ICPs use seasonal flu shots as pandemic drill

Drills reveal problems, up vaccination rates

Infection control professionals are killing two birds with one shot, administering annual flu vaccine in rapid-fire fashion to simulate immunizing health care workers against an emerging influenza pandemic.

If avian influenza A (H5N1) mutates into a pandemic flu strain, it will be critical to immunize as many health care workers as quickly as possible with whatever vaccine is available. Similarly, a bioterrorism attack or emerging infection may require rapid administration of some vaccine, treatment or prophylaxis. How to prepare for such eventualities? Why not take health care workers' historic apathy about getting the annual flu shot and energize it with a time-crunched rapid immunization drill? Such planning may be critical if for no other reason than if a pandemic flu strain emerges health care workers that wouldn't be caught dead getting an annual flu shot may now look at immunization as a matter of literal survival.

"In a true pandemic, if something were available, they will take it," says Joyce Lawhorne, RN, CIC, an ICP at Oconee Memorial Hospital in Seneca, SC.

Having never tested the ability to provide mass prophylaxis or vaccination to all workers in a short period of time at her hospital, Lawhorne and colleagues proposed a drill last year using the seasonal flu vaccine.1 Originally, the plan was to make the seasonal flu vaccine program mandatory by either taking the vaccine or signing a declination form. "Unfortunately, everybody still has a right to decline [vaccination]," she tells Hospital Infection Control. "But it's really amazing to see the ones that would not take a seasonal flu vaccine, but [said] that during a pandemic, they will take it. The trend seemed to be that even those that had never taken a seasonal flu vaccine would take it."

Get all players to the table

At any rate, mandatory attendance at the drill was considered too costly, but planners moved ahead to see how many staff they could reach in a tight time frame. The infection control, employee health and the education departments collaborated to develop a medication dispensing vaccine clinic model that could be used in any mass casualty event. "Get all of the players at the table at one time," Lawhorne advises. "Make sure that everybody understands what's going on and the importance of it." They structured the plan into the hospital emergency incident command system model, developing job action sheets for all clinic positions. Vaccinators completed mandatory competencies for injection technique. Planners worked with public health for an evaluation and after-action report of the drill. "We realized we will also serve as a resource for our public health people," she says. "They are not going to be able to vaccinate everybody either, so we will probably be called on to vaccinate first responders and volunteers."

Educational sessions on pandemic and seasonal influenza were conducted, emphasizing attendance at the drill. Fliers were posted and verbal reminders given frequently. Letters were sent to each employee explaining the drill and asking for participation. Door prizes were given. "Educate your staff prior to implementing the drill," says Lawhorne. "That helped us a great deal. We had multiple educational opportunities on pandemic preparedness leading up to the drill, then that's when we actually told them the purpose of it was to solicit their help in testing our system."

The drill was conducted for two days, 13 hours each day, with times overlapping into all shifts. Mobile vaccine clinics also were deployed. "We started with a dispensing station, but then went ahead and deployed mobile vaccination stations to outlying facilities. We know in a real event, they are not going to be able to leave their stations. We sent security guards with [vaccinators] just like in a real event," she notes.

During the two days, 1,084 vaccinations were administered and a total of 1,322 people were processed. That resulted in a 23% increase in vaccination rates of staff from 42% to 65%. Of those, 10% were first-time recipients. Still, many of the 32% of people declining did so due to never having had flu, and feeling vaccination was not necessary. Planners also used this opportunity to collect information for ordering purposes next season and to determine the number of health care workers' household members who would need prophylaxis if indicated and available. The drill established a sense of teamwork and allowed the largest bulk of vaccines to be given in a two-day period as opposed to workers reporting to employee health randomly to get vaccine. The hospital now has an up-to-date manual and online copy, with job action sheets, medication protocols, clinic supply list, emergency orders, clinic designs, and a pool of staff that have completed competencies for vaccine administration.

"I think we are much better prepared," says Lawhorne. "As a matter of fact, we are getting ready to use that same process this season, except we're going to shrink it to one day and we're going to test a different communication system."

Lessons learned included finding out that there was no method of rapid notification of staff. "We are working now with our public health and emergency preparedness in the county to see if we can tie into the reverse 911 system to put a bank of phone numbers of our health care workers in there and then send out a "canned" message that 'Vaccines will be given at this date, time and location,'" she says.

In addition, there was no centralized photo identification database for restricting access to a vaccine dispensing clinic. "The problem is not all of our volunteers in our long-term care facility had a picture ID, which we would require in a real event before we would give out medication," Lawhorne says. Plans call for the development of ID badges that can be scanned for demographic information. "Then we can go ahead and confirm they are still actively employed [and] this is where they work," she says. "Are they a direct care provider in case there is a vaccine shortage? Or is this somebody who could be triaged to get a vaccine at a later time?"

Whether it is pandemic flu vaccine or some medicine from the Strategic National Stockpile, federal emergency planners have developed the concept of the "push POD" — meaning rapid transport of a vital intervention to a given "point of distribution." Since hospitals may serve as some of these POD sites, St. Luke's/Roosevelt Hospitals in New York City used the annual flu vaccine to see how rapidly they could conduct mass vaccinations in 2006.2

"We told most people that it was coming up," Rosalyn Rapoport, RN, BSN, employee health nurse at the facility tells HIC. "We had a committee with representatives from many different areas in the hospital so everybody knew. But really the idea of push POD is to do it 'cold.'"

Still, the drill gave an indication of the kind of issues that would arise should a public health emergency require prophylactic treatment of staff. "I would really say this is something for hospitals to try," she adds. "You do get more flu vaccinations and you learn a lot about what your problems are if you had an actual disaster."

The influenza team worked in conjunction with the hospitals' emergency management team which was chaired by the same administrator. There were two major goals: 1) evaluate the hospital's ability to reach 80% of the employees during a distinctive time period; and 2) increase overall vaccination rates to 50%.

The team developed a comprehensive schedule for a 10-day period during October and November at each of the two major facilities. The schedule included coverage on evenings, nights and weekends. There were more than 100 departments between the locations. All departments were contacted by a team member to alert them to the program and to schedule visits from a mobile vaccine team or to a centralized vaccine station. Employees who declined the vaccine were asked to sign a declination form. On the ninth day of the POD drill, a special mock disaster code lasting two hours was called requiring all staff members on duty to report immediately to the central location.

Of the approximately 5,500 employees, 57% were reached during the 10-day POD exercise. One-third of the departments exceeded the goal of reaching 80% of the staff; an additional 34% of the departments reached 60% to 79% of the employees. Of the 3,157 employees who were reached, 66% were vaccinated. "That really went up for us because in previous years we had never gone over 50%," she says.

Although they did not reach 80% of the staff during the drill, several factors were identified to improve emergency preparedness, she says. That includes maintaining a more accurate telephone contact list," Rapoport says. "The first time we did the drill, we did it at Roosevelt," she explains. "We had people calling from a list of department heads. We found that the list was not up to date, and we did not have enough people making the calls. We did a better job of calling and reaching people when we did St. Luke's, [our second hospital]. We did better there because we had a more up-to-date list and more callers."

It was learned that there was a need for more coordination of the POD stations, and plans call for the development of a priority algorithm and assignment of predesignated POD team members.

"We did not expect as many people to come down and we not did have [enough] vaccinators," Rapoport says. "We did not have it as well organized as we should have. If we did it again, we have learned some things. We got a bigger response than we anticipated and we should have had more non-clinical people getting the consents and asking the questions, so the clinical people — the nurses — could just vaccinate. We got consent for every vaccination and we got declination statements. The primary reason was unfortunately, "it gives me the flu. That is a real hard one to deal with."


  1. Lawhorne, JD. Utilization of seasonal influenza vaccine to test readiness to provide mass prophylaxis or vaccination in a bioterrorism or pandemic event. Abstract 3-39. Presented at the Conference of the Association for Professionals in Infection Control and Epidemiology. San Jose, CA; June 24-28, 2007.
  2. Smith BA, Rapoport R, Gabasan AC, et al. Push point of distribution (POD) drill increases compliance with influenza vaccinations and evaluates hospital's emergency preparedness. Abstract 3-32. Presented at the Conference of the Association for Professionals in Infection Control and Epidemiology. San Jose, CA; June 24-28, 2007.