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Françoise Baylis

How much vaccine to order and who gets it? Add to ...

In mid-July, the World Health Organization reported that the production of vaccine for the H1N1 influenza pandemic was facing challenges. In response, the international media began to comment on what could/should happen if there was not enough vaccine for everyone. Meanwhile, governments around the world announced that they were developing rules and processes for prioritizing access to the vaccine.

In Canada, the federal government has said unequivocally that "the current plan is to produce sufficient quantities of vaccine for Canadians who need or want to receive it."

The government has a standing contract with drug manufacturer GlaxoSmithKline to develop, test and produce vaccine for the Canadian population, currently estimated at 34 million. As effective vaccination probably will require two doses, it can order up to 68 million doses. But will it? Should it?

Some will argue that it would be fiscally prudent to order less vaccine. Available data suggest that not everyone will need it; experience suggests that not everyone will want it (regardless of whether they need it). By ordering fewer than 68 million doses, the government could save a lot of money that could be used effectively for other aspects of the national pandemic-readiness plan.

While I understand this perspective, it is wrong-headed. It fails to take into account our global obligations. Canada currently does not meet its foreign-aid commitment. We have before us a unique opportunity to correct this by ordering the maximum amount of vaccine and planning to donate any excess to poor countries in need of assistance.

The government probably does not really intend to make the vaccine available irrespective of need. While it has said there will be sufficient vaccine for those who need or want to receive it, it has also said that vaccine "will be available for all Canadians who need and want to receive it."

It is important to notice the difference between the disjunction "or" and the conjunction "and" in the two statements. In general terms, the group of people who "need or want" is potentially larger than the group of people who "need and want." In specific terms having to do with access to vaccine, the first category (need or want) includes all Canadians who want the vaccine, but may not actually need it. The second category (need and want) is more restricted. It includes only those who need the vaccine, as determined by health professionals, and who then consent to receive it.

At this point, we do not actually know what our government is promising us. Hopefully this will be clear when the Canadian guidelines governing priority access to the vaccine are released, probably next month.

The guidelines are necessary because even if there is sufficient vaccine for all Canadians (however this is understood), there will be insufficient vaccine for everyone to be treated immediately. The government recognizes that there will be a problem with the distribution of vaccine as the delivery will have to be staged over time.

This raises an important ethical question about who should have first access to the vaccine. Answers to this question have suggested priority for at least two broad categories of people: health-care workers and individuals who are critical for the country to function well.

In the abstract, these priority groups seem to be uncontroversial, but will this be so in practice? For example, how broadly should we understand these groupings? Should the group of health-care workers, which includes everyone from physicians in hospitals to physiotherapists in private clinics, also include clerical and cleaning staff in these and other sites where health-care services are delivered? Are they not also on the front lines with the most frequent exposure and the most danger of passing on the virus?

Assuming this first category includes paramedics, should it also include other emergency-service providers, such as firefighters, police and rescue teams? Or do these groups fall under the other priority category, namely people who are key to the country's infrastructure? In some countries, this group is understood to include politicians and heads of major corporations. Should this be so in Canada?

From another perspective, what should the guidelines say with respect to priority access for the most-at-risk groups, such as children with asthma, pregnant women and aboriginal people on reserves?

Finally, as further clinical and epidemiological information becomes available, along with information about the impact of the virus on the health-care system and society as a whole, how should the guidelines be amended? Specifically, might there be a point at which the government should mandate vaccine for those most at risk of contracting and transmitting the virus?

These are challenging questions for challenging times. When all is said and done, and the pandemic is over, I hope that we, as Canadians, will be able to stand with heads held high, knowing we have "done right" by our citizens and "done good" by the world.

Françoise Baylis is a professor and Canada Research Chair in Bioethics and Philosophy at Dalhousie University.

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