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Thompson Assures High-Rick Patients of Flu Vaccine Availibility

October 18, 2004 at 12:00 AM EDT
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JIM LEHRER: Margaret Warner has our flu story.

MARGARET WARNER: The flu season begins in earnest next month. On an average year, it puts some 200,000 Americans in the hospital, and kills 36,000 of them.

When the government announced two weeks ago that only half of the expected 100 million flu vaccine doses would be available, the Centers for Disease control said the vaccines should be reserved for people 65 and older, children six to 23 months old, pregnant women, people with chronic metabolic or kidney disease, blood disorders, or weakened immune systems; and health care workers who deal directly with patients.

Since then, people have been lining up for shots at clinics, hospitals, and grocery stores throughout the country. Many leave disappointed. Today Health and Human Services Secretary Tommy Thompson said there should be enough doses to cover the high-risk patients.

TOMMY THOMPSON: We don’t want them to stand in line and wait for the vaccine because we still have approximately 20 million plus doses of vaccine that we are getting shipped out about three million doses each particular week. We’re looking all over the regions to find out where there’s a shortage, and we will redeploy the resources to make sure that the seniors get the vaccine first.

JIM LEHRER: But officials of the American College of Emergency Physicians warned today that the U.S. may be facing a catastrophic “perfect storm” in public health when a surge in flu cases hits an overburdened emergency health care system.

So how is the public health system dealing with the vaccine shortage? And what problems lie ahead? For that, we turn to Dr. Joseph Dalovisio. He’s director of infectious diseases at the Ochsner Clinic Foundation Hospital in New Orleans, where he and some 600 other doctors also see private patients. Dr. Arthur Kellermann, chairman of the Department of Emergency Medicine at Emory University and a board member of the American College of Emergency Physicians; and Dr. Allen Craig, the state epidemiologist for the Tennessee Department of Health.

Welcome to you all.

Dr. Dalovisio, let me start with you. You heard Secretary Thompson say they’re going to be plenty of doses for those who really need them. What’s the situation at your hospital and practice in New Orleans?

DR. JOSEPH DALOVISIO: Well, I’m an infectious disease specialist at a large community hospital and clinic. Every year we start planning for the flu season, usually in the springtime, we order our vaccines in based on our prior year’s experience.

This year we ordered 64,000 doses of the vaccine from the two manufacturers who are making it this year. We try to always split our order up amongst the various manufacturers who have it because we have a problem getting our supply every year.

This year we’re down to two, and we were expecting our doses when we found out recently that only half the allotment was going to come, we started being concerned about exactly how we would deploy this.

The Center for Disease Control had planned to broadly vaccinate the population this year, but once they found out the shortage was going to happen, they revised their recommendations to include the groups that you just mentioned. Our problem is…

MARGARET WARNER: So how are you making these decisions? If you only have half the number of doses you expected, what are you doing?

DR. JOSEPH DALOVISIO: It is a problem to actually translate that plan in your own hospital and clinic. We started out by getting the message out to our health care workers who don’t have hands-on contact and to our healthy patients, asking them to forgo the vaccine this year. For our sicker patients and for our hands-on health care workers, we asked them to get vaccinated as soon as possible. Realizing the bottom line here is that we, at least in this community, weren’t going to have enough vaccine to vaccinate everybody. This is really distressing for an infectious disease physician or any physician because vaccines are one of the most effective tools we have in our toolbox for preventing disease and the toolbox is about empty.

MARGARET WARNER: Dr. Kellermann, what’s the situation at emery?

DR. ARTHUR KELLERMANN: At Emory we have adequate supplies of vaccine. We ordered early and we picked the right within.

MARGARET WARNER: You picked the right supplier?

DR. ARTHUR KELLERMANN: Yes. Aventis sent their supplies to Emory, and many of us have been vaccinated. In many health systems around the country, they’re not in the same shape. Many members attending our meeting here in San Francisco are in health systems where they have not been able to get access to vaccine. In fact, we bring 1,000 doses a year to give to our members as a convenience. We had lines one and two hours long yester for that vaccine. We’re going to run out of vaccine before we run out of emergency physicians who need it.

MARGARET WARNER: Talking to your colleagues out there at this convention, are you saying that it’s not just the patients in their respective home cities and locals but even emergency workers aren’t getting…

DR. ARTHUR KELLERMANN: Absolutely. Absolutely. That’s really important to understand because if an emergency nurse or an emergency physician is laid low by the flu at the height of flu season, their ability to care for patients is lost. There aren’t enough of us on a good night do what we need to do. If we lose a significant number of our colleagues at the height of the season, that would be a problem. Also, infected health care workers can inadvertently pass on the flu early in infection to patients. We don’t want that to happen.

MARGARET WARNER: All right. Dr. Craig, you’re looking at the entire system in Tennessee from not just hospitals but clinics, private practice, grocery store chains. What’s the situation overall in Tennessee?

DR. ALLEN CRAIG: We’ve certainly been recommending, as the CDC has, that only high-risk individuals be vaccinated and that healthy individuals forgo the vaccination. We’ve been working hard to get the word out. Vaccine clinics began today around the state. There is a vaccine in most of our health departments today. We anticipate we will run out over the next few weeks. The good news is with the redistribution the CDC is planning, we anticipate vaccine will be coming in slowly over next two months.

MARGARET WARNER: Is demand higher, we’ve heard anecdotally, that demand is higher because of all the publicity about the vaccine shortage?

DR. ALLEN CRAIG: Typically in an average year, about 90 million people fit into the high-risk category talked about. We have about 55 million doses of vaccine available. So… with about half the people usually getting vaccinated, there would be enough if the demand were normal. I think you’re exactly right, the demand will be increased because of the increased concern and publicity.

MARGARET WARNER: Now, explain to us how the distribution system usually works. Is there anyone, any government agency in charge of who gets vaccine?

DR. ALLEN CRAIG: The vast majority of the flu vaccine distributed in the United States is through the private sector, hospitals and clinics and pharmacies order vaccine directly from the manufacturer or from distributors and it goes directly to them. State health departments also order directly from manufacturers. We do have a system through the Centers of Disease Control that provides vaccine for children called the Vaccines for Children’s program.

What’s unique about this year is about 33 million doses have already gone out through this distribution system. Now the CDC is working closely with Aventis to redistribute what sounds like about 22 million doses that are left in the warehouses.

That will actually go out to groups that are… only the groups taking care of high-risk individual, so doctors, nurses, practices, health departments as well as nursing homes.

MARGARET WARNER: Back in New Orleans, Dr. Dalovisio, has your hospital been given indications or word yet that you are going to be able to tap into this 20 million coming doses to cover your high-risk people?

DR. JOSEPH DALOVISIO: We haven’t. We’ve been told that we’ve gotten all the vaccine we’re going to get. So we’re trying to deal with that as it is. I’d like to say that infectious disease doctors are trying to deal with this shortage locally, but this is really a national crisis.

The Infectious Diseases Society of America has been urging medical communities, pharmacy and government to all work together to ensure that we have vaccines and antibiotics to take care of our patients. These are the two most important tools we have to take care of people, vaccines and antibiotics.

MARGARET WARNER: All right. Dr. Kellermann, back to you. You were part of a group of ER Physicians that warned of the perfect storm that’s coming. Describe it to us.

DR. ARTHUR KELLERMANN: We already have a problem in this country with our emergency departments filled with patients, intensive care units filled with patients and ambulances being diverted from hospital to hospital due to lack of emergency care capacity. That’s before the flu season strikes.

The American College of Emergency Physicians have been calling for action on this problem for four years. US News and World Report ran a cover story called “Crisis in the ER” Three years ago. The date of that issue was Sept. 10, 20001. Nothing has been done since to deal with this problem.

MARGARET WARNER: So what’s the impact? What are the ramifications here? We know there will be more flu cases. Is that a given?

DR. ARTHUR KELLERMANN: Americans have to be very concerned that if we have tens of millions of high-risk Americans that can’t get this vaccine and they’re not going to and they get sick this winter and come into emergency departments in hospitals that are already full, we could have an extraordinarily difficult situation on our hands.

We have to clear the decks now, take the careful planning and contingency steps into account to be able to ensure that America’s health care resources are there to meet the needs of these patients. That’s not happening.

That’s why my organization today issued a call to the federal government and to our partners in health care for a crisis summit to plan to deploy our resources to meet the needs of every American in this flu season.

MARGARET WARNER: Dr. Julie Gerberding, the head of the CDC, said it’s not known how serious a flu season this will be. Do you have any evidence of how serious it will be? Is it possible to know at this point?

DR. ARTHUR KELLERMANN: You know, we can hope and pray for the best, but wishful thinking is no substitute for prudent planning. We only have a limited amount of time to prepare for not only the worst-case scenario, simply a worse-than-average flu season. And I think it would be very unwise for us to simply hope that things are going to work out okay.

That’s never served public health’s interest before. It won’t serve it now. We need to be prepared for a severe flu season so we can do the best for patients. That’s what we’re committed to doing.

MARGARET WARNER: Briefly, Dr. Dalovisio, because I want to come back to Dr. Kellermann on the recommendations, do you agree hospitals aren’t prepared for this surge?

DR. JOSEPH DALOVISIO: I agree. I think it’s not there, the capacity, in terms of hospital capacity nor in terms of vaccine capacity and possibly even antibiotic capacity used to treat the complications of influenza. We really are weak on all counts.

MARGARET WARNER: Dr. Kellermann, back to you. This call to action you all issued today, part of it sounded like you were suggesting that regional or state public health officials really be in charge, what, of allocating beds, of managing beds, are we talking about rationing hospital stays?

DR. ARTHUR KELLERMANN: Well, we need to make sure that critical health care workers are vaccinated as quickly as possible. We also need to ensure that we’re looking at health care capacity on a reasonable level so every hospital is playing by the same rules.

We also need to be prepared to defer or delay elected admissions so that our very precious critical care beds and hospital beds are available to the patients who need them most.

We have to get boarded patients who are in the ER, who are admitted hours or days earlier out of the emergency department, packing the hallways of America’s ER’s with admitted patients at the height of a flu epidemic could be a disastrous situation. We simply cannot allow that to happen.

MARGARET WARNER: And just to explain to our viewers, by boarded patients, you mean patients who belong in the hospital proper but they’re being kept in the emergency room because there is no room in the hospital.

DR. ARTHUR KELLERMANN: Absolutely. We’re talking about seriously ill and injured patients who we have stabilized, had planned on admitting to the hospital but cannot move upstairs because the ICU is full or the in-patient units are full. Today many hospitals keep those folks in the ER for hours or even days at a time. That practice has never been good. It is absolutely unacceptable when we’re facing the prospects of a major epidemic.

MARGARET WARNER: Okay. So, Dr. Craig, back to you; you’re a state public health official. Do you think this has to be managed now, that the government has to get into it and start managing it in anticipation of a surge in flu cases?

DR. ALLEN CRAIG: I think this is really a wake-up call for us I guess in two regards. The first is that we need to do more planning to plan for such surge capacity, and we’ve certainly spent a lot of time with our bio-terrorism planners working with hospitals and public health to try to do that planning. The second thing is we need to be talking about the manufacturing of the vaccine for the future to make sure that there is enough vaccine and they are more than simply three manufacturers that make vaccine in this country. There’s a lot to be done, and we need to be involved in this planning effort with hospitals.

MARGARET WARNER: But is it fair to say for this year there are no other doses available, say, from overseas or from other manufacturers; that this 55 million doses, is it?

DR. ALLEN CRAIG: I think it’s very unlikely we’ll have other manufacturers from overseas get their product licensed in time to be used this season. I guess there is another thing we haven’t talked about, which is the vaccine flu mist, which is a nasal live vaccine that can be safely given to adults, low- risk adults under age 49. But it includes health care workers and parents of very young children under aged six months. That’s another resource that we certainly are encouraging hospitals in Tennessee to tap into.

MARGARET WARNER: All right, Dr. Kellermann, Dr. Craig and Dr. Dalovisio, thank you all three.