Got shots?

The Centers for Disease Control and Prevention turned to U.Va. philosophy professor John Arras and other experts for advice on how to distribute influenza vaccines when supplies were limited.

By Linda Kobert
John Arras

Photo by Jack Mellott.

Lots of Americans are knocking on wood right now. It’s the height of the flu season, and most people are still healthy, despite this winter’s severely limited supply of the vaccine designed to ward off the fever, headache, nasal congestion, cough, sore throat and muscle aches that usually accompany the flu.

A sense of panic greeted the announcement in October that manufacturing problems at one of only two companies that produce influenza vaccine would leave the United States with half of this season’s expected supply.

In making this announcement, Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention (CDC), said the situation raised some obvious questions — ethical questions concerning an aspect of health care that none of us wants to consider: rationing.

Gerberding asked experts for advice on how to respond to the dilemma of deciding who should receive this scarce resource, and who should make those decisions. U.Va.’s John Arras, Porterfield Professor of Biomedical Ethics and Professor of Philosophy, is one of those experts who now serves on the CDC’s Ethics Advisory Group.

“There are two issues we have right away,” Arras said. “The first is when you’re suddenly faced with a shortfall of vaccine, to whom do you give priority?”

Under normal circumstances, guidelines issued by the  CDC recommend immunizations be reserved for those at highest risk of complications. This includes young children, the elderly and the chronically ill. With severely limited supplies, however, the question becomes how does one choose among those identified groups?

With the milder-than-expected flu season almost past and health officials easing restrictions on vaccine supplies that still remain, the issue is less urgent. This leaves the committee’s second question, which Arras says, “is much scarier and will keep us going for quite a while.”

This question has to do with the problem of an impending world-wide influenza pandemic for which we do not now have a vaccine.

Pandemics arise on average once a decade, according to Arras. The disease becomes so dangerous because the particular strain of virus that causes it has never occurred in human beings before and people have no immunity to it. Modern air travel exacerbates the crisis, making it possible for such strains to spread throughout the world in no time.

Experts speak in terms of when not if this pandemic will occur and expect it to be equivalent to the 1918 flu pandemic that killed about half a million Americans and 20 to 100 million people world wide.

“We are not prepared,” Arras said.

When a strain of virus is identified, it takes months to prepare a vaccine to match. “We can count on major shortages,” Arras said. “Large numbers of people will be infected, especially if the virus is potent. There will definitely be rationing, but it will look much different than what we are looking at now.”

Any solution to such a crisis inevitably places strongly felt social values in conflict with one another. No one, for example, wants to choose between, say, children and the elderly. And from a wider humanitarian perspective, the question must be asked: What obligation do richer countries, such as the United States and Western Europe, have to provide vaccine for poorer countries?

When the Ethics Advisory Group meets at the end of February and begins engaging the issue of influenza pandemic, Arras suspects the rationale for rationing will shift from protecting the most vulnerable victims of disease to protecting society. A new list of priorities will likely be identified to include those who provide services needed to take care of everyone. “Who goes on that list is a matter of major debate,” Arras said.