Some links and readings posted by Gary B. Rollman, Emeritus Professor of Psychology, University of Western Ontario
Thursday, October 18, 2012
Vaccines at the pharmacy: States should let drugstores give shots - Slate Magazine
If you're looking for a flu shot, you can walk into a Walgreens or CVS or Rite Aid in any state and get one from a pharmacist.For the vaccine against the blistering skin condition shingles, however, you can go to a drugstore in San Francisco but not in Sioux Falls, S.D. And for the whooping cough vaccine, your options includeNashville, Tenn.,but not North Conway, N.H.;Brookline, Mass.,but not Brooklyn, N.Y.; Gainesville, Ga., but not Gainesville, Fla. Why the geographic hodgepodge?
Vaccines have long been the province of doctors, and as the role of pharmacists has expanded in the past few years, many state medical societies have fought the trend. They argue that moving shots to pharmacies disrupts the doctor-patient relationship and complicates record keeping. Hence the odd compromises: In New York state, for instance, the rules essentially tell pharmacists: influenza? Yes. Whooping cough? No.
It's time to end these silly inconsistencies. Pharmacists have played a key role in providing flu shots and are increasingly doing the same with other vaccines, making them more accessible and convenient. This is critical at a moment when whooping cough cases are surging and adult immunization rates are dismally low. Not everyone has a primary care doctor or will go to one to get their shots. Nor do all docs even offer vaccines. Pharmacists can and should be allowed to help—with all CDC-recommended adult vaccines in every state.
The push to turn pharmacists into vaccinators dates back at least to the mid-1990s. Donna Shalala, then secretary of Health and Human Services, saw it as a way to improve the country's immunization rates and pressed the American Pharmacists' Association to develop a plan, according to Mitch Rothholz, chief strategy officer for that organization.Some states already had laws on the books that allowed pharmacists to immunize people, even if these provisions were rarely used. The APhA developed a rigorous training program for pharmacists. State pharmacy associations also began to lobby their legislatures.But for years it was slow going.
And doctors' groups pushed back hard. In New York, for instance, a 2008 bill was written to authorize pharmacists to give all CDC-recommended adult vaccines, but after much wrangling, everything but flu was axed. (Even then, the Medical Society of the State of New York opposed the law.) This year, state legislators tried again, passing a law, taking effect this week, that allows New York pharmacists to administer the shingles vaccine to people who have a prescription from a doctor or nurse practitioner. But pharmacists still can't offer the whooping cough vaccine.
"I don't understand the resistance," Amy Paulin, a Democratic assembly member from Westchester who wrote both bills, told me. The answer from the medical societies is that letting pharmacists give vaccines makes health care more fractured. "Many primary care providers rely on the flu shot as a way to get patients in" for other services, like blood pressure screenings or colonoscopy reminders, Robert Hughes, president of the Medical Society of the State of New York, told me. "We're looking at it in terms of the overall quality of care." Doctors' groups also fret that if people can get their shots at pharmacies, it will be harder to keep track of who's gotten what.
But these concerns pale in comparison to the risk that without the pharmacy, a lot of people may not get their shots at all. In a perfect world, everyone would have a primary care doctor who offered long-term, holistic care. Yet some people don't have health insurance (in case you hadn't heard). And some just don't go to the doctor unless they're in dire need. "Ask any internist or family medicine doctor how many healthy men between the ages of 21 and 50 they generally see," said Elizabeth Rosenblum, a family medicine doctor at UCSD. "There is theory and there is practice." Not all doctors are keen on providing vaccines either, which require providers to make an upfront investment and then deal with storage, handling, and other logistical issues. Unlike pediatricians, who handle high vaccine volume, some adult doctors may decide that it just isn't worth it.
Pharmacies, meanwhile, operate at a high level of professionalism. Many keep their own records, give patients written receipts and sometimes even notify patients' doctors. Many states also require all vax providers to enter shots in a state registry.Yes, some people may get an extra dose by accident.But even that may not be so bad: Duplication is unlikely to cause side effects other than redness, swelling, or a passing low-grade fever, said Rosenblum.
Pharmacists are already crucial to the annual flu shot push. During the swine flu surge in 2009, the CDC recommended the pandemic vaccine for everyone 6 months of age or older. The following year, for the first time, they also recommended the seasonal flu shot to the same broad range of people. This vastly boosted demand, and pharmacists were increasingly allowed to step in. In 2006-07 they administered roughly 7 percent of adult flu shots. By last year that number was over 18 percent.Carolyn Bridges, associate director for Adult Immunizations at the CDC, says she's not sure the country could have kept up without the help of the pharmacists.
There's no shortage of work to be done on other vaccines either. A happy story: In California during the 2010 whooping cough outbreak that killed 10 babies, pharmacists and pharmacy students at UCSD offered free shots to all household contacts of newborns. They made it easy, with Saturday and evening hours in a little-used waiting room on the postpartum floor. And fully 84 percent of the newborns' family members received Tdap vaccination before the baby was discharged, according to Rosenblum. Since newborns can't receive the whooping cough vaccine themselves, this is one of the best ways to protect them.
Yet across the country, only 8.2 percent of adults got a Tdap shot, according to a survey in 2010. Rates are also disturbingly low for shingles (14.4 percent of adults age 60 and older in 2010) and for the pneumococcal vaccine, which protects against a bacteria that is a common cause of pneumonia and other infections. And so we need more states to pull pharmacists into the vaccination loop. Signs of progress: Earlier this year, Florida passed a law allowing pharmacists to administer vaccines protecting against shingles and pneumonia, Illinois allowed them to give the vaccine against whooping cough to children age 10 and older, and Massachusetts permitted them to give all CDC-recommended adult vaccines. Other states, including Washington, Connecticut, Colorado, Minnesota, and Kentucky, already do the same. But until we can stop pathogens from crossing state lines, they all need to get onboard.