Pharmacy-based Immunization Programs Make an Impact

Lately, media coverage regarding a potential influenza pandemic has increased awareness of vaccinations. To increase immunization coverage, public health officials have supported new and innovative settings. This situation has created a growing call for pharmacy-based vaccination programs.

Healthy People 2010 (HP 2010) established specific goals for disease, disability, and death from vaccine-preventable diseases (VPDs). Although immunization levels currently are the highest ever recorded, HP 2010 aspires to 90% coverage, an increase from levels that often are at 50% to 70%. A 90% level usually is sufficient to prevent significant outbreak of, eliminate, or eradicate VPDs.^1-3

Early vaccination programs prevent the spread of VPDs in childhood and are the ideal cornerstone for control of VPDs among adults. Later in life, people? including some care providers?tend to forget that additional or booster vaccines are required, and they may need reminders. Because of successful vaccination campaigns, polio and measles may be declared eradicated soon, and hepatitis B (and by extension, hepatitis D) may be eliminated in future decades.⁴

When offering an immunization program, protecting against influenza may be the area in which pharmacists can make the most impact. HP 2010 identified a giant gap between the number of people who should receive the flu shot and those who actually do. More than 185 million people should receive an annual flu vaccination. Only 64% of community-dwelling adults aged >65 years and 26% of community-dwelling highrisk adults aged 18 to 64 years received a flu shot in the base year, 1998. The rate was only 59% in long-term care facilities.⁴

According to the Centers for Disease Control and Prevention, ~36,000 people die and 200,000 are hospitalized with influenza in an average year.⁵ Without control measures such as vaccination and drugs, a "medium-level" influenza pandemic in the United States could kill 89,000 to 207,000 people.⁶ Pharmacists were already immunizing patients in 41 states as of July 2004, and not just for flu (Table 1⁷). The American Pharmacists Association (APhA) estimates that ~10,000 pharmacists are trained to administer vaccinations.

Pharmacists administered more than 1 million flu vaccinations during the 2004- 2005 flu season. Their typically long hours and easy accessibility make pharmacies an attractive immunization option for the >250,000 patients who visit pharmacies every week.⁸

States that allow pharmacy-based immunizations establish protocols for pharmacists to follow. These protocols include conditions that warrant referring a patient for vaccination, procedures for emergencies, and documentation requirements. In the most liberal of protocols, states allow pharmacists to initiate a prescription and administer vaccines. Many states require pharmacists to develop a relationship with an "authorizing prescriber." This individual periodically reviews the pharmacist's activities and is available to provide feedback and consultation when necessary.

After ascertaining whether immunization is covered in the appropriate state's pharmacy scope-of-practice regulations, guidelines or position papers on pharmacy- based immunization from one of the professional pharmacy organizations should be the starting point to identify program processes and structure. Pharmacies that provide immunizations also should use their state's protocol as a basis for formulating internal policies and procedures.⁹

The APhA's guidelines identify several levels of pharmacist involvement in immunization. Pharmacists can educate (motivate others to be immunized), facilitate (host other clinicians who immunize), or acquire the credentials to immunize. For pharmacies that have their own immunization program, the APhA's guidelines emphasize that pharmacybased programs must be community partnerships provided in collaboration with prescribers and health departments. The American Society of Health- System Pharmacists' guidelines indicate that 12 focus areas should be included in the training necessary to become an active immunizer. These areas include disease epidemiology, vaccine characteristics, injection technique, and emergency response.^10,11

Simple Steps

Immunization programs can be high-volume, and immunizations take about the same amount of time as filling a prescription. Simple steps, like signs advertising the service or a polite inquiry when prescriptions are filled, can prompt immunization. Recording immunizations provided in the pharmacy permanently on the patient's record is a selling point.

One very simple but often overlooked way to promote immunization is to lead by example. Make sure that pharmacy staff members are immunized, and let customers know.⁷ Pharmacists who provide services to long-term care facilities can work with their infection control, risk management, or pharmacy and therapeutics committees to increase immunization coverage and pharmacy involvement.¹²

Most pharmacies charge a flat fee for immunizations, or they may bill Medicare directly for immunizations given to its beneficiaries.⁹ Some pharmacies have capitalized on their ability to provide readily retrievable records, and they may offer patients access to their own or their children's immunization records at a kiosk that accepts credit cards.⁷

Liability

Pharmacists' primary concern about providing immunizations is time. In very busy locales, immunizing patients may be impossible. Additional support staff may be needed. Following time issues, liability is pharmacists' next concern.⁸ Pharmacists are no more likely to have patients experience adverse events than other health care providers when they vaccinate patients. To avoid liability risk, pharmacists should follow national standards concerning vaccine administration (Table 2).

Barriers to Immunization in the Pharmacy

Numerous barriers exist, and pharmacists who anticipate these barriers and possible solutions to them will surmount them with no trouble. If physicians are reluctant to refer patients, it is imperative that pharmacists demonstrate and advertise their competence. When patients hesitate to be vaccinated because of common myths, pharmacists need good communication skills to dispel these myths. If no space is available for patients to complete paperwork and receive vaccinations in privacy, pharmacists need to work with managers to establish a dedicated area.

Roll Up Those Sleeves!

Pharmacists everywhere can benefit from training in immunization, and communities benefit when pharmacists actively promote immunization as educators, facilitators, or immunizers. The advantages are not limited to more extensive patient contact, better community health, and the potential to augment income. Just taking a standard course to establish one's credential as an immunizer generally provides 20 credits of continuing education?enough to complete most states' annual requirement.

Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Md. Views expressed in this article are those of the author and not those of any government agency.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: astahl@ascendmedia.com.