Pharmacist Views on Alternative Methods for Antiviral Distribution and Dispensing During an Influenza Pandemic

Abstract

Antiviral drugs are likely to be a frontline countermeasure needed to minimize disease impact during an influenza pandemic. As part of pandemic influenza preparedness efforts, the Centers for Disease Control and Prevention, in coordination with state health departments, has plans in place to distribute and dispense antiviral drugs from public stockpiles. These plans are currently under review and include evaluation of the benefits of commercial distribution and dispensing through community pharmacies. To ensure this alternative distribution and dispensing system is viable, it is critical to assess pharmacist acceptability and to understand the pharmacist perspective on dispensing these antivirals during a response. In this study, we examine community pharmacist reactions to the proposed alternative antiviral distribution and dispensing system using a nationally representative survey of pharmacists. Overall, pharmacists were highly receptive to this alternative system and voiced a willingness to participate personally, and most thought their own pharmacy would participate in such an effort. This was true across pharmacists with different personal and professional backgrounds, as well as those in different pharmacy settings. However, sizable shares of pharmacists said they were worried about facing shortages of the antivirals, the risk of exposure to disease for themselves and their families, managing their usual patients who need their prescriptions filled for medications other than antivirals, keeping order in the pharmacy, and potential liability concerns. These findings should be interpreted as an indication of acceptability of the concept, encouragement for the next steps in alternative distribution and dispensing system design, and a guide to potential barriers that may need to be addressed proactively.

Using a nationally representative survey of community pharmacists, this study examined their reactions to an alternative systemfor distributing and dispensing antivirals through community pharmacies. Overall, pharmacists were highly receptive to the alternative system and voiced a willingness to participate personally, and most thought their own pharmacy would participate in such an effort.

Pandemic influenza poses a significant public health threat to the United States. Since the deadliest outbreak in 1918-19, which caused more than 500,000 deaths in the United States and millions worldwide, there have been 3 influenza pandemics, of which the 2009-10 H1N1 pandemic was most recent.¹ Given the potential for future pandemics to result in substantial morbidity and mortality, pandemic influenza response is a priority for US public health agencies.²

Antiviral drugs are likely to be a frontline countermeasure needed to minimize disease impact at the onset of an influenza pandemic. Antiviral drugs can reduce symptoms of disease, decreasing the number of severe cases and deaths, and can also limit the spread of the illness for viruses susceptible to the drugs.^2,3 Moreover, antivirals can be stockpiled in advance and used as soon as an outbreak occurs. By contrast, a vaccine matched to a novel pandemic virus is unlikely to be available at the beginning of an influenza pandemic. It could take several weeks to months between the time a strain is identified and the time a vaccine is developed and made available in sufficient amounts for widespread distribution.²

As part of pandemic influenza preparedness efforts, the Centers for Disease Control and Prevention (CDC), in coordination with state health departments, has plans in place to distribute and dispense antiviral drugs from public stockpiles.² To date, plans have largely relied on distribution and dispensing through public health agencies, including public health clinics. More recently, alternative planning for antiviral distribution and dispensing has considered the benefits of commercial distribution and dispensing through community pharmacies.^4,5 Such approaches could provide wider reach, greater efficiency, and ultimately quicker access for patients. Quick access could be critical, as antiviral drugs are most effective when taken within 48 hours after symptoms arise.⁶ Further, use of commercial distribution and dispensing systems could reduce strains on a public health system already burdened during a pandemic. Though widespread distribution and dispensing systems that rely on pharmacies are still in planning stages, there were small-scale efforts utilizing commercial pharmacies to dispense stockpiled antivirals during the 2009-10 H1N1 pandemic.⁷ Evaluation of some of these efforts suggests they provided crucial antiviral coverage during the pandemic, and additional measures could be put in place to enhance efficiency in the coverage of hard-to-reach populations.³

Under this alternative distribution and dispensing system, community pharmacists would play a central role in interfacing with the public and dispensing government stockpiles. Therefore, to ensure this alternative distribution and dispensing system is viable, it is critical to assess pharmacist acceptance and to understand the pharmacist perspective on dispensing these antivirals during a response. Pharmacist professional organizations and industry advocates consistently voice support for greater pharmacist involvement in public health emergencies,^8-10 and pharmacies have been taking on a greater role in public health response to seasonal flu with increased provision of vaccine, for example.¹¹ However, there is little research about the views of working pharmacists during an emergency situation, such as an influenza pandemic, where capacity issues or personal concerns may come into play.^12-15 Further, there is no research that we are aware of that focuses on pharmacist reactions to the proposed alternative antiviral distribution and dispensing system specifically.

In this study, we examine community pharmacist reactions to the proposed alternative antiviral distribution and dispensing system using a nationally representative survey of pharmacists. First, we explore pharmacist views on whether they would be willing to participate in the response by providing antiviral drugs from government stockpiles to people who have prescriptions as well as their perceived barriers to participation and possible facilitators. Second, we explore pharmacist views on whether their pharmacy would participate in dispensing antivirals and the volume they think is feasible.

Methods

Researchers at the Harvard T. H. Chan School of Public Health (HSPH) designed and analyzed a poll among a nationally representative sample of 1,076 community pharmacists between February 24 and April 23, 2012. Fieldwork, data management, and statistical analyses were conducted by SSRS (Media, PA). Staff at the National Public Health Information Coalition (NPHIC) and the Centers for Disease Control and Prevention (CDC) provided technical assistance regarding the questionnaire design and interpretation of findings. As HSPH researchers worked exclusively with anonymized datasets, the study was declared “not human subjects research” by HSPH's Office of Human Research Administration.

A randomized sample of pharmacists was drawn from KM Lists' national database, which aims to be a comprehensive list of pharmacists based on state licensing information and is updated at least annually.¹⁶ Invitations were sent via mail, and respondents could participate in the survey by returning the paper copy or by completing the survey online. Potential participants were screened to ensure they met 2 eligibility criteria: (1) that they were actively working in at least 1 community-based pharmacy that serves the public (as opposed to institutional settings like hospitals or nursing homes), and (2) that they personally dispensed prescriptions, defined as “fill, verify, and counsel on prescriptions.” Reminders were sent via mail, and telephone reminders were used when telephone numbers were available. Final data were weighted to ensure that telephone reminders did not skew the distribution of the sample.

The questionnaire included approximately 45 closed-ended questions about pharmacists' views of stockpiled public health supplies of antiviral drugs being provided through pharmacies during an influenza pandemic (see Appendix in Supplementary Material at http://online.liebertpub.com/doi/suppl/10.1089/hs.2017.0068). Questions assessed receptivity to the overall idea, willingness to participate personally, concerns about participation, and views of whether their pharmacy would participate. The description of the alternative distribution and dispensing systems indicated the government would distribute a sizable share of stockpiled antivirals to pharmaceutical distributors and that retail pharmacies would dispense them to the public. Pharmacists were told that the antivirals would be in unit-of-dose packaging and that pharmacies would be able to charge a dispensing fee, though the medication itself would be free to the public. Pharmacists were also assured that “depending on the severity of the pandemic, measures will be recommended to protect you and pharmacy staff from the virus that will reduce the chance you will get ill and thereby reduce the chance you will infect others” (see Appendix). In addition, they were asked questions about the profile of the pharmacy where they worked most often and their past experience working in emergency response.

The questionnaire was developed in part based on a review of studies concerning pharmacist views of health issues, surveys that evaluated acceptability of emergency response measures among other medical professionals, and studies of medical professionals' response to pandemic flu.^17-22 The survey instrument was pre-tested with 6 pharmacists, using cognitive interviews, and minor revisions were made subsequently to enhance comprehension and flow.

The response rate was 26.3%, calculated using the Association for Public Opinion Research's RR3 formula.²³ There are no standardized population parameter estimates for community-based pharmacists who dispense prescriptions, such as a national census of such pharmacists, that could be used to evaluate or weight the data. Therefore, to help assess the validity of the sample and findings, demographic characteristics of the final weighted data were compared to the relevant subset of the most established survey of pharmacists we are aware of, the Pharmacist Workforce Survey (PWS). The PWS is a large-scale regular survey aimed at providing data about the size and demographic features of the pharmacy workforce.²⁴ We compared the sample from our study and the sample meeting the same survey eligibility criteria from the PWS survey in the closest year (2009). On most parameters, respondents to both surveys have similar demographic distributions, though pharmacists in our study were slightly younger and more racially and ethnically diverse (see Appendix).

Analysis began with calculation of the percentage of respondents who provided each response to questions in 3 critical areas: (1) overall receptivity to the concept; (2) pharmacists' views of personal participation, worries about participation, and experiences that could facilitate participation; and (3) pharmacists' views of pharmacy participation and pharmacies' experiences or structural features that could facilitate pharmacy participation.

We then examined whether views of personal participation, worries, or personal facilitators were different among pharmacists with different personal backgrounds (age, gender, race/ethnicity, parental status [defined as having a child under 18 in the household], and marital/partner status [among those without children]) or professional backgrounds (part-time vs full-time status [defined as 35 hours per week or more]) and position: pharmacist (defined as “staff, clinical and dispensing pharmacists, but not the managing pharmacist”) or manager, which included “managing pharmacist” and “district manager” (defined respectively as “director, chief, pharmacist in charge, store level manager, or the pharmacist who is also owner of just one location” and “pharmacists in any management position responsible for more than one store such as the Vice President of Operations, district manager, executive, or a pharmacist who is owner of more than one location”).

Finally, we examined whether views of pharmacy participation and facilitators were different among pharmacists working in different settings: pharmacy with greater or fewer number of prescriptions filled per day; pharmacy serving urban, suburban, or rural patient populations; pharmacy type (defined as traditional chain, supermarket, mass merchandiser, or independent, which includes chain and stand-alone pharmacies).

Differences were tested using all-pairs dependent t-tests and were considered significant using an alpha level of 0.05. All statistically significant differences are shown in the tables, though only significant differences of at least 10 percentage points and in consistent patterns across relevant subgroups were considered to have practical implications for policy and are therefore mentioned in the text. All statistics were calculated using Mentor 3.0.

Results

Demographics, Professional Profile, Pharmacy Setting

About a fifth (19%) of respondents were 35 years old and under, with fairly equal age distribution until age 65; only 11% identified as age 66 or older (Table 1). There was a roughly equal split of men and women (54% men; 46% women), with a majority white (79%). Most were married (81%), and approximately 4 in 10 (39%) were parents with a child under age 18 living in their household.

Table 1.

Personal Demographics, Professional Profile, and Setting of Respondents (n = 1,076)

Characteristic	(%)
Age
35 and under	19
36-45	21
46-55	23
56-65	25
66+	11
Gender
Male	54
Female	46
Race/ethnicity
White (non-Hispanic)	79
Nonwhite and Hispanic (including African American, Asian, and other)	20
Marital/partner status
Married/partnered	81
Not married/partnered	19
Parental status
Children under age 18 currently living in household	39
No children under age 18 currently living in household	59
Hours worked per week
Full-time (35+ hours)	67
Part-time (<35 hours)	33
Position
Pharmacist	60
Managing pharmacist	38
District manager	1
Prescriptions filled per day
Up to 200	41
200+	57
Metro status of population served
Urban	25
Suburban	48
Rural	26
Pharmacy type
Traditional chain	34
Supermarket	20
Mass merchandiser	13
Independent (chain or stand-alone)	37

Note: Blank/no answer responses were 2% or less and are not shown in this table.

Two-thirds of pharmacists (67%) worked full-time. A majority (60%) classified their title as “pharmacist,” while approximately 4 in 10 (38%) identified as “managing pharmacists.” Only 1% identified as “district manager.”

More than half (57%) worked in a pharmacy filling 200 or more prescriptions per day. Nearly half (48%) were in pharmacies that primarily serve suburban communities, with a quarter serving rural or urban areas (26% and 25%, respectively). More than a third worked in independent (37%) or chain (34%) pharmacies, a fifth in supermarket settings (20%), and the smallest fraction in pharmacies that are part of mass merchandisers (13%).

Overall Receptivity

Pharmacists were highly receptive to this alternative distribution and dispensing system as described (Table 2). The vast majority thought it was a good idea (85%) and a good thing for the pharmacist profession (84%). Nearly all agreed it would strengthen the role of pharmacists during public health emergencies (96%) and their relationships with patients (93%). More than three-quarters agreed it would strengthen relationships with their local public health department, their state public health department, and physicians (84%, 78%, and 76%, respectively), though less than half “strongly agreed” this would strengthen relationships with any of these groups (46%, 40%, and 28%, respectively).

Table 2.

Pharmacists' Overall Receptivity (n = 1,076)

Think it would be a good/bad…	Good (%)	Bad (%)	Neither/Don't Know (%)
Idea for the government to distribute antivirals through pharmacies in this way	85	5	10
Thing for the pharmacist profession	84	3	13

Participating in this effort would…	Agree (Net: strongly or somewhat) (%)	Strongly Agree (%)	Somewhat Agree (%)
Strengthen the role of the pharmacists during public health emergencies	96	78	18
Strengthen relationships with patients	93	65	28
Strengthen relationships with your local public health department	84	46	37
Strengthen relationships with your state public health department	78	40	38
Strengthen relationships with physicians	76	28	49

Note: Blank/no answer responses were 1% or less and are not shown in this table.

Personal Participation Predictions

Predictions about personal participation were also high (Table 3). Most pharmacists (81%) favored participating personally in the effort if their own pharmacy were involved. Nearly all (97%) thought they would be likely to come to work for all 12 weeks of the described pandemic, including 91% who said they would be “very likely” to do so. More than three-quarters (79%) thought they would be likely to come for additional shifts at routine pay in order to help address the expected increase in prescription volume, though less than half (46%) said this was “very likely.” The proportion of those saying they would be likely to come rose to 91% (including 67% who said “very likely”) if they were offered higher wages or compensatory time for those shifts. More than three-quarters (79%) also reported they would be comfortable with what might be considered a more challenging aspect of dispensing in a pandemic—distributing antivirals to high-risk groups (as defined by the CDC) in the case of a shortage—though only 39% were “very comfortable” with this task.

Table 3.

Pharmacists' Views of Personal Participation (n = 1,076)

Predictions of Personal Participation
	Favor (%)	Oppose (%)	Neither/Don't Know (%)
Favor/oppose participating in such an effort personally	81	6	14

	Likely (Net: very/somewhat) (%)	Very Likely (%)	Somewhat Likely (%)
Would come to work for your regular hours for all 12 weeks of the outbreak	97	91	6
Would come to work for extended or additional shifts at routine pay rates	79	46	33
Would come for extended or additional shifts if you received a higher pay rate or received comp time for those shifts	91	67	24

	Comfortable (Net: very/somewhat) (%)	Very Comfortable (%)	Somewhat Comfortable (%)
Would be comfortable with only filling prescriptions for those identified as high risk, following CDC guidelines on high-risk groups	79	39	41

Worries About Personal Participation
Would be worried personally about…	Worried (Net: very/somewhat) (%)	Very Worried (%)	Somewhat Worried (%)
Facing shortages of the antivirals that would frustrate patients	81	33	47
The risk of carrying the pandemic influenza back to your family	71	29	41
Your personal exposure to the pandemic influenza virus	59	20	39
Your ability to manage your usual patients who need their prescriptions filled for medications other than antivirals	59	19	40
Problems with keeping order in the pharmacy if many patients expected your pharmacy to carry antivirals	58	16	42
Your personal legal liability serving so many patients in such a short amount of time	57	21	36
Applying a new billing process for reimbursement	45	15	31
Your ability to clinically manage patients who receive antivirals	44	11	33

Possible Facilitators of Personal Participation
	Yes (%)	No (%)	Don't Know (%)
Worked as a pharmacist during the 2009-10 H1N1 pandemic	96	3	0
Served as a pharmacist in any state or regional public health emergency response other than H1N1	2	97	1
Had contact with any staff of your state or local public health department in your capacity as a pharmacist in the past year^a	26	68	5
In the last 5 years, have administered the influenza vaccine to any patients	62	37	0
In the last 5 years, have compounded medication to make it appropriate for children, adults with swallowing problems, or those who need special dosing	78	22	0

“In the past year, in your capacity as a pharmacist, how many times have you had contact with any staff of your state or local public health department?” Yes = once, twice, 3-5 times, 6-10 times, or more than 10, and No = none.

Note: Blank/no answer responses were 1% or less and are not shown in this table.

Support for personal participation was consistently high across pharmacists with different personal and professional backgrounds (see Appendix Table A3-a). Interest peaked in ages 46 to 55 (88%), making interest higher in this group than among those 35 and under (75%) or 36 to 45 (76%). Managers were more likely to favor personal participation compared to those with a “pharmacist” title (87% vs 76%). Predictions that pharmacists would come to work at standard or increased pay were also consistently high; the only notable difference between groups was that the youngest pharmacists were less likely to say they would come to work for extended or additional shifts at routine pay rates. For example, 69% of those 35 and under said this, compared to 85% of those 66 and older.

Worries About Personal Participation

Despite overall support for the idea, sizable fractions of pharmacists said they had worries about the alternative distribution and dispensing system (Table 3). The top worries were that facing shortages of the antivirals would frustrate patients (81%) and the risk of bringing back influenza virus to their families (71%). Fewer, but still more than half, were worried about their own exposure to the influenza virus (59%), managing their usual patients who need prescriptions filled for medications other than antivirals (59%), keeping order in the pharmacy (58%), and their personal legal liability serving so many patients in such a short amount of time (57%). A near majority were worried about applying a new billing process for dispensing fee reimbursements that would be required under the proposed system (45%) and their own ability to clinically manage patients who receive antivirals (44%). Notably, a third or less were “very worried” about any of these challenges.

Across groups of pharmacists with different personal and professional backgrounds, worry levels had a few notable differences (see Appendix Table A3-b). Pharmacists who were parents were more worried about the risk of carrying influenza back to their family than their counterparts (82% vs 62%). However, among those without children, pharmacists who were partnered were not more likely than their single counterparts to say this. In parallel, younger pharmacists tended to be more worried about this than older pharmacists; for example, 84% of those 35 and under were worried compared to 59% of those age 66 and older. A similar pattern was seen with regard to worries about risk of personal exposure, with the addition that more women were worried than men (65% vs 53%).

Younger pharmacists were also more likely to be worried about the ability to manage their usual patients and problems keeping order in the pharmacy: For example, 71% of those 35 and under worried about problems keeping order compared to 43% of those 66 and older. Compared to those in a manager position, those with a “pharmacist” title were also more worried about keeping order (62% vs 52%), as well as being more worried about legal liability (62% vs 49%) and their ability to clinically manage patients who receive antivirals (48% vs 37%). Racial/ethnic minority pharmacists were more concerned about legal liability than were white pharmacists (65% vs 55%). Women were more concerned than men about their ability to manage their usual patients (65% vs 54%) and problems keeping order (64% vs 52%).

Possible Facilitators of Personal Participation

While nearly all pharmacists (96%) had worked during the 2009-10 H1N1 pandemic, almost none (2%) had served in any other public health emergency (Table 3). Further, relatively few pharmacists (26%) had had any contact with their state or local health department in the past year. That said, many pharmacists had had some experiences in the past 5 years that may be helpful for participation in frontline care during an influenza pandemic: Nearly two-thirds (62%) had administered influenza vaccine, and more than three-quarters (78%) had compounded medications for children or adults with swallowing problems or special dosing needs.

More male than female pharmacists and more white than racial/ethnic minority pharmacists had had recent contact with public health agencies (31% vs 21% and 28% vs 18%, respectively) (see Appendix Table A3-c). Younger pharmacists were more likely to have administered the influenza vaccine (81% of those 35 and under vs 31% of those 66 and older, for example), as were racial/ethnic minorities compared to whites (70% vs 60%) and those who work full-time compared to part-time (70% vs 46%). The oldest cohort was less likely to have compounded medications in the past 5 years; 62% of those 66 or older had done this compared to 82% of those 35 and under, for example.

Pharmacy Participation Predictions

Pharmacists' predictions about their own participation were supported by relatively high predictions about their pharmacies' participation (Table 4). Most (82%) thought their own pharmacy would participate in the proposed effort, only 1% said it would not, and 16% said they did not know whether it would. However, pharmacists did have some concerns about their pharmacies' ability to meet the need for higher dispensing volumes. More than a quarter (27%) thought their pharmacy could not handle a prescription increase of 20% for 12 weeks, while 63% thought it could, and 10% said they did not know. Much greater fractions did not think their pharmacies could handle a 50% or 100% surge for 2 to 3 weeks (53% and 72%, respectively).

Table 4.

Pharmacists' Views of Pharmacy Participation (n = 1,076)

Predictions of Pharmacy Participation
	Would (%)	Would Not (%)	Don't Know (%)
Think your pharmacy would participate in such a program if there really were a pandemic influenza outbreak	82	1	16
If your pharmacy had only its routine number of pharmacists, student pharmacist interns, and pharmacy technicians, the pharmacy would be able to handle…
20% more prescriptions—all of which were antivirals—if an outbreak lasted 12 weeks in your community	63	27	10
An increase of 50% more prescriptions—all of which were antivirals—for 2-3 weeks	34	53	13
An increase of 100% more prescriptions—all of which were antivirals—for 2-3 weeks	14	72	13

Possible Facilitators of Pharmacy Participation
	Yes (%)	No (%)	Don't Know (%)
Pharmacy can bring in more pharmacists, student pharmacist interns, and pharmacist technicians	50	28	21
Prior pharmacy participation in an influenza pandemic:
Pharmacy dispensed antivirals during H1N1	77	12	10
Pharmacy received antivirals from public health during H1N1	24	42	11
Structural features and services offered:
Pharmacy has a waiting area	86	14	^*
Pharmacy has a drive-through window	38	61	0
Pharmacy currently provides home delivery	38	61	^*
Pharmacy would provide home delivery in a pandemic	34	37	28

Note: Blank/no answer responses were 1% or less and are not shown in this table.

Equal percentage <0.5.

Across pharmacists working in different settings, predictions about pharmacy participation were consistently high (see Appendix Table A4-a). The only exception was those working in mass-merchandiser settings, who were less likely to feel optimistic (69% vs 86% in chain pharmacies, for example). This discrepancy is partly explained by the fact that many more pharmacists working in mass-merchandiser settings did not know whether the pharmacy would participate (28% vs 14% in chain pharmacies, for example). Those working in pharmacies that currently fill more prescriptions, those working in urban and suburban settings, and all those in settings except independent pharmacies were less optimistic about surge capacity than their relevant counterparts, with similar patterns for surges of 20% and 50%. For example, only 59% and 60% of those in urban and suburban pharmacies, respectively, thought they could handle 20% more prescriptions compared to 75% of those in rural settings.

Possible Facilitators of Pharmacy Participation

Overall, relatively few pharmacists felt that their pharmacies had access to operational supports that could logically facilitate participation (Table 4). To meet the additional demand, only half of pharmacists (50%) thought their pharmacy could bring in more pharmacists, student pharmacist interns, and pharmacist technicians if needed. More than a quarter (28%) thought their pharmacy would not be able to do this, and 21% said they did not know.

The degree to which pharmacies had past experience with antiviral distribution that might make future participation easier was mixed. Many pharmacists (77%) said their pharmacy dispensed antivirals during the 2009-10 H1N1 pandemic; however, only about a quarter of pharmacists (24%) said their pharmacy received antivirals directly from public health agencies.

Few pharmacists identified structural or service features at the pharmacy level that would help limit the crowding of sick patients during a pandemic flu and thus might make it easier or more appealing for pharmacies to participate in the future. While 86% said the pharmacy has a waiting area, only a little more than a third (38%) said they have a drive-through. Further, only 38% said the pharmacy currently offers prescription delivery to people's homes. About the same share (34%) thought their pharmacy would be willing to provide home delivery in a pandemic, though just over a third (37%) thought they would not be willing to, and the remaining fraction (28%) were not sure.

There was some variation in factors that could facilitate participation across pharmacies in different settings (see Appendix Table A4-b). Pharmacists in independent and chain pharmacies were more likely than those in mass-merchandiser settings to have access to more pharmacists, interns, and technicians (56% independent and 52% chain vs 41% mass-merchandiser pharmacies), while size and setting were not related. Those in mass-merchandiser and independent settings were less likely than their counterparts to say their pharmacy dispensed antivirals during the H1N1 pandemic (71% mass merchandiser and 69% independent vs 84% chain and 83% supermarket pharmacies), though part of the difference may be that they were less likely to know whether or not they had. Those in mass-merchandiser and independent settings were more likely to say that they had received antivirals from public health agencies during H1N1 than were their counterparts (11% mass merchandiser and 18% independent vs 31% chain and 30% supermarket pharmacies); the same was true of those in pharmacies filling fewer prescriptions a day (18% up to 200 vs 28% 200 or more).

Structural features and services offered varied by size and setting, with lower reported frequency in mass-merchandiser pharmacies across several metrics (see Appendix Table A4-b). Those in mass-merchandiser pharmacies were less likely to report having a sitting area compared to others (72% vs 95% chain, 84% supermarket, and 84% independent pharmacies), and those in supermarket, mass-merchandiser, and independent pharmacies were less likely to report a drive-through window than those in chains (25%, 18%, and 28% vs 63%, respectively). Those in mass-merchandiser, chain, and supermarket pharmacies were much less likely than those in independent pharmacies to offer home delivery now or in a pandemic; for example, 74% of those in independent pharmacies said they currently provide home delivery, compared to 6% in mass-merchandiser and 23% in chain or supermarket settings. Those in urban and suburban settings were also less likely than their rural counterparts to say their pharmacy currently delivered or would deliver in a pandemic. For example, 47% serving rural patients said their pharmacy currently delivers prescriptions to patients' homes compared to 33% and 39% in suburban and urban settings, respectively.

Discussion

Results from this survey suggest that among community pharmacists there is widespread appeal of the idea of the government stockpile of antiviral drugs being provided through pharmacies in the case of an influenza pandemic as described and a willingness to participate personally. This was true across pharmacists with different personal and professional backgrounds, as well as those in different pharmacy settings. This sentiment is echoed in relatively high predictions of their pharmacies' participation. Pharmacists' enthusiasm is supported by their experience with key aspects of the process, such as compounding medications, and their experience working in frontline care in providing influenza vaccines, which is particularly strong among younger pharmacists. Further, many are comfortable with challenging aspects of the process, such as focusing dispensing on high-risk populations during antiviral shortages when limited supplies may need to be prioritized.

Nonetheless, pharmacists did have worries about participating in the alternative distribution and dispensing system that could pose challenges for operations and would need to be addressed proactively in a roll-out of this concept. For example, pharmacists were worried about antiviral shortages. While shortages may be an unavoidable part of response in certain scenarios, these concerns emphasize the need for clear prioritization protocols to guide antiviral dispensing. The suitability of this approach is underscored by pharmacists' comfort in using prioritization protocols. Pharmacists' concerns about shortages may also be tied to worries about crowd control. Protocols for adding additional staff, such as security personnel, may be helpful in addressing these concerns.

As another critical example, pharmacists, particularly those with children, have substantial concerns about carrying the infection to their family. Such concerns will need to be addressed with policies that provide for protection, such as personal protective equipment (eg, masks) and possible prioritized access to antivirals and vaccine when available. Given that the hypothetical scenario in this study reassures pharmacists that measures will be taken to protect them and their families in turn, pharmacists' worries about becoming personally infected or spreading the infection to their family members may be heightened if these measures are not in place during an actual pandemic. Moreover, pharmacists' overall enthusiasm and willingness to participate in this alternative distribution and dispensing system may be substantially reduced without it. This seems especially likely given other research showing that protection against disease is a critical support in ensuring that healthcare workers, including pharmacists, come to work during an influenza pandemic.¹⁵

To a lesser extent, pharmacists also expressed concerns about operational challenges posed by this alternative distribution and dispensing system, such as having to manage a new billing process or facing personal liability issues, with the latter a particular concern among those who are not managers and racial/ethnic minorities. Working through the administrative side of their participation in advance of the pandemic will be important to ensure that frustrations do not impede participation or dispensing capacity.

Further—and perhaps most fundamental from a practical perspective—pharmacists report limits on their pharmacies' ability to dispense prescriptions at surge levels that could be needed in a pandemic. This is particularly true among larger pharmacies and those in urban and suburban settings, which is concerning given the population density in these settings. Pharmacists also note limits on their pharmacies' ability to provide services like home delivery, which could either expand capacity or help reduce patient crowding—again, particularly in larger pharmacies and those urban and suburban settings as well as mass-merchandiser settings. Notably, the proportion of pharmacies (and health insurers) that provide home delivery benefits and companies that are developing new pharmacy models that use home delivery may have increased since the survey was conducted, decreasing the number of people who may present at a pharmacy.²⁵ Further, while half of pharmacists believe they have access to additional staff if needed, many may be referring to shared staff pools that serve multiple pharmacies in the same area. Thus, they may not practically have access to additional staff if there are surge needs at multiple locations in a specific region. It will be critical to work with pharmacies to develop strategies to increase workflow and improve surge capacity in advance of a pandemic. This could include, for example, identifying bottlenecks in the dispensing process, rebalancing workflow, establishing surge plans for staffing, and adjusting patient movement and areas for triage in a store.

Finally, it is notable that few pharmacists work in pharmacies that had experience with stockpiled antivirals during the 2009-10 H1N1 pandemic, particularly in mass-merchandiser and independent settings. Few had any recent contact with public health agencies, which could include working together on surveillance related to sales of over-the-counter pharmaceuticals (that could inform public health about emergence of a community outbreak of gastrointestinal disease or influenza) or vaccination provision. Such experiences might make it easier for pharmacists to coordinate with or provide communication channels for working relationships between pharmacies and state and local public health agencies needed in the proposed alternative distribution and dispensing system. While contact between pharmacies and public health agencies may have increased since the survey was conducted, the share in this study was so low it is nonetheless concerning. Implementation of an alternative antiviral distribution and dispensing system will require close coordination and communication between public health agencies and pharmacists.²⁶ Therefore, encouraging more communication and cooperation outside of a pandemic may facilitate the kinds of close networks that can support operations in a crisis.

The study has limitations. First, the findings here may not apply to pharmacists who did not respond to the survey invitation, and those who did not respond to a survey may be less likely to be enthusiastic about participating in the proposed alternative distribution and dispensing system. It is worth noting, however, that enthusiasm was high across different subgroups of pharmacists, such as those of different genders and age groups. As these groups are well represented in the study sample, the risk of very disparate findings from the study compared to the larger population may be mitigated.

Second, the findings are from a study conducted in 2012, and positive views could have dropped in the intervening time. This seems unlikely—and enthusiasm may even have grown—given the degree to which pharmacist professional organizations and industry advocates have embraced related initiatives for emergency response.^8-10 That said, real experiences may reduce enthusiasm if the experiences are not positive. It will be important to continue to evaluate pharmacists' responses as participation in other kinds of emergency response increases and opportunity for more frontline care grows, through the rise of mini-clinics, for example.

Finally, responses here are to a hypothetical scenario that may be different from what actually occurs during a pandemic. This includes the assumption in the scenario that, depending on the severity of the pandemic, measures will be recommended to protect pharmacists from getting ill and spreading the virus to others. Pharmacists' concerns and willingness to participate, for example, may not align with findings here if these measures are not in place during an actual pandemic, or if the disease is extremely severe. Multiple studies show findings that emphasize that first responders' willingness to come to work is highly dependent on availability of these protective measures.^15,27 Thus, these findings should be interpreted as an indication of acceptability of the concept, encouragement for the next steps in alternative distribution and dispensing system design, and a guide to potential barriers needing to be addressed before pharmacists are engaged in this alternative process.

Key next steps in this work include further analyzing all of the factors that may affect feasibility and acceptability of this concept, including assessing the public's acceptance of using pharmacies, views of pharmacy executives, legal barriers, and operational considerations. Specific features may need additional evaluation as the concept and practicalities evolve.

Footnotes

Acknowledgments

The authors are grateful for the assistance of Keri Lubell, Sara Roszak, and William Lodge.

References

Centers for Disease Control and Prevention.. Past pandemics. CDC website. Updated November 2, 2017. https://www.cdc.gov/flu/pandemic-resources/basics/past-pandemics.html. Accessed February 27, 2018.

US Department of Health and Human Services.. HHS Pandemic Influenza Plan. Washington, DC: HHS; 2005. https://www.cdc.gov/flu/pdf/professionals/hhspandemicinfluenzaplan.pdf. Accessed February 27, 2018.

Singh

, Huang

, Morton

, et al. Optimizing distribution of pandemic influenza antiviral drugs. Emerg Infect Dis, 2015; 21(2):251-258.

Rubin

, Schulman

, Roszak

, Herrmann

, Patel

, Koonin

. Leveraging partnerships among community pharmacists, pharmacies, and health departments to improve pandemic influenza response. Biosecur Bioterror, 2014; 12(2):76-84.

Fain

, Koonin

, Stoto

, et al. Facilitating access to antiviral medications and information during an influenza pandemic: engaging with the public on possible new strategies. Biosecur Bioterror, 2014; 12(1):8-19.

Fiore

, Fry

, Shay

, Gubareva

, Bresee

, Uyeki

; Centers for Disease Control and Prevention (CDC). Antiviral agents for the treatment and chemoprophylaxis of influenza—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep, 2011; 60(1):1-24.

National Association of County and City Health Officials; Association of State and Territorial Health Officials. Managing Antiviral Medication During the 2009 H1N1 Influenza Pandemic: State and Local Public Health Department Responsibilities. Washington, DC: National Association of County and City Health Officials; Arlington, VA: Association of State and Territorial Health Officials; 2013. http://www.astho.org/Programs/Infectious-Disease/Antiviral-Distribution/Managing-Antiviral-Medication-during-the-2009-H1N1-Influenza-Pandemic/. Accessed February 27, 2018.

Thompson

. HHS redesigns role of pharmacy personnel in disaster preparedness. Am J Health Syst Pharm, 2010; 67(2):99-102.

Woodard

, Bray

, Williams

, Terriff

. Call to action: integrating student pharmacists, faculty, and pharmacy practitioners into emergency preparedness and response. J Am Pharm Assoc, 2010; 50(2):158-164.

10.

Menighan

. Pharmacists have major role in emergency response. Pharmacy Today, 2016; 22(8):8.

11.

Hogue

, Grabenstein

, Foster

, Rothholz

. Pharmacist involvement with immunizations: a decade of professional advancement. J Am Pharm Assoc, 2006; 46(2):168-179.

12.

Pedersen

, Canaday

, Ellis

, et al. Pharmacists' opinions regarding level of involvement in emergency preparedness and response. J Am Pharm Assoc, 2003; 43(6):694-701.

13.

Dearinger

, Howard

, Ingram

, et al. Communication efforts among local health departments and health care professionals during the 2009 H1N1 outbreak. J Public Health Manag Pract, 2011; 17(1):45-51.

14.

Seib

, Gleason

, Richards

, et al. Partners in immunization: 2010 survey examining differences among H1N1 vaccine providers in Washington state. Public Health Rep, 2013; 128(3):198-211.

15.

Stergachis

, Garberson

, Lien

, D'Ambrosio

, Sangaré

, Dold

. Health care workers' ability and willingness to report to work during public health emergencies. Disaster Med Public Health Prep, 2011; 5(4):300-308.

16.

Redi-Data.. State-licensed pharmacists email and postal lists. http://www.redidata.com/wp-content/uploads/2017/05/State-Licensed-Pharmacist-Datacard-lowres.pdf. Accessed February 27, 2018.

17.

Eades

, Ferguson

, O'Carroll

. Public health in community pharmacy: a systematic review of pharmacist and consumer views. BMC Public Health, 2011; 11:582.

18.

Madhavan

, Rosenbluth

, Amonkar

, Borker

, Richards

. Pharmacists and immunizations: a national survey. J Am Pharm Assoc, 2001; 41(1):32-45.

19.

Alexander

, Wynia

. Ready and willing? Physicians' sense of preparedness for bioterrorism. Health Aff (Millwood), 2003; 22(5):189-197.

20.

O'Sullivan

, Dow

, Turner

, et al. Disaster and emergency management: Canadian nurses' perceptions of preparedness on hospital front lines. Prehosp Disaster Med, 2008; 23(3):s11-18.

21.

Morton

, Hsu

, Shah

, Hsieh

, Kirsch

. Pandemic influenza and major disease outbreak preparedness in US emergency departments: a selected survey of emergency health professionals. Am J Disaster Med, 2011; 6(3):187-195.

22.

Paño-Pardo

, Martín-Quirós

, Romero-Gómez

, et al. Perspectives from Spanish infectious diseases professionals on 2009 A(H1N1) influenza: the third half. Clin Microbiol Infect, 2011; 17(6):845-850.

23.

American Association for Public Opinion Research.. Standard Definitions. Final Dispositions of Case Codes and Outcome Rates for Surveys. 9th ed. Oakbrook Terrace, IL: American Association for Public Opinion Research; 2016.

24.

Midwest Pharmacy Workforce Research Consortium.. 2009 National Pharmacist Workforce Survey. Alexandria, VA: Pharmacy Manpower Project, Inc.; 2010.

25.

Gormley

. Capsule corrals $20 million for new pharmacy model. Wall Street Journal May 10, 2017. https://www.wsj.com/articles/capsule-corrals-20-million-for-new-pharmacy-model-1494415800. Accessed February 27, 2018.

26.

Association of State and Territorial Health Officials. Memorandum of understanding for the coordination of a pandemic influenza vaccination campaign in planning for and responding to an influenza pandemic. http://www.astho.org/Programs/Infectious-Disease/Pandemic-Influenza/MOU-Resource-Toolkit/Template-MOU. Accessed December 19, 2017.

27.

Mackler

, Wilkerson

, Cinti

. Will first-responders show up for work during a pandemic? Lessons from a smallpox vaccination survey of paramedics. Disaster Manag Response, 2007; 5(2):45-48.

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