AJPH RESEARCH
2015 Pandemic Influenza Readiness Assessment Among US Public Health Emergency Preparedness Awardees Thomas J. Fitzgerald, MPH, Danielle L. Moulia, MPH, Samuel B. Graitcer, MD, Sara J. Vagi, PhD, and Stephanie A. Dopson, ScD, MPH, MSW Objectives. To assess how US Public Health Emergency Preparedness (PHEP) awardees plan to respond to an influenza pandemic with vaccination. Methods. The Centers for Disease Control and Prevention developed the Pandemic Influenza Readiness Assessment, an online survey sent to PHEP directors, to analyze, in part, the readiness of PHEP awardees to vaccinate 80% of the populations of their jurisdictions with 2 doses of pandemic influenza vaccine, separated by 21 days, within 16 weeks of vaccine availability. Results. Thirty-eight of 60 (63.3%) awardees reported being able to vaccinate their populations within 16 weeks; 38 (63.3%) planned to allocate more than 20% of their pandemic vaccine supply to points of dispensing (PODs). Thirty-four of 58 (58.6%) reported staffing as a challenge to vaccinating 80% of their populations; 28 of 60 (46.7%) reported preparedness workforce decreases, and 22 (36.7%) reported immunization workforce decreases between January 2012 and July 2015. Conclusions. Awardees relied on PODs to vaccinate segments of their jurisdictions despite workforce decreases. Planners must ensure readiness for POD sites to vaccinate, but should also leverage complementary sites and providers to augment public health response. (Am J Public Health. 2017;107:S177–S179. doi: 10.2105/AJPH.2017.303952)
T
he detection of avian influenza in birds in the United States and abroad1 is an important reminder of the need for vigilance in preparing for the next influenza pandemic. A well-matched vaccine will likely offer the best protection against a novel influenza virus and serve as a key component of a pandemic mitigation effort. In the event of a severe influenza pandemic, 2 pandemic influenza vaccine doses separated by 21 days may be required for all age groups for optimal immune response to the vaccination and maximal protection from infection.2 State and local public health programs will be responsible for vaccine distribution and administration. The Centers for Disease Control and Prevention (CDC) advances preparedness through the Public Health Emergency Preparedness (PHEP) program. PHEP awardees include all 50 states; Washington,
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DC; 3 locally funded jurisdictions; and 8 territories or freely associated states.3 In 2015, the CDC conducted the Pandemic Influenza Readiness Assessment (PIRA), an electronic survey designed to assess the readiness of PHEP awardees to respond to an influenza pandemic. Using PIRA data, we sought to assess the approaches of PHEP awardees to vaccinating their jurisdictions in a severe pandemic, including reliance on points of dispensing (PODs), or mass vaccination clinics.
METHODS We sent PIRA surveys in July 2015 to PHEP directors who invited input from government officials, including immunization program managers, in responding. Respondents were given a severe future influenza pandemic scenario and planning assumptions, including the following: disease will be severe for all ages and peak within 20 weeks of virus detection in the United States; beginning 60 days after notification of a national vaccination campaign, pandemic vaccine will be allocated to state health departments based on their population size; sufficient supply of an effective pandemic vaccine will be available in amounts needed to vaccinate at least 10% of the US population per week; and public demand for vaccination will be high. We instructed awardees to answer questions with respect to their expected ability to vaccinate 80% of the populations of their jurisdictions with 2 doses of the pandemic influenza vaccine, separated by at least 21 days, within 16 weeks of vaccine becoming available. PIRA also asked questions about changes in the immunization and preparedness workforces of jurisdictions over the preceding years. We used descriptive analyses of PIRA responses in Microsoft Excel (Microsoft, Redmond, WA); open-ended responses were categorized and counted for analysis. We calculated frequencies and proportions of responses to survey questions. In cases in
ABOUT THE AUTHORS Thomas J. Fitzgerald, Danielle L. Moulia, and Samuel B. Graitcer are with the Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Thomas J. Fitzgerald and Danielle L. Moulia are also with IHRC, Inc, Atlanta. Sara J. Vagi and Stephanie A. Dopson are with the Division of State and Local Readiness, Office of Public Health Preparedness and Response, CDC, Atlanta. Correspondence should be sent to Thomas J. Fitzgerald, ASPR/OEM/Fusion, C4F07 - O’Neill Federal Building, Washington, DC 20515 (e-mail: thomas.fi[email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted April 18, 2017. Note. The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the CDC. doi: 10.2105/AJPH.2017.303952
Fitzgerald et al.
Peer Reviewed
Research
S177
AJPH RESEARCH
which respondents provided multiple answers, if the answers of the respondent were coded to the same category, we counted it as a single response. Two of the 62 awardees to which PIRA was sent did not respond, which resulted in a sample size of 60.
RESULTS Twenty-eight (46.7%) PHEP awardees reported a decrease in their public health preparedness workforce between January 2012 and July 2015, and 22 (36.7%) experienced a decrease in their immunization workforce. Overall, 38 (63.3%) awardees reported that they would be able to vaccinate 80% of their population with 2 doses of the pandemic vaccine within 16 weeks of the vaccine becoming available (Table 1), although 58 awardees (including 36 that reported being able to vaccinate 80% of their population with 2 doses of the pandemic vaccine in 16 weeks) reported challenges in reaching this goal. Commonly reported
challenges were staffing (34; 58.6%), including POD staffing and vaccine provider recruitment (27; 46.6%). Ten (16.7%) awardees reported they expected up to 100% of their population to be vaccinated through the public health system (of which PODs are a component) during a pandemic. Ten (16.7%) expected up to 75%, 24 (40%) expected up to 50%, and 16 (26.7%) expected up to 25% of their population to be vaccinated through the public health system (Table 1). Although awardees reported planning to allocate pandemic influenza vaccine to a variety of other providers (e.g., pharmacies and private pediatric and adult providers),4 38 (63.3%) reported planning to provide more than 20% of their pandemic vaccine allocation through PODs. Of these, 16 (42.1%) reported having preidentified enough personnel to staff these PODs; 10 (26.3%) reported having identified staff, but funding or support was not available; 7 (18.4%) were in the process of identifying personnel to staff PODs, and 5 (13.1%) had not identified staff (Table 1).
TABLE 1—Public Health Emergency Preparedness Awardee (n = 60) Pandemic Influenza Vaccination Planning: United States, 2015 Question
No. (%)
Do you expect that your program will be able to vaccinate 80% of
38 (63.3)
your jurisdiction’s population within 16 weeks of vaccination initiation?: Yes Estimate the proportion of jurisdiction’s population you expect will be vaccinated through the public health system £ 25%
16 (26.7)
> 25% to 50%
24 (40.0)
> 50% to 75%
10 (16.7)
> 75% to 100%
10 (16.7)
Does your jurisdiction plan to provide > 20% of your vaccine
38 (63.3)
allocation through points of dispensing (PODs)?: Yes Has your jurisdiction pre-identified enough personnel to staff PODs?a Yes Yes, but funding or support for staff is not available
16 (42.1) 10 (26.3)
In progress
7 (18.4)
No
5 (13.1)
Observed decreases in workforce between January 2012 and July 2015 Preparedness staffing reduced
28 (46.7)
Immunization staffing reduced
22 (36.7)
a Among the 38 jurisdictions reporting that they plan to allocate > 20% of their pandemic vaccine allocation through PODs.
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No associations were found among or between awardees who reported being able to vaccinate 80% of their jurisdiction with 2 doses of the pandemic vaccine within 16 weeks of vaccine availability, or among awardees who reported expecting more than 75% of their population to be vaccinated through the public health system.
DISCUSSION During the 2009 H1N1 pandemic, vaccine was mostly administered at traditional medical provider sites, pharmacies, and in occupational settings.5 PODs might be particularly important for early pandemic vaccine distribution during an influenza pandemic if vaccine supplies are limited and vaccine is prioritized for specific groups, but they might be limited in their reach and sustainability. Broad reliance on PODs might be limited by staffing resources over the duration of a pandemic. In the 2009 H1N1 pandemic, many jurisdictions reported challenges with staffing and that large numbers of staff were required for PODs.5 PHEP awardees and local health departments (to which pandemic vaccine will be allocated, possibly resulting in more use of PODs than what is presented here) should incorporate a variety of providers and settings outside of PODs into their pre-pandemic planning. More effort is needed to prepare potential complementary pandemic vaccine providers to be ready to operate at maximum capacity. Challenges were reported even among awardees who expected to be able to vaccinate 80% of their jurisdiction within 16 weeks, especially staffing challenges. Despite issues with staffing, many PHEP awardees planned to rely heavily on PODs as mass vaccination clinics. Existing community vaccine providers and sites, such as medical offices and pharmacies, could be used in a vaccine response, but previous investigations indicated they might not be leveraged to their full capacity.4 An analysis of these same respondents demonstrated that many jurisdictions planned to allocate only a small supply of pandemic vaccine to pharmacies, limiting the usefulness of these venues during a pandemic.4 Pharmacies and occupational health clinics are increasingly popular venues for seasonal
AJPH
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influenza vaccination, largely because of their prevalence, familiarity, and convenient hours for working adults.6–8 Several analyses suggested a combined and coordinated response to an influenza pandemic; using a variety of vaccine provider types and settings might be an efficient approach to rapidly reaching high pandemic vaccination coverage.4–6,8,9
PUBLIC HEALTH IMPLICATIONS Public health planners must ensure coordination with immunization programs so PODs could serve as vaccination clinics. To do so, they must be able to rapidly order and receive vaccine, have training and resources to safely store and handle vaccine, be able to safely and efficiently administer vaccine, and have the systems and processes in place to document vaccine administration using an immunization information system where applicable.10–12 CDC plans to provide additional pandemic influenza vaccine program guidance and technical assistance to PHEP awardees and their partners in these areas, but more effort will be needed among jurisdictions to better understand the most efficient approach to ensuring access to vaccination during a public health emergency.
pandemic influenza vaccine response. Vaccine. 2016; 34(46):5643–5648. 5. Institute of Medicine. The 2009 H1N1 Influenza Vaccination Campaign: Summary of a Workshop Series. Washington, DC: The National Academies Press; 2010. 6. Rubin SE, Schulman RM, Roszak AR, Herrmann J, Patel A, Koonin LM. Leveraging partnerships among community pharmacists, pharmacies, and health departments to improve pandemic influenza response. Biosecur Bioterror. 2014;12(2):76–84. 7. Srivastav A, Williams WW, Santibanez TA, et al. National early season flu vaccination coverage, United States, November 2015. FluVaxView 2015. Available at: http://www.cdc.gov/flu/fluvaxview/nifs-estimatesnov2015.htm. Accessed February 1, 2016. 8. Goad JA, Taitel MS, Fensterheim LE, Cannon AE. Vaccinations administered during off-clinic hours at a national community pharmacy: implications for increasing patient access and convenience. Ann Fam Med. 2013;11(5):429–436. 9. Schwartz B, Wortley P. Mass vaccination for annual and pandemic influenza. Curr Top Microbiol Immunol. 2006; 304:131–152. 10. Centers for Disease Control and Prevention. Injection safety. 2012. Available at: http://www.cdc.gov/ injectionsafety. Accessed December 6, 2016. 11. National Adult and Influenza Immunization Summit. Checklist of best practices for vaccination clinics held at satellite, temporary, or off-site locations. 2016. Available at: https://www.izsummitpartners.org/ content/uploads/2017/02/NAIIS-Vaccination-ClinicChecklist_v2.pdf. Accessed November 29, 2016. 12. Centers for Disease Control and Prevention. Vaccine storage and handling toolkit. 2016. Available at: http:// www.cdc.gov/vaccines/hcp/admin/storage/toolkit/ storage-handling-toolkit.pdf. Accessed February 1, 2016.
CONTRIBUTORS S. B. Graitcer, S. J. Vagi, and S. A. Dopson contributed to developing the PIRA questionnaire. All of the authors contributed to analyzing the data, and writing and editing the article.
HUMAN PARTICIPANT PROTECTION Data were collected under US Office of Management and Budget approval number 0920-0879. Data collection did not involve human specimens, and were exempt from CDC institutional review board review.
REFERENCES 1. Centers for Disease Control and Prevention. Avian influenza current situation. 2015. Available at: http:// www.cdc.gov/flu/avianflu/avian-flu-summary.htm. Accessed February 2, 2016. 2. Centers for Disease Control and Prevention. Pandemic basics: questions and answers. Pandemic influenza 2016. Available at: https://www.cdc.gov/flu/pandemicresources/basics/faq.html#protect. Accessed December 12, 2016. 3. Centers for Disease Control and Prevention. Funding and guidance for state and local health departments. 2015. Available at: http://www.cdc.gov/phpr/coopagreement. htm. Accessed February 1, 2016. 4. Fitzgerald TJ, Kang Y, Bridges CB, et al. Integrating pharmacies into public health program planning for
Supplement 2, 2017, Vol 107, No. S2
AJPH
Fitzgerald et al.
Peer Reviewed
Research
S179
2015 Pandemic Influenza Readiness Assessment Among US Public Health Emergency Preparedness Awardees Thomas J. Fitzgerald, MPH, Danielle L. Moulia, MPH, Samuel B. Graitcer, MD, Sara J. Vagi, PhD, and Stephanie A. Dopson, ScD, MPH, MSW Objectives. To assess how US Public Health Emergency Preparedness (PHEP) awardees plan to respond to an influenza pandemic with vaccination. Methods. The Centers for Disease Control and Prevention developed the Pandemic Influenza Readiness Assessment, an online survey sent to PHEP directors, to analyze, in part, the readiness of PHEP awardees to vaccinate 80% of the populations of their jurisdictions with 2 doses of pandemic influenza vaccine, separated by 21 days, within 16 weeks of vaccine availability. Results. Thirty-eight of 60 (63.3%) awardees reported being able to vaccinate their populations within 16 weeks; 38 (63.3%) planned to allocate more than 20% of their pandemic vaccine supply to points of dispensing (PODs). Thirty-four of 58 (58.6%) reported staffing as a challenge to vaccinating 80% of their populations; 28 of 60 (46.7%) reported preparedness workforce decreases, and 22 (36.7%) reported immunization workforce decreases between January 2012 and July 2015. Conclusions. Awardees relied on PODs to vaccinate segments of their jurisdictions despite workforce decreases. Planners must ensure readiness for POD sites to vaccinate, but should also leverage complementary sites and providers to augment public health response. (Am J Public Health. 2017;107:S177–S179. doi: 10.2105/AJPH.2017.303952)
T
he detection of avian influenza in birds in the United States and abroad1 is an important reminder of the need for vigilance in preparing for the next influenza pandemic. A well-matched vaccine will likely offer the best protection against a novel influenza virus and serve as a key component of a pandemic mitigation effort. In the event of a severe influenza pandemic, 2 pandemic influenza vaccine doses separated by 21 days may be required for all age groups for optimal immune response to the vaccination and maximal protection from infection.2 State and local public health programs will be responsible for vaccine distribution and administration. The Centers for Disease Control and Prevention (CDC) advances preparedness through the Public Health Emergency Preparedness (PHEP) program. PHEP awardees include all 50 states; Washington,
Supplement 2, 2017, Vol 107, No. S2
AJPH
DC; 3 locally funded jurisdictions; and 8 territories or freely associated states.3 In 2015, the CDC conducted the Pandemic Influenza Readiness Assessment (PIRA), an electronic survey designed to assess the readiness of PHEP awardees to respond to an influenza pandemic. Using PIRA data, we sought to assess the approaches of PHEP awardees to vaccinating their jurisdictions in a severe pandemic, including reliance on points of dispensing (PODs), or mass vaccination clinics.
METHODS We sent PIRA surveys in July 2015 to PHEP directors who invited input from government officials, including immunization program managers, in responding. Respondents were given a severe future influenza pandemic scenario and planning assumptions, including the following: disease will be severe for all ages and peak within 20 weeks of virus detection in the United States; beginning 60 days after notification of a national vaccination campaign, pandemic vaccine will be allocated to state health departments based on their population size; sufficient supply of an effective pandemic vaccine will be available in amounts needed to vaccinate at least 10% of the US population per week; and public demand for vaccination will be high. We instructed awardees to answer questions with respect to their expected ability to vaccinate 80% of the populations of their jurisdictions with 2 doses of the pandemic influenza vaccine, separated by at least 21 days, within 16 weeks of vaccine becoming available. PIRA also asked questions about changes in the immunization and preparedness workforces of jurisdictions over the preceding years. We used descriptive analyses of PIRA responses in Microsoft Excel (Microsoft, Redmond, WA); open-ended responses were categorized and counted for analysis. We calculated frequencies and proportions of responses to survey questions. In cases in
ABOUT THE AUTHORS Thomas J. Fitzgerald, Danielle L. Moulia, and Samuel B. Graitcer are with the Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Thomas J. Fitzgerald and Danielle L. Moulia are also with IHRC, Inc, Atlanta. Sara J. Vagi and Stephanie A. Dopson are with the Division of State and Local Readiness, Office of Public Health Preparedness and Response, CDC, Atlanta. Correspondence should be sent to Thomas J. Fitzgerald, ASPR/OEM/Fusion, C4F07 - O’Neill Federal Building, Washington, DC 20515 (e-mail: thomas.fi[email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted April 18, 2017. Note. The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the CDC. doi: 10.2105/AJPH.2017.303952
Fitzgerald et al.
Peer Reviewed
Research
S177
AJPH RESEARCH
which respondents provided multiple answers, if the answers of the respondent were coded to the same category, we counted it as a single response. Two of the 62 awardees to which PIRA was sent did not respond, which resulted in a sample size of 60.
RESULTS Twenty-eight (46.7%) PHEP awardees reported a decrease in their public health preparedness workforce between January 2012 and July 2015, and 22 (36.7%) experienced a decrease in their immunization workforce. Overall, 38 (63.3%) awardees reported that they would be able to vaccinate 80% of their population with 2 doses of the pandemic vaccine within 16 weeks of the vaccine becoming available (Table 1), although 58 awardees (including 36 that reported being able to vaccinate 80% of their population with 2 doses of the pandemic vaccine in 16 weeks) reported challenges in reaching this goal. Commonly reported
challenges were staffing (34; 58.6%), including POD staffing and vaccine provider recruitment (27; 46.6%). Ten (16.7%) awardees reported they expected up to 100% of their population to be vaccinated through the public health system (of which PODs are a component) during a pandemic. Ten (16.7%) expected up to 75%, 24 (40%) expected up to 50%, and 16 (26.7%) expected up to 25% of their population to be vaccinated through the public health system (Table 1). Although awardees reported planning to allocate pandemic influenza vaccine to a variety of other providers (e.g., pharmacies and private pediatric and adult providers),4 38 (63.3%) reported planning to provide more than 20% of their pandemic vaccine allocation through PODs. Of these, 16 (42.1%) reported having preidentified enough personnel to staff these PODs; 10 (26.3%) reported having identified staff, but funding or support was not available; 7 (18.4%) were in the process of identifying personnel to staff PODs, and 5 (13.1%) had not identified staff (Table 1).
TABLE 1—Public Health Emergency Preparedness Awardee (n = 60) Pandemic Influenza Vaccination Planning: United States, 2015 Question
No. (%)
Do you expect that your program will be able to vaccinate 80% of
38 (63.3)
your jurisdiction’s population within 16 weeks of vaccination initiation?: Yes Estimate the proportion of jurisdiction’s population you expect will be vaccinated through the public health system £ 25%
16 (26.7)
> 25% to 50%
24 (40.0)
> 50% to 75%
10 (16.7)
> 75% to 100%
10 (16.7)
Does your jurisdiction plan to provide > 20% of your vaccine
38 (63.3)
allocation through points of dispensing (PODs)?: Yes Has your jurisdiction pre-identified enough personnel to staff PODs?a Yes Yes, but funding or support for staff is not available
16 (42.1) 10 (26.3)
In progress
7 (18.4)
No
5 (13.1)
Observed decreases in workforce between January 2012 and July 2015 Preparedness staffing reduced
28 (46.7)
Immunization staffing reduced
22 (36.7)
a Among the 38 jurisdictions reporting that they plan to allocate > 20% of their pandemic vaccine allocation through PODs.
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Fitzgerald et al.
No associations were found among or between awardees who reported being able to vaccinate 80% of their jurisdiction with 2 doses of the pandemic vaccine within 16 weeks of vaccine availability, or among awardees who reported expecting more than 75% of their population to be vaccinated through the public health system.
DISCUSSION During the 2009 H1N1 pandemic, vaccine was mostly administered at traditional medical provider sites, pharmacies, and in occupational settings.5 PODs might be particularly important for early pandemic vaccine distribution during an influenza pandemic if vaccine supplies are limited and vaccine is prioritized for specific groups, but they might be limited in their reach and sustainability. Broad reliance on PODs might be limited by staffing resources over the duration of a pandemic. In the 2009 H1N1 pandemic, many jurisdictions reported challenges with staffing and that large numbers of staff were required for PODs.5 PHEP awardees and local health departments (to which pandemic vaccine will be allocated, possibly resulting in more use of PODs than what is presented here) should incorporate a variety of providers and settings outside of PODs into their pre-pandemic planning. More effort is needed to prepare potential complementary pandemic vaccine providers to be ready to operate at maximum capacity. Challenges were reported even among awardees who expected to be able to vaccinate 80% of their jurisdiction within 16 weeks, especially staffing challenges. Despite issues with staffing, many PHEP awardees planned to rely heavily on PODs as mass vaccination clinics. Existing community vaccine providers and sites, such as medical offices and pharmacies, could be used in a vaccine response, but previous investigations indicated they might not be leveraged to their full capacity.4 An analysis of these same respondents demonstrated that many jurisdictions planned to allocate only a small supply of pandemic vaccine to pharmacies, limiting the usefulness of these venues during a pandemic.4 Pharmacies and occupational health clinics are increasingly popular venues for seasonal
AJPH
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AJPH RESEARCH
influenza vaccination, largely because of their prevalence, familiarity, and convenient hours for working adults.6–8 Several analyses suggested a combined and coordinated response to an influenza pandemic; using a variety of vaccine provider types and settings might be an efficient approach to rapidly reaching high pandemic vaccination coverage.4–6,8,9
PUBLIC HEALTH IMPLICATIONS Public health planners must ensure coordination with immunization programs so PODs could serve as vaccination clinics. To do so, they must be able to rapidly order and receive vaccine, have training and resources to safely store and handle vaccine, be able to safely and efficiently administer vaccine, and have the systems and processes in place to document vaccine administration using an immunization information system where applicable.10–12 CDC plans to provide additional pandemic influenza vaccine program guidance and technical assistance to PHEP awardees and their partners in these areas, but more effort will be needed among jurisdictions to better understand the most efficient approach to ensuring access to vaccination during a public health emergency.
pandemic influenza vaccine response. Vaccine. 2016; 34(46):5643–5648. 5. Institute of Medicine. The 2009 H1N1 Influenza Vaccination Campaign: Summary of a Workshop Series. Washington, DC: The National Academies Press; 2010. 6. Rubin SE, Schulman RM, Roszak AR, Herrmann J, Patel A, Koonin LM. Leveraging partnerships among community pharmacists, pharmacies, and health departments to improve pandemic influenza response. Biosecur Bioterror. 2014;12(2):76–84. 7. Srivastav A, Williams WW, Santibanez TA, et al. National early season flu vaccination coverage, United States, November 2015. FluVaxView 2015. Available at: http://www.cdc.gov/flu/fluvaxview/nifs-estimatesnov2015.htm. Accessed February 1, 2016. 8. Goad JA, Taitel MS, Fensterheim LE, Cannon AE. Vaccinations administered during off-clinic hours at a national community pharmacy: implications for increasing patient access and convenience. Ann Fam Med. 2013;11(5):429–436. 9. Schwartz B, Wortley P. Mass vaccination for annual and pandemic influenza. Curr Top Microbiol Immunol. 2006; 304:131–152. 10. Centers for Disease Control and Prevention. Injection safety. 2012. Available at: http://www.cdc.gov/ injectionsafety. Accessed December 6, 2016. 11. National Adult and Influenza Immunization Summit. Checklist of best practices for vaccination clinics held at satellite, temporary, or off-site locations. 2016. Available at: https://www.izsummitpartners.org/ content/uploads/2017/02/NAIIS-Vaccination-ClinicChecklist_v2.pdf. Accessed November 29, 2016. 12. Centers for Disease Control and Prevention. Vaccine storage and handling toolkit. 2016. Available at: http:// www.cdc.gov/vaccines/hcp/admin/storage/toolkit/ storage-handling-toolkit.pdf. Accessed February 1, 2016.
CONTRIBUTORS S. B. Graitcer, S. J. Vagi, and S. A. Dopson contributed to developing the PIRA questionnaire. All of the authors contributed to analyzing the data, and writing and editing the article.
HUMAN PARTICIPANT PROTECTION Data were collected under US Office of Management and Budget approval number 0920-0879. Data collection did not involve human specimens, and were exempt from CDC institutional review board review.
REFERENCES 1. Centers for Disease Control and Prevention. Avian influenza current situation. 2015. Available at: http:// www.cdc.gov/flu/avianflu/avian-flu-summary.htm. Accessed February 2, 2016. 2. Centers for Disease Control and Prevention. Pandemic basics: questions and answers. Pandemic influenza 2016. Available at: https://www.cdc.gov/flu/pandemicresources/basics/faq.html#protect. Accessed December 12, 2016. 3. Centers for Disease Control and Prevention. Funding and guidance for state and local health departments. 2015. Available at: http://www.cdc.gov/phpr/coopagreement. htm. Accessed February 1, 2016. 4. Fitzgerald TJ, Kang Y, Bridges CB, et al. Integrating pharmacies into public health program planning for
Supplement 2, 2017, Vol 107, No. S2
AJPH
Fitzgerald et al.
Peer Reviewed
Research
S179
