1. Five Years of Flu Seasons: A Study of Trends and Lessons Learned in Maryland Tiffany Tate, MHS Maryland Partnership for Prevention, Inc. National Immunization Conference March 8, 2006

2. Acknowledgements  Maryland’s Local Health Departments  Greg Reed, MPA, Maryland DHMH  JR Ransom, MPH, NACCHO  Journal of Public Health Management and Practice

3. Maryland Partnership for Prevention, Inc.  Maryland’s adult immunization coalition and parent to childhood immunization coalition  501(c)3 since 1999  Holds grant agreement with Maryland DHMH to complete Maryland Flu Season Final Report

4. About Maryland Population - 5,296,486 Ranks 19th in U.S. population Source: 2000 United States Census

5. Maryland Statistics  24 local health jurisdictions  Participates with MMCAP  64.6% of Maryland residents over 65 years of age report having a flu shot in the past 12 months*  LHDs administer appx. 10% of influenza vaccinations in state (Source: BRFSS, 2004)

6. Maryland Flu Season Final Report  Data from series of surveys to LHDs Vaccine ordering practices Vaccine administration data Flu season experiences Plans for subsequent years  Supply and delivery issues  DHMH flu season activities  Flu Season Wrap-Up Meeting

7. 2001-2002 Flu Season “FDA Announces Delay in Release of Wyeth Flu Vaccine Lots”

8. Preparing for ’01-’02 Season  LHDs ordered 113,350 doses of vaccine  33% LHDs placed initial vaccine order in April (Range: January – August)  58% ordered through MMCAP  16% ordered from more than one manufacturer/distributor

9. Impact of ‘01- ‘02 Delay  Supplemental vaccine ordered* (33%) Avg price: $78 per vial Range: $57 to $125 per vial – up to 500% of MMCAP price  Surplus vaccine (75%) Combined loss: $44,667 (16 LHDs)  Postponed flu clinics (66%) *50% needed additional vaccine but some were prohibited from ordering

10. Impact of 2001-2002 Delay (cont.)  Delayed advertisement of flu clinics (58%)  Loaned vaccine to others (41%)  Reduced number of clinics (37%)  Prioritized according to MD Flu Plan (37%)  Cancelled clinics (25%)  Ran out of vaccine during clinic (20%)

11. Overview ’01-’02 Flu Season  89,959 vaccinations administered by LHDs  63% of LHDs administered more vaccinations than in previous years  75% of LHDs reported a surplus of vaccine

12. ’01-’02 Lessons Learned  Order vaccine early  Order from a “reliable” source  Order from >1 manufacturer  Announce flu clinics after vaccine received  Supplemental vaccine can result in surplus  Stay informed

13. 2002-2003 Flu Season “CDC: No Flu Vaccine Supply or Delivery Issues Anticipated”

14. Preparing for ’02-’03 Season  LHDs ordered 101,750* doses of vaccine  56% LHDs ordered vaccine in March (up from April previous year)  66% ordered through MMCAP (up from 58%)  39% ordered from more than one manufacturer/distributor (up from 16%) *23 of 24 LHDs reporting

15. Overview ’02-’03 Season  Appx. 95,000 doses of vaccine administered  50% LHDs administered more vaccinations than in previous years  No LHDs needed supplemental vaccine (v. 50% previous year)

16. ’02-’03 Lessons Learned No Delays or Shortages =

17. 2003-2004 Flu Season “CDC: No Flu Vaccine Supply or Delivery Issues Anticipated” Summer 2003

18. Preparing for ’03-’04 Season  LHDs ordered 100,350 doses of injectable vaccine  41% LHDs ordered more vaccine than in previous years  >50% ordered from more than one manufacturer/distributor (up from 39%)  58% ordered from MMCAP

19. 2003-2004 Flu Season Update “CDC: Flu Activity Peaks Early” Fall 2003

20. Response to Early Peak  November ’03 Highly-publicized child deaths from flu LHDs report increased vaccine demand and shortages DHMH institutes weekly conference calls  December ‘03 Maryland Governor and Secretary of Health independently negotiate agreement with MedImmune

21. Response to Early Peak  December ‘03 Mid: LHDs receive 8,100 doses of FluMist ordered through DHMH Late: Maryland receives and distributes 1,700 doses of injectable vaccine from CDC  January ’04 Early: 2,110 doses of Chiron product shipped to LHDs

22. LHDs’ Response  Waiting lists compiled (62%)  Referred patients to private providers (56%)  Referred patients to commercial vaccinators (50%)  Loaned vaccine to others (18%)

23. Impact of Early Peak on LHDs  Ordered supplemental vaccine due to early peak (90%)  Ran out of vaccine during early peak (68%)  Had surplus after ordering supplemental vaccine (68%)

24. Overview ’03-’04 Season  LHDs administered 104,909 doses of injectable and intranasal vaccine  68% administered more vaccinations than in previous seasons

25. ’03-’04 Lessons Learned  Timely communication is important  Commercial vaccinators can be a resource in times of crisis  Media influential in public’s response to vaccine shortages  High level partnerships are essential during shortages and delays

26. ’03-’04 Lessons Learned (cont.)  Supplemental vaccine orders can result in increased surplus  Few are interested in late-season vaccinations

27. 2004-2005 Flu Season “CDC: No Flu Vaccine Supply or Delivery Issues Anticipated” Summer 2004

28. Preparing for ’04-’05 Season  LHDs ordered 134,820 doses of injectable and intranasal vaccine  54% LHDs ordered more vaccine than in previous years  60% ordered from more than one manufacturer/distributor  50% ordered from MMCAP

29. 2004-2005 Flu Season Update “Chiron Experiences Manufacturing Problems” October 5, 2004

30. Response to Shortage  Only 50% of anticipated vaccine supply available  DHMH takes control of and redistributes 50,000 doses of vaccine already delivered to LHDs  CDC nationalizes vaccine & designates priority groups  MMCAP contract for public health was honored

31. LHDs’ Response to Shortage  Loaned to LTCFs (70%)  Referred patients to commercial vaccinators (58%)  Referred to private providers (41%)  Borrowed vaccine (25%)  Compiled waiting lists (25%)

32. Impact of Shortage on LHDs  Postponed or cancelled clinics (70%)  Ordered supplemental vaccine (62%)  Loaned vaccine to other agencies (66%)  Ran out of vaccine in during clinic (4%)

33. Impact of Shortage (cont)  Surplus of vaccine 33% of LHDs quantified loss from excess injectable - $22,000 (Range: $582 to $9,134) 50% of LHDs quantified loss from excess intranasal - $50,000 (Range: $64 to $15,840)

34. Overview ’04-’05 Season  LHDs administered 109,173 doses of injectable and intranasal vaccine  70% administered more vaccinations than in previous seasons  58% of LHDs had excess injectable vaccine  63% had excess intranasal vaccine

35. ’04-’05 Lessons Learned  Order from more than one manufacturer  Public not yet receptive to intranasal vaccine  Maryland responds well to flu crises  Use recorded messages  Timely communication is critical  Delay scheduling clinics until vaccine is in hand

36. ’04-’05 Lessons Learned (cont.)  Improved expertise in mass clinics needed  Standard phone systems cannot handle surge in calls  Don’t use waiting lists  MMCAP contracts are consistently honored  Supplemental orders result in increased surplus  Few interested in late-season vaccinations

37. 2005-2006 Flu Season “CDC: No Flu Vaccine Supply or Delivery Issues Anticipated” Summer 2005

38. Preparing for ’05-’06 Season  LHDs ordered 142,840 doses of injectable and intranasal vaccine  66% ordered from more than one manufacturer/distributor  >60% ordered more vaccine than in previous years  62% ordered from MMCAP

39. 2005-2006 Flu Season Update “Chiron Lots Delayed— To Produce About Half of Planned Estimates” October 2005

40. ‘05-’06Lessons Learned  Order from more than one manufacturer  Order from MMCAP – some distributors’ redistribution illogical  Commercial vaccinators can be a resource during shortages and delays  Communication between all stakeholders is important

41. Recurring Themes: 2001-2005 Maryland Flu Seasons  Order from more than one manufacturer  Order vaccine early/pre-book  Partner with other providers to ensure vaccinations to vulnerable populations  Delay scheduling/announcement of clinics until vaccine in hand

42. Recurring Themes: 2001-2005 Maryland Flu Seasons  MMCAP is a reliable mechanism for securing vaccine, even during challenged seasons  Supplemental vaccine orders often result in increased surplus  Increased education on effectiveness of late-season vaccination needed

43. Flu Vaccine Ordered v. Administered ( Maryland 2001 – 2005)

44. LHDs Ordering from MMCAP (Maryland 2001 – 2005)

45. LHDs Ordering from >1 Manufacturer/Distributor (Maryland 2001 – 2005)

46. Conclusions Despite supply and delivery challenges:  LHDs became more savvy in ordering flu vaccine  LHDs administer more flu vaccinations than in previous years  Communications and partnerships improve each year

48. Contact Information Tiffany Tate Maryland Partnership for Prevention P.O. Box 702 Owings Mills, MD 21117 410-902-4677 mdpartnershipforprevention@msn.com