H1N1: Logistics 101

Mass vaccinations for H1N1 flu virus are scheduled to begin Oct. 26, and schools and health officials across the state are bracing for the biggest public health response since polio.

Larry Crist, director of the state’s Office of Public Health Preparedness, says the Vermont Health Department won’t know exactly how many children will be signed up for shots until later this week, but it’s planning for 70 percent “uptake.”

As many as 65,000 Vermont children are expected to be vaccinated at approximately 300 school clinics between Oct. 26 and Dec. 23, Crist says, and the clinic dates haven’t changed yet in spite of possible vaccine availability delays.

“It is a large and complex undertaking,” Crist says. “I would say relative to a public health response, it’s the largest response in recent memory. I’m not sure what we’d compare it to. You might have to go to polio. This potentially is a lot of people to be vaccinated. The logistics are considerable.”

Target population for H1N1

H1N1 presents the most risk to pregnant women, children, young people and people with compromised health, according to the department.

Vaccinations are recommended for children between the ages of six months and 24 years.

The overall target population for the H1N1 vaccine in Vermont is 385,000, Crist says. Of that group, 120,000 are children, most of whom are school age (92,000 of which attend Vermont’s public schools).

The immunizations are free, and they are not mandatory, according to the department. Parents were asked to sign consent forms for H1N1 vaccinations last week. Children under 10 must receive two shots in order to be fully immunized against the new strain of flu virus.

“An infective vaccine provides an excellent level of protection for the individual,” says Susan Schoenfeld, an infectious disease epidemiologist for the department. “And when we get higher vaccination ratios we start protecting those around us.”

Schoenfeld says the state has prepared for an H1N1 outbreak of up to 50 percent of Vermont’s population of 621,000.

“Thirty percent is a fine number to use for planning purposes for the flu; it could go higher,” Schoenfeld says. “I don’t spend a lot of time thinking too much, is it 30, is it 40 , is it 45; we always try to prepare, to have in our back pockets how we’d respond to the next level of whatever is presented to us.”

Kids bused from small schools to meet 300 minimum

In many rural school districts, small elementary schools are busing children to a centralized location because at least 300 children must be present at school clinics run by the Vermont Department of Health.

Washington Central Supervisory Union, for example, is busing schoolchildren from Berlin, Calais, Doty, East Montpelier and Rumney elementary schools to Union 32 High School for two H1N1 clinics. Superintendent Robbe Brooks says the school nurses didn’t want to give the shots because they were worried about liability. Other small schools around the state are providing in-house clinics run by school nurses.

What will immunization day look like? Jeanne Collins, superintendent of Burlington School District, compared the H1N1 immunization effort to picture day: Children will be waiting in line, classroom by classroom, waiting patiently for their turn to see the nurse with the needle behind the curtain.

In Burlington city schools, where Collins estimates about 3,600 students will be immunized for H1N1, children who balk at the shots will be not be vaccinated, she says. Volunteers and staff will gently pull them out of line.

Parents are not welcome at the clinics. A statement from the Calais Elementary School says, for example, that parents may not “attend the clinics per Vermont Department of Health procedure.”

Crist says, however, that the department is “not precluding parents from attending, we’re discouraging it.”

“We’re trying to vaccinate as many children as safely and as quickly as we can and every time you introduce a new element that wasn’t planned for, even if it’s just X number of parents will be attending, well X number of parents are going to ask Y number of questions,” Crist says. “That’s just human nature … and the time that will be spent trying to address those issues is really going to be problematic as far as expediting the vaccination process.”

Children can get shots from “participating pediatricians,” according to Crist. He recommends that parents who don’t feel comfortable with the school-based clinics go that route or wait for a public H1N1 clinic. The department didn’t create a list of participating doctors for the public because it didn’t want to swamp local practices, he says.

So who will run the clinics? The short answer: It depends on the school. The Health Department’s district offices will provide the vaccines and supplies for small schools that hold in-house clinics with the school nurse.

School-based clinics with more than 300 students will be managed by Health Department district offices. The state is hiring 40 to 50 home health nurses to administer the shots for school and public clinics. Peter Cobb, director of the Vermont Association of Home Health Agencies, says all 11 agencies are participating. (The contract between VAHHA has not yet been filed, according to Crist and Cobb.)

The federal government has given the state $5 million to provide H1N1 vaccinations. Up to $2 million of that total is slated for home health nurses.

Fifty licensed practical nurses and 197 registered nurses have signed up to provide back up support through Vermont Emergency Response Volunteers, according to Crist. The volunteers will only be used when needed. “We’re not looking at volunteers as our first line of vaccinators,” Crist says.

How many nurses will be needed is an open question, however, until the end of this week when schools report how many permission slips have been submitted by parents, Crist says.

“That’s a number we’re not going to know until we know how many kids,” Crist says. “It’s been this sort of chicken and egg thing. I’ve gone through this myself: Can’t we project? The bottom line is we can’t until we know how many kids at each school. First of all, we need to know how many schools, which schools, and then how many children in those schools because that really does determine how many nurses and other vaccinators we need.”

The department’s 12 district offices, eight of which are managed by four district directors, are handling many of the school clinics. The Barre and Morrisville offices, run by Jeff Hunsberger, for example, will be offering 32 clinics in the two cachement areas, which include Washington and Lamoille counties and parts of Caledonia, Orleans and Orange counties. Four staff employees from the Barre district office and three from the Morrisville office will be managing the clinics.

“This is what I spend all my time doing,” Hunsberger says. “The staffing alone has been very challenging.”
Hunsberger says in two years “we’ve lost about 30-35 percent of our boots on the ground workforce in the office of local health.” The H1N1 vaccinations also come on the heels of significant changes to the WIC (Women, Infants and Children) program that were implemented by the district offices at the beginning of the month, Hunsberger says. “That’s why we did a contract with the VNAs (Vermont nurses associations) to help support us because we absolutely don’t have the resources to do this kind of work.”

Hunsberger doesn’t think the vaccination programs will be affected by the staff losses, however. “We’re more concerned about having enough vaccine to deliver as opposed to people to deliver it,” he says.

Since 2007, the Department of Health has cut 69 positions statewide, according to state data collected by Public Assets Institute. The department currently has 515 full-time employees, according to Department of Human Resources data.

Debra Wilcox, chief of public health nursing, says even without the job losses the state would have had to hire home health nurses who give seasonal flu shots annually to participate in the H1N1 vaccination
program.

“We have to make sure we have the staff to run the core functions in the district offices too,” Wilcox says. “I’m really proud of the way district offices are taking this on, and they’re getting everything accomplished that they need to get accomplished.”