Pharmacists: Partners in Improving Adult Immunization Rates We promote consumer access and coverage for pharmacists' quality patient care services. John Kidwell, 1858 Pharmacists: Partners in Improving Adult Immunization Rates

Immunization Neighborhood Collaboration, coordination, and communication among immunization stakeholders dedicated to meeting the immunization needs of the patient and protecting the community from vaccine-preventable diseases. Coined by APhA in 2012 Re-inforces that everyone and all disciplines in the room are members of the immunization neighborhood. All have a stake and all can benefit. Patient and community centric An entire community can invest in assessing, administering, and/or referring patients to receive appropriate vaccines. Supports the sharing and exchanging of immunization data

Vision for Immunizing Pharmacists Pharmacists are an accessible, valued and recognized member of the immunization neighborhood who is authorized and compensated for providing immunization services related to ACIP recommended vaccinations that improve public health. CONFIDENTIAL - NOT TO BE RELEASED WITHOUT APhA APPROVAL

Recognized Partner "Each member of the immunization neighborhood has an important role to play.  We appreciate APhA's leadership and collaboration by pharmacists in addressing the immunization needs of our diverse communities.  All our immunization stakeholders must work together to ensure all our adult patients are protected from vaccine-preventable diseases. We are making progress and still have a long way to go.  Thank you for your partnership.“ - LJ Tan, PhD Chief Strategy Officer, IAC Co-chair, National Adult & Influenza Immunization Summit September 2016 My colleagues and I at the CDC applaud your accomplishments over the past twenty years and your continued efforts to improve the health of our communities by reducing the risk of vaccine-preventable diseases. Thank you for the care you provide to your communities, the enthusiasm and innovation you have shown in addressing the needs for expanded access to vaccines, and for your leadership within the Immunization Neighborhood. - Anne Schuchat, MD RADM, US Public Health Service Assistant Surgeon General CDC September 2015 "It takes a village to make an impact, and pharmacists are integral members of the immunization neighborhood focused on improving vaccination rates across the lifespan.  Pharmacists and APhA have demonstrated their commitment to public health through theIr action." - Bruce G Gellin, MD,MPH Deputy Assistant Secretary for Health Director, National Vaccine Office September 2016

US Adult Immunization Plan: Goal 2: Improve Access to Adult Vaccines Objective 2.3 Expand the adult immunization provider network (NAIP 2.3.1) Encourage in-network coverage of adult vaccinations administered in accessible health care delivery settings (e.g. public health clinics, pharmacies) (NAIP 2.3.2) Identify and promote effective collaborative models, best practices (e.g. among physicians and other immunizers) (NAIP 2.3.3) Collect more data to evaluate reported in-network adequacy concerns (NAIP 2.3.4) Strengthen the capacity of public health departments and federally qualified health centers to provide all adult vaccines by sharing effective practices for billing private insurance issuers for vaccination services provided to plan enrollees. (NAIP 2.3.5) Continue to identify the barriers that prevent or discourage pharmacist and other providers in complementary settings from accessing and entering vaccinations into state IIS and reporting vaccinations to the patients’ primary care providers. (NAIP 2.3.6) Clearly articulate the legal, practical, and policy barriers that remain so that the challenges are well understood by partners (e.g., legislators, lawyers) necessary to advance solutions. (NAIP 2.3.7) Assess the impact of providing vaccination services in accessible and complementary settings (e.g., pharmacies and community health centers) on vaccination coverage, cost-effectiveness, and care. (NAIP 2.3.8) Increase the number of community health centers that routinely administer vaccinations to adults and report vaccinations to immunization information systems and primary care providers (NAIP 2.3.9) Encourage on-site, occupational health vaccination clinics and involvement of employers to increase employee vaccination rates.

Medically underserved areas served by pharmacies (MUAs) – supports Provider Status case Geographic positioning and hours of operation of community pharmacies. One example from a nationwide community pharmacy corporation over 1/3rd of their influenza vaccines administered were in pharmacies in MUAs; in states with the largest MUAs, they provided up to 77.1% of their influenza vaccines in these areas. of all influenza vaccinations they delivered, 31% were during off-peak times (59% on weekends and 31% in the evenings), approximately 31 % of patients during off-peak times were age 65 or older, and 36% had underlying medical conditions. efforts to provide immunizations beyond those for influenza were complicated by lack of insurance coverage or recognition as in network providers. Increasing Access Points

Access Barrier – Vaccine Abandonment Study Highlights Coverage Policy Impact on Zoster Vaccine Abandonment Impact of patient out of pocket expense (co-pays) on patient abandonment of receiving zoster vaccination. Overall abandonment rate was 38.9%. Patient out-of-pocket cost (OOP) remained the most significant predictor of abandonment, Patients with OOP in the $15-$34 range (1.6 time higher) compared with those with OOP ≤$14.99, and at 5.53 times higher for those with OOP in the $105-$174.99 range. The study supports the value of recognizing pharmacists as in-network providers and modifying coverage policy regarding patient out of pocket expense.  To access the study go to: http://www.ajpb.com/journals/ajpb/2016/ajpb_julyaugust2016/factors- associated-with-zostavax-abandonment?p=1 American Journal of Pharmacy Benefits, August 2016 (2016;8(4):-e0)

Snapshot of progress over the past twenty years… All 50 states, DC, and PR authorize pharmacists to administer vaccines at some level (in 1996, 14 states authorized pharmacists for influenza vaccination) Pharmacists are trained about vaccines across the lifespan and are helping patients complete vaccine series More than 300,000 pharmacists trained to administer vaccines (up from 40,000 in 2007) Pharmacists increase access to vaccines across the lifespan and are helping patients complete vaccine series Pharmacists are an accessible and valued partner on the patient’s health care team APhA coined the concept of the “immunization neighborhood” — collaborating, coordinating, and communicating with other immunization stakeholders Pharmacies target immunization messages to patients by screening pharmacy records and patients’ medication use to identify need for specific vaccinations. Number of adults getting influenza vaccination in community pharmacy increased from 6% of adults (2004-2005) to about 25% (2015-2016) APhA House of Delegates passes policy (2007, 2011) for all pharmacists being up to date on their own vaccinations (rates have approached 90%) All ACPE-accredited schools of pharmacy required to include immunization training in their curricula (2016)

Number of States Authorizing Pharmacists to Administer Influenza Vaccine & Number of Pharmacists Trained to Administer Vaccines Updated December 2016

Legal Authority State law governs health care practice State-specific regulation Written or verbal prescriptions Protocols (similar to nurses and physician assistants) Statute, Health department or individual physician Authority varies in regards to Antigens Patient Age Process In emergency/pandemic Governor may sign a declaration that may expand authority 10

Pharmacist Administered Vaccines Types of Vaccines Authorized to Administer Based upon APhA / NASPA Survey of State IZ Laws/ Rules Any vaccine AL, AK, AZ*, AR, CA, CO, CT, DC*, DE*, FL, GA*, HI, ID, IL, IN*, IA, KS, KY, LA*, MA, ME, MD, MI, MO*, MN, MS, MT, NE, NV, NJ, NM, NC, ND, OH, OK, OR, PA, PR*, RI, SC, SD, TN, TX, UT, VT, VA*, WA, WI Influenza, Pneumo and Zoster (I, P, Z) NH Other combos NY, WV**, WY** NY - influenza and pneumococcal disease, meningococcal disease, acute herpes zoster (shingles), tetanus, diphtheria or pertussis disease WV - Influenza, pneumonia, hepatitis A, hepatitis B, Herpes-Zoster; and Tetanus, Tetanus-dipteria (commonly referred to as “Td”), or tetanus, diphtheria, and pertusis (commonly referred to as “Tdap”), meningococcal WY- (i)Tetanus, diphtheria, pertussis (Td, Tdap) (ii) Measles, mumps, rubella (MMR) (iii) Varicella (iv) Influenza (v) Pneumococcal (Polysaccharide) (vi) Hepatitis A (vii) Hepatitis B (viii) Meningococcal (ix) Human papillomavirus (HPV) (x) Zoster July 2016 update: Slide 1 – removed *from AR, HI, KY, MI, NJ, SC, SD, UT Updated July 2016 * Via Rx for some; ** broad list of vaccines

Pharmacist Administered Vaccines Prescriber issued protocols vs Rx Based upon APhA / NASPA Survey of State IZ Laws/ Rules Protocol FL, KS, MN, NV, WI Protocol or Rx (depending on age and/or vaccine) AL, AR, CO, CT, DC, DE, GA,HI, IL, IN, IA, KY, MA, MI, MS, MO, NE, NY, NC, ND, OH, OK, PA, PR, RI, TN, TX, UT, VT, WA Protocol/Rx or No Prescriber/Rx Needed (depending on age and/or vaccine) AK, AZ, CA, ID, LA, ME, MD, MT NH, NJ, NM, OR, SC, SD, VA, WV, WY Updated July 2016

Did You Know… Some private insurance plans, Medicaid and Medicare cover adult vaccinations administered by pharmacists 93% of Georgians live within 5 miles of a community pharmacy Six Georgia counties don’t have a family physician according to the GA Board for Physician Workforce According to the CDC, the four diseases pharmacists can now provide immunizations cost Georgians more than half a billion dollars in 2010 in lost income and revenue Source: Georgia Pharmacy Association

Georgia Pharmacist Immunization Authority 2009: Pharmacists authorized to administer influenza vaccines without a prescription. All other vaccines require a prescription HB 504: Effective July 1, 2015 Allowed pharmacists to administer (in addition to influenza) vaccines for the following vaccine preventable disease without a prescription Meningococcal Pneumococcal Herpes Zoster Requirements: Pharmacists must be in a protocol agreement with the physician Patients 18 years or older only for Men, Pneum, Zoster (>13yo for influenza)

Additional Georgia Requirements Enter vaccine information into Georgia Registry of Immunization Transactions and Services (GRITS) (required of all providers) Notify primary care physician within 72 hours Document attempts to identify and notify primary care physician Take history and determine if patient has seen primary care physician in past year Privacy: room or privacy barrier Observe patient at least 15 minutes post vaccination (what do other providers have to do?) Adverse event procedures

Update Report Carry Share Increase public understanding Communication / Documentation engagement of providers and patients Update Report Carry Share GEORGIA: * Provide the patient written information, developed by DPH on importance of having a primary care physician * Provide the patient a vaccine administration record card indicating date of vaccine administration, dosage, and pharmacist’s contact info

Other Georgia Tidbits Vaccine Protocol Agreement With a physician registered with DPH vaccination registry in county or contiguous county (is limited exemption to corp in public health district) Document prescribing vaccines and epinephrine, if determined appropriate by physician for administration by a pharmacist Protocol must be submitted to the composite medical board and posted in a conspicuous location and include a list of the vaccines authorized by protocol

How Does Georgia Compare?

Pharmacist Administered Vaccines Influenza - Age of Administration Authorized by Any Provision Based upon APhA / NASPA Survey of State IZ Laws/ Rules >18yo CT, FL, MA, NY, PR, VT, WV >14yo HI*, NC >12yo MT >10yo IL >9yo MD, PA, RI >7yo AR, ME, OH, WY >6yo ID, KS, MN, NJ*, WI >5yo ND >3yo AZ Any age AL, AK, CA, CO, DED,DC*, GA*,IN*, IA*, KY*, LA*, MI, MS, MO*, NE, NH, NM, NV, OK, OR*, SC*, SD, TN, TX*, UT, VA*, WA * Requires Prescription D Any age with an adult dose Updated July 2016

Pharmacist Administered Vaccines Influenza - Age of Adm Authorized by Protocol Based upon APhA / NASPA Survey of State IZ Laws/ Rules >18yo CT, FL, HI, MA, NJ, NY, PR, VT >14yo NC >13yo GA >12 yo DC, MO >11yo IN >10yo IL >9yo KY, PA, RI >7yo AR, OH, TX >6yo AZ, IA, KS, MN, WI >5yo ND Any age AL, CA, CO, DED, MI, MS, NE, NV, OK, SD, TN, UT, WA D Any age with an adult dose Updated July 2016

Pharmacist Administered Vaccines Authority to Administer Pneumococcal Vaccine Based upon APhA / NASPA Survey of State IZ Laws/ Rules States AL, AK, AZ, AR, CA, CO, CT, DC*, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT**, NE, NH, NV , NJ, NM, NC, ND, NY, OH, OK, OR, PA, PR, RI, SC, SD,TN, TX, UT, VT, VA, WA, WV, WI, WY*** Part B Vaccine *Via Rx / pt specific protocol for some **Pneumococcal polysaccharide without an Rx; all other forms under protocol ***Pneumococcal polysaccharide only Updated July 2016

Pharmacist Administered Vaccines Authority to Administer Zoster Vaccine Based upon APhA / NASPA Survey of State IZ Laws/ Rules States AL, AK, AZ, AR, CA, CO, CT, DC, DE, FL, GA, HI, ID, IL, IN, IA,KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NE, NH, NY, NV, NJ, NM, NC, ND, OH, OK, OR, PA, PR*, RI, SC, SD, TN, TX, UT, VT, VA, WA, WI, WV, WY July 2016 Update: removed * from SC *Via Rx only Updated July 2016

Pharmacist Administered Vaccines Authority to Administer Meningococcal Based upon APhA / NASPA Survey of State IZ Laws/ Rules Yes AL, AK, AZA, AR, CA, CO, CTA, DCA, DE, FLA, GAR, HIA, IDA, ILA, IAA, IN, KSA, KYA, LAA, MEA, MAA, MDA, MI, MNA, MOA, MS, MTA, NCA, ND, NE, NJA, NM, NYA, NV, OHA, OK, OR, PAA, PRR,A, RIA, SCA, SD, TN, TXA, UT, VTA, VAA, WA, WV, WI, WYA No NH R Via Rx only A Age limitations (may not allow or may require Rx for 11-18) Updated July 2016

Pharmacist Administered Vaccines Patient-Age Limitations – for Meningococcal Based upon APhA / NASPA Survey of State IZ Laws/ Rules >18yo CT, FL, GA*, HI*, IA*, KS, ME, MD*, MA, MT, NJ, NY, NC, PA, RI, PRR, SC* VT, VA*, WY >17yo LA* >14yo IL, KY*, TX* >13yo AZ*, MN, OH* >12yo DC, MO* >11yo IN*, ND >7yo AR, OR* >6yo ID, WI >3yo CA No Age Limit AL, AK, CO, DED, MI, MS, NE, NV, NM, OK, SD, TN, UT, WA July 2016 Update: Changed OR from 11 to 7 *May allow for younger ages under prescription R Via Rx only D Any age with an adult dose Updated July 2016

Pharmacist Administered Vaccines Authority to Administer Td / Tdap Based upon APhA / NASPA Survey of State IZ Laws/ Rules Yes AL, AK, AZ, AR, CA, CO, CT, DC, DE, FL, GA*, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NE, NV, NJ, NM, NY NC, ND, OH, OK, OR, PA, PR*, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY No NH July 2016 Update: removed * from SC *Via Rx only Many have age restrictions Updated July 2016

Authority to Administer HPV Vaccine Pharmacist Administered Vaccines Authority to Administer HPV Vaccine WA ID MT OR ND ME MN WI VT NH SD WY MA NY NV MI RI IA PA UT NE CT NJ IN DE CO OH IL VA MD CA KS WV MO DC AZ KY NM NC TX OK AR TN AL GA SC MS LA AK July 2016 Update: changed SC to dark blue FL HI Pharmacists can administer HPV Pharmacists can administer HPV – but only by Rx Pharmacists cannot administer HPV PR Updated July 2016

Pharmacist Administered Vaccines Patient-Age Limitations – for HPV Vaccination Based upon APhA / NASPA Survey of State IZ Laws/ Rules >18yo AR*, CT, FL, HI*, IA*, KS, ME, MD*, MA, MT, NCR, NJ, PA, PRR, RI, SC*,VA*, VT, WY >17yo LA* >14yo IL, KY*, TX* >13yo AZ*,MN, OH* >12yo DC* >11yo IN*, ND >7yo OR >6yo ID, WI >3yo CA No Age Limit AL, AK, CO, DED ,GAR, MI, MS, MOR, NE, NV, NM, OK, SC, SD, TN, UT, WA July 2016 update: Changed OR from 11 to 7 *Younger ages under prescription/protocol R Requires a prescription D Any age with an adult dose Updated July 2016

Authority to Administer HepB Vaccine Pharmacist Administered Vaccines Authority to Administer HepB Vaccine WA ID MT OR ND ME MN WI VT NH SD WY MA NY NV MI RI IA PA UT NE CT NJ IN DE CO OH IL VA MD CA KS WV MO DC AZ KY NM NC TX OK AR TN AL GA SC MS LA AK July 2016 Update: Changed SC to dark blue FL HI Pharmacists can administer Hepatitis B Pharmacists can administer Hepatitis B – but only by Rx Pharmacists cannot administer Hepatitis B PR Updated July 2016

Pharmacist Administered Vaccines Patient-Age Limitations – for Hep B Vaccination Based upon APhA / NASPA Survey of State IZ Laws/ Rules >18yo AR*, CT, FL, HI*, IA*, KS, ME, MD*, MA, MT, NCR, NJ, PA, PRR, RI, SC*,VA*, VT, WV,WY >17yo LA* >14yo IL, KY*, TX* >13yo AZ*,MN, OH* >12yo DC*, MO* >11yo ND >7yo OR* >6yo ID*, WI >3yo CA* No Age Limit AL, AK, CO, DED, GAR, INR, MI, MS, NE, NV, NM, OK, SD, TN, UT, WA July 2016 Update: Changed OR from 11 to 7 *Younger ages under prescription/protocol R Requires a prescription D Any age with an adult dose Updated July 2016

Mitchel C. Rothholz, RPh, MBA Chief Strategy Officer American Pharmacists Association 2215 Constitution Ave, NW Washington, DC 20037   Email: mrothholz@aphanet.org Phone: 800-237-2742 (APhA) ext 7549 (DC Office) 202-429-7549 (PA Office) 267-932-8386 (cell) 202-497-5350 or 703-201-6070 (FAX) 202-429-6300 Website: www.pharmacist.com