Partnership Between Public Health and Pharmacy: Opportunities to Increase Resource Sharing, Efficiency, and Improved Health Outcomes

Problem: Vaccination remains one of the most effective ways to limit virus spread, prevent infectious disease, and reduce morbidity and mortality. Ongoing research suggests that 70% or more of the US population will need to receive the COVID-19 vaccine to achieve herd immunity; however, current (51%) and projected COVID-19 vaccine uptake is far lower than the required 70%.^1–3

“Public health is not very easy...how these numbers translate into people, the importance of the messaging… [health care providers and public health leaders] need to know how to be better communicators.”— Public health leader

Many individuals in the US remain complacent, choosing not to be vaccinated or to delay COVID-19 vaccination until they feel more confident in the safety and efficacy of the vaccine against current virus, resulting in suboptimal herd immunity and an increased number of COVID-19 mutations (e.g., alpha, beta, and delta variants).

Solution: To better support COVID-19 vaccination efforts, identify and address vaccine hesitancy, and improve vaccine confidence, the Association of Immunization Managers (AIM) partnered with the Navigators—an all-volunteer group of pharmacies, pharmacy member organizations and public health professionals—to identify potential modifiable factors contributing to COVID-19 vaccine hesitancy.

“[Pharmacy vaccination of long-term care residents] took the burden off public health departments [shared responsibility].” — Public health provider

In June 2021, the Navigators in conjunction with AIM, collected COVID-19 data from Immunization Information Systems (IIS) and partner health systems, administered a national survey, and conducted a pair of 90-minute focus groups with public health and pharmacy leaders across the United States.

Five immunization managers and 5 Navigator members representing rural and urban pharmacy member organizations participated, sharing successes, challenges and most importantly pharmacist opportunities as they pertain to their critical role as immunization providers throughout the COVID-19 pandemic.

“Successes of the pharmacy public health COVID-19 vaccination collaboration include: increased access, increased uptake of the COVID-19 vaccine, and increased convenience for the public.” — Pharmacy chain administrator

Continued Infrastructure Development: The infrastructure necessary for pharmacists, student pharmacists, and pharmacy technicians across the United States to safely and effectively provide more than 80 million COVID-19 vaccinations to adults and children has been established.^4–6

Steps have been taken to ensure pharmacists have access to necessary IIS and technology platforms to schedule patients and track vaccination administration. However, additional legislative, payer, health system, and pharmacist support is necessary to ensure that infrastructure development continues and that all pharmacists have the necessary tools from the public and private payers to continue providing immunization services.

“I think the infrastructure that has been put in place broadly across pharmacies, the relationships that have been developed with pharmacy and public health…now is the perfect time to parlay that and go forward.” — AIM member

Not all pharmacists have access to bi-directional informational capture and exchange capabilities and it is vital that data collected in state and local IIS systems is shared among health care providers and state agencies. Data must be available to guide clinical, state, and national legislative decisions.

At the population level, IIS aggregate data can be used for surveillance to guide program operation and statewide response. However, many under-resourced states with increased vaccination needs have outdated technology and systems that do not allow for timely information capture and utilization, resulting in siloed health information, potential patient safety concerns, and health inequities.

“We have credentialing methods started, data access started, and some of the workloads established but are there other things that we need to do or are there ways that we need to expand those to move forward?”

Pharmacists across the country, especially in rural and underserved communities, need additional technology, training, and resources to handle the increased administrative and administration burden. Additional administrative supports include but are not limited to credentialing support, training to appropriately bill for services, and technology to address the significant documentation burden.

“If you want people to invest and do outreach…they need to be paid for that upfront.” — Pharmacy leader

Community pharmacies, especially small independent pharmacies, often need additional equipment to safely store some vaccines and computer programs and technology to efficiently document and bill for services. AIM and Navigator members participating in the focus groups identified a number of barriers to current and continued vaccine provision of the COVID-19 vaccine in a number of high-need, rural, and chronically under-served communities and potential solutions that support sustainable provision and expansion of vaccine services.

“Moving forward, now we have relationships that we want to build on…independent pharmacies can scale up and nimble enough to engage, early and often.” — Pharmacist

Expansion of Services: More patients are turning to pharmacists to receive their vaccinations across the lifespan.^2,7 Though every state allows pharmacists to administer immunizations to some level, what pharmacists are authorized to do state-by-state varies, such as which vaccine can be administered, the type of authority pharmacists possess (independent versus dependent), age limits on who can be vaccinated, and the processes that must be followedin the state.

“There is an investment that you have to make...opportunities that are presented to you may not be ideal, but when they reach out, if you can be a resource for them, then it leads to additional opportunities...” — Pharmacy chain administrator

The Affordable Care Act reduced many of the financial barriers to preventive care services, such as vaccines; however, routine adult vaccination coverage remains suboptimal and a number of gaps in immunization coverage persist.

Despite 2016 National Health Interview Survey (NHIS) recommendations that all health care providers routinely assess vaccine eligibility at every clinical visit, a lack of regular well-visits by adolescents and adults results in limited vaccine opportunities and subsequent low coverage.^8–10

“We have to tackle [suboptimal child, adolescent, and adult vaccination…” — Public health leader

Several studies have identified a substantial decrease in adult and child preventative health services during the pandemic, especially immunizations, as many health care provider offices were either closed and/or offering limited preventative health services. In 2017, only 70% of US children received all recommended vaccination doses.^10,11

In fact, according to Health Care Cost Institute (HCCI) claims data, immunizations declined 18% in 2020.¹² During the COVID-19 pandemic, the number of children and adults who did not receive their routine vaccinations increased, posing a major public health threat of increased outbreaks of preventable diseases.

“The Board of Pharmacy has been a translator for us that they have taught us to trust pharmacists…pharmacists know how to do this.” — Pharmacy leader

In August 2020, in response to increased vaccination needs, the US Department of Health & Human Services issued an amendment to the Public Readiness and Emergency Preparedness Act allowing licensed pharmacists and pharmacy interns in all states to administer vaccines to children as young as 3 years of age.¹³

The decision to allow pharmacists to provide immunizations to children was opposed by the American Academy of Pediatrics and American Medical Association, citing many pharmacies do not currently participate in the Vaccines for Children (VFC) program, a federally funded, CDC-based vaccination program, providing vaccines at no cost to children who may not otherwise be vaccinated.^14,15

“Pharmacist provider status has to be a thing…adding pharmacists to the list of providers who can be paid for services...this is still a hurdle for VFC.” — Pharmacy leader

Provider eligibility and enrollment to be a VFC provider varies by state and pharmacists’ participation has historically been limited by the ability of many pharmacists and pharmacies to meet the extensive administrative and storage requirements of the program. Highly accessible and strategically located, pharmacists are well situated to conveniently and effectively expand the number and types of vaccinations.

With appropriate equipment, technology, administrative and human resources support, pharmacists, in partnership with public health providers, could help ensure that patient concerns and misinformation are addressed, that vaccines are made more readily available to all children, adolescents, and adults, and thathealth care providers are working together to support patients where they are, addressing education and access needs.

“People were going to stores and pharmacies during the pandemic, [a missed opportunity] to get their kids vaccinated.” — AIM leader

Next Steps: The goal of this public health and pharmacy partnership was to better identify and address vaccine infrastructure and sustainability concerns. Despite the many successes and advances made during the pandemic, several opportunities exist to fortify this partnership and better leverage pharmacies as vaccine providers for people of all ages.

“We need to invest some time and energy to cultivate relationships with the medical community...whether they be a source for referral or in collaboration…They don’t really understand the way [pharmacists] contribute.” — Pharmacist leader

New recommendations from the Advisory Committee on Immunization Practices published in the Morbidity and Mortality Weekly Report around shared clinical decision-making, highlights the need for additional vaccine advocacy and education, and awareness of the training and abilities of pharmacists to assess patient vaccination and health needs and make appropriate clinical decisions, working with patients and caregivers, regarding vaccinations.

“Getting Medicaid to recognize [pharmacists] and get them paid for the childhood vaccines…just a real struggle.” — Pharmacist Leader

As trusted and knowledgeable health care providers, pharmacists can leverage the media and existing relationships with patients to address misinformation, advocate for public health, provide vaccinations, and address access inequities to recommended vaccines.

“Identify…media savvy pharmacists...to be a credible source of information.” — Pharmacist Leader

References

1. Mayo Clinic. Herd immunity and COVID-19 (coronavirus): What you need to know - Mayo Clinic. Mayo Clinic. Published June 9, 2021. Accessed July 12, 2021. https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/herd-immunity-and-coronavirus/art-20486808

2. Lee L, Peterson GM, Naunton M, Jackson S, Bushell M. Protecting the Herd: Why Pharmacists Matter in Mass Vaccination. Pharmacy. 2020;8(4):199. doi:10.3390/pharmacy8040199

3. Fine P, Eames K, Heymann DL. “Herd Immunity”: A Rough Guide. Clinical Infectious Diseases. 2011;52(7):911-916. doi:10.1093/cid/cir007

4. Immunizing during COVID-19. Accessed December 14, 2021. https://pharmacist.com/Practice/COVID-19/Immunizing-during-COVID-19

5. COVID-19 Vaccination Federal Retail Pharmacy Partnership Program | CDC. Accessed December 14, 2021. https://www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/index.html

6. Joshi A, Kaur M, Kaur R, Grover A, Nash D, El-Mohandes A. Predictors of COVID-19 Vaccine Acceptance, Intention, and Hesitancy: A Scoping Review. Front Public Health. 2021;9:698111. doi:10.3389/fpubh.2021.698111

7. Ko KJ, Wade RL, Yu HT, Miller RM, Sherman B, Goad J. Implementation of a Pharmacy-Based Adult Vaccine Benefit: Recommendations for a Commercial Health Plan Benefit. JMCP. 2014;20(3):273-282. doi:10.18553/jmcp.2014.20.3.273

8. Aris E, Montourcy M, Esterberg E, Kurosky SK, Poston S, Hogea C. The adult vaccination landscape in the United States during the Affordable Care Act era: Results from a large retrospective database analysis. Vaccine. 2020;38(14):2984-2994. doi:10.1016/j.vaccine.2020.02.057

9. Hunter P, Fryhofer SA, Szilagyi PG. Vaccination of Adults in General Medical Practice. Mayo Clinic Proceedings. 2020;95(1):169-183. doi:10.1016/j.mayocp.2019.02.024

10. Niccolai LM, Hansen CE. Suboptimal uptake of meningococcal vaccines among older adolescents: Barriers, solutions, and future research directions. Human Vaccines & Immunotherapeutics. 2020;16(12):3208-3212. doi:10.1080/21645515.2020.1754052

11. Children with all doses recommended vaccines U.S. 2017 | Statista. Accessed March 1, 2022. https://www.statista.com/statistics/657873/children-who-had-recommended-vaccines-us/

12. The Impact of COVID-19 on the Use of Preventive Health Care - HCCI. Accessed March 1, 2022. https://healthcostinstitute.org/hcci-research/the-impact-of-covid-19-on-the-use-of-preventive-health-care

13. Department of Health and Human Services - Office of the Secretary. Third Amendment to Declaration Uner the Public Readiness and Emergency Preparedness Act for Medical Countermeasures Against COVID-19. Federal Register. 2020;85(164).

14. Decline in Receipt of Vaccines by Medicare Beneficiaries During the COVID-19 Pandemic — United States, 2020 | MMWR. Accessed March 1, 2022. https://www.cdc.gov/mmwr/volumes/70/wr/mm7007a4.htm#suggestedcitation

15. AAP Opposes HHS Action on Childhood Vaccines; Calls It ‘Incredibly Misguided’ – Pennsylvania Immunization Coalition. Accessed March 1, 2022. https://www.immunizepa.org/aap-opposes-hhs-action-on-childhood-vaccines-calls-it-incredibly-misguided/