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Prioritizing Pandemic Influenza Vaccination: Public Values and Public Policy


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Title: Prioritizing Pandemic Influenza Vaccination: Public Values and Public Policy

Prioritizing Pandemic Influenza Vaccination
Public Values and Public Policy
Benjamin Schwartz, M.D. National Vaccine Program
Office, DHHS
Why prioritize pandemic vaccine?
  • Everyone will be susceptible
  • Current minimum of 20 weeks to first pandemic
    vaccine availability
  • U.S.-based production capacity currently is not
    sufficient to make vaccine rapidly for the entire
  • Targeting groups for earlier or later vaccination
    will best support pandemic response goals to
    reduce health, societal, and economic impacts

Initiatives to increase pandemic influenza
vaccine availability
Preparedness now decreases the need
for allocation decisions later
Kathy Kinlaw, MDiv, Emory Univ. CDC Ethics
  • HHS has invested over 1 billion to
  • Increase vaccine production capacity
  • Develop and license new vaccine production
    technologies (e.g., cell culture, recombinants)
    that will increase surge capacity and reduce time
    to availability
  • Evaluate adjuvanted vaccine formulations

Pandemic vaccine prioritization 2005 ACIP/NVAC
  • Joint work of HHS vaccine advisory committees
  • Process included consideration of
  • Vaccine supply and efficacy
  • Impacts of past pandemics by age and risk group
  • Potential impacts on critical infrastructures
    especially healthcare
  • Ethical concerns
  • Recommendations included in the 2005 HHS pandemic
  • As guidance for State/local planning
  • To promote further discussions

ACIP/NVAC priority groups
  • Personnel Cumulative
  • Tier and population groups ( 1,000s)
    total (1,000s)
  • 1A. Health care involved in direct patient
    9,000 9,000
  • contact essential support
  • Vaccine and antiviral drug manufacturing
    40 9,040
  • personnel
  • 1B. Highest risk groups 25,840
  • 1C. Household contacts of children lt6 mo,
    severely 10,700 45,580
  • immune compromised, and pregnant women
  • 1D. Key government leaders critical public
    151 45,731
  • health pandemic responders
  • 2. Rest of high risk 59,100 104,831
  • Most CI and other PH emergency responders
    8,500 113,331
  • 3. Other key government health decision
    500 113,831

Rationale for reconsideration of pandemic vaccine
  • Evolving planning assumptions
  • More severe pandemic increased absenteeism
  • Results from public engagement meetings
  • Preserving essential services ranked as top goal
    over protecting high-risk individuals
  • Additional analysis of critical infrastructures
  • National Infrastructure Advisory Council study of
    CI sectors and vaccination priority groups

Interagency pandemic vaccine prioritization
working group process
  • Presentation and discussion of
  • Prior ACIP/NVAC recommendations
  • Scientific public health issues
  • Analysis recommendations on critical
    infrastructure by the National Infrastructure
    Advisory Council
  • National homeland security issues
  • Consideration of ethical issues
  • Public engagement stakeholder meeting
  • Decision analysis

National Infrastructure Advisory Council analysis
of critical infrastructure (CI) for a U.S.
  • Issues considered
  • Essential functions of CI and key resource (KR)
    sectors (e.g., maintain national homeland
    security ensure economic survival maintain
    health welfare)
  • Interdependencies between sectors
  • Workforces needed to maintain critical functions
  • Process
  • Survey of CI/KR operators review of existing
    data and plans interviews of subject matter
Identifying critical employee groups all
sectors, tier 1 only
Employees Tier 1 Only Banking Finance
417,000 Chemical 161,309 Commercial Facilities
42,000 Communications 396,097 Electricity
50,000 Emergency Services 1,997,583 Food and
Agriculture 500,000 Healthcare
6,999,725 Information Technology
692,800 Nuclear 86,000 Oil and Natural Gas
223,934 Postal and Shipping 115,344 Transportatio
n 100,185 Water and Wastewater 608,000
TOTAL 12,389,977
  • Notes
  • Numbers include Tier 1 essential employees
  • State and local government numbers removed from
    gross and priority workforce numbers.

Ethics Considerations by the Interagency Working
  • Process issues
  • Transparency, inclusiveness, reasonableness
  • Content issues
  • Preserving society consider before protecting
  • Fairness value all equally treat all in a
    priority group the same
  • Reciprocity protect those who assume
    occupational risk
  • Flexibility reconsider strategy periodically
    and at the time of a pandemic

Public engagement and stakeholder meetings
  • For a rationing strategy to be successful, it
    must reflect societal values and preferences
  • There are conflicting frameworks for deciding who
    to protect first during a pandemic
  • Prevent the most deaths
  • Prevent the most years of potential life lost
  • Protect adolescents young adults (life cycle
  • Protect well-being of society
  • There is uncertainty around the impact of
    different choices
  • Need for vaccination to preserve essential

Public engagement and stakeholder meetings
  • Objective Consider the potential goals of
    pandemic vaccination and assign values to each
  • Approach
  • Background presentations
  • Group discussions
  • Electronic voting
  • Participants
  • Las Cruces, NM 108 persons culturally diverse
  • Nassau Co., NY 130 persons many older adults
  • DC 90 persons from government, CI sectors,
    community organizations

Value of pandemic vaccination goals public(Las
Cruces, Nassau Co.) and stakeholder (DC) meeting
results (7-point scale)
Vaccination goal To protect Las Cruces Nassau County D.C.
People working to fight pandemic provide care 6.7 6.0 6.8
People providing essential community services 5.9 5.7 6.5
People most vulnerable due to jobs 5.8 5.6 5.9
Children 5.9 5.7 4.9
People most likely to spread virus to unprotected 5.3 5.3 4.6
People protecting homeland security 4.6 5.2 4.7
People most likely to get sick or die 4.5 4.8 4.8
People most likely to be protected by the vaccine 4.5 5.1 4.0
People keeping pandemic out of the U.S. 4.3 5.3 3.3
People providing essential economic services 3.0 4.2 4.5
Decision analysis Approach
  • Consider 57 groups defined by job, age, and
    health status
  • Interagency group rated(0 3) extent to which
    each group met occupational objectives
  • CDC and external expertsrated extent to which
    each group met science based objectives
  • Vaccine effectiveness, risk of severe illness and
    death, and likelihood to transmit infection
  • Weights applied based on public and stakeholder
  • Sx O1w1 O2w2 O10w10

Vaccination goal To protect Score
People working to fight pandemic provide care 6.5
People providing essential community services 6.0
People most vulnerable due to jobs 5.8
Children 5.5
People most likely to spread virus to unprotected 5.1
People protecting homeland security 4.8
People most likely to get sick or die 4.7
People most likely to be protected by the vaccine 4.5
People keeping pandemic out of the U.S. 4.3
People providing essential economic services 3.9
Decision analysis Selected results
Group (11 20) Score
Medical care aides 72
Border protection 72
Pharmacists 71
Diplomats 71
Community orgs. 69
Nursing home staff 68
Government 65
Transportation 64
Communications 63
Energy 60
Group (1 10) Score
Pub. health responders 90
Medical practitioners 90
Emerg. med. services 89
Police 84
Relief orgs. (Red Cross) 80
National Guard 76
Fire protection rescue 75
Emergency mgt. 75
Military 74
Vaccine manufacturer 73
General population Infants toddlers (30)
young children (29) older children (24)
pregnant women (20) elderly (18)
Decision analysis Stratified results
Critical infrastructure
Emergency medical services
Police Law enforcement
Fire protection
Vaccine manufacturers
Energy, water, communications
Healthcare Community Suppt
Pub. health responders
Healthcare providers
Relief community support orgs.
Other healthcare personnel
General Population
Infants and toddlers
Pregnant women
High risk adults
Homeland National Security
Deployed military
Essential support personnel
Border protection
National guard
Other military
The Pandemic Severity Index (PSI)
  • Severity of 20th century pandemics differed
  • Threats to essential services and security differ
    by severity
  • PSI offers a way to characterize pandemics based
    on their case-fatality rate

Key issues in building the pandemic vaccine
prioritization strategy
  • Multiple important objectives to achieve
  • Public values of preserving healthcare
    essential services, and protecting persons at
    occupational risk children
  • Maintaining essential services requires targeting
    only a portion of the critical infrastructure
  • Need to target workers varies with pandemic
  • The timing and rate of vaccine availability
    relative to the pandemic wave is unknown
  • Draft guidance developed and vetted in additional
    public stakeholder meetings and in a web

Vaccination tiers for a severe pandemic
300 M
123 million
74 million
64 million
16 million
23 million
Tier 1 Tier 2
Tier 3 Tier 4
Tier 5
Vaccination tiers
Category Target group Estimated number Severe Moderate Less severe
Homeland and national security Deployed and mission critical pers. 700,000
Homeland and national security Essential support sustainment pers. Intelligence services Border protection personnel National Guard personnel Other domestic national security 650,000 150,000 100,000 500,000 50,000
Homeland and national security Other active duty essential suppt. 1,500,000
Healthcare and community support services Public health personnel Inpatient health care providers Outpatient and home health providers Health care providers in LTCFs 300,000 3,200,000 2,500,000 1,600,000
Healthcare and community support services Community suppt. emergency mgt. Pharmacists Mortuary services personnel 600,000 150,000 50,000
Healthcare and community support services Other important health care personnel 300,000
Critical infrastructure Emergency services sector pers. (EMS, law enforce . fire services) Mfrs of pandemic vaccine antivirals 2,000,000 50,000
Critical infrastructure Communications/IT, Electricity, Nuclear, Oil Gas, and Water sector personnel Financial clearing settlement pers. Critical operational regulatory government personnel 1,750,000 400,000
Critical infrastructure Banking Finance, Chemical, Food Agriculture, Pharmaceutical, Postal Shipping, and Transportation sector personnel Other critical government personnel 3,000,000 400,000
General population Pregnant women Infants toddlers 635 mo old 3,100,000 10,300,000
General population Household contacts of infants lt 6 mo Children 318 yrs with high risk cond. 4,300,000 6,500,000
General population Children 318 yrs without high risk 58,500,000
General population Persons 1964 with high risk cond. 36,000,000
General population Persons gt65 yrs old 38,000,000
General population Healthy adults 1964 yrs old 123,350,000
Vaccine Prioritization Tiers and Target Groups
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Not
targeted (Vaccinated in General pop.)
Critical Infrastructure Tiers and Target Groups
Target group Est. Severe Moderate Less severe
Emergency services Mfrs of pandemic vaccine antivirals 2,000,000 50,000
Communications/IT, Electricity, Nuclear, Oil Gas, Water Financial clearing settlement Critical operational regulatory government 1,750,000 20,000 400,000
Banking Finance, Chemical, Food Ag, Pharma, Postal Shipping, Transportation Other critical govt 3,000,000 400,000
Critical Infrastructure Influenza Vaccine
Prioritization for a Severe Pandemic
Tier Infrastructures Allocation Rationale
1 Healthcare Emergency services 60 90 High risk exposures Increased burden
2 Communications/IT Electricity Nuclear Oil Gas, Water 25 Products/services essential to all sectors Products cannot be stored Little fungibility
3 Banking Finance Chemical Food Agriculture Pharmaceutical Postal Shipping Transportation 7.5 Products may be stored Demand may decrease Greater fungibility
Steps in pandemic vaccine implementation
  • Ongoing planning to address each step in the
  • Challenges in identifying and vaccinating target
  • Businesses must identify targeted workers
    priority status must be validated at vaccination
  • Persons in families will be vaccinated at
    different times in different tiers

Conclusions Public values and public policy
This guidance is the result of a deliberative
democratic process. All interested parties took
part in the dialogue. We are confident that this
document represents the best of shared
responsibility and decision-making. HHS
Secretary Mike Leavitt