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Modified Scope of Practice Used by States in the 2009 H1N1 Influenza Pandemic

Fact Sheet

Each state determines the permitted scope of practice for the professions it regulates, including limiting the activities or procedures a person in that profession may undertake. Modifying scope of practice is one strategy states have used in responding to public health emergencies. The 2009 H1N1 influenza pandemic saw broader use of modified scope of practice by states than in prior public health emergencies. States primarily modified scope of practice to increase the numbers of vaccinators available to meet real or anticipated demand. States accomplished this by expanding the types of healthcare practitioners authorized to administer seasonal and H1N1 influenza vaccinations and by increasing the age range of patients that specified healthcare practitioners could vaccinate (e.g., adding children over a certain age). Pharmacists and EMT/EMS personnel were the two groups most frequently affected by scope of practice changes during H1N1. Other strategies some states used included allowing physicians to issue standing orders permitting vaccination without issuing prescriptions to individual patients. The information below summarizes the scope of practice changes that 14 states and DC enacted for each of the specified practitioners during the H1N1 outbreak.1 Because states’ practice requirements can differ, an activity that may be permitted only under a modified scope of practice in one state may be allowed under the regular scope of practice in another state. (Download a printable PDF.

Practitioners and Modified Scopes of Practice

Pharmacy

Pharmacists

  • Pharmacists could administer pneumococcal and influenza vaccinations (including H1N1) to persons 18 and older with a written protocol and standing order from physician licensed in DC. (DC)
  • Pharmacists could have protocol agreements with physicians permitting a pharmacist to order and dispense influenza vaccine without an individual prescription; limit of 10 orders per physician within the same or adjacent county to physician’s principal place of business. (GA)
  • Pharmacists’ scope of practice modified to allow them to administer seasonal and H1N1 vaccine to people 9 years or older. (IL)
  • Age range of vaccinees expanded by type of vaccine. (IN)
  • Specified pharmacists authorized to administer influenza vaccinations via written protocol rather than individual prescription. (LA)
  • Pharmacists permitted to administer influenza and other vaccines to persons aged 9 or older with a prescription. (ME)
  • Licensed, certified pharmacists authorized to vaccinate adolescents ages 13 and older. (MD)
  • Commissioner of health authorized to permit pharmacists to administer seasonal and H1N1 vaccine. (MA)
  • Commissioner of health authorized to permit pharmacists to administer vaccinations if a local board of health requests state assistance to respond to a public health threat. (MN)
  • Pharmacists allowed to administer seasonal and H1N1 vaccinations at points of dispensing (PODs) under limited circumstances. (NY)
  • Pharmacists permitted to administer influenza vaccine to persons over age 7 without a physician-patient relationship. (TX)

Pharmacy Students

  • Licensed or certified professionals authorized to administer seasonal and H1N1 vaccine as per state health agency instructions and completion of a training program. (IL)

EMT/EMS

Paramedics

  • Paramedics authorized to administer vaccines under local optional scope of practice. (CA)
  • Licensed or certified professionals authorized to administer seasonal and H1N1 vaccine as per state health agency instructions and completion of a training program. (IL)
  • Paramedics allowed to administer H1N1 vaccine to public safety and healthcare personnel as well as the general public. (MD)
  • Commissioner of health authorized to permit paramedics to administer seasonal and H1N1 vaccine. (MA)
  • Paramedics permitted to administer H1N1 vaccine and H1N1-related medications under the direction of a physician and after training. (OH)

EMT-Advanced

  • Advanced EMTs allowed to administer seasonal and H1N1 vaccinations at PODs under limited circumstances. (NY)

EMT-Intermediate

  • Licensed or certified professionals authorized to administer seasonal and H1N1 vaccine as per state health agency instructions and completion of a training program. (IL)
  • Intermediate EMTs permitted to administer H1N1 vaccine and H1N1-related medications under the direction of a physician and after training. (OH)

Cardiac Respiratory Therapists (CRTs)

  • CRTs allowed to administer H1N1 vaccine to public safety and healthcare personnel as well as the general public. (MD)

EMT/EMS (General)

  • Commissioner of health authorized to permit EMTs to administer vaccinations if a local board of health requests state assistance to respond to a public health threat. (MN)
  • Conditions of EMS vaccination authority clarified: only if there is a local/state emergency declaration, an emergency mission number issued, and EMS providers are registered as emergency workers under state law and acting under the direction of state/local emergency management or incident commander. (WA)

Dental

Dentists

  • Licensed or certified professionals authorized to administer seasonal and H1N1 vaccine as per state health agency instructions and completion of a training program. (IL)
  • Commissioner of health authorized to permit dentists to administer seasonal and H1N1 vaccine. (MA)
  • Commissioner of health authorized to permit dentists to administer vaccinations if a local board of health requests state assistance to respond to a public health threat. (MN)
  • Dentists allowed to administer seasonal and H1N1 vaccinations at PODs under limited circumstances. (NY)

Dental Hygienists

  • Dental hygienists allowed to administer seasonal and H1N1 vaccinations at PODs under limited circumstances. (NY)

Medical

Podiatrists

  • Commissioner of health authorized to permit podiatrists to administer vaccinations if a local board of health requests state assistance to respond to a public health threat. (MN)
  • Podiatrists allowed to administer seasonal and H1N1 vaccinations at PODs under limited circumstances. (NY)

Physician Assistants

  • Physician assistants allowed to administer seasonal and H1N1 vaccinations at PODs under limited circumstances. (NY)

Midwives

  • Midwives allowed to administer seasonal and H1N1 vaccinations at PODs under limited circumstances. (NY)

Medical Students

  • Licensed or certified professionals authorized to administer seasonal and H1N1 vaccine as per state health agency instructions and completion of a training program. (IL)
  • Commissioner of health authorized to permit medical students to administer seasonal and H1N1 vaccine. (MA)

Nursing

Registered Nurses

  • Registered nurses (RN) could have protocol agreements with physicians permitting a RN to order and dispense influenza vaccine without an individual prescription; limit of 10 orders per physician within the same or adjacent county to physician’s principal place of business. (GA)

Nursing Students

  • Licensed or certified professionals authorized to administer seasonal and H1N1 vaccine as per state health agency instructions and completion of a training program. (IL)
  • Commissioner of health authorized to permit nursing students to administer seasonal and H1N1 vaccine. (MA)

Other Healthcare

Assistive Personnel and Specialist Assistants

  • Specialist assistants allowed to administer seasonal and H1N1 vaccinations at points of dispensing (PODs) under limited circumstances. (NY)
  • Licensed nurses authorized to delegate technical vaccine administration activities (not professional judgment or decision making) to unlicensed assistive personnel during a defined immunization event and consistent with agency policy and procedures. (NC)

Veterinary

Veterinarians

  • Commissioner of health authorized to permit veterinarians to administer vaccinations if a local board of health requests state assistance to respond to a public health threat. (MN)
  1. Information adapted from Courtney B et al. “Expanding Practitioner Scopes of Practice During Public Health Emergencies: Experiences from the 2009 H1N1 Pandemic Vaccination Efforts.” Biosecurity and Bioterrorism. Vol. 8, No. 3. 2010.

Note: This document was compiled from June–December 2011 and reviewed in May 2013; it reflects the laws and programs current then. It reflects only portions of the laws relevant to public health emergencies and is not intended to be exhaustive of all relevant legal authority. This resource is for informational purposes only and is not intended as a substitute for professional legal or other advice. The document was funded by CDC Award No. 1U38HM000454 to the Association of State and Territorial Health Officials; Subcontractor PI Elliott, Logan Circle Policy Group LLC.