Who should MDs let die in a pandemic? Report offers answers

Now, an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn't be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia. The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services.

The proposed guidelines are designed to be a blueprint for hospitals "so that everybody will be thinking in the same way" when pandemic flu or another widespread health care disaster hits, said Dr. Asha Devereaux. She is a critical care specialist in San Diego and lead writer of the task force report.

The idea is to try to make sure that scarce resources - including ventilators, medicine and doctors and nurses - are used in a uniform, objective way, task force members said.

Their recommendations appear in a report appearing Monday in the May edition of Chest, the medical journal of the American College of Chest Physicians.

"If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing," the report states.

To prepare, hospitals should designate a triage team with the Godlike task of deciding who will and who won't get lifesaving care, the task force wrote. Those out of luck are the people at high risk of death and a slim chance of long-term survival. But the recommendations get much more specific, and include: -People older than 85.

-Those with severe trauma, which could include critical injuries from car crashes and shootings.

-Severely burned patients older than 60.

-Those with severe mental impairment, which could include advanced Alzheimer's disease.

-Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.

Dr. Kevin Yeskey, director of the preparedness and emergency operations office at the Department of Health and Human Services, was on the task force. He said the report would be among many the agency reviews as part of preparedness efforts.

Public health law expert Lawrence Gostin of Georgetown University called the report an important initiative but also "a political minefield and a legal minefield."

The recommendations would probably violate federal laws against age discrimination and disability discrimination, said Gostin, who was not on the task force.

If followed to a tee, such rules could exclude care for the poorest, most disadvantaged citizens who suffer disproportionately from chronic disease and disability, he said. While health care rationing will be necessary in a mass disaster, "there are some real ethical concerns here."

James Bentley, a senior vice president at American Hospital Association, said the report will give guidance to hospitals in shaping their own preparedness plans even if they don't follow all the suggestions.

He said the proposals resemble a battlefield approach in which limited health care resources are reserved for those most likely to survive.

Bentley said it's not the first time this type of approach has been recommended for a catastrophic pandemic, but that "this is the most detailed one I have seen from a professional group."

While the notion of rationing health care is unpleasant, the report could help the public understand that it will be necessary, Bentley said.

Devereaux said compiling the list "was emotionally difficult for everyone."

That's partly because members believe it's just a matter of time before such a health care disaster hits, she said.

"You never know," Devereaux said. "SARS took a lot of folks by surprise. We didn't even know it existed."
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DNA Jigsaw Puzzle

A new mathematical and statistical method allows the virus population in a diseased organism to be determined quickly and economically. Using this method, medicines and vaccines against diseases caused by viral infections could be developed and deployed in a more targeted way in the future.

Through their diversity resulting from continuous mutation, viruses easily develop drug resistance. This is also why the manufacture of a vaccine against HIV has been unsuccessful up to now. To bring both under control, the strains of virus present in the host must be known. A new method developed by researchers from Switzerland and America now promises help in identifying diverse virus populations.

The method is based on a next generation, high throughput DNA sequencing technique called pyrosequencing. Niko Beerenwinkel, Assistant Professor at the Department of Biosystems of ETH Zurich, explains that this involves a technique that has been in use since 2003, with which the sequencing can be carried out efficiently and economically. He is a co-author of a study published recently in the scientific journal PLoS Computational Biology, in which the researchers successfully identified the virus strains of four patients infected with the HIV virus.

Light signals identify structural elements

In their study, the scientists used the pyrosequencing technique to examine the DNA of HIV/AIDS viruses. As Beerenwinkel explains: “This involves determining the sequence of the DNA modules by synthesising the complementary DNA strand. Each newly incorporated base is recognised by a light signal. This method is reliable only for short DNA segments, but at the same time it can be highly parallelised, which ultimately leads to a very large number of short segments.”

The scientists now used a computer-assisted method which they had developed to combine together the DNA segments from the HIV samples to form virus strains. This involves piecing together matching DNA segments like a jigsaw puzzle to form the complete sequences of the various strains. Beerenwinkel explains that one does not know beforehand either how many or which strains the sample contains, or which DNA segments belong to the same strain.

Error rate minimized

But, according to Beerenwinkel, the disadvantage would be that the segments are very short and may conceal a high error rate. However, by using the mathematical and statistical error correction tools developed by the researchers, they were able to reduce the error rate with their method by a factor of 30, thus determining reliably the virus strains belonging to the DNA segments. This is shown by a comparison with conventional methods in which long DNA segments can be determined with high precision.

For this purpose they chose individual viruses at random from the population and used traditional methods to determine the sequence of the individual DNA structural elements. According to Beerenwinkel, this revealed that the results were very similar, but the pyrosequencing method works faster and more economically and – in contrast to conventional methods – enables entire virus populations to be identified more easily.

The method that has been developed allows the efficient use of new sequencing techniques with which the genetic diversity of the whole virus population of an infected patient can be determined. This can mean a big step forward for use of medicines to treat virus diseases and for vaccine development. This is because it could enable medicines to be used in a more targeted way, thus preventing the development of resistance. It could also facilitate the development of vaccines.

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