Immunization: Tips, Tools, and Total Success

It’s official: pharmacist-immunizers have improved the nation’s health! Since 1996, each state has incrementally increased pharmacists’ immunization privileges. States that jumped on the bandwagon early are now reporting immunization rates that are 10 percentage points higher than states that were slower to progress. Young adults have benefitted most from these changes; their vaccination rate almost doubled between 1993 and 2013.¹ With 17 infectious diseases now preventable with safe, effective vaccines, vaccine-wielding immunizers prevent 42,000 deaths and 20 million cases of disease, annually, in children alone.² Immunizers can continue the positive trend by staying up-to-date on changes in vaccine recommendations and encouraging patients to get immunized.

VACCINE ADMINISTRATION

Each state’s board of pharmacy regulates the scope of its pharmacists’ immunization practices. Since 2007, all candidates for the PharmD degree have been trained to immunize with intramuscular and subcutaneous injections.^3,4 For pharmacists who graduated before 2007, or who simply wish to review or improve their skills and knowledge, the American Pharmacists Association offers pharmacy- based immunization delivery training using selfstudy, a live seminar, and hands-on training.⁵ Most inactivated vaccines are administered intramuscularly in the deltoid, whereas all live-attenuated injectable vaccines are administered subcutaneously in the anterior arm (midway between the elbow and armpit). Pharmacists also need to know how to administer intranasal vaccines (for patients who need or want FluMist Quadrivalent) and intradermal vaccines, which requires a technique specific to the Fluzone Intradermal Quadrivalent Influenza Vaccine. Both of these products come with manufacturer- supplied administration directions.^6,7

VACCINE ADVERSE EVENTS AND ERRORS

Although vaccine-associated serious adverse events (AEs) are rare, certain patients and patient populations are at elevated risk. Table 1^8-12 lists some conditions and therapies that can be contraindications to vaccine administration. The CDC’s website on vaccine safety and AEs (cdc.gov/ vaccines/vac-gen/safety/default.htm) provides additional information. Some vaccine-specific contraindications and patient-specific factors are temporary, and immunization may be possible after the condition (eg, pregnancy, cancer, steroid therapies) resolves. The manufacturer’s product-specific labeling is the best source for adult contraindications. For children, the CDC offers comprehensive information about immunosuppression.

Documenting immunizations and reporting problems are crucial components of the immunizer’s responsibilities. Table 2 lists helpful resources for immunizers.

RECENT UPDATES

Increasing the immunization rate against pertussis is a focus right now, as outbreaks of whooping cough have become too common. All pertussis vaccines are combined with diphtheria and tetanus vaccines. The inactivated pertussis booster vaccine, Tdap (or dT) is generally safe for any adult patient. Defer Tdap or DtaP vaccination in patients who have progressive or unstable neurologic disorders, uncontrolled seizures, or progressive encephalopathy until a treatment regimen has been established and the condition stabilizes. Defer vaccination with Tdap until at least 10 years have elapsed since the last tetanus-/toxoid-containing vaccine in patients who report Arthus-type hypersensitivity reactions (acute, local, injection-site inflammation with skin edema, hemorrhage, and necrosis) after a previous dose of the tetanus-/toxoid-containing vaccine.^13,14 Patients who developed encephalopathy, not attributable to another cause, within 7 days of a previous dose of DTP, DtaP, or Tdap, cannot be re-immunized with these vaccines.¹⁵ Report cases of new-onset encephalopathy that occur after receipt of the Tdap or DtaP vaccine to the National Vaccine Injury Compensation Program.¹⁶

Shoulder injury related to vaccine administration (SIRVA) is an emerging concern.^17-19 This occurs when immunizers inject vaccines into the subdeltoid bursa or within the joint space. SIRVA causes shoulder pain and limited range of motion within 48 hours after intramuscular vaccine administration.^20,21 Experts advise immunizers to avoid administering vaccines in the top one-third of the deltoid. Studies show that immunizers who sit and administer vaccines to seated patients, using needles of the appropriate length, reduce the risk of SIRVA.^15,18,20

For years, the CDC advised withholding the influenza vaccine in patients who have an egg allergy and, more recently, provided a decision tree to determine whether to immunize egg-allergic patients.²² Excellent evidence now indicates that individuals with an egg allergy have no increased risk of anaphylaxis following the influenza vaccine. In February 2016, the CDC decided to remove the egg allergy warnings for all flu vaccines for the 2016-2017 season.²³ The yellow fever vaccine is the only other vaccine currently made using egg; however, the CDC has not addressed the relationship between having an egg allergy and administration of this product.²⁴

END NOTE

Pediatric patients generally receive their vaccinations at pediatricians’ offices. Adolescents and adults are more likely to miss important vaccinations and can benefit greatly from pharmacy immunization programs. Pharmacist-immunizers have improved the public’s health by offering safe, effective immunizations at convenient locations.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy.

References

• Chun GJ, Sautter JM, Patterson BJ, McGhan WF. Diffusion of pharmacy-based influenza vaccination over time in the United States. Am J Public Health. 2016;106(6):1099-1100. doi: 10.2105/AJPH.2016.303142.
• CDC. Ten great public health achievements—United States, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011;60(19):619-623.
• Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. Accreditation Council for Pharmacy Education website. acpe-accredit.org/pdf/FinalS2007Guidelines2.0.pdf. Published January 23, 2011. Accessed May 10, 2016.
• Guidance for the accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree. Accreditation Council for Pharmacy Education website. acpe-accredit.org/pdf/GuidanceforStandards2016FINAL.pdf. Published February 2, 2015. Accessed May 10, 2016.
• Pharmacy-based immunization delivery. American Pharmacists Association website. pharmacist.com/pharmacy-based-immunization-delivery. Published April 15, 2014. Accessed June 10, 2016.
• Flumist [package insert]. Gaithersburg, MD: MedImmune, Inc; 2015. azpicentral.com/flumistquadrivalent/flumistquadrivalent.pdf#page=1. Accessed June 7, 2016.
• Fluzone Intradermal Quadrivalent [package insert]. Swiftwater, PA: Sanofi Pasteur Inc.
• M-M-R-II [package insert]. Whitehouse Station, NJ: Merck & Co, Inc; 2015.
• Varivax [package insert]. Whitehouse Station, NJ: Merck & Co, Inc; 2013.
• Zostavax [package insert]. Whitehouse Station, NJ: Merck & Co, Inc; 2014.
• Rubin LG, Levin MJ, Ljungman P, et al; Infectious Diseases Society of America. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infectious Dis. 2014;58(3):309-318. doi: 10.1093/cid/cit816.
• Vaccines for pregnant women. CDC website. cdc.gov/vaccines/adults/rec-vac/pregnant.html. Updated April 19, 2016. Accessed June 10, 2016.
• National Vaccine Advisory Committee. Recommendations from the national vaccine advisory committee. Standards for adult immunization practice. Public Health Rep. 2014;129(2):115-123.
• CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(7):131-135.
• Kroger AT, Sumaya CV, Pickering LK, Atkinson WL. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2011;60(RR02):1-60.
• National Vaccine Injury Compensation Program. Health Resources and Services Administration website. hrsa.gov/vaccinecompensation/index.html. Accessed May 10, 2016.
• Bodor M, Montalvo E. Vaccination-related shoulder dysfunction. Vaccine. 2007;25(4):585-587.
• Atanasoff S, Ryan T. Lightfoot R, Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA). Vaccine. 2010;28(51):8049-8052. doi: 10.1016/j.vaccine.2010.10.005.
• Cook IF. Subdeltoid/subacromial bursitis associated with influenza vaccination. Hum Vaccin Immunother. 2014;10(3):605-606. doi:10.4161/hv.27232.
• National Vaccine Injury Compensation Program (VICP). Prevention of SIRVA. Health Resources and Services Administration website. hrsa.gov/advisorycommittees/childhoodvaccines/meetings/20150604/sirva.pdf. Published June 4, 2015. Accessed March 24, 2016.
• Cross GB, Moghaddas J, Buttery J, Ayoub S, Korman TM. Don’t aim too high: avoiding shoulder injury related to vaccine administration. Aust Fam Physician. 2016;45(5):303-306.
• 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.
• Advisory Committee on Immunization Practices February 2016 meeting information. CDC website. cdc.gov/vaccines/acip/meetings/meetings-info.html. Updated June 24, 2016. Accessed June 10, 2016.
• Who should NOT get vaccinated with these vaccines? CDC website. cdc.gov/vaccines/vpd-vac/should-not-vacc.htm. Updated April 19, 2016. Accessed June 16, 2016.