Pharmacists Have Delivered During the COVID-19 Pandemic

US deaths from COVID-19 have now exceeded more than 550,000 as of this writing. As a result of this pandemic, we have seen a faster progression in how health care is being delivered and who delivers it. Some of these changes have been a result of emergency orders by the federal or state governments. Pharmacists lead the charge in delivering health care services in various settings throughout this pandemic. Health system pharmacists have managed numerous drug shortages emerging throughout the pandemic, evaluated and often used novel therapies for patients hospitalized for COVID-19, and changed workflow to secure and preserve valuable personal protective equipment (PPE). Community pharmacists have increased the accessibility of medications by delivering medications and supplies, implemented curbside pickup, increased the use of telehealth services, and have taken lead roles in administering COVID-19 testing and the great task of vaccination. Infection preventionists (IPs) have always had a good handle of the operations of pharmacy inside of the hospital setting. As the pandemic evolved, IPs have had to step outside of the hospital to provide guidance to local health departments, school districts and businesses. Getting to know the local pharmacists—in fact developing a professional rapport with those pharmacists—should be on an IP’s to-do list. Also, IPs should know the story of how community pharmacists’ roles have evolved because of COVID-19

Changes in Regulations

Over the course of the pandemic, the government attempted to remove barriers for pharmacists that prevented them from actively taking care of patients. The act that removed the most barriers was the Public Readiness and Emergency Preparedness Act (PREP). This rule removed the patchwork of different state regulations by expanding the ability for licensed pharmacists and eventually pharmacy interns, pharmacy students, and pharmacy technicians with appropriate training to administer all ACIP approved immunizations in patients 3 and over. Subsequent to the discussion of the magnitude of the task at hand and realization of the sheer need for vaccinators, some pharmacy boards also changed regulations to allow pharmacists with valid license from out of state to begin to assist by making the process simple, and technician abilities have been expanded as well during the pandemic.

As part of the US government efforts to increase access to COVID-19 vaccinations and get "more shots in arms," the US Government, in coordination with the Centers for Disease Control and Prevention (CDC), began implementing its plan for community pharmacies to administer COVID-19 vaccines. The plan implements a collaboration between the federal government, states, territories, 21 national pharmacy partners, and independent pharmacy networks to increase access to COVID-19 vaccination across the US. The program is being rolled out incrementally, starting with just a few large chain store pharmacies, hospitals, and some select independent pharmacies, and is expanding with adjustments made as additional vaccine supplies become more readily available. Efforts initially began in January, partnering with national chains CVS and Walgreens and some independents with efforts focused on nursing home patients at high risk and then expanding to select retail locations and over time. The program will expand to include more than 40,000 pharmacies in the United States as additional vaccine products with less stringent storage requirements continue to become available.

Underserved Areas

One big advantage of pharmacist expanding role has been the partnership with public health efforts in underserved areas. Pharmacists have been able to help cover large areas that require more providers, especially in the rural area. In many of those areas, pharmacists already have personal relationships with local health departments, and they have been able to easily augment local health department efforts by expanding the number of access points and the hours that immunizations are available. As most pharmacies are already familiar with immunization providers, these pharmacies have many resources and can help achieve public health goals in these areas. We should also consider that one health department often covers a large geographic area.

Vaccine Hesitancy, Misinformation

As the pandemic continues, there has been a substantial amount of misinformation and a large amount of distrust in government efforts promogulated in the vaccines’ approval. Education needs to continue to occur with health professionals and the public on the advantages of receiving vaccines. The CDC and the AD Council have recently started promoting a large-scale public-facing messaging campaign which will support the Biden administration’s immunization completion goals. This campaign starts with health professionals, and the CDC will offer educational programs along with continuing education. As health professionals are trained, they can begin working with different groups such as churches and community centers to get the word out and decrease vaccine hesitancy, especially amongst minority groups. Several steps can be taken to overcome hesitancy, which can include education for the individual or caregiver and those that they trust. There are several ways that pharmacists will be working with officials to extend messaging efforts, dispel misinformation, and to increase immunization rates. They include:

• Working with employers.Employers play a key role in getting information about vaccines to their employees, and pharmacists can help employers reassure the vaccines' safety profile and promote the short-term advantage. In addition, some work-related activities may require an employee to have received the vaccine.
• The US Food and Drug Administration is committed to getting word to the public about the safety of the vaccines and how the FDA followed protocol as it refers to side effects and duration of effects related to vaccine administration and needs to reduce fear and concern amongst the public. Working with the FDA, pharmacists can direct patients to published information that is evidence-based.
• Providing Evidence-Based Information that is Easy for Patients to Understand: In addition to general vaccine fears, the vaccines coming to the market have been manufactured using different methods, and as such, questions will arise related to the type of vaccine received and associated efficacy (e.g., mRNA vs. adenovirus vaccine). For example, the two mRNA have an efficacy rate of 94%-95%, while the viral vector showed an efficacy of 66%, according to the CDC. This has caused some confusion among the public related to vaccines available. Pharmacists will help to reassure a skeptical patient population.

Geriatric Populations

Prior to expanding the community pharmacy channel for increased access points, pharmacies were involved in working with state and local health departments to immunize our nation’s most vulnerable patients. This involved use of mobile clinics where pharmacists and other public health officials took their services directly to the residences of these patients, helping with transportation, storage of vaccine product, monitoring of vaccine cold chain, ensuring proper storage of vaccine, aiding in the proper preparation of drugs, and assisting in public announcements of product to protect them in the first round of immunization efforts. These efforts have helped to mitigate outbreaks in these vulnerable populations.

Cold-Chain/ Supply Chain

Pharmacists have been thoroughly trained in ensuring appropriate drug storage and cold-chain integrity. Pharmacists have been involved in these efforts to ensure adequate transportation of vaccine products working with local and state-level health officials. They have been integral in using coolers/refrigeration/freezers, in proper monitoring and storage of drugs, in aiding local and state officials in immunization preparation and administration, helping with public service announcements, with scheduling patients, and with social media efforts, including word of mouth advertising, bag flyers, advertisements, etc. to help get the word out especially in underserved and rural communities.

Partnering with FEMA

Many pharmacists have been actively involved with the Federal Emergency Management Administration (FEMA). Healthcare professionals who will jump in and help as needed with emergencies. Also, FEMA and state officials have developed registries for health care workers that want to volunteer and serve during emergencies both during the pandemic and in other emergencies such as floods, hurricanes, acts of terrorism, etc. Many pharmacists have signed up for these corps and have continued to work as partners in these efforts.

Expanding Access

Pharmacies that want to participate early have two ways to participate. Each state is handling their vaccine supply slightly differently. First, pharmacists can obtain vaccines directly by working through the state health department to get allotment from the state supply, and the state health department allocates directly to immunizing pharmacies part of their supply. The second method is working through the federal network to obtain vaccine products. Only about 9000 of the 40,000 pharmacies receiving vaccine in March will go through this method but it will become more common to allow an adequate national supply.

Herd Immunity:

When we consider the COVID-19 immunization program, it is of a massive scale never seen before. Ultimately, we must vaccinate the entire world’s population in the shortest time possible. Pharmacists will continue to play an integral role in these efforts.

Pharmacists are a competent workforce embedded in the community, trusted by patients, and can rapidly expand access points to patients to receive the COVID-19 immunization. Other than increasing access points, pharmacists are trained to counsel patients, administer the vaccine, provide vaccine education, and pharmacies are readily accessible in communities, with most Americans living within 5 miles of a pharmacy. Because of these access points to care, the pharmacy will play an integral role and drive immunizations to help achieve herd immunity if that target is possible. With efforts already underway, we are beginning to see numbers of cases, hospitalizations, and deaths come down albeit it not in a straight line from their peak, although this is not a straight line, and we are not out of the woods in this pandemic with many experts worrying about a possible resurge with loosening restrictions too fast. Many retailers are adding pharmacists and technician support staff on a part-time or full time basis to support efforts. The US pharmacy retailer Walgreens has recently announced they plan to add 25,000 personnel to administer vaccines.

While there is no debate about expanding access points to pharmacies, using community pharmacies to greatly expand access points is a huge logistical endeavor. The community pharmacy part of this COVID-19 immunization program will be an ongoing rollout to increase access points everywhere an immunizing pharmacy or pharmacist is available. It will expand based on vaccine availability and will initially be provided to patients at no cost. Implementation and delivery will be greatly aided now with the emergency use authorization approval, and the 3rd major vaccine’s availability by J&J/Janssen completed on March 1, 2021.

The J&J vaccine has different storage and administration considerations that are a game-changer for expanding the community pharmacy channel’s efforts. The first two available vaccines from Moderna and Pfizer were mRNA vaccines and, while very effective, required stringent management of storage and supply chain. The Johnson and Johnson/Janssen vaccine is a viral vector vaccine. The Janssen COVID-19 Vaccine storage is simply standard refrigeration between 2°C and 8°C (36°F and 46°F) for up to the expiration or beyond use date (BUD). After first puncturing the vial, the vial should be held between 2°C and 8°C (36°F and 46°F) for up to 6 hours OR at room temperature (up to 25°C [77°F]) for up to 2 hours. Also, this vaccine only requires one dose. Due to these relaxed storage requirements and single dosing, this is a much easier vaccine to deliver in the community pharmacy setting.

As the community pharmacy COVID-19 immunization program scales up through April and May, it will eventually include COVID-19 immunization at more than 40,000 community pharmacy locations. This means more hours to access, access points, and more practitioners helping administer the immunizations very quickly. The Biden administration has promised that by the end of May 2021 that anyone who wants a vaccine will have access.

Strategic Partners

During the COVID-19 pandemic, pharmacists have been very quick to adapt with innovative ideas and have emerged as leaders in providing care in many settings and IPs would to well to seek out their professional assitance. As the pandemic evolved, pharmacists continued to play critical roles at various stages and are essential to ending the pandemic through immunizations. Pharmacists have helped ensure testing availability, drug supply chain, alternative treatments, patient care, and expanding access points throughout the pandemic. Now the profession is poised to make an impact on one of the greatest immunization efforts ever. As the community pharmacy immunization program expands, intense community outreach will be critical to educate people about the importance of vaccination and where vaccines are available in the communities, and pharmacies will be strategic partners in these and future efforts.

Craig Kimble, PharmD, MBA, MS, BCACP is the director of experiential learning and the manager of clinical support services as well as an associate professor of pharmacy practice at Marshall University School of Pharmacy.

Alberto Coustasse-Hencke, DrPH, MD, MBA, MPH, is the professor in the health care administration program management and health care administration division of Lewis College of Business at Marshall University.

Kenneth Maxik, MBA, MBB, is the vice president of operations support at CompleteRx, Ltd.