Feds look to pharmacists to boost childhood immunization rates

Reviewed by Emily Henderson, B.Sc.Dec 3 2020

Torey Watson is trained as a pharmacist but aims to do more than simply fill prescriptions.

Pharmax Pharmacy — a small drugstore chain where Watson works as a clinical services coordinator, about an hour and 30 minutes southwest of St. Louis — will soon allow him to offer childhood vaccines to patients without a doctor's prescription. This change came after the federal government expanded pharmacists' ability to administer routine immunizations to children as young as 3.

As a father of two young boys, Watson, 30, understands how difficult it can be to give a child a shot. Many pharmacists are accustomed to administering vaccines to adults, he said. Doing the same for children requires extra skill.

“We’re going to have parents asking questions," he said. His other thought: "Holy cow, I don’t think I can give a shot to a 3-year-old."

Federal officials are banking on pharmacists like Watson to undergo additional training and help reverse the slump in child immunization rates caused by the coronavirus pandemic. Fears over COVID-19 have led parents to avoid the doctor's office and pediatricians to curtail in-person care. As a result, many children are missing routine vaccinations.

Children who fall behind on vaccinations usually don't pose a health risk if kids around them are immunized, said Dr. Sean O'Leary, vice chair of the American Academy of Pediatrics committee for infectious diseases. However, large groups of children are now behind, and highly contagious vaccine-preventable diseases circulating in other parts of the world are only a plane ride away, he said.

"That's a big deal," he said in an email.

In August, the Department of Health and Human Services took steps to override restrictions in many states that kept state-licensed pharmacists from immunizing children.

“Today's action means easier access to lifesaving vaccines for our children, as we seek to ensure immunization rates remain high during the COVID-19 pandemic," HHS Secretary Alex Azar said in announcing the policy change.

However, challenges remain in getting pharmacists fully integrated into the nation's framework of childhood vaccinations, immunization experts said.

A key issue is that few pharmacists participate in the Vaccines for Children program, a federal initiative that purchases vaccines for the nation's neediest kids. Half of children in the U.S. receive immunizations through the program, which purchases government-recommended vaccines for kids ages 0 to 18 who are low-income, uninsured or belong to an indigenous group. Compared with last year, VFC-funded orders for vaccines overall are down 9.6 million doses as of Nov. 9, said a spokesperson from the Centers for Disease Control and Prevention. Measles-containing vaccines are down an estimated 1.3 million doses.

Weekly orders of non-flu vaccines and measles-containing vaccines have begun to rebound to levels seen last year, though the volume could again be affected if current COVID surges have a chilling effect on doctors' visits.

Without solving the issues that keep pharmacists from participating in the Vaccines for Children program, said Claire Hannan, executive director of the Association of Immunization Managers, the steps to give parents more access to immunizations through drugstores may ultimately help only Americans wealthy enough to use it.

“Yes, we have a situation with the pandemic that has caused a drop in routine vaccinations," Hannan said. "But I don’t want to see us go to a solution that is only serving those who can pay.”

Drugstores serve as a convenient access point. Nearly 90% of Americans in 2018 lived within 5 miles of a community pharmacy. In contrast, about 5% of rural counties in 2019 had no family physicians, according to a report from researchers at the University of Washington. Thirty-five percent of rural counties had no pediatricians. Additionally, KFF found over 51% of children in 2017 did not have a medical home, meaning they do not have a primary care doctor that manages their care. (KHN is an editorially independent program of KFF.)

"We need our pharmacists to be vaccinators" in order to catch children up on their immunizations, said L.J Tan, chief strategy officer at the Immunization Action Coalition, a national organization of physicians and health experts focused on vaccine education.

Congress established the Vaccines for Children program to remedy the immunization disparities uncovered by a measles epidemic in the early 1990s that killed hundreds of people. While doctors jumped on board, pharmacist engagement lags far behind.

This pattern continues. As of Oct. 6, out of nearly 38,000 participating providers, a CDC spokesperson said, about two-thirds work in private practices. Seventy-one are pharmacies.

Stephanie Wasserman, executive director of Immunize Colorado, an Aurora-based nonprofit organization, said boosting the number of pharmacists in VFC will be "a really critical piece" to the success of the federal authorization. However, "just because they can participate doesn’t mean they necessarily will jump on it" unless pharmacists think the program is well-supported and will help their business, she said.

Enrollees must adhere to strict storage and handling requirements that involve expensive thermometers and refrigerators used only for products delivered under the government program. And if there isn't enough demand, said vaccine experts, the investment may not be worth it.

For rural pharmacies, said Michaela Newell, president of the Community Pharmacy Enhanced Services Network of Missouri, the cost of paying for the equipment and personnel needed to handle the administrative work may price them out before they apply.

“I guess it hasn’t been worth the squeeze," said Hannan.

Added Newell: "I just think that the barriers right now are too high for the pharmacists to enter into it."

On the flip side, state administrators have trouble keeping up with the demands of the program, too. One study from 2019 showed limited success in getting Michigan pharmacies to administer the human papillomavirus vaccine through the Vaccines for Children program because the state's health department didn't have the personnel to conduct on-site inspections.

The strain on state resources has only grown worse during the pandemic, said Hannan.

"You can’t call them out for not having the bandwidth," said Rebecca Snead, executive vice president and chief executive officer of the National Alliance of State Pharmacy Associations. "They’ve been compromised.”

Payment also poses a challenge to recruit and maintain providers in the program, immunization experts said.

Medicaid, the government-sponsored health insurance program that offers health coverage for many of the children supported by the vaccine initiative, does not pay providers enough to cover expenses. Participating clinicians lose an average of $5 to $15 for every vaccine they administer through Vaccines for Children, according to a report from Immunize Colorado.

Pharmacists cannot deny a vaccine to eligible children if the family is unable to pay.

Some states run their Medicaid programs using a managed-care model, which may make it harder for pharmacists to get paid, the report said. Children enrolled in these programs are often required to obtain care from designated providers. If their local pharmacist is not on the list of approved providers, they may not get paid.

The possibility of little to no pay hasn't stopped pharmacist and drugstore owner Tim Mitchell from offering vaccines at his three pharmacies in Neosho, Missouri, about 30 minutes from the Oklahoma state line. He said he's been immunizing patients since the late 1990s after he realized children coming into his pharmacies were missing routine vaccinations.

"I saw it as a way to help my community," he said, "but I also saw it as a business opportunity."

Mitchell, 53, views offering vaccines as a way to stand out from his competitors and bring more customers to his pharmacies. He said he submitted the paperwork to enroll in Vaccines for Children.

Although he welcomes the federal authorization, he acknowledged that not all his peers can afford to offer the service.

"We can't work for free," said Mitchell.