Broward County Public Schools is the sixth largest public school system in the nation with a total of 343 schools, including 105 charter schools and over 268,000 students. Additionally, there are 207 private schools with approximately 40,000 students in Broward County. All students in grades pre-kindergarten through 12 in public and non-public schools are required to have proof of immunization status in the form of a Florida Certification of Immunization, DH 680 Form on file at their school as outlined in Section 1003.22, Florida Statutes, and Rule 64D-3.046, Florida Administrative Code Requirements for Admittance and Attendance.
Every year the immunization status of students in kindergarten and seventh grades is compiled by public and private schools and reported in the Kindergarten & Seventh Grade Annual Report of Compliance Summary. The state of Florida requirement is 95% of students in kindergarten and seventh grades will be fully immunized in all counties. This immunization goal is in keeping with the Healthy People 2020 national goal of 95% for Kindergarten students.
The November 2014 Florida Annual Immunization Assessment of Kindergarten and Seventh Grade Students reflected a total number of 21,112 kindergarten (6.6%) and 21,413 seventh grade students (4.4%) respectively in Broward County public and private schools who were not fully immunized. The public health issue in Broward County has been the inability to reach the state and national immunization compliance goal of 95% for kindergarten and seventh grade students.
The goals and objectives of the DOH-Broward Immunization Outreach Activities for School Aged Children Model Practice are twofold: first, to provide immunizations to school aged children to mitigate the risks of infectious disease outbreaks within the county and second, to meet the state goal of ensuring that 95% of kindergarten and seventh grade students are fully vaccinated.
To meet the goals and objectives of this model practice multiple strategies have been implemented by DOH-Broward to address this public health issue. Immunization planning activities begin in the spring months prior to the beginning of each school year with the provision of on-site immunizations to students at selected middle schools by DOH-Broward nursing staff. At the same time each year, an Incident Command Structure (ICS) is activated to begin the planning activities for a Back to School Immunization Point of Dispensing (POD) event held for two and one-half weeks prior to the start of school in August at a centrally accessible location in the county. DOH-Broward staff provides on-going immunization assistance to schools in the county including the review of student immunizations in Florida SHOTS and the printing and delivery of immunization records to schools as requested.
The public health impact of this model practice has been positive. Since 2012 DOH-Broward has consistently increased the number of school aged children vaccinated and the number of vaccines administered utilizing the approaches of this model practice. This positive trend is also reflected in the county’s kindergarten and seventh grade immunization compliance rates remaining above the state average since the implementation of this model practice.
The website for DOH-Broward is http://broward.floridahealth.gov/
The DOH-Broward Immunization Outreach Activities for School Aged Children is a creative response to the local issue of immunization compliance as it is based on existing public health practices. This innovative practice is a hybrid model that utilizes both Mass Prophylaxis Planning and ICS Structure tailored to address the public health issue of immunization compliance in the county’s school aged population. This model practice focuses specifically on school aged children in the county who have limited access to medical care. This is evidenced by the greater health needs in the county’s Title I schools, which are primarily located in lower socioeconomic areas with high numbers or high percentages of children from low-income families, with student’s who often times do not have a medical home. DOH-Broward has targeted these schools to provide on-site school immunization activities. The annual Back to School Immunization POD has been held in a central location, close to several Title I schools, within the county with easy access from public transportation to accommodate family needs.
Historically, the week prior to and the week of back-to-school, DOH-Broward Heath Centers have been overwhelmed with children who are in need of back-to-school immunizations. Prior to 2010, DOH-Broward supported the vaccination requirements for school-aged youth by providing required vaccines to children at DOH-Broward clinics and community health fairs throughout the county. The immunization compliance rate for kindergarten in 2008/2009 kindergarten rate was 78.8% and 89.5% for seventh grade.
In August of 2010 and 2011, in order to increase immunization compliance rates, DOH-Broward launched “Back to School Immunization Outreach” campaigns for school aged children in partnership with community-based providers and municipalities at multiple public immunization Point of Dispensing (POD) locations throughout the county scheduled for various dates and times depending on the location. In addition to providing immunizations to school-aged children, the activation of the Immunization POD demonstrated the creative use of practicing the core DOH-Broward capabilities of mass prophylaxis and the Incident Command Structure (ICS).
In 2012 DOH-Broward set up one POD in a central location of Broward County located in a shopping mall near a county bus terminal. This POD was in operation from Monday thru Friday for two weeks prior to the start of school and for the first two days of school. The POD schedule was the same each day with the exception of adding additional hours on Thursday evenings and one Saturday to meet the needs of working parents. By placing the POD in one central location, with set hours and easy access to public transportation DOH-Broward was able to better meet the needs of the community. In order to inform the parents/guardians about the immunization POD there was a mass media campaign starting before the end of the school year. Palm cards with all of the immunization POD information (dates, times, and location) were written in three languages and sent home with the students prior to the end of school. The same palm cards were distributed throughout the county to community partners such as libraries, clinics, schools, local stores, and social service organizations. Closer to the start date of the POD there were both print and radio announcements to inform the community of the immunization outreach event. Banners publicizing the immunization POD were placed at each of the DOH-Broward clinic sites as well as the location of the POD. The mall also advertised inside the mall and in their bi-weekly newsletter.
The setup of the DOH-Broward Immunization POD in a central location has proven to be a better practice than previous years when the Immunization PODS were held in multiple locations. The centralization of the two and a half week immunization event streamlined the overall operation of the POD including improved management of logistics and resources including staff, equipment, vaccines, and supplies.
The DOH-Broward Immunization Outreach Activities for School Aged Children is a creative model practice based on the existing Healthy People 2020 Evidenced-Based Resource Summary regarding the Universally Recommended Vaccinations: Community-Based Interventions Implemented in Combination (Community Guide Recommendation) that, “Community-based interventions implemented in combination to increase vaccinations in targeted populations are recommended on the basis of strong evidence of effectiveness in increasing vaccination rates. The conclusion of strong evidence was based on findings from 17 studies that evaluated coordinated interventions to: increase community demand; enhance access to vaccination services; and reduce missed opportunities by vaccination providers. Community-based interventions implemented in combination involve activities coordinated in a community to increase vaccination rates within a targeted population. Activities focus on increasing community demand for vaccinations and enhancing access to vaccination services. Efforts may also include interventions directed at vaccination providers. Programs usually involve partnerships of community organizations, local government, and vaccination providers. Coordinated interventions may include: client reminder and recall systems; the use of staff to conduct manual outreach and tracking of clients; mass and small media; and educational activities.” The Healthy People 2020 Evidenced-Based Resource Summary includes study results that are applicable to the following groups: populations with low vaccination rates, children ages 12 years and younger, groups with low socioeconomic status, and racial and ethnic minorities. The study results support the goals of the DOH-Broward Immunization Outreach Activities for School Aged Children model practice to provide immunizations to school aged children to mitigate the risks of infectious disease outbreaks within the county and meet the state goal of ensuring that 95% of kindergarten and seventh grade students are fully vaccinated. More than 30% of Broward County residents are from other countries so our immunization programs often serve as the entry point for primary healthcare for school aged children and their families.
This model practice is also in alignment with the CDC Winnable Battle of Global Immunization philosophy that protecting children from vaccine-preventable diseases (VPDs) requires an organized, accessible, and well-functioning immunization program. The practice also aligns with Public Health Accreditation Board (PHAB) Standard 4.2: Promote the community’s understanding of and support for policies and strategies that will improve the public’s health.
Results /Outcomes Due to the success of the Back to School Immunization POD, DOH-Broward has continued the practice. Statistics reflect the positive results as shown by the increasing number of children vaccinated at the POD (table 1) as well as the increasing percentage of kindergarten and seventh grade students meeting or exceeding the state immunization average (table 2) between the years of 2011 through 2015. Important factors leading to the success of this model practice are that the Immunization POD was held at the same location each year and was easily accessible to the community. The massive advertising campaign also played a key role in the success of the POD. However, there is still work to be done to reach and maintain the state’s requirement of 95% vaccination compliance for kindergarten and seventh grade students in Broward County.
Total Number of Children Vaccinated During Immunization POD:
Year Total Served # Vaccinated # 680 Forms # Vaccines Given
2012 2,665 1,840 825 4,347
2013 3,024 2,012 1,012 4,544 2014 3,113 2,102 1,037 5,014 2015 2,726 2,147 579 6,283
Broward County K & 7th Grade Immunization Rates:
School Year Broward Kindergarten% State Average % 7th Grade% State Average %2011-2012 92.90% 92.6% 93.80% 95.4%2012-2013 94.90% 92.1% 93.70% 95.3%2013-2014 93.60% 93.2% 96.60% 96.6%2014-2015 93.35% 93.3% 95.59% 95.7%
Local Health Department and Community Collaboration and Implementation StrategyDOH-Broward has led the way in the development and implementation of immunization programs and practices for the community. Collaboration with community entities has been key to the success of the DOH-Broward Immunization Outreach Activities for School Aged Children Model Practice.The operation of this model practice included collaboration and participation from DOH-Broward programs such: Immunization, Emergency Operations, Pharmacy, Nursing, School Health, and Management & Information Services. Additionally, a wide variety of departments were key in promoting the events, providing staff support, and resources and include: Women, Infants and Children (WIC); HIV/STD; Tobacco Prevention; Drowning Prevention; KidCare and the Florida Breast and Cervical Cancer Early Detection (FBCCEDP). The key outside entities that contributed to the success of the Immunization POD included the Medical Reserve Corps and Cities Readiness Initiative. Communication and support with Broward County Public Schools was a vital component to the success of the campaign.Planning for the 2015 back-to-school immunization campaign began on March 9, 2015, with the ICS Activation meeting with the Incident Command Chiefs. Weekly Incident Command Meetings were held from April 6, 2015 through August 4, 2015, with a total of 14 Situation Reports developed. An initial Incident Action Plan (IAP) was prepared on March 9, 2015, with a total of five IAPs developed over the course of the campaign. During the period August 10, 2015 through August 25, 2015, (while the POD was in operation), daily morning briefings were held with the command staff.
DOH-Broward operated a community POD at the Lauderhill Mall from August 10, 2015 through August 25, 2015. In preparation for this immunization outreach event:Vaccinator trainings were conducted July – August, 2015 with identified nursing staff. Florida Shots trainings were conducted in July, 2015. POD training was held on July 24, 2015 with a mock, simulated POD so staff could exercise their skills in a training environment. There was an all-day training conducted on August 7, 2015, for POD staff which included morning classroom presentations, just-in-time position training, and POD set up at the Lauderhill Mall. Due to the collaborative efforts of multiple program staff, the POD set-up was completed in 60 minutes, which meets the target of 60 minutes for POD set-up.A health resources fair was held on Saturday, August 22, 2015 in the mall where the POD was located. A total of 47 organizations and programs participated at the health resources fair. In addition, the School Board of Broward County, the City of Lauderhill and the Lauderhill Mall were instrumental partners during the planning and implementation phases.DOH-Broward fostered ongoing collaboration with community stakeholders throughout the preparation and planning process through open communication. Printed materials were provided to multiple community providers for dissemination to their clients. An example of this collaboration was DOH-Broward’s delivery of thousands of Immunization Palm Cards to Broward County Public Schools for distribution to all schools prior to the end of 2014 school year.
Public Health ImpactThe DOH-Broward Immunization Outreach Activities for School Aged Children Model Practice conducted each year directly supports DOH-Broward’s goals to decrease the incidence of vaccine-preventable diseases in the county and meet the state goal of 95% immunization compliance for students in kindergarten and 7th grades. This innovative immunization campaign is a model practice because it provides an opportunity for staff to work with multidisciplinary teams and community partners to exercise both the Mass Prophylaxis Plan and the Incident Command Structure (ICS).
The two key objectives of the Immunization Pod were to 1) provide back-to-school immunizations to school aged children which demonstrated the core capability of Medical Countermeasure Dispensing and 2) Organize community immunization PODs for back-to-school immunizations which demonstrated the core capability of Incident Command.
The satisfaction of results of DOH-Broward POD staff and clients were analyzed via electronic and paper surveys. An electronic survey monkey questionnaire was sent to all staff and volunteers who worked at the POD at the Lauderhill Mall. A total of 51 out of 91 the POD staff completed the survey. In response to the pre-event training provided, 65.31% of staff indicated that they had received adequate training to prepare for their POD role with 81.25% indicating that they understood their place in the POD organizational structure. 86.00% of staff indicated that they knew who their supervisor was at the POD and also knew how to get answers to their questions.Back-to-school immunization satisfaction surveys were disseminated to clients at the POD and collected prior to exit. 843 surveys were completed. The overall visit was rated as “very positive” by 75.12% of respondents. Staff courtesy and knowledge were both rated excellent at 57.91% and 58.04% respectively. Slightly more than half (53.07%) indicated that they had a previous immunization history through the Florida Department of Health.
Examples of some of the client remarks from the paper surveys include:“The service was very good. I don't think I do not have any complaint. I come here every year I would not come back if they didn't do a good job. They are very good team. May God bless them.”“From start to finish the staff was immaculate, the nurse was gentle and exceptional, thanks.”“Great that the County is making this available to the community.” “Appreciated the time spent. Good experience organized process personnel has knowledge, skills and good attitudes.”“All the staff was very courteous and efficient. My overall experience was excellent, job well done. Thank you for providing this service, I really appreciate it.”
The Immunization POD was analyzed utilizing the Strength, Weaknesses, Opportunities and Threats (SWOT) method. A debriefing and SWOT analysis was held on September 3, 2015 with the incident command team and the following is a summary of the results: Strengths - The full capability level can be attributed to the following strengths:Strength 1: Experienced personnel. Most of the incident command team has previous incident command experience which enabled the campaign to function smoothly with seamless adjustments being made in real-time.Strength 2: Training. POD staff (greeters, flow monitors, and data entry) was crossed trained in FL SHOTS. MOCK POD training was held in the Administrative Auditorium and provided a real demonstration of the flow process within a POD. Strength 3: Organization.
Areas for Improvement - The following areas require improvement to achieve the full capability level:
Area for Improvement 1: Revise registration forms.Reference All-Hazards Response Plan and COOP AnnexAnalysis: Registration forms need to be revised to include all necessary information needed in order to be inputted in the FL SHOTS and HMS systems. Forms should have easy to follow language for clients.
Area for Improvement 2: All supply boxes need to be clearly labeled inside the cages.Reference All-Hazards Response Plan and COOP Annex Analysis: All supply boxes need to be labeled appropriately and at the end of the day items need to return to the same boxes and placed in same cage in order to avoid confusion.Plan: Modifications to client registration forms and POD supply cages will be made to improve the POD for next year based on the recommendations from the SWOT.
Lessons have been learned each year in relation to the DOH-Broward Immunization POD practice:
The key lesson learned is that proper planning and the utilization of ICS for the past three years has proven to be an effective structure for the effective mobilization of a community-wide Immunization POD for school-aged children in Broward County. As a result of utilizing the ICS structure there is sufficient staff trained to operate an Immunization POD in the future. This practice has promoted mentoring of staff in all areas of the ICS structure and has allowed the annual practice of mass prophylaxis planning & implementation.
There has been consistent stakeholder commitment to sustain the Immunization POD practice in our county. Through community partnership and collaboration the stakeholders continue to be invested in support of the annual summer immunization campaign.
Cost analysis of the Immunization POD has been conducted by the DOH-Broward Finance Director. A comparison of costs from the 2014 and 2015 PODs is noted below. There has been as an increase in expenditures from the 2014-2015 fiscal year to the 2015-2016 fiscal year due to the increased volume of POD clients and vaccines utilized.
Description Operational Period Increase FY 14 FY 15 Purchases $6,346.00 $7,877.80 19%Salary $86,086.00 $129,607.11 34%Fringe $37,595.00 $51,880.60 28%Total Salary/Fringe $123,681.00 $181,487.71 32%Total cost $130,027.00 $194,629.41 33%
The only factor that may prohibit the sustainability and continuation of the annual Immunization POD event is future funding.