RHODE ISLAND MENINGITIS VACCINE EXPERIENCE - MASS VACCINATION CAMPAIGNS, POLITICS AND HEALTH POLICY, THE

Medicine and Health Rhode Island, Mar 2004 by Nolan, Patricia

EMERGENCY VACCINATION CAMPAIGNS

These days we have an intense concern about protecting Americans from the consequences of an intentional introduction of a potent biologic agent. The federal government has requested each state to prepare and test plans to distribute vaccines and/ or medications to the entire population in a ten-day period, using the support of the "Strategic National Stockpile". As the public health agency for the state of Rhode Island, we have developed plans for the emergency distribution of vaccines and prophylactic medications to very large numbers of people.

The mechanics of such a campaign are daunting. We have drawn on our experience with immunizing a quarter of a million children and youth against meningitis in 1998 to design our distribution system. Key lessons learned in that campaign have guided our decisions on the role of:

* Community physicians, nurses and pharmacists;

* Local governments;

* Hospitals;

* Volunteers, and

* Media.

The campaign to immunize our children against meningitis offers another critically important lesson: The decision-making process about whom to immunize or provide prophylactic medications and when to do so is political. Science should inform the political process, but a decision to provide or not to provide emergency mass vaccination is never going to be "purely scientific." The decisions about how to provide the service have many political dimensions, including perceptions of equity, the openness of the process, expectations for results, and the effectiveness of the solutions. The final judgment of success or failure will be made in the political arena, rather than the scientific one.

THE MECHANICS OF MASS IMMUNIZATION CAMPAIGNS

Having decided that a mass immunization campaign against meningitis was necessary on February 24, 1998, the Rhode Island Department of Health (HEALTH) put together a plan to immunize all eligible Rhode Islanders within six to eight weeks.

HEALTH implemented an intense public information campaign in an effort to reduce the level of panic. The public information campaign had three prongs:

1. Inform the public about meningitis and steps to prevent its spread.

2. Provide consistent information about eligibility to receive state-supplied immunizations.

3. Publicize the immunization clinic sites and times.

HEALTH determined that municipalities were the best entities to organize the immunization clinics, even though the state has no local health departments and little municipal involvement in public health. Each municipality was asked to plan its clinics and to involve one or more responsible physicians who would provide the medical direction for its campaign and one or more nurses to oversee clinics. HEALTH provided training on how to organize and conduct a mass immunization clinic. HEALTH provided model parental consent forms, vaccine certificates and clinic logs. HEALTH managed the purchase and distribution of vaccine to the municipalities for clinics (and to private physicians providing vaccines in their practices).

Vaccine distribution began on February 28, 1998. More than 245 community and school-based clinic sessions were approved and scheduled in the 39 cities and towns of Rhode Island. In a period of just over six weeks, nearly 200,000 were immunized.

WHAT WE LEARNED

Municipalities were able to tailor responses to their communities with a minimum of directives (a single person in charge, a physician who assumed medical direction, a nurse who took responsibility for protecting the vaccine, and simple record-keeping requirements). The responses ranged from several small communities working together with a community hospital to multiple school-based community clinics with a volunteer workforce.

Communities struggled with multi-lingual populations, and schools provided enormous expertise in reaching them.

The out-pouring of volunteers was tremendous and very helpful, especially because the municipal staff knew the people.

Emergency immunization clinics are expensive. The vaccine costs alone exceeded $5 million. HEALTH'S staff time was diverted from other programs, and the costs of overtime and compensatory time rippled through programs for the following year. Volunteer time and in-kind contributions by hospitals, clinics and schools easily doubled the $5 million in vaccine costs.

The role of the media in reducing panic, controlling the spread of disease and publicizing the availability of services is vital and not accidental. (Our experience with the media and the lessons we have learned from it are more fully discussed in articles in The Public Health Communicator, Second Quarter 2003 and in the American journal of Health Communication, Winter 1999.)

THE POLITICS OF MASS IMMUNIZATION CAMPAIGNS

Even in the Rhode Island meningitis event, important national concerns emerged, including the implications of our chosen course of action for vaccine supply to the military and the consequences to other states choosing a different course of action. The Congressional delegation was immediately interested, and requested services and direction from federal agencies at the same time the Governor and state legislators were consulting with state agencies and experts. Local government officials caucused with their local agencies and experts, and identified their own concerns and solutions.