The Community Flu Shot Challenge: Testing the public health system’s capacity for mass vaccination targets the population of Yellowstone County, Montana. The goal of the Community Flu Shot Challenge was to test the capacity of the public health system using Incident Command Structure. The objectives were:
To move participants from entrance to exit in under 15 minutes,
To coordinate the exercise by operating within the Incident Command Structure (ICS), and
To demonstrate the ability to vaccinate up to 833 participants /hour.
The exercise planned for 10,000 participants and operated for 12 hours, which averages to 833 participants/hour. The intent of the exercise was to test the system’s capacity for mass vaccination and to identify areas of weakness for improvement.
In the event of pandemic influenza or another public health emergency, local public health agencies will be essential for mass vaccination, dispensing of medicine, etc. After much discussion and review, the UHC determined that it needed to test the system’s capacity to mass vaccinate. Billings is the largest city in Montana; more than 10% of Montana’s population lives in Billings. Yellowstone County, including Billings, holds nearly 15% of the state’s population. Billings is the largest medical center in a 500 mile radius, and Yellowstone County is a statewide leader in public health. In the event of a true emergency, many communities would be relying on YCCHD for direct coordination of mass services and as a model for their own communities. All of these factors contributed to the decision to test the public health system’s capacity for mass immunization. This practice addressed preparedness in several ways. The decision was made early in the planning to use ICS. Becoming familiar with ICS and its function elevates staff members’ understanding of and facility with the system in a true event. The practice also exposes any weaknesses and areas in need of improvement so they can be addressed before a true event occurs. It was understood from the beginning that this practice would produce two outcomes critical to the handling of a true emergency: 1) establishing relationships, roles, and responsibilities among different agencies to ensure efficient response and 2) understanding the current gaps that can be filled prior to the emergency.
To assess similar practices executed by local health departments across the country, both formal and informal means were used. A review of published scholarly literature as well as searches for newspaper articles and other online media revealed that no other LHD has conducted a mass vaccination clinic that achieved the same volume, sustained through-put, use of ICS, comprehensive evaluation, or comprehensive media outreach as this practice. Furthermore, informal discussions at state and national preparedness conferences, as well as informal inquiries to other LHDs also suggest that no other LHDs have achieved an exercise of this scale. Three features distinguish the Community Flu Shot Challenge from other mass vaccination clinics, and from similar practices listed in the MP database: 1) partnerships developed through the use of ICS, 2) comprehensive evaluation, and 3) engagement of the public as volunteers, rather than simply as beneficiaries of a flu clinic. The UHC reached out to first-responder agencies to solicit their expertise and assistance. The fire chief served as incident commander, and taught ICS to the health community. The safety officer was a US Postal Service (USPS) preparedness coordinator who added another level of insight. Those relationships continue today. To our knowledge, the evaluation is the most comprehensive evaluation of a preparedness-focused mass vaccination clinic that has been conducted. The evaluation included a time study, participant evaluations, staff and volunteer evaluations, and overall evaluations from external observers. Perhaps the most unique aspect of this practice, however, was the engagement of the public. As the title suggests, the exercise was a challenge. Significant media outreach was conducted to challenge the community to participate in its own preparedness. The exercise was marketed to the public as a community challenge, and over 6,400 people took it and volunteered for the exercise. Voluntary community participation made the event successful.
Agency Community RolesThe UHC consists primarily of the two area hospitals and YCCHD. The UHC is chaired by YCCHD’s medical officer. YCCHD also has two staff members dedicated to preparedness, and administers the City Readiness Initiative. Because of those public health preparedness resources, and because YCCHD is the LHD responsible for the community, YCCHD led many of the activities required to execute the event. The UHC and other stakeholders were routinely sought for input and collaboration. The hospitals provided strategic input for the overall operation, as well as staff to administer vaccine. The fire chief and a USPS preparedness coordinator both served in the IC. The Department of Public Health and Human Services for the state observed the event and provided backup communications support with their emergency communications vehicle.
The Department of Emergency Services and Local Emergency Planning Commission assisted by attending meetings and offering suggestions and guidance from a first-responder and security perspective. They also assisted with onsite security the day of the event. Volunteers were key partners. United Way and RSVP provided volunteers to staff the exercise, which was critical to implementation. Volunteers also had valuable feedback from a different perspective than staff. Finally, the public was a stakeholder in the implementation. The community was asked to participate in the challenge, and that participation made the exercise a successful test of the system. Engaging the public helped raise the awareness of preparedness activities and began sensitizing the public to its role in those activities. Immediately following the exercise, numerous anecdotal comments suggested that the public expected another exercise the following year. The partnerships established and/or nurtured through this exercise are a primary outcome. YCCHD continues to work with first-responders, conduct public outreach, and work closely with the UHC. YCCHD is also forming a volunteer corps to engage volunteers more consistently.
Costs and ExpendituresThe total cost was split between the three United Health Command (UHC) partners (Billings Clinic, St. Vincent Healthcare, and Yellowstone City-County Health Department (YCCHD)). In addition, 500 doses of intranasal vaccine were donated by the manufacturer. The total cost of the exercise was $75,000. This includes offering free vaccination to all participants 18 years of age and under.
ImplementationPlanning for the exercise began in March 2006 and continued through the event on October 27, 2006. Each of the main units within ICS had a section chief who was responsible for overseeing their area and reporting to the Incident Commander. The exercise ran for 12 hours and was held at the MetraPark, a large multi-purpose structure centrally located in Billings. The exercise prepared for 10,000 participants, though it was unknown how many would attend or how many would be a sufficient number to test the system. The target population was Yellowstone County, population approximately 137,000.
Finances were shared equally by the Unified Health Command (UHC), which consisted of the Yellowstone City-County Health Department (YCCHD), and the area’s two major hospitals, Billings Clinic and St.Vincent Hospital. Fast passes could be purchased ahead of the clinic to expedite clinic flow. Vaccine was free for all children 18 years of age and younger. Clinic operations were managed by a public health nurse who served as the operations chief to coordinate staffing, including intensive training for nurses, clinic flow, infection control, adverse event reactions, and vaccine management. Multiple clinical trainings were held during the 6 weeks prior to the exercise. Clinic flow included registration, triage, billing, vaccination, and evaluation/observation. The logistics chief coordinated preparations for supplies, food for staff, signs, communications tools, etc. Public Information Officers from the UHC member organizations coordinated multiple media outlets: television, radio, newspaper, PSAs, and flyers to residents and schools. Nearly all news media were earned stories, and thus were not paid advertisements. Most public outreach was conducted in the last weeks before the exercise. Volunteers (169) staffed the exercise and were critical for clinic flow and directing participants. Volunteer team leads were trained before the exercise; the remaining volunteers received “just-in-time” training before transitioning to their post.
The goal of the Community Flu Shot Challenge was to test the capacity of the public health system.
Objective 1: Achieve a through-put of up to 833 participants / hour (10000 doses / 12 hours)
Performance Measures: Vaccination of 833 participants / hour, or all participants in attendance at a given time, whichever is less.
Outcome: The objective was met: the exercise demonstrated the ability of the UHC to mass vaccinate up to 833 participants/ hour.
Objective 2: Short length of time in the clinic for participants.
Performance Measures: Less than 15 minutes in the clinic, from entrance to exit.
Outcome: On average, participants traveled through the clinic in 10.5 minutes, well under the 15-minute objective. Participants were satisfied, and the system withstood the time objective.
Objective 3: Conduct a mass vaccination clinic using the Incident Command Structure (ICS)
Performance Measures: 1. Staff and volunteers understand their role. 2. Staff and volunteers receive efficient communication about relevant changes, communications, etc.
Outcome: The objective was met: the exercise demonstrated the ability of the UHC to mass vaccinate up to 833 participants/ hour.
SustainabilityIndeed, there is sufficient stakeholder commitment to perpetuate the practice. Because of the success of last year’s exercise, and in recognition of the need to continuously exercise and augment the system, the UHC has already committed to another exercise in fall 2007. The relationships built have been sustained, and the lessons learned are being implemented directly into the next exercise. In fact, plans are currently under way to repeat a mass vaccination exercise, but using a different method. This year’s exercise will involve a “push” mechanism, in which the UHC “pushes” vaccine out to the community through Points of Dispensing instead of “pulling’ participants into a single location. Other stakeholders such as first-responder agencies are also interested in continued collaboration with public health.
As mentioned above, those relationships are being nurtured, and one communications training has already been conducted with YCCHD, courtesy of the fire department. The key elements of the practice (strong partnerships, comprehensive evaluation, and solicitation of community volunteers) will be integral to this year’s practice as well. The practice is sustainable because the UHC recognizes the need for ongoing preparedness activities to sensitize the community to the YCCHD’s role in a potential emergency and to educate the community on the systems in place to respond to an emergency. In addition, the City Readiness Initiative helps provide resources for ongoing activities.
Lessons LearnedLessson learned included:
The UHC is capable of handling 833 participants/hour, but only with significant nursing staff.
More pediatric stations were added throughout the exercise.
Length of time was kept quite low; average was 10:26.
A key lesson was to separate older children (i.e., those over 11 or 12 years old) from the pediatric lines. Nurses uncomfortable with toddlers and infants are typically fine with older children. This would impact length of time, even though it was already successful.
Modifications were made to the evaluation process; in the future, time at each station will be measured instead of just the full duration.
Role of planning chief was critical; we now understand that role to be sustainability, not just management of vaccine distribution. Information flow needed to be more clear in the "trickle-down" to general staff and volunteers.
Future exercises will ensure that section chiefs are available for a broader perspective, not specific jobs that prevent them from addressing the bigger picture. A permanent volunteer corps is being recruited to have a consistent group familiar with YCCHD staff and activities.