Arguments still rage over vaccinations at pharmacies, but has the horse already bolted?
In the United States, the tipping point came when fears of the looming H1N1 swine-flu pandemic in 2009 pushed many states to allow pharmacists to administer flu vaccinations for the first time.
The practice has since expanded rapidly to cover all 50 American states, a turnaround from only 14 in 1996. According to the US Centers for Disease Control and Prevention, more than 20% of flu shots in the US are now performed in non-medical settings, such as pharmacies and supermarkets.
Australia’s tipping point has not been so well defined by a pandemic threat, but it is clearly happening in our time.
In June, Victoria became the last state in the federation to open the way for vaccinations by pharmacists, permitting them to vaccinate for pertussis as well as influenza, with stipulations the pharmacists must have completed a recognised study program, hold a recent first-aid and CPR qualification, and have a similarly qualified colleague on site.
Now comes a landmark report from Curtin University on a Western Australian trial that looked at 15,621 flu vaccinations performed at 76 WA pharmacies between March and October in 2015, primarily to measure safety aspects.
The study found there had not been a single major adverse event, such as anaphylaxis, and less than 1% of patients reported minor reactions.
It also revealed a sizeable proportion of patients – 12% to 17% at various locations – had paid for the vaccine despite being eligible for a free vaccination at a GP clinic, and that a high percentage of vaccinations were delivered by pharmacists in rural and remote areas.
Laetitia Hattingh, a pharmacist and senior lecturer at Curtin, who led the study, said the findings showed the pharmacy-based vaccinations were safe.
She said pharmacists in the WA trial had felt confident about their training in administering the vaccine and in dealing with the mild reactions they encountered, and had followed up with affected patients to confirm they were OK.
They were also required to advise patients’ GPs of the vaccination record by mail or fax.
“In our interviews after the vaccination season, some of them felt [that interaction] had improved their relationships with local GPs,” she said. However, others also reported friction or uncooperative responses from local GPs.
The fact is, many GPs remain unconvinced that the trend to pharmacy-based immunisation is a good thing, fearing it will result in further fragmentation of primary care and lost opportunity for doctors to see and treat their patients.
Dr Andrew Kirke, Vice President of the Rural Doctors Association of Western Australia, took issue with the WA study’s reliance on self-reporting by the pharmacists.
“This is clearly flawed methodology if you wish to comment on the rate of adverse reactions. Patients could and probably did have reactions and presented elsewhere to deal with them,” Dr Kirke said.
“The rate of reactions is more a comment on the safety of flu vaccines. The fact that no major anaphylactic reactions were observed or managed does not tell us whether such a reaction could be safely managed by pharmacists and their assistants,” he said.
GPs were generally best placed to handle rare, but potentially fatal, reactions, he said.
Dr Kirke said he doubted that the WA study would change GPs’ attitudes to other health professionals moving into their professional domain under the guise of easing pressure on general practice. “Cherry-picking relatively straightforward tasks and extrapolating that this is going to help GPs is a long bow to draw,” he said.
But Professor Lisa Nissen, head of clinical sciences at the Queensland University of Technology, who led the 2014-15 pharmacy vaccination trials in Queensland, said it was time Australian doctors accepted pharmacist vaccinations were here to stay.
“The horse has already bolted. It’s a system already in place,” she said.
The WA results paralleled findings from the Queensland trial, Australia’s first, in which 15% of people who received a pharmacist-administered vaccine had never had a flu vaccine previously, Professor Nissen said. “The message really is that people valued the accessibility, being able to walk into a pharmacy and get a vaccine while they waited for a script.”
Professor Nissen said Queensland Health and other health jurisdictions were happy that pharmacists were better prepared to step up in the event of a pandemic, adding that teaching how to give vaccines was now an established component of undergraduate pharmacy courses.
“What we know from overseas experience is that having pharmacy as a collaborative partner in immunisation seems to have achieved an increase in overall immunisation of 5%,” she said.
“As word got around about the Queensland pharmacy vaccination program, there was a massive increase in patients being vaccinated in pharmacies from 14% in 2014 to 20% in 2015.”
Partly this reflected the seasonal nature of demand for flu vaccines, with GP clinics becoming swamped with patients. Another factor was that pharmacies had tended to receive supplies of flu vaccine before doctors’ clinics.
The uptake by people who usually went without a flu vaccine was amplified in rural and remote communities, where a pharmacy might serve as the regional hub and access point for other health services.
Rural Queensland pharmacist Karalyn Huxhagen told TMR the program was a “no brainer” as a safe and effective way of improving herd immunity, with particular benefits to small communities.
“Patients really appreciate it. They say they would never have made the effort otherwise.”
