Understanding Off-Site Vaccination Clinics: An Expert Interview With Jeff Goad, PharmD, MPH

Pharmacy-run, off-site (ie, outside the pharmacy) vaccination clinics, first introduced as a temporary means to increase vaccine coverage rates and reach underserved communities,¹ have become increasingly important since the beginning of the coronavirus disease 2019 (COVID-19) pandemic. With the introduction of stay-at-home orders, social distancing, and the move to telemedicine, immunization rates among adults and children have declined,^2-5 prompting pharmacists to think outside the box—or in this case, the pharmacy—to offer lifesaving immunizations for vaccine-preventable diseases in a safe environment.

These clinics increase the convenience of obtaining an immunization.⁶ Research has shown that off-site vaccination clinics reduce illness-related work absences and costs to employers due to time missed while employees are being vaccinated. They have also been shown to increase wellness and morale as a result of better overall health.⁶ Data from the CDC indicate that flu vaccines have been able to reduce the risk of influenza by 40% to 60%.⁷ If more patients are able to receive the vaccine through off-site vaccination clinics, the risk of influenza may be reduced even further. To learn more about implementing off-site vaccination clinics, Pharmacy Times^® spoke with Jeff Goad, PharmD, MPH, professor and chair of the Department of Pharmacy Practice in the Chapman University School of Pharmacy in Irvine, California.

Pharmacy Times^®: Why are off-site vaccination clinics a desirable option for pharmacists, particularly during the COVID-19 pandemic?

Goad: Off-site vaccination clinics have always been desirable when it comes to flu season for communities that may not have convenient access to a pharmacy. Sometimes just seeing an outreach event gets people interested in what is going on, and if flu shots are available, they might [get one] if they are there anyway. We have always thought that outreach events can get the community involved and engaged in flu vaccination, so although having it at the pharmacy is a very convenient everyday option, hosting large events allows people to plan for it and for the community to rally behind it. Outreach events are still necessary in communities to get people thinking about vaccination and health together.

Pharmacy Times^®: How can community pharmacists start to set up an off-site vaccination clinic?

Goad: The CDC has provided several really good guidance documents on the operational level of cold chain management and storage, as well as administration.⁸ More recently, they provided [guidance for activity before, during, and after] in the form of checklists for hosting outreach clinics during the COVID-19 pandemic.

COVID-19 has led to new operational challenges, such as keeping appropriate personal protective equipment [PPE] in stock based on local recommendations. Additionally, there are structural changes for temperature stations with the need to maintain 6 ft between stations, as well as recommendations for setting up hard plastic barriers and separate areas for each step of the immunization process—versus 1 place for vaccine preparation, screening form check, and administration. The CDC recommends spacing these out to keep individuals, including staff and patients, from being too close together [to lower the risk of transmission].⁹ Some operational changes may also require a larger footprint when hosting a community outreach event. For example, many pharmacies are looking at [using] parking lots and drive-up or drive-through clinics to eliminate some of the social distancing problems [by having] people stay in their cars. The COVID-19 crisis has challenged pharmacy professionals to think about unique and innovative ways to host outreach events.

Pharmacy Times^®: How can clinics ensure that patients have the required paperwork needed upon their arrival, and how should they organize prescreening?

Goad: [Pharmacies are finding innovative ways to move] away from the old paper-and-pen system. For example, some places are utilizing their own websites (or creating new ones) to enable downloads of screening forms or online form completion. Some pharmacies have moved to a modified appointment-based system, in which patients come to the clinical during a specific range of time rather than for individual appointments. This gives patients a sense that if they show up, there won’t be a million other patients there, because the pharmacy is asking them to come during different time brackets. Email confirmations to patients about their time bracket should include the screening form, which patients can print, fill out, and bring with them to hand to the staff. Alternatively, they can fill the form out online, and the staff will then have it available at the event when someone checks in. The COVID-19 crisis has [made us rethink our normal] screening techniques, but I think these are things that will last well beyond the pandemic.

Pharmacy Times^®: Do you have any personal experience with setting up an off-site clinic?

Goad: Off-site clinics have been an evolving entity for community pharmacy. Traditionally, when we started, they were based primarily in the store, and then they began to expand. For example, if a pharmacy is part of a larger [business] like a grocery store, there are more places within that larger [business] footprint that they can utilize. We’ve also seen expansion into parking lots. Still, the pharmacist is fairly tied to their main place of employment in the pharmacy itself. As you venture outside [the pharmacy], you have to be able to staff it appropriately. For example, if you are an independent pharmacy owner, you still have to run your pharmacy and cannot shut it down to go run an event. You have to be able to rely on staffing and bring in enough people to help you do that. That might mean partnering with local public health offices, which may assist you in operating your vaccination clinic, and it could certainly mean partnering with a school of pharmacy with a workforce of student pharmacists ready to go. For example, the California Department of Public Health is very interested in what students can do to help enable these outreach events. Our outreach events at Chapman University are all run by students. Although our student health department is coordinating and organizing it, the actual workforce is student pharmacists, along with enough faculty to provide supervision.

Pharmacy Times^®: For patients who are hesitant to venture outside, what are your recommendations to let them know they can still safely go to either the pharmacy or an off-site clinic?

Goad: [To help combat these fears,] in our clinic, we went with a time-bracket, scheduling-based system. We set up an online system that lets patients check that they want to come [to the clinic] in between 12:30 and 1:00, for example, and we create time slots within that based on the number of vaccinators and the amount of time it takes to vaccinate a patient. This [method allows pharmacies to] calculate their throughput for their clinics. In the COVID-19 era, we are trying to refine the number of patients coming through at a specific time, so you really have to think about your capacity for vaccinating. Using the system, we had 400 slots open, and within an hour, all 400 slots were filled; therefore, we knew the interest was there. Additionally, I think some of the things that help to make patients feel more comfortable can be in your advertisements: talking about what patients need to do, such as filling out the screening form before they come [to the pharmacy] and the need to wear a face covering. We also have extra face coverings for patients who show up without one. For our safety and to make patients feel safe, our own staff will be in full PPE, including surgical face masks, face shields, and gloves. You have to squeeze all of that into the advertising. Patients also realize that we are still holding flu shot clinics, just as we did last year and the year before; we just made some modifications so [patients] will be safe during this pandemic.

Pharmacy Times^®: Can student pharmacists administer vaccines?

Goad: Student pharmacists absolutely can administer vaccines. They can do anything a pharmacist can do, depending on the state.¹⁰ In California, for example, the student pharmacists can do anything a pharmacist can do while under their supervision.¹¹ Because of the COVID-19 pandemic,¹⁰ we loosened the restrictions on ratios just for vaccination, to allow pharmacists to supervise more students.¹² In California, we have 13 schools of pharmacy, and [the students] are all adequately trained in immunization within the first year.

There is also an opportunity to incorporate pharmacy technicians into the immunization process. Technicians have an evolving role in immunizations. We know, for example, that at least 2 states, Idaho and Rhode Island have changed the rules on the use of technicians in the immunization process.¹³ In the next 5 years, more states will allow technicians to administer vaccines under the supervision of a pharmacist. But until then, depending on state laws,¹⁰ technicians can still aid in the immunization process, from prepping the patient to drawing up doses… as well as many of the functions before and after vaccination [specifically], such as helping the patient to a waiting area and alerting the pharmacist if the patient has any symptoms post vaccination. There are many opportunities for the technician to get involved (see How Pharmacy Technicians Can Be Certified to Administer Immunizations in 2020 on page 15), but changes to state law will be required to get them into the actual vaccination process.

Pharmacy Times^®: Do pharmacy staff members need to complete any additional training before setting up an off-site clinic, particularly in light of current guidelines specific to COVID-19?

Goad: When we have done outreach clinics, we have found it very useful to have the staff understand the environment where they are working. Every venue is different. For example, if you are setting up the vaccine venue within a church or a park, for example, you always have to do a site visit beforehand to look at your logistics and operation. The cold chain—getting the vaccine from the manufacturer or the wholesaler to your pharmacy’s refrigerator/freezer and then to the off-site clinic—is the most important part of an outreach clinic, and the CDC spends a lot of time explaining best practices.⁸ That is really important for pharmacies to understand: This has to continue outside the pharmacy, meaning you must have a portable refrigeration kit and understand that you should only draw up doses in anticipation of patients who are there or, even better, use prefilled influenza doses. Another modification you may have to make for an offsite clinic is [to consider colder temperatures] around the country as you move into fall, so your offsite venues may become limited. The important part is doing the legwork up front, which includes the preclinic preparation, knowing your site, knowing your ability to ensure cold chain, and making sure that you can mimic the same safeguards that you have in your own pharmacy in that outreach clinic.

Pharmacy Times^®: Speaking of safeguards, how should off-site clinics handle the observation period post immunization, especially for patients who are vaccine naïve?

Goad: That is a challenge, not only for pharmacy but also certainly for medicine. Many providers in medicine, especially in clinics, do not even think about the waiting period that is built in, although the CDC has recommended it for decades.⁸ Nevertheless, it is something that pharmacy has traditionally done. Pharmacy has a more standardized approach than medicine across the nation, both in training and in following recommendations from the CDC. Even for pharmacies and clinics, the CDC recommendation is that patients sit for 15 minutes in the waiting room, lobby area, or wherever else there is space, so they can be observed and/or have easy access to walk back up for help. If a patient decides to not take the recommendation to wait 15 minutes post vaccination and instead leaves the pharmacy, that does not necessarily have to be documented, although the pharmacy needs to make sure that a recommendation to wait is part of their standard operating procedure.

[A waiting area] also presents some new challenges in an outreach clinic. If we are running a drive-up clinic in a parking lot, for example, patients come in, and we scan them for their temperature while they are in their car. We then send them to a parking stall where we have vaccinators waiting to vaccinate them in their car. [Patients can then go to] another parking area to wait for 15 minutes before they leave. They cannot sit in the original stall for the 15 minutes because no one else would be able to come in for a vaccine. Again, it is a simple recommendation to say, “To make sure we can help you if you have a reaction, immediately following this vaccination, we ask that you wait for 15 minutes.” [The decision to] not stay is up to the individual. If you are doing drive-up clinics, and the driver, specifically, is getting the vaccine, we might more strongly recommend they wait 15 minutes before leaving. Although this does create some new challenges for the drive-through clinic, the basic recommendation to wait and to [designate a waiting place] really has not changed.

Pharmacy Times^®: How do you think this upcoming flu season will affect off-site clinics in light of COVID-19?

Goad: That is an interesting question. We are in the middle of conducting a survey of pharmacies in California related to their offerings of off-site clinics and the way they are offering the flu vaccine this fall. Along the way, we have learned that when we say outreach or off-site, sometimes that means just in their own parking lot. Being able to extend vaccination opportunities to an outdoor area makes some patients more comfortable, whereas some are still comfortable coming into the pharmacy. This might be something that lasts well beyond the pandemic. If we can make it as easy as possible, by having patients drive up and get a vaccine, that is probably something we should have been doing all along. But sometimes it takes a major event—like a pandemic— to spur innovation.

Pharmacy Times^®: What about off-site clinics where pharmacists set up at a place of business?

Goad: Off-site clinics at a place of business have always been a very popular option for companies so their employees do not have to take time off from work. However, for off-site clinics where the employees are no longer at the place of employment, some obstacles exist in getting them vaccinated. For organizations that have people on site, I think it is still a viable option, but it does create some challenges compared with how we may normally do it. Whereas we might have previously set up in a break room and had employees come by to get vaccinated, [during this time] many break rooms are closed, as employers do not want people congregating and eating in the same place at the same time. Instead, maybe you have to take a cart, which we used to do a long time ago, and go from cubicle to cubicle or office to office and vaccinate people as you go by. There are still opportunities to do employer-site vaccination, but you have to be a little more innovative with the approach to make sure you can get to [onsite] employees, as well as those working from home. [For those coming from home,] you can still offer an on-site event, but perhaps it is in the parking lot—almost like a health fair just for a company’s employees—so they only have to come to the lot to receive a vaccination. That is similar to what we are doing at our university because most of our employees are working remotely, as are faculty, staff, and even students who aren’t on campus; however, they are going to come back to a parking lot event and get their vaccination. It has to be modified, but I think work-based vaccination is still a viable option.

Pharmacy Times^®: Do you have any final advice for pharmacists who may be considering setting up an off-site clinic?

Goad: After running off-site clinics for decades, [I find it] very fulfilling to see members of the community [we] may not normally see come into a pharmacy or even into a clinic. We find that many, many people use the health fair or an outreach event as their annual flu vaccination location. You have to understand that some people just do not get flu shots, but if you offer another venue for them, they may come. You just have to find the right place and the right time for them to come in. Offering an off-site option gives the pharmacy a way to better connect with their community, and whether you are an independent or chain pharmacist, connecting with your community is essential. Outreach events are one way to highlight your connection to your community.

Something we saw early on in the pandemic—but that I think is getting better—is the pharmacist’s comfort level with providing vaccinations to people coming in with an unknown COVID-19 status, [especially with the current CDC guidance being to defer routine vaccines for those with suspected COVID-19].3 To reassure pharmacists that their risk will be reduced as long as they have the appropriate PPE—even if they are struggling to get adequate PPE resources—many states are providing supplies to frontline workers, including pharmacists. If they have access to the appropriate gear, if they are staffing appropriately, and if they have set up the physical environment to allow vaccinations to safely occur, pharmacists [should definitely] get involved and get back to vaccination. We need to make sure our pharmacists feel comfortable, supported, and safe in their administration of vaccines.

REFERENCES

• Tools to assist satellite, temporary, and offsite vaccination clinics. National Adult and Influenza Immunization Summit. Accessed October 12, 2020. https://www.izsummitpartners.org/naiis-workgroups/influenza-workgroup/ off-site-clinic-resources/
• Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration—United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(19):591-593. doi:10.15585/ mmwr.mm6919e2
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• Issue brief: the impact of COVID-19 on US vaccination rates. National Foundation for Infectious Diseases. Accessed October 12, 2020. https://www.nfid. org/keep-up-the-rates/issue-brief-the-impact-of-covid-19-on-us-vaccination-rates/
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• Resources on proper vaccine storage and handling. CDC. Updated July 11, 2019. Accessed October 12, 2020. https://www.cdc.gov/vaccines/hcp/admin/ storage/index.html
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• COVID-19: information from the states. National Alliance of State Pharmacy Associations. June 9, 2020. Accessed October 12, 2020. https://naspa.us/resource/ covid-19-information-from-the-states/
• Supervision of an intern pharmacist. State of California. Accessed October 12, 2020. https://www.pharmacy.ca.gov/licensees/supervision_of_ intern.shtml
• Han E, Zgarrick D. Pharmacy technicians affected by state regulator actions to address COVID-19 crisis. Pharmacy Times^®. April 6, 2020. Accessed October 12, 2020. https://www.pharmacytimes.com/news/pharmacy-techniciansaffected-by-state-regulator-actions-to-address-covid-19-crisis
• Mckeirnan KC. An update on technicians as immunizers. Pharmacy Times®. March 19, 2019. Accessed October 12, 2020. https://www.pharmacytimes.com/publications/supplements/2019/march2019/an-update-on-techniciansas-immunizers