Area H1N1 vaccine flow somewhat chaotic
If you order a sweater on Amazon.com, you can go online and track its delivery progress day by day. But doctors’ offices that have ordered H1N1 flu vaccine can’t do that.
They don’t know when or how many doses will arrive, frustrating providers and patients. There’s still not enough vaccine manufactured so far to cover even the priority recipients.
It’s like when seven people order the same sweater, but only one sweater is in stock — many customers are left with back orders, wondering when their garment will come. Orders for H1N1 vaccine across New York state are seven times the supply so far, so providers are typically receiving only part of their orders, said Dr. Guthrie Birkhead, deputy state health commissioner. That’s true in the Rochester area, although some medical offices have gotten none yet, while some have gotten all the vaccine they ordered.
Just as sweaters come in various sizes and styles, so does vaccine, further complicating the efforts to match medical practice requests to available vaccine.
The state hopes to provide accurate, detailed status reports about vaccine orders and shipments, but that’s not in place yet — six weeks after the vaccine began to arrive.
“We’d like to be like Amazon,” Birkhead said.
How much vaccine
Public health officials say that roughly half of the population falls into one of the priority groups for H1N1 vaccination — or 546,000 people in the six-county Rochester region, including 366,000 in Monroe County. The priority categories set by the U.S. Centers for Disease Control and Prevention are pregnant women, people who live with or care for infants younger than six months, children and young people ages six months through 24 years, people aged 25 through 64 whose medical conditions put them at higher risk for serious illness and influenza-related complications, and health care workers and emergency medical services personnel. So far, this region’s vaccinators have received 155,000 doses of vaccine, including 108,000 doses within Monroe County. That’s enough to vaccinate 28 percent of the region’s people in the priority groups, not counting the second doses recommended for children younger than 10.
But that doesn’t mean each office has received 28 percent of its order. Even offices that serve children and pregnant women report varying deliveries so far.
Lewis Pediatrics in Brighton has received 600 doses — about 40 percent of the 1,500 ordered initially, said Dr. Ed Lewis. He recently added 500 doses to his order.
But Unity Family Medicine at St. Bernard’s in Rochester, which serves children and adults, has gotten no H1N1 vaccine. Dr. Mike Nazar said he’s sympathetic to the huge task of manufacturers’ mobilizing to create a new vaccine on short notice. “The good news is that H1N1, the gigantic majority of the time, is a mild illness that most people recover from fine,” he said.
Not all are reassured by that fact. Multiple local doctors’ offices report that some anxious patients have gotten irate at staff, saying things as extreme as “If my child dies, it’s your fault.”
Mistakes in deliveries don’t help. Dr. Daniel Flaherty, a solo family practitioner in Irondequoit, ordered 600 adult shots to cover his priority patients. For an unknown reason, he has received only pediatric doses — 200 preservative-free, prefilled syringes for ages six months to 35 months, who get half the dose of older patients. He used 15 doses for his young patients, then redistributed the rest to pediatric offices. “I didn’t sell it on the black market,” he said jokingly. “It’s frustrating because I got the incorrect dose. But I think they’re doing the best they can.”
Greece Obstetrics and Gynecology ordered 200 single-dose vials, so they would be thimerosal-free as New York state usually requires for pregnant women, said Kathy VanDuzer, practice manager. The state waived that rule this year because of the H1N1 vaccine shortage. After waiting two weeks, the Greece practice hadn’t received anything, while they’d heard another local office received two shipments by then. A phone call to the state prompted an offer of 100 thimerosal-free doses from the local health department, followed days later by a shipment of 100 more doses, said VanDuzer. “We’re very happy,” said VanDuzer. The office first called in its 45 patients whose pregnancies are considered high risk, and then began contacting all their other pregnant patients and moms of babies younger than six months.
Penfield Obstetrics and Gynecology initially ordered 500 doses to cover their priority patients — pregnant women and those with babies under six months — and has received 200 so far. “We don’t understand,” said Judith Patterson, practice manager. “How is the manufacturer deciding?”
Who decides
The vaccine manufacturers don’t decide who gets which batches. They’re struggling to churn out as many doses as possible, using a 60-year-old production process that requires growing H1N1 flu virus in fertilized chicken eggs, the same way seasonal flu vaccine is made.
The reasons for the H1N1 vaccine shortage are that some batches haven’t grown as well as expected, some equipment to load prefilled syringes needed repair and one of the handful of vaccine manufacturers didn’t get licensed for H1N1 vaccine until recently, said Birkhead.
Unlike other vaccine distribution efforts, which are handled by the private market, the federal government took charge of coordinating H1N1 vaccine distribution so that vaccine would be distributed fairly to each state.
And distributing fairly means that size matters.
How they decide
The CDC allocates vaccine to each state by population, so New York gets 6.3 percent of the supply, mirroring its percentage of the nation’s population. Birkhead said the state then divvies up available vaccine equitably by county populations.
The doses shipped so far bear that out, on average. In each of the six counties in the Rochester region, vaccinators have gotten enough vaccine to cover between 24 percent and 29 percent of their population in the priority vaccination groups.
Within each county, Birkhead said they’ve been prioritizing orders from larger medical practices that serve children or pregnant women first, while also trying to spread around the vaccine. Orders for the nasal mist form of vaccine have been most easily filled, since relatively few have ordered that. That version of the vaccine, called FluMist, is only licensed for healthy, non-pregnant people ages 2 through 49, so can’t be used by many people in the priority groups. FluMist was the first H1N1 vaccine available to ship.
Birkhead said that during this time of limited supplies, the state is not looking so much at how many doses each medical office ordered, but rather how many patients the office has who are pregnant and how many are in each of the priority age groups. Offices were asked for those details when they registered to dispense H1N1 vaccine. The patient numbers make more sense than the orders, because vaccinators in Monroe County overall had ordered 1.2 million doses — nearly a half million more than the county’s entire population — by Nov. 13. Some of the excess ordering may be due to confusion over the state’s instructions, which initially called for offices to re-order every week but later were changed to say that any not-yet-received doses remain on back order.
The state health department finds out by daily e-mails from CDC how many doses of each formulation of vaccine are available for New York state outside New York City. New York City is so populous that it is treated as a separate entity.
The allocations are complicated by the fact that H1N1 vaccine comes in nasal spray and injectable form. Among the injections, some manufacturer’s shots are licensed only for adults, some only for ages 4 and up, some only for ages 3 and up. Some shots are packaged in multi-dose vials, which have a mercury-containing preservative called thimerosal, while some are in single-dose syringes that don’t contain thimerosal.
State health department officials compare the amount of available vaccine, by formulation, to its roughly 9,000-line spreadsheet of vaccine orders from about 5,000 providers who registered with New York state to dispense H1N1, Birkhead said. By hand, they allocate the supply in 100-dose batches, and the refrigerated vaccine is shipped directly to doctor’s offices, hospitals and county health departments.
The state has modified the approach along the way. In the first week or two, offices that ordered only prefilled syringes didn’t get any doses because that form wasn’t available, Birkhead said. Likewise, said Birkhead, “just to show how Byzantine this is,” those who ordered four packages containing 25 syringes each didn’t get orders filled initially because the only syringes available were 10 packages containing 10 syringes each. That didn’t seem fair, so they have offered substitutions, said Birkhead. “It’s been a learning experience,” he said.
People waiting in line Thursday at Monroe County’s first H1N1 vaccine clinic varied in their frustration and sympathy for the overall efforts to create and distribute vaccine.
Sherry Hardiman, 34, of Irondequoit, who’s pregnant, arrived a half-hour before the doors opened at Medley Centre on Thursday and waited for six hours for vaccine for herself and her 18-month-old son. They were at the clinic because her doctor, obstetrician and her son’s pediatrician didn’t have vaccine. “I’m very concerned about getting the swine flu because of the deaths in pregnant women,” she said. Told of the behind-the-scenes work to create and distribute vaccine, she said it’s sad that the supply is so limited that high-risk people have to wait.
The vaccine supply changes day to day, and manufacturers overpromised and have under-delivered. Birkhead is hearing that the week after Thanksgiving might be the biggest yet for vaccine availability, and those doses would arrive the following week.
“We’re asking people to be patient,” said Birkhead. “We’re clearly in a shortage situation.”
CSWINGLE@DemocratandChronicle.com
H1N1 vaccine clinics
The state Department of Health’s Web site links to each county health department’s H1N1 flu clinic information page, www.health.state.ny.us/diseases/communicable/influenza/vaccination_clinics.
Seasonal flu vaccine clinics
Flu Prevention Partners announced the following seasonal flu vaccine clinics for ages 5 and older:
Thimerosal-free vaccine will be available for pregnant and nursing women. Medicare, MVP and Blue Cross/Blue Shield Plans are accepted. If insurance is not applicable, the $30 fee will have to be paid at the time of the visit by personal check or with cash. Receipts for insurance purposes are available.
