Despite widespread efforts to educate people about the importance of vaccinations, vaccine-preventable diseases continue to negatively impact the health of the US population. According to the CDC, estimates from the 2018-2019 influenza (flu) season indicate that flu alone led to almost 43 million illnesses, about 20.1 million medical visits, more than 645,000 hospitalizations, and contributed to more than 60,000 deaths.1

Pharmacists are on the front lines of immunization efforts in the United States and can administer vaccinations in all 50 states, although regulations regarding prescriptive authority, patient age, and type of vaccine vary by state.2 More than 340,000 US pharmacists are trained to administer immunizations, according to the American Pharmacists Association (APhA),2 but to win the battle against preventable, communicable diseases, immunization education must be a priority among upcoming pharmacy practitioners.

INCREASING STUDENT PHARMACIST EDUCATION ON IMMUNIZATION

Educating student pharmacists on the importance of immunizing is essential and recognized by several major professional pharmacy societies. The Accreditation Council for Pharmacy Education 2016 accreditation standards, as well as key elements for the professional program in pharmacy leading to the Doctor of Pharmacy degree, highlight immunization training as a required element.3 In addition, the American College of Clinical Pharmacy and the American Association of Colleges of Pharmacy both support providing immunization education to student pharmacists to prepare them for future practice.4,5

Opportunities for students to practice immunizing vary. The results of a 2019 study by Prescott and colleagues, which surveyed 128 accredited US pharmacy colleges and schools regarding immunization coverage for student pharmacists, indicated that more than 90% of respondent schools offered advanced pharmacy practice experience rotations which allowed student pharmacists to engage in immunization-related activities. And, more than 80% of schools offered introductory pharmacy practice experience rotation opportunities.6 Most US colleges and schools of pharmacy also include content on a wide range of immunization-related activities beyond those offered by APhA’s pharmacy-based immunization delivery program. This demonstrates the importance that faculty place on immunization in pharmacy practice.6,7

Currently, student pharmacist interns may administer immunizations in all 50 states, as long as the student has completed a certificate training program—such as the APhA pharmacy-based immunization delivery training program—and is operating under the supervision of an immunization-trained pharmacist.2,7

THE IMMUNIZING PHARMACY TECHNICIAN 

In addition to educating and enabling student pharmacists to immunize, several states have recently adopted policy changes to allow pharmacy technicians to administer vaccines under the supervision of a pharmacist.8 Clinical aspects of immunization, including prescription verification and patient counseling, are still the responsibility of the supervising pharmacist; however, the technical task of physically administering an immunization may be delegated to a trained technician.8

This expansion to utilize technicians as immunizers has proved successful in Idaho, the first state to allow technicians to immunize patients.9

The results of a 2017 implementation study demonstrated that after completing 4 hours of training, technicians at 2 community pharmacies in Idaho were able to administer immunizations and be utilized in pharmacy workflow. Nearly 1000 immunizations were provided by 25 trained pharmacy technicians during a 6-month period, and no adverse events were reported.10 In addition, a 2018 qualitative analysis showed that the majority of pharmacists who supervised immunization-trained technicians at community pharmacies in Idaho would recommend immunization training to additional technicians and believe more immunizations are being given as a result of utilizing technicians to immunize.11

Since Idaho became the first state to make the accommodation to allow technicians to immunize in 2017, Rhode Island followed in 2018,12 and Utah is expected to follow suit in November 2019.13 Administrative policy and protocol changes are also being considered in several other states.

Within the federal system, immunization-trained pharmacy technicians have even begun immunizing pediatric patients. A presentation from the Federal Pharmacists Forum at the 2019 APhA Annual meeting explained that federal pharmacy technicians are being trained to administer many types of vaccines, ranging from seasonal influenza to pneumococcal immunizations for older adults and pediatric catch-up immunizations.14 Although the American Society of Health-System Pharmacists (ASHP) Pediatric Pharmacy Advocacy Group’s “Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems” do not specifically mention technician administration of immunizations, they do highlight recommendations regarding pharmacy technician involvement in roles caring for pediatric patients. Specifically, ASHP guidelines recommend that technicians should have previously completed an ASHP-accredited technician training program and should be certified by the Pharmacy Technician Certification Board.15

The importance of ensuring that technicians are properly trained and supervised, demonstrate competencies specific to the tasks performed, and meet requirements of applicable laws and regulations was also highlighted.15

Even in states where technicians are not yet legally allowed to immunize, technicians still have many important roles with regard to immunizations. Technicians in all states can, for instance, identify patients who are eligible for vaccination, assist with scheduling, perform vaccine and supply inventory control, and help with billing, documentation, and reporting immunizations to state immunization information systems.16

IMPACT OF PHARMACY-BASED IMMUNIZATION SERVICES

The impact of pharmacy-based immunization services is widespread. The results of a 2018 review of national individual-level immunization data merged with pharmacy- level data on the availability of immunization services at 8466 pharmacies in a national pharmacy chain showed that an estimated 6.2 million additional influenza immunizations and 3.5 million additional pneumococcal immunizations—beyond those given in nonpharmacy locations—were attributable to pharmacy-based immunization services each year.17 With pharmacy student interns now able to immunize in all 50 states, and a growing number of pharmacy technicians being able to administer immunizations, pharmacy personnel are well situated to continue to build upon these numbers.

CONCLUSIONS

As the United States continues to battle a recent resurgence in a highly contagious, yet vaccine-preventable, communicable disease—measles—the importance of vaccination vigilance and increasing immunization services cannot be overstated. According to the CDC, from January 1, 2019, to October 3, 2019, 1250 individual cases of measles had been confirmed across 31 states, the greatest number of US cases reported since 1992. More than 75% of cases were linked with outbreaks in New York, and the majority of cases were reported to be in patients who had not been vaccinated against the virus.18

Whether an immunization is administered by a pharmacist, student intern, or technician, reduction of vaccine-preventable diseases through immunization must continue to be a priority in pharmacy practice.

REFERENCES
  1. 2018-2019 U.S. flu season: preliminary burden estimates. CDC website. cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm. Updated October 22, 2019. Accessed October 23, 2019.
  2. Pharmacist administered vaccines based upon APhA/NASPA survey of state IZ laws/rules. American Pharmacists Association website. pharmacist.com/sites/ default/files/files/IZ_Authority_012018.pdf. Updated January 2018. Accessed September 12, 2019.
  3. Accreditation standards and key elements for the professional program in pharmacy leading to the Doctor of Pharmacy degree (“Standards 2016”). Accreditation Council for Pharmacy Education website. acpe-accredit.org/pdf/ Standards2016FINAL.pdf. Published February 2, 2015. Accessed September 12, 2019.
  4. The 2016 ACCP pharmacotherapy didactic curriculum toolkit. American College of Clinical Pharmacy website. accp.com/docs/positions/misc/Toolkit_ final.pdf. Published 2016. Accessed August 19, 2019.
  5. Medina MS, Plaza CM, Stowe CD, et al. Center for the Advancement of Pharmacy Education 2013 educational outcomes. Am J Pharm Educ. 2013;77(8):162. doi: 10.5688/ajpe778162.
  6. Prescott WA Jr, Bernhardi C. Immunization education in US pharmacy col- leges and schools. Am J Pharm Educ. 2019;83(5):6765. doi: 10.5688/ajpe6765.
  7. Pharmacy-based immunization delivery 2019. American Pharmacists Association website. pharmacist.com/pharmacy-based-immunization-delivery-2019. Accessed September 12, 2019.
  8. Adams AJ, Desselle SP, McKeirnan KC. Pharmacy technician-administered vaccines: on perceptions and practice reality. Pharmacy (Basel). 2018;6(4):E124. doi: 10.3390/pharmacy6040124.
  9. Public Hearing: Rules of the Idaho State Board of Pharmacy Docket Number 27-0101-1603. October 31, 2016. Rule 330.03, 264.
  10. McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training phar- macy technicians to administer immunizations. J Am Pharm Assoc (2003). 2018;58(2):174-178.e1. doi: 10.1016/j.japh.2018.01.003.
  11. Bertsch TG, McKeirnan KC, Frazier K, VanVoorhis L, Shin S, Le K. Supervising pharmacists’ opinions about pharmacy technicians as immunizers. J Am Pharm Assoc (2003). 2019;59(4):527-532. doi: 10.1016/j.japh.2019.03.008.
  12. Pharmacists, Pharmacies, and Manufacturers, Wholesalers, and Distributors (216-RICR-40-15-1), part 1.11.1B8b (2018). Rhode Island Department of State website. rules.sos.ri.gov/regulations/part/216-40-15-1. Accessed October 16, 2019.
  13. DAR File No. 44108. Rule R156-17b. Notice of proposed rule (amendment). Utah Office of Administrative Rules. Commerce, Occupational and Professional Licensing website. rules.utah.gov/publicat/bulletin/2019/20191015/44108.htm. Published October 15, 2019. Accessed October 24, 2019.
  14. Sarchet G, Helm E, McKeirnan K. Pharmacy technicians and their impact on immunization delivery. proceedings of the Federal Pharmacists Forum. American Pharmacists Association Annual Meeting 2019; March 22, 2019; Seattle, WA. pharmacist.com/sites/default/files/audience/2019_Report_of_the_APhA_House_of_Delegates-FINAL.pdf. Accessed September 27, 2019.
  15. Eiland LS, Benner K, Gumpper KF, et al. ASHP-PPAG guidelines for providing pediatric pharmacy services in hospitals and health systems. J Pediatr Pharmacol Ther. 2018;23(3):177-191. doi: 10.5863/1551-6776-23.3.177.
  16. The technician’s role in pharmacy-based vaccination programs. Western University website. ws.westernu.edu/WesternU-News/docs/TEAM-KarlHess- Final.pdf. Published January 1, 2015. Accessed September 27, 2019.
  17. Patel AR, Breck AB, Law MR. The impact of pharmacy-based immunization services on the likelihood of immunization in the United States. J Am Pharm Assoc (2003). 2018;58(5):505-514.e2. doi: 10.1016/j.japh.2018.05.011.
  18. Measles cases and outbreaks: measles cases in 2019. CDC website. cdc.gov/ measles/cases-outbreaks.html. Updated October 11, 2019. Accessed October 14, 2019.