A Review of the Pharmacist as Vaccinator - Our Published Works

Review                                                                                                    PHARMACY PRACTICE

A Review of the Pharmacist as Vaccinator
Willis M. Richardson, PharmD; Albert I. Wertheimer, PhD, MBA
Temple University School of Pharmacy

Objective: The aim of this study is to review literature about how the pharmacist’s role as vaccination providers has been financially
and clinically measured.
Methods: A broad literature search was conducted up to May 2016 to identify economic or clinical data on pharmacy vaccinations.
MEDLINE® and PUBMED databases were searched for publications useful or potentially useful for this review. The NIH and CDC websites
were also searched for relevant materials. Search terms included vaccination, pharmacist, economic, pharmacoeconomics, cost,
benefits cost-effectiveness, physicians, immunizations, vaccinations, pharmacy vaccines, cost, physician vaccines, financial, benefit,
ambulatory pharmacist vaccination, clinical pharmacist, economics, pharmacist vaccine impact.
Results: The search yielded a total of 68 articles of which 12 met the criteria to be included in this review. After examining articles for
relevance to pharmacy vaccinations, two tables were created to highlight the clinical and economic advantages of the pharmacist as
a vaccinator.
Conclusion: Pharmacists who administer vaccines are an underutilized provider. This literature review reveals a pattern among studies
measuring the pharmacist’s impact on vaccination rates, patient preferences, and cost savings. Pharmacists have a history of
demonstrated dependability, accuracy, and cost effectiveness. State laws, collaborative agreements, and health plans have continued
to prevent patients from using the pharmacy to receive the CDC recommended vaccines. These barriers ultimately delay the Healthy
People 2020 goals.

Introduction/Background                                                   took place in Seattle, Washington in 1994. In November 1996,
Increasing vaccination rates to reduce infectious diseases                the American Pharmacists Association began its nationally
remains one of the Healthy People 2020 objectives set forth by            recognized training program for pharmacists; Pharmacy-Based
the United States Office of Disease Prevention and Health                 Immunization Delivery: A National Certificate Program for
Promotion.1, 2 Vaccine innovation and increased vaccination               Pharmacists. Today, pharmacists have authority to administer
rates were linked with increased survival in the 20th century.            vaccines in all 50 states, including the District of Columbia and
However, certain infectious diseases that can be prevented by             Puerto Rico.3
vaccines, still remain a major cause of morbidity and mortality.2
Currently there are 17 vaccine-preventable diseases in the                Pharmacists are immunization advocates and act as educators,
United States1, including influenza. Although preventable,                facilitators, and vaccinators.4 Pharmacists provide education
influenza is one of the leading infections in the United States           that helps dispel the many myths concerning vaccinations that
and accounts for substantial spending on the consequences                 dissuade the public from receiving them. Among the myths are
associated with the virus.2                                               vaccinations’ link to autism, vaccinations cause sudden infant
                                                                          death syndrome, vaccines contain harmful ingredients that can
Vaccines remain the most cost-effective intervention in clinical          affect children, vaccines cause neurological conditions (i.e.,
prevention of infectious disease and their proper use is                  seizures), children are given excessive vaccines in a short period
essential.2 Specifically, children’s vaccination programs yield a         of time, and vaccines are derived from aborted fetuses.4
higher return on investment.            Children receiving their
vaccinations according to the CDC schedule saves 33,000 lives,            Pharmacists are trained to deliver adult vaccines, child vaccines
prevents 14 million instances of disease, reduces health care             and travel vaccines, but vaccination services are often subject
cost by $9.9 billion, and saves $33.4 billion in indirect cost. In        to state legislation and physician protocols. State restrictions
spite of the available vaccines, about 42,000 of adults and 300           limit pharmacists from vaccinating patients in need by dictating
children die each year from vaccine preventable diseases.2                the types of vaccines administered, the age of patients, type of
                                                                          order requiring a prescription, and standing order protocols.4
The pharmacists’ role as vaccinators dates back to the 1800’s.            However, these restrictions have been suspended in times of
The first organized formal vaccination training for pharmacists           pandemics, such as the H1N1 influenza, when additional
                                                                          vaccinators were needed.5 Additionally, the community
                                                                          pharmacy is equipped to deliver vaccines. The pharmacy has
Corresponding Author: Willis M. Richardson, PharmD                        proper refrigeration, documentation, and emergency supplies.
Temple University School of Pharmacy                                      The pharmacy often has a private area for vaccine
3307 N. Broad Street, Philadelphia, PA 19140                              administration, which is useful for patient monitoring in case of
Email: willis.richardson@temple.edu                                       allergic reactions.

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                                        DOI: https://doi.org/10.24926/iip.v10i3.940
Review                                                                                                        PHARMACY PRACTICE

A pharmacist offers significant clinical and financial benefits                        vaccination vs those who were also picking up
through vaccination services. Administering vaccines in a                              prescription.
community pharmacy has become accepted by the public,                                 Vaccines with the greatest proportion administered
especially for influenza vaccine. Commercial and governmental                          during off-clinic hours were typhoid (41.5%), Tdap
health plans are beginning to provide coverage for those                               (34.5%), HPV (33.8%), varicella zoster (31.6%),
patients receiving vaccinations at pharmacy locations.                                 influenza (31.5%), hepatitis (31.4%), and yellow fever
However, health plans stipulate vaccine coverage and may not                           (30.8%).
always pay for all recommended vaccines.6 The aim of this study                       More than 1 million vaccinations took place during
is to review literature where the pharmacist as a vaccinator, has                      lunch hours (11:00 am to 1:00 pm) out of total
been financially and clinically assessed.                                              vaccinated administered of 6,250,402.
                                                                                      The proportion vaccinated during off- clinic hours was
Objectives                                                                             similar for patients with or without chronic conditions.
The objectives for this review were to examine studies where                          More than 150,000 vaccinations occurred during the
the pharmacists served as a vaccinator and to document the                             overnight hours of 10:00 pm to
clinical and financial impacts.                                                        9:00 am.

Methods                                                                    Community Pharmacist-Administered Influenza Immunization
A broad literature search was conducted to identify economic               Improves Patient Access to Vaccines: 8
and clinical data on pharmacists vaccinating in pharmacies.                     Research pharmacists collected survey data from 4
MEDLINE®, PUBMED, NIH, and CDC databases were searched                            different community pharmacy locations in Toronto
for publications useful or potentially useful in this collection of               from October 2013 to November 2013 in order to
data. Search terms included vaccination, pharmacist, economic,                    describe demographics and possible patient risk
pharmacoeconomics, cost, benefits cost-effectiveness,                             factors for receiving the influenza vaccine in a
physicians, immunizations, vaccinations, pharmacy vaccines,                       community setting. The study also assesses patient
cost, physician vaccines, financial, benefit, ambulatory                          experiences and perceptions.
pharmacist vaccination, clinical pharmacist, economics,                         Convenience of the pharmacist is a major factor to
pharmacist vaccine impact. Articles found were examined for                       patient satisfaction.
relevance and a data table was created outlining areas where                   99% of surveys (1502 surveys total) indicated patients
additional research is needed.                                                    would recommend family and friends to be vaccinated
                                                                                  by a pharmacist.
Results                                                                        One-third indicated that they would not have been
The data examined in the literature review can be found in                        vaccinated this year if pharmacist-administered
Tables 1 and 2. The following are modified key points from the                    vaccination were not available.
original article.                                                              No patient was dissatisfied with the vaccination
                                                                                  provided by the pharmacist, pharmacy service, and
Vaccinations Administered During Off-Clinic Hours at a                            injection technique. Rather, all patients surveyed were
National Community Pharmacy: Implications for Increasing                          satisfied or very satisfied with pharmacy service and
Patient Access and Convenience:7                                                  injection technique.
     Researchers retrospectively reviewed data for all                        All patients were either very comfortable or
         vaccinations administered at Walgreens pharmacies                        comfortable with their vaccine being administered by
         between August 2011 and July 2012. Specifically                          the pharmacist.
         comparing between two time periods (standard clinic
         hours [9:00 am – 6:00 pm] and off-clinic hours), they             The Effect of Pharmacist Intervention on Herpes Zoster
         analyzed the type of vaccine given as well as patient             Vaccination in Community Pharmacies: 9
         populations in order to assess implications for access                 In this prospective intervention study, patients
         and convenience.                                                          presenting to independent pharmacies across
     The following groups were most likely to be vaccinated                       Tennessee were asked to complete a survey after
         during off-clinic hours: younger patients, patients                       receiving their vaccination. The survey aimed to
         living in metropolitan/micropolitan areas, patients                       capture patients’ comfort level, sources of vaccination
         living in states that allow pharmacists to administer all                 education and sources of influence. Questions such
         CDC-recommended vaccines, those receiving travel                          as, “How did you hear about the Shingles vaccine?”
         vaccines, and patients who receive > 2 vaccines in one                    required patients to select from the following options:
         year; this study found no difference in off-clinic hour                   doctor, family/friend, pharmacist, flyer from your
         use in patients who used the pharmacy for only                            pharmacy, newspaper, letter in the mail from
                                                                                   pharmacy and other.

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                                         DOI: https://doi.org/10.24926/iip.v10i3.940
Review                                                                                                    PHARMACY PRACTICE

        The most effective method of pharmacy-driven                               The majority (85.6 %) of all flu vaccinations were
         intervention was the personalized letter.                                   recorded between 9 am and 5 pm with peaks occurring
        Patients were more likely to receive a vaccine from                         between 11 am and 1 pm (24.0 %).
         reading pharmacy-driven interventions than by
         influences from a physician (P
Review                                                                                                    PHARMACY PRACTICE

Pharmacists as Providers: Targeting Pneumococcal                          Impact of Pharmacist Integration in a Pediatric Primary Care
Vaccinations to High-Risk Populations:14                                  Clinic on Vaccination Errors: A Retrospective Review:16
     Between August 1, 2010 and November 14, 2010, a                           At the Nationwide Children’s Hospital in Columbus,
        total of 2,095,748 patients received influenza                             Ohio, vaccine error rates and missed opportunities
        vaccinations at Walgreens. At the same time of the flu                     were compared between two pediatric primary care
        vaccine, the pharmacist also recommended the                               clinics during April, May, and June 2011. Staffing levels
        PPSV23 if any risk was identified. Of the total study                      were consistent throughout both clinics and included
        population, 1,343,751 (64%) persons were considered                        attending physicians and resident physicians,
        at-risk and met the ACIP recommendation for PPSV23.                        however, different individuals would staff each clinic.
     921,624 patients (69%) were at-risk because they were                        Specifically, the “intervention clinic” had a full-time,
        age 65 and older; 22,127 patients (31%) were at risk                       board-certified ambulatory clinical pharmacist who
        because they had one of the ACIP comorbid conditions                       provided vaccination education to provider and
        and were aged 2–64.                                                        patients. The “comparison clinic” did not include
     Pharmacists were especially effective at reaching                            pharmacy personnel to ensure appropriate use of
        patients aged 60–70 years, who are likely to be at-risk                    vaccines.
        not only due to age but also due to comorbid                            After researchers reviewed 900 total randomized
        conditions. Patients aged 60–70 years had the highest                      encounters from both clinics, 19 errors were found in
        PPSV23 vaccination rate (6.60%, 26,430/400,454) of                         the evaluation. With 2 errors identified in the
        any age group.                                                             comparison clinic and 17 from the “intervention
                                                                                   clinic,” the error rate was 0.28% and 2.7%, respectively
Improved Influenza Vaccination Rates in a Rural Population as                      (P = 0.0021).
a Result of a Pharmacist-Managed Immunization Campaign: 15                      Further research of pharmacist involvement in several
     In 1999, a pharmacy team conducted a manual chart                            areas of vaccine use is needed. This study did not
         review of 2,271 charts in a rural primary care clinic and                 include an economic evaluation of improved use of
         collected patient demographic data including                              vaccines. Additional research investigating the
         influenza     vaccine      history    and      influenza                  economic implications of pharmacist integration into
         contraindications. They identified 657 patients who                       the primary care setting on vaccine use is also needed.
         had indications for the vaccine. The team also                         Missed opportunities were defined as vaccine doses
         developed education packets, which were distributed                       due at date of encounter and not given. In the
         to the patients identified in the chart review.                           comparison clinic, 132 randomized encounters were
         Vaccinations were given in specially designated clinics                   found to have greater than or equal to one missed
         and during routine clinic visits. Campaign success and                    opportunity, compared with 46 randomized
         reasons why patients remained unvaccinated were                           encounters in the intervention clinic (P
Review                                                                                                   PHARMACY PRACTICE

       The mean (SD) total costs, which included health plan            Non-Traditional Settings for Influenza Vaccination of Adults:
        and enrollee payment, per vaccine administration at              Costs And Cost Effectiveness:18
        physician offices, other medical settings, and                        Using detailed phone interviews, researchers
        pharmacies were as follows:                                              evaluated the costs of influenza vaccination in non-
            o Physician offices: zoster vaccine—$208.72                          traditional settings. Target age population included
              (42.10), pneumococcal vaccine—$65.69 (27.54),                      18-49, 50-64, and ≥65 years with either high risk or low
              and influenza vaccine—$29.29 (15.29)                               risk for influenza-related complications. Probability,
              (P < 0.05).                                                        direct costs, and opportunity costs were derived from
            o Other medical settings (i.e., inpatient and                        primary data, unpublished and published sources.
              outpatient hospital, emergency department):                     The mean total cost (US$, year 2004 values) per
              zoster vaccine—$209.51 (50.83), pneumococcal                       vaccination, not including time cost, was estimated as
              vaccine—$72.11        (49.95),   and      influenza                $11.57 for pharmacies, $17.04 for mass vaccination
              vaccine—$24.20 (13.12) (P < 0.05).                                 clinics, and $28.67 at doctor’s office.
            o Pharmacies: zoster vaccine—$168.50 (15.66),                     The mean waiting time for mass vaccination and
              pneumococcal vaccine—$54.98 (9.72) (P < 0.05),                     pharmacy clinics was 12 minutes for both; the doctors
              influenza vaccine—21.57 (6.63) (P < 0.05).                         waiting time was over 1 hour.
       The data may help payers and policymakers                             The reported mean cost per vaccine dose ranged from
        understand the economic value of adult vaccination in                    $7.48 in the pharmacy setting to $9.24 in the doctor’s
        different settings, especially in pharmacies.                            office.
       For all 3 vaccines, the costs paid were significantly                 The patients’ time, labor, and overhead cost were
        lower in pharmacies than in either physician offices or                  higher in scheduled doctor visits.
        other medical settings (P < 0.05).
       For zoster vaccination, patients paid the least out-of-          Discussion
        pocket at physician offices ($16.95 [43.85], P < 0.05),          Pharmacists administering vaccines has effectively lowered
        whereas insurers paid the least at pharmacies                    health care cost and increased vaccination rates. The data
        ($145.72 [$38.54], P < 0.05).                                    compiled in this review has revealed ways pharmacists have
       For both the pneumococcal and influenza vaccines,                been using their practice to advance the promotion and
        patients paid the least at pharmacies, while insurers            administration of the CDC recommended vaccinations.
        paid the least in other medical settings, and the most           Pharmacists offer education, advertising, and incentives to
        at physician offices.                                            reach patient populations in need of vaccinations. Pharmacies
       For zoster vaccination, patients paid the least out-of-          also have various conveniences such as extended hours,
        pocket at physician offices, whereas insurers paid the           shortened wait times, ease of access for medically underserved
        least at pharmacies.                                             patients in urban and rural areas, and reduced vaccination
       From the patient perspective, costs paid were lower in           costs. 9-12,15 With 93% of Americans living within 5 miles of a
        pharmacies than in other medical settings for all 3              community pharmacy, community pharmacists are one of the
        vaccinations and lower than in physician offices for             most readily accessible health care professionals in the United
        pneumococcal and influenza vaccines.                             States.5
       Researchers conducted telephone interviews with
        representatives from each setting in 2004 to                     The clinical data collected has shown that pharmacy
        understand the costs of vaccination delivery in                  convenience and public trust as a vaccinator group is not a
        nontraditional settings. They found that vaccination             unique characteristic of pharmacists in the United States.10, 11
        delivery cost less in the nontraditional settings ($17 in        Many patients in the UK preferred to pay the pharmacist for an
        mass vaccination settings, $12 in pharmacies)                    influenza vaccination instead of receiving it for free from their
        compared with physician offices ($29). Additionally,             general practitioner.10,11 Several studies demonstrate that
        they found that vaccination in nontraditional settings           many patients in the UK and United States go to the pharmacy
        was projected to be cost saving for healthy adults aged          during lunch hours.7,10,11 Convenience is arguably the most
        ≥50 years and for high-risk adults of all ages.                  advantageous characteristic of pharmacies as a vaccination
       Pharmacies had lower average direct costs paid per               location. In addition, many pharmacies are open 24 hours
        adult vaccination than physician offices and other               including holidays, allowing patients to receive vaccinations
        medical settings—by 16%-26% and 11%-20%,                         during these off-clinic hours.7
        respectively—when both health plan and enrollees’
        perspectives were considered.                                    Despite the convenience, various barriers such as state laws,
                                                                         collaboration protocols, and health plan restrictions further
                                                                         prevent pharmacies from administering the full CDC
                                                                         recommend schedule. An estimated 40,000 to 50,000 adults

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die annually from vaccine-preventable disease in the United                according to the CDC guidelines. The vaccination history
States.5 Additionally, $10 billion dollars are used to treat               developed by the pharmacist will also serve as a tool to assist
patients without routine or recommended vaccinations.5 The                 various medical personnel involved with the patient. Also,
state laws restricting pharmacists as a vaccinator are                     insurance companies should extend pharmacy insurance
inconsistent and seemingly arbitrary (Table 3). Many state laws            benefits to cover vaccines as a preventative pharmaceutical
prevent pharmacists from providing vaccinations to the most                measure against disease. Expanding vaccines coverage in the
cost-effective population—children. Some states limit the                  pharmacy setting will bring current those who are irregularly
pharmacist to certain types of vaccines. The 2016 ACPE                     vaccinated and increase vaccination rates in hard-to-reach
accreditation standards for the doctor of pharmacy curriculum              populations.12
requires pharmacy schools to provide training for students to
become certified in administering injections.21 Furthermore,               The following are research proposals that can measure the
biologics and vaccines are considered pharmaceutical products              clinical and economic impact of the pharmacist as a vaccinator:
approved through the FDA, which positions pharmacists as                   comparisons of direct cost and opportunity cost for the full
vaccine experts. The expertise provided by pharmacists was                 vaccination schedule administered at the community pharmacy
demonstrated in Haas-gehres a, et al. where pharmacy                       vs. the physician’s office, cost effectiveness of travel vaccines
interventions significantly decreased missed opportunities for             given in a community pharmacy setting, a study to determine
scheduled vaccinations.16 Vaccination protocols, prescription              or estimate the average number of vaccinations a pharmacy
only orders and standing orders are additional barriers to                 administers annually, an observational claims analysis of
patient access to pharmacy service. Also, both commercial and              rejected vaccinations by an insurance provider in the
state health plans do not readily cover all scheduled vaccines5            community setting, and a literature review of pharmacy
when administered in the pharmacy setting, further hindering               protocols and state law limitations.
healthcare. With the inconsistent restrictions and lack of
medical standard, research concerning protocols and orders                 Conclusion
would assist in determining the practicality of these                      Pharmacists as vaccinators are an underutilized vaccine
restrictions.                                                              provider source. This literature review reveals a pattern among
                                                                           studies measuring pharmacists’ impact on vaccine rates,
Economically, vaccines delivered in the pharmacy lower the                 patient preferences, and cost savings. Expanding the
cost for health care.17,18 Patients have higher direct and                 pharmacists’ ability to vaccinate more population groups
opportunity costs when getting vaccinations at their physician’s           through the changing legislation has traditionally increased
office.18,19 A recent study has shown the average opportunity              vaccination rates by state.13 Inconsistency exists within the
cost per physician visit was $43, which exceeds the average                health benefits system, which complicates pharmacy
patient’s out-of-pocket payment. Total opportunity costs per               vaccination efforts. Vaccination is the most cost effective way
year for all physician visits in the United States were $52 billion        to prevent infectious disease and comorbid complications,
in 2010.19 Studies have shown that receiving vaccines in the               however commercial and governmental health plans provide
pharmacy setting was the least expensive option for patients.              limited coverage for receiving vaccinations from a pharmacy.5
In contrast, vaccines delivered in the traditional physical office         Pharmacists have demonstrated to be dependable, accurate,
setting are the most expensive.17,18 The patient may also                  and cost effective vaccination providers. State laws, collaborate
experience opportunity costs due to office wait times or                   agreement protocols, and health plans have prevented patients
appointment co-pays.17-19 Compounding the inconveniences of                from using the pharmacy to receive all CDC recommended
going to a physician office has made many patients appreciate              vaccines which can potentially delay the Healthy People 2020
the prompt service in the pharmacy setting. Additional                     goal of increasing vaccination rates and reducing preventable
electronic technologies within pharmacy software systems                   infectious diseases.
have enabled pharmacists to identify risk groups in need of
vaccinations. Researchers have conducted a study using claims              Acknowledgements: Thank you Dr. Albert Wertheimer for the
data as an identifying tool.14 Moreover, patients visit their              opportunity to conduct this research and encouraging me to
pharmacies more frequently, thus facilitating the verification of          have our work published.
vaccine history and minimizing missed opportunities.
                                                                           Conflict of Interest: We declare no conflicts of interest or
After reviewing the literature, pharmacy practice should                   financial interests that the authors or members of their
enhance the pharmacist’s role as a vaccinator by including                 immediate families have in any product or service discussed in
complete vaccination records with the patient’s medication                 the manuscript, including grants (pending or received),
profile. The community pharmacy serves as a valuable source                employment, gifts, stock holdings or options, honoraria,
of history for each patient’s prescriptions records, and adding            consultancies, expert testimony, patents and royalties.
the vaccination history to the patient profile will help identify
those who have not received their recommended vaccinations

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Review                                                                                                   PHARMACY PRACTICE

References                                                                   13. Steyer TE, Ragucci KR, Pearson WS, Mainous AG. The
    1. Centers for Disease Control and Prevention (CDC).                         role of pharmacists in the delivery of influenza
        Achievements in public health, 1900–1999: Control of                     vaccinations. Vaccine. 2004;22(8):1001-6.
        infectious diseases. MMWR. 1999 Jul 30;48(29):621-9                  14. Taitel M, Cohen E, Duncan I, Pegus C. Pharmacists as
    2. Immunization and Infectious Diseases. (n.d.).                             providers: targeting pneumococcal vaccinations to
        Retrieved March 12, 2016, from                                           high risk populations. Vaccine. 2011;29(45):8073-6.
        https://www.healthypeople.gov/2020/topics-                           15. Van amburgh JA, Waite NM, Hobson EH, Migden H.
        objectives/topic/immunization-and-infectious-                            Improved influenza vaccination rates in a rural
        diseases#star                                                            population as a result of a pharmacist-managed
    3. APhA. Pharmacists play a vital role in providing                          immunization campaign. Pharmacotherapy.
        immunizations in their communities.                                      2001;21(9):1115-22.
        http://www.pharmacist.com/AM/Template.cfm?                           16. Haas-gehres A, Sebastian S, Lamberjack K. Impact of
        Section=News_Releases2&template=/CM/ContentDis                           pharmacist integration in a pediatric primary care
        play.cfm&ContentID=23001.                                                clinic on vaccination errors: a retrospective review. J
    4. Weidman-Evans E, Mohundro B.L. (2013). Chapter 6.                         Am Pharm Assoc (2003). 2014;54(4):415-8.
        Immunization Services. In Ellis A.W., Sherman J.J.                   17. Singhal PK, Zhang D. Costs of adult vaccination in
        (Eds), Community and Clinical Pharmacy Services: A                       medical settings and pharmacies: an observational
        Step-by-Step Approach. Retrieved April, 2016 from                        study. J Manag Care Spec Pharm. 2014;20(9):930-6.
        http://accesspharmacy.mhmedical.com.libproxy.tem                     18. Prosser LA, O'brien MA, Molinari NA, et al. Non-
        ple.edu/content.aspx?bookid=684&Sectionid=451458                         traditional settings for influenza vaccination of adults:
        41                                                                       costs and cost effectiveness. Pharmacoeconomics.
    5. Events FO, Policy BO, Medicine IO. The 2009 H1N1                          2008;26(2):163-78.
        Influenza Vaccination Campaign: Summary of a                         19. Ray KN, Chari AV, Engberg J, Bertolet M, Mehrotra A.
        Workshop Series. National Academies Press; 2010.                         Opportunity costs of ambulatory medical care in the
    6. Bach, Albert and Jeffery Goad. "The Role of                               United States. Am J Manag Care. 2015;21(8):567-74.
        Community Pharmacy-Based Vaccination in the USA:                     20. NABP. Independent Pharmacy Practice. The 2016
        Current Practice and Future Directions". IPRP (2015):                    Survey of Pharmacy Law. 2016
        67. Web. 1 May 2016.                                                 21. Accreditation council for pharmacy education.
    7. Goad JA, Taitel MS, Fensterheim LE, Cannon AE.                            Accreditation standards and key elements for the
        Vaccinations administered during off-clinic hours at a                   professional program in pharmacy leading to the
        national community pharmacy: implications for                            doctor of pharmacy degree (“Standards 2016”).
        increasing patient access and convenience. Ann Fam                       Chicago, Illinois. 2015.
        Med. 2013;11(5):429-36
    8. Papastergiou J, Folkins C, Li W, Zervas J. Community
        pharmacist-administered influenza immunization
        improves patient access to vaccination. Can Pharm J
        (Ott). 2014;147(6):359-65.
    9. Wang J, Ford LJ, Wingate L, et al. Effect of pharmacist
        intervention on herpes zoster vaccination in
        community pharmacies. J Am Pharm Assoc (2003).
    10. Anderson C, Thornley T. "It's easier in pharmacy":
        why some patients prefer to pay for
        flu jabs rather than use the National Health Service.
        BMC Health Serv Res. 2014;14:35.
    11. Anderson C, Thornley T. Who uses pharmacy for flu
        vaccinations? Population profiling through a UK
        pharmacy chain. Int J Clin Pharm. 2016;38(2):218-22.
    12. Crawford ND, Blaney S, Amesty S, et al. Individual-
        and neighborhood-level characteristics associated
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        vaccinations in New York City. J Urban Health.

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                                                                     Table 1: Clinical
 Name of Study and      Type of Study / Objectives                Methods                            Results                         Implications
Vaccinations            Retrospective review.           One-year vaccination review      Pharmacist administered           The typical off clinic hour user,
administered during                                     chain pharmacy.                  6,250,402 vaccinations.           male, young, heather patient,
off-clinic hours.       Objective: Analyze the                                                                             reside highlighter more likely to
Increasing patient      types of vaccine                Categorized by traditional       30.5% provided during off         be vaccinated during off-clinical
access and              administered and patient        hours (9am-6m) vs. off clinic    clinic hours.                     hours.
convenience.7           pharmacies population           hours (evening, holidays,
                        vaccinated during off clinic    weekends).                       Patients had higher odds of       Community pharmacies are
Goad Ja et al. Ann      hours in a nationally                                            off-clinic vaccination if they    expanding the access and
Fam Med.                community pharmacy.             Compared demographic and         were younger than 65, male,       convenience of vaccines.
2013;11(5):429-36                                       types of vaccines.               reside in urban area, and did
                                                                                         not have chronic conditions.      Working population utilize the
                                                                                                                           convenience outside the
                                                                                         17.5% of all vaccines             working hours thus increases
                                                                                         administered during lunch         vaccination rates.
                                                                                         hours (11 am -1 pm).
                                                                                                                           Patient seek vaccinations at
                                                                                         Patients are more likely to use   times most convenient to them.
                                                                                         off clinic hours if they were
                                                                                         vaccinated in states that         Expanding the pharmacist ability
                                                                                         authorize pharmacist to all       to administer adults and
                                                                                         CDC-recommended vaccines          children for all vaccines in all
                                                                                         vs. states that authorize         states will have the greatest
                                                                                         pharmacist to administer          impact on vaccination rates.
                                                                                         influenza, pneumonia and
                                                                                         zoster (OR = 1.0044; 95% CI,

Community               Objective:                      Survey collected at 4            1502 surveys were collected.      Pharmacist have the potential to
pharmacist-              To describe the                community pharmacy                                                 provide a positive effect on
administered            demographics of patients        locations in Toronto in 8-       86% of patient were very          public health by improving
influenza               receiving influenza vaccines    week period.                     comfortable or comfortable        vaccination rates among high
immunization            in the community setting                                         14% with being vaccinated by      risk patients and first time
improves patient        and to understand patient                                        pharmacist.                       vaccine recipients.
access to vaccines8     perceptions of pharmacy
                        vaccinations.                                                    92% of patients were very
                                                                                         satisfied or satisfied 8% with
Papastergiou J et al.                                                                    pharmacies’ service and           Expanding pharmacist
Can Pharm J (Ott).                                                                       injection technique.              vaccination services to cover
2014; 147(6):359-65                                                                                                        other vaccines would improve
                                                                                         28% of patients indicated that    patient access and would
                                                                                         they would not have been          receive positive reception.
                                                                                         vaccinated that year if the
                                                                                         pharmacy service were not

                                                                                         46% of the patients had risk
                                                                                         factors such as heart disease,
                                                                                         respiratory disease, cancer,
                                                                                         diabetes or was receiving

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The effect of         Prospective interventional     Study of three pharmacies      Vaccination rates increased         Pharmacists can attain better
pharmacist            with pre-post design.          that serve suburban, semi-     from 0.37% (or 59/16,121)           vaccine outcomes by
intervention of                                      rural, rural demographics.     during the control period to        communication with patients
Herpes Zoster         Investigate whether                                           1.20% (or 193/16,062) during        using mediums as personal
Vaccination in        intervention by community      Two protocols: collaborative   the intervention period             letters.
community practice9   pharmacist promoting           practice and Rx all vaccines   (P
Review                                                                                                             PHARMACY PRACTICE

It’s easier in            This paper discusses           Data were collected during        Data were captured from            Patients would rather pay for
pharmacy”: why            retrospective data collected   the 2012–13 flu season as         89,011 privately paying            convenience than wait for long
some patients prefer      through a sample of Boots      part of a community               patients across 479 pharmacies     time for free service.
to pay for flu jabs       UK community pharmacies        pharmacy private flu              in England, of whom 6% were
rather than use the       during 2012–13 to help         vaccination service to help       eligible to get the vaccination
National Health           support the case for           identify whether patients         free. 921 patients completed a
Service.10                national commissioning of      were eligible to have their       survey in the 13 pharmacies
                          flu vaccinations through       vaccination free of charge on     selected. Of these, 199 (22%)
Anderson C et al.         pharmacy.                      the NHS. Additional data          were eligible to get their flu
BMC Health Serv Res.                                     were collected from a sample      vaccination for free. 131 (66%)
2014;14:35.                                              of patients accessing the         were female. Average age was
                                                         private service within 13         54 years. Of the 199 patients
                                                         pharmacies to help identify       who were eligible for free
                                                         the reasons patients paid         treatment, 100 (50%) had been
                                                         when they were eligible for       contacted by their GP surgery
                                                         free vaccination.                 to go for their vaccination, but
                                                                                           had chosen not to go. Reasons
                                                                                           given include accessibility,
                                                                                           convenience and preference
                                                                                           for pharmacy environment.
Who uses pharmacy          To understand the profile     Pharmacists requested             1741 patients from a total of      These services are highly
for flu vaccinations?     of people accessing flu        people who had been               55 pharmacies completed the        accessed by patients from all
Population profiling      vaccination services within    vaccinated in 2014/15 to          survey. Convenience and            socio demographic areas.
through a UK              a large pharmacy chain.        complete a questionnaire.         accessibility remain the key       Patients would rather pay for
pharmacy chain11                                         Data was captured                 reasons for attending              convenience than wait for long
                          Retrospective data             electronically on vaccine         pharmacy.                          time for free service.
Anderson C et al. Int J   collected through a sample     delivery levels across 1201
Clin Pharm.               of in England during the       pharmacies. Deprivation           Pharmacy services are              Health professionals and
2016;38(2):218-22         2014/15 Flu season.            profiles were calculated using    accessed by people from all        working class people tend to use
                                                         the Carstairs index.              postcode areas, including some     the pharmacy vaccine service.
                                                         Carstairs index (used to          from the most deprived
                                                         calculate deprivation             localities.
                                                         quintiles for least and most
                                                         deprived); based on four
                                                         census indicators: low social
                                                         class, lack of car ownership,
                                                         overcrowding, and male
Individual- and           New York State (NYS)           Used pharmacy staff baseline      The sample consists of 437         Evidence-supporting scale-up of
Neighborhood-Level        passed legislation             data to assess support of in-     pharmacists, non- pharmacist       vaccination efforts in
Characteristics           authorizing pharmacists to     pharmacy vaccination, which       owners, and technicians            pharmacies located in foreign-
Associated with           administer vaccines in         was measured using a Likert       enrolled from 103 eligible New     born/immigrant communities,
Support of In-            2008. Racial/socioeconomic     scale (very supportive,           York City pharmacies. Using        which has potential to reduce
Pharmacy                  disparities persist in         somewhat supportive, not          multilevel analysis, pharmacy      disparities in vaccination rates
Vaccination among         vaccination rates and          supportive, don’t know, and       staff that expressed support of    and preventable influenza-
ESAP-Registered           vaccine-preventable            refused) in response to, “How     in- pharmacy vaccination           related mortality.
Pharmacies:               diseases such as influenza.    much do you support               services were 69% more likely      The majority of pharmacy
Pharmacists’ Role in      Many NYS pharmacies            vaccination services being        to support in-pharmacy HIV         personnel are very supportive of
Reducing                  participate in the Expanded    provided in your pharmacy?”       testing services (OR, 1.69; 95%    in pharmacy vaccination despite
Racial/Ethnic             Syringe Access Program         Persons who reported being        CI 1.39–2.04).                     sociodemographics disparities.
Disparities in            (ESAP), which allows           very supportive or somewhat       There was a total of 437           Pharmacies that also offer other
Influenza                 provision of non-              supportive were classified as     pharmacy staff: 189                public health service are more
Vaccinations              prescription syringes to       supportive, and those who         pharmacists, 19 non-               likely to support in-pharmacy
in New York City12        help prevent transmission      reported not supportive were      pharmacist owners/managers,        vaccinations.
                          of HIV, and are uniquely       classified as not supportive.     and 229 pharmacy
Crawford ND et al. J      positioned to offer            Persons who reported don’t        technicians/clerks. Of these       Pharmacies are in the key
Urban Health.             vaccination services to low-   know and refused were             pharmacy staff, 38.7% were         position to vaccinate too-hard-
2011;88(1):176-85.        income communities. To         excluded from this analysis       male, most were Hispanic           to-reach population groups.
                          understand individual and      (n=4). It is important to note    (36.1%), followed by
                          neighborhood                   that support of in-pharmacy       Asian/Pacific Islander (19.3%),
                          characteristics of pharmacy    vaccination reflects individual   African American (18.2%),

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Review                                                                                                          PHARMACY PRACTICE

                        staff support for in-          attitudes and beliefs of this     White (13.1%), South
                        pharmacy vaccination, we       service rather than actual        Asian/Indian/Pakistani (8.3%),
                        combined census tract data     participation in current          and other race/ethnicity
                        with baseline pharmacy         vaccination services in their     (5.1%). Pharmacy staff worked
                        data from the Pharmacies       pharmacy. Participants were       an average of 9.4 years in
                        as Resources Making Links      probed about their level of       pharmacies. Most (86.3%)
                        to Community Services          support even if this service      pharmacy staff supported
                        (PHARM-Link) study among       was not feasible in the           vaccination being provided
                        ESAP-registered                pharmacy. Therefore, we           inside the pharmacy.
                        pharmacies.                    refer to the reported beliefs
                                                       and attitudes of in-pharmacy
                                                       vaccination as in-pharmacy
                                                       vaccination support.
The role of             The purpose of this study is   For this analysis, the 1995       Individuals aged 65 years and     Allowing pharmacists to provide
pharmacists in the      to determine whether           and 1999 Behavioral Risk          older who lived in states where   vaccinations is associated with
delivery of influenza   influenza vaccine rates        Factor Surveillance System        pharmacists could provide         higher influenza vaccination
vaccinations13          have increased in states       (BRFSS) was used. The BRFSS       vaccines had significantly        rates for individuals aged 65
                        where pharmacists can give     is an annual telephone survey     higher (P < 0.01) influenza       years and older.
Steyer TE et al.        vaccines.                      conducted by the Centers for      vaccine rates than individuals
Vaccine.                                               Disease Control and               of this age who resided in        Expanding the pharmacies
2004;22(8):1001-6.      To assess the impact of        Prevention that assesses          states where pharmacists          ability to administer more
                        legislation allowing           health risks in the US. In this   could not provide vaccines.       vaccines increases vaccination
                        pharmacists to administer      survey, individuals are asked,                                      rates in new populations.
                        vaccine.                       “During the past 12 months,                                         Expanding patient access and
                                                       have you had a flu shot?”                                           refining legal parameters in
                                                        Sixteen states were taken                                          pharmacy practice has a
                                                       from the BRFSS to compare                                           correlated effect in the groups
                                                       influenza vaccination rates                                         who are vaccinated.
                                                       for individuals both 18–64
                                                       and 65 years and older. Eight
                                                       of these states (Arkansas,
                                                       Kansas, Nebraska, North
                                                       Dakota, Oklahoma,
                                                       Tennessee, Texas and
                                                       Virginia) passed legislation in
                                                       1997 allowing pharmacists to
                                                       administer vaccines while
                                                       eight (Louisiana, Missouri,
                                                       Iowa, Wyoming, Utah, West
                                                       Virginia, Florida, and
                                                       Maryland) had no legislation
                                                       prior to 2000. Data for the
                                                       years 1995 and 1999 were
                                                       then analyzed.

                                                       Secondary analysis of the
                                                       Behavioral Risk Factor
                                                       Surveillance System (BRFSS)
                                                       from the years 1995 and
                                                       1999. Information regarding
                                                       legislation allowing
                                                       pharmacists to administer
                                                       vaccines was obtained from
                                                       the American Pharmaceutical

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Pharmacists as          The objective of this study   Using de-identified claims       Among the 1.3 million at-risk      Pharmacies have the ability to
providers: Targeting    was to evaluate the impact    from a large, national           patients, 65,598 (4.88%)           target at risk vaccination groups.
pneumococcal            of pharmacists educating      pharmacy chain, all patients     received a pneumococcal            Pharmacy electronic records can
vaccinations to high    at-risk patients on the       who had received an              vaccine. This vaccination rate     filter patient profiles based on
risk populations14      importance of receiving a     influenza vaccination            was significantly (p < .001)       risk factors characteristic.
Taitel M et al.         pneumococcal vaccination.     between August 1, 2010 and       higher than the PPSV23             Pharmacies can expand this
Vaccine.                                              November 14, 2010 and who        benchmark rate of 2.90%            function to make more health or
2011;29(45):8073-6.                                   were eligible for PPSV23 were    (34,917/1,204,104). In the         vaccine interventions and
                                                      identified for the analysis.     study group, PPSV23 rates          produce better outcomes for
                                                      Based on the Advisory            varied by age group but not by     patients.
                                                      Committee on Immunization        gender. Patients aged 60–70
                                                      Practices recommendations,       years had the highest              These results support the
                                                      at-risk patients were            vaccination rate (6.60%,           expanding role of community
                                                      identified as over 65 years of   26,430/400,454) of any age         pharmacists in the provision of
                                                      age or as aged 2–64 with a       group.                             wellness and prevention
                                                      comorbid conditions. A                                              services.
                                                      benchmark medical and
                                                      pharmacy claims database of                                         Pharmacies can help achieve the
                                                      commercial and Medicare                                             U.S. Department of Health and
                                                      health plan members was                                             Human Services’ Healthy People
                                                      used to derive a PPSV23                                             goals for vaccine coverage. This
                                                      vaccination rate typical of                                         study supports the expanding
                                                      traditional care delivery to                                        role of community pharmacists
                                                      compare to pharmacy-based                                           in the provision of wellness and
                                                      vaccination. Period incidence                                       prevention services.
                                                      of PPSV23 was calculated and
                                                      compared.                                                           .

Improved Influenza      To increase the rate of       The pharmacy team                Before intervention (1998),        This study demonstrated that
Vaccination Rates in    influenza vaccinations in     developed an education           vaccination rates were low:        this pharmacy- directed
a Rural Population as   high-risk patients by means   packet that was sent to all      182 (28%) patients with and        program, which included a
a Result of a           of a pharmacist-managed       patients who needed the          102 (6%) patients without          mailing and improved access to
Pharmacist-Managed      immunization campaign.        influenza vaccine. The packet    indications for the vaccine.       the influenza vaccine,
Immunization             Unblinded, single            contained a letter and a two-    After the pharmacy-directed        significantly increased
Campaign15              intervention.                 sided information insert         intervention in 1999, 354          vaccinations by 95% for a group
                        Rural primary care clinic.    designed in collaboration        (54%) patients with and 148        of high-risk patients in a rural
Van amburgh JA et                                     with a teaching/learning         (9%) patients without              community practice.
al. Pharmacotherapy.                                  specialist.                      indications were successfully      The education packet received
2001;21(9):1115-22.                                                                    vaccinated.                        by mail was the most common
                                                      The pharmacy team                                                   reason patients were both
                                                      developed two surveys. One       The influenza vaccination rate     convinced and reminded to get
                                                      survey, for patients who         increased from 28% at baseline     vaccinated.
                                                      received the influenza           (before program initiation) to
                                                      vaccine (entitled “We helped     54% after program initiation.
                                                      you, now you can help us”),      Unvaccinated patients were
                                                      was given by a nurse or          younger and resided in more
                                                      pharmacist to patients during    urban areas than vaccinated
                                                      the vaccination clinic, at       patients; vaccinated patients
                                                      physician appointments, or       had a higher frequency of
                                                      by mail.                         cardiovascular disease or
                                                      A follow-up letter and survey    diabetes mellitus. Vaccinated
                                                      were mailed in early             patients consistently identified
                                                      December to unvaccinated         the education packet and their
                                                      patients who had indications     health care providers as
                                                      for vaccine. The primary         primary motivators for
                                                      focus was to encourage them      vaccination.
                                                      to get vaccinated if they had
                                                      not yet done so.                 Total of 283 patients
                                                                                       completed the “We helped
                                                                                       you, now you can help us”
                                                                                       survey. Of these, 199

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Review                                                                                                          PHARMACY PRACTICE

                                                                                        respondents were patients
                                                                                        with positive indications who
                                                                                        were vaccinated against
                                                                                        influenza and had received the
                                                                                        education packet (56.4%
                                                                                        response rate). Patients
                                                                                        consistently identified the
                                                                                        mailing and their health care
                                                                                        provider as the top factors that
                                                                                        had convinced and reminded
                                                                                        them to get vaccinated.

                                                                                        The most common suggestions
                                                                                        for improving the vaccination
                                                                                        program were to provide more
                                                                                        days and times available to be
                                                                                        vaccinated and to increase the
                                                                                        number of providers to
                                                                                        administer vaccinations.
Impact of pharmacist    To measure the impact of      A retrospective, quasi-           900 encounters were randomly       Pharmacist have the ability to
integration in a        ambulatory clinical           experimental review of            selected and reviewed. The         identify CDC scheduled
pediatric primary       pharmacist integration in a   electronic medical records of     error rate was found to be         recommendation in pediatric
care clinic on          pediatric.                    visit encounters during a 3-      0.28% in the intervention clinic   population.
vaccination errors: A                                 month period compared             and 2.7% in the comparison
retrospective           Primary care clinic on        vaccine error rates and           clinic. The difference in error    Pharmacist can support
review16                vaccination error rates and   missed opportunities              rates was found to be              ambulatory clinics to increase
                        to evaluate missed            between two pediatric             significant (P = 0.0021). The      vaccination rates and decreases
Haas-gehres A. J Am     opportunities.                residency primary care clinics.   number of encounters with          the rates of missed
Pharm Assoc (2003).                                   The intervention clinic has a     greater than or equal to one       opportunities.
2014;54(4):415-8.                                     full-time ambulatory clinical     missed opportunity was
                                                      pharmacist integrated into        significantly higher in the
                                                      the health care team.             comparison clinic compared
                                                                                        with the intervention clinic
                                                      Pharmacy services were not        (29.3% vs. 10.2%; P
Review                                                                                                            PHARMACY PRACTICE

                                                                  Table 2: Economics
 Name of study and      Type of study / objectives               Methods                           Results                          Implications
Cost of Adult           Observational                  This was an observational        Of those receiving zoster,        The average direct costs paid
vaccination in          retrospective study.           retrospective study using        pneumococcal, and influenza       per adult vaccination were
Medical Settings and                                   2010 MarketScan Commercial       vaccines, 25%, 1%, and 7%,        lower in pharmacies compared
Pharmacies: An          Objective: To examine          Claims and Encounters and        respectively, received the        with physician offices and other
observational study17   whether the direct             Medicare Supplemental and        vaccines at a pharmacy.           medical settings by 16%-26%
                        medical costs paid for         Coordination of Benefits         Compared with other U.S.          and 11%-20%, respectively.
Singhal PK et al. J     adult vaccination differ by    databases. Adults receiving      regions, pharmacy-based
Manag Care Spec         vaccination setting.           herpes zoster or shingles        vaccination for these 3           These results were mostly
Pharm.                                                 vaccine, pneumococcal            vaccines was generally more       consistent across geographic
2014;20(9):930-6.                                      vaccine 23-valent, or            frequent in the West and the      regions and types of health
                                                       influenza vaccines were          South.                            plans.
                                                       identified using Current
                                                       Procedural Terminology           Mean (SD) costs paid per          These data may help payers and
                                                       codes and National Drug Code     enrollee per vaccine              policymakers understand the
                                                       numbers from medical and         administration at physician       economic value of adult
                                                       pharmacy claims files,           offices, other medical            vaccination in different settings,
                                                       respectively, between            settings, and pharmacies          especially in pharmacies.
                                                       January 1 and December 31,       were as follows: for zoster
                                                       2010, in 1 of the following 3    vaccine, $208.72 (42.10),         The data may also help medical
                                                       settings: physician offices;     $209.51 (50.83), and $168.50      or pharmacy insurance
                                                       other medical settings (e.g.,    (15.66), respectively (P
Review                                                                                                              PHARMACY PRACTICE

Non Traditional          To describe the cost of        Evaluated cost of influenza        The mean cost (2004 values)      Vaccinations given in the
settings for influenza   vaccination in non-            vaccinations in non-               was lower in mass vaccination    pharmacy setting is the most
of Adults                traditional settings such      traditional setting via detailed   ($17.04) and pharmacy            cost effective way to administer
Costs and Cost           as pharmacies and mass         telephone interviews with          ($11.57) setting than in         vaccines.
Effectiveness18          vaccinations clinics           vaccination clinics and            scheduled office visits.
                                                        pharmacists who administer                                          Vaccines given in pharmacy can
Prosser LA et al.        Evaluate the projected         vaccines                           In non-traditional settings,     lower the cost to patients and to
Pharmacoeconomics.       health benefits, cost and                                         cost savings was projected for   health providers.
2008;26(2):163-78        cost effectiveness of          Decision tree used to              healthy adults aged > 50
                         delivering influenza           compare projected cost and         years and for high-risk adults
                         vaccinations to adults of      health benefits of receiving       of all ages.
                         varying ages and risk          an influenza vaccination from
                         groups in non-traditional      non-traditional setting or         For health adults 18-49 years
                         settings compared with         during schedule doctor office      was cost effective, prevention
                         schedule doctor’s office       visit with no vaccination.         ($US90) if vaccines delivered
                         visits in the United States.                                      in pharmacy setting, $US210
                                                        Probabilities and cost (direct     by mass vaccination, and
                                                        and opportunity) for               $US870 by scheduled doctor’s
                                                        uncomplicated influenza            office visit.
                                                        illness, outpatient visits,
                                                        hospitalizations, deaths,
                                                        vaccination and vaccine
                                                        adverse events were derived
                                                        from primary data and
                                                        published and unpublished

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                        Table 3: Modified: National Association of Boards of Pharmacy: Survey of Pharmacy Law20
States                                 List of Conditions Pharmacist Administer Vaccination
Alabama , Arizona, California,         Allowed to vaccinate with fewer restricted measures.
Colorado*, Delaware, District of
Columbia, Georgia, Idaho, Illinois,
Kentucky Louisiana, Maine*,
Mississippi , Missouri, Nebraska
Nevada*,New Hampshire, New Jersey,
New Mexico, Puerto Rico, South
Carolina, South Dakota,Tennessee,
Texas, Vermont ,Virginia

Alaska                                 With board-approved collaborative practice protocol application.
Arkansas, Kansas, Oregon, West         Subject to vaccination protocol and completed course of study and training.

Connecticut,                           With restrictions. (FL – Consultant pharmacist in nursing home setting. Section 465.0125, F.S.)
Connecticut, Montana                   Pursuant to protocol only. (MT – Institutional protocol.)

Connecticut                            If pursuant to a collaborative practice protocol.

Florida, Pennsylvania, West Virginia   Pharmacists may vaccinate if they are certified by the board to administer injectables. (PA – if registered.)

Hawaii                                 Pursuant to a licensed medical — doctor’s or osteopathic physician’s order and collaborative agreement and
Indiana                                May administer vaccines under a drug order, prescription, or physician-approved protocol for influenza,
                                       shingles, pneumonia, tetanus, diphtheria, acellular pertussis, HPV, and meningitis.
Iowa, Colorado, Maine, Nevada, Ohio    Must be in accordance with a protocol.
                                       IA-By written protocol pursuant to rules of the Board of Pharmacy or when specifically directed by the
                                       prescriber for an individual patient.
                                       CO - Drug therapy management protocol.
                                       MI- May administer cholesterol, blood glucose, and international ratio, hepatitis C.
                                       NV – Protocol must be approved by the Board.
                                       OH – Pharmacists and pharmacy interns may dispense naloxone pursuant to a physician-approved protocol.
                                       They are not specifically authorized to “prescribe,” nor are they recognized as prescribers under Ohio law.)
Maryland                               Statute allows pharmacists to administer influenza vaccines to individuals age nine and above; CDC-
                                       recommended vaccinations to individuals ages 11 to 18 with prescription; CDC-recommended vaccines and
                                       travel vaccines to adults under a protocol. Pharmacists may also administer self- administered drugs.
                                       Regulations pending. Registration with the Board is required.

Massachusetts                          Approved by Department of Public Health

Michigan                               Yes, if it has been delegated to them and they have the approved training. See Section 16215 of the
                                       Michigan Public Health Code on delegation.
Minnesota                              Influenza to patients six years of age and older, all other vaccines to patients 13 years of age or older.
                                       Written protocol with a physician, APRN, or PA.

Montana                                Pharmacists are authorized to prescribe and administer vaccines without a collaborative practice agreement
                                       in place for the following vaccines: influenza to those 12 years and older; pneumococcal polysaccharide,
                                       tetanus, and diphtheria to those 18 years and older; herpes zoster to those identified in Centers for Disease
                                       Control and Prevention guidelines; and in the event an adverse reaction, epinephrine or diphenhydramine to
                                       those 12 years and older.

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New York                        May administer influenza, pneumococcal, herpes zoster, meningococcal, and tetanus, diphtheria, and
                                pertussis vaccines and drugs to treat reactions.
North Carolina                  Influenza, pneumococcal, herpes, zoster, hepatitis B, meningococcal, tetanus-diphtheria, tetanus and
                                diphtheria toxoids and peruses, tetanus and diphtheria toxoids and acellular pertussis, tetanus toxoid, and
                                all other vaccinations recommended or required by the Centers for Disease Control and Prevention.
North Dakota                    When trained and authorized by Board.
Ohio                            Certain vaccines as listed in Ohio Revised Code §4729.41 and Board Rules.
Oklahoma,                       On prescriber’s order.
Rhode Island, West Virginia     Limited to certain adult vaccines. (RI – And flu vaccines for children ages nine and older.)
Utah                            For inpatient pharmacist via institutional protocol only pursuant to the Division of Occupational and
                                Professional Licensing approved vaccine protocol.
Washington                      The definition of the “practice of pharmacy” includes “drug administration.” (WA – Definition also includes
                                the monitoring of drug therapy and use and the initiation or modification of drug therapy in accordance
                                with written guidelines or protocols in a previously established collaborative drug therapy agreement
                                between a pharmacist and practitioner authorized to prescribe drugs.)
Washington                      If appropriately certified bases upon the 12-hour Centers for Disease Control and Prevention training
                                program, the pharmacist can initiate vaccinations pursuant to a collaborative drug therapy agreement.
Wisconsin                       Yes, if requirements for coursework and insurance are met.

Wyoming                         Age 7 and older for certain vaccines.

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