Adult Immunizations: Are Your Patients Up-to-Date?

In the health-system setting, pharmacists must often prioritize their attention to treating the most acute medical condition a patient presents with. However, it is important to also consider opportunities to prevent disease. Vaccines are life-saving medications that may prevent a disease before it ever occurs. This is particularly true for patients who require hospital admission, as they are typically at high risk for contracting these vaccine-preventable illnesses. Are the patients you care for up-to-date? Before your patient is discharged, consider the TIPS mnemonic to remember 4 key vaccines that all adult patients need: Tetanus, Influenza, Pneumococcal, and Shingles.

Tetanus, Diphtheria, and Acellular Pertussis Vaccine

Pertussis is a highly contagious disease caused by the bacterium Bordetella pertussis. More commonly known as whooping cough, pertussis is transmitted by respiratory droplets when coughing or sneezing in proximity to others.¹ Pertussis most commonly affects infants younger than 1 year. It usually starts with cold-like symptoms such as a runny nose, low-grade fever, mild cough, and apnea. After 1 to 2 weeks, severe uncontrollable coughing with a loud “whooping” sound may emerge and continue for weeks. This cough is potentially lifethreatening because it may lead babies to stop breathing. Many patients who contract pertussis are infected by grandparents, parents, siblings, or caregivers.²

The best way to protect against pertussis is for adults to receive 1 dose of the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine. The vaccine takes 2 weeks to reach maximum effectiveness. Adults should use caution around young children during this time frame.³ The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommends a single Tdap dose for persons 19 to 64 years. Persons 65 years or older who have or who anticipate having close contact with an infant less than 12 months of age and who previously have not received Tdap should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission.⁴ Another vaccine called Td protects against tetanus and diphtheria, but not pertussis. A Td booster should be administered every 10 years. In individuals who have never received the Tdap vaccine, Tdap should replace 1 Td booster dose.²

Influenza Vaccines

Influenza, or the flu, is an acute respiratory illness caused by the influenza virus and is transmitted through respiratory secretions. In the United States, flu season spans from October to May each year, with peak infection rates occurring around January.⁵ The flu is responsible for significant morbidity and mortality. From October 2014 to April 2015, influenza resulted in approximately 65.5 hospitalizations per 100,000 persons and a mortality rate of 6.4%.⁶ To aid in the prevention of influenza epidemics, it is recommended that all persons 6 months and older receive the annual influenza vaccine, with rare exception. The only persons for whom influenza vaccination is not recommended are children who are less than 6 months of age or those who have a severe, life-threatening allergy to the influenza vaccine.⁵ Table 1^7,8 provides insight into the clinical use of available influenza vaccines.

Pneumococcal Vaccines

Approximately 900,000 Americans contract pneumococcal pneumonia each year; 5% to 7% of these cases result in death. In addition, 400,000 hospitalizations are attributed to pneumococcal pneumonia annually in the United States.⁹ Streptococcus pneumoniae, the most common pathogen associated with pneumococcal pneumonia, is also a leading cause of invasive diseases such as bacteremia and meningitis. Risk factors that can increase a patient’s likelihood for pneumococcal disease include:

• Chronic illnesses (lung, heart, liver, or kidney disease; asthma; diabetes; or alcoholism)
• Weakened immune system (HIV/ AIDS, cancer, long-term steroid use, or damaged/absent spleen)
• Living in nursing homes or other longterm care facilities
• Cochlear implants or cerebrospinal fluid leaks
• Cigarette smoking

There are 2 vaccines available for protection against pneumococcal disease: pneumococcal conjugate vaccine (PCV13 [Prevnar 13]) and pneumococcal polysaccharide vaccine (PPSV23 [Pneumovax 23]). On September 4, 2015, the CDC ACIP updated its recommendations on the administration intervals between these 2 vaccines.¹⁰ Online Table 2¹¹ provides an overview of the use of these vaccines in adults.

Table 2: Current Recommendations for PCV13 and PPSV23 Use in Adults¹¹

Ages 19 to 64 years

* If PPSV23 was given prior, wait 1 year before giving PCV13.

* If PPSV23 was given prior and group B (see below), wait at least 5 years before giving a second dose of PPSV23.

Population

Timeline for Vaccine Administration

Group A

Smoker

Long-term care facility resident

Chronic illnesses

PPSV23

Group B

Immunocompromised

PCV13 → wait 8 weeks → PPSV23 → wait 5 years → PPSV23

Group C

Cochlear implants

Cerebrospinal fluid leaks

PCV13 → wait 8 weeks → PPSV23

Age 65 years or older

* If PCV13 was given before 65 years, no additional PCV13 is needed

Population

Timeline for Vaccine Administration

No prior history

PCV13 → wait 1 year (8 weeks if Group B or Group C) → PPSV23

PPSV23 before age 65 years

Wait 1 year since last PPSV23 → PCV13 → wait 1 year AND 5 years from prior PPSV23 → PPSV23

PPSV23 at age 65 years and older

Wait 1 year since last PPSV23 → PCV13

PCV13 = pneumococcal conjugate vaccine 13; PPSV23 = pneumococcal polysaccharide vaccine 23.

Shingles Vaccine

Herpes zoster infection, or shingles, is the reactivation of the dormant varicella- zoster virus located in the sensory ganglia, which typically manifests as a painful, blister-filled rash wrapped around 1 side of the trunk; it can also appear on the face and scalp. Adults 50 years and older are at the greatest risk for shingles; at age 60, the risk sharply increases for developing post-herpetic neuralgia, defined as pain that persists for 90 days or more after the onset of shingles and can last for years.^12,13 Post-herpetic neuralgia can severely limit the quality of life of the individual and affect all 4 health domains: physical, psychological, functional, and social.¹³

A shingles vaccine (Zostavax) is approved by the FDA for persons 50 years and older without contraindications to the vaccine. However, the CDC ACIP guidelines do not recommend the vaccine until a patient is at least 60 years of age. Contraindications include a severe allergy to gelatin, neomycin, or any other vaccine component; immunosuppression; and pregnancy. (Contact dermatitis to neomycin is not considered a contraindication.) Whereas the risk of shingles is increased at age 50, incidence is lower in the 50-to-59 age group than in adults older than 60 years.¹⁴ Factors that might lead a health care professional to immunize an individual at age 50 to 59 years include preexisting chronic pain, severe depression, or other comorbid conditions; inability to tolerate treatment medications because of hypersensitivity or interactions with other chronic medications; and occupational considerations.¹⁵

Immunization Resources

It can become increasingly challenging for pharmacists to stay current on proper vaccine use, as recommendations for current vaccines are improved or new vaccines become available to prevent disease. It is important that pharmacists rely on credible sources for vaccine information. The CDC is the “gold standard” resource for both pharmacists and patients (www.cdc .gov/vaccines). The Immunization Action Coalition provides a wide array of resources for pharmacists, physicians, nurses, and other public health professionals (www.immunize.org). The American Pharmacists Association maintains an immunization resource center (www.pharmacist.com/immunization-center) and provides a national certificate training program that is recognized by the CDC for meeting national standards in vaccine education.¹⁶ Online Table 3¹⁷ notes select reputable applications available for download. Online Table 4^4,7,10,12 provides a snapshot of the adult immunizations covered in this article.

Table 3: Select Immunization-Related Apps¹⁷

App Name

Organization

Availability

ACP Immunization Advisor

American College of Physicians

iTunes

CDC Vaccine Schedules

Centers for Disease Control and Prevention

iTunes; Google

Shots Immunizations

Group on Immunization Education of the Society of Teachers of Family Medicine

iTunes; Google

Vaccines on the Go: What You Should Know

Vaccine Education Center of the Children’s Hospital of Philadelphia

iTunes; Google

Pharmacists’ Role

Pharmacist involvement with immunizations spans over 2 decades.^18,19 Numerous articles advocate for health-system pharmacists’ role in immunizations and document the improvements they have made in vaccination rates, particularly through use of standing orders or protocols.^20-25 Health-system pharmacists are health care professionals on the frontline of patient care. Attention to a patient’s current immunization status can be an important, life-saving measure.

Table 4: Summary of Select Vaccine Recommendations for Adults^4,7,10,12,a

Vaccine

Target Population

Vaccines Available, Brand Name (Manufacturer)

Number of Doses Needed

Route of Administration

Tdap

Not previously received and ≥18 years

Health care professionals or anyone having close contact with a child <12 months

Pregnant women between 27 and 36 weeks’ gestation

Adacel (Sanofi)

Boostrix (GSK)

1 dose

IM

Td

Booster dose when ≥18 years

Tenivac (Sanofi)

1 dose every 10 years

IM

Influenza (inactivated)

Individuals who wish to reduce the likelihood of catching the flu, ≥18 years

High-risk individuals, ≥18 years

High-risk individuals include those with chronic health conditions or weak immune systems, pregnant women, and those ≥65 years

Standard Dose

Inactivated Trivalent

● Afluria (bioCSL)

● Fluvirin (Novartis)

● Fluzone (Sanofi)

Inactivated Quadrivalent

● Fluarix (GSK)

● FluLaval (GSK)

● Fluzone or Fluzone Intradermal (Sanofi)

Inactivated Cell-Cultured

● Flucelvax (Novartis)

Trivalent Recombinant

● Flublok (Protein Sciences)

High Dose

Inactivated Trivalent

● Fluzone High-Dose (Sanofi)

1 dose annually

IM or ID

Influenza (live)

Healthy individuals 18 to 49 years of age

Standard Dose

Live Quadrivalent

● FluMist (MedImmune)

1 dose annually

Intranasal

Pneumococcal conjugate (PCV13)

Individuals ≥65 years

High-risk individuals ^b: 19 to 64 years of age

Individuals who smoke cigarettes or have asthma and are 19 to 64 years of age

Prevnar 13 (Wyeth/Pfizer)

Max 1 dose per lifetime

IM

Pneumococcal polysaccharide (PPSV23)

Individuals ≥65 years

High-risk individuals,^b 19 to 64 years of age

Individuals who smoke cigarettes or have asthma, 19 to 64 years of age

Pneumovax23 (Merck)

Max 3 doses per lifetime

IM or SC

Shingles

FDA approval: ≥50 years

ACIP recommendation: ≥60 years

Zostavax (Merck)

1 dose

SC

ACIP = Advisory Committee for Immunization Practices; GSK = GlaxoSmithKline; ID = intradermal; IM = intramuscular; PCV13 = pneumococcal conjugate vaccine 13; PPSV23 = pneumococcal polysaccharide vaccine 23; SC = subcutaneous; Td = tetanus and diptheria; Tdap = tetanus, diptheria, and pertussis.

^aPlease note that although this table focuses on recommendations for adults, some of the vaccines discussed in this article are also recommended for persons younger than 18 years.

^bHigh-risk individuals previously described in the body of this text.

Macary Marciniak, PharmD, BCACP, BCPS, FAPhA, is clinical associate professor and director of the PGY-1 community pharmacy residency program at the UNC Eshelman School of Pharmacy at the University of North Carolina at Chapel Hill (UNC). Laura Rhodes, PharmD, is a PGY-1 community pharmacy resident with UNC and Moose Professional Pharmacy. Jeannie Ong, PharmD, is a PGY-1 community pharmacy resident with UNC and Walgreens. Hannah Renner, PharmD, is a PGY-1 community pharmacy resident with UNC and Walgreens. Breanna Sunderman, PharmD, is a PGY-1 community pharmacy resident with UNC and Kroger.The authors would like to thank Jordan Ballou, PharmD; Desiree Gaines, PharmD; and Ryan Templeton, PharmD, for their suggestions regarding the content of this article.

References

• Centers for Disease Control and Prevention. Pertussis (whooping cough). www.cdc.gov/pertussis. Updated September 5, 2015. Accessed August 10, 2015.
• Centers for Disease Control and Prevention. Tdap (Tetanus, Diphtheria, Pertussis) vaccine information statements. www.cdc.gov/vaccines/hcp/vis/vis-statements/tdap.html. Published February 24, 2015. Accessed August 10, 2015.
• Centers for Centers for Disease Control and Prevention. Pertussis (whooping cough) Vaccination. www.cdc.gov/vaccines/vpd-vac/pertussis/default.htm. Accessed August 10, 2015.
• Centers for Disease Control and Prevention. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the advisory committee on immunization practices, 2010. MMRW Morb Mortal Wkly Rep. 2011;60(1):13-15. www.cdc.gov/mmwr/pdf/wk/mm6001.pdf.
• Centers for Disease Control and Prevention. What you should know for the 2015-2016 influenza season. www.cdc.gov/flu/about/season/flu-season-2015-2016.htm. Updated October 20, 2015. Accessed October 7, 2015.
• Centers for Disease control and Prevention. Situation update: summary of weekly FluView report. www.cdc.gov/flu/weekly/summary.htm. Updated October 16, 2015. Accessed October 7, 2015.
• Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder KR, Karron RA. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices, United States, 2015-16 influenza season. MMWR Morb Mortal Wkly Rep. 2015;64(30):818-825.
• PharmaJet. www.PharmaJet.com. Accessed October 7, 2015.
• Centers for Disease Control and Prevention. Pneumococcal disease: fast facts. www.cdc.gov/pneumococcal/about/facts.html. Updated June 10, 2015. Accessed October 11, 2015.
• Kobayashi M, Bennett NM, Gierke R, et al. Intervals between PCV13 and PPSV23 vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2015;64(34):944-947.
• California Department of Public Health, Immunization Branch. Pneumococcal vaccine timing tool for adults. http://eziz.org/assets/docs/IMM-1152.pdf. Accessed October 11, 2015.
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• American Pharmacists Association. Pharmacy-based immunization delivery. http://pharmacist.com/pharmacy-based-immunization-delivery. Accessed October 13, 2015.
• Immunization Action Coalition. Apps: Immunization apps for healthcare providers and their patients. www.immunize.org/resources/apps.asp. Accessed October 13, 2015.
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