The involvement of pharmacists around the country in the current seasonal flu vaccination programme has been a recent development in their role. Community pharmacists may be well placed to overcome some obstacles to increasing vaccination rates. In addition, Government officials estimate that transferring administration of the 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 consequently reduce the annual winter surge in hospital admissions and in busy GP surgeries.

Minister Reilly’s announcement last July of plans to introduce a new pharmacist-led influenza vaccination service was welcomed by the general public and healthcare professionals. Understandably, 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 campaign. 

Pilot programme

“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, a member of the National Pharmacy Reference Group, which advises the Pharmaceutical Society of Ireland (PSI) on practice development policy, and director of pharmacy at Boots Retail (Ireland).

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 (PGD). A PGD permits the supply of prescription medications to groups of patients with individual prescriptions. 

“We put between six 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, such as the UK and Portugal, and determined a framework that we felt was consistent with Irish legislation. We set ourselves to be the gold standard, so that any change in regulation would be modelled on the way we had done it,” explains Ms Burke. 

She is quick to point out that this early initiative 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. The Irish Medicines Board reported 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 deaths during that period.

Incentives for patients

Ms Burke notes that it will be interesting to see what overall impact 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 though they know it’s very important. But if you make it so easy and 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.” 

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 E20 to E35, approximately. 

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 from €15 to €25. This charge is for administering the vaccine, as the flu vaccine is free to all at-risk groups.

“I think there is huge scope for pharmacists within the vaccination area. It’s pretty straightforward; 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. The training 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. 

Lesson learned

However, the pharmacy flu vaccination service hit a bump in 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 to be recalled to receive a booster jab.

“Unfortunately some pharmacists who attended a particular training course 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. Fortunately nobody came to harm and 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 issues 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.”

Future possibilities

Travel vaccination is a potential new service that could be accessed through pharmacies in the near future: “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,” suggests Ms Burke.

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, pharmacies may well change over the coming years from community drugstores to community health destinations.