Community-Sponsored Mass Vaccination Clinics

State: WA Type: Model Practice Year: 2011

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Anticipating the arrival of H1N1 influenza vaccine, the Snohomish Health District (SHD) in northwest Washington State facilitated mass vaccination clinics (MVC) managed and staffed by the local medical community. In Snohomish County (pop. 704,000), this public-private partnership successfully vaccinated more than 25,000 people on two days in October.

The goal was to develop an effective strategy to rapidly vaccinate all vulnerable residents against H1N1 influenza.Objectives were:
1. To develop mass vaccination clinics supported by community health care providers and other community partners;
2. To assure that priority individuals could access limited supplies of H1N1 vaccine through mass vaccination clinics;
3. To identify strengths and gaps in the response partnership among the participating agencies.

In July 2009, representatives from the public and private sectors (including Public Health, hospitals, clinics, insurance representatives, emergency management, and tribes) met to begin planning how to distribute vaccine most effectively. These partners agreed to distribute H1N1 vaccine through MVCs rather than through usual community venues (e.g., provider offices). Each MVC had a hospital or major clinic sponsor responsible for operating the MVC. SHD was responsible for promoting and distributing the vaccines and staffing a Public Health Liaison at each MVC.

The Snohomish Health District provided just-in-time training materials for hospitals/clinics to use on the day of the mass vaccination clinic. Nine clinics were held on October 24 (vaccinating 5,429 people) and ten on October 31 (vaccinating 20,185 people), with clinic through-put as high as 500 people an hour; a drive-through mass vaccination clinic operated on both days. Vaccine resources were allocated depending upon the quantity and presentation available and the number of clients each site anticipated serving. The Centers for Disease Control and Prevention (CDC) defined eligibility criteria for receiving the H1N1 vaccine; criteria changed over time, depending upon vaccine availability. Prior to the MVCs, CDC had advised public health agencies to restrict the vaccine to health care workers, pregnant women, persons caring for infants less than six months old, children and young adults ages six months to 24 years, and adults ages 25-64 with certain underlying health conditions. However, limited vaccine supplies required further restriction until more vaccine became available.

Eligibility was limited to health care workers, pregnant women, and children younger than five years old for the October 24 clinics, but was extended to everyone meeting CDC criteria for the October 31 clinics. A call center was opened on mass clinic days to improve customer service and client response time. Volunteers provided information and education to more than 2,100 callers. Messages and information were also translated into languages other than English, and interpreters were available at the MVCs. Local Emergency Management agencies, together with SHD, made the decision to activate a Unified Coordination structure with representation from multiple agencies. During the mass clinic events, each clinic site submitted hourly reports to Unified Coordination; reports included vaccine supply updates, resource needs, and wait times. Logistics personnel reallocated vaccine among the clinic sites as needed. Information such as wait times was posted on the www.snocoflu.com website for public view. Federal funds covered MVC costs; availability of federal funds was critical to the success of the project. Each sponsoring agency received $7.50 per immunization given. Since each sponsor prepared to serve a minimum of 1000 individuals, they were guaranteed a minimum of $7500 for their efforts. CDC shipped vaccine and immunization supplies free of charge to SHD. Certain equipment (e.g. vests, signs) incurred one-time costs, but will be reused in future public health responses. All three objectives of the proj

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Snohomish Health District
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Community-Sponsored Mass Vaccination Clinics
Anticipating the arrival of H1N1 influenza vaccine, the Snohomish Health District (SHD) in northwest Washington State facilitated mass vaccination clinics (MVC) managed and staffed by the local medical community. In Snohomish County (pop. 704,000), this public-private partnership successfully vaccinated more than 25,000 people on two days in October. The goal was to develop an effective strategy to rapidly vaccinate all vulnerable residents against H1N1 influenza.Objectives were: 1. To develop mass vaccination clinics supported by community health care providers and other community partners; 2. To assure that priority individuals could access limited supplies of H1N1 vaccine through mass vaccination clinics; 3. To identify strengths and gaps in the response partnership among the participating agencies. In July 2009, representatives from the public and private sectors (including Public Health, hospitals, clinics, insurance representatives, emergency management, and tribes) met to begin planning how to distribute vaccine most effectively. These partners agreed to distribute H1N1 vaccine through MVCs rather than through usual community venues (e.g., provider offices). Each MVC had a hospital or major clinic sponsor responsible for operating the MVC. SHD was responsible for promoting and distributing the vaccines and staffing a Public Health Liaison at each MVC. The Snohomish Health District provided just-in-time training materials for hospitals/clinics to use on the day of the mass vaccination clinic. Nine clinics were held on October 24 (vaccinating 5,429 people) and ten on October 31 (vaccinating 20,185 people), with clinic through-put as high as 500 people an hour; a drive-through mass vaccination clinic operated on both days. Vaccine resources were allocated depending upon the quantity and presentation available and the number of clients each site anticipated serving. The Centers for Disease Control and Prevention (CDC) defined eligibility criteria for receiving the H1N1 vaccine; criteria changed over time, depending upon vaccine availability. Prior to the MVCs, CDC had advised public health agencies to restrict the vaccine to health care workers, pregnant women, persons caring for infants less than six months old, children and young adults ages six months to 24 years, and adults ages 25-64 with certain underlying health conditions. However, limited vaccine supplies required further restriction until more vaccine became available. Eligibility was limited to health care workers, pregnant women, and children younger than five years old for the October 24 clinics, but was extended to everyone meeting CDC criteria for the October 31 clinics. A call center was opened on mass clinic days to improve customer service and client response time. Volunteers provided information and education to more than 2,100 callers. Messages and information were also translated into languages other than English, and interpreters were available at the MVCs. Local Emergency Management agencies, together with SHD, made the decision to activate a Unified Coordination structure with representation from multiple agencies. During the mass clinic events, each clinic site submitted hourly reports to Unified Coordination; reports included vaccine supply updates, resource needs, and wait times. Logistics personnel reallocated vaccine among the clinic sites as needed. Information such as wait times was posted on the www.snocoflu.com website for public view. Federal funds covered MVC costs; availability of federal funds was critical to the success of the project. Each sponsoring agency received $7.50 per immunization given. Since each sponsor prepared to serve a minimum of 1000 individuals, they were guaranteed a minimum of $7500 for their efforts. CDC shipped vaccine and immunization supplies free of charge to SHD. Certain equipment (e.g. vests, signs) incurred one-time costs, but will be reused in future public health responses. All three objectives of the proj
The influenza pandemic of 1918 killed millions of people worldwide. Subsequent pandemics, while not as severe, have reminded us that influenza remains a constant threat. Recent concern about the potential for pandemic influenza has focused largely on isolated human cases of avian influenza, especially in Southeast Asia. However, in April 2009, the CDC and the World Health Organization (WHO) identified an outbreak of influenza in Mexico and the Southwest U.S. The cause was identified as a new influenza virus, H1N1, that (unlike avian influenza) was being transmitted from person to person. H1N1 influenza illness quickly spread across the United States. Early surveillance suggested that children and young adults were especially vulnerable, an alarming pattern for influenza. Public health experts, especially at CDC and WHO, raised the pandemic alert level. State and local public health agencies initiated active surveillance and control measures (such as closing schools). By July, the vaccine manufacturers were producing H1N1 vaccine for widespread use by the fall of 2009. Although CDC was developing plans to distribute the vaccine, responsibility for determining how to administer vaccine locally fell to state and local public health agencies. Most public health agencies (including SHD) have had experience directly administering vaccinations, but few (including SHD) have mobilized to administer vaccinations to tens of thousands of people within a few days. Moreover, the economic recession had already reduced SHD’s capacity to administer vaccinations to the entire community. The rapid spread and unusual age pattern of this novel influenza virus lead to a local decision to identify alternative strategies to get the vaccine into the community as soon as vaccine became available.
Agency Community RolesSHD’s primary role was to facilitate planning, coordinate the actual MVC operations, and support MVC logistics. A variation on the traditional Incident Command structure was developed to manage planning and operations, with SHD staff filling Command and General staff roles. In this structure, SHD and the local emergency management agencies coordinated activities with and among all participating providers. During the two days the MVCs operated, SHD staff were specifically responsible for 1) managing communications internally and with the public, 2) monitoring vaccine supply, 3) assuring appropriate distribution of vaccine and supplies, and 4) evaluating MVC operations. Costs and ExpendituresAnticipating the arrival of H1N1 influenza vaccine, the Snohomish Health District (SHD) in northwest Washington State facilitated mass vaccination clinics (MVC) managed and staffed by the local medical community. In Snohomish County (pop. 704,000), this public-private partnership successfully vaccinated more than 25,000 people on two days in October. The goal was to develop an effective strategy to rapidly vaccinate all vulnerable residents against H1N1 influenza. Objectives were: 1. To develop mass vaccination clinics supported by community health care providers and other community partners; 2. To assure that priority individuals could access limited supplies of H1N1 vaccine through mass vaccination clinics; 3. To identify strengths and gaps in the response partnership among the participating agencies. In July 2009, representatives from the public and private sectors (including Public Health, hospitals, clinics, insurance representatives, emergency management, and tribes) met to begin planning how to distribute vaccine most effectively. These partners agreed to distribute H1N1 vaccine through MVCs rather than through usual community venues (e.g., provider offices). Each MVC had a hospital or major clinic sponsor responsible for operating the MVC. SHD was responsible for promoting and distributing the vaccines and staffing a Public Health Liaison at each MVC. The Snohomish Health District provided just-in-time training materials for hospitals/clinics to use on the day of the mass vaccination clinic. Nine clinics were held on October 24 (vaccinating 5,429 people) and ten on October 31 (vaccinating 20,185 people), with clinic through-put as high as 500 people an hour; a drive-through mass vaccination clinic operated on both days. Vaccine resources were allocated depending upon the quantity and presentation available and the number of clients each site anticipated serving. The Centers for Disease Control and Prevention (CDC) defined eligibility criteria for receiving the H1N1 vaccine; criteria changed over time, depending upon vaccine availability. Prior to the MVCs, CDC had advised public health agencies to restrict the vaccine to health care workers, pregnant women, persons caring for infants less than six months old, children and young adults ages six months to 24 years, and adults ages 25-64 with certain underlying health conditions. However, limited vaccine supplies required further restriction until more vaccine became available. Eligibility was limited to health care workers, pregnant women, and children younger than five years old for the October 24 clinics, but was extended to everyone meeting CDC criteria for the October 31 clinics. A call center was opened on mass clinic days to improve customer service and client response time. Volunteers provided information and education to more than 2,100 callers. Messages and information were also translated into languages other than English, and interpreters were available at the MVCs. Local Emergency Management agencies, together with SHD, made the decision to activate a Unified Coordination structure with representation from multiple agencies. During the mass clinic events, each clinic site submitted hourly reports to Unified Coordination; reports included vaccine supply updates, resource needs, and wait times. Logistics personnel reallocated vaccine among the clinic sites as needed. Information such as wait times was posted on the www.snocoflu.com website for public view. All three objectives of the project were met. The MVCs were able to administer nearly all available vaccine in a very short time and with minimal disruption to community providers. All partners were invited to a debriefing to identify strengths and gaps in the response. Best practices from each agency were documented, including just-in-time training, signage to guide individuals through the clinics, and resource efficiencies. Gaps to be addressed included improvement of wait times. ImplementationObjective 1—To develop mass vaccination clinics (MVCs) supported by community health care providers and other community partners 1. Identify & meet with appropriate community partners to obtain consensus on goals. 2. Meet regularly (at least twice/month) with community partners to plan effort. 3. Clarify specific roles for every participating partner.   Objective 2—To assure that priority individuals could access limited supplies of H1N1 vaccine through mass vaccination clinics 1. During planning process, clarify priority target populations and real-time processes for revising priorities once the MVCs were underway. 2. Plan accurate system to monitor vaccine inventory and real-time processes to revise distribution of vaccine once the MVCs were underway. 3. Provide accurate and timely information to the public via multiple channels (print, electronic media, web, call center) to assure highest priority populations are reached and lower priority populations are informed. Objective 3—To identify strengths and gaps in the response partnership among the participating agencies. 1. Keep accurate and complete records of all meetings and communications with partners. 2. Conduct after-action debriefings immediately following the MVCs. 3. Document results in comprehensive report after all information about the MVCs has been reviewed.   Timeframe to carry out tasks Objective 1—To develop MVCs supported by community health care providers and other community partners 1. Staff identified community partners in less than a week. Initial meetings were scheduled within two weeks. 2. At least twice-monthly meetings with community partners over three months were needed to hammer out MVC processes and respective roles for every partner.   Objective 2—To assure that priority individuals could access limited supplies of H1N1 vaccine through MVCs 1. All planning (i.e., defining priority target populations and real-time processes for revising priorities and creating a system to monitor vaccine inventory and real-time processes to revise distribution of vaccine once the MVCs were underway) were identified during the three-month planning process described in Objective 1. 2. Starting at least a month before the MVCs media were regularly informed of possible dates for the MVCs. Within hours following notification that vaccine would be delivered on a specific date, MVCs were scheduled, the website updated, and the media alerted.   Objective 3—To identify strengths and gaps in the response partnership among the participating agencies. 1. Record-keeping occurred real-time during the MVCs on two weekend days, but also required at least two weeks to fully compile the data and another month to assure the data were accurate. 2. After-action debriefings followed the MVCs over two months and a final report was completed within three months.
To develop mass vaccination clinics (MVCs) supported by community providers and other community partners Performance measures used to evaluate the practice: number of community partners, number of MVCs Data collection: We documented the number of community partners through sign-in sheets at meetings and the number of MVCs through lists of the clinics to which SHD provided vaccine on October 24 and 31. Evaluation results: SHD recruited 15 agencies to support the effort, with more than 20 individuals regularly participating in planning meetings and many more involved in operating the MVCs. Nine MVCs were held on October 24 (vaccinating 5,429 people) and ten on October 31 (vaccinating 20,185 people). All activities were successfully implemented; this objective was achieved. Feedback: We conducted after-action discussions with community partners. Partners agreed that the planning effort and MVCs had been successful and should be replicated in future crises. Of particular relevance to the conduct of MVCs, we learned to define eligibility clearly and simply, use clear and simple questions to screen for eligibility, pilot forms thoroughly before using, thoroughly train MVC staff in how to screen, anticipate screening challenges, and assure evaluation design aligns with MVC planning. To assure that priority individuals could access limited supplies of H1N1 vaccine through mass vaccination clinics Performance measures used to evaluate the practice: number and presentation of vaccinations administered by target population, estimated proportion of eligible population reached (for age groups only) Data collection: Everyone presenting for vaccination at the MVCs completed an eligibility screening form, from which we documented the number of vaccinations administered. County population estimates based on the 2000 U.S. census provided denominators for populations by age. Evaluation results: More than 25,000 people were vaccinated on two days in October 2009. Eligibility was verified for 88% of persons on October 24 and for 95% of persons on October 31; the correct vaccine presentation (based on age, pregnancy status, and underlying chronic disease) was administered to 87% of persons presenting either day. We estimate that we reached approximately 8% of the eligible population. All activities were successfully implemented; this objective was achieved. Feedback: Evaluation results have been presented to colleagues at the 2010 NACCHO annual meeting in Memphis and the 2010 APHA meeting in Denver. Lessons learned were the same as for Objective 1. To identify strengths and gaps in the response partnership among the participating agencies Performance measures used to evaluate the practice: strengths and gaps identified during after-action debriefings Data collection: The City of Everett Office of Emergency Management conducted after-action discussions with community partners. Comments were synthesized and findings were compiled into reports. Evaluation results: The after-action report contains 17 recommendations, such as identifying a lead public information officer; promoting the mass vaccination clinics in the media, on the website, through community education contacts, and inter-agency liaisons; and disseminating weekly situational reports to all participating agencies. All activities were successfully implemented; this objective was achieved. Feedback: The after-action report was widely distributed to community partners. Many of the recommendations have been memorialized in plans for future responses.
Stakeholders are fully committed to support mass vaccination clinics when needed. We believe this commitment results from several actions. First, the Health District invited the entire medical community (hospitals, clinics, pharmacies, tribes) and emergency management agencies to participate in the planning effort. Although some organizations involved in the planning did not subsequently participate in the MVCs themselves, all organizations had an investment in assuring success, precisely because they were involved from the beginning. Second, the planning process was consensual. The Health District facilitated planning, but every participant had an equal voice. Third, recognizing the unusual nature of MVCs as an emergency event, local emergency management leadership developed a hybrid incident command structure that included the medical community in all decision-making. Fourth, the MVCs proved successful in both reaching large numbers of our target populations, setting an expectation that the community is best served by such an approach.Local media were complimentary and medical partners felt properly acknowledged. Moreover, the volunteers (from community partners) reported that they felt appreciated by the public and rewarded with a sense of contributing to the community. Fifth, debriefings confirmed to community partners that this approach is feasible and effective, and returns tremendous value for the nominal investment. Finally, the Health District assured that participating organizations were at least partially reimbursed for their efforts. A lthough the reimbursements rarely covered costs, we believe that the shared contributions created a strong sense of true partnership. Snohomish County is well positioned to replicate the MVC effort anytime needed. The most critical action to sustain local capacity and commitment to community-sponsored MVCs is keeping the medical community informed about local epidemiology (i.e., what infectious diseases are circulating in the community), availability of vaccine, and public health actions to assure vaccination efforts generally. The local Health Officer communicates regularly via e-mail and blast facsimile with health care providers, alerting the medical community to outbreaks and other issues of concern. Consequently, providers feel connected. The Health District monitors vaccine supplies only for children, but has connections with all hospitals, major clinics, tribes, and pharmacies. This connection enables public health to obtain information about vaccine inventories if needed. The Health District also offers providers ongoing technical assistance about vaccination procedures. Medical practices across the county are thus in regular contact with Health District staff, further building connection. In short, routine public health work is the foundation for enabling future community-sponsored MVCs.
 
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