*%newwin% [[http://www.google.com/url?sa=t&source=web&ct=res&cd=1&ved=0CBUQFjAA&url=http%3A%2F%2Finfluenzatraining.org%2Fdocuments%2Fs15503e%2Fs15503e.pdf&rct=j&q=thics+stand+on+guard+for+thee&ei=s3YCTPvkLoHGlQfwoLHyCQ&usg=AFQjCNFh6wAP2jTElNSmjUUEwUjUKgQOSg&sig2=KIHwfSC3OCjKjZGxjrfs0g|Stand on Guard for Thee]] [-building on the previous report, released Nov 28, 2005-]

*%newwin% [[ http://www.utoronto.ca/jcb/home/news_pandemic.htm|Stand on Guard for Thee]] [-building on the previous report, released Nov 28, 2005-]

* %newwin% [[http://www.hopkinsmedicine.org/bioethics/bellagio/statement.html|Bellagio statement]]\\

From the University of Pittsburgh's CBS [[http://www.upmc-biosecurity.org/website/resources/leadership/content/executive.html | report ]]:

see also Forum discussion [[http://www.fluwikie.com/pmwiki.php?n=Opinion.ForumTopics#HealthCareWorkers|here]] under health care workers.

*%newwin% [[http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=136080&Rendition=Web|The ethical framework for the response to pandemic influenza]] '-from the United kingdom (.pdf, 124K)-'

We would be grateful for your comments by 16 May 2007 using the attached proforma:

*%newwin% [[ http://www.utoronto.ca/jcb/home/news_pandemic.htm|Stand on Guard for Thee]] [-building on the previous report, released Nov 28,2005-]

!! [-- The Ethics of Triage --]

There are some interesting recommendations from the University of Pittsburgh's %newwin% [[ http://www.upmc-biosecurity.org/index.html | Center for Biosecurity ]] advising politicians and health officials %newwin% [[ http://www.upmc-biosecurity.org/pages/resources/leadership.html | how to lead ]] in a bioattack or epidemic:

From the University of Pittsburgh's CBS [[http://www.upmc-biosecurity.org/pages/resources/leadership/executive/trust.html | report ]]:

see also Forum discussion [[http://www.fluwikie2.com/pmwiki.php?n=Opinion.ForumTopics#HealthCareWorkers|here]] under health care workers.

see also Forum discussion [[http://www.fluwikie.com/pmwiki.php?n=Opinion.ForumTopics#sng|here]] under health care workers.

'-With support from the Rockefeller Foundation, an international group of experts in public health, animal health, virology, medicine, public policy, economics, bioethics, law and human rights met in Bellagio, Italy from 24 July to 28 July 2006 to consider questions of social justice and the threat of avian and human pandemic influenza, with a particular remit to focus on the needs and interests of the world’s disadvantaged. The Bellagio Statement of Principles, above, captures the major conclusions of the group’s deliberations.-'

<u style="display: none;">... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ...  </u>[[#top]] (:nogroup:) (:notitle:)

-> [- A synopsis of the CDC's rationing plan from the %newwin% [[ http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS | American Hospital Association ]]: \

* %newwin% [[http://www.hhs.gov/nvpo/meetings/jun2005/ethicswg.ppt|Ethical Issues in Pandemic Flu]] \

* %newwin% [[ http://www.cbc.ca/story/science/national/2005/06/24/flu-drugs050624.html | Ethics of stockpiling flu drugs for doctors' relatives questioned ]] \

* %newwin% [[ http://www.cbc.ca/story/world/national/2005/10/18/bird-flu-pharmacies051018.html | European avian flu fear leads to drug stockpiling ]] \

* %newwin% [[ http://www.washingtonpost.com/wp-dyn/content/article/2005/10/21/AR2005102102141.html | Run on Drug for Avian Flu Has Physicians Worried ]] \

* '''Essential service providers, including health care workers''' \
[- '''Goal -> Maintain essential services''' \

* '''Groups at high risk of death and severe complications requiring hospitalization''' \
[- '''Goal -> Prevent or reduce deaths and hospital admissions''' \

%newwin% [[http://www.cdc.gov/ncidod/eid/vol12no08/06-0360.htm|Virulent Epidemics and Scope of Healthcare Workers' Duty of Care]]\

** Case Studies \
2001 — Mayor Leads Mourning New Yorkers \

* %newwin% [[ http://www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/ | WHO's Outbreak Communication Guidelines ]] \

Dicuss this page in the [[ Forum | Forum ]] \

[[#top]] (:nogroup:) (:notitle:)

-> [- A synopsis of the CDC's rationing plan from the %newwin% [[ http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS | American Hospital Association ]]: \\

* %newwin% [[http://www.hhs.gov/nvpo/meetings/jun2005/ethicswg.ppt|Ethical Issues in Pandemic Flu]] \\

* %newwin% [[ http://www.cbc.ca/story/science/national/2005/06/24/flu-drugs050624.html | Ethics of stockpiling flu drugs for doctors' relatives questioned ]] \\

* %newwin% [[ http://www.cbc.ca/story/world/national/2005/10/18/bird-flu-pharmacies051018.html | European avian flu fear leads to drug stockpiling ]] \\

* %newwin% [[ http://www.washingtonpost.com/wp-dyn/content/article/2005/10/21/AR2005102102141.html | Run on Drug for Avian Flu Has Physicians Worried ]] \\

* '''Essential service providers, including health care workers''' \\
[- '''Goal -> Maintain essential services''' \\

* '''Groups at high risk of death and severe complications requiring hospitalization''' \\
[- '''Goal -> Prevent or reduce deaths and hospital admissions''' \\

%newwin% [[http://www.cdc.gov/ncidod/eid/vol12no08/06-0360.htm|Virulent Epidemics and Scope of Healthcare Workers' Duty of Care]]\\

** Case Studies \\
2001 — Mayor Leads Mourning New Yorkers \\

* %newwin% [[ http://www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/ | WHO's Outbreak Communication Guidelines ]] \\

Dicuss this page in the [[ Forum | Forum ]] \\

<u style="display: none;">... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ...  </u>[[#top]] (:nogroup:) (:notitle:)

-> [- A synopsis of the CDC's rationing plan from the %newwin% [[ http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS | American Hospital Association ]]: \

* %newwin% [[http://www.hhs.gov/nvpo/meetings/jun2005/ethicswg.ppt|Ethical Issues in Pandemic Flu]] \

* %newwin% [[ http://www.cbc.ca/story/science/national/2005/06/24/flu-drugs050624.html | Ethics of stockpiling flu drugs for doctors' relatives questioned ]] \

* %newwin% [[ http://www.cbc.ca/story/world/national/2005/10/18/bird-flu-pharmacies051018.html | European avian flu fear leads to drug stockpiling ]] \

* %newwin% [[ http://www.washingtonpost.com/wp-dyn/content/article/2005/10/21/AR2005102102141.html | Run on Drug for Avian Flu Has Physicians Worried ]] \

* '''Essential service providers, including health care workers''' \
[- '''Goal -> Maintain essential services''' \

* '''Groups at high risk of death and severe complications requiring hospitalization''' \
[- '''Goal -> Prevent or reduce deaths and hospital admissions''' \

%newwin% [[http://www.cdc.gov/ncidod/eid/vol12no08/06-0360.htm|Virulent Epidemics and Scope of Healthcare Workers' Duty of Care]]\

** Case Studies \
2001 — Mayor Leads Mourning New Yorkers \

* %newwin% [[ http://www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/ | WHO's Outbreak Communication Guidelines ]] \

Dicuss this page in the [[ Forum | Forum ]] \

[[#top]] (:nogroup:) (:notitle:)

-> [- A synopsis of the CDC's rationing plan from the %newwin% [[ http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS | American Hospital Association ]]: \\

* %newwin% [[http://www.hhs.gov/nvpo/meetings/jun2005/ethicswg.ppt|Ethical Issues in Pandemic Flu]] \\

* %newwin% [[ http://www.cbc.ca/story/science/national/2005/06/24/flu-drugs050624.html | Ethics of stockpiling flu drugs for doctors' relatives questioned ]] \\

* %newwin% [[ http://www.cbc.ca/story/world/national/2005/10/18/bird-flu-pharmacies051018.html | European avian flu fear leads to drug stockpiling ]] \\

* %newwin% [[ http://www.washingtonpost.com/wp-dyn/content/article/2005/10/21/AR2005102102141.html | Run on Drug for Avian Flu Has Physicians Worried ]] \\

* '''Essential service providers, including health care workers''' \\
[- '''Goal -> Maintain essential services''' \\

* '''Groups at high risk of death and severe complications requiring hospitalization''' \\
[- '''Goal -> Prevent or reduce deaths and hospital admissions''' \\

%newwin% [[http://www.cdc.gov/ncidod/eid/vol12no08/06-0360.htm|Virulent Epidemics and Scope of Healthcare Workers' Duty of Care]]\\

** Case Studies \\
2001 — Mayor Leads Mourning New Yorkers \\

* %newwin% [[ http://www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/ | WHO's Outbreak Communication Guidelines ]] \\

Dicuss this page in the [[ Forum | Forum ]] \\

<u style="display: none;">... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ...  </u>[[#top]] (:nogroup:) (:notitle:)

-> [- A synopsis of the CDC's rationing plan from the %newwin% [[ http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS | American Hospital Association ]]: \

* %newwin% [[http://www.hhs.gov/nvpo/meetings/jun2005/ethicswg.ppt|Ethical Issues in Pandemic Flu]] \

* %newwin% [[ http://www.cbc.ca/story/science/national/2005/06/24/flu-drugs050624.html | Ethics of stockpiling flu drugs for doctors' relatives questioned ]] \

* %newwin% [[ http://www.cbc.ca/story/world/national/2005/10/18/bird-flu-pharmacies051018.html | European avian flu fear leads to drug stockpiling ]] \

* %newwin% [[ http://www.washingtonpost.com/wp-dyn/content/article/2005/10/21/AR2005102102141.html | Run on Drug for Avian Flu Has Physicians Worried ]] \

* '''Essential service providers, including health care workers''' \
[- '''Goal -> Maintain essential services''' \

* '''Groups at high risk of death and severe complications requiring hospitalization''' \
[- '''Goal -> Prevent or reduce deaths and hospital admissions''' \

%newwin% [[http://www.cdc.gov/ncidod/eid/vol12no08/06-0360.htm|Virulent Epidemics and Scope of Healthcare Workers' Duty of Care]]\

** Case Studies \
2001 — Mayor Leads Mourning New Yorkers \

* %newwin% [[ http://www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/ | WHO's Outbreak Communication Guidelines ]] \

Dicuss this page in the [[ Forum | Forum ]] \

[[#top]] (:nogroup:) (:notitle:)

-> [- A synopsis of the CDC's rationing plan from the %newwin% [[ http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS | American Hospital Association ]]: \\

* %newwin% [[http://www.hhs.gov/nvpo/meetings/jun2005/ethicswg.ppt|Ethical Issues in Pandemic Flu]] \\

* %newwin% [[ http://www.cbc.ca/story/science/national/2005/06/24/flu-drugs050624.html | Ethics of stockpiling flu drugs for doctors' relatives questioned ]] \\

* %newwin% [[ http://www.cbc.ca/story/world/national/2005/10/18/bird-flu-pharmacies051018.html | European avian flu fear leads to drug stockpiling ]] \\

* %newwin% [[ http://www.washingtonpost.com/wp-dyn/content/article/2005/10/21/AR2005102102141.html | Run on Drug for Avian Flu Has Physicians Worried ]] \\

* '''Essential service providers, including health care workers''' \\
[- '''Goal -> Maintain essential services''' \\

* '''Groups at high risk of death and severe complications requiring hospitalization''' \\
[- '''Goal -> Prevent or reduce deaths and hospital admissions''' \\

%newwin% [[http://www.cdc.gov/ncidod/eid/vol12no08/06-0360.htm|Virulent Epidemics and Scope of Healthcare Workers' Duty of Care]]\\

** Case Studies \\
2001 — Mayor Leads Mourning New Yorkers \\

* %newwin% [[ http://www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/ | WHO's Outbreak Communication Guidelines ]] \\

Dicuss this page in the [[ Forum | Forum ]] \\

<u style="display: none;">... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ... no changes ...  </u>[[#top]] (:nogroup:) (:notitle:)

-> [- A synopsis of the CDC's rationing plan from the %newwin% [[ http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS | American Hospital Association ]]: \

* %newwin% [[http://www.hhs.gov/nvpo/meetings/jun2005/ethicswg.ppt|Ethical Issues in Pandemic Flu]] \

* %newwin% [[ http://www.cbc.ca/story/science/national/2005/06/24/flu-drugs050624.html | Ethics of stockpiling flu drugs for doctors' relatives questioned ]] \

* %newwin% [[ http://www.cbc.ca/story/world/national/2005/10/18/bird-flu-pharmacies051018.html | European avian flu fear leads to drug stockpiling ]] \

* %newwin% [[ http://www.washingtonpost.com/wp-dyn/content/article/2005/10/21/AR2005102102141.html | Run on Drug for Avian Flu Has Physicians Worried ]] \

* '''Essential service providers, including health care workers''' \
[- '''Goal -> Maintain essential services''' \

* '''Groups at high risk of death and severe complications requiring hospitalization''' \
[- '''Goal -> Prevent or reduce deaths and hospital admissions''' \

%newwin% [[http://www.cdc.gov/ncidod/eid/vol12no08/06-0360.htm|Virulent Epidemics and Scope of Healthcare Workers' Duty of Care]]\

** Case Studies \
2001 — Mayor Leads Mourning New Yorkers \

* %newwin% [[ http://www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/ | WHO's Outbreak Communication Guidelines ]] \

Dicuss this page in the [[ Forum | Forum ]] \

[[#top]] (:nogroup:) (:notitle:)

-> [- A synopsis of the CDC's rationing plan from the %newwin% [[ http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS | American Hospital Association ]]: \\

* %newwin% [[http://www.hhs.gov/nvpo/meetings/jun2005/ethicswg.ppt|Ethical Issues in Pandemic Flu]] \\

* %newwin% [[ http://www.cbc.ca/story/science/national/2005/06/24/flu-drugs050624.html | Ethics of stockpiling flu drugs for doctors' relatives questioned ]] \\

* %newwin% [[ http://www.cbc.ca/story/world/national/2005/10/18/bird-flu-pharmacies051018.html | European avian flu fear leads to drug stockpiling ]] \\

* %newwin% [[ http://www.washingtonpost.com/wp-dyn/content/article/2005/10/21/AR2005102102141.html | Run on Drug for Avian Flu Has Physicians Worried ]] \\

* '''Essential service providers, including health care workers''' \\
[- '''Goal -> Maintain essential services''' \\

* '''Groups at high risk of death and severe complications requiring hospitalization''' \\
[- '''Goal -> Prevent or reduce deaths and hospital admissions''' \\

%newwin% [[http://www.cdc.gov/ncidod/eid/vol12no08/06-0360.htm|Virulent Epidemics and Scope of Healthcare Workers' Duty of Care]]\\

** Case Studies \\
2001 — Mayor Leads Mourning New Yorkers \\

* %newwin% [[ http://www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/ | WHO's Outbreak Communication Guidelines ]] \\

Dicuss this page in the [[ Forum | Forum ]] \\

[- [[#rationing | Rationing]] · [[#triage | Ethics of Triage ]] · [[#communication | Communicating a Pandemic ]] · [[#hcw|Duty of Care]] -]

[- [[#rationing | Rationing]] · [[#triage | Ethics of Triage ]] · [[#communication | Communicating a Pandemic ]] -]

* [[http://www.yorku.ca/igreene/sars.html|Ethics and SARS: Learning Lessons from the Toronto Experience]] {-including ethics of quarantine, revealing personal info, duty to treat, and morec-]

* Content needed

* %newwin% [[ http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_RMD_2004_8/en/index.html | WHO guidelines]] [- on the use of vaccines and antivirals during an inluenza pandemic -]

* %newwin% [[ http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5430a4.htm | Tiered Use ]] [- of Inactivated Influenza Vaccine in the Event of a Vaccine Shortage `- The CDC's Rationing Plan -]


A synopsis of the CDC's rationing plan from the %newwin% [[ http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS | American Hospital Association ]]:

"The Centers for Disease Control and Prevention on Aug. 4 announced a tiered approach to prioritization in the event of a flu vaccine shortage. In the event of a shortage, CDC said people in the first tier should be vaccinated preferentially, followed by those in the second tier, then those in tier three. When local vaccine supply is extremely limited, state and local health officials and vaccine providers should vaccinate people in group 1A before all other groups, CDC said.

* Group 1A consists of people 65 and older with comorbid conditions and residents of long-term care facilities. In all other vaccine shortfall situations, CDC said people in groups 1A, 1B and 1C should be vaccinated first. Group 1B consists of people aged 2-64 with comorbid conditions and aged 65 and older without comorbid conditions, as well as children 6-23 months and pregnant women. Group 1C consists of health care personnel, and household contacts and out-of-home caregivers of children 6 months and under.

* Group 2 consists of household contacts of children and adults at increased risk for flu-related complications.

* Group 3 consists of people aged 2-49 without high-risk conditions.

* Group 4 is everyone not in one of the above categories.

“Eligible persons in group 1C and tiers 2 and 3 should be encouraged to receive live, attenuated influenza vaccine during periods of inactivated influenza vaccine shortfall,” CDC said."

At a time of resource limitations such as a pandemic, ethical issues abound. Should healthcare providers get preferential treatment? Some doctors might stockpile for their relatives. Oseltamivir (Tamiflu) may help treat an infection but unless it is taken daily (i.e. preventatively) it will not keep health care workers from getting ill. Will health care profesionals go to work if they are afraid of bringing the illness home and threaten their family members? They would be on the front lines of a disease outbreak and thus most likely exposed while tending to patients. In the case of SARS, there were "superspreaders" who passed on a very lethal variant and others whose infection caused only relatively mild symptoms. The sickest would seek professional help.

The same issues arise for essential workers in all sectors of the economy — everyone who maintains the economy's infrastructure such as electricity, water, heat, transportation. Where to draw the line? Should we provide for the doctor and not the nurse?  Unfortunately, it is easier to ask these questions than to provide answers. If you have ideas, [[ Forum | please bring them up]].

'- '''Goal -> Maintain essential services''' -' \\\
"Definition of those considered 'essential' will vary from country to country. The purpose of vaccinating these individuals would be to allow them to continue to provide services, including health care, to those in need. As vaccine supplies will most likely be inadequate, prioritization within individual categories of essential service workers may be necessary."

Note that the WHO advocates a further prioritization '''within''' individual categories of essential workers in order to deal with the global shortage of neuraminidase inhibitors and the lack of an effective vaccine. The document also has guidelines regarding the healthy — frail split:

'- '''Goal -> Prevent or reduce deaths and hospital admissions''' -' \\\
"In the interpandemic period, those who have underlying disease or are older are the ones most likely to experience severe morbidity and mortality[^Individuals (adults and children aged more than 6 months) in the community who have chronic cardiovascular, pulmonary, metabolic or renal disease, or are immunocompromised.^]. In a pandemic, previously healthy individuals are more likely to experience a severe outcome than they would in an ordinary outbreak. However, it is still individuals in the "high risk group" who have the greatest risk of hospitalization and death. Such persons should be targeted for vaccination if the goal is to prevent such events. They are individuals who are 65 years of age or older and have a high-risk condition (see above). Younger individuals with underlying disease are also at higher risk of experiencing severe morbidity and mortality. Owing to difficulties in prioritization on the basis of chronic diseases, age is often used as a surrogate for identifying those at greatest risk of complications. However, the epidemiologic characteristics of the pandemic will need to be considered, as the main population groups affected may vary." \\
[- [^#^] -]

->"There is no evidence that use of inactivated vaccine in children will reduce the spread of a pandemic in the community, and this strategy is not recommended."

->"Breaches of social trust are a common predicament for leaders during outbreaks and are likely to arise during a bioattack. Social and economic fault lines as well as preconceived notions about 'the government,' 'the public,' and 'the media' can alienate leaders and the public, and community members from one another."

At a time of resource limitations such as a pademic, ethical issues abound. Should healthcare providers get preferential treatment? Some doctors might stockpile for their relatives. Oseltamivir (Tamiflu) may help treat an infection but unless it is taken daily (i.e. preventatively) it will not keep health care workers from getting ill. Will health care profesionals go to work if they are afraid of bringing the illness home and threaten their family members? They would be on the front lines of a disease outbreak and thus most likely exposed while tending to patients. In the case of SARS, there were "superspreaders" who passed on a very lethal variant and others whose infection caused only relatively mild symptoms. The sickest would seek professional help.

* %newwin% [[ http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5430a4.htm | Tiered Use of Inactivated Influenza Vaccine in the Event of a Vaccine Shortage ]] \\
[- The CDC's Rationing Plan -]

[[#triage]] %right color=#332% [- &darr; [[ {$Name}?action=edit | edit]] · [[ #top | top ]] &uarr; -]

[[#communication]] %right color=#332% [- &darr; [[ {$Name}?action=edit | edit]] · [[ #top | top ]] &uarr; -]

>>note justify font-size=13px<<

%newwin% [[ http://www.who.int/entity/csr/resources/publications/WHO_CDS_2005_28en.pdf | english ]] · %newwin% [[ http://www.who.int/entity/csr/resources/publications/WHO_CDS_2005_28fr.pdf  | français ]] (pdf)

[[#top]] (:nogroup:) (:notitle:) (:notopmenu:)

[[#top]] (:nogroup:) (:notitle:)

>>note justify<<

< [[ Legal | Legal Issues ]] | [[ Issues | Issues ]] | [[ OtherEconomic | Economic Issues ]] >

[- %newwin% [[ http://www.who.int/entity/csr/resources/publications/WHO_CDS_2005_28en.pdf | english ]] · %newwin% [[ http://www.who.int/entity/csr/resources/publications/WHO_CDS_2005_28fr.pdf  | français ]] (pdf) -]

[[#top]] (:nogroup:) (:title Ethical Issues:)

* %apply=list box% %newwin% [[ http://www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/ | WHO's Outbreak Communication Guidelines ]] \\

>>note<<

[- %newwin% [[ http://www.who.int/entity/csr/resources/publications/WHO_CDS_2005_28en.pdf | pdf (english) ]] | %newwin% [[ http://www.who.int/entity/csr/resources/publications/WHO_CDS_2005_28fr.pdf  | pdf (français) ]] -]

* [[ Resources.Resources#SignificantEssays|Sandman and Lanard essays]]

[- [[#rationing | Rationing ] · [[#triage | Ethics of Triage ]] · [[#communication | Communicating a Pandemic ]] -]

[[#top]] (:title Ethical Issues:)
!!  Ethical Issues in Pandemics
[- [[ #Rationing | Rationing ]] | [[ #Triage | Ethics of Triage ]] | [[ #Communication | Communicating a Pandemic ]] -]




[[#Rationing]] %right% [-- [[ #top | top ]] --]
>>inset2 justify<<
!!!!! Rationing of Scarce Resources

*[[http://www.hhs.gov/nvpo/meetings/jun2005/ethicswg.ppt|Ethical Issues in Pandemic Flu]] \\
[-PowerPoint presentation by Kathy Kinlaw, Emory University Center for Ethics, given at the  Pandemic Influenza Working Group meeting on June 15, 2005-]

The %newwin% [[ http://www.who.int/en/ | World Health Organization ]] has issued %newwin% [[ http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_RMD_2004_8/en/index.html | guidelines on the use of vaccines and antivirals during influenza pandemics ]]. Regarding vaccines, the WHO advises:

"In the interpandemic period, those who have underlying disease or are older are the ones most likely to experience severe morbidity and mortality'^3^'. In a pandemic, previously healthy individuals are more likely to experience a severe outcome than they would in an ordinary outbreak. However, it is still individuals in the "high risk group" who have the greatest risk of hospitalization and death. Such persons should be targeted for vaccination if the goal is to prevent such events. They are individuals who are 65 years of age or older and have a high-risk condition (see above). Younger individuals with underlying disease are also at higher risk of experiencing severe morbidity and mortality. Owing to difficulties in prioritization on the basis of chronic diseases, age is often used as a surrogate for identifying those at greatest risk of complications. However, the epidemiologic characteristics of the pandemic will need to be considered, as the main population groups affected may vary." \\\
'- '^3^' Individuals (adults and children aged more than 6 months) in the community who have chronic cardiovascular, pulmonary, metabolic or renal disease, or are immunocompromised.-'

>><<


[[#Triage]] %right% [-- [[ #top | top ]] --]
>>inset2<<
!!!!! Ethics of Triage

>><<

[[#Communication]] %right% [-- [[ #top | top ]] --]
>>inset2<<
!!!!! Communication: "Truth-telling" vs. "Panic-mongering"

!!!!! See also

Synopsis from %newwin% [[ http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS | American Hospital Association ]]:

The Centers for Disease Control and Prevention on Aug. 4 announced a tiered approach to prioritization in the event of a flu vaccine shortage. In the event of a shortage, CDC said people in the first tier should be vaccinated preferentially, followed by those in the second tier, then those in tier three. When local vaccine supply is extremely limited, state and local health officials and vaccine providers should vaccinate people in group 1A before all other groups, CDC said.

“Eligible persons in group 1C and tiers 2 and 3 should be encouraged to receive live, attenuated influenza vaccine during periods of inactivated influenza vaccine shortfall,” CDC said.

[- [[ #Rationing | Rationing ]] | [[ #Triage | Ethics of Triage ]] | [[ #Communication | Communication: "Truth-telling" vs. "Panic-mongering" ]] -]

''Earning confidence in the use of scarce resources despite existing social and economic gaps''\\

[- [[ http://www.who.int/entity/csr/resources/publications/WHO_CDS_2005_28en.pdf | pdf (english) ]] | [[http://www.who.int/entity/csr/resources/publications/WHO_CDS_2005_28fr.pdf  | pdf (français) ]] -]

* %apply=list box% %newwin% [[http://www.who.int/infectious-disease-news/IDdocs/whocds200528/whocds200528en.pdf | WHO's Outbreak Communication Guidelines ]] on the WHO website (posted to Flu Wiki 7/05).
* [[http://www.fluwikie.com/index.php?n=Resources.Resources#SignificantEssays|Sandman and Lanard essays]]


Dicuss this page in the [[ Forum | Forum ]] (a previous thread can be found [[Main.NewEthicsAdditions42cfc6e7|here]] (no new posts)

The [[ http://www.who.int/en/ | World Health Organization ]] has some [[ http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_RMD_2004_8/en/index.html | tentative guidelines ]] regarding both vaccine and antivirals that touch on many of the above points. Regarding vaccines, for example:

''Goal: maintain essential services.''\\\
Definition of those considered “essential” will vary from country to country. The purpose of vaccinating these individuals would be to allow them to continue to provide services, including health care, to those in need. As vaccine supplies will most likely be inadequate, prioritization within individual categories of essential service workers may be necessary.

In the above document, health care workers are not the only people defined as essential. The document also has guidelines regarding the healthy vs. the frail and elderly:

''Goal: prevent or reduce deaths and hospital admissions.''\\\
In the interpandemic period, those who have underlying disease or are older are the ones most likely to experience severe morbidity and mortality'^3^'. In a pandemic, previously healthy individuals are more likely to experience a severe outcome than they would in an ordinary outbreak. However, it is still individuals in the "high risk group" who have the greatest risk of hospitalization and death. Such persons should be targeted for vaccination if the goal is to prevent such events. They are individuals who are 65 years of age or older and have a high-risk condition (see above). Younger individuals with underlying disease are also at higher risk of experiencing severe morbidity and mortality. Owing to difficulties in prioritization on the basis of chronic diseases, age is often used as a surrogate for identifying those at greatest risk of complications. However, the epidemiologic characteristics of the pandemic will need to be considered, as the main population groups affected may vary.

->'-'^3^'Individuals (adults and children aged more than 6 months) in the community who have chronic cardiovascular, pulmonary, metabolic or renal disease, or are immunocompromised.-'

->There is no evidence that use of inactivated vaccine in children will reduce the spread of a pandemic in the community, and this strategy is not recommended.

There are some interesting recommendations from the University of Pittsburgh's [[http://www.upmc-biosecurity.org/index.html|Center for Biosecurity]] advising politicians and health officials [[http://www.upmc-biosecurity.org/pages/resources/leadership.html|how to lead]] in a bioattack or epidemic:

Case Study\\
Polled Americans Expect Discrimination during Smallpox Outbreak

Also from the [[http://www.upmc-biosecurity.org/pages/resources/leadership/executive/trust.html|Biosecurity]] report:


->Breaches of social trust are a common predicament for leaders during outbreaks and are likely to arise during a bioattack. Social and economic fault lines as well as preconceived notions about “the government,” “the public,” and “the media” can alienate leaders and the public, and community members from one another.

''Preventing unproductive fear, denial, or skepticism on the part of the public when delivering crisis updates''

Case Studies\\
2001, Mayor Leads Mourning New Yorkers\\
2001, EPA Reassures Ground Zero Residents that Air Is Safe

Forum link for discussion is [[Main.NewEthicsAdditions42cfc6e7|here]]
Dicuss this page on the [[ Forum | Forum ]]

Another issue - Do you treat the old/frail because they have more medical issues and have less reserve capacity to withstand an illness or do you treat the younger person who is stronger to start off with and more likely to survive?  The younger person has more "productive years ahead" but the older person is less likely to survive without help.  What makes a person "essential"?  Role in the family, company, government, hospital?  What about finances?  What if you are pregnant or conversely if you have some developmental disability?  Will medicaid patients get treated?  Will you get sued for not treating the "correct person"?  We have never had to deal with these issues in modern times.  I suspect some of these issues will be affected by the natural history of the infection.  In 1918, the illness was more fatal to the young healthy person for reasons that still remain unknown ([[Science.PrimerCytokineStorm|cytokine storm]] is suspected).  We do not know what will be the case in the next pandemic.

!!  Ethical Issues in Epidemics
[- [[ #Rationing | Rationing of Scarce Resources ]] | [[ #Triage | Ethics of Triage ]] | [[ #Communication | Communication: "Truth-telling" vs. "Panic-mongering" ]] -]

>>inset2<<

* [[ http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5430a4.htm | Tiered Use of Inactivated Influenza Vaccine in the Event of a Vaccine Shortage ]] \\

Synopsis from [[ http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS | American Hospital Association ]]:

The Centers for Disease Control and Prevention on Aug. 4 announced a tiered approach to prioritization in the event of a flu vaccine shortage. In the event of a shortage, CDC said people in the first tier should be vaccinated preferentially, followed by those in the second tier, then those in tier 3. When local vaccine supply is extremely limited, state and local health officials and vaccine providers should vaccinate people in group 1A before all other groups, CDC said.

* [[ http://www.cbc.ca/story/science/national/2005/06/24/flu-drugs050624.html | Ethics of stockpiling flu drugs for doctors' relatives questioned ]] \\

Ethical issues abound in a time of limited resources.  As the article above discusses, do healthcare providers get preferential treatment?  Some doctors are stockpiling for their families. Tamiflu would treat them and maybe help them but unless it is taken daily it would not keep them from getting the initial illness.  Would healthcare people go to work if they are afraid of bringing the illness home and kill their family members?  They are on the front lines and the most likely to get exposed as the see the sickest patients.  In the case of SARS, there were superspreaders who passed on a very lethal variant and those who caused only relatively mild symptoms.  The sickest would seek professional help.  On the other hand these issues are also there for the people who maintain our essential infrastructure... electricity, water, heat, transportation.  Do you provide for the doctor and not the nurse.  Where do you draw the line?  Unfortunately, it is easier to ask the questions than to provide the answers.  If you have ideas, please bring them up.

Another issue- Do you treat the old/frail because they have more medical issues and have less reserve capacity to withstand an illness or do you treat the younger person who is stronger to start off with and more likely to survive?  The younger person has more "productive years ahead" but the older person is less likely to survive without help.  What makes a person "essential"?  Role in the family, company, government, hospital?  What about finances?  What if you are pregnant or conversely if you have some developmental disability?  Will medicaid patients get treated?  Will you get sued for not treating the "correct person"?  We have never had to deal with these issues in modern times.  I suspect some of these issues will be affected by the natural history of the infection.  In 1918, the illness was more fatal to the young healthy person for reasons that still remain unknown ([[Science.PrimerCytokineStorm|cytokine storm]] is suspected).  We do not know what will be the case in the next pandemic.

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!!  Ethical issues in Epidemics

[[#Rationing]]

[[#Rationing|Rationing of Scarce Resources]]\\
[[#Triage|Ethics of Triage]]\\
[[#Communication|Communication: "Truth-telling" vs. "Panic-mongering]]\\

'''Rationing of Scarce Resources'''\\


[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5430a4.htm|Tiered Use of Inactivated Influenza Vaccine in the Event of a Vaccine Shortage]], CDC Rationing Plan

Synopsis from [[http://www.hospitalconnect.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_050804_flu&domain=AHANEWS|American Hospital Association]]:

*Group 1A consists of people 65 and older with comorbid conditions and residents of long-term care facilities. In all other vaccine shortfall situations, CDC said people in groups 1A, 1B and 1C should be vaccinated first. Group 1B consists of people aged 2-64 with comorbid conditions and aged 65 and older without comorbid conditions, as well as children 6-23 months and pregnant women. Group 1C consists of health care personnel, and household contacts and out-of-home caregivers of children 6 months and under.

*Group 2 consists of household contacts of children and adults at increased risk for flu-related complications.

*Group 3 consists of people aged 2-49 without high-risk conditions.

*Group 4 is everyone not in one of the above categories.

[[http://www.cbc.ca/story/science/national/2005/06/24/flu-drugs050624.html|Ethics of stockpiling flu drugs for doctors' relatives questioned]] - Canadian story, from June 24, 2005

The [[http://www.who.int/en/|World Health Organization]] has some [[http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_RMD_2004_8/en/index.html|tentative guidelines]] regarding both vaccine and antivirals that touch on many of the above points. Regarding vaccines, for example:

->'''''Essential service providers, including health care workers'''''
->Goal: maintain essential services.
->Definition of those considered “essential” will vary from country to country. The purpose of vaccinating these individuals would be to allow them to continue to provide services, including health care, to those in need. As vaccine supplies will most likely be inadequate, prioritization within individual categories of essential service workers may be necessary.

->'''''Groups at high risk of death and severe complications requiring hospitalization'''''
->Goal: prevent or reduce deaths and hospital admissions.
->In the interpandemic period, those who have underlying disease or are older are the ones most likely to experience severe morbidity and mortality'^3^'. In a pandemic, previously healthy individuals are more likely to experience a severe outcome than they would in an ordinary outbreak. However, it is still individuals in the "high risk group" who have the greatest risk of hospitalization and death. Such persons should be targeted for vaccination if the goal is to prevent such events. They are individuals who are 65 years of age or older and have a high-risk condition (see above). Younger individuals with underlying disease are also at higher risk of experiencing severe morbidity and mortality. Owing to difficulties in prioritization on the basis of chronic diseases, age is often used as a surrogate for identifying those at greatest risk of complications. However, the epidemiologic characteristics of the pandemic will need to be considered, as the main population groups affected may vary.

[[#Triage]]
'''Ethics of Triage'''

Content needed


[[#Communication]] 
'''Communication: "Truth-telling" vs. "Panic-mongering"'''

Forum link for discussion is [[Main.NewEthicsAdditions42cfc6e7|here]]

[[http://www.usnews.com/usnews/health/briefs/infectiousdiseases/hb050720a.htm|Flu-vaccine rationing ahead?]] - July, 2005 from US News and World Report by Dr. Bernadine Healy

->The plan lays out just who will get the vaccine, in descending order of priority:

*Group 1. The highest-priority group includes 9 million healthcare workers involved in direct patient care; 40,000 people who are making the vaccine and antiflu medicines; and some 37 million people who are at greatest risk if they get the flu, namely those over age 64 with a medical illness, younger people with two serious underlying medical conditions, pregnant women, and all household contacts of children under 6 months of age. Also in this top group are key government officials and specialized pandemic flu responders.

*Group 2. In the next tier are healthy seniors; younger people with one risky health condition; young children between 6 to 23 months old (the vaccine is not recommended for infants under 6 months); and workers in critical fields like public safety, utilities, emergency response, transportation, and telecommunication. This group is 68 million strong.

*Group 3. The third priority is 500,000 people, including key government healthcare decision makers and those working in mortuary services.

*Group 4.At the bottom are the remaining 179 million healthy people, 2 to 64 years old, not included in any other category.

[[http://www.usnews.com/usnews/health/briefs/infectiousdiseases/hb050720a.htm|Flu-vaccine rationing ahead?]] - July, 20005 from US News and World Report by Dr. Bernadine Healy

'''Rationing of Scarce Resources'''

* [[http://www.cbc.ca/story/science/national/2005/06/24/flu-drugs050624.html|Ethics of stockpiling flu drugs for doctors' relatives questioned]] - Canadian story, from June 24, 2005

The [[http://www.who.int/en/|World Health Organization]] has some [[http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_RMD_2004_8/en/index.html|tentative guidelines]] regarding both vaccine and antivirals. Regarding vaccines, for example:

  

Another issue- Do you treat the old/frail because they have more medical issues and have less reserve capacity to withstand an illness or do you treat the younger person who is stronger to start off with and more likely to survive?  The younger person has more "productive years ahead" but the older person is less likely to survive without help.  What makes a person "essential"?  Role in the family, company, government, hospital?  What about finances?  What if you are pregnant or conversely if you have some developmental disability?  Will medicaid patients get treated?  Will you get sued for not treating the "correct person"?  We have never had to deal with these issues in modern times.  I suspect some of these issues will be affected by the natural history of the infection.  In 1918, the illness was more fatal to the young healthy person for reasons that still remain unknown.  We do not know what will be the case in the next pandemic.

'''Ethics of Triage'''
 
'''Communication: "Truth-telling" vs. "Panic-mongering"'''

 '''Rationing of Scarce Resources'''

 '''Ethics of Triage'''

 '''Communication: "Truth-telling" vs. "Panic-mongering"'''