November 5, 2009

Dear Maricopa County Residents:

I sympathize and understand your frustration with attempting to access the H1N1 vaccine. I share your frustration. Please allow me to offer a little background on how we got to where we are and our plans for making sure that everyone who wants vaccine eventually gets the vaccine.

First, let me give you an idea of how vaccine ordering for the novel H1N1 works. Each day, the federal government announces each state’s allotment and then our state breaks that allotment number down by percentage of each county’s population. Each county is given a few hours to break down their allotment and report back to the state where we want the vaccine shipped. The vaccine is then shipped anywhere from 5-15 business days later by the contracted distributor.

After our first week of ordering (in late September), we in Maricopa County (and all over the nation) discovered that instead of receiving one vaccine allocation per week from which Maricopa County would place its order, we would be receiving much smaller daily allocations. This has made it extremely difficult to do any sort of long term planning, since we do not know day to day how much vaccine we will be allotted. In addition, as you probably read, the entire nation is experiencing a vaccine delay.

To put it into perspective, as a community, we have been allowed to order only about 1/3 of our projected allocation through the end of October.

The CDC's Advisory Committee on Immunization Practices (ACIP) has issued guidelines for who should receive the Novel H1N1:

Pregnant women because they are at higher risk of complications and because vaccinating the mother can potentially provide protection to newborn infants who cannot be vaccinated;

Household contacts and caregivers for children younger than 6 months of age because younger infants are at higher risk of influenza-related complications and are too young to be vaccinated. Vaccination of those in close contact with infants younger than 6 months old might help protect infants by "cocooning" them from the virus;

Healthcare and emergency medical services personnel because they are likely to be exposed and then become a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity;

Children from 6 months through 18 years of age because children are at higher risk and because children in school and day care settings spread the flu most efficiently, ultimately spreading more infection to all of us, and

o Young adults 19 through 24 years of age because many cases of 2009 H1N1 influenza have been seen in young adults and they often live, work, and study in close proximity, and they are a frequently mobile population; and,

Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.

In times of limited vaccine, such as we’ve had so far, the subset of the above groups that has priority consists of:

Pregnant women

persons who live with or provide care for infants aged <6 months (e.g., parents, siblings, and daycare providers),

health-care and emergency medical services personnel who have direct contact with patients or infectious material,

children aged 6 months--4 years, and

children and adolescents aged 5--18 years who have medical conditions that put them at higher risk for influenza-related complications.

With this in mind and with limited vaccine, we stuck to two principles: 1) send the vaccine where it would reach highest-risk persons first; and 2) keep it moving – send it where it would be quickly used, rather than sit in a refrigerator for any length of time. Thus, we began distributing the very small amount of vaccine that we had to healthcare workers who treat our most vulnerable patients, emergency medical personnel, and to providers who treat the most at-risk persons: pediatricians (for young children and any children with underlying risk factors), obstetricians (for pregnant women), family practice docs (for both of the above groups), and community health centers and large multi-specialty practices that see many of these same patients.

We had always planned for school-based clinics because the only way to decrease community-wide spread is to vaccinate most children, and the only way to reach most children is through the schools. (Also, as you see, all children are on the ACIP priority list.)

In one instance, when some of the vaccine we had directed toward school clinics arrived a little earlier than other shipments, we opted not to let it sit unused, waiting for the school clinics. Rather, we decided in a short 2-day turn-around that we would try to give those doses to pregnant women, young children, children with underlying risk conditions, and those who care for infants too young to be vaccinated (the subset groups) during a public mass vaccination clinic on October 24. At the 40 locations in Maricopa County, we administered 17,000 vaccinations with the help of community partners.

Clinically, half of our hospitalizations have been in children, underscoring the ACIP recommendations. And historically, we can expect a third wave of the epidemic, perhaps as late as next spring. In order to mitigate or prevent this third wave, we need to get the vast majority of children vaccinated, preferably before schools are dismissed for winter break. With more than a million children in Maricopa County, we simply had to begin the school-based vaccinations now, even as we struggle to expand vaccine availability to all high-risk individuals who want it. In fact, only this week, we have started offering vaccine for all of our thousands of outpatient health care workers who are taking care of the ill, and we are giving vaccine at our Women, Infants and Children (WIC) sites to pregnant moms and their young children.

Many of you have also expressed frustration with our call center. Please know that this is a frustrating process for everyone, including our operators who are not public health professionals, but rather, community information advocates. They are working hard at getting information from all of the counties and communicating to all of you. Due to the size and scope of Maricopa County, along with our limited of vaccine, we have not been able to offer consistent public clinics, which have made their jobs more difficult. Please be patient with them. As soon as we have places where you can get vaccine, we will make sure our operators have this information.

We, at Public Health, recognize that this is a frustrating, confusing time and believe me, we are doing all we can to push this vaccine out to the public as fast as we can. I continue to urge all of you to consider getting the vaccine when it is available to slow the spread in our community and to assist in preventing a third wave which may occur from this virus.

Sincerely,

Bob England, MD, MPH

Director

Maricopa County Department of Public Health