Lessons Learned from Hurricane Katrina:

1. Lessons Learned from Hurricane Katrina: Ensuring Proper Vaccine Management, Handling, and Administration During a Disaster

2. What Can Happen? • Natural Disasters - Ice/Snow Storms, Hurricanes, etc • Blackouts • Delivery Strikes

3. Actions Steps for all Pediatric Practices: Before Disaster Hits! • Promote good storage and handling at every opportunity • Regularly monitor refrigerator temperatures • Follow vaccine handling & storage requirements • Check equipment function when placing vaccine orders (door seals, etc) • Develop vaccine management protocols • Display Disaster Recovery Plan

4. Action Steps for Pediatric Practices Located within Disaster Areas • Contact distributors to stop all bulk vaccine order deliveries • Contact local public health agency to confirm suspension of VFC vaccine deliveries • If available, ensure power source backup for vaccine refrigerators • Document vaccine determined not viable for later return

5. Protecting the Vaccine • Be proactive • Ensure backup energy source – if possible • Develop emergency protocols for disaster scenarios • Example: Loss of Power • Close the vaccine refrigerator door tightly • Do not discard the affected vaccines. Mark the vaccines so that the potentiallycompromised vaccines can be easily identified • Call the manufacturer(s) and notify the local or state health department • Record action taken

6. Protecting the Vaccine • Be prepared • Remind practice staff of vaccine protocols and procedures • Protect the vaccine and maintain the cold chain by following recommended vaccine temperatures, vaccine storage requirements, and temperature monitoring • If transporting vaccine to another location, maintain the cold chain during transport • CDC Guidelines: www.cdc.gov/mmwr/preview/mmwrhtml/mm5242a6.htm

7. Protecting the Vaccine • The following guidance developed for providers during the 2003 Northeast Power Outage may be helpful in the event of a temporary power outage. The Immunization Action Coalition has developed a worksheet to record this process. • Do not open freezers and refrigerators until power is restored • Most refrigerated vaccines are relatively stable at room temperature for limited periods of time • The vaccines of most concern are MMR and Varivax, which are sensitive to elevated temperatures

8. Protecting the Vaccine • Monitor temperatures; don't discard; don't administer affected vaccines until you have discussed with public health authorities • If the power outage is on-going: • Keep all refrigerators and freezers closed to help to conserve the cold mass of the vaccines. • 2. Continue to monitor temperatures if possible - Do not open units to check temperatures during the power outage. Instead, record the temperature as soon as possible after the power is restored, and the duration of the outage. This will provide data on the maximum temperature and maximum duration of exposures to elevated temperatures

9. Protecting the Vaccine Continued: • 3. If alternative storage with reliable power sources are available (i.e., hospital with generator power), transfer to that facility can be considered. If transporting vaccine, measure the temperature of the refrigerator(s) and freezer(s) when the vaccines are removed • 4. If possible transport the vaccine following proper cold chain procedures for storage and handling or try to the record the temperature the vaccine is exposed to during transport

10. Protecting the Vaccine Continued: • When power has been restored: • Record the temperature in the unit as soon as possible after power has been restored. Continue to monitor the temperatures until they reach the normal 2–8 degrees Celsius range in the refrigerator, or -15 degrees C or less in the freezer 2. Be sure to record the duration of increased temperature exposure and the maximum temperature observed

11. Protecting the Vaccine Continued: 3. If you receive vaccine from your state or local health department, they may be contacting you with guidance on collecting information on vaccine exposed to extreme temperatures 4. If you are concerned about the exposure or efficacy of any of your vaccine stock, do not administer the vaccine until you have consulted your state or local health department

12. Protecting the Vaccine Continued: 5. Keep exposed vaccine separated from any new product you receive and continue to store at the proper temperature if possible 6. Do not discard any potentially exposed vaccine. We will be working with the vaccine manufacturers to determine which vaccines may be viable

13. Action Steps for Practice Staff After Disaster Hits: Be Informed! • Contact local public health department or CDC for information and guidance: CDC Hotline: 800/232-4636 CDC Web site: http://www.cdc.gov/vaccines • Follow interim immunization recommendations (i.e., Interim Immunization Recommendations for Individuals Displaced by Hurricane Katrina and Interim Immunization Recommendations for Emergency Responders: Hurricane Katrina)

14. Continued… • Communicate interim immunization recommendations and requirements to practice staff. Examples: • Select states waived school immunization requirements post-Hurricane Katrina • VFC program was expanded to cover Hurricane Katrina evacuees

15. Displaced Persons Living in Crowded Settings In addition to recommended vaccines, persons in crowded settings should receive the following vaccines: • Influenza - Everyone ≥6 months of age should receive influenza vaccine. Children 8 years old or younger should receive 2 doses, at least one month apart •  Varicella - Everyone >12 months of age and born in the United States after 1965 should receive one done of this vaccine unless they have a history of chickenpox •  MMR - Everyone >12 months of age and born after 1957 should receive one dose of this vaccine • Hepatitis A - Everyone >2 years of age should receive one dose of hepatitis A vaccine unless they have a clear history of hepatitis A

16. Immunization Record Keeping and Documentation During a Disaster • At all times - all vaccines administered be properly documented • Immunization records should be provided in accordance with the practice of the state in which the vaccine is administered • Immunization cards should be provided to individuals at the time of vaccination • Standard immunization practices should be followed for delivery of all vaccines, including provision of Vaccine Information Statements (VIS)

17. Paying for Vaccines • In September, the U.S. Department of Health and Human Services announced that all children from birth -18 years old displaced by Hurricane Katrina are eligible to receive free vaccines through the federally-run Vaccines for Children program (VFC), regardless of whether they are staying at shelters, hotels, or with family and friends and regardless of previous health insurance coverage status • If you are not a VFC provider, contact your state VFC coordinator to find out how to enroll

18. Actions Steps for all Pediatric Practices: After the Disaster • Notify distributors to resume vaccine deliveries • Notify vaccine representatives to resume bulk order shipments • Contact local public health department to determine if VFC vaccine delivery has resumed • In the event of vaccine shortage, work with local public health to identify/distribute needed vaccine

19. Remember! Comprehensive vaccine management protocols will help practice staff address future vaccine supply challenges (i.e., vaccine shortages or supply allocations) and help ensure appropriate vaccine handling procedures throughout the year!

20. Role of Public Health and Medical Societies • Communicate emergency to provider sites in advance (mass fax, etc) • Send additional information (if available) to those practices in the path of danger • Communicate with local health departments and local health officials (stay on message, coordinate activities when possible)

21. Additional Resources How to Protect Your Vaccine Supply, 2004. CDC video (25 min.). To order 1 free copy from the CDC call 800/232-4636. CDC’s Web-based Toolkit for Vaccine Storage and Handling. Available at: http://www2a.cdc.gov/nip/isd/shtoolkit/splash.html Fact Sheet: Don’t be Guilty of These Storage & Handling Errors! Available at: http://www.immunize.org/catg.d/p3036.pdf