# 2736
On Friday the Minnesota Center for Health Care Ethics and University of Minnesota Center for Bioethics released draft ethical pandemic guidelines on the rationing of scarce resources, and is seeking public comment.
Like many others, I'm working my way through the roughly 180 pages of information. I expect these two documents will spur a number of blogs over the next few weeks.
Before we can plan for an event, we must first envision what that event will look like. We must make assumptions (which may or may not end up being correct) about the impact.
Today, we'll look at the base assumptions that the Minnesota group used, and discuss them. There are 9 broad assumptions.
Since no one can know what the next pandemic will bring, we could argue endlessly over whether these assumptions are reasonable. For the purpose of this blog, I'm going to assume that they are.
Since at least a few of my readers don't live in Minnesota, in order to help you convert these figures to your locality, it would probably help to know a little about the state.
Minnesota has roughly 5,220,000 people, which ranks it 21st in the nation. In the recent (Dec 08) Trust For America's Health (TFAH) ranking of states, and how well they did on bioterror preparedness, Minnesota scored 8 out of 10, or slightly above average.
Minnesota is fairly typical of American States. Not the most prepared, perhaps, but among the top 22 states as ranked by TFAH.
The following assumptions (indented in blue) come from the Executive Summary of For the Good of Us All: Ethically Rationing Health Resources in Minnesota in a Severe Influenza Pandemic: Preliminary Report, January 30, 2009. In some cases I've bolded statements and reparagraphed some items. My comments follow.
1. The influenza pandemic will be severe, based on projections from the ―Spanish Flu‖ pandemic of 1918–19, with a case fatality rate more than 20 times higher than that of seasonal influenza. More than 100 million people worldwide could die, over 32,000 in Minnesota alone.
Before anyone jumps on these estimates, notice the judicious use of the phrases `more than' and `over'.
That's a tacit admission that these estimates could be low.
The 32,000 deaths in Minnesota number obviously comes from the reasonably well-documented death toll in the United States from the Spanish Flu.
The next pandemic could be the same, not as bad, or worse.
2. The age-specific mortality curve will be W-shaped as opposed to the U-shaped curve associated with seasonal influenza. Healthy persons aged 15–40 will join the very old and very young in being at elevated risk of dying from the flu.
The infamous W-Shaped Curve of the 1918 pandemic (solid line) shown against the more typical U-Shaped curve of Seasonal Flu. Simply put, pandemic viruses have, in the past shown a proclivity for young, often healthy, adults.
To date, the H5N1 virus has also shown a preference for those under the age of 40.
3. 30% of Minnesotans will become ill with influenza sometime during the two year pandemic.
Again, based on the 1918 pandemic.
Here many scientists differ, with the SAG (Science Advisory Group) in the UK suggesting that the clinical attack rate could be 50%.
Note, also, that the assumption here is that a pandemic could last for as long as 2 years.
4. The pandemic has the potential to cripple essential health care, public health, public safety and other critical infrastructures.
Supply chains and trade will be disrupted in the face of voluntary and mandated travel restrictions.
Demand for medical services, drugs and other products will surge, leading to dramatic shortages.
Absenteeism attributable to illness, death, the need to care for ill family members, and fear of infection may reach 40% during the peak weeks of an outbreak.
Life, during a severe pandemic, will not go on as usual.
You simply can't remove 40% of the employees from hospitals, police departments, government offices, utility providers, transportation, or manufacturing facilities without seeing a major effect.
The HHS pandemicflu.gov website warns that
- Social Disruption May Be Widespread
- Plan for the possibility that usual services may be disrupted. These could include services provided by hospitals and other health care facilities, banks, stores, restaurants, government offices, and post offices.
- Being Able to Work May Be Difficult or Impossible
- Plan for the possible reduction or loss of income if you are unable to work or your place of employment is closed.
- Schools May Be Closed for an Extended Period of Time
- Transportation Services May Be Disrupted
As supply chains back up, and deliveries fall behind, some companies may be forced to lay off workers simply because they can't get needed materials or supplies, or because demand for their products drop during a pandemic.
The extent of this `ripple effect' is unknown, but likely to be severe.
5. During the pandemic, public health officials will collect data and begin to determine which groups are at highest risk of serious morbidity and mortality from the virus; those data will improve as the pandemic progresses.
The pandemic we start out with may not be the pandemic we end up with. In 1918, the first wave was very mild. In fact, some scientists believe that millions of people were spared a worse fate because they were at least partially immunized by the mild strain that spread during the Spring of 1918.
In any event, as the pandemic travels around the world, waxing and waning in different localities, we'll learn more about how it affects certain demographic groups. That information may be used to prioritize scarce medical resources for those likely to be most severely affected.
Implicit in all of this is the fact that in a world with scarce medical assets, such as we'll see during a severe pandemic, simply getting sick from the virus may not be enough to get you Tamiflu, or a hospital bed.
For many in developed countries, the idea that they may not be able to receive treatment for themselves, or their children, may come as quite a shock.
6. Antiviral medications (antivirals) can be used to treat patients who have influenza or other viral illnesses. They can also be prescribed for short-term post-exposure prophylaxis or for long-term prevention. Antivirals are currently being stockpiled by the federal and state governments, as well as in the private sector.
If the supply is reserved for treatment and a standard regimen is effective, Minnesota would have enough antivirals to treat approximately 21% of Minnesotans during the first wave of the pandemic.
If the dosage or duration is doubled and if Minnesota allocates portions of the supply for prevention, treatment courses will be available for fewer than 10% of Minnesotans.
Here is where the math begins to really hurt. The assumption is that 30% of the population will be sickened, but best case is that there will be enough antiviral medication to treat 21% of the population.
Best case, 1/3rd of the population who gets sick won't receive antivirals. That works out to roughly 500,000 Minnesotans who won't be getting antivirals.
And that assumes that a 10-pill regimen is effective.
This is something we've discussed before (see UK To Double Pandemic Flu Drug Stockpile , Prudence and the Pill, and How Much Tamiflu Is Enough?). It isn't at all clear that a 10-pill regimen will be effective against a novel pandemic virus.
7. Minnesota`s estimated stockpile of personal protective equipment includes 2,445,000 N95 respirators (N95s). Unknown additional numbers of N95s have been stockpiled by health care facilities and other private institutions and individuals.
MDH estimates that Minnesota will need one million N95s per week just for health care worker use.
Assuming none of the stockpile of N95s is distributed to the public, the estimated supply can protect health care workers for less than three weeks.
Since this has been an ongoing subject of discussion on this blog, I'd like to publicly thank the author's of these reports for bringing this subject up.
I've done some back-of-the-envelope calculations in the past, and came up with our nation having somewhere between 2 and 4 weeks supply of masks on hand (see The HCW Debate Continues , OSHA's Proposed Guidance On Respirators And Facemasks ).
The Minnesota estimate is 3 weeks supply. Close enough. But even if we have 4 weeks or even 5 weeks, the point is we run a very real risk of running out sometime during a pandemic wave.
Resupply, when the rest of the world is clamoring for PPE's (and factories may be shut down due to absenteeism) may be impossible.
Do we ask doctors, nurses, EMT's and Paramedics, Medical Techs, LEOs (Law Enforcement Officers), and Firefighters to work without even the barest protection?
And if we ask. . . will they? And if they do work without protection, and become sick (or die), that only increases the burden on society during a crisis, doesn't it?
8. Vaccines that are well-matched to the strain of pandemic virus cannot be manufactured or stockpiled in advance. Vaccines will not become available in any significant amount for 5 – 6 months into World Health Organization (WHO) phase six (increased and sustained transmission in the general population).
Minnesota then will receive approximately 35,000 doses weekly, for a total of 420,000 15-mcg doses rolling in over 12 weeks. Assuming two 15-mcg doses per person will be necessary, about 6% of Minnesotans will have access to two vaccine doses during the first 12 weeks that vaccines are available, and about 24% of Minnesotans will have access over the period of a year.
Young children will require smaller doses of vaccine than adults.
Barring some major advance in the manufacturing of vaccines before a pandemic occurs, the first vaccines probably won't be available until 6 months into a pandemic.
During the first year of the pandemic, only about 24% of the population is likely to receive a vaccine.
Once again, this is something we've discussed here many times. Unless you are a health care worker, first responder, military, critical to the infrastructure, or pregnant . . . don't plan on seeing a vaccine anytime early in a pandemic.
And even then, the prospects are for a 6 month wait. Then it will require 2 shots, a month apart.
As bad as that sounds, for much of the world, a vaccine is little more than a dream. The only road to immunity will be to catch the virus, and survive it.
9. The demand for mechanical ventilators (vents) is expected to increase sharply and drastically exceed supply at times during a pandemic.
Between peaks of pandemic waves, ventilator supply may be more sufficient. Approximately 12,900 flu patients in Minnesota are anticipated to suffer respiratory failure sometime during a severe pandemic and under current standards of care would be candidates for a vent.
Approximately 1200 vents are currently available in acute care institutions in Minnesota; 85% of vents are currently in use.
Talk about cold equations.
Twelve hundred ventilators for roughly 13,000 people. Of course, not everyone will need these ventilators simultaneously. But enough will to make the number available insufficient to cover the demand.
Probably by a lot.
The choice may not be between a 70-year-old man and a 7-year-old child, but rather, between 2 7-year-old's.
And like it or not, someone will have to decide.
Hence the need for this discussion, and for written guidelines for doctors and hospitals to follow. And not just in Minnesota. Every state in the union, and every country in the world will have to face these issues in a pandemic.
Minnesota, to their credit, has started the conversation.
Ignoring these issues, praying that a pandemic `doesn't happen on their watch', is not only irresponsible, it threatens the lives and safety of millions of people.
The time to hold this conversation is now.
