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University at Albany Center for Public Health Preparedness

Walk-in or Drive-thru: POD Model Comparisons from the Erie County Hepatitis A Experience

Original Satellite Broadcast: 3/26/09

Moderator: Good morning and welcome to the University at Albany Center for Public Health Preparedness Grand Round Series. I'm Kris Smith and I'll be your moderator today. Before you start, we would like you to fill out your evaluations online. Continuing education credits are available after completing the post-test and your feed back is always important to the development of our future programs. We encourage you to participate today and we will take your calls later in the hour. The toll-free number is 800-452-0662. You may also send your written questions at any time by fax to 581-426-0696, or by email to the address you see on your screen.

Here to speak with us today on point of dispensing model comparisons from Erie County is Tracy Fricano Chalmers: the regional coordinator of the office of public health emergency preparedness in Erie County, New York. Tracy thanks for joining us.

Tracy: Thanks Chris. It's great to be here.

Moderator: I want to talk about the POD took place last year in Eric County. POD stands for points of dispensing. That POD gives a wonderful example of community involvement in a very short amount of time. A lot had to be done and happen in a hurry. Can you give us an overview of the situation?

Tracy: Sure. We learned on a Friday afternoon about a potential Hepatitis A exposure. It was an actual exposure in a produce handler at one of our local grocery stores in Buffalo. Quickly the Erie department of health and the state health department conference called the Centers for Disease Control and determined they would go ahead and set up a point of dispensing.

Moderator: The threat of Hepatitis A is serious enough to set up a POD obviously, but why so?

Tracy: The concern we had here was that it was a produce worker in a large grocery store, so the exposure that could have transmitted to other persons was unknown. There could have been a high risk of exposure and secondary disease outbreak in this case, so we decided going on what the state and CDC recommended; to go ahead with the POD.

Moderator: To learn more about how Hepatitis A became a threat in the community, let's hear now from Erie County's health commissioner Dr. Anthony Billitier. We have a problem with that video, but we will get through it. Who needed to be treated at this POD and what was done about the produce at the grocery store? There is a laundry list of questions I want to ask, but let's start there.

Tracy: First of all, they decided that anyone who purchased produce during the period of time that the worker was infectious and working, which was about a span of two weeks, was eligible for prophylactic treatment. They basically determined about 64,000 households, which we narrowed down to about 13,000 heads of households for that case. Wegmans at the time sent out a telephone alert to all their consumers that purchased produce during that time frame. We identified, alerted them about the situation and advised them to seek further information and attend the point of dispensing.

Moderator: I want to get more information on that, in just a bit. I understand that our video tape is ready, so let's hear now from Dr. Anthony Billitier.

Video: I'm Dr. Anthony Billitier, the Commissioner of health in Erie County. My role is to oversee a department that includes various aspects. One of our roles is to prevent the spread of infectious diseases in Erie County. Midday on Friday we received a report from one of our local supermarket chains that one of their workers had been diagnosed with Hepatitis A. The first question we had to ask ourselves was: is this something of significance? In other words, could this infected worker have caused others to have become infected or exposed them to an infection, and so really that decision needed to be based upon science, or at least as much science that existed. We then needed to decide what action are we going to take and when are we going to take it? We decided to open the POD on the next day, which was a Saturday. We realized we couldn't get going it first thing in the morning. We needed the morning to prepare. We decided to open the POD about midday. Because it was a weekend we had significant challenges, including getting staff available and alerting our volunteer participants and many of the other agencies that had to be involved. We treated that as a push POD. The difference being, pull PODs are where you open up a building and have people come to you and give them prophylaxis, whether it be pills or shots. Push PODs are where we push vaccine or pills out into the community, and then they're distributed through that mechanism.

The supermarket chain had their employees who, not surprisingly, also buy produce from their same store, and so there was a need to also vaccinate their employees. We decided that rather than having their employees come and make our challenge in our pull POD greater, that we would do a push POD in the supermarket.

You can never foresee every barrier. Some of the barriers we had been able to overcome initially, and then others we had to think on the fly on how to deal with them. The initial event became even more complicated after we learned that the supermarket donated produce to various food pantries, and it wasn't even a direct connection where we could say that they donated to one given food pantry. They actually donated to a service that collected and then delivered to various food pantries, depending on the need in the community. So this led to the need to develop some sort of special needs kind of POD.

It's important to make sure that we have but in from the leadership and we need to keep them apprised of what we're doing. I don't think that the County executive viewed me and our department as new to this, so I think that helped assure him that we did understand the issues, and we were approaching it from a scientific and sound standpoint.

We had some glitches, especially early on, where people had to wait a fairly lengthy amount of time, perhaps three hours for a shot. We were able to reduce that over time by retooling the clinic in real time as we continued to gain experience, but people actually, despite waiting those hours, actually praised us and thanked us. I think the spirit of cooperation and appreciation in our community really was remarkable.

Moderator: That overview just sets out an enormous set of challenges.

Tracy: It does.

Moderator: Dr. Billitier told us a lot about the situation, but I think it would be helpful to drill down to some specifics. Tracy, maybe you could start with the extent of exposure. There's no way of knowing if there was a single person dealing with the produce that was purchased or if the entire family might have consumed the purchase, or what happened.

Tracy: Correct.

Moderator: So how did you try to determine the extent of exposure and what were some of the limitations you might have faced?

Tracy: Based on the information we had from Wegmans, they determined they had 64,000 produce transactions. We have no idea how many people that equated to. They were able to fine tune that number down to 13,000 households. Those were the 13,000 households they contacted and notified of potential exposure.. We had no way of knowing whether or not one person in the family consumed produce or if they had a party and served it to several of their guests as well. That was an unknown that challenged us throughout the duration of the event.

Moderator: Obviously the partnership with Wegmans was a real important piece of community involvement, but what other community involvement took place?

Tracy: We had community partnership with Wegmans. They were a critical player. We utilized all of the county health departments within Erie County. We also reached out to the town of Amherst and we had excellent participation from them. The site we chose for point of dispensing was located in the town of Amherst and we also had great interaction and partnerships with Amherst Community College, which was the actual site chosen.

Moderator: Talk to me about how you got the message to the community. I know Wegmans helped. I know you did a lot of communication, but take us through the steps.

Tracy: Initially, Dr. Billitier did a press conference Friday afternoon. That was the initial notification to the community. We also had information directing people with questions to visit our website, the state health department's website and Wegmans website. We made sure we had consistent risk communication information posted on all of those sources. We talked already about Wegmans doing the contacting of their customers as well. We relied on television and radio media to push the word out to the community.

Moderator: The last slide we saw had a bullet called "expanded operations". What did you mean by that?

Tracy: As we got into Sunday afternoon and Sunday evening, we quickly realized that the numbers of people kept coming and the lines were very long. We determined at that point it was necessary to continue the POD into Monday. At that time we utilized the media to convey that message to the public; that we would be expanding our operations into the next day. Then we went ahead and updated the information on the websites as well.

Moderator: This has been touched on a bit, but it is important to elaborate. When did you decide to have the POD and why? And what about the location? Coming up with a location on short notice must have been a challenge.

Tracy: It really wasn't a challenge for a location in this event. We have a number of points of dispensing sites that we had already determined in Erie County as per our plan. The site we chose, we had done a walk-thru before. Security assessments and the sites met all of the criteria that we needed for this event. It was a county facility, so it was available on short notice and on the weekend. It was also located in close proximity to the grocery store in which the event occurred. We thought it would be convenient for most people who shopped close to home or close to where they worked; therefore we utilized that location. As Dr. Billitier mentioned, we didn't think Friday at 9:00pm that we could have everything up and running first thing in the morning, we wanted to give ourselves time to set everything up and give the public time to make arrangements to show up at the POD, so we went for a 4:00pm start time.

Moderator: Set yourself up for success.

Tracy: We did.

Moderator: I imagine in Erie County although there is mass transit, most people would be coming to the POD by cars. Was there accessible parking?

Tracy: There was quite a bit of parking. That's one of the criteria we look for: to make sure the site has adequate parking for large volumes of people.

Moderator: I wanted to talk about the communication. You talked about risk communication. Obviously, that's paramount to the success of this type of endeavor. How did you cooperate with the community members to get the word out, and how was risk communication conducted specifically?

Tracy: We had several conference calls with all the partners involved: the local health departments, state health departments, Wegmans were participants, and we made sure that all the information going over the websites and was consistent. We also utilized our call center. We set up a call center with the local 211. When that became overwhelmed, the state health department was able to procure a larger call center that could handle the larger volume of calls that were coming in.

Moderator: Did you coordinate the scripts in the local call center and state call center?

Tracy: Yes, we did.

Moderator: That's important, so that everyone is getting same message. You found a location for the POD. You're ready to reach out to the community, then how did the operation get started and what supplies did you need on hand?

Tracy: We started Friday evening with initial contact of staff determining what supplies were necessary. We pulled supplies in from multiple locations in the county to be delivered to our location. We made notifications to critical people Friday evening and they started early Saturday morning moving supplies to the location for us. Simultaneously, while information was going out to the public, we were getting everything up and running and we were contacting staff and volunteers to alert them to the situation and to see if they were available to come in and work.

Moderator: I seem to recall that buses played a part in your response here. How were they utilized?

Tracy: We utilized buses, actually, to stage the clients when the lines became so long that at points, they actually began to line up outside. It was very cold for this particular week February, even cold for what we think of in Buffalo, very frigid temperatures - not safe for people to be outdoors for any extended period of time. We staged people on the buses and we actually utilized the buses to transport them from one location of the parking lot, a few several yards up to the next location, so that they would go in the correct door that we wanted them to enter in. At one point we started doing patient education on the buses in order to set move the PODs along quicker.

Moderator: Were patients more patient when they were able to get out of the cold?

Tracy: They were. We did everything we could to make sure people were comfortable. They understood it would be a lengthy wait at times but for the most part, they were very agreeable for the most part and very pleased. We had chairs set up and encouraged people to sit down if they were going to be waiting for a long period of time. We had water being circulated. We had information and activity sheets for children. We did everything we could to make it as enjoyable for them as possible under the circumstances.

Moderator: Almost a Disney type of setup for public health; in other words if people know what to expect then they're not quite as upset, and then they don't have to just wait and wait without any knowledge about what is going to be forthcoming.

Tracy: Right.

Moderator: In the building, what kind of spatial aspects did you have to consider to have a flow that was workable?

Tracy: We ran into challenges with the space available to us. For the weekend, it ran smoothly, but once we went into Monday operations and then Tuesday and Wednesday, school was actually open. We had to retool our POD flow several times to make sure we were accommodating the staff and students of the college campus and our clients. We determined what the volume was and moved lines accordingly. We utilized classroom space and moved people in and out of lines and hallways, utilized a cafeteria and another large student area for our vaccination center.

Moderator: How did you do that with students trying to resume classes and you having a huge POD? How did you make that work?

Tracy: We ran into some difficulty with that. That was one of our challenges that we tried to overcome. Oftentimes there would be students walking through our POD operations. It was very difficult for staff to determine: were they cutting in line, or were they trying to get to class? We took up space in their learning labs, and their kitchen culinary program. We were in their space. We had clients that were sort of inconvenienced, who were attending a dental clinic and finding difficulty parking. Because of this, we arranged for a shuttle service to transport clients at the college and also staff, faculty and students to their classroom locations, if they had difficulty parking.

Moderator: Did any particular station stand out as very much of a bottleneck?

Tracy: We thought the education station ended up being a bottleneck. There was a lot of information being handed out. It was very different from information we had given people in the past. It wasn't just a routine flu vaccination POD; that the public was used to doing. We had information on Hepatitis A: what it is, what the risks are, we had information on Hepatitis A vaccine and the immunoglobulin. People were asked to read it before they went into the education station. When they came in, they were well versed in the information we gave them, and they had many questions.

Moderator: What education levels were the fact sheets written at?

Tracy: I'm not sure. They are the typical vaccine information fact sheets that we use from the state health department. The difference was that the immunoglobulin fact sheet was worded a bit differently then the Hepatitis A vaccine. When people have time to digest information, they find every detail that is different and bring it up as a question.

Moderator: Consistency of information. In that particular instance, immunoglobulin was better for some individuals and the vaccine was indicated for others.

Tracy: It was.

Moderator: Having to make that point, I'm sure took a little bit of time as well. Can you talk about the management of medical supplies and go kits as it pertains to your POD?

Tracy: We have in Erie County several POD go kits, which are large storage containers filled with supplies and equipment we might need at point of dispensing. The picture on the screen is of the state's POD go kits. Ours are very similar. The packaging looks a little different. They are packed with anything you might need for point of dispensing. One might contain pencils, pens, clipboards and scotch tape, or another container might contain safety vests, flashlights or incident command forms. It is everything you really need to get up and ready for a point of dispensing except for the vaccine and the actual needles and syringes that you might utilize.

Moderator: I think I may have heard them referred to as POD in a box.

Tracy: Correct.

Moderator: I didn't realize how large the boxes were.

Tracy: Right.

Moderator: Were there any unknown factors that you had to adapt to? For instance, did you get a lot for more people than you expected to respond?

Tracy: We really were questioning whether or not anybody would come to this. We didn't know if the community felt that the risk of Hepatitis A warranted going to a point of dispensing and standing in line. We were very surprised. We ended up vaccinating over 10,000 people over five days, so the numbers were much higher then we anticipated. The numbers varied throughout the day. Some times of the day there would be rushes of people and the lines were very long. Other times there would be no one in line and lines they would move quickly. We were uncertain of how many people would come and how long would they continue to come. We end expanding from a two-day operation to five days.

Moderator: How did you estimate how much vaccine to order? It's almost sort of back of the envelope as people are coming through the door.

Tracy: We really didn't have a good way to estimate. It wasn't clear whether people that would be coming would require a vaccination or an immunoglobulin. A couple of times we ran out of immunoglobulin and had to prepare more in a short time frame We ended up having enough vaccine on site from what we got from the state health department's immunization program, but the immunoglobulin was certainly an issue for us.

Moderator: All said and done, how would you characterize the results of your POD and how did the response of the county differ from the response of the state or were they very similar?

Tracy: We had very different roles. Certainly we were both involved in risk communication and public information. The stat health department out of the Buffalo and Rochester regional offices did send us several hundred staff throughout the duration of the event to help with staffing. They were on site, and we also had critical personnel from the strategic national stockpile program on site with us for the duration. The state department of health staff was involved with incident command. It was a very good partnership and good working environment. I think the response overall was a local response supported by the state health department.

Moderator: Did your relationship with community members, your businesses, corporate groups, did any of those change after the POD in this incident?

Tracy: Certainly Wegmans is a prominent business in our community, but I think this event really highlighted the ability that a corporation to assist in an event like this, and they were a terrific partner. We utilized them several times for going to obtain immunoglobulin for us with their private jet and to bring in bottled water to our participants. They were a terrific partner to us throughout our event. We also relied very heavily on the town of Amherst; their emergency services coordination unit was on site working with us in unified command. They were a terrific partner as well, a partner that we will continue to work with in the next POD that we do.

Moderator: This seemed to be a very successful endeavor, obviously not one that you wished upon yourself, but even though you had to change some things on the fly, it seemed to work out well. What lessons were learned?

Tracy: We learned that even though most of our staff has gone through incident command training, we needed to push a refresher course to them. We also had personnel needs; certainly contacting our staff after hours proved to be difficult for us. We also had an issue of integration of staff coming in from the state health departments, as I mentioned, and also were fortunate to have our partner counties from the health alliance, including 8 counties in western New York to assist us as well. We had staff coming in, volunteers coming in, and trying to integrate the different agencies together, under one command structure, was difficult at times.

Moderator: Tracy, it sounds like you determined the need for additional incident command system training and call down alert training.

Tracy: Yes.

Moderator: Anything else that was identified in terms of training needs?

Tracy: Another need that is not specifically a training need was the ability to prophylax a large number of people in a short period of time. It took us five days to serve 10,000 people. If we had to serve a larger number of people in a shorter amount of time, we found our model, the pull method, was not effective for pushing large volumes of people thru. We wanted to look at something a little more efficient to process large volumes of patients.

Moderator: We will talk about a different POD in a few moments, but for now, can we talk about the staff that really had to work on a last-minute notice over the weekend, and then for five days? How did you keep their morale up, keep them in a position to perform good service?

Tracy: Once we came into Monday, and staff were reassigned, we pulled staff from every clinic in the department. It was all hands on deck. It needed to be a collaborative effort. Certainly staff was stressed out. It was a long week, long hours. We had our mental health volunteers on site walking around providing services as needed. We also had our canine therapy team of handlers come in with their therapy dogs. The dogs walked through the crowd and said hello to people standing in line and our staffing employees as well. That was helpful for us.

Moderator: So that was part of your pre-planning, the mental health aspect of it?

Tracy: Yes.

Moderator: Is that something that you think most counties have available; therapy dogs, massage chairs, and things like that?

Tracy: We didn't have massage chairs in this case. It would have been nice. Mental health is an important thing to consider in pre-event planning. It is something that can come up as an issue when it isn't addressed proactively. For Erie County, we like to include them as early on as possible; anytime we anticipate an issue with long staff hours, staff burnout and personnel related needs.

Moderator: Tracy, you gave us a hint of the follow-up POD that you did. Right now, we're going to hear from Dr. Anthony Billitier to talk about that.

Video: As a follow-up to this, we clearly recognized that if the goal is to be able to vaccinate everybody in our county, which is nearly a million people within five days, we can't do it using the model we did with the Hepatitis A POD. It took us five days to vaccinate a little over 10,000 people, and so we needed to try a different approach. We decided to try a different kind of pull POD. That pull POD was advertised to people who got their first Hepatitis A shot and might be interested in getting the second in the series and therefore be fully immunized against Hepatitis A. We conducted a drive-thru POD. Essentially that means that we collected people at a certain point and did the education and the consent and all of those things, and then had them drive through a big garage where we just vaccinated them as most of them stuck their arm out the window [of their car]. We actually used the University at Buffalo campus building. It is a community building. We did the pre-briefing and consent, and essentially staged the vaccinees and then gave them directions and had them drive to the POD at a different location in a highway garage, the town highway garage. Part of the challenge there was making sure people could find their way to the right place, also making sure that we had good traffic control, and also making sure that people were safe; anytime you have a moving car, you could have various issues. For example, carbon monoxide could be an issue and especially if it is running vehicles inside of a building, so we monitor for that. We needed to make sure our staff was safe and nobody would get run over.

We made it clear to people that for the most part, they were already protected against the outbreak. Giving them a second Hepatitis A vaccination really just provided them with protection for the future. In this scenario, we were fortunate to secure free vaccine from the state health department, so I think a lot of people came in with a different mind-set. It was an elective thing and they chose to actually help us. We told them in some ways we're experimenting with you to see if we can give you a shot as you stick your arm out the window of your car. Again, the community came through. We didn't have anywhere near the amount of people we had in the first POD, but we had enough people that we could at least test the system.

Moderator: So once again, Tracy, Dr. Billitier has given us a good overview, but let's talk about some specifics. Talk about how you determined the need for the second POD, and what kind of planning, exactly, went in to determining that there was a need?

Tracy: We actually based our decision for the second POD on the ability to take a definite number of people, people that we already have identified as needing a second vaccination and sort of use them as a test group to push this other model, this drive-thru model. We wanted to look at the after action report and the lessons learned from the first POD and utilize this training event to correct those things and revise our plan as necessary to improve those things that we determined were not very effective the first time around. We also thought it was a great opportunity for people to receive the second dose of the vaccination, to have long lasting protection.

Moderator: Were there other goals you had?

Tracy: Well, we certainly thought we would expand the partnerships that we had developed the first time around and we were testing a new model for us. We had never done a drive-thru POD in Erie County, this was the first one.

Moderator: The first time around, you really didn't know what to order in terms of vaccine or immunoglobulin, or how many supplies you needed, how many clipboards, paper, pens.

Tracy: That's correct.

Moderator: This time it was more determined, is that correct?

Tracy: It was more determined. We had a definite number of people that received the Hepatitis A vaccine the first time, about 5,000, so we started with that group. Invitations only went out to individuals who had received Hepatitis A vaccines in February. We knew that the number couldn't be any larger than 5,500.

Moderator: When you are with a line of moving cars in a garage setting, I imagine it is quite a bit different from an indoor clinical setting. What were some of the considerations that had to go into that?

Tracy: Safety was the number one issue. We had non-believers in Erie County, and I think that we still do, that this was not just a great idea and having staff around moving vehicles is very dangerous. A lot of time went into the planning, and the safety plan, making sure that we had trailers on site with traffic cones and variable message signs everywhere. Everyone was in safety vests. It was a very carefully planned event for us.

Moderator: How did you triage the patients at this type of POD?

Tracy: We sent them a letter ahead of time saying we would like you to consider coming to the second POD. It is going to be a drive-thru. They knew that ahead of time. It will be the second vaccination that you need, and you will be able to help test out this plan. We had great buy-in from the community in this aspect. In the letter, they were directed to the University of Buffalo Center for Tomorrow, and we staged them there. They didn't really know where the final administration of the vaccine was going to be, and once they got there and they were triaged, and it was determined that they had in fact been vaccinated in February, that they had no side effects or contraindications to the vaccination and they were feeling well that day, then they were given instructions on how to proceed to the vaccination site.

Moderator: Were there any unexpected surprises like people talking on their cell phones when you were giving them instructions or coming with a car-full of unhappy children or a pet barking?

Tracy: We had few instances of things like that happening. In the letter we wrote, we were careful to highlight main issues for them. We told them they would be in a vehicle. We asked them to wear short-sleeved shorts. We asked them to bring all of their family members together, that they could be waiting and to be ready for that, to have entertainment or refreshments for their children, and to make sure they used the restroom before they left the house. We also said we didn't want any pets in the car. I don't think anyone showed up with a pet in the car, but it was a concern. It was one of the safety issues that we had thought about.

Moderator: A couple of other things that occurred to me, I think carbon monoxide had sometimes been an issue in research on drive-thru PODs. Did you take this into account?

Tracy: We did. We looked at many other models of drive-thru PODs that have been done in New York State, and looked at all of their after action reports and concerns. Carbon monoxide was an issue we felt should be addressed. We had a plan in place. It turned out the highway garage that we utilized in Amherst had good preventive mechanisms in place: it was a well ventilated area. They had recently installed fans inside that would reduce the amount of carbon monoxide, because they routinely run 20 or 30 snow trucks in there at any one time. We had that measure in place, and we also did hourly on site carbon monoxide monitoring throughout the event. We had environmental health staff there with portable carbon monoxide monitors.

Moderator: How many of your staff did you need?

Tracy: We used a large number of our environmental health staff, two to three people at any one time measuring for carbon monoxide.

Moderator: Another question and perhaps it is not relevant, but the issue of patient privacy. If you have more than one person in the automobile when they're talking about their medical indications or contraindications, other can hear it. Is that a concern in a drive-thru POD?

Tracy: I guess it could be a concern. It wasn't a concern for us. This was a define population. Most people came as family units, so I think they were all pretty much familiar with each other's medical history. Most of the time a spouse was in the front seat and children in the backseat. I don't think we were discussing any medical information that they were concerned about. It certainly didn't come up from any of the clients as an issue for us.

Moderator: I guess it's something to think about.

Tracy: It is.

Moderator: Talk about the staff who participated in the drive-thru POD? How were they prepared, and you mentioned you had environmental health staff, clinical staff, but who comprised the staff?

Tracy: We invited pretty much anyone in the health department who wanted to participate in this event. They were given the opportunity. We had a couple of requirements. We asked people to attend a pre-event training session where we went over the working in a POD model and went through specific operation details regarding the drive-thru PODs. We addressed many of the safety issues and what they would expect when they got there. We did a refresher for them on the incident command systems; on the critical points that we thought needed to be reinforced for this event. That was a requirement for any staff or volunteer. We had Erie County department of health staff there. We also had our smart team, our specialized medical assistance response team, which our equivalent in Erie County to the medical reserve corps, and we extended the invitation to local community response teams and CERT as well.

Moderator: Who did you need to partner with in this instance to make the POD work? Did Wegmans take part?

Tracy: Wegmans was a terrific partner involved with us throughout the planning process. We utilized the Wegmans staff to test the model. We invited their staff to come out, and instead of pushing vaccine to them as we had done in February, we invited them out Friday evening and used them to test the flow through of the PODs.

Moderator: I think I hear you allude to the fact that it was a county-owned facility.

Tracy: The first time, it was a county-owned facility. It was held at a community college, and for this event, it was the town of Amherst highway garage. Amherst, again, was a terrific partner for us. They actually procured the site and they made sure the site was cleaned out for us ahead of time. They were involved and were represented in unified command, along with the county health department.

Moderator: Is that what you call the Center for Tomorrow?

Tracy: Center for Tomorrow at the University of Buffalo, so that's another partner. The emergency coordinator from the University of Buffalo was involved with us throughout the planning process. We reached out to our Western New York public health alliance counties and had participation from them as well.

Moderator: In terms of communicating to people about this POD, it was more direct with the letters that you sent out.

Tracy: Yes.

Moderator: Did you use media at all or any indirect coverage?

Tracy: We did use the media for coverage of the actual event. We did not utilize the media to advertise the event. We did not want the people who had not received the first dose in February showing up in this event. We did not use the media in this event to advertise, but we did utilize them to promote the fact that this was a community preparedness exercise, and we did have good participation of the media at the actual event.

Moderator: You gave us some incite how this POD flowed. Can you take us through it step by step?

Tracy: Sure. People drove in to the Center for Tomorrow and they were triaged with three basic questions when they arrived. They were asked to make sure they had received the vaccine in February, and had no side effects when they received it, and were still feeling well. They were triaged from there. They were given driving instructions. We avoided posting signs on major highways. It was straightforward. They turned right into the Amherst highway garage. As you can see up on the monitor, they came in one entrance. They were directed there. They were triaged either fast or slow, which we can get to in a minute. Then they were directed into the highway garage itself. Once they went into the garage, we queued them up in groups of four on the fast side and slow side, and asked them to pull all the way forward if possible, and we held them there. Once the vehicles were safely stopped, the environmental health people that were working advised the nurses that they could approach the vehicle, administer the vaccination[s], and then the cars as a group were directed out. They were queued up where they were held for fifteen minutes post vaccination in a waiting area where we asked them to complete a survey, which guaranteed that they would stay there for fifteen minutes. That was another safety concern; we didn't want people after vaccination, driving off. Then they were directed out of a separate entrance than the one they came in.

Moderator: That is a good point, and I was going to ask you how do you ensure that somebody doesn't faint behind the wheel of a car?

Tracy: We had directed participants if they had any medical emergencies to beep their horn and turn their flashers on and we had EMTs staffing the post-vaccination area.

Moderator: You referenced the fast and slow triage.

Tracy: Right.

Moderator: What does that mean?

Tracy: What we did was determine on a couple of different factors depending on the size of the vehicle, for example, a small sedan with a driver and passenger in the front seat, we would triage to fast, meaning they could be approached quickly from both sides, vaccinated without any complications and sent on their way. Other vehicles, an example of a slow vehicle many be a minivan with a mom in the front and three kids strapped into car seats in the back. This would mean that they went on a different side of the POD operation and a little more time and attention was spent on them and maybe the mom had to get out of the car and stand next to the child while he or she was vaccinated.

Moderator: The child in the middle seat, you can't get to their bare arms. When it came to the administration of the vaccine, what steps do the visitors have to go through?

Tracy: They started at the University of Buffalo Center for Tomorrow, and they were directed from to Amherst highway garage and directed through the process. They were given the information sheets to fill out. We didn't want them filling out sheets while they were driving. They were parked, filled out their sheets and their forms were reviewed and they were sent on their way. They did go thru medical screening, and if they had questions they could ask a physician. They were triaged again. We made sure they were re-triaged if necessary. They went through and received their vaccination and went into the queue where they waited for fifteen minutes, filled out the survey, and they were directed out the door.

Moderator: Did anyone show up that you hadn't expected to? Such as a friend of a friend who heard about it and thought it was a good idea?

Tracy: We had two people that we ended up vaccinating that had not received the Hepatitis A vaccine the first time around. They had received immunoglobulin. So, they weren't new to the POD operation, they just hadn't received the vaccine the first time around and they didn't need to be there.

Moderator: So you had the traditional pull POD to start, the clinic setting and then you have the push PODs, the drive-thru POD. In the end, what model did the staff prefer?

Tracy: The staff actually preferred the drive-thru model. They thought it was faster for the vacinees and thought it had the fewest interruptions in POD flow and flowed faster and more efficiently, and found it overall to be better. They only issue was that we had some staff that were concerned about the safety issue.

Moderator: How about the participants?

Tracy: They definitely preferred the drive-thru. They thought it was faster. Compared to February where many of them might have had to wait up to three hours, this was an in-and-out procedure for them. They were comfortable in their vehicles. Kids were entertained in their cars. They could have bottles of water, cups of coffee and they could have their radios on until they were instructed to turn them off. They were more comfortable in their vehicle. We also felt with a public health emergency with an infectious disease, a drive-thru is a better way to make sure people aren't transmitting diseases to one another.

Moderator: Tell me again what month the push POD, the drive-thru POD, was held in.

Tracy: The drive thru was held in September.

Moderator: Was weather a factor, though, in whether they [participants] were more satisfied with that one?

Tracy: I think weather is always a factor, certainly where we are in the country, but we had directed participants and staff to be prepared for all types of weather. The first day of the POD, it poured. We ended up having to procure rain ponchos, set up temporary shelters for staff to stand under. The second day it was hot and sunny and we had to pull some staff in because they didn't have proper protection. The weather is always a factor. I think the participants; they were in their climate controlled vehicle, where they could adjust the air conditioning to fit their needs. They weren't parking their cars and walking.

Moderator: It was okay to keep their cars running while they waited?

Tracy: They kept their cars running.

Moderator: And that's why you had the carbon monoxide detection ability.

Tracy: Uh-huh.

Moderator: I know you would characterize both Hepatitis A PODs as ultimately successful, but do you have final thoughts on how the two compare? Are there plans to implement other drive-thru PODs again or was this a test vehicle?

Tracy: We haven't considered whether we would test the drive-thru model again. We have considered some other models that we would like to test; other push models where we would bring a vaccination or prophylaxis to the community more directly, maybe utilizing the postal service or school buses. Things like that, we are contemplating. We will see. We will see when flu vaccination season comes up again this fall, which model we will utilize in Erie County.

Moderator: Tracy, I do have a couple more questions, but I do want to give our viewers a chance to call in. We are ready to take your calls now. The toll free number is 800-452-0662 or send your written questions by fax to 518-426-0696. Actually, I do have a question which comes from Texas. Liz Adams wants to know: throughout this process, and the original POD, was the city or county emergency operation center set up and utilized in addition to the health department's emergency operation?

Tracy: We did utilize an emergency operation center, but we had our incident command post which was co-located at the POD location. We felt that everything was contained to that location. The staff we utilized from other departments in the county, we brought to that location so that everyone was co-located there. We didn't open up the actual emergency operation center. In the city of Buffalo, participation from the city in this event was in a suburb of the city; they weren't directly involved except when we got into the issue with the food pantries that Dr. Billitier had mentioned. That required some coordination and logistics with the city to make sure they could bring those people to our location if necessary.

Moderator: Someone from the Center for Public Health Preparedness has a question and wanted to know: were there any problems of vehicles breaking down or running out of gas at the drive-thru POD?

Tracy: That was an issue we had considered: what should we do in that case? The decision was we would tow them out of the way. It didn't happen, but that was something we thought about. What happens when the vehicle breaks down; interrupts the POD flow and becomes a safety issue. Anyone considering a drive-thru POD, this is something to think about; making sure you have a plan in place to address this issue.

Moderator: Back to the original POD. From all you have told me, your corporate partner, Wegmans, just went to the nth degree to help you out. As some point, you said they actually provided their private plane.

Tracy: They did.

Moderator: Did you ask them or did they suggest that? Why was it needed?

Tracy: I'm not sure how it came up. It was something about the immunoglobulin being located in Tennessee. They said they have a jet, and so they made arrangements to utilize their private jet to go down twice and pick up immunoglobulin for us.

Moderator: One of the questions I have is about the call center: because you got a call center operation going quickly, it very quickly became overwhelmed.

Tracy: It did.

Moderator: Am I correct that the state call center and the Erie County call center were under the same state contract? Was that one of the reasons they were overwhelmed?

Tracy: I'm not sure if they were under the same contract, but the system that the state was using became overwhelmed and they went to a new system based out of Newfoundland and they had capacity for a much greater volume. That was an on the fly learning thing we came up with that the state may use in the future.

Moderator: An important lesson learned. Obviously it was important that the scripts were consistent because you didn't want any of the people who needed information calling one place and getting one set of facts, and then calling another place, getting even just slightly different facts,. That would be a problem. How about the media? Did they report correctly or were there inconsistencies in the information they were giving out?

Tracy: They were pretty good. Dr. Billitier had done several press conferences with them and we had them on site several times doing live coverage of the event. I felt they were consistent with their coverage.

Moderator: I think that's good. One of the points that I seem to recall, and I'm not sure if you are familiar with it, but I saw it in a couple of articles and it was changed, was that two were exposed and one media said if you touched the produce and touched our mouth, you should get vaccinated. How do you count on information like that?

Tracy: I think that risk information communicated is critical. I think the info that we had up on the website and that Dr. Billitier portrayed to the media was that touching the produce was not enough to cause someone to become ill. You had to have actually consumed raw produce, not have cooked it and not have washed it. I think he was very careful to make that very clear to the public.

Moderator: I seem to recall that he actually talked about the science again in clear, understandable terms, not a lot of obfuscation there.

Tracy: He did

Moderator: Let's say you have 24 hours to set up a POD. What has to happen in 24 hours? Are you going to recommend the traditional or drive-thru?

Tracy: I would recommend our traditional model, based on what our staff is most familiar and comfortable with. Depending on the location, the drive-thru, while it worked well, there was a lot of lead time and planning for that event, so I think to pull it off in 24 hours with no notice, may be more difficult.

Moderator: We have a faxed question that is actually multi-part. First of all, it talks about the documentation that was needed, and the clinical data management system (CDMS). How was it incorporated, CDMS, everybody's favorite?

Tracy: We actually had difficulty with the CDMS forms early Saturday morning. We had the state's SNS program on site with us trying to resolve that issue. We were not able to use the CDMS form in its intended purposes. We did have a form that was similar to the CDMS for that we were able to utilize. We were not able to scan the forms at the end of the event, so we had to go to manual data entry of all the forms post-event.

Moderator: Chris Crane from Monroe County sent this set of questions and they're very good. He wonders, also, did you use transmitters to broadcast info to car radios?

Tracy: We did not. We considered that for the drive-thru, but we did not actually do that.

Moderator: I supposed it is something that could be considered, in terms of education as well, saving a step.

Tracy: Sure.

Moderator: Was this the first time you created an incident action plan?

Tracy: No, it was not. In everything that we do, the county health department falls back to the incident action plan, so we are not new to incident action plans. Where we are still struggling is in trying to get them up and running sooner, so that we're not playing that catch up game into the next operational period. We had incident plans for the first Hepatitis A. Although a little bit delayed, they were there, existent. For the second one, we did a much better job of making sure that the incident action plans were published and actually distributed to the people that needed to see them.

Moderator: Can I go back to the risk communication aspect.

Tracy: Sure.

Moderator: I'm going to tell a tale out of school. The Erie County department of health did such a good job with risk communication in this incident that in fact, you were awarded the real time risk communication silver award from The National Public Health Information Coalition this year, which is a major, major award, and it's not given out easily. I would like you to brag on what you did and talk about that some more.

Tracy: Great.

Moderator: For instance, there is always the thought that if you give the public information, you might panic some members of the public. You needed to inform people who were exposed that they needed to get vaccinated or immunoglobulin. How did you do this while keeping it low-key enough not to cause panic or undue concern, and yet stimulate people so they would stand in line in the cold for three hours? That had to have been a tough sequence to follow.

Tracy: I think there are a couple of components to consider. I think the message is important that it is crafted well, that it is easy to understand and it hits all the high points. Also, the delivery of the message in Erie County, we're very fortunate with Dr. Billitier. He is an excellent public speaker. He does a tremendous job of giving the actual risk without overwhelming them. In his first press conference Dr. Billitier mentioned, if you were at a superbowl party, there might have been raw produce there, and you might have been exposed as well. He put it in laymen's terms and in a level that people can appreciate. This is Hepatitis A. It is pretty common in the United States. There is not a lot of severe morbidity or mortality associated with it. I think if it would have been something more serious like anthrax, pandemic influenza, plague or something with a lot more risk involved, I think the message would have been more difficult to craft to not alarm the public.

Moderator: On the other hand, because it's not particularly alarming to some people, you had to get them off their good intentions and to get them out there and roll up their sleeves.

Tracy: Yes.

Moderator: I think you should be really proud of it.

Tracy: Thank you.

Moderator: We have a fax from Alberta Nore, who is with the Vermont department of health. She is a public health specialist; a registered nurse, and would like you to go over the staffing numbers per POD per day, if you could, or give us your best explanation, and what specifically were the POD hours of operation?

Tracy: Well, the first POD; the push POD, we started 4:00 p.m. and ran until 10:00 p.m., I believe. I think it was 10:00pm on that Saturday evening, and we basically staffed to the maximum capacity. We only have about 42 public health nurses in Erie County, besides what we pulled in from the state health department and our alliance counties and volunteers that were able to vaccinate for us. We determined the number of vaccination stations based on a couple of things: what the staffing looked like at the time and what the patient volume was. Many times during the event we moved people [staff] around a bit; we pulled them off of Hepatitis A and brought them to the immunoglobulin side. At any one time, we probably had 25 to 35 stations set up with a vaccinator and vaccine assistant at each one for the first POD, the push POD. For the drive-thru, I don't know if you can pull up the slide of the drive-thru model? While they're doing that, at each one of those stations, each car would pull up in a queue, up to four cars, and that vehicle would be approached by a nurse on each side to vaccinate. As you can see there with all the squares, the ones in the center were double sided. That really was the maximum. It was two nurses per station approaching the vehicle from two different sides, to facilitate efficient movement through the process.

Moderator: What kind of security did you have to have in the case that people were to become disgruntled at waiting or who wanted immunoglobulin, when they really were indicated for vaccine? What kind of security did you have in place?

Tracy: We had the Erie County Sheriffs on site for the first POD, providing security for us. A few times we had some concerns with safety and security. We had issues with staff not putting their purses under their desks and things like that, but I think we only had one incident where the sheriff was paged over for a security issue. For the most part, people were very orderly and well behaved.

Moderator: I want to give our viewers a chance to call in. You have been faxing great questions. We would love to hear your voice. Let me give you that number again; it is 1-800-452-0662, and we do have time for some more faxed questions. 518-426-0696. Don't be shy. Call in with some questions if you want.

This question talks about whether considerations for the drive-thru POD would work with the wonderful New York winters? Come on, if you like to ski they are wonderful!

Tracy: I don't particularly like to ski. I think it would depend where you are doing your patient education and form review. In this case we were doing it outdoors, and in this case the weather worked out for the most part in our favor. In the winter, to have people role down their windows and to have staff stand outside would be an issue. To have everything contained to an inside facility and keep people in their vehicles, it would work. I would not recommend keeping staff outside in the winter.

Moderator: That would be difficult, even just working in slippery conditions. The weather consideration occurs to me again, because I remember at some point when you were planning whether to extend the POD operations another day, the one day had blizzard-like conditions.

Tracy: It did.

Moderator: I think a decision had to be made rapidly to extend POD operations.

Tracy: Yes.

Moderator: How difficult was it to make that decision in a hurry?

Tracy: The weather was really quite bad. There was a concern that perhaps there were people who needed to come or had intended to come that day or evening, but were unable to get there because of the inclement weather. This went into our decision to extend the operation another day. We wanted to make sure we were catching everybody possible and the weather was not a deterrent to for people to receive the treatment they needed.

Moderator: You have provided such a wealth of information and I'm sure people will have follow-up questions. Is there a way they can contact you with questions?

Tracy: They can. They can either contact me in the office or send me an email with the information on the screen there, and I will answer any questions that anyone has.

Moderator: Can we hear your question please? We have someone on the phone.

Caller: Yes, I would like to know if you have any idea of the cost of this POD. It seems like it may have been exorbitant with all of the town's people and everyone involved. I was wondering if you had any idea.

Tracy: The costs are a little bit difficult to quantify. The state health department has come up with what their costs were for the first one. For us, most of the cost was actually staff time, overtime and things like that. Supplies were minimal. We had everything pretty much on hand; and the state provided the vaccine for us. The immunoglobulin was an expense we had to prepare for with the first POD, but obviously not the second one. Most of the participation we had from our partners, our volunteers and certainly from the town of Amherst, they were in-kind or donated services. We reimbursed the town for paper we utilized and other things that we took out of their facility to utilize. I would say that for the first POD it was quite high. I don't know if I could wager a guess. The second time I would say with the staff time and everything, probably about $100,000.

Moderator: We have another call from Jeff Wade in Dallas, and we have two minutes. Go ahead Jeff.

Caller: You mentioned for your drive-thru POD that you didn't use the media, and I didn't understand how you communicated the fact that you wanted your people to come without pets and to wear short sleeves and so forth. How did you communicate that in advance?

Tracy: We had information from the first POD, so we actually sent them a letter. We sent a direct letter to the participants with the instructions in there, and date and time to report, and information if they had questions to contact our office.

Moderator: The bottom line: you learned a lot from this.

Tracy: We did learn quite a bit.

Moderator: I want to thank you for sharing your experience.

Tracy: Thank you.

Moderator: I would like our viewers to fill out the online evaluation. Your feedback is very helpful in planning future programs and continuing education credits are available after completing the post-test. This program will be available online within about a week. Please check our website for details. I'm Kristine Smith, looking forward to seeing you next time on the University at Albany Center for Public Health Preparedness Grand Round Series.

 

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