refridgeration
          

          Submitted by Roy Kamen on 12/4/07 01:05 PM

          Nick so true - if the power fails it doesnt matter how much insulin is in the fridge does it?

          • So true...
            

            Submitted by Nick Kelley on 12/4/07 01:11 PM

            You are right on Roy...there are so many examples one could pull for this discussion.
            
            Most Oxygen is made via the petrochemical industry...if we stop getting crude from overseas our availability of many critical infrastructure products just disappears.
            

      • Prioritize Supply Status
        

        Submitted by Diana Tolladay on 12/4/07 03:33 PM

        It seems to me that a blanket approach could do more harm than good. Just providing the US vaccine to overseas suppliers doesn't guarantee that the supply won't diminish or disappear. Wouldn't it make more sense to prioritize supplies crucial to the infrastructure and ensure the supply by having a national stockpile of at least some items. We cannot expect the general public to store enough food and meds for 6 to 12 weeks if the nation has no backup supply. Sounds rather cliche but people do " follow the leaders". People believed Roosevelt (FDR) and responded.
        

• Is there age-group susceptibility to H5N1?
  

  Submitted by Joel Palmer on 12/4/07 06:30 AM

  I agree with most of the post about priorities being based on when the vax is available - pre-pandemic or in the middle of it - but did have one question to raise, as much for my own clarification as the discussion. In many articles and papers there is an assumption that the cascade (seen in 1917-18) will be repeated with the next pandemic, but have the current cases (H5N1) demonstrated that? An alternate interpretation of the high death rate in the 20-40 age range is higher rates of exposure rather than any special vulnerability to the virus. Again, I'm raising this to clarify whether or not there is evidence of age-group susceptibility to H5N1.
  
  Taking the idea that reducing deaths is key, having a stronger understanding of who is most at risk of death is also key.
  
  [Joel, I've changed your subject line to attract readers to your posting - Nicholas/Facilitator]

  • re: age-group susceptibility
    

    Submitted by Mirine Dye on 12/4/07 06:42 AM

    I believe that there has not been age-specific susceptibility evidence with current H5N1 cases because at present it is transmitted from fauna to human and not human to human. The assumptions of the 15-40 age grouping is based on H2H transmission and historical data.
    

  • Heres the WHO age breakdown for H5N1
    

    Submitted by Roy Kamen on 12/4/07 06:47 AM

    http://www.wpro.who.int/NR/rdonl...

    • WHO data
      

      Submitted by Joel Palmer on 12/4/07 06:58 AM

      Thanks Roy. The graph was about what I remembered from tracking cases, lots at the lower end and few at the higher. Leaves me making my same point, that if the vax prioritization wasn't already a muddy picture, we need to keep in mind that the "high risk" groups have yet to fully emerge.
      
      Which doesn't alter the need to make sure the essential personnel referenced in Roy's first post are near the top of the list.

      • age priority first?
        

        Submitted by Roy Kamen on 12/4/07 07:00 AM

        It just seems right that we vax the critical workers within the most susceptible age ranges first.

        • Ages
          

          Submitted by Joel Palmer on 12/4/07 07:29 AM

          Agreed, my only question is in regards to the most susceptible age ranges. The more work on our plan I do, the more I realize that there are some of the recommendations and some "truths" about pandemic which are either based on a small sample (1918 only) or just don't seem to hold up to scrutiny. If we have evidence that certain ages are the most susceptible then we should hit them first and hard. If instead we have data that makes it look like certain ages are susceptible because of slanted exposure then we should keep that in mind as well.

          • certain ages are susceptible because of slanted exposure
            

            Submitted by Roy Kamen on 12/4/07 07:54 AM

            Joel are you saying that the reason the ages affected by H5N1 are because it is they who most likely handle the family birds? Does this take into account all the suspected cases where there has been NO contact with birds?

            • H5N1 infection with no exposure to birds
              

              Submitted by Sharon Hutchins on 12/4/07 04:39 PM

              Roy,
              
              There really haven't been that many cases of human H5N1 without a history of exposure to birds.
              

              • Recent upswing in cases with no exposure to birds
                

                Submitted by Katharine Fisher on 12/6/07 05:23 PM

                Sharon, that was once true. But maybe you want to review the WHO confirmed cases as noted in the WHO "situation updates" on avian influenza. If you read carefully, you'll see that there are many cases in Indonesia that have occurred in recent months that indicate no bird contact. (And they look long and hard for bird contact).
                
                China's news of a new H5N1 fatality just the other day was accompanied by a very unusual (for them) pithy statement that the victim had had no bird contact.
                
                We need to be sure that the data we are using is the most current data.
                

        • Tiers within tiers
          

          Submitted by Sharon Hutchins on 12/4/07 04:29 PM

          Roy's suggestion here is pretty important. At the moment, all critical workers in a particular sector are in the same category/tier. He is suggesting adding an age criterion on top of the occupation criterion. Roy, please bring this up in tomorrow's discussion!

        • Treat as Business Functions
          

          Submitted by Tammy Brown on 12/6/07 10:27 AM

          It's not an esay task, but you have to remove thoughts of age from the equation when you are looking at critical workers. Treat it as a business function priority. Vax your front line critical workers first then move to those who would back-fill them. For critical workers or first responders age is not going to be the factor.....it will be job function.

    • Thank you Roy
      

      Submitted by Ellen Rice on 12/4/07 07:07 AM

      This isn't the exact same chart I had seen but it conveys the same message. Thank you for posting the link.

  • Under 25 are particularly vulnerable
    

    Submitted by Ellen Rice on 12/4/07 07:06 AM

    I have seen a bar chart from about a year ago that showed the ages of the victims of H5N1. Deaths are highest for those under the age of 25. This is similiar to the 1918 flu.

  • Cannot be sure what populations will have highest risk
    

    Submitted by Marianne Yourdon on 12/4/07 09:18 AM

    We cannot predict until the pandemic arises what population will be at highest risk. I think the plan with the 5 tiers is good, but there may be a need to revise this if the pandemic behaves differently than we expect.

    • Tiering before a pandemic
      

      Submitted by Terry Adirim   on 12/4/07 09:56 AM

      I agree. Much will be learned in the early days of the next pandemic regarding what groups are at highest risk for illnees and death. There is a strategy to adjust the vaccine prioritization based on this knowledge.
      

      • Where is the strategy to be found?
        

        Submitted by Roy Kamen on 12/4/07 10:21 AM

        where is this strategy to be found?
        
        [Roy, I've changed the subject line so you get a response faster]

        • draft interim guidelines
          

          Submitted by Brant Goode   on 12/4/07 11:31 AM

          These are the draft interim guidelines you can see in the "library" tab. You can also see them through pandemicflu.gov if you follow the links.
          
          How the intermim guidelines shift during a pandemic depends on what we find through surveillance as it rolls out. If, for example, it's clear that some groups have a disproportionate burden compared to others that was not anticipated, revisions might then be made to help address these.
          
          Pan flu work generally produces many more questions than answers, and asking questions about prioritization gets to some very important concerns.
          
          Brant

      • Major Communications Challenge
        

        Submitted by Deborah Robinson on 12/4/07 11:53 AM

        I wanted to respond to Marianne’s and Terry’s point (which obviously makes sense) that once we have a human pandemic, the virus and thus the susceptible groups may change. I believe it will be a major communications/preparedness challenge to get the general public to be aware of and understand the final virus prioritization scheme that will come out of this process. I am not talking about risk communication once the pandemic starts, I am talking about communication in the preparedness phase. If successful in doing that, it will be a HUGE challenge if the virus behaves significantly differently than now, for the public to be aware of and understand a new prioritization scheme. I am not saying that it is impossible, but it is a challenge that I had not thought of before. I am particularly concerned because the average person in most communities in the US, are not even aware of the current draft scheme.

        • communication of changes
          

          Submitted by Terry Adirim   on 12/4/07 01:55 PM

          You are exactly right. Communication with the public in general is a challenge. But we need to be able to change the scheme based on the the characteristics of the pandemic. I believe that as planning progresses, this issue will need to be considered.

    • Highest risk?
      

      Submitted by Roy Kamen on 12/4/07 10:23 AM

      "We cannot predict until the pandemic arises what population will be at highest risk. I think the plan with the 5 tiers is good, but there may be a need to revise this if the pandemic behaves differently than we expect."
      
      Marianne,
      
      There certainly is enough evidence right now that H5N1 (the most likely pandemic candidate) like the young as did H1N1 in 1918.
      
      I dont see why the pandemic strain of H5N1 would be any different and with such a poor outcome, i think this would be a logical place to start.

      • Mutation could change much
        

        Submitted by Kelly Cruse on 12/4/07 11:02 AM

        Roy,
        
        I think what Marianne is getting at with her comment about not knowing which population is most at risk with H5N1 is this: what we're seeing overseas is the birds infecting people, not human to human transmission. When the virus mutates, it could behave more like a seasonal flu (and affect the young and elderly) than H5N1 infecting bird to person, although we obviously plan for the worst.
        

        • Mutation could change much?
          

          Submitted by Roy Kamen on 12/4/07 12:08 PM

          I only know what has come before... as in "lets use 1918 CFR of 2.5%"
          
          in 2003 H5N1 had a 50% CFR in 2007 its over 60% worldwide and 80% in Indonesia. Its going up.
          There have been cases of H2H documented. te CFR has not come down. We should plan for the worst case and hope for the best.

          • Avian Flu is not Pandemic Flu
            

            Submitted by Terry Adirim   on 12/4/07 02:27 PM

            Hi,
            I addressed this issues in one of the other discussions. The H5N1 virus must undergo reassortment with a human influenza virus in order to be able to facilitate human to human transmission which is necessary to cause a pandemic. Also, the next pandemic may not emanate from H5N1. It is just the more likely candidate at this time. For a virus to be easily transmittable all over the globe, it cannot have such a high mortality rate because if it kills all of its hosts (or most of its hosts) then a pandemic cannot be sustained. The virus wants to survive so to speak. This is why Ebola and SARS have not become pandemics.
            
            The worst influenza pandemic on record is the 1918 pandemic which had a 30% attack rate and 2-2.5% mortality rate and that is why the US is planning for this type of scenario--"the worst case".

            • Terry I completely Disagree with you.
              

              Submitted by Roy Kamen on 12/4/07 05:10 PM

              Terry said
              " The H5N1 virus must undergo reassortment with a human influenza virus in order to be able to facilitate human to human transmission which is necessary to cause a pandemic."
              
              Not exactly fact Terry - H2H has happened already according to WHO. There is also this growing theory called Recombination which says that very small changes can affect how the virus behave without re-assortment. Examination of the virus sequences as it moved from asia into Europ via Qinghai Lake shows this clearly.
              
              Terry also says" Also, the next pandemic may not emanate from H5N1. It is just the more likely candidate at this time."
              
              It is THE reason for all this Pandemic preparedness. I'd give it a pretty high probability based on the dollars being spent.
              
              Terry says "For a virus to be easily transmittable all over the globe, it cannot have such a high mortality rate because if it kills all of its hosts (or most of its hosts) then a pandemic cannot be sustained. The virus wants to survive so to speak. This is why Ebola and SARS have not become pandemics."
              
              Sort of like the "dead birds dont fly story". well sick live birds fly... and have spread H5N1 to Europe, Mid east and Africa.
              
              Terry says "The worst influenza pandemic on record is the 1918 pandemic which had a 30% attack rate and 2-2.5% mortality rate and that is why the US is planning for this type of scenario--"the worst case"."
              
              That is a very dangerous and short sighted position to take.

              • I'm sorry, but I disagree...info from the WHO website
                

                Submitted by Terry Adirim   on 12/4/07 06:17 PM

                You say: "It is THE reason for all this Pandemic preparedness. I'd give it a pretty high probability based on the dollars being spent."
                
                Just because we are preparing for it, doesn't prove that it is 100% certain that it is this virus that will cause the pandemic. It is just the most likely candidate at this time.
                
                You also say: "H2H has happened already according to WHO. There is also this growing theory called Recombination which says that very small changes can affect how the virus behave without re-assortment"
                
                The H5N1 virus will have to develop features of a human influenza virus for it to be easily transmissable between humans. It currently is not easily transmissable between humans. Almost all of the cases (if not all) have been in those with exposure to birds.
                
                From the WHO website:
                "Influenza viruses are normally highly species-specific, meaning that viruses that infect an individual species (humans, certain species of birds, pigs, horses, and seals) stay “true” to that species, and only rarely spill over to cause infection in other species. Since 1959, instances of human infection with an avian influenza virus have been documented on only 10 occasions."
                
                Further from the WHO website:
                "...the H5N1 virus – if given enough opportunities – will develop the characteristics it needs to start another influenza pandemic. The virus has met all prerequisites for the start of a pandemic save one: an ability to spread efficiently and sustainably among humans. While H5N1 is presently the virus of greatest concern, the possibility that other avian influenza viruses, known to infect humans, might cause a pandemic cannot be ruled out." and
                
                ..."The virus can improve its transmissibility among humans via two principal mechanisms. The first is a “reassortment” event, in which genetic material is exchanged between human and avian viruses during co-infection of a human or pig. Reassortment could result in a fully transmissible pandemic virus, announced by a sudden surge of cases with explosive spread.
                
                The second mechanism is a more gradual process of adaptive mutation, whereby the capability of the virus to bind to human cells increases during subsequent infections of humans. Adaptive mutation, expressed initially as small clusters of human cases with some evidence of human-to-human transmission, would probably give the world some time to take defensive action, if detected sufficiently early." (I fear the first mechanism and that is what we need to prepare for.)
                
                
                And more importantly "All evidence to date indicates that close contact with dead or sick birds is the principal source of human infection with the H5N1 virus."
                
                And lastly, any virus that has a high mortality rate will not last long because the host dies. You cannot get flu if there isn't someone around long enough to infect you. Preparing for the worst know severity is reasonable. And the current planning should be applicable if the pandemic has a higher than 2% mortality.
                

                • Terry, I'm sorry but
                  

                  Submitted by Katharine Fisher on 12/6/07 05:47 PM

                  reassortment is not the clear and present danger.
                  
                  You quote from the WHO website regarding the TWO ways a virus can adapt to humans (i.e. it is not true that it must do so via reassortment):
                  
                  "The second mechanism is a more gradual process of adaptive mutation, whereby the capability of the virus to bind to human cells increases during subsequent infections of humans. Adaptive mutation, expressed initially as small clusters of human cases with some evidence of human-to-human transmission, would probably give the world some time to take defensive action, if detected sufficiently early."
                  
                  Terry, this is what we are watching happen each day right in front of us in Indonesia. Every day. And the WHO site is right - it has "given the world some time to take defensive action." This is the "God given time" that Dr. David Nabarro of the U.N. has referred to.
                  
                  The virologists can watch the mutations occur in real time as long as they have virus samples and the sequences from them to study. They know where the mammalian/human adaptations are that are to be feared within the virus. They've already seen many of these mutations within H5N1. Some scientists believe we do not have far to go before H5N1 picks the final keys to that lock.
                  
                  Reassortment is truly not what I fear, and I watch the progress of this virus every day.
                  

            • WHO working group: CFR doesn't have to drop
              

              Submitted by Caroline Bridgers on 12/4/07 05:18 PM

              It is true that many people believe the high CFR will (or must) attenuate if H5N1 achieves pandemic capability. However, in 2006 a WHO working group had this to say about whether the CFR could drop.
              
              www.who.int/csr/resources/publications/influenza/WHO_CDS_EPR_GIP_2006_3C.pdf
              
              "One especially important question that was discussed is whether the H5N1 virus is likely to retain its present high lethality should it acquire an ability to spread easily from person to person, and thus start a pandemic. Should the virus improve its transmissibility by acquiring, through a reassortment event, internal human genes, then the lethality of the virus would most likely be reduced. However, should the virus improve its transmissibility through adaptation as a wholly avian virus, then the present high lethality could be maintained during a pandemic."
              
              Even a drop to say a 10% CFR would not exactly be a walk in the park. At least we should start planning for 10% if you ask me. It is very important to disucss this issue with regards to how to prioritize vaccines, in my opinion, because the fear factor of the population when faced with a high CFR pandemic will be much worse, the higher the fatality rate, and the demand for vaccine will be much greater; and the willingness to agree to other groups getting it first will be much less.
              

            • H1N1 in 1918 was not a reassortment
              

              Submitted by Katharine Fisher on 12/6/07 05:38 PM

              The H1N1 virus that caused the pandemic of 1918 was not a reassortment. It was a strain adapted straight from avians. Reassortment with seasonal human flu strains is not the only mechanism by which an influenza strain can become pandemic.
              
              For example, the H5N1 virus infected humans more easily in Turkey in part because it had picked up a mutation in the PB2 gene at position 627K. That mutation made it more mammalian-like and more transmissible to and among humans. Other mutations can confer additional mammalian-like preferences to the virus and make it more transmissible to humans.
              
              Our top scientists have generally agreed that it is not reassortment that we need to fear first and foremost with the H5N1 virus, but rather mutation within the virus itself. Each mutation within it that makes it more mammalian-like rather than avian-like takes it one step closer to becoming a pandemic strain. Some of these top scientists have stated that they believe that we may be only one or two of these mutations away from H5N1 becoming a pandemic strain. To do so, no reassortments are involved.
              
              Of course, H5N1 can conceivably reassort with seasonal human flus (or with other avian flus) even after it mutates into a pandemic strain. Then you'll simply have more than one pandemic strain to deal with - potentially one that's a mutated human-adapted avian strain, and one that's an avian/human seasonal flu reassortment.
              

• Over 80 should be last/ under 20 should be first
  

  Submitted by Ellen Rice on 12/4/07 07:03 AM

  This will sound harsh, but in the event of a truly deadly pandemic, those people over 80 should have the last priority. I write this because
  1) The oldest among us have had the most "experience" with flu strains and may have some immunity.
  2) Most grandparents would rather their grandbabies be innoculated first. We, as altruistic humans, would rather see the young survive
  3) School aged children are the people who spread an influenza the most. They live more crowded, intimate lives and are less likely to consistently use good hygiene practices. Vaccinating children first could save lives in all the other age groups.
  

  • More discussion tomorrow about prioritization among the General Public
    

    Submitted by Nicholas Dewar   on 12/4/07 07:15 AM

    Ellen,
    There will be more opportunity to discuss the prioritization of different age-groups within the General Public tomorrow (Wednesday). I hope that you'll make this point there too.

  • Age related vaccine priority
    

    Submitted by Terry Adirim   on 12/4/07 10:08 AM

    In the public sessions many people had similar views. There are many simultaneous goals for a national pandemic vaccine plan, with the ultimate aim that everyone who wants to be vaccinated will have the opportunity. For this reason, I don't think there will be a cut-off in terms of age and access to vaccine. It's important to understand that vaccine will become available over time, and that early in a pandemic other measures will be used to reduce spread. It's estimated that these measure could have a significant impact in reducing flu cases in a home, instituion, or community. During a pandemic, covering coughs and sneezes, hand washing, social separation (6 feet), wearing masks in some settings, and antiviral medications will be measures that can also reduce risk.
    

    • Prioritizing groups
      

      Submitted by John Carney on 12/4/07 01:34 PM

      So Terry are you saying a few weeks into the pandemic when the first round of the vaccine is availabe that pregnant women and infants alongside critical healthcare workers will all get vaccinated with no one being turned away, anywhere? I don't understand how we'll be able to have 20M doses ready at once. I know everyone wants to save the women and babies first, but the wave factor and the AR or susceptibility of everyone to the illness (as underscored in the prep materials) seems to dictate a different priority plan. Babies can be isolated, people who provide my electricity and water need to go to work so I can take care of my family in my home.
      

      • general population
        

        Submitted by Terry Adirim   on 12/4/07 02:13 PM

        Yes, the prioritization scheme is purposely set up so that 4 categories of persons can be vaccinated simultaneously. The four categories are 1)Homeland/National Security, 2)Healthcare, 3) critical infrastructure and 4) general population. At community engagements prior to drafting of the guidance, we heard loud and clear from citizens that one of their values was "protecting children". Pregnant women had a 50% fatality rate during the 1918 pandemic. Children under 3 years are at great risk and infants currently cannot get antiviral medication. Also, young children need only 1/2 the dose of adults plus vaccination pregnant women confers protection to the fetus. Based on this, this group was prioritized at the top of the general population list. And we continue to hear that children should be at the top of the list.
        
        With regard to amount of vaccine that can be produced---you're right it's limited. However, the numbers take into account current manufacturing capability. If we had greater capability, we might have included older children or other groups for the other categories.

        • How does pre-pandemic stockpiled vaccine fit into the prioritization scheme?
          

          Submitted by Joan Pfinsgraff on 12/4/07 02:46 PM

          Assuming an H5N1 virus causes the next pandemic, how would the stockpiled pre-pandemic vaccine fit into the prioritization scheme? Would people in Tier One who receive pre-pandemic vaccine later receive pandemic-specific vaccine? Is there consideration of increasing the pre-pandemic vaccine stockpile, and what is the current estimate for shelf-life of pre-pandemic vaccine?

          • Yes, More Info on the Pre-Pandemic Vax
            

            Submitted by Deborah Robinson on 12/4/07 03:35 PM

            Thank you Joan for your question. I also wanted to know how and when the pre-pandemic vaccine currently stockpiled will be used. For all my reading, I must have overlooked this. When it has been verified that an influenza pandemic has occurred, will the prioritization scheme be used to first administer the pre-pandemic vaccine to the highest target groups/levels?

          • How will vaccine be used....
            

            Submitted by Terry Adirim   on 12/5/07 03:43 AM

            Pre-pandemic vaccine is generally targeted to the same occupational groups as the pandemic vaccine. Pre-pandemic vaccination would not change the prioritization strategy but may change how pandemic vaccine is used - for example, a single dose rather than 2 doses. The rationale is that pre-pandemic vaccine is likely to be only partially effective so pandemic vaccination remains important but based on studies evaluating priming, a single dose may be effective (more studies are needed). We also are considering modeling results that suggest giving pre-pandemic vaccine to children but we need data on safety of pre-pandemic vaccines in children (particularly if they include a novel adjuvant) as well as a larger supply to consider this approach. Shelf life is ~30 months and counting. The greatest likelihood for expansion of the stockpile is if new adjuvants allow us to decrease the amount of antigen in each dose.
            

        • Babies and pregnant women
          

          Submitted by John Carney on 12/4/07 03:22 PM

          I agree with the general public - I'd forgo the vaccine to save my g-child or my kid if this were 20 years ago. I just want to make sure that we save the pilot first - including those folks who make sure that the water is on and the lights are working, for the 40% of us at home who can't go to work but will most likely survive.

          • Babies and Pregnant Women
            

            Submitted by Mirine Dye on 12/5/07 05:49 AM

            This is a particularly vulnerable group of course. There is research that demonstrates that seasonal flu vax given to pregnant women in the 3rd trimester extends protection to the fetus for the first 6 months of life.
            This is a "2 for 1" deal with the vaccine and holds promise for pandemic situations.
            
            However, 1/5th of total US healthcare costs is labor and delivery, and in Florida the top hosptilization is labor and delivery. Planning must include the prioritization of taking care of the pregnant women and infants.
            
            In 1918, the US had a staggering amount of orphaned children left to deal with. The US could likely not handle this again
            
            Our state has a team of 5 inidividuals working on protocols for this population http://www.keyshealthystart.org/...

        • A Senator is NOT a Homeland/Security personnel
          

          Submitted by Ellen Rice on 12/4/07 07:23 PM

          I am not naive. The first people to receive any vaccine will be our US Senators, their partners, children and grandchildren. These people, however, are NOT essential to the running of our country (at least not like the water treatment engineer or the grocery truck driver). I would love to see some real statesmanship -- as in "I'll be the last person in my district to get the vaccine" .
          
          Our Senators (and Generals) have become American Royalty. This is the truth and there should be a specific classification for these groups. We know they will be ahead of Joe Six-Pack, so it should be in the planning papers for all to see.
          

    • Virus Mutations
      

      Submitted by Glenda Ford-Lee on 12/5/07 06:57 AM

      
      Terry,
      
      Many are thinking that we will have only one vaccine that will stop the pandemic. What happens when the virus mutates? We could have one virus genotype on the east coast and another on the west coast. I will in the central part of the U.S. We are just thinking -- okay- which one will hit us first.
      Then you add the time frame of production of the vaccine- (you get my point)
      Glenda

• Time period is important to discussion
  

  Submitted by Eleanor Peters   on 12/4/07 08:37 AM

  Roy -
  
  All good points. The primary discussion on who gets vaccinated first is slated for tomorrow's agenda.

• Caution against Generalization
  

  Submitted by Diana Tolladay on 12/4/07 03:49 PM

  I understand that a decision must be made on who receives the vaccine and in what order, but to assume that the most likely to die are 20-40 year olds AND that they are the most productive of society could be a dangerous generalization that would not necessarily reduce the number of deaths or keep the infrastructure intact.
  
  Those Not amongst the 20-40 year olds include:
  - military leaders
  - politicans(the face of the most powerful/influential nation on earth
  - administrators(the minds and think tanks that organize and delegate)
  - physicians and surgeons
  - teachers
  - children (the hope of the future)
  
  Clearly, when the pandemic revels itself, patterns will develop. Then and only then, while the vaccine is being developed can we say for sure who is most vulberable. Until then perhaps a better place to start would be to productively develop categories of individuals that are essential to health care, the infrastructure, productivity etc.

  • Age Based Planning
    

    Submitted by Justin Kamen on 12/4/07 04:13 PM

    Hello,
    I am a 21 year old college student at Columbia University. As mentioned, the last severe flu pandemic killed mostly people aged 15-40. This is not considered a fluke. When confronted by a novel flu virus, a strong immune system will unleash killer T cells to try to fight the virus. Without any previous immunity, the immune system cannot destroy the virus and rather attacks infected cells. A strong immune system can cause a cytokine storm, causing the victims lungs to fill with fluid (ARDS) and eventually death. For this reason, the age distribution graph for seasonal flu deaths look like a U, while the graph for pandemic flu looks like a W, with a majority of the deaths in the middle. This was true of H1N1 and seems to hold true for human cases of H5N1. If we are planning to save the most lives and maintain critical infrastructure, we must address this historically and scientifically supported concern.
    
    - Justin

    • age based planning
      

      Submitted by Terry Adirim   on 12/4/07 06:26 PM

      Justin,
      You're right that the 1918 pandemic had a "W" shaped curve and the 20-40 year old age group was hard hit (adolescents too). However, the 1968 and 1957 pandemics were "U" shaped curves. And I wouldn't consider the groups hardest hit with H5N1 because it may just be that kids and adolescents (the majority of victims) are those who are most exposed to domestic birds.
      
      So in reality, we don't know for 100% sure what age groups will be hardest hit. The draft guidance for the severe scenario is not age based but leans more toward protection of society (critical infrastructures) and the population group at the top, pregnant women and infants were hit just as hard in 1918 as the the 20-40 age group. In fact, anecdotal evidence showed a 50% mortality rate in pregnant women

      • Age-Based, or Risk-Based Planning?
        

        Submitted by David A. Sherman on 12/4/07 09:03 PM

        I respect the previous comments that point out that we can't be sure which age groups the pandemic flu is most likely to hit the hardest. What we can be reasonably certain of is, as with so many other illnesses, the agent-host-environment model shows the importance of host factors in predicting who among those exposed to a germ is likely to get sickest: the sicker you are when you get sick, the sicker you'll get. It seems likely that, while pandemic flu may hit younger people more prominently than seasonal flu tends to, those who get the sickest and die from pandemic flu will be those with comorbidities--cardiac, respiratory--and the aged. What makes our Western civilization unique is its emphasis on preserving individual lives. In order to continue as that kind of civilization, while pandemic flu vaccine supplies are limited we must direct them toward those with complicating factors that make their deaths more likely than otherwise.

        • H5N1 like the young
          

          Submitted by Roy Kamen on 12/5/07 12:00 PM

          I know what i see and i see the most likely candidate for a pandemic packing a 60+% CFR for ages 10-40.
          
          That makes them a priority especially since they do most of the work.

        • Who can carry the food?
          

          Submitted by Alec Glucksman on 12/5/07 11:41 PM

          As I understand it, the two minor pandemics that hit were not the result of novel viruses--they produce those U-shaped curves. The pandemic of 1918 was a novel virus, and that produced a W. A novel virus turns the body on itself because the body has no idea what to do about it; it's never seen anything like it before. The healthier your body is, the more it fights back. This is what a cytokine storm is, as was already mentioned.
          
          But more to your issue, I agree that people with cardiac and respiratory illnesses should get vaccinated, so long as their illnesses do not prevent them from lifting bags of food and water, from performing responsibilities as a first-responder, from maintaining order and taking care of close family, from keeping supply lines open and the essentials running. If not, though, let's give it to someone who will.