Pharmacy-based immunizations: any role in pediatrics?

July 2001

Under-use of immunizations is not unique to pediatrics. Deaths in adults due to influenza, pneumococcal infections, and hepatitis B number 45,000 annually.

Effective vaccines are available for these infectious diseases, yet many adults do not receive them. Reasons for this are numerous, and include lack of regular access to a health care provider, or transportation and access difficulties to traditional immunization providers. To increase vaccine-seeking behavior in adults, the CDC has advocated the use of non-traditional settings, such as pharmacies, for immunization programs. While most of these programs have targeted adults, some have suggested limited roles for use of non-traditional sites for pediatric immunization. This month’s column will describe the current status of pharmacy-based immunization programs, and what implications they may have for children.

Guidelines

The American Pharmaceutical Association has formulated guidelines on pharmacy’s role in vaccine advocacy. Pharmacists should function as an educator (motivating people to be immunized), facilitator (hosting others who immunize) and immmunizer. These guidelines state that pharmacists should collaborate with health departments and community prescribers, and that pharmacists should administer vaccines only after receiving proper training in the many facets of immunization administration, such as administration technique and adverse effect management. Training programs for pharmacists have been established and typically are 2 days long and involve discussion of topics ranging from vaccine storage and handling to disease epidemiology.

There are 31 states that allow pharmacists to administer immunizations (see table). Pharmacy-based immunization programs use standing orders to allow pharmacists to administer vaccines. Standing orders are based on an institution- or physician-approved protocol to allow immunization administration without a physician’s exam.

In 2000, the CDC published guidelines and quality standards for adult immunization programs in non-traditional settings. These guidelines offer detailed guidance for institution and maintenance of immunization programs. The CDC also published recommendations of the Advisory Committee on Immunization Practices on the use of standing orders in non-traditional settings to increase adult immunization rates. Standing order protocols can be applied to a variety of settings, including inpatient and outpatient facilities, correctional, long-term care and assisted-living facilities. The advantages of using standing orders in such facilities have been shown. For example, in a study of the use of standing orders to increase pneumococcal immunization rates in a long-term care facility, pharmacists increased vaccination rates from 4.2% to 94%, vs. an increase from 0.9% to 4.0% in a control facility. In this study and others of influenza and pneumococcal vaccination, no unnecessary or inappropriate vaccinations were reported.

Pharmacy-based immunization programs

The use of pharmacies for immunization programs is based in part upon their accessibility to the public. It has been estimated that nearly the entire U.S. population, approximately 250 million people, visits a pharmacy each week. Most of these do so without an appointment. Additionally, Gallup Polls have consistently named pharmacists among the most trusted professionals. For 10 years, pharmacists had been rated No. 1, falling to number 2, behind nurses, in 1999. Influenza immunizations were first given in pharmacies and other common public areas by nurses in 1984. In the early 1990s, many pharmacies began hosting nurses to provide immunizations. These, among other reasons, have provided logic for instituting pharmacy-based immunization programs. Several recently published studies have documented the benefit and patient acceptance of these programs.

Three surveys have recently been published describing patients’ and pharmacists’ acceptance of pharmacy-based immunization programs. Madhavan surveyed more than 5,000 pharmacists nationally from various pharmacy settings (ie, independent, chain, primary care clinic, etc.) in 1998 and received more than 1,000 responses. The pharmacists were surveyed on their current immunization-related activities and willingness to provide such services. Results of the survey indicated that 2.2% of pharmacists actively administered adult immunizations, 0.9% administered childhood immunizations, 13.4% counseled on childhood immunizations, and 6.3% hosted nurses who administered childhood immunizations. Over 16% indicated that they hosted nurses who administered adult immunizations, and 18.9% of pharmacists promoted immunizations in general. Of seven immunization-related activities that pharmacists were surveyed on, their involvement in actively administering childhood immunization was the least. Similarly, of six activities that pharmacists were asked to rate on their willingness to perform, administering childhood immunizations was also the least likely.

Grabenstein surveyed more than 1,500 adults in 1998 who had been vaccinated in pharmacies in 10 states. The average patient was 54 years old, and most received influenza immunization; 8.2% had received pneumococcal immunization. Of 21 pharmacies surveyed, 12 used an internist in the development of standing orders, and 9 used a family practitioner. Of the patients surveyed, 96.7% indicated they were likely to use a pharmacy the following year for immunization, based upon their previous experiences. Over 98% would encourage others to similarly use pharmacies for this purpose.

Convenience

Ernst surveyed patients from family physician clinics, family medicine training programs, and community pharmacies in Iowa on their use of non-traditional and traditional settings for immunization delivery. More than 400 surveys were returned, and many stated it was convenient to receive immunizations in places other than a physician’s office.

As with the other surveys, most immunizations reported were for influenza, while a minority also received tetanus or hepatitis B immunization. Patients were asked to rate their support for receiving immunizations in various locations, including traditional settings (physician office, community health department) and non-traditional settings (pharmacy, dentist office, chiropractor). Sixty-five percent indicated they support influenza immunization in a pharmacy, as compared with 84.5% support for physician office-based immunization and 39.8% support for community health department-based immunization.

Conversely, 10% indicated support for use of a pharmacy for childhood immunization (up to age 3), vs. 99.3% support for physician offices and 87.1% support for community health departments.

Rosenbluth published a descriptive study of the Pharmacy Immunization Project, a pharmacy-county health department partnership model for immunizing infants and adults in rural areas. This project was targeted primarily toward children without a regular source of immunization and was conducted over 5 years (1995-2000) in 5 independent community pharmacies in rural West Virginia. Using standing orders endorsed by the county health department medical director, the pharmacists sponsored nurses in their pharmacies to administer childhood immunizations and to conduct well-baby examinations. Hours when traditional immunization sites (ie, physician offices) were not open were offered by the participating pharmacies. Children were referred to physicians when necessary and computer records of immunization administrations were maintained and shared with primary care physicians.

Outcome measures of this study included willingness of the pharmacists to continue to participate and willingness of the community to accept and use the services. Parents and caregivers across the five-county region were surveyed in the third year of the project – 58% had used the program and all were satisfied. Local physicians accepted the program as well.

ConclusionConvenience

Pharmacy-based immunization programs have been endorsed and supported by national immunization authorities in the CDC as a means to increase adult immunization rates.

While surveys have shown that most pharmacists are not actively involved in immunizing adult patients, many pharmacists are, and criteria for establishing pharmacy-based programs have successfully been established. The involvement of pharmacy-based immunization programs in pediatrics is substantially less than the adult population, and largely relates to pharmacists hosting nurses in pharmacies to administer immunizations, targeting children without a regular source for immunizations. While the role of pharmacists in increasing immunization rates needs to be further defined, it seems that neither parents nor pharmacists strongly desire the role of pharmacy-based immunization programs in pediatrics to increase.

For more information:

• Madhavan SS. Pharmacists and immunizations: a national survey. Journal of the American Pharmaceutical Association. 2001;41:32-45.
• Grabenstein JD. People vaccinated by pharmacists: descriptive epidemiology. Journal of the American Pharmaceutical Association. 2001;41:46-52.
• Ernst ME. Patients’ acceptance of traditional and nontraditional immunization providers. Journal of the American Pharmaceutical Association. 2001;41:53-59.
• Rosenbluth SA. Pharmacy immunization partnerships: a rural model. Journal of the American Pharmaceutical Association. 2001;41:100-107.
• National Vaccine Advisory Committee. Adult immunization programs in nontraditional settings: quality standards and guidance for program evaluation. MMWR. 2000;49 (No. RR-1):1-13.
• National Vaccine Advisory Committee. Adult immunization programs in nontraditional settings: quality standards and guidance for program evaluation. MMWR. 2000;49 (No. RR-1):15-26.