Implementation of COVID-19 Vaccination Drive: A Time and Motion Study

Introduction

World Health Organization (WHO) declared Coronavirus Disease 2019 (COVID-19) as a pandemic on 11th March 2020.¹ Following that various containment measures were implemented to control the spread of the disease in India. Vaccines are the lasting solutions to enhance individual immunity and thereby contain the disease spread.² After a year and nearly more than fifty vaccine clinical trials across the world, the COVID-19 vaccine is now available. India launched its first vaccine drive on 16th January 2021 with 3006 vaccination centres.³ In India, Covishield and Covaxin vaccines had received approval for emergency use during the initial vaccination drive. As per the plan, beneficiaries in the first vaccination drive included all the health care workers. This was followed by vaccinations for all front-line workers.4 The initial target was to vaccinate 30 million people by the end of March 2021.

As per the Standard Operating Procedures (SOP), beneficiaries required to register in the COVID-19 Vaccine Intelligence Network (Co-WIN) system which is a digital platform to track the enlisted beneficiaries and COVID-19 vaccines on a real-time basis. At each session site to prevent crowding and also considering the 30-minute post vaccination observation period, 100 beneficiaries per day were permitted for vaccination. This was first of its kind where vaccination drive was conducted using Information Technology (IT) and pre-registration was a mandatory step. Though many training sessions and dry runs were conducted for the implementation of this herculean task, it is essential to obtain the scientific baseline data about practical aspects of work and its efficiency for better utilisation of resources including time, money and manpower. This would help us identify the challenges and gaps, thereby aid in improving care delivery and upgrading the work systems. This can be achieved through scientific studies such as ‘Time and Motion’ studies.

A time - motion study is one of the scientific approaches to determine the amount of time required for a specific activity, work function, or mechanical process. The time motion studies will guide the public health decision-makers at various levels in further planning and implementation of vaccination programs.

Our institute is a Government tertiary care hospital, having largest vaccine beneficiaries of approximately 5500 individuals. As per SOP, each vaccination site was expected to vaccinate 100 individuals per day from 9 AM to 5 PM including one hour lunch break.² Based on simple calculation, to vaccinate 100 people, we require 4.2 minutes for each individual. But as per SOP, beneficiaries were expected to wait in the observation room for 30 minutes after taking the vaccination as a precautionary measure to address any AEFI (Adverse Event Following Immunisation). So, there is a possibility for overcrowding and obstacles for the smooth functioning of the vaccination program. Hence the current study was designed to estimate the actual time required for various activities involved at different service points at the COVID-19 vaccine session site and probable reasons for delay at each of the service points. This will also help in identifying the challenges so that necessary actions can be taken for rectification.

Materials and Methods

The study was conducted at a Government teaching medical college and hospital in Bangalore. This was one of the premier institutes with large number of vaccine beneficiaries in Karnataka. The beneficiaries list was prepared and sent for online registration before the start of vaccination. There were seven vaccination sites set up in the hospital premises. Each day a list of 100 beneficiaries per centre was released from the district vaccination coordination authorities with prior intimation to the beneficiaries through text messages. The timings of vaccination sessions were morning 9 AM to 1 PM and afternoon session was from 2 PM to 5 PM making a total of seven hours per day (420 minutes). At each of these session sites, three rooms were designated for registration, vaccination and observation. At each of these rooms, Vaccinator Officers (VO) were appointed for specific activities (Figure 1).

Data collection

The data collection was carried out during the first two days of the beginning of vaccination program to identify initial challenges and take corrective measures. Out of seven centres, four were included in the study as the remaining three centres had only one day vaccination program due to the smaller number of beneficiaries. A structured token system to mark the entry/exit time at each event site was created. All the vaccine beneficiaries who visited the vaccination session site were included and token sheets were given; among them incomplete token forms were excluded. Trained volunteers were assigned at each service point to enter the time the beneficiary approached him/her. Then the sheet was handed over to the beneficiary and asked to take it along with him/her to each service point (registration room, vaccination room and observation room.) The volunteer present at each service point was asked to enter the time in the token sheets present with the beneficiaries at the end of that particular activity. The process continued and then the sheet was collected back from the beneficiary before leaving the vaccination site in the observation room. From each centre, 25 token sheets per day were randomly selected using lottery method ensuring equal representation from morning and evening sessions. The other required information was extracted from the registers. Along with the token sheets, a member of investigation team was present at each centre observing and writing the relevant findings during the event. At the end of the day, summary was prepared. A total of 200 token sheets from four vaccination centres were analysed in this cross-sectional study.

Statistical analysis

Simple descriptive statistics were used to analyse the mean with standard deviation and median with inter quartile range.

Results

A total of 200 participants were included in the study covering four different session sites with 50 participants from each. Mean age of study population was 32.5 (±11.4) years and median (IQR) was 31.5 (22-38) years. Minimum and maximum age of the participants was 18 and 72 years, respectively. Among them, 110 (55%) were females. Majority were paramedical staff 78 (39%) (Table 1).

Average waiting time recorded in registration room, vaccination room and observation room were 1 (<1- 3) minutes, 4 (1-7) minutes and 30 (28-33) minutes, respectively. Overall time spent from registration to observation room was 37 (33-41) minutes.

Delay in registration room was noted for 17 (8%), in vaccination room for 24 (12%). Delay in observation room due to Adverse Event Following Immunization (AEFI) was noted for 9 (4%) beneficiaries while 10 (5%) stayed for a longer duration along with colleagues. Few recipients 23 (12%) left early without completing the 30-minute observation period (Figure 2) (Table 2).

On site observation findings

Delay in registration room – Due to initial technical difficulties, the session was delayed by one hour. Beneficiary turn out on an average was 60 on day 1 and 78 on day 2 at each site, the main reason being vaccine hesitancy and few had not received text messages; those willing to receive vaccine were adding to the crowd. Few of them had issues with document verification and were sent back for the correct document. There was uneven distribution of beneficiaries visiting time with more individuals coming before lunch time as they were not relieved from their routine hospital duties.

Delay in vaccination room – The vaccination process as such did not take much time, but most of them wanted to capture this moment and were taking photos, causing delay for the next person. Even after providing key messages following vaccination, a few had doubts and were cleared here. Since the observation room had limited seating capacity of 25, anticipating overcrowding, people were made to wait for longer duration in vaccination room.

Delay in observation room – Few recipients developed minor AEFI and hence were made to wait for longer duration of more than 30 minutes. Few continued to wait for longer time to give company to their friends.

Left the observation room early - Since few recipients did not develop any symptoms suggestive of AEFI, they left early before completing 30 minutes. As all of them were health care workers and had to go back to their assigned duties, their waiting time of 30 minutes was reduced.

Discussion 

The largest COVID-19 vaccine drive started in India on January 16th 2021 in a phase wise manner. The time and motion study was conducted during the initial few days of first week of vaccination drive at a Government tertiary care teaching hospital. The average time taken at all four vaccination centre sites was recorded as 37 minutes (IQR =33-41minutes).

The technical difficulties observed at the registration desk of registration room were reported to the higher authorities and were addressed accordingly. On-site addition of beneficiaries was initiated later to reduce the confusion at the registration site. Prior intimation was given to carry the listed verification documents which reduced the waiting time at registration desk. Information regarding the correct document to be submitted for receiving the vaccine was displayed in the form of posters.

Vaccination room was specifically meant only to receive the vaccine and few key messages were delivered to the beneficiaries. A kiosk was arranged outside and people were requested to take photos there and not at the vaccination site. For those who had doubts regarding the vaccine, a concerned person (doctor or nurse) addressed their concerns in the observation room. Additional observation rooms were arranged at the session site to prevent overcrowding, thus preventing the waiting in vaccination room. This also reduced unnecessary crowd in the observation room, and a compulsory 30 minute observation period was ensured for all the beneficiaries to manage any unexpected AEFIs.

Conclusion

The overall time spent at the vaccination centre was recorded as 37 minutes (IQR 33-41). Major delay was observed at the vaccination room [24 (12%)], followed by delay at registration room [17 (8%)]. The study recommends deputing a data entry operator instead of health care workers at the registration counter to ensure appropriate utilisation of human resources. Provision of uninterrupted, unlimited internet connection must be ensured at the session site. Information, education and communication regarding the place of vaccine availability and type of vaccine available should be emphasised. Inclusion of only a few session sites is the limitation of the present study.

Funding

None

Conflict of interest

None

Ethical approval

Yes

Acknowledgements

We would take this opportunity to express our gratitude to administration part of the Bangalore Medical College and Research Institute (BMCRI), Bengaluru. We are thankful to all the participants who dedicated their time to take part in this study. We also thank the Head of the department and all the faculty and post graduates of Department of Community Medicine, BMCRI, Bengaluru for giving us the platform to conduct this study