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Immunisation is the oldest and most efficient form of primary prevention provided by health workers (Wolfe & Sharpe, 2002; Salisbury et al, 2002).
For decades Australia’s pharmacies have stored and dispensed vaccines listed in the Pharmaceutical Benefits Schedule (PBS).
The value of all PBS vaccines supplied by Australia’s pharmacies has risen by 17.6% to $14.482 million in 30 June 2002 .
This equates to $3000 yearly for each registered pharmacy.
Vaccination usually entails two visits to doctors who prescribe and administer the vaccines and once to pharmacies for dispensing.
The cost of three professional fees and the low under-40% rate of influenza immunisation found in the high risk over-65 years group (Table 1) forced governments into changes to this three-step consumer process.

In November 1998 the Pharmacy Guild proposed to the National Immunisation Committee a doctor’s bag supply of 20 vaccines, and as required from pharmacies, who would be reimbursed monthly.
The claimed benefits were better storage, improved recording, low wastage and little diversion.

The Commonwealth government, unswayed by the Guild proposal, nominated an agent to distribute vaccines to medical clinics.
Manufacturers delivered vaccines to the agent and again pharmacies were excluded.
An almost-80% rate of vaccination resulted (Table 1) .

Table 1. Influenza vaccine scheme for 65+ year olds: costs and benefits in Australia

On 20 August 2002 the Federal Minister for Health extended the above process to meningococcal C vaccine to be provided free until 2017 for children aged 12 months and 15 years.

The spectre of losing subsidised vaccines for other categories of high risk patients and perhaps losing all PBS vaccines now threatens pharmacy.
Both the Pharmacy Guild and Pharmaceutical Society of Australia have advocated
(1) vaccines to be re-scheduled from S4 to registered S3 ( S3R) with the National Drugs and Poisons Scheduling Committee and
(2) pharmacists be accredited in immunisation with proper training and facilities in each pharmacy
(Greenwood, 2002).

But pharmacists face serious problems in providing vaccination such as trained staff and areas in pharmacies with proper facilities for administering vaccines by different routes and treating anaphylaxis, differentiating target and compromised vaccinees (Shepherd & Grabenstein, 2001) and to resist substituting prescribed vaccines.
The education and training of both students and practicing pharmacists is a very big challenge for national and state bodies.
The political ramifications need discussion by all levels and sectors of pharmacy because we will be seen as intruders into primary health territory held by others.
On balance, the de-scheduling of vaccines to S3-R status should, according to a US expert (Grabenstein , 1998), be tested in pharmacies first in defined populations prone to fatal infections with vaccines with the highest known benefits ( eg pneumococal and influenza).
The net yield after accounting for all these factors needs to be calculated for practitioners and the profession as a whole.

Overall, other interim practical options need to be explored.
Nurses were found in a meta-analysis of 29 studies to most significantly increase adult immunisation (Stone et al, 2002).
For pharmacies, registered nurses can facilitate approvals by licensing bodies and third party payers
(e.g. HIC), and ensure acceptance by doctors as well as the public.
Nurses are the only health workers to top pharmacists in Australia’s annual Morgan ratings.
New legislation in some states will allow nurse practitioners to prescribe some S4's in certain settings (Gregory,2002).

The responses to Curtin University’s School of Pharmacy national survey of community pharmacies closed in September 2002 and are being analysed (Berbatis,2002) .
We found 82% of pharmacies reported conforming vaccine refrigerators, 10.2% had closed dosing areas of 3-6 sq metres and 4.8% had clinics with nurses.
One group of 41 pharmacies provides registered nurses for screening activities.
That is the pharmacy areas and skills for vaccination exist already in up to 15% of Australia’s community pharmacies.
Over 50% of Australia’s pharmacies are members of marketing groups and these include the largest pharmacies, which will be the key to adopting practice initiatives such as immunisation in the 21st century.

The most sensible option is to evaluate in a controlled manner, vaccination in pharmacies for specific ages and groups of susceptible clients, such as in aborigines (Couzos & Murray,1999) and those over 65 years and under 12 months, and with defined vaccines by those pharmacies with nurses and appropriate facilities along the lines reported by overseas researchers (Grabenstein et al, 2001).
A study like this would take up to 24 months to complete, after which an assessment of all the above factors can be made by all stakeholder pharmacy, with other health groups and government agencies.

All the above efforts are vindicated by three lines of good evidence.
First, Australia’s ranks high internationally, but is still under the USA, Canada, UK and European countries in the proportions of one year olds estimated to be immunised with DPT 3, Polio 3 and measles (de Looper & Bhatia,1998).
Second, the Royal Australian College of General Practitioners has assessed immunisation as a high priority preventive activity, in its recently published "Guidelines for Preventive Activities in General Practice"
(RACGP, 2002) . Third, the latest international pharmacy review of evidence-based activities in pharmacies sponsored by Great Britain’s Royal Pharmaceutical Society and Pharmacy Healthcare Scheme ranked immunisation high as “…services which can be safely provided by community pharmacists and that they increase convenience for the public…” (Anderson et,2001)

The adverse developments in Australia threaten community pharmacies in Australia with soon losing forever their historical role in delivering this essential form of primary prevention, unless our bodies respond quickly to the challenge. See Editor's note below

Best wishes for a Happy Christmas and a prosperous (well-vaccinated) New Year From Con Berbatis

Con Berbatis, School of Pharmacy, Curtin University (WA), Email : berbatis @git.com.au
(References available on request), National survey website : www.curtin.edu.au/curtin/dept/pharmacy/survey/index.html

Editor's Note:
This article should be read in conjunction with Con Berbatis' previous article in the last edition, which was centred around the potential for new pharmacy services, particularly when offered as a complex of a nurse/pharmacist service.
In some quarters, particularly within hospitals, there is a certain reservation regarding the employment of nurses within a pharmacy structure.
Traditionally, there are so many of them in a hospital environment, coupled with strong union representation, there is a fear that nurses may have the potential to take over some of pharmacy's turf.
To a certain extent, this political power is dissipated in a community structure, but there is still the potential.
Perhaps the following comments may reduce this perceived tension.
I have had some dealings with a rural hospital and its ability to stay afloat and provide a good clinical service.
With a combination of being located rurally, and no incentives being allowed within the hospital system to provide financial inducements, the number of pharmacists working in this hospital have dwindled to 60% of their normal strength.
It has even proven difficult to provide a dispensing and distributive service, as activity has increased relentlessly in this area, at a rate of thirty percent per annum.
To stem the tide, I formed the staff of the pharmacy up into three basic teams, each with a leader, with formal reportage to be delivered on the Wednesday of each week. The pharmacy closes at 2.30 pm on Wednesdays, so that a proper evaluation of each team's activities can take place over an entire afternoon without interruption.

The teams consisted of:
1. Materials handling: stock control, bulk parenteral fluids, imprest management, all handled by a team of three persons (two males and one female for clerical back up).

2. Dispensing: All inpatient and outpatient dispensing, pre-pack manufacture, plus reception duties.
This team is managed by a pharmacy technician team leader, and comprises three pharmacy assistants, two clerical assistants, and one pharmacist to check all finished prescriptions and requisitions.
The pharmacist is, of course, in charge overall.

3. Clinical services: This team is comprised of three nurses plucked from the Workcover pool i.e. they were unable to work as nurses.
They are paid as pharmacy assistants, with Workcover picking up the remainder of the tab for registered nurse wages. A clinical plan was devised and built around ten major drug safety issues i.e the drugs that have been identified as causing discomfort and death to hospital patients world-wide.
A "blueprint" service was established in a system format, for each drug on the list.
The system is totally oriented towards a pharmacist perpsective.
The clinical service is accessed by a referral from any doctor, nurse or allied health professional (rather than waste time having a pharmacist document every patient, as was previously the norm).

Data is collected through each "blueprint" system sheet, and any items out of reference are immediately reported to one of three clinical pharmacists, for intervention.
If necessary, the pharmacist writes intervention details in the patient's notes (nurses and pre-registration pharmacists are not allowed to perform this task).
It is planned to insert a Pre-registration pharmacist in this line in January 2003 i.e the nurses reporting directly to the Pre-registration pharmacist, who in turns gets a clinical pharmacist to sign off on any proposed intervention work, and takes over any professional consults that may be required.

In this way, pharmacists are released from having to establish databases for all patients, yet those patients most in need get better attention.

The "blueprint" services have been a real hit with the Workcover nurses, and they have become enthusiastic converts to the pharmacy cause.
The profile of the entire department has risen, and we are screening more patients than when we had a full complement of pharmacists.
We are now getting requests from other ward nurses to see if they can transfer to our program.
The self esteem of the Workcover nurses has risen to new heights, after previously being condemned to "nothing work" which was provided by nursing administration, just to keep them busy.
Initially, the older pharmacists within the department expressed reservations and indicated discomfort.
This is gradually dissipating as the results are coming through.

The nurses peer group initially gave them some "stick" for deserting their group, but as mentioned above, they all want to join pharmacy right now.
I am even getting nurses working in the community ringing in to see if they can join up.

The other plus is that the "blueprint" service enables the hospital to recruit more students than it normally would, for training. They are able to take one or more "blueprint" service and work under nurse/pharmacist direction, yet still have time to perform any projects specified by their university tutors.
I am thinking of extending the project to community pharmacist locums, as a means of retraining as hospital clinical pharmacists.

Recently, and only after a few months of operation, the Northern Rivers Area Health Service in NSW, gave a Quality Award to the pharmacy department.
This is the first award the pharmacy has ever received and it really gave a boost to all of the staff- even those not directly involved.

I can see many opportunities for a parallel use of nurses in community pharmacies, and if the joint services are designed correctly, they should be an immediate success, and will drive pharmacy services further.

Don't forget that nurses are already accepted and trusted in doctor environments and can break down barriers that exist between doctors and pharmacists.
This has proven to be the case within the hospital, and even though doctors and pharmacists enjoy a mutually respectful relationship within a hospital environment, the nurses are able to go to places pharmacists would never dream of going.

I would also recommend all readers contemplating a plunge into developing nurse driven services, to read Peter Sayers' current article, where he outlines how to develop and manage new services in the total pharmacy environment.
Con Berbatis has pointed the way, and there are a significant number of pharmacists seemingly engaged in nurse-driven services.
Make sure you sign up and capture a share of the vaccine market.
It is certainly a huge market and expanding daily.