Community pharmacies that provide immunization services have proven their success time and again, but they still face roadblocks.1 Many state laws and regulations still do not allow pharmacies to take full responsibility for vaccinations, and states regulate immunization services at pharmacies in different ways.1 Although all 50 states allow pharmacists to administer vaccines, the majority still require either a prescription from a physician to administer a vaccine or that a protocol is set up with a physician.1 In addition, state laws differ on the minimum age of the patient and the types of vaccinations that are allowed.2

Pharmacists who endeavor to vaccinate patients, regardless of whether they work for large pharmacy chains or independent pharmacies, must be well versed in the laws and regulations of their state that govern vaccinations. They must also adhere to their state governmental authority’s recordkeeping and reporting requirements.2 Additionally, a pharmacist must understand by what means they have authority to vaccinate in their state. In some states, the vaccination may be administered by way of a patient-specific prescription or, alternately in others, by way of a standing order.1 Furthermore, at least 2 states, Idaho and Rhode Island, have provided pharmacy technicians with the authority to vaccinate.3,4
Here, we explore various state regulations and important differences among them.

US STATE VACCINE CERTIFICATION REQUIREMENTS
Pharmacists seeking to vaccinate should become familiar with their state certifying requirements. The State of New York’s set of requirements is a good example to highlight, as it is instructive in understanding how a state addresses pharmacist vaccination authority.5 Pharmacists in New York who are seeking a role in vaccinating patients typically must undergo a certification process after fulfilling training requirements.2,5 A pharmacist in New York can obtain certification in administration of vaccines from the State Education Department (SED)5. Once certified, a pharmacist’s registration bears an “I,” to designate immunization certification.5 A currently licensed New York pharmacist may apply for certification by submitting a completed Pharmacist Immunization Certification form with an application fee to the SED.5 The application must provide evidence that the pharmacist has completed an approved immunization course within the past 3 years and, as in most other states, the pharmacist must also provide evidence of being actively certified in cardiopulmonary resuscitation (CPR) or basic life support (BLS).5

TRAINING AND EDUCATION IN VACCINATION
The National Certificate Program for Pharmacists (Pharmacy-based Immunization Delivery) of the American Pharmacists Association (APhA) offers pharmacists a course to become eligible for certification to administer vaccinations.1,6 The course is offered at most colleges of pharmacy and through professional organizations.7 Some states require pharmacists to enroll and successfully complete this course prior to vaccinating patients; however, other states do not require it and will accept, instead, the completion of training in administering vaccinations received by a candidate as part of a Doctor of Pharmacy degree program.1 Pharmacists should research the requirements in their state.

As an added incentive for taking immunization training, credits for coursework in immunization may satisfy continuing education (CE) requirements. For example, in New York, a pharmacist may use 20 credits (8 live/12 home study) from completing the APhA program and up to 5 live credits from completing CPR/BLS training to satisfy CE requirements during the period in which the pharmacist’s credits were earned.5

IMMUNIZATION REPORTING REQUIREMENTS
Once a pharmacist is certified to vaccinate, they should be aware of the reporting requirements in their state. States typically require pharmacist immunizers to report all vac- cinations administered, as well as the individual immunization history of every patient vaccinated. For example, New York State regulations require pharmacists to report information to the New York State Immunization Information System.5 Patient consent might be required in some instances,2 and so pharmacists should research their individual state reporting requirements and learn to whom reporting should take place.

PATIENT-SPECIFIC PRESCRIPTION/ORDER VERSUS A NON–PATIENT-SPECIFIC ORDER FOR IMMUNIZATIONS
Pharmacists should be familiar with the manner in which they derive authority to vaccinate. The pharmacist may be able to administer vaccinations based on a patient-specific prescription/ order from a physician or a nurse practitioner, or they may be able to administer vaccinations based on a non–patient-specific standing order from a licensed physician or nurse practitioner. In New York, for example, the licensed physician or nurse practitioner must be located within the same county or in an adjoining county.5

Under either scheme, a pharmacist may give patients whichever vaccines the law of the state allows. In the example of New York, this includes the seasonal influenza vaccine for patients 2 years or older, and pneumococcal, meningococcal, acute herpes zoster (shingles), tetanus, diphtheria, and pertussis vaccinations for adults 18 years or older.5 Pharmacists should be familiar with their state laws as well as with the parameters of allowable vaccines that a pharmacist may administer and the corresponding age restrictions.2

PHARMACY TECHNICIANS AS IMMUNIZERS
Citing a shortage of time for pharmacists in the pharmacy, coupled with responsibilities in other areas of the pharmacy that it previously permitted technicians to have, Idaho determined in 2017 that it was just as safe and effective to permit technicians to administer vaccines when qualified. Technicians in Idaho must be certified, hold a current certification in BLS, and have completed an Accreditation Council for Pharmacy Education accredited course on immunization administration technique. Pharmacists in Idaho may delegate only the technical task of physically administering the injection. The pharmacist still must perform all other patient care tasks, such as prescription verifi- cation and patient counseling.8

Other states are expected to allow technicians to immunize in the future.9 Rhode Island followed Idaho’s example in October 2018, and Utah is expected to do the same in November 2019.4,10

BUMPS IN THE ROAD AHEAD
Community pharmacies should continue to play a leading role in providing vaccination services to patients, despite some challenges. The task can be made easier through national legislative reform, by the introduction of uniform reimbursement programs, and by nationwide pharmacy information management systems.11 There is also a growing movement among health care practitioners to permit pharmacists to screen, assess, and administer adult vaccines without either a protocol or a prescription from a physician.12

Such changes would sharply lower the regulatory costs that now burden the pharmacist, and they would give patients greater freedom in choosing vaccination services, which would result in indisputable benefits in health care quality.12

REFERENCES
  1. Bach AT, Goad JA. The role of community pharmacy-based vaccination in the USA: current practice and future directions. Integr Pharm Res Pract. 2015;4:67- 77. doi: 10.2147/IPRP.S63822.
  2. Xavioer S, Goad J. Authority and scope of vaccination: how states differ. Pharmacy Times® website. pharmacytimes.com/publications/supplementals/2017/ immunizationsupplementjune2017/authority-and-scope-of-vaccination-how- states-differ. Published June 22, 2017. Accessed September 6, 2019.
  3. Public Hearing: Rules of the Idaho State Board of Pharmacy Docket Number 27-0101-1603. October 31, 2016. Rule 330.03, 264.
  4. 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.
  5. Frequently asked questions: administration of immunizations. New York State Education Department Office of the Professions website. op.nysed.gov/prof/ pharm/pharmimmunizationfaq.htm. Updated June 11, 2019. Accessed October 9, 2019.
  6. Pharmacy-based immunization delivery. American Pharmacists Association website. pharmacist.com/pharmacy-based-immunization-delivery. Published July 15, 2017. Accessed October 18, 2019.
  7. Scott MA, McLaughlin J, Shepherd G, Williams C, Zeeman J, Joyner P. Professional organizations for pharmacy students on satellite campuses. Am J Pharm Educ. 2016;80(5):78. doi: 10.5688/ajpe80578.
  8. McKeirnan KC. An update on technicians as immunizers. Pharmacy Times website. pharmacytimes.com/publications/supplements/2019/march2019/an-up- date-on-technicians-as-immunizers. Published March 19, 2019. Accessed October 10, 2019.
  9. Adams AJ, Desselle SP, McKeirnan KC. Pharmacy technician-ad- ministered vaccines: on perceptions and practice reality. Pharmacy (Basel). 2018;6(124):E124. doi: 10.3390/pharmacy6040124.
  10. 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.
  11. Milenkovich N. The impact of community pharmacies on immunization. Pharmacy Times® website. pharmacytimes.com/publications/supplements/2019/ july2019/the-impact-of-community-pharmacies-on-immunization. Published July 21, 2019. Accessed October 11, 2019.
  12. Winegarden W. Promoting access and lowering costs in health care: the case of empowering pharmacists to increase adult vaccination rates. Pacific Research Organization website. pacificresearch.org/wp-content/uploads/2018/04/AdultVaccination_F_web.pdf. Published April 2018. Accessed September 6, 2019.