ARTICLE IN PRESS Public Health (2008) 122, 183–191
www.elsevierhealth.com/journals/pubh
Original Research
A systematic analysis of influenza vaccine shortage policies Lori Uscher-Pinesa,, Daniel J. Barnettb, Jason W. Sapsina, David M. Bishaic, Ran D. Balicerd a
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Suite 492, Baltimore, MD 21205, USA b Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Center for Public Health Preparedness, 615 N. Wolfe Street, Room E2148, Baltimore, MD 21205, USA c Department of Population and Family Health Sciences, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Suite 4622, Baltimore, MD 21205, USA d Faculty of Health Sciences, Epidemiology Department, Ben-Gurion University in the Negev, 27 Hagilgal St., Ramat-Gan 52392, Israel Received 9 May 2006; received in revised form 1 May 2007; accepted 14 June 2007 Available online 7 September 2007
KEYWORDS Influenza; Vaccine; Vaccine shortage; Resource scarcity; Pandemic; SWOT analysis
Summary Objectives: The aim of this study was to apply SWOT analysis (strengths, weaknesses, opportunities, threats) to a domestic shortage of influenza vaccine, to identify lessons learned, and to generate effective solutions for future public health rationing emergencies. Study design/methods: SWOT and TOWS techniques were employed to characterize the vulnerability of the USA to disruptions in the supply of influenza vaccine. A group of five researchers reviewed relevant literature, engaged in group brainstorming, and categorized elements according to the SWOT framework. Results: Three strengths, five weaknesses, five threats and seven opportunities were identified in the areas of vaccine production, purchasing and distribution, and provision. Four future recommendations emerged with respect to government investment, communications, sanctioning of physicians, and incident command. Conclusions: Application of the SWOT technique is highly relevant to the health policy realm and can assist public health planners in planning for future resource scarcity. & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Corresponding author. Tel.: +1 202 577 5083; fax: +1 703 978 3075.
E-mail address:
[email protected] (L. Uscher-Pines). 0033-3506/$ - see front matter & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2007.06.005
ARTICLE IN PRESS 184
Introduction On 5 October 2004, Chiron Corporation announced that it would not supply influenza vaccine to the US market for the duration of the influenza season. Although European vaccination programmes were relatively unaffected by this event, future pandemics threaten to produce shortages all over the world, especially in developing countries without any vaccine manufacturing capacity. Since 2004, planners have collected a rich literature of lessons learned to apply to future shortages of influenza vaccine and to enhance preparation for pandemic influenza. The 2004–2005 shortage, which halved the US supply of influenza vaccine of roughly 85 million doses, was particularly dramatic in its severity and impact, but it was hardly unique; in fact, shortages or delays in vaccine delivery have occurred more often than not since the 2000–2001 season.1 With firms exiting the vaccine industry, production challenges and insufficient stockpiles, shortages are anticipated in future seasons. In a normal year, nearly one-third of the 250 billion doses of influenza vaccine produced worldwide is supplied to the US market.2 Within the USA, a population of 95 million is targeted for vaccination, but demand for vaccine within the various target groups has historically been below 50%.3 Historically low and unpredictable demand is one factor making the vaccine market somewhat unattractive to industry and increasing vulnerability to shortages. In the 2003 influenza season, coverage varied from a low of 13% among pregnant women and 34% among adults aged 18–64 years with chronic health conditions, to 66% among those aged 65 years and older.4 Demand among healthy, non-priority groups was 18% in 2003; thus, this healthy group consumes approximately 30% of the US influenza vaccine supply in a routine year. During the shortage of 2004, healthy adults were the most affected, as only 9% received a vaccination.3 Despite awareness of the multifactorial nature of the shortage problem and widespread application of lessons learned from 2004 to 2005, the USA remains ill prepared for future shortages in influenza vaccine. The numerous changes made at federal, state and local level could not prevent the spot shortages reported in the autumn of 2005.5 It is clear that planners need to take measures to respond better to future vaccine rationing emergencies. Identifying the strengths and weaknesses of the current approach to seasonal shortages in influenza vaccine is also critical for pandemic preparedness.
L. Uscher-Pines et al.
SWOT analysis: principles and public health applications SWOT (strengths, weaknesses, opportunities, threats) analysis was developed by the business community to facilitate strategic planning. It provides an intuitive, yet underutilized,6 framework for evaluating plans by identifying the intrinsic strengths and weaknesses of an organization, as well as opportunities and threats in the external environment. The field of international public health is just beginning to recognize the utility of SWOT. In recent years, SWOT analysis has been used to assess the organization and financing of a healthcare system,7 explore regional tobacco control action plans,8 formulate strategic action plans for municipal solid waste management,9 and evaluate the development of breastfeeding education.10 Most relevant to this study is the use of the tool to assess the Israeli smallpox vaccination programme.11 SWOT analysis offers a simple way of characterizing the environment; it is an organized approach to brainstorming that helps to reveal insights that would not otherwise be apparent. The technique requires the analyst to identify and make explicit his or her assumptions and perceptions of the environment. Once mapped out, planners can take measures to overcome weaknesses, exploit strengths, take advantage of opportunities, and avoid threats. In this study, SWOT analysis was used to guide the assessment of current influenza vaccine shortage policies and generate recommendations for enhanced preparedness.
Generating recommendations from SWOT analysis: the ‘TOWS’ matrix One approach to generate specific recommendations from SWOT analysis makes use of the TOWS matrix tool (Table 1). Although some use the terms ‘SWOT’ and ‘TOWS’ interchangeably, others emphasize the TOWS matrix as a distinct tool that captures the SWOT analysis in its initial steps and then moves on.12 The approach in this study was to use the TOWS matrix as an extension of the SWOT analysis, as a means of combining elements identified in list form in the SWOT analysis to generate actual recommendations for action. The TOWS approach systematically integrates strengths, weaknesses, opportunities and threats to show the distinct relationships between external and internal factors.13 The procedure is to first list the strengths, weaknesses, opportunities and threats and then
A systematic analysis of influenza vaccine shortage policies Table 1
185
The TOWS matrix model.
Strengths Opportunities S–O strategies (Pursue opportunities that are good fit with strengths) Make use of the new communication channels to explain and justify prioritization decisions. Threats S–T strategies (Identify ways to use strengths to reduce vulnerability to threats) Assign role of caring for the needs of the elderly or vulnerable to a staff member within the incident command structure.
Weaknesses W–O strategies (Overcome weaknesses to pursue opportunities) Direct a portion of new government investment towards refining old technologies. W–T strategies (Establish defensive plan to prevent weaknesses from making policies susceptible to threats) Legal/licensing sanctions against physicians who provide vaccine to non-priority individuals in the face of rationing crises.
S, strengths; W, weaknesses; O, opportunities; T, threats.
combine factors in a 2 2 matrix so that strengths are matched with opportunities, strengths with threats, weaknesses with opportunities, and weaknesses with threats. Pairing factors in this way generates specific recommendations for action. Strength-opportunity strategies guide the organization to pursue opportunities that are a good fit with strengths. Weakness-opportunity strategies overcome weaknesses to pursue opportunities. Strength-threat strategies identify ways to use strengths to reduce vulnerability to threats. Finally, weakness-threat strategies establish a defensive plan to prevent weaknesses from making policies highly susceptible to threats. Although necessary at times, the weakness-threat strategy is generally undesirable if alternatives exist.12
Methods To prepare for the analysis, a small team of academic-centre-based researchers studied peerreviewed literature, congressional testimony and media sources. High-impact, high-priority issues to be addressed or leveraged in response to a rationing crisis were identified in the areas of vaccine production, purchasing and distribution, and provision. These areas were selected based on their critical relevance to influenza vaccine shortages, including the shortage of 2004–2005. Particular emphasis was placed on categorizing novel and modifiable developments in the external environment. For the analysis, it was assumed explicitly that the market and manufacturing considerations pertain to the USA specifically, and not necessarily internationally. It was also assumed
that due to technical and market challenges, future shortages of seasonal influenza vaccine can be expected in the USA. The goal of using SWOT analysis was to explore the application of the technique to the health policy realm and to generate recommendations for future planning, applicable to seasonal and pandemic influenza emergencies. To generate recommendations from the SWOT analysis, the TOWS model was used to match identified strengths with opportunities, strengths with threats, weaknesses with opportunities, and weaknesses with threats.
Results The application of SWOT analysis to vaccine shortage issues yielded the following results in three policy realms: vaccine production; purchasing and distribution; and provision. Within each of these realms, the corresponding SWOT-derived strengths, weaknesses, opportunities and threats are depicted in Table 2 and detailed below.
Vaccine production Strengths New entry. Although the number of influenza vaccine manufacturers serving the US market remains insufficient given the recent shortages, the entry of GlaxoSmithKline (GSK) into the market is promising. With the return of Chiron, there are, at present, four manufacturers of vaccine (sanofi pasteur, GSK, MedImmune and Chiron) rather than the two in operation in 2004–2005.
ARTICLE IN PRESS 186 Table 2
L. Uscher-Pines et al. SWOT matrix summary from influenza vaccine shortage policy analysis. Strengths
Weaknesses
Opportunities
Production
New entry
Reliance on egg supply
Purchasing and distribution
Newly established relationships
Limited role of MOUs
Threats
Greater acceptance Unstable demand of nasal spray vaccine Drawbacks to new Increased demand Controversy over technologies thimerosal Overemphasis on liability Large government investment Purchasing from multiple manufacturers
Purchasing from abroad
Private physician stocks Provision
Incident command system
Primacy of individuals
Priority-group identification
Darwinian implementation Continued racial disparity Inappropriate risk models End-of-season surplus
MOUs, memoranda of understanding.
Weaknesses Reliance on egg supply. As influenza vaccine is produced by injecting fertilized chicken eggs and later harvesting the incubated virus, vaccine supply is dependent on the availability of eggs. It is impossible to increase the supply of influenza vaccine rapidly in the event of a shortage because millions of eggs must be ordered far in advance of the 6- to 8-month production process. In November 2004, the US Department of Health and Human Services awarded a contract to Aventis to help ensure year-round availability of such eggs for the purpose of vaccine production, but to date this issue remains a concern. There is particular vulnerability in the case of an avian influenza outbreak which devastates the chicken population and thus the vaccine manufacturing capacity.14 Drawbacks to new technologies. Vaccine manufacturing is on the cusp of promising technological changes in production methods. However, this transitional stage actually diminishes the current capacity for response. As manufacturers aggressively pursue research into cell- rather than egg-based production technologies, they have fewer incentives to upgrade plant capacity based on existing technologies. In the short term, existing plants are the only recourse in a pressing emergency.15 Overemphasis on liability. The belief that liability to lawsuits makes the vaccine market unattractive has motivated the Bush administration’s calls for
immunity for producers of pandemic vaccines.16 This belief also prompted the addition of the influenza vaccine to the National Vaccine Injury Compensation Program in 2005.17 While some concern regarding vaccine manufacturers’ liability may be justified, many more salient explanations for inadequate vaccine supply fail to receive proper attention. As, at present, ‘there is little evidence of significant litigation involving flu vaccine,’ changes to the legal environment, prioritized by politicians over other causes, are unlikely to affect vaccine supply in the near term.17 To date, payments for litigation have not been a major liability in influenza vaccine manufacturing.18 A National Vaccine Advisory Committee report from 2003 stated that although lawsuits ‘threaten vaccine program stability’, past shortages of childhood vaccines ‘do not appear to be liabilityrelated’.19 Firms’ guarded behaviour is probably better explained by concern for potentially limited market growth opportunities in the future, in particular their need to face consolidated priceconscious buyers from the public sector. Opportunities Greater acceptance of nasal spray vaccine. Although the public prefers injectable vaccine to MedImmune’s FluMist product, greater exposure to the nasal spray vaccine during the 2004–2005 shortage, pending approval of the product for use beyond the 5–49-years age group,
ARTICLE IN PRESS A systematic analysis of influenza vaccine shortage policies and evidence of its superior effectiveness from recent clinical trials may enhance demand.20 As the public becomes more comfortable with alternative modes of vaccine delivery beyond the traditional injection, research into such technologies will increase. Increased demand. Media attention on the 2004–2005 shortage and the evolving threat of pandemic influenza may increase awareness of and demand for seasonal influenza vaccine.21 Furthermore, if an avian influenza strain is added to the annual vaccine and/or Acambis is successful in producing a universal vaccine, demand is likely to explode.22 Public health planners can seize upon this opportunity in increased demand to improve vaccination rates and meet federal government objectives. Large government investment. Government investment in influenza research continues to grow, motivated at present by pandemic influenza preparedness. In recent years, total funding for influenza research by the National Institutes of Health has grown more than five fold from $21 million in 2001 to an estimated $119 million in 2005.1 In November 2005, President Bush requested $7.1 billion in emergency funding to prepare for a pandemic. Recent funding has helped to secure a year-round supply of chickens and to experiment with alternative, cell-based manufacturing technologies. Threats Unstable demand. The problem of uncertain demand has traditionally discouraged entry into the vaccine market. It seems that demand is associated with the severity of the influenza season, which does not become apparent until well after the season’s supply is set. Due to the rationing in 2004–2005, many who typically choose to be vaccinated were forced to skip a year. It is possible that the experience of remaining healthy through the 2004–2005 influenza season will convince some former devotees that annual vaccination is unnecessary.18 Controversy over thimerosal. Despite a lack of evidence linking the mercury-containing vaccine preservative thimerosal and the increased prevalence of autism, thimerosal remains very controversial. As a response to growing public concern and as a precautionary measure, the public health service agencies, American Academy of Pediatrics and vaccine manufacturers decided to reduce or eliminate the use of thimerosal.23 However, only limited quantities of thimerosal-free influenza vaccine are produced each year, and the influenza vaccine is the only recommended paediatric vac-
187
cine in the US market to contain the preservative.23 Continued objections against thimerosal could decrease demand for influenza vaccine, especially among parents of young children.
Purchasing and distribution Strengths Newly established relationships. The 2004–2005 shortage provided a real-life crisis in which to exercise plans and establish relationships. Swiftly, many local public health agencies developed partnerships with hospices, nursing homes, organizations that serve meals to housebound populations, and non-traditional partners such as the Multiple Sclerosis Society.24 Collaborations fostered during the emergency to share scarce resources and information at local level can be leveraged in the future. Weaknesses Limited role of memoranda of understanding. Memoranda of understanding (MOUs), in which institutions agree to share resources, are compromised when the entire country faces the same dire predicament. Although planners continue to rely upon MOUs in influenza preparedness, such agreements are much more suited to a localized shortage. New Jersey’s influenza pandemic plan takes this challenge into consideration and does not expect to depend on resources from neighbouring states.25 Opportunities Purchasing from multiple manufacturers. In 2004–2005, many distributors who had negotiated single-source orders with Chiron found themselves without any vaccine. This recent experience has led private physicians and health departments to order vaccine from several different manufacturers, thereby reducing the likelihood that a supply disruption that affects any one manufacturer will leave them empty handed. The experience from 2004–2005 offered a lesson in the importance of having diversified suppliers. Threats Purchasing from abroad. The 2004–2005 shortage provided a precedent for the purchase of unlicensed vaccine from abroad by states and by individuals. This departure from Food and Drug Administration regulation is tied to a bigger debate over the importation of drugs from Canada based on price rather than, as in this case, supply concerns.26 If importation is justified during
ARTICLE IN PRESS 188 emergencies such as the vaccine shortage, the political argument over what actually constitutes an ‘emergency’ may enter the debate. Frequent (or seemingly unjustified) use of this emergency loophole could operate as a dangerous disincentive to increase domestic production. Private physician stocks. Reports from the 2005–2006 influenza season suggest that manufacturers are prioritizing the large vaccine orders of mega-stores such Costco and CVS, thus contributing to spot shortages at physicians’ offices.1,27 Physicians already have few incentives to stock vaccine; they are neither adequately reimbursed nor compensated for unused vaccine. The problem of unfilled orders coupled with insufficient incentives has major implications for the comprehensiveness of vaccine delivery, access and patient satisfaction. The notion that the physician can meet basic preventive care needs may be undermined.
Provision Strengths Incident command system. Post-9/11 funding for all-hazards preparedness and, more specifically, attention to National Incident Management System compliance have improved the overall efficiency of emergency preparedness and response. Local health departments are using the incident command approach to respond to rationing emergencies, to organize influenza clinics and to manage points of dispensing.28 Weaknesses Primacy of individuals. The orientation of clinical medicine to the needs of individual patients can cause tension during public health emergencies.29 During rationing emergencies, non-priority-group patients may encourage their physicians to ignore government guidelines and provide them with vaccines or prescriptions for antiviral medication. Opportunities Priority-group identification. There is an opportunity to apply the lessons learned from the 2004 to 2005 shortage with regard to the treatment of priority groups. In simply listing all priority groups in 2004–2005, the Centers for Disease Control and Prevention (CDC) Advisory Committee for Immunization Practices offered no guidance to states whose shortages were so severe that they had to further ration vaccine among prioritized populations.30 This gap led to inconsistent policies across states. In the 2005–2006 season, the recommenda-
L. Uscher-Pines et al. tion of tiered prioritization addressed this issue in advance of any supply problem. Threats Darwinian implementation. In theory, prioritization is supposed to reserve vaccine for the most vulnerable groups, including the young, the old and the chronically ill. However, in the actual provision of vaccine in 2004–2005, a Darwinian ‘survival of the fittest’ regime took hold. Only the elderly who could stand in line for long periods at mass clinics or repeatedly query health departments and physicians’ offices for information generally accessed the vaccine.31 This threat further undermines public confidence in the health system’s equity and fairness. Continued racial disparity. Although racial disparities in uptake of seasonal influenza vaccine have long been recognized,31 attention to this issue increased after Hurricane Katrina.32 The issue of unequal access, exacerbated in emergency situations, is becoming increasingly salient and important to address because of its effect on public confidence and capacity to cause political destabilization. Inappropriate risk models. Recent evidence suggests that influenza vaccine has limited effectiveness in elderly populations with weak immune response, and new research suggests that because school-aged children are the real drivers of epidemics, the best way to protect the elderly may be to vaccinate the young.33 These examples demonstrate how decisions regarding prioritization can be instantly undermined by emerging science.34 When new facts emerge, changing prioritization policies can create confusion and jeopardize policy makers’ and health professionals’ credibility. End-of-season surplus. Even in cases of severe shortage and rationing, the end of the influenza season routinely concludes with a surplus of vaccine. In 2004–2005, public dismay over lack of vaccine and initial restrictions on priority groups did not translate into sustained demand for vaccine in what evolved to be a particularly mild season; three million doses remained unused in April 2005.35 The tendency for shortage to turn to surplus may undermine future attempts to impose strict restrictions on who gets vaccinated. Planners may be viewed as overly cautious at the season’s start, and healthcare providers may be reluctant to comply with what they believe to be misinformed recommendations.36
ARTICLE IN PRESS A systematic analysis of influenza vaccine shortage policies
Discussion In exploring strengths, weaknesses, opportunities and threats in influenza vaccine shortage polices, an unequal distribution across the categories of production, purchasing and distribution, and provision was found (Table 1). In terms of external factors, it seems that production has ample opportunities, and provision has a disproportionate number of threats. A single strength was identified in each category, perhaps a reflection of the critical nature of the exercise or the negative bias of the news media which tends to emphasize threats and weaknesses. Systematically identifying weaknesses and threats contributing to the system’s vulnerability to vaccine shortages allows specific preventative measures to be planned and executed. Furthermore, applying the TOWS matrix to the lists generated in the SWOT analysis assists in identifying new and effective strategies to address some of these weaknesses and threats. Four particular examples of recommendations with respect to seasonal influenza preparedness planning may be considered. First, in the setting of the mass vaccination clinic, the specific role of caring for the needs of the elderly or vulnerable should be assigned to a staff member within the incident command structure. The creation of this role from among clinic operations staff represents a strengththreat strategy. Second, a weakness-opportunity strategy is to consistently direct a portion of new government investment towards refining old technologies, rather than exclusively pursing the next breakthrough. Third, a strength-opportunity strategy is to make use of the new communication channels, developed among institutions during the 2004–2005 shortage, to explain and justify prioritization decisions and/or dispel myths about thimerosal. Relationships among institutions could be leveraged to reach various subpopulations and to set public expectations about target vaccination groups far in advance of an actual rationing emergency. Also, messages regarding the known risks associated with influenza compared with the unsupported risks associated with thimerosol should be communicated to organizations serving parents and pregnant women. As most young parents lack experience with vaccine-preventable diseases, they have less appreciation of the historic effects of these diseases on society and the ongoing importance of prevention.37 Fourth, a weaknessthreat strategy (a defensive strategy by definition) could involve legal or professional licensure sanctions against physicians who provide vaccine to non-priority individuals, in the face of Darwinian
189
vaccine-seeking behaviours. For example, during the 2004–2005 shortage, states such as Massachusetts issued notices that healthcare providers who violated CDC guidelines would be punished with $50–200 fines and/or imprisonment.38 In future shortages, steps could be taken to enact and enforce such orders or to provide positive incentives to enforce CDC guidelines. Limitations of this study include certain inherent qualities of SWOT analysis and in applying recommendations in rapidly changing conditions. First, SWOT analysis is a subjective tool, exploring perceived rather than objective quantifiable factors.11 In this sense, SWOT analysis is dependent on the perspectives of those who participate. The people who participate influence which items are considered and the assignment of any one particular item to a category. For example, depending on ones’ viewpoint, one could argue that almost any threat is an opportunity.6 Also, this approach, which used a SWOT analysis followed by a TOWS analysis, is just one way of taking the list generated in the SWOT analysis and further organizing its elements to identify strategies. Other analysts may feel that using a TOWS matrix after the completion of a SWOT analysis in effect limits the possible universe of recommendations by focusing too narrowly on certain pairs (e.g. strength-threat). In theory, however, a fully developed SWOT analysis should yield similar results to a SWOT–TOWS approach. Third, the analysis in this study was academic-centre based and would have benefited from the inclusion of more direct stakeholders, such as vaccine manufacturers. Finally, SWOT analysis characterizes the environment at a given point in time. With the political will, legal frameworks and science of pandemic influenza changing at such a rapid pace, recommendations flowing out of the SWOT analysis may quickly become inappropriate, suddenly based on faulty assumptions. However, this inevitable limitation of decision making under uncertainty does not excuse planners from the important task of strategic planning. The unique applications of the SWOT analysis tool and the accompanying TOWS model to the health policy realm are at the core of this research. These analytical approaches are useful from an international planning perspective; as a pandemic influenza outbreak would likely cause the most severe vaccine shortages to date, planning for a pandemic could incorporate methods such as SWOT and TOWS. The shortages that accompany a pandemic will be global in scope, and evidence suggests that countries in the developing world (which lack domestic vaccine manufacturing capacity) may be especially vulnerable. Numerous scholarly articles
ARTICLE IN PRESS 190 have identified and described the issue of prioritizing vaccine and pharmaceutical resources both within and across countries, highlighting the need for not only increasing supply but further exploration of the ethical implications of rationing decisions.39,40 The analytical processes described here can help to divide a complex problem into more conceptually manageable components, focusing and simplifying planning activities and revealing overlooked perspectives. It is important to emphasize that the contents of a SWOT matrix are not static, but must be updated to reflect changing conditions. Future research could pair SWOT analysis with scenario planning to account more fully for evolving circumstances. Future research can also apply this technique to translate SWOT factors into strategically sound approaches for addressing resource and response challenges across a spectrum of public health emergencies, ranging from naturally occurring pandemics to bioterrorism to natural disasters. Ethical approval Not required. Funding None declared. Competing interests Preliminary findings were presented at the 2005 Annual Meeting of the American Public Health Association. David Bishai received prior grant support from sanofi aventis; however, this research was conducted independently of any funding source.
References 1. Fiely D. Doctors’ orders of flu vaccine take back seat to superstores’. Columbus Dispatch 28 October 2005;01A. 2. Gerdil C. The annual production cycle for influenza vaccine. Vaccine 2003;21:1776–9. 3. Centers for Disease Control and Prevention. Targeting and collaborations a big success. Available at: /http:// www.cdc.gov/od/oc/media/pressrel/r050331.htmS (cited 20 January 2006). 4. Harper S, Fukuda K, Uyeki T, Cox N, Bridges C. Prevention and control of influenza. MMWR 2005;54(RR08):1–40. 5. Altman L. Top official is assuring on flu vaccine. New York Times 11 November 2005;A18. 6. Gibis B, Artiles J, Corabian P, et al. Application of strengths, weaknesses, opportunities and threats analysis in the development of a health technology assessment program. Health Policy 2001;58:27–35. 7. Christiansen T. A SWOT analysis of the organization and financing of the Danish health care system. Health Policy 2002;59:99–106.
L. Uscher-Pines et al. 8. Edwards R, Brown J, Hodgson P, Kyle D, Reed D, Wallace B. An action plan for tobacco control at the regional level. Public Health 1999;113:165–70. 9. Singh SP. Sedimentation patterns of the proterozoic Delhi supergroup, northeastern Rajasthan, India, and their tectonic implications. J Geol 2000;21:79–85. 10. Lee P, Huang C. Using SWOT to analyze breastfeeding education results in a medical center. Hu Li Za Zhi 2005;52: 77–82. 11. Huerta M, Balicer R, Leventhal A. SWOT analysis: strengths, weaknesses, opportunities and threats of the Israeli smallpox revaccination program. Isr Med Assoc J 2003;5: 42–6. 12. Weihrich H. The TOWS matrix—a tool for situational analysis. Long Range Plan 1982;15:54–66. 13. Weihrich H. Daimler–Benz’s move towards the next century with the tows matrix. In: Dyson R, O’Brien F, editors. Strategic development: methods and models. Indianapolis: Wiley; 1998. p. 69–79. 14. Hellerman C. Bird flu vaccine eggs all in one basket. Available at: /http://www.cnn.com/2005/HEALTH/conditions/ 12/08/pdg.bird.flu.vaccineS (cited 25 January 2006). 15. Danzon PM, Pereira NS, Tejwani SS. Vaccine supply: a crossnational perspective. Health Affairs 2005;24:706–17. 16. Henderson D. Bush flu plan eases firm’s liability. Boston Globe 5 November 2005;D1. 17. Mello M, Brennan T. Legal concerns and the influenza vaccine shortage. JAMA 2005;294:1817–20. 18. Brookes T. A warning shot: influenza and the 2004 flu vaccine shortage. Washington DC: American Public Health Association; 2005. 19. Traynor K. Vaccine shortages persist despite lessons from past. Am J Health-System Pharmacy 2004;61:2458–62. 20. Levine S. Spray flu vaccine comes at a trickle. Washington Post 13 November 2004;B01. 21. Fox M. Flu vaccine shortage temporary. Reuters Health 10 November 2005. 22. Roos R. Acambis hopes to build a flu vaccine that lasts. Center for Infectious Disease Research & Policy; 2005. 23. Centers for Disease Control and Prevention. Mercury and vaccines. 2005. Available at: /http://www.cdc.gov/nip/ vacsafe/concerns/thimerosal/default.htmS (cited 15 January 2006). 24. Bashir Z. Full-use preparedness: addressing the 2004–2005 influenza vaccine shortage. J Public Health Manage Pract 2005;11:375–7. 25. NJDHSS. New Jersey draft influenza pandemic plan. Available at: /http://www.state.nj.us/health/flu/documents/ draft.pdfS (cited 10 November 2005). 26. Russell S. Flu shots fly in from Canada: vaccine dearth prompts SF doctor to import his own supply. San Francisco Chronicle 2 November 2004. 27. Mahoney J. NY docs dispense dose of anger over flu vaccine. Daily News 8 November 2005;16. 28. Phillips F, Williamson J. Local health department applies incident management system for successful mass influenza clinics. J Public Health Manag Pract 2005;11:269–73. 29. Lo B, Katz M. Clinical decision making during public health emergencies: ethical considerations. Ann Intern Med 2005; 143:493–8. 30. Olick R. Ethics in public health: rationing the flu vaccine. J Public Health Manag Pract 2005;11:373–4. 31. Rangel M, Shoenbach V, Weigle K, Hogan V, Strauss R, Bangdiwala S. Racial and ethnic disparities in influenza vaccination among elderly adults. J Gen Intern Med 2005; 20:426–31.
ARTICLE IN PRESS A systematic analysis of influenza vaccine shortage policies 32. Ciotti M, Karcher F, Ganter B, Tu ¨ll P. Results of a survey of national influenza pandemic preparedness in Europe. Eurosurveillance Wkly Release 2005;10. 33. Hopper L. Flu shots perhaps being aimed at wrong targets. The Houston Chronicle 1 October 2005;A1. 34. Jefferson T, Rivetti D, Rivetti A, Rudin M, Pietrantonj C, Demicheli V. Efficacy and effectiveness of influenza vaccines in elderly people: a systematic review. Lancet 2005;366:1165–74. 35. Becker A. Lessons learned from this year’s vaccine crisis. 2005; /http://www.cidrap.umn.edu/cidrap/content/ influenza/general/news/april0805flu.htmlS, Last accessed 15 January 2006.
191
36. Stein R. Vaccine shortage turns to surplus. Washington Post 22 January 2005;A01. 37. Klein J, Myers M. Strengthening the supply of routinely administered vaccines in the United States: problems and proposed solutions. Clin Infect Dis 2006;42:S97–S103. 38. Lee T. Rationing influenza vaccine. N Engl J Med 2004;351: 2365–6. 39. Uscher-Pines L, Omer S, Barnett D, Burke T, Balicer R. Priority setting for pandemic influenza. PLOS Med 2006;3. 40. Mounier-Jack S, Coker R. How prepared is Europe for pandemic influenza. Lancet 2006;367:1405–11.
