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Swine flu vaccinations were available in Montgomery County for the first time last week, but county hospitals and physicians still are waiting for the vaccine's arrival and fielding questions from anxious patients.

"I have people ask me about it every day," said Dr. Daniel Snow, who practices family medicine in North Potomac. "I've told them we do expect to have the vaccine, but we don't have it yet, and they'll have to call back."

Physicians and hospitals say they expect to receive doses of the H1N1, or swine flu, vaccine by the end of the month. Most expect to have enough supply to meet the growing demand.

Most of the calls to Snow's office aren't coming from people with symptoms, he said. Patients are wondering whether they should get the vaccine, and if so, when.

Most of the requests are from healthy, middle-aged adults "who are not going to be eligible right away," Snow said.

Priority groups identified by the Centers for Disease Control and Prevention include pregnant women, children, young adults, health care and emergency personnel, and adults at a higher risk of medical complications from influenza.

"We encourage those who are in the priority groups, and then later everyone who wants it, to please go ahead and get [vaccinated]," said Ulder J. Tillman, Montgomery County's health officer. "It's the best protection."

While older people are more susceptible to the seasonal flu, and therefore more likely to get vaccinated, health officials are concerned about the swine flu's impact on young people.

On Tuesday, state health officials announced the 10th death in Maryland from swine flu — an adult from Washington County with serious health problems.

Late last month, Destinee Alicia Parker, a 14-year-old Baltimore girl who had no other underlying health problems before being hospitalized with double pneumonia and swine flu, became the state's ninth death.

Cases like Parker's have health officials carefully monitoring whether the virus is mutating into a more severe strain.

"We are all still watching and hoping that the virus does not become more serious in severity, because that would be the impact on our hospitals," Tillman said. "And we know at some point we won't have enough ventilators, we won't have enough intensive care beds, particularly for our children."

More than 1,000 students have been removed from public schools in the county due to the illness, Tillman said. Schools are excluding students or staff who are sick, but the buildings will remain open as long as there is adequate staff, she said.

Absenteeism is up. At Winston Churchill High School in Potomac, 16 percent of the school's 2,088 students were absent Friday, said schools spokeswoman Kate Harrison.

At Martin Luther King Middle School in Germantown, 12 percent of the school's 577 students were absent. The usual absentee rate is about 5 percent.

Last week, the county health department announced that it was suspending its school-based seasonal flu vaccination campaign and focusing on distributing the swine flu vaccine to county clinics after the state health department and the CDC reported that 99 percent of the influenza cases in Maryland were caused by the H1N1 virus.

Seasonal flu vaccines for students are still available through the School Health Services Center at Rocking Horse Road Center, 4910 Macon Road in Rockville, from 8:30 a.m. to 12:30 p.m. and 1:30 to 3:30 p.m. Thursdays.

Flu shots are also available to the general public at sites around the county. The sites are listed on the county's Web site or by calling its flu hot line at 240-777-4200.

Maryland has received $15.6 million in grants for state and local health departments to promote and administer vaccine clinics and provide outreach and education about the virus.

As of Tuesday, 131,200 doses of the vaccine had been shipped or were on order to be shipped to about 300 locations across Maryland, many of them to individual doctors and providers, said David Paulson, a spokesman for the state health department.

Another 60,000 doses were ordered on Tuesday and should arrive by week's end, he said.

The U.S. Department of Health and Human Services is recommending that doctors in private practice charge no more than a $20 administration fee for the vaccinations.

Pediatric Care of Rockville has administered almost all 700 doses of the nasal spray form of the vaccine that it received two weeks ago, said Kathy Kitzinger, a nursing coordinator for the practice, which serves about 20,000 patients.

The practice received another 500 doses in the form of injections on Tuesday.

Staff members have been busy calling priority patients with underlying illnesses to tell them the vaccine is available and have been answering questions by telephone "nonstop," Kitzinger said. "We don't have enough phone lines."

Montgomery County has received 2,500 doses of the nasal spray, which is manufactured by Gaithersburg-based MedImmune.

The nasal spray contains a live but weakened form of the H1N1 virus and is licensed for the vaccination of healthy individuals ages 2 to 49.

On Friday, the Dennis Avenue Heath Center in Silver Spring opened its doors for its first clinic and vaccinated 506 people over a three-hour period. A second clinic will be held there today and officials are planning additional clinics around the county in coming weeks, said Mary Anderson, a spokeswoman for the county health department.

Lara Richmond of Takoma Park heard about the clinic while at the pediatrician's office with her 3-year-old son, Lucas. They both received the vaccination, and Richmond said she would be searching for opportunities to vaccinate her two other boys, ages 8 and 10.

"I don't have a terrible concern because my kids are healthy," Richmond said. "We don't have allergies or other things that would predispose us. But with three kids at three different schools, just anything is going to come through our house. And there's just no need to have all five of us get the flu."

Not all parents are so cool-headed.

"We're getting massive phone calls and angry parents because we don't have it, and we don't know when we're getting it," said Yanira Garcia, a billing manager and medical assistant at Milestone Pediatrics in Germantown.

The practice will vaccinate high-risk patients first and then provide the vaccine on a first-come, first-served basis, Garcia said.

"We've never had anything like this before," she said.

Holy Cross Hospital in Silver Spring has revised its visitation policy in order to minimize the virus's spread. Among the changes, people with flu symptoms and children younger than age 12 are being asked not to visit unless necessary. When circumstances dictate that a person with symptoms visit, such as to see a dying family member, they are being asked to wear a mask.

Awareness of the swine flu is leading to an upswing in people getting seasonal flu shots, said Dr. Guarov Dayal, a pediatrician and chief medical officer for Adventist HealthCare. He estimated that Shady Grove Adventist Hospital in Rockville and Washington Adventist Hospital in Takoma Park have seen the number of patients receiving flu shots in the "thousands range."

"We're way ahead of where we usually are this time of year," he said.

With such demand, Kaiser Permanente will be "very proactive" in administering the swine flu vaccine to high-risk groups, said Dr. Manish Jain, a general practitioner in internal medicine at Kaiser's Kensington Medical Center. Kaiser already is offering its members walk-in and drive-through seasonal flu vaccinations on weekends in Shady Grove and Silver Spring and will provide swine flu vaccinations the same way once they are available.

The focus on the swine flu has created challenges for the flu vaccine distribution chain.

Pharmaceutical manufacturers and suppliers appear to be concentrating on swine flu vaccines, said Dukaye Berek, owner and pharmacist at Diamond Drugs, an independent pharmacy in Olde Towne Gaithersburg.

He is having trouble acquiring regular seasonal flu vaccines, despite having pre-booked purchases.

"Nobody seems to have any right now; we're in short supply," Berek said. "Whatever they have they've shipped out."

Not everyone is lining up for the swine flu vaccine.

Montgomery General Hospital in Olney is requiring doctors, staff and volunteers to receive the seasonal flu vaccine, but not vaccinations for swine flu, said Paul Miller, an employee health nurse with the hospital.

"It's a mixed bag," Miller said. "Some are very hesitant to get the H1N1 vaccine based on the fact that it is a novel virus and concerns that it was rushed through the system as far as the approval process. But overall most people are positive and plan to take it."

Patients should have no more safety concerns about the swine flu vaccine than they do about the seasonal flu vaccine, said Dr. Roger Leonard, vice president of medical affairs at Montgomery General.

"The safety profile for the H1N1 vaccine is the same as the seasonal flu vaccine," he said. "In terms of risks from receiving the vaccine, the seasonal vaccine has an extraordinary and long-term record of safety over decades and decades with tens of millions of patients. The H1N1 doesn't have the tens of millions of trials, but the immune response is created safely, and there should be no unusual side effects."

Staff Writers Jen Beasley, Melissa J. Brachfeld, Erin Donaghue, Terri Hogan, Marcus Moore, Patricia M. Murret, Meghan Tierney and Andrew Ujifusa contributed to this report.

-Montgomery County Health and Human Services will offer injections and nasal spray vaccinations for the swine flu from 9 a.m. to noon today at the Dennis Avenue Health Center, 2000 Dennis Ave. in Silver Spring.

-The clinic will target pregnant women, youths ages 6 months to 24 years, household contacts and caretakers of infants younger than 6 months, health care workers and 25- to 64-year-olds with chronic health conditions such as asthma, heart disease, cancer or HIV.

-See the county's flu information site at www.montgomerycountymd.gov/index.asp or call 240-777-4200.