Health Department to Rank Populations in Line to Get Bird Flu Vaccine
By Jenny Lim
Stanford, CA March 2- Hollywood has its A list. Forbes has its top 500. Now the California Department of Health Services is coming up with a listing, too - and you might be interested in where you rank on it, should a bird flu pandemic hit the Golden State.
The state's health department is devising a ranked list of target groups in California that will be the first to receive vaccination during a pandemic influenza. Since vaccine production will be limited in the initial phase of a pandemic outbreak, CDHS is creating the rankings to facilitate the rationing the supply.
To formulate the ranking, the state health department will survey at least 200 players in the pandemic response, including representatives from the medical, public health, law enforcement, emergency management and business fields.
The DAST (Decision Analysis Scoring Tool) survey asks respondents to rank seven criteria that would qualify a person to receive the vaccine during a pandemic outbreak.
Four of the criteria are health-related: persons' risk of developing severe health complications from infection; their risk of transmitting the disease; their risk of becoming infected through contact with potentially infectious individuals; and the likely effectiveness of the vaccine to prevent their illness or death.
The other three criteria deal with a person's role during a pandemic: provides direct response service; provides support response service; or provides essential community role.
The survey identifies 62 target groups - such as pregnant women or medical care practitioners - that meet one or more of the criteria. In addition to ranking the importance of the seven criteria, the DAST survey respondents must indicate which target populations fit which of the criteria. The survey results should produce a vaccine prioritization list, with target populations demonstrating the highest-ranked vaccination criteria getting placed at the top of the list.
For example, if a person's role as a direct responder to the pandemic is rated the most important criteria for receiving the vaccine and healthcare workers are ranked most likely to fit that criteria, then they would be placed at the head of the prioritization list.
The 62 target populations fall into five general categories. One category includes persons with medical conditions that put them at risk, such as infants and toddlers or any person suffering from a chronic illness.
A second category is comprised of healthcare professionals, from hospital and emergency care workers to public health department employees. Another category includes government and public safety professionals, like those serving in public office or in police and fire departments.
Professionals in non-health commercial industries, such as social service agencies and postal service companies, make up a fourth category. Healthy persons who are not employed in any of the industries or occupations identified in the other categories form the final target population.
The health department anticipates administering the DAST survey in April or May and completing it by July or August, said Trevor Shoemaker, a CDHS research scientist who helped develop the prioritization plan. Shoemaker estimated it would cost $100,000 to conduct the survey at four to six regional meetings across the state.
It is important to have an evidence-based process for rationing any scarce resource like a pandemic flu vaccine, said Lisa Goldberg, research specialist at the University of California-Berkeley's Center for Infectious Disease Preparedness. The health department contracted the Center to develop the priority group list. Goldberg is coordinator of the Center's Pandemic Influenza Project, the program to spearhead the prioritization plan.
According to the California pandemic preparedness plan, the federal Centers for Disease Control predicts it will take four to six months to produce a vaccine to combat the H5N1 strain of influenza that triggers a pandemic. Once vaccine manufacturing gets underway, CDC says 3 to 5 million doses of the vaccine could be supplied to the total U.S. population each week.
CDC will distribute the vaccine according to states' populations as a percentage of the U.S. population, as well as the size of states' target group populations, Goldberg said.
Based on those calculations, Goldberg said the vaccine supply for California's 36.9 million residents would be 480,000 doses per week during the initial phase of a pandemic. "It would take 77 weeks to obtain enough vaccine for all of California's population," she said.
Vaccine production would most likely ramp up as the pandemic continues, but during the first wave of outbreaks it will be a "huge challenge" for the government to ration the vaccine, Goldberg said.
The DAST target population groups were selected from the U.S. Census Bureau's North American Industry Classification System, which catalogs different workforce industries and occupations in America. Shoemaker and Goldberg said the survey's seven vaccination criteria were based on broad recommendations by CDC and the U.S. Department of Health and Human Services.
H.H.S. released the national Pandemic Influenza Plan on Nov. 2, 2005. The federal plan directs state and local health departments to come up with more specific definitions of populations like "healthcare workers" or "groups at high risk of influenza complications."
The survey's vaccination criteria and target groups were approved by the CDHS Joint Advisory Committee on Pandemic Influenza Vaccine and Antiviral Prioritization Strategies. The committee includes representatives from 13 organizations, including the California Medical Association, Northern California Kaiser and the California Conference of Local Health Officers. Eleven the committee's 17 members completed a pilot test of the survey in June 2005.
Goldberg said the 40-question survey may be revised to include "slightly fewer" questions, but she could not specify a final count. The pilot DAST survey identified 69 target groups, but the test run of the questionnaire proved several categories could be grouped together, Shoemaker said. As a result, the final DAST will identify and rank 62 target populations.
The health department officially started collaborating with UC Berkeley's Center for Infectious Disease Preparedness on the prioritization plan in the summer of 2005, though the department had been working with CIDP on the project since 2004, Shoemaker said.
He and Goldberg said the regional meetings to conduct the survey will include a presentation on the DAST and how it developed. The survey workshops will set aside an hour for respondents to complete the 62-page questionnaire.
Goldberg said while it's important to get the list completed before a pandemic occurs, "it's also important that it be done systematically and can be justified." The survey should provide transparent reasons for the rankings to the public, she said.
If California can pin down this prioritization list before an outbreak, "the less confusion and chaos and problems we'll have," Goldberg said.
Contact Jenny Lim at jennylim@stanford.edu
