Bismarck-Burleigh Public Health (BBPH) is a local public health agency that serves the citizens of the City of Bismarck (73,000)  and surrounding Burleigh County (93,000 combined). BBPH serves a large urban Indian population, homeless individuals, privately insured, and publicly insured individuals as well.

Response efforts to the COVID-19 pandemic include contact investigation, COVID-19 testing, notification of positive individuals, providing direction to city and county departments, fielding phone calls from Bismarck/Burleigh residents, providing input and direction to local leaders, planning for COVID-19 vaccine, and other mitigation measures.  

Subsequently, BBPH's main goal for the 2020 influenza season was to increase the number of doses administered at mass vaccination clinics in order to prevent dual COVID-19 and influenza infections and increase the health and safety of the community. Planning for drive-thru vaccination clinics included staff from emergency preparedness, public information, nursing, administration, and environmental health. In addition, social media was key in providing community-wide education on the influenza vaccine and when clinics were scheduled.

Drive-thru influenza vaccination clinics were held at a large event center in Bismarck where cars could enter and exit safely. Client records were provided electronically for citizens which captured demographic information, insurance status, screening questions for vaccine safety, allergies, and signatures. Individuals were encouraged to complete the client record information prior to drive-thru clinics and bring a copy with them. Extra copies were provided at the drive-thru clinic for individuals without access to a computer and printer. Nursing staff verified that the client records were completed in their entirety, screening questions were completed, and then indicated on the forms what type of vaccine the individual should receive based on their age, insurance status, and personal preference. Cars were then ushered forward where they were directed into one of four vaccination lanes.

Once cars pulled forward they were met by nurses that reviewed their client record and then verified the 6 rights of medication administration prior to administering influenza vaccine. Chairs were available outside of vehicles for special circumstances, like pediatric vaccines where parents wanted to hold children. All vaccinators wore full personal protective equipment including N95 masks, face shields, gowns, and gloves due to the high likelihood of coming into contact with potentially infectious individuals with COVID-19 infection.

After vaccination individuals pulled forward where copies of their insurance cards were made by billing staff. Billing staff wore N95 masks, eye protection, and gloves due to having moderate contact with individuals. Individuals were encouraged to stay in line for 15 minutes after vaccination to ensure safety in case of a reaction to the influenza vaccine.

 Influenza vaccine was offered to all individuals regardless of their ability to pay, a walk-up option for individuals without vehicles was available, and clinics were scheduled on different days of the week at varying times to accommodate a large range of individuals. More individuals received influenza vaccine in a safe manner where they did not come in contact with COVID-19 because of mitigation measures in place during the drive-thru vaccination clinics.

The COVID-19 pandemic has presented many logistical challenges that have interrupted routine healthcare practices. Providing annual influenza vaccines to the community is imperative for health promotion and to reduce the spread of disease. Immunizing the general public is a core public health function and has crucial during the COVID-19 pandemic. Among other response efforts like contact tracing, community education, and urging the public to wear masks, BBPH knew mass quantities of influenza needed to be administered to the public.

The rate of mortality with a dual COVID-19 and influenza infection nearly doubled in some populations, including elderly and immunocompromised individuals. BBPH could not hold walk-in and mass influenza vaccine clinics per usual because of social distancing practices and COVID-19 exposure. In order to mitigate these issues, BBPH planned drive-thru influenza clinics where community members could receive influenza vaccine in a fast and essentially zero exposure environment to COVID-19. In order to accommodate all ages and populations of the community, drive-thru clinics were held at different times on different days including morning times, afternoon, and evening.
 

In previous years the busiest influenza vaccine clinics were evening walk-in clinics when families could receive vaccines at the same time. Several of the evening walk-in clinics in years past saw numbers as high as 300-350 individuals vaccinated in 2-3 hours. BBPH staff knew that the COVID-19 pandemic would likely affect the number of people that received influenza vaccine, hopefully it would be more people getting vaccinated instead of less. Several hundred extra vaccine doses were ordered, extra flu clinics were planned by appointment, community and business clinics were planned with social distancing and infection control procedures in place, and drive-thru clinics were planned. Plans needed to be in place to account for the maximum amount of throughput if the uptake was as predicted for the vaccine.
 

Drive-thru clinics were advertised on social media for all of Burleigh County and a media campaign was disseminated to highlight the importance of receiving influenza vaccine. Drive-thru clinic dates and times were shared with the local homeless coalition, city departments, and to community partners. A walk-up option for vaccination was also provided for individuals that did not have a vehicle. No individual was turned away for inability to pay for the vaccine.
 

Drive-thru clinics may be a viable option for future influenza seasons, as BBPH staff increased throughput drastically from previous years. The average time an individual spent waiting at walk-in influenza clinics in previous years was generally 15-20 minutes from entering the building, completing paperwork, and getting vaccinated. At drive-thru clinics, individuals spent 10 minutes or less getting vaccinated because the process and flow was significantly quicker.
 

Drive-thru vaccine clinics are not new to public health but the innovation that went in to BBPH’s drive-thru clinics based on the unique circumstances of COVID-19 were new. Adaptability was key during the 2020 influenza season because of the unprecedented challenges staff were facing due to COVID-19.

Staff had experience with COVID-19 testing in a drive-thru setting, so with additional training and adaptation the transition to drive-thru vaccination was relatively seamless. Registered nurses were utilized for screening individuals at the entrance to the drive-thru clinic and also to administer vaccines. Billing staff and other non-medical staff were utilized to direct traffic, take payments, copy insurance cards, and ensure client records were completed with necessary information.

Copiers were brought on location and each individual that utilized insurance to cover the cost of their influenza vaccine and copies were made of their insurance cards. Copies of insurance cards were attached to each individual client record. Each client record had a triple check system, which allowed for few errors in data collection and vaccine appropriation. Vaccine transportation coolers were utilized at each drive-thru lane and were labeled based on the type of influenza vaccine that was inside. 

Coolers with high-dose influenza vaccine were labeled with pink tags, private vaccine for individuals with insurance were labeled with blue tags, and state-supplied vaccine for children and adults was labeled with multi-colored tags. Clear instructions on the vaccination process, drive-thru process, and vaccine type were taped on a table at each drive-thru lane. Staff were provided orientation and time to ask questions prior to each drive-thru event.

COVID-19 numbers have remained high for the City of Bismarck and Burleigh County throughout the late summer and Fall despite community-wide education. A state-wide mask mandate and mitigation strategies were issued on November, 13^th, 2020. There continues to be strong opinions to the mask mandate across the community and state.

In conclusion, the biggest takeaway from the 2020 influenza vaccine season, where drive-thru clinics were utilized, is that throughput is dramatically increased in this type of vaccination method. In addition, staff and community members' exposure to infectious disease was reduced dramatically. Through the many changes, staff adapted well because of universal training methods, orientation time, and being paired with experienced vaccinators. Feedback from the community was positive overall and individuals were impressed with the short waiting times, ease of paperwork completion, and thankful they were able to receive influenza vaccine in a safe and low-exposure environment.

Grohskopf, Liburd, and Redfield (2020) provide an overview of addressing influenza vaccine disparities during the COVID-19 pandemic, which includes reducing barriers for high-risk populations and those of ethnic and racial disparities. Grohskopf et al. (2020) explain that individuals of certain races and ethnicities and those that are lower-income are less likely to receive an influenza vaccine due to a lack of child care, non-flexible clinic hours, inability to leave work or have paid time off, and quality health insurance coverage. BBPH addressed these barriers by offering a drive-thru clinic where families could receive vaccine together, a walk-up option for individuals without a vehicle, evening and morning clinic hours, and vaccine for all individuals regardless of their ability to pay.

Grohskopf, L., Liburd, L., & Redfield, R. (2020). Addressing influenza vaccination disparities during the COVID-19 pandemic. JAMA 324(11). 1029-1030. doi:10.1001/jama.2020.15845.

The main goal of providing drive-thru vaccination clinics during the 2020 influenza season was to increase the number of doses provided to individuals in the City of Bismarck and Burleigh County while reducing barriers for high-risk individuals. In order to reduce barriers to accessing influenza vaccine, BBPH held multiple drive-thru clinics with times in the morning, afternoon, and evening. In addition, BBPH did not turn away any individual based on their ability to pay or insurance status.

Staff from administration, billing, emergency response, nursing worked together to plan the drive-thru clinics. This allowed staff to view the process from different work backgrounds and experience. In addition, staff reached out to community partners including a family medicine residency program to provide resident physicians the opportunity to assist with vaccinating. BBPH communicated with many stakeholders including first responders, homeless coalition, clinics, private businesses, and schools regarding the dates and times that drive-thru clinics were being held.   

BBPH fosters collaboration with community stakeholders by seeking input and conversations regarding new processes and procedures. By providing community stakeholders an opportunity to provide feedback, input, and conversations a relationship and buy-in is created. Some feedback from community stakeholders included wanting later evening hours for drive-thru clinics and morning times for elderly individuals. Community stakeholders encouraged their staff and customers/residents to attend the drive-thru clinics because they were a safe and low-exposure option. This, in turn, helped BBPH to provide more doses of influenza vaccine in the community.

No new external partnerships were experienced as a response to the drive-thru vaccination clinics, but work relations among BBPH staff were strengthened during the process. Staff that have never worked together or worked in a vaccination clinic setting worked effectively and efficiently. Nurses that do not normally staff immunization or flu clinics were partnered with experienced nurse vaccinators in order to promote teamwork and learning. Staff from different nursing backgrounds got to know each other better and fostered positive working relationships. During the COVID-19 pandemic, staff have been stretched thin and have accumulated extra workloads. This has increased stress and tension for most healthcare staff; so, one unexpected benefit from the drive-thru vaccine clinics included colleagues bonding over new work relationships.  

Strategic partnerships to address health equity included working with the event center to organize the drive-thru clinic. The location of the clinic is downtown, within close walking distance to public transportation. This promoted easy access to the clinic for individuals without vehicles; these individuals were encouraged to use the walk-up location to receive vaccines. In addition, social media messaging that promoted the drive-thru clinics stated that vaccine was available for uninsured individuals.  

BBPH ordered several hundred extra doses of influenza vaccine in order to meet a foreseen need in the community. In addition to drive-thru clinic options, the community was encouraged to make appointments daily to receive influenza vaccine. Extra staff was hired to accommodate the needs of the community in relation to COVID-19 response efforts and influenza vaccine administration. Individuals in the community that were elderly or frail and did not want to leave their homes to receive vaccine due to the risk of exposure were accommodated and provided vaccination in their home environment. Staff vaccinated hundreds of adults living in assisted living settings, a local homeless shelter, private business, and City of Bismarck staff, on location while keeping social distancing and infection control measures in mind.

When individuals came a drive-thru clinic without their client record form filled out it created a bottleneck initially at the screening station. Staff improved the screening process by directing individuals without paperwork completed to pull into a designated area where they could safely complete their paperwork and still receive a vaccine. Then, individuals that brought completed paperwork could pass through after screening without being bottlenecked. Another issue that came up several times was that individuals came to the drive-thru clinic assuming it was a COVID-19 testing event. Initially there was nowhere for these individuals to pull off or pull through without being caught in one of the drive-thru lines. Staff created an express lane on the far end of the event center where individuals that did not wish to proceed with vaccination could pull through and leave the event center.

CARES funding was appropriated to cover part-time salaries for employees that assisted with the drive-thru clinics. In addition, CARES funding was utilized to purchase supplies, PPE, and printed materials. Nursing and non-nursing staff rearranged schedules with patients and meetings in order to accommodate the drive-thru clinic times. Staff worked extra hours, came early to work, and stayed late in order to have fully staffed drive-thru clinics.

Staff came together effectively to provide quality and professional care to the community. The overall process took less than 10 minutes for individuals getting vaccinated, nobody was turned away due to their ability to pay, and the community was grateful for the option to receive healthcare in a safe way. In the future, BBPH may implement drive-thru vaccination clinics to reduce the spread of disease and decrease wait times for patients. BBPH impacted public health in the City of Bismarck and Burleigh County by offering influenza vaccine to the community in a manner that accommodated citizens. More individuals received timely influenza vaccine, which could lead to reduced influenza infections during the winter months when COVID-19 may see increased spread. This, in turn, may help to lighten the burden on healthcare systems in the community.