The 2009 H1N1 Influenza Vaccination Campaign

Summary of a Workshop Series

Clare Stroud, Lori Nadig, and Bruce M. Altevogt, Rapporteurs

Forum on Medical and Public Health Preparedness for Catastrophic Events

Board on Health Sciences Policy

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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The 2009 H1N1 Influenza Vaccination Campaign Summary of a Workshop Series Clare Stroud, Lori Nadig, and Bruce M. Altevogt, Rapporteurs Forum on Medical and Public Health Preparedness for Catastrophic Events Board on Health Sciences Policy

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This project was supported by contracts between the National Academy of Sciences and the American College of Emergency Physicians, the American Hospital Association, the American Medical Association, the American Nurses Association, the Association of State and Territorial Health Officials, the Centers for Disease Control and Prevention (Contract No. 200-2005-13434 TO #6), the Department of Health and Human Services’ Agency for Healthcare Research and Quality (Contract No. HHSP233200800498P), the Department of Health and Human Services’ National Institutes of Health (Contract No. N01-OD-4-2139 TO #240), the Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (Contract Nos. HHSP233200900680P and HHSP23320042509X1), the Department of Homeland Security, Federal Emergency Management Agency (Contract No. HSFEHQ-08-P-1800), the Department of Homeland Security’s Office of Health Affairs (Contract No. HSHQDC-07-C-00097), the Department of the Army (Contract No. W81XWH-08-P-0934), the Department of Transportation’s National Highway Traffic Safety Administration (DTNH22-10-H-00287), the Department of Veterans Affairs (Contract No. 101-G09041), the Emergency Nurses Association, the National Association of Chain Drug Stores, the National Association of County and City Health Officials, the National Association of Emergency Medical Technicians, the Pharmaceutical Research and Manufacturers of America, The Robert Wood Johnson Foundation, and the United Health Foundation. The views presented in this publication are those of the editors and attributing authors and do not necessarily reflect the views of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-16021-6 International Standard Book Number-10: 0-309-16021-9 Additional copies of this report are available from The National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334- 3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: IOM (Institute of Medicine). 2010. The 2009 H1N1 influenza vaccination campaign: Summary of a workshop series. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Workshop Planning Committee* JAY BUTLER (Co-Chair), (then) Centers for Disease Control and Pre- vention, Atlanta, GA, (currently) Alaska Native Tribal Health Con- sortium, Anchorage, AK JEFFREY S. DUCHIN (Co-Chair), Public Health−Seattle & King County and University of Washington, Seattle, WA TERESA BATES, Tarrant County Public Health, Fort Worth, TX BETH P. BELL, Centers for Disease Control and Prevention, Atlanta, GA PAMELA BLACKWELL, Cobb & Douglas Public Health, Marietta, GA JAMES S. BLUMENSTOCK, Association of State and Territorial Health Officials, Arlington, VA BROOKE COURTNEY, Center for Biosecurity of UPMC, Baltimore, MD JACK HERRMANN, National Association of County and City Health Officials, Washington, DC B. TILMAN JOLLY, Department of Homeland Security, Washington, DC LISA KOONIN, Centers for Disease Control and Prevention, Atlanta, GA DAVID L. LAKEY, Texas Department of State Health Services, Austin, TX CATHY SLEMP, West Virginia Department of Health and Human Resources, Charleston, WV IOM Staff BRUCE ALTEVOGT, Preparedness Forum Director CLARE STROUD, Program Officer ANDREW POPE, Director, Board on Health Sciences Policy ALEX REPACE, Senior Program Assistant ________________________ ∗ Institute of Medicine planning committees are solely responsible for organiz- ing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. v

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Forum on Medical and Public Health Preparedness for Catastrophic Events* LEWIS GOLDFRANK (Chair until September 2010), New York Uni- versity Medical Center, New York ROBERT KADLEC (Co-Chair from September 2010), PRTM Man- agement Consultants, Washington, DC LYNNE KIDDER (Co-Chair from September 2010), Center for Excel- lence in Disaster Management and Humanitarian Assistance, Tripler AMC, Hawaii ALEX ADAMS, National Association of Chain Drug Stores Foundation, Alexandria, VA (from September 2010) DAMON ARNOLD, Association of State and Territorial Health Officials, Arlington, VA GEORGES BENJAMIN, American Public Health Association, Wash- ington, DC D. W. CHEN, Office of the Assistant Secretary of Defense for Health Affairs, Department of Defense, Washington, DC ROBERT DARLING, Uniformed Services University, Bethesda, MD (until September 2010) VICTORIA DAVEY, Department of Veterans Affairs, Washington, DC JEFFREY DUCHIN, Public Health−Seattle & King County and Uni- versity of Washington, Seattle, WA ALEXANDER GARZA, Department of Homeland Security, Washing- ton, DC JULIE GERBERDING, Merck Vaccines, West Point, PA (from Sep- tember 2010) LYNN GOLDMAN, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (until September 2010) DAN HANFLING, Inova Health System, Falls Church, VA (from Sep- tember 2010) DAVID HENRY, National Governors Association, Washington, DC (until September 2010) JACK HERRMANN, National Association of County and City Health Officials, Washington, DC ________________________ * Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. vi

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KEITH HOLTERMANN, Federal Emergency Management Agency, Washington, DC (until September 2010) JAMES JAMES, American Medical Association, Chicago, IL JERRY JOHNSTON, National Association of Emergency Medical Technicians, Mt. Pleasant, IA BRIAN KAMOIE, The White House, Washington, DC LISA KAPLOWITZ, Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washing- ton, DC (from September 2010) ALI KHAN, Centers for Disease Control and Prevention, Atlanta, GA (from September 2010) MICHAEL KURILLA, National Institute of Allergy and Infectious Diseases, Bethesda, MD JAYNE LUX, National Business Group on Health, Washington, DC ANTHONY MACINTYRE, American College of Emergency Physi- cians, Washington, DC ANGELA MCGOWAN, Robert Wood Johnson Foundation, Princeton, NJ MARGARET MCMAHON, Emergency Nurses Association, Williamstown, NJ MATTHEW MINSON, Texas A&M University, College Station, TX (from September 2010) ERIN MULLEN, Pharmaceutical Research and Manufacturers of Amer- ica, Washington, DC GERALD PARKER, Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washing- ton, DC (until September 2010) CHERYL PETERSON, American Nurses Association, Silver Spring, MD SALLY PHILLIPS, Agency for Healthcare Research and Quality, Rockville, MD (until September 2010) STEVEN PHILLIPS, National Library of Medicine, Bethesda, MD EDITH ROSATO, National Association of Chain Drug Stores Founda- tion, Alexandria, VA (until September 2010) ROSLYNE SCHULMAN, American Hospital Association, Washing- ton, DC RICHARD SERINO, Federal Emergency Management Agency, Wash- ington, DC (from September 2010) DANIEL SOSIN, Centers for Disease Control and Prevention, Atlanta, GA (until September 2010) SHARON STANLEY, American Red Cross, Washington, DC vii

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ERIC TONER, University of Pittsburgh Medical Center, Pittsburgh, PA REED TUCKSON, UnitedHealth Group, Minneapolis, MN MARGARET VANAMRINGE, The Joint Commission, Washington, DC GAMUNU WIEJETUNGE, National Highway Traffic Safety Admini- stration, Washington, DC IOM Staff BRUCE ALTEVOGT, Project Director CLARE STROUD, Program Officer ANDREW POPE, Director, Board on Health Sciences Policy ALEX REPACE, Senior Program Assistant viii

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its pub- lished report as sound as possible and to ensure that the report meets in- stitutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confi- dential to protect the integrity of the process. We wish to thank the fol- lowing individuals for their review of this report: Kristen R. Ehresmann, Minnesota Department of Health Christine G. Hahn, Idaho Department of Health & Welfare Scott Needle, Collier Health Services, Inc. Eduardo Sanchez, Blue Cross and Blue Shield of Texas Jeanne Sheffield, University of Texas Southwestern Medical Center Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the report before its release. The review of this report was overseen by Kristine M. Gebbie, City University of New York. Appointed by the Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring com- mittee and the institution. ix

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Contents 1 INTRODUCTION 1 Background: Preparing for the Vaccination Campaign, 2 Workshop Goals and Objectives, 5 About This Summary, 6 2 VACCINE SUPPLY 7 Supply and Demand, 8 Supply Projections, 10 2009 H1N1 and Seasonal Influenza, 11 Opportunities for Improving Planning Related to Vaccine Supply, 12 3 VACCINE DISTRIBUTION 15 Vaccines for Children Program, 16 Disbursed State Distribution Models, 17 Centralized State Distribution Models, 20 Situational Awareness, 21 Department of Defense Distribution System, 21 Distribution to Tribal Areas, 22 Ancillary Supplies, 23 Opportunities for Improving Distribution Systems in Future Emergency Vaccination Campaigns, 24 xi

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xii CONTENTS 4 IMPLEMENTATION OF ACIP RECOMMENDATIONS 25 Implementation of the Initial Target Group Recommendations, 25 Expanding to the General Public, 29 Flexibility and Consistency, 31 Vaccine Formulations and Target Groups, 33 Opportunities in Using Priority Groups, 35 5 VACCINE ADMINISTRATION METHODS AND PARTNERS 37 Mass Vaccination Clinics, 38 School Vaccination Programs, 40 Healthcare Providers, 42 Pharmacies, 44 Health Plans, 48 Occupational Health Clinics, 48 Opportunities for Improving Vaccine Administration and Enhancing Partners’ Roles in Future Campaigns, 49 6 VACCINATION RATES IN CERTAIN POPULATIONS 55 Pregnant Women, 56 Healthcare Workers, 57 Racial Disparities in Vaccine Uptake, 58 Opportunities for Improving Vaccination Rates in Certain Populations, 59 7 DATA COLLECTION, MONITORING, EVALUATION, AND USE 63 State and Local Public Health Data Collection Models, 65 Data Collection Challenges, 69 Opportunities for Improving Data Collection, Monitoring, Evaluation, and Use, 71 8 COMMUNICATIONS AND MEDIA 73 Communication Challenges During the 2009 H1N1 Vaccination Campaign, 73 Communication Among Public Health Authorities, 74 Communicating with Healthcare Providers, 75 Communicating with the Public, 77 Media Relations, 80 Opportunities for Improving Communications During Future Emergency Vaccination Programs, 82

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xiii CONTENTS 9 FUNDING AND PAYMENT ISSUES 85 Public Health, 85 Healthcare Providers and Pharmacies, 86 Health Plans, 87 Opportunities for Addressing Funding and Payment Issues, 88 10 RESEARCH AND PLANNING 91 Research Opportunities, 93 Planning Opportunities, 95 11 FINAL REMARKS 97 APPENDIXES A REFERENCES 99 B WORKSHOP AGENDAS 103 C WORKSHOP SPEAKERS AND REGISTERED ATTENDEES 113

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