Clinics, pharmacies must work together to streamline vaccinations amid COVID-19 pandemic

We are seeing an enormous rise in COVID-19 cases, but as we continue to focus on controlling the pandemic, it is vital that we prevent outbreaks of other vaccine-preventable infectious diseases.

There have been significant drop-offs in routine childhood and adult vaccinations amid the pandemic. We need to build more robust systems to increase vaccination rates so that we do not have to use our already overstretched public health resources to simultaneously combat additional preventable diseases that have the potential to cause outbreaks during the COVID-19 pandemic.

Further, by taking the time now to strengthen the processes and infrastructure we use to ensure high levels of vaccination for other infectious diseases, we can also ensure systems are in place that allow the future COVID-19 vaccines — when available — to be administered to every person throughout the nation and world.

Vaccine-preventable threats

Prior to COVID-19, the U.S. struggled with measles outbreaks driven by decreased childhood measles vaccination rates, and there are currently isolated global outbreaks of measles attributed to decreases in routine vaccinations during the pandemic. Further, we are now approaching our annual influenza season and risk having patients coinfected with influenza and COVID-19, adding to the usual burden that influenza alone places on our health care system each year.

As we are grappling to contain the COVID-19 pandemic, we do not have enough resources to address additional disease outbreaks such as measles and influenza. Our hospitals and ICUs are already full of patients with COVID-19, so we must maintain and increase rates of essential adult and childhood vaccinations.

At the start of the pandemic, many people across the country were asked to shelter in place, and out of fear of COVID-19 exposure, many adults and children skipped clinic visits, resulting in decreased routine vaccinations. Many outpatient practices adopted a telehealth model in response to the pandemic and are continuing to see patients virtually via video visits and phone calls. In primary care, we are still promoting routine vaccines, including the influenza vaccine, during each telehealth visit; however, since many practices are still not seeing a majority of patients in person at the clinic, we are more frequently asking our patients to go to their local pharmacies to get their essential vaccines.

Some practices might have the option of setting up nurse-only visits so that patients can come into the clinic for a vaccine, and other clinics have established drive-through vaccine events, particularly for children, as well as other novel strategies to safely increase vaccinations in non-clinic settings during the pandemic. However, since vaccine administrations cannot occur during telehealth appointments, patients must take the extra step to get vaccinated.

Strengthening vaccination systems

With an exponential rise in patients receiving their vaccines at local pharmacies instead of their primary care clinic during the pandemic, we must strengthen our ability to record and track the vaccines that are being administered in settings outside of the clinic. When a vaccine is given in the primary care office, we can automatically input the vaccine administration information into the patient’s electronic medical record (EMR). However, when a patient receives a vaccine in a pharmacy, we do not routinely get information from the pharmacy or the patient regarding when the vaccine was administered and which formulation was given. Most importantly, for vaccines that require multiple doses, automatic systems are often not in place at the pharmacy and clinic to remind the patient and alert the pharmacy and clinic when the next vaccine dose(s) must be administered to achieve immunity.

There are a number of strategies that we can use at the local level to address these issues. One is to strengthen communication between clinics and pharmacies. This means that if a pharmacy administers a vaccine, then the pharmacy should fax or electronically transmit records of the vaccine administration back to the patient’s clinic so that the primary care clinic staff can update the patient’s EMR. For vaccines not requiring a prescription for pharmacies to administer, such as the influenza vaccine, physicians can still decide to send a prescription for the vaccine to the patient’s selected pharmacy so that the pharmacy has the prescribing clinic’s contact information and can more easily send records back to the clinic once the vaccine has been administered.

It is also important to make sure that systems are in place to remind patients to complete their vaccine series when multiple vaccine doses are needed to achieve immunity. For example, the adult formulation of the hepatitis B vaccine is either a two- or three-dose vaccine that is given over a 1-month or 6-month period, depending on which brand is administered. Prior to the COVID-19 pandemic, we saw regional rises of up to 100% to 700% in acute hepatitis B fueled by both the opioid epidemic and very low adult hepatitis B vaccination rates of only 25% in the United States. During the COVID-19 pandemic, we have seen increases in the rates of opioid overdoses and opioid-related deaths coupled with decreased testing and vaccination rates for viral hepatitis. Given that the opioid epidemic and decreased vaccination rates continue to represent a public health threat, we must develop strategies to build systems that ensure patients complete their multidose vaccine series in order to prevent new outbreaks of diseases such as hepatitis B.

In the case of hepatitis B, if a patient comes into the pharmacy and gets one dose of the hepatitis B vaccine, we need to have systems in place so that either the pharmacy or clinic will be able to remind the patient when they are due for their next dose and make sure the patient completes the vaccine series with the same brand of the vaccine with which they started their vaccine series to ensure completed immunization.

We must also work at a systems level to modernize and ensure interoperability of immunization information systems and integrated health information exchanges so that all vaccines administered in clinic and non-clinic settings, including pharmacies, are recorded and viewable across health systems by all members of the health care team in real time. The ability for immunization information systems to communicate across state and regional lines is also key. If a patient receives a vaccine in one state but receives the follow-up vaccine in another state, we need to make sure that these systems are talking to each other.

Other strategies to support vaccine access in the primary care setting include having standing orders for vaccines so that any authorized member of the health care team can administer the vaccines that a patient requires, stocking an expanded range of vaccines in the clinic, and posting information on available vaccines and recommended vaccine schedules for adults and children that are easily visible to both patients and providers.

Preparing for mass COVID-19 vaccination efforts

We are about to embark on one of the largest mass public health endeavors in history when we launch widespread efforts to administer the COVID-19 vaccine, once a safe and effective vaccine has been FDA approved.

Efforts we make now to build the systems and infrastructure necessary to document vaccine administration in non-clinic settings, improve communication between clinics and pharmacies, and appropriately remind patients to complete a multidose vaccine series will be of utmost importance when a COVID-19 vaccine becomes available and we begin roll out of the vaccine with the goal of vaccinating every person across the country.

There are a couple of promising COVID-19 vaccine candidates where the manufacturers are currently or plan to soon apply for FDA emergency use authorization. The vaccines that are currently closest to potential approval require more than one dose for immunity, further highlighting the need to implement systems for tracking multidose vaccinations administered in an array of sites, including pharmacies and other non-clinic settings. This will not only help ensure that patients are adequately completing their COVID-19 vaccine series, but it will also help us ensure that the vaccine reaches and protects every person in each of our diverse communities, regardless of socioeconomic status, race, ethnicity and location, including rural areas.

As we work to modernize our immunization information systems, we must ensure that pharmacists, physicians, physician assistants, nurse practitioners, nurses, medical assistants and other individuals involved in vaccine administration can record and view instantaneously updated vaccine administration data nationwide in order to appropriately track patients’ COVID-19 vaccination status.

National stakeholders such as the Adult Vaccine Access Coalition have clearly articulated the funding and support necessary to successfully immunize our nation against COVID-19, and we must ensure this investment is made.

Further, since the most promising COVID-19 vaccine candidates require cold storage, we must  build adequate cold-storage supply chains that ensure the vaccines remain stable until they are ready to be administered, including in administration settings such as drive-through clinics, mobile clinics and pop-up clinics. In addition, we must prioritize manufacturing and stocking supplies necessary for vaccine administration such as personal protective equipment, syringes and needles so that when a COVID-19 vaccine is approved, we will not have another bottleneck in the system preventing distribution of the vaccine.

Finally, since COVID-19 represents a major global public health threat and all of us as taxpayers have funded the research, development and purchase of the COVID-19 vaccine candidates through government-led investments and/or purchase agreements with the pharmaceutical companies developing the COVID-19 vaccine, we must ensure that everyone in our nation receives the COVID-19 vaccine with no patient cost sharing and that the vaccine is rapidly and equitably distributed as soon as it is approved by the FDA, so that we may finally end the COVID-19 pandemic.

References:

Adult Vaccine Access Coalition. AVAC joins stakeholders in letter to Congress about preparing for COVID-19 vaccine. https://adultvaccinesnow.org/letters/avac-joins-stakeholders-in-letter-to-congress-about-preparing-for-covid-19-vaccine/. Accessed Nov. 18, 2020.

Adult Vaccine Access Coalition. AVAC leads stakeholder letter on equitable COVID vaccine distribution. https://adultvaccinesnow.org/letters/avac-letter-on-equitable-covid-vaccine-distribution/. Accessed Nov. 18, 2020.

American Immunization Registry Association. AIRA's Response to COVID-19. https://www.immregistries.org/aira-s-response-to-covid-19. Accessed Nov. 18, 2020.

American Immunization Registry Association. Preparing for a COVID-19 vaccine. https://repository.immregistries.org/files/resources/5eb1694a0c8ce/aira_preparing_for_covid-19_one-sheet.pdf. Accessed Nov. 18, 2020.

CDC. About immunization information systems. https://www.cdc.gov/vaccines/programs/iis/about.html. Accessed Nov. 18, 2020.

CDC. Interim guidance for routine and influenza immunization services during the COVID-19 pandemic. https://www.cdc.gov/vaccines/pandemic-guidance/index.html. Accessed Nov. 18, 2020.

Immunization Coalitions Network. Repository of resources for maintaining immunization during the COVID-19 pandemic. https://www.immunizationcoalitions.org/resource-repository/. Accessed Nov. 18, 2020.

National Foundation for Infectious Diseases. Call to action: Preventing hepatitis B in US adults through increased vaccination rates among at-risk groups. https://www.nfid.org/wp-content/uploads/2019/08/cta-hep-b-at-risk-adults.pdf. Accessed Nov. 23, 2020.