Influenza is characterized by cough, fever, headache, and other symptoms and is more severe than some viral respiratory infections, such as the common cold. Most people who contract influenza recover completely in 1 to 2 weeks, but some develop serious and potentially life-threatening medical complications, such as pneumonia. On average each year in the United States, more than 36,000 individuals die and more than 200,000 are hospitalized from influenza and related complications. People aged 65 years and older, people of any age with chronic medical conditions, children younger than 2 years of age, and pregnant women are generally more likely than others to develop severe influenza-related complications. Vaccination is the primary method for preventing influenza and its more severe complications. Produced in a complex process that involves growing viruses in millions of fertilized chicken eggs, influenza vaccine is administered annually to provide protection against particular influenza strains expected to be prevalent that year. Experience has shown that vaccine production generally takes 6 or more months after a virus strain has been identified, and vaccines for certain influenza strains have been difficult to mass-produce. After vaccination, the body takes about 2 weeks to produce the antibodies that protect against infection. According to CDC, the optimal time for vaccination is October through November, because the annual influenza season typically does not peak until January or February. Thus in most years, vaccination in December or later can still be beneficial (see fig. 1). If supplies permit, CDC recommends a vaccination for anyone who wants one. Because circulating influenza strains change, a new vaccine is created each year. For this reason, and because immunity declines over time, CDC recommends a new influenza vaccination every year for high-risk individuals and other priority groups, including close contacts of those at high risk. Two types of vaccine are recommended for protection against influenza in the United States: (1) an inactivated virus vaccine injected into muscle and (2) a live virus vaccine administered as a nasal spray. The injectable vaccine—which represents the large majority (over 95 percent) of influenza vaccine administered in this country—can be used to immunize healthy individuals and those at high risk of severe complications, including those with chronic illness and those aged 65 years and older. The nasal spray vaccine, in contrast, is currently approved for use only among healthy individuals aged 5–49 years who are not pregnant. Although vaccination is the primary strategy for protecting individuals who are at greatest risk of serious complications and death from influenza, antiviral drugs can also contribute to the treatment and prevention of the disease. In a typical year, manufacturers make influenza vaccine available before the optimal fall vaccination season. For the 2003–04 influenza season, two manufacturers—one with production facilities in the United States (sanofi pasteur) and one with production facilities in the United Kingdom (Chiron)—produced about 83 million doses of injectable vaccine, which represented about 96 percent of the U.S. vaccine supply. A third U.S. manufacturer (MedImmune) produced the nasal spray vaccine. According to CDC, MedImmune produced about 3 million doses of the nasal spray vaccine, or about 4 percent of the overall influenza vaccine supply, for the 2003–04 season. Influenza vaccine production and distribution are largely private-sector activities. Manufacturers sell influenza vaccine to resellers (such as medical supply distributors and pharmacies), to federal agencies and state and local public health departments, or directly to providers (see fig. 2). Individuals can obtain an influenza vaccination at a number of places, including physicians’ offices, public health clinics, nursing homes, and nonmedical locations such as workplaces or retail outlets. Millions of individuals receive influenza vaccinations through mass immunization campaigns in these nonmedical settings, where organizations such as visiting nurse agencies under contract administer the vaccine. HHS has limited authority to control vaccine production and distribution directly; influenza vaccine supply and marketing are largely in the hands of the private sector. In the event that the Secretary of HHS determines and declares a public health emergency, the Public Health Service Act authorizes the Secretary to “take such action as may be appropriate” to respond. Within HHS, CDC is one of the agencies that help protect the nation’s health and safety. CDC’s activities include efforts to prevent and control diseases and to respond to public health emergencies. ACIP, after consulting with CDC, makes recommendations on which population groups should be targeted for vaccination. CDC also administers a number of programs to help make vaccines, including influenza vaccine, affordable for low-income and other populations. For example, under CDC’s Vaccines for Children program, vaccines are provided free of charge for certain children 18 years of age or younger, including those who are Medicaid- eligible, uninsured, or underinsured (that is, their insurance does not include vaccinations). CDC also reserves stockpiles of certain vaccines. For the 2004–05 influenza season, CDC contracted with vaccine manufacturers to supply influenza vaccine for a national stockpile for the first time. The agency originally contracted for 4.5 million doses, including 2 million doses from Chiron, which were therefore not available. CDC also maintains stockpiles of antiviral medications that can alleviate influenza symptoms and reduce contagion in those who contract the disease. Other organizations within HHS that are involved with immunization activities include the National Vaccine Program Office, which is responsible for coordinating and ensuring collaboration among the many federal agencies involved in vaccine and immunization activities, and the Food and Drug Administration (FDA), which in approving and regulating the use of vaccines and drugs, including antiviral medications, is responsible for ensuring that they are safe and effective. In addition to federal agencies, state and local health departments are often the first responders in situations affecting public health. Initially for the 2004–05 influenza season, CDC in May 2004 recommended that about 188 million Americans receive a vaccination—about 85 million at high risk of severe complications and about 103 million in other priority groups, such as people in close contact with high-risk individuals, healthy people aged 50–64 years, and health care workers. CDC also suggested that, depending on the availability of vaccine, other individuals who should receive a vaccination include (1) any person who wished to reduce the likelihood of contracting influenza, (2) individuals who provide essential community services, and (3) students and others in institutional settings. Although Chiron had announced that it was experiencing production problems in August 2004, according to CDC, the manufacturer had assured the agency that the production issues were being resolved. Subsequently, on September 24, 2004, CDC reiterated its recommendation that 188 million individuals in high-risk and other groups be vaccinated as vaccine became available. CDC also recommended that anyone wanting to reduce the risk of contracting influenza be vaccinated. Not everyone in these high-risk and priority groups, however, receives a vaccination each year. Among health care workers, for example, about 40 percent received a vaccination in the 2002–03 and 2003–04 seasons, according to one CDC survey. Similarly, about 66 percent of individuals aged 65 years and older reported receiving influenza vaccination in the 2002–03 and 2003–04 influenza seasons, according to CDC estimates. After the October 5, 2004, announcement of the sharp reduction in expected influenza vaccine supply, federal, state, and local health officials took steps to help ensure that those at high risk of severe complications from infection had access to influenza vaccine. For example, health officials quickly revised vaccination recommendations so that the remaining supply could be targeted to those in priority groups comprising those at high risk, certain health care workers, and household contacts of children younger than 6 months of age. Other efforts focused on distributing vaccine to priority groups and on keeping providers and the public updated as to vaccine availability. Finally, late in the influenza vaccination period—from mid-December through January—health officials’ actions focused on further augmenting the vaccine supply and, once supply increased, on encouraging vaccination for anyone remaining in the priority groups and for others who had earlier deferred vaccination (see fig. 3). Several responses by public health officials took place within hours or days of the public announcement that a severe shortage of influenza vaccine was imminent. Federal and state health officials redefined priority groups for influenza vaccination. CDC immediately redefined the groups recommended to receive vaccine in 2004–05 for protection against influenza and its complications and issued revised recommendations on October 5, 2004. These revised recommendations focused on priority groups that included high-risk individuals, health care workers involved in direct patient care, and household contacts of children younger than 6 months of age. CDC’s revised recommendations decreased the number of people in groups recommended for vaccination from about 188 million to about 98 million (see table 1). At the same time, CDC also asked people not in these priority groups to forgo or defer vaccination. State and local health officials we met with reported having quickly adopted CDC’s revised recommendations. Some health departments, however, found that they did not have enough vaccine to cover everyone in CDC’s priority groups and therefore subdivided CDC’s priority groups. For example, in Maine, all health care workers were initially excluded from the state’s priority groups, although later, Maine health officials recommended vaccination for particular types of health care workers, such as those working in intensive care units and emergency departments, if local vaccine supply allowed. HHS collaborated with manufacturers to temporarily halt further distribution of injectable influenza vaccine and to ramp up production of nasal spray vaccine. At the request of CDC, sanofi pasteur, the sole remaining manufacturer of injectable influenza vaccine for the U.S. market, voluntarily suspended further distribution of the approximately 25 million doses it had not yet shipped on October 5, 2004, until the week of October 11, 2004, when CDC completed its assessment of the situation. Distribution was temporarily halted because CDC needed time to devise a plan to better target vaccine distribution to providers serving individuals in the priority groups. HHS officials also worked with MedImmune, the maker of the nasal spray vaccine, to increase its production for the 2004–05 influenza season from about 1 million doses to a total of 3 million doses. Federal officials evaluated foreign sources of influenza vaccine and assessed the federal stockpile of antiviral medications. On October 11, 2004, HHS convened an interagency team, comprising officials from HHS’s Office of the Secretary, CDC, FDA, and others, to devise a plan to import influenza vaccine not licensed for the U.S. market from foreign manufacturers; this vaccine could be administered in the United States under an investigational new drug protocol. Around the same time, FDA quickly authorized the redistribution of vaccine among hospitals and other health entities to alleviate shortages. HHS also assessed its stockpile of antiviral medications that could be used to prevent or treat influenza and began the process of purchasing more. According to HHS officials, by December 2004 the federal government purchased and stockpiled enough antiviral medicines to treat more than 7 million people. State and local health departments used existing emergency plans and incident command systems. Some state and local health departments used their emergency preparedness plans and incident command systems (the organizational systems set up specifically to handle the coordinated response to emergency situations) during the influenza vaccine shortage. The five state health departments and two of the local health departments we visited used their incident command systems to help manage shortage-related activities, and three of the state health departments reported using their emergency plans. In addition, officials from the Florida Health Care Association, an organization representing long-term-care providers in that state, reported using certain elements in their disaster planning guide, which includes plans for disasters like hurricanes or bioterrorism. Federal and state officials took measures against price gouging. Around the time (October 13, 2004) that one Florida-based distributor was sued by that state for selling influenza vaccine at significantly inflated prices, several states began issuing warnings that all suspected cases of price gouging by vaccine distributors and providers would be reported to the states’ attorneys general for further investigation and possible prosecution. In support of states’ efforts to curtail the overpricing of limited influenza vaccine, CDC began collecting reports of price gouging and shared the information with the National Association of Attorneys General and state prosecutors. On October 14, 2004, the Secretary of HHS sent a letter to the attorney general of each state, urging thorough investigation of reports of price gouging, and on October 22, 2004, HHS filed a “friend of the court” brief in support of the Florida lawsuit. Beginning in mid-October, federal, state, and local public health officials acted to distribute the remaining 25 million doses of injectable influenza vaccine across the states and directed the limited amount of available injectable vaccine to those in priority groups. State and local public health departments also took steps to help ensure that vaccine was distributed to those within their jurisdictions who were in priority groups. In October and November, working with representatives from national public health organizations and sanofi pasteur, CDC developed a plan to distribute sanofi pasteur’s unshipped vaccine. The plan consisted of two overlapping phases and was aided by the manufacturer’s voluntary sharing of proprietary information to help identify geographic areas in greatest need of vaccine. Phase I, which began the week of October 11, 2004, consisted of filling orders that were clearly identifiable as public-sector orders and orders, such as those from long-term-care facilities, that had been placed with sanofi pasteur. Orders selected for full or partial filling included those that could be immediately identified as placed by the Department of Veterans Affairs, the Indian Health Service, long-term-care facilities and hospitals, and others (see table 2). Filling these orders distributed approximately 13 million doses of vaccine over a 6–8 week period. Phase II, which was announced by CDC on November 9, 2004, consisted of distributing approximately 12 million doses: about 3 million doses for some of the remaining public-sector orders from phase I and about 9 million doses across the states according to a formula based on each state’s percentage of the estimated nationwide unmet need. CDC calculated a state’s unmet need by taking the total estimated number of individuals in priority groups in the state and subtracting the total number of doses that had been delivered before and during phase I. To help state health officials identify the regions within their states needing vaccine from phase II distribution, CDC developed an Internet-based program called the Flu Vaccine Finder on its secure data network. The program allowed state health officials to view, county by county, a list of vaccine orders shipped by sanofi pasteur to various types of customers, such as pediatricians and hospitals. Officials could then allocate vaccine available to their state under phase II to providers within their state that needed, but had not yet received, vaccine (see fig. 4). According to CDC officials, the agency understood that not all of the phase II doses would be ready to ship to states at once, so orders were partially filled and shipped in waves. Furthermore, the formula for determining each state’s allocation was imperfect, according to CDC, resulting in some states’ having more vaccine than needed to cover demand from those in priority groups and other states’ having too little. In response, CDC reallocated vaccine available for ordering by states in December 2004. In addition, some states found it necessary to redistribute vaccine within their own borders, or they attempted to purchase or sell vaccine to other states to best align supply and demand at local levels. States could begin ordering their vaccine allotments through the secure data network on November 17, 2004, and ordering continued through mid-January. Public health officials at all levels implemented various strategies to help ensure that their vaccine supplies were targeted to high-risk individuals and others in priority groups. Emergency directives issued. To help support providers in vaccinating only those individuals in CDC’s priority groups, a number of states, such as California and Florida, issued emergency public health directives requiring health care providers to limit influenza vaccination to people in priority groups and to refrain from vaccinating individuals not in CDC’s priority groups. Some of these directives, including those of the District of Columbia and Michigan, explicitly stated that providers failing to comply with these directives could face penalties, such as fines or imprisonment. But some states chose not to issue emergency directives. For example, Minnesota state health officials reported that they had such strong voluntary compliance and cooperation from the state’s provider community that they decided it was not necessary to post a directive mandating compliance. Surveys conducted of providers and long-term-care facilities. During mid-October, working with national professional organizations, CDC conducted a survey of long-term-care facilities to identify those that had placed orders with Chiron. A number of health departments, including six we visited, had also surveyed long-term-care facilities, and at least two, Minnesota and Seattle–King County in Washington State, completed their surveys before CDC began administering its version. In addition, many state health departments, including three we visited, surveyed providers about vaccine availability and the need for covering those in priority groups. In an effort to assess the degree of the vaccine supply shortage, for example, Minnesota public health officials developed and administered a survey to identify how much influenza vaccine was available in each of its 92 local public health jurisdictions, not knowing before the shortage which providers had ordered vaccine from Chiron or which ones had ordered from sanofi pasteur. Vaccine transferred among states. Because CDC’s distribution plan was based in part on estimated need for vaccine, some states received more than enough to cover demand from their priority groups, and some states received too little. To redistribute vaccine to locations that needed vaccine to meet demand from priority groups, a state could attempt to sell its available vaccine to another state. According to the Association of State and Territorial Officials, Nebraska shipped some vaccine to other states when its own demand was met. Minnesota state health officials also reported offering to sell available vaccine to other states. At the same time, states without enough vaccine, such as Maryland, tried to obtain it from another. Partnerships established with the private sector. To augment state and local vaccine supply, public health departments looked to the private sector for help. A number of state and local health departments we talked with reported facilitating redistribution or acting as brokers for donations of vaccine that had been purchased by large employers for employee vaccination campaigns before the shortage. According to health officials in Washington, for example, one large employer donated about 700 doses of influenza vaccine to the health department in Seattle–King County, which was then able to supply local nursing homes. Certain states and localities partnered with for-profit and not-for-profit home health organizations, which held mass immunization clinics and set up clinics in providers’ offices to help administer the vaccine quickly. For example, the Visiting Nurses Association of Southern Maine held a mass immunization clinic on a local college campus. These organizations followed CDC’s recommendations for vaccinating priority groups by screening potential vaccine recipients. Crowding alleviated through appointments and lotteries. In an effort to control crowding, health officials in some localities created vaccination appointments for individuals who were at high risk or in another priority group. When available supplies were insufficient to cover every qualified person who wanted a vaccination, some health departments held lotteries for available vaccine. The local public health department in Portland, Maine, for example, held a lottery for the small amount of vaccine it had received before the shortage plus the several hundred doses donated by an area medical center and the state department of health. To register for the lottery, people had to show they belonged to a priority group by supplying a note from their provider. Throughout the 2004–05 influenza vaccine shortage, federal, state, and local health officials used a variety of communication mechanisms to keep health officials, providers, and the public updated about vaccine availability and about the various strategies for distribution to providers and the public. At the federal level, CDC held frequent press conferences beginning in early October 2004. At these events, the agency updated the public on current efforts and recommendations, and it asked people who did not belong to a priority group to step aside and defer vaccination so that those in the priority groups would have access. CDC also conducted biweekly conference calls with representatives from various national health organizations to update them and obtain their feedback on distribution efforts. According to CDC officials, state and local health officials could generally access the minutes from these discussions the following day on CDC’s Health Alert Network. CDC also used this network to send advisories and updates on the influenza vaccine situation, beginning on October 5, 2004, and continuing through the end of January. The majority of the state health officials we met with reported receiving key information about the shortage from this network; the information was then forwarded to local health officials, hospitals, and medical associations that, in turn, passed the information on to providers. State and local health officials we met with also reported using various communication methods to relay national guidance, along with state and local guidance, and information about vaccine availability. These communication methods included mass e-mails and faxes; public education campaigns for influenza prevention; the media, including television, radio, and newspapers; telephone hotlines; and Web sites (see table 3). At the latest part of the influenza vaccination period, from mid-December 2004 through January 2005, federal and state health officials took several actions intended to further augment the vaccine supply and make vaccine more accessible. Four areas were addressed: broadened recommendations for groups to be vaccinated, modifications to the Vaccines for Children program, purchase of foreign-made vaccine, and release of the federal stockpile of influenza vaccine. CDC and states broadened the priority groups for influenza vaccination. On December 17, 2004, CDC announced broadened vaccination recommendations to include those aged 50–64 years and household contacts of high-risk individuals in locations where state and local health officials judged vaccine supply to be adequate. CDC’s broadened recommendations became effective January 3, 2005, allowing extra time for vaccination of individuals in the original priority groups and time for state and local health departments to prepare for increased requests for vaccine. As of January 3, 2005, however, according to information from the Association of State and Territorial Health Officials, 20 states had already expanded vaccination recommendations: 13 specified the additional groups identified by CDC, and 7 lifted all vaccination restrictions, allowing anyone wanting a vaccination to get one. On January 27, 2005, CDC endorsed states’ efforts to broaden vaccination recommendations to include all people wanting influenza immunization in states and localities where vaccine supply was sufficient to do so. Before that date, according to association officials, 27 states had already expanded recommendations to include everyone, although a few states waited longer to expand recommendations. CDC made vaccine from the Vaccines for Children program more widely available. CDC’s ACIP passed a resolution for CDC’s Vaccines for Children program, effective December 17, 2004, that expanded the groups of children eligible to receive the program’s influenza vaccine to include program-eligible children outside of CDC’s priority groups who were household contacts of people in high-risk groups. Later, on January 27, 2005, CDC authorized limited amounts of influenza vaccine from the Vaccines for Children program and held by the states to be transferred to state health departments for nonprogram use where the demand among program-eligible children had already been met. Public providers that had a reserve of program vaccine after vaccinating their program-eligible children could then use this vaccine for adults and children who were not eligible for the Vaccines for Children program. HHS purchased foreign-manufactured influenza vaccine for the U.S. market. After efforts initiated in early October to develop a plan to obtain foreign-made influenza vaccine that was not licensed for the U.S. market and make it available under an investigational new drug protocol, HHS in December 2004 purchased about 1.2 million doses from one manufacturer in Germany and, in January 2005, purchased about 250,000 doses from another manufacturer in Switzerland. CDC could then make this vaccine available to those states and localities wanting additional vaccine to alleviate shortages. According to HHS officials, however, none of the additional doses were used in the 2004–05 influenza season. CDC made stockpiled vaccine available to providers. On January 27, 2005, after the production of 3.1 million late-season doses designated for CDC’s stockpile of influenza vaccine, CDC announced that that it would make this vaccine available to sanofi pasteur, which, in turn, could market and sell the vaccine to public and private providers and then replenish CDC’s stockpile. This strategy allowed providers to order influenza vaccine directly from the manufacturer or a distributor, rather than go through state or local health departments. Providers who purchased these stockpiled doses would also be allowed to return unused vaccine for a credit and would have to pay only shipping costs for returned vaccine. Although the actions taken to address the influenza vaccine shortage helped achieve vaccination rates approaching past levels for certain priority groups (see fig. 5), a number of lessons emerged from federal, state, and local responses to the 2004–05 influenza shortage. Some lessons were specific to that season’s shortage, and others have wider ramifications for potential future shortages or a pandemic. The primary lessons can be grouped into three broad, interrelated categories: planning, timely action, and communication. Before October 5, 2004, CDC lacked a contingency plan specifically designed to respond to a scenario involving a severe influenza vaccine shortage at the start of the traditional fall vaccination period; the absence of a plan led to a delay in response. Faced with the unanticipated shortfall in the amount of influenza vaccine expected to be available for the 2004–05 influenza season, CDC revised recommendations and worked with sanofi pasteur to begin assessing available supply and to create a distribution plan for the remaining vaccine. Developing and implementing this plan took time and led to delays in response and some confusion at the state and local levels, particularly right after Chiron’s October 5, 2004, announcement. Public health officials in all five states we visited remarked that although phase I of CDC’s redistribution plan quickly and effectively distributed some vaccine to public and private providers serving priority groups, the vaccine available in phase II of CDC’s redistribution plan was too much, too late. Phase II ordering began on November 17, 2004, and continued into January 2005, but several weeks could elapse after orders were placed until vaccine was delivered. According to state and local public health officials we interviewed, by the time the vaccine was delivered through a cumbersome distribution process, demand for the vaccine had substantially waned, and public and private providers were left to redistribute the excess. The phase II distribution problem was compounded for state and local health officials because CDC restricted access to its secure data network to two people per state. This narrow restriction left several state and local public health officials, according to those we interviewed, without vital information about the supply or demand for vaccine. Our work showed that four areas of planning are particularly important for enhancing preparedness before a similar situation in the future: (1) defining the responsibilities of federal, state, and local officials; (2) using emergency preparedness plans and emergency health directives; (3) distinguishing between demand and need; and (4) identifying mechanisms for distributing and administering vaccine. Better defining responsibilities of federal, state, and local officials can minimize confusion. During the 2004–05 vaccine shortage, CDC worked with national organizations representing states and localities to coordinate roles and responsibilities. Several public health officials we spoke with reported that CDC effectively worked with sanofi pasteur and national organizations representing state and local health officials to coordinate responsibilities shortly after Chiron’s announcement. Despite these efforts, however, problems occurred. For example, to identify national demand for vaccine, federal, state, and local health officials surveyed providers in states and localities to assess existing supply and additional need. CDC worked with national professional associations to survey long-term-care providers throughout the country to determine if seniors had adequate access to vaccine. Maine and other states, however, also surveyed their long-term-care providers to make the identical determination. This duplication of effort expended additional resources, burdened some long-term-care providers in the states, and created confusion. Emergency preparedness plans and emergency health directives help coordinate local response. State and local health officials in several locations we visited reported that using existing emergency plans or incident command centers helped coordinate effective local response to the vaccine shortage. For example, public health officials from Seattle– King County said that using the county’s incident command system played a vital role in coordinating an effective and timely local response and in communicating a clear message to the public and providers. In addition, according to public health officials, emergency public health directives helped ensure access to vaccine by supporting providers in enforcing CDC’s recommendations and in helping to prevent price gouging in those states whose directives addressed price gouging. Certain officials we spoke with, however, reported that although plans and directives helped, improvements were still needed. Some health officials indicated that as a result of the past influenza season, they were revising state and local preparedness plans or modifying command center protocols to prepare for future emergency situations. For example, in Maine, after experiences during the 2004–05 influenza season, state officials recognized the need to speed completion of their pandemic influenza preparedness plan. In addition, they said the vaccine shortage experience helped identify which officials should attend which meetings during a crisis to ensure the right people have the right information. Distinguishing between demand and need for vaccine can improve distribution. In discussing the adequacy of vaccine supplies, public health officials make a distinction between demand and need for vaccine by a high-risk group. In this context, demand is the number of high-risk individuals who want to receive an influenza vaccination, and need is the total number of high-risk individuals in an area or region, regardless of whether they want to receive a vaccination. Because some individuals in high-risk groups are unlikely to be vaccinated, estimating vaccine amounts on the basis of total need, rather than demand, can overstate the amount that will likely be used in any given location. Differentiating between demand and need would have helped states avoid substantially over- or underordering vaccine from CDC or a manufacturer. California state officials said that differentiating between demand and need earlier in the season could have reduced delays and confusion during the shortage. Certain states and localities we visited had taken time before the season to address contingencies for vaccine supply fluctuations. For example, Minnesota state officials used experiences in previous influenza seasons to build a state influenza plan that educated providers and local public health officials about the difference between demand and need. According to state officials, communicating this difference to local providers and health officials helped more accurately identify how much vaccine was in demand throughout the state. The distribution and administration of vaccine can be facilitated. One mechanism used in a majority of the states and localities we visited was building partnerships between public and private sectors. This mechanism was effective in both the distribution and the administration of vaccine. In San Diego County, California, for example, local health officials worked with a coalition of partners in public health, private businesses, and nonprofit groups throughout the county. In addition, several states and localities also partnered with other organizations, including home health organizations, to increase their capacity to administer vaccine to large numbers of people. For example, public health officials, including those in California and Florida, worked with national home health organizations to quickly immunize those in high-risk and other priority groups by holding mass immunization clinics. Other mechanisms we identified, aimed mainly at addressing the challenge of administering a limited amount of vaccine, included scheduling appointments and holding lotteries. In Stearns County, Minnesota, for example, public health officials worked with private providers to implement a system of vaccination by appointment. Rather than standing in long lines for vaccination, individuals with appointments went to a clinic during a given time slot. Public health officials in Portland, Maine, emphasized the effectiveness of holding a lottery as a way to equitably administer limited amounts of vaccine to people and as an alternative to having large crowds show up for a limited number of doses. After the 2004–05 influenza season, CDC officials developed lessons learned from their experiences, including lessons on the importance of contingency planning and defining which groups have higher priority in the event of a vaccine shortage. In August 2005, CDC issued interim guidelines to assist state and other immunization programs in planning for and dealing with an influenza vaccine shortage during the 2005–06 season. Also in August 2005, CDC published potential priority groups for vaccination in the event of a shortage. Because the total vaccine supply for the 2005–06 influenza season was not then known, however, CDC did not recommend setting priorities for injectable vaccine at that time. On September 2, 2005, CDC published priority recommendations for use of injectable vaccine through October 24, 2005. During the 2004–05 influenza vaccine shortage, federal, state, and local officials needed to continually adapt to changing vaccine supply and demand, to make decisions, and to take action quickly. The actions they took after the traditional fall vaccination period, however, came too late to boost supply while demand was still high. These actions included making available foreign-manufactured vaccine that was not licensed for the U.S. market, expanding availability of vaccine from the Vaccines for Children program, and releasing vaccine reserved for the federal stockpile. HHS’s decision to purchase influenza vaccine not licensed for the U.S. market and to make it available under an investigational new drug protocol was too late to mitigate the shortage’s effects because of when such vaccines became available and because of cumbersome administrative requirements. Soon after Chiron’s October 5, 2005, announcement, HHS started looking into foreign vaccine that was licensed for use in other countries but not in the United States. Nonetheless, by the time HHS purchased this vaccine in December 2004 and January 2005, there was little demand for it. CDC officials acknowledged that one lesson learned from experience in 2004–05 was that use of foreign-licensed vaccine under an investigational new drug protocol during the influenza season requires that vaccine be shipped no later than the beginning of October. Further, recipients of such vaccines may be required to sign a consent form and follow up with a health care worker after vaccination— steps that, according to health officials we interviewed in several states, would be too cumbersome to administer and could dampen public enthusiasm for being vaccinated. Although about 1.5 million doses of this vaccine became available, none were used because demand had fallen, and injectable vaccine licensed for the U.S. market was still available. CDC’s December 2004 and January 2005 implementation of decisions to make vaccine from the Vaccines for Children program more widely available was not timely and lacked flexibility. CDC explored options to use program vaccine to vaccinate three groups of people—children eligible for the Vaccines for Children program but not in a priority group, children not eligible for the program, and adults—but only in geographic areas where the needs of eligible children in high-risk groups had been met. But by the time CDC determined that demand from eligible children had been met and announced that it was taking steps to make more program vaccine available for others, many states’ demand for additional vaccine had dropped. Because vaccine purchased under the Vaccines for Children program became available for nonprogram use so late, some states reported they were unable to vaccinate all their state’s children in CDC’s priority groups. In other states, vaccine purchased under the program remained unused after all program-eligible children were vaccinated, but completing the process to transfer the unused vaccine delayed some states from administering the remaining vaccine to individuals not eligible for Vaccines for Children. Since CDC expanded program vaccine availability too late, vaccine purchased under the Vaccines for Children program ultimately went unused. As a result, CDC is surveying epidemiologists, state health officials, and immunization managers on lessons learned to connect activities to outcomes, such as releasing program vaccine to increase immunization rates. Further, state health officials we interviewed reported that administrative difficulties in making vaccine available to a broader population hindered its ready use during the shortage. According to state health officials in California and Washington, if broadening Vaccines for Children eligibility had been more flexible and allowed more efficient transfer of vaccine to those not in the program, vaccine could have been made available sooner and more widely to people in priority groups. CDC’s decision to release influenza vaccine produced for its national stockpile was also ineffective because the action came too late. The majority of doses reserved for the stockpile were not delivered until January 2005 because CDC wanted doses produced earlier in the season to be available to fill state orders. By the time the stockpiled doses were released back to the manufacturer for purchase by providers and others in January, national demand had shrunk. Of the 3.1 million doses of injectable vaccine released from the stockpile in January 2005, only approximately 115,000 were ordered. Without exception, state health officials in the five states we visited reported that this vaccine became available too late in the season to be useful. Finally, certain states faced barriers when trying to buy available influenza vaccine from other states, preventing timely redistribution. During the 2004–05 shortage, some state health officials reported problems with their ability—both in paying for vaccine and in administering the transfer process—to purchase influenza vaccine. For example, Minnesota tried to sell its available vaccine to other states seeking additional vaccine for their high-risk populations. According to federal and state health officials, however, certain states lacked the funding or flexibility under state law to purchase the vaccine when Minnesota offered it. In response to problems encountered during the 2004–05 shortage, the Association of Immunization Managers proposed in 2005 that federal funds be set aside for emergency purchase of vaccine by public health agencies, eliminating cost as a barrier in acquiring vaccine to distribute to the public. While part of the lesson learned about communication was positive, some aspects of this lesson pointed to need for improvement. Positives can be seen, for example, in the extent of CDC’s communication. During the 2004–05 shortage, CDC communicated regularly through a variety of media as the situation evolved. Officials from most states and localities we talked with reported that CDC played an active role in communicating information despite a changing environment. Several state and local officials we spoke with said that biweekly conference calls were effective in providing updates and coordinating responsibilities. The state health officer from Alabama, for instance, noted the frequency and quality of the communications that CDC put forth during the influenza season. Despite these positives, when examining the 2004–05 influenza season, state and local officials identified areas of communication to improve for future seasons. During our visits to states and localities, we found four particularly important communication issues. These issues included maintaining consistency of communications to avert confusion, understanding the importance of changing messages under changing circumstances, using diverse media to reach diverse audiences, and educating providers and the public about prevention alternatives. Consistency among federal, state, and local communications is critical for averting confusion. Health officials in Minnesota, for example, reported that some confusion resulted when the state determined that the influenza vaccine supply was sufficient to meet demand and therefore made vaccine available to other groups, such as healthy individuals aged 50–64 years, earlier than recommended by CDC. Similarly, health officials in California reported that in mid-December, local radio stations in the state were running two public service announcements—one from CDC advising those aged 65 years and older to be vaccinated, and one from the California Department of Health Services advising those aged 50 years and older to be vaccinated. They emphasized that these mixed messages created confusion. In addition, some individuals seeking influenza vaccine in other regions could have found themselves in a communication loop that provided no answers. For example, CDC advised people seeking influenza vaccine to contact their local public health department; in some cases, however, individuals calling the local public health department were told to call their primary care provider, and when they called their primary care provider, they were told to call their local public health department. This inconsistency in information from authoritative sources led to confusion and possibly to high-risk individuals’ giving up and not receiving an influenza vaccination. Modifying messages to respond to changing circumstances can prevent unintended consequences. Beginning in October, CDC communicated a message asking individuals who were not in a high-risk group or another priority group to forgo or defer vaccination, or to step aside, so that that those in priority groups could have access to available vaccine. According to CDC, this message resulted in an estimated 17.5 million individuals who specifically deferred vaccination to save vaccine for those in the priority groups. Public health officials we interviewed, however, lamented the fact that this nationwide effort did not also include a message to individuals who did step aside to check back with their providers or to seek an influenza vaccination later in the season. State and local officials suggested that CDC should have had a message to step aside until a certain estimated date, when more vaccine would be available and demand from individuals in the narrowed CDC priority groups would ease. These officials noted that many people in priority groups, including those aged 65 years and older who should have been vaccinated, stepped aside. These officials also said that they were concerned about other individuals, particularly those aged 50–64 years, who were not vaccinated during the moderate 2004–05 influenza season and, as a result, might think vaccination was not important enough to seek in future seasons. Using diverse media helps reach diverse audiences. During the 2004–05 influenza season, public health officials reported the importance of using a variety of communication methods to help ensure that messages reached as many individuals as possible. For example, officials from the health department in Seattle–King County, Washington, reported that it was important to have a telephone hotline as well as information posted on a Web site, because some seniors calling Seattle–King County’s hotline reported that they did not have access to the Internet. Further, public health officials in Miami–Dade County in Florida said that bilingual radio advertisements promoting influenza vaccine for those in priority groups helped increase the effectiveness of local efforts to raise vaccination rates. Education is important in alerting providers and the public about prevention alternatives. Educating health care providers and the public about all available influenza vaccines and forms of prevention may increase the number of vaccinated individuals and also reduce the spread of influenza. Experience with the nasal spray vaccine in 2004–05 illustrates the importance of education. Approximately 3 million doses of nasal spray vaccine were ultimately available during the season for vaccinating healthy individuals. According to public health officials we interviewed, however, some individuals were reluctant to use this vaccine because they feared that the vaccine was too new and untested or that the live virus in the nasal spray could be transmitted to others. State health officials in Maine, for example, reported that the state purchased about 1,500 doses of the nasal spray vaccine for their emergency medical service personnel and health care workers, yet 500 doses were administered. Further, public health officials we interviewed said that education about all available forms of prevention, including the use of antiviral medications and good hygiene practices, can help reduce the spread of influenza. According to CDC officials, as part of preparations for the 2005–06 influenza season, the agency developed a draft communication plan— separate from the interim guidelines issued to states—from lessons learned, which includes messages for responding to the fluctuations in supply and demand anticipated throughout the season. As of August 2005, CDC officials said that this plan will remain in draft form because tactics will be changed and updated as circumstances change. Aided by a relatively moderate influenza season, efforts to mitigate the sudden and unexpected shortage of influenza vaccine for the 2004–05 season were largely successful, although the season was not without problems. Lacking a preseason plan to address a significant shortfall after the beginning of the traditional fall vaccination period, the federal government reacted to the shortage and its aftereffects as they unfolded throughout the season. This lack of preseason planning created confusion and delays during the optimal fall influenza vaccination window, when state and local public health agencies and health care providers most needed vaccine to protect individuals at high risk of severe complications. Conversely, federal efforts to boost supply late in the season had little effect, because demand fell off sharply in December and January, and vaccine became available too late. In some instances, uncoordinated communication from federal to state and local jurisdictions, and to providers and the general public, contributed to confusion, frustration, and individuals’ failure to seek or receive an influenza vaccination. Drawing from experiences during the 2004–05 shortage, CDC has taken a number of steps, including issuing interim guidelines in August 2005, to assist in responding to possible future shortages. It is too early, however, to assess the effectiveness of these efforts in coordinating actions of federal, state, and local health agencies and others who play a part in the annual influenza vaccination process. In commenting on a draft of this report, HHS noted that the draft summarized in detail the activities undertaken by CDC and its public- and private-sector partners to deal with the influenza vaccine shortage of 2004–05, and the agency concurred with our finding that contingency planning will greatly improve response efforts. The agency also provided details on other actions, such as approval of additional influenza vaccines for the U.S. market, that were under way. HHS also agreed that adjustments to vaccination recommendations and vaccine supply ideally should occur earlier in the influenza season, but such adjustments cannot always be implemented in a shortage year. HHS’s written comments appear in appendix I. As arranged with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution of it until 30 days after its issue date. At that time, we will send copies of this report to the Secretary of HHS, the Directors of CDC and the National Vaccine Program Office, and other interested parties. We will also make copies available to others upon request. In addition, the report will be available at no charge on the GAO Web site at http://www.gao.gov. If you or your staff members have any questions, please contact me at (202) 512-7119 or crossem@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff members who made major contributions to this report are listed in appendix II. In addition to the contact named above, Kim Yamane, Assistant Director; George Bogart; Ellen W. Chu; Nicholas Larson; Jennifer Major; Terry Saiki; and Stan Stenersen made key contributions to this report. Influenza Pandemic: Challenges in Preparedness and Response. GAO-05- 863T. Washington, D.C.: June 30, 2005. Influenza Pandemic: Challenges Remain in Preparedness. GAO-05-760T. Washington, D.C.: May 26, 2005. Flu Vaccine: Recent Supply Shortages Underscore Ongoing Challenges. GAO-05-177T. Washington, D.C.: November 18, 2004. Infectious Disease Preparedness: Federal Challenges in Responding to Influenza Outbreaks. GAO-04-1100T. Washington, D.C.: September 28, 2004. Public Health Preparedness: Response Capacity Improving, but Much Remains to Be Accomplished. GAO-04-458T. Washington, D.C.: February 12, 2004. Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have Improved Public Health Response Capacity, but Gaps Remain. GAO-03- 654T. Washington, D.C.: April 9, 2003. Bioterrorism: Preparedness Varied across State and Local Jurisdictions. GAO-03-373. Washington, D.C.: April 7, 2003. Flu Vaccine: Steps Are Needed to Better Prepare for Possible Future Shortages. GAO-01-786T. Washington, D.C.: May 30, 2001. Flu Vaccine: Supply Problems Heighten Need to Ensure Access for High- Risk People. GAO-01-624. Washington, D.C.: May 15, 2001. Flu Pandemic: Plan Needed for Federal and State Response. GAO-01-4. Washington, D.C.: October 27, 2000.

Summary: In early October 2004, the nation lost about half its expected influenza vaccine supply when one of two major manufacturers announced it would not release any vaccine for the 2004-05 season because of potential contamination. The Centers for Disease Control and Prevention (CDC) had earlier recommended vaccination for 188 million individuals, including those at high risk of severe complications from influenza (such as seniors and those with chronic conditions), and other groups (such as their close contacts). Although health officials took actions to distribute the limited supply of influenza vaccine, reports persisted of high-risk individuals and others in priority groups who could not find a vaccination, including those who were turned away and never returned when supplies became available. Such reports raised questions about the adequacy of U.S. preparedness to respond to significant vaccine shortages. GAO was asked to examine actions taken at federal, state, and local levels to ensure that high-risk individuals had access to influenza vaccine during the shortage, including any lessons learned. Federal, state, and local health officials took several actions beginning in October 2004 to help ensure that individuals at high risk of severe complications from influenza had access to vaccine. Federal officials, for example, quickly revised vaccination recommendations to target available vaccine to high-risk individuals and to other priority groups. Additional actions were aimed to distribute vaccine expeditiously and to communicate with providers and the public as events unfolded and vaccine supplies changed. Beginning in mid-December, health officials took steps to distribute additional vaccine, broadening recommendations on who should be vaccinated. Although these actions helped achieve vaccination rates approaching past levels for certain priority groups, such as those aged 65 years and older, several lessons emerged, including some that could help with future shortages. First, unless planning for problems is already in place, action is delayed. CDC's lack of a contingency plan contributed to delays and uncertainty about how to ensure that high-risk individuals had access to vaccine. Second, when actions occur late in the influenza season, they are likely to have little effect. Third, effective response requires communication that is both clear and consistent. CDC has taken a number of steps, including issuing interim guidelines in August 2005, to respond to possible future shortages. It is too early, however, to assess the effectiveness of these efforts in coordinating actions of federal, state, and local health agencies and others. In commenting on a draft of this report, HHS concurred with GAO's finding that contingency planning would improve response efforts, and the agency indicated that additional preparations were under way.