Review of Pharmacy-Based Vaccination in Hong Kong

CHAN, Philip Pana; LI, Johnny Chun-Wing; WONG, Janet Kit-Tingb*

a Fortune Pharmacal Co. Ltd., Block A & Block B, 50-68 Wang Lok Street, Yuen Long Industrial Estate, Yuen Long, New Territories, Hong Kong, China

b Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China



Primary Care and OTC
HKPharm J Volume 30 (2), May-Aug-2023 (2023-12-27): P.54

ABSTRACT

Community pharmacies as venues for immunisation are not utilised as they should be in Hong Kong. A fully implemented pharmacy-based vaccination scheme can enhance vaccination coverage and minimise health costs. Currently, pharmacists’ role in immunisation in Hong Kong is mostly limited to stock management, cold chain assurance, and quality management within community vaccination centres. Even with training programmes in place, there is still a long way for pharmacists in Hong Kong to be authorised as independent vaccinators. With at least 13 countries already enlisting their pharmacists to contribute to immunisation in various ways, Hong Kong can take reference from their policies or programmes to devise local guidance for pharmacybased vaccination.

INTRODUCTION 

Although immunisation is widely considered to be one of the greatest achievements of public health, the vaccination programme of the COVID-19 vaccine in Hong Kong has brought the issue of vaccine hesitancy to the forefront. Vaccine hesitancy, which is defined as “the reluctance or refusal to vaccinate despite the availability of vaccines”, is listed as one of the top ten threats to global health by the World Health Organization.(1)


 To address vaccine hesitancy, the 3Cs Model (i.e., Confidence, Complacency, Convenience) and the 5As Model (i.e., Access, Affordability, Awareness, Acceptance, Activation) are usually adopted to analyse the problem and establish relevant measures.(2,4) Being renowned for the accessibility, wide distribution, and expertise in medicines, community pharmacists are in a privileged position to provide vaccination. In at least 13 countries such as the United States (US), the United Kingdom (UK), Australia, Canada, and New Zealand, pharmacists are not only responsible for advocating vaccination and ensuring the safe supply of vaccines, but they are also empowered to play an active role in immunisation programmes where they are legally authorised to administer vaccines.

 

 In Hong Kong, pharmacists are minimally involved in any vaccination programme. Even under the recent community COVID-19 vaccination programme, pharmacists’ role is mainly limited to ensuring the safe supply and reconstitution of vaccines. Emerging worldwide evidence demonstrates the cost-effectiveness of pharmacy-based vaccination as well as the potential expansion of vaccination coverage through pharmacies during epidemics. This article aims to review the possible roles of pharmacists in vaccination in Hong Kong by highlighting the benefits of pharmacy-based vaccination, current challenges faced by pharmacists, and the worldwide landscape of pharmacy-based vaccination.

 

WHY PHARMACY-BASED VACCINATION?

Pharmacists are well-equipped to provide vaccination services as they possess extensive clinical knowledge and skills including medication management, history taking, health assessment, counselling, and optimising medication therapy. Pharmacists are also among the most accessible and frequently consulted healthcare professionals for health advice. As such, pharmacists can serve as advisors and educators to facilitate vaccine uptake.(2)

 

 Delivering vaccination services at pharmacies in addition to conventional sites offers numerous advantages including expansion of coverage, reduced physician workload and wait times, as well as cost savings for the healthcare system.(3)

 

a) Enhance Vaccination Coverage

The wide distribution and the long opening hours of community pharmacies make them an ideal location for people to receive vaccination in a casual and friendly environment which can in turn improve community vaccine uptake.

 

A study on influenza vaccination in community pharmacies of the US reported an eightfold increase in the number of vaccines administered when pharmacists offered vaccination daily compared to nurses offering vaccination on a single day.(4) Evidence supporting pharmacy-based vaccination in Canada is also growing. A study in Canada comparing the estimated influenza vaccine coverage before and after pharmacy-based vaccination reported that the vaccine coverage increased from 26% in 2012 – 2013 to 36% in 2013 – 2014.(5)

 

 The studies highlight the potential positive impact of pharmacy-based vaccination services in promoting vaccine uptake rates.

 

b) Indirect Cost Savings

Pharmacy-based vaccination not only costs less than vaccine administration by a general practitioner, but also helps alleviate the burden on other healthcare providers. Pharmacy-based vaccination can bring the flexibility of mobilising the healthcare workforce, which can be crucial in addressing the rapidly evolving demands for health services in peak seasons. In the states and territories of the US where pharmacists are allowed to vaccinate, higher vaccination rates and lower vaccination-related healthcare resource utilisation and costs have been observed.(6)

 

 Utilising an agent-based model and a clinical and economic outcomes model for simulation, a US study has shown that administering vaccines through pharmacies in addition to traditional locations (hospitals, clinic / physician offices, and urgent care centres) during an influenza epidemic can avert up to 23.7 million symptomatic influenza cases. The reduction in influenza cases can be translated to a substantial cost-savings up to $2.8 billion to third-party payers and $99.8 billion to society.(7)

 

PHARMACY-BASED VACCINATION WORLDWIDE

The role of pharmacists in vaccination varies in different healthcare systems. In some parts of the world, pharmacists are responsible for vaccine education and supply management; while in other countries, they are legally authorised to administer vaccines.

              

According to a global survey conducted by the International Pharmaceutical Federation (FIP), 13 out of 45 countries authorise pharmacists to legally administer vaccines. These countries include Argentina, Australia, Canada, Costa Rica, Denmark, Ireland, New Zealand, the Philippines, Portugal, South Africa, Switzerland, the UK, and the US.(8) In these countries, in addition to the requirements on the pharmacies with regard to records, premises, equipment, materials and waste management, there is also a restriction that only accredited personnel could perform the vaccinations.

 

a) Accreditation of Vaccinators

In the UK, pharmacy personnel and other providers who wish to administer vaccines are required to undergo extensive training on immunisation knowledge defined in Public Health England’s “National Minimum Standards and Core Curriculum for Immunisation Training for Registered Healthcare Practitioners”.

 

 The curriculum covers 12 core areas of immunisation knowledge, among others, includes legal issues, vaccine administration, anaphylaxis and adverse reactions, record keeping and reporting.(9) The training also comprises face-to-face practical training on injection techniques and basic life support. Furthermore, the UK Health Security Agency has developed a “Flu Vaccinator Competency Assessment Tool” to periodically verify competency that includes knowledge, core clinical skills, clinical process and procedures for vaccine administration.(10)

 

 Starting from the 2022/23 flu vaccination season, pharmacists and other vaccinators could determine the frequency of face-to-face training for both injection technique and basic life support instead of every three years, providing that ongoing competence of an individual vaccinator can be demonstrated.(11)

 

b) Scope of Pharmacy-based Vaccination Services

The scope of pharmacy-based vaccination services varies among countries as presented the Table 1.(7)

 

Table 1. Vaccination Provided at Community Pharmacies in Different Countries

Country

Scope of Pharmacy-Based Vaccination Services

Argentina

Vaccination included in the National Vaccination Schedule such as influenza and varicella

Australia

Vaccinations provided vary across different jurisdictional legislation. For example, some only allow influenza vaccine, while some cover a wider range of vaccines such as measles and pertussis.

Canada

Vaccinations provided differ in different provinces. Some only allow influenza vaccine; some cover a wider range of vaccines such as influenza, hepatitis, human papillomavirus (HPV), chickenpox, and rabies post-exposure; Quebec only authorises pharmacists to administer vaccines for demonstration/education purposes

Ireland

Seasonal influenza, pneumococcal, and shingles for adults

New Zealand

▪          Vibrio cholerae and enterotoxigenic Escherichia coli vaccine

▪          Influenza vaccine (for ≥ 3 years old)

▪          Diphtheria, tetanus, and pertussis (acellular, component) vaccine (Tdap) (for ≥ 18 years old)

▪          Meningococcal vaccine (for ≥ 16 years old)

▪          Varicella (shingles) vaccine (for ≥ 50 years old)

Portugal

Vaccinations not included in the National Health Service Vaccination Plan such as Cholera, Herpes Zoster, and Rabies

South Africa

Measles, mumps, and rubella (MMR) and influenza vaccine, and vaccination included in the Expanded Programme on Immunisation (EPI) such as Hepatitis B and HPV

Switzerland

Vaccination varies across different Cantons in Switzerland

The Philippines

Influenza and pneumococcal vaccines for adults

UK

Vaccination strategy varies among England, Scotland, Northern Ireland, and Wales. The scope of services can cover most of the vaccines such as influenza and childhood immunisations (measles, mumps, and rubella) under the National Health Service Immunisation Plan

US

Vaccination strategy varies across different states in the US.

 

c) Legal Framework for Pharmacy-Based Vaccination

 

Different countries have developed different legal frameworks to enable pharmacy-based vaccination.

 

 For instance, New Zealand has implemented the reclassification of vaccines   since 2011 so that selected vaccines can be supplied at a pharmacy without a prescription when administered by an accredited registered pharmacist, and in compliance to the immunisation standards of the Ministry of Health. For example, varicella (shingles) vaccine does not require a prescription when (a) administered for the prevention of herpes zoster (shingles) to (b) a person 50 years of age or over (c) by an accredited registered pharmacist.(12) The pharmacist accreditation involves the completion of a vaccinator training course approved by the Ministry of Health.

 

 Meanwhile, the UK defined “Patient Group Directions (PGDs)” in the Regulation 213 of the Human Medicines Regulations 2012 as an administrative approach that enables registered health professionals (e.g. registered pharmacists) to supply and administer prescriptiononly medicines to patients without prescription under specific planned circumstances where patient care can be enhanced without compromising patient safety.(13) PGDs are applied in various scenarios such as routine immunisation programmes, and emergency response. PGDs are written instructions established by a multidisciplinary group composed of a doctor, a pharmacist, and a representative of any professional group expected to supply the medicines under the respective PGDs. Established PGDs require further endorsement and authorisation by the NHS organisation and signing by all individual health professionals working under the directions. PGDs for immunisation cover aspects of staff authorisation, documentation, audit requirements, and general guidance on best practices required to safely administer vaccines such as COVID-19 vaccine and HPV vaccine.(14) Thus, PGDs serve as a mechanism that allows the administration of prescription-only vaccines by community pharmacists.

 

CHALLENGES TO PHARMACY-BASED VACCINATION IN HONG KONG

a) Access to Vaccination

Despite the absence of legal restriction on personnel administering injectable, registered vaccines are currently classified as prescription-only medicines in Hong Kong (except certain veterinary vaccines).(15) All vaccines are supplied and administered after medical assessment and prescription by medical practitioners.

 

 Under the Vaccination Subsidy Scheme (VSS) which covers vaccination for COVID-19, seasonal influenza, and pneumococcal infection, only doctors listed in the “Primary Care Directory” are eligible to enrol in the scheme. The registered medical practitioner is responsible for the entire vaccination service, from assessing patients’ clinical suitability for vaccination, supervising the administration, to managing vaccinerelated adverse effects and emergencies. Healthcare professionals such as nurses, pharmacists and other trained personnel can only perform vaccination under doctors’ supervision.(16)

 

 The doctor-dependent supply and administration of vaccines can limit the access and scalability of vaccination services in the local community. As in other healthcare systems, vaccines with favourable safety profile can be delivered by other qualified healthcare professionals such as registered pharmacists and nurses. Quality assurance and regulatory framework can be established to empower non-medical disciplines to contribute to the vaccination services while safeguarding patient safety.

 

b) Perceived Role of Pharmacist in Vaccination

Pharmacists’ primary role in vaccination service sites is to manage the distribution of vaccines and to ensure their quality. However, this division of labour limits the flexibility of sharing workload with other healthcare professionals.

 

 Furthermore, some medical associations in the UK and Australia have raised concerns about pharmacybased vaccination hindering follow-up care for at-risk patient groups due to a lack of record sharing between pharmacists and physicians. Others have expressed concerns over inadequate experience in injectable administration and training on handling potential anaphylaxis after vaccination.(2,7)

 

c) Lack of Ready Pharmacy Infrastructure

According to the VSS Doctor’s Guide, service providers should have readily available equipment and medications on-site to manage anaphylaxis. Suitable purposebuilt vaccine refrigerators equipped with temperature monitors and cold box picking are also necessary for providing vaccination service.(17) The setup of venue for vaccination services requires space and comprehensive design. Most existing community pharmacies in Hong Kong have not been designed in a way that can fulfil the requirement for vaccination services and conversion can be immensely resource-demanding. The establishment of vaccination-ready pharmacies and the implementation of pharmacy-based vaccination compounds the dilemma of the chicken or the egg.

 

WHERE ARE WE?

Various stakeholders have been dedicating efforts to pharmacy-based vaccination in Hong Kong and to overcoming the aforementioned challenges. Pharmacists in Hong Kong are assuming greater roles in vaccination services. Trained pharmacists have been working closely with nurses and doctors in implementing vaccine services and administering vaccines in nonprofit non-governmental organisations, chain pharmacy company, private and public medical clinics. The growing involvement of pharmacists in vaccination services offer opportunities to promote cross-disciplinary collaboration and development of expertise in vaccination among pharmacists.

 

 Since 2018, local professional societies and universities have delivered multiple in-person vaccination workshops to local pharmacists and pharmacy students. In 2021, the University of Hong Kong (HKU) and Health in Action, a local non-profit non-governmental organisation which promotes health equity through innovations in primary healthcare services, led the Hong Kong Pharmacists Immunisation Training Working Group and together they established the “Immunisation Training Programme for Registered Pharmacists – Standards and Framework”. The document sets out the general standards and framework of immunisation training for Hong Kong to ensure confidence, competence, safety, and effectiveness of the promotion and administration of vaccinations in different healthcare settings. Based on the developed standards and framework, HKU has successfully delivered the immunisation training to over 300 local pharmacists and pharmacy students since early 2021. The local pharmacist immunisation training programme consists of (a) face-to-face immunisation practice, (b) basic life support including cardiopulmonary resuscitation (CPR) in response to an emergency such as anaphylaxis, and (c) clinical skill and competency assessment by qualified vaccinators.

 

 Meanwhile, pharmacy programmes of the Chinese University of Hong Kong and HKU have incorporated immunisation training in the local pharmacy undergraduate curricula since 2021. All graduates would be expected to be qualified for immunisation services.

 

 As current and future pharmacists are becoming equipped for vaccination, professional societies and their management team can advocate for the integration of pharmacist-led vaccination in clinical care pathways to promote the local immunisation coverage. For example, influenza and pneumococcal conjugate vaccines can be inoculated and managed by pharmacists in hospital ambulatory clinics and community vaccination outreach programmes. These are the steps forward that will ultimately bring the pharmacy profession, the regulatory authority, and the healthcare system to better utilisation of pharmacists in the local immunisation programmes.

 

CONCLUSION

As demonstrated in overseas healthcare systems, the high accessibility of community pharmacies and community pharmacists can promote immunisation rates. Despite recent advancement in the training pathway for pharmacist-led vaccination, the territorywide implementation of pharmacy-based vaccination still faces crucial barriers with regard to vaccine access, expectation of pharmacists’ roles and the difficulties for community pharmacies to fulfil infrastructure-related requirements.

 

 Overcoming these obstacles requires a constant supply of trained pharmacists, widespread distribution of vaccination-ready pharmacies, and potential updates in legislation or policies. Continuing collaborations and engagement among healthcare providers, academia, professional bodies, pharmaceutical industry and regulatory authorities will undoubtedly accelerate the introduction of pharmacy-based vaccination in Hong Kong.

REFERENCES

 

1.   Ten health issues who will tackle this year [Internet]. World Health Organization. World Health Organization; [cited 2023Apr12]. Available from: https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

 

2.   Poudel A, Lau ETL, Deldot M, Campbell C, Waite NM, Nissen LM. Pharmacist role in vaccination: Evidence and challenges. Vaccine. 2019Sep20;37(40):5939–45.

 

3.   Ecarnot F, Crepaldi G, Juvin P, Grabenstein J, Del Giudice G, Tan L, et al. Pharmacy-based interventions to increase vaccine uptake: Report of a multidisciplinary stakeholders meeting. BMC Public Health. 2019Dec18;19(1).

 

4.   Grabenstein JD. Daily versus single-day offering of influenza vaccine in community pharmacies. Journal of the American Pharmacists Association. 2009;49(5):628–31.

 

5.   Buchan SA, Rosella LC, Finkelstein M, Juurlink D, Isenor J, Marra F, et al. Impact of pharmacist administration of influenza vaccines on uptake in Canada. Canadian Medical Association Journal. 2017 Jan 30;189(4). doi:10.1503/cmaj.151027

 

6.   Steyer TE, Ragucci KR, Pearson WS, Mainous AG. The role of pharmacists in the delivery of influenza vaccinations. Vaccine. 2004Feb25;22(8):1001–6.

 

7.   Bartsch SM, Taitel MS, DePasse JV, Cox SN, Smith-Ray RL, Wedlock P, et al. Epidemiologic and economic impact of pharmacies as vaccination locations during an influenza epidemic. Vaccine. 2018Nov12;36(46):7054–63. 

 

8.   Rosado H, Bates I, Pyzik O, Sousa Pinto G, Besançon L. [Internet]. An overview of current pharmacy impact on immunisation. A global report 2016. [cited 2023Apr13]. Available from: https://www.fip.org/files/fip/publications/ FIP_report_on_Immunisation.pdf

9.   National Minimum Standards and Core Curriculum for Immunisation Training for Registered Healthcare Practitioners. [cited 2023Apr13]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/ uploads/attachment_data/file/679824/Training_standards_and_core_ curriculum_immunisation.pdf

 

10.  Appendix C. flu vaccinator competency assessment tool - GOV.UK [Internet]. UK Health Security Agency; 2020 [cited 2023 Apr 23]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/ uploads/attachment_data/file/1097794/UKHSA-flu-immunisation-trainingrecommendations-2022-to-2023-appendix-C.pdf

 

11.  Flu vaccination - training requirements and resources [Internet]. PSNC Website. Pharmaceutical Services Negotiating Committee; 2022 [cited 2023Apr13]. Available from: https://psnc.org.uk/national-pharmacy-services/ advanced-services/flu-vaccination-service/flu-vaccination-training/

 

12.  Flu vaccination - training requirements and resources [Internet]. PSNC Website. Pharmaceutical Services Negotiating Committee; 2022 [cited 2023Apr13]. Available from: https://psnc.org.uk/national-pharmacy-services/ advanced-services/flu-vaccination-service/flu-vaccination-training/

 

13.  Patient group directions: Who can use them [Internet]. GOV.UK. Medicines & Healthcare products Regulatory Agency; 2017 [cited 2023Apr13]. Available from: https://www.gov.uk/government/publications/patient-group-directionspgds/patient-group-directions-who-can-use-them

 

14.  Immunisation Patient Group Direction (PGD) templates [Internet]. GOV. UK. Medicines & Healthcare products Regulatory Agency; 2023 [cited 2023Apr13]. Available from: https://www.gov.uk/government/collections/ immunisation-patient-group-direction-pgd

 

15.  Cap. 138A Pharmacy and Poisons Regulations (HK Legislation) [2023] Sch. 3

 

16.  Monitoring and management of adverse events following vaccination [Internet]. 2022/23 Vaccination Subsidy Scheme Doctors’ Guide. Centre for Health Protection, Department of Health, HKSAR; 2022 [cited 2023Apr13]. Available from: https://www.chp.gov.hk/files/pdf/vssdg_ch5_appendix_f.pdf

 

   17.Chapter 6 – Requirements on vaccine storage and handling under VSS [Internet].       VSS Doctors’ guide - participating in VSS. Centre for Health Protection, Department of   Health, HKSAR; 2022 [cited 2023Apr13]. Available from:   https://www.chp.gov.hk/files/pdf/vssdg_ch6_vaccine_storage_and_ handling.pdf


2023-12-27 於2021月03月11日

INTRODUCTION 

Although immunisation is widely considered to be one of the greatest achievements of public health, the vaccination programme of the COVID-19 vaccine in Hong Kong has brought the issue of vaccine hesitancy to the forefront. Vaccine hesitancy, which is defined as “the reluctance or refusal to vaccinate despite the availability of vaccines”, is listed as one of the top ten threats to global health by the World Health Organization.(1)


 To address vaccine hesitancy, the 3Cs Model (i.e., Confidence, Complacency, Convenience) and the 5As Model (i.e., Access, Affordability, Awareness, Acceptance, Activation) are usually adopted to analyse the problem and establish relevant measures.(2,4) Being renowned for the accessibility, wide distribution, and expertise in medicines, community pharmacists are in a privileged position to provide vaccination. In at least 13 countries such as the United States (US), the United Kingdom (UK), Australia, Canada, and New Zealand, pharmacists are not only responsible for advocating vaccination and ensuring the safe supply of vaccines, but they are also empowered to play an active role in immunisation programmes where they are legally authorised to administer vaccines.

 

 In Hong Kong, pharmacists are minimally involved in any vaccination programme. Even under the recent community COVID-19 vaccination programme, pharmacists’ role is mainly limited to ensuring the safe supply and reconstitution of vaccines. Emerging worldwide evidence demonstrates the cost-effectiveness of pharmacy-based vaccination as well as the potential expansion of vaccination coverage through pharmacies during epidemics. This article aims to review the possible roles of pharmacists in vaccination in Hong Kong by highlighting the benefits of pharmacy-based vaccination, current challenges faced by pharmacists, and the worldwide landscape of pharmacy-based vaccination.

 

WHY PHARMACY-BASED VACCINATION?

Pharmacists are well-equipped to provide vaccination services as they possess extensive clinical knowledge and skills including medication management, history taking, health assessment, counselling, and optimising medication therapy. Pharmacists are also among the most accessible and frequently consulted healthcare professionals for health advice. As such, pharmacists can serve as advisors and educators to facilitate vaccine uptake.(2)

 

 Delivering vaccination services at pharmacies in addition to conventional sites offers numerous advantages including expansion of coverage, reduced physician workload and wait times, as well as cost savings for the healthcare system.(3)

 

a) Enhance Vaccination Coverage

The wide distribution and the long opening hours of community pharmacies make them an ideal location for people to receive vaccination in a casual and friendly environment which can in turn improve community vaccine uptake.

 

A study on influenza vaccination in community pharmacies of the US reported an eightfold increase in the number of vaccines administered when pharmacists offered vaccination daily compared to nurses offering vaccination on a single day.(4) Evidence supporting pharmacy-based vaccination in Canada is also growing. A study in Canada comparing the estimated influenza vaccine coverage before and after pharmacy-based vaccination reported that the vaccine coverage increased from 26% in 2012 – 2013 to 36% in 2013 – 2014.(5)

 

 The studies highlight the potential positive impact of pharmacy-based vaccination services in promoting vaccine uptake rates.

 

b) Indirect Cost Savings

Pharmacy-based vaccination not only costs less than vaccine administration by a general practitioner, but also helps alleviate the burden on other healthcare providers. Pharmacy-based vaccination can bring the flexibility of mobilising the healthcare workforce, which can be crucial in addressing the rapidly evolving demands for health services in peak seasons. In the states and territories of the US where pharmacists are allowed to vaccinate, higher vaccination rates and lower vaccination-related healthcare resource utilisation and costs have been observed.(6)

 

 Utilising an agent-based model and a clinical and economic outcomes model for simulation, a US study has shown that administering vaccines through pharmacies in addition to traditional locations (hospitals, clinic / physician offices, and urgent care centres) during an influenza epidemic can avert up to 23.7 million symptomatic influenza cases. The reduction in influenza cases can be translated to a substantial cost-savings up to $2.8 billion to third-party payers and $99.8 billion to society.(7)

 

PHARMACY-BASED VACCINATION WORLDWIDE

The role of pharmacists in vaccination varies in different healthcare systems. In some parts of the world, pharmacists are responsible for vaccine education and supply management; while in other countries, they are legally authorised to administer vaccines.

              

According to a global survey conducted by the International Pharmaceutical Federation (FIP), 13 out of 45 countries authorise pharmacists to legally administer vaccines. These countries include Argentina, Australia, Canada, Costa Rica, Denmark, Ireland, New Zealand, the Philippines, Portugal, South Africa, Switzerland, the UK, and the US.(8) In these countries, in addition to the requirements on the pharmacies with regard to records, premises, equipment, materials and waste management, there is also a restriction that only accredited personnel could perform the vaccinations.

 

a) Accreditation of Vaccinators

In the UK, pharmacy personnel and other providers who wish to administer vaccines are required to undergo extensive training on immunisation knowledge defined in Public Health England’s “National Minimum Standards and Core Curriculum for Immunisation Training for Registered Healthcare Practitioners”.

 

 The curriculum covers 12 core areas of immunisation knowledge, among others, includes legal issues, vaccine administration, anaphylaxis and adverse reactions, record keeping and reporting.(9) The training also comprises face-to-face practical training on injection techniques and basic life support. Furthermore, the UK Health Security Agency has developed a “Flu Vaccinator Competency Assessment Tool” to periodically verify competency that includes knowledge, core clinical skills, clinical process and procedures for vaccine administration.(10)

 

 Starting from the 2022/23 flu vaccination season, pharmacists and other vaccinators could determine the frequency of face-to-face training for both injection technique and basic life support instead of every three years, providing that ongoing competence of an individual vaccinator can be demonstrated.(11)

 

b) Scope of Pharmacy-based Vaccination Services

The scope of pharmacy-based vaccination services varies among countries as presented the Table 1.(7)

 

Table 1. Vaccination Provided at Community Pharmacies in Different Countries

Country

Scope of Pharmacy-Based Vaccination Services

Argentina

Vaccination included in the National Vaccination Schedule such as influenza and varicella

Australia

Vaccinations provided vary across different jurisdictional legislation. For example, some only allow influenza vaccine, while some cover a wider range of vaccines such as measles and pertussis.

Canada

Vaccinations provided differ in different provinces. Some only allow influenza vaccine; some cover a wider range of vaccines such as influenza, hepatitis, human papillomavirus (HPV), chickenpox, and rabies post-exposure; Quebec only authorises pharmacists to administer vaccines for demonstration/education purposes

Ireland

Seasonal influenza, pneumococcal, and shingles for adults

New Zealand

▪          Vibrio cholerae and enterotoxigenic Escherichia coli vaccine

▪          Influenza vaccine (for ≥ 3 years old)

▪          Diphtheria, tetanus, and pertussis (acellular, component) vaccine (Tdap) (for ≥ 18 years old)

▪          Meningococcal vaccine (for ≥ 16 years old)

▪          Varicella (shingles) vaccine (for ≥ 50 years old)

Portugal

Vaccinations not included in the National Health Service Vaccination Plan such as Cholera, Herpes Zoster, and Rabies

South Africa

Measles, mumps, and rubella (MMR) and influenza vaccine, and vaccination included in the Expanded Programme on Immunisation (EPI) such as Hepatitis B and HPV

Switzerland

Vaccination varies across different Cantons in Switzerland

The Philippines

Influenza and pneumococcal vaccines for adults

UK

Vaccination strategy varies among England, Scotland, Northern Ireland, and Wales. The scope of services can cover most of the vaccines such as influenza and childhood immunisations (measles, mumps, and rubella) under the National Health Service Immunisation Plan

US

Vaccination strategy varies across different states in the US.

 

c) Legal Framework for Pharmacy-Based Vaccination

 

Different countries have developed different legal frameworks to enable pharmacy-based vaccination.

 

 For instance, New Zealand has implemented the reclassification of vaccines   since 2011 so that selected vaccines can be supplied at a pharmacy without a prescription when administered by an accredited registered pharmacist, and in compliance to the immunisation standards of the Ministry of Health. For example, varicella (shingles) vaccine does not require a prescription when (a) administered for the prevention of herpes zoster (shingles) to (b) a person 50 years of age or over (c) by an accredited registered pharmacist.(12) The pharmacist accreditation involves the completion of a vaccinator training course approved by the Ministry of Health.

 

 Meanwhile, the UK defined “Patient Group Directions (PGDs)” in the Regulation 213 of the Human Medicines Regulations 2012 as an administrative approach that enables registered health professionals (e.g. registered pharmacists) to supply and administer prescriptiononly medicines to patients without prescription under specific planned circumstances where patient care can be enhanced without compromising patient safety.(13) PGDs are applied in various scenarios such as routine immunisation programmes, and emergency response. PGDs are written instructions established by a multidisciplinary group composed of a doctor, a pharmacist, and a representative of any professional group expected to supply the medicines under the respective PGDs. Established PGDs require further endorsement and authorisation by the NHS organisation and signing by all individual health professionals working under the directions. PGDs for immunisation cover aspects of staff authorisation, documentation, audit requirements, and general guidance on best practices required to safely administer vaccines such as COVID-19 vaccine and HPV vaccine.(14) Thus, PGDs serve as a mechanism that allows the administration of prescription-only vaccines by community pharmacists.

 

CHALLENGES TO PHARMACY-BASED VACCINATION IN HONG KONG

a) Access to Vaccination

Despite the absence of legal restriction on personnel administering injectable, registered vaccines are currently classified as prescription-only medicines in Hong Kong (except certain veterinary vaccines).(15) All vaccines are supplied and administered after medical assessment and prescription by medical practitioners.

 

 Under the Vaccination Subsidy Scheme (VSS) which covers vaccination for COVID-19, seasonal influenza, and pneumococcal infection, only doctors listed in the “Primary Care Directory” are eligible to enrol in the scheme. The registered medical practitioner is responsible for the entire vaccination service, from assessing patients’ clinical suitability for vaccination, supervising the administration, to managing vaccinerelated adverse effects and emergencies. Healthcare professionals such as nurses, pharmacists and other trained personnel can only perform vaccination under doctors’ supervision.(16)

 

 The doctor-dependent supply and administration of vaccines can limit the access and scalability of vaccination services in the local community. As in other healthcare systems, vaccines with favourable safety profile can be delivered by other qualified healthcare professionals such as registered pharmacists and nurses. Quality assurance and regulatory framework can be established to empower non-medical disciplines to contribute to the vaccination services while safeguarding patient safety.

 

b) Perceived Role of Pharmacist in Vaccination

Pharmacists’ primary role in vaccination service sites is to manage the distribution of vaccines and to ensure their quality. However, this division of labour limits the flexibility of sharing workload with other healthcare professionals.

 

 Furthermore, some medical associations in the UK and Australia have raised concerns about pharmacybased vaccination hindering follow-up care for at-risk patient groups due to a lack of record sharing between pharmacists and physicians. Others have expressed concerns over inadequate experience in injectable administration and training on handling potential anaphylaxis after vaccination.(2,7)

 

c) Lack of Ready Pharmacy Infrastructure

According to the VSS Doctor’s Guide, service providers should have readily available equipment and medications on-site to manage anaphylaxis. Suitable purposebuilt vaccine refrigerators equipped with temperature monitors and cold box picking are also necessary for providing vaccination service.(17) The setup of venue for vaccination services requires space and comprehensive design. Most existing community pharmacies in Hong Kong have not been designed in a way that can fulfil the requirement for vaccination services and conversion can be immensely resource-demanding. The establishment of vaccination-ready pharmacies and the implementation of pharmacy-based vaccination compounds the dilemma of the chicken or the egg.

 

WHERE ARE WE?

Various stakeholders have been dedicating efforts to pharmacy-based vaccination in Hong Kong and to overcoming the aforementioned challenges. Pharmacists in Hong Kong are assuming greater roles in vaccination services. Trained pharmacists have been working closely with nurses and doctors in implementing vaccine services and administering vaccines in nonprofit non-governmental organisations, chain pharmacy company, private and public medical clinics. The growing involvement of pharmacists in vaccination services offer opportunities to promote cross-disciplinary collaboration and development of expertise in vaccination among pharmacists.

 

 Since 2018, local professional societies and universities have delivered multiple in-person vaccination workshops to local pharmacists and pharmacy students. In 2021, the University of Hong Kong (HKU) and Health in Action, a local non-profit non-governmental organisation which promotes health equity through innovations in primary healthcare services, led the Hong Kong Pharmacists Immunisation Training Working Group and together they established the “Immunisation Training Programme for Registered Pharmacists – Standards and Framework”. The document sets out the general standards and framework of immunisation training for Hong Kong to ensure confidence, competence, safety, and effectiveness of the promotion and administration of vaccinations in different healthcare settings. Based on the developed standards and framework, HKU has successfully delivered the immunisation training to over 300 local pharmacists and pharmacy students since early 2021. The local pharmacist immunisation training programme consists of (a) face-to-face immunisation practice, (b) basic life support including cardiopulmonary resuscitation (CPR) in response to an emergency such as anaphylaxis, and (c) clinical skill and competency assessment by qualified vaccinators.

 

 Meanwhile, pharmacy programmes of the Chinese University of Hong Kong and HKU have incorporated immunisation training in the local pharmacy undergraduate curricula since 2021. All graduates would be expected to be qualified for immunisation services.

 

 As current and future pharmacists are becoming equipped for vaccination, professional societies and their management team can advocate for the integration of pharmacist-led vaccination in clinical care pathways to promote the local immunisation coverage. For example, influenza and pneumococcal conjugate vaccines can be inoculated and managed by pharmacists in hospital ambulatory clinics and community vaccination outreach programmes. These are the steps forward that will ultimately bring the pharmacy profession, the regulatory authority, and the healthcare system to better utilisation of pharmacists in the local immunisation programmes.

 

CONCLUSION

As demonstrated in overseas healthcare systems, the high accessibility of community pharmacies and community pharmacists can promote immunisation rates. Despite recent advancement in the training pathway for pharmacist-led vaccination, the territorywide implementation of pharmacy-based vaccination still faces crucial barriers with regard to vaccine access, expectation of pharmacists’ roles and the difficulties for community pharmacies to fulfil infrastructure-related requirements.

 

 Overcoming these obstacles requires a constant supply of trained pharmacists, widespread distribution of vaccination-ready pharmacies, and potential updates in legislation or policies. Continuing collaborations and engagement among healthcare providers, academia, professional bodies, pharmaceutical industry and regulatory authorities will undoubtedly accelerate the introduction of pharmacy-based vaccination in Hong Kong.

Author’s background

CHAN, Philip Pan is currently a Quality Assurance Manager at Fortune Pharmacal Co. Ltd in Hong Kong. His email address is philipchanpan@gmail.com

LI, Johnny Chun-Wing is currently a Registered Pharmacist in Hong Kong. His email address is johnny_pharm@hotmail.com

WONG, Janet Kit-Ting is currently a Part-Time Lecturer at the Department of Pharmacology and Pharmacy, the University of Hong Kong, Hong Kong, China. Her email address is janetwkt@hku.hk

Related Articles:








HKPharmJ

Tel: 23763090

Email: editor@hkpj.org

Room 1303, Rightful Centre, 12 Tak Hing Street, Jordon, Kowloon, Hong Kong