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H1N1 vaccine to be allocated differently

December 1, 2009
By MARY VORSINO, The Honolulu Advertiser

In response to mounting criticism about how the short supply of swine flu vaccine is being distributed in Hawaii, the state will change the way it doles out the vaccine.

The state Health Department had been distributing swine flu vaccine based on when providers placed orders.

But the first-come, first-served distribution method has forced many pediatricians to set up waiting lists for swine flu vaccinations, even as many pharmacies statewide still have the H1N1 flu vaccine in stock. And it has left some of the largest health care providers in the state with little or no vaccine to give to patients for weeks.

Several doctors, health care industry experts and others say they've been left frustrated and perplexed at how the Health Department is handling the distribution of the vaccine, and they're concerned that the vaccine isn't getting to those who need it the most. Many are asking for more transparency on where the vaccine is going, including a list of how much vaccine each provider has received. They also say the state should better track who is getting vaccinated to ensure that doses are getting to all priority groups.

State Sen. David Ige, D-16th (Pearl City, Aiea), chairman of the Senate Health Committee, said there have been "obvious . . . shortcomings" in the distribution of the vaccine and concerns about why more isn't being done to track who is and isn't getting the vaccine. "Clearly, I think we should examine what we're doing," he said.

The H1N1 vaccine distribution is the first real-life test of the state's ability to handle a pandemic flu emergency, and some onlookers say if swine flu were more virulent, Hawaii could be in serious trouble.

Nearly two months after the state began distributing swine flu vaccine to providers - with the first shipment coming in on Oct. 5 - state health officials don't have a readily available list on where the vaccine has gone.

There also seems to be confusion about where to get the vaccine, and some who are eligible can't find it.

And health officials don't have a clear picture of who is vaccinated because that information is largely not collected.

"We have no idea who we're vaccinating," said Jay Maddock, University of Hawaii public health department chairman. He added, "This is the time to address these issues. (Swine flu) has really shown us where there are system failures."

The state says part of the problem is that providers aren't doing a good job of reporting back to them on how many doses of flu vaccine they've administered. In part to address that, the state says it will alter the way it decides where swine flu vaccine goes.

Dr. Sarah Park, state epidemiologist for the Health Department, said providers will get the vaccine based on a new formula starting as early as this week, meant to reward those who are submitting information quickly on vaccine administrations, while also taking into account a provider's client base.

Those who have the most clients and serve multiple islands will get more weight under the formula. Also, medical specialties will be considered, with priority given to pediatricians.

"I know not everyone is going to be happy" with any distribution formula, Park said.

She added, "We're going to be more mathematical" with the distribution.

Already, more vaccine has been targeted for certain priority groups and big providers, including Kaiser. Last week, the Health Department shifted gears with its most recent order, deciding to send more vaccine to large health care providers and the rest to pediatricians and obstetricians.

The change is a dramatic switch for the state.

"The central issue is not only the distribution (of vaccine), but also lack of transparency. Nobody knows where it's going," said Toby Clairmont, emergency services director for the Healthcare Association of Hawaii, which represents 115 organizations, including hospitals, long-term-care homes and other health care providers.

Clairmont added that the new distribution formula appears to address some concerns.

"What it sounds like is that they're becoming more sensitive to the reality of it," he said.

A representative from Kaiser, which serves about 224,000 people statewide, couldn't immediately say how many doses of the vaccine the organization has received, but she did say, "We're not able to provide the vaccine to all of our high-risk members."

The Health Department said it's trying to distribute the vaccine equitably, and is grappling with vaccine distribution amid the state's budget crisis and with a short staff. And, health officials add, they're frustrated, too, but with providers who are slow to hand over required information on the doses they've administered. As of Wednesday, the state had received information on about 25 percent of vaccines administered statewide.

The Health Department acts as the intermediary between the national Centers for Disease Control and Prevention, which decides how much vaccine Hawaii gets, and vaccinators, who place orders with the Health Department. Once an order is made, the vaccine is shipped directly to the provider or in some cases, is sent to Health Department sites to be picked up by providers.

Some industry experts say the distribution missteps should be seen as a learning experience - and an invaluable chance to see what works and what doesn't when it comes to managing a flu crisis and getting vaccine to those in priority groups.

Dr. Alan Tice, one of the state's leading infectious disease experts, said that anecdotally it appears the vaccine is not getting to health care workers and other high-risk groups as quickly as it should. He added that the state needs to do a better job of talking to providers so the needs of the community are understood and met.

"The practitioners should be involved early on and help establish the criteria for distribution of vaccine," Tice said, adding that providers and clinicians have so far gotten no significant say in how the vaccine has been distributed, though some have voiced concerns with the state Health Department. "This is our opportunity to learn so much about how to manage an epidemic like this. There are some very important lessons here."

Dr. Galen Chock, president of the American Academy of Pediatrics-Hawaii chapter, called the vaccine distribution a "learning process," and said the DOH is doing the "best job they can" with their staffing levels and furlough days.

"This is a new process," said Chock. "What it really takes is everyone to be patient."

Swine flu has sickened thousands of people in the islands and been linked to 11 deaths, including several in which patients had no pre-existing conditions. Health officials say the H1N1 virus remains relatively mild, with most experiencing symptoms comparable to or less severe than seasonal influenza.

Also, though H1N1 appears to be the dominant strain of flu in Hawaii, health officials say that the state is currently experiencing something of a lull in the number of cases of swine flu compared to the Mainland, where swine flu activity is being called "widespread." Nationwide, the death toll from the flu is at more than 3,900.



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