The COVID-19 pandemic presents complex challenges for the US health care system and social safety net programs. In our latest blog post series, IMPAQ experts bring you timely updates and informed insights on the intersection of COVID-19 and pressing policy issues.
Over the past few months, the U.S. Department of Health and Human Services (HHS) has recognized the value of pharmacies in addressing the unique health care demands of the COVID-19 pandemic. As communities turned towards telehealth for their health care needs, pharmacies have become central providers of basic medical services, such as routine vaccinations and COVID-19 testing.
HHS expanded the immunization capabilities of pharmacies for the duration of the pandemic through multiple regulations. While all 50 states and the District of Columbia allowed qualified pharmacists and pharmacy interns to administer vaccinations to various extents before the pandemic, a recent HHS regulation extended this ability to qualified pharmacy technicians. Previously, only three states had specifically permitted technicians to immunize.
Below, we discuss the new HHS regulation in terms of its impact on pharmacy technicians, the history and evidence surrounding pharmacy technicians’ ability to immunize patients, and implications for the adoption of this practice during the COVID-19 pandemic.
Recent Regulatory Changes in Pharmacy Immunization
In response to the pandemic, HHS passed several regulations through the Public Readiness and Emergency Preparedness Act (PREP Act) to expand the scope of services that pharmacists and their support staff may provide. It is important to note that federal regulations enacted through the PREP Act supersede state and local laws.
Expanding access to childhood vaccines
After the Centers for Disease Control and Prevention (CDC) reported a “notable decrease” in the number of routine childhood immunizations, HHS amended the PREP Act in August 2020 to allow qualifying pharmacists and supervised pharmacy interns (state-licensed or registered) to order and administer childhood vaccines to children ages three years and older.
Increasing capacity to deliver a future COVID-19 vaccine
HHS then further expanded their immunization abilities by qualifying certain pharmacists and supervised pharmacy interns as “covered persons” that will be able to administer the forthcoming COVID-19 vaccine. Overall, these two regulatory changes allow pharmacists and pharmacy interns, who are already providing vaccinations, to extend immunization services to a larger pool of people for the duration of the pandemic.
Additional expansion measures
In a move that has been heavily supported by large chain pharmacies, HHS announced on October 21 that supervised pharmacy technicians and pharmacy interns may administer routine childhood vaccines, future COVID-19 vaccines, and COVID-19 tests under the PREP Act with certain restrictions. This regulation does not encompass flu and other adult vaccinations. To administered authorized immunizations, pharmacy technicians must meet many requirements to qualify, including:
- Be licensed or registered in their state or have a Certified Pharmacy Technician certification from either the Pharmacy Technician Certification Board or National Healthcareer Association.
- Have a qualified pharmacist supervise the vaccination.
- Complete a practical training program that is approved by the Accreditation Council for Pharmacy Education (ACPE).
Pharmacy Techs as Immunizers Prior to the Pandemic
Idaho was the first state to authorize pharmacy technicians to vaccinate in 2017, with Rhode Island and Utah following in 2018 and 2019, respectively. Federal healthcare facilities and a few additional states also allowed technicians to immunize before the pandemic through regulations that did not explicitly prohibit this expanded scope of practice. For example, CVS employed immunizing pharmacy technicians in Michigan, Nevada, and Washington State, in addition to Idaho, Rhode Island, and Utah. Before the HHS announcement in October, Indiana took action in March to allow qualified pharmacy technicians to administer flu vaccines and Nevada’s governor signed an emergency regulation in September to authorize trained and supervised pharmacy technicians to immunize.
While only a few states previously allowed pharmacy technicians to vaccinate, research exists on the efficacy of allowing technicians to immunize through pilot programs. The Washington State University (WSU) College of Pharmacy enrolled 30 Idaho pharmacy technicians in a 2016 pilot immunization training program, which consisted of a two-hour home study and a two-hour in-person training session. An evaluation published in the Journal of the American Pharmacists Association reported 953 immunizations with no adverse outcomes were administered over a six-month period by the 25 pharmacy technicians who completed the training.
The official WSU immunization training course, in collaboration with the American Pharmacists Association (APhA), has been approved by the ACPE and includes two hours of independent study and a four-hour in-person training session. As of early 2019, more than 500 pharmacy technicians had completed the training program. Another evaluation examined the outcomes of seven WSU-trained pharmacy technicians working in an Indian Health Services federal facility. Over the course of a year, the seven pharmacy technicians administered 4,852 vaccinations to patients ranging in age from two months to 85 years.
What are the Potential Impacts of the New HHS Policy?
The two prominent potential public health benefits of the recent HHS regulation that permits qualified pharmacy technicians to immunize include higher childhood vaccination rates and increased access to a COVID-19 vaccine.
Impacts on childhood vaccination likely limited
Though pharmacy technicians are now authorized to administer childhood vaccinations under supervision, this practice is unlikely to become widespread without buy-in from pharmacists. Pharmacy technicians will not be able to immunize children if their supervising pharmacists do not first take the steps to do so. An October CNN investigation found that a large majority of pharmacies were not vaccinating children ages three years and older in the 30 states that prohibit pharmacists from ordering and administering childhood vaccinations, even though the August HHS declaration through the PREP Act supersedes those state laws. Many of the pharmacists contacted were not aware of the new regulation, according to CNN.
Impacts on COVID-19 vaccine distribution appear more promising
The federal government is investing in pharmacies to distribute the forthcoming COVID-19 vaccine. On November 12, HHS announced a partnership with regional pharmacy chains and independent community pharmacies, representing approximately 60 percent of pharmacies across the United States, to distribute a COVID-19 vaccine for free when one is made available.
In the announcement, HHS specifically highlighted the role of pharmacists, interns, and technicians as “crucial public health partners for increasing access and convenience of COVID-19 vaccines.” Additionally, CVS and Walgreens have teamed with the federal government to administer COVID-19 vaccines to nursing homes residents when one is made available. To prepare for this initiative and overall distribution of a COVID-19 vaccine to the general public, CVS announced that it is hiring 10,000 pharmacy technicians.
Given these partnerships, in addition to the vocal support of large chain pharmacies for this regulation, it is likely that pharmacies will mobilize and certify their pharmacy technician workforce to administer a COVID-19 vaccine.
By the time HHS suspends the public health emergency declaration, many pharmacy technicians will have completed an ACPE-approved training to administer vaccinations. However, these technicians will not be permitted to continue immunizing unless their individual states formalize this expanded scope of practice.
States will base this decision largely on the participation of immunizing pharmacy technicians in distributing the upcoming COVID-19 vaccine. Though supervising pharmacists may have some initial discomfort with overseeing immunizing technicians, a 2017 study found that supervising pharmacists perceived increases in vaccination rates and ultimately expressed greater support for the training of additional pharmacy technicians to administer vaccinations.
The COVID-19 pandemic has transformed health care delivery, such as with the proliferation of telehealth. Whether or not pharmacy technicians will maintain and practice their legal immunizing abilities will be an area to monitor for long-term changes.
Olivia Bundschuh, Research Analyst, IMPAQ Health