Vaccinating Adults Amid Crisis Poses Challenges
Pharmacists can greatly contribute to herd immunity during this unprecedented health crisis.
Vaccinations are some of the most cost-effective preventive health care tools available and have significantly contributed to the steady rise in life expectancy.1
Despite this, adult vaccination rates in the United States remain below Healthy People 2020 goals, leaving individuals vulnerable to otherwise preventable diseases, as illustrated by recent outbreaks of hepatitis A, measles, and mumps.2-5 As a result, there is a continuing need to maintain high vaccination rates to prevent future outbreaks of vaccine-preventable diseases (VPDs). In light of the coronavirus disease 2019 (COVID-19) pandemic, pharmacists face the challenge of keeping patients and staff members safe from this new infectious disease while continuing to provide patient care. Pharmacists should consider several factors when deciding to vaccinate during this pandemic.
Worldwide, the COVID-19 pandemic has affected more than 4.3 million people and counting, with about 1.4 million confirmed cases in the United States alone as of May 13, 2020.6-8 The coinfection rate with other bacterial, viral, and/or fungal pathogens and a coinfection’s impact on patient outcomes remain unknown. Recent reports of coinfection with influenza and other pathogens suggest that coinfection may be more prevalent than thought, perhaps as high as 21%.9-12 Given the unknown coinfection rate and because influenza and pneumococcal disease have historically been leading causes of US deaths, hospitalizations, and office visits,13-15 it is important that patients continue receiving routine vaccinations to decrease their risk of VPDs, which may potentially increase the risk of complications with COVID-19.16
Recognizing vaccines’ positive impact, the National Committee for Quality Assurance, National Vaccine Advisory Committee, and Centers for Medicare & Medicaid Services have incorporated vaccination quality measures into their standards that incentivize vaccination activities during emergency department or routine provider visits and during hospital discharge.17-19 After the implementation of adult vaccination programs in clinics, hospitals, and nursing homes, influenza and pneumococcal vaccination rates have increased by as much as 83% and 78%, respectively, in some institutions.20-25 However, with recent reports about the pandemic-related closure of many outpatient clinics, low hospital censuses, and the temporary halt of vaccination activities in some community pharmacies, the United States may see vaccination rates fall over time, resulting in increased VPD-related morbidity and mortality.
Ninety percent of the US population lives within 5 miles of a pharmacy, and it is estimated that during any given week, almost the entire US population will walk through a pharmacy.26 This makes pharmacists the most accessible health care providers in the United States. Pharmacists have become widely accepted as vaccinators, as pharmacy law authorizes pharmacists to administer vaccines in all 50 states. However, the extent of this authority varies from state to state with regard to patient age and/or vaccine type.27,28
Community pharmacies have become the second most common destination for administration of the seasonal influenza vaccine, just behind physician offices. Consequently, millions more adults have been vaccinated against influenza, resulting in an estimated 81,000 to 134,000 fewer cases because of pharmacist involvement.29-32 Pharmacies’ extended hours of operation, particularly when other health care settings are closed, further improves the public’s access to vaccines and could greatly contribute to strengthening our nation’s vaccination rates during this pandemic.33 Therefore, continuing vaccination activities in community pharmacies during the COVID-19 pandemic may help maintain vaccination rates of common VPDs. Pharmacists played a crucial role in providing patient education and vaccinating during previous pandemics, such as the 2009 H1N1 influenza pandemic.34-38 In a simulation model of the H1N1 pandemic, including pharmacists as vaccinators shortened the time to achieve an 80% vaccination rate at the population level by increasing administration to 25 million doses per week.37
Should the decision be made to vaccinate during the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) suggests combining these services with others for which a patient must be seen in person or when the benefits of the vaccine outweigh the risk of exposure.39-42 For example, patients picking up medications for chronic conditions could be offered an influenza vaccine at the point of dispensing. However, presenting to the pharmacy solely for a vaccine should be discouraged, because this may unnecessarily increase the risk of exposure to COVID-19 for patients and/or staff members.42 In addition, the CDC recommends that personal protective equipment, such as face masks and shields and gowns, be made available and used by both the patient being vaccinated and staff members. All these recommendations are in addition to the administrative and engineering controls that the CDC recommends to minimize such contact (see Table).40,42
Although a vaccine for COVID-19 is not yet available, significant research is under way, with several candidates in the pipeline.43,44 Once a commercial vaccine is available, pharmacists should be legally authorized to administer it to help improve national vaccination coverage levels.32,45 Considering the unknown coinfection rate with other infections and possible complications from such coinfections, it is crucial to maintain vaccination activities to protect the public from VPDs. Given their accessibility and expertise in vaccines and vaccine administration, pharmacists have the potential to greatly contribute to improving vaccination rates and herd immunity during this pandemic.46,47
KIMBERLY WON, PHARMD, BCCCP, an assistant professor, and KARL HESS, PHARMD, APH, CTH, FCPHA, FAPHA, AFTM, RCPS (GLASG), an associate professor, are both in the Department of Pharmacy Practice at Chapman University School of Pharmacy in Irvine, California.
- Office of Disease Prevention and Health Promotion. Immunization and infectious diseases. HealthyPeople.gov. Accessed April 27, 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases
- Foster MA, Hofmeister MG, Kupronis BA, et al. Increase in hepatitis A virus infections - United States, 2013-2018. MMWR Morb Mortal Wkly Rep. 2019;68(18):413-415. doi:10.15585/mmwr.mm6818a2
- Albertson JP, Clegg WJ, Reid HD, et al. Mumps outbreak at a university and recommendation for a third dose of measles-mumps-rubella vaccine - Illinois. MMWR Morb Mortal Wkly Rep. 2016;65(29):731- 734. doi:10.15585/mmwr.mm6529a2
- Patel M, Lee AD, Redd SB, et al. Increase in measles cases - United States, January 1-April 26, 2019. MMWR Morb Mortal Wkly Rep. 2019;68(17):402-404. doi:10.15585/mmwr.mm6817e1
- Phadke VK, Bednarczyk RA, Salmon DA, Omer SB. Association between vaccine refusal and vaccine-preventable diseases in the United States: a review of measles and pertussis. JAMA. 2016;315(11):1149-1158. doi:10.1001/jama.2016.1353. Published correction appears in JAMA. 2016;315(19):2125.
- Cases in the U.S. CDC. Updated May 21, 2020. Accessed May 26, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-inus.html
- COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Johns Hopkins University & Medicine. Accessed May 3, 2020. https://coronavirus.jhu. edu/map.html
- Coronavirus disease 2019 (COVID-19) situation report — 74. Updated April 3, 2020. Accessed May 2, 2020. https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200403-sitrep-74-covid-19- mp.pdf
- Khodamoradi Z, Moghadami M, Lotfi M. Co-infection of coronavirus disease 2019 and influenza A: a report from Iran. Arch Iran Med. 2020;23(4):239-243. doi:10.34172/aim.2020.04
- Kim D, Quinn J, Pinsky B, Shah NH, Brown I. Rates of co-infection between SARS-CoV-2 and other respiratory pathogens. JAMA. Published online April 15, 2020. doi:10.1001/jama.2020.6266
- Wu X, Cai Y, Huang X, et al. Co-infection with SARS-CoV-2 and influenza A virus in patient with pneumonia, China. Emerg Infect Dis. 2020;26(6). doi:10.3201/eid2606.200299
- Duployez C, Le Guern R, Tinez C, et al. Panton-valentine leukocidin-secreting Staphylococcus aureus pneumonia complicating COVID-19. Emerg Inf Dis. 2020;26(8). doi:10.3201/eid2608.201413
- Weekly U.S. influenza surveillance report. CDC. Accessed May 3, 2020. https://www.cdc.gov/flu/weekly/index.htm
- CDC. Fast facts you need to know about pneumococcal disease. Updated November 21, 2019. Accessed May 3, 2020. https://www.cdc. gov/pneumococcal/about/facts.html
- Pneumococcal disease: surveillance and reporting. CDC. Updated September 6, 2017. Accessed May 3, 2020. https://www.cdc.gov/pneumococcal/surveillance.html
- Guidance on routine immunization services during COVID-19 pandemic in the WHO European Region. World Health Organization Regional Office for Europe. March 20, 2020. Accessed May 3, 2020. http://www.euro.who.int/__data/assets/pdf_file/0004/433813/Guidanceroutine-immunization-services-COVID-19-pandemic.pdf?ua=1%20 Published%20March%2020,%202020
- Specifications manual for Joint Commission national quality measures. The Joint Commission. Published March 30, 2020. Accessed May 3, 2020. https://manual.jointcommission.org/releases/TJC2020B1/
- The Joint Commission national quality measures global initial patient population. The Joint Commission. Published October 30, 2019. Accessed May 3, 2020. https://manual.jointcommission.org/releases/ TJC2020A2/GlobalInitialPatientPopulation.html
- Providing a Safer Environment for Health Care Personnel and Patients Through Influenza Vaccination: Strategies From Research and Practice. The Joint Commission on Accreditation of Healthcare Organizations; 2009. Accessed May 3, 2020. https://www.jointcommission.org/en/resources/ patient-safety-topics/infection-prevention-and-control/vaccination/
- Required HEDIS and CAHPS measures for HEDIS reporting year 2020. National Committee for Quality Assurance. Accessed May 4, 2020. https://www.ncqa.org/wp-content/uploads/2019/07/2020-List-ofRequired-Performance-Measures_Final_07.19.19.pdf
- Immunization of adults and children in the emergency department. American College of Emergency Physicians. Updated June 2015. Accessed May 4, 2020. https://www.acep.org/patient-care/policy-statements/ immunization-of-adults-and-children-in-the-emergency-department/
- McKibben LJ, Stange PV, Sneller VP, Strikas RA Rodewald LE; Advisory Committee on Immunization Practices. Use of standing orders programs to increase adult vaccination rates. MMWR Morb Mortal Wkly Rep. 2000;49(RR-1):15-16.
- Schaffer SJ, Fontanesi J, Rickert D, et al. How effectively can health care settings beyond the traditional medical home provide vaccines to adolescents? Pediatrics. 2008;121(suppl 1):S35-S45. doi:10.1542/ peds.2007-1115E
- Tartof SY, Qian L, Liu IA, et al. Safety of influenza vaccination administered during hospitalization. Mayo Clin Proc. 2019;94(3):397-407. doi:10.1016/j.mayocp.2018.11.024 25.
- Martin DR, Brauner ME, Plouffe JF. Influenza and pneumococcal vaccinations in the emergency department. Emerg Med Clin North Am. 2008;26(2):549-xi. doi:10.1016/j.emc.2008.02.004 26.
- CDC. How pharmacists can improve our nation’s health. October 21, 2014. Updated February 28, 2018. Accessed April 27, 2020. https:// www.cdc.gov/grand-rounds/pp/2014/20141021-pharmacist-role.html
- Pharmacist immunization authority. National Alliance of State Pharmacy Associations. April 12, 2020. Accessed April 27, 2020. https:// naspa.us/resource/pharmacist-authority-to-immunize/
- Xavioer S, Goad J. Authority and scope of vaccination: how states differ. Pharmacy Times®. June 22, 2017. Accessed May 2, 2020. https://www. pharmacytimes.com/publications/supplementals/2017/immunizationsupplementjune2017/authority-and-scope-of-vaccination-how-statesdiffer
- National and state-level place of flu vaccination among vaccinated adults in the United States, 2014—15 flu season. CDC. Updated April 10, 2018. Accessed May 2, 2020. https://www.cdc.gov/flu/fluvaxview/ place-vaccination-2014-15.htmhttps://www.cdc.gov/flu/fluvaxview/ place-vaccination-2014-15.htm
- Steyer TE, Ragucci KR, Pearson WS, Mainous AG 3rd. The role of pharmacists in the delivery of influenza vaccinations. Vaccine. 2004;22(8):1001-1006. doi:10.1016/j.vaccine.2003.08.045
- Taitel M, Cohen E, Duncan I, Pegus C. Pharmacists as providers: targeting pneumococcal vaccinations to high risk populations. Vaccine. 2011;29(45):8073-8076. doi:10.1016/j.vaccine.2011.08.051
- Pharmacy organization’s joint policy recommendations to combat the COVID-19 pandemic. American Pharmacists Association. Accessed April 27, 2020. https://www.pharmacist.com/sites/default/files/files/ APHA%20Meeting%20Update/PHARMACISTS_COVID19-Final-3-20-20. pdf
- Goad JA, Taitel MS, Fensterheim LE, Cannon AE. Vaccinations administered during off-clinic hours at a national community pharmacy: implications for increasing patient access and convenience. Ann Fam Med. 2013;11(5):429-436. doi:10.1370/afm.1542
- Balick R. In pandemic planning, pharmacists play a crucial role. Pharmacy Today. 2016;22(8):63. https://www.pharmacytoday.org/article/ S1042-0991(16)30704-6/fulltext
- Fitzgerald TJ, Kang Y, Bridges CB, et al. Integrating pharmacies into public health program planning for pandemic influenza vaccine response. Vaccine. 2016;34(46):5643-5648. doi:10.1016/j.vaccine.2016.09.020
- Miller S, Patel N, Vadala T, Abrons J, Cerulli J. Defining the pharmacist role in the pandemic outbreak of novel H1N1 influenza. J Am Pharm Assoc (2003). 2012;52(6):763-767. doi:10.1331/JAPhA.2012.11003
- Schwerzmann J, Graitcer SB, Jester B, et al. Evaluating the impact of pharmacies on pandemic influenza vaccine administration. Disaster Med Pub Health Prep. 2017;11(5):587-593. doi:10.1017/dmp.2017.1
- Klepser ME, Klepser DG, Dering-Anderson AM, Morse JA, Smith JK, Klepser SA. Effectiveness of a pharmacist-physician collaborative program to manage influenza-like illness. J Am Pharm Assoc (2003). 2016;56(1):14-21. doi:10.1016/j.japh.2015.11.008
- Preparedness tools for healthcare professionals and facilities responding to coronavirus (COVID-19). CDC. Updated May 12, 2020. Accessed May 20, 2020. https://www.cdc.gov/coronavirus/2019-ncov/ hcp/preparedness-checklists.html
- Guidance for pharmacies. CDC. Updated April 14, 2020. Accessed April 27, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/pharmacies.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-resources%2Fpharmacies.html
- Interim guidance for businesses and employers responding to coronavirus disease 2019 (COVID-19). CDC. Updated May 6, 2020. Accessed May 26, 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/ guidance-business-response.html
- Schedule changes & guidance. CDC. Updated April 14, 2020. Accessed May 4, 2020. cdc.gov/vaccines/schedules/hcp/schedule-changes.html
- Chen W-H, Strych U, Hotez PJ, Bottazzi ME. The SARS-CoV-2 vaccine pipeline: an overview. Curr Trop Med Rep. 2020:1-4. doi:10.1007/s40475- 020-00201-6
- Amanat F, Krammer F. SARS-CoV-2-vaccines: status report. Immunity. 2020;52(4):583-589. doi:10.1016/j.immuni.2020.03.007
- Pharmacy readiness for corona disease 2019 (COVID-19): recommendations for federal policy makers. American Society of HealthSystems Pharmacists. March 2020. Accessed May 2, 2020. https:// www.ashp.org/-/media/assets/advocacy-issues/docs/PharmacyReadiness-for-Coronavirus-Disease-2019-COVID-19-FEDERAL.ashx- ?la=en&hash=94E0B4D8426BE700190B71651387D8005067FA96
- Cadogan CA, Hughes CM. On the frontline against COVID-19: community pharmacists’ contribution during a public health crisis. Res Social Adm Pharm. 2020;S1551-7411(20)30292-30298. doi:10.1016/j. sapharm.2020.03.015
- Bukhari N, Rasheed H, Nayyer B, Babar ZU. Pharmacists at the frontline beating the COVID-19 pandemic. J Pharm Policy Pract. 2020;13:8. doi:10.1186/s40545-020-00210-w