Vaccination coverage and community pharmacy: A strategically necessary and operationally feasible binomial?

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"apellidos" => "Salleras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Consell de Col·legis de Farmacèutics de Catalunya, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Ciències de la Salud Blanquerna URL, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Preventiva, Agencia de Salut Pública de Catalunya, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Cátedra de Medicina Preventiva, Facultad de Farmacia, Universidad de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Col·legi de Farmacèutics de Barcelona, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Sociedad Española de Farmacéuticos Comunitarios (SEFAC), Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Cátedra de Medicina Preventiva, Universidad de Barcelona, Barcelona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Coberturas vacunales y farmacia comunitaria: ¿un binomio estratégicamente necesario y operativamente factible?" ] ] "textoCompleto" => "There is ample corroborated evidence to support the benefits of vaccination and it is recognised as one of the most effective and cost-effective preventive interventions ever known. Over the past thirty to forty years, preventive immunisation against communicable diseases has produced great achievements, such as eradicating smallpox, reducing the worldwide incidence of polio and reducing the burden of disease due to infections including diphtheria, tetanus, measles, Haemophilus influenzae type b and meningitis. Substantial progress has also been made in recent times through the introduction of vaccines against pneumococcal disease and rotavirus diarrhoea, and even vaccines whose effects stretch as far as prevention of the incidence of certain neoplasms such as liver cancer or cervical cancer.<a class="elsevierStyleCrossRef" href="#bib0245">1</a>In the words of Seth Berkley, executive director of the Global Vaccine Action Plan (GVAP), “We are facing a pivotal moment in history. Right now, the global health community has an unprecedented opportunity to coordinate with governments to develop and implement plans and strategies that will improve the lives of millions of people around the world through universal access to appropriate vaccines”.<a class="elsevierStyleCrossRef" href="#bib0245">1</a>For the experts, the vision for the Decade of Vaccines (2011–2020) was for a world in which all individuals and communities enjoy a life free of preventable diseases through vaccination.<a class="elsevierStyleCrossRef" href="#bib0250">2</a>However, in spite of the progress made so far, communicable diseases will continue to be one of the main causes of death, especially in low income countries. There are differences in vaccination coverage between different countries, but differences are particularly striking within countries themselves,<a class="elsevierStyleCrossRef" href="#bib0255">3</a> and among vulnerable groups and those of low socioeconomic status.<a class="elsevierStyleCrossRef" href="#bib0260">4</a> In March 2018, the European Parliament, in its parliamentary committee on the Environment, adopted a draft resolution in which it expressed concern about the decrease in coverage rates in Europe to insufficient levels and the possible consequences for public health.<a class="elsevierStyleCrossRef" href="#bib0265">5</a> The coverage of recommended vaccines in the paediatric age group has stagnated in recent years all over the world. According to World Health Organisation estimates in their 2018 report, vaccine coverage varies from 25% to 86%, depending on the particular vaccine preparation and part of the world. If world vaccine coverage were improved, a further 1.5 million cases of communicable diseases could be prevented.<a class="elsevierStyleCrossRef" href="#bib0270">6</a>In the conclusions of the GVAP, the focus is on a future operational objective to generate evidence on the most effective use of existing resources and to explore the innovative impact of new scenarios or actors.<a class="elsevierStyleCrossRefs" href="#bib0245">1,7,8</a>The role of pharmaceutical professionals in the healthcare systems of the countries around us has been changing for years, with a recent acceleration in pace. The close relationship of the pharmacist with the therapeutic process places them in an extremely advantageous position to identify the health needs of citizens and intervene in their therapeutic process, closing the circle of the patient's continuum of care.<a class="elsevierStyleCrossRef" href="#bib0275">7</a>Documents such as the 2012 Health Solutions Opportunity Map<a class="elsevierStyleCrossRef" href="#bib0285">9</a> stressed that, in a scenario of limited economic resources, existing models should be redesigned to create new scenarios where rationalisation, polarisation of services and the creation of a more effective public–private partnership are brought together. This document also suggested that it was necessary to move away from satisfying health needs towards healthcare models closer to the sufferer or to the place where those needs are expressed.There are many examples of operational planning towards the new model, including the approaches contained in documents such as The Road Map: The strategic direction for Community Pharmacy 2010,<a class="elsevierStyleCrossRef" href="#bib0290">10</a> published by the Pharmacy Guild of Australia; the document published in 2009 by the National Health Service-Lothian, Pharmacy Strategy 2009–2012.<a class="elsevierStyleCrossRef" href="#bib0295">11</a> More recent documents published by the Royal Pharmaceutical Society<a class="elsevierStyleCrossRef" href="#bib0300">12</a> and in 2015 by the University of Montreal<a class="elsevierStyleCrossRef" href="#bib0305">13</a> emphasise the role community pharmacists can develop in their care provision aspect in the field of primary and secondary prevention, drug therapy monitoring and resolution of acute illness of very low or low complexity.Modern healthcare systems have a point in common with the new models of community pharmacy: managing to succeed in making the current models, essentially based on the provision of medicines or medical devices, evolve towards the transformation of the pharmacy into a health centre and the pharmaceutical professional into a healthcare professional capable of adequately satisfying health service demands from individuals themselves. Most experts agree that the community pharmacy has specific attributes that can place it in an advantageous position for satisfying certain health demands. It is a dense network, with a multitude of highly accessible “points of care” with great proximity and social capillary action. It is very often the first point of contact where the need for health care is expressed. In fact, it is recognised that an individual may go to their community pharmacy about seven times for every visit to their primary care team. The community pharmacy has a greater degree of territorial equity than other health centres and, lastly and most importantly, is fronted by a trained healthcare professional who inspires a high level of trust in their patients/customers and is interconnected with broad implementation of new information and communication technologies (ICT).<a class="elsevierStyleCrossRef" href="#bib0310">14</a>The role of the community pharmacist in vaccine activities and strategies is not new. As far back as 1988, among the contents of the White Paper for the integration of preventive actions in pharmacy outlets,<a class="elsevierStyleCrossRef" href="#bib0315">15</a> published by the Department of Health of the Generalitat de Catalunya [Catalan Autonomous Government] and the Consell de Col·legis de Farmacèutics de Catalunya [Catalonia Council of Pharmacists Associations], in chapter 5 there are a total of nine activities that the community pharmacist had to perform in the area of vaccination strategies set out by the health authorities. These activities were agreed on through the participation of five scientific societies, three professional associations, a business federation and the academic world linked to the health sciences.In said document, the pharmacist was given the faculty and professional competence to act in favour of the effectiveness and safety of preventive immunisations, with special emphasis on compliance with the vaccination calendar in force at that time.However, careful reading of the secondary objectives that were proposed reveals an extension of the role of simple vehicle of information. The pharmacist was given a de facto function of opportunistic identification of the vaccination status of the susceptible healthy population. Other authors also agreed on that aspect, highlighting the role of pharmacists in children under 15<a class="elsevierStyleCrossRefs" href="#bib0280">8,16</a> and in candidates for immunisation against infections such as influenza or pneumococcal disease, especially the chronically ill and people over the age of 65.The seed was also planted for the current network of epidemiological surveillance pharmacies, implemented in some regions, with the recommendation that pharmacies have responsibility for detecting and reporting adverse reactions to vaccines and detecting the interactions between vaccine preparations and some medications.It was early 1996 before the American Pharmacists Association (APhA) introduced a specific training programme to accredit community pharmacists as vaccine agents. As a result of the training project, community pharmacists began to be recognised as experts in preventive immunisation.<a class="elsevierStyleCrossRef" href="#bib0325">17</a>Nobody doubted that the community pharmacist, because of the inherent strengths as a health agent, and the community pharmacy, because of its characteristics as a centre, could perform a valuable function in the provision of proactive structured counselling for vaccination, verifying errors and misunderstandings with respect to vaccine preparations<a class="elsevierStyleCrossRef" href="#bib0280">8</a> and, finally, perform a catch-up activity in at-risk individuals with inadequate vaccination coverage.<a class="elsevierStyleCrossRef" href="#bib0330">18</a> With this model, new strategies to increase vaccination against seasonal influenza began to be explored in the United States, such as taking advantage of home visits, empowering nurses to prescribe, giving medical counselling assisted by physicians and sending emails directly to susceptible patients. Finally, it was decided to allow community pharmacists to immunise in their pharmacies. By 2002, this strategy already covered 35 states.<a class="elsevierStyleCrossRef" href="#bib0335">19</a>The strategy based its premises on the fact that the community pharmacist is in an optimal situation to correct the main barriers presented by the implementation of population-based vaccination activities. Unquestionably, they were far more accessible than any healthcare professional,<a class="elsevierStyleCrossRef" href="#bib0340">20</a> they were in ideal locations and they were open to provide care for far longer hours than other centres.<a class="elsevierStyleCrossRef" href="#bib0325">17</a> It was estimated that over 250,000 users visited community pharmacies at least once a week.<a class="elsevierStyleCrossRef" href="#bib0345">21</a> The pharmacists in these states were not limited to issuing structured advice about the need to get vaccinated against the flu; they began to administer vaccines.There have been studies on the potential of community pharmacists to increase vaccine coverage.<a class="elsevierStyleCrossRefs" href="#bib0350">22,23</a> Back in 2003, Steyer et al.<a class="elsevierStyleCrossRef" href="#bib0360">24</a> tried to determine from a large national database to what extent vaccination coverage rates had increased in the states where pharmacists had been administering vaccines to their patients. Their results showed that among subjects over 65, coverage was significantly higher in states which had incorporated the community pharmacist as a vaccine agent. At the same time, they observed that beliefs and attitudes towards vaccination were substantially better among subjects who resided in states where legislation allowed vaccination by pharmacists. These differences persisted after the analysis stratified by factors such as gender, ethnicity, economic income, type of health insurance and perceived health status.<a class="elsevierStyleCrossRef" href="#bib0360">24</a>Coinciding with the influenza pandemic due to the AH1N1pdm09 virus, and in view of the results obtained, all states then allowed vaccination by pharmacists.<a class="elsevierStyleCrossRef" href="#bib0365">25</a> In November 2015, one in every four adults who received vaccination against the circulating influenza virus did so at the pharmacy.<a class="elsevierStyleCrossRef" href="#bib0370">26</a> Subsequently, in 2017, Schwerzmann et al.<a class="elsevierStyleCrossRef" href="#bib0375">27</a> evaluated the impact of vaccine administration during the pandemic, concluding that pharmacists could increase the number of vaccines administered and achieve over 80% coverage in less time if single-dose vaccines were used. This led to pharmacists being integrated into the Vaccine Response Plan against influenza pandemics.<a class="elsevierStyleCrossRef" href="#bib0380">28</a>In Canada, the paradigm shift in the integration of the pharmacist into vaccine strategies arrived in 2013.<a class="elsevierStyleCrossRef" href="#bib0385">29</a> In Ontario in 2012 about 250,000 people received their vaccines from their pharmacist. By 2014 that figure had tripled. The results urged the Canadian government to request the expansion of this pharmaceutical service for other types of vaccine preparations.<a class="elsevierStyleCrossRef" href="#bib0390">30</a>Portugal joined the initiative in 2007, allowing pharmacists to expand their traditional roles, including the administration of vaccines not included in their National Health Plan.<a class="elsevierStyleCrossRef" href="#bib0395">31</a> The first influenza vaccination campaign in 2008–2009 focused on communication about the new service, stressing the role of the community pharmacist as a health educator. Subsequently, 3600 pharmacists were accredited and more than 2100 community pharmacies provided services linked to vaccination. It was estimated that the participation of community pharmacies had increased coverage by 26%, especially among the over 65s.<a class="elsevierStyleCrossRef" href="#bib0400">32</a> In 2012, 55.1% of immunisations were carried out in Portuguese pharmacies.<a class="elsevierStyleCrossRef" href="#bib0390">30</a> After four years of experience, users clearly preferred community pharmacies, not only for their accessibility or territorial equity, but also based on what patients consider most useful, a decrease in the opportunity cost of being immunised. In addition, the integration of the pharmacist in national influenza vaccination strategies increases the confidence of the population in vaccination and changes pharmacists’ perceptions of vaccination, this being a determining factor for exercising an exemplary role in vaccination.<a class="elsevierStyleCrossRef" href="#bib0405">33</a>In the United Kingdom, 11% of all immunisations against the influenza virus in certain areas of London<a class="elsevierStyleCrossRef" href="#bib0410">34</a> are carried out in the community pharmacy and in rural areas, such as the Isle of Wight, this represents a third of all immunisations in people over 65 with comorbidities.<a class="elsevierStyleCrossRef" href="#bib0415">35</a>In 2015, pharmacists in Western Australia offered vaccination services. Between the months of March and October of that year, 15,621 vaccines were administered in 76 community pharmacies there. The proportion of adverse effects recorded was less than 1% and all were of a minor nature. Between 12% and 17% of the population eligible for the National Immunisation Programme chose to be vaccinated at the pharmacy, above all in rural areas or where accessibility to other health services was poorer. The participating pharmacists said they were satisfied with the programme and agreed to expand their service to other vaccinations. All the pharmacies that participated in the 2015 campaign adhered to the following season's campaign. The initial assessment by the heads of the National Immunisation Programme was that the administration of vaccines in the community pharmacy was safe. Accessibility and user comfort were the aspects considered most relevant.<a class="elsevierStyleCrossRef" href="#bib0420">36</a>The last example is found in France, where in 2017 flu vaccination in community pharmacies was registered as a social security-funded project.<a class="elsevierStyleCrossRef" href="#bib0425">37</a> Although the provision was criticised, it was considered necessary based on previous experiences in the interests of increasing vaccination coverage in France, especially after the excess mortality rates in 2015 which mostly affected the over 65s.<a class="elsevierStyleCrossRef" href="#bib0430">38</a>The experience of the users of these services, integrated in a collaborative way with other health centres or actors, is highly positive. The assessments carried out express a high, significant and consistent degree of perceived satisfaction.<a class="elsevierStyleCrossRefs" href="#bib0395">31,39,40</a>Nonetheless, the real impact of these strategic initiatives should continue to be analysed, as the latest meta-analyses show contradictory outcomes,<a class="elsevierStyleCrossRef" href="#bib0445">41</a> although these are mainly due to differences in approaches and designs. They all conclude, however, that the inclusion of the community pharmacist performing the functions of educator, facilitator or administrator of certain types of vaccines (influenza or pneumococcal pneumonia) increases vaccination coverage compared to traditional models which do not have such integration.<a class="elsevierStyleCrossRefs" href="#bib0260">4,7,42–44</a>In spite of all the above, all the evidence and the efforts to integrate community pharmacists into the European health services vaccine policies,<a class="elsevierStyleCrossRef" href="#bib0430">38</a> the approach is heavily criticised by other health agents who, from ideological or corporate positions,<a class="elsevierStyleCrossRef" href="#bib0425">37</a> see the activity of the pharmacists as a clear invasion of their area of competence and even as highly intrusive practices.<a class="elsevierStyleCrossRef" href="#bib0310">14</a> Functional barriers to proper integration are also pointed out, such as training or certification of competencies, the legal systems that regulate the exercise of competence, the provision of vaccine preparations when they are within the public portfolio, remuneration for these pharmaceutical services, the shared records of the information generated, the relationships with other professionals and, last of all, the awareness and knowledge of the general public about the role community pharmacists are able to perform.<a class="elsevierStyleCrossRefs" href="#bib0255">3,4,36,45–47</a>Although we agree with other authors on the positive benefits of the inclusion of community pharmacists in overall vaccination strategies,<a class="elsevierStyleCrossRefs" href="#bib0375">27,40,43,44</a> we believe that these should clearly respond to the specific vaccination needs based on local epidemiological data, and be closely coordinated with the Health Plans or the agendas of the National Public Health Agencies. Only then can the strengths and capacity of community pharmacists be fully exploited in an integrated approach to vaccine strategies, thus maximising their effectiveness. We believe that experiences such as that of an interdisciplinary group formed by representatives of the North American territorial public health services and pharmacist representatives<a class="elsevierStyleCrossRef" href="#bib0480">48</a> could provide a standardised model to facilitate such integration and create credible operating procedures for the role that pharmacists may play in the future. Such models enable a broader and more flexible framework of collaboration, adapting to the legal situation, the existing framework of competence and the need observed from the epidemiological data, in order to effectively and efficiently adapt the response of the pharmaceutical services. In short, it is a skill-mix strategy through which the response can be adapted to an integrated shared management framework for vaccine strategies.In 2017, the professional, business and scientific organisations of the pharmaceutical world agreed, in Catalonia, on the creation of a collaborative framework that defined pharmaceutical care services as they apply to vaccine policy. They put together a programmatic document to help identify the opportunities and generate the necessary changes to increase the role of the community pharmacy as public health infrastructure for dealing with seasonal influenza. The document included an internal analysis of community pharmacies, highlighting the strengths that might constitute an element of value in their position in the market as health centres, with benchmarking proving clearly positive. It was determined that they could exercise the following functions: (1) development of the exemplary role increased the vaccination rate among pharmacists and community pharmacy staff; (2) personalised information about the medication (vaccine); (3) identification by opportunistic screening of candidates for immunisation in view of the characteristics of their treatment plan (diagnostic inference); (4) dissemination of specific campaigns (awareness campaigns) to the general population or specific risk groups; (5) protocolised pharmacological follow-up to improve compliance and adherence to the vaccination calendar, especially in the case of multidose or seasonal repeat doses; and (6) syndromic surveillance.Some of these activities were started in the 2017–2018 seasonal influenza vaccination campaign, protocolised and suitably coordinated with the Catalan Public Health Agency.Without any doubt, this was an important and decisive first step. However, we must continue to work consistently to convince other health actors, authorities and the population in general that it is always positive to refer to facts and science, an aspect that many have begun to call “evidence-based pharmacy”.Conflict of interestsThe authors declare that they have no conflicts of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:3 [ "identificador" => "xres1142654" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1073298" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1142653" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1073297" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-03-15" "fechaAceptado" => "2018-05-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1073298" "palabras" => array:3 [ 0 => "Vaccines" 1 => "Community pharmacy" 2 => "Pharmaceutical Care" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1073297" "palabras" => array:3 [ 0 => "Vacunas" 1 => "Farmacia comunitaria" 2 => "Atención farmacéutica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "This article aims to analyse the existing information on the suitability and effectiveness of the community pharmacy in the shared management of vaccination strategies on population at risk, especially against seasonal influenza, which have developed in different countries around us.Although the real impact of this integration presents different results, mainly due to the fact that its implementation is carried out in health systems of different models and presents different approaches and designs that must be taken into account in its evaluation, the conclusion that can be reached is that the inclusion of the community pharmacist developing the functions of educator, facilitator or administrator of certain types of vaccines (anti-flu or pneumococcal, for example), increases vaccination coverage when compared to traditional models that integrate us. Being, in addition, highly positive the experience of the users of these services, integrated in a collaborative way with other centres or health actors.However, the integration of the community pharmacist in strategic and operational planning to increase vaccine coverage must clearly respond to specific needs based on local epidemiological data. And be closely coordinated with the Health Plans or the agendas of the National Public Health Agencies. This is the only way to take full advantage of the strengths and capabilities of community pharmacists in an approach that maximises the effectiveness of their actions." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El presente artículo pretende analizar la información existente sobre la idoneidad y la efectividad de la farmacia comunitaria en la gestión compartida de las estrategias vacunales sobre población de riesgo, especialmente contra la gripe estacional, que se han desarrollado en distintos países de nuestro entorno.Aunque el impacto real de dicha integración presenta resultados dispares debido fundamentalmente a que su implantación se realiza en sistemas sanitarios de modelos distintos y presenta enfoques y diseños diferentes que deben tenerse en cuenta en su evaluación, la conclusión a la que puede llegarse es que la inclusión del farmacéutico comunitario desarrollando funciones de educador, facilitador o administrador de ciertos tipos de vacunas (antigripal o antineumocócica, por ejemplo) aumenta las coberturas vacunales cuando se compara con modelos tradicionales que nos los integran. Siendo, además, altamente positiva la experiencia de los usuarios de estos servicios, integrados de manera colaborativa con otros centros o actores sanitarios.Con todo, la integración del farmacéutico comunitario en la planificación estratégica y operativa para aumentar las coberturas vacunales debe responder claramente a las necesidades específicas basadas en datos epidemiológicos locales. Y estar estrechamente coordinada con los Planes de Salud o las agendas de las Agencias Nacionales de Salud Pública. Solo así podrán aprovecharse plenamente las fortalezas y las capacidades de los farmacéuticos comunitarios en un abordaje que permita maximizar la efectividad de sus actuaciones." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Guayta-Escolies R, Urbiztondo L, Domínguez A, Bagaria G, Gascón P, de Dalmases J, et al. Coberturas vacunales y farmacia comunitaria: ¿un binomio estratégicamente necesario y operativamente factible? 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