Immunization nation: Pharmacists flex their clinical muscles, build revenue

BY Sandra Levy

In 2008, when New York became the 49th state to authorize pharmacists to provide certain vaccinations, Heather Ferrarese, owner of Bartle’s Pharmacy in Oxford, N.Y., went back to school to become certified so that she could provide vaccinations in her small, rural town.

Fast forward to 2019, and Ferrarese now provides thousands of vaccines each year and she is enrolled in the Centers for Disease Control and Prevention’s Vaccines for Children Program, which enables her to provide free vaccines to uninsured or under-insured children.

Shelby Leheny, pharmacy manager at CVS Pharmacy in Bedford, Ohio, graduated two years ago from pharmacy school. During flu season, she gave 45 immunizations in one day. She also gives flu vaccinations at local companies.

Cynthia Moreau is an assistant professor in the department of pharmacy practice at Nova Southeastern University College of Pharmacy in Fort Lauderdale, Fla., where first-year pharmacy students are required to complete the American Pharmacists Association’s pharmacy-based immunization delivery certificate training program. She also is an ambulatory care specialist pharmacist in a physician’s office where she educates patients about vaccines.

Ferrarese, Leheny and Moreau are not alone in embracing their role as vaccinators.

According to the National Community Pharmacists Association’s 2018 Digest, 73% of independent pharmacies are immunizing. “The percentage of independents [that] are immunizing has steadily grown over the last five years,” said John Beckner, NCPA’s senior director of strategic initiatives.

As of December 2018, more than 340,000 pharmacists have been trained to administer vaccines across the patient lifespan. This is a substantial increase from the 40,000 who had been trained in 2007, according to Janet Engle, department of pharmacy practice professor and senior associate dean for professional and international affairs at the University of Illinois at Chicago College of Pharmacy. Engle said that all accredited schools of pharmacy are required to include immunization training as part of their core curriculum.

Although state laws vary for the need for a protocol and/or prescription to give a vaccine, minimum age limit, and the vaccines pharmacists are authorized to administer, pharmacists have the authority to prescribe vaccines in all 50 states, as well as Puerto Rico and the District of Columbia.

Indeed, pharmacists have made substantial headway as immunizers, even overcoming pushback from many physicians who viewed pharmacists as a threat to their revenue stream to become a trusted resource and accessible source for patients’ vaccination needs.

Education is Key
Like many healthcare providers who vaccinate, pharmacists face challenges, including the growth of the anti-vaccination movement, which has been spreading misinformation that vaccines cause illnesses and such conditions as autism. The movement has been tied to the current measles outbreak, as the majority of cases are occurring among unvaccinated children, the CDC said.

Between Jan. 1 and May 24, 940 individual cases of measles have been confirmed in 26 states, according to the CDC This is the greatest number of cases reported in the United States since 1994 and since measles was declared eliminated in 2000.

Pharmacists can be instrumental in providing accurate information to parents since they more usually are accessible than other healthcare providers, experts said.

Beckner believes pharmacists have an opportunity and an obligation to educate patients about vaccine safety and to dispel myths. “It’s a shame that there’s so much misinformation. Pharmacists and the pharmacy community really need to step up and be as vocal as the anti-vaccine movement has been,” he said.

Billy Chow, vice president of pharmacy at Washington-based Bartell Drugs, a 68-store chain that has been providing vaccinations for a quarter-century, agreed that pharmacists can play a monumental role in preventing such diseases as influenza or measles.

“Whether it’s lack of information or misinformation, some people are very skeptical about vaccinations. Pharmacists are easily accessible and can help educate those seeking answers, while debunking popular misinformation about vaccines,” Chow said. “Many people are unsure if they have ever received important vaccinations. CDC guidelines suggest revaccinating when in doubt.”

Mitchel Rothholz, APhA’s chief strategy officer, echoed Chow’s thoughts. “Part of the guidelines for pharmacy-based immunizations is for pharmacists to keep up to date with current recommendations so that they can address the myths and facts,” Rothholz said. “Pharmacists are able to take the information that emanates from the CDC and other reputable organizations and share those consistent messages with the public, and answer some of those questions that arise when there is misinformation.”

Beckner said that the CDC releases new guidelines each year regarding vaccines and age indications, and he also pointed to the Immunization Action Coalition as a good resource.
Yet pharmacists are not the only stakeholders aiming to educate patients about vaccines — drug manufacturers also are interested in spreading the word and raising awareness to increase immunization rates.

Sanofi is among the drug manufacturers that are stepping up to educate consumers about vaccines. “Sanofi is committed to numerous educational programs to help raise awareness about the importance of adult, adolescent and pediatric immunization, and has years of experience in sharing evidence-based practices that help improve vaccine acceptance and increase immunization rates,”said Julian Ritchey, head of public affairs and patient advocacy at Sanofi’s U.S. vaccines business. “We seek behavioral science and consumer research to inform our vaccine education and implementation strategies. We support ongoing educational initiatives to help address patient-provider communication gaps on vaccination and disease risks.”

GlaxoSmithKline, which makes shingles-prevention vaccine Shingrix, also is doing its part to educate patients. “Vaccines are studied extensively before, during and following licensure, and there is a vast body of scientific evidence that overwhelmingly supports their safety and impact in preventing serious and even life threatening infectious disease,” GSK said. “Through our government affairs and medical teams, we look to provide factual content about vaccine science and the value of vaccines to multiple social channels.”

Besides educating patients, manufacturers are hoping to provide resources for pharmacists — a goal that pharmacy technology companies share.

GSK has a dedicated team made up of retail medical science liaisons who work to educate pharmacists about the company’s full vaccines portfolio.

“As part of our educational efforts, we also create and disseminate resources for pharmacists to use within the pharmacy and with their patients,” GSK said.

Sanofi and its VaxServe subsidiary also educate the pharmacy community about vaccine products, including clinical differences, safety and benefits through multiple channels. These include partnerships with professional organizations, publication and journal ads, training programs, and marketing material to help guide pharmacists’ discussions with consumers.

Pharmacy technology company Amplicare is playing a role in helping pharmacists increase the rate of vaccinations through Amplicare Assist, an in-workflow notification system. “When working on a patient profile in the pharmacy management system, pharmacists receive a notification about clinical care opportunities, including immunizations, so they are prompted to take a key action in the moment,” Amplicare CEO Matt Johnson said. “The timely, patient-specific information delivered really helps enhance patient care.”Amplicare also provides educational material through its platform to help facilitate crucial conversations with patients.

New Opportunities
A crucial part of administering vaccinations for pharmacists is keeping abreast of the range of immunizations available to them.

For instance, Merck’s Zostavax has been in use since 2006, but since the introduction of GSK’s Shingrix in 2017, Shingrix has become the CDC’s preferred vaccine for prevention of herpes zoster and related complications in healthy adults age 50 years old and older, GSK said. Other changes include expanded age indications for certain immunizations and new immunizations for dengue or protecting children against diphtheria, tetanus, pertussis, polio and hepatitis B all at once.

It also is imperative that pharmacists are aware of their state’s regulations. For example, New York State has a sunset on the legislation that gives pharmacists the authority to vaccinate, and it has to be renewed every two years.

Bartle’s Ferrarese said that the Pharmacy Society of the State of New York, of which she is a board member, is seeking removal of the sunset, as well as immunization authority to offer all of the adult immunizations recommended by the Advisory Committee on Immunization Practices, opening up the opportunity to New York pharmacists to administer travel vaccines — a growing revenue stream for pharmacies nationwide.

APhA, which 25 years ago created a certificate training program in immunizations across the lifespan, had immunizing pharmacists who saw a need in their community for travel health services. The only access for travel health was on university and health system campuses, or with hard-to-find practitioners who had limited hours and access.

APhA now has an advanced practice training program for travel health services, and pharmacists also can obtain an international certification.

“Pharmacists doing travel health provide more than vaccinations; they also address other healthcare needs if people are traveling to areas where there is a water or food issue,” APhA’s Rothholz said. “Pharmacists can educate patients on how to protect themselves.”

As part of Bartell Drugs’ travel program, pharmacists work with patients to come up with a regimen of prophylaxis medications or vaccines 4-to-5 weeks before they travel abroad. “Usually, there’s a two-week period that your body needs in order to develop the antibodies necessary for an immune response,” Chow said. “While traveling to new locations, it’s important to be aware of any risks.” Bartell offers a vaccine for Yellow Fever, despite a nationwide manufacturer shortage. “The CDC, in partnership with a European manufacturer, helped make available an alternative yellow fever vaccine for use in the U.S. under a special release provision,” Chow said. “We’re one of the select pharmacies across the country that can provide that vaccine because of our robust travel and immunization program.”

As more pharmacists become involved with immunizations and travel clinics, they have an opportunity to expand their health-and-wellness services.

“Providing immunizations can drive your prescription business. It can also be a springboard into other patient care services such as MTM, point of care testing and smoking cessation,” Beckner said, noting that pharmacists should inform physicians, travel agents and churches that they offer vaccinations.

“Pharmacists’ roles continue to evolve in the industry, Chow said. “Utilizing immunizations is just one platform to help prevent disease. Assisting patients regarding overall wellness, adherence and medication compliance are a few more ways we help them stay healthy.” It appears likely that pharmacists will play a key role in the growth of vaccination rates, especially if vaccination registries, which are voluntary in some states, become mandatory.

“Everybody is encouraging the use of registries to keep track of which immunizations have been given and to identify gaps where immunizations need to be given,” Beckner said.

Amplicare’s Johnson pointed out that progressive pharmacies see an opportunity to become a healthcare cornerstone of their communities, especially considering the rising tide of healthcare costs and the accessibility strain caused by a shortage of primary care physicians. “Immunizations are a paramount disease-state service offered by pharmacists and are a key way for them to utilize their clinical skills to the fullest extent to help their patients,” he said.

Ferrarese’s enrollment in the Vaccines for Children Program is proof that pharmacists can boost children’s immunization rates, as well as their pharmacy’s bottom line. “Last year, with the flu outbreak, we had tons of calls from parents who couldn’t get in to their doctors to get their children vaccinated,” she said. “The state provides vaccines to the pharmacy at no charge. Most insurance companies will pay an administrative fee in addition to the vaccine. We get paid, on average $20 for a vaccine administration. That can add up.”

Finally, Leheny, who affixes vaccine reminders on prescription bags, said, “Push for vaccines, ask a question. You can truly make an impact on people and prevent many diseases.”


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