The scientists fear a chill may be descending on their field, particularly related to key studies on how viruses that normally infect birds and pigs evolve to infect people. In the short term, it may also become harder to publish any work looking at this question if it relates to the dangerous H5N1 avian flu.

The panel of biosecurity experts that advised the government on its decision may also recommend that journals agree to a short-term moratorium on publishing research about what makes H5N1 viruses more transmissible.

“We know that there is a lot of research occurring in this specific area and with every paper, the situation changes,” said Paul Keim, an anthrax expert who is acting chair of the National Science Advisory Board on Biosecurity. “Setting policy in such an environment is difficult and it is hard enough already.”

It’s not yet clear that the biosecurity board will ask for the moratorium. Nor is it certain how journals would react to that request if it comes.

But the two journals involved in the controversy, Science and Nature, have both indicated they are at least willing to discuss a compromise, so long as a system can be devised that would give scientists and public health authorities access to the withheld information on a need-to-know basis, CBS News reported.

If the studies are published in abbreviated form, it may be a first for the life sciences. Scientists who work in nuclear physics are often unable to publish their work, for security reasons. But in most areas of science, the paradigm is that if researchers find something or achieve a goal, they must publish how they did the work so that others can try to replicate it and build on it, deterring fraud and ensuring advancement.

Scientists looking for answers that would help the world better assess the risk the H5N1 virus poses are particularly worried that the biosecurity concerns might stop them from seeking answers to questions that might tell the world how likely – or unlikely – bird flu is to adapt to human-to-human spread.

“That is an absolutely key question,” says flu researcher Dr. Malik Peiris, chair of the department of microbiology at the University of Hong Kong. He said restricting this research “would be a huge loss.”

Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases (which funded the two disputed studies), says he’ll fight to keep the biosecurity concerns from restricting science.

“I will do everything in my power to ensure that it doesn’t inhibit the research,” Fauci said. “The research we’re interested in is the legitimate research done by scientists who have a legitimate interest.”

But Dr. D.A. Henderson, who led the campaign that eradicated smallpox, thinks flu researchers have good reason to worry. “I can see where they’d be concerned about it,” Henderson said. “I think we ought to be concerned about working with H5N1.”

Henderson, a distinguished scholar at the Center for Biosecurity at the University of Pittsburgh Medical Center, believes the studies that drew the biosecurity board’s concern should not have been done, that the risks of the work outweighed any potential benefit.

Some researchers agree with Henderson.

“This research should not have been done,” Dr. Richard H. Ebright, a chemistry professor and bioweapons expert at Rutgers University, told the New York Times. “It will inevitably escape, and within a decade.”

But some flu researchers disagree and say these studies had to be done to help humans one day.

“If someone makes a virus, specifically only for making it more pathogenic without learning any biology and in such a way that cannot occur in nature but can only be man-made, then I would be concerned because there is no purpose for this experiment,” says Adolfo Garcia-Sastre, an influenza researcher at Mount Sinai Hospital in Manhattan.

But Garcia-Sastre insists the viruses made in the two studies that triggered this debate could occur in nature. He fears the controversy will lead to more layers of bureaucracy that will box out all but the best financed labs from doing this type of work.

Dr. Michael Osterholm, director of the Center for Infectious Diseases Research and Policy at the University of Minnesota and a member of the panel that advised the government on this decision, said the block may add a sense of urgency to the field.

“I think it will create a temporary slowdown, just because we’re all going to be looking at what should be done, how should it be done and why it should be done,” said Osterholm. “But in the end I think it will actually cause a great acceleration of H5N1 research. Because now that we know what we know, we can make the clear case that we need a lot more research. People can’t write this (virus) off.”

Dr. Sara Alexander, an applied social anthropologist at Baylor who conducts much of her research in Central America, studied different households in several coastal communities in Belize. While climate change has been an emerging topic of interest to the world community, little scientific data exists on exactly how people respond to different climate-related “shocks” and events such as more intense hurricanes and prolonged drought.

Using a livelihood security approach, Alexander and her team identified vulnerable households in these communities and examined how they adapted and coped with major climate events and shocks such as droughts, hurricanes and floods. The Baylor researchers also developed tools to measure each household’s long-term resilience, an area that has not been extensively researched, and identified specific behaviors and strategies that allowed some families to “weather the storm” better than others. The results indicate:

• Sixty-two percent of vulnerable households made the assertion that chronic weather-related threats such as floods and prolonged drought are a greater concern than “one-off” disasters like hurricanes.
• Perception about climate change and weather patterns played a key role in determining whether a household prepares adequately for a harsh weather event. For instance, 57 percent of households believed that storms today are more intense than they were five to 10 years ago, the household is more likely to prepare when weather forecasters predict threatening weather.
• Vulnerable and more secure households differ in coping strategies when dealing with weather-related events. Forty-nine percent of vulnerable households turn to their faith, 43 percent to their family, and 36 percent turned to their friends for emotional support. Only 19 percent turned to financially-based responses and only 8 percent made attempts to secure credit to gain resources to make repairs rebuild. Households that have the highest levels of security are more likely to use their savings or sell their assets to engage in a financially based response by repairing and rebuilding, many times finding emotional support through this work.
• A critical ingredient for reducing vulnerability and enhancing resilience is empowerment of marginalized groups and the associated access to resources.
• Although the capacity of households to adapt to harsh weather is a function of perception of risk and access to resources, resilience of communities depends on the ability of people to think and act collectively.

“The results suggest that both vulnerable and secure households respond to weather-related events, but they do so in different ways,” said Alexander, associate professor and chair of the department of anthropology, forensic science and archaeology at Baylor’s College of Arts and Sciences.

The results will be published in the journal Climatic Change and Mitigation and Adaptation Strategies for Global Change.

Alexander said over the last 150 years, data shows surface temperatures have increased and the associated impacts on biological and physical systems have become more evident. Some of the more notable changes that have gradually occurred are sea level rise, shifts in climatic zones, changes in precipitation patterns and increases in frequency and magnitude of extreme weather events like droughts, floods and storms.

Alexander said she has always maintained that by definition, more vulnerable households are not able to respond as effectively to a natural disaster as those households whose livelihoods are more secure, that is, their capacity for response is influenced by their weakened ability to guard against risk.

Alexander and her team developed a resilience-measuring index for human responses that examined certain long-term security indicators, including economic stability, human health conditions, adult education levels, social connectedness, environmental health, and food and nutrition security. The researchers then tracked those indicators as different weather-related events naturally occurred.

The project was funded through a $235,000 grant from the National Oceanic and Atmospheric Administration (NOAA).

Also collaborating on the project as a co-investigator is Dr. Susan Stonich, professor of anthropology and environmental studies at the University of California, Santa Barbara.

Members of the World Health Organization meet on Wednesday to begin debating the future of what is left of what was one of the world’s most lethal viruses before it was eradicated more than 30 years ago: samples kept in tightly guarded freezers at the Centers for Disease Control and Prevention in Atlanta and a Russian government lab near Novosibirsk.

The U.S. says it needs to maintain the virus samples to develop new drugs and vaccines to counter a potential bioterror attack or accidental release of smallpox from an unsanctioned stock. “Our position is that we need to have the virus collections maintained for the foreseeable future,” said a U.S. official familiar with the matter.

Russia also believes the virus should be kept for research and is likely to concur with the U.S. position, said Vladimir Starodubov, an official in the Russian delegation to the WHO executive board.

But Washington and Moscow must win over other governments and public-health officials who fear the virus could be stolen or unleashed by accident.

Smallpox is estimated to have killed hundreds of millions of people—roughly a third of those it infected—and left millions more scarred or blind over thousands of years before a global campaign finally halted the virus by 1980. It is the only human disease ever to have been eradicated by vaccination, and its extermination is considered a milestone in medical history.

Whether to extinguish the remaining smallpox strains has been one of the fiercest debates in global public health over the past two decades. Some say the argument is moot: Smallpox could eventually be synthesized in a lab, making total eradication impossible. Others argue the threat of a synthetic virus is all the more reason to get rid of the remaining strains.

The U.S. could face opposition from developing countries, where the memory of smallpox is freshest. “To put it bluntly, it is the same logic by which the superpowers continue the possession of the nuclear weapons; they wish to hold on to the smallpox virus as a super bio-weapon,” said Kalyan Banerjee, a virologist from India, former member of a WHO advisory committee on smallpox research and now a committee adviser.

Destroying the virus is “not good public policy,” said Kenneth Bernard, a health security expert in the administrations of Bill Clinton and George W. Bush. He said strains could exist outside of the U.S. and Russian facilities, posing a global threat.

Some scientists also argue the smallpox virus should be retained to unlock the secrets to its unique ability to target the human immune system.

On Wednesday, representatives of 34 countries, including the U.S. and Russia, are scheduled to discuss whether enough research has been completed on developing medical defenses to the virus to set a deadline for destroying the remaining samples. The group’s executive board will then pass the debate on to the agency’s larger decision-making body, the World Health Assembly, which will issue a decision at a meeting in May.

Once the virus stocks are destroyed, “any lab, scientist or country found to have the virus after the date of destruction is de facto guilty of very serious crimes against humanity,” said D.A. Henderson, head of the WHO’s eradication campaign and a former top government bioterror scientist after the attacks of Sept. 11, 2001. He is now a distinguished scholar at the Center for Biosecurity at the University of Pittsburgh.

The World Health Assembly agreed in 1996 that surviving smallpox stocks be destroyed. But the virus has won multiple stays of execution as fears of bioterrorism spread.

A review completed late last year by a WHO advisory committee concluded samples of the virus were needed for the development of antiviral medications, as well as a vaccine with fewer side effects. The U.S. and Russian labs conduct research in both areas.

“There are scientifically valid reasons to continue to study the virus in safe and secure circumstances,” said Inger Damon, chief of the CDC’s poxvirus section and rabies branch. She is one of fewer than 10 CDC scientists with access, via security codes and retinal scans, to the high-security laboratory where 451 smallpox samples are kept frozen in liquid nitrogen.

U.S. officials say they need in particular to finish developing and licensing antiviral medications to treat infected people. None are currently approved.

The Russian State Research Center for Virology and Biotechnology Vector has 120 samples, with access controlled by guards and security systems. The WHO conducts inspections of the U.S. and Russian facilities.

U.S. officials say they fear a lethal strain of smallpox could be developed into a weapon through genetic engineering or synthesis and unleashed against a generation of people who have never been vaccinated.

While smallpox doesn’t naturally spread as easily as some other infectious diseases—infected people aren’t contagious until they are sick—world travel creates new risks, say experts.

Some worry about secret stockpiles of smallpox. Inspections in Iraq during 2003 and 2004 yielded some “credible intelligence and information that suggests it was there” but “no smoking gun,” according to a former U.S. official and inspector for the United Nations familiar with the matter.

The U.S. has spent $1.8 billion since 2001 on smallpox countermeasures, mostly to buy vaccine. The government has stockpiled more than 300 million doses—enough for every person in the U.S.

No one is known to have synthesized smallpox, but terrorists could eventually learn how, said geneticist J. Craig Venter. “At the moment it requires a pretty sophisticated scientific team,” he said. The smallpox virus is also quite large, he said: “Only a few labs in the world have the skill set for handling large pieces of DNA. It gets very brittle as it gets larger.”

In a paper posted online last week, smallpox expert Jonathan B. Tucker proposed partial destruction of the virus stocks as a compromise. The U.S. and Russia could winnow their collections to 10 strains, he wrote in the journal Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science.

Write to Betsy McKay at betsy.mckay@wsj.com

Since the Health Ministry announced the World Health Organization-backed measles vaccination plan last week, authorities have been flooded with queries and Internet bulletin boards have been plastered with worried messages. Conspiracy theories saying the vaccines are dangerous have spread by cell phone text messages.

The public skepticism has even been covered by state-run media, which noted the lack of trust was about more than vaccines.

“Behind the public’s panic over the rumors is an expression of the citizens’ demands for security and a crisis in confidence,” a columnist wrote in the Chongqing Daily newspaper.

“The lack of trust toward our food and health products was not formed in one day,” said the Global Times newspaper. “Repairing the damage and building credibility will take a very long time. The public health departments need to take immediate action on all fronts.”

In recent years, government agencies have dragged their feet or withheld information about the spread of SARS, bird flu and, last month, an outbreak of cholera. China’s slow response to SARS, or severe acute respiratory syndrome, was widely blamed for causing the outbreak that swept the globe in 2003, and led to deep mistrust both internally and internationally.

Milk products contaminated with industrial chemicals are still found despite mass recalls and several criminal convictions, including executions, after tainted infant formula sickened 300,000 babies and killed at least six two years ago.

Feeding into worries about the measles vaccine were media reports in March that vaccines for encephalitis, hepatitis B and other diseases possibly killed four children and seriously sickened dozens in one province. The health ministry said an investigation showed those vaccines were improperly stored but subsequent illnesses were unrelated. Many remain unconvinced.

Meanwhile, two Chinese vaccine makers recently said they shut operations after rabies vaccines they produced were found to be substandard.

The ministry has tried to calm the public’s anxieties about the 10-day measles immunization drive, which started Saturday. It has busily issued statements, refuted rumors and held briefings to emphasize the need for the vaccine as well as its safety.

The campaign, likely the world’s largest, targets all children ages 8 months to 4 or 14 years, depending on locality, and is intended to include remote areas, migrant communities and other places where previous vaccination coverage has been spotty.

Yet the publicity is not likely to easily reassure a public increasingly skeptical of reassurances from a government often seen as opaque and unaccountable, especially where public health is involved.

“This time how could the public have no doubts? They are asking: ‘Is there an outbreak of the disease? Are previous vaccinations not working? Are the people in the government trying to make money from this?’” newspaper commentator Wei Yingjie said in an interview.

The public push-back marks a turnaround from the mass campaigns in the communist heyday under Mao Zedong and shows how prosperity and greater access to information are creating a more assertive populace.

“This campaign would have been no problem in the Mao era, but today we know with globalization, the Internet, the information explosion, this increasingly assertive civil society, they want to participate in the public policy process,” said Yanzhong Huang, senior fellow for global health at the Council on Foreign Relations in New York.

Measles is a highly contagious viral disease that can develop into blindness, pneumonia and encephalitis and lead to death, and health experts say China needs an effective vaccination program.

Despite previous vaccination drives, China recorded 52,000 measles cases last year, including 39 deaths. The infection rates mean China is far from meeting its national pledge from 2005 to eradicate measles by 2012.

Mass drives in other parts of the world have either virtually eliminated measles or significantly reduced the number of infections. The disease has been nearly nonexistent in the Americas since 2002 and cases in seven countries in southern Africa fell from 60,000 in 1996 to 117 by 2000, according to the WHO.

Dr. Lisa Cairns, head of immunization at WHO China, said many of those infected with measles in China are young children who were likely never vaccinated.

“Because the disease is not as common as it used to be, it is easy to forget how serious it is,” she noted.

China’s Health Ministry has repeatedly said that the measles vaccine is safe, with random samples tested from stores around the country, and has tried to assure the public that medical personnel are prepared for emergencies, including any adverse reactions.

On Friday, a senior ministry official promised that no one would be forced to take the vaccination.

“Vaccination will only proceed after parents sign an agreement,” the ministry’s deputy director for disease control Hao Yang said. “We heard that some places were linking vaccination with admission to kindergartens and schools. So yesterday we issued a notice that admission to school should never be used to force children to vaccination.”

Health care professionals, however, have questioned the immunization drive’s broad scope, given that many children have previously been inoculated and thus would be vaccinated again.

A blog posting by a prominent immunization expert, Wang Yuedan of Peking University, urged the government to focus on formerly underserved groups like the children of rural migrants now living in urban areas, instead of vaccinating some children again. By Friday, Wang withdrew his reservations and backed the campaign, saying he was convinced by the Health Ministry’s explanations.

Still, Wang said in an interview that he winced at the thought of his 4-year-old daughter suffering a possible fever from the vaccine.

“I’m a man and a father first, who has emotions and who can’t watch his child suffer pain blindly,” he said.

Associated Press researcher Xi Yue contributed to this report.  Copyright © 2010 The Associated Press. All rights reserved.

This conclusion is based on an analysis of Israel’s rejections of applications submitted by Gaza patients during 2009, which found a strong correlation between cases considered life-threatening and permit approval rates. It should be stressed that cases which are not defined as life-threatening, and which were denied by Israel, can still be clinically urgent: this includes, for example, conditions that can lead to the loss of limbs, organs, or eyesight.

The organizations argue that Israel must allow every patient requiring medical treatment that is unavailable in Gaza access to treatment outside the Strip without delay.

The policy, which was first adopted on June 2007, is still in effect today. In the past few weeks, PHR-IL has received about 40 applications from Gaza patients whose requests to exit Gaza to receive medical treatment had been rejected by the Israeli security authorities. This is an extraordinarily high number of rejections in a relatively short period of time, which calls for special attention, given that all of these patients suffer from non-life-threatening medical conditions. On June 15, 2010, after 11 individual requests submitted by PHR-IL to the Israeli security authorities had been rejected, PHR-IL submitted a collective request in behalf of the 28 remaining patients, asking the security authorities to reconsider their cases.

Distinguishing between a life-threatening medical state and one that hinders quality of life – while denying medical treatment in cases which are not life-threatening – contradicts the principles of medical ethics. These principles mandate that all patients are entitled to the best available medical treatment, regardless of the urgency of the treatment or the severity of their clinical state.

Such a policy also contradicts international humanitarian law and international human rights law, which uphold the rights to life, physical integrity and dignity. The right to medical treatment is integral to these rights, which are also recognized as fundamental rights under Israeli law.

Dr. Harel Arzi, Specialist in Orthopedic Surgery and PHR-IL volunteer: ‘The difference between causing individuals to suffer from defects on purpose and causing them to suffer from defects or disability by denying them medical treatment for an existing condition – this difference is merely semantic. Whoever prevents patients from accessing medical treatment by restricting their movement is directly responsible for their medical condition, even if he or she did not cause this condition.’

According to the organizations, the withholding of treatment from Gaza patients who do not fall within Israel’s delineated medical criteria is the result of considerations that are foreign to medicine, among which are political considerations. Furthermore, deliberately withholding medical treatment from patients in need in order to achieve political goals is a form of collective punishment, prohibited under international humanitarian law. It constitutes a further layer of Israel’s policy of tightening the closure of the Gaza Strip, imposing hardship on its residents and limiting their movement, and should be halted immediately.

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In her letter to the editors, Chan said “potential conflicts of interest are inherent in any relationship between a normative and health development agency,” and conceded that the agency “needs to establish, and enforce, stricter rules of engagement with industry, and we are doing so.” However, she said she took “issue with the assumption that WHO simply dismisses these hard questions.”

Chan also responded to questions regarding the decision not to disclose members of its emergency committee, which directly advised the WHO about pandemic planning, noting that the “decision not to make these names public was motivated by a desire to protect the experts from commercial or other influences.” She added that committee members had welcomed the anonymity and that “the names will be released when the committee finishes its work, as has always been intended.”

Noting that the BMJ report “will leave many readers with the impression that WHO’s decision to declare a pandemic was at least partially influenced by a desire to boost the profits of the pharmaceutical industry,” Chan countered that “decisions to raise the level of pandemic alert were based on clearly defined virological and epidemiological criteria. It is hard to bend these criteria, no matter what the motive.”

[Economist] MORE than a week after the earth convulsed beneath it, Haiti has still to plumb the depths of suffering and want. The numbers are still only more-or-less informed guesses, but their magnitude is grim: perhaps 200,000 killed, 250,000 more injured and some 3m in desperate need of help. The generosity of the world’s response has also been profound. Barack Obama led the way, dispatching 16,000 American troops and marines, but others, from Europe to Brazil, Cuba, China and Israel, responded too. Immediate promises of aid added up to around nearly $1 billion.

The urgent task is to connect this supply of help with the demand. That is proving extraordinarily hard (see article). Seven days after the earthquake, the United Nations had got food to only 200,000 people. Lessons from other disasters are not always relevant to Haiti. The Asian tsunami, for example, struck a ribbon of remote, mainly rural, areas. The governments of the affected nations could lead the relief effort. But Haiti’s institutions were weak even before the disaster. Because the quake devastated the capital, both the government and the UN, which has been trying to build a state in Haiti since 2004, were decapitated, losing buildings and essential staff. So did many NGOs. The president, René Préval, and his cabinet have been reduced to meeting in a police station.

Into that vacuum stepped the United States. Inevitably the dispatch of marines, Black Hawks and an aircraft-carrier looked to some like an invasion (after all, they have been there before). A brief caricature of great-power prickliness ensued as the Americans took charge of the airport and seemed to some others to give priority to their own flights. But by mid-week the airport was receiving three times as many flights as it did before the earthquake. The American forces are well-equipped for the vital task of setting up a supply chain for aid. That is what they are doing under a sensible division of labour eventually hammered out (the Brazilian-led UN peacekeeping force remains in charge of security, and the UN will co-ordinate the aid effort). Certainly most ordinary Haitians seemed pleased to see the Americans.

They are just desperate for water, food, fuel, medicines and shelter. Contrary to some reports, there were only isolated cases of looting and fighting. But delay and disarray has cost many lives. The longer it lasts, the more likely that desperation turns to violence. The UN called for more peacekeepers. Brazil offered 800; it may take weeks to muster the rest. If ever a situation cried out for the UN to have a standing army at its disposal, as The Economist has urged, this is it.

From relief to building a better country

Amid such chaos, it might seem premature to think about a long-term strategy for rebuilding Haiti. Actually, it is vital. Already Haitians’ resilient response to disaster is creating new facts on unstable ground: the spontaneous refugee camps around the capital will be hard to shift. Even before the earthquake Haiti was poor, environmentally degraded and aid-dependent and had few basic services. This means that “building back better” must be more than just a slogan. It also means that time is short before the world’s generosity turns to cynicism.

Fortunately there is a blueprint, drawn up by Haiti’s government and presented to donors last year. It calls for investment to be targeted on infrastructure, basic services and combating soil erosion to make farmers more productive and the country less vulnerable to hurricanes. The pressing question is who should do it and how. Haiti’s government is in no position to take charge, yet the country needs a strong government to put it to rights. Paul Collier, a development economist who worked on the plan, reckons that the answer is to set up a temporary development authority with wide powers to act.

Given the local vacuum of power, this is the best idea around. The authority should be set up under the auspices of the UN or of an ad hoc group (the United States, Canada, the European Union and Brazil, for example). It should be led by a suitable outsider (Bill Clinton, who is the UN’s special envoy for Haiti, would be ideal, perhaps to be followed by Brazil’s Lula after he steps down as president in a year’s time) and a prominent Haitian, such as the prime minister. To provide services, it should work with aid groups.

Some will object that this would undermine a democratically elected government. But there is not much left to undermine. Done well, it could create a state in Haiti able to do more than preside over chaos and corruption. Otherwise the suffering of the past ten days risks being repeated.

The businesses registered with the city’s Department of Health to offer the vaccine through employee health clinics, and a department spokeswoman said they were sent doses as part of a plan to reach more high-risk adults. “When vaccine first became available, we directed all available doses to pediatricians, ob/gyns, community health centers and private and public hospitals,” said the spokeswoman, Jessica Scaperotti. “Then, as vaccine became more available, we expanded it to adult providers.”

She called large employee health clinics an important outlet for reaching at-risk adults. The firms had to sign an agreement to administer vaccines only to the highest-priority groups identified by the CDC, including pregnant women and adults between the ages of 25 and 64 who have medical conditions that put them at risk of complications from the flu, she said. But criticism of the move showed how much tension has emerged as thousands of children and others considered at risk of complications have waited hours in lines to be inoculated. Rep. Frank Pallone (D-N.J.) demanded an explanation from government officials. “I am concerned that the distribution of the vaccine is resulting in favored treatment for the privileged,” he said. The vaccine, which is paid for by the government, is being distributed to state and major city health departments, which then decide where to send the doses. Doses are sent to providers and clinics that applied. New York City has received more than 800,000 doses. In a letter, CDC Director Thomas Frieden asked state and local officials to review their vaccine-distribution plans. “Any vaccine-distribution decisions that appear to direct vaccine to people outside the identified priority groups have the potential to undermine the credibility of the program,” he wrote. The CDC said 35.6 million doses of vaccine were available as of Thursday. The agency recommends which groups should get the vaccine first, and jurisdictions must agree to follow those recommendations, but the CDC doesn’t sign off on which providers get the vaccine, a spokesman said. Goldman Sachs has received 200 of 5,400 doses it ordered. A spokeswoman said the firm “will supply it only to employees who qualify based on the requirements laid down by the CDC and Department of Health.” Citigroup spokesman Alex Samuelson said the firm received limited supplies of vaccine and they were being provided “only to employees in high-risk categories as defined by the CDC.” A Morgan Stanley spokeswoman confirmed that the firm received 1,000 doses it ordered. But it has decided to send them to several hospitals in or near New York City after hearing that many hospitals don’t have the vaccine yet. —David Enrich, Susanne Craig and Aaron Lucchetti contributed to this article. Write to Betsy McKay at betsy.mckay@wsj.com

In a normal flu season, 90% of deaths are in elderly people. But since September, 88% of deaths have been in people under age 65 — with almost a quarter of the deaths in young people under age 25.

“It is almost completely reversed. Nearly 90% of our fatalities are occurring in people under 65,” CDC respiratory disease chief Anne Schuchat, MD, said at a news conference. “This illustrates this H1N1 virus is disproportionally affecting the young.”

As might be expected from the death toll, most people hospitalized with severe H1N1 swine flu are young. Surveillance data from 27 states show that more than half of swine flu hospitalizations — 53% — are in people under age 25. Only 7% of people hospitalized with swine flu are elderly.

While the majority of severe H1N1 swine flu cases are in people with conditions that put them at risk of flu complications, not all these conditions are severe. Well-treated asthma, for example, is common. And pregnancy isn’t an illnesses at all. Yet the risk is there.

“Completely healthy pregnant women are coming down with horrible, horrible illnesses — and, tragically more deaths,” Schuchat said. “And some conditions like asthma which is well controlled. So even if you have diabetes that’s well controlled, if you have asthma that’s well controlled, we want to you think of yourself as a higher risk and recommend that you be vaccinated.”

H1N1 Swine Flu Vaccine Rollout Still Bumpy

If you’re thinking of taking the CDC’s advice and getting the H1N1 swine flu shot (or sniff), it’s time to start making plans.

The flu.gov web site has a flu vaccine finder that links to each state. Most states have detailed information that show which providers near you will be offering the H1N1 swine flu vaccine.

The first vaccines are going to health care workers and people at risk of flu complications. So far, about 13 million doses have been available to states, more than half in the form of flu shots. States have placed orders for about 11 million of those doses; those orders are being filled quickly.

Spread nationwide, that means not everyone who should get the vaccine will be able to get it this week, or even next week. Availability is increasing, but it’s unlikely that the vaccine will reach everyone who wants it before the end of November.

Will that be too late? The CDC’s mantra is, “It’s too early to say it’s too late.”

Schuchat points to what happened in 1957, when pandemic flu hit hard in the early fall — and was followed by a second wave of flu.

“In 1957, the pandemic hit early around September/October, like what we’re seeing here. They had another big wave after the first of the year,” Schuchat said. “And I think we have an opportunity right now to try to limit the disease and to protect as many people as we can with the vaccine as it becomes available.”

Meanwhile, Schuchat said, the CDC is not planning to stop its H1N1 swine flu effort when all 250 million doses of the vaccine have been delivered.

“At CDC, we’re planning a long response. We don’t want to let our guard down too soon on this,” she said.

SOURCES:

Anne Schuchat, MD, director, National Center for Immunization and Respiratory Diseases, CDC, Atlanta.

CDC news conference.

The plan, which would guide Florida hospitals on how to ration scarce medical care during a severe flu outbreak, also calls for doctors to remove patients with poor prognoses from ventilators to treat those who have better chances of surviving. That decision would be made by the hospital.

The flu causes severe respiratory illnesses in a small percentage of cases, and patients who need ventilators and are deprived of them could die without the breathing assistance the machines provide.

In June, Florida Surgeon General Ana M. Viamonte Ros sent the draft guidelines — which had already undergone a series of internal revisions — to 16 state medical organizations for their feedback.

But the state has not yet publicized the guidelines or solicited input from the general public. The Florida Department of Health released a copy of the draft plan at the request of ProPublica, a nonprofit news organization, which provided it to the Sun Sentinel.

The document addresses one of the most heart-rending issues in medicine: What to do if the number of people in need of ventilators and other treatment dramatically exceeds what is available.

The goal, the plan says, is to focus care on patients whose lives could be saved and who would be most likely to improve. While it says those decisions are not to be made based on patients’ perceived social worth or role, the plan calls for different rules for some populations.

The list of conditions that disqualify hospital admission would be applied to most people only in the two most severe levels of a pandemic. However, they would also be applied in the first level ofa pandemic for patients transferred to hospitals from “other institutional facilities,” such as nursing homes and mental health facilities.

Florida’s planning effort reflects a growing acknowledgment that hospitals across the nation would be unable to cope with the flood of patients that a severe influenza pandemic, like the one that gripped the nation in 1918, would unleash. That resource gap is in the spotlight now, as the country is battered by a second wave of pandemic swine flu, also known as the H1N1 virus.

“What we have seen are real stresses, particularly on the emergency departments,” Thomas Frieden, commissioner of the Centers for Disease Control and Prevention, said at a press conference last week.

The H1NI virus is much milder than the 1918 flu, but a small proportion of H1N1 patients, including some who have no risk factors and are young and healthy, develop severe breathing problems requiring mechanical ventilation and life support.

So far, intensive care units in the U.S. haven’t been overwhelmed with people needing ventilators.

“That’s something that we’re tracking closely,” Frieden said.

In Winnipeg, Canada, all regional critical care beds were full at the peak of the outbreak last spring, and in Mexico, patients experienced long delays before being admitted to ICUs. Four died before being transferred from the emergency room.

Florida health officials believe that the number of severely ill flu patients will likely remain at a manageable level, provided residents get vaccinated, that they know when to stay home and when to seek medical care (visit myflusafety.com or call               877-352-3581         877-352-3581 for information), and that the existing flu strain does not mutate into a more virulent form.

In the case of a much severer scenario, Florida’s draft guidelines call for hospitals to turn away anyone whose doctor has signed a “Do Not Resuscitate” order, which instructs rescuers not to revive a patient whose heartbeat or breathing stops.

A recent report from a panel of national experts convened by the Institute of Medicine urged states not to use DNR orders for this purpose, because they reflect preferences about end-of-life planning “more than an accurate estimate of survival.”

The Florida plan also calls for intensive care unit patients and those using ventilators to be reassessed after 48 to 72 hours.

Those whose chances of survival have significantly worsened would be taken off the machines or discharged from critical care to make way for others who may have a better chance of survival. If needed, they would be given palliative care to keep them comfortable.

One goal of Florida’s plan is to “reduce or eliminate” the legal liability of health care workers who, in good faith, deny or withdraw treatment from some patients in an emergency. The plan includes sample executive orders that the governor could issue to shield workers and authorize hospitals to implement the guidelines.

The draft document also outlines how the health care system should stretch critical resources before moving to ration care.

The guidelines suggest reusing supplies, canceling surgeries that are not absolutely necessary, training staff to perform additional tasks and drawing on stockpiles. The general public’s responsibilities include treating certain sick family members at home and monitoring public health messages.

Florida’s draft guidelines aim to provide the “greatest good for the greatest number” when doing the best for all patients is no longer possible.

That goal needs to be balanced with an effort to distribute scarce resources in the least discriminatory way, said professor Ken Goodman, who directs the University of Miami bioethics program and the Florida Bioethics Network.

“Among the ways we can do that is to somehow take the evidence about what we think works and bolt it to the values that I think are uncontroversially shared: Namely, life is good, suffering is bad.”

He said that methods included in the draft are still imperfect: “It’s a very difficult problem to figure out how the world of science can help ensure that our strategies for allocating resources are fair and effective.”

Viamonte Ros will have final approval authority and the plan will remain voluntary and subject to review, according to Doc Kokol, the health department’s information officer.

The Florida health department’s original goal was to have a final draft of the plan ready by December.

But with public health workers scrambling to cope with other aspects of the H1N1 pandemic, that is now unlikely, state officials said.

“People would like to have that policy,” said Goodman, who chaired an ethics meeting on these issues at Jackson Memorial Hospital in Miami last week. He said that staff at the hospital have drawn up their own draft plan to cope with a potential surge of patients needing care. Florida plans to accept public input after the guidelines are revised by health officials. Kokol wrote in an e-mail that that “will likely include regional meetings for public input as well as electronic receipt of comments.”

In many states, that type of input has been largely absent. Groups of doctors, lawyers and ethicists have hammered out the plans with little engagement with the public or with groups that represent children, the elderly and those with chronic illnesses or disabilities.

When Utah tested a similar plan in late August, the drill revealed difficulties that Florida clinicians and patients are likely to encounter.

Utah family physician Pete DeWeerd had to tell a mock patient’s mother that her 7-year-old daughter, who had cerebral palsy and was suffering from the flu, would be turned away from the hospital and likely die.

“I don’t like to tell you this,” he said he told her, “it feels unfair, but our list is our list is our list.” He added: “It was awful. You get a huge lump in your throat.”

Dr. Tom Kurrus, medical director of St. Mark’s Hospital in Salt Lake City, called it “emotionally draining” when mock patients and family members yelled, screamed and took issue with who was denied treatment.

“The major weakness in our preparedness had to do with security,” he said.

Kurrus said that although the exercise was covered widely in Utah’s media, the public isn’t aware that the disaster plans call for rationing.

“Even with the scenarios played out and the discussions entertained, they still don’t understand,” he said. “It’s, ‘Why can’t I get into the hospital, why can’t grandma get put on a respirator?’”

Goodman, the University of Miami ethicist, said open conversation about the complex, value-laden decisions that will determine who receives treatment in the most extreme circumstances is crucial, and that hospital, state or federal guidelines should always be subject to revision.

“This should be an ongoing process that includes new evidence as it becomes available and that includes, in an open society, the participation of citizens,” he said.

Sheri Fink is a reporter for ProPublica, a nonprofit journalism organization in New York City. To see more of her stories about emergency preparedness, go to propublica.org/sherifink

http://www.sun-sentinel.com/news/nationworld/sfl-swine-flu-crisis-propublica-sboct18,0,2027387,full.story