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Story from the Field


Name of Health Department/Agency: Tennessee Department of Health
State: TN
Date Added: 03/10/2010
Themes: Vaccine Planning and Administration
Issue Summary: Decision-making Process to Expand H1N1 Vaccination Beyond ACIP Target Groups
Description of Issue(s):
The immunization program is the lead for vaccine distribution in Tennessee, which allows for a streamlined decision making process. Officials are responding to concerns about waning demand that might occur after Thanksgiving (as has been shown with seasonal vaccine and was suggested by evidence that an increasing number of local health departments were no longer running out of vaccine between shipments). Efforts focus on ensuring that the vaccine gets distributed quickly and does not linger on shelves.
 
Tennessee does not follow a set formula and uses a decentralized approach to vaccine distribution – distributing among health departments and private sector providers, giving preference to facility types that serve more persons in target groups. The ordering system allows demand to be unofficially tracked as providers place or cancel orders. Because some providers prefer certain formulations over others, the state has been able to widely distribute vaccine.
 
For example, public health departments would prefer to not use the vaccine that is only licensed for individuals 18 years and older (e.g. CSL before the license change, and GSK vaccine), which created a reservoir of vaccine for internists and other providers that serve adult populations. Tennessee has experienced good uptake. This is reflected in the CRA reporting database in which Tennessee comprises 2% of the population, but reports 4-6% of the national doses administered reported each week.
 
On the issue of prioritizing the ACIP target groups and/or subgroups, Tennessee has taken a flexible approach and encouraged local/facility level decision-making. Early on in the program, Tennessee encouraged all providers to follow the ACIP recommendations for prioritization and sub-prioritization (where needed). In addition, during the ordering process the Tennessee immunization program priority ranked orders by categorizing them into 14 standard provider types to ensure that the providers who serve large numbers of high-risk persons received vaccine first. However, as soon as feasible, Tennessee would ship at least 1 box of 100 doses to all providers who placed orders, so that they had at least a small quantity to reach their own highest priority recipients.
Actions taken to address the issue(s): Additionally, the Department of Health established weekly conference calls with local public health leadership as well as a hotline for H1N1 vaccine providers to answer questions and ask about changes in demand. The immunization program has been attentive to decreases in demand for vaccine among local health departments and took note when private providers began to cancel the balance on their orders. Tennessee noticed a decrease in spontaneous demand among priority recipients accompanied by accumulating vaccine supplies reported in a number of health departments just before Thanksgiving, which they felt correlated to the decrease in the burden of disease since September-October (when disease peaked in TN).

There are variations in demand across the health jurisdictions in the state. In general, rural areas are seeing decreases in demand whereas metro areas are still seeing high demand among target groups. This is due, in part, to the large number of school vaccination clinics that are being held in metro areas.

Tennessee recommends that local health departments and private providers continue to prioritize target group members, and as supplies permit these providers are encouraged to expand vaccination to all eligible persons requesting vaccination. Vaccine providers should do a situational assessment to determine whether to expand to additional populations in their facility, whether a private office or a health department.

Expanding vaccination to additional populations, supply permitting, in health departments did not become an official recommendation until December 1, 2009. Tennessee did not put out a statewide press release. Instead, the state felt that these announcements should be developed and disseminated at the local level. They informed locals of this change in a memo that included the phrase ?Providers should still give preference to patients in target groups and make efforts to reach out to people in those groups; however, as supplies permit, facilities may vaccinate other people who request it.?

Outcomes that resulted from actions taken: Tennessee?s pre-registration system for private providers engaged those interested in receiving vaccine early on. TN permitted providers to place specific orders for vaccine, rather than making our own assumptions about quantities they needed based on target populations. Providers all receive a weekly H1N1 vaccine update via email from the immunization program to highlight common questions, keep them abreast of the latest changes and explain the distribution process. They have a dedicated H1N1 distribution telephone hotline and email address for questions, or for cancelations or changes to orders.

Anxiety and frustration among providers willing to vaccinate was greatly mitigated by getting at least one 100-dose box of vaccine to any provider with an order as soon as possible, even while the bulk of vaccine was directed to early high priority sites (e.g., hospitals, obstetricians, health departments, pediatricians).

Frequent small shipments to providers have helped keep them vaccinating, even if they did not have adequate supplies to offer a single mass clinic. It also allowed them to cancel order balances if demand turned out to be far less than they anticipated when they placed their order in October.

Survey Monkey online questionnaires were very useful tools for collecting orders and collecting the weekly doses administered reports that we summarized for CRA.

The streamlined ordering process, allowing those in the Immunization Program with the most expertise with influenza vaccine and distribution to manage the process, has worked very smoothly.

Challenges:
The design of the order management database was incredibly complex ? but has successfully provided decision support for allocations made by the Immunization Program Medical Director. Initially, TN attempted a SAS-based program, which failed and had to be redesigned emergently. TN now uses an Access database with Excel Macros designed to update order balances after each formulation is allocated.

The immunization program heard from providers that they were experiencing pushback from people 65 and older who were very upset and confused about repeatedly being told that they could not be vaccinated. These providers wanted the state to ease the restrictions and expand the eligible populations to include older adults.

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