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Ethics in Public Health and Health Policy pp 175–191Cite as

Distributing Vaccine Fairly During Influenza Pandemics – A Case Study from Berlin

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Part of the book series: Public Health Ethics Analysis ((PHES,volume 1))

Abstract

At the beginning of an influenza pandemic, scarcity of vaccine is unavoidable. This raises questions about fair distribution and prioritisation of particular groups. During the H1N1 pandemic in 2009 and 2010, the prioritisation of patient groups for the vaccination against influenza raised a series of ethical concerns. These related to the problems of uncertainty about outcomes at the onset of a pandemic, the difficulty of defining a clear goal of vaccination campaigns, and the practical problems brought about by the intense challenges that health care systems are faced with in a pandemic. In this paper, Berlin is used as a case study to show that at least some of these problems are related to a failure to integrate pandemic policy between different organisational levels. This failure proved problematic in two instances, first where policies overlapped and contradicted each other, and second where the minutiae of vaccine provision created problems for more abstract assumptions about fair allocation of scarce resources. It will be shown that some aspects of these problems may be remediable by applying principles of procedural justice. However, in order to properly integrate the micro and the macro scale, bioethicists will have to work alongside those with clinical expertise, and deploy models of thinking both from conventional doctor-patient bioethics and more population-level public health ethics.

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Notes

  1. 1.

    N.B. This is not to say that we should accept current rates of morbidity and mortality due to ­seasonal influenza as given and unavoidable. However, a discussion of appropriate responses to seasonal influenza goes beyond the scope of this article.

  2. 2.

    See http://www.rki.de

  3. 3.

    In particular, the author would like to thank Dr. med. Marlen Suckau.

  4. 4.

    At this point, however, it was still assumed that two doses of vaccine would be needed per person, which turned out to be unnecessary, meaning that in practice there was actually more vaccine available.

  5. 5.

    Data provided by SenGUV Berlin.

  6. 6.

    The vaccination may in fact not have been entirely risk-free, as some studies confirmed a higher incidence of narcolepsy in Finnish patients who had received the pandemic influenza vaccine in 2009 (Montastruc et al. 2011). However, this information was not available at the outset of the immunisation campaign and can thus not account for the unwillingness of the German public to receive the pandemic flu vaccine.

  7. 7.

    See U. Buchholz et al., Nationaler Pandemieplan Teil 3, available at http://www.gesundheitsamt.de/alle/seuche/infekt/viru/influ/npp/npp_t2/06.2.3.htm; Bundesministerium für Gesundheit, Verordnung über die Leistungspflicht der gesetzlichen Krankenversicherung bei Schutzimpfungen gegen die neue Influenza H1N1 (out of print); SenGUV, Rahmenplan Influenzapandemie, available at http://www.gpk.de/downloadp/Influenzapandemieplan_200804_Berlin.pdf

  8. 8.

    See discussion on the next page.

  9. 9.

    It should be noted, however, that the prediction of high-risk cases was overall quite successful. The RKI noted that of the 237 deaths due to H1N1 that occurred in Germany between 2009 and 2010, 86 % displayed one or more risk indicators (Robert-Koch 2010).

  10. 10.

    The literature on fair distribution of scarce resources is far too extensive to be discussed in this context. For the purposes of this paper, it shall therefore suffice to acknowledge that so far competing principles of distributive justice have not been successfully reconciled.

References

  • Arras, J.D. 2005. Rationing vaccine during an avian influenza pandemic: Why it won’t be easy. Yale Journal of Biology and Medicine 78: 283–296.

    Google Scholar 

  • Barry, J. 2009. The great influenza: The story of the deadliest pandemic in history. New York: Penguin.

    Google Scholar 

  • Battin, M.P., L.P. Francis, J.A. Jacobson, and C.B. Smith. 2009. The patient as victim and vector: Ethics and infectious disease. New York: Oxford University Press.

    Book  Google Scholar 

  • Brock, D.W. 1987. Truth or consequences: The role of philosophers in policy-making. Ethics 97(4): 786–791.

    Article  Google Scholar 

  • Bryson, C., and B. New. 2000. Health care rationing – A cut too far? In British social attitudes: The 17th report, ed. R. Jowell, J. Curtice, A. Park, et al., 42 ff. London: Sage.

    Google Scholar 

  • Buda, S., H. Wilking, B. Schweiger, U. Buchholz, K. Köpke, and W. Haas. 2010. Influenza-­Wochenbericht KW 9, vol. 9. Berlin: Robert-Koch-Institut.

    Google Scholar 

  • Joint Committee on Vaccination and Immunisation. 2010. Protocol for the work of the JCVI and a Code of Practice for JCVI members and members of its Sub-committees. Available at http://www.dh.gov.uk/health/about-us/public-bodies-2/advisory-bodies/jcvi/.

  • Coleman, C., and A. Reis. 2007. Ethical considerations in developing a public health response to pandemic influenza. Geneva: World Health Organization.

    Google Scholar 

  • Cribb, A. 2010. Translational ethics? The theory–practice gap in medical ethics. Journal of Medical Ethics 36(4): 207–210. doi:10.1136/jme.2009.029785.

    Article  Google Scholar 

  • Daniels, N. 2009. Just health: Meeting health needs fairly. Cambridge: Cambridge University Press.

    Google Scholar 

  • Daniels, N., and J. Sabin. 1997. Limits to health care: Fair procedures, democratic deliberation, and the legitimacy problem for insurers. Philosophy & Public Affairs 26(4): 303–350.

    Article  Google Scholar 

  • Goldman, A. 2001. Experts: Which ones should you trust? Philosophy and Phenomenological Research LXIII(1): 85–110.

    Article  Google Scholar 

  • Hine, D. 2010. The 2009 Influenza Pandemic – an independent review of the UK response to the 2009 influenza pandemic. Trans. P.F.R.R. Team. Cabinet Office.

    Google Scholar 

  • Kass, N.E., J. Otto, D. O’Brien, and M. Minson. 2008. Ethics and severe pandemic influenza: Maintaining essential functions through a fair and considered response [Review]. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 6(3): 227–236. doi: 10.1089/bsp. 2008.0020.

    Article  Google Scholar 

  • Kaufmann, S. 2007. The new plagues: Pandemics and poverty in a globalized world. Trans. C. M, The Sustainability Project. Frankfurt a.M.: Haus Publishing.

    Google Scholar 

  • Kotalik, J. 2010. Examining the principle of subsidiarity for bioethics. Kennedy Institute of Ethics Journal 20(4): 371–390.

    Google Scholar 

  • Krause, G., A. Gilsdorf, J. Becker, K. Bradt, C. Dreweck, B. Gartner, et al. 2010. First exchange of experiences concerning the H1N1 pandemic in Germany 2009/2010: Report on a workshop held March 22–23, 2010, in Berlin. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 53(5): 510–519. doi:10.1007/s00103-010-1074-3.

    Article  Google Scholar 

  • Littmann, J. 2010. Ethische Implikationen bei der Bekämpfung von Infektionskrankheiten – das Beispiel der Impfpriorisierung in Berlin während der H1N1-Pandemie. Berlin: Berlin School of Public Health.

    Google Scholar 

  • Löwer, J. 2010. Pandemieimpfstoffe: Überlegungen zum Design im Vorfeld der Influenzapandemie. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 53: 1238–1241. doi: DOI 10.1007/s00103-010-1159-z.

    Article  Google Scholar 

  • Malm, H., T. May, L.P. Francis, S.B. Omer, D.A. Salmon, and R. Hood. 2008. Ethics, pandemics, and the duty to treat. The American Journal of Bioethics: AJOB 8(8): 4–19. doi:10.1080/15265160802317974.

    Article  Google Scholar 

  • Marcic, A., J. Dreesman, B. Liebl, C. Schlaich, M. Suckau, W. Sydow, et al. 2010. H1N1 pandemic. Measures and experiences on the state level. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 53(12): 1257–1266. doi:10.1007/s00103-010-1164-2.

    Article  Google Scholar 

  • Martin, T. 2010. Pandemic as a communication challenge for the governmental authorities – an overview of the governmental public relations measures for the new influenza (“swine flu”). Basic communication features. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 53(12): 1304–1307. doi:10.1007/s00103-010-1167-z.

    Article  Google Scholar 

  • McDougall, C.W. 2010. A survey of ethical principles and guidance within selected pandemic plans, 2nd ed. Montréal: National Collaborating Centre for Healthy Public Policy.

    Google Scholar 

  • Medlock, J., and P. Gavalli. 2009. Optimizing influenza vaccine distribution. Science 25: 1705–1708.

    Article  Google Scholar 

  • Montastruc, J.-L., G. Durrieu, and O. Rascol. 2011. Pandemrix°, (H1N1)v influenza and reported cases of narcolepsy. Vaccine 29(11): 2010–2010, doi:10.1016/j.vaccine.2010.12.092

    Google Scholar 

  • Nationaler Pandemieplan Teil I: Überblick über die Maßnahmen. 2007. Berlin: Robert-Koch-Institut.

    Google Scholar 

  • Parfit, D. 1997. Equality and priority. Ratio 10(3): 202–221.

    Google Scholar 

  • Robert-Koch Institut. 2009. Epidemiologisches Bulletin 41. Available at https://www.rki.de/DE/Content/Infekt/EpidBull/epid_bull_form.html.

    Google Scholar 

  • Robert-Koch Institut. 2010. Epidemiologisches Bulletin 31. Available at https://www.rki.de/DE/Content/Infekt/EpidBull/epid_bull_form.html.

  • Schaade, L., A. Reuß, W. Haas, and G. Krause. 2010. Pandemieplanung. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 53(12): 1277–1282. doi:10.1007/s00103-010-1162-4.

    Article  Google Scholar 

  • Seitz, R., and G. Krause. 2010. Pandemien: Was haben wir aus der H1N1-Influenza gelernt? Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 53(12): 1221–1222. doi:10.1007/s00103-010-1169-x.

    Article  Google Scholar 

  • Selgelid, M.J. 2009. Pandethics. Public health 123(3): 255–259. doi:10.1016/j.puhe.2008.12.005.

    Article  Google Scholar 

  • Straetemans, M., U. Buchholz, S. Reiter, W. Haas, and G. Krause. 2007. Prioritisation strategies for pandemic influenza vaccine in 27 countries of the EU and the global health security action group: A review. BMC Public Health 7(236).

    Google Scholar 

  • Transcript of Virtual Press Conference with Gregory Hartl Dr. Marie-Paule Kieny. 2009. Geneva: World Health Organization.

    Google Scholar 

  • Upshur, R., K. Faith, J. Gibson, A. Thompson, K. Wilson, and P.A. Singer. 2005. Stand on Guard for Thee: Ethical considerations in preparedness planning for pandemic influenza. Trans. J. C. f. Bioethics). Toronto: University of Toronto.

    Google Scholar 

  • Vaccination Guideline for Pandemic Influenza in Japan. 2007. ed. P. I. E. A. Committee. Japanese Ministry of Health, Labour and Welfare.

    Google Scholar 

  • van Delden, J.J., R. Ashcroft, A. Dawson, G. Marckmann, R. Upshur, and M.F. Verweij. 2008. The ethics of mandatory vaccination against influenza for health care workers. Vaccine 26(44): 5562–5566. doi:10.1016/j.vaccine.2008.08.002.

    Article  Google Scholar 

  • Vynnycky, E., and R.G. White. 2010. An introduction to infectious disease modelling. Oxford: OUP.

    Google Scholar 

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Authors and Affiliations

  1. Division of Medicine, University College London, London, UK

    Jasper Littmann

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  1. Jasper Littmann
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Correspondence to Jasper Littmann .

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Editors and Affiliations

  1. Carl-Neuberg-Str. 1, Hannover, 30625, Niedersachsen, Germany

    Daniel Strech

  2. Carl-Neuberg-Str. 1, Hannover, 30625, Niedersachsen, Germany

    Irene Hirschberg

  3. Ludwig-Maximlians-University Munchen, Lessingstr 2, Munchen, 80336, Germany

    Georg Marckmann

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Littmann, J. (2013). Distributing Vaccine Fairly During Influenza Pandemics – A Case Study from Berlin. In: Strech, D., Hirschberg, I., Marckmann, G. (eds) Ethics in Public Health and Health Policy. Public Health Ethics Analysis, vol 1. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-6374-6_12

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