Pharmacists as immunizers in Lebanon: a national survey of community pharmacists’ willingness and readiness to administer adult immunization

Immunization is considered as one of the most cost-effective strategy for disease prevention [1]. Despite its known benefits, adult immunization rates worldwide fall below desired targets [2]. Many factors have been identified as barriers towards achievement of target immunization coverage rates, including general public apathy, concerns and misconceptions about the safety and efficacy of vaccines, cost, lack of access to immunizers and convenience [3]. Thus, in order to improve immunization rate, there is an urgent need to address these barriers.

Since the focus of healthcare has shifted toward prevention, pharmacists were highly encouraged to expand their practice to incorporate preventive measures including immunization [4, 5]. Besides, one of the suggested strategies to succeed in an immunization program and increase the coverage rates among adults lies in involving pharmacists in vaccine administration [6]. This extension in the practice scope can be achieved through different ways such as starting by advocating immunization through raising awareness about the benefits of vaccine among the public, particularly pharmacy visitors, discussing the patient’s immunization status and recommending vaccines during the patient’s visit to the pharmacy. Lastly, pharmacists, especially community ones, can be potential immunizers by administering vaccines in their practice setting [7].

In their attempt to increase the rate of immunization, many countries have adopted the strategy of involving non-traditional immunization providers and, thus, allowing pharmacists to administer vaccines [8]. Many studies intended to highlight the positive effects of implementing vaccinations in community pharmacies. The results of these studies showed that pharmacists increase the availability of vaccinations, accelerate immunization, effectively educate patients, affect the vaccination coverage rate, prevent new cases of diseases, and by reducing the number of diseases or complications, they bring savings to the healthcare system [9‐13]. Experiences in countries, who adopted the mentioned strategy such as England, Portugal, and the United States, prove the benefits of pharmacy-driven vaccination for both patients and the healthcare system [14]. Similarly, in Canada, following the implementation of vaccination administered by pharmacists, the proportion of people vaccinated in the general population has increased significantly [15].

In Lebanon, the distribution of community pharmacies among Lebanese province is not equitable and its ownership is private on a for-profit basis [16]. According to the Lebanese Order of Pharmacists (OPL) and the Ministry of Public Health (MOPH) laws, pharmacists should be omnipresent during the pharmacy’s opening hours. However, they are not permitted by law to administer vaccines. Their role is only restricted to dispense vaccines received from pharmaceutical companies. This year has witnessed a debate about allowing pharmacists to administer influenza vaccine as applied in other countries. Subsequently, MOPH has issued a memorandum No. 149 in October 6th 2020 to assert the restricted role of CPs with regard to vaccine administration. However, based on some observations, it is commonly found that many pharmacists CPs influenza vaccines to their patients as part of their current practices. In addition, it is well known that Lebanese pharmacists are actively involved in raising awareness and public health promotion [17]. In the light of COVID-19 pandemic and the need to enroll a national vaccination plan and prior to embarking on a program expanding the scope of pharmacy practice to include the provision of immunizations, it is important to understand the intention of the Lebanese pharmacist to become an immunization provider. Such information highlights the importance of policy change and legal reform toward expanding the scope of pharmacy practice. Thus, our study aims to assess the knowledge, attitudes and beliefs of community-based Lebanese pharmacists with respect to expanding their scope of practice, in addition to their willingness to participate in vaccine administration.

This study was conducted during the preparedness phase for the roll-out of COVID-19 vaccines in Lebanon. It has particular importance during the COVID-19 pandemic as pharmacists could have a responsibility to take a prominent role in combating infectious diseases and control programs in health-care systems, in addition to their significant impact on the vaccination coverage rate. To the best of our knowledge, this is the first representative national Lebanese study aiming to explore readiness and willingness of community pharmacists to expand their practice scope into administering vaccines for adults.

The main findings in our study were that more than half of the surveyed community pharmacists are willing to start in the meantime the administration of vaccines in case they were legally permitted to do it without additional training. However, this willingness to incorporate this service into their practice rises to more than 90% if the legislation was combined to an education or certification program. This could be explained by the fact that despite their willingness to proceed, many pharmacists felt not well prepared, given that their education was not sufficient to begin at this time incorporating immunization services at their practice, and that formal certification should be required to do so. In this context, many pharmacist regulatory bodies have recognized the stipulation of proper immunization training prior to service provision, hence, the need of developing immunization training programs to ensure safe and effective administration of vaccines by pharmacists [19]. Such programs show their success in the Maritimes, in which 97% of pharmacists felt prepared to administer immunizations following completion [2].

In regard to community pharmacists’ knowledge, our results showed that the majority of respondents were knowledgeable in different domains except the domain related to vaccine contraindications and precautions. Good knowledge is crucial to expand the scope of practice of pharmacists as it supports them in providing adequate education to the public and, consequently, improving their performance and confidence in administrating vaccines. However, this study indicates that respondents lack the necessary knowledge of precautions and contraindications of vaccines, and those related to its administration such as the possibility of administration of inactivated vaccines at the same time or at any time before or after a live vaccine. Also, knowledge regarding the fact that local adverse reaction occurring at the injection site within few hours of administration and that are usually mild and self-limited, was not well recognized. These gaps in knowledge may need to be narrowed and underline a crucial need for strategies to educate community pharmacists about particular aspects of the contraindications and precautions of vaccines through continuing medical education, supplementary professional information, and additional patient educational materials [20]. It should be noted that a good proportion of the participants recognized the need for further education in this field.

It is notable that our results proved positive attitude toward utilization of pharmacists as immunizers. Most of pharmacists appraised the importance of their role in advertising and promoting vaccination among public. This is consistent with the findings of a study conducted in Italy that investigated KAP regarding vaccinations by community pharmacists in Italy [21]. Moreover, pharmacists believed that allowing them to vaccinate can reduce costs paid by patients and that pharmacies are easily accessible to the community which will improve the overall vaccination rate among adults as they feel more comfortable. Our results aligned with the findings of many studies that showed that vaccination costs were less when this service was provided by pharmacists, compared to those that were physician-administered [22]. Another study showed that immunization rates against influenza were higher for individuals aged more than years old in areas where pharmacists provided vaccinations, most likely due to improved accessibility and convenience [23, 24]. Finally, increased vaccination rate will be translated by a decrease in mortality and hospitalizations rates in elderly patients; hence, reduction of the cost related to direct medical care [25, 26].

In addition, 84.7% of pharmacists agreed that they should be legally permitted to administer vaccines. This highlights the importance to focus on statutory reform to enable pharmacists to provide vaccination under the umbrella of law [27].

Since only half of respondents agreed that pharmacists have received adequate teaching/training about vaccine administration during their education, additional training for proper immunization practices is highly recommended. This should be synchronized with regulation changes anticipated by the profession and pharmacy schools to expand the scope of practice and enable pharmacist-administered vaccination.

Regarding the factors necessary for the implementation of vaccination services in community pharmacies, participants indicated that support of health authorities (Ministry of Public Health and Order of Lebanese Pharmacists), statutory allowance, patient demand, pharmacist interest and continuous education and training workshops on immunization, safe administration and handling of vaccines are needed. Consistently, many studies found similar results with respect to essential elements identified, such as legal liability and formal education [28, 29]. With respect to patient demand, CDC estimates that almost 20% of the 2010–2011 influenza adult vaccinations were administered by pharmacists [30].

In terms of factors associated with CPs’ good knowledge, our findings showed that CPs with older age, and working in pharmacies in Bekaa and North have lower knowledge score than their counterparts. However, CPs with high educational level, previous experience in immunization and working in urban areas showed higher tendency to have good knowledge level. Our results were comparable to the findings of a study conducted in Italy that revealed that higher level of knowledge was reported among younger CPs and those with a lower number of years since degree [21]. The role of higher education in predicting better vaccination knowledge might be due that they have more opportunities to learn and receive adequate education and training through their university pharmacy curricula. Given that CPs can be a key point of contact for patients especially who live in rural areas, our findings highlighted the importance of improving the knowledge of the CPs who worked in such areas.

Continuous education and training workshops on immunization, safe administration and handling of vaccines are recommended in addition to the formal certification in vaccine administration as requisite for allowing pharmacists to be immunizers. Vaccine adverse event reporting systems are essential to ensure vaccine safety and surveillance, and maintain people's confidence in vaccines. There is need to establish immunization records which allow pharmacists to identify missed vaccinations, offer reminders to patients, and update immunization records to improve reporting of immunization coverage. Further integration of such systems and procedures across healthcare providers are needed for pharmacists to be incorporated in the overall health system to present a united front in offering vaccination services. Lastly, it is necessary to prepare standards as well as a legal framework for the provision of such services.

Most of Lebanese community pharmacists are willing to offer immunizations. Thus, the expansion of CPs scope of practice to include the provision of vaccine required the implementation of a national plan. This plan can encompass the following pillars that should be incorporated in parallel: strengthening knowledge and education about the topic for graduated pharmacist, incorporating vaccines and immunization in the academic curricula, offering post-graduate certificate and diploma for eligibility to administer vaccines with periodic re-certification, enhancing the role of pharmacovigilance and reporting within this scope and, statutory reform. Future studies are needed to examine pharmacists’ perceived barriers about immunization, as well as the determinants of their willingness to administer vaccines.