2004-2005 Influenza Vaccine Shortage: Vaccine Redistribution Model

State: NY Type: Model Practice Year: 2005

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The Monroe County Vaccine Redistribution Model addressed the needs resulting from the shortage of vaccine in the nation for the 2004-2005 influenza season by assessing the community’s need for vaccine among high-risk paitents, and establishing a system of redistribution of vaccine throughout the county. The target population was high-risk priority groups as outlined by the ACIP guidelines. Our main goals were to ensure that only high-risk individuals, as many as possible, be vaccinated, to allay public concern or panic, and to eliminate the difficulties associated with public clinics during times of crisis.

In this emergency response model, the Monroe County Department of Public Health (MCDPH) requested the cancellation of all public and employer clinics, and asked that vaccine be redirected to physicians who could best determine a patient’s need. In addition, MCDPH asked that private physicians who had excess vaccine make it available to those in need. For local nursing agencies that typically conduct public clinics, MCDPH facilitated administration of their vaccine to long-term care facilities and other high-risk populations. Within twelve weeks, 60,000 doses of influenza vaccine had been redistributed and all high-risk patients had been vaccinated, as identified by providers. More than 160 physicians and health related organizations participated in this community collaboration.

Overall, MCDPH developed and implemented the plan, encouraged cooperation of partnering agencies, and enabled the equitable redistribution of resources. The program staff worked diligently and closely with all partners to obtain information and foster cooperation. Their trust in the program staff was relied on to make the best decisions for the good of public health. This model practice is a planned response to an emergency situation. There is no specific funding for it, nor is it meant to be sustainable. The required tasks were challenging and time consuming, but with the support of the community the program was able to be proactive and successful.

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Monroe County Department of Public Health
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2004-2005 Influenza Vaccine Shortage: Vaccine Redistribution Model
The Monroe County Vaccine Redistribution Model addressed the needs resulting from the shortage of vaccine in the nation for the 2004-2005 influenza season by assessing the community’s need for vaccine among high-risk paitents, and establishing a system of redistribution of vaccine throughout the county. The target population was high-risk priority groups as outlined by the ACIP guidelines. Our main goals were to ensure that only high-risk individuals, as many as possible, be vaccinated, to allay public concern or panic, and to eliminate the difficulties associated with public clinics during times of crisis. In this emergency response model, the Monroe County Department of Public Health (MCDPH) requested the cancellation of all public and employer clinics, and asked that vaccine be redirected to physicians who could best determine a patient’s need. In addition, MCDPH asked that private physicians who had excess vaccine make it available to those in need. For local nursing agencies that typically conduct public clinics, MCDPH facilitated administration of their vaccine to long-term care facilities and other high-risk populations. Within twelve weeks, 60,000 doses of influenza vaccine had been redistributed and all high-risk patients had been vaccinated, as identified by providers. More than 160 physicians and health related organizations participated in this community collaboration. Overall, MCDPH developed and implemented the plan, encouraged cooperation of partnering agencies, and enabled the equitable redistribution of resources. The program staff worked diligently and closely with all partners to obtain information and foster cooperation. Their trust in the program staff was relied on to make the best decisions for the good of public health. This model practice is a planned response to an emergency situation. There is no specific funding for it, nor is it meant to be sustainable. The required tasks were challenging and time consuming, but with the support of the community the program was able to be proactive and successful.
On October 5, 2004, Chiron Corporation announced that none of its influenza vaccine (Fluvirin) would be available for distribution in the US for the 2004-05 influenza season due to suspension of its license in the UK. This action reduced the expected supply of trivalent inactivated vaccine (TIV) for the US by 50%. The CDC issued ACIP guidelines regarding priority groups for influenza vaccination (see Interim Influenza Vaccination Recommendations – 2004-05 Influenza Season, CDC, 10/5/04) and recommended vaccination of high-risk patients only. There was an immediate need to prepare for a potential public health emergency related to an influenza outbreak, and related to problems inherent to vaccine rationing. The Monroe County Vaccine Redistribution Model addressed the needs resulting from the shortage of vaccine in the nation for the 2004-2005 influenza season by assessing the community’s need for vaccine among high-risk paitents, and establishing a system of redistribution of vaccine throughout the county. Community need and supply was assessed within one week from the announcement; by week five health officials covered all of the highest-risk populations (long-term care facilities, hospitals, HIV and cancer clinics, and pediatrics); and by the end of December had redistributed vaccine to private physicians to cover all of their identified high-risk patients who requested vaccination. Of note, this model was first implemented in 2000 in response to an influenza vaccine shortage and has been modified, as needed, each year in response to shipment delays and shortages. In 2000, over 4000 doses of vaccine were redistributed to medical practices for use with high-risk patients. In 2001, 2002 and 2003, approximately 2000 – 3000 influenza vaccine doses were redistributed annually. This season, over 60,000 doses of vaccine were redistributed. The usual approach in the community is that the majority of influenza vaccination is provided at large public health clinics (run by private nursing agencies), at places of employment and by private providers. In this emergency response model, given the severe shortage, the health department thought it best that physicians determine which patients should be considered highest priority. Health officials requested the cancellation of all public and employer clinics, and asked that vaccine be redirected to physicians who could best determine a patient’s need. In addition, private physicians who had excess vaccine were asked to make it available to those in need. According to the New York State Department of Health, they were unaware of any other county that handled redistribution in this way.
Agency Community RolesThe Monroe County Department of Public Health (MCDPH) was the lead in this redistribution effort. Overall, the department of public health developed and implemented the plan, encouraged cooperation of partnering agencies, and enabled the equitable redistribution of resources. MCDPH distributed some of the vaccines to community agencies that serve the homeless, and near the end of the process, held private, invitation-only clinics for high-risk patients who did not have a primary care physician. Public health officials collaborated with many agencies in order to accomplish the plan, including: the Monroe County Medical Society (MCMS), New York State Department of Health (NYSDOH), Monroe County Adult Immunization Coalition (MCAIC), Office for the Aging, licensed nursing agencies, occupational health organizations, home care agencies, neighborhood health centers, private physicians, local municipal government, universities and colleges, work places and the media. It was important that all of the parties involved presented an allied front with the public health perspective, and enforced this message to the public. Several partners were crucial to the implementation of the practice: 1) MCMS provided access to their physician database, communication system and resources. They worked side-by-side with the department of public health to survey the community in order to identify vaccine surplus and deficit. They informed the public and medical community, assisted with physical collection and redistribution of the vaccine, and provided coordination for private physicians. Throughout this effort, they spent a great deal of time conducting one-on-one conversations with physicians. They helped promote the public health point of view to all parties involved, including those who typically had a profit-making stake in influenza vaccine administration. 2) The media were very involved in the situation. They helped to spread the message of the reasons behind MCDPH decisions (why the public health officials were handling things differently than other places being shown on television), reinforced the CDC guidelines to the community, and provided information about the Flu Hotline and website resources. Their efforts helped to keep the public calm and informed. 3) The nursing agencies cooperated with the redistribution plan even though it meant lower revenue for them. The program would not have succeeded if they held public clinics rather than providing vaccine to nursing homes and those identified by their physicians as being high-risk. 4)MCAIC met to assure coordination of efforts and discuss parameters around redistribution of vaccine. MCDPH, NYSDOH, MCMS, local insurers, vaccine administrators, Sanofi Pasteur and Merck are among the MCAIC members. The Monroe County Department of Public Health regularly meets with community stakeholders about policy issues, as well as partnering with them on various health improvement initiatives. This relationship fosters collaboration and cooperation in times of crisis. The MCAIC meets regularly to discuss issues related to vaccine supply, review timely immunization updates and share information regarding public immunization clinics. MCDPH publishes the annual master calendar of flu clinics offered by all coalition members, providing free publicity for the agencies. Historically, MCAIC members have worked cooperatively in times of vaccine shortages.  Costs and ExpendituresThis model practice is a planned response to an emergency situation. There is no specific funding for it, nor is it meant to be sustainable. Due to the privatization of influenza immunization in our community, resulting in a small public health immunization staff, this practice put a strain on public health by diverting existing resources. The biggest cost was staff time for MCDPH and MCMS. The MCDPH Coordinator of the Immunization Program and Disease Control Unit, and the Executive Director of the MCMS, spent approximately 12 weeks full time to implement this practice. Others, such as the Deputy Director of MCDPH, the Director of Communicable Disease Prevention and Control, immunization staff, and others dedicated a substantial amount of time and effort as well. The licensed nursing agencies incurred costs as a decrease in expected revenue for the season. They typically provide 60,000 vaccines to the community each year, and reimbursement for administration constitutes a substantial portion of their revenue. By arranging for them to cover the nursing homes and other high-risk facilities, and conduct the private clinics, health officials attempted to minimize their loss as much as possible. The department of public health estimates that they had approximately 39,000 doses for administration this year and also fell short of the expected revenue target for influenza vaccine this year.  ImplementationThe specific tasks and associated timeline for the redistribution efforts are described below: Week One: Assessment On the day of the announcement from Chiron, MCDPH requested that public flu clinic providers voluntarily stop public clinics until the local vaccine situation could be assessed and information from CDC interpreted.  MCDPH and MCMS immediately began surveying the medical community. Health officials surveyed all area nursing homes and other long-term care facilities, home care agencies, local physicians, private nursing agencies and public flu clinic providers. Information was compiled to determine the vaccine deficit based on high-risk need, as well as how much vaccine was in the community. Within one week, more than 150 physicians or practices responded to the survey, identifying a total need of more than 56,000 doses for high-risk individuals in the community and 7,000 doses for nursing homes.  This deficit resulted in the decision to restrict vaccine for use with high-risk individuals only, and to cancel all public clinics for the remainder of the season, as health officials felt that screening for priority groups could be difficult in a public clinic setting. The local public clinic providers (nursing agencies) were adversely affected financially, but agreed to cooperate.  A regional conference call was conducted with local health departments of surrounding counties alerting them to the MCDPH decision to not hold public clinics, and they agreed to do the same. Weeks Two to Five:Initial Redistribution The nursing agencies were redirected to the long-term care facilities and other high-risk populations. This was accomplished through providing facility contact information and requirements to the nursing agencies for direct contact and arrangements on their part. All nursing homes and their associated living centers in need of vaccine were covered (approximately 30 facilities and 7,000 doses). Vaccine was included for residents and direct care staff. Public health officials also asked the nursing agencies to assist community organizations serving special populations, such as the Rochester Psychiatric Center and ARC of Monroe. This plan enabled the agencies to use their vaccine and obtain revenue. MCDPH redistributed vaccine to the highest risk population by the end of October, before any nationally redistributed supply arrived. MCDPH and MCMS identified potential sources of excess vaccine, and coordinated the process of provider-to-provider exchange. For example, health officials matched some pediatricians who had met their high-risk patient needs with adult practitioners who had no vaccine. Vaccine was transferred per the NYSDOH guidelines, including transportation safeguards and vaccine lot tracking. By early November, 28% of our private physician needs were covered. Weeks Six to Twelve: Continued Assessment and RedistributionWhen vaccine became available from NYS and the CDC, health officials redistributed enough to a local HIV care provider to cover their population.  The remainder of the State and Federal vaccine that came to the community was sold or given directly to small physician practices for administration in their offices. For large practices, invitation-only clinics were coordinated to be conducted by the nursing agencies. Physicians identified their high-risk patients and alerted them to the date/time and location of a private clinic via a letter that health officials crafted. Much of the redistribution plan relied on getting vaccine to people via the physician. However, it became apparent that a segment of the population would be missed if health officials adhered strictly to this model. To prevent that from happening, some vaccine was redistributed to community agencies that serve the homeless, uninsured, and those without medical providers.
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SustainabilityThis practice is designed to assess need and redistribute vaccine in the community to members identified as high-risk. It is intended for a crisis response, to ensure the high-risk are covered, allay public concern or panic, and eliminate the difficulties associated with public clinics at times of crisis. Lessons Learned Effective community partnerships are invaluable. Not all community partners share the same goal, so performance expectations must be stated clearly and frequently. Understand what motivates your partners.  Many physician practices could not easily identify their high-risk patients. Public health officials will be working with MCMS to help implement a system for easier and quicker response in the future.  Communication strategies were effective. The website, information lines, faxes and emails to the medical community, and media communications were all used extensively.<br. A complete and up-to-date physician database and communication system is invaluable. However, health officials need to develop a practice database vs. inidividual physician database for streamlined communications during emergencies.  We found more people than expected who did not have physicians or whose primary care physicians do not give immunizations.  Initially, local health units will have to rely on themselves and their community to respond quickly in the event of a mass public health emergency. Difficult decisions about the distribution of scarce resources may have to be made initially by the LHUs without guidance from the State or CDC because the response at the local level is quicker.
 
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