Pharmacists as vaccination providers

Bill 41, an act to extend the role of pharmacists in Quebec, was passed by the National Assembly on December 8, 2011.1 Implementation was slated to begin in September of this year but has been delayed. Once the bill is enacted, pharmacists will be allowed to renew and adjust prescriptions, prescribe and substitute medications under certain conditions and order laboratory analyses for monitoring purposes.1 Unfortunately, the injection of vaccines has been limited to educational demonstrations only.1 This is a far cry from the United States, where by 2009, all 50 states had granted pharmacists the right to vaccinate.2 This is also a step behind Alberta, British Columbia, Manitoba, Ontario, New Brunswick and Nova Scotia, which have all rolled out pharmacist-administered vaccination schemes.3 Although regulations vary by state or province, at bare minimum, community pharmacists in these jurisdictions are allowed to provide the influenza vaccine to adults. With extended opening hours and drop-in services with short wait-times, pharmacists are in an excellent position to increase accessibility.4 The evidence clearly illustrates that states that first allowed pharmacists to immunize have significantly better flu shot coverage.5,6 Pharmacists are also effective patient educators; several studies have indicated that pharmacists’ recommendations can lead to better vaccination outcomes, even compared with traditional care.7-9 Moreover, pharmacists’ impact on vaccination rates is especially important in rural and medically underserved areas, which are often disproportionately affected by vaccine-preventable diseases.5,10,11 Despite the evidence, Bill 41 intentionally omitted this service. The Federation des medecins omnipracticiens du Quebec (FMOQ) commented: On the issue of vaccination, complications after injection are still possible and it is essential to properly assess the patient, conduct clinical monitoring after vaccination and to provide emergency treatment, if necessary. Only doctors and nurses have the training and skills to take such actions.12 This statement ignores the fact that pharmacists are only allowed to vaccinate after having received appropriate training. In Canada, certification is typically achieved by completion of either the Canadian Council on Continuing Education in Pharmacy’s (CCCEP) accreditation or another course approved by the provincial pharmacy organization.13-16 Furthermore, all pharmacists wishing to vaccinate are required to provide proof of current CPR and first aid certification.13-16 Additional safety measures include the requirement to recertify every few years, the need to submit an annual declaration of competency, or both.13,15-17 These precautions, if followed closely, can lead to the successful use of pharmacists as regular immunizers; a pharmacy chain in the United States reported no serious injection site or allergic reactions following almost 20,000 injections.18 In addition to safety, several other concerns have been raised. Fragmentation of care is one of the main reasons why doctors are hesitant to refer their patients to a pharmacist.19 This issue will be difficult to reconcile until patient information is available on electronic health records.20 For the time being, patients receive paper immunization records for their vaccination booklet and some public health data are collected. For example, in British Columbia, pharmacists keep records in their electronic database, and for some immunizations, like influenza, they report aggregate injection data to local health authorities. Additionally, pharmacists must report adverse events following immunization.21 Another issue commonly cited by the medical community is the risk that pharmacists will be motivated by economic interests if they sell and administer vaccines. However, pharmacists who choose to vaccinate do so out of an interest in public health and not because it represents a fiscal opportunity; in contrast, remuneration is often considered to be inadequate and a barrier to providing vaccines.22 Demands for pharmacists to vaccinate are coming from pharmacists and their clients. A 2010 survey by the Institut national de sante publique du Quebec (INSPQ) found that nearly half of pharmacists would be interested in vaccine injection.23 Similarly, when Ipsos Reid conducted a poll to determine Canadian perspectives on expanding pharmacy services, individuals from Quebec were most likely to support having “trained pharmacists administer doctor-prescribed vaccines.”24 With influenza coverage in the province being the lowest in Canada in 2011, it appears that patients in Quebec have good reason to want their pharmacists to vaccinate.13 Although the concerns that physicians raise may be well intended, there is an undeniable “territory” struggle. As Diane Lamarre, head of the Ordre des pharmaciens du Quebec (OPQ), remarked, vaccinations were left out of Bill 41 negotiations because of their potential to cause friction between health professional groups. However, given that these groups are dedicated to improving the health of individuals, they must learn to check their vested interests at the door. ■

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