Health center rallies to give vaccines for hepatitis A

For Eastport and some neighboring communities, the start of the Memorial Day weekend on May 28 was not the usual long weekend of welcoming the summer. Instead of relaxing with family around the grill, residents were calling the Eastport Health Center (EHC), their primary care providers and pharmacies to see if they could get the first of two vaccines for the highly contagious virus hepatitis A. By 10 a.m., "We were flooded with calls," says EHC CEO Ellen Krajewski.
R&M IGA's Merilyn Mills was notified on May 27 by the Maine Center for Disease Control and Prevention (MCDC) that one of her staff had been infected with hepatitis A. Mills and the MCDC representative went over that staff person's work schedule at the store's deli to determine possible exposure to IGA staff and shoppers. What became clear very quickly to Krajewski from the volume of calls received the next morning at EHC was just how many deli shoppers were out there and that using the primary care model to get vaccines to patients wasn't going to work.
MCDC Director of Communications Robert Long explains that MCDC "confirmed the hepatitis A case in the early afternoon on May 27, and the store was notified at that time, shortly after noon." He adds, "The MCDC asked the store owner to assist in contact tracing and forwarding hepatitis A prophylaxis recommendations to any exposed co workers. We also asked the store owner to provide the sick employee's working schedule to help quickly alert others who might have been exposed." MCDC's public health alert release went to healthcare providers at 5 p.m., and a news release was sent to media outlets just before 9 p.m.
The MCDC release states that anyone who had eaten food prepared at the deli from May 13 to 22 should receive the vaccine within 14 days of their possible exposure. There is a 14 day window during which the vaccine is effective after exposure, it stated. Anyone who ate food from May 3 through 12 was considered "outside the window" for which vaccine is recommended. "Those individuals are advised to watch for symptoms and seek medical attention should they develop symptoms." Symptoms include fatigue, nausea, abdominal pain, loss of appetite and low grade fever.

Vaccine supply too low for demand
On the morning of May 28 the EHC was provided just over 24 vaccines to give to patients. The MCDC "worked like crazy to get us 57 vaccines to arrive at 7 a.m." for a by appointment clinic the next day, May 29, says Krajewski. The Pleasant Point Health Center was also instrumental in helping locate and provide some vaccine and staffing help. But clearly that were not going to be even close to what was going to be needed, Krajewski realized. "We were flooded with calls from patients and non patients." Even before she was contacted by the MCDC about vaccine supply, she knew that the health center had to "pull the switch" from primary care mode to community health mode, which meant steering all patients to a vaccine clinic instead of to primary care providers.
Krajewski explains, "We are a community health center, but the problem was we couldn't schedule vaccines when we didn't have any; we only had 24."
The health center also didn't have time to stop and do some training for front desk and other staff so that everyone was on the same page about the switch from primary care to community health mode.
The next issue was that by 2:30 p.m. on May 28 the EHC still had no more vaccine coming in for the May 29 clinic, and hundreds of people were asking for the vaccine. The CEO was calling everywhere she could think of that might have a handful of vaccine on hand. She was fully prepared to drive to Fort Kent for 10, to somewhere else for five, but it was not enough vaccine to even make a dent.
Many residents, particularly those who were on the verge of being outside of the 14 day window, had already taken matters into their own hands and secured a vaccine from the few available at pharmacies in the county.
More calls were made throughout the evening, and finally Krajewski was able to get assurances from a vaccine manufacturer in Tennessee that vaccines would be flown to Portland and then driven to Bangor. But they wouldn't be driven to Eastport, Calais or Machias or anywhere else closer than Bangor. By 4:15 a.m. on May 29 Krajewski had been at the job with other EHC and MCDC staff throughout the night to figure out the vaccine logistics. They ended up finding a courier service that would drive it from Bangor to Eastport to deliver it by early afternoon, but, being unfamiliar with Eastport, the courier ended up late and arriving at Federal Marine Terminals at Estes Head rather than the Eastport Port Authority Welcome Center. The vaccines then finally arrived at the clinic, and shots began to roll.
"We got that clinic up and running in less than 24 hours," Krajewski says with gratitude to all the different entities and staff who gave their time and energy to make it happen. She's also grateful to the members of the public who waited outside the clinic at the welcome center with good humor and patience while the courier tried to find Eastport and arrived later than the expected time. "Most everyone was so grateful [for the vaccine access]," she says. "And people who were waiting were willing to wait, were friendly and understanding."
MCDC's Long says that the MCDC "appreciates the important role that EHC played in limiting potential transmission of the hepatitis A virus in its region."
The MCDC delivered a total of 640 hepatitis A vaccine doses on May 29. EHC provided 306 shots on May 29, and over 100 will have been given the week of June 1 through June 4 with an on site vaccination clinic held at EHC.
Booster shots will need to be given six months after the first shot. Long notes that the Maine Immunization Program will work with healthcare providers if they request support "to ensure that everyone who needs a booster can receive one." Krajewski says, "We told people we'd contact them about details for the booster. Our plan is to determine the vaccination location and dates in the summer and then reach out to each person who received a vaccination."
Long notes that most insurance companies are required to cover the cost of routine vaccinations. "Individuals who are uninsured or underinsured can access certain vaccines at no patient cost through Federally Qualified Health Centers (FQHC) and 317 sites." The health center is a FQHC.

Learning from the crisis
The EHC and MCDC held a debriefing to discuss ways that the process can be made to run more smoothly in the future, should another crisis of this nature occur. Krajewski says that lessons learned include ensuring timely communication, not only from the MCDC but internally at the EHC; creating a plan to help determine when to flip the switch from a primary care to community care health path; creating training and scripts for staff to use for high volume and stressful events like this; providing education about when MCDC should reach out to the health center - the earlier the better, stresses Krajewski; and creating a plan and agreement with a Bangor entity as a holding place for vaccine delivery and for a courier service to get it to Eastport in a timely manner.
"People's stress was legitimate," adds Krajewski. "It was a public health crisis."
She notes that if any business or individual ever has questions about public health concerns she welcomes calls to her direct office line at 853 4045. However, she stresses that she cannot answer questions or concerns of an individual nature because of HIPAA confidentiality issues.
For those with questions about their own health and/or the hepatitis A vaccine, they should call their primary care provider or the health center's front desk for a referral.