**3. Results**

#### *3.1. Board of Pharmacy Survey Results*

Of the 50 states and the District of Columbia polled, 22 (43%) states successfully completed the survey. State boards of pharmacy who finished the survey included the following: Arizona, Hawaii, Idaho, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oregon, Rhode Island, Texas, Vermont, Virginia, Washington and Washington D.C. One state submitted past the 6th November deadline (submitted 9th November). Of the states responding, 16 (72%) reported that there were statutes (state legistlation, public health code ... etc.) that prohibit pharmacists from delegating the task of vaccine administration to a properly trained pharmacy technician. For the similar question regarding regulation, 13 (59%) states reported prohibition via rule. Eight (36%) respondent states answered "yes" to if there had been any discussion from their board on this topic to date. Table A3 in Appendix A outlines a few selected free responses from the survey. For both question eight and question nine of the survey, six (27%) of the

responding states gave an answer equivalent to "no comment". When asked about initial impressions in question eight, 17 (77%) free responses were recorded. In question nine, when asked about risks, 15 free responses were recorded (68%). All 22 states (100%) provided statute or regulation citation when required. Overall, there were also multiple free responses that respondents declined to answer or did not directly answer the question(s). For those purposes, Table A3 includes free responses that were thought provoking and/or provided insight based on the question asked.

**Figure 1.** Manual Review Search Protocol.

#### *3.2. Peer-Review Classification Results*

The following data was collected per protocol from all 50 states and D.C.: overall, one (2%) state was found to be Permissive, 21 (41%) states were classified as Prohibited Directly, 20 (39%) states were classified as Prohibited Indirectly, and nine (17%) states were classified as Not Expressly Prohibited. The above classification considered both statute and regulation and the stricter of the two findings per state (including D.C.). Regarding statute only, zero (0%) states were found to be Permissive, 11 (21%) states were classified as Prohibited Directly, 15 (29%) were classified as Prohibited Indirectly, and 25 (49%) of states were classified as Not Expressly Prohibited. When regulations were examined, 1 (2%) state was classified as Permissive, 14 (27%) states were found to be Prohibited Directly, 23 (45%) states were classified as Prohibited Indirectly, and 13 (25%) were classified as Not Expressly Prohibited. See Figure 2 for a graphical representation of the data. To further provide examples of how the categorization occurred, selected examples that were most transparent are provided below.

**Figure 2.** State Categorization (including D.C.).

Rhode Island, being the only state to expressly permit pharmacy technicians to administer immunizations within rules, is the example of a Permissive state. Statute contains no explicit prohibitions when examining the definitions of "pharmacist" or "pharmacy technician" and includes the following definition of "practice of pharmacy" found in RI Gen L 5-19.1-2(x): "Practice of pharmacy...includes...administration of adult immunizations in accordance with regulations and training requirements promulgated by the department of health" [15]. Considering regulation, administrative code 216-RICR-40-15-1.11 (8, b.) outlines "A technician II who has completed a recognized certificate training course on appropriate immunization administration technique and holds a current basic cardiopulmonary resuscitation (CPR) training certificate, shall be permitted to administer vaccinations under the direct supervision and with the authorization of an immunizing pharmacist ... " [16]. Rhode Island's responses to the survey also indicated answers of "no" to questions two and four. The above language is an example of Permissive categorization.

South Carolina provides example of a state in which pharmacy technicians are Prohibited Directly. Within statutes, Section 40-43-190 (B,3) clearly prohibits with the following language: "A pharmacist may not delegate the administration of vaccines to a pharmacy technician or certified pharmacy technician" [17]. Seeing that a majority of pertinent language relating to pharmacy technicians or

vaccines are within statute, there were no prohibitions found within regulations, therefore deeming Not Expressly Prohibited. Interestingly, prohibition is further reinforced through the Pharmacy Policies and Procedures document within Approved Technician Duties Policy and Procedure #140 which states "The pharmacy technician is prohibited from performing the following functions:...administering immunizations" [18]. Although no clear indication, authors assumed Policy #140 is referring back to Section 40-43-190 (B,3), as the document often cited other specific statutes. South Carolina additionally prohibits technician immunization through language within statewide protocol: "A pharmacist may not delegate the administration of vaccines to a pharmacy technician ... " [19]. According to survey results, South Carolina started a response but failed to complete the survey, therefore there was no data to reconcile during the peer review process. As documented in South Carolina law, this state was categorized as Prohibited Directly.

North Carolina illustrates the Prohibited Indirectly category. NC Gen Stat § 90-85.3.i1 outlines that "'Immunizing pharmacist' means a licensed pharmacist who meets all of the following qualifications.[lists qualifications]" [20]. This statute does not implicitly disallow pharmacy technicians, ye<sup>t</sup> it does specifically list a pharmacist. Regulations in North Carolina also provided Prohibited Indirectly language as seen in 21 NCAC 46.2507: Administration of Vaccines by Pharmacists with "A) an Immunizing Pharmacist or a Pharmacy Intern who is under the direct, in-person supervision of an Immunizing Pharmacist;" [21]. It is worth noting that while pharmacy technicians may be technically prohibited via exclusion, a regulatory artifact exists that permits "(B) the patient at the direction of either an Immunizing Pharmacist or a health care provider" to administer their own immunization [21]. This indicates that a pharmacist or other healthcare professional may teach a layperson to administer their own vaccine, ye<sup>t</sup> a trained pharmacy technician may not qualify. Because of the lack of specific prohibition of pharmacy technician immunization administration combined with the explicit listing of those who can administer, North Carolina was classified as Prohibited Indirectly.

Idaho was found to be an example of Not Expressly Prohibited categorization, being that pharmacy technician immunization was not defined within their statute or regulation per the protocol defined. In both statutes ID Code 54-1704 and regulations IDAPA Rule 27.01.01.100 no mention was made to pharmacy technicians being able, or unable, to provide immunization administration [22–24]. Rather within 27.01.01.100, it states "To evaluate whether a specific act is within the scope of pharmacy practice in or into Idaho, or whether an act can be delegated to other individuals under their supervision, a licensee or registrant of the Board must independently determine whether: ... " and then lists a few lines of guidance. According to survey results, Idaho also answered questions two and four with "no", indicating similarities with peer review findings.

Only one state was found to be categorized as Permissive (Rhode Island), which both the survey and peer-reviewed classification agreed upon. A total of 41 states (80%) were classified as Prohibited Directly or Prohibited Indirectly through statute or regulation. This finding was not surprising considering the minority of states (three) in which pharmacy technicians currently can administer immunizations [8–11]. The remaining two states (Idaho, Utah) which currently have pharmacy technician administration of immunizations are classified as Not Expressly Prohibited. This peer-review classification was in agreemen<sup>t</sup> with the results from the Idaho Board of Pharmacy survey. Utah board survey data was unavailable.

#### *3.3. Comparison of Survey to Peer-Review*

When comparing survey respondent states to their collected peer-review data, the authors were in agreemen<sup>t</sup> with the state board of pharmacy 16 out of 22 times (73%) regarding statutes. When comparing data for regulation, the authors were in agreemen<sup>t</sup> with survey respondents 16 out of 22 times (73%). Of the disagreements, the authors disagreed with the categorization of both statute and regulation with four states of the 22 states who completed the survey. Four state board survey findings (Kentucky, Louisiana, Minnesota, and Washington) were misaligned with the results from the peer-reviewed classification. Of note, three of these states (Kentucky, Minnesota, and Washington) reported board survey information that was more conservative (i.e., the authors found their state to be Not Expressly Prohibited rather than Prohibited Indirectly) than the peer-review classification, while Louisiana reported a more liberal interpretation (i.e., the authors found their state to be Prohibited Indirectly rather than Not Expressly Prohibited) than the peer-review classification. An encompassing state-specific compilation of both survey results and peer-reviewed classifications complete with rationale is available in Table A4 in Appendix A.
