The Nassau County Department of Health (“NCDOH”) provides services to nearly 1.4 million residents on Long Island, New York. Nassau County is the immediate Eastern neighbor of New York City and is a suburban community with significant health and socioeconomic disparities. According to the most recent US census, residents are predominantly white (73.4%), with the largest minority groups being Hispanic/Latino (17.5%), Black (13.1%), and Asian (10.9%).

These minority populations are concentrated in a few select communities, most of which have a high Social Vulnerability Index (SVI) and are more urban than other parts of the county. These urban areas were at the epicenter of the COVID-19 pandemic, with the highest COVID-19 cases and deaths in Nassau County. This demanded an immediate, all-encompassing enhanced disease control response by county employees across all units. Once NCDOH received its first shipment of vaccines, a tremendous effort was initiated to vaccinate the county residents.

To combat health disparities with regards to the COVID-19 vaccine distribution, NCDOH’s strategy was twofold. First, engage the community through outreach programs with the assistance of the Department of Human Services, the Office of Minority Affairs, the Office of Hispanic Affairs, and the Office of the Aging, along with elected officials and community leaders, all of whom have established relations with local leaders in minority communities, pastors, minority owned businesses, political leaders. Next, leverage our relationship with Northwell Health, a local healthcare provider network, and use a data driven approach to set up targeted pop-up COVID-19 vaccination sites in communities that have lower rates of vaccination using real-time data.

Although this practice set out to reduce COVID-19 vaccine disparities, its impact has and will be felt beyond just its stated goal. The tremendous partnership with Northwell Health and collaboration with different departments and offices of local government, elected officials, community leaders, private businesses, and other private healthcare providers led the immense reduction of COVID-19 vaccination disparities. This program will also improve health outcomes among these populations by providing a model for comparable interventions that include expansion to other communities challenged by distance or fiscal obstacles accessing medical services, including receiving other vaccinations.

This practice’s success is evident in the vaccination rates of minority communities as compared to other communities within Nassau County. For example, Hempstead, a minority community with a high SVI and a Non-White population of 83.6%, had a first dose vaccination rate of 17% as of March 2021. In comparison, Wantagh, a zip code with a predominantly white population (95%), had a first dose vaccination rate of 43%. Over time, NCDOH's approach of increasing vaccination demand through education and outreach and enhancing vaccination services by hyper-localized vaccination sites, the first dose vaccination rate in Hempstead rose to 92%, which is comparable to Wantagh’s 95% vaccination rate.

Although Nassau County has consistently been ranked as one of the top 5 counties for Health Outcomes and Health Factors in New York State significant health and socioeconomic disparities still exist within the county, especially within minority communities.⁽¹⁾ According to the most recent US census, residents of Nassau County are predominantly white (73.4%), with the largest minority groups being Hispanic/Latino (17.5%), Black (13.1%), and Asian (10.9%).

While recent census estimates state that 5.7 percent of residents live in poverty, these residents make up a majority of the population in a few select communities. For example, in Roosevelt, a community in Nassau County that's home to more than 18,000 people, about half of the public-school students are eligible for free or reduced-price lunch, an indicator of poverty. About 98 percent of residents in Roosevelt are black or Hispanic. Many minority residents of Nassau County are concentrated in these select communities, most of which are more urban than other parts of the county. These urban areas were at the epicenter of the COVID-19 pandemic, with the highest COVID-19 cases and deaths in Nassau County.

A community health assessment conducted by NCDOH between 2016 and 2018⁽²⁾ identified nine minority communities within Nassau County, including Roosevelt, as areas where “population pockets are disproportionately burdened with a poorer health status.” This is evident by the shorter life expectancies, higher disease prevalence, and less accessible health care that the residents of these nine communities face. According to the assessment, these nine communities have significantly higher rates of asthma, type 2 diabetes, liver disease, and chronic obstructive pulmonary disease than the rest of Nassau County. Additionally, the rates of asthma and type 2 diabetes hospitalizations are more than doubled in these minority communities than the rest of the county. These preexisting health disparities that have been prevalent within Nassau County were only exacerbated by the COVID-19 pandemic.

Ensuring that Nassau County is truly an equitable place to live requires a targeted focus on health, which is what this practice set out to do. To combat health disparities with regards to the COVID-19 vaccine distribution, NCDOH implemented a strategy that involved the use of two coordinated efforts to increase vaccination rates within targeted populations. This evidence-based strategy comes from the best practices cited in the Guide to Community Preventive Services “Increasing Appropriate Vaccination: Community-Based Interventions Implemented in Combination” publication. These efforts involved partnerships between different departments and offices of local government, elected officials, private businesses, and private healthcare providers to implement and coordinate the following:

• Actions to increase community demand (client and community-wide education, client scheduling, reminder and recall systems, manual outreach and tracking, and client incentives)

• Enhancement of access to vaccination services (hyper-local targeted vaccination sites within the community, vaccination sites at local businesses, and home visits)

In the past, NCDOH would open influenza vaccination sites when there were a very high number of cases of influenza in Nassau County, or when demand for the influenza vaccine was too great for local doctors and pharmacies to manage. NCDOH would set up sites with community partners, reach out to local news organizations, and put the vaccination dates and times on the county website. This practice builds upon NCDOH’s previous experience and partnerships to offer a more targeted approach to vaccinating historically underserved communities. Through continually collecting and analyzing data NCDOH provides outreach to these communities by increasing the demand for COVID-19 vaccines and by rapid proliferation of access to vaccination services. This data-driven approach allowed NCDOH to use resource intensive efforts in a targeted way that allowed NCDOH to remain efficient and agile, being able to change at a moment’s notice.

For this practice to be effective, resources needed to be reallocated and everyday procedures adapted. Most staff members were reassigned from their regular duties in other programs to working on helping NCDOH’s COVID-19 vaccination program. Some roles had staff analyzing vaccination numbers and data, coordinating with our partners, and performing geographic information system (GIS) mapping. NCDOH partnered with Northwell Health, a local healthcare provider network, to quickly set up targeted pop-up COVID-19 vaccination sites in communities that have lower rates of vaccination. To determine where these pop-up COVID-19 vaccination sites should be set up, NCDOH utilizes vaccine data from the New York State Immunization Information System (NYSIIS). All county residents who receive a COVID-19 vaccine, regardless of medical provider, will have their information entered into NYSIIS. NCDOH then downloads all the vaccine data each day and filters out Personal Identifiable Information (PII) and only keeps information on age, vaccination status, ethnicity, and address. Although GIS mapping has been used by NCDOH and in public health before, this mapping is specific to targeting vulnerable communities and their COVID-19 vaccination status. Partnering with Northwell Health’s Feinstein Institutes for Medical Research, the vaccine data is mapped using GIS and cross-checked using population statistics. This results in NCDOH being able to see where in each community vaccination rates are low and what demographic groups are lagging in vaccinations. NCDOH is also able to see which communities are more likely to not complete their vaccination series. With this information, NCDOH is able to set up targeted pop-up COVID-19 vaccination sites with Northwell Health. Some sites are specifically for individuals to get their first dose, whereas others are for individuals to complete their vaccine series. This knowledge also allows the Department to focus certain resource intensive outreach efforts to specific areas, targeting their use for maximum efficiency.

Sources:

1. County Health Rankings and Roadmaps. (https://www.countyhealthrankings.org)
2. Community Health Assessment and Community Health Improvement Plan 2016-2018. (https://www.nassaucountyny.gov/DocumentCenter/View/17688/2016-2018-NCDOH_CHA-and-CHIP-FINAL?bidId=)

Community collaboration and partnerships are vital pillars in the Nassau County Department of Health’s mission to promote and protect the health of all who live, work, and play in Nassau County. The COVID-19 pandemic disproportionately affected minority groups by exacerbating the existing social, geographic, political, and economic challenges minority groups already face. In order to combat these challenges, NCDOH partnered with Northwell Health, New York’s largest healthcare provider, other county agencies including the Department of Human Services, the Office of Minority Affairs, the Office of Hispanic Affairs, and the Office of the Aging, along with elected officials and community leaders.

The goal of this practice is to take a proactive approach to reduce COVID-19 vaccination disparities by using data analytics to refine and support targeted outreach to vulnerable minority communities. To achieve this goal a two-pronged approach was implemented; one, increase community demand for vaccinations and two, provide equitable access to vaccination services. To increase vaccination demand in minority communities and provide equitable access to vaccination services, NCDOH looked to the feedback provided by the Community Health Assessment which conducted surveys, held focus groups, and conducted in-depth interviews of community-based organizations. This community engagement yielded insight into the perception of barriers and determinants of health at the community level.

NCDOH took several steps to increase community demand for the COVID-19 vaccines. First, a coordinated plan was discussed and implemented with the help of the Office of Minority Affairs, the Office of the Aging, the Department of Human Services, elected officials, and community leaders. Initial vaccination locations were determined by collaborating with these partners. Locations were chosen with focus on transcending physical barriers and social determinants of health. The Office of Minority Affairs helped develop health communication strategies with culturally and linguistically responsive materials, promoting scientifically accurate information on prevention of COVID-19 and importance of vaccinations. The NCDOH COVID-19 call center is staffed with personnel from NCDOH, the Office of Minority Affairs, and the Department of Human Services. The members of this workforce have diverse racial and ethnic backgrounds with multi-lingual and multi-generational representation present. Staff were given in person and video trainings that were culturally and linguistically tailored to best serve the vulnerable minority communities. The NCDOH COVID-19 call center provided culturally and linguistically sensitive information to residents calling in about vaccinations, scheduled appointments over the phone for those unable to or without access to a computer, and set scheduled reminders when residents were scheduling second doses.

With the help of several partners and stakeholders, NCDOH also endeavored to improve upstream determinants of health by increasing access to vaccination services. In collaboration with Northwell, vaccination data from New York State Immunization Information System (NYSIIS) was aggregated and mapped using GIS. Personal Identifiable Information (PII) was removed and NCDOH could visually identify vaccine disparities down to street level. With this information, NCDOH in collaboration with Northwell was able to set up hyper targeted pop-up vaccination sites.

In addition to establishing vaccination sites in strategic locations, NCDOH partnered with the Emergency Ambulance Bureau of the Nassau County Police Department (EAB) to vaccinate residents who are homebound. Residents who cannot physically make it to a vaccination site, due to mobility or immunodeficiency, can contact the COVID-19 call center and staff will facilitate a homebound vaccination appointment. These residents then receive vaccinations in the comfort of their own homes and simultaneously receive a wellness check as residents’ health conditions may have deteriorated since the start of the pandemic. Furthermore, EAB is prepared to potentially transport these individuals to nearby hospitals.

As Nassau County expanded vaccination efforts, unexpected partnerships were formed. Local businesses like McDonald’s and Hicks Nurseries reached out to NCDOH and inquired if vaccinations could take place at their places of business. This launched NCDOH’s local business vaccination program, where establishment employees like fast food workers could receive a vaccination at their place of work and not be concerned about immigration status or providing identification. NCDOH also provided bilingual vaccinators at business that requested them to ensure that employees felt as comfortable as possible. Additionally, these local business vaccination clinics directly addressed one’s physical environment as a social determinant of health, where the barrier of relying on personal or public transportation to reach a vaccine clinic was nullified and the clinic came to the individual at the workplace. NCDOH also collaborated with various community organizations like churches and synagogues for pop-up sites to get vaccines in the arms of those most in need. The practice was further benefited by local news station coverage of these clinics which increased vaccination demand from other businesses.

NCDOH has become a national model for COVID-19 vaccination, running three extremely successful vaccine centers at Nassau Community College, LIU Post College, and the “Yes We Can” Community Center. NCDOH has administered over 98,000 vaccinations to date, contributing to the 95% of adult residents 18 and older receiving at least one dose, and establishing Nassau County as first in New York State and second in the United States for adult vaccination rates for large counties. Nassau County has reached tens of thousands of residents through its SMS text system, which provides information about vaccination appointment availabilities in multiple languages. The COVID-19 Call Center has made/received over 150,000 calls and NCDOH has responded to over 15,000 emails, all towards the goal of increasing health equity of underserved communities with focus on upstream determinants of health by providing education and insight into the importance of vaccinations. NCDOH continues to distribute vaccines to hospitals and other community providers, working with Northwell Health and other medical partners to hold pop-up distribution events targeting hard to reach populations. For young residents, Nassau County pioneered a first-of-its-kind Student Vaccination Initiative, which vaccinated thousands of eligible students and engaged and trained youth ambassadors to support and encourage peers to roll up their sleeves. Nassau County drew national attention with this program and has been contacted by other Health Departments seeking guidance and detail on the County’s model.

In order to continually provide the best service to our residents, NCDOH has remained flexible and open to change using a data-driven approach to make adaptations and improvements. As the COVID-19 pandemic continued and federal and state guidance changed, it was imperative NCDOH and its partners stayed apprised of the latest information to best inform and educate residents, while focusing on combating health inequities.

NCDOH initially opened vaccination sites based on the most recent Community Health Assessment, US census data, and Social Vulnerability Index (SVI) maps for Nassau County. To better target vulnerable communities, NCDOH then utilized vaccine data from the New York State Immunization Information System (NYSIIS). This data-driven approach is used to identify areas, down to street level, where COVID-19 vaccine disparities are the greatest. With this information, NCDOH is able to set up hyper-local, targeted pop-up COVID-19 vaccination sites with Northwell Health. Continual data collection and analyzation from the NYSIIS database allows NCDOH to adapt at a moment’s notice, being able to set up new vaccination sites in the most vulnerable communities using real-time data. When COVID-19 vaccinations first started to be administered, disparities were evident in total vaccination numbers. Hempstead, a minority community with a high SVI and a Non-White population of 83.6%, had a first dose vaccination rate of 17% as of March 2021. In comparison, Wantagh, a zip code with a predominantly white population (95%), had a first dose vaccination rate of 43%. Over time with the NCDOH two-pronged approach of increasing vaccination demand through education and outreach and enhancing vaccination services by hyper-localized vaccination sites, the first dose vaccination rate in Hempstead rose to 92%, which is comparable to Wantagh’s 95% vaccination rate.

In addition to targeted pop-up COVID-19 vaccination sites, NCDOH adapted by scaling up vaccinations, including increasing staffing capacity and increasing vaccination sites to continue to provide vaccinations to marginalized populations. From serving 398 people at its first event, NCDOH vaccinated 3,200 people a day at its peak. To respond to demand, vaccination sites offer extended hours for each vaccination event. These extended hours help promote health equity and are especially important to working individuals who cannot normally attend a vaccine clinic due to long work hours.

For this practice to be effective, resources needed to be reallocated and everyday procedures adapted. A majority of staff members were reassigned from their regular duties in other programs to working on helping NCDOH’s COVID-19 vaccination program. These new roles had public health nurses providing medical consultations and administering vaccines to patients. Other roles involved screening individuals at vaccinations sites, answering calls at the call center, analyzing vaccination numbers and data, coordinating with our partners, and performing geographic information system (GIS) mapping. NCDOH’s existing resources were enhanced with grant funds from New York State through Health Research Incorporated, a nonprofit organization that provided NCDOH with dozens of capable and competent employees to answer the thousands of phone calls received daily at the call center. These additional resources for the call center allowed NCDOH to focus on staffing vaccination sites and other outreach programs to increase vaccinations within the county.

This practice created a foundation for implementing a rapid mass vaccination program, while focusing on combating health disparities, with great success. This practice can attribute much of its success to the tremendous partnership with Northwell Health and collaboration with different departments and offices of local government, elected officials, community leaders, private businesses, and other private healthcare providers.

The main lessons learned from implementing this practice are:

·      - Continually collecting and analyzing data to guide decision making and assess health outcomes is imperative to having a successful public health initiative.

·      - Being able to promptly adapt to changes in guidance and data is a huge added value, saving precious time and resources, keeping the practice efficient and effective.

·      - Continuously maintaining and strengthening public and private partnerships is of the utmost importance to best provide equitable services and outreach to communities.

The key components of this practice, focusing on reducing health inequities by using data analytics to refine and support targeted outreach to minority communities, will continue to be sustained and will play a role in future Department initiatives. Some efforts that were taken as part of this practice have been resource intensive. Manual outreach and tracking, COVID-19 vaccination sites at local businesses, and home visits have higher costs than other efforts that NCDOH implemented. These resource intensive efforts were deemed necessary to increase COVID-19 vaccination rates among the populations with lower rates and the communities where health disparities consistently exist. For future public health initiatives, efforts can be categorized and then implemented through the use of a tiered system. Less resource-intensive efforts like client reminders and recall systems would be used at the start of an initiative, and more resource-intensive efforts can be added later on to adequately scale-up as needed.

Although this practice set out to reduce COVID-19 vaccine disparities, its impact has and will be felt beyond just its stated goal. Efforts to increase COVID-19 vaccinations increased contact between health care providers and clients, allowing for opportunities to deliver other clinical care and preventive services. Homebound visits especially provided additional opportunities to help vulnerable clients address barriers to medical services and identify other health concerns while in the comfort of their home. Through using timely data-driven analytics, focusing on minority communities, and addressing upstream determinants of health, this practice helps to ensure that Nassau County is truly an equitable place to live.