During the 2009-10 H1N1 vaccination campaign, state-level immunization programs employed a variety of strategies to expand their programmatic and technological capacity to distribute H1N1 influenza vaccine in an efficient and timely manner. More than three-quarters of immunization program managers indicated their health department activated an ICS, nearly half indicated their health department opened an EOC to manage the vaccine campaign, and 40% indicated having shared the role of programmatic lead for the campaign with their state-level emergency preparedness program. Immunization program managers' perception of the helpfulness of their department's emergency preparedness staff was also perceived to be higher if they had previously collaborated with the emergency preparedness program for simulation or other emergency preparedness activities. More than half of immunization program managers working in jurisdictions with IISs required providers to enter data into their system, and more than one-third of managers indicated using their IIS as a way to push important communications out to providers. Each of these strategies used during the H1N1 vaccination campaign illustrates the value of the perspective of immunization program managers to collaborating with their emergency preparedness program partners. In addition, immunization program managers also shared input on the importance of IIS to the management of vaccine-related public health emergencies.
The extent to which ICS/EOC structures were used for this vaccination campaign was substantial, given that these management structures were largely foreign to public health agencies prior to the 2003 adoption of the national incident management system (NIMS) that uses ICS for emergency response.11
Since the hierarchical nature of the ICS is not typically used to manage state and local health departments, implementation of the relatively unfamiliar ICS was initially met with some reticence by public health agencies.12
Results from our survey suggest that while some immunization program managers indicated resistance and frustration with the culture of ICS, more felt that using ICS helped them to work effectively and efficiently with collaborators, especially their emergency preparedness partners. Additionally, use of existing pandemic influenza plans was high; many immunization program managers asserted their value in having provided a structured basis for planning and operations as well as in enacting previously established partnerships with entities like hospitals and federally qualified health centers that proved integral to the coordination of the campaign.
In addition to the roles ICS/EOC systems and pandemic influenza preparedness plans played in managing the H1N1 vaccination campaign, shared programmatic leadership and degree of prior collaboration among immunization and emergency preparedness programs also had an impact on program managers' perceptions of their emergency preparedness counterparts during the campaign.
These 2 programs have very different histories in state health departments; immunization programs have existed for nearly 50 years with funding provided by the Vaccination Assistance Act (Section 317 of the Public Health Service Act) and the Vaccines for Children (VFC) program, a federally funded entitlement program that provides childhood vaccines free to children who might otherwise be unable to afford vaccines.13,14
Public health emergency preparedness programs were largely created following the enactment of the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, and they receive the majority of their funding through grants from the CDC and the Health Resources Services Administration (HRSA).15
Since both programs operate largely on discretionary funding that varies from year to year and has either remained constant or declined in recent years, it may be mutually beneficial for these 2 programs to share resources and personnel.
This survey found that among jurisdictions in which the responsibility of campaign management was shared between the immunization program and the emergency preparedness program, the majority of the work needed to establish PODs was also shared. Immunization program managers' perception of the helpfulness of their emergency preparedness colleagues was also affected by their degree of prior collaboration with the emergency preparedness program. While results suggest that immunization program managers' perceptions of their emergency preparedness programs' general helpfulness in facilitating their jurisdiction's mass vaccination response was not significantly associated with exercise collaborations in the previous 2 years, perceptions of the emergency preparedness program's helpfulness on more specific, targeted activities was significantly associated with prior collaborations. Taken together, these findings underscore the importance of interprogram preevent planning and highlight benefits to structuring exercises and responding to actual events in ways that familiarize staff from each program with the specific needs and nuances of the other. Many of the successes and challenges cited by immunization program managers in working with the emergency preparedness program can be achieved or addressed through preevent planning. Developing a mutual understanding of each other's programs and assigning leadership structures that are both flexible and clear when the 2 programs unite are 2 examples. Methods for streamlining and targeting communications as well as determining resource allocation plans can contribute greatly to the success of programmatic collaborations.
In addition to the importance of strong personnel management, the use of IIS technology was also emphasized during the H1N1 influenza vaccination campaign. Mandating provider participation in IIS was an approach some states took to improve the ability to track vaccine, with states more frequently reporting problems tracking vaccine administration if their state did not require mandatory reporting through their state registries.16
Lack of provider compliance with entering data into a registry system limits the benefits these systems can have for activities like inventory management, reminder/recall, and strategic planning on behalf of health departments. While our results suggest that such a requirement did not have a sweeping impact on immunization program managers' perceived value of all IIS's functionalities, it may have assisted the program managers' ability to use their IIS for the registration of nontraditional vaccine providers and tracking recalled vaccine. These functionalities, as well as the ability to use IIS to push communications out to vaccine providers, are especially important in an emergency situation when mass quantities of vaccine need to be distributed and monitored across a diverse population. While many immunization program managers realized the value of having an IIS with these capabilities during the H1N1 vaccination campaign, more than 40% indicated their IIS could not facilitate the registration of nontraditional vaccine providers or push communications out to providers. Enabling more IISs to include these types of functionalities would benefit management of future vaccine-related emergencies. For those programs that did require providers to participate in their IIS for the H1N1 influenza vaccine campaign, it will be important to assess how this affects their willingness to participate in the system over the long term. Moreover, with the push toward adoption of electronic medical records, it remains to be seen how IIS will interface with these systems. As this transition occurs, more research is needed to determine the most effective ways to either merge IIS into electronic health records or enable the 2 systems to exchange information efficiently.
This survey has several limitations. It was not conducted in parallel among state directors of emergency preparedness, so complementary data from their perspectives are currently unavailable. Results from this survey have been shared and discussed with directors of emergency preparedness, and obtaining their responses to similar questions would be particularly useful to comprehensive planning for future public health emergencies. Further, respondent self-report may be biased due to an inability to precisely recall events from the prior year. Another limitation is that the beliefs of immunization program managers regarding collaborations with emergency preparedness programs, use of ICS/EOCs, characteristics of IIS reporting requirements, and other issues were not correlated with outcome measures such as immunization coverage in their respective jurisdictions. Despite this limitation, the results clearly show differences in perceptions of immunization program managers regarding effectiveness of a variety of measures and point the way forward to improved collaborations and preparedness.
Strong partnerships among staff within immunization and emergency preparedness programs are integral to preparedness against future vaccine-related emergencies. Considering the importance of collaboration among immunization programs and emergency preparedness programs, as well as the most effective ways to use information systems like IIS, are especially appropriate in light of the current public health funding landscape. Reductions to Health and Human Services budgets, as well as to state health department budgets, are likely to result in corresponding reductions in state and local public health programs and staff. Fostering alignment of immunization and emergency preparedness programs at a national level could help diffuse the consequences of tighter budgets. Given that the federal governance structure in the U.S. provides autonomy to the states regarding budgetary decisions, encouraging discussions of programmatic collaborations at the level of professional organization might be most practical. Despite such budgetary constraints, maintaining and improving the capacity of public health to respond to health threats remains more important than ever due to the increasing threat of catastrophic illness or injury resulting from natural or man-made disasters.17,18
Understanding which aspects of collaboration worked well and which did not work well during the 2009-10 H1N1 influenza vaccination campaign is important to sustaining these programmatic partnerships over time and across a variety of emergency and nonemergency events.