ASHP (American Society of Health-System Pharmacists) respectfully submits the following statement for the record to the Senate Committee on Health, Education, Labor and Pensions (HELP) hearing on “Vaccines Save Lives: What Is Driving Preventable Disease Outbreaks?”
ASHP represents pharmacists who serve as patient care providers in acute and ambulatory settings. The organization’s nearly 50,000 members include pharmacists, student pharmacists, and pharmacy technicians. For more than 75 years, ASHP has been at the forefront of efforts to improve medication use and enhance patient safety.
ASHP’s vision is that medication use will be optimal, safe, and effective for all people all of the time. This includes the safe and effective use of vaccines to reduce preventable infectious disease. Pharmacists and student pharmacists have a role in improving public health and increasing patient access to immunizations.1 Pharmacists’ unique training and expertise in all aspects of the medication-use system can help expand patients’ access to immunizations and promote disease prevention in all practice settings. Patients in rural areas, where a pharmacy may provide the only convenient access to a healthcare professional, will benefit from increased pharmacist immunization authority.
As the HELP Committee recognizes, vaccines have and continue to save lives across the entire lifespan from infancy to late adulthood. Although the morbidity for vaccine preventable diseases (VPDs) continues to decrease, outbreaks are a reality.2 Vaccines promise the potential eradication of certain infectious diseases; however, research indicates ecological obstacles (e.g., limited access to vaccines) and social barriers (e.g., vaccine refusal) limit eradication efforts as VPD incidence decreases.3 For example, lack of adherence to CDC recommendations for polio, measles, and smallpox vaccines results in a plateaued effect over time as the incidence of disease falls but never reaches full eradication.4 Pharmacists are educated and prepared to assist in breaking down vaccine adherence barriers such as patient access to vaccines and patient education of the personal and public health benefits of vaccination. In this statement, we propose five suggestions for improving vaccination rates and preventing disease outbreaks.
BROADEN PATIENT EDUCATION AND SCREENING
In an age in which healthcare information is readily available online, patients and caregivers often give preference to internet search engines and family members as sources of information on vaccines, rather than healthcare professionals.5 It is the healthcare professional, however, who has the most accurate information related to vaccine safety, efficacy, and public health benefits. Critical factors in influencing a patient or caregiver to vaccinate include:
- Trusting the healthcare provider.
- Feeling satisfied by the discussion.
- Understanding that vaccination is part of the cultural norm.
- Believing in the social contract of herd immunity.
- Having positive past experiences with vaccinations, and wanting to prevent disease.6
These factors represent an enormous opportunity for patient education and screening by the healthcare team, including pharmacists. It is crucial that all healthcare professionals take into consideration a patient’s situation and concerns while offering counseling. Through resources and a supportive infrastructure, pharmacists can increase awareness of an important public health issue.
EXPAND PHARMACIST AUTHORIZATION TO INITIATE AND ADMINISTER ADULT AND PEDIATRIC IMMUNIZATIONS
The pharmacist’s ability to offer vaccines in ambulatory and community settings increases immunization rates and improves vaccine timeliness.7 Despite this, pharmacists are an underused resource for vaccine administration. Although all states permit pharmacist administration of some vaccines, state laws differ in the range of vaccines pharmacists may administer and in the patient populations they are permitted to vaccinate. ASHP advocates at a state level for a standardization of pharmacy immunization practice within and among states; pharmacists and student pharmacists who have completed a training and certification program that is acceptable to state boards of pharmacy and that meets the standards established by the Centers for Disease Control and Prevention (CDC) may provide such immunizations.8 Pharmacists and student pharmacists who undergo appropriate training and certification should be authorized by state boards to provide immunizations. To ensure their consistency and quality, those training and certification programs should meet CDC standards.
ESTABLISH INTEROPERABLE IMMUNIZATION REPORTING PROGRAMS
To aid in sharing important patient immunization information, ASHP advocates for the use of centralized databases of patient immunizations. All authorized immunization providers, including pharmacy personnel, should be required to document immunizations in those databases when they become available.8 In addition, patient immunization databases should contain real-time information and be interoperable with health information systems, public health entities, and pharmacy software. This interoperability would enable efficient sharing of standardized information among healthcare providers, aiding in care coordination and ensuring continuity of care with immunization schedules.
PROVIDE AUTHORITY FOR ACUTE INFECTIOUS POC TESTING AND INITIATION OF THERAPY
Point-of-care (POC) testing is a diagnostic test that occurs at the time and place of patient care, offering ease and efficiency of diagnosing infectious diseases with limited infrastructure.9 It is available for use at any healthcare facility to enable rapid infectious disease patient care decisions and outbreak containment. Many of the POC tests are waived under the Clinical Laboratory Improvement Amendments (CLIA) of 1988 and can therefore be offered in pharmacies by trained pharmacy personnel. For example, a patient experiencing influenza-like symptoms can visit a local pharmacy and undergo POC diagnostic testing; if an influenza infection is affirmed, the pharmacist would initiate antiviral therapy in accordance with state and federal authorizations. ASHP supports providing pharmacists the authority to offer POC testing and initiate antiviral therapy as necessary to contain the spread of outbreaks.
EXPAND INFECTIOUS DISEASE SURVEILLANCE
Surveillance is critical to public health and must be supported by adequate infrastructure. Leadership and technical assistance from the CDC are essential to developing, deploying, and sustaining surveillance systems. Real-time, integrated, and interoperable surveillance systems must be accessible to all healthcare providers to input and access data. Improvements in surveillance efforts and capabilities will enable rapid response to outbreaks, support research of infectious diseases trends, and inform public health decisions.10 Pharmacists and pharmacy personnel can support local and national infectious disease surveillance to a greater extent than they are authorized currently. Policies that authorize and support pharmacist and pharmacy technician access to local and national infectious disease surveillance data, as well as the ability to enter data into infectious disease surveillance systems, must be implemented.
CONCLUSION
Pharmacists are the most accessible patient care providers, working on the frontlines of patient care across the continuum of care. Pharmacists have expertise and experience in managing vaccines throughout the medication-use cycle, spanning from vaccine procurement, storage, and administration to patient and prescriber education. Pharmacists embrace their roles as trained immunizers and are prepared to do more to educate on, screen for, and administer vaccines in their communities. In addition, pharmacy personnel should be enabled to do more in responding to disease outbreaks such as initiating the appropriate therapy and reporting surveillance data.
ASHP thanks the Senate HELP Committee for holding this important hearing. ASHP remains committed to working with Congress and industry stakeholders to ensure that patients have affordable access to lifesaving and life-sustaining medications.
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1 ASHP Policy 1309, Pharmacist Role in Immunizations
2 National Center for Immunization and Respiratory Diseases. Historical Comparisons of Vaccine-Preventable Disease Morbidity in the U.S. Available at: https://www.cdc.gov/vaccines/ed/surv/downloads/VPD-morbidity-slide1-mmwr-508.pdf. Accessed 23 February 2019.
3 Saint-Victor DS, Omer SB. Vaccine refusal and the endgame: walking the last mile first. Philos Tran R Soc Lond B Biol Sci. 2013; 368(1623):20120148.
4 Phadke VK, Bednarczyk RA, Salmon DA, Omer SB. Association between vaccine refusal and vaccine-preventable diseases in the United States: A review of measles and pertussis. JAMA. 2016;315(11): 1149-1158.
5 Weiner JL, Fisher AM, Nowak GJ, et al. Childhood immunizations: First-time expectant mothers’ knowledge, beliefs, intentions, and behaviors. Am J Prev Med. 2015. 49(6 Suppl 4):S426-S434.
6 Benin A, Wisler-Scher D, Colson E, et al. Qualitative analysis of mothers’ decision making about vaccines for infants: The importance of trust. Pediatrics. 2006; 117: 1532-1541.
7 Higginbotham S, Stewart A, Pfalzgraf A. Impact of a pharmacist immunizer on adult immunization rates. J Am Pharm Assoc. 2003; 2012. 52(3): 367-371.
8 ASHP Policy 1309, Pharmacist Role in Immunizations
9 Kozel TR, Burnham-Marusich AR. Point-of-care testing for infectious diseases: Past, present, and future. J Clin Microbiol. 2017; 55(8): 2313-2320.
10 Hyde TB, Andrus JK, Dietz VJ, et al. Critical issues in implementing a national integrated all-vaccine preventable disease surveillance system. Vaccine. 2013; 31(3): C94-C98.