Immunization Nation: Pharmacist vaccination offers key resource against disease
Pharmacists’ ability to prevent disease by vaccinating patients is one of the biggest health boons for many communities.
Take Derrell Massey and Heather Ferrarese as two examples.
In 2018, when a hepatitis A outbreak occurred in his town, Massey, owner of Section Pharmacy, in Section, Ala., administered 1,000 vaccines in conjunction with the Alabama Department of Public Health. His pharmacy is one of three pharmacies participating in Alabama’s free vaccines program for children.
Last year, Ferrarese, owner of Bartle’s Pharmacy in Oxford, N.Y., immunized 2,500 adults in her small, rural town. When New York State authorized pharmacists to administer the influenza vaccine to children 2 years old and older in 2019, she eagerly stepped up to give the vaccine.
Massey and Ferrerase are just two examples of how the nation’s pharmacists are a critical part of keeping communities safe from preventable disease. The National Community Pharmacists Association’s 2019 Digest noted that 78% of independent pharmacies are immunizing, an increase from 73% in 2018, according to John Beckner, NCPA’s senior director of strategic initiatives.
To date, more than 360,000 pharmacists have been trained to administer vaccines across the lifespan. This represents an increase from 340,000 in 2018. Thirty percent of influenza vaccines administered to adults each year are done by pharmacists, according to Mitchel Rothholz, the American Pharmacists Association’s chief strategy officer.
Retail pharmacy chains are not sitting on the sidelines when it comes enabling more pharmacists to be vaccinators.
Walgreens is a case in point. The chain, which started its immunization program in the mid-2000s, has administered more than 60 million vaccines since 2010, including influenza, pneumococcal, meningitis, measles, typhoid, polio and travel-related vaccines.
“Walgreens has expanded its vaccination program so that all of its certified pharmacists can now administer all CDC-recommended vaccines in our stores nationwide,” said Tasha Polster, Walgreens vice president of pharmacy quality, compliance and patient safety.
Additionally, in 2015, Walgreens introduced an immunization outreach program, which has resulted in pharmacists leading nearly 150,000 clinics in the community outside of its stores. Since 2013, Walgreens has partnered with the United Nations Foundation for “Get a Shot. Give a Shot,” which provides lifesaving vaccines to children in need. “Last year, we eclipsed 50 million vaccines donated to children in other countries,” Polster said.
With an upcoming flu season expected this fall, and adult and pediatric vaccinations that have been put on hold during the pandemic, as well as the expectation for a COVID-19 vaccine to be available by early 2021, pharmacists are in the perfect position to expand their role as immunizers.
Confronting Skeptical Patients
Despite the role vaccines play in preventing disease, some consumers still are leery about receiving vaccines for a variety of reasons, including misinformation from anti-vaccine groups, who blame vaccines for causing certain diseases, such as autism.
In fact, while most Americans expect a vaccine against COVID-19 to be available by some point in 2021, only half said they will get vaccinated and many are unsure, according to a poll conducted by The Associated Press-NORC Center for Public Affairs Research from May 14-18.
If a vaccine against the coronavirus becomes available to the public, 49% said they plan to get vaccinated and 20% said they will not. Another 31% said they were not sure. Among the 20% of Americans who said they will not get the vaccine, concern about side effects is overwhelmingly the top reason for avoiding the vaccine, according to the survey.
A 2019 survey conducted for the National Foundation for Infectious Diseases, “Attitudes about Influenza and Pneumococcal Disease Prevention,” found a similar number — 52% of respondents said they planned to get vaccinated against the flu that season.
“Some people still don’t have the confidence that the flu vaccine really works, and then you have people who are convinced that vaccines cause autism,” NCPA’s Beckner said. “The science behind it doesn’t bear that out, and pharmacists are in a really good position to try to dispel those myths.”
Kelly Fine, executive director of the Arizona Pharmacy Association, which trains pharmacy students and pharmacists on immunizations, said that while vaccine hesitancy has increased over the last few years, research over the last 50 years has shown that vaccines are safe and an effective strategy in helping to prevent and minimize the impact of infectious diseases in our communities.
Ferrarese said that even though an article linking vaccines to autism was retracted by the author, many consumers still believe the information circulating on social media, and they are afraid to get vaccines or to have their children immunized.
APhA’s Rothholz advises pharmacists to provide consumers with science-based vaccine facts to allay their fears. “What evidence-based medicine shows is what immunization providers and policymakers should keep the focus on. They should keep emotions out of it,” he said. “At the end of the day, it’s an individual’s and a parent’s decision, but we can provide the information and then take appropriate action. Their discussions need to be evidence based. Just be fact oriented, focused, and provide the best case for why a patient should benefit from getting immunized.”
Beyond dispelling vaccine myths, Beckner said that pharmacists can take the initiative to inform consumers that they are trained to do immunizations. They also can increase awareness that pharmacies are a good resource for vaccines by displaying their immunization certificates at the pharmacy and prominently posting a list of all of the vaccines that they offer.
“When people come in for their prescriptions, it’s right there in front of them, so they realize, I also can get my immunizations here,” Beckner said.
Utilizing text messages, stapling vaccine information on prescription bags, putting up shelf reminders, and signage can help make consumers knowledgeable and confident about getting vaccines. “These are all the things that pharmacy has available to communicate with that many other healthcare providers don’t,” Rothholz said.
Initiating conversations with patients about vaccinations early on in the patient-pharmacist relationship and being bold and confident about recommendations also are paramount to increasing customers’ comfort level.
“Instead of passively saying, ‘Do you want your flu shot?’ ‘Do you want the pneumococcal vaccine?’ take a more active approach and instead say, ‘Today we are going to give you your flu shot,’ or ‘I noticed you are due for your pneumococcal vaccine,’” Fine said. “This demonstrates to the patient that you are confident in your recommendation.”
Massey’s approach illustrates Fine’s point. He uses a computer software program to remind consumers that they are due for a certain vaccine. He also partakes in the state’s ImmPrint database system to document which vaccines he has given to patients. “It’s pretty powerful when you are sitting down with someone and you can say, “I see you are on COPD medication, but I don’t see that you had the pneumonia vaccine,” Massey said.
Be Candid About Possible Side Effects
Alongside informing customers that they are due for certain vaccines, it’s crucial to have inform patients about possible common side effects of certain vaccines so they know what to expect.
“Consumers need to understand how immunity works, and that they are receiving a non-live attenuated vaccine. You cannot get flu from the flu vaccine. By exposing your body to little bits and pieces of the vaccine, you mount immunity,” Ferrarese said. “You can run a little fever or have some aches and pain, or your arm can be sore and tender and you can have a red mark at the injection site. It means that your body is mounting the proper immune response to that vaccine and offering you protection down the road.”
Pharmacists can recommend that patients ice the injection site or take Tylenol to relieve pain, and they also can reassure them that the reaction will only last a day or two, Ferrarese said.
Fine concurred that pharmacists should address patients’ concerns about vaccines without being dismissive. “Being upfront and opening up that dialogue is important. There are probably a lot of people we are missing who can be convinced to get the recommended vaccines if pharmacists take the time to address their questions and educate them on the seriousness of the diseases they are at risk for,” she said.
Pharmacists also can allay consumers’ misconceptions about vaccine ingredients. “Vaccines do not contain toxins,” Fine said. Some vaccines may contain trace amounts of chemicals from their production process, however, if any of these trace chemicals is in a vaccine, it is at a lower level than found naturally in the body or the environment, she said.
For example, aluminum is added to some vaccines to boost the immune response. During the first six months of life, a breastfed infant will consume more aluminum through their diet than they will acquire via a recommended vaccination, Fine said.
In addition, some vaccines contain thimerosal, which is a preservative that helps maintain the sterility of vaccines and helps prevent bacterial contamination. Fine said that thimerosal, or ethylmercury, often is confused with methylmercury, which is found in tuna and does not accumulate in the body.
Aside from addressing consumers’ worries about vaccine ingredients, pharmacists also can help consumers confront their fears about having a needle placed in their arm. Fine suggests making the setting comfortable, and explaining to patients that the needles used today are very sharp and fine, making injections less painful than they used to be. Pharmacists also can desensitize the injection site by tapping or rubbing the muscles to reduce pain, she advised.
The Pharmacy Staff Is Key
Rallying the entire pharmacy staff to engage with patients can play a big role in encouraging patients to get vaccinated.
Beckner suggested that pharmacy technicians can jump-start the discussion. “Technicians are usually the first point of contact, and they can say: ‘Mrs. Jones, you can get your flu vaccine here and, at the same time, we can immunize you against pneumonia;’ or ‘You can get your shingles vaccine if you are a certain age;’ and ‘Yes, we also offer hepatitis A and hepatitis B;’ or, if you’re a grandparent, ‘We offer the pertussis vaccine.’ There are lots of opportunities to showcase the pharmacy as a destination for vaccinations,” Beckner said.
Rothholz also underscored the contribution that the pharmacy team can make. “Immunizations are a team sport. It’s not just the pharmacist who engages in the activity, it’s the whole staff within the pharmacy,” he said. “Everyone who comes into contact with the customer, the front clerks, techs, student pharmacists, pharmacists, store management and marketing can all help deliver that immunization message.”
Massey uses community events as an educational opportunity. For instance, when he attends such local events as ball games, he speaks with parents. “We talk about so and so who is sick, and if they’ve been vaccinated that they rebound pretty quickly, so all you need is to be vaccinated,” he said.
Training and Educational Resources
There is a plethora of training and resources for vaccinations that pharmacists can use to help inform patients about vaccines and increase the public’s confidence in getting vaccines.
GlaxoSmithKline is among the drug manufacturers that are taking steps to educate pharmacists. Leonard Friedland, vice president and director of scientific affairs and public health at GSK Vaccines, said the company has a dedicated team of retail medical science liaisons who work to educate pharmacists about its full vaccines portfolio. The company also creates and disseminates resources for pharmacists to use within the pharmacy and with their patients.
“Even during the pandemic, we are in regular, virtual contact with our pharmacy and retail partners to ensure that they have information they need to educate consumers about vaccines,” Friedland said. GSK also has collaborated with APhA on a resource center on immunizations on APhA’s website that helps pharmacists have discussions with patients.
Retailers like Walgreens also do their part to keep pharmacists updated on vaccines. Each year, all of Walgreens’ pharmacists receive extensive training and assessments to ensure they can properly educate customers about immunizations and administer them. Walgreens also offers information at Walgreens.com/Immunizations for patients to gain an understanding of what vaccines they may want to consider, depending on their age or upcoming travel.
Additional educational resources include the Immunization Action Coalition and the Centers for Disease Control and Prevention, which updates guidelines every year and provides information about new vaccines.
For instance, the CDC recently announced two new vaccines licensed for use during the 2020-21 flu season. The first is a quadrivalent high-dose vaccine licensed for use in adults 65 years old and older. This vaccine will replace the previously licensed trivalent high-dose vaccine. The second new vaccine that will be available is a quadrivalent adjuvanted vaccine licensed for use in adults 65 years old and older. This vaccine is similar to the previously licensed trivalent vaccine containing MF59 adjuvant, but it has one additional influenza B component.
The COVID-19 Environment
As the public awaits the development of a COVID-19 vaccine, pharmacists also can increase patients’ comfort level by helping them realize the importance of catching up on the vaccines they and their family members have fallen behind on. They also can remind consumers of the importance of getting the flu vaccine this fall, especially since it is likely to coincide with a second wave of COVID-19.
Rothholz said that it is important to encourage patients, especially in this COVID environment, that getting immunizations is one of the best ways the public can protect themselves from vaccine preventable diseases and to reduce the potential when they do get symptoms of the disease they are fighting. “By getting vaccinated, you are giving yourself extra protection from diseases that are preventable,” he said.
Friedland echoed Rothholz’s sentiments. “It will be important, as restrictions ease, for pharmacists and other providers to educate and encourage people to receive immunizations they may have missed during the shutdown. Pharmacists can convey to consumers the importance of influenza vaccination this fall,” Friedland said. “Influenza is a respiratory illness, as is COVID-19, and decreasing respiratory illness this fall in people of all ages — in particular older adults and people with underlying medical conditions — will be very important to reduce the burden on the health system.”
Rothholz said that pharmacists also should advise seniors about getting a pneumococcal vaccine. “A person with the flu or COVID is at risk of developing pneumonia. We want to make sure they are protected,” he said.
The Future of Pharmacists as Vaccinators
Experts agreed that COVID-19 has created a heightened awareness of vaccines among consumers, and they see an increased role ahead for pharmacists as vaccinators. During the 2009 H1N1 pandemic, pharmacies accounted for 23% of vaccines distributed during a three-month window, according to the National Association of Chain Drug Stores. Looking forward to the availability of COVID-19 vaccines, NACDS cited a CDC study that found retail pharmacies help to vaccinate 80% of the population seven weeks sooner during a pandemic than otherwise would be possible.
Beckner said there is an opportunity for pharmacists to leverage the heightened sense of awareness and interest in vaccinations to promote other vaccines. “There are going to be people who think that with the regular flu shot there will be some protection afforded for COVID,” he said. “The demand for the COVID vaccine is going to be unprecedented, and you are going to need all hands on deck to deliver as many vaccines as possible.”
The Arizona Pharmacy Association’s Fine said that it’s a good time to inform consumers that pharmacists follow CDC guidelines and protocols throughout the year. “The immunization rates have gone down significantly during this pandemic because people aren’t going in for their routine visits,” she said. “There’s going to be a lot of catch up that needs to happen. If we educate our patients on what procedures your pharmacy is taking to maintain a safe environment for patients, that will help people feel more comfortable when they are coming in to get those services,” she said.
Consumers need to understand that pharmacists are one of the top trained medical front-line professionals, and evidence of this is the way they have been ready, willing and able to handle the pandemic crisis with their participation in COVID-19 testing, Ferrarese said. “We’re ready to give a vaccine when there is a COVID-19 vaccine available,” she said. “Pharmacists are very up to date on what the newest guidance is, whether it’s from the WHO, CDC or state board of pharmacy.”
Walgreens’ Polster agreed that pharmacists are ready to vaccinate against COVID-19 when a vaccine is available.
“During the H1N1 pandemic, pharmacists and pharmacies played a critical role in being able to quickly implement convenient immunization services to the communities that they serve. Today, about one-third of patients receive their flu shots at a pharmacy, and we expect that number to increase when the COVID-19 vaccine becomes available,” she said. “As we move through this constantly changing environment, we believe that making immunizations available at convenient locations like a neighborhood Walgreens pharmacy allows us to further our mission to protect our communities from vaccine-preventable illnesses and improve patient health outcomes.”
Rothholz pointed out that the public needs to be aware that any interaction with healthcare providers, including pharmacists is going to be different. “They should not be surprised when they see a physician, nurse and pharmacists wearing masks and gloves when they are getting services from these individuals. That’s the new norm that the public is going to have to get used to during this time period,” he said.
While it depends on the level of COVID-19 cases in each community, Rothholz foresees that vaccinations potentially can be done in the pharmacy with social distancing, or by appointment when there are fewer people present. Vaccinations also may be administered outside of the pharmacy at a curbside table and chair set up, or outside event. “It will vary depending on what’s available in terms of facilities and resources, and human resources,” he said.
In late June, Walgreens resumed its immunization services with CDC-recommended safety measures in place for its staff and patients to vaccinate patients ahead of the coming flu season.
Beckner is optimistic that pharmacists have proven that they have the expertise to allay patients’ uneasiness about vaccines as they expand their role as vaccinators. “People are looking for a credible source of information, and pharmacists are in an ideal position to be that because of that trust factor,” he said.