Nov 18, 2004 (CIDRAP News) Kris Ehresmann, RN, MPH, clearly recalls when she learned the United States had just lost nearly half of its flu vaccine.
At 9:50 a.m. on Oct 5, Ehresmann knew that her job as manager of the immunization, tuberculosis, and international health section for the Minnesota Department of Health (MDH) had instantly become much harder. That moment marked the beginning of a series of difficult decisions under fast-changing circumstances.
To Minnesota's advantage, the health department had been developing distribution plans for vaccine since 2000-2001, when delayed deliveries prompted discussion of the issue. To the state's detriment was that 50% of its supply was to have come from Chiron Corp., whose entire production of 48 million doses was lost because of contamination problems at the company's plant in Liverpool, England.
The numbers were daunting, Ehresmann told an audience at the University of Minnesota in Minneapolis on Nov 12. There were 1,572,000 Minnesotans in priority groups for vaccination under federal guidelines, but only 925,770 doses of vaccine. If everyone in the priority groups wanted a dose, Minnesota could meet only 60% of the need, she said.
It quickly became clear that some priority groups would have to come before others, Ehresmann said.
Nursing-home residents versus health workers
Talks quickly focused on the state's long-term care and healthcare worker populations. The Centers for Disease Control and Prevention (CDC) has recommended that both nursing-home residents and healthcare workers who directly care for patients have priority for flu shots during the current shortage.
The MDH was particularly concerned about nursing-home residents because they are a very vulnerable population who essentially can't speak for themselves, according to Ehresmann. For example, they can't easily attend a flu-shot clinic in the community, so the vaccine needs to be brought to them.
Minnesota has 204,000 licensed healthcare workers. Nationally, about 38% of healthcare workers are vaccinated yearly for the flu. If that figure held for Minnesota, it would amount to 61,200 doses of vaccine, which would more than cover people in each of the state's 37,000 licensed long-term care beds.
The health department made vaccinating nursing-home residents its top priority, Ehresmann said. From there it was a short step to a controversial break with national guidelines: asking healthcare workers not to get that shot in the arm.
"As this situation was emerging, we felt there was not enough vaccine for both the high-risk people and healthcare workers," Ehresmann said.
MDH recommended Oct 19 that health workers forgo flu shots. The department suggested an alternative: those who wished could obtain FluMist, the live attenuated intranasal vaccine. Because FluMist is recommended only for healthy people aged 5 to 49 years, health workers who receive it aren't cutting into the vaccine supply for the vulnerable.
Some doctors and hospital workers immediately asked the health department to reconsider that decision.
Some healthcare providers and organizations remain reluctant to take or recommend the intranasal vaccine, Lynn Bahta, the immunization unit supervisor for programming at the MDH, said in a phone interview. The issues include skepticism about the safety of live virus, a concern that it isn't appropriate for workers in some areas of hospitals, and the fact that some workers are too old for FluMist.
The health department created a FluMist fact sheet, explaining in part that workers can be vaccinated unless they don't qualify or they work with patients who are so immunocompromised that they are in protective isolation.
"Some counties have said they're having a really hard time moving FluMist to healthcare workers," Bahta said.
"The healthcare worker issue really hit some raw nerves and showed a departure in thought processes in terms of population-based health and clinic-based health" philosophies, she said.
In her Nov 12 speech, Ehresmann summed it up: "We have learned the hard way that prioritizing limited resources is hard."
Reaching those at risk
As the state waded through that fallout, MDH employees sought to locate vaccine and redirect it to the neediest people, chiefly in nursing homes. The state helped redistribute 70,000 doses of vaccine, and local public health agencies moved several thousand more, Bahta said.
One month after the Chiron news, officials announced that Minnesota's nursing homes had enough vaccine for residents. It was a big turnaround in short time, since about 90% of those facilities lacked vaccine in October, according to a Star Tribune story. Many companies and clinics voluntarily surrendered doses they had purchased.
Rick E. Carter is president and CEO of Care Providers of Minnesota, a trade association representing about 300 nursing homes and assisted-living facilities. He lauded the department's efforts at redirecting vaccine.
"What they did was simply through the power of persuasion," Carter said. "The coordination of effort at the health department was quite remarkable."
Now that long-term care facilities are covered, Bahta said, the state is moving to a second stagepublic flu-shot clinics for those at risk. It became clear that some people who should be getting shots were not seeking them, so the state is changing its language. Now high-risk patients are being termed "at-risk," so that healthy people over 65 "see they're part of this category," Bahta said. "Age alone is a risk factor."
It also became clear that those who most needed information, the elderly, were least likely to use the MDH's extensive flu Web site, officials said. The department quickly established a hotline and activated volunteers to staff it. That flu hotline had taken more than 15,000 calls by Nov 5, Bahta said. It's still receiving about 400 calls a day, a number she expects will increase as public flu clinics are scheduled and if flu cases increase.
Minnesota could receive up to 81,000 more doses of vaccine, depending on need, Bahta added. Or the state could waive its claim to a portion of those vaccines so other states could use them. That decision will require a lot of collaboration, she said.
Minnesota has seven confirmed flu cases to date and has experienced no major outbreaks in institutions, Bahta said yesterday. But it's too early to relax.
Making it clear that Minnesota is still taking this flu season one day at a time, she noted wryly, "Thanksgiving could turn everything around."