REVIEWS
Pharmacist Involvement with Immunizations: A Decade of Professional Advancement

https://doi.org/10.1331/154434506776180621Get rights and content

ABSTRACT

Objective

To review achievements in pharmacist-administered immunizations, emphasizing the period 1995 to 2004.

Data Sources

Published articles identified through PubMed (1995–2004) using the search terms pharmacist, pharmacy, and vaccine, immunization, or shots. Additional sources were identified from personal bibliographies collected by the authors during this decade, as well as the bibliographies of the retrieved articles. The later two sources resulted in manuscripts of primarily historical significance.

Study Selection

More than 300 manuscripts were identified. The authors selected 15 studies that most clearly document the effect of pharmacist-administered immunizations for review.

Data Extraction

By the authors.

Data Synthesis

While pharmacists have been involved with vaccines dating back to the mid-1800s and the distribution of smallpox vaccine, only 10 years have passed since pharmacists began routinely immunizing patients in their communities as a standard practice activity. The Washington State Pharmacists Association initiated the first ongoing formalized training of pharmacists in vaccine administration in 1994. On November 1, 1996, the American Pharmaceutical (now Pharmacists) Association (APhA) began its nationally recognized training program for pharmacists, Pharmacy-Based Immunization Delivery: A National Certificate Program for Pharmacists. By 2004, an estimated 15,000 pharmacists and student pharmacists had been formally trained through recognized programs as vaccine experts, and the practice of pharmacist-administered immunizations, particularly for adult patients, has become routinely accepted as an important role of the pharmacist. Arguably, few initiatives have done more to move the pharmacy profession forward in direct patient care than the pharmacist-administered immunization movement.

Conclusion

Pharmacists have made significant strides in immunizations over the past decade. Limited activities in the hospital sector have been particularly well documented, as have the perceptions of patients regarding acceptance of pharmacists as immunizers. The activities of community pharmacists are less well documented. More research is needed into novel approaches to pharmacist involvement in public health—focused immunization initiatives, along with continued research evaluating the current practice of pharmacist-administered immunizations.

Section snippets

Decade of Postgraduate Training

Washington State pharmacists represented the first organized movement in pharmacist-administered immunizations. Jacqueline S. Gardner, MPH, PhD, a non-pharmacist epidemiologist and faculty member at University of Washington School of Pharmacy, provided much of the initial support and development for the initiative. In 1994 the Centers for Disease Control and Prevention (CDC) was highlighting childhood immunization disparities and missed opportunities for vaccination in the public health

Academia Begins Closing Educational Gap

While postgraduate training in immunizations for pharmacists has produced immediate success in practice, academic institutions have been slower to respond with formalized vaccine and public health training despite a long-standing call for such training. A 1965 American Association of Colleges of Pharmacy (AACP) report titled Public Health in the Curricula of Colleges of Pharmacy stated that pharmacy schools should “upgrade the public health components of their curricula.”16 Froh17 reported in

Support from Medicine

External factors, including support from the public health community, have also moved the profession forward. In 2002, a joint position paper on the pharmacist's scope of practice was published by the American College of Physicians—American Society of Internal Medicine (ACP—ASIM).22 Among several position statements in the document, one directly addressed the pharmacist's emerging role in immunization: The ACP—ASIM “supports the use of the pharmacist as immunization information source, host of

Training Results in Positive Activity

Neuhauser and colleagues23 at the University of Houston College of Pharmacy compared the demographics, professional activities, and job satisfaction of immunization-certified and other pharmacists in Texas. This cross-sectional study found that significantly more certified pharmacists were involved in immunizations as an advocate, partner (hosting immunization providers in the practice), and provider (99%) when compared with noncertified pharmacists (24%; P < .001). Of those certified, 74%

Early Literature Predicts Success

An important study conducted by Grabenstein and colleagues envisaged the success pharmacists would have as immunizers.24 This randomized controlled trial explored the persuasiveness of pharmacists in advocating that patients seek immunization from a third party (i.e., health department or physician) source. Vaccination rates among those receiving the mailed vaccine advice were compared with those of a control group that received a poison-prevention letter. Unvaccinated people encouraged by the

Pharmacists as Immunization Advocates

A 1999 study of 655 patients considered at high risk for contracting influenza were sent an information packet by the pharmacy team at a rural clinic in New York.26 At that time, New York's pharmacy practice act did not explicitly allow pharmacists to administer vaccine. However, a pharmacy team conducted a chart review to identify high-risk patients, collected patient information, screened patients for appropriateness of vaccination, compiled the mailing to targeted patients, conducted patient

Studies of Patient Perceptions

Published studies on patient perceptions of pharmacist-administered vaccinations are summarized in Table 3. A 2001 report by Grabenstein et al.29 described the characteristics of people vaccinated by pharmacists in pharmacies. Patient surveys collected in January 1999 from 21 pharmacies in 17 cities in 10 states were analyzed. A total of 8,266 vaccine recipients were reported at these pharmacies, and 1,730 (21%) surveys were completed for analysis. Both rural and urban pharmacies participated.

Health-System Pharmacists and Immunizations

Even though community pharmacy—based immunizations receive the greatest amount of attention in the pharmacy literature, hospital and health-system pharmacists have a comparably important role to play, and have done an admirable job of documenting their efforts over the past decade. David Fedson, MD, in a 1990 letter to the editors of the American Journal of Hospital Pharmacy, commented, “Although many patients cared for in hospitals meet well-accepted criteria for immunization, physicians often

Pharmacists Increase Overall Vaccination Rates

Perhaps the most important unsolved research problem is the evaluation of the effect of pharmacist-administered vaccinations on overall vaccination rates. A 2004 study compared influenza vaccination rates in states where pharmacists were or were not authorized to administer vaccines during the study period (1995–1999).40 The Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey conducted annually by CDC to assess overall health risks and activities over the previous 12 months,

Looking Ahead to the Next Decade

Pharmacists are well-accepted by the public as immunizers, and pharmacies are logical sites for vaccine clinics. As pharmacy begins its second decade in immunization administration and advocacy, institutional pharmacists should continue to capitalize on a strong foundation of eliminating missed opportunities for vaccination of patients before discharge. Community pharmacists should continue to promote the unique access they provide to vaccines. Community pharmacists should also partner with

Conclusion

The decade of 1995 through 2004 was one of monumental advancement in pharmacist involvement with immunizations. Because of the convergence of practitioners eager to prove their skills in nondispensing activities with that of readily available payment sources for immunization services, we believe that the national movement toward pharmacist-administered immunizations may prove to be the most significant catalyst in moving the profession beyond dispensing to direct patient care. Whether serving

Learning Objectives

After reading this continuing education article, the pharmacist should be able to:

  • List three roles pharmacists can serve in the area of immunization.

  • State specific actions health-system pharmacists can take to improve immunologic policies of the health system.

  • State the national influenza immunization rate for health care providers and recommend ways in which pharmacists can improve these rates.

  • State the published position of organized medicine relative to pharmacist-provided immunizations.

  • State

Assessment Questions

Instructions: You may take the assessment test for this program on paper or online. For each question, circle the letter on the answer sheet corresponding to the answer you select as being the correct one. There is only one correct answer to each question. Please review all your answers to be sure that you have circled the proper letters. To take the CE test for this article online, go to www.pharmacist.com/ education.cfm, and click on the “Get CE Now” box. Once you are on the CE welcome page,

References (41)

  • GrabensteinJ.D.

    Pharmacists and immunization: Increasing involvement over a century

    Pharm Hist

    (1999)
  • H.K. Mulford Company

    Biological products and retail druggists

    Am Druggist

    (1921(Apr))
  • Druggists distributors for board of health

    Pharm Era

    (1904)
  • Illinois State Board of Health

    Pharm Era

    (1905)
  • Anonymous

    Vaccine virus should always be kept on ice

    Pub Health Rep

    (1917)
  • Anonymous

    Pharmacists answer call in oral polio immunization programs

    J Am Pharm Assoc

    (1962)
  • Anonymous

    Report of the Task Force on the Pharmacist's Clinical Role

    J Am Pharm Assoc

    (1971)
  • Anonymous

    APhA promotes pharmacists' vaccine role

    Am Pharm

    (1994)
  • HogueM.D. et al.

    Pharmacy-based immunization delivery: a national certificate program for pharmacists

    (2004)
  • Fact sheet: States where pharmacists have the authority to immunize patients [American Pharmacists Association Web site]

    (December, 20, 2004)
  • Cited by (0)

    Continuing education credits: See learning objectives and assessment questions at the end of this article, which is ACPE universal program number 202-000-06-122-H04 in APhA's educational programs. The CE examination form is located at the end of this article. To take the CE test for this article online, go to www.pharmacist.com/education.cfm and follow the links to the APhA CE center.

    Disclosure: Dr. Hogue has served as a consultant for MedImmune and GlaxoSmithKline and is a former employee of the American Pharmacists Association (APhA). Dr. Grabenstein has no conflicts of interest to disclose. The opinions expressed in this manuscript are those of the authors and are not necessarily the opinions of the United States Army. Dr. Foster serves as a consultant for sanofi pasteur, Merck Vaccine Division, and is the APhA representative to the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Mr. Rothholz is a current employee of APhA. Drs. Hogue and Grabenstein and Mr. Rothholz were instrumental in the creation of APhA's Pharmacy-Based Immunization Delivery: A National Certificate Training Program for Pharmacists discussed in this manuscript, and all four authors serve as faculty, writers, and/or advisors to this program.

    Acknowledgments: To Jacqueline S. Gardner, Rod D. Shafer, and Dennis B. Worthen for their assistance with the historical aspects of this manuscript.

    See related article on page 183.

    View full text