Influenza Vaccine Shortage Research Articles

Summary of the National Advisory Committee on Immunization (NACI) Statement-Recommendations on Fractional Influenza Vaccine Dosing in the Event of a Shortage: Pandemic preparedness.

At the commencement of a pandemic, it is important to consider the impact of respiratory infections on the health system and the possibility of vaccine shortages due to increased demand. In the event of an influenza vaccine shortage, a strategy for administration of fractional influenza vaccine doses might be considered. This article reviews the available evidence for efficacy, effectiveness, immunogenicity and safety of fractional influenza vaccine dosing, and summarizes the National Advisory Committee on Immunization (NACI) recommendations on fractional dosing strategies by public health programs in Canada. Two rapid literature reviews were undertaken to evaluate the efficacy, effectiveness, immunogenicity and safety of fractional influenza vaccine dosing via the intramuscular or intradermal route. The NACI evidence-based process was used to assess the quality of eligible studies, summarize and analyze the findings, and apply an ethics, equity, feasibility and acceptability lens to develop recommendations. There was limited evidence for the effectiveness of fractional influenza vaccine dosing. Fractional dosing studies were primarily conducted in healthy individuals, mainly young children and infants, with no underlying chronic conditions. There was fair evidence for immunogenicity and safety. Feasibility issues were identified with intradermal use in particular. NACI recommended that, in the event of a significant population-level shortage of influenza vaccine, a full-dose influenza vaccine should continue to be used, and existing vaccine supply should be prioritized for those considered to be at high risk or capable of transmitting to those at high risk of influenza-related complications or hospitalizations. NACI recommended against the use of fractional doses of influenza vaccine in any population.

Evaluating vaccination effectiveness of group-specific fractional-dose strategies

<p style='text-indent:20px;'>In this paper, we formulate a multi-group <i>SIR</i> epidemic model with the consideration of proportionate mixing patterns between groups and group-specific fractional-dose vaccination to evaluate the effects of fractionated dosing strategies on disease control and prevention in a heterogeneously mixing population. The basic reproduction number <inline-formula><tex-math id="M1">\begin{document}$ \mathscr{R}_0 $\end{document}</tex-math></inline-formula>, the final size of the epidemic, and the infection attack rate are used as three measures of population-level implications of fractionated dosing programs. Theoretically, we identify the basic reproduction number, <inline-formula><tex-math id="M2">\begin{document}$ \mathscr{R}_0 $\end{document}</tex-math></inline-formula>, establish the existence and uniqueness of the final size and the final size relation with <inline-formula><tex-math id="M3">\begin{document}$ \mathscr{R}_0 $\end{document}</tex-math></inline-formula>, and obtain explicit calculation expressions of the infection attack rate for each group and the whole population. Furthermore, the simulation results suggest that dose fractionation policies take positive effects in lowering the <inline-formula><tex-math id="M4">\begin{document}$ \mathscr{R}_0 $\end{document}</tex-math></inline-formula>, decreasing the final size and reducing the infection attack rate only when the fractional-dose influenza vaccine efficacy is high enough rather than just similar to standard-dose. We find evidences that fractional-dose vaccination in response to influenza vaccine shortages take negative community-level effects. Our results indicate that the role of fractional dose vaccines should not be overestimated even though fractional dosing strategies could extend the vaccine coverage.</p>

Contracting for On-Time Delivery in the U.S. Influenza Vaccine Supply Chain

Although influenza vaccine shortage is often attributed to low supply, it has been observed that even with abundant supply, a major shortage can still occur because of late delivery. In this paper, motivated by the influenza vaccine industry, we study a supply chain contracting problem in the presence of uncertainties surrounding design, delivery, and demand of the influenza vaccine. In this supply chain, a manufacturer has insufficient incentive to initiate at-risk early production prior to the design freeze because it is a retailer who reaps the most benefits from selling more vaccines delivered on time. Anticipating that late delivery will lead to potential loss in demand, the retailer tends to reduce the order size, which further discourages the manufacturer from making an effort to improve its delivery performance. To break this negative feedback loop, a supply contract needs to achieve two objectives: incentivize at-risk early production and eliminate double marginalization. We find that two commonly observed supply contracts in practice, the delivery-time-dependent quantity flexibility (D-QF) contract and the late-rebate (LR) contract, may fail to coordinate the supply chain because of the tension between these two objectives. To resolve such a tension, we construct a buyback-and-late-rebate (BLR) contract and show that a properly designed BLR contract can not only coordinate the supply chain but also can provide full flexibility of profit division between members of the supply chain. Numerical experiments further demonstrate that the BLR contract significantly improves supply chain efficiency compared to the contracts used in the industry.

Contracting for On-Time Delivery in the U.S. Influenza Vaccine Supply Chain

Although influenza vaccine shortage is often attributed to low supply, it has been observed that even with abundant supply, a major shortage can still occur due to late delivery. In this paper, motivated by the influenza vaccine industry, we study a supply chain contracting problem in the presence of uncertainties surrounding design, delivery, and demand of influenza vaccine. In this supply chain, a manufacturer has insufficient incentive to initiate at-risk early production prior to the design freeze because it is a retailer who reaps the most benefits from selling more vaccines delivered on time. Anticipating that late delivery will lead to potential loss in demand, the retailer tends to reduce the order size, which further discourages the manufacturer from making an effort to improve its delivery performance. To break this negative feedback loop, a supply contract needs to achieve two objectives: incentivize at-risk early production and eliminate double marginalization. We find that two commonly observed supply contracts in practice, the Delivery-time-dependent Quantity Flexibility (D-QF) contract and the Late-Rebate (LR) contract, may fail to coordinate the supply chain because of the tension between these two objectives. To resolve such a tension, we construct a Buyback-and-Late-Rebate (BLR) contract and show that a properly designed BLR contract can not only coordinate the supply chain but also can provide full flexibility of profit division between members of the supply chain. Numerical experiments further demonstrate that the BLR contract significantly improves supply chain efficiency compared to the contracts used in the industry.

Impact of the 2004–2005 Influenza Vaccine Shortage on Pediatric Practice: A National Survey

A severe influenza vaccine shortage occurred during the 2004-2005 influenza season because of the loss of all vaccine made by Chiron (Emeryville, CA) for US distribution. The objectives of this study were to assess among pediatricians nationally: (1) influenza vaccine-delivery strategies; (2) reported vaccine shortages and factors associated with experiencing shortages; and (3) the impact of shortages on vaccine redistribution, patient referral, and clinical practice, including patient prioritization. A survey was administered in March 2005 through June 2005 to 427 pediatricians who participated in a national network representative of the American Academy of Pediatrics membership. RESULTS. Our response rate was 82%. Thirty-nine percent of the pediatricians had a computerized method for identifying patients at high risk needing vaccination. Ninety-four percent and 79% reported giving high-priority to children >/=24 months old with high-risk conditions and children 6 to 23 months old, respectively, whereas 41% gave high-priority to household contacts and caregivers of children <6 months old. Forty-three percent reported experiencing shortages of vaccine for patients at high risk, whereas only 14% ordered Chiron vaccine. In multivariate analyses, ordering vaccine from Chiron and ordering Aventis Pasteur (Lyon, France) vaccine solely from a vaccine distributor were associated with experiencing a shortage. Forty-eight percent of respondents obtained additional vaccine from another source, most frequently the public health sector, whereas 37% reported selling or giving away vaccine. In addition, 47% referred patients at high risk elsewhere for vaccination, primarily to public health clinics. Forty-nine percent reported having unused vaccine remaining at the end of the season. Although few pediatricians ordered Chiron vaccine, substantial influenza vaccine shortages were reported, highlighting the tenuousness of injectable influenza vaccine supplies for children. The extensive redistribution of vaccine suggests that cooperative efforts between the private and public sectors were widespread. Efforts to vaccinate patients at high risk during shortages would be aided by better systems to identify and recall these patients.

Half- vs Full-Dose Trivalent Inactivated Influenza Vaccine (2004-2005)

Optimal public health strategies for managing influenza vaccine shortages are not yet defined. Our objective was to determine the effects of age, sex, and dose on the immunogenicity of intramuscular trivalent inactivated vaccine (TIV). Healthy adults aged 18 to 64 years, stratified by age (18-49 and 50-64 years) and sex, were randomized to receive full- or half-dose TIV. Hemagglutination inhibition titers against vaccine antigens were measured before and 21 days after immunization. A primary outcome of noninferiority was defined as a difference of less than 20% in the upper 95% confidence interval (CI) of the proportion of subjects with strain-specific hemagglutination inhibition antibody titers of 1:40 or higher after vaccination. Secondary outcomes included geometric mean titers, after vaccination side effects, and occurrences of influenza-like illnesses. Among previously immunized subjects (N = 1114) receiving half- vs full-dose TIV (age, 18-49 years, n = 284 [half] and n = 274 [full]; and age 50-64 years, n = 276 [half] and n = 280 [full]), CIs for proportions of subjects with hemagglutination inhibition antibody titers of 1:40 or higher excluded substantial reduction for all antigens in the 18- to 49-year age group and for B/Shanghai/361/2002 (B) and A/Fujian/411/2002 (A/H3N2) in the 50- to 64-year age group. Geometric mean titer in the female 18- to 49-year age group exceeded male responses for all strains: responses to half-dose TIV that were comparable with male full-dose responses for A/New Caledonia/20/99 (A/H1N1) antigen, 25.4 (95% CI, 20.9-30.9) vs 25.6 (95% CI, 21.3-30.9); A/H3N2 antigen, 60.8 (95% CI, 50.8-72.7) vs 44.1 (95% CI, 37.6-51.8); and B antigen, 64.4 (95% CI, 53.9-76.9) vs 60.7 (95% CI, 51.4-71.7) (findings were similar for the 50- to 64-year age group). Some injection site and systemic reactions (myalgias and/or arthralgias [P < .05], headache [P < .001], and impact of fatigue [P < .05]) were significantly lower in men. The relative risk of medical visits and hospitalizations for influenza-like illnesses were similar in the half- and full-dose groups regardless of age. Antibody responses to intramuscular half-dose TIV in healthy, previously immunized adults were not substantially inferior to the full-dose vaccine, particularly for ages 18 to 49 years. Significantly higher geometric mean titer responses in women were identified for all ages, regardless of dose or influenza strain. Half-dose vaccination may be an effective strategy for healthy adults younger than 50 years in the setting of an influenza vaccine shortage.

When the Cat Is Out of the Bag

Whereas the annual influenza season in the United States is fairly predictable, the influenza vaccine supply is variable, leaving providers vulnerable to supply and demand fluctuations each season. During the 2004-2005 influenza vaccine shortage, Oregon invoked Oregon Revised Statute 433-030 to target vaccine supplies to protect persons at highest risk for complications from influenza. This case study describes Oregon's efforts to ration vaccine at the point of administration by limiting the number of individuals eligible for vaccination. An evaluation of this process found that providers responded positively to the mandatory prioritization of vaccine recipients; however, limitations in assessing and affecting redistribution of privately held vaccine supplies and challenges in enforcement of the plan were revealed.

U.S. Healthcare Personnel and Influenza Vaccination During the 2004–2005 Vaccine Shortage

Healthcare personnel with direct patient contact were prioritized for influenza vaccination during the 2004-2005 vaccine shortage. Data about vaccination coverage among healthcare personnel during vaccine shortages are limited. Behavioral Risk Factor Surveillance System 2005 data were analyzed in 2007 for a sample of healthcare facility workers (HCFW) aged 18-64 with (n=3456) and without (n=1153) direct patient contact and non-HCFWs (n=39,405). Chi-square tests and logistic regression were used to identify factors associated with influenza vaccination among HCFWs and to compare HCFWs with non-HCFWs with regard to the main reason for nonvaccination during the shortage. Vaccination coverage was 37% (SE +/- 3.1) among HCFWs with direct patient contact and 25% (SE +/- 5.7) among those without. In multivariate analysis, coverage was higher among HCFWs who were older, more educated, and with higher incomes and better access to health care. The reason most commonly reported by HCFWs and non-HCFWs for nonvaccination was the belief that they did not need vaccination (35% versus 40%, respectively; p<0.05). Even in a time of influenza-vaccine shortage, when most healthcare personnel were targeted for vaccination, their uptake of the vaccine remained suboptimal. Continued efforts are needed to develop effective interventions to improve the use of influenza vaccination among healthcare workers.

An Industrial Organization Perspective on the Influenza Vaccine Shortage

This paper analyzes reasons advanced for the recent shortage of influenza vaccine in the United States and numerous other similar shortages in recent years. Explanations have included high regulatory costs, inadequate profitability, and mergers. Building from the information base developed through an Institute of Medicine study and other work, it advances the discussion in several respects. Using Census data, it shows that vaccine producers realize unusually high pricecost margins, but are probably also unusually capital-intensive. Applying theories of scale economies to existing information, it identifies the extent to which, for diverse types of vaccines, economies of scale limit the number of vaccine producers, exposing the nation to stochastic shortage risk. It proposes a hypothetical but plausible cost function for influenza vaccine production. A benefit/cost analysis then explores whether it is economically worthwhile to maintain additional production sources with surge capacity. It is found that under plausible demand, external benefit, and stochastic supply failure conditions, such multiple sourcing yields more benefits than its cost. One implication of the analysis is that better data on vaccine costs and profits are needed - data the Federal Trade Commission has the power and mission to assemble.

Impact of a Severe Influenza Vaccine Shortage on Primary Care Practice

Because of influenza vaccine shortages during the 2004-2005 influenza season, vaccine was targeted for high-risk priority groups. To assess among primary care physicians: (1) ability to identify priority patients; (2) extent of shortages; and (3) effects of shortages on vaccine redistribution, patient referral and future plans for vaccine delivery. Mailed surveys of pediatric (Peds), family medicine (FM), and general internal medicine (GIM) physicians randomly selected from the American Medical Association master file. Response rate was 37% and the study population included 377 Peds, 319 FM, and 251 GIM physicians. Seventy-five percent of Peds, 58% of FM and 60% of GIM had some method to identify priority patients, although only 39%, 21%, and 18%, respectively, had a computerized method. Forty-five percent of Peds, 73% of FM, and 75% of GIM experienced shortages, for a median of 2-3 months. Approximately 48%-50% of Peds, FM, and GIM obtained additional influenza doses; among these, 53% received vaccine from a public health entity. Fifty-one percent of Peds, 79% of FM, and 80% of GIM referred high-risk patients for immunization, 94% of the time to a public health clinic. More than 95% planned to administer influenza vaccine next season. The majority of physicians experienced influenza vaccine shortages for prioritized patients, especially those providers caring for adults. There was significant vaccine redistribution and patient referral, primarily involving the public health system. Enhancing methods of targeting priority patients and increasing cooperation with public health entities should be priorities in dealing with future influenza vaccine shortages.

A systematic analysis of influenza vaccine shortage policies

The aim of this study was to apply SWOT analysis (strengths, weaknesses, opportunities, threats) to a domestic shortage of influenza vaccine, to identify lessons learned, and to generate effective solutions for future public health rationing emergencies. SWOT and TOWS techniques were employed to characterize the vulnerability of the USA to disruptions in the supply of influenza vaccine. A group of five researchers reviewed relevant literature, engaged in group brainstorming, and categorized elements according to the SWOT framework. Three strengths, five weaknesses, five threats and seven opportunities were identified in the areas of vaccine production, purchasing and distribution, and provision. Four future recommendations emerged with respect to government investment, communications, sanctioning of physicians, and incident command. Application of the SWOT technique is highly relevant to the health policy realm and can assist public health planners in planning for future resource scarcity.

Pandemic Influenza Planning in Nursing Homes: Are We Prepared?

Avian influenza or Influenza A (H5N1) is caused by a viral strain that occurs naturally in wild birds, but to which humans are immunologically naïve. If an influenza pandemic occurs, it is expected to have dire consequences, including millions of deaths, social disruption, and enormous economic consequences. The Department of Health and Human Resources plan, released in November 2005, clearly affirms the threat of a pandemic. Anticipating a disruption in many factions of society, every segment of the healthcare industry, including nursing homes, will be affected and will need to be self-sufficient. Disruption of vaccine distribution during the seasonal influenza vaccine shortage during the 2004/05 influenza season is but one example of erratic emergency planning. Nursing homes will have to make vital decisions and provide care to older adults who will not be on the initial priority list for vaccine. At the same time, nursing homes will face an anticipated shortage of antiviral medications and be expected to provide surge capacity for overwhelmed hospitals. This article provides an overview of current recommendations for pandemic preparedness and the potential effect of a pandemic on the nursing home industry. It highlights the need for collaborative planning and dialogue between nursing homes and various stakeholders already heavily invested in pandemic preparedness.

The impact of the 2004-2005 influenza vaccine shortage in the Veterans Health Administration.

The Veterans Health Administration (VHA) serves a population at high risk of influenza-related morbidity and mortality. The national public health response to the vaccine shortage of the 2004-2005 season resulted in prioritization of recipients and redistribution of available supply. To characterize the impact of the 2004-2005 influenza vaccine shortage on vaccination among users of VHA facilities. Analysis using data from the cross-sectional VHA Survey of Healthcare Experiences of Patients. Outpatients seen in VHA clinics during the months September 2004-March 2005. Sociodemographics, vaccination prevalence, setting of vaccination, and reasons cited for not getting vaccinated. Influenza vaccination prevalence among VHA outpatients aged 50-64 was 56% and for those aged > or = 65 was 86%. Compared to the 2 previous seasons, this estimate was lower for patients age 50-64 but similar for patients > or = 65. After adjustment for patient characteristics, unvaccinated patients aged 50-64 were 8.3 (95% CI 6.0, 11.4) times as likely to cite that they were told they were not eligible for vaccination because of the national shortage compared to patients > or = 65. Regional VHA variation in vaccination receipt and shortage-related reasons for nonvaccination was small. The national influenza vaccine shortage of 2004-2005 primarily affected VHA users aged 50-64, consistent with the tiered prioritization guidance issued by the Centers for Disease Control and Prevention and Advisory Committee on Immunization Practices. Despite the shortage, vaccination prevalence among VHA users > or = 65 remained high.

An industrial organization perspective on the influenza vaccine shortage

AbstractThis paper analyzes reasons advanced for the recent shortage of influenza vaccine in the United States and numerous other similar shortages in recent years. Explanations have included high regulatory costs, inadequate profitability, and mergers. Using Census data, it shows that vaccine producers realize unusually high price‐cost margins, but are probably also unusually capital‐intensive. Applying theories of scale economies to existing information, it identifies the extent to which, for diverse types of vaccines, economies of scale limit the number of vaccine producers, exposing the nation to stochastic shortage risk. A benefit/cost analysis explores whether it is economically worthwhile to maintain additional production sources with surge capacity. It is found that under plausible demand, external benefit, and stochastic supply failure conditions, such multiple sourcing yields more benefits than its cost. Copyright © 2007 John Wiley &amp; Sons, Ltd.

Survey of State Practices during the 2004–2005 Influenza Vaccine Shortage

To describe state-level actions and policies during the 2004-2005 influenza vaccine shortage and determine whether these or other factors were related to vaccination coverage, we surveyed all state health departments (including the District of Columbia). We included 2004-2005 Behavioral Risk Factor Surveillance System data to examine whether state-level actions, policies, or other factors like vaccine supply were related to changes in vaccination coverage in adults aged > or = 65 years from the previous non-shortage year. We found that 96% (n = 49) of states reported adopting or recommending adherence to the initial national interim influenza vaccination recommendations. Of these, at some point during the season, 22% (n = 11) reported local public health agencies issued prioritization recommendations that differed from the state health department's guidance. Eighty percent (n = 41) initiated at least one emergency response activity and 43% (n = 22) referred to or implemented components of their pandemic influenza plans. In 35% (n = 18), emergency or executive orders were issued or legislative action occurred. In a multivariable linear regression model, the availability and use of practitioner contact lists and having a relatively high vaccine supply in early October 2004 were associated with smaller decreases in coverage for adults aged > or = 65 years from the previous non-shortage season (p = 0.003, r2 = 0.26). States over-whelmingly followed national vaccination prioritization guidelines and used a range of activities to manage the 2004-2005 vaccine shortage. The availability and use of practitioner contact lists and having a relatively high vaccine supply early in the season were associated with smaller decreases in coverage from the previous non-shortage season.

Local Health Department Responses During The 2004–2005 Influenza Vaccine Shortage

During the 2004-2005 influenza vaccine shortage, the Centers for Disease Control and Prevention (CDC) coordinated distribution of post-October 5th 2004 doses of influenza vaccine to state and local health departments (LHDs), who subsequently distributed vaccine to community providers. The National Association of County and City Health Officials (NACCHO) conducted three Web-based surveys throughout the 2004-2005 influenza season to assess in real-time how LHDs were 1) dealing with the vaccine shortage, 2) implementing the interim recommendations from the Advisory Committee on Immunization Practices (ACIP), and 3) making efforts to reallocate and redistribute doses of influenza vaccine toward high-priority populations within their communities. This paper highlights LHD responses that alleviated adverse impacts during this public health emergency. The first survey asked LHDs to quantify their community's vaccine supply; the second survey asked them to describe their specific responses to the crisis; and the third survey asked them to reflect and evaluate the effectiveness of their efforts to vaccinate high-priority groups during the crisis. Six hundred five (605) of 717 (84%) LHDs in 44 states responded to the three surveys. Results show that LHDs leveraged preparedness plans, formed strategic community partnerships, and practiced vaccination drills to address the problems of vaccinating high-priority and hard-to-reach populations that arose out of the vaccine shortage. The practices used by LHDs during this shortage may provide valuable response lessons to minimize the impact of future influenza vaccine shortages and other public health emergencies.

Access To Influenza Vaccine In East Harlem And The Bronx During A National Vaccine Shortage

In October 2004, one of the major producers of the U.S. influenza vaccine supply announced that their vaccine would not be available because of production problems, resulting in approximately half of the anticipated supply suddenly becoming unavailable. This study was part of a larger effort using community-based participatory research (CBPR) principles to distribute influenza vaccine to hard-to-reach populations. Given the extant literature suggesting economic and racial disparities in influenza vaccine access in times of adequate supply and our inability to distribute vaccine due to the shortage, we sought to examine vaccine access as well as awareness of the vaccine shortage and its impact on health-seeking behaviors in eight racially-diverse and economically-disadvantaged neighborhoods in New York City (NYC) during the shortage. In our study few people had been vaccinated, both among the general community and among high risk groups; vaccination rates for adults in priority groups and non-priority groups were 21.0% and 3.5%. Awareness of the 2004 vaccine shortage was widespread with over 90% being aware of the shortage. While most attributed the shortage to production problems, almost 20% said that it was due to the government not wanting to make the vaccine available. Many respondents said they would be more likely to seek vaccination during the current and subsequent influenza seasons because of the shortage. The target neighborhoods were significantly affected by the national influenza vaccine shortage. This study highlights the challenges of meeting the preventive health care needs of hard-to-reach populations in times of public health crisis.

Impact of the 2004 influenza vaccine shortage on patients from inner city health centers.

In the fall of 2004, the FDA and British authorities suspended the license of one of only two manufacturers that provided the US supply of inactivated influenza vaccine. With a 50% reduction in supply, a severe vaccine shortage resulted. This situation necessitated the development of priority groups for vaccination including those > or =65 years, when ordinarily, influenza vaccine is recommended for those > or =50 years old. A sample of patients > or =50 years old (n = 336), who had been seen at one of four inner-city health centers, was interviewed in summer 2005 using computer-assisted telephone interviewing. Associations of survey responses were examined for three groups: those vaccinated in the 2003-2004 and 2004-2005 influenza seasons (n = 142), those vaccinated in 2003-2004 but not vaccinated in 2004-2005 because of the shortage (n = 63), and those unvaccinated in both seasons (n = 83). Bivariate and multivariate logistic regression analyses were used to determine factors significantly influencing the likelihood of vaccination status. A significantly larger proportion of patients 50-64 years of age were unvaccinated due to the shortage (73%) compared to those who were vaccinated during both seasons (36%, P < 0.001), but there were no racial disparities in vaccination rates. Compared with patients who were vaccinated during both seasons, those who were unvaccinated due to the shortage were more frequently employed, self-reported their health positively, saw their physician less frequently, rated the US government's response to the shortage as "terrible," and blamed the US government for the shortage. Vaccination during the influenza vaccine shortage appears to have followed preferential vaccination of the CDC-established priority group (> or =65 years) and did not result in racial disparities in inner-city health centers.

From Bioterrorism Exercise to Real-life Public Health Crisis

Although public health agencies routinely operate hotlines to communicate key messages to the public, they are rarely evaluated to improve hotline management. Since its creation in 2003, the New Jersey Department of Health & Senior Services' Emergency Communications Center has confronted two large-scale incidents that have tested its capabilities in this area. The influenza vaccine shortage of 2004 and the April 2005 TOPOFF 3 full-scale bioterrorism exercise provided both real-life and simulated crisis situations from which to derive general insights into the strengths and weaknesses of hotline administration. This article identifies problems in the areas of staff and message management by analyzing call volume data and the qualitative observations of group feedback sessions and semistructured interviews with hotline staff. It also makes recommendations based on lessons learned to improve future hotline operations in public health emergencies.

Response to the 2004-2005 Influenza Vaccine Shortage in Veterans With Spinal Cord Injuries and Disorders and Their Providers

Background/Objectives: To assess patient and provider behaviors regarding influenza vaccination, diagnosis, and testing strategies and the availability of influenza vaccine during the 2004-2005 nationwide influenza vaccine shortage.Design/Methods: Multisite, anonymous, cross-sectional surveys of patients and providers and qualitative interviews after the 2004-2005 influenza season.Setting: Department of Veterans Affairs (VA) health care facilities with spinal cord injury centers or clinics.Participants: Stratified random sample of 3,958 veterans with spinal cord injuries and disorders (SCI&D; 31% response rate), 177 providers who treat persons with SCI&D, and 17 key informants.Results: Most patient respondents (96.1%) reported awareness of a vaccine shortage (n = 938). When asked whether the shortage affected their ability to get the vaccine, 64.8% said they had no problem, whereas 12.1% reported an inability to get the vaccine. The vaccination rate was 71.8%; most veterans received the vaccine early (October-November) at the VA, and vaccination rates increased with age (P < 0.0001). Although vaccine shortages were reported by 47.5% of provider survey respondents (n = 177), most reported that the vaccine shortage did not affect availability of vaccine for patients with SCI&D. Few clinicians conducted diagnostic tests for influenza more often than in past years (4.9%). Although providers reported shortages at 12 centers (n = 23), patients with SCI&D had priority at 11 of 12 centers.Conclusions: Most patients were aware of the vaccine shortage, and the vaccination rate remained high and comparable with previous years. VA providers and facilities targeted SCI&D as a high-risk group and prioritized use of the limited vaccine supply for them.