Miami Herald - November 16, 2004
Jacob Goldstein, jgoldstein@herald.com

A few doors down, at Jackson Memorial Hospital, the old, those with compromised immune systems and toddlers under 2 had equal claim.

At North Broward Medical Center, hospital employees who work with high-risk patients were among those with top priority.

As the flu-shot shortage drags into its second month, doctors in South Florida and around the country are faced with an ugly mathematical reality: There aren't enough flu shots for the high-risk patients who account for most of the 36,000 flu-related deaths each year.

That, combined with limited guidance from federal and state officials, has left hospitals, clinics and doctors struggling to decide who should get flu shots -- and who should go without.

"You ask a question that you don't want to answer," said Huston Powell, regional pharmacy manager for North Broward Medical Center. "How do you decide who gets vaccine?"

SUPPLY VS. DEMAND

Last year's supply of 86 million flu shots was not enough to meet demand, and manufacturers planned to deliver 100 million shots this year.

But last month, the vaccine maker Chiron said regulators had closed its factory and the company would not be able to deliver any of the 48 million doses it had promised.

Officials at the Centers for Disease Control and Prevention said vaccine should go only to those at highest risk -- infants between 6 and 23 months and everyone over 65, as well as people with chronic heart and lung illnesses, patients with compromised immune systems and caregivers for those at high risk.

About 100 million people fit those categories; projections based on past experience called for half of those to seek flu shots.

When last-ditch efforts brought this year's supply to more than 60 million doses, some officials were optimistic that all high-risk patients who wanted vaccine would get it.

Not so. By the time the shortage emerged in early October, 30 million doses had already been distributed, and many had gone to people not at high risk.

And, in one of the season's darker ironies, news of the shortage sent more people than usual clamoring for vaccine -- a situation Florida Secretary of Health Dr. John Agwunobi called "hyper-demand."

Officials now say some high-risk patients won't find a flu shot.

"There's still not enough vaccine for everyone who needs it," CDC Director Dr. Julie Gerberding said last week.

The CDC has not advised doctors how they should choose who will get a shot, citing a lack of scientific data.

"A head-to-head comparison of this group and that group goes beyond available evidence," said Lance Rodewald, director of the CDC's immunization services division.

Some states have stepped in. In Massachusetts, state health officials cut healthy adults between the ages of 65 and 74 from the CDC list. The New Hampshire health department told doctors to give sick seniors priority over healthy seniors.

Florida, like many other states, has left doctors, hospitals and county health departments to decide how to ration flu shots.

"Each county will design a plan on how they're going to distribute the doses that they do receive," Agwunobi said.

Miami-Dade's health department sent its first shipment of 3,600 doses of vaccine to six hospitals and clinics, which used the shots for immune-compromised patients and their caregivers.

A second shipment of 3,000 doses is bound for nursing homes, where the high concentration of elderly residents -- who tend to have weaker immune systems than younger people -- raises the risk of flu outbreaks.

In Broward, the health department has forwarded most of its vaccine to the county's two public hospital systems, Memorial and North Broward.

Because the nation's supply of pediatric vaccine was not directly affected by the shortage, high-risk children have largely been spared from rationing.

For adults, many of the region's hospitals and clinics have cut the CDC high-risk list into smaller pieces. High on the list: chemotherapy, transplant and AIDS patients.

There is no hard data showing these patients are at higher risk than others on the CDC list, but doctors have a collective hunch.

"Our decisions are old-fashioned -- they're not evidence based," said Dr. William Schaffner, director of preventive medicine at Vanderbilt Medical Center and a member of the CDC's vaccine advisory committee. "They're clinical-experience based. You might also say clinical-anxiety based."

Many hospitals and clinics, including North Broward Medical Center, have also put staff who work with high-risk patients at or near the top of the list.

"If you don't have healthcare providers to care for the sick, no one gets treated," North Broward's Powell said.

The hospital gave most of its initial shipment of 130 doses to key staff, but set aside 20 shots for patients at highest risk. Why 20?

"It was purely arbitrary," Powell said. "I don't think there was any kind of consensus. It was left as best guess."

At Jackson, a team of top doctors collaborated to figure out who should get shots -- and came up with a different list from the one at nearby University of Miami, where UM infectious disease chief Dr. Gordon Dickinson decided how shots would be rationed.

"There's room for people to disagree about how the subprioritization should be," Dickinson said.

SEEKING GUIDANCE

Late last month, the CDC began consulting with ethicists from around the country. Officials hope ethics might help guide distribution in the absence of hard data.

The consultations probably will not result in specific guidance this year, but Rodewald said the work would be useful the next time a flu pandemic emerges.

Pandemics arise every few decades, when a new, particularly virulent strain of flu unexpectedly develops and spreads rapidly around the world. Experts estimate the next global pandemic will kill at least 2 million people.

Vaccine will almost certainly be in short supply -- making this year's rationing efforts look simple by comparison, said Dr. John Sinnott, chief of infectious diseases at the University of South Florida.

"It's a pale shadow of the pandemonium that would be going on if we had a pandemic," he said.

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