1. H1N1 Vaccine Distribution in Minnesota: The Struggle for Efficiency and Equity
Elizabeth Parilla
Minnesota Department of Health
April 2010
National Immunization Conference

2. Presentation Outline Minnesota demographics
Our vaccine allocation and distribution process
Challenges for vaccine allocation and distribution
Balancing local flexibility with consistency and efficiency
Distributing vaccine in a equitable manner
Ensuring that the process is perceived as fair
Lessons learned

3. Minnesota Demographics
Basic information:
12th largest state by area
21st largest by population
54% of the population live in the 7-county Twin Cities metro
Public health
89 local health departments
7 state health department district offices
State health department in St. Paul
Private healthcare
Majority of medical care provided through private clinics
~90% of pediatric medical care
Several large health systems
~40% of pediatric medical care

4. H1N1 Vaccine Allocation Considerations
Overall goal: Target vaccination to ACIP recommended groups and expand to general public ASAP
ACIP guidelines
Ethical considerations
Practical considerations
Formulations available

5. Doses of H1N1 Vaccine Ordered by Week and Formulation, Minnesota 10/09-12/09
Open to entire population
Open to full ACIP priority groups and 2nd pre-book
LPH & Hospitals
1st pre-book

6. Challenge 1: Balancing flexibility with consistency and efficiency
Counties in MN differ in terms of:
Population size
Diversity
SES
Private healthcare capacity
Public health capacity
Public health experience with immunization
Public demand for immunization
Counties also wanted differing levels of involvement in ordering for private providers and redistributing vaccine through their LHD.

7. Minnesota Population by County

8. Ordering and Distribution Process
MDH managed ordering at the state level.
VFC is managed at the state level Immunization program in MN.
VFC staff had experience working with centralized distribution, private providers, and the complexity of vaccine ordering.
Counties had three options:
Providers pre-book directly with MDH and vaccine orders are sent directly to the provider (n=62).
The LHD manages the pre-book and sends the information to MDH. Vaccine orders are sent directly to providers (n=10).
The LHD manages the pre-book and sends the information to MDH. All orders for providers in the county are sent to the LHD to be redistributed (n=15).

9. County Choices of Vaccine Options
Blue: Providers pre-book with MDH and directly receive vaccine
Green: Providers pre-book with their LHD and directly receive vaccine
Yellow: Providers pre-book with their LHD and the LHD redistributes all vaccine

10. Effects of Having Local Options
Made pre-booking more complex.
Led to confusion when counties made last minute changes in their option.
Made communication to providers more complex and time consuming because the messages had to fit the county’s vaccine option.
Took more time to manage the orders.
If the county redistributed vaccine, it took more time for orders to reach the provider + possible risk to cold chain.

11. Effects of Local Options on Health Systems
Health systems have clinics in many different counties and it can be overwhelming for them to get conflicting messages from different counties on ordering and distribution.
Many systems use a central warehouse to receive and redistribute pharmaceuticals and are concerned about not being able to use their normal vaccine distribution process.
Ultimately, large health systems were exempted from county ordering and distribution plans and worked directly with MDH.
Small health systems in greater MN were often frustrated that counties were managing vaccine differently from one another.

12. Challenge 2: Distributing vaccine equitably
Only certain types of clinics could request vaccine in the 1st pre-book
Those considered a medical home for persons in the initial ACIP priority groups
Specific populations were given priority based on ACIP recommendations and the vaccine presentations available
FluMist: HCP
Injectable: Children and pregnant women
Clinics were randomized

13. Randomization: Ethics
A panel organized by MDH, the University of Minnesota and the Minnesota Center for Health Care Ethics developed a report on ethics of rationing scarce resources between 2006 and 2009.
Ethics panel recommended that several clinical, population health, and fairness considerations be applied before employing random selection techniques.
“At some point, random selection techniques will be required to decide how to allocate resources among equally prioritized persons.”
DE Vawter, et al. For the Good of Us All: Ethically Rationing Health Resources in Minnesota in a Severe Influenza Pandemic. [Preliminary Report] Minneapolis: Minnesota Center for Health Care Ethics and University of Minnesota Center for Bioethics (2009).

14. Randomization: Lessons Learned
Initially our partners accepted the concept of randomization for distribution of scarce resources.
However those who received lower random numbers became quite frustrated.
The longer providers had to wait for vaccine the more they expressed concerns about the process being unfair.

15. Equitable Distribution: Factors
Medical hubs
Lack of accurate information about clinic type and patient population size
Overestimated need because patients were double counted (LHDs, clinics, and specialty sites might all request vaccine for the same people)
County-level distribution and vaccination plans
Presentations of vaccine available
Differing levels of demand for vaccine

16. Processes to support equitable distribution
Creating maps of statewide distribution
Analyzing surveys of LHDs and clinics
Holding conference calls with LHDs
Meeting with the vaccine allocation workgroup

17. Public Demand: “Does your county have enough vaccine for the ACIP priority group?”
Percentage of persons within the county that could be vaccinated with the number of doses shipped to sites within the county
Yes
Yes
Yes
Unsure
Yes No
Yes
Unsure
Yes
Yes
No Response
Yes

18. Challenge 3: Ensuring the process is viewed as fair
Distribution of a scarce resource can easily be perceived as inequitable by medical providers, local health departments, or the public.
If one person or clinic receives vaccine and another has to wait it can make people feel they have been treated unfairly.
This becomes more challenging when a resource is scarce for long periods.
Rumors can increase feelings of inequity.

19. Perception of Inequity: A Case Study
Reported concern: County X has not received as much vaccine as other counties.
Reality: County was near or above average in terms of the number of doses sent to sites in the county by population.
There was high demand for H1N1 vaccine in County X so a pro-rata allocation felt unfair to them.
Date
County X
MN average
11/6 8% 7%
11/16 9%
10%
12/7
20%

20. MDH Communication about Fair Allocation and Distribution
Weekly conference calls with LHDs
Special editions of monthly Got Your Shots newsletters
Weekly s to all pre-registered sites
Conference calls with private providers
Webinars, conference calls for schools and post-secondary institutions
Website
Vaccine order confirmation s
Weekly vaccine distribution data summaries on web
News conferences

21. MDH Communication about Fair Allocation and Distribution: Challenges
Frustration and anger over the changing and limited vaccine situation made it harder for people to internalize complex messages.
Too many complex messages coming from public health and it was difficult to simplify messages related to vaccine.
People don’t read.

22. Transparency about Fair Allocation and Distribution
Weekly communication to LHDs and providers
Vaccine information on website for public
Number of doses ordered in MN
Who can receive H1N1 vaccine?
LHDs had access to pre-registration, pre-booking, and ordering data via a secure website
Challenges:
Safety and logistic concerns about releasing clinic specific data
Legal protection for ordering data

23. Lessons Learned
Balancing local flexibility with consistency and efficiency
Flexibility is important so that LHDs can manage vaccine in the most appropriate way for their communities.
However it is a good idea to only allow a limited number of ordering and distribution options for counties to chose between.
Keep all ordering and distribution options in mind while designing ordering processes like pre-book.
Health systems should have the option to order and receive vaccine directly from the state.
Distributing vaccine in an equitable manner
Find or create data sources for clinic type and patient population data as part of the pre-pandemic planning.

24. Lessons Learned, Continued
Ensuring that the process is perceived as fair
Communication
Simplify messages as much as possible.
Use more “personal” communication like conference calls rather than s.
Offer more basic education about vaccines to new partners that may not have experience with immunization.
Try to address the emotional difficulties that arise in a pandemic.
Recognize that messages may not be heard because providers are overwhelmed.
Transparency
Legally protect distribution data

25. A Fairly Happy Ending! 2009 H1N1 Vaccination Coverage Estimates as of January 2010, BRFSS and NHFS

27. Acknowledgements Thank you for your time today!
Special acknowledgements:
MDH staff working on H1N1 vaccine distribution and vaccine guidance: Denise Dunn, Margo Roddy, Kris Ehresmann, Josh Rounds, Sudha Setty, Judy Bifulk, Lisa Harris, Jennifer Heath, Amy Hockett, Lynn Bahta, Jill Marette, Heather Pint, Susan Ersted, Chris VanBergen, Stefani Kloiber
MIIC (Immunization Registry): Emily Peterson, Erin Roche, Karen White
MDH Immunization Program staff
MDH Office of Emergency Preparedness staff
Local Public Health
Minnesota’s dedicated medical providers
CDC with a special thanks to Rosanna Boyd and Pascale Wortley
Thank you for your time today!