October 24, 2004
If Edith Coe gets the flu, her already labored breathing from a chronic respiratory condition would worsen and she might have to go back to the hospital for the third time this year.
At 86, Coe is one of millions of people nationwide who are at high risk for flu complications and should have priority for vaccinations this year, according to the U.S. Centers for Disease Control and Prevention. But Coe hasn’t been placed at the front of any flu shot lines. She can’t even find a line to stand in.
"I’ve gone to the hospital and the doctor’s office and the drug stores and nobody could give me any information," Coe said. "I’d get (the flu) quicker than anyone else."
Coe’s dead end reflects more than just a serious flu shot shortage. Her experience shows how ill-equipped the state and nation are to protect their most vulnerable people from a serious disease, according to local leaders and public health authorities.
Today, Arizona officials have little idea where high-risk people can go for flu shots, or how many doses are left. With nearly every flu shot clinic shut down, community organizations are telling people to check with their doctor for flu vaccine. Many doctors’ offices, however, do not provide flu shots or have not received their vaccine orders this year.
Providers who have doses for their patients are sometimes hesitant to say they do, fearing a rush of flu-shot seekers.
Meanwhile, those who are eligible for a shot are left running in circles.
"We people out here, out on our own, we don’t have any resources but to try and find (flu shots)," said Sharron Thomas, 66, of Mesa, who was vaccinated after searching for a week. "Nobody is speaking for us."
PRIVATE SECTOR CONTROL
The problem exists because vaccine supply is left almost entirely in the hands of the private sector, according to public health authorities. When the flu season came early last year, manufacturers didn’t have enough of the vaccine ready in time to meet intense demand.
This year, one of only two major manufacturers producing flu vaccine for the United States had its supply halted by British regulators over contamination fears. About half the nation’s flu vaccine was lost.
"The vaccine production system is vulnerable to a disruption like this because there are too few manufacturers," said Will Humble, a spokesman for the Arizona Department of Health Services. "It just shows how vulnerable the system is overall."
Those vulnerabilities include:
• The inability to ensure that enough vaccine is available every year. The federal government helps determine which type of vaccine the manufacturers need to produce, but leaves the amount produced up to manufacturers, many of which no longer actually manufacture it. There are no government incentives for the private sector to produce what the public needs, and no significant stockpiling of flu vaccine by the government in case of emergencies.
• The inability to ensure that at-risk people — the very young, the old and those with a health condition — get the vaccinations they need. The federal government has little control over the distribution system, with doctor’s offices and clinics ordering directly from distributors and manufacturers.
By the time the shortage was announced this month and the government halted remaining supplies to save them for the most needy, about 25 million doses had already been distributed.
The Arizona Department of Health Services’ order for 164,000 flu vaccine doses continues to be filled weekly, but those doses can go only to children who qualify for the federal Vaccines For Children Program. No such program exists for adults.
"The problem is one where the federal government has failed to take a substantial position on a policy to prevent 36,000 deaths and 200,000 hospitalizations each year," said Dr. Jonathan Weisbuch, director of the Maricopa County Department of Public Health. "People are going to be sick this year, people are going to be hospitalized this year, and people are going to die."
A decade ago, the U.S. had five flu vaccine manufacturers. One of them was Wyeth Pharmaceuticals, which announced in November 2002 that the company would stop producing the vaccine after 25 years in the business.
With other manufacturers in the market place, Wyeth decided to concentrate on a new nasal flu vaccine, said spokesman Doug Petkus. Wyeth was throwing out millions of unused doses once they expired each year, he said. In the last five years it produced the vaccine, Wyeth destroyed more than 20 million doses worth about $50 million.
"The margins were small but the need was there, and as time evolved, the need seemed to subside," Petkus said.
Flu vaccine also is more difficult to produce, manufacturers said. Unlike other vaccines, which are always formulated the same way, flu vaccine must be composed differently each year because the virus changes, said Anita Larsen, spokeswoman for Merck.
Merck stopped manufacturing flu vaccine in the mid-1980s, choosing to focus instead on other pediatric vaccines, she said. "There’s a big unknown about what (kind of vaccine) to put together. You also don’t know the quantities," she said.
Federal regulatory requirements for vaccine manufacturers are arduous, plus there are liability concerns — issues that still exist today, Petkus said.
But human behavior is perhaps the biggest obstacle to maintaining flu vaccine supply, according to public health officials. When flu shots are readily available, many people don’t bother to get vaccinated. When the supply is running low, people rush to get their flu shot.
"What you can’t have, you want," said Andie Denious, immunization services manager for the state health department. "I wish I knew how to fix this. I can assure you, I wish we weren’t taking the telephone calls we’re taking."
Fixing the problem will require a new approach, one that guards against shortfalls in the private sector, public health officials said. The federal government needs to be more involved to ensure enough flu vaccine is available, especially when supply problems occur. And health care providers need to better educate the public about getting flu shots every year, said Sheri Dahlstrom, chief nursing officer for Banner Mesa Medical Center.
"For the manufacturers, it’s about money; for the health care provider, it’s about public health," she said. "The government or health care (providers) have to help."
Help is needed to prevent a year like this one, when hospitals like Banner Mesa Medical Center are bracing for flu shots to run out for health care workers and their sickest patients, Dahlstrom said.
Public health authorities said they are worried about Arizona’s many seniors getting flu shots, especially those in assisted living facilities and nursing homes. The state health department has surveyed many of the long-term care facilities in the state to see how short each of them is on flu shots, and is sending the results to the Centers for Disease Control and Prevention, Humble said.
The hope is that the information will increase the chances the facilities get flu vaccine as the CDC figures out where to send the remaining vaccine doses, he said.
Dr. Art Mollen, whose clinics provide the most flu shots in the state, said he has sent a letter to the CDC asking for more vaccine. Mollen closed his clinics this month and brought what little was left of his 70,000 doses to nursing homes last week.
"I just feel we’re in a very serious situation," he said. "If Arizona gets hit by a serious flu season, seniors in this state could be seriously impacted. We could have a major epidemic."
Who is high risk
• Adults 65 or older
• Children 6 to 23 months old
• People age 2 or older with chronic lung or heart disorders, chronic metabolic diseases, kidney diseases, blood disorders or weakened immune systems
• Children 6 months to 18 years who take aspirin daily
• Residents of nursing homes or other chronic-care facilities
• Caregivers of infants younger than 6 months
• Health care workers who provide direct patient care Source: U.S. Centers for Disease Control and Prevention
CIGNA Healthcare of Arizona plans to hold flu shot clinics until Dec. 11. For nformation on where and when shots will be available, call (602) 906-2750 for Scottsdale locations and (480) 345-5355 for other East Valley locations.