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2010 Model Practice Application (Public)
Application Name: 2010 Model Practice Application (Public) : Boston Public Health Commission : Boston's Comprehensive H1N1 Flu Response Plan
Applicant Name: Mrs. Barbara Ferrer, MEd, MPH
Boston's Comprehensive H1N1 Flu Response Plan
Boston Public Health Commission
Boston’s Comprehensive H1N1 Flu Response Plan was designed to address the first flu pandemic in more than 40 years. The integrated response framework helped coordinate many elements related to the response to the second wave of 2009 H1N1 Influenza. The goal of Boston’s comprehensive H1N1 pandemic response plan was to reduce morbidity and mortality caused by 2009 H1N1 influenza, particularly among those most vulnerable to the disease. To achieve the goal, Boston officials set out specific objectives that an that included; Organize a multidisciplinary team to manage and sustain an H1N1 flu response from at least August 2009 through the end of February 2010. Develop a comprehensive strategy to plan and conduct at least 100 public vaccine clinics throughout the city of Boston in approximately a 12 week period beginning in late October 2010 (this strategy would be in addition to vaccine provided at hospitals and private healthcare providers). Conduct a culturally competent prevention, education and outreach effort, commencing in September 2009 and in parallel to the mass vaccination efforts, which will reach residents in each of the 21 neighborhoods of Boston. BPHC and its community response partners were able to achieve much of what they set out to do during the second pandemic wave. Despite the frustrations of vaccine shortages and delays, progress was made in the areas of emergency response and management, mass vaccination, public information, outreach and prevention, and training and education. Achievement was also noted in utilizing technology to improve information gathering and evidence based decision-making. Specific outcome measures are included in the Evaluation section of this application.
Responsiveness and Innovation
The obvious public health issue that this practice addressed was the spread of a novel influenza virus in the city of Boston. Boston’s plan surely addressed traditional prevention and control measures that are brought to bear during infectious disease outbreaks, but the plan did much more than that. Every pandemic causes fear, disruption and frustration and 2009 H1N1 Influenza was no different. Boston’s plan addressed the fear of residents by providing a system of nearly daily updates at the height of the outbreak, and making sure that public health messages were communicated in multiple languages and through many different channels. This was particularly important in communicating the oft-changing vaccination guidance. Boston health officials also had to deal with the inherent disruption caused by H1N1 flu, particularly in education settings, by working closely with school officials to prevent school closures, and communicating clear criteria to evaluate when considering closure. Boston was among one of the hardest hit cities in the U.S. during the first pandemic wave of influenza in April 2009. As with almost all elements of the plan, a review of available data from the first wave of illness was conducted in order to help develop a comprehensive and relevant flu response plan. Over the last several years, the Boston Public Health Commission has worked tirelessly to implement and refine a surveillance system that is both nationally-recognized, and the most comprehensive public health surveillance system in Massachusetts. That system, developed by the BPHC’s Communicable Disease Control Division, captures important streams of data and has contributed to evidence-based decision making throughout the 2009 H1N1 response. Through case investigation, reviewing information from its syndromic and emergency room surveillance systems, and by daily reviews of EMS trip data, school attendance data and reports from college health services, BPHC officials have developed a more complete picture of how the epidemic is impacting city residents. This improved situational awareness for public health officials, but it also helped quickly identified disparities in the burden of illness. During the spring wave of 2009 H1N1, three out four hospitalized patients were either black or Latino. In addition, 44% of identified cases in the spring wave were between the ages of five and 17 years of age. These data findings, along with others, were key to devising the Comprehensive 2009 H1N1 Flu Response Plan for the second wave of the pandemic. Other qualitative methods, such as public inquiries, review sessions with response partners, and the Boston H1N1 Flu Summit offered important feedback opportunities for Boston health officials so that they could improve response activities during the second wave of illness in the fall and winter.Boston’s plan in addressing the 2009 H1N1 flu pandemic was a model response because in covered all the elements of successful public health practice in an emergency. It effectively monitored the health status of the community and identified vulnerable populations and neighborhoods; it informed and educated the residents of Boston about flu prevention and treatment in a timely and culturally competent manner; it mobilized community partners to assist in the pandemic response particularly to protect vulnerable communities; it linked residents to needed care by developing a strategy of public vaccination clinics at dozens of community health centers throughout the city of Boston. The plan also helped assure clinical competence of health partners throughout the city by providing a framework to deliver detailed guidance and training throughout the response. The plan employed new technologies to assist with communication, and insure that patient information at vaccine clinics was collected securely, efficiently, and in a way that would assist with evaluation and decision-making during the response.
Agency Community Roles
The Boston Public Health Commission was the lead agency for the City of Boston during the 2009 H1N1 Influenza pandemic response. City health officials developed a framework of response activities for 10 community sectors. Those sectors included; businesses, childcare, school and after school programs, colleges and universities, community organizations, faith-based organizations, government agencies, healthcare professionals and organizations, parents and caregivers, residential care organizations and labor unions. The Health Commission was responsible for coordinating activities with all partners, issuing clinical guidance to the city’s healthcare providers. City health officials were responsible for scheduling, coordinating and supporting more than a hundred public clinics that took place in community health centers throughout the city, and for organizing several large-scale supplemental clinics in neighborhoods where clinics were not located. In addition to the emergency preparedness responsibilities, the Health Commission, as previously mentioned, performed traditional public health roles related to epidemiology and surveillance, public health nursing practice, public information, as well as education and training. The Commission also took the lead in providing information and training to other public-facing agencies in city government. As part of the effort to include City employees in the vaccination effort, Mayor Menino mandated that every municipal employee (approx. 30,000) be allowed up to 2 hours leave so that they could receive a flu vaccination. Each sector partner had a role in developing the response grid and the overall plan through a series of meetings, including a citywide summit held in August 2009 that drew hundreds of key stakeholders. The plan provided a framework for each of the ten sector partners to devise response activities and strategies that dovetailed with Boston’s comprehensive plan. Expectations for each sector partner (businesses, healthcare, schools, childcare, etc…) were communicated through sector-specific grids that provided flu prevention and mitigation advice. It also provided guidance on modulating response activities by severity levels (1 mild, 2 moderate, 3 severe). Activities differed based on the sector. For example, while all sectors were urged to encourage vaccination among their community members, that task was a higher order of priority for healthcare partners early in the second wave response.
Costs and Expenditures
The Boston Public Health Commission (BPHC) organized the first H1N1 Flu Summit in Massachusetts in August 2009, to brief sector partners about Boston’s plan and to solicit feedback. The Summit, held at Harvard Medical School, was hosted by Mayor Thomas M. Menino, and drew more than 400 clinicians, business, civic and community leaders. City health officials developed a plan that built a framework of response activities for 10 community sectors. Those sectors included; businesses, childcare, school and after school programs, colleges and universities, community organizations, faith-based organizations, government agencies, healthcare professionals and organizations, parents and caregivers, residential care organizations and labor unions. The plan was communicated through sector-specific grids to provide flu prevention and mitigation guidance. The plan also was organized by severity level (1 mild, 2 moderate, 3 severe), to help sector partners modulate their response activities accordingly. A system of Flu Alerts was also instituted, which allowed for on-going communication between public health and key response partners – including the public. Also. during the implementation stage several units within the Commission began their responsibilities under the plan; the BPHC Communication staff began executing a multi-faceted communication strategy that would receive significant statewide and national notice. During this time, the Health Commission formed a standing team of staff members as outreach liaisons assigned to assist each of the sectors identified in the plan. This group was the support system for the 10 response sectors that made up the integrated response plan, acting as liaisons for any requests for information. When requests for materials (fact sheets, posters, etc) or information sessions were received, members of the team coordinated to fulfill the request. They also acted as the “grassroots” team, executing communication strategy and distributing materials throughout the neighborhoods of Boston. The Communicable Disease Control Division began producing detailed epidemiological reports to give senior leadership regular situation updates on the spread and burden of illness in the community. The Emergency Preparedness and EMS/MMRS groups went about the tasks of carrying out and tracking the progress of the Mass Vaccination campaign by leveraging Boston’s existing health care infrastructure, and supplementing it by planning several large-scale public clinics. The DelValle Institute for Emergency Preparedness also began to implement a comprehensive training program to support flu response operations. Start-up costs are described below. Cost of planning and response was borne by the Commission through a variety of sources, including city funding, its annual award of public health preparedness funding, and utilizing homeland security funding for certain activities. Supplemental funding through PHEP was also utilized during the second wave response.
Development of an Emergency Management Leadership Team An interdisciplinary team from throughout the BPHC, was formed and led by Executive Director Dr. Barbara Ferrer, met weekly to discuss the current situation, strategy and plans for response. This was the venue for senior managers to come together for a weekly evaluation of the response, and to discuss any adjustments that might need to be made given changes in the situation. The team represented the management structure for all elements of the response, including planning, operations, logistics, clinical, finance and communications. Design of a Robust & Creative Public Communication Strategy The fist wave of the pandemic demonstrated quickly the importance of developing culturally competent, relevant materials to keep the residents of Boston informed and protected from 2009 H1N1 flu. The BPHC Communications Office led the development of a multi-faceted communication strategy that included media relations, ethnic media outreach, paid advertising through broadcast, display and internet channels, and through creative and innovative use of social media channels. Creating a Sustainable Outreach Team and Strategy: The outreach function of the plan was a key element of its success. Given that many of the sectors targeted for outreach had limited experience in dealing with public health issues, a crucial task of the response was building an outreach structure designed to meet the varying needs of all of the sector partners. Leveraging Public Health Systems & Technology to Support Response: BPHC’s tailoring of existing surveillance systems, and innovative use of record keeping technology was very helpful in providing data to continuously monitor and evaluate the overall response. Capitalizing on Key Neighborhood Partnerships: The BPHC’s early push to involve many community sectors contributed to a well-coordinated response that has improved city’s response during the fall wave of the pandemic.
As the first wave of H1N1 flu began to ebb in Boston, public health planners barely had a chance to catch their breath as they looked to the fall and winter flu season. They, like their counterparts around the country, faced a daunting task of providing flu vaccinations to more residents than ever before. Launching a mass vaccination campaign in the best of times is difficult, however these were not the best of times -- due to the economic downturn, many public health departments were under great stress due to cuts in funding and personnel. To meet the demands of mass vaccination on such a short timeline, the backbone of the BPHC’s strategy involved one of the city’s greatest strengths – its network of independent, non-profit, Community Health Centers (CHC’s). Rather than creating public Seasonal and H1N1 Flu vaccine clinics from scratch throughout the city (with all the logistical challenges that poses) the Commission leveraged the infrastructure of the city’s 22 health centers located in all but two of Boston’s 21 neighborhoods. Utilizing a staff sharing agreement, put in place through Boston’s Metropolitan Medical Response System, BPHC was able to supplement health center vaccinators with nurses from area hospitals at seasonal public flu clinics hosted at the health centers. Paramedics from Boston Emergency Medical Services served as supplemental vaccinators for the health centers at public H1N1 clinics. CHC flu clinics were open to all people recommended for vaccination, whether or not they were health center patients. Health centers are trusted sources of care in the communities they serve. That trust has been an important asset as the health officials have dealt with vaccine supply problems and community resistance to the vaccine itself. Incorporating a Training Program into the Response: Hundreds of clinicians, first responders, volunteers and community members received training on influenza and how mitigate its spread in
While the response was difficult, and at times frustrating, a significant amount of commitment was built among stakeholders during the implementation and mangement of the H1N1 flu response plan. Strong bonds of trust and collaboration were built and strengthened among Boston's flu response team, and whole sectors who had not had much exposure to public health officials learned a great deal about the field and about the expertise that exists locally. The greatest limiting factor to continued improvement and success of such efforts in the future will be the amount of financial resources available. Local and state governments have experienced very difficult budget difficulties over the last few years, and it was only because of the supplemental funding that was provided that Boston, and communities like it, were able to mount an effective response. Whole new networks of communications have been developed because of this response, and BPHC and its partners are committed to strengthen thoses connections. This could take the form of continued collaboration on infectious disease response, or even on non-emergency public health projects.
Outcome Process Evaluation
The goal of Boston’s comprehensive H1N1 pandemic response plan was to reduce morbidity and mortality caused by 2009 H1N1 influenza, particularly among those most vulnerable to the disease. To achieve this goal, the Boston Public Health Commission would Organize a multidisciplinary team to manage and sustain an H1N1 flu response from at least August 2009 through the end of February 2010Frequency of meetings of the Senior H1N1 Flu Response TeamThe Communicable Disease Control Division collected data from its Syndromic and Emergency Room Surveillance System, from daily review of EMS trip data, school attendance data, and reports from college and university health services. The Emergency Preparedness Program would gather relevant data on the planning and logistics of upcoming public clinics being coordinated, including location, staffing and operational issues. The Community Initiatives staff (Prevention Unit) would gather relevant data from public outreach opportunities. Such reports would include the number and location of public education events, number and type of flu related calls to the Mayor’s Health Line, and the number of material requests fulfilled for the week. The Communications Office would also report on the number and nature of media requests, and provide and update on the progress of materials development. Most of the data presented was tracked daily, but collected weekly for the purposes of the meeting.The weekly Senior Team meeting was attended by the Executive Director and members of her office, including the Medical Director, the Chief Financial Officer and the Chief of Staff. In addition, the meeting was attended by representatives from the Communicable Disease Control Division, the Emergency Preparedness Program, the Community Initiatives Bureau (Prevention Unit), Emergency Medical Services and the Metropolitan Medical Response System. The meetings were crucial in setting a framework for information sharing and decision-making related to the flu response. The surveillance reports in particular were helpful in helping to identify gaps and where additional resources were needed. One such example found during case investigations was the recurring complaint of parents who were unable to locate liquid oseltamivir (Tamiflu) after it was prescribed for their children. Health officials were able to act on and share that information before the shortage of such medication had become widely reported by the CDC.The BPHC was successful in meeting this objective by virtue of the Senior Team meeting weekly from mid-August 2009 to mid-March 2010. The meeting clearly produced short and intermediate term benefits by providing a place where challenges could be discussed and corrective actions taken. The team and meetings also will have longer term benefits because it provides clear model to manage a large emergency response of long duration. Develop a comprehensive strategy to plan and conduct at least 100 public vaccine clinics throughout the city of Boston in approximately a 12 week period beginning in late October 2010 (this strategy would be in addition to vaccine provided at hospitals and private health care providers) Number of vaccination clinic scheduled throughout Boston's 21 neighborhoods.Through a series of meetings and follow-up contact via phone and email, the Emergency Preparedness Program and the MMRS collected data on each community health center in Boston, including locations, description of physical plants, number of patients served (with limited age and demographic information), and number of staff and their clinical capabilities. The information was collected once from the 22 participating community health centers between August and September 2009.Based on the information received from the health centers, BPHC developed Memoranda of Understanding (MOU) for each of the 22 health centers, and Staff Sharing Agreements were also activated between the health centers and the MMRS to supplement the