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As U.S. government officials roll out what may be the nation's "largest-ever mass vaccination effort" for the H1N1 virus, beginning this week with the expected arrival of between 6 million and 7 million doses, state and local budget constraints and limits on who can administer the vaccines may make the process "bumpy" at first, the Wall Street Journal reports. To date, the U.S. government has spent $2 billion to purchase approximately 250 million H1N1 vaccine doses from five pharmaceutical companies, including Sanofi Aventis SA, CS Ltd., MedImmune, Novartis AG and GlaxoSmithKline. The first to arrive will be MedImmune's nasal spray vaccine, with approximately 600,000 doses expected to be delivered in the first week of October. Each state has been allotted a number of vaccinations based on population size. According to the Centers for Disease Control and Prevention, 47 states have ordered 1.38 million doses, with more orders expected to come from a total of 90,000 states, counties, cities and individual buyers, according to the Wall Street Journal. Approximately 40 million doses of the nasal spray and injectable vaccine will be available by mid-October, with another 10 million to 20 million expected to be made available each subsequent week. Although an extensive vaccine-distribution system has been established to facilitate quick distribution, the director of the University of Minnesota's Center for Infectious Disease Research and Policy notes that the system already is "under great stress." Notably, 12,000 public health positions were eliminated in 2008, bringing the number of public health workers down to 102,000, not including employees of local health departments, the Wall Street Journal reports. To help meet the anticipated high demand for the H1N1 vaccine, public health officials are considering hiring volunteers and private providers to administer doses in public clinics. In addition, some states are now relaxing rules governing vaccine administration to accommodate the potential high demand for the vaccine. For example, Massachusetts will allow pharmacists, paramedics, dentists, and third- and fourth-year medical students to administer vaccines. Meanwhile, the New York Times reports that many primary care physicians are becoming concerned about the logistics of the H1N1 vaccine distribution process. Although physicians normally directly order vaccines from manufacturers, the New York Times reports that the H1N1 vaccine will be distributed at no cost to city and state health departments, which are recording orders from physicians, hospitals, school systems and others. However, deliveries will lag, "adding confusion" about when physicians will receive their orders. U.S. Department of Health and Human Services Secretary Kathleen Sebelius has acknowledged concerns, but says it is local health departments' responsibility to coordinate with physicians, hospitals and the federal government (McKay, Wall Street Journal, 10/5/09 [subscription required]; Fox, Reuters 10/5/09; Stein, Washington Post, 10/5/09 [registration required]; Hartocollis, New York Times, 10/5/09 [registration required]).