Like many pediatricians, Dr. Stefan Kramarczuk has had a lot of practice saying "no" this fall.

No, we don't have the vaccine.

Or no, we only have a small amount and we can't give it to your child. Or children. Or some of your children.

"There's a lot of frustration," said Kramarczuk, who practices at Park Nicollet's Bloomington clinic. "And I share that, because we just don't have the vaccine."

The result is that anxious parents are going underground -- trading tips on where to find shots for their kids, crossing state borders in search of looser rules, and cajoling, demanding or even making threats to try to get their hands on vaccine.

"We're getting people calling the [state flu] hot line saying they're going to sue the department because they don't like how we're distributing the vaccine," said Kris Ehresmann, who is coordinating the H1N1 vaccine program for the Minnesota Department of Health.

Like all states in the midst of a national shortage, Minnesota is trying to steer its share of H1N1 flu vaccine to the most vulnerable. But it has been noticeably more close-lipped about how much vaccine is available and which clinics have it -- and more strict about who should get it until supplies increase.

While other states have held flu-shot clinics in schools or shipped vaccine to private employers, Minnesota has told the public: Wait until your clinic calls you.

But experts say Minnesota is handling the vaccine rollout better than most states.

For people such as Ehresmann, who have been preparing for a flu pandemic for years, the challenge isn't just managing the vaccine supply but managing people's expectations in the midst of the outbreak.

"I know that Minnesotans are frustrated because of just the general lack of vaccine," she said. But unlike residents of some other states, "they're not lining up at midnight and sitting all night outside or wherever, waiting for a clinic to start at 8 a.m. They're frustrated in the comfort of their own home."

In fact, Minnesota is getting about the same amount of vaccine, based on population, as other states, and following the same federal guidelines on how to prioritize patients, Ehresmann said.

But each state has its own strategy for carrying out those guidelines. And that's led to some glaring differences.

In California and elsewhere, people have lined up for blocks to try to get vaccines at mass immunization clinics, many walking away empty-handed. Flu-shot clinics have popped up in schools around the country, with mixed results. Last week, news broke that a dozen Wall Street firms received shipments of vaccine -- officially, for high-risk employees only.

The problem, in those situations, is that it's hard to know if the people lining up are really the ones who need the vaccine most, said Jason L. Schwartz, director of the Ethics of Vaccines project at the University of Pennsylvania Center for Bioethics (and editor of

"You rely on individual honesty," he said. Other than visibly pregnant women or children, it's not always obvious who's at high risk, a list that includes those with asthma, heart disease, cancer or other chronic conditions.

Minnesota, on the other hand, puts the onus on medical clinics to identify their high-risk patients and call them in when the vaccine's available. Schwartz called it "an important step" in ensuring the vaccine gets to the right people. "That's what I like about it."

Another advantage: People can spread the disease while they're waiting in line for a flu shot. Minnesota's approach, said Schwartz, avoids crowds, and relies instead on individual appointments.

At the same time, it's no surprise that criticism has mounted all across the country.

"Part of it is that the government, in spite of their best efforts to give us good information about when vaccine would be available, has been proven wrong," said Jeff Kahn, director of the University of Minnesota Center for Bioethics. "They certainly didn't intentionally mislead," he said. But they relied on early projections that millions of additional doses would be ready by now.

As of Monday, 31 million doses of the H1N1 vaccine have been shipped, with 8 million more coming.

As of last week, Minnesota's total was 459,600 doses.

Scientifically, the vaccine proved much harder to produce than expected because the virus didn't grow well in the lab; and that slowed production dramatically.

But by that time, the damage was done, said Mary Ann Blade, CEO of the Minnesota Visiting Nurse Agency, which has run flu-shot clinics for years. "Once the public gets the promise and you don't keep it, that's when they start kind of rebelling," she said.

Blade notes that this is the first time in history that a flu vaccine became available in the midst of a worldwide pandemic. Under the circumstances, she said, bumps in the road are inevitable.

Ellie Garrett, a medical ethicist who has studied flu pandemics, agrees. "No matter how well prepared we are, the nature of influenza is such that we need to expect chaos and confusion, and not get too frustrated," said Garrett, assistant director of the Minnesota Center for Health Care Ethics.

But the story of this pandemic isn't over, notes Schwartz, of the University of Pennsylvania. Within a few weeks, he predicts, the shortage will ease, and people will start worrying about doses going to waste.

"There are tens and tens of millions [of doses] of vaccine that will be produced between now and the end of the year," he said. So far, polls show nearly half the country doesn't want the vaccine, and "it's going to be a significant challenge" to change people's minds, he said. "They have their work cut out for them."

Maura Lerner • 612-673-7384