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Revised April 16, 2012

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SARANG DEO

Optimizing Flu Vaccine Planning at


NorthShore University HealthSystem

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It was mid-October 2009, and Stan Kent, assistant vice president of pharmacy at NorthShore
University HealthSystem, was at the gym. Running on the treadmill, he watched a media
broadcast about the rising nationwide flu epidemic. Kent had already fielded multiple questions
and concerns about NorthShore’s flu vaccine supply from its patient community in the past few
days. He felt that this latest media coverage would fuel even more demand for the vaccine and
more concern regarding the vaccine supply.

Kent was responsible for ensuring an adequate supply of flu vaccine at NorthShore. It had
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already received half of the total flu vaccines for the year from the manufacturers; Kent was
anxiously awaiting the remainder. Since early September, an increasing number of people had
been seeking flu vaccines at NorthShore hospitals and physicians’ offices, quickly prompting a
shortage. From September 14 to October 7, NorthShore had had to send patients to other
pharmacies for the vaccine. “We’re surprised that medical offices as prestigious as yours don’t
have the vaccine” was a common patient complaint. Though NorthShore subsequently had
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received a small vaccine shipment, it was not enough to meet ongoing demand.

Michael McEvoy, the pharmacy purchasing coordinator at NorthShore, had repeatedly called
suppliers to inquire about new vaccine shipments. “It’s on its way” was the typical response. But
McEvoy and Kent knew it could be weeks before any new vaccines arrived. Puzzled by the
shortage, Kent had investigated the issue further, uncovering a complex picture of the flu vaccine
supply chain. Among the factors affecting supply, demand, and distribution speed were
manufacturing challenges (e.g., growing new virus strains), production capacity limitations, and
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complex distribution routes.

As Kent watched the broadcast, he recapitulated his findings and regained a sense of urgency
to optimize vaccine planning at NorthShore for future seasons.
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©2012 by the Kellogg School of Management at Northwestern University. This case was prepared by Ilya Kolesov ’09, with the
assistance of Sachin Waikar and Hilary Richardson, under the supervision of Professor Sarang Deo. Cases are developed solely as the
basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or
ineffective management. To order copies or request permission to reproduce materials, call 800-545-7685 (or 617-783-7600 outside
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otherwise—without the permission of the Kellogg School of Management.
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Influenza Epidemics and Vaccination

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Influenza—the “flu”—is a contagious respiratory illness caused by influenza viruses. A
serious disease of the nose, throat, and lungs, it is known for complications that range from
dehydration and sinus infections to bacterial pneumonia and worsening of chronic medical
conditions such as diabetes and asthma.1 In some instances the flu can even be fatal. The

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symptoms, including cough, fever, and aches, can persist for weeks. Seasonal epidemics—not to
be confused with the more serious pandemics—in the United States represent a large medical and
economic burden, resulting in 36,000 deaths and 226,000 hospitalizations annually.2 Exhibit 1
explains how pandemics differ from epidemics.

The best method for preventing influenza in the general population is the annual distribution
of influenza vaccines. Because circulating influenza strains differ over time, the Advisory
Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention

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(CDC) recommends a new influenza vaccination every year for high-risk individuals and other
priority groups, including those who routinely come in close contact with high-risk populations.
Exhibit 2 shows how recommendations for high-risk groups have changed over the years. In
making those recommendations, the ACIP Influenza Vaccine Work Group considers factors such
as the cost-effectiveness of the vaccine, the feasibility of implementing the recommendations, and
in part the estimated vaccine supply for the season.3 The final decision and responsibility for
seeking vaccination, however, rests with individual citizens.
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Flu season in the United States typically begins in the autumn (around September) and runs
until early spring (around April). The exact timing for the beginning and peak of the influenza
season varies annually, however, as is shown in Exhibit 3. Moreover, the virulence of the
circulating virus strain could also differ from year to year, thus affecting the magnitude of the
peak (see Exhibit 4).
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In the 2006–2007 season, the demand for flu shots was at its highest levels in October but
vaccine delivery to distributors stalled during that period. On the other hand, in the 2003–2004 flu
season, vaccine demand rose after reports circulated of influenza-related deaths among children;
vaccine shortages meant that many consumers could not obtain it. During the 2000–2001 flu
season, manufacturing difficulties resulted in an overall shipment delay of six to eight weeks,
creating an early shortage. That season, many purchasers who had placed orders received only
partial shipments in time for the high-demand autumn period.
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Planning for Influenza Vaccine


Complexities in the production of influenza vaccine partly explain the challenges inherent in
providing an adequate supply of the product.

1
National Institute of Allergy and Infectious Diseases, “Key Facts about Influenza (Flu) & Flu Vaccine,”
http://www3.niaid.nih.gov/topics/Flu/understandingFlu/keyFacts.htm.
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2
Influenza pandemics, or infections spread across very wide regions (e.g., multiple continents) could cause as many as 675,000 deaths
at a time, as in 1918. However, pandemics are very rare; in the twentieth century, only three cases of pandemic flu were reported. In
contrast, seasonal flu follows predictable patterns with annual frequency.
3
CDC, “Prevention and Control of Seasonal Influenza with Vaccines,” Morbidity and Mortality Weekly Report 58 (2009): 3,
http://www.cdc.gov/mmwr/pdf/rr/rr5808.pdf.

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Influenza Virus Strain Selection

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The first step in planning for influenza vaccine entails virus strain selection, or generating
best guesses regarding which flu strains are most likely to circulate in the upcoming season. The
U.S. Food and Drug Administration (FDA) works with its Vaccines and Related Biological
Products Advisory Committee to anticipate the strain.4 The viruses used to plan the seasonal flu
vaccine are chosen annually based on information about the influenza strains that affected

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humans the previous year and the likelihood that those strains might change. Each winter, the
FDA uses input from the National Vaccine Advisory Committee and surveillance data and
analysis from the World Health Organization (WHO) and CDC to select the three virus strains
most likely to cause infections in the United States during the next influenza season.5 The chosen
strains are incorporated into the next season’s vaccine. Of the three strains selected for inclusion,
one or two usually differ from the prior season’s strains. Exhibit 5 depicts how flu strains
included in the vaccine have changed over the years.

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Production

After virus strain selection, the next step is the production and purification of the flu vaccine.
At this point, manufacturers collect samples of the three selected virus strains from WHO
collaborating centers and increase the virus amount by injecting the samples into batches of
fertilized chicken eggs.6 The FDA then tests the resulting so-called “seed” viruses. Manufacturers
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then inject the seed viruses into millions of fertilized chicken eggs for further replication.
Production of the virus-replicating eggs is more challenging than that of eggs for human
consumption, in part because the fertilized eggs must meet stringent FDA sanitation and other
requirements. After the virus strain grows to a certain level within the eggs, it is harvested,
inactivated, and purified.7 At the time of production planning, there is significant uncertainty
regarding the quantity of virus each egg will yield and consequently the number of vaccine doses
that will be produced.
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The next phase of vaccine production involves testing, filling, and packaging. Working with
the FDA, manufacturers use biological materials to test the virus strains for yield, purity, and
potency, determining whether the amount is sufficient for immunization. The manufacturers then
combine the three strains into the vaccine for that season, filling vials and syringes with
individual doses and designating lot numbers and expiration dates. At this juncture, the FDA
might conduct additional tests on each lot before releasing it for official distribution; an FDA-
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approved lot typically is released within three weeks. Manufacturers are then free to ship the
released vaccine to customers, which include state and local health departments, hospitals,
medical-supply distributors, and individual physicians.

The quantity and distribution speed of the vaccine is affected by its total production capacity,
that is, by the maximum amount manufacturers can produce and ship at any one time. Even in

4
U.S. Government Accountability Office (GAO), “Influenza Vaccine: Issues Related to Production, Distribution, and Public Health
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Messages,” Report No. GAO-08-27, October 2007, http://www.gao.gov/new.items/d0827.pdf, p. 8.


5
Sarah A. Lister, “Influenza Vaccine Shortages and Implications,” CRS Report for Congress, October 29, 2004,
http://www.policyarchive.org/handle/10207/bitstreams/2262.pdf, p. 7.
6
Ibid.
7
U.S. GAO, “Influenza Vaccine: Issues Related to Production, Distribution, and Public Health Messages,” p. 11.

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years with few manufacturing challenges, the number of vaccine doses produced is limited and

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usually spread out over several months. Thus, the total amount of vaccine required for a given
season typically is not available at the beginning of that season. Manufacturers send out vaccine
as it becomes available; the amount and proportion of vaccine distributed varies by month and
year.

The challenges involved with growing influenza virus strains have at times caused vaccine

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manufacturers to fall behind schedule in meeting demand. During the 2006–2007 flu season, for
example, several manufacturers reported problems producing one of the new virus strains needed
that year. The only major manufacturer licensed to produce a vaccine for children under 4
experienced a three-week production delay, which limited providers’ ability to offer this high-risk
population the vaccine.8

Challenges maintaining vaccine safety and quality control can also negatively affect influenza

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vaccine quantity and distribution time. A manufacturer with more than twenty years’ experience
producing influenza vaccine left the U.S. market in 2002 after the FDA fined the company for
manufacturing deficiencies. Two years later, another manufacturer did not release any of the
vaccine it had produced—which was half of the estimated supply needed for the upcoming flu
season—to the U.S. market after one of its product samples failed sterility tests. In May 2007 the
FDA issued a warning letter to yet another manufacturer regarding observed deviations—
including those associated with potential sterility problems—from good manufacturing practices;
four months later, the manufacturer announced it had resolved those issues.9
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The number of vaccine manufacturers grew from three in 2001 to six in 2008, but the number
of suppliers remained limited (see Exhibit 6). Failure to produce flu vaccine by one manufacturer
could significantly truncate the supply. For example, Aventis and Chiron had planned to make
about 100 million doses of flu vaccine (evenly split between them) for the 2004–2005 season,
thus rendering vaccine availability highly dependent on their successful production outcomes.
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Distribution

The influenza vaccine supply chain can be divided into two channels. In one, manufacturers
sell vaccine doses directly to customers (e.g., pharmacies and hospitals) that then vaccinate
consumers. In the other, manufacturers sell vaccines to distributors, which in turn deliver the
product to the vaccine providers. During the 2008–2009 influenza season, manufacturers shipped
about 50 percent of the flu vaccine supply directly to customers, while distributors delivered the
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remaining 50 percent of the supply.10 Once it is ready for shipment, manufacturers distribute
vaccine to their customers within three days. This duration depends on the route a given
provider’s order takes; direct shipment results in shorter delivery times, but the movement of
vaccine through multiple medical-supply distributors or a central distribution location (the case
for some state health departments) will lengthen the delivery time. The total amount of vaccine
distributed up to a given point in time during the season varied considerably across years (see
Exhibit 7).
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8
Ibid., p. 17.
9
Ibid., p. 17–18.
10
Health Industry Distributors Association, “2008–2009 Influenza Vaccine Production and Distribution Market Brief,” October 2009,
http://www.flusupplynews.com/documents/09_FluBrief_000.pdf, p. 3.

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In some seasons, CDC has recommended vaccine distribution in multiple shipments to all

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providers simultaneously so they can vaccinate high-risk populations quickly, even when product
supply is limited. However, several physicians and health departments have reported receiving
vaccine orders after other providers (e.g., retail pharmacies), which means that the providers
receiving faster shipments have been able to vaccinate any consumer seeking vaccination before
doctors and health departments have received sufficient doses for their higher-risk patients.11

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Vaccination

Most vaccinations in the United States occurred in October and November (see Exhibit 8).
According to a 2005 Gallup poll sponsored by CDC, adults received influenza vaccinations in the
following locations: physician’s office (39 percent); workplace (17 percent); health centers or
other clinics (10 percent); stores or pharmacies (10 percent); health departments (8 percent);
hospitals (6 percent); senior or recreational centers (4 percent); other locations (4 percent); and

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schools (2 percent).12

Priority-related policy set by the government is one of the drivers of demand for vaccination.
Each year, CDC recommends that high-risk groups, such as pregnant women and senior citizens,
receive vaccination.13 CDC, state and local health departments, and provider associations also
promote vaccination through press releases and public service announcements, among other
communications. These feature content related to preferential vaccination of high-risk groups
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(during vaccine shortages, for instance) and to the timing of vaccinations. (CDC traditionally
recommends starting vaccinations in October, although those done in December or even later can
still be beneficial.)14

Individual behavior also drives vaccination demand. According to a 2001 Healthstyles


survey, barriers to vaccination include cost, safety concerns, inconvenience related to time and
place, and poor awareness of need for some segments of the population.15 Consumers generally
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tend to seek vaccination in the early part of the influenza season, to ensure preparedness, but this
pattern varies annually. During the 2009–2010 influenza season, for example, about three times
as many adults had received seasonal influenza vaccine by early September than had done so at
the same time the previous year, but demand had faded by mid-November.16 Media broadcasts
and press releases also tend to result in spikes for vaccination demand.

Vaccination availability is another factor affecting demand. Production limitations early in


the flu season affect the ability of some providers, particularly physicians’ offices and
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departments of public health, to offer the vaccine. In some cases, hospitals must turn away
patients seeking vaccination; these consumers often secure the vaccine at retailers.

11
U.S. GAO, “Influenza Vaccine: Issues Related to Production, Distribution, and Public Health Messages,” p. 25.
12
Ibid., p. 13.
13
Ibid., p. 1.
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14
Ibid., p. 6.
15
U.S. Department of Health and Human Services, “Driving Increased Influenza Vaccination Uptake,” 2001, http://www0.ama-
assn.org/ama1/pub/upload/mm/36/summit_2005_strikas.pdf.
16
Steven Reinberg, “Seasonal Flu Vaccination Rates Still Too Low,” HealthDay, December 9, 2009, http://www.healthline.com/
healthday/seasonal-flu-vaccination-rates-still-too-low.

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Managing Flu Vaccine at NorthShore

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In 2009, NorthShore was a comprehensive, fully integrated healthcare delivery system
serving patients residing north of Chicago. NorthShore comprised four hospitals—Evanston,
Glenbrook, Highland Park, and Skokie—as well as the NorthShore Medical Group, which had
more than 70 offices and more than 800 primary and specialty care physicians. NorthShore had

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annual revenues of $1.5 billion and a total staff of more than 8,000, with treatment offerings for
cancer, heart conditions, maternity, and pediatrics, among others. The healthcare system was
recognized nationally for having high-quality care and for leading innovations such as enhanced
electronic medical records (EMRs).17

Although some 130,000 adult patients within NorthShore were eligible for vaccination, only
about 30,000 were vaccinated each year, with little variability across the years.18 During regular
clinical check-ups, the new EMR system prompted physicians to check whether the patients had

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received the flu vaccine that year. These prompts were generated depending on the patient’s
characteristics, that is, if the patient belonged to a high-risk category. During the EMR
implementation, physicians had expressed concerns about having to respond to several such
prompts. Consequently, they were given the flexibility of overriding the prompts if they were
interfering with the primary task of caring for the patient.

NorthShore had developed relationships with two manufacturers of the flu vaccine, Sanofi-
Pasteur and GlaxoSmithKline. The former accounted for the majority (70 to 80 percent) of
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NorthShore’s annual supply. Around January each year, Michael McEvoy placed orders for flu
vaccines with the two manufacturers. The contract with both of these manufacturers specified that
NorthShore could return up to 25 percent of its order for credit. Its suppliers sent the vaccine to
NorthShore in multiple shipments. It was expected that NorthShore would receive 25 percent of
its order quantity by August, 50 percent by September, and another 25 percent by October.
However, historical data showed that there was considerable uncertainty in the quantity and the
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timing of shipments over the years (see Exhibit 9).

Receiving multiple small shipments was an administrative burden for NorthShore. For each
shipment, an administrator had to determine how much of the vaccine would be shipped to
physicians’ locations, a number based on how much stock a given office had used in previous
years. In general, NorthShore tried to ship the majority of vaccine to doctors’ locations because
the central office’s refrigerator had limited storage capacity. At the same time, the amount of
vaccine shipped to a given physician’s office was also constrained by how much that office’s
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refrigerator could store. When an office had only two or three days of vaccine stock remaining, it
contacted NorthShore to request more. The administrator made a list of such requests, checked in
with other offices regarding their needs, and sent out new vaccines accordingly. When vaccine
supply was limited, the administrator tried to identify and prioritize the offices with the greatest
need, based in part on rates of usage in the current and previous years. On rare occasions,
NorthShore arranged for inter-office transshipment if the central office lacked sufficient vaccine
stock and some offices had a surplus.
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17
NorthShore University HealthSystem, Organization Profile, http://www.northshore.org/about-us/organization-profile.
18
NorthShore University HealthSystem, interview with the authors.

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Given the nature of the biological process involved in producing the flu vaccine, Kent did not

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expect the underlying steps in the supply process to change. But he felt that the uncertainty could
be better managed by making the suppliers commit to some aspects of the supply process. In the
initial discussions, Sanofi-Pasteur had indicated that it would be willing to commit to either a
fixed shipment quantity or a definite shipment time, but not both. With the first option, it would
aggregate several smaller shipments and deliver the entire order quantity in one shipment
whenever it was ready. With the second option, it would deliver whatever quantity was available

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at an agreed-upon date, preferably by the end of September, before the vaccination season began.

Retail Chains as a Benchmark for Flu Vaccine Management

Kent had been studying other vaccination providers in order to evaluate operations at
NorthShore. He was particularly interested in benchmarking retail chains, given the recent rise in
their popularity as destinations for vaccination. Just last month at one of the pharmaceutical

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industry expos, Kent had bumped into a friend who headed supply chain planning at a leading
national retail pharmacy chain. He had previously managed the supply chain operations at a
multinational fashion apparel company. During their conversation, Kent’s friend had remarked
that his job really had not changed much, as the two supply chains were very similar. He went on
to describe the major features of his company’s flu vaccine supply chain.

The pharmacy chain had placed an order for 5 million doses of flu vaccine and planned to sell
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the vaccine at a retail price of $24.99. At each store in that retail chain, the pharmacy
administrator placed vaccine orders with manufacturers based on historical demand patterns. The
administrator assumed demand generally remained flat from season to season but built an excess
buffer into the order, to be safe. All vaccine orders were placed by January to ensure sufficient
time for production and planning and delivery by October–November.

Consumers could receive flu shots at the chain’s regular pharmacy stores and walk-in clinics.
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Each store was capable of administering sixty vaccines daily, with no appointments necessary.
The retailer placed vaccine orders with Novartis (70 percent) and another supplier (30 percent) to
boost bargaining power during price negotiations. Unlike NorthShore, the chain had not
experienced delivery delays for its vaccine orders; its shipments typically followed this schedule:
40 percent arrived in August; another 40 percent in September; and the remaining 20 percent in
October. Manufacturers sent their first shipments directly to central depot locations that covered
about forty stores each, distributing the vaccine evenly among these. Manufacturers sent their
subsequent shipments to the retailer’s fifteen warehouses located across the United States. Each
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retail pharmacy store used an automated system to track the vaccine stock. If a store began to fall
short on vaccine, the warehouse was notified to distribute more.

Future Flu Vaccine Planning at NorthShore


Going forward, Kent wanted to solve the problem of flu vaccine planning once and for all. At
the strategic level, he also wanted to identify best practices of managing complex supply chains
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within and outside the healthcare sector. A natural benchmark was that of other vaccines procured
by NorthShore. For some reason, these products did not face the same magnitude of supply chain
challenges. He also wondered whether there was something fundamentally different in the supply
chain of the retail pharmacy that resulted in its better performance. Finally, he could not help but
think of the half-joking remark of his friend about similarities between fashion apparel and flu
vaccine.

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At the tactical level, Kent wanted to initiate a more systematic method of deciding the order

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quantity of vaccine. In addition, he had to decide which of the two options given by Sanofi-
Pasteur would be more beneficial for NorthShore.

Kent had less than two months to streamline these issues for the next season while continuing
to firefight for the current one. He immediately got off the treadmill, canceled his evening plans,
and headed for his office to pore over the shipment data from past seasons.

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Exhibit 1: Pandemic and Epidemic Influenza

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Three virus types—influenza A, B, and C—can cause respiratory illness and are easily
transmitted among humans. Regional and widespread epidemics are most often attributed to
influenza A and B viruses, whereas type C is associated with mild illness, sporadic cases, or
minor outbreaks. Influenza A causes the most severe disease in humans and is the most likely to
trigger a pandemic.

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Influenza pandemics occur when an animal species transmits a new virus strain to humans,
consequently causing infection to spread over a wide geographic area and affecting an unusually
high proportion of the population. Species able to transmit influenza viruses to humans include
chickens, ducks, and pigs. Influenza A viruses can be transmitted from wild birds to domestic
poultry, for example, thus allowing transmission to humans.19 The novel strains are resistant to
humans’ immunity to older influenza strains, which means they can spread very rapidly.

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According to the World Health Organization, three conditions promote influenza pandemics:

 Emergence of a disease new to a population


 Infection of humans by agents, causing serious illness
 Easy and sustainable spread of agents among humans20
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Influenza pandemics have been documented since the sixteenth century. Intervals between
recent pandemics have ranged from 11 to 39 years (with twentieth-century occurrences in 1918,
1957, and 1968), with no discernible pattern of timing. Uncertainty lingers regarding both the
timing and the impact of a future pandemic—that is, the severity of the illness, rapidity of its
spread, and the groups it affects most.21
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Whereas pandemics result from a significant change in human influenza antigens (“antigenic
shift”) that leaves humans no protection from the virus, epidemics—affecting less widespread
areas—may result from a minor change in influenza antigens (“antigenic drift”). Epidemics are
less severe than pandemics because the population remains partially protected from past exposure
to similar viruses.
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19
Kurt J. Vandegrift et al., “Ecology of Avian Influenza Viruses in a Changing World,” Annals of the New York Academy of Sciences
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1195 (2010): 119.


20
Congressional Budget Office, “U.S. Policy Regarding Pandemic-Influenza Vaccines,” September 2008, Chapter 1,
http://www.cbo.gov/ftpdocs/95xx/doc9573/Chapter1.5.1.shtml.
21
UK Health Departments, “UK Influenza Pandemic Contingency Plan,” October 2005, http://news.bbc.co.uk/2/shared/bsp/hi/pdfs/
19_10_05_bird_flu.pdf.

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Exhibit 2: ACIP Influenza Vaccination Recommendations by Season

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Persons at Increased
Risk for Influenza-
Related 2000– 2001– 2002– 2003– 2004– 2005– 2006– 2007–
a b c d d
Complications 2001 2002 2003 2004 2005 2006 2007 2008
Children aged 6 to 23
months
e Encouraged Encouraged    

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All women who will
be pregnant during    
the influenza season
Pregnant women in
second or third
trimester during the        
influenza season
Adults aged 65 years
and older        

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Residents of nursing
homes and other        
chronic-care facilities
Persons aged 6
months and older
with certain chronic        
medical conditions

Source: U.S. Government Accountability Office (GAO), “Influenza Vaccine: Issues Related to Production, Distribution, and Public Health
Messages,” Report No. GAO-08-27, October 2007, Table 3, p. 48, http://www.gao.gov/new.items/d0827.pdf.
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Notes: A check mark () indicates vaccination was recommended for that group for that season.
a
ACIP generally refers to persons at increased risk for influenza-related complications as the “high-risk” groups within the target population
and the other persons in the target population for annual vaccination as the “other target groups.” For the 2007–2008 influenza season,
ACIP also considered as part of the high-risk groups those persons at higher risk for influenza-associated clinic, emergency department, or
hospital visits—including adults aged 50 through 64 years and children aged 24 to 59 months.
b
The check marks in this column represent those target groups ACIP recommended for vaccination for the 2000–2001 influenza season
prior to ACIP issuing revised recommendations in October 2000.
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c
The check marks in this column represent those target groups ACIP recommended for vaccination for the 2004–2005 influenza season
prior to ACIP issuing revised recommendations in October 2004.
d
For the 2006–2007 and 2007–2008 seasons, ACIP also recommended that healthy children aged 6 months through 8 years who had not
been previously vaccinated receive two doses of vaccine.
e
For the 2002–2003 and 2003–2004 seasons, ACIP encouraged vaccination of healthy children aged 6 to 23 months when feasible
because they were at increased risk for influenza-related hospitalization. For the 2007–2008 season, ACIP recommended vaccination of
children aged 6 to 23 months because they were at increased risk for influenza-related hospitalization.
No
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Exhibit 3: Months of Peak Influenza Activity, 1976–2006

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50
45
40
Percent of years

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30
25
20
45
15
10 19
5 13 13
0 3 3 3

yo
ay
r

ch
y

il
r

ry
be

be

r
r

Ap
ua

ua

ar

M
em

em

M
n

br
Ja
ov

ec

Fe
N

Month
Notes: The peak month of activity was defined as the month with the greatest percentage of respiratory specimens testing positive for
influenza virus. Percentages do not add to 100 because of rounding.
op
Source: CDC, “Prevention and Control of Influenza,” Morbidity and Mortality Weekly Report 56 (2007): 1–54, http://www.cdc.gov/mmwr/
preview/mmwrhtml/rr5606a1.htm.

Exhibit 4: Summary of the Influenza Season


% ILI 2005-06
% ILI 2004-05
tC

% ILI 2003-04
11
10
9
8
% of visits for ILI

7
6
No

5
4
3
2
1
0
40

46

52

12

18
6
Do

Week

Note: ILI stands for influenza-like illness; it denotes patients with symptoms similar to those of influenza visiting primary care physicians.
Source: CDC, Seasonal Influenza (Flu), “United States Surveillance Data: 1997–1998 through 2007–2008 Seasons,”
http://www.cdc.gov/flu/weekly/ussurvdata.htm.

KELLOGG SCHOOL OF MANAGEMENT 11


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Permissions@hbsp.harvard.edu or 617.783.7860
FLU VACCINE AT NORTHSHORE UNIVERSITY HEALTHSYSTEM KEL625

t
Exhibit 5: Influenza Virus Vaccine Strains

os
Influenza Season Virus Vaccine Strains (A) Virus Vaccine Strains (A) Virus Vaccine Strains (B)
2008–2009 A/Brisbane/59/2007 (H1N1)- A/Brisbane/10/2007 (H3N2)- B/Florida/4/2006-like virus
like virus like virus
2007–2008 A/Solomon Islands/3/2006 A/Wisconsin/67/2005 (H3N2)- B/Malaysia/2506/2004-like
(H1N1)-like virus like virus virus
2006–2007 A/New Caledonia/20/99 A/Wisconsin/67/2005 (H3N2)- B/Malaysia/2506/2004-like

rP
(H1N1)-like virus like virus virus
2005–2006 A/New Caledonia/20/99 A/California/7/2003 (H3N2)- B/Shanghai/361/2002-like
(H1N1)-like virus like virus virus
2004–2005 A/New Caledonia/20/99 A/Wyoming/03/2003 (H3N2) B/Shanghai/361/2002-like
(H1N1)-like virus virus
2003–2004 A/New Caledonia/20/99 A/Panama/2007/99 (H3N2) B/Hong Kong/330/2001-like
(H1N1)-like virus virus
2002–2003 A/New Caledonia/20/99 A/Panama/2007/99 (H3N2) B/Hong Kong/330/2001-like

yo
(H1N1) virus
2001–2002 A/Moscow/10/99-like (H3N2) A/New Caledonia/20/99 B/Sichuan/379/99-like
(H1N1)-like virus antigens

Sources: U.S. Food and Drug Administration, “Postmarketing Clinical Trials (Biologics): Influenza Virus Vaccine Composition and Lot
Release,” http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Post-MarketActivities/Phase4Trials/
ucm062928.htm; in-person interviews with employees of Walgreens and of NorthShore University HealthSystem.
op
tC
No
Do

12 KELLOGG SCHOOL OF MANAGEMENT


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t
Exhibit 6: Manufacturers of Seasonal Influenza Vaccine for U.S. Market

os
2000– 2001– 2002– 2003– 2004– 2005– 2006– 2007–
a
Manufacturer 2001 2002 2003 2004 2005 2006 2007 2008
Sanofi-Pasteur
(Aventis Pasteur,
b
       
Inc.)
Wyeth Laboratories,

rP
Inc.   
Novartis Vaccines
and Diagnostics
Limited (Chiron
Vaccines Limited;
PowderJect      d
  
Pharmaceuticals plc;
Medeva Pharma
Limited; Evans

yo
c
Vaccines Limited)
MedImmune
Vaccines, Inc.
e  f
   
GlaxoSmithKline
Biologicals
g
  h
 h

ID Biomedical
Corporation of  h
 h

Quebec
op
CSL Limited 
Source: U.S. GAO, “Influenza Vaccine: Issues Related to Production, Distribution, and Public Health Messages,” Report No. GAO-08-27,
October 2007, Table 2, p. 45, http://www.gao.gov/new.items/d0827.pdf.

Notes: Table shows manufacturers of seasonal influenza vaccine licensed for the U.S. market for the 2007–2008 season as of September
28, 2007.
a
For the 2004–2005 season, in addition to the three manufacturers, two foreign manufacturers’ vaccines were made available by the FDA
tC

under an investigational new drug protocol. Although the Department of Health and Human Services purchased about 1.5 million doses of
these vaccines, no doses were distributed that season.
b
Aventis Pasteur, Inc. became Sanofi-Pasteur in January 2005.
c
In 2006 Novartis Vaccines and Diagnostics Limited acquired Chiron Vaccines Limited. In 2003 Chiron Vaccines Limited acquired
PowderJect Pharmaceuticals plc. In 2001 PowderJect acquired Medeva Pharma Limited; Medeva previously had acquired Evans Vaccines
Limited.
d
Chiron’s license was suspended by the United Kingdom in October 2004 because of contamination at its manufacturing facility there, and
Chiron ceased production of the vaccine for the U.S. market for the 2004–2005 season.
No

e
MedImmune Vaccines, Inc. manufactured live attenuated vaccine administered as a nasal spray, sold under the trade name FluMist. All
other manufacturers produced inactivated virus vaccine administered as an injection.
f
Wyeth Laboratories, Inc. distributed MedImmune’s FluMist vaccine during the 2003–2004 season.
g
GlaxoSmithKline Biologicals’s vaccine was not licensed for the United States for the 2004–2005 season, but the manufacturer’s vaccine
was made available by the FDA under an investigational new drug protocol. Although the Department of Health and Human Services
purchased about 1.2 million doses of GlaxoSmithKline’s vaccine, no doses were distributed that season.
h
ID Biomedical Corporation of Quebec, the licensed manufacturer of one influenza vaccine (FluLaval), was a subsidiary of
GlaxoSmithKline plc. GlaxoSmithKline Biologicals, also part of GlaxoSmithKline plc, was the licensed manufacturer of another influenza
vaccine, Fluarix.
Do

KELLOGG SCHOOL OF MANAGEMENT 13


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Permissions@hbsp.harvard.edu or 617.783.7860
FLU VACCINE AT NORTHSHORE UNIVERSITY HEALTHSYSTEM KEL625

t
Exhibit 7: Cumulative Monthly Influenza Vaccine Distribution

os
120

100

rP
80
Dose (Millions)

2005-06
2006-07
60
2004-05
2002-03
40

yo
20

0
July Aug Sept Oct Nov Dec Jan
Month
op
Source: National Influenza Vaccine Summit Presentation 2007, http://www.preventinfluenza.org/presentations_2007.asp.

Exhibit 8: Vaccination for Influenza by Month, 2005–2006 and 2006–2007


Influenza Seasons
45
tC

40
Weighted no. of persons (millions)

35

30

25 2006-07
No

20 2005-06

15

10

0
Sept Oct Nov Dec Jan Feb
Do

Month
Note: Based on the number of people reporting vaccination for influenza, by month, in the United States; National Health Interview Survey,
2005–2006 and 2006–2007 influenza seasons, http://www.cdc.gov/nchs/nhis.htm.

14 KELLOGG SCHOOL OF MANAGEMENT


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Permissions@hbsp.harvard.edu or 617.783.7860
KEL625 FLU VACCINE AT NORTHSHORE UNIVERSITY HEALTHSYSTEM

t
Exhibit 9: Historical Data on Flu Vaccine Shipments Delivered to NorthShore by

os
Sanofi-Pasteur (in quantity of doses)
2004–2005 2005–2006 2006–2007 2007–2008 2008–2009
Total quantity ordered 21,000 24,000 20,000 22,000 21,000
Timing
Sept., Week 1 4,900 1,440 2,800 1,500 3,360

rP
Sept., Week 2 3,360 6,240 4,500 3,500 2,100
Sept., Week 3 2,240 2,880 2,400 6,300 7,000
Sept., Week 4 3,080 8,800 8,700 8,000 3,920
Oct., Week 1 1,680 480 1,600 1,600 4,620
Oct., Week 2 1,260 1,440 1,100
Oct., Week 3 1,120 1,600
Oct., Week 4 1,260 1,120
Nov., Week 1 980

yo
Nov., Week 2 1,120
op
tC
No
Do

KELLOGG SCHOOL OF MANAGEMENT 15


This document is authorized for educator review use only by Harish V, PSG Institute of Management (PSGIM) until December 2018. Copying or posting is an infringement of copyright.
Permissions@hbsp.harvard.edu or 617.783.7860