Drive-through HPV vaccination for school-age children during Covid-19

Introduction

In early 2020, the first wave of the coronavirus pandemic hit the UK and, on 23 March, schools were closed to all but key workers’ children. In the school vaccination team at Derbyshire Community Health Services NHS Foundation Trust, we had just completed the majority of our meningitis vaccination programme and were due to begin human papillomavirus (HPV) vaccination. In England, girls and boys aged 12-13 years are routinely offered the first HPV vaccination when they are in year eight at school. The second dose is offered 6-24 months later.

Within days, our entire team had been redeployed to work in other services, including community wards and district nursing. As the head of the team, I was required to stay in my current post; I felt helpless and frustrated, and was desperate to do something to help.

Our schedule for routine vaccinations in school-age children is very tight and there is little room for manoeuvre; we vaccinate >100,000 children every year. We calculated that if we were to miss the 13,000 HPV vaccinations due that term, it would take at least two years to catch up due to the additional complication that, once children reach 15 years of age, they need to have three, rather than two, doses. It would also have a knock-on impact on other routine vaccinations.

A colleague highlighted a GP practice that had started doing drive-through vaccinations for infants. We began to consider whether this was a way to keep our service running, despite schools being closed. We felt a huge amount of responsibility to ensure the service continued, and no children suffered further because of Covid-19.

Planning

Our team does all vaccinations for school-aged children (from reception to age 18) on school premises, including private, independent and special schools. As we could no longer use this system, we started to make plans for a drive-through service.

We spoke to our director of health and wellbeing inclusion to make our case. It was agreed that redeployment of the 24 members of the team to other services would end and 12 additional staff would be moved to work in the vaccination team. We calculated we needed to vaccinate a minimum of 400 children per day and so opted to have two drive-through locations every day – one in the north of Derbyshire and one in the south, with the aim of carrying out 400 to 500 vaccinations per day.

The delivery of these vaccinations had to be done safely and following Covid-19 protocols, including wearing full personal protective equipment. To deliver mass vaccinations in a drive-through clinic, we drew up a standard operating procedure and carried out relevant risk assessments. We sourced all our own equipment including chairs and gazebos. Fortunately, the previous year we had implemented an online consent system, but we still needed to identify and establish an online booking system. This would normally take six weeks to install but we had it up and running within five days. At this point we also had to order vaccinations.

The most challenging aspect was identifying suitable sites for the drive-through vaccination centres. We contacted potential venues but were also offered site locations as word of our service spread. I visited potential sites in person to check suitability, for example toilet facilities. We considered a wide range of venues from a gymnastics club, a racecourse, our community hospitals, as well as school car parks. Cooperatively, we worked with the British Army who were setting up Covid-19 testing sites and could provide us with some useful knowledge.

We began to contact schools with information about the plans so they could advertise the service and pass on to parents details of the online booking system. We also asked schools to send out online consent forms to parents who had not yet completed one. We advertised through social media and our trust’s website. This allowed us to send out links to our online consent system. Unfortunately, the e-consent system did not link to the booking system but the administration team worked around the clock to ensure clinics were set up and the correct consent forms attached.

We worked closely with NHS England throughout, and presented the plans to senior managers in the trust. Staff were then trained in the new standard operating procedure. We allowed three weeks to set up the project before conducting a pilot test on the premises of a local school. We vaccinated 70 children and the system worked well.

“Through rain, shine, welly boots and poetry, they worked across boundaries with diverse partners to improve outcomes for children and young people, and to create a blueprint for new ways of working” (Judges’ feedback)

Implementation and results

The drive-through clinics began in May 2020 and were run by a team of 37 personnel, which included nurses, healthcare assistants and administrative staff. Parents were sent the booking link (which was widely publicised) to book a suitable slot. Over a 10-week period, we vaccinated more than 10,000 students through 69 clinics at 18 locations, including in hard-to-reach, rural and inner-city areas.

It took around two minutes to vaccinate each child, and this would not have been possible if we had not been completely paperless. On some days, staff were working in poor weather conditions, such as high winds, and a paper system would have raised serious governance issues.

We also made provisions so children with additional needs and those who were shielding could attend a clinic. We ensured that some vaccination sites were near bus routes and also made provision for walk-ins for those who did not have access to a car. We also did some home visits for vulnerable children. Parents and carers could not believe the team had been able to achieve this and were all truly grateful.

While we were around 10% below our usual uptake of student HPV vaccination (80-90%), we have been able to reach additional students through usual routine schools programmes this year without having to do any additional clinics. We also held extra clinics over the summer, which covered all routine vaccinations, not just HPV. In 2021, the vaccination team has been under immense pressure: along with the HPV vaccines, it is also delivering Covid-19 vaccinations in schools and an additional 70,000 influenza vaccines. The drive-through programme meant the team did not fall far behind and has been able to deliver all these vaccinations without recruiting extra staff. If this programme had not been put in place, some of these children would now be two years behind on their routine vaccinations.

Future practice

In Derbyshire and in Derby city there has been minimal impact on the uptake of teenage vaccinations during the global pandemic. The drive-through vaccination programme was put together at incredibly high speed and has given the team the confidence to ‘think out of the box’. In the future, this model will be adopted for hard-to-reach areas and summer clinics. The model itself was that used as the basis for pop-up Covid-19 mass vaccination centres and influenza clinics in the region, and we provided lots of feedback on areas such as marshalling and equipment.

We were under no obligation or pressure from NHS England to continue this routine vaccination service in such a difficult climate, but all members of the team deserve recognition for their contribution towards public health at the most difficult and challenging of times.

Our approach was shared widely on social media and, as a result, we were very quickly inundated with requests to share practice with other teams throughout the country. We made our standard operating procedure and all our risk assessments freely available to those asking for guidance. We have also shared our experience through numerous webinars and at the National Immunisation Conference. As a team we are always looking for ways in which we can improve our service.

Conclusion

Our decision to continue carrying out routine HPV vaccinations in school-aged children during the pandemic, by pivoting rapidly to a drive-through service, has benefited many thousands of children, not only in Derbyshire but also beyond as our approach was adopted by organisations across the country. The success of our approach highlights the importance of flexibility while maintaining gold-standard levels of care.