CDC Guidelines for Large-Scale Influenza Vaccination Clinic Planning

To facilitate the most efficient and safe delivery of available vaccine via large community clinics, these recommendations and guidelines have been developed to assist with planning large-scale influenza vaccination clinics by public and private vaccination groups. Ideally, plans from private and public groups should be shared to identify best practices, avoid unnecessary overlapping of services, and maximize the effective and efficient delivery of influenza vaccinations.

This document provides general guidance to help ensure smooth operations at large-scale vaccination clinics under 8 major headings:

1. Leadership roles
2. Human resource needs
3. Vaccination clinic location
4. Clinic lay-out and specifications
5. Crowd management outside of the clinic
6. Crowd management inside of the clinic
7. Clinic security
8. Clinic advertising

Leadership Roles

• Designate local clinic leaders for overall vaccination campaign operations, and leaders for communications systems from both the public and private sectors
• Designate a clinic manager and a team leader each for supplies, logistics, medical personnel, support functions and their respective backups

Human Resource Needs

• Secure staff to fill the positions of greeters-educators, priority client screeners, registration personnel, medical screeners, form/payment collectors, clinic flow controllers, vaccination assistants, vaccination administrators, security and emergency medical personnel
• Meet the language needs of the community using multi-lingual staff
• Prepare staff members to know and execute their responsibilities and be able to correctly answer questions from clients
• Cross-train staff members, if possible, to enable flexibility in meeting needs at various stations as demands fluctuate
• Make provisions for surge capacity staffing, particularly at clinic opening time, where pre-scheduling will not be done or large numbers of unscheduled clients are anticipated
• Request surge capacity staff from out-of-area city/county agencies and health departments, local private nursing agencies, local nursing associations, local law enforcement, local medical community, health care worker and pharmacy students, volunteer groups and personnel working at the retail stores/corporations that might be used as the clinic sites
• Ensure staff well-being by scheduling times for rests and snacks in a designated area

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Vaccination Clinic Location

• Seek out school gyms, churches, auditoriums, theaters or other large covered public spaces accessible to the elderly and persons with disabilities
• Ensure proximity to population centers and mass transit, ample parking, separate entry and exit doors, adequate lighting and heating, functional and accessible restrooms, and adequate space for all clinic functions such as screening, registration, vaccine storage, vaccination, and staff breaks
• Select a facility with space for reasonably large and well-delineated covered gathering areas outside and inside of the clinic

Clinic Lay-Out and Specifications

(See a visual of this layout.)

• Set up for unidirectional client flow from an external gathering area → eligibility screening area (multiple stations) → clinic entrance → facility waiting area(s) → registration/question and answer/form completion area (multiple stations) → medical screening/treatment area (as needed) → Medicare and other payment area (multiple stations) → vaccination area (multiple stations) → exit at a location distant from the entrance
• Use liberal amounts of rope, stands and signs in multiple languages, as needed, in outside waiting area(s) and inside clinic to delineate routes for clients to follow from station to station
• Provide seating for clients at each vaccination station and one or more vaccination stations with surrounding screens where over-clothed clients can discreetly bare their arms for vaccination
• Section off private area(s) where clients who experience acute adverse events after vaccination or who have medical problems can be evaluated and treated
• Ensure the presence of an onsite emergency medical kit and a designated trained physician, emergency medical technician (EMT), pharmacist, or nurse certified in basic cardiopulmonary resuscitation who can administer treatment for allergic reactions and address urgent medical problems

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Crowd Management Outside of the Clinic

• Schedule staff to arrive 1 to 2 hours before clinic opening time to welcome and screen clients even if pre-scheduling is being used
• Arrange accommodations for special-needs clients (e.g., persons with disabilities, very advanced age or fragility) for expedited access into the clinic
• Direct arriving clients into several lines and use numerous signs and announcements to clarify who falls into high-risk groups
• Communicate the number of vaccine doses available at the clinic to the clients
• Instruct clients to assess their eligibility to receive vaccination by reviewing the CDC, or similar, self-screening form and vaccine information statement (VIS); provide language translation services where necessary
• Update clients on their estimated waiting times to be screened
• If vaccine supplies are limited and vaccine is being prioritized for certain groups, inform waiting clients that high-risk populations only will be served and a client numbering system will be in use. More information about ACIP’s recommendations for priority groups in the setting of limited TIV vaccine.
• Schedule at least 2 screeners per line to reduce crowd size and waiting times by rapidly identifying and retaining high-risk clients and dispersing non-priority individuals
• Distribute sequentially numbered tickets, VIS or other forms in appropriate languages that permit entry into the clinic to high-risk clients only
• Provide clients who cannot be served for lack of vaccine an up-to-date listing of alternative clinics providing vaccinations

Crowd Management Inside of the Clinic

• Vaccinate clients in the order of their numbered tickets
• Arrange accommodations for special-needs clients (e.g., persons with disabilities, very advanced age or fragility) to receive expedited vaccination – consider a dedicated vaccination line
• Communicate clinic updates and wait times for vaccination so that clients are free to leave and return to be vaccinated
• Provide entertainment materials, TV and/or refreshments if wait times are anticipated to be long
• Assist clients in completing required forms (e.g., consent forms and/or vaccination cards) by having sufficient registration staff available
• Utilize runners to keep staff stocked with ample supplies so that they can remain at their stations
• Maintain a steady flow of clients through the clinic so that vaccinators are never without a client at their stations; redirect clients who create bottlenecks
• Fill syringes with vaccine at the time of vaccination only – prepare just enough vaccine to meet the clinic's ongoing needs if providers insist upon pre-filling syringes; never pre-fill before clinic opening hours
• Discard any vaccine-filled syringes remaining after the clinic closes
• Provide adequate facilities (e.g., waiting areas, restrooms, water) to meet the needs of the clients

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Clinic Security

• Require all staff to wear identification cards color coded for their job functions
• Consider using uniformed presence to act as security and assist in managing crowds
• Employ security personnel to monitor the mood of waiting crowds and communicate deteriorating situations to the clinic manager
• Secure the vaccine and protect clinic staff and their valuables
• Recruit local volunteers familiar to clinic customers since they may be especially effective in diffusing crowd-related tension

Clinic Advertising

• Use multi-lingual and multimedia channels to widely post clinic purpose, dates, locations, times, and which populations will be served
• Provide instructions on how to set up appointments via telephone, in person, or other systems if pre-scheduling will be used
• Know how much vaccine is available for a scheduled clinic and how to reallocate vaccine through centralized or individual clinic efforts to meet the acute needs of other providers
• Recognize that scheduling may be overwhelmed and therefore not be maintainable or able to meet clients’ needs during a time of severe vaccine shortage; direct clients to other facilities as required

High-volume influenza vaccination clinic with 1) screening area with screeners outside the clinic area to determine high-risk patients to enter the clinic or not high-risk to exit. 2) A client waiting area for education and communication is at the clinic entrance. Staff greet and guide clients. 3) Registration and form completion area with multiple stations consist of tables and chairs for filling out forms. Medical and other staff are available to answer questions. 4) Next station is for payment, Medicare, or insurance. 5) Staff directs clients to vaccination lines. 6) Staff directs clients to vaccination tables. 7) Vaccinators and assistants are at each station. Runners keep vaccinators and assistants supplied. 8) Staff directs vaccinated clients to exit.

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References

These vaccination clinic planning considerations are a compilation of concepts and practices from many sources – published, unpublished and personal communication.
Published sources:

• Prevention and Control of Influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP)
• HHS Pandemic Influenza Plan [6 MB, 396 pages]
• Vaccination Ventures: Explanation and Outcomes of Mass Smallpox Vaccination exercises. San Francisco Department of Public Health [3 MB, 27 pages]

Unpublished Draft Document Sources

• Outbreak Control and Vaccination Campaign Management; Meningitis and Special Pathogens Branch, NCIS, CDC
•  Community-Based Mass Prophylaxis: A Planning Guide for Public Health Preparedness October 2004. Agency for Healthcare Research and Quality, Rockville, MD. 
• General Guidelines for Pandemic Influenza Vaccination Clinics; Health Services Research and Evaluation Branch, NIP, CDC
• Pandemic Influenza: Clinic Preparation Checklists; Health Services Research and Evaluation Branch, NIP, CDC
• State and county health pandemic influenza preparedness plans; selected states
• State, county and city after action reports on exercises of mass prophylaxis and immunization plans; selected states

Personal Communication

• National Influenza Vaccine Summit; Community Vaccinators Working Group members Department of Health and Human Services Centers for Disease Control and Prevention