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.
Several routine childhood immunizations remain in short supply.
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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.
The CDC recommends prioritizing who gets what vaccine when.
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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?
Back to top.
A booster shot for returns
Reminder calls and letters to patients asking that they return to the
office or the clinic for needed immunizations worked well, a team of
researchers concluded after reviewing the available literature.
The findings, published in the Oct. 11, 2000, issue of JAMA, show
that the notices generated a 5% to 20% increase in vaccination rates in 33
of the 41 studies examined. The increases were seen in rates for the range
of childhood vaccines as well as for adult pneumococcus or tetanus
vaccinations.
The researchers, from the University of Rochester (New York) School of
Medicine and Dentistry, the University of North Carolina at Chapel Hill and
the Centers for Disease Control and Prevention, also noted that, although
the use of reminders is often recommended, few physicians and other health
care professionals actually make use of them.
They found that all types of reminders were effective whether through
postcards, letters, telephone or autodialers (a computerized telephone
dialer). They also said telephone contacts were the most costly.
Costs varied widely across the studies examined, said the researchers,
with several studies showing that costs for mailed reminders were less than
$1 per patient. The few studies that estimated cost effectiveness, had the
cost per additional patient vaccinated varying from $9.80 per patient using
an autodialer to $10.50 per patient using a letter reminder.
Regardless, they concluded, "Primary care physicians should use patient
reminders to improve immunization delivery."
Back to top.
Weblink
CDC National Immunization Program on
current vaccine shortages
(http://www.cdc.gov/nip/news/shortages/)
Back to top.
Copyright 2002 American
Medical Association. All rights reserved.
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