1.24: Immunizing during a pandemic- considerations for COVID-19 vaccinations
At the end of this case, the student pharmacist should be able to:
- Discuss the impact of COVID-19 vaccinations on public and global health
- Describe the role of the pharmacist in the acquisition, administration, patient education, and counseling of COVID-19 vaccines
- List strategies for improving access to immunizations, specifically the COVID-19 vaccine
- Identify requirements for pharmacists who provide immunization services
- Examine partnerships with immunization stakeholders to promote COVID-19 vaccination
Introduction
Pharmacists have served as frontline workers throughout the COVID-19 pandemic, playing a vital role in providing both the COVID-19 vaccine and COVID-19 testing to expand access. 1,2 Additionally, other public health contributions of pharmacists may apply to COVID-19 vaccinations, such as health promotion efforts (e.g., addressing vaccine hesitancy), health education, patient counseling, concurrent point-of-care testing, and screenings. 3 Since the American Pharmacists Association (APhA) Pharmacy-Based Immunization Delivery training program started in 1996, pharmacists have provided immunizations, 4 making them well-suited to take on this role during a pandemic. The program offers the necessary training for pharmacists to develop the skills needed to administer vaccines, provide patient education (i.e., addressing factors related to vaccine hesitancy), and serve as an advocate for available vaccinations. Since 2009, all 50 states have allowed pharmacists to administer vaccinations with their authority limited by the laws and regulations governing each state. 4,5
Given the unique circumstances of the ongoing pandemic, pharmacists in the United States have seen their authority to administer vaccinations broadened in various ways. As of August 2020, pharmacists were authorized to provide a COVID-19 vaccine, when available, to patients three years of age and older. 6 At the same time, all state-licensed pharmacists and pharmacy interns were given the authority to order and administer vaccines for patients aged three through 18 years. 7 The Centers for Disease Control and Prevention (CDC) also provided guidance for pharmacists and pharmacy technicians in community pharmacies during the COVID-19 response, including routine clinical services such as vaccinations. In February 2021, the Federal Retail Pharmacy Program launched its first phase, in which pharmacies across the country could provide the COVID-19 vaccine to eligible individuals. This public-private partnership aims to expand access to vaccines for the American public. 8,9 Such a program highlights the role of pharmacists in mass vaccination efforts during a public health emergency, given their training in vaccine administration, vaccine education, patient counseling, and their rapport and access among the public. Pharmacists also participate in appropriate handling and acquisition of the vaccine supply, particularly in the preservation of the cold chain for many vaccines, including COVID-19 vaccines. 10 Pharmacists may advise using available resources on proper storage of vaccines, equipment selection to preserve the cold chain (e.g., maintenance of temperature in transport/receipt of vaccine, freezer and refrigerator temperatures), handling of temperature excursions, beyond use dating (BUD), and appropriate documentation practices as specified by current information from the CDC. 11
Beyond the COVID-19 pandemic, it is also essential to understand pharmacists’ roles worldwide during emergencies more generally. Pharmacists’ roles seek to reduce the potential for patient harm and hardship with focusing historically on medical supply activities in emergent situations such as pandemics, manmade, or natural disasters. 11 Described extensively in a 2006 International Pharmaceutical Federation (FIP) Statement of Professional Standards, these roles include vaccination services and many other services. 12-14
Case (part 1)
You are a pharmacist in a local community pharmacy. A patient comes into your pharmacy seeking advice about reducing his risk of contracting the COVID-19 virus.
CC: “I’m nervous about getting this virus.”
Patient: FM is a 62-year-old male (68 in, 130 kg). His primary care physician told him that he is at risk for severe illness related to COVID-19. He presents to the pharmacy today to pick up some refills for his medications.
PMH: HTN; T2DM; coronary artery disease
Medications:
- Aspirin 81 mg daily
- Amlodipine 5 mg daily
- Lisinopril 20 mg daily
- Metoprolol succinate 50 mg daily
- Metformin 1000 mg twice daily
Additional context: FM is a software engineer, which has allowed him to work from home during the pandemic. He has been wearing a mask and washing his hands frequently, but unfortunately, has not seen his children and grandchildren in almost a year. He is divorced from his husband.
Case Questions (part 1)
- What are some components of FM’s past medical history that put him at risk for severe illness? What are other risk factors (other than the ones FM has) that may increase a patient’s risk of developing severe illness from COVID-19?
- What are some ways that patients can protect themselves from getting COVID-19? If in-person visits with family and friends occur, what are some ways patients can help protect themselves and their loved ones?
- In addition to taking precautions to limit contracting COVID-19, what other advice would you give to FM regarding self-care during a pandemic situation?
Case (part 2)
You are a pharmacist in a local community pharmacy. FM returns to your pharmacy a month after your initial conversation, and after Pfizer and Moderna received emergency use authorization (EUAs) from the FDA.
CC: “I heard about these new vaccines, but what’s this mRNA thing?”
Patient: FM’s grandson’s second birthday is coming up in a couple of months, and he desperately wishes to see him if possible. He has heard about the new vaccines and wonders about this new technology. FM shares his concerns that the vaccines were rushed and that they have not been appropriately tested. Additionally, he has been told the vaccines utilize new technology – something called mRNA – that he doesn’t understand. He has received other vaccines in the past (e.g., his influenza vaccine this past Fall) but worries the COVID-19 vaccines could be harmful. FM is anxious about what the new vaccine means but is excited about the prospect of being immunized so he can see his children and grandchildren again.
Case Questions (part 2)
- How would you explain to FM (someone with no medical background) the way mRNA vaccines work?
- How would you address FM’s concerns related to the timing of the vaccines’ development? What information can you provide about safety/efficacy and the process for vaccine development during a global pandemic?
- Vaccine hesitancy is a common barrier to vaccination campaigns during times of crisis. What are some ways that pharmacists can help decrease this barrier and thus, increase vaccination rates in communities?
Case (part 3)
During your conversation with FM, you mention that as the vaccines start becoming available pharmacies and pharmacists will likely administer the vaccines, which means he may get his vaccine at the pharmacy when he is eligible. FM did not realize that vaccines, especially the new COVID-19 vaccines, would be available at pharmacies or that pharmacists are allowed to vaccinate.
CC: “I didn’t realize pharmacists had anything to do with this.”
Case Questions (part 3)
- Pharmacists must achieve competency to provide vaccine administration. What are some of the skills that must be covered through these training programs?
- Describe some ways in which pharmacists can help increase access to vaccinations for the general public through collaboration with public health or community partners, particularly in areas where patients may otherwise have difficulty accessing immunizations?
Case (part 4)
FM calls the pharmacy a couple of weeks later with more questions about the COVID-19 vaccinations.
CC: “I just want to get the vaccine so that my life can go back to normal.”
HPI: Despite his careful consideration, FM is confused by all of the information in the news surrounding who is eligible for the vaccine. He does not believe he is eligible yet, but he has been told by friends in other states that they are already eligible for the vaccine even though they are younger than him and do not seem to be at higher risk. He is frustrated that this can be true and wants to know how to find out when he is eligible. Additionally, he expresses anger at wasting his time trying to Google how to sign up for a vaccine and not finding any information. He is confused as to whether he is supposed to contact his primary care provider to sign up for a vaccine or do it on his own. FM also expresses concern that if he is to find a way to get a vaccine on his own, he doesn’t know where to start. Is he supposed to get one at his doctor’s office, through the local hospital, or at the pharmacy like you previously mentioned? He wants to know if he could just come to your pharmacy. FM is overwhelmed and asks you to help direct him to understand eligibility criteria and the best way to find information on where he can register. He would like to get the vaccine as soon as possible.
Case Questions (part 4)
- What resources can a pharmacist refer to in seeking information related to current immunization schedules and guidance for COVID-19 vaccinations?
- List some resources that pharmacists could make available to patients seeking guidance on safety and efficacy of the COVID-19 vaccine.
Author Commentary
As the novel coronavirus spread worldwide in 2020 and countries looked to potential vaccine development, a significant concern in the United States was whether a large enough workforce existed to administer COVID-19 vaccinations once they were available. A key component to increasing access to the vaccine, particularly in medically underserved communities where easy access to a primary care provider may not exist, is utilizing existing pharmacies and the pharmacy workforce. Additionally, members of underserved communities may have unique transportation issues, and in these circumstances, easy access to a local pharmacy may increase access to vaccination sites. The use of mobile clinics can further enhance access and address barriers such as transportation. 15,16 Pharmacists can also help establish vaccination sites and expand access to care by completing an immunization delivery training program. The expertise pharmacists gain can be leveraged to deliver immunization services in compliance with legal and regulatory standards, communicate effectively with stakeholders, and provide knowledge on supply chain logistics related to vaccine supply.
The pharmacists’ role in expanding the vaccination effort of routine immunizations and the COVID-19 vaccine amidst the pandemic should not be understated. For example, pharmacists can aid with vaccine dilution, preparation, and administration, as well as play a vital role in the storage and transport of vaccinations. This is particularly true for COVID-19 vaccinations that require a cold chain with ultra-cold freezers. 17,18 Their unique access to the public, patients’ trust, knowledge of available vaccines, and training in vaccine administration place them in a prime position to serve in this role. Pharmacists in various settings are at the forefront of expanding vaccine access, both for routine immunizations and during emergencies, to the general population.
Patient Approaches and Opportunities
Pharmacists are one of the most accessible healthcare professionals in the United States, with over 90% of Americans living within five miles of a pharmacy in 2015. 19 Moreover, pharmacist involvement in providing immunizations is not a new concept, with many adults getting their annual influenza vaccine at a local pharmacy annually. Evidence shows that adults who do not get their influenza vaccine in medical settings, such as doctors’ offices and hospitals, often receive them at a pharmacy or workplace. 20 During the pandemic, pharmacies remained open, and pharmacists served as accessible health professionals providing in person access and vital information.
Throughout a pandemic, pharmacists play an important role in expanding access to vaccines, as well as providing other services such as testing, disease education, telepharmacy, and medication counseling often through collaborative practice agreements. 21 Pharmacists may play a role in addressing health system disparities and access barriers caused by structural injustice, discrimination, socioeconomic factors, and historical mistrust of the health system. 22-24 They must recognize causes of vaccine hesitancy and distrust, such as abuses of biomedical sciences, lack of insurance, vaccine related factors (i.e., cost and availability), transportation challenges, language barriers, and social factors (e.g., immigration status). 22-24 To address language barriers and health inequities, strategies include more targeted outreach efforts, and more robust language translation resources. Partnerships should be fostered with trusted civic community leaders/organizations, particularly in areas heavily impacted by COVID-19, to foster relationship building and trust in efforts to reduce vaccine hesitancy and access issues. 25,26 Materials with clear messaging in multiple languages should be available.
Other chapters of interest:
- Deciphering immunization codes: making evidence-based recommendations
- Getting to the point: importance of immunizations for public health
- Anticipating anthrax and other bioterrorism threats
- Staying on track: reducing missed immunization opportunities in the pediatric population
External resources:
- APhA Pharmacy-Based Immunization Delivery training. https://pharmacist.com/Education/Certificate-Training-Programs/Immunization
-
CDC General Resources:
- COVID-19 vaccination toolkits. https://www.cdc.gov/vaccines/covid-19/toolkits/index.html
- COVID-19: people with certain medical conditions. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fneed-extra-precautions%2Fgroups-at-higher-risk.html
- Vaccines for COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html
- COVID-19 vaccination: clinical resources for each COVID-19 vaccine. https://www.cdc.gov/vaccines/covid-19/index.html
-
Explanation of how vaccines work:
- The New York Times. How the Pfizer-BioNTech mRNA vaccine works. https://www.nytimes.com/interactive/2020/health/pfizer-biontech-covid-19-vaccine.html
- The New York Times. How Moderna’s vaccine works. https://www.nytimes.com/interactive/2020/health/moderna-covid-19-vaccine.html
- Centers for Disease Control and Prevention. Understanding mRNA COVID-19 vaccines. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/mrna.html
-
Emergency Use Authorization (EUA) fact sheets:
- Food and Drug Administration. Pfizer-BioNTech COVID-19 vaccine. https://www.fda.gov/media/144414/download
- Food and Drug Administration. Moderna COVID-19 vaccine. https://www.fda.gov/media/144638/download
-
Vaccine access/equity:
- VaccineFinder. https://vaccinefinder.org/
- Centers for Disease Control and Prevention. Ensuring equity in COVID-19 vaccine distribution. https://www.cdc.gov/vaccines/covid-19/planning/health-center-program.html
- Centers for Disease Control and Prevention. Communication toolkit: for migrants, refugees, and other limited-English proficient populations. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/communication-toolkit.html
References
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- Hedima EW, Adeyemi MS, Ikunaiye NY. Community pharmacists: on the frontline of health service against COVID-19 in LMICs. Res Social Adm Pharm 2021;17(1):1964-1966.
- Aruru M, Truong HA, Clark S. Pharmacy Emergency Preparedness and Response (PEPR): a proposed framework for expanding pharmacy professionals’ roles and contributions to emergency preparedness and response during the COVID-19 pandemic and beyond. Res Social Adm Pharm 2021;17(1):1967-1977.
- Terrie YC. Vaccinations: The expanding role of pharmacists. Pharmacy Times 2010;76(1). https://www.pharmacytimes.com/publications/issue/2010/January2010/FeatureFocusVaccinations-0110 . Accessed April 9, 2021.
- American Society of Health-System Pharmacists. ASHP guidelines on the pharmacist’s role in immunization. Am J Health-Syst Pharm 2003;60:1371-7.
- Department of Health and Human Services. Trump administration takes action to expand access to COVID-19 vaccines. September 9, 2020. https://www.hhs.gov/about/news/2020/09/09/trump-administration-takes-action-to-expand-access-to-covid-19-vaccines.html . Accessed September 25, 2020.
- US Department of Health and Human Services. HHS expands access to childhood vaccines during COVID-19 pandemic. August 19, 2020. https://www.hhs.gov/about/news/2020/08/19/hhs-expands-access-childhood-vaccines-during-covid-19-pandemic.html . Accessed September 25, 2020.
- The White House Briefing Room. Fact sheet: President Biden announces increased vaccine supply, initial launch of the federal retail pharmacy program, and expansion of FEMA reimbursement to states. February 2, 2021. https://www.whitehouse.gov/briefing-room/statements-releases/2021/02/02/fact-sheet-president-biden-announces-increased-vaccine-supply-initial-launch-of-the-federal-retail-pharmacy-program-and-expansion-of-fema-reimbursement-to-states/ . Accessed February 7, 2021
- Centers for Disease Control and Prevention. Understanding the federal retail pharmacy program for COVID-19 Vaccination. 2021. https://www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/index.html . Accessed February 7, 2021.
- Bushell M. Cold chain management and vaccines. Australian Pharm; Clin Profess Devel Modul 2020:32-41.
- Center for Disease Control and Prevention. COVID-19 Vaccination. 2021. http://www.cdc.gov/vaccines/covid-19/index.html . Accessed May 15, 2021.
- Alkhalili M, Ma J, Grenier S. Defining roles for pharmacy personnel in disaster response and emergency preparedness. Disaster Med Public Health Prep 2017;11(4):496-504.
- International Pharmaceutical Federation. FIP Statement of Professional Standards: The Role of the Pharmacist in Crisis Management: Including Manmade and Natural Disasters and Pandemics. 2006. https://www.fip.org/www/uploads/database_file.php?id=275&table_id= . Accessed May 24, 2021.
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- Chen KL, Brozen M, Rollman JE, et al. How is the COVID-19 pandemic shaping transportation access to health care? Transp Res Interdiscip Perspect 2021; 12:100338.
- Centers for Disease Control and Prevention. Pfizer-BioNTech COVID-19 vaccine storage and handling summary. 2021. https://www.cdc.gov/vaccines/covid-19/info-by-product/pfizer/downloads/storage-summary.pdf . Accessed March 21, 2021.
- Centers for Disease Control and Prevention. Moderna COVID-19 vaccine storage and handling summary. 2020. https://www.cdc.gov/vaccines/covid-19/info-by-product/moderna/downloads/storage-summary.pdf . Accessed March 21, 2021
- Bach AT, Goad JA. The role of community pharmacy-based vaccination in the USA: current practice and future directions. Integr Pharm Res Pract 2015;4:67-77.
- Centers for Disease Control and Prevention. National and state‐level place of flu vaccination among vaccinated adults in the United States, 2014-15 flu season. 2018. https://www.cdc.gov/flu/fluvaxview/place-vaccination-2014-15.htm . Accessed March 21, 2021.
- Adunlin G, Murphy PZ, Manis M. COVID‐19: How can rural community pharmacies respond to the outbreak? J Rural Health 2021;37(1):153-155.
- Silva C. It’s life and death: non-English speakers struggle to get COVID-19 vaccine across the US. 2021. https://www.usatoday.com/story/news/nation/2021/02/22/covid-19-vaccine-registration-non-english-speakers-left-behind/4503655001/ . Accessed April 9, 2021.
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- Bibbins-Domingo K, Petersen M, Havlir D. Taking vaccine to where the virus is—equity and effectiveness in coronavirus vaccinations. JAMA Health Forum 2021;2(2): e210213-e210213.
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