In response to mounting criticism about how the short supply of swine flu vaccine is being distributed in Hawai'i, the state will change the way it doles out the vaccine.

The state Health Department had been distributing swine flu vaccine based on when providers placed orders.

But the first-come, first-served distribution method has forced many pediatricians to set up waiting lists for swine flu vaccinations, even as many pharmacies statewide still have the H1N1 flu vaccine in stock. And it has left some of the largest health care providers in the state with little or no vaccine to give to patients for weeks.

Several doctors, health care industry experts and others say they've been left frustrated and perplexed at how the Health Department is handling the distribution of the vaccine, and they're concerned that the vaccine isn't getting to those who need it the most. Many are asking for more transparency on where the vaccine is going, including a list of how much vaccine each provider has received. They also say the state should better track who is getting vaccinated to ensure doses are getting to all priority groups.

State Sen. David Ige, D-16th (Pearl City, 'Aiea), chairman of the Senate Health Committee, said there have been "obvious ... shortcomings" in the distribution of the vaccine and concerns about why more isn't being done to track who is and isn't getting the vaccine. "Clearly, I think we should examine what we're doing," he said.

The H1N1 vaccine distribution is the first real-life test of the state's ability to handle a pandemic flu emergency, and some onlookers say if swine flu were more virulent, Hawai'i could be in serious trouble.

Nearly two months after the state began distributing swine flu vaccine to providers — with the first shipment coming in on Oct. 5 — state health officials don't have a readily available list on where the vaccine has gone.

There also seems to be confusion about where to get the vaccine, and some who are eligible can't find it.

And health officials don't have a clear picture of who is vaccinated because that information is largely not collected.

"We have no idea who we're vaccinating," said Jay Maddock, University of Hawai'i public health department chairman. He added, "This is the time to address these issues. (Swine flu) has really shown us where there are system failures."

PRIORITY LISTS

The state says part of the problem is that providers aren't doing a good job of reporting back to them on how many doses of flu vaccine they've administered. In part to address that, the state says it will alter the way it decides where swine flu vaccine goes.

Dr. Sarah Park, state epidemiologist for the Health Department, said providers will get the vaccine based on a new formula starting as early as this week, meant to reward those who are submitting information quickly on vaccine administrations, while also taking into account a provider's client base.

Those who have the most clients and serve multiple islands will get more weight under the formula. Also, medical specialties will be considered, with priority given to pediatricians.

"I know not everyone is going to be happy" with any distribution formula, Park said.

She added, "We're going to be more mathematical" with the distribution.

Already, more vaccine has been targeted for certain priority groups and big providers, including Kaiser. Last week, the Health Department shifted gears with its most recent order, deciding to send more vaccine to large health care providers and the rest to pediatricians and obstetricians.

The change is a dramatic switch for the state, and it comes in advance of a meeting today at the Health Department with the Healthcare Association of Hawaii and administrators from several large health care providers to discuss concerns over how the vaccine is being distributed.

"The central issue is not only the distribution (of vaccine), but also lack of transparency. Nobody knows where it's going," said Toby Clairmont, emergency services director for the Healthcare Association, which represents 115 organizations, including hospitals, long-term- care homes and other health care providers.

Clairmont added that the new distribution formula appears to address some concerns.

"What it sounds like is that they're becoming more sensitive to the reality of it," he said.

DATA LACKING

A representative from Kaiser, which serves about 224,000 people statewide, will also be at today's meeting. A spokeswoman couldn't immediately say how many doses of the vaccine the organization has received, but she did say, "We're not able to provide the vaccine to all of our high-risk members."

The Health Department said it's trying to distribute the vaccine equitably, and is grappling with vaccine distribution amid the state's budget crisis and with a short staff. And, health officials add, they're frustrated, too, but with providers who are slow to hand over required information on the doses they've administered. As of Wednesday, the state had received information on about 25 percent of vaccines administered statewide.

"Where are the doses?" Park said last week.

The Health Department acts as the intermediary between the national Centers for Disease Control and Prevention, which decides how much vaccine Hawai'i gets, and vaccinators, who place orders with the Health Department. Once an order is made, the vaccine is shipped directly to the provider or in some cases, is sent to Health Department sites to be picked up by providers.

Some industry experts say the distribution missteps should be seen as a learning experience — and an invaluable chance to see what works and what doesn't when it comes to managing a flu crisis and getting vaccine to those in priority groups.

Dr. Alan Tice, one of the state's leading infectious disease experts, said that anecdotally it appears the vaccine is not getting to health care workers and other high-risk groups as quickly as it should. He added that the state needs to do a better job of talking to providers so the needs of the community are understood and met.

"The practitioners should be involved early on and help establish the criteria for distribution of vaccine," Tice said, adding that providers and clinicians have so far gotten no significant say in how the vaccine has been distributed, though some have voiced concerns with the state Health Department. "This is our opportunity to learn so much about how to manage an epidemic like this. There are some very important lessons here."

Dr. Galen Chock, president of the American Academy of Pediatrics-Hawai'i chapter, called the vaccine distribution a "learning process," and said the DOH is doing the "best job they can" with their staffing levels and furlough days.

"This is a new process," said Chock. "What it really takes is everyone to be patient."

11 DEATHS IN ISLES

Swine flu has sickened thousands of people in the Islands and been linked to 11 deaths, including several in which patients had no pre-existing conditions. Health officials say the H1N1 virus remains relatively mild, with most experiencing symptoms comparable to or less severe than seasonal influenza.

Also, though H1N1 appears to be the dominant strain of flu in Hawai'i, health officials say that the state is currently experiencing something of a lull in the number of cases of swine flu compared to the Mainland, where swine flu activity is being called "widespread." Nationwide, the death toll from the flu is at more than 3,900.

State health officials say the number of cases in Hawai'i could spike at any time, especially as people gather for holiday celebrations. With that in mind, the state Health Department last week (in addition to deciding to institute a new formula for H1N1 vaccine distribution in early December) threw out the first-come, first-served system of distribution.

They also wanted to get more doses to big providers.

Some 360 providers, including many pediatricians, last week were allotted 50 doses each. And on Wednesday, the bulk of the 73,800 doses ordered for this week went to Kaiser, Tripler Army Medical Center, The Queen's Medical Center and Hawai'i Pacific Health. The rest went to pediatricians and obstetricians .

Statewide, there are 567 registered vaccinators.

Park said the change in how the vaccine is distributed for the latest order is evidence that the state is tracking distribution well, listening to community concerns and making informed decisions on where to send it.

And she added that the new distribution formula set to go into effect shortly represents a further compromise, while also ensuring the state Health Department isn't being swayed by a few "squeaky wheels." She said, "The only way we are going to survive this is if we think about it as a 'we' situation, not a 'me' situation."

QUESTIONS ABOUND

Park and others also pointed out that Hawai'i is not the only state struggling to distribute vaccine — or facing heat for where vaccine is going. In one example that made headlines, New York distributed vaccine to big name companies such as Citigroup, even as children and health care workers were on waiting lists for it.

Onlookers agree that the distribution of any vaccine in short supply will likely always be met with criticism.

But several providers also said the state should have a more streamlined, open distribution system, especially given years of pandemic flu planning.

Several readers have asked why they weren't able to get the vaccine from their doctor or health care provider, but did get it at pharmacies. Or why some pharmacies have been turning away those younger than 18, while others haven't.

At least through the first waves of distribution, pharmacies appear to have gotten larger quantities of the swine flu vaccine, because they ordered the vaccine first, Park said.

Miri Yi, vaccination clinic administrator for Mina Pharmacy, which has four locations statewide, said many doctors are calling the pharmacy to see whether they can direct their patients there.

Yi could not immediately say how many doses of vaccine Mina Pharmacy has received — or how many it still had on hand — but she said that every shipment that comes in "is gone in just a few days."

"The demand is very great," she said.

NUMBER OF PEOPLE IN PRIORITY GROUPS UNCERTAIN

The state has so far been allocated 266,400 doses of vaccine by the national Centers for Disease Control and Prevention, which is distributing the vaccine, as it is produced, to states based on population.

The vaccine is in such short supply that only priority groups are able to get it. Those groups include pregnant women, children and young adults from 6 months to 24 years, health care employees and emergency medical services personnel and people at risk of complications from flu.

Those who care for children under 6 months old are also eligible.

It's unclear just how many people are in priority groups in Hawai'i.

The state's pandemic flu plan estimates that number at 114,000.

But those estimates don't include children over 11 months old or other priority groups.

The state can't say how many people statewide have been vaccinated, partly because it has not been receiving information promptly on vaccinations from providers, officials say, and also because the only information it collects on those who have been vaccinated is age.

The Health Department last week said that providers have sent in required vaccine information to the state on 36,255 doses, or about 25 percent of distributed vaccine.

Of those doses, about 16 percent went to children under 5. About 29 percent went to children 5 to 18.

The city said that as of Nov. 20, about 765 essential city workers had been vaccinated. Bill Brennan, city spokesman, said that number included 322 from the Honolulu Police Department, 175 people from the Honolulu Fire Department and 53 from the Emergency Services Department.

Altogether, 7,237 city employees are considered essential and so are eligible to get the vaccine.

Some 7,174 state workers are also deemed essential.