The Tennessee Department of Health partnered with private providers throughout the state to ensure that its H1N1 vaccine distribution plan was serving the immediate and long-term needs of the community. These partnerships enabled the health department to carry out its vaccine program by 1) monitoring vaccine distribution and demand among different groups; 2) prioritizing target groups and re-allocating vaccine based on changing needs; and 3) expanding vaccine eligibility to the general public. Throughout this process, the health department also distributed small amounts of vaccine to as many ordering providers as feasible to maximize the number of points of access for target recipients throughout the state. These activities, and a constant flow of communication between the health department and providers, allowed the vaccine program to smoothly adjust to changing circumstances and enable providers to best serve their patients' needs.
Monitoring Vaccine Demand and Distribution
The immunization program is the lead program for vaccine distribution in Tennessee, which allows for streamlined decision-making. In November 2009, state health officials responded to concerns that demand might wane after Thanksgiving. Their concern was based on experience with demand for seasonal vaccine as well as the growing number of health departments that did not exhaust novel H1N1 vaccine supplies between bi-weekly shipments. Efforts focused on ensuring that the vaccine was distributed quickly and did not linger on shelves.
Tennessee does not follow a formula for vaccine distribution and uses a decentralized approach that involves distributing among health departments and private-sector providers while giving preference to facilities that serve more people in target groups. To assure equitable geographic distribution, providers were grouped by public health region and were allocated doses of each formulation proportional to the regional population. As orders were filled within one region, subsequent allocations were redistributed to other needy regions. The system allows demand to be unofficially tracked as providers place or cancel orders. Because some providers prefer certain formulations over others, the state has been able to widely distribute vaccine to a broad range of provider types.
For example, public health departments and pediatricians preferred to use vaccine licensed for all individuals 6 months and older. That created a reservoir of vaccine licensed only for ages 4 and up, or ages 18 and up, that could be directed to internists and other providers for older children and adults. Tennessee's excellent uptake of vaccine is reflected in CDC's Countermeasure Response Administration (CRA) reporting database. Tennessee makes up 2 percent of the Nation's population, but reported between 2.1 and 4.5 percent of the national doses administered each week from when the program began in October 2009 through the reporting period that ended November 21, 2009. Early unpublished coverage estimates from CDC also demonstrated that estimates of H1N1 vaccine coverage in Tennessee were higher than estimates from elsewhere in both the region and the nation.
Prioritizing Target Groups and Re-Allocating Vaccine
Tennessee has encouraged local and facility level decision-making about prioritizing the ACIP target groups and/or subgroups. Initially, Tennessee encouraged all providers to follow the ACIP recommendations for prioritization and sub-prioritization where needed. However, as soon as feasible, Tennessee would ship at least one box of 100 doses to all providers who placed orders, so that they had at least a small quantity to reach their own highest-priority patients. Planners credit that approach with reducing anxiety and frustration among providers.
Tennessee's pre-registration system for private providers engaged those interested in receiving vaccine early in the program. Tennessee permitted providers to place specific orders for vaccine, rather than the public health department making its own assumptions about quantities that providers needed based on target populations. Providers order vaccines by the age of intended recipients. They can also specify the quantity of LAIV or injectable formulation. Providers all receive a weekly H1N1 vaccine update via email from the immunization program to highlight common questions, keep them abreast of the latest changes, and explain the distribution process. Providers also can use a dedicated H1N1 distribution telephone hotline and email address for questions, or for cancellations or changes to orders.
The design of the order management database was complex, but has successfully provided decision support for allocations made by the Immunization Program Medical Director. Tennessee settled on a simple Access-based system that permitted allocations to be placed by hand and used Excel Macros to update order balances after each formulation was allocated. Each morning, members of the distribution team updated and verified orders or changes submitted the day before, assessed the regional breakdown of the day's vaccine allocations, made allocations, updated order balances between each formulation allocated, and uploaded the orders into the VACMAN system for transmission to CDC. The process involved a minimum of three people, yet four or five people were usually required.
Frequent small shipments to providers have kept vaccine flowing, even when supplies were inadequate to offer a single mass clinic. Such shipments also allowed the health department to cancel order balances, as demand turned out to be far less than anticipated. SurveyMonkey online questionnaires were useful tools for collecting orders and the weekly doses-administered reports that were summarized for the CRA reporting process. The streamlined ordering process worked smoothly and allowed a small team of those in the Immunization Program who had the most expertise with influenza vaccine and distribution to manage the process.
Expanding Vaccine Eligibility
The immunization program staff heard from providers that they were experiencing pushback from people 65 and older who were upset and confused about repeatedly being told that they could not be vaccinated. These providers wanted the state to expand the eligible populations to include older adults and ease the restrictions as soon as their supplies could meet demand among recipients in the target groups that their facility served.
The Department of Health established weekly conference calls with local public health leadership during which public demand was regularly discussed. The Immunization Program's dedicated hotline and email address for H1N1 vaccine providers also provided critical insight into changes in demand.
On November 20, 2009, the Tennessee Immunization Program distributed its weekly H1N1 Provider Update by e-mail, notifying its private provider partners to continue to prioritize target group members. As supplies permit, these providers were also encouraged to expand vaccination to all eligible persons requesting vaccination. Vaccine providers were prompted to do a situational assessment to determine whether to expand to additional populations in their facilities, whether through a private office or a health department.
Expanding vaccination to additional populations in health departments, supply permitting, did not become an official recommendation until December 1, 2009. Tennessee did not put out a statewide press release immediately. Instead, the state felt that these announcements should be made locally. The state health department informed local health departments of this change in a memo that included the phrase "Providers should still give preference to patients in target groups and make efforts to reach out to people in those groups; however, as supplies permit, facilities may vaccinate other people who request it."