Vaccine choices are complicated

In July, well before a vaccine was available, Angela Gubler lost her husband, 51-year-old Brantley George Gubler, to the H1N1 flu.

His fight for his life was complicated by an underlying medical condition, leukemia.

Today, when a vaccine is available, Angela Gubler wonders about the fairness of a public health policy that does not provide vaccinations to people 25 to 64 with underlying health problems.

"It doesn't seem fair," said the woman, who hopes other families don't have to go through what her family did. "These are the people who need it the most. It seems like they would be a priority."

A dearth of the H1N1 vaccine, especially the one using a dead virus and given through shots, has placed public health officials in a position in which they would rather not be: prioritizing among high-risk groups.

It is particularly uncomfortable when, of the 18 people who have died of swine flu in Clark County, all have been adults and at least 10 with underlying medical conditions were in the 25 to 64 age range.

"Sometimes we have to make difficult decisions about how to do the best with what we have," said Brian Labus, senior epidemiologist with the Southern Nevada Health District.

One of those local decisions has been to rule that of the five priority groups listed by the Centers for Disease Control and Prevention for receiving H1N1 vaccinations, people between ages of 25 and 64 with chronic health conditions aren't as much of a priority as the other four priority groups: pregnant women; caregivers or those who live with children less than 6 months old; health care workers and emergency responders; and those between 6 months and 24 years old.

Influencing the decision were two circumstances:

• Of the 50,000 doses of the vaccine received by the health district, about 17,000 were the injectable vaccine needed by those in priority groups.

• Fewer people than expected took advantage of the inhaled FluMist version of the vaccine that could be safely offered to three priority groups: people who live with or care for children less than 6 months old, children between 2 and 4, and health care and emergency responders with direct patient contact.

Stephanie Bethel, a health district spokeswoman, said if the inhaled version of the vaccine had been more widely used, the injectable vaccine very probably could have been offered to people with medical conditions between the ages of 25 and 64, who are unable to receive FluMist.

"It's all about the numbers," Bethel said Friday.

On Oct. 13, the Review-Journal reported that a dozen or fewer emergency first responders with the Las Vegas Fire Department received the inhaled vaccine on the first day the FluMist was available. A fire official said it probably was because they were concerned about problems that might arise from a vaccination involving a live virus.

Dr. Dale Carrison, head of the emergency department at University Medical Center, told the Review-Journal: "A significant number of health care workers, paramedics and firefighters are concerned about the FluMist. I wish it weren't that way, but it is."

The Centers for Disease Control and Prevention and scientists around the world have said the FluMist is safe. No problems have been reported with either version of the vaccine.

On Friday, Bethel said the health district had administered 23,000 vaccinations, with 11,000 of those injected. She didn't know how many people got shots when they could have received the inhaled vaccine.

Dr. John Middaugh, the district's director of community health, said the remaining 6,000 doses of injectable vaccine have not been offered to those with chronic health conditions in the 25 to 64 age bracket, because "we want to make sure we have enough for pregnant women" and others in priority groups.

The inhaled vaccine is in so little demand that the district is essentially allowing anyone in good condition between 2 and 49 to get it, regardless of whether they are in a priority group.

Though spokesman Tom Skinner said the Centers for Disease Control and Prevention views all priority groups as being equally at risk of complications from H1N1, the agency does recommend that, in case of a vaccine shortage, people 25 to 64 with health conditions be excluded from receiving the vaccine.

But local health officials do not have to follow the recommendation, Skinner said.

"If local health officials are seeing this play out a little bit differently in their jurisdiction ... they're in a better position to make the call whether to further prioritize vaccinations," he said.

Skinner stressed that CDC recommendations "were made by taking the epidemiology of the disease as it affects the nation as a whole."

Labus said data used by local officials to prioritize considers both national and regional statistics. "The data we go by is not just based on deaths. That is the extreme end and doesn't paint the whole picture."

He said health officials make their decisions based largely on in which groups the flu is most prevalent.

"When supplies are scarce, you target the group where there is the most disease. We have to do what we think will prevent the most deaths."

In making tough decisions about who gets vaccinated, Labus said public health officials know the vaccine works best on younger people.

"As people get older, their immune system weakens. There's less chance that the vaccinations will work well."

Labus noted that locally the highest rates of flu involve those 10 to 14, with 400 cases per 100,000 Clark County residents. That's about eight times as many as those in the 40 to 44-year-old age group.

"The highest rate by far is people under 20," he said, citing the district's most recent surveillance report.

In raw numbers, 1,033 cases of H1N1 have been reported among the four age groups under 20 compared to 382 for the nine age groups between the ages of 25 to 64. No statistics are available for the latter age bracket regarding underlying medical conditions.

Dr. John Middaugh, the district's director of community health, said not all cases of H1N1 are reported, since most are mild and people recover without going to the doctor. Based on surveys elsewhere in the United States, he said, public health officials estimate 250,000 Southern Nevadans have had H1N1.

"It's so mild that most people continue doing whatever they do," he said.

Labus said there have been a small number of hospitalizations for the flu, only 159 since August.

The highest number of children, 20, have been hospitalized in the 0 to 4-year-old age bracket, compared to 16 hospitalized in the 45 to 49 age bracket, the highest number for adults.

There have been 53 hospital admissions for those in the four age brackets under age 20. There have been 93 hospital admissions in the nine age groups for people 25 to 64. Again, there are no statistics for the latter age bracket regarding underlying medical conditions.

More flu vaccine comes in early next month, Labus said, and it's possible the health district will start making vaccine available to people age 25 to 64 with medical conditions.

One of the most difficult aspects of public health, he said, is prioritizing when you don't have enough medication for everyone "knowing that there are people who could also benefit from the vaccine."

"You make all these decisions based on numbers, but you also have to ask the question, 'What does this mean in terms of the real world.'"

Contact reporter Paul Harasim at pharasim @reviewjournal.com or 702-387-2908. Contact reporter Mike Blasky at mblasky @reviewjournal.com or 702-383-0283.