Flu vaccination in pharmacies: the study of the pilot projects

A team around the clinical pharmacy group at the Universität des Saarlandes (Saarland University) analysed 11,571 questionnaires from the pilot projects on flu vaccination in pharmacies. Werthner and colleagues published the analysis, which covers eight federal states and the flu seasons 2020/21 to 2022/23, in the journal Vaccine in December 2024.

Why flu vaccination was trialled in pharmacies

Under § 132j(1) of the Sozialgesetzbuch V (SGB V), Book V of the German Social Code, the pilot projects were meant to improve the vaccination rate. The Masernschutzgesetz, the Measles Protection Act, added the section, which has applied since 1 March 2020. Subsection 7 requires the projects to be evaluated according to generally accepted scientific standards.

The vaccination rate falls short of the European Immunization Agenda 2030, whose target is 75% among everyone for whom flu vaccination is recommended. According to billing data from the Kassenärztliche Vereinigungen, the regional associations of statutory health insurance physicians, 35% of people aged 60 and over were vaccinated against flu in the 2024/25 season, as were 12% of adults aged 18 to 59 with an underlying condition. The Robert Koch-Institut, Germany’s federal public health institute, gives both figures and the target in Epidemiologisches Bulletin 38/2026.

Where the data come from

The analysis covers the pilot projects in Baden-Württemberg, Bavaria, Lower Saxony, Rhineland-Palatinate, Saarland, Saxony, Schleswig-Holstein and North Rhine-Westphalia, where the two regions of Westfalen-Lippe and Nordrhein each had a project of their own. Berlin also had a pilot project but did not pass on its data.

The ABDA, the federal association of German pharmacists, developed the questionnaire together with the Paul-Ehrlich-Institut, the German federal institute for vaccines and biomedicines, and the Robert Koch-Institut. The pharmacist who gave the vaccination filled in one part, the vaccinated person filled in the other afterwards, and both parts were anonymous. The number of respondents rose from 1,228 in the first season to 4,810 in the second and 5,374 in the third. For seven of the nine regions the number of participating pharmacies is known as well, and it grew from 104 to 293 and then to 477.

Who was vaccinated at the pharmacy

People aged 60 to 69 made up the largest age group, at 23.1% of respondents, just ahead of those aged 50 to 59 at 22.7%. Women made up 57.5% of respondents.

The pharmacists recorded whether the person had an indication under the recommendation of the Ständige Impfkommission (STIKO), the standing vaccination committee at the Robert Koch-Institut, that is, whether the person belonged to a group for which the committee recommends flu vaccination. For the respondents as a whole, they recorded

• a health risk from a pre-existing condition in 26.9%,
• a raised risk of infection at work in 20.3%,
• an age of 60 or over with no other indication in 18.7%,
• no indication under the STIKO recommendation in 25.1%.

The risk of infection at work was the most common reason both among respondents under 40, at 41.1%, and among those aged 40 to 59, at 38.3%. Among those aged 60 and over it stood at 12.8%.

How many had their first flu vaccination

For 13.6% of respondents it was their first flu vaccination ever. This share fell from 25.7% in the 2020/21 season to 7.1% in the 2022/23 season. Among respondents under 40 it was 22.0%, while among those aged 60 and over it was 8.7%.

Of all respondents, 86.4% had been vaccinated against flu before, and 66.9% named their family doctor’s practice as the place where that happened. The pharmacy was not one of the options offered for that earlier vaccination. In the 2020/21 season 1.8% named some other place, and in the 2022/23 season 21.1% did.

Whether they would have been vaccinated without the pharmacy

If the vaccination had not been available at the pharmacy, 17.0% of respondents said they would not have been vaccinated. A further 11.5% were unsure, and 56.9% would have gone to a doctor’s practice or somewhere else.

Among respondents who were having their first flu vaccination, 27.6% would not have been vaccinated without the pharmacy, 34.5% were unsure and 35.0% would have been vaccinated elsewhere.

How respondents heard about the service

Pharmacy staff were the most common source, at 35.0%, followed by printed notices in the pharmacy at 26.4%. Respondents could give more than one answer. There was no dedicated public campaign for flu vaccination in pharmacies, but the ABDA supplied the pharmacies with flyers and posters.

From the first to the third season, the share who heard about the vaccination from pharmacy staff rose from 28.9% to 42.1%, and the share who heard about it from printed notices rose from 15.2% to 27.6%. The share citing notices from the health insurers fell from 8.9% to 2.1%.

Why they chose the pharmacy

Easy access was the most common reason, named by 66.7% of respondents, and here too more than one answer was possible. The next most common reasons were

• no waiting time, at 52.5%,
• trust in the pharmacists’ expertise, at 42.6%,
• suitable opening hours, at 35.7%,
• being a regular customer of the pharmacy, at 26.1%.

In the 2020/21 season 13.1% named the worry of catching an infection at a doctor’s practice, and in the 2022/23 season 5.0% did. Over the same period, the share who said that their doctor’s practice did not offer the vaccination went from 10.4% to 3.3%. Older respondents named being a regular customer more often, 16.6% of those under 40 compared with 31.5% of those over 60.

How long a vaccination took

The consultation and the vaccination together took a median of 12 minutes. The middle half of the vaccinations took between 10 and 16 minutes. In the first season the median was 15 minutes, while in the third it was 11. Most vaccinations were given in October, at 28%, and in November, at 46.6%.

How satisfied respondents were

Of the respondents, 93.8% were very satisfied with the vaccination at the pharmacy, and 93.9% would have their flu vaccination at a pharmacy again. The information they were given before the vaccination was rated very good by 88.5%. Against other diseases, 79.7% would be vaccinated at a pharmacy and a further 16.3% probably would. The share who said so was 69.5% in the 2020/21 season and 81.1% in the 2022/23 season.

Respondents filled in their part at the pharmacy, with the pharmacist who had vaccinated them present. The authors therefore consider it possible that this made the answers more favourable. Between 14.2% and 14.4% of the answers to these four questions are missing.

A survey that Rose and colleagues ran on COVID-19 vaccinations in eleven German pharmacies from February to April 2022 found similar figures. Of 427 respondents, 91.5% gave the best rating and a further 7.8% were fairly satisfied. There too, respondents filled in the questionnaire straight after the vaccination.

Which incidents were reported

A reaction after the vaccination is recorded in 9 of the 11,571 questionnaires:

• three anaphylactic reactions,
• three respiratory emergencies,
• one cardiovascular emergency,
• one emergency caused by bleeding,
• one case of circulatory problems with dizziness.

None of the nine cases needed emergency measures, either in the pharmacy or from the ambulance service. Since the questionnaires give no further details on them either, the authors suspect that a box was ticked in the wrong place or that the reaction was not severe. No questionnaire documents a shoulder injury caused by the injection.

Pregnant women, people on anticoagulant therapy and people who had once had a severe reaction to a vaccination were among those the pilot projects referred to a doctor’s practice. According to the authors, the study was too small to determine how often rare severe reactions occur.

What is known about shoulder injuries after vaccination

A prolonged, painful restriction of shoulder movement after a vaccination is a very rare vaccination complication, according to the Paul-Ehrlich-Institut. The institute analysed it in its drug safety bulletin, the Bulletin zur Arzneimittelsicherheit 3/2016. In the specialist literature it is called SIRVA, short for “shoulder injury related to vaccine administration”. From 2001 to June 2016 the institute confirmed 59 cases, compared with around 35,000 reports of suspected vaccination complications from Germany over the same period.

Most suspected SIRVA reports followed a flu vaccination, and the institute’s most likely explanation is the number of these vaccinations. As the cause, it names accidental injury to structures of the shoulder when the injection goes into the deltoid muscle. It describes a technique by Cross and colleagues that is meant to lower the risk, in which the injection goes in midway between the acromion and the deltoid tuberosity, with the arm abducted by 60 degrees.

Where the analysis reaches its limits

Pharmacies and respondents took part voluntarily. In the authors’ assessment, the sample may therefore mainly reflect people who were already inclined towards vaccination at the pharmacy. The questionnaires differed between the regions, and not every federal state took part in all three seasons.

Four of the twelve authors received funding for the project from health insurers and pharmacists’ associations, two of them also from a pharmaceutical wholesaler. The authors declare that they have no competing financial interests.

What studies from other countries found on vaccination rates

A 2016 review by Isenor and colleagues found a higher vaccination rate in all 36 included studies when pharmacists were involved. This held for each of their roles, whether they educated patients, organised vaccinations or gave the vaccinations themselves. Each comparison was with vaccination in which pharmacists were not involved. The authors name as a weakness that many of the studies were not randomised and differed widely in design.

An updated meta-analysis by Le and colleagues of 14 randomised and 79 observational studies reached the same result in 2022, above all for flu vaccination in the USA and some high-income countries. The authors rate the quality of the evidence as moderate or low.

According to a 2024 report by the International Pharmaceutical Federation (FIP), vaccination in pharmacies is permitted in 56 countries and territories, 47.9% of those covered. In 13 of them the people who vaccinate in the pharmacy belong to other health professions. Pharmacists vaccinate against flu in 31 countries.

What evaluations from Western Australia show about safety

In 15,621 flu vaccinations at 76 pharmacies in Western Australia from March to October 2015 there were no severe incidents, and mild ones occurred in less than 1% of those vaccinated. This is the result of the evaluation by Hattingh and colleagues, which is based on information from the pharmacies.

For the 2020 season, Salter and colleagues compared flu vaccinations in 22 pharmacies there with flu vaccinations in 90 doctors’ practices and clinics. Vaccinated people over the age of 10 were asked about reactions by text message. After vaccination in a pharmacy, 4.8% of those who replied reported a reaction, compared with 6% after vaccination elsewhere. Among those over 65 the shares were similar, at 5.8% and 6%. The authors consider it possible that the people vaccinated in pharmacies differ from those vaccinated in practices.

What has applied since the pilot projects

Since 30 June 2022 pharmacies have been allowed to vaccinate against flu outside pilot projects as well. To allow this, the Pflegebonusgesetz, the act on a care bonus, added § 20c on flu vaccination of adults to the Infektionsschutzgesetz (IfSG), the German Infection Protection Act. Under § 132e(1a) SGB V, payment and billing are set by a contract between the GKV-Spitzenverband, the national association of statutory health insurers, and the Deutscher Apothekerverband, the association of pharmacy owners. The pilot projects had to end within nine months of that contract, as § 132j(8) SGB V required.

Since 2 July 2026, § 20c IfSG has allowed trained pharmacists to vaccinate adults with any vaccine that is not a live vaccine. Pharmacists who completed the training that applied until 1 July 2026 may go on vaccinating against flu and COVID-19 without new training. What this changed is set out under vaccination as a pharmacy service.

How many pharmacies vaccinate against flu today

According to the ABDA’s fact sheet of August 2026, about 1,700 pharmacies offer vaccinations, which is one in ten in Germany. In the 2025/26 season they vaccinated 218,000 people with statutory health insurance against flu. For the seasons before that, the ABDA’s Statistisches Jahrbuch 2026, its statistical yearbook, gives

• 400 pharmacies with 5,600 vaccinations in the 2021/22 season, still in pilot projects,
• 1,200 pharmacies with 67,300 vaccinations in the 2022/23 season,
• 1,500 pharmacies with 101,300 vaccinations in the 2023/24 season,
• 1,400 pharmacies with 121,900 vaccinations in the 2024/25 season.

According to the ABDA, almost 15,000 pharmacists are trained to vaccinate. Pharmacies supplied doctors’ practices with 14.2 million doses of flu vaccine for people with statutory health insurance in the calendar year 2025.

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