Background: Although legislation permits New Brunswick pharmacy professionals to administer a wide range of immunizations, public funding for these services is currently limited to immunizations against influenza and COVID-19 and was recently extended to include pneumococcal immunization (Pneu23) in individuals aged 65 years or older. We used administrative data to project health and economic outcomes associated with the current Pneu23 program and with extension of public funding to include: 1) younger adults aged 19 years or older in the Pneu23 program, and 2) tetanus boosters (Td/Tdap). Methods: Two model scenarios were compared: a Physician-Only model in which physicians remain the only practitioners to administer publicly funded Pneu23 and Td/Tdap, and a Blended model in which this service is also provided by pharmacy professionals. Immunization rates by practitioner type were projected based on physician billing data accessed via the New Brunswick Institute for Research, Data and Training in conjunction with trends observed with influenza immunization by pharmacists. These projections were used along with published data to estimate health and economic outcomes under each model. Results: Public funding of Pneu23 (65+), Pneu23 (19+) and Td/Tdap (19+) administration by pharmacy professionals is projected to yield increased immunization rates and physician time savings compared with the Physician-Only model. Public funding of Pneu23 and Td/Tdap administration by pharmacy professionals in those aged ≥19 years would result in cost savings, owing primarily to productivity losses avoided in the working age population. Discussion: Increased immunization rates, physician time savings and cost savings may be realized if public funding were extended to include administration of Pneu23 in younger adults and Td/Tdap, by pharmacy practitioners. Presenter: Dr. Chris Folkins

1. Projected outcomes of public funding
for pharmacist-administered
pneumonia and tetanus
immunizations
Dr. Chris Folkins, PhD, BScPhm
Research Scientist, NB-IRDT
Nov 29, 2023

2. Acknowledgements
2
This work was supported by the Department of Health of the Province of New Brunswick under a
contract with the New Brunswick Institute for Research, Data and Training at the University of New
Brunswick. The results and conclusions are those of the authors and no official endorsement by the
Government of New Brunswick was intended or should be inferred.

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Canadian pharmacists journal. 2023. 156(4): 215-224

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NB Pharmacist Scope of Practice - Immunizations
- NB pharmacists have authority
to administer immunizations
- NB pharmacists have authority
to prescribe several
immunizations

5. 5
Provincial coverage of pharmacist immunization services in NB
Public funding limited to immunizations for:
- influenza
- COVID-19
- pneumococcal disease (age 65+)

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Pharmacists are a highly accessible source of immunizations
many locations
open evenings and weekends
do not require existing relationship
walk-ins or appointment
- most immunizations are not covered by
public funding when administered by
pharmacists
Barrier to accessible care

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Research question: What are the anticipated impacts of extending public funding of
pharmacist immunization services?
- economic impacts?
- health impacts?
 Approach: Predict impacts using a combination of administrative and published data

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Methods Overview:
Vaccines examined:
1. Pneu23 – Pneumococcal vaccine
Indicated for prevention of pneumococcal disease in:
- all adults aged 65+
- routine immunization of infants/children; those who missed childhood vaccines
- high risk individuals: medical conditions, smoking, alcoholism, homeless, LTC residents
*Single dose for adults
Rationale: Currently funded for age 65+  examine impacts of this program and potential
expansion to include younger adults

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Methods Overview:
Vaccines examined:
Indicated for prevention of tetanus/diphtheria/pertussis in:
- routine immunization of infants and children; those who missed childhood vaccines
- booster every 10 years in adults
2. Td/Tdap – Tetanus/diphtheria/pertussis
Rationale: Funded for pharmacists in other provinces, easy assessment criteria,
broadly indicated

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Physician-Only model
Methods Overview:
Compare health and economic outcomes in:
Blended model
Vs.
Pneu23 and Td/Tdap
not administered by
pharmacists
1. Pneu23 to age 65+
2. Pneu23 to age 19+
3. Td/Tdap to age 19+
Pharmacists administer:

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Methods Overview:
Outcomes examined:
1. Number of immunizations administered
2. Product and service costs
3. Physician hours saved
4. Pneumonia hospitalizations avoided
5. Productivity losses avoided – avoided illness cases
6. Productivity losses avoided – time off work to obtain immunization

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Methods Overview:
Administrative data source:
NB Physician Billing – records of physician services billed to Medicare,
including immunizations

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1. Number of immunizations administered
Physician-Only model
NB Physician Billing
data
# vaccines administered
2005 - 2018
Extrapolate to
2023

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1. Number of immunizations administered
Physician-Only model
Projected immunizations in 2023 if administered by physicians only
Projected # immunizations
Physician-Only
Pneu23 – 65+ 6420
Pneu23 – 19+ 9069
Td/Tdap – 19+ 11,743

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1. Number of immunizations administered
Blended model
From literature* – avg. 12.3% increase in total flu immunizations when
Canadian pharmacists began vaccinating
* Buchan et al 2017 CMAJ 189(4): E 146-52; Isenor et al 2018 BMC Public Health 18(1): 787
Projected # immun.
Physician-Only 2023
Pneu23 – 65+ 6420
Pneu23 – 19+ 9069
Td/Tdap – 19+ 11,743
Projected # immun.
Blended 2023
7210
10,184
13,187
Increase
12.3%

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1. Number of immunizations administered
Additional vaccinations under Blended model in 2023:
Projected # immun.
Physician-Only 2023
6420
9069
11,743
Projected # immun.
Blended 2023
Pneu23 – 65+ 7210
Pneu23 – 19+ 10,184
Td/Tdap – 19+ 13,187
Additional immun. Under
Blended model 2023
790
1115
1444
- =

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2. Product and service costs
Product costs: Avg distributor cost (McKesson Canada), minus typical market price discount
for provincial vaccine purchases (42.5%*)
*O’Reilly et al 2018 Clincoecon Outcomes Res 10: 655-63
Cost per dose
($CAD)
Pneu23 16.98
Td/Tdap 21.00
Additional product costs under
Blended model 2023 ($CAD)
Pneu23 – 65+ $13,408.80
Pneu23 – 19+ $18,940.71
Td/Tdap – 19+ $30,333.04
x projected
# of additional
doses

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Physician – 2023 avg. service cost per dose extrapolated from service cost
data from 2005 – 2018 (Pneu23 $13.90; Td/Tdap $14.32)
Pharmacist - $13/dose (current professional service fee for pneumonia vaccine)
Total service costs (Physician-Only) = total doses x physician fee per dose
2. Product and service costs
Service costs per dose:

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2. Product and service costs
Blended model service costs:
Estimate proportion of immunizations administered by pharmacists under Blended model
Assume equivalent proportion as for influenza
2023 pharmacist and physician influenza vaccine totals extrapolated from historical
data (2014-2019)
of immunizations administered by pharmacists under Blended model
61.1%

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Total service costs (Blended) = total doses x 0.611 (pharm %) x pharm fee per dose
total doses x 0.389 (phys %) x physician fee per dose
+
2. Product and service costs
Blended model service costs:

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2. Product and service costs
Total service costs
Physician-Only 2023
($CAD)
89,394.86
125,807.11
168,150.79
Total service costs
Blended 2023
($CAD)
Pneu23 – 65+ 96,321.65
Pneu23 – 19+ 135,855.26
Td/Tdap – 19+ 178,204.91
Additional service
costs under Blended
model 2023 ($CAD)
6926.79
10,048.15
10,054.12
- =
Total projected service costs 2023:

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2. Product and service costs
Total projected additional costs under Blended model 2023:
Additional product
costs under Blended
model 2023 ($CAD)
Pneu23 – 65+ $13,408.80
Pneu23 – 19+ $18,940.71
Td/Tdap – 19+ $30,333.04
Additional service
costs under Blended
model 2023 ($CAD)
6926.79
10,048.15
10,054.12
=
+
Total additional costs
under Blended
model 2023 ($CAD)
20,335.59
28,988.86
40,387.16

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3. Physician hours saved
# immunizations ‘taken over’ by pharmacists from physicians:
Total immunizations under Blended model = Physician-only total x 12.3% increase
Increase when pharmacist immunization
became available – assumed to be exclusively
administered by pharmacists – not taken over
from physicians

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3. Physician hours saved
# immunizations ‘taken over’ by pharmacists from physicians:
= Blended model immunizations x 0.611 (pharm %) – 12.3% increase
Physician hours
saved under Blended
model in 2023
= immunizations ‘taken over’ x avg physician vaccine appointment time
(10.4 min)*
*Crocker-Buque et al 2018 Implement Sci 13(1): 132

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3. Physician hours saved
Physician hours saved under
Blended model 2023
Pneu23 – 65+ 627
Pneu23 – 19+ 885
Td/Tdap – 19+ 1146

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4. Pneumonia hospitalizations avoided
Additional pneumonia hospitalizations avoided among age 65+ under Blended model
= additional # Pneu23 vaccines age 65+ under Blended model
base risk of pneumonia hospitalization for age 65+ in NB (974/100,000)*
estimated vaccine effectiveness of Pneu23 (0.152)**
x
x
*The Conference Board of Canada. The economic burden of pneumonia in Canada—a status quo forecast. 2017;
Statistics Canada. Table 17-10-0005-01 Population estimates on July 1st, by age and sex. 2020
**Dominguez A et al 2017 PLoS ONE 12(2): e0171943

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4. Pneumonia hospitalizations avoided
Additional pneumonia hospitalizations avoided among age 65+ under Blended model:
Hospitalizations
avoided
Pneu23 – 65+ 1.17
Pneu23 – 19+ 1.17
Td/Tdap – 19+ -
Hospitalization cost
savings ($CAD)
12,201.70
12,201.70
-
est. 2023 cost per
pneumonia
Hospitalization
($10,436.60)*
*The Conference Board of Canada. The economic burden of pneumonia in Canada—a status quo forecast. 2017
x =

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5. Productivity losses avoided – avoided illness cases
= additional # Pneu23/Tdap vaccines age 19-64 under Blended model
base risk of pertussis/IPD illness**
estimated vaccine effectiveness of Pneu23/Tdap***
x
x
Additional pertussis/invasive pneumococcal disease(IPD) cases avoided under Blended model
in working population
NB employment rate*
x
*Statistics Canada. 2021. Table 14-10-0287-03 labour force survey
**Government of Canada. Invasive pneumococcal disease. 2021; Pertussis (whooping cough): for health professionals. 2021.
***Government of Canada. Pneumococcal vaccine: Canadian Immunization Guide. 2021.; Koepke R et al 2014 J Infect Dis 210(6): 942-53

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Additional illness cases
avoided under Blended model
Pneu23
(IPD)
0.023
Td/Tdap
(pertussis)
0.038
5. Productivity losses avoided – avoided illness cases
x x
Avg. time
off work
per case*
Avg. NB
hourly
wage**
Additional productivity losses avoided
under Blended model 2023 ($CAD)
23.90
47.80
=
Additional productivity losses due to illness avoided in 2023 under Blended model:
*Marrie TJ et al 2004 J Infect 49(4): 302-9 ; Lee LH et al 2000 Arch Fam Med 9(10):989-96
**Statistics Canada. Table 11-10-0238-01 distribution of market, total and after-tax income of individuals, Canada, provinces and selected census
metropolitan areas. 2021

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6. Productivity losses avoided – time off work to obtain immunization
Rationale: Pharmacies are open evenings and weekends, physicians are generally
available during working hours only
Assumption: Individuals vaccinated by physicians will take time off work for immunization
appointment, whereas individuals vaccinated by pharmacists under Blended
model will obtain immunization during off hours
Time off work avoided due to pharmacist immunizations under Blended model

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6. Productivity losses avoided – time off work to obtain immunization
Additional productivity losses avoided due to time off work for immunization under Blended model
2023
= # Pneu23/Tdap immunizations ‘taken over’ from physicians age 19-64 under Blended model
2 hours off work per immunization
Estimated avg. NB hourly wage**
x
x
NB employment rate*
x
*Statistics Canada. 2021. Table 14-10-0287-03 labour force survey
**Statistics Canada. Table 11-10-0238-01 distribution of market, total and after-tax income of individuals, Canada, provinces and selected census
metropolitan areas. 2021

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6. Productivity losses avoided – time off work to obtain immunization
Additional productivity losses avoided
under Blended model 2023 ($CAD)
Pneu23 64,651.18
Td/Tdap 220,222.67

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Summary of projections under Blended model
1. Number of immunizations administered
2. Product and service costs
3. Physician hours saved
4. Pneumonia hospitalizations avoided
5. Productivity losses avoided – avoided illness cases
6. Productivity losses avoided – time off work to obtain immunization

34. Summary of projections under Blended model (vs. Physician-Only) in 2023
(similar projections expected annually)
Pneu23 age 65+ Pneu23 age 19+ Td/Tdap age 19+
Additional immunizations 790 1 115 1 444
Additional product + service costs -$20,335.59 - $28,998.86 - $40,387.16
Physician hours saved 627 885 1 146
Pneumonia hospitalizations avoided 1.17 1.17 ---
Hospitalization cost savings $12,201.70 $12,201.70 ---
Lost productivity hours avoided --- 2 706 9 217
Productivity cost savings --- $64,675.08 $220,270.47
Net cost difference - $8,133.89 $47,887.92 $179 883.31
Additional
costs
Cost savings Cost savings

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Summary
• Current pharmacist immunization program for Pneu23 in age 65+ is beneficial in
terms of increased vaccination rates and physician hours saved, but incurs a net
additional cost overall compared to Physician-Only vaccine administration driven
by vaccine product and service fees

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Summary
• Current pharmacist immunization program for Pneu23 in age 65+ is beneficial in
terms of increased vaccination rates and physician hours saved, but incurs a net
additional cost overall compared to Physician-Only vaccine administration driven
by vaccine product and service fees
• Extended pharmacist immunization funding for Pneu23 to younger adults (19+)
is projected to yield a further increase in vaccination rates and physician hours
saved, and result in a net cost savings compared to Physician-Only model, driven
by avoided productivity losses

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Summary
• Current pharmacist immunization program for Pneu23 in age 65+ is beneficial in
terms of increased vaccination rates and physician hours saved, but incurs a net
additional cost overall compared to Physician-Only vaccine administration driven by
vaccine product and service fees
• Extended pharmacist immunization funding for Pneu23 to younger adults (19+) is
projected to yield a further increase in vaccination rates and physician hours saved,
and result in a net cost savings compared to Physician-Only model, driven by avoided
productivity losses
• Extension of pharmacist immunization funding to include Td/Tdap is similarly
projected to yield increased vaccination rates, save physician hours, and a net cost
savings compared to Physician-Only vaccine administration

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Limitations
• Assumed increase in vaccination rate under Blended model is same as for influenza
vaccine
 Assumes sufficient unvaccinated individuals to support 12.3% increase
 Physician-Only model does not account for patients paying for pharmacist
immunization out of pocket
• Assumed proportion of immunizations administered by pharmacists under Blended
model is same as for influenza
 Public may be less inclined to accept new immunization options from pharmacists,
at least initially

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Limitations
• Assumes that all immunizations taken over by pharmacists under Blended model
translates directly to physician time saved
 Physicians often delegate immunization responsibilities – could interpret as
‘clinic time saved’ instead
 Physicians often administer immunization in context of existing appointment for
other reasons, so time savings may be less than projected
• Accuracy of projections beyond 2023 is not guaranteed due to shifting regulatory
and market conditions

40. Contact
Dr. Chris Folkins
Research Scientist
NB-IRDT
chris.folkins@unb.ca
www.unb.ca/nbirdt