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pdfPublic Health and Pharmacy
Collaboration in an Influenza
Pandemic: Summary of Findings
from an Exploratory Interview
Project
Acknowledgements
This project was directed by Connie Jorstad, director of emerging infections at the Association of State
and Territorial Health Officials (ASTHO) and Kathy Talkington, senior director of immunization and
infectious disease at ASTHO. Ericka McGowan, director, infectious disease preparedness, and Kimberly
Martin, director, immunization, provided helpful guidance throughout the project, and James
Blumenstock, chief program officer for public health practice, reviewed drafts of this report. The
stakeholder interviews were conducted by the Cole Communications, Inc. team of Nicole Lezin, MPPM,
Susan Baker, MPH, and Bob Kingon, MPA.
The project’s design relied on interviews with senior public health leaders at the state and local levels,
public health immunization and emergency preparedness officials, representatives of chain and
independent pharmacies, and representatives of health provider associations. Nearly 70 people
representing these different fields generously made room in their busy schedules to share their insights
with the project team. We are grateful for their candor and willingness to explore complex issues with
the team members.
The authors of this report assured respondents that they would not be quoted by name, but we do want
to acknowledge the individuals who participated. They are listed in Appendix A, along with their
affiliations.
This project was funded by the Centers for Disease Control and Prevention (CDC) and ASTHO, under
Cooperative Agreement U5U38HM000454‐05.
2 Public Health and Pharmacy Collaboration in an Influenza Pandemic
TABLE OF CONTENTS
Executive Summary .............................................................................................................................. i
Introduction and Project Background ................................................................................................... 1
Findings ............................................................................................................................................... 5
Capacity: Confidence and Concerns .................................................................................................. 6
Allocations of Vaccine .................................................................................................................... 13
Distribution and Redistribution ...................................................................................................... 16
Fiscal and Compensation Issues ...................................................................................................... 21
Data, Tracking, and Reporting ........................................................................................................ 26
Coordination Between Pharmacy and Public Health ....................................................................... 33
Communicating with the Public ...................................................................................................... 39
Team Recommendations ................................................................................................................... 40
Conclusion ......................................................................................................................................... 43
Appendix A: Acknowledgements ........................................................................................................ 44
Appendix B: Interview Instrument ..................................................................................................... 50
Appendix C: Sample Public Health‐Pharmacy MOU ............................................................................ 58
Endnotes ........................................................................................................................................... 68
3 Public Health and Pharmacy Collaboration in an Influenza Pandemic
EXECUTIVE SUMMARY
We know the next influenza pandemic is
coming—but not how or when. In an ideal
scenario, an early alert will offer enough weeks
or months to develop and manufacture an
effective vaccine and activate an efficient,
accessible infrastructure to deliver it to the
millions of people who will need to be
vaccinated, all over the country.
Public health agencies at the federal, state, and
local levels, in coordination with their private
sector partners, are charged with coordinating
the response to pandemic influenza, including
pandemic vaccine allocation, distribution,
administration, and any necessary vaccine
tracking.
The 2009‐2010 H1N1 influenza pandemic
taught us many things. Among these lessons
learned are the importance of planning,
partnerships, and leveraging of resources.
While federal, state, and local public health
agencies effectively weathered the H1N1 storm,
in a more severe crisis, such as the 1918
influenza pandemic, much greater demands and
impacts on public health and healthcare, and
society in general, can be expected. Such a
severe pandemic will overwhelm existing
capacities and capabilities with a predictable
1
Harvard School of Public Health. The Voice of
Pharmacists: A Poll about Alternative Methods for
Antiviral Distribution During a Pandemic Influenza. 2012.
increase in morbidity and mortality. It is,
therefore, essential that agencies examine new
or innovative approaches to ensure the timely
and effective distribution of countermeasures.
Pharmacists have become significant providers
of seasonal flu vaccine in many communities
and will be on the front line providing vaccines
to the public during such an emergency. Many
state and local public health officials have
already strengthened their relationships with
pharmacists and pharmacy associations across
the country since the 2009‐2010 H1N1
pandemic, though for some public health
agencies, working closely with pharmacies is a
relatively new and recent venture. A 2012
Harvard School of Public Health poll on antiviral
distribution found that more than two‐thirds of
pharmacists working in community settings
reported that they had had no contact with
health department staff in the past year.1
To explore how public health and pharmacies
could better coordinate their vaccine
distribution and administration efforts during a
severe pandemic, the Association of State and
Territorial Health Officials (ASTHO) contracted
with Cole Communications, Inc., to interview
nearly 70 public health leaders, immunization
Available at http://www.hsph.harvard.edu/horp/.
Accessed 5‐13‐2014.
i Public Health and Pharmacy Collaboration in an Influenza Pandemic
and emergency preparedness managers, chain
and independent pharmacy representatives,
and health provider association representatives.
The interviewers posed a scenario of unlimited
vaccine supply available for distribution within
30 days of the declaration of an influenza
pandemic, with a distribution volume of
approximately 30 million doses per week—
roughly four times the volume of peak vaccine
administration during the H1N1 pandemic in
2009.
This report is a synthesis of the general
comments, opinions, and professional
judgments shared by those interviewed as part
of this project and does not necessarily reflect
a consensus of all participants nor should it be
construed as conveying the position or policy
of ASTHO and/or CDC. The information
gleaned from this process will help motivate
and focus future discussion and actions to
improve the nation’s readiness for a severe
influenza pandemic.
Capacity: Concerns and Confidence
What would public health and pharmacies need
from each other to make the allocation,
distribution, and administration of vaccine as
efficient as possible under such a scenario?
What systems and relationships are already in
place to foster better coordination, and what
are the main areas of concern and potential
improvement? How do public health and
pharmacy respondents view the trade‐offs
between speed and efficiency on the one hand,
and keeping track of and determining
distribution on the other?
This executive summary highlights findings and
recommendations describing the interview
respondents’ perspectives on public health and
pharmacy capacity, allocation and reallocation,
distribution and redistribution, fiscal and
compensation issues, data and tracking issues,
and overall coordination and communication.
Both pharmacy and public health respondents
expressed some concerns and anticipated
obstacles to smooth distribution and
administration of this volume of vaccine.
However, they generally expressed optimism
that each sector could meet the challenge, with
additional work and coordination among other
vaccine providers within the healthcare system.
The overall message from both sectors: It won’t
be easy, but it can be done.
The pharmacy sector’s confidence stemmed
from their growing experience and comfort with
providing seasonal flu vaccinations, their
distribution networks for medications and other
goods, and their ability to draw on retired
pharmacists and nurses in a surge situation
(especially among chains).
Public health respondents expressed
confidence, too, but for different reasons. The
intensive investments in preparedness planning
ii Public Health and Pharmacy Collaboration in an Influenza Pandemic
since 2001 are one source of confidence, but so
are more recent experiences such as the 2009‐
2010 H1N1 pandemic. However, the scope of
coordination and logistics of distribution and
vaccine administration will be entirely different
in a severe pandemic, with the possibility of
much larger vaccine supply early in the
response and greater demand for vaccine.
Public health’s overall confidence in its ability to
meet the needs posed in the scenario is
tempered by the fact that budget cuts have, in
many health departments, reduced staffing and
capacity for vaccination activities and oversight
of vaccine distribution and reporting
requirements. The ability to effectively respond
to a future severe pandemic is predicated, in
large part, on the infusion of sufficient
additional federal funding to meet program
demands across the country. For many
respondents, the attrition and reduced capacity
has spurred greater recognition of the
pharmacies and pharmacists’ potential to serve
as a resource in a pandemic scenario.
For public health agencies (at all levels) that
have not yet worked closely with pharmacies in
emergency response and pandemic
preparedness planning but would like to in the
future, options include:
Identifying more opportunities for
pharmacists and their associations to
collaborate with public health, such as
inviting pharmacists to participate in
emergency planning groups or having cross‐
representation from public health and
pharmacy groups on mutually relevant task
forces. In some areas, public health also has
been a supportive partner as pharmacists
seek a larger role in immunization.
Developing formal but flexible memoranda
of agreement (MOAs) or understanding
(MOUs) with pharmacies, working closely
with state boards of pharmacy and state
pharmacy associations. Because state laws
governing pharmacists’ roles vary, the
specifics of these agreements need to be
negotiated at the state and local levels.
Assessing state and local pharmacy
capacity more systematically through
surveys, joint exercises, and simulations.
Few public health respondents felt they had
a current, comprehensive picture of state
and local pharmacy capacity in their
jurisdictions or even understood chain and
independent pharmacy interest and
capacity in participating at various levels in
a pandemic scenario. A lack of basic data
about pharmacies, their interests, and their
capacity hinders informed collaborative
decision making about allocation, reporting,
and compensation options.
Allocations of Vaccine
The scenario utilized for key informant
interviews suggested an unlimited, steady
vaccine supply. Nevertheless, public health
respondents expressed a keen sense of
iii Public Health and Pharmacy Collaboration in an Influenza Pandemic
responsibility and accountability for ensuring
the best match between vaccine supply and
demand in their jurisdictions. To do this, they
would need near‐real‐time information to
detect imbalances and take necessary
corrective action. For public health
respondents, accountability requires data, and
ensuring the flow of data requires systematic
oversight and a certain degree of control to
ensure that data was reported to public health
by vaccine providers/administrators. Indeed,
this is public health’s charge during a crisis; only
the public health system maintains a broad
picture of how an epidemic is unfolding and
where and how it can be stemmed, including
through tracking of available resources. While
pharmacies and distributors conduct this type
of allocation for their inventories daily, there
remain barriers to presenting these data to
public health agencies systematically.
Specifically, local and state public health
respondents want to know:
Which providers (pharmacy and others) are
available to provide vaccinations?
What do providers need from public health
(training, guidance, prior agreements, and
supplies)?
What local/state population variations
could affect pro rata allocations and
subsequent secondary redistributions (e.g.,
populations crossing state borders to live or
work, or large student or employer
populations)?
To redistribute vaccine supplies from areas with
a surplus to those with a shortage, accurate
data on vaccine distribution and dispensing are
needed. Public health’s confidence in whether
pharmacies can supply these data varied
considerably, while pharmacies generally
suggest they can and do on a daily basis.
State and local jurisdictions reported using a
variety of information to allocate initial doses of
vaccine during the 2009‐2010 H1N1 pandemic,
including demographic data, past seasonal flu
vaccination activity among providers, and data
regarding ongoing dispensing of vaccine.
Collecting examples of basic allocation
algorithms used or contemplated for the
purpose of planning future allocations might be
helpful, predicated on the types of data
available.
Respondents recognized that a pandemic
requires flexibility in responding to changing
conditions. However, if allocation decisions are
based on clear criteria, these should be adhered
to as much as possible with as much
transparency as possible regarding changes in
allocation decisions as situations evolve during
a response. One way to do so is to convene an
oversight or planning group, as several states
have done, to reach consensus on allocation
decisions and provide broader support for the
rationale behind these decisions. This group
can convene periodically during a response. If
groups are convened for this purpose (either as
part of the state or local incident command
iv Public Health and Pharmacy Collaboration in an Influenza Pandemic
structure or separately), pharmacy
representatives should be included as active
members.
concern about the lack of collaborative planning
between public health and pharmacists at state
and local levels.
Distribution and Redistribution
Public health respondents generally maintained
that they would prefer to use a tested
mechanism like McKesson (the contracted
distributor for the Vaccines for Children [VFC]
program and during the 2009‐2010 H1N1
pandemic) in a future pandemic. They would be
open to another model of directing stockpile or
manufacturer shipments to chain distribution
centers, but only if they could track, influence,
and direct the amount of vaccine being shipped
to each store.
Public health respondents who worked with
pharmacies during H1N1 reported that direct
distribution to chain pharmacy distribution
centers provided both speed and flexibility in
moving vaccine. If non‐shortage but high‐
volume conditions prevailed, many agreed that
direct chain distribution would offer some
significant advantages in speed and efficiency of
both distribution and administration.
Speed and efficiency, however, are not enough
to overcome public health’s concerns about
potential loss of visibility and oversight—and
thus loss of opportunities for state and local
public health input regarding where vaccine is
within distribution systems, as compared to
where it should be.
Public health officials are not yet confident that
they will receive the data they need from
pharmacies to confirm that vaccine is moving to
the people and places where it should be within
a state, county, or city. Both pharmacy and
public health respondents acknowledged that
this is not necessarily due to any flaws or
reluctance on the part of pharmacies to share
data, but instead is due to variations in state
information systems and their ability to
communicate bilaterally between various
providers and public health. There was also
In effect, if there were 1) a sufficient supply of
vaccine, 2) strong reporting and tracking that let
all parties know exactly where vaccine was
being distributed and administered in
something close to real time, and 3) the ability
to draw on state and local expertise on
allocation of vaccine, then public health would
feel more comfortable with direct‐to‐chain
distribution (for redistribution to their stores).
This would yield the most rapid and efficient
distribution of vaccine, shortening the time
between vaccine manufacture and
administration.
Given this reality, how can we take advantage
of chain distribution and tracking systems’
efficiencies, while reassuring public health that
vaccine is reaching the right people and places?
v Public Health and Pharmacy Collaboration in an Influenza Pandemic
Some respondents believe the answer is local:
Allow direct shipment of vaccine from
stockpiles or manufacturers to chain
distribution centers for redistribution, but have
store managers initiate the requests after
consulting with the local or state health
department, as appropriate. This, of course,
depends on local health departments having
the capacity and interest in playing this role.
This approach also depends on pharmacy chains
delivering the store‐level data within their reach
to public health. In addition, this approach
significantly increases the number of providers
health departments would need to frequently
follow up with on ordering, in VTrckS, and
manually. Finally, some large pharmacy chains
may not be able to manage individual store
requests but would be able to move vaccine
store to store through regional or national
communications networks in their systems.
The positive experiences with CDC’s VFC
distributor, McKesson, are reassuring, and
many respondents would like to preserve this as
an effective and familiar arrangement.
However, in a pandemic situation, relationships
would need to be developed with other major
wholesalers to distribute to the independent
pharmacy stores that often serve rural and
frontier communities, based on store orders
and coordinated again with local and/or state
public health.
Fiscal and Compensation Issues
Respondents recognized that vaccinating every
eligible person who seeks vaccination at a
specific location regardless of their insurance
status or ability to make a co‐payment is the
most efficient and rapid option for reaching the
entire population. Just as with 2009‐2010 H1N1,
the scenario envisioned vaccine supplied to
pharmacies free of charge, but pharmacies still
must bill insurers or seek modest vaccine
administrative fees to cover the costs of staff
time and other resources. During 2009‐2010
H1N1, incomplete or inadequate
reimbursement was an issue for some (but not
all) pharmacies; this scenario, with a fourfold
increase in the number of vaccine doses that
might be available per week over 2009‐2010
H1N1, changed the financial equation.
Many respondents are optimistic that expanded
insurance coverage under the Affordable Care
Act (ACA) beginning in early 2014 will reduce
the number of uninsured. Yet all recognized
that there always will be some proportion of
the population without coverage, including low‐
income undocumented workers who remain
ineligible for subsidized coverage.
If pharmacies are encouraged or required to
vaccinate all who present to be vaccinated (and
who meet age and other criteria that would
allow them to be vaccinated in that setting),
then they should be reimbursed for
vaccinations not covered by an existing
payment mechanism.
vi Public Health and Pharmacy Collaboration in an Influenza Pandemic
Respondents agreed that a federal
reimbursement mechanism is the most feasible
approach, in a model similar to the Emergency
Prescription Access Program. Such a program
could either establish a standard
reimbursement to all providers or come into
play when certain thresholds of uncompensated
care are reached.
Public health respondents opted for a federal
fund not only because of budget challenges and
limitations at the state and local levels, but also
because they do not want to add complex fiscal
reimbursement and tracking responsibilities to
their pandemic portfolio.
Even for those patients who are insured, states
vary on whether or not pharmacists can be
reimbursed as medical service providers. This is
not a new challenge; ASTHO and others have
been working on this issue with America’s
Health Insurance Plans, the trade association
representing the health insurance industry,
since 2009‐2010 H1N1. Pharmacy groups also
are advocating for status as healthcare
providers and members of a patient’s team of
healthcare providers on a state‐by‐state and
individual health plan basis. If this change were
made consistently across all states, some
reimbursement issues identified here would be
resolved.
Since reimbursement is tied to reporting,
another suggestion (from pharmacies) was to
set up systems in which influenza vaccine would
be treated like a prescription for reporting and
reimbursement purposes, with a zero co‐pay
option to include those who were not insured.
This would track store‐level immunization doses
and billing simultaneously, without requiring
changes to existing pharmacy data systems.
Data, Tracking, and Reporting
Many individuals from each sector were able to
describe an ideal reporting and tracking system:
It is bidirectional, exchanging data between
providers and public health, and generates data
in real time. That system is possible in some
locations with a highly functional immunization
information system, but it is not in place in
many others. State‐by‐state differences in IIS
make data entry and sharing challenging for
pharmacies. Yet, as noted above, most of the
reassurance public health seeks from
pharmacies (and other providers) to fulfill its
role of protecting and monitoring the public’s
health rests on reporting system and data
sharing.
The biggest reporting frustration for pharmacy
chains will come as no surprise: the variation
across states in requirements, protocols, and
procedures for participation in immunization
registries or other mechanisms that would fulfill
the tracking/reporting functions required during
a pandemic. Even among the relatively small
sample of states represented in our interview
pool, we heard about a wide range of registry
capabilities among immunization grantees. The
American Immunization Registry Association
vii Public Health and Pharmacy Collaboration in an Influenza Pandemic
(AIRA) Immunization Information Systems (IIS)
Functional Standards2 for registries should be
promoted among state immunizations
programs, with incentives provided to those
immunization programs that do not meet them.
When asked what belonged in a minimum data
set for a pandemic situation, interviewees had
different preferences and not all had an
opinion. The most commonly cited minimum
list of items included the following:
Name.
Date of birth
Patient ZIP code or address.
Vaccine Universal Product Code
(vaccine product and lot number).
Adjuvant and antigen uses (if
adjuvanted pandemic vaccine required).
Date of vaccine administration.
To address the issues of incompatible data
systems and inconsistent state requirements,
one company saw an opportunity to develop an
interface between pharmacy data systems and
state immunization registries. As of June 2013,
the system was being used by a major
pharmacy chain in 28 states, with another 17
state registries expected to be participating by
the end of 2013, for a total of 45. The pharmacy
chain’s central database is mined for data
related to immunization activities; these are
2
CDC. “Immunization Information System (IIS)
Functional Standards.” Available at
then tailored to meet the specific, unique
requirements of each state’s registry without
requiring further data entry or customization by
the pharmacy’s system or the registry. The costs
for data collection and transmission to state IIS
are borne by Walgreens, not the states.
This interface between pharmacy data systems
and state registries may serve as a model for
tracking and reporting issues for a significant
portion of pharmacy‐based immunizations,
both routine and pandemic‐related. However,
this solution is still months or years away,
depending on the chain and state IIS, and is
unlikely to be adopted by smaller‐volume
independents or even smaller state or regional
chains. It may also be difficult for some state IIS.
If CDC and the states agreed to apply the
already established AIRA IIS Functional
Standards and offer options for providing these
data through the registries or other
mechanisms, perhaps this, along with targeted
outreach by state and local health departments,
would help bring the remaining pharmacies into
the fold. This solution would also support
reporting by other providers, who performed in
some cases more poorly than pharmacies in
terms of reporting H1N1 vaccination doses to
public health authorities. For inventory
management, the ordering and delivery
tracking systems of McKesson or other
http://www.cdc.gov/vaccines/programs/iis/func‐
stds.html. Accessed 5‐9‐2014.
viii Public Health and Pharmacy Collaboration in an Influenza Pandemic
wholesalers or the CDC Inventory Management
and Tracking System (IMATS) could be utilized
for this reporting.
These and other options require a
determination of what public health really
needs to know during and after a pandemic and
consensus within public health about the
rationale behind data tracking and reporting
requirements so that more consistent requests
can be communicated to those being asked to
provide the data. Coordination among the
states would greatly help, especially for large
chain pharmacies that work across multiple
states with data reporting requirements.
independent store representatives in their
planning efforts.
In particular, respondents saw ICS as well
positioned to adjust to the expected waves of a
pandemic and their uneven geographic impact.
Through ICS, some observed, crucial
reallocation functions could be coordinated,
especially if the initial pro rata allocations of
vaccine did not match the pandemic’s
progression.
Options for improving coordination for both
routine and pandemic situations include:
Reviewing state pandemic flu plans to
determine whether pharmacy roles during
different phases of a pandemic response
are delineated or could be strengthened,
and how pharmacies may be appropriately
engaged earlier in pandemics.
Exploring local, state, and federal MOU
options, as noted above, and engaging
boards of pharmacy in reviewing,
supporting, and disseminating them.
Assessing existing ICS and other emergency
planning groups to determine how they
include pharmacy representatives.
Identifying specific information gaps and
training needs among pharmacists and
other vaccine providers about
immunization, and working with partners
to address those needs through webinars,
workshops, conferences, or other means.
Coordination
Despite concerted efforts in many states to
increase contact and coordination between the
pharmacy and public health sectors since H1N1,
room for improvement remains.
An important existing mechanism for
coordination is the incident command system
(ICS) that would be activated by a crisis as
severe as a global influenza pandemic. Many
public health respondents pointed to their ICS
relationships as a natural and useful platform
for better coordination with pharmacies, but
not all had used their ICS structures and
planning groups in this way. Respondents
suggested that if they have not already done so,
state health departments should include state
boards of pharmacy, pharmacy associations,
schools of pharmacy, and individual chain and
ix Public Health and Pharmacy Collaboration in an Influenza Pandemic
Building on public health‐pharmacy
partnership guidance and templates from
ASTHO’s 2009 Operational Framework3
and a partnership checklist and best
practices described in a recent NACCHO
report4 to identify ways that state and local
public health agencies and pharmacies can
plan together for anticipated pandemic
situations.
Considering support of pharmacy efforts to
change legislative restrictions on their
scope of practice regarding routine and
emergency‐related immunization
administration to all ages and reporting of
vaccine data.
Exploring opportunities for public health
officials to support pharmacies in these
roles, including offering training on specific
topics, conducting joint training/tabletop
exercises, speaking at each other’s
conferences, and other options relevant to
individual states and counties.
as joint training exercise or basic MOUs) to
more ambitious and complex (making
immunization registries more consistent,
creating a national vaccine administration cost
reimbursement plan for immunizing the
uninsured during a pandemic).
As a starting point to decide which options
could be addressed, how, and by whom, the
project team recommends convening a
roundtable/planning process that provides an
ongoing forum for stronger coordination
between pharmacies and public health. This
group could tackle specific barriers and
solutions in three phases:
Most urgently for a pandemic occurring
soon, before some of the major concerns
and barriers identified in this report and
elsewhere could be addressed.
On an ongoing basis, to adjust to changes in
the underlying conditions (such as data and
reporting systems, vaccine demand, and
vaccine prioritization) that would affect a
pandemic response.
The suggestions raised by interviewees range
from relatively feasible in the short term (such
as fostering more pharmacy‐public health
contact and partnerships through activities such
Beyond pandemic scenarios, to explore
other opportunities for pharmacy/public
health collaboration once the most urgent
3
4
Recommendations
ASTHO. “Operational Framework for Partnering with
Pharmacies for Administration of 2009 H1N1 Vaccine.”
Available at
http://www.astho.org/Display/AssetDisplay.aspx?id=261
3. Accessed 5‐9‐14.
NACCHO. “Building and Sustaining Strong Partnerships
between Pharmacies and Health Departments at State
and Local Levels.” Available at
http://preparednesssummit.org/wp‐
content/uploads/2014/03/NACCHO‐Pharmacy‐
Report.pdf. Accessed 5‐9‐14.
x Public Health and Pharmacy Collaboration in an Influenza Pandemic
and complex pandemic planning items were
addressed.
A recurring theme in these interviews was the
lack of current information that local and state
public health officials have about pharmacy
capacity to assist in a pandemic. To remedy this
situation, CDC, ASTHO, and NACCHO (among
others) could support the development of
community‐level pharmacy profiles about
pharmacy capacity and other features. Staffing
and logistics associated with surge capacity,
store locations, populations served (especially
high‐risk or unique in other ways), data
collection and reporting capacity, levels of
experience and interest in participating as
vaccinators during a pandemic, and pharmacy
connections to other community resources are
all important data points that could be collected
and mapped more systematically before a
pandemic makes this information urgent.
Whether or not a planning group is convened,
CDC and ASTHO could identify several high‐
priority recommendations from this report that
would advance pharmacy/public health
collaboration. Our nominees include:
1. Develop a model for integrating pharmacy
representation into ICS structures to
enhance communication, coordination,
and problem‐solving. Some states have
successfully integrated pharmacy
representation into their ICS structures,
which assists in coordination and
communication at the state and local level.
These entities can help address issues
around reporting, distribution, and
redistribution as necessary.
2. Explore options for pharmacy and state
immunization registry electronic interface
options, including the current model in
place in 17 states through Walgreens (and
specifically how it could be made accessible
beyond the major chains) or others.
3. Standardize, and if possible reduce, the
required minimum data set for reporting
immunization doses to IIS during a
pandemic.
4. Work with stakeholders to develop
distribution/redistribution tracking
strategies. Instead of relying exclusively on
McKesson or any single VFC contractor to
distribute vaccine to independent
pharmacies, consider working with other
wholesalers to develop a direct
distribution route to them comparable to
that used for pharmacy chains, with
reporting and tracking systems supporting
this approach. State and local health
departments should work with pharmacists
in advance about reporting expectations
and their flexibility in being able to
redistribute vaccine to meet public health
needs in areas needing greater vaccine
access.
xi Public Health and Pharmacy Collaboration in an Influenza Pandemic
5. Examine payment/reimbursement options
for pharmacies to cover or defray vaccine
administration costs, including working
with varying plans and insurers to
reimburse pharmacy‐based vaccinations as
a medical service.
jurisdiction’s needs, but in others it may be an
untapped and largely unexplored surge
resource. As these relationships mature, it will
be critical to communicate effectively with the
public about roles and responsibilities so they
know where to go when for vaccine.
Conclusion
If a pandemic follows the scenario outlined in
these interviews, it will be a crisis, but one that
remains the best‐case scenario because vaccine
supplies would be plentiful and arriving as
planned and announced (unlike H1N1). This
best‐case scenario still yielded plenty of
concerns and barriers that need to be
addressed, but the most basic one may be that
even after H1N1, public health does not have a
universal expectation that it should be working
closely with pharmacies, nor do pharmacies
necessarily expect to be in routine contact and
partnership with public health. In addition, the
views of corporate pharmacy leaders may not
be shared at the store level, where the day‐to‐
day logistical challenges are likely to be most
intense.
Pandemic flu plans, tabletop exercises,
emergency preparedness and immunization
conferences, 2009‐2010 H1N1 after‐action
reviews and improvement plans, ASTHO’s 2009
Operational Framework guidance, and more
recent work on pharmacy distribution of
antivirals, collections of best practices, CDC
cooperative agreements dedicated to public
health/pharmacy collaboration—all of these
investments and insights have moved public
health and pharmacies further into each other’s
arenas, often in very constructive and
productive ways that will pay off during a future
crisis. Further, the role of pharmacies in
seasonal influenza vaccination has expanded
significantly since 2009, with 18‐20 percent of
influenza vaccines for adults administered in
pharmacies nationally.
Across the country, progress has been made to
integrate pharmacists in public health vaccine
response, but it has not been uniform nor has
its full potential been characterized or realized.
Some of the variation is natural, as each state
and local jurisdiction constructs the most
appropriate mix of partners and capacity for a
pandemic response to meet its respective
Changing these expectations at all levels—local,
state and federal, corporate chain
headquarters, and individual store—will be an
ongoing challenge, but one that is already being
met by many of the people interviewed for this
report.
The next pandemic is inevitable, and so is the
after‐action report that will follow. Whether
that pandemic occurs in the near future or after
xii Public Health and Pharmacy Collaboration in an Influenza Pandemic
the luxury of a longer planning interval, it is our
hope that a future after‐action report will
document that public health and pharmacies
made significant progress in strengthening their
shared pandemic preparedness to ensure the
most efficient and effective responses to a
pandemic and reduce morbidity and mortality
as much as possible.
ii Public Health and Pharmacy Collaboration in an Influenza Pandemic
INTRODUCTION AND PROJECT BACKGROUND
“Imagine that in the not‐too‐distant future, a severe influenza pandemic is declared …”
This was the opening of a pandemic influenza scenario posed to interviewees in a recent CDC and
ASTHO study designed to explore opportunities for improving collaboration between public health and
pharmacies during a pandemic.
Interview respondents—drawn from the arenas of public health immunization, emergency
preparedness, state and local health department leadership, and chain and independent pharmacies
and their associations—did not need much imagination to place themselves in this scenario. Indeed, as
the interviews began in spring 2013, a new subtype of influenza, H7N9, had been found in China. Two
months later, it had killed 36 people, with an alarming fatality rate of 25 percent among known cases
(much higher than the 2 percent fatality rate of the 1918 influenza pandemic).5 The H7N9 story is an
unnecessary reminder to public health, pharmacy, healthcare, and emergency preparedness
professionals that the threat of the next pandemic is always hovering.
Four years before H7N9, the 2009‐2010 H1N1 pandemic had sounded similar alarms, although it
affected different age groups. Although H1N1 ultimately killed an estimated 12,000 people in the United
States, it fortunately was less lethal than prior pandemics, like 1918.
Still, the 2009‐2010 H1N1 pandemic provided public health agencies the opportunity to test what nearly
a decade of focused efforts had achieved in the realm of preparedness. It also demonstrated areas in
which federal, state, and local public health agencies could improve, be it through further planning
efforts or improved partnerships with one another as well as community and healthcare partners.
Should a more severe influenza pandemic emerge, these enhanced partnerships may prove critical in
ensuring the health and well‐being of communities. One such partnership, with pharmacies, has
received increased attention due to pharmacists’ potential reach and expertise, as well as their
increasing role in seasonal influenza vaccine administration and the extensive distribution networks
supporting them.
Over the last decade, pharmacists and retail pharmacies have rapidly expanded their roles as providers
of seasonal influenza vaccinations for adults. During the 1998‐1999 influenza season, just 5 percent of
1 Public Health and Pharmacy Collaboration in an Influenza Pandemic
adults were vaccinated in chain supermarket or drug store settings. By 2010‐2011, this had jumped to
18.4 percent—nearly one in five of all adults vaccinated against seasonal influenza. Only physicians’
offices were more common settings, at 39.8 percent.
The increase in vaccinations in nonmedical settings reflects changes in state laws designed to boost
vaccination rates by making access more convenient and affordable. The number of states allowing
pharmacists to administer influenza vaccinations to adults rose from 22 states in 1999 to all 50 states by
mid‐2009.
Just as pharmacists and pharmacies have become integral to providing routine seasonal influenza
vaccine, they will play a crucial role in dispensing vaccinations during a severe influenza pandemic.
Interview Respondents and Methods
To learn more about how collaboration between public health agencies and chain and independent
pharmacies could be improved before the next pandemic, a team of interviewers under contract to
ASTHO through a CDC‐funded cooperative agreement used the scenario of a global influenza pandemic
as a backdrop for interviews with nearly 70 respondents from the public health and pharmacy sectors,
as well as several health provider associations. In most cases, these interviews were conducted as
individual telephone interviews; some were conducted with two or three people if several respondents
from the same state, agency, or pharmacy organization could be scheduled together. In addition to
individual and small group telephone interviews, a group discussion was conducted with 18 NACCHO
members in April 2013. Interviewees in each category were identified by ASTHO and CDC and are listed
in Appendix A, along with their affiliations.
Interview Topics and Methods
This report presents a summary of findings from these interviews, organized into the major categories
covered during the conversations:
Overall capacity to distribute and administer vaccine.
Allocating vaccine to different sectors.
Redistribution of vaccine.
Fiscal and compensation issues.
Reporting and tracking.
Coordination across sectors and partners.
2 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Communication with the public.
Legal issues.
Respondents also were asked to complete a table before the interviews that listed options in four main
categories: allocation, distribution, vaccinating the uninsured or those otherwise unable to pay, and
information sharing.
Interviewees were asked to rate each option using five‐point Likert scales to gauge the feasibility and
acceptability of the options presented and predict how they might affect the speed with which the
public could be vaccinated. For example, if the respondent had a choice of whether or not to allocate
vaccine to chain pharmacies as part of the U.S. government’s pro rata (population‐based) distribution of
vaccine to states, would he or she rate these options as very acceptable/preferable (5); not sure,
depending on various pros and cons (3); or unacceptable (1)? In terms of feasibility, regardless of
whether the option would be preferred or not, could it be done relatively easily (5), possibly, with some
difficulty (3), or not at all (1)? What about the effect on speed of distribution and administration of
vaccine—would it contribute to faster and more efficient distribution and administration (5), slow things
down considerably (1), or fall somewhere in between (3)?
The table was intended to stimulate more detailed, concrete discussion during the interviews and
worked well for that purpose. As each feature (allocation, distribution, vaccinating uninsured adults, and
information sharing) was discussed and rated, the interviewers probed to find out why the specific
ratings were given, whether any low ratings constituted “deal‐breakers” that would prevent such
collaboration between pharmacies and public health, and how smooth implementation and speedy
vaccination of a large proportion of the U.S. population could be helped or hindered.
Although not everyone completed the table before (or even during) the interviews, this report presents
some of the differences in ratings from three main categories of respondents: public health agency
directors and immunization managers (n=21); emergency preparedness managers (n=10); and pharmacy
representatives (n=17, with two representing small, independent pharmacies).
One major caveat: While intriguing in the context of a qualitative interview project, these results should
not be interpreted as quantitative data. As noted above, not everyone who was interviewed completed
the table. Moreover, as with any Likert scale, there was considerable gravitational pull toward the
middle‐of‐the‐road answer (i.e., a score of 3), which essentially translates to “it depends.” Finally, in
group interviews that included both immunization and emergency preparedness perspectives, the
3 Public Health and Pharmacy Collaboration in an Influenza Pandemic
respondents often combined their answers into a single score, after discussing why they may have
differed initially. In the tables and preliminary analysis that introduce related discussion of the findings,
these caveats should be kept in mind in interpreting the results.
The scenario, table, and questions posed to interviewees are included in a copy of the interview
instrument in Appendix B.
Analysis
The interviews were recorded, transcribed, coded, and analyzed using Dedoose qualitative analysis
software. Each interviewer’s list of interviewees included representatives from all the major categories
included in the study: federal public health (CDC), public health immunization managers, emergency
preparedness managers, public health leadership (state and local), chain pharmacies, independent
pharmacies, pharmacy associations, and health provider associations.
Team members debriefed periodically to compare notes from their ongoing interviews. Once the
interviews were completed, transcribed, and coded, the team reviewed all the transcripts in their coded
categories and again compared their analyses, impressions, and recommendations to develop the
findings presented here.
4 Public Health and Pharmacy Collaboration in an Influenza Pandemic
FINDINGS
Setting the Scene: A Pandemic Flu Scenario Quadrupling Peak 2009‐2010 H1N1 Vaccine Dose Volume
As noted above, the interviews began with a specific scenario:
Imagine that in the not-too-distant future, a severe influenza pandemic is declared. Although we won’t know
the exact details until this actually happens, we can make some educated guesses about likely features that would
affect vaccine distribution. We want to use variations in these features to stimulate your thinking about what barriers
to rapid, efficient vaccine distribution and vaccine administration can be anticipated, and potential solutions.
Assume that stockpiled H5N1 vaccine will be available for distribution within 30 days of the declaration of an
influenza pandemic. We anticipate 30 million vaccine doses could be distributed per week. This number of doses
per week is more than four times the peak number of doses distributed during the 2009-2010 H1N1 outbreak.
So, state public health departments, private providers, and chain and independent pharmacies will have about 30
days to receive and start rapidly administering vaccine to patients as soon as vaccine arrives. Rapid vaccine
administration is key in this scenario as rapid spread of the pandemic virus is anticipated. Ensuring large numbers
of vaccine providers are preidentified is likely key to being prepared for rapid administration of vaccine.
Not surprisingly, interviewees quibbled with some of the assumptions underlying this scenario. Because
vaccine had not been available steadily and in the expected volume during the 2009‐2010 H1N1
outbreak, the notion that there would be no shortages (and thus no disputes over who received vaccine
first or how much) was questioned and would have altered responses to our questions considerably. The
scenario also did not stipulate priority populations eligible to receive vaccine before others. It did not
specify a vaccine format (e.g., multiple doses, nasal administration), which again would affect answers
to some interview questions, particularly regarding reporting on doses administered. Overall, many
respondents questioned whether H1N1 and seasonal flu experience provide much valid insight, since
vaccine providers generally have not had to contend with the panic and fear generated by high fatality
rates.
Despite these reservations, respondents did react to the main point of the scenario: a fourfold increase
in volume compared to 2009‐2010 H1N1, with just 30 days to prepare and an approximately 10‐week
stretch of sustained surge to vaccinate the bulk of the U.S. population.
5 Public Health and Pharmacy Collaboration in an Influenza Pandemic
The sections that follow present these reactions, with illustrative quotes from respondents throughout
and insights from the table described above where relevant. Each section concludes with options for
addressing concerns or gaps identified during the interviews. These are summarized and reviewed with
overarching recommendations for next steps in a final section of the report.
Capacity: Confidence and Concerns
Both pharmacy and public health respondents anticipated obstacles to smooth distribution and
administration of this volume of vaccine, but generally expressed optimism that each sector could and
would rise to the occasion, along with other providers of vaccine within the healthcare system.
Why Pharmacies Are Confident
Confidence from pharmacy respondents—especially those working within large pharmacy chains—
stemmed from experience with their distribution networks for both pharmacy/medical supplies and
other goods. “This is what we do,” said one, “and we’re really good at it.” Along with finely honed
distribution networks comes the use of predictive modeling to predict fluctuations in demand, the
capacity to generate and adjust store‐level data in real time for ordering purposes, and the ability to
shift or augment resources by calling in retired pharmacists or nurses. Many schools of pharmacy are
now providing immunization training during their programs’ first year, increasing the pool of student
pharmacists prepared to help during a pandemic.
Independent pharmacies, while willing to do their part, were understandably less confident about their
ability to staff up to meet elevated demand for vaccine for a 10‐week period, although many do have
plans in place to do so if required. Independent pharmacies also would find it more difficult to institute
reporting and tracking mechanisms if they have not already done so (e.g., to report to a state
immunization registry). However, because they rely on centralized distribution chains, their capacity to
order and receive vaccine is less of a concern than the data/reporting and fiscal issues raised by
vaccinating uninsured patients, described in greater detail below.
Why Public Health Is Confident
Public health respondents at all levels—federal, state, and local—also expressed confidence in their
ability to respond to the scenario’s predicted timing and volume, but for different reasons. First and
foremost, despite glitches and difficulties, public health respondents are proud of their track record in
H1N1 and other crises. Over the past 15 years, investments in emergency planning and preparation at all
levels of public health have accelerated, including pandemic flu planning (with some plans more up to
date than others, but at least in place), tabletop exercises, and related planning (such as the distribution
6 Public Health and Pharmacy Collaboration in an Influenza Pandemic
and dispensing of antivirals) that brings many of the same players to the table to coordinate. In addition,
public health is confident in its role of identifying areas of need, targeting hard‐to‐reach populations,
providing services regardless of ability to pay, and remaining accountable to the public.
Points of dispensing (PODs) for mass vaccination of the public
(open PODs) or specific populations (e.g., closed PODs for large
“If pan flu could just wait
employers) were cited as viable, immediately available options for
another 4-5 years, we’ll be
expanding capacity. Likewise, many public health respondents
ready!”
reported that their data systems keep improving, and so does their
— State Health Official
ability to train and entice other providers (pharmacists as well as
private providers) to use them for consistent reporting. However,
these gains are inconsistent across the country, as discussed in greater detail below. As one respondent
noted, things are improving on all these fronts—overall capacity, reporting and data systems,
preparedness planning—but a little more time would be extremely helpful. “If pan flu could just wait
another 4‐5 years,” she said, “we’ll be ready!”
Public health’s overall confidence in its ability to meet the needs posed in the scenario is tempered by
the fact that budget cuts have, in many health departments, reduced staffing and capacity for direct
vaccination services, training and technical assistance to vaccine providers, and oversight of the
distribution of vaccine and reporting required of others. For some, this attrition and reduced capacity
has spurred greater recognition of pharmacies and pharmacists’ potential to serve as a resource in a
pandemic scenario. Among the existing network of additional providers who could vaccinate large
numbers of patients, many public health respondents reasoned, pharmacies are the ones with the
greatest untapped (i.e., surge) potential.
Pharmacies offer other benefits, as well. Their locations are familiar to customers, including potentially
high‐risk populations, such as those receiving multiple prescription medications for chronic diseases or
those such as adolescents who might not routinely access healthcare.
Pharmacies are increasingly thought of as routine locations for seasonal flu vaccination, and they often
have parking lots that could serve as optional open POD sites. Pharmacies are open late and on
weekends (and, in grocery store locations, could be open 24/7 during a pandemic), and more than 90
percent of the U.S. population lives within 5 miles of a pharmacy.
7 Public Health and Pharmacy Collaboration in an Influenza Pandemic
“The equivalent of the U.S. population passes through a pharmacy every 30 days. That’s 300 million
people. I used to tell my public health colleagues, ‘If you aren’t working with pharmacy, you’re blind.’
We’re missing opportunities, because that’s where the population is.”
— State Health Official
8 Public Health and Pharmacy Collaboration in an Influenza Pandemic
The quote below represents this point of view on the importance of partnering with pharmacies:
“It extends the reach of public health. It takes the burden off of public health. If you’ve got all these
other entities that are reaching out in your community offering a life-saving measure like this, then
you’ve got others who are taking the load off of you.”
“At the time [H1N1], I remember thinking that we really didn’t want vaccine to go directly to pharmacies
— Federal
Health
Official
because we’d lose control of it then. But I’m more willing to do that now and more willing
to say
that
using their distribution system, which is proven and is a fast and efficient system as far as I can tell …”
— State Health Official
Another public health respondent expressed how her view of the role of pharmacies had shifted over
time:
Public Health and Pharmacy Perspectives and Concerns
While many public health respondents had gained confidence since 2009 in pharmacies’ capacity to
assist with vaccine distribution and administration during a pandemic, this view was far from universal.
For some, the view that pharmacies/pharmacists are unable, unwilling, or unprepared to take on a
sustained surge in vaccination activities remains. For example, in a group discussion among local health
officials on this topic, one said:
“I’ve watched big pharmacies, comparatively big, in my community take 30 minutes to fill a prescription.
And so what’s in it for them? … Do they really want to take on this public health task? And are they
willing to do it at the same rate that we’re willing to do it? Our nurses get tired, but they come back the
next day and they continue to do it.”
— Local Health Official
Some public health respondents worried that pharmacists/pharmacies may not be fully prepared to turn
people away if priority guidelines are set, nor would they be adept or experienced in crowd control if
long (and potentially unruly) lines form inside and outside their stores. Some concerns also were
expressed about logistics—particularly storage space for supplies and vaccine (including cold storage
capacity), especially among smaller independent pharmacy stores.
9 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Public health respondents were also concerned that pharmacies have a workflow and business model
that may not be compatible with what would be asked of them during a pandemic, because they would
have to suspend or delay some of their primary medication‐dispensing activities—a stance shared by
representatives of health provider associations. Some in public health voiced the opinion that excess
pharmacy capacity might best be reserved for distributing antivirals, not vaccinations. In this view,
public health could set aside teen pregnancy or STD control for a few months and concentrate fully on
pandemic activities, while pharmacies would have more difficulty setting aside their normal operations,
especially for a 10‐week (or longer) period.
Pharmacists, on the other hand, assert that many in public health who hold these views may have an
incomplete or outdated understanding of the modern pharmacy. At the individual pharmacist level,
corporate chain representatives, and chain and independent pharmacy associations, respondents
reiterated that today’s pharmacy is a different animal from the pharmacy of the past:
“Most of my classmates, we got into pharmacy … We didn’t go into medicine because we didn’t want to
actually have to touch people, but that’s not who’s graduating from pharmacy school now. The
pharmacists that we’re educating with the doctor of pharmacy degree are expecting to go and take
people’s blood pressures and really interact with them and make a difference on their clinical course, as
opposed to just being a service provider. So anything we can do to keep them happy in their profession
and practicing to the extent of their education and their scope of practice is a very good thing.”
— Pharmacy Representative
With a rapidly expanding role in providing vaccinations for seasonal influenza, pharmacy respondents
noted that they have incorporated vaccine administration into their training and certification processes.
Although they have faced resistance from private providers, pharmacists and their associations also
have worked to change state laws to expand the age ranges and options for pharmacists to act as
vaccinators.
As several respondents noted, pharmacies were the last to receive vaccine during 2009 H1N1. One
reason for this was their inability to provide vaccine to children in most states. Still, many believed
public health had included them late in the game almost as an afterthought, which may be related to
10 Public Health and Pharmacy Collaboration in an Influenza Pandemic
lack of pre‐pandemic planning to incorporate pharmacies. Pharmacies are eager to avoid the
“afterthought” scenario in the future. As one pharmacy respondent put it,
“I’m not saying that I want to be the first player in the game, but I do want to be considered at least an
equal in my ability to service the people in the areas that our stores are in.”
— Pharmacy Representative
Representatives of chain pharmacies interviewed for this project were primarily corporate officers and
staff who reflected flexibility and sincere willingness to work with public health and fully engage in
responding to a pandemic. But, as one public health representative noted, “The chains at the corporate
level are enthused and committed. The store managers—not so much.”
Pharmacy respondents also did not express concerns about managing long lines and crowds in and
around their store locations, although public health respondents did express concerns that pharmacy
managers may not be prepared for such scenarios.
Options for Increasing Capacity and Addressing Concerns
Options to address these issues include:
Identifying more opportunities for pharmacists and their associations to collaborate with public
health, thus debunking some misconceptions or mistrust. For example, some states and local
jurisdictions have invited pharmacists to participate in emergency planning groups or have cross‐
representation from public health and pharmacy groups on various task forces. In some areas,
public health has been a supportive partner as pharmacists seek a larger role in immunization,
countering some opposition from private providers.
Developing formal but flexible MOAs or MOUs with pharmacies. In some areas, public health
agencies have developed local or state agreements governing vaccine distribution, administration,
compensation, and reporting, working closely with state boards of pharmacy and state pharmacy
associations. Because of variations in state laws governing pharmacists’ roles, the specifics of these
agreements need to be negotiated at the state and local levels. (An example from Washington state
is provided in Appendix C.)
11 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Assessing state and local pharmacy capacity systematically, through surveys, joint exercises, and
simulations. Few public health respondents in these interviews felt that they had a current,
comprehensive picture of state and local pharmacy capacity in their jurisdictions or even
understood chain and independent pharmacy interest and capacity in participating at various levels
in a pandemic scenario. A lack of basic data about pharmacies, their interests, and their capacity
hinders informed decision‐making about allocation, reporting, and compensation options.
Conducting state‐level simulations at pharmacies on the impact of vaccine administration in
combination with antiviral dispensing, dispensing of normal medications, security needs, and
other features to test pharmacy capacity under these assumptions. It remains to be seen how a
pharmacy might handle many competing demands and priorities in an emergency situation, and
questions from public health remain about how pharmacies would balance competing priorities
should the vaccine campaign interfere with normal business activities.
12 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Allocations of Vaccine
Respondents were asked to rate two main allocation options: whether the vaccine allocation to
pharmacies would be part of a state’s pro rata allocation, or not. Table 1, below, shows little difference
among the three perspectives regarding whether the allocation of vaccine to pharmacies in each state
should be part of the pro rata distribution allocated by CDC to each state. This primarily reflects what
occurred in 2009 during the H1N1 program. The pharmacy representatives see this as an extra step in
getting vaccine to their stores and thus gave a lower rating on the effect on speed, but found this option
to be equally feasible and acceptable.
Table 1: Allocation of Vaccine
Option
Public Health
Immunization
and Sr. Mgrs.
Public Health
Preparedness
Pharmacy
Representatives
Acceptability
3.7
4.1
3.7
Feasibility
4.0
4.1
4.0
Effect ‐ speed
3.9
3.7
3.3
Acceptability
2.8
2.9
4.0
Feasibility
3.5
3.8
4.4
Effect ‐ speed
3.6
3.1
4.3
Independents part of
state pro rata
Acceptability
3.7
4.1
3.5
Feasibility
3.8
3.8
3.7
Effect ‐ speed
3.6
3.8
3.2
Independents not part of
state pro rata
Acceptability
2.8
2.8
3.8
Feasibility
3.5
3.6
4.0
Effect ‐ speed
3.7
3.1
3.9
The major difference between the public health and pharmacy perspectives is allocating vaccine directly
to pharmacies above/outside the state pro rata share of the national supply. The predominant public
health heath position in these interviews was that allocating vaccine outside of the pro rata state
allocation would impinge on their ability to direct vaccine within the state. The more carefully public
health representatives considered the underlying scenario (through discussions of the factors
influencing their rating), the higher the rating they provided for the acceptability of this option. The
Chains part of state pro
rata
Chains not part of state pro
rata
13 Public Health and Pharmacy Collaboration in an Influenza Pandemic
pharmacy representatives clearly see allocation of vaccine to them outside the pro rata shares as more
acceptable, more feasible, and more rapid.
We saw minimal differences between ratings of chain and independent pharmacies, but it should be
noted that most of the pharmacy representatives interviewed were from the chain store sector.
Given a plentiful supply of vaccine and no shortages, respondents from all sectors were asked to
describe ballpark allocations of vaccine allocated to public health, pharmacies, and private providers.
Most respondents felt they did not have adequate information to offer an opinion about these rough
allocations; many added that if vaccine supplies were indeed plentiful, it would be less of an issue.
Respondents had used various methods to determine allocations in the past. One, described as “a fairly
complex allocation methodology,” applied Census and Behavioral Risk Factor Surveillance System data
to allocate vaccine amounts during H1N1 by county based on percentages of births, numbers of
pregnant women, and other demographic data. Those data were then matched to hubs for providers
and the healthcare delivery system, where people would be likely to access care. Counties with a higher
provider/access point score were allocated a higher percentage of vaccine than others, but the local
health departments still made the decisions about whether vaccine would be shipped directly to
pharmacies or would it come through the health department (e.g., for schools or other sites).
More relevant than initial allocation, especially to public health respondents, was the issue of
reallocation and secondary distribution or redistribution. As was true for the answers about basic
capacity, many respondents noted that they lacked adequate local data to make informed allocation
and reallocation decisions about the proportion of vaccine supply that should flow to pharmacies or
other providers.
“Last time, we had hospitals that couldn’t move vaccine through their system. We can’t just take it and
move it to a different provider in a different region because that would be unfair to that area. So what we
need is a system that allows us to move to more effective or efficient providers in the same region so the
redistribution will be in how quickly it has been moved to the right populations.”
— State Health Official
14 Public Health and Pharmacy Collaboration in an Influenza Pandemic
A major concern voiced by public health program respondents about allocating vaccine was their keen
sense of responsibility and accountability to ensure the best match between vaccine supply and demand
in their jurisdictions. They indicated the need for near‐real‐time information to monitor this and take
any necessary corrective action should an imbalance be detected. For public health respondents,
accountability requires data, and ensuring the flow of data requires systematic oversight and a certain
degree of control over those who would be providing vaccine and reporting data to IIS. Specifically, local
and state public health respondents want to know:
Which providers (pharmacy and others) are available to provide vaccinations?
What do they need from public health (training, guidance, prior agreements, and supplies)?
What local/state variations in populations could affect pro rata allocations and subsequent
reallocations (e.g., populations crossing state borders to live or work, large student populations
with different home addresses/ZIP codes, movement of large populations of tourists or other
temporary residents; the existence of large employers who might be able to obtain vaccinations
through a closed POD system)?
In order to redistribute vaccine supplies from areas with a surplus to those with a shortage, accurate
data on vaccine distribution and dispensing are needed. These issues are discussed in greater detail in
the section on tracking and reporting, below.
Options for Addressing Concerns About Allocation
Collecting examples of basic allocation algorithms (for in‐state or in‐county allocations) might be helpful,
predicated on the types of data available.
Respondents recognize that a pandemic requires flexibility in responding to changing conditions.
However, if allocation decisions made by public health agencies are based on clear criteria, these
decisions should be adhered to and as much transparency as possible maintained. One way to do so is to
convene an oversight or planning group, as several states have done, to reach consensus on allocation
decisions and provide broader support for the rationale behind these decisions. If groups are convened
for this purpose, either as part of the state/local incident command structure or separately, pharmacy
representatives should be included.
15 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Distribution and Redistribution
Interview respondents were asked to compare two distribution options for getting vaccine to chain
pharmacy sites during an influenza pandemic: 1) directly through a U.S. government contract with a firm
like McKesson, which distributes vaccine for the VFC program as directed by state immunization
programs, or 2) through regional or national pharmacy distribution channels.
Distribution of vaccine to individual stores by McKesson was the standard operating procedure during
the 2009‐2010 H1N1 pandemic and thus is known to be feasible. As Table 2 shows, this was the
approach immunization program staff preferred and works primarily by enrolling individual pharmacies
as VFC providers (in some cases, with streamlined enrollment procedures and fewer restrictions).
Pharmacy representatives clearly, and not surprisingly, prefer that they distribute vaccine to their stores
through their normal daily distribution system, which they believe to be absolutely feasible and much
more efficient/rapid than the alternative. Chain representatives generally gave this option ratings of 5
Table 2: Distribution of Vaccine to Chain Pharmacies
Option
Public Health
Public Health
Pharmacy
Immunization
Preparedness
Representatives
and Sr. Mgrs.
Distribution to
stores by McKesson
4.2
3.7
3.8
as directed by state Acceptability
public health
Feasibility
4.0
3.6
4.3
Effect ‐ speed
3.7
3.0
3.5
Distribution direct
Acceptability
3.6
4.6
4.8
to chains for
redistribution
Feasibility
3.8
4.4
4.6
Effect ‐ speed
3.8
4.6
4.4
across the board. They found the alternatives feasible and acceptable, but saw them as inserting an
extra step at the expense of speed and efficiency.
Interestingly, the emergency preparedness staff’s ratings are more in line with the pharmacy
perspective than that of their public health counterparts. Emergency preparedness staff seemed to be
more in tune with the underlying scenario of rapidly moving vaccine to the community and into people,
while immunization staff seemed more concerned with dealing with shortages and population priorities.
16 Public Health and Pharmacy Collaboration in an Influenza Pandemic
In addition to the ratings provided in the table exercise, respondents were asked to comment on various
aspects of distributing and redistributing vaccine, including how state pro rata allocations could be
maintained if pharmacies were able to use their own distribution channels, optimal approaches for
distributing a high volume of vaccine, and possible barriers to be addressed before such distribution
becomes necessary.
During the early stages of H1N1, state health departments directed the amount of vaccine that would be
provided to each individual pharmacy as part of the overall allocation and distribution within the state.
In states with relatively autonomous local health departments, such as home rule states, local health
officials played a role in proposing provider allocations to the state for approval, including pharmacists
within these allocations. In these scenarios, states were still directing the flow and reallocation of
vaccine as needed, but with more input from local health departments. According to respondents, this
system generally worked well, especially because it had to take into account vaccine shortages and
placing some populations at higher priority to receive vaccine than others. Notably, these elements—
vaccine shortages and priority populations—were not part of the scenario presented in the interviews.
Concerns and Trade‐Offs
Two concerns raised by respondents about distribution were not related to distribution mechanisms or
allocations per se, but are worth noting. The first is that CDC required a 100‐dose minimum for orders,
which posed a problem for lower‐volume providers, including pharmacies. In these situations, the 100‐
dose packages had to be divided into smaller batches—an extra step that felt unnecessarily
cumbersome and time‐consuming to many. The other concerned supplies that accompanied the vaccine
doses. Some pharmacy respondents noted that while providing ancillary supplies (syringes, swabs,
“Don’t dictate to us what we should be using. Everybody has their own sharps guides. We’ve done our
own training. We comply with OSHA regulations. We have approved sharps. During the last pandemic
they tried to say, ‘Here’s the kind of syringe that you need to use because that’s what we’re supplying to
you.’ Well, don’t supply us with those kinds of things. We don’t need them. I mean, we always worry
about running out of sharps and Band-Aids and that sort of thing, but that, once again, is on the supply
side of things, just to make sure that we have enough of those. But I would say stay out of the
businesses acquiring the supply side of things and just worry about the vaccine itself.”
— Pharmacy Representative
17 Public Health and Pharmacy Collaboration in an Influenza Pandemic
sharps containers) was intended to be helpful, in practice it sometimes led to problems (e.g., receiving
syringes without instructions, no process for disposal or return of unused items).
During the later stages of 2009‐2010 H1N1 vaccine response, CDC and states allowed shipments of
vaccine to central chain distribution centers, which in turn allowed chains to redistribute vaccine to
individual stores through their established networks. At this point, shortages had eased, demand had
dropped, and the main concern was improving access to vaccine and increasing coverage. Not
surprisingly, pharmacy representatives preferred this option for distribution, although they also
expressed flexibility in working with (or around) other arrangements. If they were to receive vaccine
directly and cut out the middleman (McKesson), pharmacies believe they could distribute the vaccine
more efficiently without sacrificing tracking, inventory, and redistribution. Many believe they are in a
good position to determine how much vaccine each of their stores would need based on their current
customer data and projections and patterns of demand from seasonal influenza vaccine. Pharmacists
also provided weekly reporting to VTrckS regarding vaccine doses available per jurisdiction, and the data
was made available on a weekly basis to health departments.
Public health respondents who worked with pharmacies during H1N1 reported positive experiences
with pharmacy distribution in terms of speed and flexibility. Their ratings in the table reflected the view
that in a non‐shortage but high‐volume scenario, direct chain distribution would offer some significant
advantages if speed and efficiency were paramount.
The advantages of speed and efficiency, however, are not enough to overcome public health’s concerns
about losing necessary oversight over where vaccine is within distribution systems, as compared to
where it should be. As noted above, health officials at all levels feel sense of responsibility for ensuring
that vaccine is directed to the places and populations where it is needed.
“You’ve got to somehow build in systems that do, that allow for reallocation. Public health has to have
the ability to maintain visualization across the community to understand where vaccine is, who’s getting
it and who’s not, and the ability to readjust that.”
— State Health Official
18 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Pharmacy representatives, too, recognize this crucial role and responsibility of public health.
“If you’re getting who is administering where and you’re seeing a provider who hasn’t had any activity in
a week, you need to get on the phone and say, ‘What’s going on?’ You’ve got vaccine, you’re not
administering it. If you don’t need it anymore, let’s give it to somebody else. I think it would be the health
department or whoever it is that distributed the vaccine. There should be some flag criteria that would get
somebody to say, oh, we’d better make an outreach to this provider … that’s any provider who is getting
the vaccine. If it’s sitting on their shelf during a time of emergency, and we’re not seeing any movement,
somebody’s got to raise the question.”
— Pharmacy Representative
Public health officials are not yet confident that they will receive the data they need from pharmacies to
confirm that vaccine is moving to the people and places where it should be within a state, county, or
city. Both pharmacy and public health respondents acknowledged that this is not necessarily due to any
flaws or reluctance on the part of pharmacies to share data, but has more to do with the inefficiencies
of variations in state immunization registries and their ability to communicate bilaterally between
providers and public health. This is discussed in more detail in the section on tracking and reporting
(page 24), but the point is that inconsistent data systems currently hinder the degree of collaboration
and options that these two sectors could agree to ahead of time.
In responses to interview questions, public health respondents generally maintained that they would
prefer to use a mechanism like McKesson in a future pandemic. They would be open to another model
of direct stockpile or manufacturer shipments to chain distribution centers, but only if they could track,
influence, and direct the amount of vaccine being shipped to each store. (This sentiment was strongest
among state public health respondents, but was certainly voiced by local public health officials as well.)
In effect, if there were 1) an unlimited supply of vaccine, 2) strong reporting and tracking that let all
parties know exactly where vaccine was being distributed and administered in something close to real
time, and 3) the ability to draw on state and local vaccine allocation expertise, then public health would
feel more comfortable with direct‐to‐chain distribution for redistribution to stores. CDC, ASTHO,
NACCHO, and the Association of Immunization Managers as representatives of federal, state, and local
19 Public Health and Pharmacy Collaboration in an Influenza Pandemic
public health would of course play a major role in determining the initial amounts, but the actual
distribution and redistribution would occur within the chain‐to‐store hierarchy. This would yield the
most rapid and efficient distribution of vaccine, shortening the time between vaccine manufacture and
administration.
No matter how alluring the efficiency gains, however, this is extremely unlikely. Initially, respondents
found it difficult to conceptualize and accept unlimited vaccine supply. And as noted above, data
systems are still far from this ideal, although there is some progress in this direction for some chains and
some states. Still, we have noted these conditions because they suggest that if data systems were
improved, the improved efficiency would become much more palatable to public health.
Options for Balancing Efficiency and Accountability
Given what is known or believed to be known about pandemic vaccine distribution, what are possible
options for taking advantages of the efficiencies of chain distribution and tracking systems, while
reassuring public health that vaccine is reaching the right people and places?
Some respondents believe the answer is local: allow direct shipment of vaccine from stockpiles or
manufacturers to chain distribution centers for redistribution, but have store managers initiate the
requests after consulting with the local (or state, in other cases) health department. This, of course,
depends on local health departments having the capacity and interest in playing this role, potentially
many times over, since it would require conversations and negotiations with many entities. This
approach also depends on pharmacy chains delivering to public health the store‐level data they believe
are within their reach, which can be used to make timely decisions about redistribution of vaccine. If this
approach worked well in some jurisdictions, building on pharmacy/public health collaboration that has
been strengthened since H1N1 and in some cases was in place long before, then it could reassure state
and local public health officials who are skeptical about the flow of data from pharmacies.
The interview scenario specifically mentioned McKesson, and respondents drew on their experience
with McKesson under the VFC program and during H1N1. Certainly, this arrangement should be
preserved where it is already in place and working well. However, in a pandemic situation, CDC and
ASTHO also could develop relationships with other major wholesalers to distribute to independent
pharmacy stores based on store orders, coordinated again with local or state public health. In this
option, the wholesalers would provide distribution data to state immunization registries so that state
and local public health officials would be able to “maintain visualization across the community.”
20 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Fiscal and Compensation Issues
During H1N1, doses of vaccine supplied to pharmacies (and other providers) were provided by the U.S.
government at no cost, but providers still incurred administrative costs associated with staff time and
reporting responsibilities. When uninsured individuals and others who could not afford a co‐pay to cover
administrative fees sought vaccinations at pharmacies, in many cases there were no mechanisms in
place to defray these costs.
During the table exercise posed at the beginning of the interviews, respondents from the public health
and pharmacy sectors were asked to rate the acceptability, feasibility, and effect on speed of three
options:
1) Requiring pharmacists to vaccinate anyone who showed up, regardless of their insurance status
or ability to pay.
2) Not requiring pharmacists to vaccinate everyone, meaning that they would be encouraged to
refer those who could not pay to go to public health clinics to receive their vaccinations.
3) Not requiring pharmacists to vaccinate everyone, but compensating them if they did vaccinate
those who were uninsured or unable to pay.
Table 3: Vaccinating Uninsured Adults and Others Unable to Pay
Options
Public Health
Public Health
Immunization
Preparedness
and Sr. Mgrs.
Pharmacies required
to vaccinate all
4.7
4.2
regardless of ability to Acceptability
pay
Feasibility
4.6
3.7
Effect ‐ speed
4.7
4.8
Pharmacies not
required to vaccinate
1.7
2.3
all—refer to PH clinics Acceptability
Feasibility
2.7
2.9
Effect ‐ speed
1.9
2.0
Pharmacies to
vaccinate all and be
Acceptability
1.6
2.4
Pharmacy
Representatives
3.5
3.6
4.6
2.8
3.5
2.2
4.7
21 Public Health and Pharmacy Collaboration in an Influenza Pandemic
reimbursed for
administration
Feasibility
Effect ‐ speed
1.6
1.9
2.7
3.0
4.3
4.2
Table 3, below, shows that while all respondents generally agreed that the second option (referring
uninsured or unable‐to‐pay patients to public health clinics) was not desirable, 11 of the 21
immunization staff and senior managers gave this option the lowest rating: 1. Respondents from every
sector recognized that many patients in this category, if referred and required to make an additional
attempt to find a vaccination option, would end up not being vaccinated at all. All agreed to various
degrees that this would be unacceptable and would severely undermine the shared public health goal of
containing the pandemic’s spread.
Across categories, respondents recognized that vaccinating everyone is the most efficient and rapid
option. However, immunization staff tended not to identify some of the feasibility issues raised by
pharmacists, such as dealing with patients standing together in line and singling out those unable to pay
in a public space—an awkward as well as time‐consuming conversation. Many are optimistic that
expanded insurance coverage under ACA beginning in early 2014 will reduce the number of uninsured,
yet all recognized that there always will be some proportion of the population that remains without
coverage, including low‐income undocumented workers who remain ineligible for subsidized coverage
and those living in states whose governors and legislators have declined to expand Medicaid coverage.
Thirteen of the 21 immunization staff and senior managers gave a rating of 1 to the third option—
reimbursing pharmacies for administering vaccine—while 10 of 17 pharmacy representatives gave a
rating of 5 to this option. Pharmacy representatives were also not in favor of incurring the costs of
administration without reimbursement. In subsequent responses to interview questions, public health
staff tended to agree that pharmacies should be reimbursed—just not from their state or local budgets.
They see this as a federal responsibility; pharmacies largely agree.
22 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Respondents from all sectors recognize that the financial calculus is different for chains and
independents. Smaller independent stores operate within tighter margins and would be more
vulnerable if they had to suddenly absorb an influx of uncompensated staff time that diverted
pharmacists from their ongoing operations.
“They’d have to look at it in terms of, they’re
getting people through the store and how much
is that worth to them, in terms of additional
sales …”
“We weren’t looking to make money [in H1N1].
But we weren’t interested in giving our good
services away.”
— Pharmacy Representative
— State Public Health Representative
Here again, different perspectives from the public health and pharmacy arenas come into play. Many
public health respondents suggested that pharmacies should absorb the administrative costs because
these would be more than offset by additional sales as patients/customers enter their stores (the “loss
leader” view). Pharmacists argued that they should break even by having their administrative costs
reimbursed or at least defrayed.
Even though most agree that pharmacies and other providers should be reimbursed for vaccines
administered without compensation, those in public health also believe that in the absence of a
compensation mechanism, pharmacies still should be required or highly encouraged to vaccinate
everyone. For most, that is the current (and somewhat uneasy) status quo.
Some in public health believe that pharmacies that are unwilling to vaccinate everyone will simply
choose not to participate, since participation is voluntary. Others noted that during H1N1, some who
were reluctant to participate under these conditions did so, yielding to pressure from
patients/customers and competitors who did participate. Respondents agreed that a larger‐scale
pandemic and national/global emergency would change both the pros and cons of participating,
regardless of whether compensation mechanisms are devised between now and then.
“They do it because at that time [during disasters] money is not the object and everybody works double
to do what they have to do …”
— Pharmacy Representative
23 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Options for Addressing Fiscal/Compensation Concerns
If pharmacies are encouraged or required to vaccinate all who present to be vaccinated and who meet
age and other criteria that would allow them to be vaccinated in that setting, many respondents agreed
they should be reimbursed for those not covered by an existing payment mechanism.
Respondents agree this is most feasible from a federal reimbursement mechanism, in a model similar to
the Emergency Prescription Access Program, which assists with individuals’ access to prescriptions and
durable medical equipment when a federal disaster has been declared. This could either cover a
standard reimbursement to all providers or come into play when certain thresholds of uncompensated
care were reached. (Some pharmacy respondents reportedly did attempt to track the number of
unreimbursed vaccinations they administered during H1N1, but they had no one to bill for them.)
Public health respondents opted for a federal fund not only because of the lack of funding available for
this purpose at the state and local levels, but also because they do not want to add complex fiscal
reimbursement and tracking responsibilities to their pandemic portfolio.
Even for patients who are insured, pharmacists face variations across states in terms of whether or not
they can be reimbursed as medical service providers. This is not a new idea; ASTHO has been working on
this issue with America’s Health Insurance Plans, the trade association for health insurance industry,
since H1N1, and pharmacy groups also are advocating for recognition as healthcare providers and
members of a patient’s team of healthcare providers on a state‐by‐state basis. If this change were made
consistently across more states, some of the reimbursement issues identified here could be resolved.
Since reimbursement is tied to reporting, another suggestion from pharmacies was to set up systems in
which influenza vaccine would be treated like a prescription for reporting and reimbursement purposes,
with a zero co‐pay option to include those who were not insured. This would track store‐level
immunization doses and billing simultaneously, without requiring changes to existing pharmacy data
systems.
In a pandemic with significant fatalities and public fear, lines in pharmacies (and elsewhere) will be long
and the urgency of rapid processing greater. Pharmacy representatives suggested that a roster‐type
procedure (e.g., name and date of birth) should be sufficient documentation for insurance billing
purposes in that situation.
24 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Some respondents suggested the option of issuing vouchers to employees or population groups that
could then be redeemed at pharmacies for free immunizations, with no co‐pays. In one example, a
private university provided vouchers to its employees and their family members. In another, a pharmacy
chain provided vouchers to community‐based organizations in its headquarters city.
No matter how these options are addressed at the federal and state levels and with insurers, the
arrangements should be made before the next pandemic:
“Because that’s going to be the holdup … if we’re having to deal with how to bill and the pharmacists have
any doubt on if we’re going to get paid or anything along those lines, then that’s going to hold everything
up.”
— Pharmacy Representative
25 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Data, Tracking, and Reporting
If vaccine were allocated directly to chain pharmacies and distributed to stores through their own
distribution networks, respondents were asked to rate options for two aspects of information sharing by
pharmacies: dose administration and vaccine location (tracking).
Table 4, below, shows that all agree that reporting should occur, although the pharmacy representatives
did recognize that it is certainly feasible/easier not to report. Daily and weekly reports are equally
acceptable to immunization staff and senior managers. Pharmacy representatives preferred weekly to
daily and consider it more feasible, primarily because it decreases the demands on pharmacy staff.
Table 4: Information Sharing by Pharmacies About Dose Administration
Option
Public Health
Public Health
Pharmacy
Immunization
Preparedness
Representatives
and Sr. Mgrs.
Require reporting to
registries DAILY—
Acceptability
4.2
3.3
3.8
direct by
pharmacies
Feasibility
3.4
2.6
3.5
Effect ‐ speed
3.4
3.9
4.0
Require reporting to
registries WEEKLY—
direct by
Acceptability
4.2
4.1
4.4
Pharmacies
Feasibility
4.2
3.6
4.4
Effect ‐ speed
3.6
3.6
4.0
No requirement for
reporting vaccines
Acceptability
1.1
1.4
2.2
administered
Feasibility
2.8
3.7
4.3
Effect ‐ speed
2.0
2.2
3.7
Table 5, below, again shows that all agree that reporting should occur, although the pharmacy
representatives did recognize that it is certainly feasible/easier (though not acceptable) not to report.
Immunization staff and senior managers prefer to have the chains reporting to them by store as
opposed to aggregate state data. While the format of the table linked these choices to daily versus
weekly, most found weekly reporting by store very acceptable. The pharmacy representatives found
26 Public Health and Pharmacy Collaboration in an Influenza Pandemic
reporting by store very acceptable, but preferred weekly to daily reporting—again, as with dose
reporting, because this would lessen the demand on already stretched pharmacy staff. In any case, this
Table 5: Information Sharing by Pharmacies About Vaccine Location
Option
Public Health
Public Health
Immunization
Preparedness
and Sr. Mgrs.
Require reporting of
distribution at STATE
Acceptability
3.5
4.2
level only—WEEKLY
Feasibility
4.2
4.2
Effect ‐ speed
3.4
3.9
Require reporting of
distribution at STORE
level—DAILY
Acceptability
4.5
3.9
Feasibility
4.0
3.3
Effect ‐ speed
3.6
3.9
No requirement for
reporting where
Acceptability
1.1
1.4
chains distributed
Feasibility
2.9
3.4
Effect ‐ speed
1.5
2.2
reflects nearly full agreement across respondent categories.
Pharmacy
Representatives
3.9
4.6
3.8
4.4
3.8
3.8
2.1
4.3
3.3
Closing the Gap Between Ideal and Real Data and Reporting Systems
Many individuals from each sector were able to describe an ideal reporting and tracking system: it is
bidirectional, exchanging data between providers and public health, and generates data in real time.
“We could provide daily on hands at the pharmacy that shows how many doses are being carried by every
single one of our pharmacies across the country. That’s just the press of a button.”
— Pharmacy Representative
27 Public Health and Pharmacy Collaboration in an Influenza Pandemic
That system is possible and in some places tantalizingly close, but it is not yet in place at the scope and
national scale that would make it useful to all parties in a pandemic. Yet, as noted above, most of the
reassurance public health seeks from pharmacies (and other providers) to fulfill its role of protecting and
monitoring the public’s health rests on an improved and more consistent system.
Immunization Registries
One of the questions posed to interviewees was whether they considered their state immunization
registries an effective mechanism for tracking pharmacies’ vaccine administration. Like everything about
registries, the answer varies considerably by state. While many state public health and immunization
managers are proud of their individual registries, they do recognize their limitations, especially in a
pandemic situation. Registry limitations cited by respondents included requiring consent forms,
cumbersome enrollment procedures for providers, and issues with user‐friendliness. During H1N1, some
worked with CDC to implement alternate simplified reporting and tracking tools (for all providers, not
just pharmacies) or used IMATS to track inventory and supplies. If a pandemic unfolds in the near future,
these tools will probably be necessary and may remain the only options for some states.
The biggest reporting frustration for pharmacy chains will come as no surprise: the variation across
states in requirements, protocols, and procedures for participation in immunization registries or other
mechanisms that would fulfill required tracking/reporting functions during a pandemic.
“I guess the other part of the reporting piece would be a consistent reporting format from one locality to
another. What we saw in the H1N1, especially as we were involved with the different states, is that
everybody wanted a different level of information. In some cases they were fine with ‘give us an aggregate
number for all of your stores across the state,’ in some cases they wanted it by store by day, in some cases
they wanted it even in differing formats from that perspective. If there was a way to come up with a
consistent request, and I know that every state is different and that kind of thing, but for this kind of
activity, if we’re expected to do a lot of work in a little amount of time to service folks, then the needs have
to be fairly simple and consistent across the board.”
— Pharmacy Representative
28 Public Health and Pharmacy Collaboration in an Influenza Pandemic
An Approach to Bilateral Data Systems
To address the issues of incompatible data systems and inconsistencies across state requirements, one
company saw an opportunity to develop an interface between pharmacy data systems and state
immunization registries. The system is currently being used by a major chain pharmacy in 28 states, with
another 17 state registries expected to be participating by the end of 2013, for a total of 45. The
pharmacy chain’s central database is mined for data related to immunization activities; these are then
tailored to meet the specific, unique requirements of each state’s registry without further data entry or
customization required by the pharmacy’s system or the registry. The costs are borne by Walgreens, not
the states.
An immunization manager in one of the participating states described how it works: Walgreens stores
upload vaccine information daily to their corporate office, at which point the data are simultaneously
uploaded to the state immunization registry. Local health departments then have instant access to the
registry data and thus real‐time access to immunization information for local Walgreens stores in their
communities. If this system were more widely implemented, it could resolve most of the vexing data
and reporting issues on which so much public health/pharmacy coordination depends, not only during
pandemic emergencies but also in the more routine provision of seasonal flu and other immunizations.
Other pharmacy and grocery‐based pharmacy stores have developed similar systems that allow direct
reporting to registries or use products such as McKesson’s EnterpriseRx, but these were reported to be
less efficient. If more chains follow Walgreens’ lead and use the option described above (developed by
Surescripts), this offers the potential for greater standardization and comprehensiveness in reporting,
without requiring changes by chains or registries. However, the costs may be prohibitive for some
chains, depending on their immunization volume and whether they consider their existing systems to be
adequate for the states in which they operate. This approach also may be out of reach for independents,
although that remains to be seen.
Reporting Through Wholesale Distributors
McKesson holds the current CDC contract for distributing vaccine through the VFC program; during a
pandemic, this system would expand to other providers, including pharmacies. However, at least two
other wholesalers serve independent pharmacies and small chains. All three are apparently capable of
providing store‐specific distribution data to states, though not all may be able to do so electronically. A
review of distributor capabilities and willingness to integrate their data with state registries would be
worthwhile. Otherwise, small independent pharmacies could be integrated into a VFC‐like system (or
29 Public Health and Pharmacy Collaboration in an Influenza Pandemic
streamlined VFC option) for reporting and tracking purposes. However, thought must be given to
addressing the potential for duplicate dose reporting due to redistribution.
One pharmacy respondent described an inventory dashboard that CDC developed during 2009‐2010
H1N1, with manufacturers, distributors, and pharmacies reporting the status of vaccine in their
respective pipelines—green for a plentiful supply, yellow for supply on its way but perhaps not keeping
pace with demand, and red for out of stock (and not forthcoming).
“It would be phenomenal if everyone was able to report instantaneously what they had at hand, but I’m not
sure that’s as important, as useful as folks would think it would be, knowing that we have a national
distribution system and spot shortages can be relieved in 24 hours.”
— Pharmacy Representative
Minimum Data Sets
Despite the existence of the AIRA IIS Functional Standards, few interviewees referenced them when
asked about a minimum data set for a pandemic scenario. Instead, when asked what belonged in such a
data set, interviewees had different preferences. Some interviewees did not have an opinion. The most
commonly cited minimum list of items included the following:
Name
Date of birth
ZIP code (or address)
Vaccine Universal Product Code (vaccine product and lot number)
Date of vaccine administration
Other items added by individual respondents (i.e., without the underlying consensus reflected in the
above list) included gender, target/high‐priority group status, risk factors, administration route, and
insurance status.
30 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Some respondents suggested that during a pandemic, pharmacies could collect and retain patient
locating and vaccine information, but could report just the number of people they had vaccinated, their
dates of birth, and remaining doses of vaccine.
“In a severe pandemic, do we want to require, do we want to slow down the vaccination enough to get
really picky about how and what providers report to our state immunization registry? I’m not sure that
the value will be worth however much it might slow down our vaccination effort.”
— Emergency Preparedness Manager
Options for Addressing Data/Tracking Concerns
The interface between pharmacy data systems and state registries described above, if adopted more
widely by more chains, may resolve tracking and reporting issues for a significant portion of pharmacy‐
based immunizations (both routine and pandemic‐related). However, this solution is still months or
years away, depending on the chain, and is unlikely to be adopted by smaller‐volume independents or
even smaller state or regional chains.
If CDC and states could agree on a streamlined data set and options for providing these data (through
the registries or other mechanisms), this might bring the remaining pharmacies into the fold. This
solution would also support reporting by other providers, who apparently performed more poorly than
pharmacies in some cases in terms of reporting H1N1 vaccination doses to public health authorities.
Another option, at least for inventory management, is to use the ordering and delivery tracking systems
of McKesson or other wholesalers or CDC’s IMATS for this portion of the reporting.
These and other options require a determination of what public health really needs to know during and
after a pandemic and consensus within public health about the rationale behind data tracking and
reporting requirements so that more consistent requests can be communicated to those being asked to
provide the data.
Even among the relatively small sample of states represented in our interview pool, we heard about a
wide range of registry capabilities among immunization grantees. Minimum performance standards for
registries should be established, and incentives provided to grantees that do not meet them.
31 Public Health and Pharmacy Collaboration in an Influenza Pandemic
32 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Coordination Between Pharmacy and Public Health
Despite concerted efforts in some states to increase contact and coordination between the pharmacy
and public health sectors since H1N1, room for improvement remains. As noted in a recent NACCHO
report on building and sustaining partnerships between pharmacies and state and local health
departments,6 a 2012 Harvard School of Public Health poll regarding antiviral distribution found that
more than two‐thirds of pharmacists working in community settings reported that they had had no
contact with health department staff in the past year.7
This lack of contact was echoed in many of the interviews for this project, but we also learned about
creative and productive partnerships across the country. The NACCHO report lists several examples of
partnership best practices that involve dispensing drills, marketing and awareness campaigns designed
to boost access and immunization rates, joint training and tabletop exercises with pharmacy students
and faculty, and emergency orders waiving age restrictions that prevent pharmacists from serving as
immunizers for a larger proportion of the population. Additional examples from the interviews with
public health agencies for this project include:
Collaborating with a local chapter of the American Academy of Pediatrics to survey pharmacists
about their education and knowledge needs regarding immunization, and then connecting them
to webinars and other training events to respond to those needs.
Inviting pharmacists and association representatives to state immunization conferences, and
offering them continuing education units for attending.
6
NACCHO. “Building and Sustaining Strong Partnerships between Pharmacies and Health Departments at State
and Local Levels.” Available at http://preparednesssummit.org/wp‐content/uploads/2014/03/NACCHO‐Pharmacy‐
Report.pdf. Accessed 5‐9‐14.
7
Harvard School of Public Health. “The Voice of Pharmacists: A Poll about Alternative Methods for Antiviral
Distribution During a Pandemic Influenza.” Available at http://www.hsph.harvard.edu/horp/. Accessed 5‐9‐14.
33 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Involving public health medical officers in authorizing collaborative practice agreements with
pharmacists where these are required, to speed access and provide opportunities for developing
relationships. An added bonus, one respondent noted, was some added leverage:
ICS and Coordination
“You can say, ‘Look, if you’re not going to send in your reports, I’m going to rescind the collaborative
practice agreement and you’re not going to be able to do this vaccination anymore.’”
— Pharmacy Representative
An important existing mechanism for coordination is ICS, which would be activated by a crisis as severe
as a global influenza pandemic. Many public health respondents pointed to their ICS relationships as a
natural and useful forum for better coordination with pharmacies, but not all had used their ICS
structures and planning groups in this way. Respondents suggested that, if they have not already done
so, state health departments should include state boards of pharmacy, pharmacy associations, schools
of pharmacy, and individual chain and independent store representatives in their planning efforts.
Boards of pharmacy and associations also can serve as conduits for communication and updates,
although some state pharmacy association interviewees noted that their membership encompasses
relatively small proportions of their states’ pharmacies.
In particular, respondents saw ICS groups as well positioned to adjust to the expected waves of a
pandemic, with uneven geographic impact across the country. Through ICS, some observed, crucial
reallocation functions could be coordinated, especially if the initial pro rata allocations of vaccine did not
match the pandemic’s progression. ICS also are conduits for communication from the ICS Joint
Information Centers (among partners, across political and government entities, and directly to the
media and general public) and potentially for funding from emergency funds to compensate pharmacies
for administrative fees.
Many respondents described frequent convening of their ICS, not just for training, tabletop exercises,
and crises, but for more routine responses as well. In one state, the ICS worked well during H1N1, but:
34 Public Health and Pharmacy Collaboration in an Influenza Pandemic
“Once [H1N1] was over, we kind of stopped. And then we had an outbreak where we didn’t stand up
incident command. We kind of just let it all fall together. It didn’t work as smoothly, so the decision was
made that we just do that all the time now when we have outbreaks.”
— State Health Official
For public health respondents, an important attribute of ICS is the recognition, in a pandemic situation,
that public health would have the authority over vaccine allocation, distribution, and
reallocation/redistribution (i.e., that public health is accountable and directing the response). Being
clear, direct, and transparent about public health’s role and responsibilities was recommended at both
the state and local levels, especially if partnerships with pharmacies are relatively new.
Within the ICS and general emergency response structure, most participants reported strong
relationships between emergency preparedness and immunization personnel. However, some strained
relationships and difficulties were noted as well.
Tools to Guide Future Coordination and Collaboration
ASTHO’s Operational Framework for Partnering with Pharmacies for Administration of 2009‐2010 H1N1
Vaccine recommended that state health departments formulate agreements with pharmacies at the
corporate level, so that state and local health departments would not need to negotiate store‐by‐store
agreements.8 The Operational Framework provided a template agreement as a starting point, along with
discussion of other planning considerations relevant both to H1N1 and future pandemics.
Because of variations in state laws governing the role of pharmacists in providing immunizations (in
general, and during emergencies), state‐specific agreements are required, even if these follow a general
national template. In general, state and local public health respondents recognized the value of
8
ASTHO. “Operational Framework for Partnering with Pharmacies for Administration of 2009 H1N1 Vaccine.”
Available at http://www.astho.org/Display/AssetDisplay.aspx?id=2613. Accessed 5‐9‐14.
35 Public Health and Pharmacy Collaboration in an Influenza Pandemic
consistency and basic parameters that everyone could follow but are wary of anything that looks or
sounds like an all‐purpose “one‐size‐fits‐all” solution.
Although templates and models exist (see, for example, Washington state’s MOU between local health
departments and pharmacies in Appendix D), respondents from both pharmacy and public health
reported that they were not readily available, although most agreed they would be useful starting
points. Some of the difficulty lies in anticipating so many specific variations and unknowns in a general
document:
“Without knowing the specifics of a particular emergency, it’s hard to say what those procedures would be
or what procedures you would need. If there’s a shortage of vaccine and then prioritizations need to be
made, that’s a completely different procedure than just giving out the vaccine and recording this data …
What needs to be worked into the MOU is just that agreement to follow the procedures that are given.”
— State Health Official
From the pharmacy side, several respondents noted that pharmacies would naturally need to conduct
legal reviews of such documents, but that once they are in place, they would be followed:
“Pharmacists are very good at following rules, and they listen to their lines of authority very directly. On the
whole, public health has not engaged with the regulatory part of pharmacy, the board of pharmacy, to be
part of their communication piece. I can tell you that any pharmacist working at any community pharmacy,
if they’re told by their board of pharmacy that they need to do something, they are 300 times more likely to
listen to it than the governor saying it!”
— Pharmacy Representative
36 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Beyond a more binding MOU, respondents also expressed interest in a protocol that essentially updates
the 2009 ASTHO Operational Framework from H1N1. Such a document, developed in close consultation
with public health and pharmacy representatives, would cover:
Specific roles and responsibilities of pharmacy and public health in a pandemic, including known
variations that could affect these roles (such as home rule states).
Reimbursement procedures or options.
Requirements for provider enrollment processes, including any streamlining that would
encourage pharmacies or other providers to participate and enroll ahead of time.
Sample standing orders.
Reporting expectations and templates.
Storage and handling guidance.
Communications guidance.
ICS coordination.
Contingencies and what‐if scenarios, based on various possibilities.
Options for Strengthening ICS and Other Coordination
Review state pandemic flu plans to determine whether pharmacy roles are delineated or could
be strengthened, if appropriate.
Explore local and state MOU options and engage boards of pharmacy in reviewing, supporting,
and disseminating them.
Assess existing ICS or other emergency planning groups to determine whether they include
pharmacy representatives.
Identify specific information gaps and training needs among pharmacists about immunization,
and work with partners to address those needs through webinars, workshops, conferences, or
other means. Topics could include information and training on registries and enrollment,
guidance on vaccine storage/handling, and vaccinations for specific populations or age groups,
among others.
Review the 2009 ASTHO Operational Framework and templates (geared to state‐level
partnerships) as well as the 2013 NACCHO report (aimed at local partnerships between public
health and pharmacies) to identify opportunities for strengthening and formalizing partnerships.
37 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Consider supporting pharmacy efforts to change legislative restrictions on their scope of practice
regarding immunizations, both routinely and during emergencies.
Explore specific opportunities for public health officials to support pharmacies in these roles,
including offering training on specific topics, conducting joint training/tabletop exercises,
speaking at each other’s conferences, and so forth.
38 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Communicating with the Public
Although communicating with the public was not a major topic of discussion during the interviews,
respondents did offer some suggestions and insights based on their prior experience with H1N1 and
other crises.
Again, they noted that the scenario posed in these interviews—plentiful vaccine, no designated priority
groups—would alter the communications messages and urgency considerably. The messages,
respondents suggested, would be straightforward in the proposed scenario:
We have vaccine and it will work.
Here’s where you should go to get it (including pharmacies, as appropriate, and coordinated
with their own marketing). Any state‐specific restrictions, such as age restrictions that would
prevent pharmacists from providing vaccine to an entire family, should be clarified as early as
possible and reinforced consistently.
Here’s what to do if you get sick.
Here’s when you should go to the hospital, and when you shouldn’t.
In terms of conduits for messages to the public, most opted for primary messages crafted and cleared by
CDC and then disseminated through their ICS’s joint communications structure. However, they noted
that this sometimes creates unnecessary delays as information is cleared. With widespread access to
Google, Twitter, and other rapid‐fire social media, the challenge of conveying accurate information has
grown. Especially in a pandemic, respondents recognize that the web, television, and radio are the most
likely venues for communication, not print media.
Respondents noted that although the ICS is set up to provide consistent, accurate information from a
central source, partners can amplify those messages once they are determined. Health plans, insurers,
providers, and of course pharmacies can all assist with getting accurate information out about vaccine
availability and options and countering misinformation.
39 Public Health and Pharmacy Collaboration in an Influenza Pandemic
RECOMMENDATIONS
Throughout this summary, the members of the interview team have identified opportunities for CDC,
ASTHO, and their partners to address some of the concerns and barriers identified by interview
respondents. In addition to those specific suggestions, we offer this condensed list of recommended
next steps:
1. Convene a roundtable/planning process that provides an ongoing forum for stronger
coordination between pharmacies and public health. This group could tackle barriers and
solutions in three phases:
Phase 1: Immediate pandemic planning. Many interview respondents’ suggestions
anticipated that data and other systems will improve in the near future—within several
years. However, a pandemic could strike much sooner than that. The group could consider
an immediate threat first, including what could be accomplished with current resources and
systems. Identification of resources, including current plans and MOUs that can be shared
across jurisdictions, would be a useful process for this group. Then, the group could turn to
options if an influenza pandemic were to occur several years hence. What could be
different? What would be the first items to address? For example, the group could consider
the specific pros and cons of three broad distribution options: the current system, shipping
directly to pharmacies, or a hybrid in which shipments would go directly to the pharmacies
through the state’s ICS (which, with pharmacy representation and input, would determine
allocations for the state).
Phase 2: Updated pandemic planning. In a second phase, the group could consider updated
conditions and adapt its Phase 1 plans and recommendations accordingly. This envisions a
group that meets periodically to consider the landscape, rather than a one‐time workshop
or roundtable.
Phase 3: Other post‐pandemic opportunities. Although pandemic response is the main
focus, strengthening collaboration before a pandemic is likely to yield many other
opportunities for pharmacy/public health collaboration. In the future, the group or a subset
could serve as a venue for exploring these opportunities, once the most urgent and complex
pandemic planning items were addressed.
40 Public Health and Pharmacy Collaboration in an Influenza Pandemic
2. Support community‐level pharmacy profiles about pharmacy capacity and other features. A
recurring theme in these interviews was local and state health officials’ lack of current
information about pharmacy capacity to assist in a pandemic. Staffing and logistics associated
with surge capacity, store locations, populations served (especially high‐risk or unique in other
ways), data collection and reporting capacity, levels of experience and interest in participating
as vaccinators during a pandemic, and pharmacy connections to other community resources are
all important data points for informed decision making that could be collected and mapped
more systematically before a pandemic makes this information urgent.
3. Select specific barriers/concerns to address. Whether or not a planning group is convened, CDC
and ASTHO could identify several high‐priority recommendations from this report that, if
addressed, would advance pharmacy/public health collaboration in the future. Our nominees
include:
Develop a model for integrating pharmacy representation into ICS structures to
enhance coordination and visibility. Some states have successfully integrated pharmacy
representation into their ICS structures, which can assist in state and local coordination
and communication. These entities can address issues around reporting, distribution,
and redistribution as necessary.
Explore options for pharmacy and state immunization registry electronic interfaces—
either the Surescripts interface model (and specifically how it could be made accessible
beyond the major chains) or others.
Standardize, and if possible reduce, the required minimum data set for reporting
immunization doses during a pandemic. While the AIRA IIS Functional Standards for
reporting exist, they are not applied consistently across jurisdictions, nor would they
necessarily be wholly applicable or essential in a pandemic scenario. These standards
are a useful starting point for discussion among the states and other stakeholders.
Instead of relying exclusively on McKesson (or any single VFC contractor) to distribute
vaccine to independent pharmacies, consider working with other wholesalers to
develop a direct distribution route to them comparable to that used for chains, with
reporting and tracking systems supporting this approach.
41 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Examine payment/reimbursement options for pharmacies to cover or defray
administration costs, including working with plans and insurers to reimburse pharmacy‐
based vaccinations as a medical service.
42 Public Health and Pharmacy Collaboration in an Influenza Pandemic
CONCLUSION
Pandemic flu plans, tabletop exercises, emergency preparedness and immunization conferences, H1N1
after‐action reviews, ASTHO’s 2009 Operational Framework guidance and more recent work on
pharmacy distribution of antivirals, collections of best practices, CDC cooperative agreements dedicated
to public health/pharmacy collaboration—all of these investments and insights have moved public
health and pharmacies further into each other’s arenas, often in very constructive and productive ways
that will pay off during a crisis no matter when it may occur.
Despite these ongoing efforts across the country, though, progress remains uneven. Some of this is
natural and appropriate, as each state and local jurisdiction constructs the most appropriate mix of
partners and capacity for a pandemic response. But some of the variation appears to leave a potential
surge resource for a pandemic response—in some areas, perhaps the only untapped surge resource—
largely unexplored.
If a pandemic follows the scenario outlined in these interviews, it will be a crisis situation, but one that
remains the best‐case scenario because vaccine supplies would be plentiful and arriving as planned and
announced (unlike H1N1). This best‐case scenario still yielded plenty of concerns and barriers that need
to be addressed, but the most basic one may be that even after H1N1, public health does not have a
universal expectation that it should be working closely with pharmacies, nor do pharmacies necessarily
expect to be in routine contact and partnership with public health. In addition, the views of corporate
pharmacy leaders may not be shared at the store level, where the logistical challenges are likely to be
most intense.
Changing these expectations at all levels—local, state and federal, corporate chain headquarter and
individual store—will be an ongoing challenge, but one that is already being met by many of the people
interviewed for this report.
The next pandemic is inevitable, and so is the after‐action report that will follow. Whether that
pandemic occurs in the near future or after the luxury of a longer planning interval, it is our hope that a
future after‐action report will document that public health and pharmacies made significant progress in
strengthening their shared pandemic preparedness.
43 Public Health and Pharmacy Collaboration in an Influenza Pandemic
A P P E N D I X A: A C K N O W L E D G E M E N T S
Public Health Representatives
Claudia L. Aguiluz
VFC Program Coordinator
Immunization Branch
California Department of Public Health
Charles Alexander
Program Administrator
Immunization Program
Florida Department of Health
Rick Bays
Michael Poole
Karen Hess
Response and Recovery Unit
Texas Department of State Health Services
Lynn C. Berger
Director, Bureau of Immunization
New York State Department of Health
Debra S. Blog
Director, Division of Epidemiology
New York State Department of Health
Jim Craig
Director, Health Protection
Mississippi State Department of Health
Mary Currier
State Health Officer
Mississippi State Department of Health
Deirdre Depew
Ralph Iler
Lou Ann Lance
Office of Health Emergency Preparedness
New York State Department of Health
44 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Joan M. Duwve
Chief Medical Officer
Indiana State Department of Health
Terry Dwelle
State Health Officer
North Dakota Department of Health
Kris Ehresmann
Division Director
Infectious Disease Epidemiology, Prevention
and Control
Health Protection Bureau
Minnesota Department of Health
John Erickson
Special Assistant
Public Health Emergency Preparedness and
Response
Washington State Department of Health
Amanda Fuller‐Moore
SNS Coordinator
North Carolina Department of Health and
Human Services
Rahul Gupta
Health Officer and Executive Director
Kanawha‐Charleston Health Department
Also: Adjunct Clinical Assistant Professor of
Medicine at West Virginia University School of
Medicine and Adjunct Associate Professor at
University of Charleston's School of Pharmacy
Claire Hannan
Executive Director
Association of Immunization Managers
Maxine Hayes
Previously Washington State Health Officer
Molly Howell
Immunization Program Manager
North Dakota Department of Health
H. Bruce “Jeff” Jeffries
Acting Deputy Director, Division of Health
Protection
Georgia Department of Public Health
Lisa M. Koonin
Chief, Private and Public Partners Branch and
Director, Business Partnerships Division of
Partnerships and Strategic Alliances
National Center for Health Marketing
Coordinating Center for Health Information and
Service
Centers for Disease Control and Prevention
David Lakey
Commissioner
Texas Department of State Health Services
Donna Lazorik
Deputy Program Manager for Program
Development
Immunization Program
Massachusetts Department of Public Health
Joe Legee
SNS Planning and Exercise Coordinator
Division of Public Health Systems
Office of Public Health Emergency Preparedness
Maine Center for Disease Control and
Prevention
Aggie Leitheiser
Assistant Commissioner
Health Protection Bureau
Minnesota Department of Health
A.J. Lorenzen
Epidemiologist/Preparedness Pharmacist
45 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Alaska Department of Health and Social Services
Joe McLaughlin
State Epidemiologist and Chief, Alaska Section
of Epidemiology
Alaska Department of Health and Social Services
José Montero
Director, Division of Public Health Services
New Hampshire Department of Health and
Human Services
Also: 2012‐2013 President, Association of State
and Territorial Health Officials
Lyle Moore, Jr.
Director, Office of Emergency Preparedness and
Response
Colorado Department of Public Health and
Environment
Julie Morita
Deputy Commissioner
Medical Director, Immunization Program
Chicago Department of Public Health
Jeff Neccuzi
Program Manager
Immunization Program
Bureau for Public Health
West Virginia Department of Health and Human
Resources
Eleanor B. Peters
Epidemiology Specialist
Division of Communicable Disease Control
Services
St. Louis County Department of Health
Saroj Rai
Immunization Branch Manager
Texas Department of State Health Services
Jeanne Santoli
Chief, Vaccine Supply and Assessment Branch
Immunization Services Division
National Center for Immunization and
Respiratory Diseases
Centers for Disease Control and Prevention
46 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Joshua Robinette
Acting Cities Readiness Initiative Coordinator
for the SNS
District of Columbia Department of Health
Cathy Slemp
Previously Acting Health Officer
West Virginia Department of Health and Human
Resources
Nathaniel Smith
State Health Official
Arkansas Department of Health
Bob Swanson
Director, Division of Immunization
Michigan Department of Community Health
Lynn Trefren
Nurse Manager
Tri‐County Health Department (Colorado)
Maria Volk
Immunization Branch
VFC Chief of Field Services and Program
Coordination
California Department of Public Health
Steve Wagner
Chief, Bureau of Public Health Preparedness
Ohio Department of Health
Thomas Weiser
Medical Epidemiologist
Portland Area Indian Health Service
Jane Zucker
Assistant Commissioner
Bureau of Immunization
New York City Department of Health and
Mental Hygiene
47 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Pharmacy Representatives
Alex J. Adams
Vice President, Pharmacy Programs
National Community Pharmacists Association
Jack Cantlin
Vice President, Retail Clinical Services
Walgreens
Ed Cohen
Senior Director, Clinical Solutions
Walgreens
Brian Hille
Vice President, Patient Care Services
Safeway
Chris Humberson
Tim Fuller
Washington State Board of Pharmacy
Wesley Knecht
Corner Druggist
Elk Rapids, Michigan
Kathy Lewis
Surescripts
Rick Mohall
Senior Director
Field Clinical Services
Rite Aid Corporation
Erin Mullen
Director
Rx Response
Jennifer Pytlarz
Previously with Publix
48 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Mitchel C. Rothholz
American Pharmacists Association
Michael Sherry
Manager, Retail Clinical Operations
CVS Caremark
Rebecca Snead
Executive Vice President
National Alliance of State Pharmacy
Associations
Ken Whittemore
Surescripts
Gregory R. Pachmayr
Director
Indiana Professional Licensing Agency
Indiana Board of Pharmacy
Jason Rubin
Senior Manager, Immunization Services
Walgreens
Lawrence J Sage
Executive Vice President
Indiana Pharmacists Alliance
Lisa Schwartz
Director, Management Affairs
National Community Pharmacists Association
President and CEO
National Hispanic Medical Association
Herbert F. Young
Division Director
Health of the Public and Science
American Academy of Family Physicians
Provider Representatives
Debra Hawks
Senior Director
American College of Obstetricians and
Gynecologists
Elena Rios
49 Public Health and Pharmacy Collaboration in an Influenza Pandemic
A P P E N D I X B: I N T E R V I E W I N S T R U M E N T
Prior to each interview, respondents will have received:
A one‐page description of the project.
A table summarizing the possible variations in vaccine allocation, distribution, vaccination of
uninsured adults, and information sharing.
A list of the major categories of questions (but not the questions themselves).
Overall Scenario
Imagine that in the not‐too‐distant future, a severe influenza pandemic is declared. Although we won’t
know the exact details until this actually happens, we can make some educated guesses about likely
features that would affect vaccine distribution. We want to use variations in these features to stimulate
your thinking about what barriers to rapid, efficient vaccine distribution and vaccine administration can
be anticipated and potential solutions.
Assume that stockpiled H5N1 vaccine will be available for distribution within 30 days of the declaration
of an influenza pandemic. We anticipate 30 million vaccine doses could be distributed per week. This
number of doses per week is more than four times the peak number of doses distributed during the
2009‐2010 H1N1 outbreak.
So, state public health departments, private providers, and chain and independent pharmacies will have
about 30 days to receive and start rapidly administering vaccine to patients as soon as vaccine arrives.
Rapid vaccine administration is key in this scenario, as rapid spread of the pandemic virus is anticipated.
Ensuring large numbers of vaccine providers are pre‐identified is likely key to being prepared for rapid
administration of vaccine.
We want to explore the implications of possible variations as this scenario could unfold related to:
Whether or not the vaccine allocation to pharmacies would be part of a state’s pro rata
(population‐based) allocation from the U.S. government (USG).
Whether chain pharmacies would receive vaccine directly to their central distribution sites for
secondary distribution to their individual stores/locations, or whether distribution to individual
stores would occur through the same system that state immunization programs will use to
identify and approve other vaccine administration locations for direct shipment from the CDC
contractor (McKesson).
Whether or not pharmacies will be required to vaccinate all patients who request vaccine at their
location regardless of the patients’ insurance status or ability to pay.
50 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Whether pharmacies will be required to enter vaccine administration data into state‐specific
registries or use third‐party software or contract.
Whether pharmacies would be able to frequently report state‐ or store‐level data about vaccine
distribution and availability.
Whether pharmacists would be able to adhere to vaccine prioritization recommendations from
public health.
Features, Options, and Ratings Table
Each interviewee will be walked through the rows of the table on the next page, using a rating scale of 1‐
5 to rate each option in terms of its acceptability (how desirable/acceptable the option would be),
feasibility (whether it could be done), and effect on speed (how fast).
Acceptability: How desirable/acceptable would this option be, if you had a choice? (5 = very
acceptable, would prefer it; 3 = not sure, has pros and cons; 1 = unacceptable)
Feasibility: Could it be done? (5 = yes, highly feasible; 3 = maybe—might be tough, but
manageable; 1 = no way, not feasible)
Effect on Speed: Does it contribute to faster (re)distribution/administration (5), potentially slow
things down (1), or somewhere in between?
As each feature (allocation, distribution, vaccinating uninsured adults, information sharing) is discussed
and rated, ask these overall questions related to the rating/scores:
Which aspects (of allocation, distribution, vaccinating uninsured adults, and information
sharing):
Are feasible to implement or could be managed, even with difficulty (i.e., got high or medium
feasibility ratings)? Why?
Would absolutely not work (i.e., deal‐breakers), and why? (lowest feasibility ratings)
Would make it/them possible or easier to implement? (for those with lower ratings)
Would support or hinder speedy/efficient administration of vaccine?
51 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Features of Pandemic
Response
1.
Allocation
of vaccine
To chain
pharmacies
To
independent
pharmacies
Options
Accept‐
ability
Rating
Feasi‐
bility
Rating
Effect
on
Speed
A. Part of pro rata state distribution
B. Not part of USG pro rata state distribution
in state
A. Part of pro rata state distribution
B. Not part of USG pro rata state distribution
in state
2.
A. Directly through USG McKesson contract
to individual provider locations as directed
Distribution of vaccine to
by individual immunization programs
pharmacies
B. Separate contract and distribution system
for regional or national pharmacies for
redistribution through their established
channels
3.
A. Required to vaccinate all who show up
regardless of insurance status or ability to
Vaccinating uninsured
pay out‐of‐pocket
adults and non‐VFC‐eligible
B. Not required to vaccinate all; uninsured or
children without ability to
unable to pay out‐of‐pocket have to go to
pay at pharmacies
public health to get vaccinated
C. Not required to vaccinate all; public health
reimburses pharmacy for vaccinating
uninsured, after they are vaccinated at
pharmacy
A. Reporting required into state‐specific
4.
On dose
registries, daily direct inputs by
administra‐
Informa‐
pharmacies
tion sharing tion
(frequency)
B. Required into state‐specific registries,
by
weekly direct inputs by pharmacies
pharmacies
C. No requirement for reporting vaccines
administered through registry
A. Required to report vaccine distributed at
On vaccine
the state level on weekly basis (e.g., how
location, if
many doses distributed to each state or
redistributed
immunization program jurisdiction)
52 Public Health and Pharmacy Collaboration in an Influenza Pandemic
by chains
(tracking)
B. Required to report vaccine distributed at
the store location level on daily basis
C. No requirement to report where pharmacy
chains distributed vaccine
What are your major concerns about ramping up to deliver 30 million vaccines weekly within 30
days?
What specific policies, procedures, and practices from pharmacies would be most helpful to
public health during a pandemic? Is this different than during regular influenza season?
Are there any other features/options (relevant to pharmacy/public health coordination during a
pandemic) we should explore regarding pandemic vaccine distribution and administration?
Questions on Specific Topic Areas
Capacity
Allocating vaccine to different sectors
Redistributing vaccine (from chains to stores) and administering vaccines in pharmacy settings
Coordination/administration of guidelines and agreements
Communication across sectors
Communication with the public
Fiscal/compensation issues
Reporting/tracking
Legal issues
53 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Capacity
For Public Health
Do you believe state public health has the capacity to receive and rapidly redistribute influenza vaccine
under this scenario? Why or why not?
What is the existing capacity of states [or, for state‐specific respondents, your state] to distribute your
pro rata share of the 30 million vaccines per week? (Assume you get 4x more a week than what you got
during H1N1.)
What is the existing capacity of states to vaccinate their share of 30 million people per week?
Are vaccine providers (outside VFC) pre‐enrolled, or could they be identified within the 30 days after a
pandemic is declared?
If pharmacies now provide seasonal flu vaccine to 20% of the adult population, would you expect this
proportion to stay the same in a pandemic/30‐million‐dose scenario, or increase?
If increase — to what percentage?
Do you believe chain pharmacies currently have the capacity to receive and rapidly distribute 10% of
the approximately 30 million vaccines per week? 25%?
Why or why not?
How long would it take for pharmacies to ramp up to reach this capacity?
What about their capacity to vaccinate millions or more per week, quadrupling current peak
demand during seasonal influenza vaccination?
Why or why not?
Do you believe independent pharmacies have the capacity to receive and rapidly distribute 10% of the
approximately 30 million vaccines per week? 25%?
Why or why not?
How long would it take for pharmacies to ramp up to reach this capacity?
What about their capacity to vaccinate millions more per week, quadrupling current peak
demand during seasonal influenza vaccination?
Why or why not?
54 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Allocating Vaccine to Different Sectors
Under the pandemic scenario with large amounts of vaccine available from the stockpile, what
proportion of vaccine should go to pharmacies and to public health? (Do you have a ballpark ratio in
mind, such as 50/50 or 80/20?)
Private providers?
How would you determine the proportion of vaccine to allocate to each sector?
What factors should influence the allocation? Why?
What factors would make you more comfortable with the allocation of vaccine to each sector? Why?
Redistributing Vaccine (from Chains to Stores) and Administering Vaccines in Pharmacy Settings
If vaccine is allocated to states pro rata, how should the pharmacy allocation be handled, since national
chains would distribute to individual stores in each state?
How should pharmacies assure USG that state‐level pro rata allocation is preserved (even though
pharmacies may be distributing using a separate mechanism than states)?
If state‐level pro rata allocation is not feasible for pharmacies to maintain, how would state‐level
allocation by USG be adjusted?
If the decision is made for chains to distribute vaccine via their own distribution channels, and not as
part of CDC’s system, will pharmacies be able to assure USG and states that state‐to‐state allocations
remain fair, equitable, and consistent with the pro rata format? If so, how?
With such a high volume of vaccine being shipped daily, what is the optimal approach for distributing it
to stores in an efficient, timely way?
If a portion of the available vaccine is shipped directly to pharmacies, what needs to be in place to make
such distribution possible?
What needs to be in place to make sure rapid vaccine administration is possible?
What information do pharmacies need to provide—e.g., quantities/shipments, vaccine administration
(patient information, vaccine lot numbers)?
What else is needed for smooth distribution and vaccine administration?
What recommendations would you make to ensure transparency in the decision making and timing of
distribution?
55 Public Health and Pharmacy Collaboration in an Influenza Pandemic
In general, would pharmacy chains prefer to distribute vaccine themselves, using their existing medical
distribution systems, or would they prefer to have vaccine distributed by the same system as other
vaccine providers?
How would pharmacies assure USG that these systems could handle a weekly volume of vaccine of 7+
million doses?
Coordination/Administration of Guidelines and Agreements; Communication Across Sectors
What tools from public health would be helpful to pharmacies and public health in adhering to
guidelines during a pandemic (e.g., memoranda of agreement, requirements to enter data into
registries, policies/regulation about authority to vaccinate all ages during a pandemic, etc.)?
How would information about vaccine shipments, availability, priority groups, and vaccine
administration best be communicated and shared between pharmacies and public health during a
pandemic?
What formats would you recommend?
How would the distribution of vaccine across pharmacies and state/local public health be integrated into
existing emergency operations centers or incident command systems?
Communication With the Public
What messages are critical to communicate to the public about vaccine availability in a pandemic
scenario?
What messages would be effective in communicating with the public about who should go to different
settings—pharmacies, public health clinics, or primary care providers?
How should those messages be communicated and by whom?
Fiscal/Compensation Issues
If pharmacies are required to provide vaccine to those uninsured and unable to pay out‐of‐pocket:
How would pharmacies cover costs for administering vaccine?
How would public health compensate pharmacies for the administration cost?
If pharmacies bill public health payers in advance, how would billing work?
Are there any mechanisms that should be in place other than the standard systems for billing health
insurers, including Medicare and Medicaid (e.g., MOUs)?
Is there anything that could be done in advance to minimize the financial risk to pharmacies?
56 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Tracking/Reporting
Are registries an effective mechanism for tracking the administration of vaccines (e.g., do they capture
all persons in your state? Do all providers, including pharmacists, have access to it in your state)? Why or
why not?
Are there ways to streamline registry data entry for providers given the high volume of vaccine
administered rapidly in this scenario (e.g., weekly instead of daily entry)?
Is there a minimum data set pharmacies need to provide to state programs?
What systems (for pharmacies) need to be in place to simplify reporting to state and local public health?
How would third‐party reporting work for pharmacies? (What would need to be in place to make this
work more effectively?)
What are the costs for third‐party reporting (by chains, by independent pharmacies)?
Legal Issues
What are some legal issues that could be anticipated during a pandemic (e.g., allowing pharmacies to
provide vaccinations for adolescents or children during an emergency, instead of adults only; other
liability concerns)?
Wrap‐up
If a protocol or guide were available to support smoother collaboration between public health and
pharmacies in the event of pandemic influenza, what topics/tools would be most useful to you that are
not currently available?
Are there existing guidelines (even for other topics) that you’ve found particularly useful/accessible?
Is there anything we haven’t asked about (!) that would be relevant to improving pharmacy/public
health collaboration in these types of scenarios?
57 Public Health and Pharmacy Collaboration in an Influenza Pandemic
A P P E N D I X C: S A M P L E P U B L I C H E A L T H ‐P H A R M A C Y MOU
WASHINGTON STATEWIDE PHARMACY‐LOCAL HEALTH JURISDICTION
MEMORANDUM OF UNDERSTANDING
This Washington Statewide Pharmacy‐Local Health Jurisdiction Memorandum of Understanding
(“MOU”) is made and entered into by the signatory Health Department or signatory Health District, or
signatory County within the State of Washington that operates a public health department or division
within its county government, (“Local Health Jurisdiction” or “LHJ”) and each signatory pharmacy entity
licensed in the State of Washington (“Pharmacy”), individually, and with all other signatory LHJs and
signatory Pharmacies.
ARTICLE I
PURPOSE
The purpose of this MOU is to utilize existing Pharmacy infrastructure to assist in addressing health and
medical needs of an affected population during a Public Health Incident, Emergency or Disaster
(“Incident”), using coordinated and standardized protocols statewide. The Washington State
Department of Health (“DOH”) supports the development of this MOU.
ARTICLE II
DEFINITIONS
Local Health Jurisdiction: A signatory health department, health district, or county within the State of
Washington that operates a public health department or division within its county government,
pursuant to authority granted under Chapters 70.05, 70.08, 70.46 RCW or other applicable law. Each
signatory party shall designate a representative for purposes of accepting requests for assistance and
notice.
Pharmacy: A signatory to this MOU who meets the definition of a pharmacy as that term is defined in
RCW 18.64.011.
Plan: a written Operation Plan or procedure developed pursuant to this MOU.
Public Health Incident, Emergency, or Disaster (“Incident”): Any occurrence, or threat thereof, whether
natural or caused by man, in war or in peace, to which an LHJ may respond pursuant to its authority
58 Public Health and Pharmacy Collaboration in an Influenza Pandemic
under chapter 70.05, 70.08 or 70.46 RCW, or other applicable law, and that, in the judgment of the LHJ,
results or may result in circumstances sufficient to exceed the day to day operational capabilities of
immediate local or regional public health response.
ARTICLE III
PARTICIPATION
The Pharmacies have a desire to assist the LHJs in addressing health and medical needs of an affected
population during an Incident. The LHJs and Pharmacies agree that this MOU, however, does not create
a legal duty to do so. The LHJs and Pharmacies agree that any and all actions taken pursuant to this
MOU shall be voluntary and in each LHJ’s and Pharmacy’s sole discretion.
ARTICLE IV
HOW TO INVOKE ASSISTANCE
An LHJ may request assistance of a Pharmacy by contacting the designated representative of that
Pharmacy. The provisions of this MOU shall only apply to requests for assistance made by and to such
designees. Requests may be verbal or in writing. If verbal, the request shall be confirmed in writing as
soon as possible to the extent practical. LHJs intend to activate community‐wide mass vaccination and
dispensing plans, to include delivery of medications by Pharmacy with Pharmacy’s agreement, only (a)
after a declaration of “Public Health Emergency” made by the Secretary of the Department of Health
and Human Services under the Public Readiness and Emergency Preparedness Act (PREP Act), 42
U.S.C.A. §247d‐6d, or (b) a locally or state declared emergency, under chapter 38.52 RCW, requiring a
public health and medical response, or (c) the issuance of an event mission number by the Emergency
Management Division of the State Military Department for a public health and medical response.
ARTICLE V
EFFECT OF DECLARATION OF EMERGENCY
The LHJs and Pharmacies recognize that state or federal declarations of emergency, or orders related
thereto, may supersede the arrangements made or actions taken pursuant to this MOU. Nothing in this
MOU should be construed as independent of or bypassing established emergency management
procedures, the provisions of county or state declarations of emergencies, or any conditions for the
distribution and dispensing of the Strategic National Stockpile (SNS) or administration of vaccines
established by the federal or state governments.
ARTICLE VI
RESPONSIBILITIES OF LOCAL HEALTH JURISDICTIONS
59 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Local Health Jurisdictions responsibilities includes:
Coordinate with DOH and/or signatory pharmacies to ensure statewide consistency with
screening forms, tracking, training and other Pharmacy requirements if applicable.
Provide planning and technical assistance to Pharmacy, including but not limited to, supply lists,
fact sheets, dispensing algorithms, and applicable requirements
Provide statewide consistent medical screening forms to Pharmacy as a guidance for
implementing dispensing operations
Provide technical assistance and training, as mutually agreed upon by LHJ and Pharmacy
Activate community‐wide mass vaccination and dispensing plans as necessary
Notify Pharmacy that community dispensing plans should be implemented
Request appropriate amounts and type of medication or vaccine, and available supplies, from
local, state or federal sources, including use of SNS resources
Facilitate a discussion with Pharmacy regarding the most appropriate locations for distribution
Request DOH to deliver, or have delivered medications to distribution centers as determined by
the local health jurisdiction in consultation with the DOH and Pharmacy
Provide Pharmacy with statewide consistent medical protocols regarding the Pharmacy’s
response including, but not limited to, dosing and follow‐up procedures
Provide Pharmacy with releasable information regarding the public health emergency situation
Manage public information activities with regard to the overall health and medical response
across the LHJ’s jurisdiction
Provide educational materials, if appropriate, to Pharmacy for the purposes of distributing to all
persons in emergencies impacting the public’s health
Make arrangements to retrieve or dispose of any unused medications from Pharmacy facilities
and collect documentation forms in coordination with DOH
Provide guidance and criteria to Pharmacy for tracking levels of activity, supplies and inventory,
as applicable to the response and consistent across signatory LHJ jurisdictions
60 Public Health and Pharmacy Collaboration in an Influenza Pandemic
If no statewide mission number has been issued by the State Emergency Management Division,
Pharmacy and Local Health Jurisdiction agree that prior to invoking this Agreement during emergencies,
Local Health Jurisdiction, through the local department of emergency management, will request the
issuance of a mission number from the Washington Military Department, Emergency Management
Division.
ARTICLE VII
RESPONSIBILITIES OF PHARMACIES
Pharmacies’ responsibilities include:
Coordinate with DOH and/or signatory LHJs to insure statewide consistency with screening
forms, tracking, training, and other Pharmacy requirements
Comply with Pharmacy standards in effect during the Incident
Identify the approximate number of medication doses that could be administered by Pharmacy
in a specified time period and communicate that information to the LHJ
Identify Pharmacy sites to receive medication deliveries and communicate site locations to the
LHJ
Communicate to LHJs each site location’s scope of Pharmacy practice regarding affected
populations, e.g., convey age or prescriptive authority limitations
Receive and store medication deliveries, consistent with federal, state or local government
requirements, at Pharmacy‐identified facilities during Incidents
Ensure that Pharmacy site locations serve the general public
At Pharmacy’s discretion, ensure that its own employees, including those employed by its
parent company, and their families, are cared for consistent with public health
recommendations
Conduct medical screening of individuals receiving medications, based on guidance provided by
LHJ, to identify potential contraindications and complications, and assure dispensing and
administration consistent with federal, state and local government requirements
In the absence of the issuance of an emergency use authorization, or a declared emergency
triggering RCW 38.52.180 (6) waiving license requirements for registered emergency workers,
prescribe and dispense medications under a collaborative agreement with a licensed health care
prescriber or lawful health order issued by a local health officer
61 Public Health and Pharmacy Collaboration in an Influenza Pandemic
Maintain accurate records of medications dispensed, administered, and remaining inventory
Maintain and inventory the local, state or federal stock of medications, vaccines and supplies
and physically separate them from the regular inventory. The local, state and federal stock
cannot be used in place of commercial pharmacy stock at any time. Pharmacy stock may be
used as a substitute for the local, state or federal stock and Pharmacy may seek reimbursement
for this action, if available, in accordance with the then current state or federal guidance
Track contact information of individuals receiving medications
Communicate information regarding medications dispensed, administered, and contact
information to local health jurisdiction as required by local health jurisdiction
Provide education materials, supplied by local health jurisdiction to all individuals receiving
medications
Secure any unused medications until a time when LHJ can make arrangements for retrieval or
disposal
Participate, as appropriate, in LHJ‐sponsored mass vaccination or medication dispensing or
administration training and exercises
Register and maintain qualifications of all Pharmacy personnel working under this Agreement as
Emergency Workers within the Local Health Jurisdiction pursuant to Chapters 38.52 RCW et
seq., Chapters118‐04 WAC et seq., and any other applicable statute, regulation or law in order
to obtain immunity from liability and the benefits of workers compensation protection to the
extent allowed by law.
ARTICLE VIII
COST AND PAYMENT
Local Health Jurisdiction shall provide the medications that are to be dispensed or administered by
Pharmacy as specified in this Agreement at no cost to Pharmacy. Pharmacy shall dispense or administer
these medications to patients or customers at no charge to the patient or customer except for an
administrative fee not to exceed the lesser of that reimbursed by the Medicare Part D schedule, or
emergency federal or state current guidance at the time. Pharmacy agrees to waive this fee if required
by then current federal or state guidance. Pharmacy may also, in its discretion, waive this fee for
patients or customers who demonstrate an inability to pay.
All other costs incurred by either Local Health Jurisdiction or Pharmacy through implementation of this
Agreement shall be borne by each respective agency.
ARTICLE IX
62 Public Health and Pharmacy Collaboration in an Influenza Pandemic
IMMUNITY, INDEMNIFICATIONS AND LIMITATIONS
The Parties acknowledge that if this Agreement has been triggered after a federal public health
emergency declaration by the Secretary of the Department of Health and Human Services under the
PREP Act, immunity under state and federal law will extend to covered persons involved in dispensing,
distributing, and administering countermeasures/prophylaxis under 42 U.S.C.A. §247d‐6d. Immunity
under the PREP Act does not apply to willful misconduct or acts conducted outside the scope of the
declaration.
The Parties further acknowledge that if this Agreement has been triggered after a locally or state
declared emergency under chapter 38.52 RCW or after the issuance of an event mission number by the
Emergency Management Division of the Military Department, immunity and indemnification are
provided under RCW 38.52.180 for activities within the scope of assigned responsibilities and under the
direction of the local emergency management organization. Immunity and indemnification does not
apply to gross negligence, willful or wanton misconduct, or acts outside the scope of the assigned
responsibilities or not under the direction of the local emergency management organization.
The Parties agree to assert immunity as applicable to any action against one or more of them. The
Parties acknowledge that the indemnification and defense provisions herein do not abrogate any
statutory immunity.
If this Agreement has been triggered in circumstances when there is not a federal public health
emergency declaration or issuance of a state event mission number, or to the extent immunity and
indemnification under 42 U.S.C.A. §247d‐6d or RCW 38.52.180 are determined by a court of general
jurisdiction in the State of Washington to be inapplicable, each party agrees to be responsible and
assume tort liability for its own wrongful acts or omissions, or those of its officers, agents or employees
to the fullest extent required by law, and agrees to save, indemnify, defend and hold other parties
harmless from any such tort liability. In the case of a determination of negligence or wrongful acts by
the Local Health Jurisdiction and one or more Pharmacy, any damages allowed shall be levied in
proportion to the percentage of fault attributable to each party, and each party shall have the right to
seek contribution from the other parties.
Notwithstanding anything to the contrary in this Agreement, once the Local Health Jurisdiction has
delivered the inventory to the Pharmacy, the LHJ will retain the risk of loss with respect to the inventory
unless the loss is the result of the Pharmacy’s negligence, gross negligence or intentional act or failure to
act.
ARTICLE X
INFORMATION SHARING
Pharmacy will provide Local Health Jurisdiction with information Local Health Jurisdiction deems
necessary for documentation of the actions taken and services provided under this Agreement, all of
63 Public Health and Pharmacy Collaboration in an Influenza Pandemic
which is available under the public health exemption of HIPAA, 45 CFR §164.512(b), and the Health Care
Information Act, RCW 70.02.050 (2)(a).
Local Health Jurisdiction will advise Pharmacy of the information needed to protect the public health
and to prevent or control disease, injury or disability and will only request the information necessary to
protect the public health and to prevent or control disease, injury or disability.
ARTICLE XI
TERM AND TERMINATION
This Agreement shall become effective immediately upon its execution by any one Pharmacy and one
Local Health Jurisdiction. After the first two such executions, this Agreement shall become effective as
to any other Pharmacy or Local Health Jurisdiction upon its execution by such Pharmacy or Local Health
Jurisdiction. The Agreement shall remain in effect as between each and every Pharmacy and Local
Health Jurisdiction until participation in this Agreement is terminated by a withdrawing Pharmacy or
Local Health Jurisdiction by written notice to all of the other signatories to the Agreement. Termination
of participation in this Agreement by a withdrawing Pharmacy or Local Health Jurisdiction shall not
affect the continued operation of this Agreement as between the remaining Pharmacies and Local
Health Jurisdictions so long as at least one Pharmacy and one Local Health Jurisdiction remain.
Either Local Health Jurisdiction or Pharmacy may terminate this Agreement for convenience with written
notification to all of the other signatories to the Agreement no less than thirty (30) calendar days in
advance of the termination date.
ARTICLE XII
AMENDMENTS
No provision of this Agreement may be modified, altered or rescinded by any individual Pharmacy or
Local Health Jurisdiction without the unanimous concurrence of the other Pharmacies and Local Health
Jurisdictions. Modifications to this Agreement must be in writing and will become effective upon the
approval of the modification by all Pharmacies and Local Health Jurisdictions. Modifications must be
signed by each Pharmacy and Local Health Jurisdiction.
ARTICLE XIII
INDEPENDENT CAPACITY
The employees or agents of Pharmacy or Local Health Jurisdiction who are engaged in whole or in part
in the performance of this Agreement shall continue to be employees or agents of that party and shall
not be considered for any purpose to be employees or agents of any other party to this Agreement.
64 Public Health and Pharmacy Collaboration in an Influenza Pandemic
ARTICLE XIV
SEVERABILITY
If any provision of this Agreement or any document incorporated by reference shall be held invalid, such
invalidity shall not affect the other provisions of this Agreement which can be given effect without the
invalid provision, if such remainder conforms to the requirements of applicable law and the
fundamental purpose of this Agreement, and to this end the provisions of this Agreement are declared
to be severable.
ARTICLE XV
NO THIRD PARTY BENEFICIARIES
This Agreement is entered into solely for the mutual benefit of the parties to this Agreement. This
Agreement is not entered into with the intent that it shall benefit any other person and no other such
person shall be entitled to be treated as a third‐party beneficiary of this Agreement.
ARTICLE XVI
DISPUTE RESOLUTION
If a dispute between any parties to this Agreement arises out of or related to this Agreement, or the
breach thereof, the parties agree to endeavor to settle the dispute in an amicable manner by direct
communication between or among each other before terminating the Agreement.
65 Public Health and Pharmacy Collaboration in an Influenza Pandemic
ARTICLE XVII
NOTICES
Whenever this Agreement provides for notice to be provided by one party to another, such notice shall
be in writing and directed to the designated representative of the party.
ARTICLE XVIII
SURVIVORSHIP
The following clauses survive the termination of this Agreement:
IX.
Immunity, Indemnification, and Limitations
XIV.
Severability
XV.
No Third Party Beneficiaries
ARTICLE XIX
OTHER OR PRIOR AGREEMENTS
If a Pharmacy and Local Health Jurisdiction have a prior written agreement that relates to the subject
matter of this Agreement, namely, using existing Pharmacy infrastructure to assist in addressing health
and medical needs of an affected population during an Incident, including but not limited to mass
dispensing of antibiotics, antiviral medications or vaccines to the general public during times of health
and medical disasters, then, at such time that said Pharmacy and said Local Health Jurisdiction both
execute this Agreement, such prior written agreement between them shall become null and void and of
no further force and effect.
Notwithstanding the above provision in this Article XIX, any Pharmacy and/or Local Health Jurisdiction
may enter into other agreements with other Pharmacies and/or Local Health Jurisdictions provided such
other agreements govern subject matter not governed by this Agreement
ARTICLE XX
GOVERNING LAW
This Agreement shall be interpreted, construed and enforced in accordance with the laws of the State of
Washington.
ARTICLE XXI
EXECUTION IN COUNTERPARTS
66 Public Health and Pharmacy Collaboration in an Influenza Pandemic
This Agreement may be executed in two or more counterparts, each of which shall be deemed an
original, but all of which together shall constitute one and the same instrument. For purposes hereof, a
facsimile copy of this Agreement, including the signature pages hereto, shall be deemed to be an
original.
IN WITNESS WHEREOF, this Agreement has been executed and approved and is effective and operative
as to each Pharmacy and each Local Health Jurisdiction as herein provided.
_____________________________________
Signature
__________________________________
Print Name and Title
_______________________________
Date:
67 Public Health and Pharmacy Collaboration in an Influenza Pandemic
ENDNOTES
68 Public Health and Pharmacy Collaboration in an Influenza Pandemic
| File Type | application/pdf |
| File Title | Microsoft Word - ASTHO PH Pharmacy Summary Final 5-8-14 with citation edits LAJ formatting check |
| Author | cjorstad |
| File Modified | 2014-07-07 |
| File Created | 2014-07-07 |