Our pharmacist team at Osterhaus Pharmacy has been providing immunizations to our patients for the past 2 decades. However, in the past 3 years we have become more proactive in our approach to discussing immunizations. Today, when patients come to pick up their prescriptions, we print out a vaccination history and forecast and include it with their medications. This information is generated from our state’s immunization information system (IIS); similar systems are available in all 50 states. The vaccination history and forecast print-out help facilitate a discussion about immunizations. Previously, we would simply initiate a conversation without this patient-specific information, but what we quickly learned is that most patients will report they are up-to-date with their immunizations when they are not.

Compared with childhood vaccination rates, adult vaccination rates are lower and considerably below the goals of Healthy People 2020. A review of the data shows that only the herpes zoster vaccination rate for adults 60 years of age and older exceeded its target (30%), with a rate of 30.6%. Most other vaccination rates fall well below the goals. For example, fewer than 45% of adults received the annual influenza vaccine, yet the Healthy People 2020 goal is 70%.

Numerous studies have shown the positive impact a pharmacist can have on improving adult immunization rates.

 As community pharmacists, we are among the most accessible health care providers; 93% of patients live within 5 miles of a community pharmacy.

 Therefore, we are well positioned to continue to make an impact on vaccination rates if we initiate conversations with our patients and help them develop an action plan to become fully immunized.

The Pharmacy Quality Alliance Adult Immunization Task Force advises that “all health care providers should assess adult patients for their immunization status at every patient encounter. Therefore, every health care provider, including pharmacists, carries the responsibility to screen patients in an effort to increase vaccination rates and to improve overall health.”

We have the opportunity to empower patients to take a proactive role in their health care through immunization awareness. As pharmacists, we can incorporate a review of immunization history into our patient care process. We can also facilitate education about the need for the vaccine and the risks each disease may carry. In addition, we can encourage our patients to carry their immunization record with them, just as they would a medication list. The Immunization Action Coalition is a readily accessible website with a multitude of resources including a downloadable history form.

 Additionally, phone apps such as My Immunizations App and MyIR are available to assist with patient record-keeping. Some states allow patient access to their IIS.

Despite the benefits of the IIS, pharmacists need to be aware of its limitations. First and foremost, not all health care professionals are required to enter immunizations into the system, and so the information may not be fully up-to-date. This creates a need to coordinate immunization information among the patient, the pharmacy, and other health care providers to produce an accurate immunization history. Furthermore, most systems forecast age-related immunization schedules and neglect conditions such as pregnancy or chronic disease (ie, asthma, diabetes) recommendations. Additionally, when new recommendations are released from the CDC’s Advisory Committee on Immunization Practices (ACIP), there may be lag time before the IIS is updated. Therefore, it is important for pharmacists to keep up with current CDC and ACIP guidelines and schedules. These schedules are available by the CDC online at cdc.gov/vaccines/schedules/hcp/imz/adult.html. Being prepared with information about the effectiveness of a particular vaccination and potential patient risk can be beneficial when discussing indicated vaccinations with patients who are hesitant to vaccinate.

What’s the best approach to getting started? It’s 1 patient, 1 conversation at a time.

Gain access to your state’s IIS in order to have your patient’s immunization history readily available. Assessing the immunization history should be part of your patient care process, regardless of whether or not your pharmacy administers vaccinations. Review your pharmacy’s workflow process to incorporate this assessment. Below is a step-by-step guide.

Step 1: Begin with patients who request a vaccination.

 Assess their history to discuss any past due or additional vaccinations indicated for the patient. Assist the patient in updating their immunization record or provide a printout from IIS.

Step 2: Expand to include immunization assessment as part of medication therapy management (MTM) services.

 This should be completed for patients involved in MTM-based platforms, appointment-based model programs, and medication sync programs. Print out their vaccination forecast to have it available when the patient picks up their medications, noting past due or upcoming vaccinations.

Step 3: Make assessing immunization histories part of your dispensing workflow.

 Look at high-risk patients, ie, those who smoke, are 65 years or older, or have chronic conditions. Think critically about the information provided by the IIS. Use this as a starting point, in combination with the patient’s medication profile, to determine which vaccinations are recommended.

Documentation of immunizations by all health care professionals in any setting is key. When we have access to up-to-date immunization histories, we can make better recommendations and avoid unnecessary vaccinations. Educating patients about the importance of having their immunization history accessible electronically or via wallet card helps provide accurate information. Document historical immunizations if your state’s IIS offers the ability to do so.

At Osterhaus Pharmacy, we encourage our patients to request that their health care providers enter their vaccinations in the IIS. In addition, we utilize the electronic patient chart within our dispensing system to document patient interactions, which allows continuity of care among our pharmacy team members. The chart includes patient responses to immunization inquiries, highlights opportunities to educate patients at future encounters, and creates scheduling reminders for upcoming vaccinations.

An estimated 40,000 to 50,000 adults die annually from vaccine-preventable diseases in the United States.

 Treating patients who are not properly vaccinated give rise to health care costs of $10 billion annually.

 Pharmacists are obligated to improve outcomes and reduce health care costs by discussing with patients their immunization history, encouraging patients to keep an up-to-date immunization record, and helping them make informed decisions about available immunizations. Remember: 1 patient, 1 conversation at a time.

 is the clinical pharmacy coordinator at Osterhaus Pharmacy in Maquoketa, Iowa.

 is co-owner of Osterhaus Pharmacy in Maquoketa, Iowa.

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Pharmacy Quality Alliance Adult Immunization Task Force. Recommendations for improving adult vaccination rates and reporting within community pharmacy practice. Pharmacy Quality Alliance website. pqaalliance.org/ assets/library/White%20Paper%20-%20Adult%20Immunization%20Recommendations_FINAL_09_28_2016.pdf. Published September 2016. Accessed July 16, 2019.

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Articles

Registries and Information Sharing

Our pharmacist team at Osterhaus Pharmacy has been providing immunizations to our patients for the past 2 decades. However, in the past 3 years we have become more proactive in our approach to discussing immunizations.

Empowering Patients to Know Their Immunization History

Life-saving vaccines have had a profound impact in this country and worldwide. According to the CDC, from 2006 to 2017, almost 3.5 billion doses of vaccines were distributed in the United States.

 From an economic perspective, every $1 spent on vaccines amounts to $3 in direct benefits, and these benefits can go up to $10 if societal costs are included.

 Globally, 2 to 3 million fewer deaths in the world occur each year because people are vaccinated and protected.

Today, almost anyone can receive immunizations against 17 once common and potentially deadly infectious diseases in the United States.

 However, many patients still fall through the cracks because providers fail to ask about topics such as travel plans, school health needs, or if they have received immunizations for high-risk environments. Although we have made great strides, nearly eradicating numerous vaccine-preventable illnesses, we still have some work to do to get our current immunization trends and populations up to date. For example, on one end of the spectrum, the percentage of patients across every age group has improved for influenza coverage in the United States.

 Conversely, the need for immunization improvement continues in the area of pneumococcal disease, which is lingering below Healthy People 2020 targets

Pharmacists have been involved with vaccines since the 1800s, but have actively been involved in the routine immunization of patients only for the past 20 years or so. The role of pharmacists in the provision of vaccines has changed and expanded considerably since the first immunization training program in 1994. Since then, pharmacists have progressed from being vaccine advocates to becoming full partners in providing immunizations. Today, many patients may not imagine going anywhere but a pharmacy to get their flu shot.

As the emphasis on preventive care continues to grow, many states are expanding the role of pharmacists as experts in immunizations. According to the most recent update from the American Pharmacists Association in January 2018, pharmacists in all 50 states, as well as the District of Columbia and Puerto Rico, are permitted to administer immunizations.

 Depending on the state, pharmacists can administer vaccines pursuant to a prescription or according to a protocol, while in others, no physician oversight is required. In all but 4 states, pharmacists can provide any vaccine to patients, and in about half of states, pharmacists can provide vaccinations to patients of any age. In every state, pharmacists can administer the most commonly sought adult vaccines for influenza, pneumococcal disease, shingles, and tetanus/diphtheria/pertussis. In 2017, Idaho became the first state to allow pharmacy technicians to administer immunizations, although a pharmacist is still required to perform all of the clinical elements of the immunization, such as prescription verification and patient counseling.

Currently, immunization is the #1 patient care service offered by community pharmacists, highlighting the important role pharmacists play in public health. A total of 73% of community pharmacies offer immunization services, according to 2018 NCPA Digest.

 If one subscribes to the glass-halfempty mentality, only 73% of independent community pharmacies offer immunizations. Clearly, with less restrictive state laws and regulations, that number needs to be, and should be, higher. If your pharmacy is not offering vaccinations as a patient service, consider that you are missing out on an opportunity to help your patients and expand your business.

Look at the recent multistate measles outbreak as an example.

 This resurgence of a disease that had nearly been eradicated may offer the perfect opportunity for pharmacists to start a conversation with patients and employers about the services that are offered which go beyond dispensing. As the most accessible health care providers, community pharmacists have the opportunity, and the obligation, to help patients understand vaccine safety and help dispel the myths created by the small but vocal antivaccine movement.

More than 100 million Americans get a flu shot every year,

 which produces $4 billion to $5 billion in revenue,

 yet the immunization market remains largely untapped. A huge opportunity is waiting to be uncovered beyond the flu shot. Pharmacists should use the flu shot “encounter” to access the patient immunization record, identify gaps in care, and proactively recommend other age-appropriate vaccines. As Beverly Schaefer, RPh, pharmacist and owner of Katterman’s Sand Point Pharmacy in Seattle, Washington, stated, “If you want to add profit to your bottom line, increase the number of immunizations that you’re doing. Every single immunization that you do adds to your bottom line. There are no exceptions.”

Offering immunizations provides opportunities for pharmacies far beyond the revenue that is generated from this service. Pharmacy-based immunization services help build a relationship based on trust between the patient and the pharmacist, leading the patient to rely more on the pharmacist for a wide array of services such as medication synchronization, diabetes education, over-the-counter recommendations, prescription delivery, health screenings, medication therapy management services, and traditional prescription dispensing. Immunizations go a long way toward branding the pharmacy as a destination for health and wellness, an important differentiator in today’s competitive marketplace, which includes a growing number of online and mail-order pharmacies.

Finally, immunizations are a core service set for pharmacies participating in enhanced services networks such as the Community Pharmacy Enhanced Services Network. These pharmacies are required to screen patients for Advisory Committee on Immunization Practices—recommended immunizations, educate patients about needed immunizations, and, if necessary, refer to other health care providers. In today’s health care environment, with the focus on collaborative, team-based care, it is critical that health care providers try to eliminate any remaining and, in some cases, perceived barriers (ie, physician opposition) to providing this important public health service.

Immunizations are among the best ways for pharmacists to demonstrate their value. Pharmacy-based immunization services not only save costs and produce revenue, but also improve patient health and contribute to better outcomes, illustrating the value that pharmacists bring to the entire health care team. Let’s seize the opportunities before us and leverage our position as America’s most accessible health care providers to positively impact public health.

 is the senior director, strategic initiatives, at the National Community Pharmacists Association in Richmond, Virginia.

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Vaccine statistics and numbers. Vaxopedia website. vaxopedia.org/2018/01/10/vaccines-statistics-and-numbers/. Updated February 2, 2019. Accessed July 16, 2019.

10 facts on immunization. World Health Organization website. who.int/features/factfiles/immunization/en/. Updated March 2018. Accessed July 16, 2019.

Table 1. recommended child and adolescent immunization schedule for ages 18 years or younger, United States, 2019. CDC website. cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. Published February 5, 2019. Accessed July 16, 2019.

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2020 topics & objectives: immunization and infectious diseases: national snapshots: IID-7.7. children receiving 4+ doses of PCV by age 19-35 months (percent) by race/ethnicity. Office of Disease Prevention and Health Promotion website. healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/national-snapshot. Accessed July 16, 2019.

Hogue MD, Grabenstein JD, Foster SL, Rothholz MC. Pharmacist involvement with immunizations: a decade of professional advancement [published correction appears in J Am Pharm Assoc (Wash DC). 2006;46(3):308]. 

(2003). 2006;46(2):168-179; quiz 179-182.

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Bright D, Adams AJ. Pharmacy technician-administered vaccines in Idaho.

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Measles (rubeola): measles cases and outbreaks: measles cases in 2019. CDC website. cdc.gov/measles/cases-outbreaks.html. Reviewed July 15, 2019. Accessed July 16, 2019.

Influenza (flu): historical reference of seasonal influenza vaccine doses distributed. CDC website. cdc.gov/flu/prevent/vaccinesupply.htm. Reviewed August 23, 2018. Accessed July 16, 2019.

How to make immunizations a pharmacy profit center. PBA Health website. pbahealth.com/how-to-make-immunizations-a-pharmacy-profit-center/. Published March 15, 2019. Accessed July 16, 2019.

Billing and Reimbursement

Immunizing Patients Is Worth Pharmacists' and Technicians' Time

The goal of the Healthy People initiative is to “provide science-based, 10-year national objectives for improving the health of all Americans.” The most recent initiative, Healthy People 2020, which launched in 2010, has a vision of “a society in which all people live long, healthy lives.” To reach this vision, the goals of Healthy People 2020 include

Longer, better-quality lives without preventable disease, disability, injury, or premature death

Better health and health equity without disparities

Social/physical environments that encourage better health

Better quality of life and healthy development/ behaviors

A total of 42 topics and objectives are incorporated into Healthy People 2020; however, one that is especially important to pharmacists is the topic of immunization and infectious disease. The goal under this topic is to “increase immunization rates and reduce preventable infectious diseases.”

 Despite an increase in life expectancy largely due to immunizations, infectious diseases are still a major cause of illness, disability, and death.

Vaccines, particularly childhood immunizations, continue to be a cost-effective preventive service and provide a high return on investment. For each birth cohort vaccinated with routine immunizations, 33,000 lives are saved, 14 million cases of disease are prevented, spending is reduced by $9.9 billion, and another $33.4 billion in indirect costs are saved.

Still, about 42,000 adults and 300 children die from vaccine-preventable diseases each year in the United States (not including deaths from the 2009 H1N1 influenza outbreak and influenza deaths in general).

 Communities with areas of unvaccinated or undervaccinated populations are at increased risk for outbreaks.

Improved surveillance is critical in reducing illness, hospitalization, and death from vaccine-preventable and other infectious diseases. Better surveillance will save lives by allowing maximum time for public health response, as well as rapid sharing of information and identification of patients in need of immediate treatment.

The immunization recommendations for Healthy People target 17 diseases. Below, we discuss the progress that has been made to meet the Healthy People 2020 goals for vaccination in 4 of these diseases.

The Healthy People 2020 goal for human papillomavirus (HPV) vaccination for adolescents aged 13 to 18 years is an 80% vaccination rate for the HPV series in females.

 There was a 5% increase from 2016 to 2017 in adolescents who completed the HPV vaccination. In 2017, approximately 66% of adolescents received the first dose, and 49% completed the series.

Acute respiratory infections, including pneumonia and influenza, are the eighth leading cause of death in the United States with 56,000 deaths annually. More than 200,000 hospitalizations and 36,000 deaths occur each year due to influenza.

 The goal of Healthy People 2020 is to “increase the percentage of children and adults who are vaccinated annually against seasonal influenza.”

 Using the baseline rate of 38.1% of noninstitutionalized adults 18 years and older vaccinated against influenza during the 2010-2011 influenza season, the Healthy People 2020 target is 70%.

The CDC reported that, as of November 2018, 44.9% of adults had received the influenza vaccine.

The Healthy People 2020 goal for pneumonia is to “reduce invasive pneumococcal infections.”

 Goals for adults do not center around vaccination, but rather the number of cases reported. The baseline was “40.7 new cases of laboratory-confirmed invasive pneumococcal infection per 100,000 adults aged 65 years and over” in 2008, and the target for 2020 is 31.0 cases per 100,000.

 In 2012, there were 29.6 new cases per 100,000, and in 2013, the latest year for which data are available, there were 30.5 per 100,000.

 From 2015 to 2016, pneumococcal vaccination increased 3.3% to 66.9% among adults 65 years and older.

The goal of Healthy People 2020 is to “increase the percentage of adults who are vaccinated against zoster (shingles).”

 In 2008, the baseline year, 6.7% of adults 60 years and over received the shingles vaccine. The target for 2020 is 30%.

 Although Shingrix (recombinant zoster vaccine) is recommended as the preferred shingles vaccines by the ACIP,

 data are not yet available on Shingrix vaccination rates for adults 50 years and older. In 2016, 33.4% of adults 60 years and older reported receiving Zostavax (live zoster vaccine), an increase from the 31% reported in 2015.

Healthy People 2020 is not yet completed; however, planning is already underway for Healthy People 2030, the fifth edition of Healthy People. The developers aim to address new challenges and build on lessons learned from previous decades.

 Much progress has been made in past years; but, the United States still lags behind other developed countries on “key measures of health and well-being: including life expectancy, infant mortality, and obesity, despite spending the highest percentage of its gross domestic product on health. A challenge for Healthy People 2030 is to guide the United States in achieving our population’s full potential for health and well-being so that we are second to none among developed countries.”

Pharmacists play an important role in increasing vaccination rates. As frontline health care providers, pharmacists can consult with patients to access their vaccination status, educate them on the importance of vaccines, recommend which vaccinations are needed, and administer vaccinations. Vaccines should always be documented in Immunization Information Systems, and patients should also keep documentation of vaccinations received, for their personal records.

 is a pharmacist at an independent pharmacy in northern New Jersey.

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Feature

The goal of the Healthy People initiative is to “provide science-based, 10-year national objectives for improving the health of all Americans.” 

Healthy People 2020: Immunization Goals

Vaccine hesitancy and resistance to mandatory vaccination are as old as vaccines themselves.

 Throughout the nearly 200-year history of modern vaccines, there have been groups who, at times through vocal or violent protest, have denied the value of vaccines or exaggerated their risks.

 Ironically, it is often during times when vaccine-preventable disease rates are lowest that public opposition to them is most pervasive. This certainly seems to be the case with contemporary antivaccination movements in the United States. Most parents of today’s young children have never lived in a time or place where infectious diseases such as measles and polio sickened and killed large numbers of people.

Those of us who study public health or work in health care understand that this is because vaccines are arguably the most effective public health intervention in human history. However, it is not irrational for members of the public with varying levels of health literacy to question the necessity of vaccines that prevent diseases to which they have never felt susceptible. In the setting of hyperbolic and widespread discussion in social media venues of purported risks to health and personal liberty, it should be no surprise that some patients and parents wonder whether they should avoid seasonal influenza (flu) shots or even entire schedules of pediatric vaccines.

Very little published research exists to specifically guide pharmacists in addressing vaccine hesitancy. However, as frontline health care providers and a major source of vaccinations in many states, pharmacists have an opportunity to communicate with patients and parents regarding the safety, efficacy, and public health value of vaccines. Several strategies pharmacists can use to reduce the burden of vaccine hesitancy are discussed below. 

BE PREPARED TO RESPOND TO COMMON MISCONCEPTIONS

Multitudes of resources are freely available to all pharmacists through the CDC and other organizations that provide continually updated information about vaccines. In addition to clinical recommendations, educational materials for patients and information to help guide discussion of vaccines are available, see below:

Being well versed in the clinical evidence related to vaccine recommendations is vital in addressing vaccine hesitancy on an individual patient level, and all pharmacists should be prepared to confront a number of very common myths, misconceptions, and misinformation campaigns (table

WORK TO IMPROVE VACCINATION RATES OVERALL

Perhaps one of the most straightforward ways to minimize the impact of vaccine avoidance is to work to improve vaccination rates by other means. This includes ensuring that patients and their parents have access to vaccines, and are aware of recommended vaccines, and know where they can go to get vaccinated. Pharmacy-based vaccine services improve access to vaccines, specifically flu, and can serve an important role for working families who may have difficulty making appointments during regular business hours.

Additionally, pharmacists and other health care providers are encouraged to be mindful of their own vaccination status and receive all recommended vaccines. Not only does every vaccine help improve community-wide coverage, but we should not ask patients to do anything we are not willing to do ourselves.

 is an associate professor in the Department of Pharmacy Practice at West Coast University School of Pharmacy in Los Angeles, California.

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Engaging Patients

Ironically, it is often during times when vaccine-preventable disease rates are lowest that public opposition to them is most pervasive, and this certainly seems to be the case with contemporary antivaccination movements in the United States.

Tackling Vaccination Hesitancy Unrelated to Medical Exemption

The immunization status of pregnant and lactating women should be routinely assessed, and indicated vaccines should be recommended.

 Patients may choose not to get vaccinated for a variety of reasons including short-term and long-term safety concerns, moral grounds or religious beliefs, cost, amount of injections, and lack of knowledge.

 A complete review of vaccine safety is beyond the scope of this article; however, all vaccine providers should be aware of the public perception as well as expert opinion in order help patients make evidence-based decisions. Additionally, some resources to aid clinicians in vaccine administration are listed in the table.

During the 2015-2016 flu season, most pregnant women received their influenza vaccine at an obstetrician gynecologist (OBGYN)/midwifery office (36.6%) or another physician office (28.4%); however, a substantial proportion of women (13.2%) received their influenza vaccine at a pharmacy or store.

 Although many OBGYN offices can administer influenza and tetanus, diphtheria, and pertussis (Tdap) vaccines, pharmacists are more easily accessible to help meet this health care need. A routine vaccination, such as influenza, is an important recommendation that pharmacists can provide expecting women to help close gaps in care. Pregnant women are more likely to experience complications from influenza than nonpregnant women,

 yet less than 50% of US pregnant women were vaccinated during (or in the months prior to) the 2016-2017 flu season.

 The influenza virus causes more severe outcomes in pregnant women compared with nonpregnant women and can lead to adverse birth outcomes including low birth weight. Additionally, infants younger than 6 months of age have a high burden of complications due to influenza, yet no efficacious influenza vaccines are indicated for this age group. Therefore, the influenza vaccine is recommended for all pregnant women and can be administered during any trimester of pregnancy.

Additionally, vaccination with Tdap during week 27 through week 36 of pregnancy provides fetal and neonatal benefit through passive transport of protective antibodies across the placenta to help prevent pertussis or whooping cough in the neonate.

Pharmacists can promote preconception health by educating all women of childbearing age on the importance of vaccinations and administering these immunizations when appropriate. Although there have been no adverse reports in pregnant women or their infants after receiving the influenza (flu) vaccine, there has been increasing controversy over the safety of the flu vaccine, and vaccinations in general, especially in children. Pharmacists who administer vaccines can help increase vaccination rates by providing education to patients with proven lower direct cost

 and convenience. Education can include explaining which vaccines are recommended before and during pregnancy, the infections these vaccines can prevent, and the appropriate timing of administration. Discussions should focus on reviewing evidence related to the risks and benefits of vaccinations and dispelling myths about adverse effects. Because some vaccines are not indicated during pregnancy—such as the measles, mumps, rubella and varicella vaccines&mdash;pharmacists can help patients plan for administration at least 1 month prior to conception or postpartum. Vaccines for hepatitis A and hepatitis B may be given in some patients, depending on risk factors.

Pharmacists can consult the available references to help stay up-to-date on vaccination recommendations, use proven communication strategies to speak with patients on the importance of vaccines, provide patients education materials, and give patients time to discuss their concerns in order to help improve vaccine adherence.

 Dispensing prenatal vitamins and other medications specific to pregnancy are additional opportunities for initiating vaccination discussions.

During patient counseling sessions, questions may arise regarding the place in therapy for preservative-free vaccines including concerns regarding thimerosal, a mercury containing preservative found in the multidose vials of the influenza vaccine. Pharmacists can advise patients that there is no scientific evidence that thimerosal-containing vaccines cause health or developmental problems in children born to women who received thimerosal-containing vaccines during pregnancy. Although thimerosal-free formulations are available, the CDC’s Advisory Committee on Immunization Practices does not indicate a preference for their use in any population. Some states have legislation in place regarding the use of preservative vaccines and so it is important for pharmacists to be aware of the legislation in their state of employment. Specific information on states can be found at the Immunization Action Coalition website (Table).

Other inactive ingredients or preservatives found in vaccines include 2-phenoxyethanol, phenol, and bacteria. Adjuvants such as aluminum salts can improve potency and immune response. Other additives such as gelatin, albumin, sucrose, lactose, monosodium glutamate, and glycine have been found to prevent vaccine deterioration and sticking to vial walls. Residuals are remains of the vaccine production process and include formaldehyde, antibiotics (neomycin), egg protein, and yeast protein. For further details on inactive ingredients, pharmacists can refer to the prescribing information or the FDA’s resource (Table).

Pharmacists can also aid in helping pregnant women prepare for travel. The CDC has information on its Traveler’s Health website specific to the destination of travel (Table). Helping patients plan for vaccinations, as well as counseling them on other ways to prevent illness during travel such as washing their hands, avoiding drinking the water in certain geographic areas, and using mosquito repellent to prevent Zika virus, are areas in which a pharmacist may have a positive impact.

Pharmacists should advocate for vaccine administration when counseling on preconception, prenatal, and postpartum care, and optimize partnerships with local provider groups to offer bidirectional referrals. In addition to receiving vaccinations themselves, pharmacists should stay abreast of clinical and practice updates regarding vaccinations to best serve their patients.

 is a professor of pharmacy practice at Midwestern University Chicago College of Pharmacy in Downers Grove, Illinois.

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Ventola CL. Immunization in the United States: recommendations, barriers, and measures to improve compliance: part 1: childhood vaccinations. 

Ding H, Black CL, Ball S, et al. Influenza vaccination coverage among pregnant women — United States, 2016-17 influenza season. 

2017;66(38):1016-1022. doi:10.15585/mmwr.mm6638a2.

Omer SB. Maternal immunization. N Engl J Med. 2017;376(13):1256-1267. doi: 10.1056/NEJMra1509044.

Arnold LD, Luong L, Rebmann T, Chang JJ. Racial disparities in US maternal influenza vaccine uptake: results from analysis of pregnancy risk assessment monitoring system (PRAMS) data, 2012-2015. 

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Singhal PK, Zhang D. Costs of adult vaccination in medical settings and pharmacies: an observational study. 

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Addressing Immunizations in Pregnant and Lactating Women

The hepatitis B virus (HBV) is spread through contact with infected blood or bodily fluids. The virus usually passes into a host via damaged skin (eg, lesions, needlesticks) or mucous membranes, such as the eyes or genitalia. HBV is viable for at least 7 days outside a host; therefore, the virus can be spread for days in areas visited by an infected individual. HBV can incubate for 40 to 90 days before signs and symptoms are detected.

 With a lack of early and specific symptomology, many cases of HBV infection go undetected until severe liver damage has occurred.

 Because of these factors, vaccination for HBV is critical for almost everyone, especially anyone working or living in a high-risk environment such as a health care setting, or among household contacts or sexual partners who are infected with HBV.

The most commonly reported risk factors for HBV infections are injection-drug use and having multiple sex partners.

 In addition to living in a high-risk environment or having a sexual partner who is hepatitis B surface antigen (HBsAg)-positive, other risk factors include being treated for a sexually transmitted infection, and traveling to areas with high rates of HBV infection. Specific populations at risk for infection include men who have sex with men, victims of sexual assault or abuse, health care personnel or others working in areas where blood or bodily fluids may be present, residents and staff of correctional facilities or homes for developmentally disabled persons; and persons with chronic liver disease, kidney disease, HIV infection, or diabetes.

Vaccines for HBV were first introduced in the mid-1980s.

 Successful vaccination and reliable serologic response to vaccinations have been recognized as lead initiatives responsible for a decline in acute viral hepatitis B infections in the United States since the early 1990s.

 After a significant decline in infections, rates of acute infection have been relatively stable since 2009; however, reported numbers may be lower than actual infections because of the infection’s nonspecific symptoms and lack of testing.

Five FDA-approved hepatitis B vaccines (HepB) are available. They differ in their antigen composition (single or multiple), dosing guidelines, and approved patient populations.

Three recombinant HBsAg vaccines are on the market. Engerix-B (GlaxoSmithKline Biologicals) and Recombivax HB (Merck & Co, Inc) are used for vaccination against HBV infection starting at birth. They are normally administered in a series of 3 doses at 0, 1, and 6 months of age.

 Adolescents aged 11 to 15 years may receive a 2-dose series of the adult formulation (1 mL) of Recombivax HB separated by at least 4 months.

 Heplisav-B (Dynavax Technologies Corporation) is approved to prevent HBV infection in adults 18 years and older.

Two combination products with various antigens are also available. Pediarix (GlaxoSmithKline Biologicals) is used for the vaccination of children aged 6 weeks to 6 years and contains recombinant HBsAg, diphtheria and tetanus toxoids and acellular pertussis adsorbed, and inactivated poliovirus. Twinrix (GlaxoSmithKline Biologicals), used for the vaccination of adults 18 years and older, contains recombinant HBsAg and inactivated hepatitis A virus.

The most recent addition is the Heplisav-B (HepB-CpG) vaccine, which is a single-antigen formulation manufactured without aluminum.

The hepatitis B virus (HBV) is spread through contact with infected blood or bodily fluids, usually passing into a host via damaged skin (eg, lesions, needlesticks) or mucous membranes, such as the eyes or genitalia. 

Immunization Guide for Pharmacists

Empowering Patients to Know Their Immunization History

Immunizing Patients Is Worth Pharmacists' and Technicians' Time

Healthy People 2020: Immunization Goals

Tackling Vaccination Hesitancy Unrelated to Medical Exemption

Addressing Immunizations in Pregnant and Lactating Women

Hepatitis B Virus: Who Is at Risk, and What Can We Do?

New Vaccines in the Pipeline 2019