For the past six years, there have been influenza vaccine supply and distribution disruptions.1 In December 2003, there were spot shortages in certain jurisdictions when public demand surged in response to an early-onset influenza season and to media coverage of pediatric deaths.2 However, the supply and distribution problems for the 2004-2005 season were worse-exacerbated by a severe nationwide shortfall of vaccine.* Assessing county and city public health agencies' performance and reviewing responses to the influenza vaccine shortage can yield important lessons regarding preparedness for future vaccine shortages and other public health emergencies. This article will highlight the importance, utility, and full use of public health preparedness plans as they were applied to the challenges public health agencies faced during this year's influenza vaccine supply crisis. This article will also review model local responses to the vaccine shortage and document some of the exemplary practices employed by these jurisdictions, especially those identified as advanced practice centers (APCs).+

Public Health Preparedness

Local public health agencies (LPHAs) have addressed preparedness issues for several years. Their efforts have ranged from building partnerships with community stakeholders and first responders, developing procedures for rapidly notifying local and state authorities, and creating emergency plans for identifying responsibilities of response partners, to testing preparedness plans through exercises and drills, developing educational and training material for public health officials and communities, and enhancing surveillance systems that rapidly detect illness patterns. These efforts not only help LPHAs respond more effectively to public health emergencies due to intentional attacks, but have helped build an infrastructure that is stronger and more able to respond to unintentional events. This season's influenza vaccine shortage is the most recent example of how LPHAs leveraged the knowledge and experience gained through preparedness planning to quickly and appropriately address a public health emergency.

Activating a Command Center

At the Montgomery County (Maryland) Department of Health and Human Services, much of the work that had taken place to plan for public health emergencies set the stage for addressing the influenza vaccine shortage. Montgomery County designed a Public Health Command Center to improve emergency response to a biological disaster. A similar structure was used to address the influenza vaccine shortage, using the same policies and protocols. In addition, telephone hotlines, volunteer recruitment procedures, and a system for sending out volunteer requests, all of which were built for public health preparedness, proved invaluable in addressing the vaccine shortage. Furthermore, their syndromic surveillance system* was used to detect influenza-like-illness+ activity throughout the county. Not only did it help to have these plans and systems in place, but using them to respond to the shortage also allowed Montgomery County to exercise some of their procedures and identify gaps in their preparedness plans.

Employing Incident Command

Staff at the Dallas County (Texas) Health and Human Services (DCHHS) Bioterrorism Preparedness Division received incident command system (ICS)++ training to coordinate emergency response and improve communication with other responding agencies. During December 2003, DCHHS experienced a critical shortage of influenza vaccine while in the midst of investigating a large-scale influenza outbreak. The ICS was applied both to manage and investigate the vaccine shortage. In using the ICS to respond to the shortage, the DCHHS leveraged their resources effectively and handled the situation in a structured manner. Roles and responsibilities for staff were clearly defined, and working relationships between agencies that may not have collaborated in the past were strengthened.

Legal Authority and Quarantine and Isolation

Many jurisdictions declared public health emergencies[S] as part of their aggressive efforts in seeking out high-priority populations to vaccinate. Exercising these emergency orders had tremendous implications for local control of reallocation and redistribution of scarce doses of vaccine. The emergency orders helped these jurisdictions establish a public health on-scene command system, institute appropriate enhanced influenza vaccine inventory surveillance, coordinate activities with other local public and private partners, and coordinate strategic efforts with neighboring jurisdictions and state public health agencies on matters requiring assistance from other jurisdictions.

Lessons Learned

The LPHAs worked with various city and county agencies, and many developed new partnerships with hospices, nursing homes, organizations that serve meals to at-risk and vulnerable home-bound populations, and nontraditional partners such as the Multiple Sclerosis Society. The existence and implementation of preparedness plans helped make these efforts easier and better coordinated.

The use of preparedness plans helped them overcome barriers such as the HIPAA privacy regulations that could keep some strategic partners from sharing client information and help them deal with union issues because volunteer doctors and nurses are not routinely covered by malpractice insurance policies.3 The plans also helped highlight gaps in the plans such as recognizing the difficulty in reaching several subgroups of high-priority populations to connect them with life-saving vaccine and realizing that key community partners had not been included when preparedness plans were developed.

The vaccine supply emergency also helped LPHAs recognize solutions to those gaps-the infrastructure changes and the strategic partnerships developed can help them with emergencies about how to give out other vaccines and prophylaxes quickly in any public health emergency, particularly during a pandemic. The APCs and jurisdictions that employed preparedness plans were successful in dealing with the shortage and in coordinating vaccination efforts within their communities by operationalizing effective response strategies to ensure optimal resource allocation and improve operational efficiency of the plan and using the plan as a structure to reach consensus on the following:

* Decisions on prioritizing schemes and implementing them judiciously and ethically;

* Efficiency of allocating resources (and staff) according to emergency response strategies yet maintaining capacity to maintain routine activities;

* Methods to strengthen systems to ensure more efficient distribution or redistribution of vaccine supplies as needed;

* Method for overall planning for reaching and immunizing high-priority populations; and

* Determining short- and long-term priorities and planning for future vaccine shortfalls, which can help in planning future mass vaccination efforts and help prevent exacerbation of racial, ethnic, and socioeconomic disparities in influenza vaccination rates.*

Conclusions

During recent public health responses involving influenza, having preparedness plans in place set the stage. The LPHAs took leadership roles to fashion unified preparedness plans to minimize confusion during the vaccine shortage emergency and to show the public that they were doing all they could to secure doses of influenza vaccine for its high-priority constituents. Public health used their contingency plans to coordinate the community response to avoid duplication and replication of efforts and to minimize adverse impacts on routine public health services. Capabilities developed after the terrorist and intentional biological attacks of 20014 are demonstrating their value in responding to unintentional events and emergencies. Putting these plans into practice is an invaluable part of exercising roles, identifying gaps, and keeping skills current to maintain a level of readiness regardless of the source of the public health emergency.

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