With multiple Covid-19 vaccines rapidly heading toward approval, optometrists and dentists are pushing for the authority to immunize patients during routine eye exams and dental cleanings.
These medical professionals say their help will be needed to distribute the vaccines to millions of Americans — and they already have the know-how.
"When you look at what dentists do and how many injections they give day in and day out, I think they're more than qualified," said dentist Jim Wood, a California state Assembly member. "It's kind of a no-brainer."
In California, the professional organizations representing dentists and optometrists are in talks with state officials to expand their job descriptions to include administering vaccines. Oregon has already begun training and certifying dentists to give vaccines. And at least half the states have considered allowing dentists to administer Covid-19 vaccines once they're available, according to the American Association of Dental Boards.
The dentists and optometrists argue that their help would take some of the pressure off hospitals and doctors' offices. It could also bring some extra money into their practices.
"Everyone in our specialized health care system should also play a preventive role," said Dr. William Sage, a professor of law and medicine at the University of Texas at Austin. "Pandemic or not, being alert to preventive health in any setting is a good thing."
But it's too early to know how those professionals could factor into the Covid-19 vaccination effort, in part because the distribution strategy is still being worked out and because it's unclear which vaccines will be administered.
Pfizer, Moderna and AstraZeneca announced this month that their Covid-19 vaccine candidates delivered promising results in clinical trials and that millions of doses could be ready before the end of the year. Pfizer's has to be stored at ultracold temperatures, while Moderna's and AstraZeneca's can be kept at standard refrigerator temperatures.
It wouldn't be the first time health professionals other than doctors have administered vaccines during a pandemic. Nursing students, EMTs and midwives in a handful of states were granted temporary, limited authority to administer flu vaccines during the H1N1 swine flu pandemic of 2009-10. Dentists in Massachusetts, Illinois, New York and Minnesota were also temporarily deputized as vaccinators.
Since then, Minnesota and Illinois have adopted laws to allow dentists to give flu shots to adults. And last year, Oregon became the first state to allow dentists to give any vaccine to any patient, child or adult.
So far, more than 200 dentists and dental students in Oregon have completed the training course offered by the Oregon Health & Science University's School of Dentistry, with 60 others expected to finish by the end of December, said Mary Pat Califano, an instructor who helped develop the hands-on part of the training.
Students spend around 10 hours in online classes. They then undergo hands-on training, during which they practice injections on shoulder pads before practicing injecting partners with saline solution. They're taught how to counsel patients about vaccines and avoid injuring patients' shoulders.
Once dentists pass an exam, they can register with the Oregon Health Authority and begin getting their staff members trained to handle vaccines and procuring refrigerators to store them in.
The goal, Califano said, isn't to replace family doctors or primary care physicians but to supplement them. The federal Agency for Healthcare Research and Quality found that, in 2017, 31.1 million Americans saw dentists but not physicians.
"We just need as many people as possible to give flu shots and Covid-19 vaccines when they're available," Califano said. "If it happens that they're in a dental office and that provider is educated and capable of giving a vaccine, why not?"
The California Dental Association is exploring options for gaining vaccine authority, which would be likely to require the Legislature to step in. California passed a law this year allowing pharmacists to administer Covid-19 vaccines approved by the Food and Drug Administration.
Wood, who introduced the measure, hasn't yet committed to sponsoring a bill that would let dentists give vaccines, but he said he supports the idea.
"We give injections in the mouth all day long, and these are very precise kinds of injections," Wood said. "I think the learning curve for a dentist would be small."
Dr. William Schaffner, a professor of preventive medicine and infectious disease at Vanderbilt University, said proposals to expand the vaccine workforce are promising. Flu vaccines, which are relatively low-risk and simple to administer, would be the perfect candidate to stock in dental and optometric fridges to start.
But Schaffner said he doesn't believe dentists and optometrists will play a major role in the Covid-19 immunization effort. It would take too long to pass legislation to expand the scope of practice for every professional who wants it in every state, he said. And because some Covid-19 vaccines have specific shipping and subzero storing requirements, they will probably be distributed only to specially trained personnel at a small number of locations, he said.
There's also the question of payment. It's hard — but not impossible — to make a profit administering vaccines, Schaffner said.
Providers have to decide each season how many doses to buy, and any that go bad or remain in the fridge at the end of their shelf life equal monetary losses.
"Unless you're very assiduous about moving the vaccine from the fridge into arms, you're not going to make money," Schaffner said. "People who do that can augment their income, but nobody is going to drive a Porsche because of vaccines."
Jeff McCombs, an associate professor of health economics at the University of Southern California School of Pharmacy, agreed that it might not make business sense for most dentists to start vaccinating. He said it would be hard to keep well-stocked vaccine fridges with enough variety to meet patients' needs without wasting doses. Generally, adults who choose not to get vaccinated do so because they're uneducated about vaccines or they're afraid, he said, not because they can't access them.
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"I don't think it's going to harm people," McCombs said. "I just don't think they'll make any money at it."
While the California Department of Public Health said the state's vaccine infrastructure is sufficient for flu shots and routine immunizations, it is "carefully considering the need to include additional types of immunizers" to get Californians vaccinated against Covid-19, according to a statement from the department.
The California Optometric Association said it is in talks with Gov. Gavin Newsom's vaccine task force about how to get optometrists into the mix, and is exploring legislative options as well.
"We can serve the dual role of assisting with vision needs and protecting from Covid," said David Ardaya, an optometrist in Whittier who chairs an association committee that is looking into the issue. "Our whole hope is to assist our nation in regaining its health and in returning to a sense of normal."
A 2017 state law technically allows optometrists who have undergone a certification program to give adults flu, shingles and pneumococcal vaccines.
But three years after AB-443 was signed, the regulations implementing it have yet to be finalized.
That didn't stop Frank Giardina, an optometrist in Nipomo, from going through a certification program anyway.
The 20-hour course, which includes online lectures, hands-on lessons and an exam, is the same course pharmacists take when they're learning how to give all vaccines to people of all ages.
Giardina pointed to the shingles, or herpes zoster, virus as an example of why optometrists are well suited to give vaccines. The virus can infect the eyes, and even though he's allowed to treat shingles, he can't give a vaccine to prevent it.
For now, he's holding out hope that he will get permission to administer vaccines, including those for Covid-19. He envisions a world in which patients come in for contact lenses and he can offer them flu or Covid-19 vaccines while they're there.
"We're another member of the health care team. It's a waste of manpower not to," Giardina said. "If you're trying to vaccinate all these people, especially in rural areas, you need whoever you can find."