The involvement of pharmacists in Ireland in the seasonal flu vaccination programme is a recent and welcome development. Community pharmacists are well placed to overcome many obstacles to increasing vaccination rates and Government officials estimate that transferring the administration of the flu vaccine from GPs to pharmacists will trim between €5 million and €13 million every year off the State immunisation bill.
Health Minister James Reilly is also convinced that this new convenient and cheaper service offered by pharmacists will achieve greater penetration into the community of vaccine uptake, which will consequent reduce the annual winter surge in hospital admittances and in busy GP surgeries.
Influenza is a highly infectious acute respiratory illness that is self-limiting and short lived in most healthy adults but in high-risk patients, including the very young and the elderly, the effects of influenza can be severe and can cause serious illness and death.
In such patients, serious respiratory complications can develop, including pneumonia and bronchitis. Tragically, between 300 and 400 people die annually from influenza and its complications.
Prevention is the key; influenza immunisation prevents between 70 to 90% of influenza-specific illness among healthy adults and reduces severe illnesses and complications by up to 60%, and deaths by 80%, in the elderly.
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| Health Minister James Reilly (and halo) |
Minister Reilly’s announcement last July of plans to introduce a new pharmacist-led influenza vaccination service was widely welcomed by the general public and healthcare professionals, although the Irish Medical Organisation, which represents most of the country’s doctors, voiced some reservations concerning aspects of the new regulations that allow pharmacists to deliver the flu vaccine.
The profession of pharmacy was more than ready and willing to embrace this new challenge and expanded role. Following the Minister’s announcement almost 1,000 pharmacists enrolled in accredited national vaccination training courses. In fact, hundreds of pharmacists had already received this training in the 12 months prior to the Minister’s formal confirmation of their involvement in the 2011/2012 seasonal flu campaign.
The Boots pharmacy chain had tested the proverbial waters in 2010 with what was effectively viewed by health authorities as a ‘pilot’ flu vaccination service in its 60 stores nationwide.
A subsequent satisfaction survey revealed that almost 100% of people who received their flu jab from Boots pharmacists were delighted with the service. Significantly, about a third stated they wouldn’t have received the vaccination but that the option to “drop in” to a local pharmacy for the flu shot was too convenient to miss.
“The skill set of pharmacy and the spread of pharmacy - the penetration into the community – have long been underutilised in our health services, but I think we’re beginning to see that this is changing for everyone’s benefit,” says Mary Rose Burke, Director of Pharmacy at Boots Retail (Ireland) and a member of the National Pharmacy Reference Group which advises the Pharmaceutical Society of Ireland (PSI) on practice development policy.
Although the necessary legislative amendment was only introduced in mid October last year, which permitted pharmacists in Ireland to administer the flu jab, Boots Ireland was able to introduce its new service in 2010 through a Patient Group Direction (PGDs).
A PGD is a written direction relating to the supply and or administration of a prescription only medicine (subject to specific inclusions and exclusions) and is developed, authorised and signed by the Boots Medical Director, Dr Graham Marshall.
“We put between 6 to 12 months of work into defining a flu vaccination service and developing it to higher clinical governance standards because we knew obviously it would come under a lot of scrutiny. We looked at best international practice, examining the protocols, training and experience of other countries that offer a pharmacy-led vaccination service was introduced, such as in the UK and Portugal, and determined a framework that we felt was consistent with Irish legislation. We set ourselves to be the gold standard that any change in regulation would model itself on the way we had done it,” explains Ms Burke.
She is quick to point out that this early initiative by Boots and the recent involvement of pharmacists nationwide in the influenza vaccination programme by no means reinvents the wheel; “all protocols and procedures are identical to receiving the vaccine in your GP surgery, except that you don’t necessarily need an appointment and our opening hours are more flexible. It’s all about ensuring broader uptake of the flu vaccine so that those who need it can get it.”
Under the Medicinal Products (Prescription and Control of Supply) (Amendment) Regulations 2011, registered pharmacists can now supply and administer the seasonal influenza vaccine to patients, and if necessary adrenaline injections for the emergency treatment of anaphylactic shock arising from the flu jab – although this latter provision is a very rare occurrence with the Irish Medicines Board reporting that only three patients out of millions who had received the “ordinary” seasonal flu vaccine (excluding the ‘09/’10 pandemic swine-flu jab) suffered anaphylactic-type reactions over the past decade, and there have been no related death during that period.
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| Mary Rose Burke |
In 2010, more than 5,000 people received their flu vaccine in Boots pharmacies around the country. While this figure wasn’t sufficient to detect any measurable impact on hospital attendances for influenza-related complications, Ms Burke notes that it will be interesting to see what the overall outcome of the first national pharmacy-led flu vaccination campaign has had on uptake levels and hospitalisations.
“If somebody isn’t sick it can be hard to get them into a doctor’s surgery. A flu vaccination is one of those things that a person could just keep putting off, even thought they know it’s very important. But if you make it so easy and so accessible and convenient and at a time of their choosing, there’s a far greater chance that these at-risk groups will get their flu shots.
“We saw this in our Boots campaign; about a third of the people who received their flu vaccination in our pharmacies said they wouldn’t have got them otherwise. If this pattern is repeated in the new national flu vaccination programme, we could see an increase in uptake levels of more than 30%. In fact, that figure could be higher because it’s even more convenient now that there are so many more pharmacies involved.”
The lower cost should also prove an incentive. While there is no set price in pharmacy for the flu vaccine – the Competition Authority prohibits price setting among independent enterprises such as pharmacies – the overall fee for the vaccine and consultation ranges from €20 to €35 approximately. Of course, the flu vaccine in pharmacies is free of charge for people over 65 years of age with a valid Medical Card, GP Visit Card or Health Amendment Act (HAA). Customers over 65 years of age not eligible for any of those schemes will be asked to pay a reduced amount of approximately €15. This charge is for administering the vaccine, as the flu vaccine is free to all at-risk groups.
“I think there is a huge scope for pharmacists within the vaccination area. It’s pretty much straight forward; there is no diagnosis involved and most vaccinations are part of national programmes so I believe pharmacists can play a significant role in making sure that as a country we meet the WHO hurdles of penetration rates. Pharmacists could successfully offer other vaccination programmes such as for cervical cancer, possibly even childhood immunisations, although that may be somewhere further down the road, not least because you’d need waiting room facilities and the infrastructure in pharmacy would need to be right for that, but there’s no reason why we wouldn’t look at all of those services,” says Ms Burke.
More than 1,600 pharmacists have now received training in vaccination techniques from Hibernian Healthcare, which was initially commissioned by Boots in 2010 to provide training for their pharmacists on vaccination consultation, administration of the vaccine and post vaccination issues and complications. The training company’s programme was devised in conjunction with the Irish Pharmacy Union and is accredited by the School of Pharmacy and Pharmaceutical Sciences at Trinity College Dublin.
However, the pharmacy flu vaccination service hit a bump on the road early on when it emerged towards the end of November that an inadequate dose of the vaccine had been administered in error, requiring about 800 people – approximately 20% of patients vaccinated by pharmacists at that time – to be recalled to receive a booster jab.
“Unfortunately some pharmacists who attended a particular training course by Hibernian Healthcare were shown a DVD on how to administer the vaccine but which demonstrated the paediatric dose not the adult dose. As soon as this error came to light, within Boots, and I believe replicated around the country, we went back to our records, identified which pharmacists were at the training day, and ascertained from those pharmacists if they followed that incorrect procedure or not,” recounts Ms Burke.
“Many had realised that what they were shown didn’t make sense and had corrected their technique so we identified the pharmacists involved, pulled the records of any of the vaccinations they had administered, contacted the patients and invited them to come back. Many patients had seen the news reports and they understood the issue, so most of them came back in the next couple of days for revaccination.
“It’s a very unfortunate and regrettable incident but I think we have a lot to learn from that, and fortunately nobody came to harm, everybody was contacted. It has demonstrated the robust method of record keeping as we were able to do a very rapid follow up and contact the patients to get them back in very, very quickly. But absolutely we need to recognise that there was a number of issue that led to this happening and we need to address these and ensure that, for the next service that develops in pharmacy, we build in steps that would make sure that something like this would not happen again with something potentially more serious.”
As Director of Pharmacy at Boots (Ireland), Ms Burke leads all pharmacy activities in Boots, including future strategy and development. She maintains that travel vaccination is a potential new service that could be accessed through pharmacies in the near future.
“This is certainly an area that Boots is looking very seriously at. The growing popularity of long haul holidays means that more people may need these travel vaccinations, but often they can get swept away with the excitement and glamour of their trip and may neglect to think about the various vaccines they need.
"I think pharmacy would have a big role to play in making travel vaccinations available to people in a way that fits in with the planning of their holiday. Again, it’s the convenience factor that makes it easier for them to access this service as pharmacy has a higher penetration rate into the community so that everyone who is going abroad to those high-risk destinations would firstly know that they need to get vaccinated and secondly, we’d make it easy for them to avail of it,” she says.
Pharmacists in Ireland are expected to inject new vigour into the national flu vaccination programme, with the involvement of pharmacy in other immunisation programmes increasingly likely in the future as health authorities explore options for the safe, efficient and cost-effective delivery of public health services. This and similar service development will no doubt see pharmacy change over the coming years from community drugstores to community health destinations.
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