A Mall Setting in Georgia for H1N1 Vaccinations

During the 2009 H1N1 pandemic, the county health departments serving Gwinnett, Newton, and Rockdale Counties – approximately one million people – leased store space at the Mall of Georgia in Buford to distribute free H1N1 vaccinations to the public over two weekends in the middle of December 2009. The H1N1 vaccinations were available during normal business hours at local health centers, but the health departments wanted to target a portion of the population that might not normally visit a health department center.

The unique mall location was selected because it brought the vaccination effort out of the health centers and into a community setting where a large number of local residents were likely to be doing their holiday shopping. As District Health Director Dr. Lloyd Hofer pointed out, “We understand that people are busy trying to get their last-minute holiday shopping done and find it difficult to come to our clinics.  We hope that by partnering with the Mall of Georgia we will make the vaccine easily available to those who are interested.”

At the beginning of the 2009 H1N1 vaccination efforts, a national vaccine shortage restricted vaccinations to certain high-risk target groups – defined by the U.S. Centers for Disease Control and Prevention (CDC). Working within the CDC guidelines, the Gwinnett, Newton, and Rockdale county health departments offered H1N1 vaccinations in the health centers during regular weekday business hours, on Saturdays in H1N1-only vaccination clinics, and at a large school-based community clinic.

As the national supply of vaccines increased, the health departments developed plans to maximize vaccination efforts by providing a clinic that would be open to all of those interested in being vaccinated. On December 9, 2009, the Georgia Department of Community Health announced that the state would no longer place restrictions on H1N1 vaccination groups. At the same time, a short-term lease agreement was executed with Simon Malls by the county health departments. Because planning was already underway to provide a vaccination clinic at the Mall of Georgia in mid-December, the health departments’ leadership felt that the clinic should be scheduled immediately to reach as many members of the community as possible before demand declined.

Press Releases, Plus a Panda, Plus Pre-Loaded Syringes

To notify the community quickly of the free H1N1 vaccination clinic, the health departments’ public information officer sent a press release, targeted to reach the metropolitan Atlanta market, to the local internet, television, and newspaper media.  The press release also was e-mailed to over 400 community partners, who were asked to share the information as widely as possible. Signs in the mall not only advertised the clinic location but also emphasized its most important selling point: “Free H1N1 Vaccinations Here.” A staff member dressed as “Panda McFlu” also attracted a lot of attention to the clinic and provided entertainment to clients who were either waiting in line or being vaccinated.

To organize clients and offer information about various vaccination options, greeters stood at the entrance to the line and distributed clipboards containing Vaccine Information Statements and consent forms (in both English and Spanish).  Nurses and other staff members answered questions for clients in line.  Allowing clients to complete the forms while in line prevented what might have been a long backup inside the store.  Staff members verified that consent forms were completed correctly before the clients moved into the store space to be vaccinated; data entry into Georgia’s immunization registry was carried out later. Six nursing stations (a maximum of two nurses at each station) were set up inside the 1,400-square-foot store space. Stations also were set up to: (a) pre-load the clipboards with forms; (b) copy insurance information; and (c) pre-draw the vaccine into syringes.

The clinic operated under ICS (Incident Command System) guidelines, using a Point of Dispensing (POD) manager and section leads for operations, planning, nursing, and logistics. Using approximately 25 people per shift, the staff and volunteers participating administered 5,900 H1N1 vaccinations over a total of 52 hours – but had the capacity to serve many more. The final statistics – based on time-tracked data and client self-reporting – showed that the wait from the end of the line through the vaccination process was never greater than 15 minutes, even when the line passed multiple stores. Connie Russell, district program director as well as 2009 H1N1 event incident commander [and co-author of this article] said that, “We learned that we could vaccinate a large number of people in a very small space with relatively few staff.  This was very different from our large-scale clinic in a school setting that was heavily staffed and resource-intensive.”

The Cost & Community-Service Equation

This type of dispensing setup worked very well for H1N1 vaccinations; however, the health departments’ leadership does not view the same type of setting as ideal for chargeable services – e.g., routine immunizations and seasonal influenza vaccinations.  Exchanging money and providing several different types of vaccines not only would require additional supplies – cash registers and credit card readers, for example, as well as freezers and both computer and internet connectivity – but also would likely slow down the process that made the H1N1 clinic so successful. Moreover, the cost of leasing a store space could be prohibitive. However, the donation of the store space could be presented to mall management as a community service that would bring more potential customers into the mall.

“The use of private property in emergency situations requiring mass prophylaxis presents a unique set of challenges,” summarized Environmental Health Director Joseph Sternberg. “Many agents, such as anthrax, can cause persistent environmental contamination, rendering the property unusable. A prophylaxis campaign would likely result in lost revenue for the property owner … [because] the stigma associated with the congregation of potentially contaminated individuals may dissuade clients from patronizing retail establishments on the property.”

The vaccination clinic at the Mall of Georgia was the largest individual vaccination clinic conducted by the Gwinnett, Newton, and Rockdale county health departments during the 2009 H1N1 influenza pandemic. Following the holidays, demand declined significantly, and subsequent clinics had limited turnout. Nonetheless, the push-method distribution at the mall undoubtedly reached many members of the community who would not have been vaccinated in the county health department centers, and it provided a positive experience to many who had never used public health services.


Environmental Health Director Joseph Sternberg, Public Information and Media Services Director Suleima Salgado, and Emergency Preparedness Coordinator Mark Reiswig all assisted in the preparation of the preceding article. Help and support during the 2009 H1N1 vaccination efforts were provided by the Medical Reserve Corps-Georgia East Metro and Director Sherwin Levinson.

Elizabeth Hausauer

Elizabeth Hausauer, RN, is the Emergency Preparedness Specialist for the East Metro Health District in Lawrenceville, Georgia. She acted as POD manager, vaccination nurse, and triage leader at various mass vaccination clinics during the 2009 H1N1 pandemic. Hausauer earned her MSN with a concentration in Public Health Nursing Leadership from Emory University, and is currently working on a PhD in Business Administration, with a concentration in Homeland Security, at Northcentral University.

Connie Russell

Connie Russell, a graduate of Georgia State University – where she earned her masters degree in Psychological Sciences – was coordinator of the Early Intervention for Infants and Toddlers program at the health department prior to becoming district program director. She became supervising manager for the district’s emergency preparedness program in 2005 and served as operations chief for local public health response to Hurricane Katrina, an assignment that included support for American Red Cross sheltering, a Joint Resource and Recovery Center, and the National Disaster Medical System.



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