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    Tuesday, November 29, 2005

    Flu Fiascos - Present and Future: Governments worldwide are busy making plans for a potential influenza pandemic. Around the world there are plans for stockpiling the anti-viral drug Tamiflu, plans for quarantine, and plans for extra treatment facilities , although Britain's plan to shoot invading birds appears to have failed.

    The U.S. government has announced it's plan, one pillar of which is the widespread distribution and administration of a vaccine against the virus. The plan is vague on particulars. The Department of Health and Human Services has left it up to each state and local health department to decide how the vaccine will be obtained, distributed and administered. If they so wish, they can rely on the current free market method we use for the normal influenza season. Local health departments and providers purchase the vaccine and distribute it to the community and to their patients. On the surface this seems the ideal choice. It minimizes the work (and money) state and local health departments have to spend to plan for a pandemic by building on a system that's already in place. Unfortunately the system that's already in place doesn't work.

    Consider this year's efforts to vaccinate against influenza. Supplies are said to be plentiful, yet around the nation, providers are having trouble getting flu shots. In New York, 60% of physicians report having no vaccine, in North Carolina, 85% of family doctors have none. Even large purchasers of vaccine such as Maxim Health Systems, whose business it is to provide flu shots at drugstores and corporations nationwide and HMO giant Kaiser are running out of vaccine. It doesn't matter how plentiful the supply is if you can't get it to the people. And clearly, we can't.

    Part of the problem is that our current system is a free market system. Although the free market works well for many things, it's inadequate for vaccines. Manufacturers and distributors tend to favor their big customers over their small customers, thus large purchasers of vaccine, such as Maxim Health Systems, get their vaccine shipments well before private physicians receive theirs. The end result is that the general public has early access to the vaccine at drugstores and their place of employment, but the elderly and the chronically ill - who benefit most from the vaccine, and who tend to rely on their physicians for it, go without.

    Part of the problem is that demand has exceeded supply to a degree that manufacturers simply can not keep up. Until recently, flu vaccine was recommended only for the elderly and those with diseases that put them at risk for complications from the flu. But in the past two years, the CDC has expanded its recommendations for vaccination to include, well, basically everyone. So why don't the manufacturers just produce more? That's the hope behind the expanded recommendations - that ramped up production would put everything in place to make large-scale vaccine production possible in the event of a deadly flu pandemic. (That and to try to eliminate as much normal influenza illness as possible.) At the same time, however, money is being invested in finding quicker, more reliable methods of manufacturing the vaccine. It's probably expecting too much to think any company would spend money to expand production methods that have a good chance of becoming obsolete within a few years.

    Imagine if an influenza pandemic were to strike now. Given the current production methods, there's little reason to believe that the supply will be adequate to vaccinate everyone. Demand would outstrip supply much more so than occurs in normal flu seasons. The national pandemic flu plan calls for prioritizing the vaccinations so that those at high risk would be vaccinated first - just as we were supposed to do this year for the normal influenza vaccine. But, under the current system, the large providers who buy vaccine for the general public are more likely to receive vaccine than those who serve high risk populations.

    Given the importance of influenza vaccine in controlling a pandemic, it's a problem that needs to be addressed. If the free market approach to influenza vaccination isn't working in a time of "plenty" it's not likely to work in a time of crisis. Now is the time for our public health officials to roll up their sleeves and take responsibility for planning and implementing a national vaccination program - right down to purchasing and distributing the vaccine. It will mean more work on their part - but that's what we pay them for, isn't it?

    UPDATE: Health Care Renewal points to this San Diego Tribune story about the maldistribution of flu shots:

    "What went wrong? According to the Union-Tribune article, vaccine manufacturers preferentially shipped supplies of vaccine to high-volume customers, like big-box stores such as Costco, Wal-Mart, and Albertsons on the west coast of the US. Quoting Dr. Wayne True, a physician in La Mesa, 'This year's vaccines are going to where the money is - to the 'big box' customers first.' Physicians often 'go through pharmaceutical distributors for their vaccine supplies, while some big retailers are able to place bulk orders directly from vaccine manufacturers.'

    Neither the vaccine manufacturers, distributors, nor 'big-box' stores seem to want to take responsibility for this situation.

    Alison Marquiss, a spokeswoman for Chiron, one of the three remaining US vaccine suppliers, admitted that 'its priority shipments were earmarked for high-volume customers, as standard practice for all manufacturers of vaccine, according to the Union-Tribune. Marquiss said, 'there are different contractual terms for different orders. It would be a bit naive not to realize that.'

    David Aguilar, of Physicians Sales and Service, a distributor of vaccines, accused, 'Physicians are panicking.' Furthermore, 'there are a lot of sales reps here that don't want to deal with the flu (shots) because of what's been happening.... It's a headache for everyone.'

    Michael Mastormonica, coordinator of Costco' influenza program, said it should be up to the government, and that the Center for Disease Control (CDC) should 'step in and stipulate distribution, saying these providers take priority over others.' But a spokesman for the CDC noted that the agency 'has no regulatory authority whatsoever to mandate anything when it comes to supply and demand of influenza vaccine.

    Some of the doctors quoted in the article think that there should be some sort of national legislation to correct the imbalance, as does the frail, high risk elderly patient who could not get her flu vaccine from her doctor:

    All the talk and fingerpointing are hard for Frances Lindner to comprehend.

    "The doctors are getting (their orders) in dribs and drabs when they should get the shots before Wal-Mart," she said. "It's terrible, and I don't understand why our government allows this to happen."

    I'm inclined to agree. And why is it that this doesn't get covered by the national press, but only the local press? Is it that they aren't sufficiently skeptical of the claims by public health officials that "everything's OK with the flu vaccine supply?"

    posted by Sydney on 11/29/2005 08:35:00 AM 7 comments


    Why wouldn't state medical societies partner with a CostCo or a Wal-Mart to access supplies of vaccines that can then be distributed among physicians? My suspicion: that would be "beneath them" and so they will not consider it.

    By Anonymous Anonymous, at 9:36 AM  

    Some of your readers may want to have their 'flu' awareness (and other diseases) extend to gift items. http://www.iawareables.com is a site I ran across that provides ties and other fashion accessories (incl. 'scrubs') with various viruses (or other pathogens) as the design. A reality Christmas gift for your favorite medical professional?

    By Anonymous biohombre, at 11:35 AM  

    If flu vaccine demand is outstripping supply, then why don't manufacturers raise the price? This is how the free market would *truly* work in this situation: you charge what the market will bear. Those who can afford it get vaccinated; those who can't are out of luck. The fact that big box stores are running out of vaccine indicates to me that they ought to be charging more for it. I know that physicians are not allowed to charge what the market will bear because of government interference--so I'm disagreeing with you that the free market system is at fault here. What is at fault is our semi-socialized system of mixed economics that tries to provide everything for everyone and ends up with debacles like we're currently seeing with this year's vaccine.

    By Anonymous Ice Scribe, at 12:20 PM  

    Money controls access and facts. Flu vaccine probably is not needed for everyone. It is questionable if we need a bird-flu vaccine also. But, billions of dollars are at play here. There is no one to hold accountable. Facts are in short supply, shorter than vaccine availability.

    If we hold the companies harmless for any potential problem with the vaccines they produce, then the distribution should be fair and equitable and not determined by who has the money, but who has the need.

    We need more facts about who is really in need and about what is really necessary and less hype and less unsubstantiated claims. 100 cases of bird-flu aren't a pandemic.

    What do we really need and who do we need to provide it to for their protection?

    By Blogger Bruce, at 6:55 PM  


    Are you suggesting that state and local medical societies create purchase partnerships with Costco and Walmart? What would be the advantage to Costco and Walmart? They like to give the vaccines because it's a promotion for their stores. It brings people in. What's more, people end up standing in line, looking at the merchandise, and buying stuff they might not by.

    I might be mistaken, but I believe that only distributors and makers of vaccine can sell them to providers. Last year, when there was a shortage, the government lifted a rule about that so pharmacies could sell their left over vaccines to doctors and doctors could sell theirs to other doctors.


    If the time period for purchasing the vaccine were indefinite, then they would probably raise the price. But, the flu vaccine is only given for a few months of each year. The manufacturers set the price before they know how much vaccine they'll end up having, and how great the demand will be. Drug stores have to purchase their vaccine in advance and they usually announce the price they'll be charging before they even know what the demand will be like. They'd lose customers if they suddenly jacked up the price. And remember, their prime motivation for giving them is to bring customers into their stores - not to provide a public health service.

    The purchase and distribution of the vaccine to providers is completely free market. That's why the makers make sure their biggest customers get theirs delivered before the small customers. The problem is that those who need the vaccine the most (the elderly and the sick) are the least able to stand in long lines at drug stores and grocery stores. The upshot is that the young and the healthy, who are merely inconvenience by an ordinary influenza infection - get the vaccine, while those who could die from an ordinary influenza infection go without protection.

    By Blogger sydney, at 7:03 PM  


    the advantage to Costco and Walmart?

    Well, I'd sure like to talk with them about it. For one thing, the people that physicians are most worried about are their more vulnerable patients who arguably should be seeing their physician for the inoculation, but whose physician has no vaccine. That person is not going to wander into Wal-Mart for the shot and if they do Wal-Mart should be worried about liability. And there's not that many of them. Wal-Mart's "target" demographic is a younger, healthier person. I think.

    So public relations & risk management are two things I could talk with them about. I'm a bit cynical but I still hope this is not playing out as one side fiddling with the other, while feverish patients burn.

    By Anonymous Anonymous, at 9:18 PM  


    I still think that if the manufacturers treated the flu vaccine like the valuable commodity that it has obviously become over the past few years, they could price it appropriately. For instance, say the vaccine cost the consumer $100 a pop--the big box stores wouldn't want it anymore.Physicians and hospitals still would, although they'd have to buy much less of it. Raising the price would let each individual patient decide just how much he or she really wanted that vaccine--some people would still want it, others would not. For the poor and the impoverished elderly, Medicare and Medicaid could interfere as they are doing now to keep vaccine costs artificially low.

    I retired from internal medicine practice back in 2000, before these flu vaccine shortages began. Back then, my practice used to throw away hundreds of unused vaccine doses at the end of each flu season: most people, even among the population that "needed" it, didn't want it. Since the media flu hype has begun, I gather that more people do want it now. Since it does not appear that suppliers can meet demand, maybe it should be looked at as a medical specialty item (like IV IG) rather than a generally administered vaccine. (Wouldn't the politicians scream about that, though?)

    By Anonymous Ice Scribe, at 10:56 AM  

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