NIH ethicists take stance on bird flu

People 13-40 should get vaccine, drugs first, they say


WASHINGTON -- Answering a question left unresolved by the White House plan for dealing with an outbreak of bird flu, two bioethicists say people ages 13 to 40 should be the first among the public to receive the limited supply of vaccines and antiviral drugs.

The bioethicists, who work at the National Institutes of Health in Bethesda, argue in today's Science magazine that if supplies for healthy Americans are short, the drugs should go to those entering or in the prime of their life.

"Most people who think about it say, `Yeah, I'd like to have a long life and live to 65,' [rather than] at age 65 live another 15 years," Dr. Ezekiel J. Emanuel, who wrote the article with Alan Wertheimer, said in a telephone interview.

FOR THE RECORD - An article yesterday about National Institutes of Health bioethicists' recommendations for prioritizing the distribution of bird flu vaccines and antivirals should have said the Bush administration predicted that, in a worst-case scenario, as many as 2 million Americans could die during an outbreak, not 40 million.
The Sun regrets the error.

In November, two federal advisory panels recommended the opposite, saying that the elderly and very young children from 6 months to 23 months should have priority among the healthy public, because they're at greatest risk of dying.

Dr. Sharon Humiston, an adviser to the advocacy group Parents of Kids with Infectious Diseases of Vancouver, Wash., said it makes more sense to protect the most vulnerable, especially if the flu strain isn't so virulent that it's killing healthy teenagers and adults.

"I'm a pediatrician, my bias is toward protecting the youngest people," said Humiston, an associate professor of emergency medicine and pediatrics at the University of Rochester. "They are very vulnerable."

Prioritizing vaccination and treatment is an issue because of the limited supply of medications. Last week, the Department of Health and Human Services awarded more than $1 billion in contracts to spur development of technologies for making vaccines.

The Bush administration wants to stockpile enough doses to immunize 20 million Americans and sufficient numbers of antivirals to treat 75 million people after they get sick. Even after meeting the goals, there would not be nearly enough for everyone.

All sides agree that workers who produce and distribute vaccines - along with the doctors, nurses and rescue workers treating the infected - should get the drugs first. Infirm elderly and key government leaders are next. Who then?

The Bush administration's flu response implementation plan, a 227-page report released May 3, said Washington is developing guidelines, but state and local governments will ultimately decide.

Setting priorities is especially difficult because authorities don't know whether an outbreak would resemble regular flu seasons or milder pandemics, when the young and old are at highest risk, or the serious 1918 epidemic, which most threatened Americans 20 to 40 years old.

In either scenario, the NIH bioethicists wrote, the risk to the elderly remains about the same - it's the risk to healthy adults that varies depending upon the virulence of the disease.

The government should try to protect healthy teenagers and adults first, the authors wrote, because they "have more developed interests, hopes and plans but have not had an opportunity to realize them."

Infected birds have been carrying the H5N1 virus from Asia into Europe and Africa. The virus has not mutated into a form easily spread among humans. Still, more than 200 people have been infected and 115 have died after being infected handling poultry.

Should the virus become transmissible among people, scientists fear a widespread outbreak. The Bush administration, in a worst-case scenario, predicted that as many as 40 million Americans could die and 40 percent of the work force would miss time at their jobs.

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