H1N1 Vaccine Distribution in Minnesota: The Struggle for Efficiency and Equity Elizabeth Parilla Minnesota Department of Health April 2010 National Immunization Conference Elizabeth.Parilla@state.mn.us 651-201-5532

Presentation Outline Minnesota demographics Our vaccine allocation and distribution process Challenges for vaccine allocation and distribution Balancing local flexibility with consistency and efficiency Distributing vaccine in a equitable manner Ensuring that the process is perceived as fair Lessons learned

Minnesota Demographics Basic information: 12th largest state by area 21st largest by population 54% of the population live in the 7-county Twin Cities metro Public health 89 local health departments 7 state health department district offices State health department in St. Paul Private healthcare Majority of medical care provided through private clinics ~90% of pediatric medical care Several large health systems ~40% of pediatric medical care

H1N1 Vaccine Allocation Considerations Overall goal: Target vaccination to ACIP recommended groups and expand to general public ASAP ACIP guidelines Ethical considerations Practical considerations Formulations available

Doses of H1N1 Vaccine Ordered by Week and Formulation, Minnesota 10/09-12/09 Open to entire population Open to full ACIP priority groups and 2nd pre-book LPH & Hospitals 1st pre-book

Challenge 1: Balancing flexibility with consistency and efficiency Counties in MN differ in terms of: Population size Diversity SES Private healthcare capacity Public health capacity Public health experience with immunization Public demand for immunization Counties also wanted differing levels of involvement in ordering for private providers and redistributing vaccine through their LHD.

Minnesota Population by County

Ordering and Distribution Process MDH managed ordering at the state level. VFC is managed at the state level Immunization program in MN. VFC staff had experience working with centralized distribution, private providers, and the complexity of vaccine ordering. Counties had three options: Providers pre-book directly with MDH and vaccine orders are sent directly to the provider (n=62). The LHD manages the pre-book and sends the information to MDH. Vaccine orders are sent directly to providers (n=10). The LHD manages the pre-book and sends the information to MDH. All orders for providers in the county are sent to the LHD to be redistributed (n=15).

County Choices of Vaccine Options Blue: Providers pre-book with MDH and directly receive vaccine Green: Providers pre-book with their LHD and directly receive vaccine Yellow: Providers pre-book with their LHD and the LHD redistributes all vaccine

Effects of Having Local Options Made pre-booking more complex. Led to confusion when counties made last minute changes in their option. Made communication to providers more complex and time consuming because the messages had to fit the county’s vaccine option. Took more time to manage the orders. If the county redistributed vaccine, it took more time for orders to reach the provider + possible risk to cold chain.

Effects of Local Options on Health Systems Health systems have clinics in many different counties and it can be overwhelming for them to get conflicting messages from different counties on ordering and distribution. Many systems use a central warehouse to receive and redistribute pharmaceuticals and are concerned about not being able to use their normal vaccine distribution process. Ultimately, large health systems were exempted from county ordering and distribution plans and worked directly with MDH. Small health systems in greater MN were often frustrated that counties were managing vaccine differently from one another.

Challenge 2: Distributing vaccine equitably Only certain types of clinics could request vaccine in the 1st pre-book Those considered a medical home for persons in the initial ACIP priority groups Specific populations were given priority based on ACIP recommendations and the vaccine presentations available FluMist: HCP Injectable: Children and pregnant women Clinics were randomized

Randomization: Ethics A panel organized by MDH, the University of Minnesota and the Minnesota Center for Health Care Ethics developed a report on ethics of rationing scarce resources between 2006 and 2009. Ethics panel recommended that several clinical, population health, and fairness considerations be applied before employing random selection techniques. “At some point, random selection techniques will be required to decide how to allocate resources among equally prioritized persons.” DE Vawter, et al. For the Good of Us All: Ethically Rationing Health Resources in Minnesota in a Severe Influenza Pandemic. [Preliminary Report] Minneapolis: Minnesota Center for Health Care Ethics and University of Minnesota Center for Bioethics (2009).

Randomization: Lessons Learned Initially our partners accepted the concept of randomization for distribution of scarce resources. However those who received lower random numbers became quite frustrated. The longer providers had to wait for vaccine the more they expressed concerns about the process being unfair.

Equitable Distribution: Factors Medical hubs Lack of accurate information about clinic type and patient population size Overestimated need because patients were double counted (LHDs, clinics, and specialty sites might all request vaccine for the same people) County-level distribution and vaccination plans Presentations of vaccine available Differing levels of demand for vaccine

Processes to support equitable distribution Creating maps of statewide distribution Analyzing surveys of LHDs and clinics Holding conference calls with LHDs Meeting with the vaccine allocation workgroup

Public Demand: “Does your county have enough vaccine for the ACIP priority group?” Percentage of persons within the county that could be vaccinated with the number of doses shipped to sites within the county Yes Yes Yes Unsure Yes No Yes Unsure Yes Yes No Response Yes

Challenge 3: Ensuring the process is viewed as fair Distribution of a scarce resource can easily be perceived as inequitable by medical providers, local health departments, or the public. If one person or clinic receives vaccine and another has to wait it can make people feel they have been treated unfairly. This becomes more challenging when a resource is scarce for long periods. Rumors can increase feelings of inequity.

Perception of Inequity: A Case Study Reported concern: County X has not received as much vaccine as other counties. Reality: County was near or above average in terms of the number of doses sent to sites in the county by population. There was high demand for H1N1 vaccine in County X so a pro-rata allocation felt unfair to them. Date County X MN average 11/6 8% 7% 11/16 9% 10% 12/7 20%

MDH Communication about Fair Allocation and Distribution Weekly conference calls with LHDs Special editions of monthly Got Your Shots newsletters Weekly emails to all pre-registered sites Conference calls with private providers Webinars, conference calls for schools and post-secondary institutions Website Vaccine order confirmation emails Weekly vaccine distribution data summaries on web News conferences

MDH Communication about Fair Allocation and Distribution: Challenges Frustration and anger over the changing and limited vaccine situation made it harder for people to internalize complex messages. Too many complex messages coming from public health and it was difficult to simplify messages related to vaccine. People don’t read.

Transparency about Fair Allocation and Distribution Weekly communication to LHDs and providers Vaccine information on website for public Number of doses ordered in MN Who can receive H1N1 vaccine? LHDs had access to pre-registration, pre-booking, and ordering data via a secure website Challenges: Safety and logistic concerns about releasing clinic specific data Legal protection for ordering data

Lessons Learned Balancing local flexibility with consistency and efficiency Flexibility is important so that LHDs can manage vaccine in the most appropriate way for their communities. However it is a good idea to only allow a limited number of ordering and distribution options for counties to chose between. Keep all ordering and distribution options in mind while designing ordering processes like pre-book. Health systems should have the option to order and receive vaccine directly from the state. Distributing vaccine in an equitable manner Find or create data sources for clinic type and patient population data as part of the pre-pandemic planning.

Lessons Learned, Continued Ensuring that the process is perceived as fair Communication Simplify messages as much as possible. Use more “personal” communication like conference calls rather than emails. Offer more basic education about vaccines to new partners that may not have experience with immunization. Try to address the emotional difficulties that arise in a pandemic. Recognize that messages may not be heard because providers are overwhelmed. Transparency Legally protect distribution data

A Fairly Happy Ending! 2009 H1N1 Vaccination Coverage Estimates as of January 2010, BRFSS and NHFS

Acknowledgements Thank you for your time today! Special acknowledgements: MDH staff working on H1N1 vaccine distribution and vaccine guidance: Denise Dunn, Margo Roddy, Kris Ehresmann, Josh Rounds, Sudha Setty, Judy Bifulk, Lisa Harris, Jennifer Heath, Amy Hockett, Lynn Bahta, Jill Marette, Heather Pint, Susan Ersted, Chris VanBergen, Stefani Kloiber MIIC (Immunization Registry): Emily Peterson, Erin Roche, Karen White MDH Immunization Program staff MDH Office of Emergency Preparedness staff Local Public Health Minnesota’s dedicated medical providers CDC with a special thanks to Rosanna Boyd and Pascale Wortley Thank you for your time today!