HEALTH & SCIENCE

Shortages confound vaccination logistics

The hassle factor is high as physicians help patients play catch-up when vaccines, long on back order, arrive at their offices.

By Susan J. Landers, AMNews staff. May 13, 2002. Additional information

Washington -- Physicians are vaulting additional hurdles as they try to meet the goal of immunizing patients while contending with widespread vaccine shortages.

They must flag patients' charts, keep careful records and try to get patients to return for missed shots when vaccine becomes available.

Many find this to be a time-consuming and frustrating -- although vital -- task.

"It is complicated and difficult," said Julia McMillan, MD, professor of pediatrics at Johns Hopkins University in Baltimore. "Depending on the size of the practice, the resources of the practice and the computer-based record availability of the practice, the process can vary from simply telling a parent that they need to come back, and hoping that they do, to a very sophisticated sending out of postcards or making calls when vaccine becomes available."

"Clearly a lot of practitioners are having difficulties," said Keith Powell, MD, chair of the pediatrics department at Children's Hospital Center in Akron, Ohio. "And there are probably as many solutions as there are practices," he added.

The Centers for Disease Control and Prevention realizes that recalling patients is a big problem for physicians. "We know that very few physicians actually have a tracking system where they could easily do recalls," said Abigail Shefer, MD, a branch chief at the CDC's National Immunization Program.

A CDC survey of immunization program managers in every state found that 75% have sent memos, educational materials and tracking forms to help physicians recall patients. "But what we don't know is how well they are being used by physicians," Dr. Shefer said.

Dr. Powell lamented the lack of a "nice little software program" to help track the children who are missing doses of any vaccines in short supply at the moment. Most physicians keep track of patients' needs manually, which means they compile many lists.

The CDC does weekly updates of its own list indicating the vaccines in short supply. As of mid-April, it listed vaccines to combat diphtheria, tetanus and pertussis; measles, mumps and rubella; varicella and pneumococcal infection.

One of the biggest physician worries is that patients won't return or parents won't bring their children back in when the vaccine is available. While no one seems certain just how effective reminder notices and calls are during the current shortages, the fear is that many patients may fall behind on immunizations, and diseases that were once on the way out may stage a return.

The CDC has offered recommendations intended to stretch existing vaccine supplies and minimize the risk of leaving children without any protection at all by prioritizing who receives the limited supplies on hand. For example, in February the agency recommended that physicians delay administering the varicella vaccine until a child is 18 to 24 months old. The vaccine is usually administered at 12 to 18 months.

If the vaccine's use must still be prioritized, those first in line should include health care workers, family contacts of immunocompromised people, adolescents, and adults and children infected with HIV.

Similarly, the CDC recommended delaying the fourth dose of the DTaP vaccine in order to ensure that sufficient supplies are available to give infants the first three doses.

This necessary delay in vaccination schedule should not cause a problem with the effectiveness of a series of vaccines, said Jane Seward, MD, MPH, acting chief of the CDC's Child Vaccine Preventable Diseases Branch.

Longer intervals between shots aren't a problem, she said, as the intervals are intended to be the minimal times between shots. "It never matters if you go longer. You never have to restart the series."

Patient education

Laurie Mortara, MD, an infectious diseases specialist in Long Beach, Calif., is troubled by the lack of public awareness of the vaccine shortage problem. "The first thing we need to do is to make the patient aware that there is a shortage," she said.

Shortages tend to vary by area of the country, and Dr. Mortara has experienced shortages of tetanus and influenza vaccines and, more recently, pneumococcal vaccine.

"We also need to make patients aware of when they are due for their next vaccination and, in the case of the tetanus vaccine, what kinds of injuries should prompt them to go to the emergency room for a tetanus shot," she said.

Recalling patients for vaccine when it becomes available is a serious problem, she said. "You have to maintain a list that is almost a calendar to indicate when people are due for their shots."

Patients are also not likely to return immediately if the only reason is for a shot, said Dr. Mortara. Instead they wait for their next office visit, a situation that makes her uncomfortable.

There could be some improvement in patients' return trips "if we could make the population understand the protective nature and importance of the vaccines," she said.

But the largest frustration for physicians, said Dr. Mortara, comes from not understanding why, "all of a sudden we're not able to routinely get all of the vaccines at a reasonable price. Now there seem to be back orders not only for vaccines but for many other drugs as well."

Timothy Tobolic, MD, is a member of a five-physician family practice near Grand Rapids, Mich., and, while he is keeping lists of patients who are missing shots, he questions the effectiveness. "Can we capture everybody? And if a limited amount of the vaccine becomes available, who do you call first?

"It's not an equitable or fun system to deal with," he said.

Both Dr. Tobolic and Dr. Mortara fault the supply system for their plight. Dr. Mortara suggested having some level of federal control to assure that people at high risk are able to receive needed vaccine.

"I think we are at the mercy of the manufacturers," said Dr. Tobolic. "Before, we had four or five manufacturers of a particular vaccine, and you could shop for price and there was availability." Now there are only one or two manufacturers for a vaccine.

Acknowledging that there are frustrations all around that are associated with the current shortages, Bruce Gellin, MD, executive director of the National Network for Immunization Information praised the efforts of primary care doctors. "The pediatricians and family physicians on the front line know how important it is for kids to be vaccinated."

He also recommended issuing recall notices. After all, he noted, automobile mechanics send reminders to get the oil changed and the vet sends reminders on the dog's shots. So why not reminders on tetanus shots?

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CDC National Immunization Program on current vaccine shortages (http://www.cdc.gov/nip/news/shortages/)

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Copyright 2002 American Medical Association. All rights reserved.