Rationing, lack of public clinics limits access for children under 5 to H1N1 vaccine

Photo of the H1N1 virus

Photo of the H1N1 virus

Swine flu vaccine has been slow to arrive in Vermont, and because of the shortage, health officials have been forced to ration inoculations.

Vermont Department of Health has given top priority to the mass vaccination of schoolchildren, and the first school clinics start this week.

The youngest, most at-risk children, age 6 months to five years, must get vaccinations from private doctors who are typically backlogged with patient requests, or wait for immunizations at public clinics, even though the Centers for Disease Control and Prevention recommends that this age group receive inoculations first when vaccine is in short supply.

Dr. Wendy Davis, commissioner of VDH, says she has directed the initial shipments of vaccine to local providers and school clinics. The department won’t launch public clinics until next week. So far it has only posted announcements on its Web site for public clinics in Manchester Center and Middlebury.

“I think the challenge people are feeling as parents and health care provider offices is related to the vaccine delays,” Davis says. “Providers are receiving vaccine, but they are going through it very quickly. I can understand how a parent might call on a certain day and they might be told ‘Call us back next week and we’ll see what we get.’ I’m hearing that provider offices have different strategies for doing this. Some are planning weekend clinics. Some are doing walk-in clinics every afternoon. Some are doing it by appointment.”

On Monday, VDH launched the first of its clinics in 330 Vermont schools. Because of the vaccine shortage, 19 out of 49 school clinics planned this week have been delayed, according to The Barre-Montpelier Times Argus.

As of Oct. 23, the Centers for Disease Control and Prevention shipped 34,200 doses to Vermont – about half of what is needed to inoculate the 65,000 schoolchildren VDH estimates will be immunized in Vermont.

Last Wednesday, Davis confirmed 45 cases of swine flu for the week ending Oct. 17 and announced that the virus is now widespread in Vermont. At schools around the state, dozens of absences had been reported because of suspected illness. Most of the cases in Vermont, according to Davis, have been mild.

Dr. Louis DiNicola, the president of the Vermont chapter of the American Academy of Pediatrics, says his office has been extremely busy. He’s seeing many cases of flu-like illness, most of which he says are H1N1.

DiNicola, who has practiced medicine for 30 years, said, “It’s been the most difficult (flu) year I can remember.”

Given the current shortages of vaccine, it’s not clear yet how the department is planning to ensure the vaccination of very young children, who are at greater risk of complications from the swine flu, hospitalizations and death, according to the CDC.

Nationally, H1N1 vaccine has been allocated to states based on population numbers, according to VDH. The first few thousand doses (all that was available until this week) were given to health care providers, staff and the most vulnerable patients.

“While we wish we had the vaccine sooner, it’s certainly not slowing down our planning,” Davis said. “We are just receiving shipments that are ramping up from thousands per week to 10s of thousands per week. The expectation is that there will be more vaccine flowing in larger quantities as we move through the (flu) season, ultimately with the goal of making it available to anyone who wants it.”

The CDC guidelines, which VDH is obliged to follow, state that specific groups, including children under age 4, should be inoculated first when supplies are not yet widely available. (The other most vulnerable
“subsets” include children with medical conditions, pregnant mothers and adults with health problems, such as asthma, cystic fibrosis and heart disease.)

Patsy Tassler, epidemiologist for VDH, says, “We’re rolling it out as equitably as we can, as we get allocations of vaccine, making sure so that hospitals and providers, and in the coming weeks, schools, have vaccine.”

DiNicola recommends that parents call providers twice a week until they can get an appointment.

“Doctors are distributing the vaccine as fairly as possible to the highest risk populations,” DiNicola says.

At his own practice, DiNicola is scheduling same-day appointments for very young children when vaccine is available, and referring most school-age children to the clinics. He has a nurse on his staff whose primary responsibility is immunization.

“If someone dropped enough vaccine on our doorstep, we’d open an immunization clinic for patients,” he says.

Not all pediatricians, however, agreed to give swine flu shots. Some private physicians opted out of the government vaccination program, DiNicola says, because the required paperwork was too onerous.

So why didn’t the Department of Health publish a list of “participating” physicians? Larry Crist, director of the Office of Public Health Preparedness, says the department didn’t want to swamp local practices.

DiNicola says they really didn’t have time to publish it. Physicians were asked to turn in their paperwork three weeks ago, he says.

“The Health Department officials are doing the best they can,” DiNicola says. “We should have had 3,000 to 4,000 vaccines (by Friday), and we only had 100 last week.”

DiNicola highly recommends vaccinating children even if it appears that they may have already been exposed or had a flu-like illness. He says the peak of the H1N1 flu outbreak may be a month or so away.

Davis agrees. At a press conference last week she said, “With this first wave that has come through, although many people may be affected, many people may be spared.” She said in the second wave of the pandemic, many people could benefit from vaccination.

The U.S. Department of Health and Human Services describes H1N1 as a pandemic, a global disease outbreak of a new highly contagious influenza virus that causes serious illness among people who have little or no immunity to it.

On Saturday, President Barack Obama announced a national emergency in order to enable hospitals to set up off-site facilities for patients, if necessary. Swine flu is now considered widespread in 46 states.

The CDC has confirmed 95 pediatric deaths from H1N1 since April 2009. Of these, the majority were among children between the ages of 6 months to 2 years, according to DiNicola. The incidence of hospitalization has been the highest among children under 4, according to the CDC.

The swine flu has caused the hospitalization of 20,000 people in the United States, and more than 1,000 deaths have been attributed to the virus, according to The Washington Post.

Seasonal flu typically causes 36,000 deaths a year nationwide, according to Davis. What makes swine flu worrying is that it attacks healthy young people under the age of 24, while seasonal flu typically leads to complications and death among the very young, the sick and the very old.

What follows is a press release from VDH sent on Oct. 23 to schools and health care providers in Vermont.
2009-2010 H1N1 Influenza Season Update #4
Vaccination of School-Age Children

To: Health Care Providers, Hospitals, Infection Control Practitioners, Schools, Home Health Agencies
From: Wendy Davis, MD, Commissioner of Health
Date: October 23, 2009

– Please Distribute Widely –

School based vaccination clinics
Last week, the Centers for Disease Control & Prevention (CDC) notified states that vaccine manufacturers are experiencing delays in the production of the 2009 H1N1 vaccine. Since that time, the Vermont Department of Health (VDH) has been working with our many partners – including health care providers and schools – to review our vaccination plans and make adjustments as needed.

The first school clinics will begin on October 26; subsequent school clinics will occur less frequently than previously planned and some will need to be rescheduled. We will continue to provide vaccine to health care providers, hospitals, health agencies, and to schools as soon as we can, based on vaccine supply.

Our goal continues to be to move vaccine to providers and clinics as quickly as possible, to ensure vaccination of those individuals who need it most, including school-aged children.

Public and Private schools
• All private, parochial, independent and public schools were offered the opportunity to provide vaccine to their students in a school setting. The vaccination efforts are voluntary.
• Schools with 300 or more students were offered Health Department-run clinics.
• Schools with fewer than 300 students were asked to run their own clinics. Some chose to combine with other schools making them eligible for a Health Department-run clinic.
• We collaborated with small schools which are without a school nurse, and schools with a nurse working limited hours, to provide vaccinator staffing from either the Vermont Emergency Response Volunteer (VERV) vaccinator pool or contracted nursing staff.
• Schools that have not already scheduled a vaccination clinic are still able to do so. If interested in providing vaccine to students, schools may call their Health Department district office. Due to vaccine supply delays, newly scheduled clinics may not occur until December/January.
Parents in schools during vaccination clinics
• Parents have been encouraged to not attend the Health Department-run school based clinics. This is for logistical and security reasons, including making sure clinic flow is not slowed to a point where we are not able to vaccinate all the children scheduled for that day.
• Ultimately, the decision to allow parents to accompany their child during clinic is a local school decision.

Vaccine in provider offices
• It is our hope that vaccinating children at the school based clinics will help keep providers from being overwhelmed by calls and demand for vaccine from parents of children who can receive it at school. At the same time, we recognize that not all these children will be vaccinated at a school clinic, and that providers are faced with managing the currently limited supply of vaccine.
• Health Department continues to follow the CDC guidance, and is focusing its vaccination efforts on the ACIP identified target groups – taking care of those individuals who need it most. Please see the attached ACIP guidance for when initial supply of vaccine is not adequate to meet immediate and short term demand.
• Because of vaccine supply delays, Health Department recommends that providers balance the CDC guidance with their patient needs when determining which patients should receive the H1N1 vaccine. The attached guidance should help providers in making these determinations.

Other (non-school) vaccine availability sites
Public Clinics
• VAHHA agencies will begin conducting public clinics for the target group population in early November.
• Once scheduled, a frequently updated list of these public H1N1 clinics will be available online at the Health Department Web site: http://healthvermont.gov/prevent/flu/flu_clinics_h1n1.aspx. Members of the public may also dial 2-1-1 for information.

Provider Offices
• Health Department is recommending that patients not be instructed to call around to other providers to seek H1N1 vaccine. Patients should be in contact with their own provider, can check the above Health Department Web site, or dial 2-1-1 .

Anne Galloway

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