JEFFERSON CITY - As the first H1N1 vaccines arrive in Missouri, the state's Health Department says it's leaving it up to local health agencies to decide who gets and who does not get the medicine.

"Every county is different. We think that the local health departments know best how to get (the vaccines) efficiently out to the public," Health Department spokesperson Kit Wagar said.

Within the week, nearly 20,000 doses of FluMist, a nasal vaccine for novel H1N1 flu virus, should be arriving to local health departments who have placed orders for the vaccine based on their population, said several local health department spokespersons. It is up to local health departments to distribute the vaccines through their own departments and local hospitals, clinics, doctors offices and schools.

Initial orders for FluMist have been capped by the state Health Department. Each local health department gets 100 vaccinations and then gets additional vaccines based on population demographics including the number of children age 2 to 4, the number of first responder health care workers and the number of people who have contact with children under 6 months old, said Jeff Hershberger, spokesman for the Kansas City Health Department. The state is told how many vaccines it can get from the Centers for Disease Control and Prevention, which distributes vaccines to states based on population as well.

Missouri was allocated 35,000 doses, but many providers chose not to take this week's shipment.

"This first shipment is really very small. A lot of providers said, 'The portion that's coming to me is too small (so) I don't want to hassle with it. We'll just put in our order the second week when we can get a much bigger shipment,'" Wagar said. "This was their choice."

The available amount is small because the vaccines have only been in production for a week or two, Wagar said.

"We couldn't even put any orders out until last Wednesday," he said. "For people to expect this to be on the street already, that's a little unreasonable. This stuff has to be shipped."

The Columbia-Boone County Health Department has ordered 900 vaccines -- the maximum number the state Health Department allotted them based on the area's number of children and first responders. That means fewer than one in 100 residents can get one this week.

"The federal government has assured us there will be enough vaccines for everyone who wants one to get one. When there are more abundant supplies, there will be more caps," said Claire Rainey, a public health emergency preparedness planner with the Columbia-Boone County Health Department. In Boone County, that could mean as many as 150,000 vaccinations.

Columbia is focusing their efforts primarily at getting vaccinations to healthy 2 to 4 year olds and 5 to 18 year olds with chronic health conditions. The vaccines will largely be available through pediatricians and family care physicians, Rainey said.

"We'll be getting the vaccines in waves," she said. "So we're initially focusing on pediatricians and family practice offices, but nursing homes will get them when they can, but they're not on the first distribution list."

Other local health departments are taking different approaches in distributing their vaccines.

John Shelton, a spokesman for the St. Louis County health department, said a number of their 5,000 vaccines will go to schools and doctors' offices, but several will also go to the hospital, not for public distribution, but to go to hospital staffers and other first responders. The vaccines will also be available in three public clinics.

The Missouri side of the Kansas City metropolitan area, along with a few of the surrounding counties, is getting a total of 7,100 vaccines. The Kansas City Health Department is focusing primarily on vaccinating young children rather than first responders or giving vaccines to clinics.

"Different jurisdictions are reaching out to different high-risk groups, but our reach is pediatric groups," Hershberger said. "Because we have such a limited amount, that's where we've chosen to target."

Health care providers were invited to distribute the vaccine, but until the caps are removed somewhere down the line, local officials are responsible for serving priority groups as set by the CDC. Priority groups include young children and older school-aged children with existing health problems as defined by the CDC. 

Although pregnant women are a priority group, they will have to wait until a preservative-free vaccine becomes available later this month.

While the first shipment won't cover most Missourians, more doses are on their way to the state, Wagar said. Next week, Missouri will take in 70,000 vaccines, with nearly 300,000 to come two weeks from now.

Many local health care providers have been calling with questions on the process for getting and distributing the vaccines, Shelton said. Some doctors have said they haven't been informed how they'll receive the vaccines or who they're supposed to distribute them to.

"We have sent numerous health updates; we have got this posted all over our Web site. If they don't know, they haven't been trying," Wagar said.

Health care providers chosen to assist a local health department must sign an agreement saying they will serve priority populations and must also have enough refrigerator space to house the vaccine, keep them at the proper temperature and test the temperature with a calibrated thermometer.

Providers must also agree not to charge for the vaccine -- the federal government is picking up the tab for that -- but they can charge for administrative costs, such as the nurse's time. All vaccines must be administered by a health care professional.

The state will oversee the dosage orders and allocation, but Wagar said recent budget cutbacks won't affect the state Health Department's ability to monitor the process.

"We've had budgetary cutbacks," Wagar said.

He added later, however, that the cutbacks "should not get in the way of any effort to get (the vaccine) out. One of the reasons we have chosen to do it the way we have, where you're having it shipped directly to the local health departments from the manufacturer or from the manufacturer to the health care providers, is that we saw no reason for the state to be handling these vaccines," Wagar said. "It was much faster just to have the manufacter ship them to where they're going to be given directly to the public."