Pandemic Influenza Vaccine Prioritization:Rationale and Process

Pandemic Influenza Vaccine: Doses Administered and Safety Training Conference

Tom Shimabukuro, MD, MPH, MBAImmunization Services Division

Centers for Disease Control and Prevention (CDC)

August 21, 2008

Goal

• The goal of the pandemic influenza vaccination program is to vaccinate all persons in the U.S. who choose to be vaccinated

• However:– Vaccine supply will not be available all at once– Decisions on who will be vaccinated first will have to be made– Overarching objectives are to reduce the impact on health

and minimize disruption to society and the economy

2005 ACIP/NVAC recs

http://www.pandemicflu.gov/vaccine/allocationguidance.pdf

Process

• Federal interagency working group meetings/discussions (co-led by DHS and HHS)

• Historical analysis of previous pandemics• Public engagement and stakeholder meetings• Formal decision analysis process

Specific objectives

• Protecting those who are essential to the pandemic response and provide care for persons who are ill

• Protecting those who maintain essential community services

• Protecting children• Protecting workers who are at greater risk of

infection due to their job

General principles and guidance

• Takes into account “pandemic severity index” (PSI)

• Pro rata allocation• Recommend state and local governments

follow national recommendations• Epidemiology of the pandemic will determine

if modification of recs is necessary• Guidance will be reassessed periodically

Framework

• Categories– Homeland and national security– Health care and community support services– Critical infrastructure– General population

• Target groups: specific occupations / occupational groups

• Tiers (1-5)

The following slides are courtesy of Ben Schwartz, MD

HHS/NVPO

Vetting the draft guidance with the public Vetting the draft guidance with the public and stakeholdersand stakeholders

• Presentations to ACIP and NVAC

• Public engagement meetings

– Milwaukee, WI

– Hendersonville, NC

• Stakeholders meeting

– Washington, DC

• Web dialogue

• Request for comments posted in the Federal Register and at www.pandemicflu.gov

Outcomes of vetting process with the Outcomes of vetting process with the public and stakeholderspublic and stakeholders

• From public engagement and stakeholders meetings, and web dialogue

– Votes of participants

• On general agreement with goals and guidance

• On suggested potential changes

– 7-point scale from strongly agree to strongly disagree

• From request for comments in the Federal Register and at www.pandemicflu.gov

– 124 written suggestions from organizations and individuals

Overall agreement with the guidance by Overall agreement with the guidance by the public and stakeholdersthe public and stakeholders

Polling results

(% Agree to Strongly Agree)

Milw Hend Web Stake

Overall agreement with goals of the guidance

93% 74%

Agree with targeting children before older adults

82% 91% 76% 83%

General agreement with draft guidance

58% 79% 80% 83%

Changes considered at public & Changes considered at public & stakeholders meetings: stakeholders meetings:

General PopulationGeneral Population• Supported

– Prioritize healthy adults before ill or elderly

– Move very elderly or incapacitated to Tier 5

– Prioritize children 3-18 before infants and toddlers

• Neutral

– Prioritize parent or healthy head of household (32.5 M households with children <18 yrs old)

• Opposed

– Prioritize persons in communal settings – prisoners, nursing home residents, homeless

Suggestions from written comments: Suggestions from written comments: General PopulationGeneral Population

• Describe priorities if mortality during the pandemic were highest in young adults (“W” shaped curve as in 1918)

• Target healthy adults before ill and elderly

• Vaccinate parents before children (to care for them)

• Sub-prioritize among healthy adults

– “Farmer before fry cook”

– Employed before unemployed

– “Gifted” persons first

Should family members of HCWs & emergency Should family members of HCWs & emergency services workers be targeted?services workers be targeted?

• Concerns with targeting household or family members

– Adds substantially to size of targeted population

– Unclear whether truly needed to avoid absenteeism

– Other protective measures may be used

– Raises equity concerns

Group Number

Additional persons

Household (x1.6) Family (x2.2)

Healthcare 7.4 M 11.8 M 16.3 M

Emergency serv. 2.0 M 3.2 M 4.4 M

Suggestions from vetting process: Suggestions from vetting process: Government WorkersGovernment Workers

• Every meeting strongly agreed with moving politicians to their Gen. Pop. group (i.e., T4 or 5)

– Voting results (Agree/disagree): Milw: 77%/15%, Hend: 79%/16%, Web: 85%/8%, Stakeholders: 63%/33%

• Several comments suggested the same

– “Politicians, those cheerleading panderers who are useless in an emergency, should be stuck at the bottom with the rest of us.”

The findings and conclusions in this presentation have not been formally disseminated by CDC and should not be construed to represent any agency determination or policy.