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Education, Access, and Other Practical Considerations for Pharmacy-Assisted Immunization Services
AJMC®:
Could you discuss the trajectory of vaccinations in healthcare, particularly when it comes to population health?
Gershman: The goal is to remove barriers to vaccinations with various measures including school clinics, back-to-school immunization clinics, public health clinics, influenza vaccination clinics, tracking of childhood immunizations, and government-sponsored financing of vaccines. State laws vary regarding which patient age groups pharmacists can immunize. For example, many states do not permit pharmacists to vaccinate children. Pharmacists should continue to counsel caregivers on the importance of staying up-to-date on their children’s vaccines. There have been recent measles outbreaks among nonimmunized individuals, and it is important to eradicate this disease globally.
AJMC®:
Can you review recent clinical advances in the immunization spectrum and assess their impact on current practices?
Gershman: In 2012, the Centers for Disease Control and Prevention (CDC) began recommending that pregnant women receive the tetanus-diphtheria-acellular pertussis (Tdap) vaccination at 27 to 36 weeks (third trimester) of pregnancy, preferably during the earlier part of that time frame. This allows for the optimal transfer of protective antibodies from mothers to their babies. Additionally, the Tdap vaccine should be given to pregnant women during each pregnancy. Infants do not begin their own vaccine series against pertussis until approximately 2 months of age, so maternal vaccination is extremely important. It is important for pharmacists to educate pregnant patients about the importance of receiving the Tdap. The CDC also recommends that pregnant patients receive the influenza vaccine. According to the CDC, as of November 2017, only about 35% of pregnant women received the influenza vaccine. Pharmacists can play an important role as educators to increase this vaccination rate in pregnant women.
AJMC®:
What role does technology play in the evolving immunization landscape?
Gershman: Technology is continuously advancing, especially for vaccine delivery methods. The influenza vaccine is a good example of an immunization with a variety of delivery methods to assist with patient preference. The delivery methods include intramuscular, intradermal, and intranasal. The live attenuated influenza vaccine through intranasal administration was not recommended during the 2017-2018 flu season due to concerns of lack of efficacy. However, it may be available during the 2018-2019 flu season. During the 2017-2018 flu season, inactivated vaccines were produced using egg-based, cell culture-based, and recombinant technologies.
AJMC®:
With insurers now offering free preventive care, why are coverage rates for preventable infections still below the recommended target?
Gershman: According to the CDC, vaccine rates in adults are considered suboptimal, and the greatest barrier to vaccine coverage is lack of knowledge among patients and providers. Unknown vaccine records are also a barrier; however, adults can receive most immunizations if no previous record exists. Patients also have misconceptions regarding certain immunizations, such as the influenza vaccine. It is important to educate patients that the influenza vaccine cannot cause the flu, and it takes about 2 weeks for it to become effective. Vaccine hesitancy exists among parents leading to lower rates of influenza vaccination for their children. Most pediatric deaths associated with the flu occur in those children that did not receive the influenza vaccine. It is also important for pharmacists to educate patients that evidence has demonstrated vaccines do not cause autism.
AJMC®:
From a practical perspective, can you discuss the difference between immunization as a pharmacy/prescription benefit versus as a medical benefit?
Gershman: Vaccines may be covered either as a prescription or medical benefit. Pharmacies can run patients’ insurance to determine the best way for them to receive coverage for vaccines either through prescription drug coverage or as a medical benefit. All Health Insurance Marketplace plans must cover certain vaccines without charging co-payment or co-insurance when provided by an in-network provider. Health plans are required to cover new vaccine recommendations in the next plan year. Medicare Part D plans identify covered vaccines through formularies as part of the prescription drug coverage.
AJMC®:
How do clinical innovations drive administrative and health policy efforts in the arena of immunization?
Gershman: According to a recent report to Congress from the US Department of Health and Human Services, there are over 120 vaccine candidates under development for the prevention of more than 40 infectious diseases. The FDA ensures that vaccines are safe and effective and continuously monitors the immunizations. Pharmacists can play an important role in the postmarketing surveillance process by reporting adverse effects associated with vaccines through the Vaccine Adverse Event Reporting System.
AJMC®:
What are some of the unmet needs that remain when it comes to health policy and immunization and how can they be addressed?
Gershman: Previous vaccine history may not always be accessible at the point-of-care in hospitals and community pharmacy settings. This can make it difficult for pharmacists to determine whether patients have recently received certain vaccines such as influenza, pneumococcal, or herpes zoster. The American Pharmacists Association (APhA) has established project IMPACT immunizations through an initial pilot program to identify unmet vaccines and increase immunization rates. The initial results revealed a 41.4% increase in the number of vaccines administered and improvements in immunization rates. There should be federal databases for pharmacists to see patient vaccine information to ensure that individuals are receiving the appropriate immunizations. States have different reporting requirements when it comes to immunizations.
AJMC®:
How would you assess the role of pharmacists as healthcare providers in both the administration of vaccines and education about immunization?
Gershman: The CDC and WHO recognize the importance of pharmacists in the role of vaccine administration and education and their global impact to increase immunization rates and prevent vaccine-preventable diseases. Studies have shown that pharmacist-led education can boost immunization rates. Provider status has historically been a struggle, and federally pharmacists are not recognized as providers but progress is being made in certain states.
AJMC®:
How are pharmacists seen by other healthcare providers when it comes to vaccine education and administration?
Gershman: The path to pharmacists administering immunizations was initially a struggle in many states. The first organized vaccine training program began in Seattle, Washington in 1994. The APhA Pharmacy-Based Immunization Delivery certificate training program is nationally recognized for immunization training through CDC educational standards. However, pharmacist vaccine authority has continued to expand despite initial opposition by other healthcare professionals. The American College of Physicians supports pharmacists as vaccine immunizers and educators.
AJMC®:
How do pharmacists and community pharmacies figure into broader efforts to bolster immunization coverage?
Gershman: Pharmacists are 1 of the most accessible healthcare professionals, especially those practicing in community pharmacies. Community pharmacies generally have longer business hours than physician offices, which makes it more convenient for patients to receive vaccines. Pharmacists have the authority to administer immunizations in all 50 states, the District of Columbia, and Puerto Rico. This has substantially expanded the role of the pharmacist. According to a recent study published in the Journal of the American Pharmacists Association, pharmacy-based immunization services have increased influenza and pneumococcal vaccinations by millions since they became more common in the community pharmacy setting.
AJMC®:
Over the last several years, how has pharmacist-led immunization impacted vaccination rates, and has it freed up physicians to focus their medical care on other areas?
Gershman: Pharmacist-led immunization has increased vaccination rates across the country and allowed physicians to spend more time with their patients during office visits. 
