Not Pregnant? Cut In Line for H1N1 Vaccine

Worried officials: Non-eligible may game the system to get scarce vaccine.

Oct. 29, 2009 — -- The swine flu vaccine is available now -- you just need to cut in front of a pregnant woman to get it.

Large numbers of people clamoring to get the H1N1 vaccine as it became available -- potentially spurred by President Obama's declaration that the H1N1 pandemic was a national emergency -- led many health care professionals to wonder whether publicizing guidelines on who should get the vaccine first was enough.

It might be necessary, some said, to screen interlopers actively -- and turn them away until more vaccine is available.

"It is ludicrous to leave the allocation of scarce vaccine to individual judgment and self-interest," said Arthur Caplan, professor of bioethics at the University of Pennsylvania.

The U.S. Centers for Disease Control and Prevention has not made recommendations for screening high- or low-priority cases at public clinics because it would be logistically difficult.

"We have made it clear to providers who we want vaccinated first. At the end of the day, it is up to that provider to decide who to vaccinate," said Tom Skinner, a CDC spokesman.

The CDC suggests that people at high risk for H1N1 infection be first in line. They include pregnant women, young people between 6 months and 24 years of age, caretakers for infants, health care workers, and people with chronic medical conditions.

ABC News correspondents Lisa Stark, who dropped in at a vaccination clinic in Montgomery County, Md., and Lisa Fletcher, who observed several clinics around Los Angeles, Calif., reported that indeed, it appeared that most of those lining up for shots were in these priority groups.

Still, some said steps should be taken to ensure this remains the case.

"It should be clear and shouldn't be fudged: People who do not fall within the high risk groups will be turned away," said Rosamond Rhodes, a professor of bioethics at Mt. Sinai School of Medicine in New York. "This is a statement health departments and vaccine centers should make very pronounced... Unless everyone can be confident that the rules are being enforced, people will not want to comply."

Screening Could Be A Deterrent

However, some fear rigorous screening could reduce efficiency in busy clinics.

"Clearly those who are not at increased risk from H1N1 should not commit fraud to jump to the front of the line," said Dr. Robert Schooley, head of the Division of Infectious Diseases at the University of California, San Diego. "[But] if in the effort to prevent a few people who shouldn't be vaccinated from jumping to the front of the line, vaccine lines grind to a virtual halt, those who do need to be vaccinated might well just decide to stay home and take their chances. Not a winning approach."

States Screen People Differently

According to CDC data, a total of 43,677 laboratory-confirmed cases of H1N1 were reported in the U.S. through July 2009 and researchers estimate that there may have been up to 5.7 million infections.

But some states have opted not to screen people based on risk, to avoid gumming the workflow.

David Paulson, director of the Maryland Department of Health and Mental Hygiene, said they encourage people to allow high risk groups be the first to receive the vaccine, but won't turn anyone away.

"Extensive screening would require a burden of proof... This would not only waste time, it would discourage people from getting the vaccine by making the entire process longer and more frustrating for everyone involved," Paulson said. "And everybody who gets vaccinated protects the population as a whole, so the sooner everybody gets vaccinated, the better."

While they will vaccinate anyone who asks, Paulson said their strategy is to distribute the bulk of the vaccine to providers within target communities, such as pediatricians, family practitioners and OB-GYNs.

Gregory Poland, director of the Mayo Vaccine Research Group at the Mayo Clinic in Rochester, Minn., added that "the issue is that health care workers staffing these clinics are overwhelmed as it is -- they don't have time, nor should they be 'vaccine cops' doing detective work to determine is the person in front of them being honest."

Some Type of Screening Important, Doctors Say

Still, some doctors insist that a perfunctory screening method would not compromise efficiency or a patient's privacy.

"If priority strategies are to mean anything, they have to have teeth... Honor-based systems usually don't work, especially when health and life are involved," said Robert Field, a health law professor at Drexel University.

And several states have developed their own systems to ensure the majority of the people receiving H1N1 vaccines have the greatest need.

CDC Declined to Issue Screening Guidelines for Vaccine Distribution

Dr. Elizabeth Turnipseed, the medical director of infectious diseases for the Jefferson County Department of Health in Alabama, said public health clinics have plans in place to try and restrict the vaccine to high priority cases.

"We will not be asking people to prove their status in any of the groups, but at least to offer a compelling and plausible explanation," she said. "It is not a foolproof method, but we hope one that will be fair, reasonably efficient and possible to implement in a mass setting."

In some parts of New York and Washington and in Baltimore, health officials require those waiting for vaccine to fill out a signed form concerning risk conditions. In Wisconsin, vaccination clinics set up two lines for the H1N1 injection, one for those in high risk groups and one for everyone else.

CDC Fears Another Vaccine Stockpile

Still, the CDC may prefer not to actively restrict access to vaccination for fear of ammassing a stockpile of unused H1N1 vaccine, as happened in 2004, when a shortage of seasonal influenza vaccine resulted in strict allocations to high-risk groups only, after which demand fell.

But the demand for the H1N1 vaccine has not yet waned, which may not be desirable, according to Philip Alcabes, an infectious disease specialist at CUNY Hunter College, who argued that mass immunization was the wrong approach for dealing with the virus.

"The vaccine is good but far from perfect at protecting against infection," Alcabes said. "It doesn't reduce infectiousness of those people who do get infected despite immunization, and people who are in 'priority' groups for immunization are in constant contact with people who are not immunized. It's a flawed strategy at best."

In addition, Alcabes pointed out that ceaseless advisories about H1N1 from federal agencies may have raised public awareness about what is a mild virus for the majority of the population -- though a real threat to some -- to something catastrophic.

"In this situation, where the virus has been circulating in the population for some time and the vaccine is just beginning to be available, it is shortsighted to imagine that mass immunization is going to make much difference to the outbreak," Alcabes said. "It's shocking that in 2009, knowing what we know, our public health establishment still deals with the flu as if it were 1957."

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