Monica Schoch-Spana, PhD, and Joseph Fitzgerald, MHS, MPH, are Senior Associates, Center for Biosecurity of the University of Pittsburgh Medical Center, Baltimore, Maryland. At the time the article was written, Bradley R. Kramer was an Analyst at the Center; he is currently at the University of Maryland Medical School, Baltimore. BIOSECURITY AND BIOTERRORISM: BIODEFENSE STRATEGY, PRACTICE, AND SCIENCE Volume 3, Number 3, 2005 © Mary Ann Liebert, Inc. Influenza Vaccine Scarcity 2004–05: Implications for Biosecurity and Public Health Preparedness MONICA SCHOCH-SPANA, JOSEPH FITZGERALD, BRADLEY R. KRAMER, and THE UPMC INFLUENZA TASK FORCE In the event of a bioterrorist event or a pandemic flu outbreak, it might be necessary to ration vac- cine or other treatments. In this article, researchers examine how medical and public health decision makers negotiated the unanticipated 2004–05 influenza vaccine shortage, using the regional hospital system headquartered in Pittsburgh, Pennsylvania, as the focal study site. This account of that case study describes the circumstances that contributed to the national and local vaccine shortage; the improvisation by health policymakers, hospital administrators, physicians, and nurses to prevent in- fluenza cases despite the shortfall; and some of the legal, fiscal, logistical, social, and political pres- sures that local health professionals faced in deciding who should receive the limited supply of in- fluenza vaccine. This instance of an acute vaccine shortage provided an opportunity to examine the practical and ethical dilemmas of managing medical resources during a public health emergency. S CARCITY OF LIFE-SAVING RESOURCES is one of the most complex challenges that decision makers may face when managing the impact of a biological attack, in terms of medical outcomes, social stability, and confi- dence in government. 1–5 Rationing also qualifies as one of the most troubling public health dilemmas anticipated during a pandemic of influenza: When everyone is vul- nerable to a novel, potentially lethal virus, who should be vaccinated first and why? 6 Apart from dramatic “tragic choices,” governments, healthcare administrators, practi- tioners, and patients around the globe contend routinely with questions about prioritized access to healthcare. 7–10 To understand more fully what sudden and urgent ra- tioning might imply, researchers examined how medical and public health decision makers negotiated the unantic- ipated 2004–05 influenza vaccine shortage. Investigators took a regional hospital system headquartered in Pitts- burgh, Pennsylvania, as the focal study site. This account of that case study describes the circumstances that con- tributed to the national and local vaccine shortage; the improvisation by health policymakers, hospital adminis- trators, physicians, and nurses to prevent influenza cases despite the shortfall; and some of the legal, fiscal, logisti- cal, social, and political pressures that local health pro- fessionals faced in deciding who should receive the lim- ited supply of influenza vaccine. This instance of an acute vaccine shortage—followed by an unintended excess several months later—provides an opportunity to examine the practical and ethical dilemmas of managing medical resources during a public health emergency. Case study observations are coupled with their implications for a hypothetical crisis as well as investigators’ suggestions for improving the ability of healthcare systems and public health agencies to handle scarcity conditions. BACKGROUND National Flu Vaccine Shortage On October 5, 2004, the British Medicines and Health- care Products Regulatory Agency suspended the license 224