2005 Model Practice Application (Public)

WHACK the Flu

Berkeley Public Health

In the face of the national flu vaccine shortage of 2004-2005, the Berkeley Public Health Division, in collaboration with the University of California, Berkeley and the Berkeley Unified School District, initiated a community education campaign focusing on the primary target (intermediate) of the flu virus – children. The “WHACK the Flu” campaign was conceptualized by a group of graduate students from the Berkeley School of Public Health and was further developed by a multi-disciplinary staff from the Berkeley Public Health Division. The project was targeted towards Berkeley elementary school children with accompanying resource materials for their parents and teachers. The goal of the WHACK the Flu project was to provide strategies for children to employ to reduce the transmission of communicable diseases to their families and other contacts.

The WHACK acronym stands for:

• W: Wash your hand often
  
  
• H: Home is where you stay when you are sick
  
  
• A: Avoid touching your eyes, nose and mouth
  
  
• C: Cover your coughs and sneezes
  
  
• K: Keep your distance from sick people.

With a budget of less than $1,500 (exclusive of personnel costs) over 2,500 students participated in the 10-minute program that included a skit and hands-on activities conducted by trained graduate students from the Berkeley School of Public Health. Berkeley Public Health will be comparing past and current flu-related emergency room visits to local hospitals and school absentee rates once the flu season has concluded. Whereas vaccination campaigns have immediately definable results, the effectiveness of this behavior-change intervention is difficult to measure, but will impact disease transmission rates over the long-term.

Each year, the Berkeley Public Health Division conducts an influenza vaccination program, targeting high-risk community members, including seniors and those with chronic illness. In a typical year, the division’s Immunization Coordinator implements this program nearly single-handedly with assistance from community volunteers. However, with the announcement of the flu vaccine shortage by the Centers for Disease Control in October 2004, Berkeley Public Health immediately activated its Department Operations Center (DOC) and proceeded to address the flu vaccine shortage as a public health emergency. This was Berkeley’s first activation of the DOC in response to a potential flu epidemic, engaging the entire public health staff as disaster service workers. Since it appeared that vaccination would not be the primary mode of influenza control, Berkeley Public Health made the decision to conduct a secondary preventative intervention through targeted outreach and education. In addition to implementing the recommended CDC guidelines including vaccine sequestering, prioritization and reallocation, Berkeley Public Health devised a collaborative educational campaign targeted to the primary “spreaders” of disease, school-aged children.

The intervention was designed to be cost-effective, long range, community engaging, and supplemental/complementary to our limited vaccine efforts. The rationale behind the program was to design a simple message for children to limit disease transmission and to reinforce this message by providing accompanying resources to the adults that are most often in the presence of the children – parents and teachers. Public Health staff provided the program leadership while working closely with Berkeley School of Public Health volunteers and Berkeley Unified School District staff and teachers.

The WHACK the Flu campaign was successful based on the collaboration of Berkeley Public Health, graduate students from University of California at Berkeley, and elementary school staff from the Berkeley Unified School District. Overall, Public Health staff designed and coordinated the intervention, volunteers delivered the intervention message and schools reserved suitable times for the volunteers to visit classrooms and reinforced the prevention messages with their students. Based on the pre-existing working relationships between the Berkeley Unified School District and Public Health programs such as Tobacco Use Prevention and the Berkeley High School Health Center, the first step was to survey the schools for interest level and identify contacts for classroom presentations. Once the agreement was established, public health staff (nurses and health educators) and volunteers worked together to clarify the key messages for preventing the spread of influenza and tailoring the message for elementary school children. Public health staff trained the graduate student volunteers to use the WHACK the Flu curricula in the classroom, as well as gain a better understanding of the repercussions of a vaccine shortage and the role of communicable disease infection control. Volunteers worked in pairs to deliver 105 presentations to K-5 classrooms.

The financial costs were modest and shouldered entirely by the Berkeley Public Health Division. They included $150 for supplies and food for two training sessions and a recruitment meeting. The educational material costs were approximately $1000 and each volunteer was given a public health backpack with incentive items (e.g. pens, key chains, etc.) at a total cost of $150. Recruitment, training, and coordination of the volunteers was time consuming for Berkeley Public Health, with the workload distributed among 5 core staff members it was only an average of 12 hours of work a week per person for 3 weeks. The graduate student intern coordinated several components of the program including the time-consuming presentation scheduling, spending approximately 10 hours per week for 6 weeks. Volunteers were active according to their schedules. School secretaries generally coordinated the scheduling of volunteers within the classrooms. Among the 18 volunteers that were trained, 12 ended up conducting presentations consuming an average of 10 hours each. The program was designed to minimize interruption to the local schools. Teachers were asked for 10 minutes of their class time for presentations and were asked to encourage students to review the take home pamphlet and brochures with their families.

After it was determined that a targeted community education campaign was critical to address a potential flu epidemic, in a rare collaborative effort, a multidisciplinary team (made of Public Health staff from Chronic Disease Prevention, Tobacco Control, Public Health Emergency Preparedness, Injury Prevention, and the Berkeley High School Health Center) devised a method for engaging graduate students from the Berkeley School of Public Health to serve as WHACK the Flu volunteers. A graduate student intern, working with the Public Health Emergency Preparedness Program, served as a liaison to the Berkeley School of Public Health. This intern took the lead in making presentations at classes and student groups, outlining the problem and inviting the students’ assistance as volunteers. Criteria for selection of volunteers was based on their familiarity with public health and experience working with children. 18 volunteers were trained as Flu Prevention Presenters in a two-hour session which covered the following topics: (1) Introduction/Purpose of the Training; (2) Influenza Prevention 101; (3) Working in the Berkeley Unified School District; (4) Sign-Up for Presentation at Schools; and (5) Demonstration and Practice Session. Coinciding with the volunteer training, Public Health staff worked with the Berkeley Unified School District Associate Superintendent of Instruction to gain access for the volunteers to work in the elementary schools.

The Superintendent presented the WHACK the Flu proposal to the BUSD principals for their approval. There was unanimous support from the principals who then granted the volunteers access to the schools. Scheduling was arranged by the Public Health graduate intern and coordinated to accommodate volunteer and school schedules on an individual basis. During their actual presentations, volunteers re-enacted a skit that encouraged students to practice good health and hygiene habits such as sneezing into the crooks of their elbows and drinking adequate fluids. A 30-second song (“The Bubble Song”), emphasizing hand washing, was the centerpiece of each 10-minute presentation. Educational material was provided for both students and teachers to reinforce lessons learned during the volunteer presentations. The material was designed to be simple yet engaging and entertaining. Materials included a take-home pamphlet with a word search puzzle, a brief question and answer section, and a resources section. WHACK the Flu Posters were designed and distributed along with multi-lingual hand washing posters produced by the California Department of Health Services. After presentations were delivered to schools, volunteers and teachers were solicited for feedback on how to refine or improve the message.

Scheduling with the schools was initiated in early November, while recruitment and training was conducted in mid-November and early December. Actual classroom presentations began in early December and ended in mid-January, coinciding with the ending and beginning of school semesters. All-in-all, this intervention was conceptualized, developed, implemented and evaluated, involving three large public agencies, within a two-month period.

Berkeley Public health will conduct a simple non-experimental, post intervention evaluation using comparison groups, once the 2005 flu season has concluded. Baseline data will be drawn from four sources : School absentee rates among students in the intervention BUSD elementary schools from December 2003 through March 2004; School absentee rates from both intervention and control BUSD elementary schools from December 2004 through March 2005; Flu-related emergency room visits in Berkeley from December 2003 through March 2004; Flu-related emergency room visits in two other San Francisco Bay Area hospitals from December 2003 through March 2004.

The baseline data will be compared to the following groups to measure intervention effects: School absentee rates among students in the control BUSD elementary schools from December 2004 through March 2005; School absentee rates from both intervention and control BUSD elementary schools from December 2004 through March 2005; Flu-related emergency room visits in Berkeley from December 2004 through March 2005; and Flu-related emergency room visits in Berkeley from December 2004 through March 2005.

The control schools are from a convenience sample and were not randomized. These were the schools that did not implement the intervention due to scheduling and logistical problems. One school received only materials and the presentation script. This school can serve as a control to measure the effect of the presentation as compared to having the college student volunteers deliver the presentation. It is expected that intervention effects may have a lasting effect upon students, parents and teachers, which can be reinforced with booster presentations and materials distribution during the fall semester 2005.