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The experiences of a mass immunisation exercise

Disease outbreaks or pandemics are inevitable and often occur unexpectedly. In the event of such an outbreak, the expertise of healthcare practitioners would be called upon to immunise large numbers of people in a short space of time. Would you be ready?

Martin Samangaya
RN BSc(Hons) MSc
Health Protection Nurse Practitioner
Health Protection Agency

David Baxter
MB ChB MSc PhD FFPH DTM&H
Consultant in Communicable Disease Control
Greater Manchester Health Protection Unit
Control of Infection Unit
Stockport PCT

Donna Davenport
RGN BSc(Hons)
Practice Development Nurse
Practice Nursing
Stockport PCT

The Civil Contigencies Act 2004 requires every major organisation to have plans in place that aim to reduce the risk from emergencies, such as flooding, terrorism attack, disease outbreaks or a human pandemic influenza, so that people can go about their business freely and with confidence. The Act, along with supporting regulations and statutory guidance, establishes a clear set of roles and responsibilities for those involved in emergency preparation and response at the local level. Primary care trusts (PCTs) have a key role to play, and in order to comply with the Civil Contigencies Act the Stockport PCT has been developing their pandemic influenza preparedness plan since 2005.

Why the exercise
As a way of assessing the pandemic influenza preparedness plan, the PCT conducted a mass immunisation exercise in October 2007. The exercise had the following objectives:

  • To assess the practicalities of immunising a large number of the population in Stockport within a short space of time.
  • To increase the knowledge and skills required to conduct a mass immunisation.
  • To enhance our capacity to respond to a pandemic or bioterrorism attack.
  • To provide a learning opportunity and experience for staff.
  • To collect data and feedback, which will enable us to evaluate the exercise and identify areas of improvement.

The exercise
Organising the premises
The mass immunisation exercise was held at a centre used by the local community for various activities. The PCT, mass immunisation exercise planning group and other pandemic influenza subgroups have been meeting since 2006, and have identified about 21 venues that could potentially be used for mass immunisation clinics in the event of a pandemic outbreak or bioterrorist attack. For the purpose of this exercise the community centre utilised was deemed suitable because it was a venue belonging to the Stockport Metropolitan Borough Council (SMBC), which has a good working relationship with the PCT.

Staff involved
The staff involved in the planning of the exercise came from the PCT, SMBC, Stockport NHS Foundation Trust, Age Concern and the Health Protection Agency (HPA). Three planning meetings were organised before the event to discuss the practicalities of the exercise and the different roles needed. For the purposes of the exercise, the following roles were identified as vital to facilitate the smooth running of the day's activities: 

  • An exercise coordinator.
  • A clinical team leader.
  • An administration/clerical team leader.
  • A vaccinating/triage nurse.
  • A doctor.
  • A facility manager.
  • A recovery nurse.
  • Support staff.
  • Administration/clerical staff.

Each of the above roles had an "action card" with the description of their role and space to add anything extra that they had performed on the day that was not written on the card. The mass immunisation exercise took place from 10:00am to 16:00pm. The staff involved in the exercise met for debriefing and setting up the venue from 08:30am and were ready to commence vaccinations at 10:00am. For the purpose of this exercise invitations were sent to the frontline staff in the SMBC, PCT, police and fire services eligible for the seasonal flu vaccine to come and get their flu jabs as part of the mass immunisation exercise. Participants were asked to choose a slot either in the morning or afternoon.

Vaccines
The vaccines were supplied by Stepping Hill Hospital pharmacy department and one of the senior pharmacists had been involved in the planning meetings of the exercise. The vaccines were collected by an SMBC van, which had been booked for the day. The vaccines were transported in cooler boxes and the cold chain was maintained throughout the exercise. Two trips were made to the pharmacy to collect the vaccines during the exercise.
The centre was set up with a reception area, waiting area, vaccination area and recovery area. Signs were placed around the centre highlighting the different areas. As people arrived at the reception area they were welcomed by the administration staff and given a consent form to complete. The completed form and people's identification documents were then checked. People were directed to the vaccination area where they handed their consent forms to the vaccinating nurse. Using the "Aide Memoire for immunisations" according to the PCT's protocols, a final check was performed before giving the vaccine. People were given a postvaccine advice sheet and observed in the recovery area for about 15-20 minutes according to the PCT's protocol. The vaccinating staff comprised two qualified staff and two healthcare assistants (HCAs) in both the morning and afternoon. The two HCAs each worked with a qualified member of staff who observed and checked their competence.
 
Administration staff
The administration staff came from the various departments in the PCT. The administration/clerical team leader in charge gave a team briefing to ensure that each staff member understood their role. The rota for the exercise was organised in a manner that there were four administration staff in the morning and another four in the afternoon. The administration staff's responsibilities included welcoming the people to the centre, helping them to complete the forms, liaising with the vaccinating staff and directing people accordingly to the various areas during the exercise.

Vaccinating staff
There was a total of five vaccinating staff (three qualified and two HCAs) who vaccinated all the people during the exercise. It was estimated that the qualified vaccinating staff were capable of immunising an average of 10-12 people per hour. In the summer of 2007, Stockport PCT commenced a pilot for HCAs and assistant practitioners (APs) to undertake influenza and pneumococcal vaccination for adults.(1) They undertook a robust, bespoke three-day training programme, which was fully evaluated. It was decided to use the mass immunisation exercise to assess some of the participant's competency and level of understanding in relating theory to practice following the training. Competencies and protocols were developed using both the Working in Partnership Programme and Skills for Health, which were invaluable in supporting this development.
It was also necessary for the purposes of this exercise to provide patient-specific directions because the unqualified staff cannot work to patient group directions.(2) Assessments were undertaken by qualified nurse immunisers at each station. The opportunity to work so closely over such a prolonged period was invaluable for both parties. While the trainees were initially extremely nervous (only one had ever given an injection before), by the end of the session they demonstrated a high level of competent and safe practice. Their communication skills improved, as did their level of understanding and knowledge in terms of answering patients' questions and knowing when to refer appropriately.
We also set up a simulated anaphylaxis scenario, which the HCAs and APs were asked to respond to. They did this in a calm and efficient manner making good assessments and were able to provide appropriate rationale for their actions at each stage. By the end of the day all the HCAs and APs had achieved their competencies to a high standard. They were also involved in the debrief session and gave useful feedback about their experience and areas that required addressing in future training and developments within this area.
 
Results
People vaccinated
The mass immunisation exercise was a success and we vaccinated 162 people with the seasonal influenza vaccine on the day, from 10:30am to 15:30pm. Our original aim was to vaccinate 300 people, but this was not possible due to lower attendance than expected. A possible explanation for the low attendance might be the fact that the vaccine had been offered to PCT, SMBC and other frontline responders, who might have been off work because the exercise coincided with half term. Those vaccinated were kindly asked to complete an evaluation form; a total of 148 evaluation forms were received after the exercise. The objectives of the exercise were met and helpful lessons learned, which will enhance planning for future exercises or vaccination clinics.

Evaluation forms
The evaluation forms received from those vaccinated highlighted general satisfaction with the way in which the mass immunisation exercise was conducted. Some of the people found it difficult to locate the centre, others complained about signposting and parking around the centre. Among the evaluation forms one person made the following comment: "As an exercise it appears to work well. A TV and video with information in different languages with signing (British sign language) and subtitles would be have been useful, as the setting would have not been ideal for people with a hearing impairment."
Evaluation comments from the staff who were involved in implementing the exercise were positive and highlighted a general consensus among the group on how things had been handled.

Lessons learned
As previously discussed the implementation of the mass immunisation exercise went well and all the intended objectives were met. There was, however, a few lessons learned throughout the day. The following observations and comments were highlighted as necessary for future implementation of a mass immunisation clinic:

  • A number of people didn't know the name of their GP or which surgery or health centre they were based at. For future exercises we might need to provide a GP list for the area and perhaps send the forms (postvaccination slip) to the GPs instead of relying on patients to take them to their own GP.
  • Although there was a screened-off area for the immunisers, it was felt that we could have done with a much larger screened-off area to facilitate much needed privacy; some of the females receiving the vaccine came to the exercise wearing tops without easy access to their arms and had to take their tops off making it a bit uncomfortable for them because of the way the area was screened off. It was noted that for future exercises and actual events the PCT needs to think of different ways of screening off areas between immunisers/administrators or improvising in order to preserve the dignity of those having their vaccines, especially in smaller venues. It is important to bear in mind that in an actual pandemic or mass immunisation clinic, screens might be difficult to obtain for every vaccinating centre as resources might be stretched. 
  • It was also noted that a number of people who came for their vaccines struggled to find the centre because of poor signs or no signs on how to get there. For future exercises it would be advisable to provide directions to those attending the exercise via email, post or websites. For the purposes of this exercise since most people vaccinated had access to the internet and email, so a global email with directions on how to get to the centre should have been sent. For those without access to email, information should have been circulated via the different heads of services and newsletters.

Conclusion
The implementation of the mass immunisation exercise enabled the PCT to review the practicalities of immunising large numbers of people in a short space of time. Although only 162 people where vaccinated, implementing the exercise enabled those involved in the pandemic influenza plans to assess the preparedness and how well equipped the PCT is to deal with mass immunisation. The use of the HCAs to immunise during this exercise gave them the opportunity to acquire their competencies under supervision, as they had to immunise a large number of people in a short space of time. The venue used also allowed the PCT to make the most of limited space, but at the same time maintaining the dignity of those getting the vaccine. The good working relationship between the various agencies highlighted the importance of team working and what part each agency can play in an actual disease outbreak or mass immunisation clinic.

References

  1. Falconer M, Baxter D, Davenport D. HCAs and immunisation training: results of a pilot programme. NiP 2008;40:58-62.
  2. Department Of Health. Medicines matters: a guide to the mechanisms for the prescribing, supply and administration of medicines. London: The Stationery Office; 2006.