Enlarging Access to Vaccination in Italy According to the Citizens and the Pharmacists’ Perspective

In light of the ongoing COVID-19 pandemic, it has become even more important than ever to continue routine vaccinations in order to protect the population from vaccine-preventable diseases and safeguard the sustainability of our healthcare systems. Building resilient health and immunisation systems and improving access to vaccination become essential in the context of COVID-19. To achieve this objective, all possible efforts should be made to engage all healthcare providers as each of the actors in the vaccines ecosystem contributes to strengthening the resilience of the immunisation system. 

For example, community pharmacists are part of the healthcare professionals with the ability to deliver vaccination services conveniently, competently and safely to citizens. Pharmacy based immunization has already been implemented in numerous countries in Europe, such as the United Kingdom (2002), Portugal (2007), Ireland (2011), and more recently France (2019) and has been proved to be an effective measure in increasing VCR, with a high level of satisfaction from the population. In example, pharmacy-based immunization has led to a global rise in influenza vaccination in the UK and Ireland where 20 and 23%, respectively, of the patients receiving pharmacist-delivered vaccination were vaccinated for the first time [1]. On the possibility of introducing also in Italy, as it already occurs in other European countries, a civic survey realized in Italy along 2020 by Cittadinanzattiva shows that about the chance of carrying out vaccinations and serological testing in pharmacies, 66.4% of pharmacists would be favourable, in particular for the flu vaccination (99%) and the anti-Covid-19 vaccination (77.4%). Specifically, 66.2% of pharmacies claim to be available also to carry out serological testing for Covid-19. For their part, citizens are in favour (in 63% of cases) of the possibility of getting vaccinated in pharmacies as well as getting serological testing (an option that collects as much as 77.6% of positive opinions). Data and suggestions have been taken into consideration by the Institutions in charge to define and implement the national immunization plan across the country; in fact, during the second half of March 2021 the Italian Government announced the future administering of vaccines by adequately trained pharmacists.

Methodological note

The Civic Evaluation Agency [2] of Cittadinanzattiva prepared a survey, in 2020, aimed at pharmacies and a survey aimed at citizens. Data collection began at the end of July 2020 and ended in mid-October 2020. The 633 pharmacies that contributed to the annual survey are mainly located in northern Italy, in fact, 56% of the answers come from only 4 regions: Piedmont, Emilia Romagna, Lombardy, Veneto. While the territories of Trentino Alto Adige, Abruzzo, Molise and Val d’Aosta are scarcely represented. Almost 40% of the pharmacies involved are located in a subsidized rural or rural area, 17.4% within an area declared “red” during the pandemic (fig.1).

 Fig.1: Source: Third edition of the Annual Report on Pharmacies, Cittadinanzattiva, 2020

The origin of the 664 citizens who responded to the survey results to be more balanced, compared to the data related to pharmacies, since the most represented regions are, in the order, Campania, Lombardy, Piedmont, and Lazio. Among the poorly represented territories, we find again Valle d’Aosta, Trentino Alto Adige and Molise, followed by Basilicata. Most of the respondents were women (56.5%), while the most represented age groups are 51-63 years (30%), followed by 64-74 years (28.6%) and 31-50 years (24.5%). Basically, in 80% of cases, the citizens who responded come from non-rural and not declared “red areas” during the emergency (fig.2). 

Fig.2: Source: Third edition of the Annual Report on Pharmacies, Cittadinanzattiva, 2020

Values and limits of this work 

The collected data does not claim to represent a scientifically representative statistical sample; however, this does not reduce the value of the monitoring and analysis process carried out. In fact, the survey itself can be considered indicative of the most relevant issues among those under investigation, and sufficient to develop proposals aimed at strengthening the role of the Pharmacy in its ability to respond to the social and health needs of citizens in the context of the Covid-19 emergency. For more details on the project, please refer to the relevant webpage [3].

The ongoing crisis has reopened the debate on the competencies of the operators and professionals who work in the field of health. In Italy it might have come the time for the National Health System to plainly discuss major tasks, for example for nurses and pharmacists. Concretely, a pharmacist administers vaccines in pharmacy, in several countries of the European Union. Facing the possibility of introducing in Italy a similar service, 66.4% of pharmacists would be favourable compared to 21.3% who are against it. The pharmacists in favour of the vaccinations in pharmacy believe it possible to involve their category in the anti-flu vaccination (99%), while less favourable is the option on other vaccinations (46.2%). On the contrary, there seems to be more openness towards the option of a vaccination anti-Covid-19 (77.4%). Not by chance, 66.2% of the pharmacies claim to be also available for the administering of serological testing for Covid-19 (fig.3). 

 Fig.3. Source: Third edition of the Annual Report on Pharmacies, Cittadinanzattiva, 2020 

The pharmacists, who are in favour of introducing vaccinations in pharmacy, underline some essential pre-conditions to satisfy so that this could become reality. Among these, in order of priority, there are:

1) Introducing adequate guarantees for the pharmacist through a change of the law in force, in order to define clear rules on the roles/ competencies as well as on civil/ criminal responsibilities (e.g., abuse of medical profession in the injection process, etc.).

2) Adequate risk insurance.

3) Education (e.g., theoretical and practical courses of qualification, Continuing Medical Education courses, support period/coaching).

4) Protocols with other professional figures/ health facilities (e.g., management of adverse reactions; access to the vaccination register, etc.).

5) Suitable environment/ certification of the premises.

6) Adequate information and communication campaigns addressed to citizens. 

Moving from words to deeds will be a long process for every single pharmacy too. Upon the occurrence of necessary and desired preconditions, the pharmacies that believe to be ready are 66.2% of those who answered to the survey. For their part, citizens are in favour (in 63% of cases) of the possibility of getting vaccinated in pharmacies as well as getting serological testing (an option that collects as much as 77.6% of positive opinions) (fig.4).

Fig.4. Source: Third edition of the Annual Report on Pharmacies, Cittadinanzattiva, 2020

In Italy, the pandemic has particularly highlighted the fragility of an unbalanced system in the hospital field with respect to territorial assistance, whose strengthening can no longer be deferred, starting from the new organizational models to which we all should contribute. In this regard, there is the urgent need to trace and carry out new scenarios for our National Health Service. In particular, concerning the active role of pharmacies in opposing the spread of Covid-19, Cittadinanzattiva - together with Federfarma – agree about:

• • The possibility of carrying out serological testing and rapid swabs in the pharmacy or through the pharmacy, also in the sight of interesting local experiences that could embrace the entire national territory, in order to lighten the organizational burdens depending on public structures, obviously guaranteeing the highest levels of security through specific protocols;
• • The involvement of pharmacies in vaccination campaigns, starting from the anti-influenza and anti-pneumococcal one. In this field as well, as it occurs in other countries, focusing on pharmacies would contribute to maximizing vaccination coverage in our country. The pharmacy network makes itself available to give its contribution also in this area, with the necessary security guarantees for everyone. It is desirable that the institutions seize this availability and adequately exploit the pharmacies’ network’s potentialities, creating a synergy with other operators, with a view to the complementarity of roles, inter-professional collaboration, enhancement of each one’s specificities and strengths.

The agreement upon these proposals would contribute- through a service offered by pharmacies in the entire national territory, from the areas most affected by the virus to the internal areas- to lessening inequalities that, in health care, still characterize Italy, and risk to be notably amplified due to the emergency context we are experiencing. Also, for this reason, Cittadinanzattiva welcome the decisions adopted in March 2021 by the national government: pharmacists, properly trained e after obtaining consent, will have the possibility to carry out vaccinations in pharmacies, excluding doctors’ supervision. This possibility is allowed upon stipulation of specific agreements with the trade union organizations representing pharmacies after consultation with the competent professional order. As part of the aforementioned agreements, it will be necessary to regulate also the aspects related to the minimum structural requirements of the premises for the administration of vaccines, as well as the appropriate measures to guarantee patients’ safety [4].

This kind of decisions represents one of the various concrete examples whereby institutions and other actors attempted to oppose the Covid-19 pandemic. Experiences that will be presented and discussed during the XV edition of the European Patients’ Rights Day, organized on May 5^th-6^th 2021 by the European branch of Cittadinanzattiva, Active Citizenship Network, focused on valuing the role of civic society and Patients Advocacy Groups for more resilient Health Care Systems.

HCPs: Health Care Professionals

NHS: National Health Service

PAGs: Patients Advocacy Groups

VCR: Vaccination Coverage Rate

All data shown in the present article comes from a broader civic survey, summarised in the “Third Edition of the Annual Report on Pharmacies”, realised in Italy along 2020 by the Civic Evaluation Agency of Cittadinanzattiva with the collaboration of Federfarma and the Teva’s unconditional contribution.

The authors whose names are least in the first page declare that they do not have any conflict of interest.

Each of the authors confirms that this manuscript has not been previously published and is not currently under consideration by any other journal. Additionally, all of the authors have approved the contents of this paper and have agreed to the Journal of Vaccines Research & Vaccination’s submission policies.