‘Ring o’ Rosies’ Mass Vaccination Clinic Exercise
Hunter New England Area Health Service
Abstract
The World Health Organization has assessed a future influenza pandemic as inevitable. The Commonwealth Department of Health and Ageing containment strategy aims to limit the spread of pandemic influenza in Australia permitting development and deployment of a pandemic vaccine. In NSW this will be delivered by mass vaccination clinics coordinated by Area Health Services.
Hunter New England Health conducted a mass vaccination clinic exercise in the township of Aberdeen in the Upper Hunter region during March 2008. 498 individuals were vaccinated with the 2008 influenza vaccine. The mass vaccination exercise was an Australian-first.
Evaluation, using an integrated quantitative and qualitative approach, identified opportunities for streamlining clinic operations, increasing throughput, ensuring greater involvement of external agencies, and modifying roles. These findings are informing revisions of state plans.
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Aim
The exercise was conducted to test the HNE Health Mass Vaccination Clinic Operational Plan. The aim was to identify any deficiencies that could result in considerable excess morbidity and mortality during a pandemic response.
Nature of the Problem
Influenza pandemics occur three to four times each century. This happens when a novel strain of influenza, which is transmissible between people, causes significant illness and to which no one has pre-existing immunity, emerges. The World Health Organization has warned member countries to prepare for an inevitable pandemic (WHO, 2005).
Containment strategies, including social distancing, isolation of cases and quarantine of contacts, will be rigorously applied in Australia to limit virus spread so that a pandemic-strain specific vaccine can be developed and rapidly administered to the susceptible population.
No exercise to test the effectiveness of mass vaccination plans has previously been conducted in Australia.
Extent of the Problem
There were three 20th century pandemics: 1918-1919, 1957-1958 and 1968. These pandemics incapacitated cities and paralysed healthcare systems in many countries, with 50-million deaths in 1918-1919. In NSW, 37 per cent of the population was infected, with a case fatality rate of 1.3 per cent (Curson & McCraken, 2006).
Australian modelling indicates that with an attack rate of 25 per cent, 13,000-44,000 Australians will die if a pandemic-specific vaccine is not rapidly administered to the susceptible Australian population (Commonwealth of Australia, 2005). The deployment of two doses of vaccine one month apart must reach as many individuals as efficiently as possible to limit unnecessary transmission, morbidity, mortality, social and economic disruption (NSW Health, 2005).
Drawing on international experience and expert consultation a field exercise mimicking closely the NSW mass vaccination clinic plan was planned. This exercise was endorsed by the NSW Health Special Committee Influenza Pandemic Exercise (SCIPE).
Strategic Importance
This exercise is in line with strategic direction 7 under the NSW Health’s ‘State Health Plan Towards 2010’, ensuring that NSW Health is optimally prepared to respond to the threat of a future influenza pandemic.
It sought to test and refine mass vaccination clinic plans under the NSW Health Interim Influenza Pandemic Action Plan and the HNE Health Pandemic Influenza Plan.
Exercise outcomes are being use to re-draft the NSW mass vaccination clinic plan. As the results are of national and international importance, they will be presented at a national conference and published in an international peer-reviewed public health journal.
Planning and Implementing Solutions
The exercise scenario: Pandemic influenza alert - Overseas Phase 6, Australia Phase 6 (i.e. six months post importation of the first confirmed pandemic influenza case into Australia.) A pandemic vaccine is available and activation of the mass vaccination clinic roster had been requested.
The mass vaccination clinic plan was activated for Upper Hunter Shire in the Hunter Valley, specifically individuals who lived and worked in postcode 2336, i.e. Aberdeen township and surrounding rural properties. Approximately 1,800 residents and workers aged > 6 months were invited to attend a mass vaccination clinic between 2pm and 8pm on 11 March 2008 at St Joseph’s High School.
Multi-agency staff training was conducted on 18 February 2008, with a briefing on 6 March 2008 and pre-exercise briefing on 10 March 2008. A hot debrief was convened on 12 March 2008 and a cold debrief on 6 May 2008. A strategic consultative meeting with NSW Health Bio-preparedness and Immunisation Units was convened on 8 May 2008.
The exercise coordinating group, sponsored by HNE Health Executive and supported by NSW Health Bio-preparedness and Immunisation Units, extensively consulted with Local Emergency Management Committee, Upper Hunter Shire Council, St Josephs High School Aberdeen, HNE Health security contractors, St John Ambulance and the local SES. Additionally, Hunter Rural Division of General Practice, local general practitioners at Aberdeen, Muswellbrook and Scone, HNE Health staff at Muswellbrook and Scone including emergency departments and community nursing, Catholic Schools Office, and NSW Ambulance Service were consulted.
The US Health Department with the greatest experience in mass community treatment dispensing, Philadelphia Health Department, provided valuable advice.
The Chief Umpire, the Commander of Upper Hunter Command, NSW Police, was supported by umpires from NSW Health’s Immunisation and Bio-preparedness Units, two NSW Area Health Services and HNE Population Health.
Significant time and resources were spent communicating with the community of Aberdeen to encourage them to be part of the exercise.
Outcomes and Evaluation
Data was collated using a client survey, detailed time and flow analysis, umpires’ reports, exercise situation reports, hot and cold de-briefs, providing rich qualitative and quantitative data that allowed formulation of a detailed exercise evaluation report and recommendations.
Of 498 community members vaccinated; 60 per cent rated clinic management as excellent and 38 per cent as good. One minor self-limiting adverse event was reported post-vaccination and vaccine cold chain management adhered to current standards.
Exercise learning has resulted in far-reaching modification to the current plan:
- Clinic planning and preparation – governance of mass vaccination clinics transferred from Public Health to Clinic Operations; Standing Operations procedures and Job Action Sheets revised; and modified procedures for vaccine delivery from state to periphery.
- Streamlining of operations – reduction in clinic stations from seven to four; dispensing of observation period; decreased average attendance time; reduction in immunisation staff tasks; fast-tracking of special needs individuals; enhanced queuing management; and improved signage and communication.
- The modifications to the NSW Health State Plan from this exercise will shorten the expected throughput time through a clinic to a minimum of 16 minutes.
- Role of external agencies – to be negotiated at state level through SEMC building on whole of government approach.
Sustaining Change
Consultation with NSW Health has resulted in a commitment at state level that the recommendations outlined in the exercise report will be incorporated into the NSW pandemic influenza plan. This will ensure a standardised approach and benefits to the entire NSW population during a future pandemic (Durrheim & Ferson 2006; Ferguson et al 2006). Concrete local planning within each cluster is now possible.
These plans will also be available for use during public health responses to large vaccine-preventable incidents, for example possible importation of measles during World Youth Day 2008 and the need for large-scale community vaccination clinics.
Future Scope
When the recommendations are incorporated into the NSW pandemic plan, all NSW Area Health Services and thus the entire NSW population will benefit.
Being the first exercise of its kind in Australia, the lessons from this field exercise will be shared nationally and will assist other states and territories.
Many countries are not as advanced as Australia in preparing for a future pandemic (Poland et al 2007). The desktop exercise plan was only truly tested in the field exercise leading to recommendations for change. This study will be the benchmark international study published so that other countries can also benefit from our experience.
Reference List
- Commonwealth of Australia 2006, Australian Health Management Plan for Pandemic Influenza. Australia Government Department of Health and Ageing, Canberra.
- Curson, P, McCraken, K 2006, An Australian perspective of the 1918-1919 influenza pandemic. NSW Public Health Bulletin, vol. 17, pp. 103-107.
- Durrheim, D, Ferson, M 2006, Preparing for the inevitable - an influenza pandemic. NSW Public Health Bulletin, vol. 17, pp. 97-98.
- Ferguson, NM, Cummings, DA, Fraser, C, Cajka, JC, Cooley, PC, Burke, DS 2006, Strategies for mitigating an influenza pandemic. Nature, vol. 442, pp. 448–452.
- New South Wales Health 2005, NSW Health Interim Influenza Pandemic Action Plan. NSW Health, Sydney.
- Poland, GA, Jacobson, RM, Targonski, PV 2007, Avian and pandemic influenza: an overview. Vaccine, vol. 25, pp. 3057-3061.
- World Health Organization 2005 Global influenza preparedness plan, 2005. World Health Organization, Geneva.
Project Team
Dr Debbie Jaggers, Dr Chris Carr, Dr David Durrheim, Meredith Caelli, Peter Massey, Keith Eastwood, Leigh Schalk, Tanya Carlyle, Linda Winn, Chris Kewley.
Steering Committee: Dr Chris Carr (chair), Dr David Durrheim, Meredith Caelli, Linda Winn, Keith Eastwood, Tanya Carlyle, Peter Massey.
Umpires: Commander John Gralton (chief umpire), Dr Paul Armstrong, Chabela Torres, Sonya Nicholl, Josh Edmonds, Keith Eastwood, Peter Massey, Gosta Liljeqvist, Maree Lamb.
Clinic participants: Leigh Schalk (Site Commander); Dr David Durrheim (Exercise Controller); Linda Winn (Acting HSFAC), Dr Chris Carr (Vaccination Response Advisor); Nicholas Rayner (Entry Pod Leader); Debbie Pont (Clinical Pod Leader); Danny Lewis (Exit Pod leader); Meredith Caelli (OH&S Officer), Tanya Carlyle (Communications Officer); HNEAHS Upper Hunter Cluster staff; St John Ambulance volunteers; NSW State Emergency Service volunteers.
Engagement with: Sue Campbell-Lloyd (NSW Health), Colleen Pinkerton (Upper Hunter Shire Council, Local Emergency Management Officer), Allan Davidson (SES, Scone), Edwina Hamilton (SES Aberdeen), John Tobin (St Josephs High, Aberdeen), Steven McPherson (St Josephs High Aberdeen), Danny Lewis (St John Ambulance), Barry Levick (Aberdeen Public School), Shannon Fitzgerald (Philadelphia Health Department).
Contact
Area Director Nursing & Midwifery Services
Hunter New England Area Health Service
Phone: 02 4921 4915
This project was entered in the 2008 NSW Health Awards, Be Ready for New Risks and Opportunities category.
