Vaccine Shortage 2002: National Problem . . . Local Proaction National Immunization Conference 2003 Melanie Benge Koch, BSN, RN Public Health Nurse, Allen County Department of Health Kelly Zachrich Executive Director, Super Shot, Inc.

Agenda  Background  Objectives  Process Protocol Development Protocol Implementation  Communication  Deferment  Recall  Conclusions and Future Directions

Background  Allen County has a population of 331,849 (2000 census) In 2002, 6,745 babies were born in Allen County  40% of Allen County children seek free immunizations through public sector

Background  In 1999, a unique collaboration was begun. + = SUCCESS!

Total Doses Administered Background Total Doses Administered Collaboratively By DOH and Super Shot

The Problem: DTaP, April 2002-January 2003

Objective To ensure that vaccines were available to those Allen County children most vulnerable to disease.  To  morbidity and mortality of infections by immunizing those at greatest risk for complications.  To provide some immunity to a greater # of children rather than greater immunity to a lesser # of children.

Protocol Development 1. Called together a collaborative group of community immunization stakeholders.

Protocol Development 2. Reviewed CDC and ISDH recommendations. (continued) 2. Reviewed CDC and ISDH recommendations. 3. Researched vaccine efficacy considering a sub-optimal number of doses. 4. Collaboratively authored the “Protocol for Vaccine Administration During Vaccine Shortage”. Group periodically revised protocols and implementation process as needed.

The Protocol: DTaP  Trigger (%) = doses available/ doses needed Level Action Trigger Percent of Needed Doses Available Baseline Defer Dose #4 and #5 for all ages 86-100% Level One Children < 12 months Provide only 1st three doses 75-85% Level Two Provide only the 1st two doses 50-74% Level Three Children < 6 months* Provide only the 1st two doses for children with at least one of the following considerations : Chronic medical condition with physician’s prescription Childcare attendee with proof of attendance (cancelled check, receipt of payment, or note from daycare provider documenting attendance) Children living at the poverty level (documented by possession of a Hoosier Healthwise Package A card or food stamps) Refugee child with I-94 card 25-49% Level Four Children < 6 months Provide only the 1st two doses only for children with a chronic medical condition documented by a physician’s prescription <24%  Trigger (%) = doses available/ doses needed  Baseline based on CDC and ISDH recommendations  As vaccine available ↓’s, the level ↑’s, and the vulnerability of the vaccinated child ↑’s  Vulnerability based on scientific research and consultation with a field expert * A child who started the vaccine before 6 months of age and meets this criteria, may receive dose #2 even if they are beyond 6 months of age.

Implementation  Initially, inventory was counted and levels were determined on a weekly basis.  In November, change was made to determine levels as shipments of vaccine arrived.  This prevented levels from always being high or low for specific clinics.

Communication: Professional  Mass fax to area physicians of initial and revised protocols. Fax of weekly levels sent to physicians upon request. Weekly levels published in evening newspaper.  Presentation about protocol offered to physician offices.

Communication: General Public Op-ed piece published in 5 different newspapers requesting that parents: Be proactive Be prepared Be flexible Be understanding Be trusting Weekly levels published in evening newspaper.  Providing information per phone as requested.

Vs. Actual Doses Received of DTaP, Minimum Doses Needed Vs. Actual Doses Received of DTaP, April 2002-January 2003 (based on 2001 usage) *June (100), July (50), October (100), and December (70) figures include Trihibit received.

Deferment From April 2002 to January 2003, 8,568 doses were deferred for all vaccines. From April 2002 to January 2003, ~3000 DTaP doses were deferred. The process for deferment included several steps: Parental completion of postcards at intake to be sent at a later date for recall. ACCESS database used to: * Sort names as needed for recall. * Create ASCII files to implement autodialer use.  Creation of deferment list has ceased.

Vaccinated and Deferred for DTaP, Children < 12 months Vaccinated and Deferred for DTaP, April 2002-January 2003

Vaccinated and Deferred for DTaP, Children > 12 months Vaccinated and Deferred for DTaP, April 2002-January 2003

Recall How and when?  When the # of doses in current inventory exceed estimated immunization usage (based on previous years), that # of recalls are made.  Most vulnerable children recalled first.  Recall occurs in the order (by date) that the deferment list was created.  As of today, only 698 recalls have been completed.

Recall Why has the recall process halted? (continued) Why has the recall process halted? • Sufficient vaccine rarely became available through the VFC program to implement recalls. • Tobacco settlement monies were allocated to purchase vaccine for the over 3000 children on the deferral list. This vaccine was ordered in December 2002, and we still await arrival of the complete order.  Insufficient Vaccine Supply • The Department of Health Immunization Clinic has temporarily closed due to Small Pox-Phase I implementation. • Due to the closure, Super Shot is serving an increased number of children with limited resources.  Impact of Small Pox Program

Conclusions  The protocol worked well by allowing us to cover those children most vulnerable to disease.  The deferral list and recall process have become a bureaucratic nightmare!

Future Directions The original collaborative group will reconvene to revise the recall process. Super Shot will increase vaccine availability to families in our community by becoming a VFC provider. The DOH will research the impact of the vaccine shortage on disease incidence in Allen County (ie. Pertussis and Measles).