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Review PHARMACY PRACTICE
A Review of the Pharmacist as Vaccinator
Willis M. Richardson, PharmD; Albert I. Wertheimer, PhD, MBA
Temple University School of Pharmacy
Abstract
Objective: The aim of this study is to review literature about how the pharmacist’s role as vaccination providers has been financially
and clinically measured.
Methods: A broad literature search was conducted up to May 2016 to identify economic or clinical data on pharmacy vaccinations.
MEDLINE® and PUBMED databases were searched for publications useful or potentially useful for this review. The NIH and CDC websites
were also searched for relevant materials. Search terms included vaccination, pharmacist, economic, pharmacoeconomics, cost,
benefits cost-effectiveness, physicians, immunizations, vaccinations, pharmacy vaccines, cost, physician vaccines, financial, benefit,
ambulatory pharmacist vaccination, clinical pharmacist, economics, pharmacist vaccine impact.
Results: The search yielded a total of 68 articles of which 12 met the criteria to be included in this review. After examining articles for
relevance to pharmacy vaccinations, two tables were created to highlight the clinical and economic advantages of the pharmacist as
a vaccinator.
Conclusion: Pharmacists who administer vaccines are an underutilized provider. This literature review reveals a pattern among studies
measuring the pharmacist’s impact on vaccination rates, patient preferences, and cost savings. Pharmacists have a history of
demonstrated dependability, accuracy, and cost effectiveness. State laws, collaborative agreements, and health plans have continued
to prevent patients from using the pharmacy to receive the CDC recommended vaccines. These barriers ultimately delay the Healthy
People 2020 goals.
Introduction/Background took place in Seattle, Washington in 1994. In November 1996,
Increasing vaccination rates to reduce infectious diseases the American Pharmacists Association began its nationally
remains one of the Healthy People 2020 objectives set forth by recognized training program for pharmacists; Pharmacy-Based
the United States Office of Disease Prevention and Health Immunization Delivery: A National Certificate Program for
Promotion.1, 2 Vaccine innovation and increased vaccination Pharmacists. Today, pharmacists have authority to administer
rates were linked with increased survival in the 20th century. vaccines in all 50 states, including the District of Columbia and
However, certain infectious diseases that can be prevented by Puerto Rico.3
vaccines, still remain a major cause of morbidity and mortality.2
Currently there are 17 vaccine-preventable diseases in the Pharmacists are immunization advocates and act as educators,
United States1, including influenza. Although preventable, facilitators, and vaccinators.4 Pharmacists provide education
influenza is one of the leading infections in the United States that helps dispel the many myths concerning vaccinations that
and accounts for substantial spending on the consequences dissuade the public from receiving them. Among the myths are
associated with the virus.2 vaccinations’ link to autism, vaccinations cause sudden infant
death syndrome, vaccines contain harmful ingredients that can
Vaccines remain the most cost-effective intervention in clinical affect children, vaccines cause neurological conditions (i.e.,
prevention of infectious disease and their proper use is seizures), children are given excessive vaccines in a short period
essential.2 Specifically, children’s vaccination programs yield a of time, and vaccines are derived from aborted fetuses.4
higher return on investment. Children receiving their
vaccinations according to the CDC schedule saves 33,000 lives, Pharmacists are trained to deliver adult vaccines, child vaccines
prevents 14 million instances of disease, reduces health care and travel vaccines, but vaccination services are often subject
cost by $9.9 billion, and saves $33.4 billion in indirect cost. In to state legislation and physician protocols. State restrictions
spite of the available vaccines, about 42,000 of adults and 300 limit pharmacists from vaccinating patients in need by dictating
children die each year from vaccine preventable diseases.2 the types of vaccines administered, the age of patients, type of
order requiring a prescription, and standing order protocols.4
The pharmacists’ role as vaccinators dates back to the 1800’s. However, these restrictions have been suspended in times of
The first organized formal vaccination training for pharmacists pandemics, such as the H1N1 influenza, when additional
vaccinators were needed.5 Additionally, the community
pharmacy is equipped to deliver vaccines. The pharmacy has
Corresponding Author: Willis M. Richardson, PharmD proper refrigeration, documentation, and emergency supplies.
Temple University School of Pharmacy The pharmacy often has a private area for vaccine
3307 N. Broad Street, Philadelphia, PA 19140 administration, which is useful for patient monitoring in case of
Email: willis.richardson@temple.edu allergic reactions.
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A pharmacist offers significant clinical and financial benefits vaccination vs those who were also picking up
through vaccination services. Administering vaccines in a prescription.
community pharmacy has become accepted by the public, Vaccines with the greatest proportion administered
especially for influenza vaccine. Commercial and governmental during off-clinic hours were typhoid (41.5%), Tdap
health plans are beginning to provide coverage for those (34.5%), HPV (33.8%), varicella zoster (31.6%),
patients receiving vaccinations at pharmacy locations. influenza (31.5%), hepatitis (31.4%), and yellow fever
However, health plans stipulate vaccine coverage and may not (30.8%).
always pay for all recommended vaccines.6 The aim of this study More than 1 million vaccinations took place during
is to review literature where the pharmacist as a vaccinator, has lunch hours (11:00 am to 1:00 pm) out of total
been financially and clinically assessed. vaccinated administered of 6,250,402.
The proportion vaccinated during off- clinic hours was
Objectives similar for patients with or without chronic conditions.
The objectives for this review were to examine studies where More than 150,000 vaccinations occurred during the
the pharmacists served as a vaccinator and to document the overnight hours of 10:00 pm to
clinical and financial impacts. 9:00 am.
Methods Community Pharmacist-Administered Influenza Immunization
A broad literature search was conducted to identify economic Improves Patient Access to Vaccines: 8
and clinical data on pharmacists vaccinating in pharmacies. Research pharmacists collected survey data from 4
MEDLINE®, PUBMED, NIH, and CDC databases were searched different community pharmacy locations in Toronto
for publications useful or potentially useful in this collection of from October 2013 to November 2013 in order to
data. Search terms included vaccination, pharmacist, economic, describe demographics and possible patient risk
pharmacoeconomics, cost, benefits cost-effectiveness, factors for receiving the influenza vaccine in a
physicians, immunizations, vaccinations, pharmacy vaccines, community setting. The study also assesses patient
cost, physician vaccines, financial, benefit, ambulatory experiences and perceptions.
pharmacist vaccination, clinical pharmacist, economics, Convenience of the pharmacist is a major factor to
pharmacist vaccine impact. Articles found were examined for patient satisfaction.
relevance and a data table was created outlining areas where 99% of surveys (1502 surveys total) indicated patients
additional research is needed. would recommend family and friends to be vaccinated
by a pharmacist.
Results One-third indicated that they would not have been
The data examined in the literature review can be found in vaccinated this year if pharmacist-administered
Tables 1 and 2. The following are modified key points from the vaccination were not available.
original article. No patient was dissatisfied with the vaccination
provided by the pharmacist, pharmacy service, and
Vaccinations Administered During Off-Clinic Hours at a injection technique. Rather, all patients surveyed were
National Community Pharmacy: Implications for Increasing satisfied or very satisfied with pharmacy service and
Patient Access and Convenience:7 injection technique.
Researchers retrospectively reviewed data for all All patients were either very comfortable or
vaccinations administered at Walgreens pharmacies comfortable with their vaccine being administered by
between August 2011 and July 2012. Specifically the pharmacist.
comparing between two time periods (standard clinic
hours [9:00 am – 6:00 pm] and off-clinic hours), they The Effect of Pharmacist Intervention on Herpes Zoster
analyzed the type of vaccine given as well as patient Vaccination in Community Pharmacies: 9
populations in order to assess implications for access In this prospective intervention study, patients
and convenience. presenting to independent pharmacies across
The following groups were most likely to be vaccinated Tennessee were asked to complete a survey after
during off-clinic hours: younger patients, patients receiving their vaccination. The survey aimed to
living in metropolitan/micropolitan areas, patients capture patients’ comfort level, sources of vaccination
living in states that allow pharmacists to administer all education and sources of influence. Questions such
CDC-recommended vaccines, those receiving travel as, “How did you hear about the Shingles vaccine?”
vaccines, and patients who receive > 2 vaccines in one required patients to select from the following options:
year; this study found no difference in off-clinic hour doctor, family/friend, pharmacist, flyer from your
use in patients who used the pharmacy for only pharmacy, newspaper, letter in the mail from
pharmacy and other.
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The most effective method of pharmacy-driven The majority (85.6 %) of all flu vaccinations were
intervention was the personalized letter. recorded between 9 am and 5 pm with peaks occurring
Patients were more likely to receive a vaccine from between 11 am and 1 pm (24.0 %).
reading pharmacy-driven interventions than by
influences from a physician (PReview PHARMACY PRACTICE
Pharmacists as Providers: Targeting Pneumococcal Impact of Pharmacist Integration in a Pediatric Primary Care
Vaccinations to High-Risk Populations:14 Clinic on Vaccination Errors: A Retrospective Review:16
Between August 1, 2010 and November 14, 2010, a At the Nationwide Children’s Hospital in Columbus,
total of 2,095,748 patients received influenza Ohio, vaccine error rates and missed opportunities
vaccinations at Walgreens. At the same time of the flu were compared between two pediatric primary care
vaccine, the pharmacist also recommended the clinics during April, May, and June 2011. Staffing levels
PPSV23 if any risk was identified. Of the total study were consistent throughout both clinics and included
population, 1,343,751 (64%) persons were considered attending physicians and resident physicians,
at-risk and met the ACIP recommendation for PPSV23. however, different individuals would staff each clinic.
921,624 patients (69%) were at-risk because they were Specifically, the “intervention clinic” had a full-time,
age 65 and older; 22,127 patients (31%) were at risk board-certified ambulatory clinical pharmacist who
because they had one of the ACIP comorbid conditions provided vaccination education to provider and
and were aged 2–64. patients. The “comparison clinic” did not include
Pharmacists were especially effective at reaching pharmacy personnel to ensure appropriate use of
patients aged 60–70 years, who are likely to be at-risk vaccines.
not only due to age but also due to comorbid After researchers reviewed 900 total randomized
conditions. Patients aged 60–70 years had the highest encounters from both clinics, 19 errors were found in
PPSV23 vaccination rate (6.60%, 26,430/400,454) of the evaluation. With 2 errors identified in the
any age group. comparison clinic and 17 from the “intervention
clinic,” the error rate was 0.28% and 2.7%, respectively
Improved Influenza Vaccination Rates in a Rural Population as (P = 0.0021).
a Result of a Pharmacist-Managed Immunization Campaign: 15 Further research of pharmacist involvement in several
In 1999, a pharmacy team conducted a manual chart areas of vaccine use is needed. This study did not
review of 2,271 charts in a rural primary care clinic and include an economic evaluation of improved use of
collected patient demographic data including vaccines. Additional research investigating the
influenza vaccine history and influenza economic implications of pharmacist integration into
contraindications. They identified 657 patients who the primary care setting on vaccine use is also needed.
had indications for the vaccine. The team also Missed opportunities were defined as vaccine doses
developed education packets, which were distributed due at date of encounter and not given. In the
to the patients identified in the chart review. comparison clinic, 132 randomized encounters were
Vaccinations were given in specially designated clinics found to have greater than or equal to one missed
and during routine clinic visits. Campaign success and opportunity, compared with 46 randomized
reasons why patients remained unvaccinated were encounters in the intervention clinic (PReview PHARMACY PRACTICE
The mean (SD) total costs, which included health plan Non-Traditional Settings for Influenza Vaccination of Adults:
and enrollee payment, per vaccine administration at Costs And Cost Effectiveness:18
physician offices, other medical settings, and Using detailed phone interviews, researchers
pharmacies were as follows: evaluated the costs of influenza vaccination in non-
o Physician offices: zoster vaccine—$208.72 traditional settings. Target age population included
(42.10), pneumococcal vaccine—$65.69 (27.54), 18-49, 50-64, and ≥65 years with either high risk or low
and influenza vaccine—$29.29 (15.29) risk for influenza-related complications. Probability,
(P < 0.05). direct costs, and opportunity costs were derived from
o Other medical settings (i.e., inpatient and primary data, unpublished and published sources.
outpatient hospital, emergency department): The mean total cost (US$, year 2004 values) per
zoster vaccine—$209.51 (50.83), pneumococcal vaccination, not including time cost, was estimated as
vaccine—$72.11 (49.95), and influenza $11.57 for pharmacies, $17.04 for mass vaccination
vaccine—$24.20 (13.12) (P < 0.05). clinics, and $28.67 at doctor’s office.
o Pharmacies: zoster vaccine—$168.50 (15.66), The mean waiting time for mass vaccination and
pneumococcal vaccine—$54.98 (9.72) (P < 0.05), pharmacy clinics was 12 minutes for both; the doctors
influenza vaccine—21.57 (6.63) (P < 0.05). waiting time was over 1 hour.
The data may help payers and policymakers The reported mean cost per vaccine dose ranged from
understand the economic value of adult vaccination in $7.48 in the pharmacy setting to $9.24 in the doctor’s
different settings, especially in pharmacies. office.
For all 3 vaccines, the costs paid were significantly The patients’ time, labor, and overhead cost were
lower in pharmacies than in either physician offices or higher in scheduled doctor visits.
other medical settings (P < 0.05).
For zoster vaccination, patients paid the least out-of- Discussion
pocket at physician offices ($16.95 [43.85], P < 0.05), Pharmacists administering vaccines has effectively lowered
whereas insurers paid the least at pharmacies health care cost and increased vaccination rates. The data
($145.72 [$38.54], P < 0.05). compiled in this review has revealed ways pharmacists have
For both the pneumococcal and influenza vaccines, been using their practice to advance the promotion and
patients paid the least at pharmacies, while insurers administration of the CDC recommended vaccinations.
paid the least in other medical settings, and the most Pharmacists offer education, advertising, and incentives to
at physician offices. reach patient populations in need of vaccinations. Pharmacies
For zoster vaccination, patients paid the least out-of- also have various conveniences such as extended hours,
pocket at physician offices, whereas insurers paid the shortened wait times, ease of access for medically underserved
least at pharmacies. patients in urban and rural areas, and reduced vaccination
From the patient perspective, costs paid were lower in costs. 9-12,15 With 93% of Americans living within 5 miles of a
pharmacies than in other medical settings for all 3 community pharmacy, community pharmacists are one of the
vaccinations and lower than in physician offices for most readily accessible health care professionals in the United
pneumococcal and influenza vaccines. States.5
Researchers conducted telephone interviews with
representatives from each setting in 2004 to The clinical data collected has shown that pharmacy
understand the costs of vaccination delivery in convenience and public trust as a vaccinator group is not a
nontraditional settings. They found that vaccination unique characteristic of pharmacists in the United States.10, 11
delivery cost less in the nontraditional settings ($17 in Many patients in the UK preferred to pay the pharmacist for an
mass vaccination settings, $12 in pharmacies) influenza vaccination instead of receiving it for free from their
compared with physician offices ($29). Additionally, general practitioner.10,11 Several studies demonstrate that
they found that vaccination in nontraditional settings many patients in the UK and United States go to the pharmacy
was projected to be cost saving for healthy adults aged during lunch hours.7,10,11 Convenience is arguably the most
≥50 years and for high-risk adults of all ages. advantageous characteristic of pharmacies as a vaccination
Pharmacies had lower average direct costs paid per location. In addition, many pharmacies are open 24 hours
adult vaccination than physician offices and other including holidays, allowing patients to receive vaccinations
medical settings—by 16%-26% and 11%-20%, during these off-clinic hours.7
respectively—when both health plan and enrollees’
perspectives were considered. Despite the convenience, various barriers such as state laws,
collaboration protocols, and health plan restrictions further
prevent pharmacies from administering the full CDC
recommend schedule. An estimated 40,000 to 50,000 adults
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die annually from vaccine-preventable disease in the United according to the CDC guidelines. The vaccination history
States.5 Additionally, $10 billion dollars are used to treat developed by the pharmacist will also serve as a tool to assist
patients without routine or recommended vaccinations.5 The various medical personnel involved with the patient. Also,
state laws restricting pharmacists as a vaccinator are insurance companies should extend pharmacy insurance
inconsistent and seemingly arbitrary (Table 3). Many state laws benefits to cover vaccines as a preventative pharmaceutical
prevent pharmacists from providing vaccinations to the most measure against disease. Expanding vaccines coverage in the
cost-effective population—children. Some states limit the pharmacy setting will bring current those who are irregularly
pharmacist to certain types of vaccines. The 2016 ACPE vaccinated and increase vaccination rates in hard-to-reach
accreditation standards for the doctor of pharmacy curriculum populations.12
requires pharmacy schools to provide training for students to
become certified in administering injections.21 Furthermore, The following are research proposals that can measure the
biologics and vaccines are considered pharmaceutical products clinical and economic impact of the pharmacist as a vaccinator:
approved through the FDA, which positions pharmacists as comparisons of direct cost and opportunity cost for the full
vaccine experts. The expertise provided by pharmacists was vaccination schedule administered at the community pharmacy
demonstrated in Haas-gehres a, et al. where pharmacy vs. the physician’s office, cost effectiveness of travel vaccines
interventions significantly decreased missed opportunities for given in a community pharmacy setting, a study to determine
scheduled vaccinations.16 Vaccination protocols, prescription or estimate the average number of vaccinations a pharmacy
only orders and standing orders are additional barriers to administers annually, an observational claims analysis of
patient access to pharmacy service. Also, both commercial and rejected vaccinations by an insurance provider in the
state health plans do not readily cover all scheduled vaccines5 community setting, and a literature review of pharmacy
when administered in the pharmacy setting, further hindering protocols and state law limitations.
healthcare. With the inconsistent restrictions and lack of
medical standard, research concerning protocols and orders Conclusion
would assist in determining the practicality of these Pharmacists as vaccinators are an underutilized vaccine
restrictions. provider source. This literature review reveals a pattern among
studies measuring pharmacists’ impact on vaccine rates,
Economically, vaccines delivered in the pharmacy lower the patient preferences, and cost savings. Expanding the
cost for health care.17,18 Patients have higher direct and pharmacists’ ability to vaccinate more population groups
opportunity costs when getting vaccinations at their physician’s through the changing legislation has traditionally increased
office.18,19 A recent study has shown the average opportunity vaccination rates by state.13 Inconsistency exists within the
cost per physician visit was $43, which exceeds the average health benefits system, which complicates pharmacy
patient’s out-of-pocket payment. Total opportunity costs per vaccination efforts. Vaccination is the most cost effective way
year for all physician visits in the United States were $52 billion to prevent infectious disease and comorbid complications,
in 2010.19 Studies have shown that receiving vaccines in the however commercial and governmental health plans provide
pharmacy setting was the least expensive option for patients. limited coverage for receiving vaccinations from a pharmacy.5
In contrast, vaccines delivered in the traditional physical office Pharmacists have demonstrated to be dependable, accurate,
setting are the most expensive.17,18 The patient may also and cost effective vaccination providers. State laws, collaborate
experience opportunity costs due to office wait times or agreement protocols, and health plans have prevented patients
appointment co-pays.17-19 Compounding the inconveniences of from using the pharmacy to receive all CDC recommended
going to a physician office has made many patients appreciate vaccines which can potentially delay the Healthy People 2020
the prompt service in the pharmacy setting. Additional goal of increasing vaccination rates and reducing preventable
electronic technologies within pharmacy software systems infectious diseases.
have enabled pharmacists to identify risk groups in need of
vaccinations. Researchers have conducted a study using claims Acknowledgements: Thank you Dr. Albert Wertheimer for the
data as an identifying tool.14 Moreover, patients visit their opportunity to conduct this research and encouraging me to
pharmacies more frequently, thus facilitating the verification of have our work published.
vaccine history and minimizing missed opportunities.
Conflict of Interest: We declare no conflicts of interest or
After reviewing the literature, pharmacy practice should financial interests that the authors or members of their
enhance the pharmacist’s role as a vaccinator by including immediate families have in any product or service discussed in
complete vaccination records with the patient’s medication the manuscript, including grants (pending or received),
profile. The community pharmacy serves as a valuable source employment, gifts, stock holdings or options, honoraria,
of history for each patient’s prescriptions records, and adding consultancies, expert testimony, patents and royalties.
the vaccination history to the patient profile will help identify
those who have not received their recommended vaccinations
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References 13. Steyer TE, Ragucci KR, Pearson WS, Mainous AG. The
1. Centers for Disease Control and Prevention (CDC). role of pharmacists in the delivery of influenza
Achievements in public health, 1900–1999: Control of vaccinations. Vaccine. 2004;22(8):1001-6.
infectious diseases. MMWR. 1999 Jul 30;48(29):621-9 14. Taitel M, Cohen E, Duncan I, Pegus C. Pharmacists as
2. Immunization and Infectious Diseases. (n.d.). providers: targeting pneumococcal vaccinations to
Retrieved March 12, 2016, from high risk populations. Vaccine. 2011;29(45):8073-6.
https://www.healthypeople.gov/2020/topics- 15. Van amburgh JA, Waite NM, Hobson EH, Migden H.
objectives/topic/immunization-and-infectious- Improved influenza vaccination rates in a rural
diseases#star population as a result of a pharmacist-managed
3. APhA. Pharmacists play a vital role in providing immunization campaign. Pharmacotherapy.
immunizations in their communities. 2001;21(9):1115-22.
http://www.pharmacist.com/AM/Template.cfm? 16. Haas-gehres A, Sebastian S, Lamberjack K. Impact of
Section=News_Releases2&template=/CM/ContentDis pharmacist integration in a pediatric primary care
play.cfm&ContentID=23001. clinic on vaccination errors: a retrospective review. J
4. Weidman-Evans E, Mohundro B.L. (2013). Chapter 6. Am Pharm Assoc (2003). 2014;54(4):415-8.
Immunization Services. In Ellis A.W., Sherman J.J. 17. Singhal PK, Zhang D. Costs of adult vaccination in
(Eds), Community and Clinical Pharmacy Services: A medical settings and pharmacies: an observational
Step-by-Step Approach. Retrieved April, 2016 from study. J Manag Care Spec Pharm. 2014;20(9):930-6.
http://accesspharmacy.mhmedical.com.libproxy.tem 18. Prosser LA, O'brien MA, Molinari NA, et al. Non-
ple.edu/content.aspx?bookid=684&Sectionid=451458 traditional settings for influenza vaccination of adults:
41 costs and cost effectiveness. Pharmacoeconomics.
5. Events FO, Policy BO, Medicine IO. The 2009 H1N1 2008;26(2):163-78.
Influenza Vaccination Campaign: Summary of a 19. Ray KN, Chari AV, Engberg J, Bertolet M, Mehrotra A.
Workshop Series. National Academies Press; 2010. Opportunity costs of ambulatory medical care in the
6. Bach, Albert and Jeffery Goad. "The Role of United States. Am J Manag Care. 2015;21(8):567-74.
Community Pharmacy-Based Vaccination in the USA: 20. NABP. Independent Pharmacy Practice. The 2016
Current Practice and Future Directions". IPRP (2015): Survey of Pharmacy Law. 2016
67. Web. 1 May 2016. 21. Accreditation council for pharmacy education.
7. Goad JA, Taitel MS, Fensterheim LE, Cannon AE. Accreditation standards and key elements for the
Vaccinations administered during off-clinic hours at a professional program in pharmacy leading to the
national community pharmacy: implications for doctor of pharmacy degree (“Standards 2016”).
increasing patient access and convenience. Ann Fam Chicago, Illinois. 2015.
Med. 2013;11(5):429-36
8. Papastergiou J, Folkins C, Li W, Zervas J. Community
pharmacist-administered influenza immunization
improves patient access to vaccination. Can Pharm J
(Ott). 2014;147(6):359-65.
9. Wang J, Ford LJ, Wingate L, et al. Effect of pharmacist
intervention on herpes zoster vaccination in
community pharmacies. J Am Pharm Assoc (2003).
2013;53(1):46-53.
10. Anderson C, Thornley T. "It's easier in pharmacy":
why some patients prefer to pay for
flu jabs rather than use the National Health Service.
BMC Health Serv Res. 2014;14:35.
11. Anderson C, Thornley T. Who uses pharmacy for flu
vaccinations? Population profiling through a UK
pharmacy chain. Int J Clin Pharm. 2016;38(2):218-22.
12. Crawford ND, Blaney S, Amesty S, et al. Individual-
and neighborhood-level characteristics associated
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ESAP-registered pharmacies: pharmacists' role in
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2011;88(1):176-85.
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Table 1: Clinical
Name of Study and Type of Study / Objectives Methods Results Implications
Description
Vaccinations Retrospective review. One-year vaccination review Pharmacist administered The typical off clinic hour user,
administered during chain pharmacy. 6,250,402 vaccinations. male, young, heather patient,
off-clinic hours. Objective: Analyze the reside highlighter more likely to
Increasing patient types of vaccine Categorized by traditional 30.5% provided during off be vaccinated during off-clinical
access and administered and patient hours (9am-6m) vs. off clinic clinic hours. hours.
convenience.7 pharmacies population hours (evening, holidays,
vaccinated during off clinic weekends). Patients had higher odds of Community pharmacies are
Goad Ja et al. Ann hours in a nationally off-clinic vaccination if they expanding the access and
Fam Med. community pharmacy. Compared demographic and were younger than 65, male, convenience of vaccines.
2013;11(5):429-36 types of vaccines. reside in urban area, and did
not have chronic conditions. Working population utilize the
convenience outside the
17.5% of all vaccines working hours thus increases
administered during lunch vaccination rates.
hours (11 am -1 pm).
Patient seek vaccinations at
Patients are more likely to use times most convenient to them.
off clinic hours if they were
vaccinated in states that Expanding the pharmacist ability
authorize pharmacist to all to administer adults and
CDC-recommended vaccines children for all vaccines in all
vs. states that authorize states will have the greatest
pharmacist to administer impact on vaccination rates.
influenza, pneumonia and
zoster (OR = 1.0044; 95% CI,
1.040-1.049).
Community Objective: Survey collected at 4 1502 surveys were collected. Pharmacist have the potential to
pharmacist- To describe the community pharmacy provide a positive effect on
administered demographics of patients locations in Toronto in 8- 86% of patient were very public health by improving
influenza receiving influenza vaccines week period. comfortable or comfortable vaccination rates among high
immunization in the community setting 14% with being vaccinated by risk patients and first time
improves patient and to understand patient pharmacist. vaccine recipients.
access to vaccines8 perceptions of pharmacy
vaccinations. 92% of patients were very
satisfied or satisfied 8% with
Papastergiou J et al. pharmacies’ service and Expanding pharmacist
Can Pharm J (Ott). injection technique. vaccination services to cover
2014; 147(6):359-65 other vaccines would improve
28% of patients indicated that patient access and would
they would not have been receive positive reception.
vaccinated that year if the
pharmacy service were not
provided.
46% of the patients had risk
factors such as heart disease,
respiratory disease, cancer,
diabetes or was receiving
immunosuppressant.
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DOI: https://doi.org/10.24926/iip.v10i3.940Review PHARMACY PRACTICE The effect of Prospective interventional Study of three pharmacies Vaccination rates increased Pharmacists can attain better pharmacist with pre-post design. that serve suburban, semi- from 0.37% (or 59/16,121) vaccine outcomes by intervention of rural, rural demographics. during the control period to communication with patients Herpes Zoster Investigate whether 1.20% (or 193/16,062) during using mediums as personal Vaccination in intervention by community Two protocols: collaborative the intervention period letters. community practice9 pharmacist promoting practice and Rx all vaccines (P
Review PHARMACY PRACTICE
It’s easier in This paper discusses Data were collected during Data were captured from Patients would rather pay for
pharmacy”: why retrospective data collected the 2012–13 flu season as 89,011 privately paying convenience than wait for long
some patients prefer through a sample of Boots part of a community patients across 479 pharmacies time for free service.
to pay for flu jabs UK community pharmacies pharmacy private flu in England, of whom 6% were
rather than use the during 2012–13 to help vaccination service to help eligible to get the vaccination
National Health support the case for identify whether patients free. 921 patients completed a
Service.10 national commissioning of were eligible to have their survey in the 13 pharmacies
flu vaccinations through vaccination free of charge on selected. Of these, 199 (22%)
Anderson C et al. pharmacy. the NHS. Additional data were eligible to get their flu
BMC Health Serv Res. were collected from a sample vaccination for free. 131 (66%)
2014;14:35. of patients accessing the were female. Average age was
private service within 13 54 years. Of the 199 patients
pharmacies to help identify who were eligible for free
the reasons patients paid treatment, 100 (50%) had been
when they were eligible for contacted by their GP surgery
free vaccination. to go for their vaccination, but
had chosen not to go. Reasons
given include accessibility,
convenience and preference
for pharmacy environment.
Who uses pharmacy To understand the profile Pharmacists requested 1741 patients from a total of These services are highly
for flu vaccinations? of people accessing flu people who had been 55 pharmacies completed the accessed by patients from all
Population profiling vaccination services within vaccinated in 2014/15 to survey. Convenience and socio demographic areas.
through a UK a large pharmacy chain. complete a questionnaire. accessibility remain the key Patients would rather pay for
pharmacy chain11 Data was captured reasons for attending convenience than wait for long
Retrospective data electronically on vaccine pharmacy. time for free service.
Anderson C et al. Int J collected through a sample delivery levels across 1201
Clin Pharm. of in England during the pharmacies. Deprivation Pharmacy services are Health professionals and
2016;38(2):218-22 2014/15 Flu season. profiles were calculated using accessed by people from all working class people tend to use
the Carstairs index. postcode areas, including some the pharmacy vaccine service.
Carstairs index (used to from the most deprived
calculate deprivation localities.
quintiles for least and most
deprived); based on four
census indicators: low social
class, lack of car ownership,
overcrowding, and male
unemployment.
Individual- and New York State (NYS) Used pharmacy staff baseline The sample consists of 437 Evidence-supporting scale-up of
Neighborhood-Level passed legislation data to assess support of in- pharmacists, non- pharmacist vaccination efforts in
Characteristics authorizing pharmacists to pharmacy vaccination, which owners, and technicians pharmacies located in foreign-
Associated with administer vaccines in was measured using a Likert enrolled from 103 eligible New born/immigrant communities,
Support of In- 2008. Racial/socioeconomic scale (very supportive, York City pharmacies. Using which has potential to reduce
Pharmacy disparities persist in somewhat supportive, not multilevel analysis, pharmacy disparities in vaccination rates
Vaccination among vaccination rates and supportive, don’t know, and staff that expressed support of and preventable influenza-
ESAP-Registered vaccine-preventable refused) in response to, “How in- pharmacy vaccination related mortality.
Pharmacies: diseases such as influenza. much do you support services were 69% more likely The majority of pharmacy
Pharmacists’ Role in Many NYS pharmacies vaccination services being to support in-pharmacy HIV personnel are very supportive of
Reducing participate in the Expanded provided in your pharmacy?” testing services (OR, 1.69; 95% in pharmacy vaccination despite
Racial/Ethnic Syringe Access Program Persons who reported being CI 1.39–2.04). sociodemographics disparities.
Disparities in (ESAP), which allows very supportive or somewhat There was a total of 437 Pharmacies that also offer other
Influenza provision of non- supportive were classified as pharmacy staff: 189 public health service are more
Vaccinations prescription syringes to supportive, and those who pharmacists, 19 non- likely to support in-pharmacy
in New York City12 help prevent transmission reported not supportive were pharmacist owners/managers, vaccinations.
of HIV, and are uniquely classified as not supportive. and 229 pharmacy
Crawford ND et al. J positioned to offer Persons who reported don’t technicians/clerks. Of these Pharmacies are in the key
Urban Health. vaccination services to low- know and refused were pharmacy staff, 38.7% were position to vaccinate too-hard-
2011;88(1):176-85. income communities. To excluded from this analysis male, most were Hispanic to-reach population groups.
understand individual and (n=4). It is important to note (36.1%), followed by
neighborhood that support of in-pharmacy Asian/Pacific Islander (19.3%),
characteristics of pharmacy vaccination reflects individual African American (18.2%),
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staff support for in- attitudes and beliefs of this White (13.1%), South
pharmacy vaccination, we service rather than actual Asian/Indian/Pakistani (8.3%),
combined census tract data participation in current and other race/ethnicity
with baseline pharmacy vaccination services in their (5.1%). Pharmacy staff worked
data from the Pharmacies pharmacy. Participants were an average of 9.4 years in
as Resources Making Links probed about their level of pharmacies. Most (86.3%)
to Community Services support even if this service pharmacy staff supported
(PHARM-Link) study among was not feasible in the vaccination being provided
ESAP-registered pharmacy. Therefore, we inside the pharmacy.
pharmacies. refer to the reported beliefs
and attitudes of in-pharmacy
vaccination as in-pharmacy
vaccination support.
The role of The purpose of this study is For this analysis, the 1995 Individuals aged 65 years and Allowing pharmacists to provide
pharmacists in the to determine whether and 1999 Behavioral Risk older who lived in states where vaccinations is associated with
delivery of influenza influenza vaccine rates Factor Surveillance System pharmacists could provide higher influenza vaccination
vaccinations13 have increased in states (BRFSS) was used. The BRFSS vaccines had significantly rates for individuals aged 65
where pharmacists can give is an annual telephone survey higher (P < 0.01) influenza years and older.
Steyer TE et al. vaccines. conducted by the Centers for vaccine rates than individuals
Vaccine. Disease Control and of this age who resided in Expanding the pharmacies
2004;22(8):1001-6. To assess the impact of Prevention that assesses states where pharmacists ability to administer more
legislation allowing health risks in the US. In this could not provide vaccines. vaccines increases vaccination
pharmacists to administer survey, individuals are asked, rates in new populations.
vaccine. “During the past 12 months, Expanding patient access and
have you had a flu shot?” refining legal parameters in
Sixteen states were taken pharmacy practice has a
from the BRFSS to compare correlated effect in the groups
influenza vaccination rates who are vaccinated.
for individuals both 18–64
and 65 years and older. Eight
of these states (Arkansas,
Kansas, Nebraska, North
Dakota, Oklahoma,
Tennessee, Texas and
Virginia) passed legislation in
1997 allowing pharmacists to
administer vaccines while
eight (Louisiana, Missouri,
Iowa, Wyoming, Utah, West
Virginia, Florida, and
Maryland) had no legislation
prior to 2000. Data for the
years 1995 and 1999 were
then analyzed.
Secondary analysis of the
Behavioral Risk Factor
Surveillance System (BRFSS)
from the years 1995 and
1999. Information regarding
legislation allowing
pharmacists to administer
vaccines was obtained from
the American Pharmaceutical
Association.
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Pharmacists as The objective of this study Using de-identified claims Among the 1.3 million at-risk Pharmacies have the ability to
providers: Targeting was to evaluate the impact from a large, national patients, 65,598 (4.88%) target at risk vaccination groups.
pneumococcal of pharmacists educating pharmacy chain, all patients received a pneumococcal Pharmacy electronic records can
vaccinations to high at-risk patients on the who had received an vaccine. This vaccination rate filter patient profiles based on
risk populations14 importance of receiving a influenza vaccination was significantly (p < .001) risk factors characteristic.
Taitel M et al. pneumococcal vaccination. between August 1, 2010 and higher than the PPSV23 Pharmacies can expand this
Vaccine. November 14, 2010 and who benchmark rate of 2.90% function to make more health or
2011;29(45):8073-6. were eligible for PPSV23 were (34,917/1,204,104). In the vaccine interventions and
identified for the analysis. study group, PPSV23 rates produce better outcomes for
Based on the Advisory varied by age group but not by patients.
Committee on Immunization gender. Patients aged 60–70
Practices recommendations, years had the highest These results support the
at-risk patients were vaccination rate (6.60%, expanding role of community
identified as over 65 years of 26,430/400,454) of any age pharmacists in the provision of
age or as aged 2–64 with a group. wellness and prevention
comorbid conditions. A services.
benchmark medical and
pharmacy claims database of Pharmacies can help achieve the
commercial and Medicare U.S. Department of Health and
health plan members was Human Services’ Healthy People
used to derive a PPSV23 goals for vaccine coverage. This
vaccination rate typical of study supports the expanding
traditional care delivery to role of community pharmacists
compare to pharmacy-based in the provision of wellness and
vaccination. Period incidence prevention services.
of PPSV23 was calculated and
compared. .
Improved Influenza To increase the rate of The pharmacy team Before intervention (1998), This study demonstrated that
Vaccination Rates in influenza vaccinations in developed an education vaccination rates were low: this pharmacy- directed
a Rural Population as high-risk patients by means packet that was sent to all 182 (28%) patients with and program, which included a
a Result of a of a pharmacist-managed patients who needed the 102 (6%) patients without mailing and improved access to
Pharmacist-Managed immunization campaign. influenza vaccine. The packet indications for the vaccine. the influenza vaccine,
Immunization Unblinded, single contained a letter and a two- After the pharmacy-directed significantly increased
Campaign15 intervention. sided information insert intervention in 1999, 354 vaccinations by 95% for a group
Rural primary care clinic. designed in collaboration (54%) patients with and 148 of high-risk patients in a rural
Van amburgh JA et with a teaching/learning (9%) patients without community practice.
al. Pharmacotherapy. specialist. indications were successfully The education packet received
2001;21(9):1115-22. vaccinated. by mail was the most common
The pharmacy team reason patients were both
developed two surveys. One The influenza vaccination rate convinced and reminded to get
survey, for patients who increased from 28% at baseline vaccinated.
received the influenza (before program initiation) to
vaccine (entitled “We helped 54% after program initiation.
you, now you can help us”), Unvaccinated patients were
was given by a nurse or younger and resided in more
pharmacist to patients during urban areas than vaccinated
the vaccination clinic, at patients; vaccinated patients
physician appointments, or had a higher frequency of
by mail. cardiovascular disease or
A follow-up letter and survey diabetes mellitus. Vaccinated
were mailed in early patients consistently identified
December to unvaccinated the education packet and their
patients who had indications health care providers as
for vaccine. The primary primary motivators for
focus was to encourage them vaccination.
to get vaccinated if they had
not yet done so. Total of 283 patients
completed the “We helped
you, now you can help us”
survey. Of these, 199
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respondents were patients
with positive indications who
were vaccinated against
influenza and had received the
education packet (56.4%
response rate). Patients
consistently identified the
mailing and their health care
provider as the top factors that
had convinced and reminded
them to get vaccinated.
The most common suggestions
for improving the vaccination
program were to provide more
days and times available to be
vaccinated and to increase the
number of providers to
administer vaccinations.
Impact of pharmacist To measure the impact of A retrospective, quasi- 900 encounters were randomly Pharmacist have the ability to
integration in a ambulatory clinical experimental review of selected and reviewed. The identify CDC scheduled
pediatric primary pharmacist integration in a electronic medical records of error rate was found to be recommendation in pediatric
care clinic on pediatric. visit encounters during a 3- 0.28% in the intervention clinic population.
vaccination errors: A month period compared and 2.7% in the comparison
retrospective Primary care clinic on vaccine error rates and clinic. The difference in error Pharmacist can support
review16 vaccination error rates and missed opportunities rates was found to be ambulatory clinics to increase
to evaluate missed between two pediatric significant (P = 0.0021). The vaccination rates and decreases
Haas-gehres A. J Am opportunities. residency primary care clinics. number of encounters with the rates of missed
Pharm Assoc (2003). The intervention clinic has a greater than or equal to one opportunities.
2014;54(4):415-8. full-time ambulatory clinical missed opportunity was
pharmacist integrated into significantly higher in the
the health care team. comparison clinic compared
with the intervention clinic
Pharmacy services were not (29.3% vs. 10.2%; PReview PHARMACY PRACTICE
Table 2: Economics
Name of study and Type of study / objectives Methods Results Implications
description
Cost of Adult Observational This was an observational Of those receiving zoster, The average direct costs paid
vaccination in retrospective study. retrospective study using pneumococcal, and influenza per adult vaccination were
Medical Settings and 2010 MarketScan Commercial vaccines, 25%, 1%, and 7%, lower in pharmacies compared
Pharmacies: An Objective: To examine Claims and Encounters and respectively, received the with physician offices and other
observational study17 whether the direct Medicare Supplemental and vaccines at a pharmacy. medical settings by 16%-26%
medical costs paid for Coordination of Benefits Compared with other U.S. and 11%-20%, respectively.
Singhal PK et al. J adult vaccination differ by databases. Adults receiving regions, pharmacy-based
Manag Care Spec vaccination setting. herpes zoster or shingles vaccination for these 3 These results were mostly
Pharm. vaccine, pneumococcal vaccines was generally more consistent across geographic
2014;20(9):930-6. vaccine 23-valent, or frequent in the West and the regions and types of health
influenza vaccines were South. plans.
identified using Current
Procedural Terminology Mean (SD) costs paid per These data may help payers and
codes and National Drug Code enrollee per vaccine policymakers understand the
numbers from medical and administration at physician economic value of adult
pharmacy claims files, offices, other medical vaccination in different settings,
respectively, between settings, and pharmacies especially in pharmacies.
January 1 and December 31, were as follows: for zoster
2010, in 1 of the following 3 vaccine, $208.72 (42.10), The data may also help medical
settings: physician offices; $209.51 (50.83), and $168.50 or pharmacy insurance
other medical settings (e.g., (15.66), respectively (PReview PHARMACY PRACTICE
Non Traditional To describe the cost of Evaluated cost of influenza The mean cost (2004 values) Vaccinations given in the
settings for influenza vaccination in non- vaccinations in non- was lower in mass vaccination pharmacy setting is the most
of Adults traditional settings such traditional setting via detailed ($17.04) and pharmacy cost effective way to administer
Costs and Cost as pharmacies and mass telephone interviews with ($11.57) setting than in vaccines.
Effectiveness18 vaccinations clinics vaccination clinics and scheduled office visits.
pharmacists who administer Vaccines given in pharmacy can
Prosser LA et al. Evaluate the projected vaccines In non-traditional settings, lower the cost to patients and to
Pharmacoeconomics. health benefits, cost and cost savings was projected for health providers.
2008;26(2):163-78 cost effectiveness of Decision tree used to healthy adults aged > 50
delivering influenza compare projected cost and years and for high-risk adults
vaccinations to adults of health benefits of receiving of all ages.
varying ages and risk an influenza vaccination from
groups in non-traditional non-traditional setting or For health adults 18-49 years
settings compared with during schedule doctor office was cost effective, prevention
schedule doctor’s office visit with no vaccination. ($US90) if vaccines delivered
visits in the United States. in pharmacy setting, $US210
Probabilities and cost (direct by mass vaccination, and
and opportunity) for $US870 by scheduled doctor’s
uncomplicated influenza office visit.
illness, outpatient visits,
hospitalizations, deaths,
vaccination and vaccine
adverse events were derived
from primary data and
published and unpublished
articles.
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Table 3: Modified: National Association of Boards of Pharmacy: Survey of Pharmacy Law20
States List of Conditions Pharmacist Administer Vaccination
Alabama , Arizona, California, Allowed to vaccinate with fewer restricted measures.
Colorado*, Delaware, District of
Columbia, Georgia, Idaho, Illinois,
Kentucky Louisiana, Maine*,
Mississippi , Missouri, Nebraska
Nevada*,New Hampshire, New Jersey,
New Mexico, Puerto Rico, South
Carolina, South Dakota,Tennessee,
Texas, Vermont ,Virginia
Alaska With board-approved collaborative practice protocol application.
Arkansas, Kansas, Oregon, West Subject to vaccination protocol and completed course of study and training.
Virginia
Connecticut, With restrictions. (FL – Consultant pharmacist in nursing home setting. Section 465.0125, F.S.)
Connecticut, Montana Pursuant to protocol only. (MT – Institutional protocol.)
Connecticut If pursuant to a collaborative practice protocol.
Florida, Pennsylvania, West Virginia Pharmacists may vaccinate if they are certified by the board to administer injectables. (PA – if registered.)
Hawaii Pursuant to a licensed medical — doctor’s or osteopathic physician’s order and collaborative agreement and
authorization.
Indiana May administer vaccines under a drug order, prescription, or physician-approved protocol for influenza,
shingles, pneumonia, tetanus, diphtheria, acellular pertussis, HPV, and meningitis.
Iowa, Colorado, Maine, Nevada, Ohio Must be in accordance with a protocol.
IA-By written protocol pursuant to rules of the Board of Pharmacy or when specifically directed by the
prescriber for an individual patient.
CO - Drug therapy management protocol.
MI- May administer cholesterol, blood glucose, and international ratio, hepatitis C.
NV – Protocol must be approved by the Board.
OH – Pharmacists and pharmacy interns may dispense naloxone pursuant to a physician-approved protocol.
They are not specifically authorized to “prescribe,” nor are they recognized as prescribers under Ohio law.)
Maryland Statute allows pharmacists to administer influenza vaccines to individuals age nine and above; CDC-
recommended vaccinations to individuals ages 11 to 18 with prescription; CDC-recommended vaccines and
travel vaccines to adults under a protocol. Pharmacists may also administer self- administered drugs.
Regulations pending. Registration with the Board is required.
Massachusetts Approved by Department of Public Health
Michigan Yes, if it has been delegated to them and they have the approved training. See Section 16215 of the
Michigan Public Health Code on delegation.
Minnesota Influenza to patients six years of age and older, all other vaccines to patients 13 years of age or older.
Written protocol with a physician, APRN, or PA.
Montana Pharmacists are authorized to prescribe and administer vaccines without a collaborative practice agreement
in place for the following vaccines: influenza to those 12 years and older; pneumococcal polysaccharide,
tetanus, and diphtheria to those 18 years and older; herpes zoster to those identified in Centers for Disease
Control and Prevention guidelines; and in the event an adverse reaction, epinephrine or diphenhydramine to
those 12 years and older.
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New York May administer influenza, pneumococcal, herpes zoster, meningococcal, and tetanus, diphtheria, and
pertussis vaccines and drugs to treat reactions.
North Carolina Influenza, pneumococcal, herpes, zoster, hepatitis B, meningococcal, tetanus-diphtheria, tetanus and
diphtheria toxoids and peruses, tetanus and diphtheria toxoids and acellular pertussis, tetanus toxoid, and
all other vaccinations recommended or required by the Centers for Disease Control and Prevention.
North Dakota When trained and authorized by Board.
Ohio Certain vaccines as listed in Ohio Revised Code §4729.41 and Board Rules.
Oklahoma, On prescriber’s order.
Rhode Island, West Virginia Limited to certain adult vaccines. (RI – And flu vaccines for children ages nine and older.)
Utah For inpatient pharmacist via institutional protocol only pursuant to the Division of Occupational and
Professional Licensing approved vaccine protocol.
Washington The definition of the “practice of pharmacy” includes “drug administration.” (WA – Definition also includes
the monitoring of drug therapy and use and the initiation or modification of drug therapy in accordance
with written guidelines or protocols in a previously established collaborative drug therapy agreement
between a pharmacist and practitioner authorized to prescribe drugs.)
Washington If appropriately certified bases upon the 12-hour Centers for Disease Control and Prevention training
program, the pharmacist can initiate vaccinations pursuant to a collaborative drug therapy agreement.
Wisconsin Yes, if requirements for coursework and insurance are met.
Wyoming Age 7 and older for certain vaccines.
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