Shortage feared as flu vaccine strained by anthrax worry

Physicians report record demand for flu shots, but some worry supply will fall short in a season again marked by delays.

By Victoria Stagg Elliott, AMNews staff. Nov. 19, 2001. Additional information

Barbara Yawn, MD, MSc, a family physician in Rochester, Minn., has had patients asking for flu vaccine because they're afraid of anthrax.

Their requests -- which were fueled by statements by New York Mayor Rudolph Giuliani and media pundits -- are based on the idea that if they are immunized against the flu, they are less likely to experience flu-like symptoms and confusion between this everyday ailment and signs of anthrax will be reduced. Diagnosis will be by elimination.

"That doesn't make a lot of sense," Dr. Yawn said. "A cold, which is much, much, much more common, has the same kind of symptoms, too."

But Dr. Yawn, director of research at the Olmsted Medical Center, has no more vaccine to give anyway.

"It's not the easiest thing to say no, especially if they happen to be a postal worker," she said.

So far, the delivery of flu vaccine depends on where individual physicians or other vaccine providers ordered their supply. The lucky ones received all their vaccine at the end of September. But others still have none. This scenario is being blamed primarily on delays with Wyeth Laboratories Inc., which, because of problems culturing one of the strains, just started shipping the vaccine at the end of October, three weeks later than expected. There are also only three companies now producing it, down from four in 2000.

"These companies are really having to ratchet up production," said Keiji Fukuda, MD, MPH, chief of the epidemiology section in the Centers for Disease Control and Prevention's influenza branch. "In doing so, they're actually able to go and produce more vaccine than they have in the past, but it's taken a fair amount of time and effort to ratchet up the vaccine production."

With only a quarter of Dr. Yawn's order arriving in October -- about 3,000 doses -- she has had just enough to vaccinate her highest-risk patients. She has told her otherwise healthy patients ages 65 to 70, who should have been among the first vaccinated according to CDC guidelines, to come back. She also has not vaccinated herself, although as a health worker she should have been among the first to receive it.

"As soon as the rest of the doses come in and I feel confident that every high-risk person that needs it has access to it, then I'll get mine," she said.

She's been told that she will be receiving 9,000 doses, the remainder of her order, at the end of November or the beginning of December. But she wonders about the accuracy of this timetable and if the balance of her supply will arrive too late to be useful.

Mass vaccinators such as those who provide shots at grocery stores and pharmacies are also reporting lines out the door, a level of demand they suspect is partly fueled by the anthrax scare.

"Lots and lots of people are showing up for the high-risk clinics," said Sunny Hynds, national sales manager of Flu-Central, based in Littleton, Colo. "And the ones we have planned for workplaces are calling us back and telling us they need to double the number of shots. The anthrax has scared people."

Her organization thus far has received 37% of the 1 million-dose order she placed in January. They have been scrambling to cover the shortfall and have acquired a total 450,000 doses to date. But they don't know if they'll ever get all they need.

"It's another challenging year," Hynds said.

And that's the irony. There actually will be more vaccine this year than last -- 85 million doses versus 75 million. More than half -- 54% -- already has been shipped out. The rest is expected in November and December. But public health officials worry that the demand spurred by anthrax scares will outstrip supply and those at highest risk will not get the shot.

"This has been one of the more confusing things for everyone this year," Dr. Fukuda said.

A hot commodity

In addition to increased demand, physicians are reporting significant price increases compared with last season. Manufacturers already had announced early this year that the vaccine price would increase between 20% and 50%. But layers of suppliers and distributors can mean that the price hike is even greater.

This year, Ronald Bangasser, MD, medical director of Beaver Medical Group in Redlands, Calif., ordered his vaccine expecting to pay $23.85 for a 10-dose vial. But it didn't arrive in time. He has since been paying as much as $120 a vial from a local supplier to provide vaccinations to his sickest patients until his regular order of 35,000 doses arrives. He has received calls offering him the vaccine for as much as $200 a vial.

This story is similar to many others -- told both last year and in this flu season. As a result, the CDC announced last month that they would be studying the pricing issue.

"The vaccine manufacturers sell some of their vaccine directly to physicians, but they also sell some of the vaccine to distributors and then distributors sell it to other distributors. It's a complicated system," Dr. Fukuda said. "Clearly, some people are having to buy vaccine at inflated prices. This is a practice that all of us have worked pretty hard to discourage. But, again, it's a private market system out there, and CDC doesn't have any direct control over how much the vaccine costs," he said, or over what prices people can set.

Physicians are also reporting mixed success with the sharing networks set up during last year's flu season in an attempt to maximize the amount of vaccine going to high-risk people and minimize price-gouging.

"The system worked, but no one's got any to share," said Dr. Bangasser, who is also speaker of the house for the California Medical Assn. and set up such a network locally this year.

Dr. Bangasser's regular order has started to trickle in, and he expects to vaccinate the remainder of his patients, his staff and himself this month. He doesn't know what the demand will be like, although he does not expect to have to go back to the high-priced distributors.

But there may be a bright side to the anthrax scare. The record wait times and patient demand may have catapulted the flu vaccine to the top of the agenda.

"We may have the highest compliance rate ever this year," said Timothy T. Flaherty, MD, chair of the AMA Board of Trustees.

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 ADDITIONAL INFORMATION: 

Thirty-four percent of Americans believe there will be a flu vaccine shortage this year. Here's how the delivery is breaking down so far:

54% of the vaccine supply was delivered by the end of October.
33% of the supply is expected to be delivered by the end of November.
13% of the supply is due in December.

Sources: American Society of Health-System Pharmacists, Centers for Disease Control and Prevention

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CDC influenza page (http://www.cdc.gov/nip/flu/)

AMA flu vaccine page (http://www.ama-assn.org/ama/pub/article/1826-4907.html)

Flu-Central, immunization specialists (http://www.flu-central.com/)

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Copyright 2001 American Medical Association. All rights reserved.