Patience wearing thin over flu shot distribution woes

When it became clear to Brian Bachelder, MD, a family physician in Mt. Gilead, Ohio, that none of the 250 doses of influenza vaccine he had ordered were going to get to his office through the usual channels, he hatched a plan. He made a deal with the pharmacist from the local grocery store, which had an ample supply, to hold two clinics at his office.

"It's not ideal, but we're getting some service for the patients," he said.

Dr. Bachelder is one of many physicians across the country dealing with a flu vaccination season characterized by maldistribution.

High on the list of physician complaints: Many retail outlets appear to have plenty, while some medical practices seem to have none.

According to the Centers for Disease Control and Prevention, more than 80 million doses are expected to be delivered before this season is done. Several surveys suggest, however, that so far the vaccine may not be reaching physicians. One conducted by the Medical Society of the State of New York found that as of the beginning of November about 60% of physicians had received less than 25% of what they ordered and many had received none. Another by the California Medical Assn. found that 46% had not received a single shot.

"We should have vaccine in the hands of doctors," said Jack Lewin, MD, CMA chief executive officer. "This is a terrible mess. All of the big box stores have vaccine. Something stinks in the way vaccine is distributed."

But experts say these rapidly carried out surveys may not offer a completely accurate picture because physicians who are having difficulties may be more likely to respond, thereby skewing results. The CDC and the AMA are currently conducting their own randomized, scientific survey to gain a better understanding. The data are expected to be presented at the National Influenza Vaccine Summit in January 2006.

But while the distribution picture is murky, what is clear is that some physicians are angry about what they have experienced.

"It is time for the federal and state governments to consider stepping in and taking over the vaccine distribution system to assure that those most in need actually get their shots," said MSSNY President Robert A. Scher, MD. "Why should the flu shot be a loss leader for an enterprise like a discount store?"

Community vaccinators counter, though, that the impression that clinics in retail settings have adequate supplies is not entirely accurate. Companies in these venues report that they, too, have cancelled many of their clinics. They also say it's not true that they only reach healthy individuals.

"There are a variety of issues here, and it's a legitimate concern," said Stephen Allred, clinical director of Getaflushot.com, the largest provider of flu vaccines in Washington and Oregon. "But we do service the high risk and work with the [CDC] guidelines. We get a lot of referrals from medical practices, and we have contracts with hospitals for both their patients and for their staff."

The company has received less than half of what it ordered, but this total amount is regarded as proprietary information.

More on the way?

Public health officials are calling for doctors to be patient because more supplies are on the way, and an increasing number of physicians will be receiving at least some of what they ordered. At press time, millions more doses were expected from Chiron, one of the three manufacturers of the injectable version this season. The CDC also expects to receive 800,000 doses at the end of November to distribute to areas with shortfalls.

"In those locations where the clinics have been closed and the doctors don't have vaccine, CDC will be able to offer a little bit of help and potentially even more help in December," said CDC Director Julie Gerberding, MD, MPH.

Still, doctors say their patience is wearing thin and the logistics of providing flu shots are becoming a nightmare. "All we have heard for the past few months is be patient and wait," said James Cunnar, MD, a family physician in Naperville, Ill., who has not received any of the 300 doses he ordered. "Influenza is going to be here, and we're not going to have any more time."

Many had scheduled regular appointments in October and November for their high-risk patients so they could get the shot in conjunction with their routine care. Calling those patients back is an enormous burden. Caretakers may be less willing to take more time off work for an extra office visit. Snowy winter sidewalks may make elderly patients less willing to risk going outside.

"It's not always easy to get them in to just come back for their flu shot. It's a massive headache for us, massive work for my office staff and an additional visit for the patient," said Ellen Brull, MD, a family physician in Niles, Ill. She ordered 400 shots for her practice but had received just over 100 as of mid-November. Those have been used, and she has been told she will receive no more.

Although some physicians are concerned that they are more likely to get stuck with shots that arrive in December and beyond, many agree that late-season shots are a good idea, and 70% of those surveyed in California said they planned to continue to vaccinate into January.

But doctors also say that late-season shots are a high-risk business proposition. Patients may have gotten shots elsewhere, be unwilling to come in to get them, or may not see the sense in getting a late-season shot.

"I understand that it can be given in January," said Dr. Bachelder. "But if I was offered another 100 doses, I'd have to turn it down. I can't spend several hundred dollars on vaccine I may not be able to use."