Who Are the Vaccinators? A Look at the Vaccination Workforce

April 21, 2021|1:35 p.m.| ASTHO Staff

As the U.S. continues to undertake the largest vaccination campaign in almost a century, it has required government at all levels to surge workforce capacity. The federal government, states, territories, and local jurisdictions are acting to meet the immediate demand for vaccination as well as expand the long-term vaccination workforce. Looking ahead, expansion of the vaccination workforce long-term will help support potential COVID-19 booster shots and expand vaccine access broadly.

The Biden Administration has a goal to have 90% of Americans living within five miles of a vaccination site. To achieve this, CDC is exploring a partnership with Dollar General to increase access to the initial COVID-19 vaccine. While this partnership will exceed the Administration’s goal, establishing vaccination clinics in a non-clinical space—like a Dollar General—will require a much larger vaccination workforce.

Temporary Federal Expansion of the Vaccination Workforce Through the PREP Act
The Public Readiness and Emergency Preparedness (PREP) Act authorizes the HHS secretary to limit the legal liability of covered entities and persons who develop and deploy medical countermeasures, such as the COVID-19 tests and vaccines, during a public health emergency. In March 2020, the HHS secretary issued a PREP Act declaration for COVID-19 and, as the pandemic response evolved, issued a series of amendments. In preparation for the vaccination workforce needs, the third amendment to the PREP Act included state-licensed pharmacists as covered persons, extending liability protections to all licensed pharmacists administering any Advisory Committee on Immunization Practices (ACIP) recommended vaccine for those three years and older. In its seventh amendment, HHS extended PREP Act liability protections to 15 additional health professionals including dentists, midwives, and podiatrists.

State and Territorial Expansion of the Vaccination Workforce Both Long- and Short-Term
States and territories also can determine the scope of practice of health professionals, codifying which professionals are authorized to administer immunizations in state law. Exercising emergency powers, governors and health officials have also temporarily expanded scope of practice for a variety of professionals to administer the COVID-19 vaccine. For example, an executive order issued by Kansas Gov. Laura Kelly temporarily granted pharmacists, dentists, podiatrists, and other professions authority to administer the vaccine. The success of leveraging these additional health professionals in vaccination efforts may permanently expand scope of practices in administering COVID-19 vaccination, or vaccinations generally.

ASTHO identified over 100 bills across 32 states to expand a health professional’s scope of practice to include vaccine administration or prescribing authority during the 2021 legislative sessions. Eight states (Arkansas, Indiana, Maine, Minnesota, North Dakota, South Carolina, Virginia, and Wisconsin) have enacted at least one bill to expand a provider scope of practice to administer the COVID-19 vaccine. States are considering over 20 health professions for expanded scope of practice to increase vaccination. Some proposals would expand the scope of practice of certain professionals just for the duration of a public health emergency. For example, New Jersey is considering a bill that would authorize EMTs to administer ACIP-authorized vaccines under the supervision of certain licensed healthcare professionals. Others would broadly expand the scope of practice to include administering any vaccination in accordance with ACIP protocols.

The most common profession considered for a scope of practice expansion are pharmacists, with ASTHO identifying 47 bills across 21 states that would expand pharmacist scope of practice. Prior to the pandemic, pharmacists were authorized to administer at least one vaccine in all 50 states, Puerto Rico, and D.C. In most jurisdictions, pharmacists were authorized to administer any vaccine to adults in accordance with ACIP/CDC guidelines. Pharmacists in at least 18 states also had the authority to prescribe at least one immunization prior to the pandemic. With many states already granting pharmacists vaccine administration authority, many bills, like one Iowa is considering, would grant pharmacists authority to prescribe and administer the COVID-19 and other vaccines broadly.

In addition to pharmacists, nine states are considering expanding the scope of practice of pharmacy technicians and five states are considering expanding the scope of practice for pharmacy interns. For example, North Dakota is considering a bill to authorize pharmacy technicians to administer COVID-19 vaccines under the direction of a pharmacist and Ohio is considering a similar measure for pharmacy interns.

Dentists are the second most common profession being considered for broader immunization authority, with ASTHO identify over 25 bills across 14 states to include immunization in dentists’ scope of practice. Dentists in several states had authority to administer vaccinations prior to the pandemic, with states like Oregon extending vaccine prescription and administration authority to dentists with an existing patient-provider relationship. At least 28 states identified dentists as potential vaccinators to address COVID-19 workforce limitations before the seventh amendment to the PREP Act authorized dentists to vaccinate nationwide. States will likely continue to leverage dentists in vaccination efforts to provide better access to the estimated 9% of Americans who annually see a dentist but not a physician. This is already seen in states like Wisconsin, which is considering a bill that would provide dentists authority to administer both COVID-19 and flu vaccines.

States are also considering expanding the scope of practice of non-traditional vaccinators to support immunization efforts long-term. California is considering authorizing optometrists to administer immunizations broadly, while Illinois is considering similar authorization for podiatrists. South Carolina and several other states are considering authorizing retired medical professionals. Maryland considered authorizing athletic trainers to administer COVID-19 vaccines. Pennsylvania is considering authorizing veterinarians to administer COVID-19 vaccines.

Impact of Expansion of the Vaccine Workforce
Federal, state, and territorial efforts to expand the vaccination workforce, both through executive emergency powers and legislative authority, have successfully increased COVID-19 vaccination rates to upwards of 4.1 million doses administered in a single day across the nation. But with COVID-19 variants of concern beginning to circulate in communities, booster shots may be needed to reach or maintain herd immunity in the future. While CDC does not currently recommend booster shots, both Moderna and Pfizer are studying the impact of booster doses. If CDC recommends booster shots, there may be need for a large vaccination workforce to administer those shots without the current infrastructure created with assistance of the PREP Act and state emergency orders. Once the PREP Act sunsets, state and territorial scope of practice measures will have to determine which professions can administer COVID-19 vaccines or a potential COVID-19 booster.

States and territories will need to assess how their jurisdiction is adapting to broader immunization efforts before the PREP Act ends to determine which healthcare professions should be authorized to vaccinate long-term. In making this determination, jurisdictions should consider factors like medical professional interest, capacity, and health equity. Some newly authorized medical professionals may not have capacity to administer vaccinations in addition to their traditional workload while others, like dentists, may seamlessly integrate vaccination into their existing practice. Some medical professionals may be interested in retaining vaccine authority beyond the COVID-19 pandemic. Regardless, expansion of the vaccine workforce through jurisdiction legislation will impact both dissemination of COVID-19 booster shots and vaccine access generally.

ASTHO will continue monitoring this important public health issue and provide updates on proposed legislation.


Annie Evans, MPH is a senior analyst of preparedness and disability integration at ASTHO
Maggie Davis, JD, MA is the director of state health policy at ASTHO