**4. Discussion**

The vision for the project was to be eventually used as a tool for all interested parties. Stakeholders may consider findings, elicit discussion, and spread awareness across the nation in the future. State agencies or other stakeholders may enter discussions on the topic and want to better understand the landscape of laws from a national overview. This project does not serve as legal interpretation or was not meant to be misinformed or misconstrued as so.

As mentioned prior, three states, Idaho, Rhode Island, and Utah have expanded practice by making regulatory or protocol changes. From the federal level, the Commissioned Corps of the U.S. Public Health Service announced that credentialed pharmacists have the chance to provide federal pharmacy technicians an opportunity to obtain training to administer vaccines [24]. In Whiteriver, Arizona within the Indian Hospital, pharmacy technicians have administered vaccines to patients of all ages (including children) with oversight from a federal pharmacist [25]. With change on the horizon and precedent set, investigation and categorization of laws in other states were identified as gap areas within published literature.

The topic itself does not lend to an array of literature examples or studies to draw from, therefore this presents as a novel area to provide insight. A comparator study would be the 2015 study by Stewart and colleagues which examined the state laws and standing orders for immunization services. Within this study, authors did not examine pharmacy technicians specifically, but looked more broadly at non-physician health professionals. Interestingly, it was found that medical assistants (comparable to pharmacy technicians in training, education, and roles) had delegated authority to administer vaccines in fourteen (14 ) states, own authority in one (1) state and laws were silent within thirty-six (36) states and D.C. [13]. State laws also varied, but a general trend noted was that physicians are able to delegate the task of vaccine administration to medical assistants in many states. The study by Stewart and colleagues had conceptual similarities but did not endure a triangulation peer review methodology. Of note, training and education requirements of medical assistants and pharmacy technicians also vary from state to state, which can make it challenging to argue that education requirements are mandatory for one to succeed outside of a training program designed specifically for the task.

When considering the topic of pharmacy technician administered vaccines within law, there arose a few theme areas investigators identified for state agencies and others to consider after completion of data analysis and discussing results. One area includes the training requirements and availability of a training program. McKeirnan et al. and Washington State University (WSU) developed a training program that is specific for pharmacy technicians [26]. The program was designed to be less time intensive or in-depth (2-hour self-study, 4 hour live) compared to the pharmacist/student program (~20 hours) with a clear separation of the technical versus clinical aspects of vaccine administration [27]. There have also been speculations as to if the WSU program has been recently acquired by a national association and may soon be featured as a nationally recognized program.

The second theme to consider includes the platform by which changes would need to occur. Would the state require rule promulgation or amendments, a statute change, or both? Are amendments to statewide protocols or collaborative practice agreements needed? Maybe a state currently has no true prohibitions and it may be up to employers to kickstart the practice model? While there were (9) states identified in the categorization of Not Expressly Prohibited, readily available opportunities may exist to begin implementation of technician vaccine administration within these states. It serves important for stakeholders to work closely with state agencies, boards, and others on moving initiatives

forward. If rules or statutes need to be amended or changed, states could also consider utilizing a pharmacist delegatory model. This model would allow for pharmacists to use professional judgement to delegate technical tasks such as immunization administration to support personnel. Similar to physician, optometry, or dentistry models, it may enable pharmacists to practice and manage their practices at a level that may be conducive to the public and patient safety. This model also supports the recent NABP Task Force developed to investigate moving pharmacy to a "Standard of Care" model [28]. To continue to evolve, the profession of pharmacy must evolve as a team and utilize teamwork to provide patient care that is safe and e ffective.

A third and final theme to consider involves fears and emotions that arise when considering any type of changes. Atkinson et al. describes in depth the typical fears and emotions brought up whenever having discussions on the topic as deliberated in initial discussions in Idaho [29]. Many points of concern highlighted within Atkinson et al. are theories based on precautionary principle, and lack evidence to support rationale. To properly evaluate the topic, it is crucial to consider what concerns are present, but to not let theories supersede and prohibit positive public health initiatives backed by evidence. Within the survey, when asked about safety concerns or risks, comments trended towards being majorly positive on the topic. Boards mentioned key phrases such as "with the same training", "if properly trained" or "just as untrained lay persons have", indicating a sense that proper training is key. A minority of respondents mentioned phrases such as "clinical education", "clinical judgement", or "the medical community may not be accepting". Therein lies the di fferentiation of clinical versus technical knowledge and roles. McKeirnan et al. demonstrated safety data which showcased 953 immunizations delivered by technicians with zero adverse events [26]. Three other studies, Burgess et al., Zahn et al., and Coleman et al. all demonstrated that even laypersons exhibited positive safety data when taught to administer their own vaccines [30–32]. Bertsch et al. surveyed pharmacists who supervise immunizing technicians and showed that opinions revealed positive morale of teams and can help to increase the number of vaccinations given by the pharmacy [33]. Not only has this practice shown safe data, but also has demonstrated another route to increasing public access to vaccines, a highly impactful public health initiative. Similar fears or emotions often arise when other expanded roles of pharmacy technicians are discussed. Within other well studied roles such as Technician Product Verification (Tech-Check-Tech), Verbals, Transfers, Clarifications, or, Point of Care Testing, evidence suggests similar a ffirmations around positive safety data and historical success in various jurisdictions for over 40 years for some roles [34–39].

Findings from the manual scanning of all states may have been subject to investigator expectations. Naturally, a majority of states were expected to include language that directly or indirectly may prohibit pharmacy technicians from administering immunizations. The survey responses helped to provide investigators with a comparator for the manual survey. Seeing that all states did not participate in the survey, this is an obvious limitation. Another limitation was the search protocol may not have encompassed all possible language included in regulations or statutes. While the protocol was designed to include as many relevant keywords or areas as possible, there was a chance that areas may have been missed. Free responses provide a snapshot of thoughts, discussions, and considerations by various boards across the country. Overall, respondents seemed to showcase the notion that the topic has been of interest or brought up, therefore validating that law changes or continued discussions may come in the near future.
