Vaccination for Justice-Involved Youth Free

This advocacy effort was initiated by members of the Division of Adolescent and Young Adult Medicine at UPMC Children’s Hospital of Pittsburgh under the leadership of the division director who additionally serves as the medical director of the Allegheny County Juvenile Detention Center and the Community Intensive Supervision Program (CISP). At any one time in Allegheny County, there are approximately 1500 youth who are under supervision of the Juvenile Probation Office. Youth eligible for this initiative included those residing at the Allegheny County Juvenile Detention Center or enrolled in CISP. The county-run detention center houses youth ages 10 to 21, with a mixture of youth awaiting detention hearings, youth detained awaiting court, and adjudicated youth awaiting transfer to long-term placement. The facility’s daily census was between 30 and 40 youth during the time of this initiative. CISP includes male youth on home detention with electronic monitoring and had an average census of around 100 youth during the time of this initiative.

The core team who developed and led this initiative included attending physicians, advanced practice providers, and Adolescent and Young Adult Medicine fellows at the UPMC Children’s Hospital of Pittsburgh. Community collaborators were also critical partners in the initiative (Table 1). The nursing team had day-to-day contact with the youth that allowed them to engage frequently in conversations about vaccination and provide post vaccination symptom management. The CISP Assistant Chief Probation Officer and Juvenile Probation Supervisor took on central roles in planning, strategizing, and outreach to youth and their families. These leaders connected us with individual site supervisors at each CISP center, who provided important insights into strategies to reach the youth in their care. Justice-involved youth and their families were the most highly prioritized collaborators. Input was elicited from youth and families during our community listening sessions, the vaccine consent process, and the process of coordinating second doses. Their input was critical to inform our approach. Together, we developed a multistep plan to enhance access to COVID-19 vaccination for justice-involved youth and their families.

We conducted virtual COVID-19 educational sessions for justice-involved youth and their families during May and June of 2021. These sessions featured physicians who provide care to justice-involved youth and were moderated by CISP site supervisors and staff who were familiar to youth and their families. The goal of these sessions was to build trust with youth and caregivers by fostering transparent dialogue about vaccine safety and efficacy. The sessions were well-attended, with 60 to 70 participants, and many youths and their family members actively participated in discussion. These sessions used a question-and-answer format that gave youth and their caregivers opportunities to voice their perspectives. It was critical to validate concerns and acknowledge histories of medical abuse and experimentation that Black and Brown communities have experienced. One limitation was that the physicians did not share the same racial background as the majority of youth and their families in attendance. This made it especially important to include moderators who were also community members. The role of the moderators included calling on attendees, asking for clarification of questions when indicated, eliciting physician input, summarizing physician comments, and thanking both attendees and physicians for each contribution. In this way, the locus of control remained with the moderators instead of the physicians. This helped to bridge the gap in power and privilege between the physicians and the attendees and created an approachable, affirming climate for dialogue. Several moderators provided impactful testimonials about why they chose to pursue vaccination for themselves and their families, despite their initial concerns.

Following these community discussions, we collaborated with detention center leadership to begin offering COVID-19 vaccination to justice-involved youth within the center 12 days later in late June 2021. Before our first vaccination clinic on June 28, 2021, we coordinated with the UPMC pharmacy team and detention center nurses to plan a weekly vaccine clinic schedule. We obtained standardized verbal consent forms from our institution and provided education to the nursing staff and all medical providers about how to obtain verbal consent by phone from guardians of any youth 17 and younger.

We followed a structured process to provide vaccine education and obtain caregiver consent and youth assent for COVID-19 vaccination. Every youth who presents to the detention facility must have an intake physical within 72 hours of admission. We decided to integrate vaccine counseling and consent into the intake physical to make sure that every youth received this uniformly. Additionally, it was important that this process was initiated as quickly as possible after admission, because many youths are released soon after admission. Youth aged 18 years or older received counseling on COVID-19 vaccination during their intake physical. For youth <18 years of age, the clinician called the guardian for consultation regarding COVID-19 vaccination immediately after the intake physical. We found the calls were more personalized when completed after meeting and evaluating the young person because we could provide caregivers with an update regarding their child’s wellbeing and could speak to their child’s strengths. Demonstrating investment in the wellbeing of the guardian’s child fostered successful conversation. We also found it helpful to maintain continuity if there was a clinician who had contacted the guardian previously.

After providing vaccine counseling, the clinician obtained verbal consent, completed a consent form, and placed the form in the patient’s chart. The patient was added to the list for the next vaccine clinic. Unfortunately, it was not feasible to have pharmacy support on site every day to supply and administer vaccines immediately after each intake physical. Therefore, vaccine clinics were scheduled once weekly, and all youth consented in the previous week were scheduled for a medical appointment for vaccine counseling on the day of the clinic. Using this strategy, guardian consent was already in place and vaccine administrators were already on-site at the time of vaccine counseling with a young person. Once a young person provided assent, they were vaccinated immediately. This strategy helped to overcome ambivalence and minimize anxiety and anticipation.

The health care provider engaged each young person in dialogue about vaccination using individualized education and motivational interviewing. All providers were previously trained in motivational interviewing before this initiative. We discussed key messaging and helpful strategies as a team but allowed interviews to be unstructured and youth-directed. Many young people were ambivalent about vaccination. By having the guardian’s consent first, we were able to use an “opt out” rather than “opt in” approach, which was more successful for ambivalent youth. Additional strategies we found effective included appealing to the altruism of young people and their desire to protect younger siblings and vulnerable family members. We also appealed to their desire to return to activities they previously enjoyed. The more that we knew about a young person’s particular family structure, who matters most to them, and what they enjoy doing, the more successful we were. It was important to honor the voice and values of the young person while maintaining clear, consistent messaging that COVID-19 vaccination is important for their health and the health of their families and communities.

In preparation for each vaccine clinic, a medical provider coordinated with the pharmacy team to determine the number of doses needed. The pharmacist transported the vaccines to the detention center. Vaccine storage was maintained as recommended by the procedures from the CDC and doses were prepared according to manufacturer recommendations. Vaccines were administered by the pharmacist in an exam room in the clinic during normal clinic hours while a medical provider was also on site. Pharmacist support was required for approximately 5 hours per vaccine clinic, including preparation, administration, documentation, and clean up, which equated to a cost of approximately $250 per clinic. The vaccines were free. The additional supplies, such as gloves, alcohol swabs, band aids, and biohazard waste disposal, were obtained on-site from the Juvenile Detention Center. Youth returned to their units after receiving the vaccine, as they were under constant supervision at the facility and could be monitored for adverse effects without interruption to daily routine. Administrations were recorded in our healthcare system’s electronic vaccination database, which updates the administrations in the state registry.

There was a protocol in place for management for post vaccination side effects, which included every youth receiving 1000 mg of acetaminophen after vaccination and 600 to 800 mg of ibuprofen at bedtime on the night of vaccination. Additional doses of analgesic were available as needed. Youth tolerated vaccination well and rarely needed additional doses.

Having solidified weekly vaccination clinics within the detention center (Advocacy Goal 1) by mid-July, we moved to expand COVID-19 vaccine access for justice-involved youth and their families in community settings (Advocacy Goal 2). Many justice-involved youth remain in the community on probation. Males ages 10 to 18 who are not placed in residential treatment may be assigned to a local CISP center. There are a total of 6 CISP centers in Allegheny County. Youth are required to report to their assigned center daily, including weekends. CISP staff provide transportation.

Initially, in July we attempted to hold vaccination clinics at a centralized location for all justice-involved youth and their families. However, we had extremely low turn-out. Barriers included lack of transportation, distance, and needing to provide advanced notice to probation officers. This approach placed a significant burden on families, who often have competing responsibilities. Vaccine ambivalence further diminished uptake.

Subsequently, during August and September, we coordinated with the CISP site supervisors to arrange vaccination clinics on-site at each CISP center. As youth are transported to their center every weekday afternoon, no excess burden is placed on youth or families. CISP supervisors have been invaluable partners because they understand the daily schedule, workflow, and unique needs of the youth at their center. Therefore, we can arrange a pharmacy team and medical provider to be present on-site at each CISP center at a time that fits with the center’s schedule and needs.

For every youth enrolled in CISP, clinicians call each guardian in advance of a planned clinic, obtain verbal consent, and then approach the young person in-person on the day of the vaccination clinic. When assent is obtained, the vaccine is administered immediately.

We incorporated the Pfizer-BioNTech COVID-19 vaccine into our initiative because it is FDA-approved for youth 12+. The Pfizer-BioNTech COVID-19 vaccine requires coordination of a second dose at a minimum of 21 days later. Justice-involved youth move through the system quickly and relocate frequently, and there is no shared tracking system in our county. This necessitated diligent follow up to facilitate second doses. For each youth, the status of guardian consent, youth assent, and administered vaccinations was tracked by our providers using a password-protected, web-based spreadsheet on a shared secure network drive. Medical providers updated the spreadsheet each time they obtained consent for vaccination and after each vaccine clinic they supervised. Following the first dose, the expected date of the second dose was recorded, and youth were tracked closely to facilitate administration of their second dose. As youth transitioned to different settings within the juvenile court system, the medical director of the Allegheny County Juvenile Detention Center and CISP coordinated with leaders of these programs to determine youths’ latest location and updated the spreadsheet accordingly. For youth released before their second dose, an individualized plan was developed to support each youth in receiving their second dose. Individualized plans included coordinating second doses at CISP centers, long-term placement facilities, with the young person’s primary care provider (PCP), or at the UPMC Center for Adolescent and Young Adult Health if the patient did not have an identified PCP.

We effectively implemented COVID-19 vaccination for justice-involved youth at the detention center and present outcomes of the first 2 months of this initiative (Fig 1). From June 28, 2021 to August 30, 2021, 108 youth were detained. Ten were discharged or transferred before contact with us. Five individuals were fully vaccinated and 3 were partially vaccinated at the time of presentation.

A total of 93 individuals were approached for vaccine counseling. Five were age 18 or older and were offered individual counseling on COVID-19 vaccination. We attempted to contact caregivers of all remaining unvaccinated (n = 85) or partially vaccinated youth (n = 3; total n = 88). Thirty-two caregivers could not be reached due to nonworking or incorrect contact information or nonresponse to voicemails from the clinical team. We connected with the 5 detained young adults and 56 caregivers to offer counseling on COVID-19 vaccination (total n = 61). 17 caregivers declined vaccination for their youth. Three of these youth had specifically requested COVID-19 vaccination, but we were unable to provide vaccination because we lacked caregiver consent. Ten caregivers consented to vaccination, but the youth declined after counseling. Twenty-nine caregivers consented to vaccination and youth provided assent. This included all 3 partially vaccinated youth.

We obtained individual consent (n = 3) or caregiver consent and youth assent (n = 29) for a total of 32 individuals. Thirty of the 32 individuals for whom we received consent received at least 1 dose of the Pfizer-BioNTech COVID-19 vaccine while detained. Two individuals were discharged or transferred before receiving vaccination on-site. We provided assistance with completing the vaccination series at a community site for one of these youth who was partially vaccinated at presentation. We attempted to support the other in accessing vaccination in the community, but they have been lost to follow-up. Fourteen individuals completed the vaccination series while detained (including 2 who were partially vaccinated at presentation). Seven received their first vaccination on site and were assisted with completing the vaccination series in the community. Nine youth have thus far received only their first vaccination on site. Three are not yet due for the second dose, 3 have declined their second dose, and we are working to support the remaining 3 to access vaccination but have experienced challenges with contacting them and establishing a plan for vaccination in the community.

From June 28, 2021 to August 30, 2021, a total of 42 doses of the Pfizer-BioNTech COVID-19 Vaccine were administered to youth in detention. Including doses arranged in the community, a total of 50 doses of the Pfizer-BioNTech COVID-19 vaccine have been administered to justice-involved youth in Allegheny County as a result of this initiative.

Our advocacy to expand vaccine access to justice-involved youth and their families in community settings is ongoing. For youth enrolled in CISP, we anticipate that every youth and family member will have the opportunity for vaccination at their local CISP site. Two of the clinics are scheduled and planning is underway for the remaining 4 CISP centers.

This initiative has substantiated our concern that justice-involved youth face barriers to vaccination. Of the 108 youths detained during the first 2 months of this initiative, only 5 were fully vaccinated upon arrival, despite vaccination being readily available at pharmacies and health care facilities throughout Allegheny County. We encourage providers who take care of adolescents to invest in healthy futures for justice-involved youth, which includes providing access to COVID-19 vaccination and offering individualized education and motivational interviewing to address concerns, questions, and ambivalence. Vaccination within a juvenile detention setting can be successful with commitment on the part of the medical team, collaboration with justice system personnel, and thoughtful engagement of youth and families. We learned that community organizations that work closely with justice-involved youth should be engaged from the outset and included as co-developers of these initiatives.

Through in-depth, one-on-one discussions with justice-involved youth, we learned a lot about the reasons underlying vaccine hesitancy, including limited parental involvement to help access vaccination, feeling unlikely to be infected with COVID-19 or unlikely to become significantly ill, mistrust of the vaccines, influence by adults who express mistrust, and misinformation about vaccine safety. Youth expressed that they value their health highly and engaged in thoughtful discussion. Many were agreeable to vaccination once they spoke with a health care provider they trusted and felt their concerns were heard and addressed. We recommend approaching these conversations humbly, with a willingness to listen and the mindset that it is the responsibility of the health care provider to demonstrate trustworthiness. We learned that it is important to respect the agency of the young person while reinforcing that COVID-19 vaccination is important for their health and the health of their families. We found that it was helpful to name the power differential that exists when White-presenting medical professionals discuss vaccination with youth from Black and Brown communities. Our experiences reinforced that it is critical to explicitly acknowledge the history of abuse and experimentation that Black and Brown communities have experienced from the medical community and the warranted distrust that has resulted.

The greatest challenge we faced in this initiative was tracking youth to initiate or complete both doses of the COVID-19 vaccine. Justice-involved youth are transferred out of and within the system frequently and sometimes abruptly, making a multidose vaccine series difficult to complete. Furthermore, there was often a delay between the intake physical and the administration of the COVID-19 vaccine as we were only able to offer once weekly vaccine clinics. This created an opportunity for youth to be discharged or transferred before getting access to the COVID vaccine. Ideas to address these challenges include on-site and readily available vaccines at detention centers that can be administered by medical staff to minimize delays in vaccination from time of admission. Partnering with local residential treatment and rehabilitation facilities to increase COVID-19 vaccine availability may also increase series completion, as youth are often transferred to these sites from detention.

Additional barriers we encountered were not unique to justice-involved youth and included concerns related to time and transportation. For example, we initially coordinated a centralized vaccination clinic at a single community site, but this was poorly attended. We achieved greater success with local clinics that used existing infrastructure and transportation, namely vans and buses operated by CISP staff to transport youth to and from sites during usual programming.

The inability of youth 17 and younger to consent to vaccination also made the vaccination process significantly more difficult. We frequently struggled to reach guardians, and significant time was needed for counseling and discussion with guardians. These conversations were particularly challenging because they occurred via phone and therefore lacked the opportunity for face-to-face rapport. Nonetheless, modeling flexibility and prioritizing personal connection in our approach to these conversations (eg, offering to follow up with families at times that worked for them and providing our personal phone numbers for questions and concerns) was important to demonstrate trustworthiness to communities that have previously experienced marginalization.

Using a community-engaged approach, we enhanced access to COVID-19 vaccine education for justice-involved youth and their families and initiated a coordinated vaccination program in a juvenile detention center and the associated community-based surveillance program. Through this initiative, 56 youth and their families received COVID-19 vaccine counseling and 31 youth received at least 1 dose of the Pfizer-BioNTech COVID-19 vaccine. Our dedicated team of health care providers and community partners will continue to provide educational outreach and vaccination clinics to expand reach of this initiative. This case study can serve as a model for advocates looking to enhance access to COVID-19 vaccination for justice-involved youth in their own communities.

We thank the UPMC Children’s Hospital of Pittsburgh Department of Pharmacy for logistical and on-site coordination of vaccination clinics, with special thanks to lead Pharmacist Rachel Marini. We are grateful for the collaboration of Rich Gordan (Director, Shuman Juvenile Detention Center), Russell Carlino (Chief Probation Officer), David Evrard and Kimberly Booth (Assistant Chief Probation Officers), and all other CISP supervisors and staff. We appreciate the mentorship of Dr Elizabeth Miller and the support of the Division of Adolescent and Young Adult Medicine.

COVID-19

coronavirus disease 2019

CISP

Community Intensive Supervision Program

PCP

primary care provider