1. H1N1 Vaccination Campaign Targeting School-age Children in New York City (NYC) Presented by Jane R. Zucker, MD, MSc Assistant Commissioner, NYC DOHMH Bureau of Immunization The NYC Department of Health and Mental Hygiene (DOHMH) and the Department of Education National Immunization Conference April 21, 2010

2. Overview NYC Description –Setting and population Background: H1N1 in the Spring Project Description Results Lessons Learned Plans for 2010-2011 CDC Data

3. New York City Background Population: 8.3 million Annual birth cohort of ~127,000 1.4 million school-age children (K-12) –1.1 million public school children –300,000 private school children More than 1,500 public school buildings Schools nurses are present in nearly all elementary schools with >200 students

4. High School A Outbreak 4/25 Riding the H1N1 Wave

5. Spring 2009 H1N1 Outbreak: Many Infections, Particularly in Children An estimated 12%, or ~1 million, New Yorkers became ill Most recovered completely within 4 to 5 days Rapid spread, high rates of illness in children –Approximately 22% of children 5 to 17 years of age reported ILI during June 2009 School closures –>50 schools closed due to high rates of ILI

6. Planning for the Fall Department of Education (DOE) schools policies – No school closure – Emphasis on preventive measures DOHMH responsible for vaccine distribution – Doctors’ offices – 60 Hospitals – >100 community health centers – Health Department immunization clinics – Other venues, such as pharmacies Special initiative to offer H1N1 vaccinations in school to target school-age children

7. School Vaccination Strategy I Offer vaccine at all elementary schools –Public and non-public Provide vaccine for middle and high school students at weekend clinics (Point of Dispensing sites [PODs]) –For 5 weekends throughout the city Would supplement the vaccine available at the child’s primary care provider

8. School Vaccination Strategy II Small elementary schools: <400 students –Use regular school nurse Mid-size schools: 400-600 students –Regular school nurse plus a contract nurse Large schools: >600 students –9-person vaccination teams –1 team leader, 4 nurses, and 4 support staff Vaccine only –19 private schools

9. School Vaccination Strategy: Planning Established planning committee Logistics, staffing, scheduling, forms, training, data management, schools lead (public, private, charter), and weekend clinics Partnerships: DOE, Office of Emergency Management Planning assumptions: –All students 4 years and older –2 rounds –H1N1 vaccine only, both inactivated and LAIV –Deployment for 8 to 10 week period

10. School Vaccination Implementation Pilot program with seasonal flu vaccine in September Phase I: small elementary schools –Started Oct 28th Phase II: initial team deployment –Started Nov 4 th with 15 teams Phase III: started Nov 9th –Expanded to 52 teams –Began mid-size schools

11. School Vaccination: Staffing School-located vaccination –DOHMH staff Command and control Team leaders Team members Field supervisors PODs –DOHMH staff –Medical Reserve Corps volunteers Mobilization from 19 other city agencies

13. School Vaccination: Promotion Materials sent home to all students –Cover letter, volunteer recruitment, consent, screening, VIS, HIPAA –Translated into 9 languages Press conferences and releases Paid and unpaid media –TV, radio, print 311 (NYC hotline) Website: nyc.gov/flu Online flu locator

14. Results: School-Based Program 571,282 eligible elementary school children 150,989 consents (26.4%) 208,887 total doses given 128,228 first doses (22.4%) 80,659 second doses 1,232 schools at 1,078 sites Public (n=774) Non-public (n=309) Special education (n=149)

15. Results: PODs 58 total PODs held 49,986 persons vaccinated 39% were of school age Each successive weekend, eligibility criteria to attend the POD were expanded

16. * Based on CIR data, as of April 14, 2010 H1N1 Doses and Where They Were Given 2009-2010 season*

17. Age* # with 1 H1N1 (per CIR)* Census Denominator % with 1 dose (per CIR) 6 months - 3 years119,621394,47530.3% 4 -10 years244,452716,67834.1% 11 - 18 years119,578839,34714.2% Total483,6511,950,50024.8% *The number of children in each age group includes all children that were at that age at the time of the H1N1 administration. Some children may have aged out of that cohort at the time of this report. As a consequence coverage for that age group is slightly overestimated Estimated Coverage for H1N1 Vaccine Based on CIR Data as of 4/14/2010

18. Based on CIR data, as of April 14, 2010 Seasonal Influenza Vaccination among Children who Received H1N1 Vaccination in School or at PODS Age (years) # Children Who Received H1N1 Vaccine in School or PODs % Who Received Seasonal Flu vaccine in 2008-09 % Who Received Seasonal Flu vaccine in 2009-10 % Who Ever Received Seasonal Flu vaccine 6m-3y1,25014% 25% 4y-10y116,69026%27%53% 11-18y22,73719%21%40%

19. Results: Staffing Numbers* School Program PODs**Total DOHMH3001,0301,330 Other City Agencies 1501,9352,085 Other staff 300 contract nurses 187 MRC volunteers 487 Total7503,152***3,902 *=preliminary, staff may have worked both the school program and PODs **= 58 PODs were held over 5 weekends *** = some people worked more than 1 POD

20. Timeline Sept 1, 2009 - Decision to go ahead with school program Sept 9- Planning committee formed Sept – Forms development, completed Oct 2nd Oct 5 – Materials were translated Oct 12 - Distribution of materials began Oct 28 - Phase I Nov 4 - Phase II Nov 7-8 - First POD weekend Nov 9 - Phase III Nov 30 - Round 2 started Dec 12-13 - Last POD weekend Jan 8, 2010 - Round 2 completed March - Special education schools completed March - Supplies picked up April - Red bag waste pick up

21. Cost Infrastructure developed with public health emergency preparedness funds were critical to the success of this program –Examples are investments in SNS and PODs and use of an existing scannable form to collect vaccination information School campaign supported with PHER funds School-located program: >$ 4.6 million* PODs: >$4.4 million* Estimates do not include vaccine and supplies which were provided by CDC for free Estimates do not include cost of in-kind resources such as personnel *= preliminary figures

22. Lessons Learned I Participation –Increased consent rates associated with increased participation by parent coordinators and principals Partnerships –Working closely with DOE was critical for success –Challenges with private schools –Importance of addressing labor issues

23. Lessons Learned II Implementation –Effective command and control structure –Logistics infrastructure –Obtaining feedback early in the process –Need adequate time line –Need for robust data management system Including for school scheduling, consent and vaccination number, payroll –Provide more guidance and best practices to schools –Pilot program was helpful for planning

24. Conclusion Citywide school-based vaccination is feasible in a large urban area Was effective in reaching children who had never received a flu vaccine before Requires adequate resources and planning time to sustain Maintaining preparedness infrastructure and continued investments are key for implementing such programs

25. Looking to Next Flu Season: What Does the Future Hold? Should we do this again in 2010-11? How would we finance? –Feasibility of billing Evaluation underway –Cost analysis –More detailed analysis underway about what worked, what didn’t work Other approaches –Restrict to one round and team approach –Community vaccinators

26. Acknowledgements Thank you to my colleagues in DOHMH, DOE, OEM DOHMH DOE Linda MayAnne RinchiusoPaul McCulloughStephanie Keating Allison ScacciaMark MisenerRoberta Holder-MosleyAngelo Lisa Beth MaldinPeter JohnRose GasneDespina Zaharakis PreetiPathelaLindsay SenterSarantosSoumakis Carmen JonesChris ZimmermanShadi Chamay Nora PuffettAndy GoodmanSondra Carter Susan O’BrienAnilkumar ShahSonia Angell OEM Colin StimmlerAnnabel GeorgeSusan BlankJohanna Conroy Heather NarciscoBeth BergierTom MerrillAlex Markowski Wilson WangCathy NonasTracy Agerton Susan KansagraChrispin KambiliYasemin Murad Office School Health David StarrDeborah LomaxChristina ChangRoger Platt Matt MotherwellDiana NilsenThomas FarleyOxiris Barbot Vikki PapadoukaElisa DunnDennis KingCarol Marchese Susan O’BrienElliott MarcusAngel LapazGary Krigsman Bonnie UmAnna CaffarelliIsaac WeisfuseLinda Moskin Eric FriedenbergEve CaganSheila PalevskyChristine Edillon Felicia DworkinLisa HeineEdward WakeRichard Fox Jane BedellKaren LeeKelly Carr Kevin KosharLorraine CamuratiMorgan Johnson Louise CohenLynn Silver MaryMastersonMeggan Schilkie Mercedes YoumanMillicent Freeman And many, many more …..

27. Thank you