Incorporating Vaccination Services into Your Practice

Ms. Cong and Ms. Wu are both PharmDcandidates, Class of 2009, at WesternUniversity of Health Sciences, College ofPharmacy, Pomona, California. Dr. Hessis an assistant professor of pharmacypractice at Western University of HealthSciences, College of Pharmacy.

More than 60,000 people dieannually from influenza andpneumonia; however, in 2006,only 64% and 57% of adults aged 65 yearsand older received their influenza andpneumococcal vaccines, respectively.^1,2Healthy People 2010 is a national healthpromotion and disease prevention initiativewhose goal is to have 90% of ambulatoryand institutionalized adults aged65 years and older vaccinated againstinfluenza and pneumococcal disease.³Pharmacists can play vital roles to helpachieve these goals by becoming immunizationadvocates, facilitators, and/or active immunizers.⁴ As immunizationadvocates, pharmacists can identifyhigh-risk patients and educate and provideresources for them. As facilitators,they can direct patients to vaccinationsites or use their pharmacy to host animmunization event. As active immunizers,however, pharmacists can play theirbiggest role by screening patients andadministering vaccines.

Training and Legal Requirements

Pharmacists have the legal authority tovaccinate in all states except for Maineand the District of Columbia; however,immunization laws may vary fromstate to state, so it is important to firstcheck with your state board of pharmacyfor the most current regulations.⁵Before pharmacists can start offeringimmunizations, they must be properlytrained to store, handle, and administervaccines. The American PharmacistsAssociation provides immunization trainingat its annual meeting. This trainingprogram focuses on the characteristicsof vaccine-preventable diseases andthe vaccines currently used for theirprevention,as well as the precautions,contraindications, adverse reactions,and storage requirements for these vaccines.Training programs need to providehands-on instruction on vaccineadministration. Pharmacists also needto be trained for emergency situationsthat might arise and have a plan to managethem. Therefore, becoming certifiedin cardiopulmonary resuscitation is vitalfor patient safety.

As part of Occupational Safety andHealth Administration requirements,pharmacy staff also need to be trainedto manage blood-borne pathogens (eg,hepatitis B, hepatitis C, and HIV) inorder to help prevent and control infections.This training should include theproper disposal of sharps and otherbiohazardous waste. State-specific permitsalso may be required, however, forthe pharmacy to generate waste and/or transport it. All staff members alsoshould be vaccinated against hepatitisB; however, individuals have the optionof declining vaccination by signing ahepatitis B declination form.

Pharmacists who choose to immunizemust develop vaccine administration protocolsor standing orders in conjunctionwith a physician and/or other licensedhealth care providers. Standing ordersallow the pharmacist to independentlyscreen and administer necessary vaccinesto their patients when indicated,based either on package insert guidelinesor on recommendations from theAdvisory Committee on ImmunizationPractices. Standing orders must besigned by a prescriber, the pharmacistresponsible for vaccine administration,and any other individual that the prescriberdeems necessary. In addition toobtaining standing orders, pharmacistsalso should create protocols to help managepatients in case emergencies such asallergy or anaphylaxis occur during vaccination.These protocols should includethe use of epinephrine and diphenhydramineand also should be signed by theprescriber and pharmacist.

Accurate documentation of vaccinationsshould be kept for each individualpatient and should include the screeningquestionnaire form and recordof vaccination. A vaccine informationstatementis required to be given to thepatient for each administered vaccine.⁶By being properly trained and keepingaccurate records, adverse events, accidents,and possible legal issues can beminimized or prevented.

Table 1

Supplies for VaccineAdministration

Basic Supplies

• Gloves
• Alcohol swabs
• Cotton balls
• Bandages
• Sharps disposal containers
• Biohazard waste containers
• Syringes^a

Emergency Supplies

• Epinephrine
• Diphenhydramine
• Airway masks
• Sphygmomanometer
• Stethoscope

^aPlease refer to the Advisory Committee onImmunization Practices? General Recommendationson Immunization for specific syringe sizes.

Site Preparation

Pharmacies need adequate space tohouse all necessary immunization supplies(Table 1), to provide the service in aprivate area, and to have an observationarea to monitor for adverse events. Alladverse events should be reported to theVaccine Adverse Event Reporting System.The pharmacy can use a room wheresupplies are kept and where consultation,preparation, and administration canbe performed. Sectioning a corner of thepharmacy off with a privacy barrier alsois adequate. Consultations and administrationcan be done at that corner, whilestorage and preparation can be doneelsewhere. A refrigerator and/or freezeralso are necessary dependingon the vaccinesbeing stocked. To better maintaina controlled temperature environment,a single unit with separate refrigeratorand freezer doors is preferred. Influenzaand pneumococcal vaccines need to bestored refrigerated (3?C-8?C), whereasthe shingles vaccine needs to be storedfrozen (-15?C).

Reimbursement

Several options for reimbursement areavailable, including billing MedicarePart B or D or other third-party privateinsurers. To enroll in Medicare and billunder Part B, the Centers for Medicare& Medicaid Services (CMS) form 855Bmust be filled out. Medicare Part B covers1 annual influenza vaccine and 1 lifetimepneumococcal vaccine. CMS form1500 is used to bill for the vaccine, whichreimburses for the cost of the vaccineand administration. Vaccines not coveredunder Medicare Part B may be coveredunder Medicare Part D (eg, Zostavax).Submitting claims to Medicare Part Dis done similar to prescription billing.Some third-party prescription drug plansalso may reimburse for the cost of thevaccine but not for its administration, sopatients may be charged separately forthe service. Alternatively, cash paymentalso can be accepted from patients whodo not have insurance.

Marketing Strategies

Using the pharmacy dispensing database,patients can be prescreened and offeredvaccines as appropriate. Additionally,placing signs on the pharmacy's windows,using bag stuffers, placing ads inthe newspaper, or sending out mailingsalso can help advertise to the public.Health care providers are another groupto target, as they may have patients torefer to your service.

Resources

It is important to stay current with newvaccines coming to market, as well as updatesto vaccination recommendationsand schedules, to ensure optimal care foryour patients. The organizations listedin Table 2 can help pharmacists stayinformed.

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Table 2

Links to Immunization Resources

Organization

Resources Provided

Web Site

American Heart Association

CPR training

www.americanheart.org/presenter.jhtml?identifier=3012360

American LungAssociation

Influenza clinicdirectory

www.flucliniclocator.org

AmericanPharmacistsAssociation

CE

www.pharmacist.com/Content/NavigationMenu3/ContinuingEducation/OnlineCECenter/Online_CE_Center.htm

Immunizationcertification

www.pharmacist.com/Content/NavigationMenu3/ContinuingEducation/CertificateTrainingProgram/PharmacyBasedImmunizationDelivery/Pharmacy_Based_Immun.htm

Centers for DiseaseControl andPrevention

Vaccine recommendations,guidelines

www.cdc.gov/vaccines/recs/default.htm

Centers for Medicare& Medicaid Services

Medicare information

www.cms.hhs.gov/home/medicare.asp

Health and HumanServices

Vaccine Adverse EventReporting System

http://vaers.hhs.gov/

Immunization ActionCoalition

Screening forms

www.immunize.org/printmaterials/ topic.asp#screen

Standing orders

www.immunize.org/standingorders/

Vaccination administrationrecord

www.immunize.org/catg.d/p2023.pdf

Vaccine informationstatement

www.immunize.org/vis/

Merck

Adult vaccinationlocator

www.merck.com/product/mav/home.html

National CommunityPharmacistsAssociation

CE

www.cecity.com/ncpa/catalogue.htm

OccupationalSafety and HealthAdministration

Blood-borne pathogensand needlestick preventioninformation

www.osha.gov/SLTC/blood bornepathogens/otherresources.html

Hepatitis B declinationform

www.osha.gov/SLTC/etools/hospital/hazards/bbp/declination.html

VaxAmerica

Adult vaccinationnetwork and locator

www.vaxamerica.com

CE = continung education; CPR = cardiopulmonary resuscitation.

References

• Influenza. Centers for Disease Control and Prevention Web site. National Center for Health Statistics - Fast Stats. www.cdc.gov/nchs/FASTATS/flu.htm. Accessed: December 16, 2008.
• Pneumonia. Centers for Disease Control and Prevention Web site. National Center for Health Statistics - Fast Stats. www.cdc.gov/nchs/FASTATS/pneumonia.htm. Accessed December 16, 2008.
• Healthy People 2010: Immunization and Infectious Diseases. Centers for Disease Control and Prevention Web site. www.healthypeople.gov/Document/HTML/Volume1/14Immunization.htm. Accessed December 1, 2008.
• Weitzel KW, Goode JV. Implementation of a pharmacy-based immunization program in a supermarket chain. J Am Pharm Assoc. 2000;40(2):252-256.
• State Information: States Authorizing Pharmacists to Vaccinate. Immunization Action Coalition Web site. www.immunize.org/laws/pharm.asp. Accessed November 13, 2008.
• Fact Sheet for Vaccine Information Statements. Centers for Disease Control and Prevention Web site. www.cdc.gov/vaccines/pubs/vis/vis-facts.htm. Accessed: December 12, 2008.