In military medicine, exercises, such as a mass vaccination points-of-dispensing (POD) scenario, test preparedness capacity, and drill for potential real-world public health emergency scenarios. Exercises are designed to challenge medical teams to work under pressure and problem solve according to conditions presented in the exercise scenario. A benefit of medical exercises in the military is that they facilitate integrating the public health team with medical providers and other supporting agencies on the base and in the community through regular training, which carries over to real-world partnerships when actual public health emergencies arise. Exercises such as these provide the preparation and training required for when real-world incidents, such as the COVID-19 pandemic, occur.
Military Exercise – Vaccine Points-of-Dispensing
We participated in a military medical exercise simulating mass administration of interferon for a simulated Severe Acute Respiratory Syndrome (SARS) outbreak in the fall of 2015 at Vandenberg Air Force Base, California. Our public health officer chose simulated interferon administration to engage the public health emergency officer (PHEO) and the medical providers in the process of evaluating military members for the severity of illness in the wake of a simulated SARS outbreak. Participants received the flu shot and not interferon. The exercise provided an additional benefit to the base to also increase the number of flu vaccinations given to the active duty service members. The exercise’s primary intent was to assess the medical group’s ability to conduct a high-throughput vaccine points-of-dispensing.
We utilized the 2015-16 influenza vaccination effort as our training event. During the exercise, we immunized base personnel from three squadrons with the lowest vaccination rate (approximately 300 active duty service members) within 24 hours. That way, we were able to run the simulation and give the flu shot to catch up on readiness requirements. All of the exercise participants agreed to vaccination with the actual flu shot as part of the exercise.
We conducted a drive-through vaccine points-of-dispensing and scheduled squadron vaccination appointments to facilitate safe and rapid vaccination. The drive-through vaccine POD also reduced the virus’s possible spread by asymptomatic people inside a clinic or other vaccination site. For the exercise, medical techs administered vaccinations. Nurses responded to positive vaccine questioner answers, and providers assessed and treated adverse reactions to the vaccination. The PHEO was onsite overseeing the operation. The exercise ran smoothly. Fortunately, there were only mild reactions to the influenza vaccination that onsite providers assessed and treated.
Military Response to an Infectious Outbreak
An infectious outbreak is always a concern—accordingly, the military trains for scenarios similar to this. Following a SARS outbreak, the Emergency Management Working Group (EMWG) would start making preparations and meet as a team. The EMWG for a military base is an established group that meets regularly, planning and preparing for possible public health emergencies [pdf]. In the case of a SARS outbreak, the EMWG would be assembled by the base commander to respond to the public health emergency. The EMWG involves all of the resources on base to support the POD. Some POD resources are civil engineering setting up tents, security forces directing traffic and providing security, and the JAG office providing legal guidance on quarantine orders.
Following a SARS outbreak, the first step would be isolating symptomatic cases and administering prophylactic medication or vaccination to all personnel via a POD. For outbreaks where vaccine or prophylaxis medication is limited, instead of mass dispensing, an alternative is only to vaccinate or administer medicines to individuals identified via contact tracing [pdf]
Points-of-Dispensing
Public health officials traditionally carry out distributing medications or vaccinations for treatable or vaccine preventive illnesses at PODs. Most commonly, drugs or vaccines are delivered free of charge at PODs set up in community locations. Points-of-dispensing during a public health emergency deliver vaccines, antibiotics, or chemical antidotes safely and rapidly. Points-of-dispensing can treat and protect the public and prevent the spread of infectious diseases. PODs can also distribute food, water, and respiratory masks, for forest fires.
Mobile delivery PODs deliver supplies via trucks and vans to rural communities where people may face transportation barriers. Direct delivery PODs are at fixed locations such as hospitals. Emergency dispensing sites are PODs where community sites such as a sporting arena are temporarily converted to a POD site in response to a public health emergency [pdf]. Vaccine PODs are the most difficult to perform because everyone needs to be present to receive the vaccination. To limit the number of people that need to be present at the POD site, medication PODs may have medication picked up by the head of household.
Additionally, there are open and closed PODs. Open PODs are for the public. Closed PODs are for specific groups, such as the military or employees of a particular employer. During a public health emergency, both open and closed PODs should be used at the same time. We have had versions of both open and closed PODs with the COVID 19 vaccine roll-out.
Lessons Learned from our Vaccine POD Exercise
Regarding drive-through vaccine PODs, traffic control is one of the main factors to consider. Therefore, we assigned security forces members (i.e., base police) to manage traffic during the POD. Directing traffic helped to decreases confusion and improved flow through the POD. Additionally, we set up a pre-registration process to give out vaccination appointments. Vaccine appointments helped to limit incoming traffic and prevent long wait times. We predicted that the post-vaccination wait time would be the rate-limiting step. We adjusted for this by having post-vaccination parking waiting area big enough to accommodate more than enough vehicles per incoming appointments. Additionally, drive-through vaccine PODs control of disease spread among participants receiving a vaccination and spread to staff.
We were fortunate that we did not encounter bottlenecks that could lead to long waiting times. We also benefited from having a staff familiar with PODs who received previous training in similar public health emergency scenarios. Our PHEO allowed for on-the-spot corrective action to improve the process as needed, such as adjusting the ratio of screeners to vaccinators.
The factors we found to promote high vaccine points-of-dispensing throughput were:
- Good availability of vaccinators.
- Low adverse events from vaccination.
- Low vaccine hesitancy due to flu shot requirements.
- A relatively young and healthy population of active-duty members who didn’t have a lot of comorbid conditions.
Every exercise has challenges and benefits to learn from. We believe that these training scenarios are an excellent way to make PODs successful in the future for any medical or public health group.
Stephen Edstrom