In late September 2020, Carlton County Public Health & Human Services planned and administered a drive-through seasonal influenza clinic.  The clinic was a preparatory step for administering a future Covid-19 vaccine.  Public Health & Human Services partnered with county staff from the Land Department, the IT Department, Building Maintenance, the Sheriff's Department, the Transportation Department, and the GIS Department.  Together, they began creating a technology solution that would significantly reduce concerns regarding Covid-19 transmission at the clinic.  The clinic plan, from start to finish, was reviewed and contact points with pen and paper as well as individuals standing in lines were eliminated.  Online forms were developed with a GIS program called Survey 123.  The program made registration simple and collected data in real-time about how many individuals had registered.  Vaccine data was also incorporated and entered into the online form, showing numbers of individuals vaccinated and numbers waiting to be vaccinated in real-time.  

County IT staff assisted with the configuration and setup of iPads and Wi-Fi coverage in the drive-through location.  Planning and executing a drive-through vaccination clinic versus a wait-in-line traditional model was made easier with the use of a county transportation facility. Staff were strategically placed at check-points around the facility, and a small transmitter broadcast vaccination information over a local radio channel.  Participants could listen to the information while waiting their turn to be vaccinated.  Donned in PPE, clinic staff communicated with individuals in their vehicles, guiding them to the next open vaccine station.  Flu vaccine was administered by public health nurses at 4 stations in the transportation garage.  Vaccination supplies were laid out on a stainless steel utility cart on wheels right next to the parked vehicles.  Public Health and Human Services administration staff, alongside the nurses, pulled up and verified registration and health screening information of the individual on an iPad.  If the individual had not pre-registerd, clinic staff were available to help with this as well.  Vaccination information was entered on the iPad when the immunization process was complete.     

After receiving a vaccination, staff reviewed a quick survey with the participants to gauge the satisfaction and record feedback.   Individuals were directed to a rest and recovery area if needed, where county staff were on hand to assist with behavioral health or medical needs.  The survey results were then broadcast on a live dashboard.  The dashboard was displayed to staff working the clinic on a 50-inch screen.  Survey results were listed along with how many individuals had registered, how many had been vaccinated, how many have registered but not yet vaccinated.  Other data gathered, included traffic volume in relation to time of day, all in a colorful visual.    

Due to the success of this flu clinic, Carlton County successfully hosted the first drive through Covid-19 vaccine clinic on Tuesday, December 29, 2020 for EMS personnel of Carlton County.  The clinic was surrounded with great pride of achievement as a marking point of the start of many Covid-19 clinics to come in 2021.  

All Carlton County residents were soon to be facing 2 serious respiratory diseases, Covid 19, which was already circulating in the community, and seasonal influenza.  US census website population estimates for Carlton County, as of 7-1-2019 are as follows:  89% white, 1.7% black, and 6.0% Native American.  Age estimates as of 7-1-19 are as follows:  5.3% under 5 years, 22.3% 5-18 years, 54.9% 19-64 years, and 17.5% 65 and over.

 The immunization program in Carlton County was affected by Covid 19 because of strict guidelines in Minnesota on social distancing.  Because Covid 19 is believed to be spread via droplets in close contact, a traditional immunization clinic was not practical nor safe for the public or staff.  The new plan for administering flu vaccines included a drive through clinic, which promoted minimal contact with fellow community members, and eliminated standing in lines for a vaccine.  Immunizations were available to everyone in the county, knowing some individuals did not have regular health care providers to go to.  Immunizations were also provided free of change to those in our community who were uninsured or underinsured.

In the past, Carlton County Public Health consistently offered community seasonal flu vaccines for all populations in Carlton County.  Each fall, Public Health planned and scheduled several public community clinics. Traditional, stand-in-line, paper-form registration, and high contact clinics were offered after hours at local schools, to ensure convenient public access to clinics.  Annually, the 65+ population has been made a priority by the County Health Department in regard to the offering of “high-dose” flu vaccines. 

The practice for the drive-through flu vaccinations of 2020, was much improved by the convenience to the public for pre-registration on an electronic form, which was collected prior to the vaccination clinic using a GIS-based software.  Benefits included:  paperless registration, contactless registration, review of live data, and capture of numbers registered.  Also, knowing the flu vaccines help ease the burden to local hospitals and clinics as co-occurring respiratory disease was prevalent in the community.  Flu vaccines improve the overall health of the county population, lowering transmission rate, serious flu infections, hospitalizations, and death. 

This practice was innovative for Public Health to partner with county GIS staff. Moving to paperless and contactless registration was immensely beneficial to the public, as a simple and convenient way to enter data using a smart cellular device, a tablet, laptop or computer.  To ensure all individuals were served, they could also work with county staff, the day of the clinic to get registered.  Registration data using the GIS software was kept secure and was easy to retrieve the day of the clinic.  Limited data entry from the public included only gathering the necessary data to input for immunizations, also, the real-time data from the GIS software that was produced as the clinic took place was helpful.  Numbers of throughput, details on times, number of immunizations, number registered, and also a satisfaction component were collected and made visible to staff working the clinic on a 50” monitor at the clinic site. 

This was a new use for GIS in our county health department.  In the past, the interactions with GIS software and staff had been limited.  Opening lines of communication between other county departments and asking what could be possible was the key to starting this project.  This clinic has been cited by several national news outlets and a GIS publication, bringing attention to the collaborative efforts of county GIS and county public health.  This practice was creative in its use and made minimal personal contact successful between county public health staff and the public. 

Because Covid 19 was present in Carlton County at the time of planning for influenza vaccinations, intentional efforts in planning were made with future Covid 19 vaccinations in mind.   Testing the process and lessons learned from the drive through influenza clinic process was vital to preparation for a successful drive through Covid vaccination clinic.  Top priority was paid to PPE supplies, keeping nursing and administrative staff safe, keeping the public safe, and giving an effective vaccine to protect against emerging seasonal influenza.

Existing resources of iPads were used during the registration and check-in process at the transportation facility the day of the clinic.  Programed forms were loaded and tested prior to clinic day with a dry run for “staff-only” a day ahead of the public clinic.  Wi-Fi technology and cellular data plans on the tablets were utilized on-site.  County Sheriff’s department radios were used for clinic staff for efficient and effective communications.  At the county transportation building itself, resources such as pickup trucks, 4-wheelers, and meeting room facilities were available.  GIS staff worked behind the scenes to produce a visual of statistics in real-time.  Transportation staff assisted with signage on the highway leading to the clinic site, Sheriff’s department deputies helped direct traffic when needed, and IT assisted in setting up a radio transmitter for local radio broadcast of vaccination messaging. 

Carlton County, located in Northeastern Minnesota, saw incrasing cases of Covid 19 due to community spread.  Cold temperatures and poor weather begin as early as October.  Activities outdoors would soon be limited, driving more people indoors effectively, closer to one another.  The anticipation of more Covid cases due to these factors, made providing a flu clinic early in the flu season important due to the co-occurring respiratory infections.  This practice of a drive through flu clinic, eliminated close contact of the public.  Anyone working the clinic was in strict adherence to the PPE and distancing requirements.  Controlling the contact points where the public interacted with staff was guaranteed by staff using PPE and by the starting check-point offering free masks to those entering the drive-through clinic.  A list of transportation resources in the community were gathered for those with transportation challenges. 

The current practice was based on the best science and research available around Covid 19.  Carlton County used data and guidance from the Minnesota Department of Health, Governor Tim Walz, and the Centers for Disease Control and Prevention. 

One of the goals of the practice was to plan, test, and successfully execute a drive through clinic for the seasonal flu vaccine in preparation for the mass public Covid vaccinations.  Another goal was to vaccinate members of the community, keeping them protected against influenza as a second major respiratory disease, co-occurring with Covid 19.  Establishing a paper-free, easy to register, web-based approach to data entry and collection for registration and health screening, was also a major goal in the practice. 

Carlton County Public Health and Human Services prides itself on its many community partners.  Through years of outreach and solid communication, relationships have been built with community hospitals, clinics, long term care and skilled nursing facilities, law enforcement, EMS/fire, local school districts, and the Fond du Lac reservation.  These partners are also a part of Carlton County Public Health and Human Services Emergency Preparedness committee.  This committee has met for upwards of 20 years, planning for health events or natural disasters. The committee has given all who attend a pulse on the community, what the needs are, where the gaps are, and how best to respond to citizens.  Regional partners also play a major part in the planning and implementation for Carlton County.  Carlton County is a part of a Community Health Board, which consists of 4 regional counties in Northeastern Minnesota.  It was vital to contiue to meet during the pandemic.  Use of video meetings was relied on heavily to obtain feedback and expertiese from those regional county health departments as well as the Minnesota Department of Health staff.

Locally, partners in Carlton County have been meeting via video presence since March 2020 in an incident command capacity, to discuss the pandemic, best practices, guidelines, CDC and State of Minnesota/Minnesota Department of Health recommendations and information.  As well as discussing outbreaks, numbers of infections, school closings, and community impact.  The drive-through clinic plan was well received by partners and messaging about the clinic was shared among them and on to the public, through their organizations. 

As noted, Carlton County is a part of the Community Health Board and by Minnesota State Statute, must engage a Public Health Advisory Committee made up of a county commissioner, and appointed members from all the county commissioner districts.  Meetings are held monthly with the goal of the committee to inform and obtain feedback from members on how to best prioritize the needs and serve the community.  Engagement with community partners is practiced in monthly Emergency Preparedness meetings which involve large segments of participation from school leaders, businesses, clinics and hospitals, long term care and skilled nursing facilities, corrections staff from state and local facilities, the Fond du Lac Reservation Public Health and Human Services staff, EMS, fire, and law enforcement.

The relationship with the community of Carlton County has consistently been made a priority for the local public health department.  The importance of recognizing, understanding, and planning for public health delivery for the needs of the community, are vital to the success of the people of Carlton County and to improve their health outcomes.  The Fond dul Lac Reservation is a part of Carlton County.  Carlton County has made a priority to help foster and grow the relationship with Fond du Lac Public Health and Human Services, to learn from and support their agency and the people of the Fond du Lac Reservation as best as possible.  Carlton County Public Health practice goals are furthered by serving populations of citizens who do not have a regular care provider for vaccinations.  Also, by consistently providing vaccinations free of charge for those underinsured or uninsured.  Consideration is made annually for the 65+ population to provide the high-dose vaccine, as they are at a higher risk for adverse health outcomes. 

New partnerships were created and strengthened by the cooperation of other county departments, namely the GIS department.  Public Health relied on the expertise and skill of those in the County GIS department to create and configure a paper-free, online registration for the drive through flu vaccine clinic using a GIS-based software.  This partnership was a benefit to the process, utilizing the automation of the software to be specialized to the needs of public health.  The staff in GIS were well versed in the needs of Public Health to create the process from scratch and have it function effectively for a minimal contact drive through clinic.  For public health, that meant a clinic that minimized the risk of Covid transmission in a way to prioritize safety more so than a traditionally hosted clinic. 

The most impactful strategic partnership to this practice, was the relationship with the County GIS staff.  In creating the registration forms, it was significant to plan for access for everyone regardless of available technology.  Pre-registration was developed, however on-site registration was also incorporated into the process with the assistnace of the software and staff on-site to assist individuals with registration.  

The drive through clinic was offered as soon as possible in September of 2020 to address the co-occurring infections of Covid-19 and seasonal influenza.  Local public health made flu vaccines available to all populations in the county to help positively impact health as well as to ease the potential burden on the health care systems dealing with co-occurring respiratory disease.  The needs of the community were met by quickly and successfully hosting a drive through flu clinic to mitigate the risk and transmission of Covid-19. 

The original plan was for the clinic to be held outside of the facility.  Due to rain forecast the day of the public clinic, a shift in plan took place to utilize the garage of the transportation facility.  The garage houses a repair shop, and upward of 15 full size utility and road maintenance trucks, with doors on the east and west side; the facility was ideal for an inside option.   Clean up work to the garage floor was completed quickly the morning of the clinic.  Stations were spread out within the driving route area, so utilizing an ATV to transport PPE, supplies, water, and food to workers at stations outside was helpful.  This factor was not included in the planning but was easily incorporated. 

In addition, a satisfaction survey was developed and implemented on the fly the day of the clinic.  It wasn’t discussed as part of the initial plan but made sense to understand the public experience.  As cars began to line up, the survey was in place.   Again, GIS staff were involved in using the software program to capture the survey answers from participant experiences and to display the data in real time for staff to review. 

The number of flu doses was increased exponentially for the clinic. The number of vaccinations given at this one clinic was greater than any past year.  More than 700 people received their flu shot at the clinic.  In an average year, that number is how many individuals are immunized in a flu season, or a spread of about five months’ time.  The increase in vaccination numbers at the very beginning of the flu season helped to reduce the stress to the health care systems in our community.  Being vaccinated early and while Covid-19 transmission rates increased in Carlton County, was a proactive way of delivering effective disease control and prevention.

High numbers of Public Health and Human Services staff were utilized in the event.  Many staff were needed to fill in gaps of job detail at the clinic.  This was the largest clinic event that Carlton County Public Health had ever hosted.  For a rural, small-sized Public Health department, staffing from Human Services and other county departments was necessary.  The option to downsize was not considered.  Staff volunteered to assist at the clinic and received just in time training to keep the integrity of the program and keep the scale as large as possible for the community. 

The Public Health department receives calls for information and referral on a daily basis.  As details of the clinic were advertised, phone calls to the department increased.  Consistent, clear messaging from the Public Health and Human Services receptionist indicated that pre-registration was available and much information could be found on the county website.  The receptionist was given as much information as possible to help callers regarding the flu clinic.  An on-call nurse for the day was also given updates to clinic information and registrations to share with callers asking specific questions via phone.  Social media accounts highlighted the program and gave details about the registration process and date and times of the clinic. 

The digital approach for a vaccination clinic was a more efficient use of resources and staff time. Moving forward into future clinics, the use of a digital format will become the standard, omitting the use of paper forms. The concept of a drive-through clinic was a safer approach this year due to COVID-19 but overall, the number of county citizens vaccinated was greater than any other in years past. From the participant survey feedback, attendees liked the drive-through approach as it was easier for them. The drive-through approach allowed citizens to stay in their vehicles the entirety of the event.  The digital forms allowed attendees to pre-register online making the on-site vaccination process much shorter.  From staff observations, it appeared to also be a much more enjoyable experience for families with children who have found vaccinations intimidating in the past.

The digital format of the registration and data collection on vaccine information made the transfer of data between the county health department and the State of Minnesota Immunization Information Connection registry more efficient due to batch data submissions and entry.

This experience reaped the benefits of maintinaing established partnerships and growing those relationships in the county and community.   Staff and technology were adaptable and using the Incident Command System within the event made internal work easier, more cohesive, and manageable. Elements of the program that will be sustained are the use of website and digital registration, and simple radio broadcast messaging.   The location and facility were excellent and will likely be built into further plans and programs as needed.  Understanding and upholding the supporting role that County Public Health has to the Tribal Public Health in our community and continuing to make that connection a priority when serving all citizens is important into the future.  Continuing to strengthen the realtions with Tribal Public Health to help health outcomes be more successful for native people in our community. 

Public Health was visible and in the community providing safe and effective measures to help prevent the spread of influenza during a world-wide pandemic.  Providing immunizations for free to underinsured or uninsured community members to ensure equity in availability to the vaccine.  When possible, prioritizing populations of  65+, the under or uninsured, and the higher native populations in our county who are all disproportionately affected by disease.