How do we choose who gets the flu vaccine in a pandemic – paramedics, prisoners or the public?

Ideally, everyone who needs to be immunised against influenza has access to the flu vaccine. But in a pandemic, initially there will be more people needing protection than there are doses.

So how do authorities decide who to vaccinate first? Is it based on who’s most vulnerable? Who would benefit most? Or are other factors at play?

The next global pandemic

The World Health Organisation has urged nations to plan for future pandemics, which it predicts will happen when a highly contagious and deadly disease emerges and spreads around the world rapidly.

The potential impact of a pandemic is, however, difficult to predict. The last severe pandemic, estimated to have claimed about 50 million lives, was Spanish flu (1918). The severe acute respiratory syndrome or SARS outbreak (2003) and swine flu (H1N1) pandemic (2009) were mild by comparison.

In a pandemic, vaccines may not be available immediately and could take four to six months to produce. Once available, difficult distribution decisions arise.

Assuming Australia can manufacture a stockpile, the issue may not be so much scarcity, but who to protect first. Decisions need to be explained to the public, and some may be controversial or unpopular.

Health workers first

A lot will depend on the severity of the outbreak. A highly infectious and deadly disease that can kill anyone regardless of factors affecting immunity, such as existing ill health, will make medical needs roughly equal. This would be the case in a severe pandemic. An outbreak like H1N1, where some people are less likely to recover if infected, can be called a mild pandemic.

In either case, national plans stress the importance of protecting health workers first, including doctors, nurses, paramedics and other front-line medical personnel. This would limit absenteeism, prevent health workers from transmitting disease and ensure treatment was available to those in need.

Although several ethical principles support prioritising health workers, there may be conflict.

The ethical principle of utilitarianism would have us protect people who promote the greatest good, in this case treating the most patients. So, if we follow this principle, it may make sense to prioritise those who are socially valuable, like doctors.

However, a principle of fairness and non-discrimination would constrain us from giving the flu vaccine to everyone who was perceived to be socially valuable, like poets, philosophers or footballers. So, we’d still need to define who was socially valuable.

A more general egalitarian principle might be that prioritising health workers increases the chances that everyone, including the worst off, receives treatment.

Whichever ethical principle you apply, the community would likely support priority protection for those who risk their lives for others, such as front-line health workers.

Vulnerable groups next, but not always

In a mild pandemic, compromised immunity makes some people more vulnerable. Children, for example, were more likely to be hospitalised during the H1N1 pandemic and are likely to be vulnerable in terms of infection, complication and mortality in future pandemics.

So, it is likely to be uncontroversial to prioritise people facing a greater risk of dying from infection, including the very young, pregnant women, those with existing ill health and the elderly.

However, we still need to weigh up vulnerabilities and the benefits or fairness of possible vaccine allocations.

For example, would age-based rationing be fair? According to the fair innings argument, a child, who is yet to enjoy a “fair share of life”, would have a stronger claim to a scarce and vital resource than an elderly person. This position does not, however, specify what would be a fair share of life and thus what would be a cut-off point for prioritisation.

Alternatively, utilitarianism and promoting the greatest good might guide us to prioritise children because of life years gained, or protecting those needed for the future (maximising good outcomes). This would mean prioritising youth ahead of, for example, the terminally ill.

Although the community would likely support prioritising children, they may be less keen on measures that deny or delay lifesaving resources for the medically vulnerable. And terminally ill patients and those over a certain age may support prioritising the young.

The best general principle may be that when there is no relevant difference between two patients, each should have an equal chance of protection. But then we need to decide whether age or life-years gained are relevant differences.

When there is no difference, a vaccine lottery may be fairest, where everyone has the same chance of receiving help.

Poor and disadvantaged need protection

Overcrowded living and poor sanitation promote the spread of disease. And contagion in a disadvantaged, or impoverished community, can spread rapidly. So a pandemic may disproportionately impact the less well off.

So, the greater likelihood of becoming infected and suffering economic and social losses should entitle disadvantaged groups to special protection. This is because of the wider social benefits of interrupting disease spread, limiting vulnerability to harm and preventing stigmatisation of groups who, through no fault of their own, spread disease.

Due to overcrowding, lack of infrastructure and lack of health and education services, Australia’s Indigenous population is especially vulnerable to infectious diseases. So part of a just pandemic response must include limiting this burden.

Prisoners and obese people at risk too

Not all vulnerable groups are equal in the eyes of the public. So prioritising vaccination for some groups – like prisoners or people who are severely obese as happened in several Canadian jurisdictions in 2009 – can be unpopular if the public blames these vulnerabilities on poor life choices.

With prisoners, close living and regular person-to-person contact means a highly contagious disease could spread quickly. Infected people returning to the community could pose a health risk to others. In Canada, public disapproval caused some decision makers to retreat from the proposal. If adopted, authorities would likely secure public support by communicating the benefits to community health.

Obese people have a greater risk of becoming sick and dying from infectious diseases. So, protecting this group is consistent with a principle of non-discrimination and prioritising the vulnerable, regardless of any possible perception that vulnerability is the fault of the individual.

Tough decisions will test us all

Just because allocating vaccines to particular groups can be unpopular is no reason to stop authorities from doing so.

Whether unpopular measures turn into some form of social unrest or dissent will likely turn on how effectively authorities communicate their ethical decision-making to the public and secure support before and during the pandemic.

In some cases of vulnerability, there may not be the requisite political will to make just, yet unpopular, decisions. The next pandemic may not only claim many lives it will also test our character and that of our institutions.