Who'll get flu vaccine poses dilemma for doctors

As news of the national flu-shot shortage trickled down to family practitioners, Dr. Stanley Garlick came face to face with a stark reality: Not all of his high-risk patients were going to be vaccinated.

So Garlick and four colleagues at Family Medicine of Port Angeles went to work, choosing which patients would get a flu shot.

Should a 70-year-old with healthy — but old — lungs trump a 45-year-old with asthma? Should a pregnant woman be vaccinated before a health-care worker? The federal Centers for Disease Control says they all are at high risk for complications from the flu and should be vaccinated.

But the agency skipped a step, Garlick said. "They don't tell us what to do in the event of a scarce resource, like we have now, and we have to choose."

Primary-care doctors and county health officials have been plunged into sobering decision-making over the past few weeks as they wait for their portion of 160,000 vaccine doses the CDC says the state will receive over the next two months.

Washington, like other states, can expect only a fraction of the vaccine necessary for all high-risk patients, health officials say.

Clinics could give shots on a first-come, first-served basis. But that could leave the most vulnerable patients unprotected. Or they could choose among high-risk patients to allocate scarce doses. But how?

In Port Angeles, Garlick and his colleagues used the clinic's electronic patient-records system to pick their top-priority patients: those over 65 with chronic lung disease, heart failure or asthma.

That means skipping patients over 65 with no chronic lung disease, although they're also on the CDC's high-risk list.

Garlick, who heads the Washington Academy of Family Practitioners, says he's grateful the clinic could base the decisions on medical reasons, rather than social or ethical considerations. He'd be troubled, he said, "if it comes to the point where I have to make a decision between two frail elderly people with asthma."

To help sort out such flu-shot ethics, the CDC has established a panel of experts in philosophy and medicine. "Everybody is freaking out because of the shortage," said John Arras, a professor at the University of Virginia and one of the CDC experts.

But panel members quickly realized that even comparing the vulnerability of different patient groups was going to be difficult. Public-health experts, for example, can't say whether a healthy 75-year-old would do as well without a flu shot as a healthy 65-year-old.

"There are a lot of important gaps in the scientific knowledge we have," Arras said.

The panelists began to chew on other questions. Should first responders, such as police and firefighters, be on the vaccination priority list? Should elderly people be ahead of children? Can providers differentiate between patients with "a little" asthma and "a lot"?

Even the choice by Public Health — Seattle & King County to put long-term-care facilities at the top of the vaccine list is controversial: Should an 80-year-old with severe dementia get vaccine before a 75-year-old living in the community?

Some people were outraged when members of Congress got flu shots last month, just after the shortage was announced. And although high-risk patients in institutions are particularly vulnerable, some were irked to hear that prisoners in many states, including Washington, got flu shots.

The Northwest Kidney Center issued its own plea and was flooded with vaccine. Kidney patients are at high risk for flu complications. But so are many others with debilitating diseases who haven't gone public with their need.

"I have a list of the sickest of my HIV patients — those whom I feel may die if they got the flu," said Dr. Rob Killian, a Seattle family practitioner who treats many HIV/AIDS patients. So far, he has gotten no vaccine.

A week after the shortage was announced, the "flu crew" at The Everett Clinic knew it had to make some choices, said Dr. Yuan-Po Tu, who heads the flu-shot program for the 225-doctor clinic system.

"We sat down in a dark and dingy room in the basement and said, 'How are we going to do this?' If we say 65 and over, we'll get the 65-year-old marathon runner running to the head of the line."

Programmers sorted the clinic's records by age, specific disease codes, even types of medications. After about 12 hours, the computer spit out lists of patients, grouped by the number of risk factors and the number of clinic visits in the last 12 months.

"All of a sudden, that's a very useful list," Tu said.

From there, it will be up to each doctor. "We figured the physicians would know who are the sickest of the sick," Tu said. "The intention was to give them enough information to make a logical decision."

The flu-shot shortage, some ethics experts say, has pulled back the curtain to reveal some uncomfortable realities.

"Americans like to pretend to ourselves that hard choices never have to be made in health care, that everybody can get everything they need. But it's never been true," said Tom Murray, president of The Hastings Center, an independent bioethics institute in New York state.

"Now we're faced with a very uncomfortable question: how to allocate a tragically scarce resource."

There's no system of allocation that all regard as fair, Murray said.

"Every principle we could invoke to justify a particular distribution system will have competing principles that are every bit as sound," he said.

For example: Some would give priority to the sickest people. But an equally compelling system might give first priority to the group of people "who would have the most to gain in years of life if we prevented them from dying from the flu," Murray said.

That would place babies before older people, and might rank sick people according to their life expectancy. Or there's the "strict egalitarian" principle, which has led to flu-shot lotteries around the country.

As for Garlick, he and his colleagues were still wrestling with their priority list Friday. Pregnant women, they decided, would be tier three, between patients under 65 with serious asthma, and those whose lung problems are less severe.

A few weeks ago, they received a bit of vaccine and began calling first-tier patients. Some rushed to the clinic within the hour.

"There were a number of people pretty grateful to get the phone call," Garlick said.

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com