As the United States gears up for one of the largest vaccination programs ever conducted, the broad outlines of the campaign to vaccinate nearly 100 million Americans against pandemic H1N1 influenza virus by Christmas are beginning to fall into place.
Many key questions remain, however, including precisely when the vaccines will become available and exactly where the public will be able to get shots. The situation is further complicated by the need to vaccinate about the same number of people against seasonal flu during roughly the same period. One key question was cleared up Friday when it became apparent that only one dose of the swine flu vaccine will be required.
The seasonal flu vaccination effort will be handled as usual, but the "unprecedented" effort against H1N1 is "very complicated logistically," said Dr. Jonathan Fielding, Los Angeles County's health officer. The only reason it is possible at all, he added, is because the 2003 outbreak of severe acute respiratory syndrome, or SARS, and the subsequent fears of an avian flu pandemic led public health officials to prepare plans for a mass vaccination program such as that now being undertaken.
The key difference between the current H1N1 campaign and past immunization programs is that the federal government is paying for the vaccine this time, rather than sticking the consumer and local health departments with the bill. The U.S. Department of Health and Human Services has ordered the ingredients for 195 million doses of vaccine against the virus, commonly known as swine flu.
The government has also ordered corresponding quantities of syringes, needles, sharps disposal containers, alcohol swabs and other paraphernalia required for swine flu immunization. All "will be provided at no cost to those who will vaccinate," said Dr. Pascale Wortley, chief of the Centers for Disease Control and Prevention's health service research and evaluation section.
Who will vaccinate? Most everyone who normally provides seasonal flu shots, and a lot of other people as well.
The distribution chain for the vaccine is like a massive pyramid, with the CDC at the top and pharmacies, physicians, clinics, hospitals, schools and others below.
Those people and institutions will place their orders for vaccine with county and state health departments, which will triage the requests to make sure the vaccine is allocated fairly and to ensure that the most crucial vaccine targets receive it first. Those targets include pregnant women; healthcare providers; caretakers of young children; children and young people between the ages of 6 months and 24 years; and non-elderly adults with underlying medical conditions, such as heart problems and diabetes. Healthy adults will be able to get it after the target groups needs are met.
The high-priority group totals 159 million people. But no one expects all of them to show up for shots. In a normal flu season, about half those eligible for vaccination receive it, and that percentage is likely to be considerably smaller for the vaccination against the new flu strain because of unsubstantiated concerns about the safety and testing of the vaccine.
If there proves to be a shortage of the vaccine, the CDC has a priority list of about 40 million people who should go to the head of the line -- pregnant women; parents and caretakers of children younger than 6; healthcare workers with direct exposure to infected patients or to the virus; children between 6 months and 4 years of age; and those ages 5 to 18 with underlying risk factors.
Most hospitals in the area are providing the vaccine free to employees and strongly encouraging them to get it. Vaccination is typically voluntary, but UC Irvine Medical Center is mandating it for all employees, said media relations director Cathy Lawhon. Past experience at most hospitals indicates that 50% to 70% of employees receive flu vaccines. Those who don't must, by state law, sign a letter of declination.
Colleges and universities will offer the vaccine to students and, in many cases, to faculty as well, either free or for a nominal charge of perhaps $10 to $15 to cover administrative costs.
Most elementary and high schools will not offer the vaccines, however. "Schools have told us that it is too logistically complicated to send a permission slip home and have it returned," Fielding said. Some schools may serve as vaccination sites, but only as part of a broader community program. Orange County has not yet determined whether it will run school programs, said county health director Dr. Nancy Bowen.
Other vaccination sites in Los Angeles County may include fairgrounds, civic centers, community centers and other facilities that can handle a high traffic flow, provide security and have sufficient parking. They should also be near bus stops or Metro stations, Fielding said. At most sites, the vaccines will be free, but pharmacies and physicians will most likely charge a small fee for administration of the vaccine.
To administer the shots, the health department will mobilize all of its employees, each of whom has been trained as a first responder and can give vaccinations. The county also has a reserve group of physicians and nurses that it can call on, and it will enlist students at nursing schools and other county agencies. Moreover, it will need help from the police to help secure the facilities and from other agencies to help coordinate logistics, he said.