Question

After a natural disaster or an infectious disease outbreak, immunizations are necessary to reduce the risk of infection. This is because immunizations work with the body’s natural defenses to help the body safely develop immunity to a potentially life threatening disease. The Centers for Disease Control and Prevention (CDC) has established protocols to initiate mass immunizations to reduce the risk and spread of infectious diseases.Consider the CDC’s public health response to an infectious disease outbreak in the aftermath of a hurricane Using the readings for this week and the Internet, respond to the following:

What is the CDC’s procedure for mass immunizations that are necessary for certain types of infectious outbreaks such as influenza, mumps, and tetanus? How does the CDC communicate information on mass immunization clinics to the public? What is the procedure for establishing a mass immunization clinic for tetanus in the aftermath of a hurricane because of the likelihood of injuries during the cleanup? Is this similar to the protocol established for influenza? Compare the two protocols. What are some of the controversies surrounding such vaccinations?

Answer 1

To facilitate the most efficient and safe delivery of available vaccine via large community clinics, these recommendations and guidelines have been developed to assist with planning large-scale influenza vaccination clinics by public and private vaccination groups. Ideally, plans from private and public groups should be shared to identify best practices, avoid unnecessary overlapping of services, and maximize the effective and efficient delivery of influenza vaccinations.

1. Leadership Roles

• Designate local clinic leaders for overall vaccination campaign operations, and leaders for communications systems from both the public and private sectors
• Designate a clinic manager and a team leader each for supplies, logistics, medical personnel, support functions and their respective backups
• Designate a leader to oversee infection control at the clinic, which includes ensuring that healthcare personnel who are preparing and administering the vaccinations are appropriately trained on safe injection practices

2. Human Resource Needs

• Secure staff to fill the positions of greeters-educators, priority client screeners, registration personnel, medical screeners, form/payment collectors, clinic flow controllers, vaccination assistants, vaccination administrators, security and emergency medical personnel
• Meet the language needs of the community using multi-lingual staff
• Prepare staff members to know and execute their responsibilities and be able to correctly answer questions from clients
• Cross-train staff members, if possible, to enable flexibility in meeting needs at various stations as demands fluctuate
• Make provisions for surge capacity staffing, particularly at clinic opening time, where pre-scheduling will not be done or large numbers of unscheduled clients are anticipated
• If a surge in vaccine demand is possible, consider requesting surge capacity staff from out-of-area city/county agencies and health departments, local private nursing agencies, local nursing associations, local law enforcement, local medical community, health care worker and pharmacy students, volunteer groups and personnel working at the retail stores/corporations that might be used as the clinic sites
• Ensure staff well-being by scheduling times for rests and snacks in a designated area

3. Vaccination Clinic Location

• Seek out school gyms, churches, auditoriums, theaters or other large covered public spaces accessible to the elderly and persons with disabilities
• Ensure proximity to population centers and mass transit, ample parking, separate entry and exit doors, adequate lighting and heating, functional and accessible restrooms, and adequate space for all clinic functions such as screening, registration, vaccine storage, vaccination, and staff breaks
• Select a facility with space for reasonably large and well-delineated covered gathering areas outside and inside of the clinic
• Select a facility that has adequate on-site space in units that can be used to store vaccines, preferably that the vaccine can be shipped directly. If vaccine must be transported to the clinic, ensure cold chain is maintained during transport and confirmed upon arrival.

4. Clinic Lay-Out and Specifications

• Set up for unidirectional client flow from an external gathering area → eligibility screening area (multiple stations) → clinic entrance → facility waiting area(s) → registration/question and answer/form completion area (multiple stations) → medical screening/treatment area (as needed) → Medicare and other payment area (multiple stations) → vaccination area (multiple stations) → exit at a location distant from the entrance
• Use liberal amounts of rope, stands and signs in multiple languages, as needed, in outside waiting area(s) and inside clinic to delineate routes for clients to follow from station to station
• Provide adequate number of copies of Vaccine Information Statements in the Question and Answer area. Staff should be trained to answer common questions.
• Provide seating for clients and the person administering the vaccine at each vaccination station and have one or more vaccination stations with surrounding screens where over-clothed clients can discreetly bare their arms for vaccination. Each station must also have adequate administration supplies.
• Section off private area(s) where clients who experience acute adverse events after vaccination or who have medical problems can be evaluated and treated
• Adequate number of computers/tablets and internet access to determine immunization history in the state or regional Immunization Information system of clients presenting for vaccination.
• Ensure the presence of an onsite emergency medical kit and a designated trained physician, emergency medical technician (EMT), pharmacist, or nurse certified in basic cardiopulmonary resuscitation who can administer treatment for allergic reactions and address urgent medical problems

5. Crowd Management Outside of the Clinic

• Schedule staff to arrive 1 to 2 hours before clinic opening time to welcome and screen clients for vaccine eligibility, indications and contraindications and for insurance, if insurance will be billed for the vaccination, even if pre-scheduling is being used
• Arrange accommodations for special-needs clients (e.g., persons with disabilities, very advanced age or fragility) for expedited access into the clinic
• Direct arriving clients into several lines and use numerous signs and announcements to clarify who falls into high-risk groups
• Communicate the number of vaccine doses available at the clinic to the clients
• Provide all clients with an up-to-date vaccine information statement (VIS);
• Provide language translation services where necessary
• Update clients on their estimated waiting times to be screened
• Schedule at least 2 screeners per line to reduce crowd size and waiting times by rapidly identifying and retaining prioritized clients and letting others know about vaccination priorities of the clinic.
• Consider distributing sequentially numbered tickets, VIS or other forms in appropriate languages that permit entry into the clinic to persons in prioritized patient groups only.
• Provide clients who cannot be served for lack of vaccine an up-to-date listing of alternative clinics providing vaccinations

6. Crowd Management Inside of the Clinic

• Vaccinate clients in the order of their numbered tickets
• Arrange accommodations for special-needs clients (e.g., persons with disabilities, very advanced age or fragility) to receive expedited vaccination – consider a dedicated vaccination line
• Communicate clinic updates and wait times for vaccination so that clients are free to leave and return to be vaccinated
• Provide entertainment materials, TV and/or refreshments if wait times are anticipated to be long
• Assist clients in completing required forms (e.g., consent forms and/or vaccination cards) by having sufficient registration staff available
• Maintain a steady flow of clients through the clinic so that vaccinators are never without a client at their stations; redirect clients who create bottlenecks.
• Provide adequate facilities (e.g., waiting areas, restrooms, water) to meet the needs of the clients

7. Clinic Security

• Require all staff to wear identification cards color coded for their job functions
• Consider using uniformed presence to act as security and assist in managing crowds
• Employ security personnel to monitor the mood of waiting crowds and communicate deteriorating situations to the clinic manager
• Secure the vaccine and protect clinic staff and their valuables
• Recruit local volunteers familiar to clinic customers since they may be especially effective in diffusing crowd-related tension

8. Clinic Advertising

• Use multi-lingual and multimedia channels to widely post clinic purpose, dates, locations, times, and which populations will be served
• Provide instructions on how to set up appointments via telephone, in person, or other systems if pre-scheduling will be used
• Know how much vaccine is available for a scheduled clinic and how to reallocate vaccine through centralized or individual clinic efforts to meet the acute needs of other providers

Recognize that scheduling may be overwhelmed and therefore not be maintainable or able to meet clients’ needs during a time of severe vaccine shortage; direct clients to other facilities as required

High-volume influenza vaccination clinic with 1) screening area with screeners outside the clinic area to determine high-risk patients to enter the clinic or not high-risk to exit. 2) A client waiting area for education and communication is at the clinic entrance. Staff greet and guide clients. 3) Registration and form completion area with multiple stations consist of tables and chairs for filling out forms. Medical and other staff are available to answer questions. 4) Next station is for payment, Medicare, or insurance. 5) Staff directs clients to vaccination lines. 6) Staff directs clients to vaccination tables. 7) Vaccinators and assistants are at each station. 8) A designated area for vaccine preparation and storage 9) Staff directs vaccinated clients to exit.

Vaccine Storage, Handling, and Administration
1. Vaccine Storage and Handling

• Ensure that clinic staff are trained and demonstrate competency in vaccine, storage, handling and administration
• Ensure plans are in place for maintaining vaccine at appropriate temperatures while it is stored and throughout the clinic day.
• Vaccine should be shipped directly to the clinic site if at all possible
• If vaccine must be transported to the clinic, ensure cold chain is maintained during transport and confirmed upon arrival.
• Follow vaccine storage and handling guidelines, including but not limited to: vaccine transport, temperature monitoring and trouble shooting.
• For more information on the Vaccines for Children Program (VFC) and specific storage and handling requirements for mass clinics, contact the state/city/territorial VFC Program in your area.

2. Vaccine Administration
Staff Education Improper administration of vaccines may result in injuries or prevent the vaccines from providing optimal protection. All personnel who will administer vaccines should receive comprehensive, competency-based training regarding vaccine administration policies and procedures before administering vaccines. Validate staff’s knowledge and skills regarding vaccine administration.

Patient Screening for contraindications and precautions

• Screening should be done prior to vaccine administration
• Staff should be knowledgeable of all possible contraindications and precautions to vaccination with the vaccines being administered at the clinic

Vaccine preparation

• Prepare vaccines using aseptic technique in a clean, designated medication area not adjacent to any area where potentially contaminated items are placed, and also not adjacent to patient care area
• Disinfect the rubber septum of the vaccine vial with alcohol prior to piercing
• Use a new needle and new syringe to withdraw each dose.
• Prepare vaccines just prior to administration. Each vaccinator should prepare the vaccine they administer.
• CDC does not recommend provider pre-drawing syringes. Consider using manufacturer-filled syringes for large immunization events because they are designed for both storage and administration.
• At clinic site, no more than 1 multidose vial or 10 doses should be drawn up at one time by each vaccinator. If not immediately administered, the syringes should be appropriately labeled.
• If more than one vaccine type is being administered, set up separate administration stations for each vaccine type to prevent medication errors.
• Patient flow should be monitored to avoid drawing up unnecessary doses.
• At end of workday, any remaining vaccine in provider predrawn syringes should be discarded.
• Additional guidance on vaccine preparation at Epidemiology and Prevention of Vaccine-Preventable Diseases and Vaccine Storage& Handling

Vaccine administration

• Adequate supplies should be available including, but not limited to, hand hygiene supplies (e.g. bottles of alcohol-based hand rub), individually packaged sterile alcohol wipes, syringes, a supply of needles in varying lengths appropriate for the facility’s patient population, bandages, and biohazard containers that are closable, puncture-resistant, leakproof on sides and bottom and labeled or color-coded.
• Hand hygiene should be performed before vaccine preparation, between patients, and any time hands become soiled.
• Occupational Safety and Health Administration (OSHA) regulations do not require gloves to be worn when adminis­tering vaccines unless the person administering the vaccine is likely to come into contact with potentially infectious body fluids or has open lesions on the hands. If gloves are worn, they should be changed and hand hygiene performed between patients.
• Vaccine recipients should always be seated during vaccine administration.
• An appropriate gauged needle should be used for each patient.
• A new needle and new syringe should be used for each patient. Needles and syringes should never be used to administer vaccine to more than one patient.
• The needle and syringe should be immediately placed in a sharps container following administration (Do not recap the needle).
• Additional vaccine administration guidelines should be followed; see Epidemiology and Prevention of Vaccine-Preventable Diseases.

Observation after vaccination

• Syncope has been most often reported among adolescents after vaccination.
• Clinicians should consider observing recipient for 15 minutes after vaccination. This can be done in a separate waiting area to keep the flow moving.

Comforting techniques for children during and after vaccination

• Patients should be prepared for vaccination with consideration for their age and stage of development.
• When determining patient positioning and restraint, consider the patient’s comfort, safety, age, activity level, and the site of administration.
• Although pain from immunizations is, to some extent, unavoidable, there are some things that parents and healthcare providers can do to help when children and adults need vaccines. Use evidence based strategies to ease the pain associated with the injection process; see Epidemiology and Prevention of Vaccine-Preventable Diseases.

3. Documenting Vaccines Administered and Use of Immunization Information Systems

• All vaccines administered should be fully documented including
• Date of administration
• Vaccine manufacturer
• Vaccine lot number
• Name and title of the person who administered the vaccine and the address of the facility where the permanent record will reside
• Vaccine information statement (VIS) date printed on the VIS and the date VIS given to patient or parent/guardian
• Vaccine type
• Expiration date
• Provide documentation of vaccines administered to patients for their personal records. Additionally, clinic leaders should ensure vaccinations administered at the clinic are recorded in the patient’s medical record, if possible. Clinic leaders should also coordinate submitting documentation of vaccinations administered in the jurisdiction’s immunization information system (IIS) or vaccine registry. IIS are confidential, population-based, computerized databases that record all immunization doses administered by participating providers to persons residing within a given geopolitical area. Consult your jurisdiction or state immunization program for more information as requirements and specifics may vary. (IIS State/Territory/City Registry Staff – Main & Technical Contacts). If clinic leaders are not submitting to IIS, then there should be a plan in place to send the vaccination information to the primary health care provider