Use of the Emergency Incident Command System forSchool-located Mass Influenza Vaccination Clinics

abstractIn Palm Beach County, Florida, the fall 2005 influenza vaccination sea-son was interrupted by Hurricane Wilma, a particularly destructivestorm that resulted in flooding, power outages, extensive propertydamage, and suspension of many routine community services. In itsaftermath, all public health resources were immediately turned tothe response and recovery process. School-located mass influenza vac-cination (SLV) clinics were scheduled to begin in 1 week, but were nec-essarily postponed for a month. The juxtaposition of these 2 majorpublic health events afforded the school district, health department,and other community services an opportunity to see their similaritiesand adopt the Incident Command System structure to manage the SLVclinics across West Palm Beach County, Florida, a geographically largecounty. Other lessons were learned during the hurricane concerningorganizations and people, processes, and communications, and were ap-plicable to school-located mass influenza vaccination programs, and viceversa. Those lessons are related here. Pediatrics 2012;129:S101–S106

AUTHORS: Marsha Fishbane, MD, ScM,a Anne Kist, RN, BSN,NCSN,a and Richard A. Schieber, MD, MPHb

aPalm Beach County Health Department, West Palm Beach,Florida; and bEpidemiology and Analysis Program Office, Office ofSurveillance, Epidemiology, and Laboratory Services, Centers forDisease Control and Prevention, Atlanta, Georgia

KEY WORDSinfluenza vaccination, immunization programs, mass vaccination,school-aged population, school health services

ABBREVIATIONSHCD—health care districtICS—Incident Command SystemPBC—Palm Beach CountySLV—school-located mass influenza vaccination

The 3 authors made substantive intellectual contributions to thispublished study and met the following criteria: (1) madesubstantial contributions to conception and design, acquisitionof data, or analysis and interpretation of data; (2) drafted thearticle or revising it critically for important intellectual content;and (3) approved its final version to be published.

The views and opinions expressed in this article are those of theauthors and do not necessarily reflect the official position orpolicy of the Palm Beach County Health Department of theFlorida Department of Health or of the Centers for DiseaseControl and Prevention, Department of Health and HumanServices. Medimmune, Inc. had no role in the informationcollected or interpretation of the data and did not help prepare,review, or approve the manuscript.

www.pediatrics.org/cgi/doi/10.1542/peds.2011-0737J

doi:10.1542/peds.2011-0737J

Accepted for publication Nov 29, 2011

Address correspondence to Richard Schieber, MD, MPH,Epidemiology and Analysis Program Office, Office of Surveillance,Epidemiology, and Laboratory Services, Centers for DiseaseControl and Prevention (CDC), 1600 Clifton Rd NE, MS E33, Atlanta,GA 30333. E-mail: RSchieber@cdc.gov

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2012 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

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The period from September to De-cember 2005 provided an unusual ed-ucational opportunity for public healthplanners in Palm Beach County, Florida(PBC), when a hurricane interruptedthe influenza vaccination season. Countyhealth and school district officials hadmetduring the lastweekofSeptember tobegin planning a school-located massinfluenza vaccination (SLV) program forall elementary schools in the county,subject to approval by their principals.During October, school nurses had beentrained to manage all elements of theprogram, and principals were makingtheir final decision concerning possibleparticipation of their school. The firstschools were scheduled to begin vacci-nating children November 1.

However, on October 24, HurricaneWilma struck PBC and diverted allpublic health services to the manage-ment of this emergency. HurricaneWilma was a Category 5 hurricanebefore landfall, the most intensehurricane recorded to date in the At-lantic basin.1 After the storm madelandfall in an adjacent county as aCategory 3 storm, its winds dimin-ished but were still destructive asthe storm moved through PBC. In itsaftermath, schools were closed for 2weeks; some were used as shelters,and others sustained serious stormdamage or prolonged power outage.After a disaster, local governmentsare usually eager to reopen class-rooms for education, in part becauseschool reopenings are a visible signthat community life is returning tonormal and to minimize the amountof curriculum time lost. Integrity ofperishable vaccine was threatenedby a lack of power. Personnel, espe-cially American Red Cross nurses andhealth department staff, were rede-ployed to meet the disaster responseneeds.

The hurricane response completelydisrupted the timelineandplansalready

made for the SLV clinics* and delayedtheir initiation for 4 weeks. PBC HealthDepartment was involved in bothevents, thereby permitting real com-parisons to be made between the 2events. The Incident Command Systemused for hurricane rescue and re-covery was adopted for the SLV pro-gram.2 We derived a set of lessonslearned from the hurricane responsethat we could apply to the SLV program,and vice versa.

PRESENTATION

Lesson 1: People and InstitutionsNeed to Be Credible and Trusted

In many cases, the same organizationsand their personnel from public health,

schools, emergency response, andvolunteer groups participated in boththe Hurricane Wilma response and theSLV program. Some organizationsserved a very similar role, whereas theroles of others differed (Table 1). Ineither case, it became clear from thehurricane response that a major re-quirement of these organizations wasto be credible and trusted by the af-fected community. The reputation ofsuch organizations relied on positivepast experiences within the communityduring emergencies or new and un-expected community threats. We knewthat in the public health managementof natural, man-made, or terroristdisasters it was imperative to quicklyidentify the key professional peoplewith success in past disaster man-agement, as well as those with exper-tise in anticipating and managing thetype of problems likely to arise from

TABLE 1 Comparison of the Roles and Responsibilities of Organizations and People Involved inPBC Disaster Response to Hurricane Wilma and the SLV Program

Organization Role in SLV Role in DisasterResponse

Palm Beach County HealthDepartment (PBCHD)

Provided leadership andsome nurse assistanceto SLV clinics

Provided public healthnurses in response toareas of need

School District of PalmBeach County (PBC)

Principal authorizedparticipation; school staffdisseminated information,collected consents, andsupported clinic functionsand student flow

Provided school facilitiesas shelters

Health Care District(HCD) of PBC

HCD nurses staffed SLV clinics;HCD pharmacists providedproper cold-chain storageof vaccine, repackaging ofvaccine, and epinephrinefor treatment of anaphylaxis

School nurses volunteeredat safe-haven shelters;pharmacy provided staffand pharmaceuticalson-site for the specialneeds shelter

American Red Cross (ARC) Although their participationwas anticipated, the disasterresponse made it impossiblefor them to help staff SLVclinics

Provided coverage at schoolshelters and other facetsof response

PBC Fire Rescue Provided same-day deliveryservice of vaccine to eachschool clinic

Provided emergency medicalcare and fire suppression

Local pediatrician Volunteered time to train schoolnurses and ARC nursesin advance

Volunteered in local medicalreserve corps

Area hospitals Provided incineration facilitiesto handle biomedical wastefrom the clinics

Provided emergency andother medical care

*Note that the use of the word “clinics” in thisarticle refers only to SLV clinics, not to massvaccination clinics after the hypothetical releaseof a bioterrorist weapon.

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each type of disaster. However, experi-ence and expertise are not sufficientto gain trust. These leaders need thecommunity to respond with vigor totheir direction, and that leadership roleis only effective to the extent that lead-ers are trusted. The trust developedduring both previous discussions and inpast emergencies converted to trust ofSLV programs and their clinics.

Lesson 2: School Facilities andPersonnel Are a Very Broad andDeep Resource

Schools offer many of the necessaryfunctions, personnel, and facilities alsoneeded in the SLV program. Many havelarge gymnasiums that can be used asSLV clinic sites and are commonlypreferred sites for managing or shel-tering large numbers of people afterdisasters such as Hurricane Wilma.Schools are accustomed to providingservices in addition to education, suchas providing space for polling places,emergency shelters,meeting places forafter-school activities, PTA meetings,and community fairs.

School personnel make excellent part-ners. Teachers, particularly at the ele-mentary school level, are accustomed tomanaging the location of all their stu-dents at any given moment. Studentslook to them completely for guidance.School principals generally knowwhattheir facility, staff, and teachers arecapable of doing on a day when a clinicis occurring. Office staff members arelikely to know the parents, which helpsin obtaining consent. Parent volun-teers are already identified for eachclass and expect to help on suchoccasions.

In the days before the hurricane struck,school principals were making theirfinal decision about whether theirschool would take part in the clinicprogram. As often occurs in a naturaldisaster, all schools were closed assoon as the hurricane struck, andmany

schools not severely affected by thehurricane were converted into tempo-rary shelters. The principals needed tomake a final decision whether to allowthe clinic to take place. This was a dif-ficult decision, given their priorities ofreturning to normalcy and catching upon missed lessons. The multiple se-quential uses of school property in-dicated the depth of resources of theschool system and its flexibility.3 Ittook several weeks after the stormfor schools to clean up. Resumingschool activities was a high priorityfor those managing the response,keeping the loss of curriculum timeto a minimum.

Lesson 3: Keep the Plan Simpleand Flexible

A disaster response is likely to bemaximally successful if it is simple,flexible, easy to execute, and not tooresource-intensive. This is likewise trueof an SLV program. One method com-monly used to reduce costs and achieveearlyprogramsuccess is topiggyback itonto existing services or model it afteran existing, successful system. The ex-istence of multiple countywide ser-vices in PBC (including the school nurseprogram, fire rescue department,county pharmacy, and American RedCross)made it easier to develop the SLVprogram in a piggyback manner. Theplan was kept simple yet flexible byusing the Incident Command System,discussed below.2 A successful disasterresponse that was developed throughcareful and detailed advance planningshould not be modified when disasterstrikes with the hope of generatingamore perfect system. In that situation,such efforts are often counterproduc-tive, because they often waste precioustime and resources. An after-actionreview of a disaster response is con-ducted at the end of the disaster periodto critique performance, policy, plan-ning, and logistics. An after-action re-view of a school vaccination program

will likely benefit from critiquing clinicperformance after each day’s clinicends, or the following day, to craft andengage interim changes.

Lesson 4: Adopt the IncidentCommand System to Help Planand Manage the Program

The Incident Command System (ICS) isa standardized, on-scene, all-hazardincident management concept. TheICS is an integrated, predesigned or-ganizational structure that can grow orshrink to match the degree of com-plexity and demands of an incident (eg,forest fire, hurricane, earthquake),without being hindered by jurisdic-tional boundaries. It can generate amore powerful response and operationbecause it enhances the effectivenessand efficiency of groups working to-gether, thereby reducing the likelihoodof errors, gaps, inadvertent miscom-munication, or duplicated efforts oc-curring, while ensuring that a necessaryaspect of the process has not beenoverlooked. Thestrengthof the ICSarisesfrom its clear reporting system, clear jobdefinitions, accountability, and appro-priate span of control by supervisorsovera limited numberof subordinates.3,4

The PBC Health Department relies onthe ICS to conduct disaster planningand response, both complex matters. Itseemed reasonable to adapt this sys-tem to another complex situation, theseasonal influenza school vaccinationclinics.3 There were several unex-pected benefits. The most notable onewas the ability to clearly identify whichstaff or volunteer person held eachparticular job before, during, and afterthe clinics, and based on job descrip-tions that were developed, what thatjob entailed (Fig 1, Table 2). Use of theICS for the SLV programwas a principalreason the components of the clinicprogram ran efficiently. It helped usgain buy-in from organizations andvolunteers who were reluctant at firstto participate. It did so by providing in

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detail our expectations and the jobboundaries, and allowing those hesi-tant to join us to estimate reliably, inadvance, what their anticipated work-load would be.

Lesson 5: Developing PartnershipsWith Other Agencies Involved inDisaster Preparation

PBC is a large county, covering .2500square miles (larger than either RhodeIsland or Delaware) and containing 1.2million people, including the cities ofWest Palm Beach and Boca Raton.Organizations that routinely providepublic services on a countywide basis,especially the Palm Beach County FireRescue and the School District of PalmBeach County, had their resources dis-tributed and coordinated better acrossthis entire county than the health de-partment. Their services were alreadydistributed countywide proportionalto the direct and daily needs of thepublic.

We consider it important for membersof different groups and agencies todevelop relationships with one anotherbeforeanyemergencyorclinic. This canbe a positive byproduct of disasterplanning and disaster drills or school-located mass influenza vaccinationprograms. Better relationships helppeople perform their duties betterbecause they more thoroughly un-derstand the procedures, assets, andlimitations of the other party. Trust builtduring disasters or disaster exercisescan help during SLV clinics by teachingparticipants how to solve new, urgentproblems together. For us, this waspossible at the county level becausemany persons fill the same role innonemergency vaccination clinics asthey do in disaster response.

Lesson 6: Many Groups NeedSpecific Training

Training is needed on several fronts.Other than those involved in emergency

preparedness and response, mostpublic health workers, school officials,and volunteers have not used the ICS,and need such instruction. Training forSLV clinics can support county disasterpreparedness because it retrainsmanyschool nurses about the use of properand current vaccination techniques,roles, and responsibilities during adisaster.5

Well-prepared paid personnel and vol-unteers would benefit from advanceparticipation in community interagencycollaborations and attendance at oneanother’s training programs. For exam-ple, a school nurse could benefit by ob-serving a public health nurse in animmunization administration clinic andlearning health department protocolsand priorities. Better preparation yieldsa quicker, more appropriate, and moreflexible response. This level of hands-oncommitment goes beyond acquaintingoneself with another agency’s policiesand assets by simply holding a meeting

FIGURE 1Use of Incident Command System for School-Located Mass Influenza Vaccination Program in Palm Beach County, Fall 2005.

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or giving a lecture. However, this typeof educational program requires visionand commitment from those at a highlevel to develop deep interagency

familiarity and collaboration. Such aprogram is difficult to accomplish giventhe hectic schedule of public healthworkers today.

Lesson 7: Communication May BeMore Important Than It FirstAppears

Good communication reassures peopleand helps them prepare for additionaldifficulties in the near future. Poor orinaccurate communication can spreaderroneous information among thepublic that may be hard to dispel.ManagingbothdisastersandSLVclinicsrequires a strong, well-conceived, andwell-executed communication programthat disseminates information from thelead agency to other public agencypartners, parents, the school system,and the general public. This approachhelps to improve understanding, ac-ceptability, and even participation bystaff, volunteers, parents, and olderstudents. Good initial communicationduring the drill phase (for disasterplanning) and the planning phase (forschool clinic programs) helps teammembers work together better fromthe outset. For our SLV program, publicinformationofficers(PIOs)wereprovidedfrom the health department, school dis-trict, health care district, and a vaccinemanufacturer. All were helpful, and to-gether they effectively functioned asa Joint Information Center of the ICS.For communications concerning theseclinics, we recommend that eachmajor county agency provide itspublic information officer or spokes-person, because he or she is keenlyaware of what types of informationand presentation are needed and ef-fective in communicating with thelocal public.

Accurate and timely communicationwill help reduce panic and help thepublic better understand what theyneed to do to help take care of them-selves and their families. PIOs use tele-vision and radio stations to disseminateknowledge and instructions in disasterresponse. For the clinic program, weused print media as well as a toll-freephone line that we provided to give the

TABLE 2 Division of Roles and Responsibilities Among the 3 Public Institutions Essential to the SLVProgram in PBC, Fall 2005

Organization Roles and Responsibilities Incident CommandSystem (ICS) Chart

Palm Beach CountyHealth Department(PBCHD)

• Oversight of SLV program • Incident commander• Oversight of financial contract • Finance/administration• Provide guidance on any issues

concerning safety (ie, vaccinestorage, standing order foradministration of epinephrineat school site by school nurse)

• Assist in planning schooloutreach

• Planning

• Provide needed paperwork to schoolnurses and school site coordinators

Assist in providing nurses atindividual school sites

• Provide nurses to participatingcharter schools

• Operations

• Coordinate with all supportagencies

• Liaison officer

• Provide hotline for parents to call andask questions with epidemiology

• Coordinate media contacts

• Information officer

Health Care District (HCD)of Palm Beach County (PBC)

• Coordinate shipment of vaccine toHCD warehouse with MedImmune,Inc.

• Planning

• Purchase or rent freezer for storageof all vaccine, dry ice, and coolersfor transport of vaccine to schools

• Finance/procurement

• Package immunizations for transportto schools in coordination with firerescue

• Provide needed supplies to theschool nurse: epinephrine, coolers,ice packs, and vaccines

• Create schedule for delivery andoutreach in coordination withschool sites

• Logistics/vaccinestorage/assembly

• Coordinate vaccine administrationactivities at schools includingreporting of data

• Schedule nursing groups forassistance of vaccineadministration at schools

• Operations

• Provide support for media • Information officer

School District of PBC • Communicate with SLV schoolsite coordinators

• Information officer

• Provide nonnursing supportfor all schools participating

• Operations

• Provide additional gloves,biohazard sharps containers,and biohazard waste bags toschool sites; and plan forpickup of biohazard waste

• Safety officer

• Provide liaison support formedia

• Information officer

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public specific answers about the vac-cine and the program.

DISCUSSION

SLV clinics bear many similarities to di-saster response, such as rapid distribu-tion of goods and services to a greatnumber of people in a short time. Ac-cordingly, sharing information and les-sons learned from these 2 types of eventscanbenefit futureplanningforeach.Givensome forethought, SLV clinics could beused as tests of disaster planning per-formance. Our use of the ICS gave agen-cies valuable experience in its applicationand hence enhanced the effectiveness ofthe SLV program. A well-conceived and

well-executed mass school vaccinationprogram can empower its participantsand their organizations and contribute topreparedness efforts.

ACKNOWLEDGMENTSWe thankMedImmune, Inc. (Gaithersburg,MD) for providing all vaccine andmuch of the supplies used as partof their 2005 FluMist for Schools Pro-gram. Their staff also helped conducttechnical training in vaccine storageand administration. From the HealthCare District of Palm Beach, AnneHedges, RN, MSN, School Health Admin-istrator, Ginny Keller, RN, MBA, Assis-tant School Health Administrator, andJose Rodriguez, RPh, MBA, Director of

Pharmacy, provided health and pharma-ceutical services. We thank LashrandaSpan, MS, PT, Health Services Special-ist, and other members of the SchoolDistrict of Palm Beach County for theirkey role in coordinating the efforts ofvarious groups, recruiting schools toparticipate, preparing anddisseminatinginformation, and providing clinicspace. Tommy Schechtman, MD, helpedtrain school nurses and served asa program spokesperson to the media.Kevin Applegate, Captain, Palm BeachCounty Fire Rescue, coordinated theircountywide deployment of vaccine toall participating schools. Boca RatonCommunity Hospital managed the dis-posal of biomedical waste.

REFERENCES

1. National Oceanic and Atmospheric Adminis-tration. Climatic data center. HurricaneWilma. Available at: http://www.ncdc.noaa.gov/special-reports/wilma.html. Accessed February11, 2011

2. FEMA. Incident Command System (ICS).Available at: www.fema.gov/emergency/nims/

IncidentCommandSystem.shtm. AccessedFebruary 11, 2011

3. Phillips FB, Williamson JP. Local health de-partment applies incident managementsystem for successful mass influenza clin-ics. J Public Health Manag Pract. 2005;11(4):269–273

4. Kim-Farley RJ, Celentano JT, Gunter C, et al.Standardized emergency management sys-tem and response to a smallpox emergency.Prehosp Disaster Med. 2003;18(4):313–320

5. Matteson LM. Using seasonal influenza clin-ics for public health preparedness exer-cises. Am J Nurs. 2006;106(10):28–29

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DOI: 10.1542/peds.2011-0737J2012;129;S101Pediatrics 

Marsha Fishbane, Anne Kist and Richard A. SchieberInfluenza Vaccination Clinics

Use of the Emergency Incident Command System for School-located Mass

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Marsha Fishbane, Anne Kist and Richard A. SchieberInfluenza Vaccination Clinics

Use of the Emergency Incident Command System for School-located Mass

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