On July 29, 2009, the Advisory Committee on Immunization Practices (ACIP) recommended a phased approach for administration of influenza A (HlNl) 2009 monovalent vaccine, with certain high-risk groups in the United States receiving the first doses (1). In Illinois, state authorities gave responsibility for initial vaccine administration to local health departments and hospitals. This report describes the vaccination campaign of the Skokie Health Department (SHD), during October 1 6-December 31, 2009. The SHD campaign initially was planned to cover the 67,000 persons residing in Skokie only, but that plan was expanded on November 4, when, in response to a nationwide vaccine shortage, the state health director urged local health departments to vaccinate any person in the ACIP priority groups regardless of jurisdictional boundaries. SHD, with the assistance of 1,075 volunteers, either administered or distributed to medical providers 40,850 HlNl vaccine doses during a 9-week period, including 8,904 doses administered at 52 Skokie schools and day-care facilities, and 12,876 doses at mass vaccination clinics visited by residents of 193 of the 1,313 Illinois municipalities. At the time of the campaign, widespread illness from 2009 HlNl in Illinois, with highly publicized deaths, contributed to a public sense of urgency about vaccination. Consistent with published studies (2,3), mass clinics in Skokie were an effective means to vaccinate large populations rapidly. The campaign highlighted the need for flexible plans, including the possibility of vaccinating persons who resided well beyond SHD's jurisdictional borders.

SHD is one of six state-certified local health departments in Cook County, Illinois, and typically administers 3,000 seasonal influenza vaccinations each year. Beginning in July 2009, following ACIP guidelines, SHD staff members used census data and direct contacts with schools and medical practices to estimate that 38,900 residents and commuters' were members of the initial priority groups recommended by ACIP for vaccination, including 14,900 children in schools or day-care facilities. Based on priority group calculations, on September 27, SHD ordered 40,000 doses of influenza A (HlNl) 2009 monovalent vaccine through the Illinois Department of Public Health (IDPH). SHD initially targeted children in schools and day-care facilities. Planners anticipated that area healthcare providers and retail pharmacies would have sufficient vaccine by mid-October to begin vaccinating the other high-risk target groups. SHD mass clinics were scheduled for early December to ensure all residents would have access to the vaccine. During October 5-16, SHD received 15,000 doses for schools and day-care facilities, 67% of the doses in the nasal spray formulation. SHD received an additional 25,000 doses during November 6-16. In all, SHD administered or distributed 40,850 doses,* in what evolved into a fivephase campaign (Figure 1 , Table) that resulted in SHD administering influenza A (HlNl) 2009 monovalent vaccine to persons who resided far beyond the village boundaries (Figure 2). Overall, 54% of vaccine recipients at SHD clinics were not residents of Skokie.

Five-Phase Campaign

Phase 1. Vaccination clinics were held during October 21-November 20 at 39 public and private schools and 13 day-care facilities in Skokie. Vaccinations were offered to children, staff members, and caregivers of children aged <6 months. Overall, 8,904 persons received vaccine, 53% of the estimated target population. At school clinics, a greater percentage of persons aged >19 years (71%) received vaccine than persons aged 6 months- 18 years (49%), based on the actual target populations. Among those vaccinated at school and day-care clinics, 40% resided outside of Skokie.

Phase 2. During October 16-November 24, SHD administered 2009 HlNl vaccinations to persons who volunteered to assist in the vaccination campaign. SHD also offered vaccine to emergency medical services (EMS) personnel from Skokie and seven neighboring municipalities, and a regional private helicopter 911 service. Altogether, SHD vaccinated 254 EMS workers, or 24% of the actual target population; 179 (70%) worked for municipalities other than Skokie.

Phase 3. During November 9-25, because approximately 48% of the vaccine allocated for schools had not been utilized, a total of 8,141 doses were distributed to 30 Skokie medical practices that had placed vaccine orders with IDPH; an additional 2,717 doses were distributed to a local hospital. Because of an ongoing national vaccine shortage and preferential ordering of single-dose syringes, which were not yet available, the medical practices had received only 3% of their 20,850 ordered doses by mid- November, and a four-hospital system in the area had received only 10% of 120,000 ordered doses. SHD did not collect information regarding the recipients of these vaccine doses; the medical practices signed an agreement with IDPH to abide by ACIP guidelines.

Phase 4. SHD conducted four mass vaccination clinics during December 3-12 that were open to anyone in the ACIP priority groups, ignoring jurisdictional borders as requested by IDPH. An online appointment system and a phone bank were established to schedule vaccinations, limiting participants to 600 per hour. At the clinics, 12,876 persons were vaccinated; 73% of recipients resided outside of Skokie.

SHD was able to modify procedures rapidly to improve clinic flow. For the first clinic, several hundred persons arrived well before the scheduled start time and could not be allowed to enter the building, which contributed to a slow start and resulting waits of 1-2 hours. For the remaining three clinics, SHD implemented refinements to reduce the entire vaccination process time to <30 minutes per vaccinée. Refinements included establishing an adults and teens express vaccination room, reorganizing patterns within the building to maintain a continuous flow, ensuring adequate staffing, and opening 1 hour earlier than scheduled to accommodate early arrivals. Overall, 25 persons were vaccinated per vaccinator, per hour.

Phase 5. During December 14-31, because of increased vaccine supply, IDPH opened 2009 HlNl vaccinations to any person aged ≥6 months. SHD administered an additional 3,261 doses at the village hall, the public library, and to the homebound. At the same time, SHD distributed 3,780 doses to neighboring health departments, Skokie medical practices, and a long-term care facility.

Staffing and Communication

SHD, which has a staff of 18 persons, including one physician, two full-time nurses, and one part-time nurse, relied on 1,075 community volunteers to administer vaccinations and fill support roles; most of these persons had never served in large vaccination clinics and had no previous emergency preparedness training. Volunteer recruitment efforts included a letter from the mayor to all Skokie boards and commissions, Internet postings, e-mail requests, and broadcast messages on the local emergency radio station and cable television news. Recruiting messages described specific tasks that would be assigned to volunteer support staff members, such as assisting with completion of consent forms or movement of persons through the clinic. The 172 volunteer vaccinators included 108 nurses, 36 nursing students, 22 paramedics, four physicians, and two pharmacists; many volunteered on more than one occasion.

Teleconferencing was established and used along with mass e-mails for simultaneous communication with schools and day-care facilities. Local medical practices and retail pharmacies received regular updates via blast fax. Skokie residents and businesses were kept informed of the vaccination campaign through local newspapers, flyers, billboards, Internet postings, 10 radio station updates, five cable television spots, and 12 mass e-mailings. Twice, "reverse-911" calls with critical clinic information were sent to village businesses and residences. Monthly visits to the Village of Skokie website doubled during December, from 17,000 to 34,000. Chicago news coverage was instrumental in promoting the availability of vaccine in Skokie; within 4 days of Chicago news coverage, all mass clinic appointments had been filled. To defray costs of the campaign, SHD received $260,000 in federal Public Health Emergency Response funds, distributed through IDPH.

Editorial Note

The 2009 HlNl vaccination campaign presented substantial challenges to SHD. The initial, two-part plan devised in July was to offer vaccine first to children, the largest ACIP target population in Skokie, through school and day-care clinics during October and November. Planners anticipated that community medical providers would, at the same time, vaccinate members of the other ACIP priority groups, and SHD would finish up with four mass clinics in December, targeting Skokie residents who had not yet been vaccinated. However, because the vaccine shortage prevented many persons at high-risk for complications from 2009 HlNl strain from getting vaccinated, the SHD plan quickly became to vaccinate a broader population as requested by IDPH, including persons who resided outside the village limits.

CDC has indicated previously that the convenience of school-located vaccination clinics might improve pediatric vaccination rates for seasonal influenza and during outbreaks of vaccine-preventable diseases (4). During an outbreak of pertussis at an Illinois high school, the vaccination rate among students, which had increased from 16% to 37% in the 3 months after parents and health-care providers were first notified, rose to 68% after a 4-day school-based vaccination clinic (S). The 49% 2009 HlNl vaccination coverage among children in Skokie schools and day-care facilities is substantially higher than the preliminary vaccination rate estimates for this population nationally (36.8%) and in Illinois (37.5%) (6). However, caution should be used in comparing the Skokie coverage rate, which was calculated from administrative data, with national and state survey data.

Large numbers of community volunteers were essential to the success of the Skokie vaccination campaign; most were identified through established relationships. Effective use of volunteers during public health emergencies requires a clear organizational framework and well-defined job duties. This level of support will be required for future efforts to rapidly vaccinate the entire Village. Historic accounts of the 1918 influenza pandemic in the United States describe a similar reliance on volunteers to carry out local response efforts (7).

Rapid vaccination of the United States population during a pandemic is achieved through local efforts. SHD was able to quickly adjust its 2009 HlNl vaccination plans at multiple junctures as the event unfolded and to provide vaccine to many persons not included in original plans. These adjustments were possible because of strong support from village officials of public health initiatives, an early commitment to administer 40,000 vaccine doses, and wellestablished lines of public health communication at the state and local level.

Acknowledgments

This report is based, in part, on contributions from school and day-care administrations and staff members, the Skokie Park District administration and staffmembers, and approximately 1,000 persons who volunteered their services to the vaccination campaign.

* Persons aged 6 months-24 years, household contacts and caregivers of infants aged <6 months, pregnant women, health-care and emergency medical services personnel, and adults ages 25-64 years with underlying health conditions that increased the risk from influenza.

[dagger] Nonresidents who worked at or attended school or day-care facilities in Skokie.

§ Total number of doses administered exceeded 40,000 because young children received half doses.

References

1. CDC. Use of influenza A (HlNl) 2009 monovalent vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR2009;58(No. RR-10).

2. Schwartz B, Wortley P. Mass vaccination for annual and pandemic influenza. Curr Top Microbiol Immunol 2006;304:131-52.

3. Fontanesi J, Hill L, Olson R, Bennett NM, Kopald D. Mass vaccination clinics versus appointments. J Med Pract Manage 2006;21:288-94.

4. CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2009;58(No. RR-8).

5. CDC. Use of massTdap vaccination to control an outbreak of pertussis in a high school - Cook County, Illinois, September 2006-January 2007. MMWR 2008;57:796-9.

6. CDC. Interim results: state-specific influenza A (H1N1) 2009 monovalent vaccination coverage - United States, October 2009-January 2010. MMWR 2010;59:363-8.

7. Jones MM. The American Red Cross and local response to the 1918 influenza pandemic: a four-city case study. Public Health Rep 2010;125(Suppl 3):92-104.

Author affiliation:

Reported by

CCounard, MD, A Rigoni, MPA, J Locker by, MPA, A Tennes, MPA, R Czerwiniski, D Prottsman, MPA, M Sknkard, MPA, A LeTendre, MPA, B Silverberg, P Hanley, JD, H Mueller, JD, B Nowak, MBA, B Gilley, MIT, M Aleksic, M DiFrancesca, C Ballowe, B Johnson, MS, B Jones, S Reisberg, MSN, C Braden, MPH, J Hartford, B Neirick, D Codd, B Kok, D McLin, C Starks, J Gaulin, L Kaphn, M Maggi, D Mohrlein, H Coleman, P Staffhey, J Prendi, MPA, L Goons, K Norwood, J Silva, N Wyatt, H Peters, J Scher, B Riplinger, J Gill, J Lyerly, D Nygren, J Puffi LRukavina, C Markoutsas, I Kalota, J Reichert, N Tharwani, S Collins, L Brangan, Village of Skokie. K Whitney, Municipal GIS Partners, Inc. D Nimke, MPH, private epidemiology contractor. C Conover, MD, LG Gallagher, MPH, K McMahon, Illinois Dept of Public Health. D Swerdlow, MD, National Center for Immunization and Respiratory Diseases, CDC.