The 2005-06 influenza season found local health departments (LHDs) grappling yet again with vaccine supply and distribution problems. And yet again governmental public health is faced with this critical question: How do we enable all levels of public health to respond adequately and competently to this problem that does not seem to want to go away, that desperately needs a solution, but where no one arm of public health can manage or control it? With regard to influenza control and prevention, much depends on well-functioning public health systems, and governmental public health always has to think years in advance to be prepared for what might happen next to disrupt influenza vaccine distribution. Governmental public health needs to become more user-friendly and modify its systems so that it is more integrated and information can navigate its way easily across local, state, and federal levels and out to the broader public health partnership. However, developing such systems has been slow coming. Since the 2000-01 influenza season, LHDs and their community partners have struggled through vaccine supply disruptions and distribution problems.1 With the nation's, and indeed the world's, current focus on the march of H5N1 strains of influenza throughout Asia and the near East,2 the need for a systems modification is more pressing than ever. Governmental public health must focus on finding smarter methods to address influenza vaccine supply and distribution problems.
Overview
Why do influenza vaccine supply disruptions and distribution problems keep happening? Many LHDs, private providers, and healthcare centers are asking that question as yet another season of maldistribution of influenza vaccine ends and finds vaccine in surplus in some places, while others scrambled to purchase enough doses to meet demand. Nationwide, enough vaccine was produced to meet demand,3 but getting it out to the places where it is needed and wanted continues to be a problem. On October 3, 2005, the National Association of County and City Health Officials conducted a brief online query of 120 sentinel LHDs to determine the early season status of their influenza vaccine supply and ask if they were having problems with their influenza vaccine orders. Most of the respondents reported significant delays in receiving their ordered doses.4 This came on top of last year's absolute shortage of vaccine due to production problems by one of the two manufacturers of inactivated influenza vaccine.5
The Flow of Information
The shortage of 2005-06 challenged governmental public health and reinforced images of poor and incompetent leadership at all levels as well as the inability to respond quickly to a growing public health crisis. One of the chief complaints from the sentinel LHDs was that they did not receive any advance communication about the supply problems so that they could activate contingency plans. Instead, they had to cancel or delay planned clinics. Chiron ultimately produced approximately 50 percent less vaccine than it originally projected, and thus 50 percent less than the amount upon which orders were based,3 so those providers depending on Chiron for vaccine also experienced a second year of shortage, not just delayed delivery. Public health needs to be more sophisticated in managing relationships-at all levels of government and among private providers, manufacturers, and nonprofits. In these instances, public health's role will be as coordinator over this complex network.
The lack of coordination across this network is manifested in low uptake of influenza vaccine. Most of those populations recommended to receive influenza vaccine do not bother to get one.6 Efforts to improve influenza immunization rates among these groups are lost opportunities that are not helped by repeated supply disruptions. Failure to develop systems that reach all high-priority groups will cause more problems and that cannot be offset by better vaccine-manufacturing technology. Every aspect of these supply disruptions is worse for the elderly, ethnic and racial minorities, and the poor-another important issue that improved vaccine-manufacturing technology cannot address.
Vaccine Development Versus Vaccine Distribution
LHDs are admonished by state and federal public health agencies to close these gaps and connect their constituents to life-saving doses, and there are steps that many are taking to do this despite the year-to-year crises. However, it is unreasonable to expect them to fix the problem without making larger systems changes-LHDs cannot, without adequate support, create the 21st-century tools, eg, Web-based vaccine inventory surveillance systems, needed to close these gaps. In a world that has embraced modern information technology, LHDs are stuck in the 20th century, relying on telephones and fax machines to develop vaccine supply surveillance systems because they do not have the resources to ramp up to information technology systems that simplify inventory data collection and reporting.
The crux of all of the focus on vaccine development and manufacturing should take a step back to acknowledge one thing: People must have access to those vaccines for them to mean anything. We need a balance between developing new vaccines and investing in systems that deliver them equitably. If we continue down the path of maldistribution and delayed deliveries, how do we ever hope to meet our Healthy People 2010 or our pandemic preparedness goals? Solutions that make delivery of influenza vaccine more systematic are just as important as new cell-based technologies, and they are just as likely to save lives.
Model Responses and Plans
As was noted in 2004, the Centers for Disease Control and Prevention (CDC) and Aventis developed a secure data network-a partnership that allowed public health to "broker" vaccine and distribute it. This was an emergency operation that was to stave off more maldistribution, but its effectiveness was limited, as it depended on states to report their need. That was a limited snapshot of statewide need because the print of administration is not with the state but at the local level, and whether there was adequate input from locals to that process is not well known.
Now we are faced with preparations for a possible pandemic, and many are criticizing public health for failing to prepare-if we cannot handle supply and distribution during interpandemic seasons, how can we ever hope to manage during a pandemic season?
If we do not discuss the systems issues underlying the now-annual occurrences of maldistribution of influenza vaccine, then we may just carry on with these cycles of supply problems season after season.
Preparing for Pandemic Strains of Influenza
If policymakers do not understand these issues, how will they allocate resources, such as assuring adequate funding for routine public health practice and exercising to prepare for various pandemic scenarios? The National Association of County and City Health Officials and the CDC are committed to collaborating and bringing innovative ideas to the forefront. We want to showcase novel approaches to the problem that work in the field, irrespective of resources, or bring partners together to address the barriers. NACCHO and CDC are developing a special issue of this journal in July 2006 to focus on many of these issues. Articles in this special issue will focus on some key broad areas that need to be addressed.
* Strategic planning-developing a sense of direction for all levels of governmental public health and our partners
* Key recommendations-establishing multidisciplinary approaches to the problems and barriers such as legal issues and public health authority, risk communication, and modeling influenza disease
* Areas of infrastructure that need strengthening as well as strategic cores to provide the latest technology and expertise to LHDs struggling with these problems
* Focus on even more basic infrastructure-mechanisms for improved planning, communications, marketing, and support services
* Transformation of the delivery of vaccines-the growth in it and the need to focus on this neglected area
* The core mission of public health has not changed, but the landscape has changed tremendously. The basic needs of LHDs' constituents have not changed, but the information technologies available to them and the organizational framework, including financing, by which the potential of these technologies will be made available to their constituents have transformed
* A pandemic puts even more pressure on the supply and distribution systems-necessitating the need to locate, deliver, and distribute necessary medicines, personal protective equipment, and other emergency items in addition to maybe needing to ramp up a mass vaccination clinic in a matter of hours, not days
Preparing for the Worst-Case Scenario: A Pandemic Strain of Influenza
Handling the ever-changing scenario of influenza, especially of pandemic influenza, requires an integrated contingency plan to prepare all levels of public health for the worst-possible outcomes. Identifying how LHDs dealt with the past years of shortages can provide valuable information for resource planning-and part of the point of the special July 2006 issue is to do exactly that. LHDs' most important asset is the trust that their constituents have in them to deliver the services they depend on them for. LHDs provide indispensable services that state and federal public health agencies cannot provide. A case in point is the unique and novel responses to the past years of influenza vaccine supply disruptions, where LHDs acted as clearinghouses of vaccine supply information for the entire community. In cases of emergencies and disasters, LHDs will be, and have been, important community actors and coordinators for implementation of response plans.
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