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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.
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