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Quantifying the ‘heroic’ work of pharmacists during the pandemic
James Keagy 3888

Quantifying the ‘heroic’ work of pharmacists during the pandemic

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On the Cover

Loren Bonner

Nearly 3 years have passed since COVID-19 upended the world and pharmacists’ roles expanded. Now the time has come for that history to be documented. In a new research paper published in JAPhA, the contributions of pharmacists and their teams that took place as COVID-19 spread across the country have not only been recorded, but they have been quantified.

Reviewing published literature, relevant web pages, and queries to national and state professional pharmacy associations and government agencies, John Grabenstein, RPh, PhD, FAPhA, found that from February 2020 through September 2022, pharmacists and their teammates conducted over 42 million COVID-19 tests, provided over 270 million COVID-19 vaccinations within community pharmacy programs alone, and gave over 50 million influenza and other vaccinations per year.

“Pharmacists plausibly accounted for more than 50% of COVID-19 vaccinations in the United States,” wrote Grabenstein in the research study.

Pharmacist outdoor testing

In an interview with Pharmacy Today, Grabenstein said he did not expect that number to be so high. “We knew pharmacists helped, but this was half and it speaks to the volume,” said Grabenstein, who is director for Scientific Communications at Immunization Action Coalition. “The convenience, access, and competence of pharmacists was important and bore out in this enormous percentage.”

Findings from the research also point out that pharmacists prescribed, dispensed, and administered an “enormous” number of antibody products and antiviral medications, including care for 5.4 million inpatients and countless outpatients.

Using conservative estimates, interventions by pharmacists and their teams averted over 1 million deaths, over 8 million hospitalizations, and nearly $450 billion in health care costs, according to the study.

“This is the first peer-reviewed study that documents the incredible impact that pharmacy had on the health and well-being of our nation, across the entire spectrum of potential patient interventions,” said Ilisa BG Bernstein, PharmD, JD, FAPhA, interim CEO and executive vice president of APhA. “There’s only one conclusion to draw from this impressive report—the work of pharmacists during the pandemic has been heroic.”

Start at the beginning

The study comprised data from pharmacists and pharmacy personnel from all practice settings: Community, ambulatory care, hospital inpatient, long-term care, academia, public health, and
others. Interventions within these practice settings ranged from prevention, treatment, and support to diagnostic testing, convalescent plasma, monoclonal antibodies, antiviral medications, supportive therapies, and, of course, vaccination.

Findings conclude that pharmacists and pharmacy personnel supplied more than 350 million clinical interventions to more than 150 million people via testing, parenteral antibodies, vaccinations, antiviral therapies, and inpatient care.

“The paper is organized in time,” said Grabenstein, who is also president of Vaccine Dynamics. “The first thing pharmacists could do was deal with the crisis and the crush of extra patients.”

As the virus spread quickly in early 2020, hospitals began to overflow and supply shortages were felt everywhere. Grabenstein wrote in the research study that the first priority for pharmacists was to continue providing prescription medications, medication therapy management, and consulting services for hundreds of millions of Americans each week.

Hospitals soon began to overflow and supply shortages were felt everywhere. “Pharmacists hastened to require extra distance between an increased volume of clients, arrange plexiglass barriers, and protect inventory. They moved scarce hand sanitizer, alcohol swabs, masks, thermometers, sterile water (for sleep-apnea devices), and other products behind the pharmacy counter to preclude hoarding,” according to the study.

In the hospital setting, managing shortages amid workflow disruption was an ongoing effort.

According to an American Society of Health-System Pharmacists survey from 2021, 46% of U.S. hospital pharmacists increased intensive care unit bed capacity in 2020.

The study found that almost all had to change their usual pharmacy supply-chain acquisition processes. Hospitals experienced shortages of many medications, including asthma inhalers (60%), sedatives and anesthetic agents (58%), neuromuscular blockers (43%), corticosteroids (34%), cardiovascular agents (24%), investigational agents (24%), and dialysis solutions (6%). Medication-use changes were put in place by 86% of hospitals across the country, most commonly involving guidelines for COVID-19 treatment (79%) and opening compassionate use or investigational drug studies (55%). Shortages of personal protective equipment and other basic supplies compounded the struggle to continue care delivery, the study found.

COVID-19 testing

COVID-19 testing became available in April 2020, and the federal government gave pharmacists permission to order and administer FDA-authorized COVID-19 tests. The study found that pharmacists administered more than 42 million COVID-19 tests.

In April 2020, the federal government also formed a partnership with community pharmacies for pharmacist-based COVID-19 testing, integrating pharmacists into the Community-Based Testing Sites (CBTS) program. This began with 362 sites across 45 states and the District of Columbia.

The pharmacist-based components of the program grew quickly:

  • By June 2020: 623 sites in 48 states, DC, and Puerto Rico (PR); >700,000 samples tested (cumulative).
  • By January 2021: 3,300 sites in 50 states, DC, and PR; >5.6 million samples tested.
  • By March 2021: 6,211 sites in 50 states, DC, and PR; >9.8 million samples tested.

In January 2021, HHS noted that more than 70% of pharmacy sites within the CBTS program were located in communities with moderate-to-high social vulnerability.

Under the PREP Act, not only did HHS authorize pharmacists to order or administer FDA-authorized COVID-19 tests, but also pharmacy interns and pharmacy technicians.

Convalescent plasma

Convalescent plasma—or passive immunization using preformed antibodies to prevent or ameliorate infection—came next when clinicians needed to find ways to treat the SARS-CoV-2 virus early on in the pandemic.

Grabenstein wrote that pharmacists in many hospitals contributed to multidisciplinary efforts to recruit plasma donors, harvest and process the plasma, and administer it to eligible patients. The Expanded Access Protocols (EAPs) for COVID-19 convalescent plasma eventually included more than 2,700 U.S. hospitals through August 2020. The EAPs were succeeded by an EUA issued by FDA in August 2020.

Convalescent plasma was short lived, however, due to several obstacles and regulatory hurdles. Plus, the availability of specific monoclonal antibody products from November 2020 onward offered therapeutic products in ready-to-use formulations with more standardized potency and a clearer basis of evidence, the study pointed out.

Monoclonal antibodies

Findings from the JAPhA study indicate that pharmacists provided more than 100,000 monoclonal antibody treatments for COVID-19, although Grabenstein noted that figure is probably an underestimate.

In November 2020, FDA issued EUAs for Lilly’s bamlanivimab and Regeneron’s casirivimab with imdevimab (also called REGEN-COV) for certain adult and pediatric patients with an elevated risk for severe COVID-19. Both products are administered by I.V. infusion.

Pharmacists at most U.S. hospitals stepped up to engage in patient selection, counseling, administration, and monitoring for this clinical service.

Grabenstein said he was particularly struck by one pharmacist at the University of Pittsburgh Medical Center who administered casirivimab/imdevimab as a set of 4 subcutaneous injections and led monoclonal treatments for more than 22,000 patients.

“These were the pharmacists who filled the needs of their hometowns,” said Grabenstein during the interview with Pharmacy Today.

In the study, Grabenstein said statistics are interspersed with vignettes to help bring dry numbers to life.

Under the PREP Act, HHS authorized pharmacists to order and administer certain COVID-19 therapeutics, like monoclonal antibodies, by injection or I.V. infusion. They allowed pharmacy interns and pharmacy technicians to administer these products. Several states, including Arkansas, Mississippi, and Oregon, put in place statewide standing orders or protocols to allow pharmacists to independently order and administer casirivimab/imdevimab COVID-19 monoclonal antibodies.

Later, subcutaneous or intramuscular injection products were suitable for administration by outpatient providers, including pharmacists. An Arkansas pharmacist, the study pointed out, who treated more than 300 patients this way reported that her patients had often been placed on waiting lists at nearby hospitals, but were able to receive the medication conveniently in her community practice. Overall, pharmacists administered monoclonal antibodies in community, inpatient, and nursing home settings.

COVID-19 vaccination

The federal government singled out pharmacists as critical partners in vaccinating the public from the get-go. In fact, HHS announced an initial plan in November 2020 to distribute vaccines through large community pharmacies as well as networks like Community Pharmacy Enhanced Services Network (CPESN) USA, which are high-performing pharmacies clustered together by state or region.

In the first few months of COVID-19 vaccine availability, pharmacists were the most frequent vaccinators at long-term care facilities, according to the study. Vaccination for residents and staff of long-term care facilities occurred first during the phased rollout plan beginning in December 2020 when FDA granted EUA status to mRNA vaccines.

In January 2021, the White House released updated vaccination plans featuring community pharmacies as prominent providers of COVID-19 vaccinations. The federal program developed into a partnership with 21 national pharmacy chains, independent pharmacy networks, and long-term care pharmacists offering COVID-19 vaccinations at more than 41,000 community and long-term care pharmacy locations across the country. Vaccine distribution through this channel began in February 2021 and accounted for a large piece of COVID-19 vaccinations across the board:

  • Between mid-December 2020 and September 2022, pharmacists’ teams administered more than 270 million doses of the COVID-19 vaccine. These doses include 8.1 million doses administered onsite at long-term care facilities. During this interval, the total number of COVID-19 vaccinations reported across all 50 states and U.S. territories numbered 606 million.
  • Through the Federal Retail Pharmacy Program alone, community pharmacists and their teammates delivered 45% of COVID-19 vaccinations across the United States, although that proportion has been higher or lower at specific points in time.
  • Pharmacists within health systems often led their institutions’ vaccination programs for workers and surrounding communities. Through August 2021, CDC officials reported that pharmacists had administered 3,203,104 vaccine doses at 11,449 mobile clinics across the country.
  • Between October 2021, when the Pfizer–BioNTech pediatric COVID-19 vaccine received EUA status for children aged 5–11 years in the United States, and January 2022, pharmacists and their teammates administered 46.4% of doses to this pediatric age group. This included 48.7% of doses in areas of high social vulnerability and 44.4% in low social vulnerability index areas.

Under the PREP Act, HHS not only authorized pharmacists to provide COVID-19 vaccination, but also pharmacy interns and pharmacy technicians.

By the end of 2022, pharmacists and their teams are projected to have given over 300 million COVID-19 vaccinations. Visit CDC’s website at to see the most updated numbers.

Equitable COVID-19 vaccination and beyond

Roughly 70% of vaccinating pharmacies are located in communities with moderate-to-high social vulnerability. According to the study, pharmacy teams vaccinated a disproportionately greater share of non-Hispanic Asian and Hispanic or Latino individuals.

Grabenstein wrote that “Pharmacies collaborated with rideshare companies, deployed mobile vaccination units, and went door to door through underserved communities. Community pharmacies helped address the needs of those with limited mobility, such as the elderly or people with disabilities. In multiple instances, people opted to receive their second COVID-19 vaccine dose from local, trusted, and easy-to-access community pharmacies, rather than returning to a mass-vaccination clinic or another venue.”

Pharmacy teams also filled a significant gap in vaccinating people against influenza and other vaccine-preventable diseases, the study found.

A CDC report released in May 2020 found that rates of childhood immunizations had sharply declined nationwide as a result of the pandemic.

In August 2020, HHS authorized pharmacists to provide all Advisory Committee on Immunization Practices (ACIP)–recommended vaccines to children aged 3 to 18 years during the COVID-19 public health emergency, regardless of state laws and regulations. Soon after, HHS issued federal guidance authorizing pharmacists to order and administer FDA-authorized or licensed COVID-19 vaccines to patients aged 3 years and older. The guidance applied to pharmacy intern administration of COVID-19 vaccines as well.

Antiviral prescribing

In the study, Grabenstein wrote that the next big advance was the availability of oral antiviral medications. In December 2021, FDA issued an EUA for Pfizer’s Paxlovid (nirmatrelvir tablets co-packaged with ritonavir tablets), and an EUA for molnupiravir capsules (Lagevrio–Merck with Ridgeback Bio).

Recognizing the benefits of improving COVID-19 antiviral access and equity, FDA amended the Paxlovid EUA in July 2022 to allow skilled pharmacists with access to patient-specific information to order and prescribe this medication.

As this story went to press, pharmacists prescribing Paxlovid are still not being reimbursed for the associated clinical services required for prescribing. Pharmacists providing patient assessment and prescribing Paxlovid are currently requiring patients to self-pay for the service.

Grabenstein said that the research was conducted not only for pharmacists, but for those outside of the profession to realize what pharmacists are capable of. ■



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