Individuals who are homeless, homebound, lack health insurance, speak limited English, or have limited access to financial resources or medical care are typically the most in need of and have the greatest challenges accessing the influenza vaccine.
The Oregon Adult Immunization Coalition is a volunteer, statewide network of health and community partners dedicated to the prevention and control of vaccine-preventable diseases through immunization for all adults regardless of age, economic status, race, or ethnicity. During the winter of 2009-2010, the coalition focused on distributing the H1N1 influenza vaccine to hard-to-reach populations through an outreach and education project, initially called Free, Local, Underserved, but more recently shortened to the Underserved Project.
- Accessing services can be challenging for many populations, including homeless, low income, racial and ethnic minorities, home-bound and disabled persons, sexual and gender minorities, and limited English-proficient speakers
- Budget cuts for local health departments forced agencies to scale back on community outreach and services for hard-to-reach populations
- Surplus vaccine was going to waste each flu season and providers were looking for organizations that would receive vaccine donations
- Nursing and pharmacy students lacked clinical training in immunizations and had a shortage of clinical rotation opportunities
- Public outreach and community partnerships are a priority for the state’s immunization program
- Immunization myths (eg, vaccines cause autism, misunderstanding contraindications)
- Provider resistance to changing outdated techniques (eg, aspiration of syringe, too small of a needle, site of administration, paperwork requirements)
Through the Underserved Project, the Oregon Adult Immunization Coalition gathers donated vaccine and clinical supplies, trains nursing and pharmacy students in immunizations, and organizes free clinics for people who otherwise may not get vaccinated.
The Underserved Project accesses state-owned vaccine under the 317 funding stream, and takes donations of privately owned vaccine supplies to off-site clinics that provide nonmedical services to at-risk and high-need communities. Off-site clinics are run at health fairs, food banks, migrant worker agencies, detox facilities, and homeless outreach centers with the assistance of volunteer nursing and pharmacy student injectors who provide vaccines at no cost.
The project partners with nursing and pharmacy schools to train students in administering vaccines. Training consists of:
- A 2-hour vaccine theory lecture conducted by project staff
- Short-term projects
- A 1-hour just-in-time training by school clinical instructors at the vaccination clinic site
- Supervision of students performing immunizations at off-site clinics by school instructors
The project primarily recruits clinical sites through local health departments, who cannot fill requests that come to them, and also through word-of-mouth.
Project participants identified the following lessons learned:
- The time-intensive nature of managing volunteer training, scheduling, and credentialing
- The need to prioritize agencies that host vaccine clinics due to high demand
- The need to be aware of individual schools’ policies while coordinating lectures and clinics
- The importance of having a vaccine insurance policy that covers liability issues with clinic sites, clinical schools, and volunteers
- The need for many volunteers when transporting, setting up, running, and tearing down for a large clinic if there is limited paid staff time on the project
- The value of requiring clinical instructors and community volunteers to also undergo vaccine theory training before they are allowed to oversee students at a clinic so that all participants are on the same page
What made this practice possible?
- Partnerships were instrumental to the successful coordination and implementation of the project. Partners included:
- Oregon Immunization Program provided a coordinator position, storage for clinical supplies and vaccine, access to government-owned vaccine, use of their standing orders, and additional project funding.
- Local health departments often donated vaccine and clinical supplies, advertised clinics to low-income clients, and offered staff time at clinics.
- Nursing and pharmacy schools allowed project staff into the classroom to present a vaccine theory lecture, sent instructors and students to run off-site clinics, helped discover new target sites for vaccine clinics, and provided occasional interns to do specific projects (eg, developing training videos on vaccine administration).
- Nongovernmental organizations across Oregon assisted with giving referrals to clinics and hosting clinics. Further, organizations assisted with translation, interpretation, and donation of clinical supplies.
- Local businesses donated cash, supplies, and vaccine using the coalition’s charity foundation.
- Fundingfrom a variety of sources contributed to program implementation:
- The Oregon Immunization Program supported the Underserved Project ($6,000) and the coalition’s overall budget ($25,000).
- Friends of the Oregon Adult Immunization Coalition, the coalition’s charity foundation, organized small grants and collected private donations online and from the Board of Directors.
Volunteers. Project staff is volunteer-based except 20 hours per week for a coordinator position and 10 hours per week for clinical oversight from a public health nurse.
Access to state vaccine supply. Oregon’s immunization program dedicates program funding for high-risk adults who cannot afford to pay for immunizations; however requirements to provide state-owned vaccine can be a barrier in other states depending on the funding mechanism. Requirements include strict storage, inventory processes, dose reporting to the registry, special permissions for eligibility screening, and access to a medical provider willing to sign standing orders.
- The coalition has grown from solely providing flu vaccines during the winter (about 400 shots each year) to providing 5 vaccines (about 6,000 doses each year) at a variety of off-site clinics year-round, including flu (nasal, intramuscular, and high dose), pneumococcal, Tdap, HPV, and Hepatitis A/B.
- Strong partnerships with clinical schools have improved the knowledge and proper use of vaccines among students and will allow the coalition quick access to hundreds of immunization providers during times of medical surge. In 2010, the project provided over 4,000 clinical learning-hours to 14 clinical schools across Oregon. In addition, in one day at the Diabetes EXPO, 50 student vaccinators served over 1,000 clients.
- The interdisciplinary mix among nursing and pharmacy students, plus other community practitioners, at the vaccination clinics is a positive learning experience that has built relationships across specialties.
Running direct services, like the Underserved Project, is atypical for state-level public health; however, the clinical training role aligns with the state’s mission. In the future, this project plans to continue partnerships with the clinical schools, scale-back on the number of clinics and doses, and explore additional ways to engage private providers in the state’s immunization program.