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PHARMACY-BASED IMMUNIZATION DELIVERY:INCREASING ADULT VACCINATION RATES IN THE PHILIPPINESHaniah N. Marohomsalic

Immunization is the act of injecting vaccines to a patient to induce his/her immunity against certain diseases, most of which are communicable (Immunization: The Basics, 2014). Vaccines, or suspensions of whole or part of microorganisms (The College of Physicians of Philadelphia, 2014), were considered to be one of the breakthroughs of the 20th century due to significant reductions in incidences, and even eradication, of vaccine-preventable diseases worldwide (Ten Great Public Health Achievements, 2013). However, despite being well-studied and highly beneficial, vaccination remains unacceptable to some populations due to safety and efficacy issues, as implied by low immunization rates especially among the adults (Office of Disease Prevention and Health Promotion [ODPHP], 2015). Healthy People 2020 states that the recommended immunization rate for adults ages 18-64 should be 80%, and 90% for older adults. Immunization rates are increasing, but ideal statistics are yet to be accomplished (Taitel, Cohen, Terranova, Baloun, Kirkham, Duncan, & Pegus, 2011).Physicians and nurses are two of the common immunizers among the healthcare team. But due to expected sudden increase in demand for vaccines after the swine flu pandemic, there had been efforts to increase vaccination rates by involving pharmacists in the US (Wick, 2006). Pharmacists in clinical setting are responsible for most processes involving medical products such as vaccines, from choosing the best therapy up to post-administration monitoring for adverse drug reactions (American Association of Colleges of Pharmacy [AACP], 2015). Because of their expertise, along with other perceived advantages such as higher accessibility, the concept of immunizing pharmacists began to gain acceptance from the US population (Taitel et al., 2011) However, since immunization is already a niche for other health care professionals, studies explore on perceptions of other health care professionals on pharmacy-based immunization programs, particularly those of the physicians perspective. While community pharmacists in the US have already been involved in vaccination for 19 years now (Hogue, Grabenstein, Foster, & Rothholz, 2006), the Philippines has not yet experienced this service. The Philippine Food and Drug Administration recently released FDA Advisory No. 2014-067 which states that they community pharmacists will soon be allowed to administer adult vaccinations after training and special authorization. The training course will include five modules and a practicum, and will be facilitated by a licensed immunizing pharmacist (Hartigan-Go, 2014). But researchers will still have to find out if pharmacy-based immunization delivery will work out in Philippine setting, considering the present curriculum of pharmacy schools in the Philippines and level of acceptance from patients and other health care professionals.The training will soon commence and bring out competent immunizing pharmacists, but the question remains on whether pharmacy-based immunization delivery will be acceptable to Filipino patients and other health care professionals. In other countries, there had been increased interest in studying work dynamics among pharmacists, other health care professionals, and patients (Blake, Blair, & Couchenour, 2012; Njoku et al., 2013; Papastergiou, Folkins, Li, & Zervas, 2014; Hurley et al, 2014). However, since the service has not yet been implemented in the country, there are no available studies using the Philippine setting. This paper attempts to defend the applicability of pharmacy-based immunization delivery in Filipino communities by stating perceived advantages based on studies done in countries previously employing the service. This will be followed by a list of possible barriers to implementing the service in the Philippine setting. These barriers will then be refuted by stating some efforts done by certain authorities to improve the pharmacy practice, in preparation to this service.While the idea of having immunizing pharmacists is still at its conception here in the Philippines, it has already been extensively studied in other countries. Pharmacists around the world have been vaccinating patients for over 10 years now and the controversy in having non-physician immunizers resulted to many studies regarding their ability to support national health goals. Some good points established regarding pharmacy-based immunization include greater accessibility of information regarding vaccines and higher savings for the patient.Greater accessibility of vaccine information in one advantage of pharmacy-based immunization delivery. Pharmacists can facilitate comprehensive patient counselling sessions almost anywhere making them the most accessible among healthcare professionals (Terrie, 2010). Many factors play in when it comes to information accessibility, and among them are the length of time dedicated to information dissemination and position of information source.The length of time dedicated for information dissemination is longer from a pharmacist. In addition to their extensive knowledge about drug products, pharmacists are also available for longer periods due to longer operation hours of pharmacies compared to regular clinics (Pharmacists as Immunization Providers, 2011). Many pharmacies here in the country are open for even up to 24 hours, some even during holidays. Private clinics, on the other hand, are often available only during weekdays, and most of those days cannot be dedicated to vaccination counselling since an appointment with a doctor requires pre-scheduling. In addition, pharmacists spend as much time as needed in explaining the patients medications (Bounthavong et al., 2010), in contrast to quick doctor visits since medical doctors have limited time to stay in the clinics and many of them have to reach a certain number of patients, or the quota, depending on the policies of the hospital or clinic administration (Rabin, 2014).Aside from being available for longer hours, another advantage of having pharmacists as immunizers is that pharmacies are located strategically closer to communities with the target population, or those at high-risk of infectious diseases (Ko et al., 2014). Compared to a regular clinic or a hospital, it is easier to find a pharmacy since they are very abundant (Reyes, Lavado, Tabuga, Asis, & Datu, 2011). They are also visibly poised nearer to residential areas. Here in the Philippines, some pharmacists even know their regular customers because of greater contact with these people. The level of familiarity and frequency of contact between pharmacists and the target population makes community pharmacy a good venue for appraisal of immunization.While accessibility of vaccine products and information is increased, the cost of vaccination, on the other hand, is decreased after implementation of pharmacy-based immunization delivery. The American Pharmacists Association and Academy of Managed Care Pharmacy affirms that pharmacy-based immunization is not only cheaper, but also cost-effective (American Pharmacists Association & Academy of Managed Care Pharmacy [APhA & AMCP], 2011). A cost effectiveness analyses done in 2011 revealed that aside from greater immunization coverage, getting vaccinated by a pharmacist would result to savings of up to $6 per vaccine due to removal of expenses related to getting sick such as hospitalization, outpatient visits to the doctors, self-medication, absenteeism or decreased in productivity at work, and death (Duncan, Taitel, Zhang, & Kirkham, 2012). Also, it is cheaper to purchase vaccines in bulk, making it cheaper to avail vaccine-related services from mass vaccination clinics and pharmacies than from a regular visit to a doctor (Prosser et al., 2008). Despite advantages such as high accessibility and affordability of vaccines, pharmacy-based immunization delivery still faces some barriers to implementation in the Philippines. Some studies show that patients are still hesitant to acquire their vaccine shots from a non-physician immunizer (Blake, Blair, & Couchenour, 2012). Reasons range from personal preference and patient mistrust, to lack of referrals from doctors (Njoku et al., 2013). While there are studies that point to low preference towards pharmacists, more studies prove otherwise. In a study done last 2011, findings show very high satisfaction rates among patients receiving their vaccine shots from pharmacies, particularly on the services provided and the work etiquette of pharmacists. Their survey revealed 95-99% satisfaction in relation to advice and counselling provided, the pharmacists knowledge, the perceived level of care, professionalism, courtesy/friendliness and helpfulness of the pharmacists (Pharmacists as Immunization Providers, 2011).Another study explored the level of comfort and willingness to be referred to a pharmacist in a patients perspective. Majority of patients receiving their vaccines from pharmacies reported that they were comfortable during the process, and that they wold like their family and friends to try getting their own vaccines from the pharmacists, too. What is note-worthy in this study is that if not for these immunizing pharmacists, around 21% of high-risk patients, such as immunocompromised and elderly patients, would not have been vaccinated (Papastergiou, Folkins, Li, & Zervas, 2014). This is particularly important for high-risk patients, or those patients at risk for infectious diseases such as influenza and pneumococcal infections.Another barrier that prevents pharmacy-based immunization from being implemented is poor communication among pharmacists, patient and physicians. Issues regarding inadequate documentation of vaccination history under the supervision of a pharmacist and questionable injection techniques prevent doctors from referring their patients to pharmacists. Because of this, there is less patient-pharmacist interaction (Hurley et al, 2014). In addition to lack of referrals, common Filipinos naturally have more reverence towards medical doctors compared to pharmacists because they more often associate expertise with length and level of education rather than professional experience. It is a widely accepted idea the doctor is the head of the medical team. It is the doctor who usually do referrals to other health care professionals depending on the patients needs. But medical doctors and other health care professionals only communicate through charts or medication orders in the hospital setting. The members of the healthcare team only have the slightest idea of the strengths and weaknesses of the other team members thus the lack of effective referral systems. This will make pharmacy-based immunization harder to implement in the Philippine setting, if it ever happens.In contrast poor communication stated by Hurley et al., studies prove that patients do communicate more with pharmacists through time. Counselling regarding immunization was well accepted by the patients, making vaccines more acceptable to the public (Bounthavong et al., 2010). Many patients are generally information seekers, but their search is usually limited to internet and doctor consultations. However, internet sources are often too general (Cline & Haynes, 2001) and doctor consultations too short (Rabin, 2014), thus patients are bound to look for other sources of more tailored information. Pharmacists, on the other hand, are trained specially for counselling in community setting, making the counselling process more spontaneous and tailored to specific patient needs. This is probably the reason why patients are becoming more satisfied with their interactions with the pharmacist (Bounthavong et al., 2010).In order to further enhance communication among pharmacists, patients and physicians, the Philippine pharmacy curriculum continuously evolving to include better simulations of the actual patient-physician-pharmacist interaction. Modifications in the curriculum include Objective Structured Clinical Examination (OSCE), longer internships, patient counselling courses, and Interprofessional education.In the Philippines, pharmacy curriculum include Dispensing and Patient Counseling courses, where Objective Structured Clinical Examination (OSCE) and internships were required along with lectures. This was done so future pharmacists will know not only theories and concepts of dispensing medical products, but will also have communication skills needed to talk patients into being compliant with their medication regimen, including vaccine shots. OSCE is a simulation of actual scenarios of that would require patient counselling. In undertaking such examinations, the mentors can check their students for possible areas for improvements regarding interaction with patients, thus improving the patient medication counselling process. Like the communication between pharmacists and patients, communication between pharmacists and other health care professionals is starting to progress and become more dynamic. This semester, the UP Manila College of Pharmacy started to involve its graduating students into Interprofessional Education in the community setting by working closely with students of other medical and non-medical courses to improve the health status of an assigned community. In this course, the students are required to do face-to-face communication instead of charts and notes in exchanging information. This change is expected to expand each students knowledge about the different healthcare professions, and address one of the barriers to implement pharmacy-based immunization by improving the medical referral system.To conclude, this paper has proven that pharmacists might need to be directly involved in immunization to increase the adult immunization rates here in the Philippines. This is due to many advantages that patients and physicians might benefit from pharmacy-based immunization delivery. Studies suggest that in implementing pharmacy-based immunization services, vaccination becomes more accessible, affordable and acceptable for older patients. High accessibility and acceptability can be attributed to availability of pharmacists with competent communication skills, while affordability can be attributed to savings upon removal of costs related to acquiring the disease and doctor visits. Barriers that hinder this service from being implemented in the Philippines include the alleged low patient preference towards pharmacists and poor communication between pharmacists and patients, and among healthcare professionals, particularly between pharmacists and physicians. Low patient preference has been disproved, as indicated by high satisfaction rates, high levels of comfort and willingness to be referred to immunizing pharmacists as a result of some studies. Poor communication among pharmacists, physicians, and patients are now being addressed by certain adjustments in the pharmacy curriculum such as Objective Structured Clinical Examinations (OSCE) and Interprofessional education. These findings may have implications on policies, research and education in the Philippines: researchers should explore on the actual interactions between pharmacists, physicians and patients upon implementation of the service, while the OSCE and interprofessional education can be extended to other schools aside from the University of the Philippines. These interventions are expected to help in increasing vaccination rates among adults, and decreasing incidences of vaccine-preventable diseases in the country. Certain amendments must be done to our existing professional regulatory laws to accommodate the monitoring of new roles bestowed upon pharmacists, particularly on authorization of competent pharmacists to handle and administer vaccines.

REFERENCES

American Association of Colleges of Pharmacy. (2015). Role of a Pharmacist. Retrieved from American Association of Colleges of Pharmacy: http://www.aacp.org/resources/student/pharmacyforyou/Pages/roleofapharmacist.aspxAmerican Pharmacists Association and Academy of Managed Care Pharmacy. (2011, November/December). Pharmacist-provided immunization compensationand recognition: White paper summarizing APhA/AMCP stakeholder meeting. Journal of the American Pharmacists Association, 51(6), 704-712. Retrieved from http://www.amcp.org/pharmacist_immune_compensation/Blake, E., Blair, M., & Couchenour, R. (2003). Perceptions of Pharmacists as Providers of Immunizations for Adult Patients. Pharmacotherapy, 248-254. Retrieved from http://onlinelibrary.wiley.com/doi/10.1592/phco.23.2.248.32083/abstract;jsessionid=4F4CFB24ADAA4AE05BF9FC71DEA1FDDE.f02t01Bounthavong, M., Christopher, M. L., Mendes, M. A., Foster, E. B., Johns, S. T., Lim, L., . . . Stewart, A. G. (2010, April). Measuring patient satisfaction in the Pharmacy Specialty Immunization Clinic: a pharmacist-run immunization clinic at the Veterans Affairs San Diego Healthcare System. International Journal of Pharmacy Practice, 18(2), 100 - 107. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20441119Centers for Disease and Prevention. (2013, April 26). Ten Great Public Health Achievements in the 20th Century. Retrieved from http://www.cdc.gov/about/history/tengpha.htmCenters for Disease Control and Prevention. (2014, September 25). Immunization: The Basics. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/vaccines/vac-gen/imz-basics.htmCline, R., & Haynes, K. (2001, February 13). Consumer health information seeking on the Internet: the state of the art. Health Education Research, 16(6), 671-692. doi:10.1093/her/16.6.671Duncan, I., Taitel, M., Zhang, J., & Kirkham, H. (2012). Planning influenza vaccination programs: a cost benefit model. Cost Effectiveness and Resource Allocation, 10. Retrieved from http://www.resource-allocation.com/content/10/1/10Hartigan-Go, K. Y. (2014, September 9). FDA Advisory No. 2014-067 || Food and Drug Administration (FDA) and Philippine Pharmacists Association (PPhA) Mull Plan to Authorize Community Pharmacists to Administer Vaccines. Retrieved from Philippine Food and Drug Administration: http://www.fda.gov.ph/attachments/article/192675/FDA%20Advisory%20No.%202014-067.pdfHogue, M., Grabenstein, J., Foster, S., & Rothholz, M. (2003, March-April). Pharmacist involvement with immunizations: a decade of professional advancement. Journal of American Pharmacists Association, 46(2), 179-182. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16602227Hurley, L. P., Brodges, C. B., Harpaz, R., Allison, M. A., O'Leary, S. T., Crane, L. A., . . . Kempe, A. (2014, February 4). U.S. Physicians Perspective of Adult Vaccine Delivery. Annal of Internal Medicine, 160(3), 161-170. Retrieved from http://annals.org/article.aspx?articleID=1819120&csrt=13524432661802248065Ko, K., Wade, R., Yu, H., Miller, R., Sherman, B., & Goad, J. (2014). Implementation of a Pharmacy-Based Adult Vaccine Benefit: Recommendations for a Commercial Health Plan Benefit. Journal of Managed Care Pharmacy, 273-82. Retrieved from http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=17731Madhavan, S. S., Rosenbluth, S. A., Amonkar, M., Borker, R. D., & Richards, T. (2001). Pharmacists and Immunizations: A National Survey. Journal of American Pharmacists Association, 41.Njoku, D. O., Rao, V., Bailey, M. R., Madden, M., Sitler, J. A., & Frame, T. R. (2013). Patients' Perceptions of Community Pharmacists Giving Vaccinations. Pharmacy and Pharmaceutical Sciences Commons. Retrieved from http://digitalcommons.cedarville.edu/research_scholarship_symposium/2013/poster_presentations/41/Office of Disease Prevention and Health Promotion. (2015, March 25). Immunization and Infectious Diseases. Retrieved from HealthyPeople.gov: https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseasesPapastergiou, J., Folkins, C., Li, W., & Zervas, J. (2014, Nov). Community pharmacistadministered influenza immunization improves patient access to vaccination. Canadian Pharmacists Journal, 359-365. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25364353Prosser, L., O'Brien, M., Hohman, K., Nichol, K., & Messonnier, M. L. (2008). Non-traditional settings for influenza vaccination of adults: costs and cost effectiveness. Pharmacoeconomics, 163-178. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18198935Rabin, R. C. (2014, April 21). 15-minute doctor visits take a toll on patient-physician relationships. Retrieved from Public Broadcasting Service Newshour: http://www.pbs.org/newshour/rundown/need-15-minutes-doctors-time/Reyes, C., Lavado, R., Tabuga, A., Asis, R., & Datu, M. (2011, May). A Profile of the Philippine Pharmaceutical Sector. Philippine Institute for Development Studies, 1.Taitel, M., Cohen, E., Terranova, B., Baloun, L., Kirkham, H., Duncan, I., & Pegus, C. (2011, September 16). Pharmacists as Immunization Providers: Patient Attitudes and Perceptions. Pharmacy Times. Retrieved from http://www.pharmacytimes.com/publications/issue/2011/September2011/Pharmacists-as-Immunization-Providers-Patient-Attitudes-and-PerceptionsTerrie, Y. C. (2010, January 15). Vaccinations: The Expanding Role of Pharmacists. Retrieved from Pharmacy Times: http://www.pharmacytimes.com/publications/issue/2010/January2010/FeatureFocusVaccinations-0110The College of Physicians of Philadelphia. (2014, July 31). Different types of vaccines. Retrieved from The History of Vaccines: http://www.historyofvaccines.org/content/articles/different-types-vaccinesWick, J. Y. (2006, April 1). Pharmacy-based Immunization Programs Make an Impact. Pharmacy Times. Retrieved from http://www.pharmacytimes.com/publications/issue/2006/2006-04/2006-04-5476