News & Events

Globe Nov 8 2009 A day in the life of a pandemic (MDPH story)

On Thursday it was 63,500 swine flu doses, and hundreds of thousands in need. So who will get the vaccine? Inside the world of the state officials and doctors who must make that sobering choice, and of the worried people clamoring to be next in line

By Stephen Smith, Globe Staff  |  November 8, 2009

The e-mail landed at 9:35 Thursday morning on a computer screen deep inside an austere state building perched above the Forest Hills transit station:
“Subject: H1N1 Vaccine Allocation Balance Report.’’

The news, this day, was good. A bumper supply of the season’s most precious commodity, swine flu vaccine, was bound for Massachusetts. To be precise, 63,500 doses.
But who would get it?

Never before have public health agencies, scientists, and drug makers attempted to brew so much vaccine – 250 million doses nationally – and deliver it in so little time. In the race between virus and vaccine, the virus has the head start, fostering a demand for flu shots and spray with few parallels in medical history.

In a drab office crammed with steel desks, two state workers began to parcel out the vaccine like modern-day Solomons, making decisions that would reverberate through every doctor’s office, health center, and hospital in the state and help determine which patients, this week, would be lucky enough to get the vaccine.

“Can you bring everybody up to at least 7 percent?’’ Donna Lazorik plaintively asked a colleague glued to an Excel spreadsheet. That might be the best they could hope for on this day, to give every physician or clinic enough shots to ensure at least 7 percent of children under 3 would be vaccinated.

For the first time since the frenzied hunt for swine flu inoculations began last month, the state Department of Public Health agreed to let a reporter observe the divvying up of vaccine to health providers. It is a task that is equal parts science and art, supply and demand.

It takes into account which of eight different vaccine formulations are being made available by the US Centers for Disease Control and Prevention, the agency that buys all the doses and functions as the national clearinghouse. Some doses are for infants and toddlers. Some can be used only in children and adults with no underlying health conditions, such as asthma. Some are for nearly everyone.

Then the doses must be matched with the appropriate facility. It would be a waste, for instance, to ship toddler doses to a nursing home. The state must also order ancillary supplies and make sure the right needles, syringes, and alcohol swabs arrive at the same time with the right vaccine.

“We can’t control the amount of vaccine that’s available,’’ said Lazorik, one of the state immunization specialists in charge of H1N1 vaccine distribution. “So our job is to make sure it’s allocated as equitably as possible across the whole state, to make sure there aren’t pockets that don’t have access to vaccine, to reach as many different people as possible.’’
. . .
The calls from families in pursuit of vaccine crackle across the phone lines at the pediatric office of Mass. General West Medical Group in Waltham. By 8:55 Thursday morning – just 40 minutes before the state officials in Boston would find out more vaccine was bound for Massachusetts – the phones were already trilling relentlessly.

“Just keep listening to the recording and as soon as we do get something, they will update it and then you can press a certain number and then we’ll be able to book something. OK? All right. Bye-bye,’’ said Dena Cutulle, one of three secretaries at the medical practice who answer phones and assuage anxieties with orchestral precision.
It has been like this for weeks, Cutulle lamented, sighing heavily. By her estimate, 85 percent of callers are inquiring about either swine flu vaccine or inoculations against seasonal influenza.

Right now, the math isn’t in their favor. The practice has received only 590 doses for a roster of about 5,000 children. The young have borne the brunt of swine flu infections, so they have been placed at the front of the vaccine line.

“Most parents are very frustrated, and they’re very angry with us,’’ said Cutulle, herself a mother of twin toddlers who have yet to receive their vaccine. “They say, ‘Well, if my child gets the flu, I’m going to blame it on you.’ ’’

Susan Chick, who flanks Cutulle to the right at the practice’s reception desk, has worked for Mass. General West for 11 years. Never has she experienced something like this, she said. “This is insane this year, insane.’’

As doses of vaccine dribble in, parents like Johanna Himes quickly stake their claim. Her daughter Ella, who is 2 1/2, received the spray version Friday. Himes called five times before vaccine was finally available. “Persistence,’’ she said.
Jim Tracey had no such luck. Wearing a tie and a look of anxiety, he dropped into the pediatric office hoping to get vaccine for his daughter, Madelyne, who just turned 10. “You keep calling here or wherever, and they say they don’t have it and they don’t know when they’re going to have it, and that’s the frustrating part, the not knowing,’’ Tracey said.

Making flu vaccine is a notoriously sluggish, antiquated process, subject to the vagaries of chickens and eggs. As they have for decades, drug makers produce the vaccine in eggs, and the H1N1 vaccine has grown less robustly than expected, meaning that production schedules are several weeks behind original forecasts.

For now, doctors and health departments are being told to give it only to patients considered most vulnerable to the lethal complications of flu. That includes pregnant women and children. Because they have contact with people at risk, health care workers and people taking care of infants under 6 months also fall on the priority list. So far, Massachusetts has been allotted more than 800,000 doses, most of which has arrived in the state – but that is only half of what is needed to vaccinate the 1.6 million patients on the priority roster.

State health authorities predict it will be the middle of December before they have enough vaccine – at least 2 million doses – to make it widely available. Ultimately, Massachusetts is supposed to get 3.7 million doses of swine flu vaccine.

Close to a quarter of the doses are now being directed to local health boards, which have broad latitude in dispensing the vaccine, as long as they restrict it to the priority groups. So, in Wellesley, shots were given to middle school and high school students with asthma and other medical conditions. And pregnant women have received injections at the health department. Yesterday, nurses gave healthy children the vaccine at a townwide clinic held at a church.

The Boston Public Health Commission, recipient of about 6,000 doses so far, devoted 400 to nurses, paramedics, and other city workers who encounter people especially susceptible to flu’s ravages. Remaining doses have been spread among Boston’s vast network of community health centers, with the expectation those clinics will give them to neighborhood residents in priority groups, even if they aren’t clinic patients.

The journey of a swine flu shot or spray bottle begins at one of four manufacturers. As vaccine rolls off their factory lines, they alert the federal CDC, which, in turn metes out vaccine caches to states based on population.

On Thursday, the CDC told the Massachusetts health agency it was getting three types of vaccine: prefilled syringes for children 6 through 35 months, multishot vials for patients 6 months and older, and the spray. It was then up to the Massachusetts team, hunkered down in the Department of Public Health offices in Jamaica Plain, to determine the vaccine’s destination.

Weeks ago, doctors, clinics, hospitals, and other health providers had to register with the state, describing their practices and reporting how many patients they had in various age groups. That information was compiled into a spreadsheet that one of the workers, intent on distributing 19,600 shots for young children, swiftly scanned.

First, he decided where it made sense to send that vaccine. Because the shots are used exclusively in toddlers and infants, no doses would go to nursing homes, prisons, or colleges; there will, over time, be other types of vaccine available for them. Among those who would get a shipment: pediatricians, family practices, and big multispecialty practices such as Harvard Vanguard Medical Associates.

Then, the official – he did not want to be identified, in part, because he worried about being inundated with calls from vaccine-seekers – looked to see how many doses each eligible practice had received previously. His goal: to make sure similar-type practices had comparable amounts of vaccine.

In roughly 30 minutes, all the shots and sprays were assigned. Then, another worker placed orders for needles, syringes, and medical waste containers for all the practices. By the end of the day, the requests were beamed back to the CDC in Atlanta.

A private company ships the vaccine (from a warehouse in Georgia) and the supplies (from a warehouse in Ohio) to doctors and clinics in Massachusetts, with most orders arriving two or three days after the state places its order.

In the next few days, a package containing more vaccine should be delivered to Mass. General West’s pediatric practice, but the phones will doubtless continue to ring.
Stephen Smith can be reached at  

© Copyright 2009 The New York Times Company