QUALITY PARTNERS(TM) OF RHODE ISLAND: INFLUENZA 2004-2005

Medicine and Health Rhode Island, Jan 2005 by Schwager, Mark

THE VACCINE SHORTAGE

The Influenza season for 2004-2005 started abruptly on October 5, 2004, before a single case of the disease had been detected, when US health officials learned that 50% of anticipated influenza vaccine would be unavailable for distribution. On that day, Chiron Corporation announced that British authorities had impounded 48 million doses of flu vaccine, intended for the United States, because of bacterial contamination at its manufacturing plant outside Liverpool. ' At the time of Chiron's announcement, the nations other remaining injectable vaccine manufacturer, Aventis Pasteur, had shipped 33 million of its expected 58 million doses. The Centers for Disease Control and Prevention (CDC), working with Aventis, took the unprecedented step of applying a reallocation plan to the distribution of the remaining 25 million doses by designating eight priority groups for influenza vaccination (http:// www.cdc.gov/flu/). In managing this acute shortage, our public health system has been forced to confront the vulnerability of the nation's vaccine supply.

In the first phase of distributing the remaining vaccine, the CDC and Aventis targeted high-risk patients, shipping 14.2 million doses of vaccine over a six-week period to Veterans Administration facilities, nursing homes, acute care hospitals, and pediatricians. Veterans Administration facilities and pediatricians were allocated at 100%, with hospitals, nursing homes, assisted living facilities and adult day care receiving appropriate amounts of vaccine to immunize residents and direct care staff. Private sector Aventis customers, as well as state and local public health departments, were told they would recieve up to 50% of their initial orders, based on needs.

In phase two of distribution, CDC and Aventis will ship another 10.2 million doses of vaccine to state health departments by the end of January. This will be based on how many high-risk people each state has and the number of doses already received.

Paradoxically, the shortage of influenza vaccine may motivate people at risk who never get the flu vaccine to seek it now because of the publicity surrounding the vaccine shortage. In the most recent National Health Interview Survey, only 43 million doses of vaccine would be required in 2004 to immunize the CDC high-priority groups at the same rates reported for the 2002-2003 season.2

THE RHODE ISLAND RESPONSE

Rationing of vaccine dictates that some high-risk citizens will not be immunized. All local health departments, therefore, are in the difficult role of deciding how to ensure available vaccine is allocated in the fairest way possible.

When the vaccine shortage came to light, the Rhode Island Department of Health (HEALTH) published the "State Influenza Outbreak Plan" (http://www.health.state.ri.us/flu/ fluoutbreakplan.pdf) and convened a Flu Vaccine Shortage Advisory Group comprised of physicians, healthcare providers, medical ethicists and insurers. Vaccine Updates have been faxed to the physician community and are also available at the HEALTH website, www.healthri.org. The advisory committee, with little evidence-based criteria available, developed expert opinion-based criteria for prioritizing within the CDC high-risk group. On November 16, 2004, HEALTH recommended moving up the age for vaccinating healthy adults in the community from age 65 to age 75 and excluding adults under 50 with intermittent asthma and diabetics managed by diet and exercise alone.

Approximately 185,000 doses of flu vaccine have been shipped to Rhode Island and delivered to pediatricians, hospitals, long-term care facilities, assisted living residences and adult day care facilities. Approximately 50,000 additional doses of vaccine will be distributed by HEALTH through January 2005. HEALTH will maximize the benefit of the vaccine that is available by focusing vaccination efforts on the most vulnerable among the high-risk population.3

VACCINE VULNERABILITY

The vaccine shortage of 2004-2005 and an Institute of Medicine (IOM) report, "Financing Vaccines in the 21st Century," have highlighted weaknesses in the structure of the US vaccine supply and distribution system. Our public healrh system has not addressed the relationship between financing and availability of vaccine while the market-driven purchasing and acquisition system for vaccine has caused a consolidation of vaccine manufacturers. A public-private partnership which involves financial incentives is necessary to protect the existing vaccine supply and to develop new products and vaccines. In addition, the low reimbursement providers receive for vaccine administration exacerbates the problems of distribution. To address vaccine-access disparities and ensure higher overall immunization rates, the IOM recommended government vaccine subsidies be substantially increased, that every health insurance policy include full coverage for vaccination, and that uninsured individuals receive vouchers to obtain recommended vaccines.(4