RESEARCH ARTICLE
Learning From Successful School-Based Vaccination Clinics During 2009 pH1N1 TAMAR KLAIMAN, PhD, MPHa KATHERINE O’CONNELL, BS, BSNb MICHAEL A. STOTO, PhDc
ABSTRACT BACKGROUND: The 2009 H1N1 vaccination campaign was the largest in US history. State health departments received vaccines from the federal government and sent them to local health departments (LHDs) who were responsible for getting vaccines to the public. Many LHD’s used school-based clinics to ensure children were the first to receive limited vaccine supplies, but the success of school-based distribution strategies varied in different locations. The goal of this project was to identify and learn from high-performing school-based vaccination clinics in order to share successes and improve performance in future school-based vaccination campaigns. METHODS: We used a combination of process mapping and comparative analysis to identify and derive lessons from positive outlier cases observed during 2009 H1N1 school-based vaccination clinic implementation. We created process maps to identify the activities of LHDs conducting school-based vaccinations and used them as the basis for in-depth interviews of LHD staff. We asked interviewees to describe their activities during the 2009 H1N1 pandemic (pH1N1) school-based vaccination campaign with a focus on successful processes. RESULTS: We identified positive deviants, that is, those that performed better than expected, and categorized qualitative data from in-depth interviews with 13 successful LHDs according to the process maps. Key mechanisms for school-based vaccination success included having a relationship with local school authorities, communicating effectively with parents, and ensuring clinic logistics allowed for an easy flow of students through the vaccination process. CONCLUSIONS: Utilizing rigorous methodology, we defined and learned lessons from successful LHDs when conducting school-based vaccination clinics, which can be applied to future school-based vaccination campaigns. Keywords: vaccination; pandemic; emergency preparedness. Citation: Klaiman T, O’Connell K, Stoto MA. Learning from successful school-based vaccination clinics during 2009 pH1N1. J Sch Health. 2014; 84: 63-69. Received on April 16, 2012 Accepted on December 2, 2012
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he 2009 H1N1 pandemic (pH1N1) required a concerted effort from the entire public health system of the United States. Because the outbreak emerged in children and young adults, health officials believed that children were at increased risk, and consequently, the Centers for Disease Control and Prevention (CDC) placed children at the top of their vaccine priority list.1 Local health departments (LHDs) were responsible for getting vaccines to local communities across the United States, and many
LHDs used school-based vaccination clinics to ensure children received vaccines first. In many ways the public health system responded well to the challenge. In less than a year, for instance, a new 2009 H1N1 vaccine was developed, produced, and delivered to 81 million people. From another perspective, however, the response had its limitations. For instance, less than half of the population was vaccinated and nearly half of the 162 million 2009 H1N1 vaccine doses produced went unused.2-4
a Assistant Professor of Health Policy and Public Health, ([email protected]), University of the Sciences in Philadelphia, 600 South 43rd St., Philadelphia, PA 19104. bFormer
Research Assistant, ([email protected]), Jefferson School of Population Health, Thomas Jefferson University, 1015 Walnut St., Suite 115, Philadelphia, PA 19107. c Professor of Health Systems Administration and Population Health, ([email protected]), Georgetown University School of Nursing & Health Studies, 3700 Reservoir Road, NW Room 236, Washington, DC 20057-1107. Address correspondence to: Tamar Klaiman, Assistant Professor of Health Policy and Public Health, ([email protected]), University of the Sciences in Philadelphia, 600 South 43rd St., Philadelphia, PA 19104. This research was funded by the Pfizer Corporation’s Fellowship in Public Health and the ‘‘Linking Assessment and Measurement to Performance in PHEP Systems’’ project funded by the Centers for Disease Control and Prevention—grant #1P01TP000307.
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effective practices in health care organizations,11 community health programs,12 health intervention planning,13 and most recently H1N1 public vaccination clinics.14 The positive deviance approach typically involves 4 key steps: (1) identification of positive deviants - those that consistently perform beyond expectations; (2) indepth study of these units using qualitative methods to generate hypotheses or theories about practices that lead to success; (3) hypotheses testing in a statistically representative sample; (4) working in partnership with key stakeholders to disseminate best practices.11 Because objective performance measures to identify positive deviants are lacking, as an initial effort, this analysis focused on steps 1 and 2, in which we defined positive deviants, and used a rigorous qualitative approach, realist evaluation, to learn ‘‘best practices’’ from LHDs that implemented successful school vaccination campaigns. We chose not to use vaccination rates as our primary indicator of success because the vaccine supply varied with geographic location and over time. Additionally, the demand for vaccine was initially high with low supply, and later, demand was low and supply was high. Our interest was in the clinic implementation process, rather than the number of vaccinations alone.
School-based vaccination programs have been shown to increase childhood vaccination rates for seasonal influenza.5-7 However, the success of schoolbased distribution during pH1N1 varied in different locations across the country.8,9 The variation in schoolbased clinics was not only geographic, but also included a variety of factors such as the process for vaccinating in schools, which schools were included in the vaccination process, and how parents were included in the process. Rhode Island focused primarily on schoolbased vaccination clinics and had the highest childhood vaccination rate in the country.8 Data suggest that a focus primarily on school-based vaccination clinics led to higher vaccination rates in children. Although some of the variation in school-based clinic implementation may reflect local conditions and capabilities, the need to improvise approaches when the vaccine supply was delayed suggests that there was more variation than necessary. Such excess variability indicates that there is room for improvement in the quality and efficiency of the school-based clinic process.8 Recommendations to improve mass vaccination policy and processes have been suggested.10 However, we are aware of no formal evaluations about the process for establishing and implementing school-based vaccination clinics during an emergency. Understanding the strategies that led to successful school-based vaccination clinics in varying circumstances can help strengthen preparedness strategies for future mass childhood vaccination campaigns as well as seasonal school-based vaccination campaigns. The goal of this project was to take a take a more in-depth look at the pH1N1 school-based vaccination response to understand the nuances of what made some LHDs successful in order to share those lessons with others. We focused specifically on LHD activities in this analysis as they were the organizers and implementers of school-based clinics. We used a ‘‘positive deviance’’ approach to identify and learn from LHDs that were successful in schoolbased vaccine distribution. We then used a realist evaluation perspective to conduct in-depth analyses of a sample of top performers to discern mechanisms for successful school-based vaccine distribution in specific contexts. The findings of this work are intended to offer LHDs evidence-based mechanisms for rapidly and effectively distributing medications, vaccines, and/or supplies to school children in need in future public health emergencies.
Realist Evaluation Realist evaluation is an approach that assumes that the ‘‘context’’ in which an organization operates (its resources, staff, funding, etc) and the nature of the population it serves make a difference in the outcomes it achieves. Different contexts might enable or prevent certain ‘‘mechanisms’’ from being effective. Thus, there is always an interaction between context and mechanisms that influences outcomes, represented as: Context + Mechanisms = Outcomes or C + M = O.15 Furthermore, rather than simply asking whether a program works, realist evaluation seeks to understand how context and program mechanisms interact so findings can be generalized to similar situations.
METHODS Identifying Positive Deviants Initially, we reviewed the National Association of County and City Health Officials (NACCHO) Model Practices Database for model health departments in the areas of emergency preparedness and/or vaccination. The Model Practices Database is an online searchable collection of innovative best practices across public health areas. Health departments self-select to share their experiences with NACCHO, and if their work is deemed to be a promising or model practice after review by NACCHO staff, it is entered into the online database. We searched the NACCHO database for all
Positive Deviance Approach The ‘‘positive deviance approach’’ is a framework for identifying and learning from top performers in a system, in our case the ‘‘public health system’’ is broadly defined to include schools. The positive deviance framework also been used to learn about 64
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2009 submissions for model or promising practices (N = 55). We included only those submissions focused on emergency preparedness, immunization, and/or infectious diseases of which there were 18. We also reviewed a sample of state and local After Action Reports—reports describing LHD responses and lessons learned which must be submitted to the federal government for emergency response reimbursement—which we compiled from practice partners through the Harvard Preparedness and Emergency Response Research Center (PERRC), attendance at the NACCHO Emergency Preparedness Summit, and recommendations from LHDs with whom we had an existing emergency preparedness research relationship. We reviewed 10 state and local AARs. We also reviewed over 100 published reports, mass media reports, and other relevant documents.2 Working with local emergency preparedness and response public health partners, we developed an initial list of high-performing LHDs in the 2009 pH1N1 vaccination campaign (N = 35). We used a snowball sampling method in which we asked LHD staff to recommend peers who they believed performed well in the distribution of H1N1 vaccine from the perspective of our process map. Our interest was in a purposive sample of LHDs, rather than a representative sample. We sampled LHDs to ensure those with varying contexts (size, demographics, and geography) were represented. Learning From Positive Deviants We created process maps (Figure 1) to identify the key activities LHDs conducted during schoolbased vaccination clinics and used them as the basis for in-depth interviews of LHD staff. Process maps were vetted with experts in emergency preparedness to ensure they included the key elements necessary for evaluating performance. We focused on activities conducted in public vaccination clinics and schoolbased clinics because they were most prevalent, and they were the methods for vaccine distribution that were most dependent on local public health system infrastructure unlike the use of pharmacies or private providers for vaccine distribution. We conducted in-depth interviews with health department officials from 20 LHDs that were defined as high performers based on the process maps and peer recommendations and agreed to participate. One of the authors (Klaiman) conducted each of the interviews by telephone and took notes as she was able. A research assistant attended each interview as well and took notes verbatim. We typed up all notes within 24 hours to ensure accuracy. We interviewed LHD staff who were in charge of the local H1N1 vaccination campaign and included emergency planners, immunization program coordinators, and Medical Reserve Corps (MRCs) Journal of School Health
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coordinators. We asked interviewees to describe their activities during the 2009 pH1N1 school-based vaccination campaign with a particular focus on successful processes. After identifying positive deviants, we categorized qualitative data from in-depth interviews with successful LHDs according to the processmaps. Key domains in the school-based vaccination administration process are noted in Figure 1. We focused on 2 modes of vaccine administration—school-based and public clinics. We report the findings from the school-based vaccination clinic analysis in this article. A companion article addresses clinics conducted by LHDs directly.14
RESULTS The 20 LHDs chosen for in-depth analysis represented a variety of geographic locations across the contiguous US states. The LHDs served populations in urban, suburban, and rural communities in Washington, Texas, California, Illinois, Pennsylvania, New York, Massachusetts, Louisiana, and Kansas. There were 5 LHDs in communities with less than 100,000 people, 6 with populations less than 500,000, 4 with between 500,000 people and 1 million people, and 5 serving communities with over 1 million people. The number of employees working in LHDs during the vaccination campaign ranged from as small as 2 to over 1800 full-time employees. Of the 20 LHDs studied, 8 held both public and school vaccination clinics, 5 held only public clinics, and 5 held only school clinics. One LHD held public clinics and contracted with pharmacists to administer the vaccine, while one LHD held public clinics and distributed vaccine to primary care providers to administer as well. We are only reporting the results of the school-based clinic analysis (N = 13) in this article. Table 1 notes specific examples of C + M = O stories we discovered in our interviews. We found 3 overarching areas of success as noted below, and specific context and mechanism examples are shared. Relationship With Local School Authorities LHDs initially had to choose the schools where they would hold clinics for local children. Some chose to hold clinics at all schools in a local district, whereas others chose key, centrally located schools. Many of the successful LHDs that we interviewed had previously established relationships with the school districts in their jurisdiction, making the vaccination location decision clear. Some LHDs previously held mass vaccination drills or seasonal flu clinics in local schools, so the clinic setup and implementation had already been practiced. Most successful LHDs had worked with school officials in the emergency preparedness planning process. Small, rural LHDs often had fewer
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Figure 1. School Distribution Process Map Choose school clinic location
Determine staff leadership
Determine timing of flu clinic
Recruit and Train Staff
Parental Involvement/ Communication
Data collection protocol
Administer vaccine
Quality Assurance/ Accountability
Line/crowd control
Evaluate feedback
Security
Table 1. Select Context + Mechanism = Outcomes Stories Defining Priority Groups Local vulnerable populations + access to vulnerable populations (through shelters, nursing homes, etc) = higher vaccination rates among underserved. Small local health department (LHD) + large Orthodox Jewish community+ Sunday clinics = Jewish attendance at clinic. Limited English speaking community+ materials in multiple languages = higher immigrant vaccination rates. Communicating With the Public Public questions/concerns + LHD hotline+ website= informed public. Public questions about clinics + social media (eg, Facebook and Twitter) = informed public. LHDs had to advertise clinics + multiple media outlets (TV, newspaper, website, radio, and religious institutions) = reaching the public. Rural LHD+ flashing road sign borrowed from police= public notification about clinic. Reverse 911 system+ clinic information= public notification about clinic. Staffing Small LHD+ large population+ trained Medical Reserve Corps (MRC) = clinic staff. Large population+ trained MRC= clinic staff. Numerous clinics + local health professions schools = clinic staff. Small LHD+ Public Health Emergency Response (PHER) funds = contract nursing staff for clinics. Small LHD+ local health professions students + clinic training added to school curriculum= well-trained clinic staff. Community Partnerships Community venues + existing memoranda of understanding (MOU) = clinic location. Large turnout expected+ relationship with large venue= clinic location. Many local churches + meeting with clergy= coordination with local partners and higher vaccination rate. Rural community+ close relationship with venue security= clinic security staff. Large LHD+ formal memoranda of understanding (MOU) with local police= clinic security. Local police engagement in LHD activities + traffic direction= clinic safety. Flexibility High demand for vaccine+ large community event (eg, County Fair) = high vaccination rate. multiservice LHD+ weekend clinics = minimal service interruptions. Small LHD+ limited budget + completed registration forms = reimbursement from insurance companies for those vaccinated who were privately insured. Emergency declaration+ access to additional resources = more effective vaccination campaign.
nonemployee school nurses to coordinate the clinics, and some had to initially convince school nurses that school-based vaccination would be an effective and feasible way to reach children. Most LHDs held regular conference calls with school nurses and administrators once or twice per week, especially in the early days of the pandemic response when LHDs did not know when they would receive vaccines. Global buy-in of the school system, intensive planning, constant communication, and trusting relationships between health department staff and the school districts were vital for the success of the school vaccination campaign.
locations to visit, but sometimes had more children to vaccinate in each location. Small, rural LHDs also had more informal relationships with school officials while large, urban LHDs often had formalized agreements with school officials for clinic implementation. School nurses served a vital role in the relationship between LHDs and local schools. The school nurses helped with planning and organization of the clinics and acted as a liaison between the LHDs and the schools. In some locations, school nurses were employees of the LHD, which solidified the relationship between the schools and the LHD. In other locations, the LHD had to work closely with 66
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LHDs had to plan carefully when timing schoolbased vaccination clinics. Most school districts we interviewed allowed the LHD to hold clinics during the day while school was in session to vaccinate as many children as possible. LHDs typically visited each public school in the district, elementary through high school as well as preschools. Some LHDs, particularly those in smaller communities, also offered vaccinations to private and parochial schools. Some schools were uncomfortable with holding vaccination clinics during the day because of class disruptions or because school administrators wanted parents to be present. When that was the case, clinics were held after school or in the evening so parents could be present. The placement and timing of the clinic was largely dependent on what the school district felt was the least disruptive to classroom activities. Communicating Effectively With Parents LHDs had to work closely with schools to decide if parents would be required to attend vaccination clinics. As noted above, some schools decided to hold clinics outside normal school hours to ensure parental participation. Regardless of parental attendance, all children in school-based clinics had to submit permission slips to receive the vaccine. Most LHDs depended on schools to distribute and collect permission slips. Smaller schools in which the school nurse knew most of the children and parents seemed to have more returned slips than those schools in which the nurse did not know most of the children. Schools used a variety of mechanisms for distributing forms and communicating with parents about vaccinations. Schools that had active listservs used those to reach out to parents. Other schools used the school’s website, whereas some sent paper slips home with children. Some large school districts used an automated phone system to notify parents about the clinics. LHDs found that using media outlets like the newspaper, radio, and local television stations as well as sending notes out to parents also proved to be an effective way to communicate. Schools that reached out directly to parents received more feedback than those who sent slips home with children without following up with another form of communication. Ensuring Clinic Logistics LHDs that held clinics during the school day primarily used LHD staff to run the clinics. MRC and other volunteers often worked other jobs during the day and many could not attend daytime clinics. MRC volunteers were used in the after-hours clinics and some were able to help with the in-school clinics as well. Because of security concerns, however, only volunteers who had submitted to background checks were allowed in many of the schools. Most LHDs we Journal of School Health
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interviewed did not have the staff available to conduct background checks on new volunteers in addition to planning for the clinics and training existing staff. Training was challenging in school-based clinics. LHDs, for instance, had to educate first responders and teachers about vaccination priority groups, and often had to explain why children were receiving vaccines first. Some successful LHDs held just-in-time trainings to ensure that all staff and volunteers received the same training. This was a challenge in large LHDs that held multiple school-based vaccination clinics. In such situations, debriefing sessions at the end of each week helped vaccinators fine-tune their processes based on feedback from others, implementing an informal PlanDo-Study-Act cycle. For the most part, school nurses were responsible for data collection and management. Students handed in vaccine registration forms to their schools where school nurses collected and aggregated the data. School nurses were also responsible for ensuring that each child who received a vaccine had a permission slip. School nurses submitted data from the forms to the LHD or directly into the state vaccine tracking system. In larger communities where the LHD had the capacity to do so, LHD staff or volunteers entered data into the state tracking system. One particular LHD in a midsized community color-coded the forms to keep track of them. This system reduced confusion when entering the data into the state system, and it also helped to prevent medication errors from occurring as data regarding how many shots students received was entered and searchable. School nurses looked over each form to make sure information was correct prior to the child receiving the vaccine. In some instances the nurse had to call a parent or guardian to verify information on the form. Some LHDs were able to use electronic databases to store the information, and they did not need to physically store the forms. However, the majority of LHDs that participated in school-based clinics, regardless of population size, kept a physical copy of the form. Many LHDs do not have the financial resources to invest in scanning systems or other databases to house this information. Manually entering the data is also time intensive and many LHDs had to hire extra staff to complete this process. It took one LHD 9 months to enter all of the children’s forms. Because it took so long for most LHDs to enter the information about those vaccinated, they resorted to counting the forms to determine how many children were vaccinated at each clinic, thus undermining the value of the system for providing real-time tracking information. Some children had to receive 2 doses of the vaccine, and many LHDs and schools found it challenging to track whether students had received their second dose. Some LHDs with enough staff and vaccine supply went back to schools a second time and provided the second
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dose to students, whereas others sent information about where children could receive a second dose to parents and put the onus on them to ensure their child was immunized. LHD staff worked with school administrators to set clinics up in a way that ensured rapid flow, accurate data collection and quality controls, and calm children. In most clinics, qualified LHD staff and nurses vaccinated the children, and many broke into teams with 2 vaccinators per team. At larger schools, the school nurses also vaccinated children, especially if the LHD was relatively small or understaffed. One LHD was able to vaccinate a school district by visiting each of their 21 buildings in a matter of 3-1/2 weeks. Vaccination in other locations sometimes took longer because of scheduling concerns, whether or not parents would be in attendance, and whether or not the clinic would be held during school hours or after school. Teachers aided in controlling the flow of the students and most schools opted to bring classes to the clinic one at a time to reduce possible issues. Two schools gave snacks to the children after they received the vaccine as a way to keep them calm. Schools that separated the vaccinators from the entrance of the vaccination room experienced success at keeping children who were waiting in line calm. Children who saw others being vaccinated tended to have more anxiety about receiving a vaccine.
local context makes a difference in how interventions are designed and how they work. Rather than a ‘‘one size fits all’’ approach, LHDs can reach their constituents as they see fit. However, the challenge with such a system is that there is a limited evidence base for what works, when it works, and how it works. We know that school-based vaccination leads to higher vaccination rates in children,5,6,17 and that the H1N1 school vaccination campaign delivered vaccines at lower cost per dose than public clinics,18 but there is a limited evidence base of effective, replicable practices for distributing vaccines in schools, especially during emergencies. Lessons learned from a large LHD in a major city, may not apply in a rural community. Our research shows how context and mechanisms interact, leading to better (or worse) outcomes. The key is in understanding what works, when, and for whom. Limitations One key limitation to our study is that we only interviewed LHD staff about school-based vaccination clinics. The intention of the project was to understand the LHD experience as the coordinator and implementer of school-based vaccination clinics. Future research should include interviews with school staff and administrators, as well as LHD staff to gain a more complete picture of the vaccination process from both perspectives. Given the important role of school nurses in the school-based vaccination clinic process, it would have been helpful to understand more about school nurse demographics. Although we did ask whether school nurses were employed by LHDs, we do not have information about nurse-to-student ratios, education level of nurses, or nursing certifications. Future work in this area should include more in-depth analysis of school nurse demographics and their influence on outcomes.
DISCUSSION Our positive deviance approach allowed us to learn from successful LHDs during the schoolbased vaccination process in response to pH1N1. There is great variation in the size, structure, and function of LHDs16 and the goal of this project was to understand how LHD context (including the community it serves) triggered specific mechanisms which led to positive outcomes so similar LHDs can learn from peers. As noted in Table 1, LHDs creatively addressed the challenges they faced given their specific circumstances. For example, small, rural LHDs depended on informal relationships with school administrators and nurses, whereas larger, more urban LHDs utilized more formal relationships. This is a reflection of the local community where the school nurse may be the neighbor or fellow community group member of the local emergency planner. Personal relationships allow for less formality in partnerships, whereas formal relationships may solidify partnerships that would not exist otherwise. The US public health system allows for great local autonomy in practice with oversight from state and federal authorities. The benefits of local control are that context can be considered when planning public health interventions, and based on our findings we know that 68
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IMPLICATIONS FOR SCHOOL HEALTH School-based clinics have been shown to be an effective way to reach those at highest risk for contracting and spreading viruses. This study shows us that context matters; an LHD’s size, staff levels, relationship with school administrators, and schools’ relationships with parents all effect the mechanisms which are triggered to produce successful outcomes. Learning about what worked well in different contexts during the 2009 H1N1 school-based vaccination campaign can assist LHDs and school districts in planning for future events. For example, including school nurses in the clinic development and implementation process can lead to better interaction between health department staff, school officials, •
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parents and teachers. LHDs can look to schools to be champions of health in safety in their communities, particularly during emergency events. Our findings show that lessons from similar contexts may be replicable in similar circumstances. Human Subjects Approval Statement This study reviewed by the Thomas Jefferson University Institutional Review Board (where the study was conducted) and was ruled exempt.
REFERENCES 1. Centers for Disease Control and Prevention (CDC). The 2009 H1N1 pandemic: summary highlights April 2009-April 2010. Available at: http://www.cdc.gov/h1n1flu/cdcresponse.htm. Accessed March 7, 2012. 2. Institute of Medicine. The 2009 H1N1 influenza vaccination campaign - summary of a workshop series. Available at: http://iom.edu/Reports/2010/The-2009-H1N1Influenza-Vaccination-Campaign.aspx. Accessed March 11, 2012. 3. Association of State and Territorial Health Officials (ASTHO). Assessing policy barriers to effective public health response in the 2009 H1N1 influenza pandemic. Available at: http://www.astho.org/Display/AssetDisplay.aspx?id=4933. Accessed April 2, 2012. 4. National Association of County and City Health Officials (NACCHO). NACCHO H1N1 policy workshop report. Available at: http://www.naccho.org/topics/H1N1/upload/NACCHOWORKSHOP-REPORT-IN-TEMPLATE-with-chart.pdf. Accessed April 3, 2012. 5. Effler PV, Chu C, He H, et al. Statewide school-located influenza vaccination program for children 5-13 years of age, Hawaii, USA. Emerg Infect Dis. 2010;16(2):244-250. 6. King JC, Cummings GE, Stoddard J, et al. A pilot study of the effectiveness of a school-based influenza vaccination program. Pediatrics. 2005;116(6):e868-e873.
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7. King JC, Stoddard JJ, Gaglani MJ, et al. Effectiveness of schoolbased influenza vaccination. N Engl J Med. 2006;355(24):25232532. 8. Lu P, Ding H, Euler G, et al. Interim results: statespecific influenza A (H1N1) 2009 monovalent vaccination coverage—United States, October 2009--January 2010. MMWR. 2010;59(12):363-368. 9. Gupta R, Isaac B, Briscoe J. A local health department’s schoollocated vaccination clinics experience with H1N1 pandemic influenza. J Sch Health. 2010;80(7):325. 10. Russo T. Pandemic vaccine distribution policy for the twenty-first century. HSAJ. 2012;8(4). Available at: http://www.hsaj.org/?article=8.1.4. Accessed August 1, 2012. 11. Bradley EH, Crurry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM. Research in action: using positive deviance to improve quality of health care. Implementation Sci. 2009;4(25). Available at: http://www.implementation science.com/content/4/1/25. Accessed December 14, 2009. 12. Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ. 2004;329(7475):11771179. 13. Walker LO, Sterling BS, Hoke MM, Dearden KA. Applying the concept of positive deviance to public health data: a tool for reducing health disparities. Public Health Nurs. 2007;24(6):571-576. Available at: http://www.positive deviance.org/pdf/research/Walker%20et%20al.%20Positive% 20Deviance.pdf. Accessed December 14, 2009. 14. Klaiman T, O’Connell K, Stoto M. Local health department public vaccination clinic success during 2009 pH1N1. J Public Health Manag Pract. 2013;19(4):E20-6. 15. Pawson R. Evidence-based policy: in search of a method. Evaluation. 2002;8(2):157-181. 16. Berwick DM. The science of improvement. JAMA. 2008;299(10):1182-1184. 17. Davis MM, King JC Jr, Moag L, Cummings G, Magder LS. Countywide school-based influenza immunization: direct and indirect impact on student absenteeism. Pediatrics. 2008;122(1):e260-e265. 18. Kansagra SM, McGinty MD, Morgenthau BM, et al. Cost comparison of 2 mass vaccination campaigns against influenza A H1N1 in New York City. Am J Public Health. 2012;102(7):13781383.
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Learning From Successful School-Based Vaccination Clinics During 2009 pH1N1 TAMAR KLAIMAN, PhD, MPHa KATHERINE O’CONNELL, BS, BSNb MICHAEL A. STOTO, PhDc
ABSTRACT BACKGROUND: The 2009 H1N1 vaccination campaign was the largest in US history. State health departments received vaccines from the federal government and sent them to local health departments (LHDs) who were responsible for getting vaccines to the public. Many LHD’s used school-based clinics to ensure children were the first to receive limited vaccine supplies, but the success of school-based distribution strategies varied in different locations. The goal of this project was to identify and learn from high-performing school-based vaccination clinics in order to share successes and improve performance in future school-based vaccination campaigns. METHODS: We used a combination of process mapping and comparative analysis to identify and derive lessons from positive outlier cases observed during 2009 H1N1 school-based vaccination clinic implementation. We created process maps to identify the activities of LHDs conducting school-based vaccinations and used them as the basis for in-depth interviews of LHD staff. We asked interviewees to describe their activities during the 2009 H1N1 pandemic (pH1N1) school-based vaccination campaign with a focus on successful processes. RESULTS: We identified positive deviants, that is, those that performed better than expected, and categorized qualitative data from in-depth interviews with 13 successful LHDs according to the process maps. Key mechanisms for school-based vaccination success included having a relationship with local school authorities, communicating effectively with parents, and ensuring clinic logistics allowed for an easy flow of students through the vaccination process. CONCLUSIONS: Utilizing rigorous methodology, we defined and learned lessons from successful LHDs when conducting school-based vaccination clinics, which can be applied to future school-based vaccination campaigns. Keywords: vaccination; pandemic; emergency preparedness. Citation: Klaiman T, O’Connell K, Stoto MA. Learning from successful school-based vaccination clinics during 2009 pH1N1. J Sch Health. 2014; 84: 63-69. Received on April 16, 2012 Accepted on December 2, 2012
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he 2009 H1N1 pandemic (pH1N1) required a concerted effort from the entire public health system of the United States. Because the outbreak emerged in children and young adults, health officials believed that children were at increased risk, and consequently, the Centers for Disease Control and Prevention (CDC) placed children at the top of their vaccine priority list.1 Local health departments (LHDs) were responsible for getting vaccines to local communities across the United States, and many
LHDs used school-based vaccination clinics to ensure children received vaccines first. In many ways the public health system responded well to the challenge. In less than a year, for instance, a new 2009 H1N1 vaccine was developed, produced, and delivered to 81 million people. From another perspective, however, the response had its limitations. For instance, less than half of the population was vaccinated and nearly half of the 162 million 2009 H1N1 vaccine doses produced went unused.2-4
a Assistant Professor of Health Policy and Public Health, ([email protected]), University of the Sciences in Philadelphia, 600 South 43rd St., Philadelphia, PA 19104. bFormer
Research Assistant, ([email protected]), Jefferson School of Population Health, Thomas Jefferson University, 1015 Walnut St., Suite 115, Philadelphia, PA 19107. c Professor of Health Systems Administration and Population Health, ([email protected]), Georgetown University School of Nursing & Health Studies, 3700 Reservoir Road, NW Room 236, Washington, DC 20057-1107. Address correspondence to: Tamar Klaiman, Assistant Professor of Health Policy and Public Health, ([email protected]), University of the Sciences in Philadelphia, 600 South 43rd St., Philadelphia, PA 19104. This research was funded by the Pfizer Corporation’s Fellowship in Public Health and the ‘‘Linking Assessment and Measurement to Performance in PHEP Systems’’ project funded by the Centers for Disease Control and Prevention—grant #1P01TP000307.
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effective practices in health care organizations,11 community health programs,12 health intervention planning,13 and most recently H1N1 public vaccination clinics.14 The positive deviance approach typically involves 4 key steps: (1) identification of positive deviants - those that consistently perform beyond expectations; (2) indepth study of these units using qualitative methods to generate hypotheses or theories about practices that lead to success; (3) hypotheses testing in a statistically representative sample; (4) working in partnership with key stakeholders to disseminate best practices.11 Because objective performance measures to identify positive deviants are lacking, as an initial effort, this analysis focused on steps 1 and 2, in which we defined positive deviants, and used a rigorous qualitative approach, realist evaluation, to learn ‘‘best practices’’ from LHDs that implemented successful school vaccination campaigns. We chose not to use vaccination rates as our primary indicator of success because the vaccine supply varied with geographic location and over time. Additionally, the demand for vaccine was initially high with low supply, and later, demand was low and supply was high. Our interest was in the clinic implementation process, rather than the number of vaccinations alone.
School-based vaccination programs have been shown to increase childhood vaccination rates for seasonal influenza.5-7 However, the success of schoolbased distribution during pH1N1 varied in different locations across the country.8,9 The variation in schoolbased clinics was not only geographic, but also included a variety of factors such as the process for vaccinating in schools, which schools were included in the vaccination process, and how parents were included in the process. Rhode Island focused primarily on schoolbased vaccination clinics and had the highest childhood vaccination rate in the country.8 Data suggest that a focus primarily on school-based vaccination clinics led to higher vaccination rates in children. Although some of the variation in school-based clinic implementation may reflect local conditions and capabilities, the need to improvise approaches when the vaccine supply was delayed suggests that there was more variation than necessary. Such excess variability indicates that there is room for improvement in the quality and efficiency of the school-based clinic process.8 Recommendations to improve mass vaccination policy and processes have been suggested.10 However, we are aware of no formal evaluations about the process for establishing and implementing school-based vaccination clinics during an emergency. Understanding the strategies that led to successful school-based vaccination clinics in varying circumstances can help strengthen preparedness strategies for future mass childhood vaccination campaigns as well as seasonal school-based vaccination campaigns. The goal of this project was to take a take a more in-depth look at the pH1N1 school-based vaccination response to understand the nuances of what made some LHDs successful in order to share those lessons with others. We focused specifically on LHD activities in this analysis as they were the organizers and implementers of school-based clinics. We used a ‘‘positive deviance’’ approach to identify and learn from LHDs that were successful in schoolbased vaccine distribution. We then used a realist evaluation perspective to conduct in-depth analyses of a sample of top performers to discern mechanisms for successful school-based vaccine distribution in specific contexts. The findings of this work are intended to offer LHDs evidence-based mechanisms for rapidly and effectively distributing medications, vaccines, and/or supplies to school children in need in future public health emergencies.
Realist Evaluation Realist evaluation is an approach that assumes that the ‘‘context’’ in which an organization operates (its resources, staff, funding, etc) and the nature of the population it serves make a difference in the outcomes it achieves. Different contexts might enable or prevent certain ‘‘mechanisms’’ from being effective. Thus, there is always an interaction between context and mechanisms that influences outcomes, represented as: Context + Mechanisms = Outcomes or C + M = O.15 Furthermore, rather than simply asking whether a program works, realist evaluation seeks to understand how context and program mechanisms interact so findings can be generalized to similar situations.
METHODS Identifying Positive Deviants Initially, we reviewed the National Association of County and City Health Officials (NACCHO) Model Practices Database for model health departments in the areas of emergency preparedness and/or vaccination. The Model Practices Database is an online searchable collection of innovative best practices across public health areas. Health departments self-select to share their experiences with NACCHO, and if their work is deemed to be a promising or model practice after review by NACCHO staff, it is entered into the online database. We searched the NACCHO database for all
Positive Deviance Approach The ‘‘positive deviance approach’’ is a framework for identifying and learning from top performers in a system, in our case the ‘‘public health system’’ is broadly defined to include schools. The positive deviance framework also been used to learn about 64
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2009 submissions for model or promising practices (N = 55). We included only those submissions focused on emergency preparedness, immunization, and/or infectious diseases of which there were 18. We also reviewed a sample of state and local After Action Reports—reports describing LHD responses and lessons learned which must be submitted to the federal government for emergency response reimbursement—which we compiled from practice partners through the Harvard Preparedness and Emergency Response Research Center (PERRC), attendance at the NACCHO Emergency Preparedness Summit, and recommendations from LHDs with whom we had an existing emergency preparedness research relationship. We reviewed 10 state and local AARs. We also reviewed over 100 published reports, mass media reports, and other relevant documents.2 Working with local emergency preparedness and response public health partners, we developed an initial list of high-performing LHDs in the 2009 pH1N1 vaccination campaign (N = 35). We used a snowball sampling method in which we asked LHD staff to recommend peers who they believed performed well in the distribution of H1N1 vaccine from the perspective of our process map. Our interest was in a purposive sample of LHDs, rather than a representative sample. We sampled LHDs to ensure those with varying contexts (size, demographics, and geography) were represented. Learning From Positive Deviants We created process maps (Figure 1) to identify the key activities LHDs conducted during schoolbased vaccination clinics and used them as the basis for in-depth interviews of LHD staff. Process maps were vetted with experts in emergency preparedness to ensure they included the key elements necessary for evaluating performance. We focused on activities conducted in public vaccination clinics and schoolbased clinics because they were most prevalent, and they were the methods for vaccine distribution that were most dependent on local public health system infrastructure unlike the use of pharmacies or private providers for vaccine distribution. We conducted in-depth interviews with health department officials from 20 LHDs that were defined as high performers based on the process maps and peer recommendations and agreed to participate. One of the authors (Klaiman) conducted each of the interviews by telephone and took notes as she was able. A research assistant attended each interview as well and took notes verbatim. We typed up all notes within 24 hours to ensure accuracy. We interviewed LHD staff who were in charge of the local H1N1 vaccination campaign and included emergency planners, immunization program coordinators, and Medical Reserve Corps (MRCs) Journal of School Health
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coordinators. We asked interviewees to describe their activities during the 2009 pH1N1 school-based vaccination campaign with a particular focus on successful processes. After identifying positive deviants, we categorized qualitative data from in-depth interviews with successful LHDs according to the processmaps. Key domains in the school-based vaccination administration process are noted in Figure 1. We focused on 2 modes of vaccine administration—school-based and public clinics. We report the findings from the school-based vaccination clinic analysis in this article. A companion article addresses clinics conducted by LHDs directly.14
RESULTS The 20 LHDs chosen for in-depth analysis represented a variety of geographic locations across the contiguous US states. The LHDs served populations in urban, suburban, and rural communities in Washington, Texas, California, Illinois, Pennsylvania, New York, Massachusetts, Louisiana, and Kansas. There were 5 LHDs in communities with less than 100,000 people, 6 with populations less than 500,000, 4 with between 500,000 people and 1 million people, and 5 serving communities with over 1 million people. The number of employees working in LHDs during the vaccination campaign ranged from as small as 2 to over 1800 full-time employees. Of the 20 LHDs studied, 8 held both public and school vaccination clinics, 5 held only public clinics, and 5 held only school clinics. One LHD held public clinics and contracted with pharmacists to administer the vaccine, while one LHD held public clinics and distributed vaccine to primary care providers to administer as well. We are only reporting the results of the school-based clinic analysis (N = 13) in this article. Table 1 notes specific examples of C + M = O stories we discovered in our interviews. We found 3 overarching areas of success as noted below, and specific context and mechanism examples are shared. Relationship With Local School Authorities LHDs initially had to choose the schools where they would hold clinics for local children. Some chose to hold clinics at all schools in a local district, whereas others chose key, centrally located schools. Many of the successful LHDs that we interviewed had previously established relationships with the school districts in their jurisdiction, making the vaccination location decision clear. Some LHDs previously held mass vaccination drills or seasonal flu clinics in local schools, so the clinic setup and implementation had already been practiced. Most successful LHDs had worked with school officials in the emergency preparedness planning process. Small, rural LHDs often had fewer
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Figure 1. School Distribution Process Map Choose school clinic location
Determine staff leadership
Determine timing of flu clinic
Recruit and Train Staff
Parental Involvement/ Communication
Data collection protocol
Administer vaccine
Quality Assurance/ Accountability
Line/crowd control
Evaluate feedback
Security
Table 1. Select Context + Mechanism = Outcomes Stories Defining Priority Groups Local vulnerable populations + access to vulnerable populations (through shelters, nursing homes, etc) = higher vaccination rates among underserved. Small local health department (LHD) + large Orthodox Jewish community+ Sunday clinics = Jewish attendance at clinic. Limited English speaking community+ materials in multiple languages = higher immigrant vaccination rates. Communicating With the Public Public questions/concerns + LHD hotline+ website= informed public. Public questions about clinics + social media (eg, Facebook and Twitter) = informed public. LHDs had to advertise clinics + multiple media outlets (TV, newspaper, website, radio, and religious institutions) = reaching the public. Rural LHD+ flashing road sign borrowed from police= public notification about clinic. Reverse 911 system+ clinic information= public notification about clinic. Staffing Small LHD+ large population+ trained Medical Reserve Corps (MRC) = clinic staff. Large population+ trained MRC= clinic staff. Numerous clinics + local health professions schools = clinic staff. Small LHD+ Public Health Emergency Response (PHER) funds = contract nursing staff for clinics. Small LHD+ local health professions students + clinic training added to school curriculum= well-trained clinic staff. Community Partnerships Community venues + existing memoranda of understanding (MOU) = clinic location. Large turnout expected+ relationship with large venue= clinic location. Many local churches + meeting with clergy= coordination with local partners and higher vaccination rate. Rural community+ close relationship with venue security= clinic security staff. Large LHD+ formal memoranda of understanding (MOU) with local police= clinic security. Local police engagement in LHD activities + traffic direction= clinic safety. Flexibility High demand for vaccine+ large community event (eg, County Fair) = high vaccination rate. multiservice LHD+ weekend clinics = minimal service interruptions. Small LHD+ limited budget + completed registration forms = reimbursement from insurance companies for those vaccinated who were privately insured. Emergency declaration+ access to additional resources = more effective vaccination campaign.
nonemployee school nurses to coordinate the clinics, and some had to initially convince school nurses that school-based vaccination would be an effective and feasible way to reach children. Most LHDs held regular conference calls with school nurses and administrators once or twice per week, especially in the early days of the pandemic response when LHDs did not know when they would receive vaccines. Global buy-in of the school system, intensive planning, constant communication, and trusting relationships between health department staff and the school districts were vital for the success of the school vaccination campaign.
locations to visit, but sometimes had more children to vaccinate in each location. Small, rural LHDs also had more informal relationships with school officials while large, urban LHDs often had formalized agreements with school officials for clinic implementation. School nurses served a vital role in the relationship between LHDs and local schools. The school nurses helped with planning and organization of the clinics and acted as a liaison between the LHDs and the schools. In some locations, school nurses were employees of the LHD, which solidified the relationship between the schools and the LHD. In other locations, the LHD had to work closely with 66
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LHDs had to plan carefully when timing schoolbased vaccination clinics. Most school districts we interviewed allowed the LHD to hold clinics during the day while school was in session to vaccinate as many children as possible. LHDs typically visited each public school in the district, elementary through high school as well as preschools. Some LHDs, particularly those in smaller communities, also offered vaccinations to private and parochial schools. Some schools were uncomfortable with holding vaccination clinics during the day because of class disruptions or because school administrators wanted parents to be present. When that was the case, clinics were held after school or in the evening so parents could be present. The placement and timing of the clinic was largely dependent on what the school district felt was the least disruptive to classroom activities. Communicating Effectively With Parents LHDs had to work closely with schools to decide if parents would be required to attend vaccination clinics. As noted above, some schools decided to hold clinics outside normal school hours to ensure parental participation. Regardless of parental attendance, all children in school-based clinics had to submit permission slips to receive the vaccine. Most LHDs depended on schools to distribute and collect permission slips. Smaller schools in which the school nurse knew most of the children and parents seemed to have more returned slips than those schools in which the nurse did not know most of the children. Schools used a variety of mechanisms for distributing forms and communicating with parents about vaccinations. Schools that had active listservs used those to reach out to parents. Other schools used the school’s website, whereas some sent paper slips home with children. Some large school districts used an automated phone system to notify parents about the clinics. LHDs found that using media outlets like the newspaper, radio, and local television stations as well as sending notes out to parents also proved to be an effective way to communicate. Schools that reached out directly to parents received more feedback than those who sent slips home with children without following up with another form of communication. Ensuring Clinic Logistics LHDs that held clinics during the school day primarily used LHD staff to run the clinics. MRC and other volunteers often worked other jobs during the day and many could not attend daytime clinics. MRC volunteers were used in the after-hours clinics and some were able to help with the in-school clinics as well. Because of security concerns, however, only volunteers who had submitted to background checks were allowed in many of the schools. Most LHDs we Journal of School Health
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interviewed did not have the staff available to conduct background checks on new volunteers in addition to planning for the clinics and training existing staff. Training was challenging in school-based clinics. LHDs, for instance, had to educate first responders and teachers about vaccination priority groups, and often had to explain why children were receiving vaccines first. Some successful LHDs held just-in-time trainings to ensure that all staff and volunteers received the same training. This was a challenge in large LHDs that held multiple school-based vaccination clinics. In such situations, debriefing sessions at the end of each week helped vaccinators fine-tune their processes based on feedback from others, implementing an informal PlanDo-Study-Act cycle. For the most part, school nurses were responsible for data collection and management. Students handed in vaccine registration forms to their schools where school nurses collected and aggregated the data. School nurses were also responsible for ensuring that each child who received a vaccine had a permission slip. School nurses submitted data from the forms to the LHD or directly into the state vaccine tracking system. In larger communities where the LHD had the capacity to do so, LHD staff or volunteers entered data into the state tracking system. One particular LHD in a midsized community color-coded the forms to keep track of them. This system reduced confusion when entering the data into the state system, and it also helped to prevent medication errors from occurring as data regarding how many shots students received was entered and searchable. School nurses looked over each form to make sure information was correct prior to the child receiving the vaccine. In some instances the nurse had to call a parent or guardian to verify information on the form. Some LHDs were able to use electronic databases to store the information, and they did not need to physically store the forms. However, the majority of LHDs that participated in school-based clinics, regardless of population size, kept a physical copy of the form. Many LHDs do not have the financial resources to invest in scanning systems or other databases to house this information. Manually entering the data is also time intensive and many LHDs had to hire extra staff to complete this process. It took one LHD 9 months to enter all of the children’s forms. Because it took so long for most LHDs to enter the information about those vaccinated, they resorted to counting the forms to determine how many children were vaccinated at each clinic, thus undermining the value of the system for providing real-time tracking information. Some children had to receive 2 doses of the vaccine, and many LHDs and schools found it challenging to track whether students had received their second dose. Some LHDs with enough staff and vaccine supply went back to schools a second time and provided the second
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dose to students, whereas others sent information about where children could receive a second dose to parents and put the onus on them to ensure their child was immunized. LHD staff worked with school administrators to set clinics up in a way that ensured rapid flow, accurate data collection and quality controls, and calm children. In most clinics, qualified LHD staff and nurses vaccinated the children, and many broke into teams with 2 vaccinators per team. At larger schools, the school nurses also vaccinated children, especially if the LHD was relatively small or understaffed. One LHD was able to vaccinate a school district by visiting each of their 21 buildings in a matter of 3-1/2 weeks. Vaccination in other locations sometimes took longer because of scheduling concerns, whether or not parents would be in attendance, and whether or not the clinic would be held during school hours or after school. Teachers aided in controlling the flow of the students and most schools opted to bring classes to the clinic one at a time to reduce possible issues. Two schools gave snacks to the children after they received the vaccine as a way to keep them calm. Schools that separated the vaccinators from the entrance of the vaccination room experienced success at keeping children who were waiting in line calm. Children who saw others being vaccinated tended to have more anxiety about receiving a vaccine.
local context makes a difference in how interventions are designed and how they work. Rather than a ‘‘one size fits all’’ approach, LHDs can reach their constituents as they see fit. However, the challenge with such a system is that there is a limited evidence base for what works, when it works, and how it works. We know that school-based vaccination leads to higher vaccination rates in children,5,6,17 and that the H1N1 school vaccination campaign delivered vaccines at lower cost per dose than public clinics,18 but there is a limited evidence base of effective, replicable practices for distributing vaccines in schools, especially during emergencies. Lessons learned from a large LHD in a major city, may not apply in a rural community. Our research shows how context and mechanisms interact, leading to better (or worse) outcomes. The key is in understanding what works, when, and for whom. Limitations One key limitation to our study is that we only interviewed LHD staff about school-based vaccination clinics. The intention of the project was to understand the LHD experience as the coordinator and implementer of school-based vaccination clinics. Future research should include interviews with school staff and administrators, as well as LHD staff to gain a more complete picture of the vaccination process from both perspectives. Given the important role of school nurses in the school-based vaccination clinic process, it would have been helpful to understand more about school nurse demographics. Although we did ask whether school nurses were employed by LHDs, we do not have information about nurse-to-student ratios, education level of nurses, or nursing certifications. Future work in this area should include more in-depth analysis of school nurse demographics and their influence on outcomes.
DISCUSSION Our positive deviance approach allowed us to learn from successful LHDs during the schoolbased vaccination process in response to pH1N1. There is great variation in the size, structure, and function of LHDs16 and the goal of this project was to understand how LHD context (including the community it serves) triggered specific mechanisms which led to positive outcomes so similar LHDs can learn from peers. As noted in Table 1, LHDs creatively addressed the challenges they faced given their specific circumstances. For example, small, rural LHDs depended on informal relationships with school administrators and nurses, whereas larger, more urban LHDs utilized more formal relationships. This is a reflection of the local community where the school nurse may be the neighbor or fellow community group member of the local emergency planner. Personal relationships allow for less formality in partnerships, whereas formal relationships may solidify partnerships that would not exist otherwise. The US public health system allows for great local autonomy in practice with oversight from state and federal authorities. The benefits of local control are that context can be considered when planning public health interventions, and based on our findings we know that 68
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IMPLICATIONS FOR SCHOOL HEALTH School-based clinics have been shown to be an effective way to reach those at highest risk for contracting and spreading viruses. This study shows us that context matters; an LHD’s size, staff levels, relationship with school administrators, and schools’ relationships with parents all effect the mechanisms which are triggered to produce successful outcomes. Learning about what worked well in different contexts during the 2009 H1N1 school-based vaccination campaign can assist LHDs and school districts in planning for future events. For example, including school nurses in the clinic development and implementation process can lead to better interaction between health department staff, school officials, •
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parents and teachers. LHDs can look to schools to be champions of health in safety in their communities, particularly during emergency events. Our findings show that lessons from similar contexts may be replicable in similar circumstances. Human Subjects Approval Statement This study reviewed by the Thomas Jefferson University Institutional Review Board (where the study was conducted) and was ruled exempt.
REFERENCES 1. Centers for Disease Control and Prevention (CDC). The 2009 H1N1 pandemic: summary highlights April 2009-April 2010. Available at: http://www.cdc.gov/h1n1flu/cdcresponse.htm. Accessed March 7, 2012. 2. Institute of Medicine. The 2009 H1N1 influenza vaccination campaign - summary of a workshop series. Available at: http://iom.edu/Reports/2010/The-2009-H1N1Influenza-Vaccination-Campaign.aspx. Accessed March 11, 2012. 3. Association of State and Territorial Health Officials (ASTHO). Assessing policy barriers to effective public health response in the 2009 H1N1 influenza pandemic. Available at: http://www.astho.org/Display/AssetDisplay.aspx?id=4933. Accessed April 2, 2012. 4. National Association of County and City Health Officials (NACCHO). NACCHO H1N1 policy workshop report. Available at: http://www.naccho.org/topics/H1N1/upload/NACCHOWORKSHOP-REPORT-IN-TEMPLATE-with-chart.pdf. Accessed April 3, 2012. 5. Effler PV, Chu C, He H, et al. Statewide school-located influenza vaccination program for children 5-13 years of age, Hawaii, USA. Emerg Infect Dis. 2010;16(2):244-250. 6. King JC, Cummings GE, Stoddard J, et al. A pilot study of the effectiveness of a school-based influenza vaccination program. Pediatrics. 2005;116(6):e868-e873.
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7. King JC, Stoddard JJ, Gaglani MJ, et al. Effectiveness of schoolbased influenza vaccination. N Engl J Med. 2006;355(24):25232532. 8. Lu P, Ding H, Euler G, et al. Interim results: statespecific influenza A (H1N1) 2009 monovalent vaccination coverage—United States, October 2009--January 2010. MMWR. 2010;59(12):363-368. 9. Gupta R, Isaac B, Briscoe J. A local health department’s schoollocated vaccination clinics experience with H1N1 pandemic influenza. J Sch Health. 2010;80(7):325. 10. Russo T. Pandemic vaccine distribution policy for the twenty-first century. HSAJ. 2012;8(4). Available at: http://www.hsaj.org/?article=8.1.4. Accessed August 1, 2012. 11. Bradley EH, Crurry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM. Research in action: using positive deviance to improve quality of health care. Implementation Sci. 2009;4(25). Available at: http://www.implementation science.com/content/4/1/25. Accessed December 14, 2009. 12. Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ. 2004;329(7475):11771179. 13. Walker LO, Sterling BS, Hoke MM, Dearden KA. Applying the concept of positive deviance to public health data: a tool for reducing health disparities. Public Health Nurs. 2007;24(6):571-576. Available at: http://www.positive deviance.org/pdf/research/Walker%20et%20al.%20Positive% 20Deviance.pdf. Accessed December 14, 2009. 14. Klaiman T, O’Connell K, Stoto M. Local health department public vaccination clinic success during 2009 pH1N1. J Public Health Manag Pract. 2013;19(4):E20-6. 15. Pawson R. Evidence-based policy: in search of a method. Evaluation. 2002;8(2):157-181. 16. Berwick DM. The science of improvement. JAMA. 2008;299(10):1182-1184. 17. Davis MM, King JC Jr, Moag L, Cummings G, Magder LS. Countywide school-based influenza immunization: direct and indirect impact on student absenteeism. Pediatrics. 2008;122(1):e260-e265. 18. Kansagra SM, McGinty MD, Morgenthau BM, et al. Cost comparison of 2 mass vaccination campaigns against influenza A H1N1 in New York City. Am J Public Health. 2012;102(7):13781383.
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