5
Vaccine Administration Methods and Partners

In each workshop, in every session, partnerships were mentioned as essential in the vaccination campaign. Lisa Koonin, senior advisor in the CDC’s Influenza Coordination Unit, emphasized, “We learned through this response that public health cannot do this alone. The private sector can’t do this alone. Government cannot do this alone. It really is necessary to leverage the unique talents and capabilities of a wide variety of partners, essentially at a community level, to make this work.” Public health authorities relied on relationships and partnerships that existed before the event as well as on new partnerships that developed during the 2009 H1N1 response. Box 5-1 shows some of the many partners involved in the 2009 H1N1 vaccination campaign.

BOX 5-1

Stakeholders Involved in the 2009 H1N1 Vaccination Campaign

  • Public health authorities–federal, state, tribal, territorial, and local

  • Other government agencies and offices, including Department of Defense, Veterans Administration, Department of Homeland Security, and Indian Health Service

  • Hospitals and large health systems

  • National and local disease organizations or support groups

  • Association of State and Territorial Health Officials

  • National Association of County and City Health Officials

  • Emergency medical service providers



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5 Vaccine Administration Methods and Partners In each workshop, in every session, partnerships were mentioned as essential in the vaccination campaign. Lisa Koonin, senior advisor in the CDC’s Influenza Coordination Unit, emphasized, “We learned through this response that public health cannot do this alone. The private sector can’t do this alone. Government cannot do this alone. It really is neces- sary to leverage the unique talents and capabilities of a wide variety of partners, essentially at a community level, to make this work.” Public health authorities relied on relationships and partnerships that existed before the event as well as on new partnerships that developed during the 2009 H1N1 response. Box 5-1 shows some of the many partners in- volved in the 2009 H1N1 vaccination campaign. BOX 5-1 Stakeholders Involved in the 2009 H1N1 Vaccination Campaign • • Public health authorities− National and local disease organi- zations or support groups federal, state, tribal, territorial, and local • • Other government agencies Association of State and Territorial and offices, including De- Health Officials partment of Defense, Veter- ans Administration, De- • National Association of County partment of Homeland Secu- and City Health Officials rity, and Indian Health Service • • Hospitals and large health Emergency medical service systems providers 37

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38 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN • • Private healthcare providers Federally qualified health centers • • Pharmacies and retail clinics State pharmacy associations • • Health insurers Sports teams • • Community groups Faith-based organizations • • Mass immunizers Medical Reserve Corps • • Schools Colleges and universities • • Grassroots immunization State medical associations and groups (e.g., Action for Com- specialty associations munity Enrichment) Mass Vaccination Clinics Many public health authorities used mass vaccination clinics to ad- minister 2009 H1N1 vaccine. Although mass clinics are an efficient way to vaccinate large numbers of people, in the case of 2009 H1N1, there were also some challenges, particularly about the use of ACIP recom- mendations to prioritize vaccine for the target groups. In most places, people were asked to self-assert their eligibility for priority vaccination; public health officials did not ask for verification of a person’s high-risk status. This meant people could “game the system” and receive vaccine even if they were not in the targeted groups. However, the positive aspect of self-identification of eligibility was that it was easier for those administering the clinics. “You have to rely on people being honest,” explained Plough of LA County. “You will vacci- nate a few people who are not high risk, but you will get a number of people who are uninsured—marginalized, and advance some of your eq- uity principles.” Some participants were fine with this risk, and others had mechanisms in place (e.g., questionnaires, people walking the line) to reduce the risk of vaccinating people who were not in the prioritized groups. However, this concern of eligibility may change in the face of a more severe pandemic or public health emergency, given an adequate amount of vaccine.

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39 VACCINE ADMINISTRATION METHODS AND PARTNERS Contract Immunizers Large numbers of staff were required for the mass vaccination clin- ics. “Had we more vaccine, I am not sure that we would have been able to give it to all the people that wanted it, because we just did not have the manpower to do it,” said Chicago’s Morita. To increase staffing, some jurisdictions hired temporary workers who served as mass immunizers. They stressed the importance of paying mass immunizers by the hour and not by the shot. This ensured that the appropriate populations were vaccinated. They also urged that volunteer immunizers be screened out- side the clinics and actually be observed giving shots. This is not a just- in-time hiring process that can happen the day of a clinic, they said, but something that needs to be planned and organized. Participants noted one question regarding contract immunizers that should be investigated further: Will they be available in a much more severe epidemic or during a time with ample vaccine supply but sus- tained high demand? If plans call for their use, alternate backups should be investigated in case those vaccinators are not available. Emergency Medical Service Providers To ease the staffing shortage, Ohio activated rules from 2004 that al- lowed EMS personnel to function as vaccinators so long as the governor had declared a public health emergency, the personnel had been trained, and all vaccinators were under the direction of a physician. Ohio also created an online training session for vaccinators. Austin, Texas, used off-duty firefighters organized in strike teams as vaccinators for city employees. This worked well, several participants said, because of the ample flexibility. Teams could go out any time of day or night and meet city employees who needed vaccination at their job sites. Even with the cost of paying the off-duty firefighters to per- form this service, this model was more efficient than a contractor ap- proach, the competing alternative. Because of the success, the Austin Fire Department is proposing to use this strategy for the city’s annual flu vaccinations, which will allow it to have a mass exercise once a year on pandemic response.

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40 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN Creative Locations for Mass Vaccination Sites Beyond traditional mass vaccination sites, workshop participants shared some unique operational ideas and novel clinic sites. In West Virginia, a vaccination clinic at the Bass Pro Shop one Saturday was able to give 1,000 vaccinations in just 4 hours. In Alaska, a ski-up clinic was held at the U.S. Cross-Country Olympic trials in Anchorage, and another was held during former Governor Sarah Palin’s book signing. Champaign−Urbana, Illinois, Public Health coordinated with the Muscular Dystrophy Association to offer a call-ahead, curbside vaccine service for patients and their family members in order to decrease the risk of disease transmission to vulnerable patients. School Vaccination Programs Many jurisdictions used school-based or school-located vaccination clinics. The Baltimore program relied on an immunization team that had been meeting monthly for more than 10 years, said Anne Bailowitz, act- ing chief medical officer for the Baltimore City Health Department. To prepare for the 2009 H1N1 vaccination campaign, the team started plan- ning 4 months in advance and continued to meet with the city school sys- tem for 4 months after clinics began. “Reach out early and often to your school system,” Bailowitz advised. In Baltimore, 18,500 of 30,000 doses went to school-age children. West Virginia scheduled school clinics as vaccine became available and used county and city paramedics as vaccinators in the middle and high schools. They were careful to schedule clinics at a wide mix of schools: public and private, urban and rural. Washington, DC, began school clinics in October by vaccinating public schoolchildren. However, because a relatively high proportion of the city’s children and youth at- tend private and charter schools instead of public schools, there were concerns about equity. In the end, clinics were opened for everyone in the priority groups and did not focus exclusively on children attending public schools. Massachusetts started school clinics in November with some school-based and some school-located clinics (the difference was who ran the program). Some were held during the school day and others after school.

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41 VACCINE ADMINISTRATION METHODS AND PARTNERS Not all jurisdictions used school vaccination programs. Chicago, for example, did not hold school-based clinics because of a poor history of success in previous campaigns. The big stumbling block was lack of re- turn of consent forms. Morita reported that in previous campaigns, fewer than 30 percent of consent forms were returned. Baltimore had difficul- ties getting consent forms back from parents as well, and on those forms that were returned, inadequate history was sometimes a problem. Addi- tionally, some second doses were given that may not have been needed, an error that is less likely to occur when a parent or caregiver accompa- nies a child to a vaccination site. In the Houston area, schools requested that clinics be held on the weekend to avoid disrupting the school day. The benefit of weekend clin- ics was that consent was in person—the parents were present. The schools’ automated phone systems were used to send out reminders on the day of the clinics. School clinics were effective in reaching large numbers, West Vir- ginia’s Slemp noted, but repeating that success is an ongoing challenge because of vaccine financing. The 2009 H1N1 vaccine was free, which helped in running the school clinics. Slemp wondered if pilot programs could be chartered to look at how to sustain school vaccination programs. She shared an example in which one community is looking at—and hav- ing some preliminary success with—partnering with businesses. The businesses donated seasonal flu vaccine for the health department to use in schools. This is good public relations for the businesses and good for the businesses because it keeps their workforce at work, not home with sick children. David Lakey, commissioner of the Texas Department of State Health Services, noted that school-based clinics need to be analyzed and the fol- lowing questions asked: Were the right individuals reached? Should school-based clinics be used in more states? Do they need to be used in seasonal flu efforts? Don Williamson, state health officer for the Alabama Department of Public Health, also raised interesting questions: Would uptake have been better in schools and would we have made any difference in disease bur- den if the vaccine had been hoarded, then given to schools in December? What would have been the impact of delaying the start of school? In Alabama, where school started on August 10, disease rates increased within a week of school starting. What if school had been delayed a month? Would the disease curve have shifted enough so that vaccine

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42 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN demand would have lined up more closely to when more vaccine was available? College Student Health Clinics Student health clinics located on college and university campuses faced unique challenges. Even though the college-age student population was part of the ACIP recommendations, most student health clinics were erroneously identified as regular physician offices, said James Turner, president of the American College Health Association. This misidentifi- cation meant that vaccines were shipped in small amounts of approxi- mately 100 doses at a time without considering the size of the student population. He also noted that shipments to colleges were often unan- nounced, sporadic, and unpredictable. Unfortunately, the timing of vac- cine manufacture and delivery meant that most students were taking exams when vaccine was distributed to colleges. Then they went home for the holidays. This contributed to lower than ideal vaccination rates in many areas. Students may or may not have received vaccinations during the winter holiday break, but student health offices had no way to gather that information. Healthcare Providers Healthcare providers played an integral role in the distribution and administration plans, particularly for vaccination of pregnant women and other high-risk adults, as well as children. Workshop participants in- cluded pediatricians, OB/GYNs, family practice physicians, nurses, and other healthcare providers. This section describes how healthcare provid- ers were recruited to participate in the 2009 H1N1 vaccination campaign, the challenges they encountered while administering vaccine, and some individual suggestions for addressing these challenges. Recruiting Healthcare Providers For healthcare providers to take part in the 2009 H1N1 vaccination campaign, they needed to be enrolled in a system that tracks and man-

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43 VACCINE ADMINISTRATION METHODS AND PARTNERS ages allocations. Many states used existing VFC provider registries as a starting point for enrolling vaccinators, but the majority of those already in the program were pediatricians. Neil Kaneshiro, past president of the Washington State chapter of the American Academy of Pediatrics, noted, “The use of our established state vaccine network as our base was really critical to getting most of the providers who were familiar with the sys- tem instantly on board.” Workshop participants noted, however, that it was important to reach physicians that care for other high-risk patient populations, such as OB/GYNs. It is also important to remember that family practitioners often see all types of patients, including those in the targeted groups. Jeanne Sheffield, director of the Maternal–Fetal Medicine Fellow- ship at the University of Texas Southwestern Medical Center, said the OB/GYNs around Dallas, as well as in the rest of Texas, did not readily understand how to vaccinate, how to request vaccine, or what the process was. She worked with the Texas Association of Obstetrics and Gyne- cologists and the American College of Obstetricians and Gynecologists (ACOG) to disseminate information through faxes and e-mails. She even called some large provider groups to make sure they had the information. Additionally, the Society of Maternal–Fetal Medicine provided links to the CDC website and listed protocols on its own website. Many work- shop participants emphasized that this kind of direct outreach to provider groups and associations was critical to engaging physicians in the vacci- nation campaign. Administering Vaccine Once they had registered and received vaccine, healthcare providers faced more logistical challenges: vaccine storage, staff training and time for data entry and/or registry requirements, and decisions on who would administer vaccinations. Even pediatricians accustomed to providing rou- tine and seasonal vaccinations to their patients had to develop plans for administering the 2009 H1N1 vaccine. Would they require appointments or hold open clinics for patients? These and other planning measures had to be completed before vaccine was delivered. The CDC developed, through a contractor, a tool kit for primary care provider offices to assist in their planning efforts (ORISE, 2009).

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44 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN For healthcare providers who did not routinely offer vaccinations to their patients, this was a completely new system to implement. “Individ- ual offices had to come up with a way in setting up who was going to provide the vaccines [and] how they were going to store it,” Sheffield said. She noted this was also a learning opportunity for OB/GYN prac- tices because in theory OB/GYNs should be doing seasonal flu, hepatitis B, and tetanus-diptheria-pertussis (Tdap) vaccinations and should be a primary vaccine delivery source for pregnant women. The lack of predictable vaccine delivery or advance notification of shipments was frustrating for healthcare providers. Terk, a pediatrician with Cook Children’s Physician Network in Keller, Texas, spoke of a 3- week delay in receiving requested vaccine and of being limited to 80 doses. During those 3 intervening weeks, he was dealing with a huge wave of influenza, at one point treating 208 patients in 4.5 days. For a new provider this situation was surprising, but for those who are regu- larly part of the immunization process, it is an unfortunate status quo. Kaneshiro noted, “Providers who do vaccines routinely have a very acute awareness of dealing with shortage. We have dealt with vaccine short- ages off and on for many years.” He noted that as long as clear directions were given from “the powers that be,” shortages were dealt with success- fully. But transparency and communication are critical. Physicians with private practices noted that several financial con- cerns arose from participation in the 2009 H1N1 vaccination campaign. These are discussed in more detail in the section below on funding and payment issues. Pharmacies Independent and large chain pharmacies and retail clinics are in- volved extensively in seasonal influenza vaccination campaigns, and many were ready to assist in the 2009 H1N1 vaccination effort. The ex- tent to which pharmacies were used to administer 2009 H1N1 varied widely across the nation. Participants discussed some of the issues and concerns that were considered when deciding when it was most appro- priate for pharmacies to begin administering vaccine and under what guidelines. Many arguments can be given for the use of retail pharmacies in ad- ministering vaccine, but the most compelling is availability: Large num-

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45 VACCINE ADMINISTRATION METHODS AND PARTNERS bers of immunizers are ready and available to administer vaccine. For example, Walgreens, as of the time of the workshops, had trained 85 per- cent of its pharmacists as immunizers, with a goal to increase that to 100 percent. Pharmacies know their markets; they are in the community and have established relationships with local, state, and national public health. Distribution networks are already in place and easily accessed by high-risk individuals. Also, pharmacies are open during evening, week- end, and holiday hours, when public health clinics and doctors’ offices may be closed. Retail clinics located inside pharmacies also provided 2009 H1N1 vaccinations. The United States has about 1,200 of these clinics, usually staffed by nurse practitioners (Merchant Medicine, 2010). Opening up vaccination through retail pharmacies increases the number of access points the population has to receive vaccine. Additionally, noted Jay Bueche, director of pharmacy compliance at H-E-B, a large grocery chain in Texas, consumers tend to look to the fa- miliar. They tend to go back to where they get their seasonal vaccina- tions, a trend that should be kept in mind when planning for future events such as a pandemic or other emergency. When vaccine was given to Chicago pharmacies, Morita noted that they heavily promoted it and used their retail presence to spread the word in the community about vaccination at a time when demand for vaccine had fallen. There was also discussion about the most appropriate role, timing, and remaining challenges for integrating pharmacies into the vaccine distribution system. These issues were in the areas of implementation of priority groups, equitability, scope of practice, and data reporting and are discussed in more detail below. Priority Groups Much of the discussion about the use of pharmacies concerned tim- ing: When is it appropriate to use retail pharmacies to administer vaccine, especially during a pandemic when resources are scarce? Participants dis- cussed various scenarios based on vaccine supply levels. When ample supply of vaccine is available, participants seemed to generally acknowl- edge that using retail pharmacies is appropriate to increase vaccine ac- cessibility, as in the case for the administration of seasonal influenza vaccine. When supplies are scarce, the issue is less clear.

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46 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN Many participants believed that if priority groups are set based on objective criteria—age, pregnancy status, etc.—then the use of pharma- cies would be appropriate. More debate took place about whether to use pharmacies when priority groups are set based on medical conditions. Pharmacists attending the workshops noted that they do know who their high-risk patients are because they are filling their prescriptions on a regular basis. “While [pharmacies] may not be the primary medical home for many . . . they are the second medical home,” said James Blumen- stock of the Association of State and Territorial Health Officials (ASTHO). “We need to realize that, and utilize them. Plus, they do have quite an enviable infrastructure with regard to materials, management, and data management.” Another concern was that retail pharmacists would not adhere to the prioritization groups because of the potential negative impact on busi- ness. Alabama’s Williamson explained, “Our pharmacy association spe- cifically asked us not to ship them any vaccine if they had to prioritize. They only wanted it once you could open it up to everybody.” In other states, pharmacies were used earlier, and adhering to the guidelines was not a problem. Cooper of Tennessee noted that pharmacies in her state were probably more stringent in adhering to the guidelines than some other providers in the system. In North Carolina, there was a mispercep- tion that pharmacies were vaccinating anyone who came in if supplies were available, but public health was able to distribute the pharmacies’ screening criteria to counteract the misinformation. As discussed above, large chain pharmacies with locations in multi- ple jurisdictions encountered challenges because of cross-jurisdictional variations in vaccine distribution plans and differences in the implemen- tation of priority groups. There was some discussion at the workshops about whether pharmacies in this situation should have flexibility in im- plementing the priority groups, although several pharmacy representa- tives noted their preference for stricter national guidelines. Equitability Issues Although pharmacies are good at reaching their markets, it was ac- knowledged that they might be missing uninsured, low-income, and other vulnerable populations because of the cost associated with receiv- ing vaccine at a pharmacy. Public health may be better able to reach un-

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47 VACCINE ADMINISTRATION METHODS AND PARTNERS insured and low-income vulnerable populations, and by using pharmacies, public health can focus on underserved populations. Vaccine administra- tion should take place within a larger coordinated public health strategy, in which retail pharmacies are one component. Participants also noted that the decision to begin distributing vaccine through pharmacies may depend on whether there is a shortage or an ample supply of vaccine. Scope of Practice Another issue raised during the workshop was related to the licen- sure of pharmacists as vaccinators. Every state and Washington, DC, has authorized trained pharmacists to administer vaccine (APhA, 2009). However, not all pharmacists are trained as immunizers. Furthermore, there are state variations in vaccination scope of practice laws and regu- lations for pharmacists, particularly with regard to the limits on the age of patient they can immunize. In some states, pharmacists are only au- thorized to immunize adults; this is particularly disadvantageous in cam- paigns in which children and teenagers are prioritized for vaccination. It was challenging for pharmacy chains to deal directly with a large number of state and local public health departments, as well as with state varia- tions in vaccination scope of practice laws and pharmacist regulations. Participants suggested that it would be useful to examine whether a na- tional standardized age should be set. Data Reporting Another challenge highlighted by the 2009 H1N1 vaccination cam- paign is that reporting was a significant problem for pharmacies. Each jurisdiction had different reporting requirements, adding huge adminis- trative challenges for the pharmacy chains that had to report to multiple health departments in a variety of formats. Also, not all retail pharmacies have convenient Internet access, so multiple reporting pathways were needed, such as fax or paper forms.

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48 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN Health Plans Several health plan representatives participated in the regional work- shop series, including Eduardo Sanchez, vice president and chief medical officer of Blue Cross Blue Shield of Texas; Richard Justman, national medical director for UnitedHealth Group; and Grossman of Group Health Cooperative, a large nonprofit healthcare system based in Seattle. These speakers noted that health plans were very involved in the 2009 H1N1 response and that this model of engagement should be further lev- eraged to address other public health priorities. “Health plans want to be at the table. We want to be collaborators before, during, and after public health emergencies and feel that we have resources that can be part of an integrated response, not only data and policy, but also communication,” Sanchez said. Health plans can communicate with their covered patients, physi- cians, and other healthcare providers as well as employer groups they serve, providing a way to dispense information and education where needed. They can also provide data and other information to health de- partments. A specific area where health plans can be used is to provide information to their pregnant population. Many health plans already do outreach to this population through healthy pregnancy programs. Al- though used by some health plans, these programs were an underused resource that could have been used to actively disseminate information to pregnant women about the need for 2009 H1N1 vaccinations. Of the challenges health plans faced during the 2009 H1N1 vaccina- tion campaigns, many were related to payment—perhaps not surprising given their role in the health system. These challenges are discussed be- low in the section on funding and payment issues. Occupational Health Clinics Many large companies have occupational health clinics appropriate for vaccine administration programs. Participants noted that it is impor- tant to integrate the private sector in vaccine administration plans be- cause they have access to thousands of employees and family members. In addition, private-sector contributions provide a benefit to the commu- nity in terms of public health and sustaining the economy, and lessen the burden on a public health system that is already stretched thin.

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49 VACCINE ADMINISTRATION METHODS AND PARTNERS However, during the 2009 H1N1 vaccination campaign, a number of challenges had to be addressed. First, large companies often operate in multiple jurisdictions—The Boeing Company, for example, is a multi- state, multinational company that had to work with 300 U.S. counties, each with potentially different administration plans and different inter- pretations of the ACIP recommendations. Second, there is a delicate line to walk when a scarce resource like 2009 H1N1 vaccine is given to a big company to give to its employees. Public health has to be open and stress to the public that the vaccine is being distributed and administered according to the same guidelines as everywhere else and that the private sector is just one of many admini- stration systems that is being used to reach the target populations. Many participants cited the story circulating in the media in early November 2009 that accused Wall Street of receiving vaccine before hospitals or those in high-risk groups. They noted that this kind of story is likely to discourage companies from participating or keep them from being al- lowed to participate. Blumenstock of ASTHO noted that it is important to resist the temptation to overcompensate when things go wrong, point- ing out that after the poor publicity about the use of occupational health clinics at Goldman Sachs for vaccine distribution, the opportunity was lost in some areas to open work site vaccination programs, even after vaccine supply levels had risen. Opportunities for Improving Vaccine Administration and Enhancing Partners’ Roles in Future Campaigns Numerous individual suggestions were made about opportunities to improve vaccine administration methods and to further enhance the role of partners in future emergency vaccination campaigns. These sugges- tions are compiled here as part of the factual summary of the workshops and should not be construed as reflecting consensus or endorsement by the workshops, the Preparedness Forum, or The National Academies.

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50 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN Vaccine Administration and Mass Clinics There were several suggestions for public health authorities related to vaccine administration generally as well as more specifically related to the organization of mass clinics. These included • Continue to cultivate and enhance partnerships with a wide variety of stakeholders, including healthcare providers; the private sector, including pharmacies and other businesses; DoD, Department of Veterans Affairs, IHS, and other rele- vant federal agencies; community and faith-based organiza- tions; EMS; school systems, colleges, and universities; contract nurses; national and state medical associations and specialty societies; and health insurers, among many others. Look for ongoing opportunities for partners to work together on public health initiatives to build and sustain partnerships during the times between public health emergencies. • Simplify systems where possible. The city of Boston was able to simplify parts of the administration process by minimizing the lot numbers used during mass clinics and color coding vaccines and all supplies related to each vaccine. For example, the Sanofi Pasteur vaccine came in a green box, so all syringes, once drawn, went into a green box; guidance documentation was on green paper; vaccine information was on green stickers; the scanner that read that specific dose was green, and so on. • Different formulations, including formulations of seasonal flu vaccine, should all look different to help prevent medical errors. Pamela Falk, director of healthcare epidemiology at the University of Texas Medical Branch (UTMB) at Galveston, raised the issue of similarities between the labeling of the 2009 H1N1 vaccine and the seasonal vaccine, noting how easy they could be confused. • Use school-located clinics. Work with school systems in ad- vance to increase the likelihood that they might allow the use of instructional time. • Consider college censuses when distributing vaccine rather than treating student health centers as regular provider offices.

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51 VACCINE ADMINISTRATION METHODS AND PARTNERS Healthcare Providers There were several individual suggestions related to healthcare pro- viders for public health authorities to consider. These included • Simplify the provider registration process to increase par- ticipation in vaccination campaigns. Use web-based systems. Explore methods of prepopulating and/or registering healthcare providers in advance—for example, using information from ex- isting immunization registries. • Recognize and address the time and financial costs for pri- vate practitioners. • Look for innovative ways to reach out to healthcare provid- ers and build relationships. Participants noted disparities in how private healthcare providers engaged with public health, de- pending on their relationship prior to the 2009 H1N1 vaccination campaign. Public health officials have knowledge and skills that may help private-provider offices plan for mass vaccinations and maintain business continuity during a public health emergency. Public health can also train office staff in tasks such as the proper use of vaccine preparations and N95 masks, a practice common in Virginia, for example. This is valuable for both the physicians and their staff, and it also builds relationships be- tween public health and private healthcare providers. • Investigate an alternative to the 100-dose minimums, which created a barrier for some healthcare providers, including some tribes and rural area providers, during the 2009 H1N1 response. • Facilitate the development of mechanisms by which private healthcare providers could share best practices on how to manage communications with clients. • Cultivate partnerships with state medical associations and specialty societies as partners to reach healthcare providers who treat high-risk patients.

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52 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN Pharmacies There were several individual suggestions related to pharmacies for public health authorities to consider. These included • Continue to engage with pharmacies and integrate them into vaccine and other countermeasure distribution and admini- stration systems. Efforts should continue to address issues such as payment, legal and regulatory barriers, standardized reporting requirements, and interstate variability in age restrictions on who a pharmacist can vaccinate. • Examine the possibility of harmonizing vaccination age lim- its in scope of practice laws for pharmacists. • Analyze data from the 2009 H1N1 response to determine when pharmacies can be used most effectively as part of the distribution and administration system, while ensuring equi- tability and fairness. Public health may be better able to reach uninsured and low-income populations, whereas pharmacies may be well suited to reaching insured populations. Public health au- thorities should explore how best to incorporate pharmacies in providing vaccines during a public health emergency, even when there is a shortage of vaccine. • Develop distribution plans that integrate large pharmacy chains’ central distribution systems. Pharmacy chains found challenges in dealing directly with a large number of state and local public health departments. However, pharmacies were able to distribute hundreds of thousands of doses of 2009 H1N1 vac- cine as part of the federal direct-ship initiative. • Consider engaging wholesale pharmacy distributors to reach independent and chain pharmacies. Health Plans There were several individual suggestions related to health plans for public health authorities to consider. These included

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53 VACCINE ADMINISTRATION METHODS AND PARTNERS • Engage and use health plans before, during, and after public health emergencies. • Convene a national meeting for large health plans to discuss lessons learned during the 2009 H1N1 response; the role of health plans in future emergency responses; and how to ad- dress issues such as reimbursement, funding, and informa- tion sharing so that health plans can be more fully integrated into the response system. Occupational Health Clinics There were several individual suggestions related to occupational health clinics for public health authorities to consider. These included • Continue to explore partnerships with private-sector compa- nies with occupational health clinics; such companies have the potential to play an important role in future emergency vaccination campaigns. • Improve communications with the public and media about why vaccine is being provided to companies. For example, public health authorities should explain that vaccine will be dis- tributed in a variety of settings to be able to immunize as many people as possible in a community and ensure that vaccine will be offered only to employees in the priority groups during a vac- cine shortage. As discussed above, many representatives from multijurisdictional healthcare systems, large chain pharmacies, large companies with occu- pational health programs, and tribal authorities whose reservations crossed multiple state boundaries said that having different strategies in different jurisdictions was problematic for them. Several participants suggested that stricter national guidelines for vaccine distribution and administration would be useful, although as was also noted above, many of the public health authorities emphasized the value of flexibility to tai- lor plans to their specific populations. Many workshop participants noted that further consideration of this issue would be useful.

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