What H1N1 taught the US about delivering pandemic vaccines

How convenient.
How convenient.
Image: AP Photo/Mary Ann Chastain
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The 2009 pandemic caused by H1N1 pales in comparison to coronavirus. Just six months after the first case of the flu variant was detected on US soil, doctors had a vaccine in hand. Technically, the pandemic was over by the time they could administer the shots.

The H1N1 vaccine was deployed ideally—with urgency, but not necessity. It also spurred a dramatic change in vaccine delivery that’s lasted to this day: It triggered laws that allow retail pharmacists to administer vaccines within their communities. Now, as the race for a Covid-19 vaccine continues, that groundwork could make it easier to immunize against the novel coronavirus once a shot reaches the market.

In the US, a number of different healthcare providers can administer vaccines, from clinical nurses to midwives. But H1N1 highlighted the need for pharmacists to administer immunizations. It’s much more convenient to drop into a pharmacy than it is to schedule an appointment at a doctor’s office, and in a pandemic situation where large populations need to get vaccinated at the same time, the healthcare system needs all hands on deck.

Pharmacists’ ability to administer vaccines is regulated at the state level, and before the H1N1 pandemic, most states allowed pharmacists to vaccinate customers. But the practice wasn’t nearly as common as it is today. It took the H1N1 pandemic, which killed over 10,000 people in the US, to spark legislation that mobilized pharmacists in all 50 states to give flu jabs. Ever since, pharmacists across the country have given about a quarter of flu shots annually.

Mitch Rothholz, the chief strategy officer of the American Pharmacists Association, says that some 360,000 pharmacists across the country have received training in giving vaccines. Adding a Covid-19 vaccine (or several) to the mix would only require training on the nuances of that vaccine, like whether it needed multiple doses and how far apart to give them. It’s hard to say exactly how many people pharmacies could immunize against Covid-19, but generally, they’re considered an underutilized resource for vaccine distribution.

In the last decade, pharmacists have shown their success at giving out flu vaccines. But they still may encounter legal red tape when giving out a new Covid-19 vaccine. The reason? A mosaic of state regulations.

Every state has different rules about which vaccines pharmacists can deliver, says Allie Jo Shipman, the director of state policy at the National Alliance of State Pharmacy Associations. Some states allow pharmacists to give out any vaccine that is approved by the US Food and Drug Administration. Others require the US Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices to recommend the vaccine for pharmacist administration. And a handful of states have a set list of only a handful of immunizations that pharmacists can give. These same laws also vary by age; some pharmacists in some states are not allowed to vaccinate children of a certain age.

Those varying regulations are manageable, because Covid-19 vaccine deployment will likely be administered by individual states. In the case of H1N1, “the federal government procured the vaccines and made it available to states,” explains Snead. “States determined priority groups, states determined how many vaccines had to be in different geographic areas, and found partners to distribute.” They started with hospitals, nursing homes, other essential personnel, and eventually made it down to  community pharmacies. For pharmacists to administer new Covid-19 vaccines in states with stricter requirements, the governor of that state would have to sign an executive order to temporarily change the rules.

For now, pharmacies are in a good position: While they wait for Covid-19 vaccines to wind their way through clinical trials, they have some time to prepare themselves to deploy a successful shot. They can work with state and local governments to figure out a game plan, including establishing the necessary executive orders and putting safety measures in place to prevent the spread of coronavirus.

“We’re trying to right now encourage members to do these Covid-19 readiness self-assessments,” says Hannah Fish, associate director of strategic initiatives at the National Community Pharmacists Association (NCPA). This means looking at how many of their usual customers are in a high-risk category for Covid-19 and estimating how much additional personal protective gear they’d need.

One thing that will definitely look different: Pharmacies will need enough space to allow for safe social distancing, says John Beckner, a pharmacist and NCPA senior director of strategic initiatives.

That might be especially important if Covid-19 vaccine availability aligns with the regular flu season. Already, the CDC has stated that it expects this season’s flu vaccine supply to increase by 20 million doses—many of which will be administered in pharmacies. Even though flu vaccines can’t protect against Covid-19, they can reduce the incidence and severity of flu cases, hopefully keeping more hospital beds empty for those who really need them.