In the past several weeks, as the H1N1 flu has swept through the nation and health officials scrambled to find scarce vaccine, questions have been raised about how Pennsylvania chose to handle the process of distributing the limited doses available.
"There's no rhyme or reason as to how it's being delivered. It's very chaotic. Until it arrives on our doorstep, we're not aware of what we're getting or in what amounts," said Kathy Guatteri, executive director of Children's Community Pediatrics, a group of 28 pediatric practices associated with Children's Hospital. Each of those practices had to place its own separate request for vaccine.
The combination of a vaccine shortage with a distribution system based on pre-registration by individual providers and schools resulted in haphazard -- and sometimes unexpected -- deliveries that sent doctors offices or school officials scrambling and forced at-risk patients to chase information.
With the Allegheny County Health Department holding four free H1N1 vaccine clinics for at-risk groups tomorrow, as well as 18 state health department clinics scheduled across the state this weekend, some are wondering what took so long.
"Clearly, that's the way it should have been done," said Dr. Bruce Dixon, director for the Allegheny County Health Department.
Dr. Dixon said he had lobbied for a distribution system similar to that used in Ohio and West Virginia that would have sent vaccine to county or municipal health authorities that could then make sure those at highest risk, such as pregnant women, got the first doses.
"I was overruled," he said.
Instead, state health department officials decided to have individual providers, schools and universities pre-register for batches of vaccine, believing that approach could best target the highest-risk groups in the quickest manner and respond to sudden outbreaks in different regions.
The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices identified five initial target groups for vaccination: pregnant women, people who live with or care for infants younger than 6 months of age, health care and emergency medical services personnel, children and young adults ages 6 months to 24 years old, and people 25 to 64 years old who have medical conditions that put them at higher risk for influenza-related complications.
Pennsylvania's decision to set up the pre-registration system was meant to reach key groups.
Last night in Moon, schoolchildren and their parents lined up for vaccinations that were provided by the Moon Area School District.
Amanda Hartle, spokeswoman for the district, said it had requested 619 injectable vaccines and 1,445 doses of nasal mist. The district received 600 injectable doses but none of the nasal mists.
The district sent information and consent forms home with children and those who returned it filled out by their parents were eligible for the shots last night on a first-come, first served basis.
The line of those outside the middle school formed well before the start time of 6 p.m.
One of those parents near the front of the line was Greg Jeffries, 38, of Moon, who brought his two sons, Caleb, 8, and Jose, 6.
"We thought this was very important," Mr. Jeffries said of his and his wife's thinking. "We've gotten them flu shots before, and we didn't give this a second thought. We don't want to leave anything to chance."
Nancy Kennedy, 44, of Moon, brought her four children ranging in age from 7 to 14.
"This actually is the first year they've gotten flu shots," Ms. Kennedy said. "I wasn't convinced that I was going to [have them get shots], but I talked to my sister-in-law, who's a school nurse, and she thought it would be a good idea."
Michael Huff, assistant secretary of health planning and assessment who has overseen the vaccine distribution, noted the individual pediatric practices, schools and universities work directly with the vulnerable young. Getting vaccine to them seemed the most direct route to getting children vaccinated.
With vaccine shipments coming to Pennsylvania in small increments, "It made sense for us to identify provider networks so we always had groups in the queue to receive the vaccine," said Mr. Huff.
That approach assumed there would be enough vaccine, or at least minimal delay before adequate doses became available.
When that didn't happen, doctor's offices were swamped with callers as they waited for vaccine shipments, which usually came in only partial amounts.
More importantly, some children most at-risk -- those with histories of asthma or other severe respiratory ailments -- might be told to wait because their pediatrician couldn't get vaccine, while others without that medical history got vaccinated because their doctor happened to get a shipment.
"It wasn't good planning. I think it was very poorly distributed. I don't think it's been well handled at all," Dr. Dixon said.
Pediatricians have been frustrated, too.
Dr. William Coppula with the Pediatric Alliance, a group of eight pediatric practices, said call volume jumped three-fold, including calls from families who were not their patients. "Our own patients could not call in," he said, which only added to families' worry.
Children's Community Pediatrics has a Web site listing each of its practices and whether it has vaccine available. Only recently has the number of offices with vaccine available pushed past the halfway mark.
That led to families in one practice, which didn't have vaccine, to call one of the other practices, which did. It also attracted families from outside the practice, calling to see if they could make an appointment. They were told, "No."
"The way the process is set up, we have to order doses for our own patients. We're not a mass inoculation clinic," said Ms. Guatteri.
Dr. Coppula said they had a similar experience at Pediatric Alliance and they also declined to vaccinate those outside their practice other than pregnant women. "It's just really hard to make exceptions," he said.
To date, Pennsylvania has been allocated 1.8 million doses, about half what state health officials were expecting. Meanwhile, there have been 10,077 confirmed cases of H1N1 flu, resulting in 38 deaths.
Correction/Clarification: (Published Nov. 21, 2009) The Moon Area School District requested 1,445 nasal vaccines for dispersal at a school clinic. This story as originally published Nov. 21, 2009 on flu vaccines had an incorrect number.
Dan Majors contributed to this report. Steve Twedt can be reached at firstname.lastname@example.org or 412-263-1963. First Published November 20, 2009 5:00 AM