Impact of pharmacist interventions on immunisation uptake: a systematic review and meta-analysis

Figures & data

Figure 1. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow chart for study selection. RCT, randomised controlled trial.

Table 1. Characteristics of studies included in the meta-analysis.

Author and year	Country	Study design	Setting	Pharmacists role	Intervention	Brief detail on intervention	Type(s) of immunisation	Outcome	Duration of interventional practice	Age group	n, intervention/control	Bias assessment
Abu-rish et al., 2021	Jordan	Non-RCT^a	Hospital	Advocator^f	Monitoring system^l	Pharmacists discussed and provided booklet regarding the risk of the disease, the disease transmission, pneumococcal vaccines’ (PPSV23 and PCV13) indications, and possible side effects as per guideline recommendations. Comparison: Usual care	Pneumococcal	Number of vaccine recipients	2 months	≥65	683/844	Moderate risk
Are et al., 2022	United States	Non-RCT^b	Community^c	Immuniser	Monitoring system^k	Pharmacists immunsation authority in different states that are categorised into 3 groups, independent authority, statewide protocol and collaborative practice agreement. Comparison: Without pharmacists immunisation authority	Influenza	Number of vaccine recipients	1 year	≥18	344,126/27,681	Critical risk
Bacci et al., 2019	United States	Non-RCT^a	Community^c	Advocator^i/ Immuniser	Monitoring system^j	A technology system, integrated in the pharmacies workflow that enable proactive checking of the immunisation information system and forecasting of and recommendation to patients about their vaccine needs. Comparison: Usual care	Influenza Pneumococcal Pertussis Herpes zoster	Number of vaccine doses administered	1 year	≥18	84,488/84,488	Moderate risk
Bayraktar-Ekincioglu et al., 2022	Turkey	Non-RCT^a	Community^e	Advocator^f	Monitoring system^l	Pharmacists provide education to participants regarding vaccines. Comparison: Usual care	Pneumococcal Herpes zoster	Number of vaccine recipients	6 months	≥50	122/249	Serious risk
Cebollero et al., 2020	United States	Non-RCT^a	Community^d	Advocator^f,g,h,i,m /Immuniser	Monitoring system^l	Pharmacists ensure stock availability, promoting,screening, vaccine administration,education, creation of vaccine workflow for HCP with daily and weekly support visits. Comparison: Usual care	Human papillomavirus	Number of vaccine doses administered	2 months	18–26	80/241	Serious risk
Deslandes et al., 2020	United Kingdom	Non-RCT^b	Community^c	Immuniser	Monitoring system^l	Pharmacists invlovement in NHS Seasonal Flu Vaccination programe as immuniser. Comparison: Vaccination administered by CPs during 6 flu seasons and vaccination administered in other facilites (GP, etc.)	Influenza	Number of vaccine recipients	6 years	≥18	635,957/552,966	Critical risk
Fathima et al., 2021	Australia	Non-RCT^a	Community^c	Advocator^f,i	Monitoring system^l	Consultant pharmacists provided referrals to GP for patients who had overdue vaccinations for influenza and pneumonia at visit 1 (baseline) and prompt the patient for immunisation at visti 2 and 3. Comparison: Usual care	Influenza Pneumococcal	Number of vaccine recipients	6 months	40–80	27/37	Serious risk
Gatwood et al., 2022	United States	Non-RCT^a	Community^c	Advocator^i/Immuniser	Monitoring system^j	A record system (code) able to detect first dose and provide alert for second dose adminisration (at least 8 weeks post 1st dose). The alert will be notified untill 2nd dose is given or after 6 months. The alert prompt pharmacist to call patients for the second dose. Comparison: Usual care	Herpes zoster	Number of vaccine doses administered	8 months	≥50	71,459/41,982	Moderate risk
Goldsworthy et al., 2022	United States	Non-RCT^a	Community^d	Advocator^f,i	Monitoring system^l	Pharmacists provided telephone outreach programe in assesing vaccination assesment, answer frequently asked questions, address common concern and facilitate vaccine administration. Comparison: Usual care	Pneumococcal Influenza	Number of vaccine recipients	2 months	≥19	398/1591	Low risk
Goode et al., 2023	United States	Non-RCT^a	Community^d	Advocator^f,g,h	Monitoring system^l	A lead champion (pharmacist) to oversee the programe. Healthcare team (includes pharmacist) were responsible for promoting influenza vaccines, providing staff education and supporting new clinic procedures Comparison:Usual care	Influenza	Number of vaccine recipients	4 months	≥18	2623/2885	Moderate risk
Heaton et al., 2022	United States	RCT	Community^c	Advocator^i/Immuniser	Monitoring system^j	A technology system that enable pharmacists to query on patients immunisation records from any states immunisation information system to identify vaccine recommendations. Comparison: No intervention	Influenza Pneumococcal Herpes zoster Td/Tdap	Number of vaccine doses administered	3 months	≥19	16,841/17,062	Some concerns
Howe et al., 2022	New Zealand	Non-RCT^a	Community^c	Advocator^i/Immuniser	Monitoring system^n	Funding and promoting pertussis vaccines in pregnancy in pharmacies in between 3 regions (intervention). Comparison: Usual care	Tdap	Number of vaccine doses administered	3 years	12–50	11,748/3581	Low risk
Klassing et al., 2018	United States	RCT	Community^c	Advocator^f,i	Monitoring system^l	Particpants randomised to 3 arms phone call, mailed, and no intervention. Both phone call and letter referenced the 2014 CDC immunisation schedule and guidelines. Comparison: No intervention	Influenza Pneumococcal	Number of vaccine recipients	1 month	≥18	280/140	Some concerns
Ozdemir et al., 2023	Turkey	RCT	Institution	Advocator^f,i	Monitoring system^l	Pharmacist provide face to face education on vaccine. Comparison: Usual care	Pneumococcal	Number of vaccine recipients	3 months	≥18	114/107	High risk
Page et al., 2020	United States	Non-RCT^b	Community^c	Advocator^i/Immuniser	Monitoring system^l	Pharmacist identify patients diagnosed with diabetes and is without history of vaccination. Pharmacists educated and recommended that the patient receive the vaccine. Comparison: Usual care	Pneumococcal	Number of vaccine recipients	4 months	≥19	68/351	Serious risk
Rihtarchik et al., 2018	United States	Non-RCT^a	Hospital	Advocator^,^i	Monitoring system^j	Pharmacy driven electronic tracking system that allows pharmacists to document and use tracking tools within the EMR to ensure appropriate vaccinations were administered to asplenic patient. Comparison: Usual care	Pneumococcal Meningococcal Haemophilus influenza type B	Number of vaccine doses administered	2 years	≥18	119/242	Moderate risk
Scherrer et al., 2020	United States	Non-RCT^a	Hospital	Advocator^f,i	Monitoring system^l	Pharmacists provide post-splenectomy counselling that describes the recommended vaccinations and their importance in disease prevention.Patients are provided with handouts contains information on vaccines. Comparison: Usual care	Pneumococcal Meningococcal ACWY Meningococcal serogroup B	Number of vaccine doses administered	6 months	≥18	31/95	Moderate risk
Stolpe & Choudhry, 2019	United States	RCT	Community^c	Immuniser	Monitoring system^j	A vaccination prompt system was used to inform patients, that they are scheduled to receive and offered either pneumococcal vaccine, herpes zoster vaccine, or both. If patient accepted a notification will be relayed to the pharmacists. Comparison: No intervention	Pneumococcal Herpes zoster	Number of vaccine doses administered	10 months	≥65	11,009/10,962	Some concerns
Villaverde Piñeiro et al., 2022	Spain	Non-RCT^b	Hospital	Advocator^f,i	Monitoring system^l	Cohort A (hospital A& intervention) received phone call from pharmacists and nurses on importance of influenza vaccination, gave campaign dates, and directions on how to arrange an appointment for the vaccine to be administered. Comparions: Cohort B (hospital B) no intervention	Influenza	Number of vaccine recipients	1 month	≥65	148/207	Moderate risk

RCT, randomised controlled/clinical trial; dTap, tetanus, diphtheria, pertussis; Td, tetanus, diphtheria.

Non-RCT: ^aBefore & after, ^bCohort/longitudinal with minimum two groups.

Community: ^cComunity pharmacy, ^dPrimary healthcare clinics, ^eCommunity centre.

Advocator: ^fEducation, ^gTraining, ^hCampaign, ⁱRecruitment, ^mStocking vaccine.

Monitoring system: ^jTechnology based, ^kState law regulations, ^lQuality improvement programme, ⁿFunding.

Figure 2. A detailed description of the ROB assessment for RCTs.

Figure 3. Summary plot of ROB assessment for RCTs.

Figure 4. A detailed description of the ROB assessment for non-RCTs.

Figure 5. Summary plot of ROB assessment for non-RCTs.

Table 2. Summary of analyses of the impact of pharmacist interventions on immunisation uptake.

Study (author, year)	Risk ratio (95% confidence interval), inverse variance, random effect
Abu-rish et al., 2021	1.03 [0.86, 1.23]
Are et al., 2022	0.98 [0.97, 0.99]
Bacci et al., 2019	1.20 [1.19, 1.21]
Bayraktar-Ekincioglu et al., 2022	0.18 [0.09, 0.37]
Cebollero et al., 2020	1.44 [1.05, 1.99]
Deslandes et al., 2020	20.10 [19.11, 21.13]
Fathima et al., 2021	1.73 [1.23, 2.43]
Gatwood et al., 2022	1.05 [1.04, 1.05]
Goldsworthy et al., 2022	1.99 [1.76, 2.25]
Goode et al., 2023	1.56 [1.46, 1.67]
Heaton et al., 2022	1.19 [1.11, 1.27]
Howe et al., 2022	1.01 [0.99, 1.03]
Klassing et al., 2018	0.68 [0.52, 0.89]
Ozdemir et al., 2023	3.29 [1.47, 7.35]
Page et al., 2020	1.11 [0.79, 1.55]
Rihtarchik et al., 2018	1.35 [0.94, 1.96]
Scherrer et al., 2020	5.04 [2.14, 11.87]
Stolpe & Choudhry, 2019	1.04 [0.87, 1.25]
Villaverde Piñeiro et al., 2022	5.31 [2.74, 10.32]
Pooled RR: 1.51 [1.28, 1.77] Heterogeneity: τ^2 = 0.10; χ^2 = 14230.16, df = 18 (P < 0.00001); I² = 100% Test for overall effect: Z = 4.99 (P < 0.00001)

Figure 6. Overall impact of pharmacist’s involvement on immunisation uptake.

Figure 7. Subgroup analysis on the impact of pharmacist intervention on immunisation uptake according to their roles as immunisers, advocators, or both.

Figure 8. Subgroup analysis of the impact of pharmacist interventions on immunisation uptake according to setting (hospital, community, or institution).

Figure 9. Funnel plot demonstrating the presence of publication bias (overall effect size).

Figure 10. Funnel plot demonstrating the presence of publication bias (subgroup analysis of pharmacist roles).

Figure 11. Funnel plot demonstrating the presence of publication bias (subgroup analysis of study setting).

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Data availability statement

The data that support the findings of this study are available in the supplementary material section of this article.