A Decision Analysis Approach to the Swine Influenza Vaccination Decision for an Individual

Author(s): David L. Zalkind and Richard H. Shachtman

Source: Medical Care, Vol. 18, No. 1 (Jan., 1980), pp. 59-72
Published by: Lippincott Williams & Wilkins
Stable URL: http://www.jstor.org/stable/3764381
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MEDICAL CARE
January 1980, Vol. XVIII, No. 1

A Decision Analysis Approach to the Swine

Influenza Vaccination Decision
for an Individual

DAVID L. ZALKIND* AND RICHARD H. SHACHTMANf

We present a method to analyze the decision by an individual whether to

receive the swine influenza (A/New Jersey) vaccine, including an approach for
health care personnel to use in informing an individual about the personal costs,
benefits and probabilities, as well as indicated choices of actions, associated
with such decisions. This analysis is a prototype for cases where informed
consent requirements have prompted increased patient involvement in per-
sonal medical decisions. Probabilities and personally assessed values that affect
the decision are: reaction to the injection, attack rates, vaccine efficacy, chances
for an epidemic and concomitant probabilities of contracting influenza, and
mortality. We specify a preference ordering for consequences of receiving the
vaccine. The analysis yields a preference ordering for possible actions because
relative values reflecting preferences are compared on a fixed consistent scale.
The solution exhibited, determined in the fall of 1976, indicates conditions
when selection of the action to receive the vaccine is automatic. In cases where
the decision is not automatic, an individual needs additional information about
the personal value of death (life), relative to other possible outcomes. We previ-
ously have developed a noneconomic approach to the determination of the
value of death15 and the results, briefly described in this paper, are used to
construct a decision region for the choice of receiving the vaccine that depends
on both the probability of an epidemic and the value of death. Surprisingly,
inclusion of information about the Guillain-Barre syndrome does not necessar-
ily alter the decision to receive the vaccine, even though recognition of the
increased incidence of the syndrome caused by the vaccine caused cancellation
of the federal program.

THE FEDERALLY-SPONSORED swine in- expectedly and abruptly aborted high-

fluenza vaccination campaign that was un-
* medical patients. There is a need for
Faculty Fellow, Office of Assistant Secretary for
Planningand Evaluation,U.S. Departmentof Health,
Education,and Welfare,Washington,D. C. and Duke
University, Durham, North Carolina.
i Associate Professor,Director of SENIC Project,
Departmentof Biostatisticsand Curriculumin Opera-
tions Research and Systems Analysis, University of
North Carolina,Chapel Hill, North Carolina.
This project was partially supported by Grant #
HS-01971-2fromthe NationalCenter for Health Ser-
vices Research, Health Resources Administration,
and Contract# 200-77-0705,Center for Disease Con-
trol, Atlanta,Georgia.
lights the current ethical and legal prob-
lems attendant to informed consent by
mechanisms that provide patients with the
information and tools to be active decision
makers in the medical care process.
Decision analysis provides a systematic
framework for rational decision making
that can be utilized by knowledgeable
health care personnel to inform a patient
about potential consequences of medical
actions, and that can be used with the pa-
tient's own values to help make a decision

0025-7079/80/0100/0059/$01.20 ? J. B. LippincottCo. 59
ZALKIND AND SCHACHTMAN
that is best for him. In other words, indi-
viduals can use the tool of decision
analysis, perhaps under the guidance of
specially trained health technicians, to
educate themselves to make more rational
decisions in the face of hard data, soft data,
nonexistent data and personal preferences.
Equally important, public health analysts
can use decision analysis to help deter-
mine whether advice about what actions
individuals should take is rational from the
viewpoint of each individual being ad-
vised to take the action. Such an under-
standing may be of use in devising both
one-on-one and mass media educational
efforts for preventive health measures.
There are at least four different view-
points for the decision, or four different
decisions. The first is the federal govern-
ment decision of whether to have such a
program and, if so, who should fund it.
Schoenbaum et al.10 have discussed the
first part of this decision from an economic
viewpoint. The second is that of a local
health administrator who must decide how
to pay for the program. We do not consider
these problems here. A health professional
who must advise individuals whether or
not to receive the vaccine has a third view-
point. The individuals who would receive
the vaccine has the fourth viewpoint. For
the latter two viewpoints, certain parame-
ters characterizing the individual's values
for consequences and probabilities for out-
comes may affect the decision. Factors to
take into consideration include the proba-
bility of an epidemic, reaction to receiving
the vaccine, etc. Thus, this article proposes
a rational procedure for an individual to
follow in deciding whether to obtain a
swine influenza vaccination. Many Ameri-
cans made this decision during the fall of
1976 and similar decisions will be made
year after year as new or altered viral
strains threaten to cause national
epidemics,j for which acceptance of the
vaccine is not mandated by law.
t As this is being written, the upcoming example
appears to be the "Russian Influenza" (A/USSR).
60
MEDICALCARE
The methodology developed here can
be used in several contexts. First, with the
aid of an easy-to-use computer package or
programmable calculator, a patient in con-
junction with medical personnel can use
informed consent to its fullest extent. Sec-
ond, the systematic approach to problem
solving inherent in decision analysis
makes it an excellent tool for training of
health care personnel. We will not review
the use of decision analysis in medical care
here. The interested reader can find an ex-
tensive bibliography in Albert.1 An exam-
ple of a typical application in the literature
is that of Plisken and Beck 7describing how
a physician and a patient incorporate some
of their subjective feelings and value
judgments in a decision analysis model
used to determine the treatment of end-
stage renal failure.
An individual is faced with a choice-
receive the vaccine, or decline to receive
the vaccine. In large part, the consequence
of such a choice depends on whether the
individual in question is exposed to swine
influenza virus, or is never exposed to
swine influenza virus. In the terminology
of classical statistics, one might say that
receiving the vaccine and not being ex-
posed to the virus is a Type I error and that
not receiving the vaccine and being ex-
posed to the virus is a Type II error. Al-
though classical statistics develops trade-
offs between probabilities of committing
Type I and Type II errors, the methodol-
ogy of decision analysis, described in this
paper, goes further, because it allows the
individual decision maker to incorporate
his own values (and probabilities) for the
potential consequences of his actions and
the true state of nature that is unknown at
the time the decision is made. For exam-
ple, at the time the immunization decision
is made, the individual does not know
whether he will be exposed to the virus.
Furthermore, this technique provides the
opportunity for the decision maker to ex-
plore the sensitivity of his decision to al-
ternative probability estimates and value
assessments.
 Vol. XVIII, No. 1
The A/New Jersey? virus is antigen-
icallyt' similar to both the swine influenza
virus and the virus assumed to cause the
pandemic# of 1918, for which the death toll
was 20 million. Public health officials
mounted the swine influenza program be-
cause, like the A/Japan ("Asian") influenza
of 1957, the A/New Jersey virus repre-
sented a radically different strain from re-
cently prevalent strains, and excess mortal-
ity during the A/Japan pandemic was the
highest of all influenza epidemics in the
past 20 years. Also, there was a theory that
the next epidemic would come from a
swine influenza type virus.
We structure the decision tree and indi-
cate parameters for individuals in any age/
sex cohort within the age range 20 to 45.
Some of the probabilities used are for the
authors' cohort of healthy males in their
early thirties. Similar calculations may be
made for other age/sex cohorts. We con-
struct the tree in Section 1 and derive
probabilities and scale values in Sections 2
and 3, respectively. At the end of Section 3,
we enumerate conditions under which the
individual can make the vaccination deci-
sion without specifying a personal value of
death. In Section 4, we report the results of
a method we have developed for determin-
ing the value of death (or life) to the indi-
vidual in this context and show how this
method may be used to complete the deci-
sion. We represent the decision regions
graphically.
Because the possibility of contracting
the Guillain-Barre syndrome was not
widely known by the public at the time
individual decisions were made to receive
the vaccine, we did not include this possi-
? Hattwicket al.3 contains a description of stand-
ardized nomenclature for describing influenza
viruses.
"An antigen is any substance capable of
inducing
antibody formation and of reacting specifically in
some detectable manner with the antibodies so
induced.
# A pandemic is a majorepidemic due to a single
virus type which sweeps aroundthe world in a short
period of time and causes marked increases in
mortality.
SWINE FLU VACCINE DECISION
bility in the main part of the analysis.
However, public health officials now rec-
ognize that an outbreak of Guillain-Barre
syndrome cases might occur with any mass
viral immunization program. In Section 5,
we modify the decision tree to take the
Guillain-Barre syndrome into account.
Thus, in the future, a person can include
this possible consequence when making a
decision.
1. The Basic Decision Tree
When the government decided to pro-
vide swine influenza vaccine injections to
the public free of charge, individuals were
faced with the decision of whether to re-
ceive it. Although the authors are not ex-
perts on swine influenza, we show in this
paper how the methodology known as de-
cision analysis can be used as an aid in
making the decision. In the age group we
consider, it was the belief of experts at the
Center for Disease Control (CDC), that the
vaccine would be efficacious for at least 1
year and perhaps as long as 2 or 3 years.
This period is also a function of the change
in the strain of virus to which the individu-
als are susceptible. Thus it is realistic to fix
a 1-year time period for the decision.? The
basic data for the decision will be those
available in October 1976, when individu-
als were deciding whether to receive the
vaccine.
The problem has four basic components:
1. The decision by an individual of
whether to receive the vaccine.
2. Values**and probabilities associated
with having a reaction to the injection.
3. Value and probabilities associated
with contractingswine influenza.
4. Values and probabilities associated
with dying as a directresultof having swine
influenza.
? The potential additionalbenefit of added protec-
tion fromgetting additionalvaccinationin subsequent
years is not considered in our analysis because of the
1-yeartime horizon.
** Relative values will be determined on a fixed
scale in Section 3.
61
ZALKIND AND SCHACHTMAN
.0075
.02
.9925
.025
NO SHOT
.975
The decision problem is represented in
the decision tree of Figure 1. The square,
called the decision node, represents the
human decision of whether or not to re-
ceive the vaccine. The circles, called the
chance nodes, represent chance events
(nature's decisions). There are nine differ-
ent consequences represented in the tree,
labeled "A" through "I." For example, "A"
represents the human choice to receive the
vaccine, followed by a reaction to the vac-
cine, followed by contracting swine in-
fluenza, followed by dying as a direct result
of swine influenza. Consequence "B" is
the same as "A" except that the decision
maker does not die as a result of getting
swine influenza (a rather important differ-
62
MNEDICAL
CARE
FIG. 1. Decision tree for
individual decision to re-
ceive swine influenza shot
with probabilities, assum-
ing the epidemic probabil-
ity is 0.1.
ence). Note that consequence "B" does not
preclude the possibility of the decision
maker dying from something else during
the upcoming year. Similarly, we can see
that consequence "C" involves taking the
vaccine and not getting swine influenza;
thus we do not have to consider dying as a
result of getting swine influenza. We inter-
pret the other consequences in a similar
manner.
In order to analyze the decision tree we
must assign probabilities to the branches
emanating from each chance node (the cir-
cles representing nature's decisions) and
assign a personal value to each conse-
quence. These are explained in Section 3.
The methodology of decision analysis pre-
 Vol. XVIII, No. 1
scribes that we make the choice of Shot
(receiving the vaccine) versus No Shot (not
receiving the vaccine) that yields the high-
est expected value. t f
We use information available from CDC
to determine some of the appropriate prob-
abilities and values. When "objective"
probabilities and values are unavailable,
decision analysis relies on the use of sub-
jective or personal judgments of the deci-
sion maker. Of course, the decision maker
may wish to rely heavily on "expert" opin-
ion. The probabilities and values we use
were valid as of October 1976 for healthy
males in their early thirties. t We assume
that only the monovalent shot (providing
protection against one strain of influenza}
is available to us.
2. Probabilities
Although as many as 50 per cent of vac-
cine recipients might get sore arms, the
swine influenza vaccination field trials in-
dicated that only slightly more than 2 per
cent of those getting the vaccine would
suffer some other kind of side effect. These
additional reactions might include fever,
headache or malaise ranging from mild to
severe, usually lasting no longer than one
day. Moreover, any type of foreign protein
injected, ingested or inhaled into the body
could produce an anaphylactic?? reaction
which could be dangerous, even fatal.
However, prior to the vaccination program,
experts believed the chances of death from
anaphylaxis would be quite small; in fact,
ff For our purposes, expected value is the same as
weighted average. The weights are calculated from
the probabilities we assign to potential consequences.
The quantities to be "averaged" are the scale values
we will assign to the consequences.
t t It is straightforward to substitute values for indi-
viduals in other groups. Any conclusions drawn are
only for individuals not allergic to eggs, with no cur-
rent respiratory problems or other current medical
contraindications. We do not consider the problem for
ages younger than 25 or older than 45, although the
approach would be the same.
?? Anaphylaxis is an exaggerated reaction of an or-
ganism to a foreign protein or other substance to
which it has previously become sensitized.
SWINE FLU VACCINE DECISION
CDC was unaware of any such case occur-
ring during the field trials or program
through October 1976. (See, however, Sec-
tion 5 for a discussion of the effect of the
Guillain-Barre syndrome.) In this paper
we use 0.02 for the probability of a reaction
for our cohort.
The probability of suffering from in-
fluenza is, of course, dependent on
whether an individual receives the vac-
cine. Other factors affecting this probabil-
ity are the probability of an epidemic and
the attack rate for our cohort if there is an
epidemic. A typical expert estimate for an
epidemic, as of August 1976, was 0.1.6
Using the information in Schoenbaum et
al.,10 as well as CDC expert opinion, the
assumption is made that if there is an
epidemic the attack rate will be 25 per cent
for those not protected from the disease.
That is, if an individual does not receive
the vaccine and there is an epidemic, he
has a 0.25 probability of contracting in-
fluenza. If there is no epidemic, the proba-
bility of contracting swine influenza is
assumed to be negligible. Thus, if the indi-
vidual does not receive the vaccine, the
probability of his contracting influenza is
the probability of an epidemic times the
attack rate: (0.1) (0.25) = 0.025. (Later in
the article we will consider a range of val-
ues for the probability of an epidemic,
since as of late October 1976, the lack of
new cases caused most individuals to esti-
mate a much lower probability of an
epidemic occurring. We analyze the deci-
sion using a range of epidemic probability
from 0.01 to 0.1.)
We assume, based on expert advice, the
vaccine has 70 per cent efficacy for the
cohort under consideration. That is, if an
individual chooses to get the shot, the
probability of his contracting influenza is
reduced by a factor of 0.7. Thus, assuming
that an epidemic occurs with probability
0.1, if he takes the shot his probability of
contracting swine influenza is (0.3) (0.025)
= 0.0075. Our assumptions also rely on
expert judgment that there is no significant
63
ZALKIND AND SCHACHTMAN
chance of death from the shot itself, and
that a reaction to the shot will not affect its
efficacy; see, however, Section 5.
We next assess the probability of dying
from swine influenza. If the individual
does not get the shot and eventually con-
tracts influenza, expert opinion is that the
probability of dying is about 0.0005 for our
cohort (which is between 0.004 for the
1918-19 pandemic and 0.00014 for the 1968
"Hong Kong" influenza). Experts believe
the shot will reduce the severity of a case if
contracted and will reduce the probability
of dying from influenza by about 70 per
cent. Hence, the probability that an indi-
vidual dies from influenza, given that he
received the vaccine but contracts it any-
way, is 0.00015. (It is straightforward to test
the sensitivity of our decision to this as-
sumption.) The probabilities discussed
above appear on the tree in Figure 1 for an
epidemic probability of 0.1.
Values
The consequences of the decision tree of
Figure 1 naturally cluster in three groups
according to relative "value" to the indi-
vidual. These clusters are: no influenza
(consequences C, F and I), influenza but
not death from it (consequences B, E and
H) and death from influenza (conse-
quences A, D and G). A reasonable pref-
erence ordering for the consequences that
do not involve death is, from best to worst,
I, F, C, E, H, B. For purposes of computa-
tion and interpretation these conse-
quences will be assigned values from 0.0 to
1.0. In the first group assign a value of 1.0 to
I, since it is the best consequence. Assign
(somewhat arbitrarily) slightly lower per-
sonal values for F and C, namely 0.98 and
0.90 respectively."" (Because the decision
It has been suggested that we are ignoring a moral
1Itl
.obligation to contribute to "herd immunity" by get-
tingthe shot and shouldn't rate consequence I as high.
Also, we are not taking potential medical care costs or
lost personal income into account in our analysis here.
For our current purposes, we are just considering our
attitudes about our own health and mortality. These
other factors can be taken into account.
MEDICALCARE
will be found to be sensitive to the value
assigned to F, and F may plausibly have a
value as high as I, i.e. 1.0, we will sub-
sequently solve the decision tree using
values for F from 0.98 to 1.0.)
In the second group of consequences,
we believe B should be assigned the value
0.0 since it is the worst consequence. For
the other consequences in this group we
decided that values of 0.2 and 0.1 for E and
H, respectively, would be appropriatefor
the authorsas decision makers. This judg-
ment is based on the supposition, sup-
ported by expert opinion, that even though
the shot would not prevent us from con-
tracting influenza, it would enable us to
have a milder case than we would have had
otherwise. We tested the sensitivity of our
decision to ranges aroundthe above values
of E and H and found that the decision is
relatively insensitive to changes of these
values.
In the third group, the consequences in-
volve dying during the upcoming year as a
result of contracting swine influenza. As
we have discussed,15we assume it is not
consequential to differentiate values
among them and so assign a value of -X to
each of the consequences A, D and G. The
value -X is a large negative number re-
flecting the individual's value of death and
is a point on a scale which includes the
values for consequence I (assigned a value
of 1.0) and consequence B (assigned a
value of 0.0). The decision tree now looks
like Figure 2. The (conditional) prob-
abilities in the righthand column are calcu-
lated by multiplying the probabilities
along the path leading to each conse-
quence. For example, the probability of
consequence A, given that an individual
gets the shot, is written as P(A/shot)and is
calculated as:
P(A/Shot) = P(Reaction/Shot)
x P(Influenza/Shot, Reaction)
x P(Death/Shot, Reaction,
Influenza)
= (0.02) (0.0075) (0.00015) =
0.0000000225 = 2.25 x 10-8.
Vol. XVIII, No. 1 SWINE FLU VACCINE DECISION

Consequence Value Probability

,Qwell?i -X 2.250 x 10'8

FnO II E0.00I 1.500 x 10'4

- C 0.90 1.985 x 10'2

AIFLUE D -x 1.103 x 10-6

FltQIATIFL E0.20 7.349 x 10'3

FIG. 2. Swine influenza

decision tree with prob- F 0.98 9.727 x 101
abilities and values, as-
suming the epidemic
probability is 0.1.

DEAT
-X 1.250 x 10'5
FROM
FLUH
INFLUENZA

;K'ASf 0.10 2.4" x 10-2

IglU

I 1.00 9.750 x 1'1

At this point decision analysis calls for
evaluating the tree by the method known
as "averaging out and folding back."8'11'13
E(S) and E(NS) denote the expected values
associated with getting the shot and with
not getting the shot, respectively. Assum-
ing an epidemic probability of 0.1, these
values are:
E(S) = (-X) (2.25 x 10-8) + (.0) (1.5 x
10-4) + (0.9) (1.985 x 10-2) +
(-X) (1.103 x 10-6) + (0.2)
(7.349 x 10-3) + (0.98) (0.97265)
= (1.125 x 10-6) (-X) + 0.97253
and
E(NS) = (-X)(1.25 x 10-5) + (0.1) (2.496
x 10-2) + (1.0) (0.975)
= (1.25 x 10-5)(-X) + 0.9775.
A rational decision maker would choose
to receive the vaccine if and only if E(S) is
greater than (or, perhaps, equal to) E(NS).
This is equivalent to (1.25 x 10-6)(-X) +
0.97253 > (1.25 x 10-5)(-X) + 0.9775,
which reduces to approximately X > 437.
Thus the decision depends on the numeri-
cal value a person assigns to X.
Before further specification of X, we
point out two possible conclusions not re-
quiring specification of X:
1) If the value 1.0 was assigned to con-
sequence F, the expected value of getting
the shot is E(S) = 1.125 x 10-6 (-X) +
0.99198 and the expected value of not get-
ting the shot is E(NS) = 1.25 x 10-5(-X) +
0.9775. For all negative values of -X, E(S)
> E(NS) and the individual should decide
to get the shot, since the expected value for
this action is always greater than that for
not getting the shot.## There are other
## E(S) >E(NS) if and only if 1.1375 x 10-5(X) 3
(0.9775 - 0.99198). But the right hand side of the last
inequality is negative and admissible values of X are
non-negative. Hence the inequality is true for any
admissible value assigned to X.

65
ZALKIND AND SCHACHTMAN
f abilities of dying from swine influenza,
(.0822,1)
0.995
0.990
e= Prob(Epidemic)
r = Prob(Reoction)
f =V(F)
0.985 =Value assigned to
consequence F
0.980
0 .02 .04 .06 .08 .10 .12 .14 .16
FIG. 3. Decision regions for automatic choice of
receiving the vaccine (not requiring specification of
value of death).
values of F for which this conclusion also
holds. Figure 3 shows regions of values for
F and for the personal probability of having
a reaction (possibly different from 0.021?)
where the choice of the shot does not de-
pend on X. These regions are bounded by
lines that depend on the subjective proba-
bility estimate for an epidemic actually oc-
curring during the coming year. Using the
notation e = probability of an epidemic, r =
probability of a reaction and f = value as-
signed to consequence F, the decision is
automatic for any pair of values (r, f) falling
in a shaded region above the curve corre-
sponding to a given epidemic probability,
e. If the individual's values do not fall into
one of these automatic decision regions, he
should continue the analysis.
2) One can observe that the sum of the
coefficients of -X in the expressions for
E(S) and E(NS), respectively, are the prob-
T? Some individuals assess their personal probabil-
ity of a reaction, r, to be much higher than the field
trials indicated.
66
MEDICALCARE
depending on whether or not the shot is
taken. Thus, one can see that receiving the
vaccine reduces the (subjective) probabil-
ity of dying from the swine influenza from
about 12.5 out of a million to slightly more
than one out of a million. (Naturally, these
figures would be altered if we had used
different probabilities in the decision tree.)
Some decision makers may wish to stop at
this point. They may feel that considera-
tion of the relative probabilities of death is
sufficient for making the decision (with
other potential consequences taken into
account in some "intuitive" manner).
However, we believe that a more thorough
analysis including a personal estimation of
the value of X should be carried out.
4. Personal Value of Death (or Life)
We have presented15 the derivation of a
personal value of life relative to other val-
ues in the swine influenza vaccination de-
cision tree (see Figure 2) using the tree
structure presented here.
A brief description of the approach used
follows. Using a simplifying assumption,
the derived value of X depends on only two
parameters-s, the probability of death for
the cohort under investigation during the
upcoming year in the absence of a swine
influenza epidemic, and p, a fractional re-
duction of s, more fully described below.
Given these two parameters, the value of X
is derived as
X = (1/s - l)/p = (1 - s)/ps.
Note that X does not depend on any conse-
quence values or other probabilities used
in the original tree (i.e. reaction, epidemic,
attack rate, efficacy of vaccine or dying
from swine influenza). Values of s are avail-
able from the National Center for Health
Statistics12 for most cohorts which would
be analyzed, since s is an overall probabil-
ity of dying during the upcoming year, as-
suming no special risk such as contraction
of swine influenza.
Vol. XVIII, No. 1
s - t
Take TA
1 - s +
s /
Don't Take TA
1 - s
FIG. 4. Decision tree used to derive the reduction probabilityt.
Briefly, the death rate reduction factor p
is derived in the following way: Let t = ps,
so that s - t = s(l - p) is the (reduced)
probability of dying resulting from using a
special therapeutic agent (TA) which en-
hances one's chances of living during the
coming year. However, TA also has a nega-
tive effect: taking it will definitely make
one temporarily ill with the same reaction
as one might get from the swine influenza
shot, including any immediate reaction
such as a temporary malaise plus an illness
with symptoms that mimic swine influenza
symptoms. The interpretation oft is that it
is a decrement in the probability of death
that is sufficient to induce one to take a TA.
This situation is represented by the deci-
sion tree in Figure 4.
Each individual decision maker must
find a probability decrement t sufficiently
large so that he is indifferent between tak-
SWINE FLU VACCINE DECISION
Death from ing year
with reaction to TA
Life, upcomingyear
r
with reaction to TA
with no reaction to TA
Life, upcomingyear
--
with no reaction to TA
ing TA and not taking TA. If t = 0, one
clearly would not take TA. Ift is very close
to s, the authors believe most people in
their cohort would choose to take TA.
Hence, somewhere between 0 and s there
exists a t for which the decision maker is
indifferent between the two possible ac-
tions. In 15 we derive a value for X as a
function of s and t, namely X = (1 - s)/t.
Since it may be easier for an individual to
think about a reduction in the probability
of death as a proportional factor rather than
a difference we write t = ps and ask the
decision maker to make a personal esti-
mate for p rather than directly for t. Then
the expression for X becomes X = (1/s-
1)/p.
For the authors' cohort at the time the
decision was made, s = .002 and X = (1/s -
l)/p = 499/p. In Section 3 we found that
the shot should be taken for X > 437 when
67
ZALKIND AND SCHACHTMAN MEDICAL CARE

the probability of an epidemic is 0.1. Since
for p < 1 we have X > 499, it is clear that the
"correct" decision is to get the vaccination.
We can also resolve the decision prob-
lem assuming that the probability of an
epidemic is only 0.01. The numerical val-
ues for the probabilities of the various con-
sequences are given in Table 1. For the
values in Table 1, we can calculate that
E(S) = 1.1255 x 10-7 (-X) +
and
.97780828,
E(NS) = 1.25 x 10-6(-X)+ .997749875.
From these figures we see that the shot
should be taken if X > 17,532, which is
<
equivalent to 499/p > 17,532 or p
0.02846. Therefore, in this case, an indi-
vidual following the expected value model
should receive the vaccination if the pro-
portional reduction in the probability of
death which is sufficient to induce him to
take action TA is only about 3 per cent.
The values of the proportional reduction
p sufficient to imply that action TA should
be taken are shown in Figure 5 for varying
(subjective or objective) probabilities e for
the occurrence of an epidemic. The swine
influenza vaccine should be taken for any
point (e,p) in the shaded region. For exam-
ple, if one believes that the probability of
an epidemic is less than 0.02 and if one
requires a reduction proportion for death
during the upcoming year of at least 0.25 to
induce him to take action TA, then he
should choose not to take the swine in-
fluenza vaccination.
It can be seen in Figure 5 that for the
consequence values on the right hand side
of Figure 2, the vaccine should be taken by
the individual for any personal probability
estimate for an epidemic greater than 9.7
per cent, regardless of the reduction pro-
portion value.
5. The Guillain-Barre Syndrome
The Guillain-Barre Syndrome (GBS) is a
neurologic disease which may be induced
by the introduction of foreign matter into
the body, for example, by a swine influenza
vaccination. Possible outcomes for a victim
of GBS include death, permanent dis-
abling paralysis, temporary disabling
paralysis or other less severe permanent or
temporary effects. Intensive respiratory
care may be required for the paralysis
outcomes.
Before October 1976, most individuals
facing the vaccination decision would not
have been aware of the additional risks due
to GBS. We indicate a modification of the
decision tree of Figure 1 which reflects
GBS outcomes.
Attached to the ends of each of the con-
sequences labeled B, C, E and F in Figure
1 are the additional branches shown in
Figure 6. We will analyze the personal cost
for these branch modifications using infor-
mation about probabilities and types of
health outcomes provided by CDC.6
By mid-January 1977, CDC gave an es-
timate of about 10 out of a million for the

TABLE 1. Values and Probabilities for Decision Tree Consequences for an

Epidemic Probability of 0.01

Receive Vaccination Decline Vaccination

Consequence Value Probability Consequence Value Probability

A -X 2.25 x 10-9 G -X 1.25 x 10-6

B 0.0 1.5 x 10-5 H 0.1 2.4988 x 10-3
C 0.9 1.9985 x 10-2 I 1.0 9.975 x 10-'
D -X 1.103 x 10-7
E 0.2 7.349 x 10-4
F 0.98 9.7926 x 10-1

68
Vol. XVIII, No. 1 SWINE FLU VACCINE DECISION

)
augmented attack rate of GBS during the
[
first few weeks after receiving the swine (0.097,l)
1.0 I0

influenza vaccine. The mortality rate for

those contracting the GBS in our cohort is 0.9 -

approximately 0.05. Precise estimates for 0.8- ...

the probabilities of other outcomes are not NO

0.7-
available; hence, we proceed with the SHOT
0.6-
analysis below using both relatively high
probabilities and highly negative personal 0.5 -
values (approaching that for death) as well 0.4 -
as nominal estimates for the severe out-
0.3- 0r i?
comes. This provides a risk averse analysis,
0.2- SHOT
i.e. fairly conservative with respect to the
9*.
GBS, for individuals specifically wanting 0.1-
to take into account the potential ia- tJ - - , . - 'Y`
-I '' '' -"1- L
" _-P
I-i Y-
I -t-'
I -t-
I -S-
I i. I
trogenic* effect of receiving the 0 01 .02 .03 .04 .05 .06 .07 .08 .09 .10
vaccine. f
FIG. 5. Decision region for choice of receiving
We can estimate the values for the con- the swine influenza shot given epidemic probabilities
sequences of the branches of Figure 6 by and reduction proportions.
first finding the expected value for the set
of branches using the above probabilities
and then adding this value to the values
to consequences of these branches. For
already computed for branches B, C, E and this reason, we have not further disaggre-
F, respectively, in our basic tree in Figure
2. The hypothesis that these values can be gated paralysis outcomes.
We give "reasonable" upper and lower
summed is fairly innocuous, since it is
bounds for values of the branches of Figure
based on the assumption that the occur-
6 as well as probabilities of each conse-
rence of influenza, GBS and other reaction
outcomes are independent events and that quence conditional on the fact that we
have already reached the end of the corre-
the probability associated with non-GBS
outcomes when the shot is taken is of the sponding branches in Figure 2. The value
order of 10 -6, which is much larger than the ranges for consequences involving
paralysis were determined by considering
probability of dying from GBS induced by
the shot. Although the GBS could occur for typical decision analysis "lottery" ques-
tions involving the outcomes. Using Fig-
branches A and D representing death from
ure 7 we assessed a value for temporary
influenza following vaccination, the prob-
paralysis by considering sequential
ability of such an event is of the order of choices between contracting swine in-
10-11. Hence, corresponding values are in-
fluenza for certain and a hypothetical lot-
significant relative to all other outcome
values. Moreover, we will show the ulti- tery between the status quo and temporary
mate decision about taking the vaccine to paralysis where the probabilities q and 1 -
be rather insensitive to the values assigned q, respectively, of the latter two outcomes
were varied until a range was established.
* An From Figure 7, we see that
iatrogenic effect is an abnormal state or condi-
tion produced by a physician, other health care pro-
vider or intervention in a patient by inadvertent or
0 = q(l.0)+ (1- g)(k), or
erroneous treatment. k = -q/(l - q).
f It is taken as given that a person has not contracted
GBS unless there is physiological muscle involve- The authors feel that their probability q is
ment, e.g. at least some temporary paralysis. between 0.5 and 0.95 implying that k is

69
ZALKIND AND SCHACHTMAN
1 - 10-5
TEMPORARY
FIG. 6. Additional branches for Guillain-Barr6 syndrome with associated probabilities and ranges of values.
between -1.0 and -19.0. This procedure
is a standard one for assessing subjective
values for decision analysis. Thus, the ex-
pected value to be added to branches B, C,
E and F of Figure 2 is between 3.5 x 10-6
(-X) - 1.52 x 10-4 and 1.25 x 10-6 ( -X)
- 8.0 x 10-6, where ( -X) is the personal
value of death. Returning to the calculation
in Section 4, we see that in the case of the
severe value estimates, the value to which
X must be compared becomes 650 and in
the case of the moderate value estimates,
the comparable value is 492.
We recall that the previous value was
437. The reason that this difference is rela-
tively small is that relative to other out-
comes the probability of actually contract-
ing GBS and suffering a severe outcome is
quite small.t
The decision here remains automatic
since X = 499/p > 492 for p < 1; that is, take
the shot. For X = 499/p > 650, p < 0.767;
although the decision is not automatic, we
believe that if a proportional reduction of
three-fourths in the probability of death
t In fact, in the past the probability of getting GBS
from a "typical" influenza vaccine (other than for
swine influenza) was thought to be negligible and had
never been a serious consideration in the decision of
whether or not to take such vaccines.
70
MEDICAL CARE
Value Bounds
Severe Moderate Probability
3 0 0.99999
- --X 5 x 10
IS -2X -.5X 1.5 x 10'6
-19
PARALYSIS
-1 8 x 10
during the upcoming year could be ob-
tained by taking TA, most people would do
so. Therefore, following the line of reason-
ing in this paper, we believe that most
people should take the swine influenza
vaccination.
Hence, rather surprisingly, for the au-
thors' cohort, probabilities and values,
analysis of the tree augmented with GBS
branches indicates no change in the deci-
sion. That is, if the original decision were
clearly in favor of getting the shot and if
there had been no concomitant drop in the
subjective estimates for the occurrence of a
swine influenza epidemic about the same
time that the increased incidence of GBS
was being recognized, the individual's de-
cision to get the shot might not have
changed.
6. Summary and Conclusions
We have illustrated that the systematic
methodology of decision analysis can be
applied to problems viewed in a distinctly
non-economic manner-in this case, the
personal decision based on potential
health consequences of whether to get an
influenza vaccination. It was shown that
once the problem was formulated, the
Vol. XVIII, No. 1 SWINE FLU VACCINE DECISION

Swine Influenza for sure after taking shots

and getting reaction

1.0 0.0
,
()~~~~~~~~~~~,

versus

FIG. 7. Lottery to deter-

mine value range for tem- 1.0
Status
porary paralysis.
q

1 -q
Temporary Paralysis k

k = value assigned to temporary paralysis.

"best" personal decision might be evident
without having to make value judgments
about conceptually difficult-to-measure
outcomes, such as death. Furthermore, we
used a (derived) personal non-economic
value of the decision maker's own life in
making a decision where recognition of the
appropriate choice without knowledge of
such a value was not automatic. One rather
unexpected result is that the inclusion of
the possibility of contracting the
Guillain-Barre Syndrome, a pos sibility that
effectively ended the massive federal
swine influenza vaccination program, was
unlikely to alter the personal decision
about getting the vaccine.
Public health authorities have been con-
cerned with "high-risk groups" when con-
sidering influenza immunization policy
and programs. In general, high-risk groups
have been characterized by age, respira-
tory ailments and certain chronic dis-
eases.2, 4-6,9 In the case of swine influenza,
no specific identification of high risk was
made.6 However, for individuals who or-
dinarily would receive influenza vaccine, a
bivalent vaccine (including A/New Jersey)
was recommended. Accordingly, to
employ our methodology to such cohorts,
one would alter the probabilities of mor-
bidity and mortality in the decision tree
and perform sensitivity analyses. Clearly,
such individuals may also reflect their at-
titudes about consequences by adjusting
the corresponding values in the tree.
Currently, HEW officials are revaluating
federal policy on influenza immunization.
There is an ensuing controversy on the key
cost-effectiveness issue, which involves
the estimation of excess morbidity and
mortality from influenza viruses with and
without consideration of high risk.2,4-6,9
Regardless of the outcome of federal dis-
cussions, including, possibly, revised es-
timates of risks and benefits, our analysis
remains appropriate for individuals faced

71
ZALKIND AND SCHACHTMAN MEDICAL CARE

with the decision of using available
vaccines.
A relatively inexpensive package could
be developed which would allow a para-
professional, working with a patient in any
risk group, to use personal values in
evaluating the decision. The authors hope
that this paper will contribute toward mak-
ing informed consent by patients about
medical care more prevalent as they be-
come intelligent participants in decisions
about their own health care.
References
1. Albert D. Decision theory in medicine: a review
and critique. Milbank Mem Fund Q 1978;56(3).
2. Gregg B, Bergman J, O'Brien RJ, Millar JD.
Influenza-related mortality. JAMA 1978;239.
3. Hattwick MAW, O'Brien RJ, Hoke CH, Dowdle
WR. Pandemic influenza, the swine influenza virus
and the national influenza immunization program.
Center for Disease Control, DHEW, 1976.
4. Housworth J, Langmuir AD. Excess mortality
from epidemic influenza, 1957-1966, Am J Epidemiol
1974;100.
5. -, Spoon MM. The age distribution of excess
mortality during A2 Hong Kong Influenza epidemics
compared with earlier A2 outbreaks. Am J Epidemiol
1971;94.
6. O'Brien RJ, Schoenberger L, Bregman DJ,
Goodman, R. Center for Disease Control, DHEW,
personal communications, 1976 and 1978.
7. Pliskin JS, Beck CH. Decision analysis in indi-
vidual clinical decision making: a real-world applica-
tion in treatment of renal disease. Methods Inf Med
1976;15(1):43.
8. Raiffa H. Decision analysis: introductory lec-
tures on choices under uncertainty. Reading, Mass.:
Addison Wesley Co., 1968.
9. Sabin AB. Mortality from pneumonia and risk
conditions during influenza morbidity during
nonepidemic years. 1977;237(26).
10. Schoenbaum S, McNeil BJ, Kavet J. The
swine-influenza decision. New Engl J Med
1976;295(14).
11. Shachtman RH, Blau RA. A syllabus for deci-
sion analysis. Chapel Hill: University of North
Carolina, 1974.
12. Vital Statistics of the United States, Vol. 11,
Section 5. Rockville, MD: National Center for Health
Statistics, 1976.
13. Zalkind DL, Shachtman RH. An introduction to
decision analysis for health professionals. Unpub-
lished manuscript, presented at the American Public
Health Association Meeting, Miami, Florida,
November, 1976.
14. , Shachtman RH. The swine flu vaccina-
tion decision for an individual. Presented at the
American Public Health Association Meeting, Miami,
Florida, November, 1976.
15. , Shachtman RH. A non-economic per-
sonal value of life.

Call for Abstracts

American Public Health Association
108th Annual Meeting

The Medical Care Section of the American Public Health Association is calling for
abstracts of studies ready to report by summer 1980. The papers selected will be presented
at the 108th Annual Meeting, to be held October 19-23, 1980, in Detroit.

Abstracts must use the standard form appearing in the January through March 1980
issues of The Nation's Health or available from the contact below. All submissions to the
Medical Care Section must be postmarked no later than March 15, 1980. Please submit
abstracts to
Lyman Dennis, Ph.D.
Vice President
Medicus Systems Corporation
7315 Wisconsin Avenue
Washington, D. C. 20014
Authors of selected abstracts will be asked to submit a 3-5 page draft later in the spring.
Final selections will be made from these drafts.

72