/publications/issue/2009/2009-03/2009-03-10048

Incorporating Vaccination Services into Your Practice

Author: Thao M. Cong, PharmD Candidate, Cinda Wu, PharmD Candidate, and Karl Hess, PharmD


Ms. Cong and Ms. Wu are both PharmD candidates, Class of 2009, at Western University of Health Sciences, College of Pharmacy, Pomona, California. Dr. Hess is an assistant professor of pharmacy practice at Western University of Health Sciences, College of Pharmacy.


More than 60,000 people die annually from influenza and pneumonia; however, in 2006, only 64% and 57% of adults aged 65 years and older received their influenza and pneumococcal vaccines, respectively.1,2 Healthy People 2010 is a national health promotion and disease prevention initiative whose goal is to have 90% of ambulatory and institutionalized adults aged 65 years and older vaccinated against influenza and pneumococcal disease.3 Pharmacists can play vital roles to help achieve these goals by becoming immunization advocates, facilitators, and/ or active immunizers.4 As immunization advocates, pharmacists can identify high-risk patients and educate and provide resources for them. As facilitators, they can direct patients to vaccination sites or use their pharmacy to host an immunization event. As active immunizers, however, pharmacists can play their biggest role by screening patients and administering vaccines.

Training and Legal Requirements

Pharmacists have the legal authority to vaccinate in all states except for Maine and the District of Columbia; however, immunization laws may vary from state to state, so it is important to first check with your state board of pharmacy for the most current regulations.5 Before pharmacists can start offering immunizations, they must be properly trained to store, handle, and administer vaccines. The American Pharmacists Association provides immunization training at its annual meeting. This training program focuses on the characteristics of vaccine-preventable diseases and the vaccines currently used for their prevention, as well as the precautions, contraindications, adverse reactions, and storage requirements for these vaccines. Training programs need to provide hands-on instruction on vaccine administration. Pharmacists also need to be trained for emergency situations that might arise and have a plan to manage them. Therefore, becoming certified in cardiopulmonary resuscitation is vital for patient safety.

As part of Occupational Safety and Health Administration requirements, pharmacy staff also need to be trained to manage blood-borne pathogens (eg, hepatitis B, hepatitis C, and HIV) in order to help prevent and control infections. This training should include the proper disposal of sharps and other biohazardous waste. State-specific permits also may be required, however, for the pharmacy to generate waste and/or transport it. All staff members also should be vaccinated against hepatitis B; however, individuals have the option of declining vaccination by signing a hepatitis B declination form.

Pharmacists who choose to immunize must develop vaccine administration protocols or standing orders in conjunction with a physician and/or other licensed health care providers. Standing orders allow the pharmacist to independently screen and administer necessary vaccines to their patients when indicated, based either on package insert guidelines or on recommendations from the Advisory Committee on Immunization Practices. Standing orders must be signed by a prescriber, the pharmacist responsible for vaccine administration, and any other individual that the prescriber deems necessary. In addition to obtaining standing orders, pharmacists also should create protocols to help manage patients in case emergencies such as allergy or anaphylaxis occur during vaccination. These protocols should include the use of epinephrine and diphenhydramine and also should be signed by the prescriber and pharmacist.

Accurate documentation of vaccinations should be kept for each individual patient and should include the screening questionnaire form and record of vaccination. A vaccine information statement is required to be given to the patient for each administered vaccine.6 By being properly trained and keeping accurate records, adverse events, accidents, and possible legal issues can be minimized or prevented.

Table 1

Supplies for Vaccine Administration

Basic Supplies

  • Gloves
  • Alcohol swabs
  • Cotton balls
  • Bandages
  • Sharps disposal containers
  • Biohazard waste containers
  • Syringesa

Emergency Supplies

  • Epinephrine
  • Diphenhydramine
  • Airway masks
  • Sphygmomanometer
  • Stethoscope

aPlease refer to the Advisory Committee on Immunization Practices? General Recommendations on Immunization for specific syringe sizes.


Site Preparation

Pharmacies need adequate space to house all necessary immunization supplies (Table 1), to provide the service in a private area, and to have an observation area to monitor for adverse events. All adverse events should be reported to the Vaccine Adverse Event Reporting System. The pharmacy can use a room where supplies are kept and where consultation, preparation, and administration can be performed. Sectioning a corner of the pharmacy off with a privacy barrier also is adequate. Consultations and administration can be done at that corner, while storage and preparation can be done elsewhere. A refrigerator and/or freezer also are necessary depending on the vaccines being stocked. To better maintain a controlled temperature environment, a single unit with separate refrigerator and freezer doors is preferred. Influenza and pneumococcal vaccines need to be stored refrigerated (3?C-8?C), whereas the shingles vaccine needs to be stored frozen (-15?C).

Reimbursement

Several options for reimbursement are available, including billing Medicare Part B or D or other third-party private insurers. To enroll in Medicare and bill under Part B, the Centers for Medicare & Medicaid Services (CMS) form 855B must be filled out. Medicare Part B covers 1 annual influenza vaccine and 1 lifetime pneumococcal vaccine. CMS form 1500 is used to bill for the vaccine, which reimburses for the cost of the vaccine and administration. Vaccines not covered under Medicare Part B may be covered under Medicare Part D (eg, Zostavax). Submitting claims to Medicare Part D is done similar to prescription billing. Some third-party prescription drug plans also may reimburse for the cost of the vaccine but not for its administration, so patients may be charged separately for the service. Alternatively, cash payment also can be accepted from patients who do not have insurance.

Marketing Strategies

Using the pharmacy dispensing database, patients can be prescreened and offered vaccines as appropriate. Additionally, placing signs on the pharmacy's windows, using bag stuffers, placing ads in the newspaper, or sending out mailings also can help advertise to the public. Health care providers are another group to target, as they may have patients to refer to your service.

Resources

It is important to stay current with new vaccines coming to market, as well as updates to vaccination recommendations and schedules, to ensure optimal care for your patients. The organizations listed in Table 2 can help pharmacists stay informed.

Table 2

Links to Immunization Resources

Organization

Resources Provided

Web Site

American Heart Association

CPR training

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

American Lung Association

Influenza clinic directory

www.flucliniclocator.org

American Pharmacists Association

CE

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

Immunization certification

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

Centers for Disease Control and Prevention

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 Human Services

Vaccine Adverse Event Reporting System

http://vaers.hhs.gov/

Immunization Action Coalition

Screening forms

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

Standing orders

www.immunize.org/standingorders/

Vaccination administration record

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

Vaccine information statement

www.immunize.org/vis/

Merck

Adult vaccination locator

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

National Community Pharmacists Association

CE

www.cecity.com/ncpa/catalogue.htm

Occupational Safety and Health Administration

Blood-borne pathogens and needlestick prevention information

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

Hepatitis B declination form

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

VaxAmerica

Adult vaccination network and locator

www.vaxamerica.com

CE = continung education; CPR = cardiopulmonary resuscitation.


References

  1. 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.
  2. 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.
  3. 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.
  4. Weitzel KW, Goode JV. Implementation of a pharmacy-based immunization program in a supermarket chain. J Am Pharm Assoc. 2000;40(2):252-256.
  5. State Information: States Authorizing Pharmacists to Vaccinate. Immunization Action Coalition Web site. www.immunize.org/laws/pharm.asp. Accessed November 13, 2008.
  6. 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.