March 2019 Immunization Guide for Pharmacists

, included a review of the history of immunization information systems (IISs) in the United States and the drivers that, over time, have increased their value. The case was made that after 21⁄2 decades of expansion and growth, these population-based data repositories are no longer just data storage systems; they are now “opportunity systems.”

Consider the value of these data systems across the immunization ecosystem to engage, empower, and influence individual, community, and cultural behavior. Health care professionals would struggle to find a similar health data framework so universally valuable to providers and patients as the IIS.

Let’s explore an example of how to put these data to work.

Public health professionals want to close immunization care gaps. An initiative to accomplish this could start with payers who can measure a provider’s performance in patient coverage rates. Payers could implement a pay-for-performance incentive program to office-based or pharmacy immunization providers. Incentives from such a program could result in more immunizations delivered. Payers, clinicians, caregivers, and, most of all, the patient can reap the benefits of this model through lower health care costs, increased provider revenue, and, perhaps most important, increased disease prevention.

The opportunity to leverage patient immunization history and data at the point of care in a pharmacy environment can increase the trust and credibility of the pharmacist as a member of the patient’s health care team. This opportunity can also create a new framework in which to integrate prescription, prevention, and consultation services. For example, as discussed in part 1 of this series, the US population is nearing 330 million people. In an 11-state sample, 95% of those state populations had an immunization record in their state’s IIS. Even if 80% of a state’s population has information on immunizations in the state’s IIS, pharmacists would have access to the patient immunization histories of more than 260 million individuals across all age ranges.

In 2019, it is not uncommon for a public health immunization information system to capture 10 immunization events per individual. An understanding of the potential power of these data systems begins with realizing that reaching 1 billion patient immunization records in a nationwide IIS requires only an average of 3.7 immunizations per patient. If all IISs captured data from electronic medical records and pharmacies, the health care community could achieve this in no time.

In 2017, results from a pharmacy/public health partnership study evaluated the impact of a real-time connection to immunization decision support.

 The investigators found that 82% of adult patients presenting at the pharmacy counter for an influenza immunization were behind on 1.6 other immunizations. When patients were asked whether they would like to also receive their missing immunizations, the pharmacy team was able to close 41% of those immunization gaps at the same point-of-care moment.

For additional context, consider the recent measles and pertussis outbreaks, which have led to a significant increase in vaccine awareness in the United States.

 This increased public awareness has caused many individuals to wonder, “Am I protected?” Pharmacist consultations, backed with the knowledge of the patient’s immunization history, can influence and encourage action on the patient’s part. More patients may then agree to not just receive their flu shot, but also potentially a tetanus, diphtheria, pertussis vaccine, the pneumococcal polysaccharide vaccine (PPSV23), or a vaccine to protect against hepatitis A or B virus infection.

The following summaries describe these and other opportunities to use immunization data systems to generate outcomes.

OPPORTUNITY NO. 1: CLOSE PATIENT IMMUNIZATION CARE GAPS

Clinicians should ensure their pharmacy immunization data link with public health data and support 2-way information and decision-support tools. This can lead to not only increased disease prevention but also added revenue. The table illustrates a potential revenue gain linked to patients who request a flu shot and consultation services provided by pharmacists about other immunizations needed concurrently.

If pharmacy consultations continue to improve, resulting in a 60% gap closure rate during a flu shot encounter, the monthly revenue on the same 500 flu shots would be more than $67,000 per retail location.

OPPORTUNITY NO. 2: SUPPORT PATIENT-INTEGRATED CARE SERVICES

Immunization gaps are like any other gap in care that pharmacies track through their medication therapy management (MTM) efforts. A solid MTM program that can query patients’ immunization records and identify their gaps in immunizations prior to prescription alignment outreach creates the opportunity to engage the patient in other needed services. MTM outreach can encourage patients to both schedule a flu shot and add on past-due immunizations. If a proactive MTM effort included the immunization component and this effort led to another 500 flu shots with results similar to those illustrated above, that model could translate to another $46,000 to $67,000 in monthly revenue.

OPPORTUNITY NO. 3: FOCUS ON SERIES COMPLETIONS

By focusing on current pharmacy customers who have not been receiving their immunizations in store, retailers can expand pharmacy loyalty and create the opportunity for more in-store visits. Immunization series reminders are a suggested approach to achieving this goal. Sending an alert to an existing patient who started an immunization series elsewhere, via text or by linking this information to MTM tools, can improve consumer health engagement and empowerment.

OPPORTUNITY NO. 4: STRENGTHEN PARTNERSHIPS

Create a patient-centric “immunization ecosystem” that surrounds the patient with immunization education, opportunity messages, and access to administration. This ecosystem should include health care providers that immunize, public health officials, payers, vaccine manufacturers, immunization coalitions, and health advocates. A retail pharmacy with a proactive immunization team that makes its state IIS data a resource can leverage demographics and analytics to assess patient immunization gaps as well as the immunization gaps of the general population living within a given radius of each retail location. These collaborative patient-centric campaigns create an opportunity to reduce the risk of vaccine-preventable disease in a community.

A quick calculation of the potential revenue increase per retail pharmacy per month, using 500 patients per month as a baseline, reveals that establishing opportunity No. 1 (above) leads to an average of $50,000 in new revenue per month. Moreover, proactively collaborating in the 3 other opportunity areas (targeting $25,000 for each) creates a total goal and return on investment of $125,000 per month.

Not all pharmacists, with their limited time constraints, will find taking advantage of these opportunities feasible; however, pharmacy management should be able to implement these programs. Managers can accomplish this by making a phone call to the state public health department or an IIS technology partner and setting the first goal as automating compliance reporting and establishing a 2-way data exchange. At that point, the key technical framework would be in place, with a window into each pharmacies’ patient immunization histories.

The door to opportunity is ready to open, and pharmacy managers should consider these repositories as “data pipes” similar to pipelines linked to oil and gas wells. Pharmacy leadership should feel empowered when collaborating with key partners to turn a valuable, raw resource into intelligence that allows their pharmacists to engage customers with timely, meaningful information.

Pharmacists will play a bigger role in reducing the risk of vaccine-preventable disease in the future. Armed with opportunity systems of state IISs filled with data ready to improve the health of individuals, pharmacists will have the tools to empower their customers and influence health behavior. 

is the CEO of Scientific Technologies Corporation.

Popovich M. Exploring the history and rise of data opportunity systems, part 2. 

® website. pharmacytimes.com/publications/supple- ments/2019/march2019/exploring-the-history-and-rise-of-data-opportunity-systems-part-1. Published March 16, 2019. Accessed April 16, 2019.

Bluml BM, Brock KA, Hamstra S, Tonrey L. Evaluation of the impact of an innovative immunization practice model designed to improve population health: results of the project IMPACT immunizations pilot. 

 2018;21(1):55-62. doi: 10.1089/pop.2017.0049.

Cacciatore MA, Nowak G, Evans NJ. Exploring the impact of the US mea- sles outbreak on parental awareness of and support for vaccination. 

. 2016;35(2):334-340. doi: 10.1377/hlthaff.2015.1093.

Articles

Registries and Information Sharing

The opportunity to leverage patient immunization history and data at the point of care in a pharmacy environment can increase the trust and credibility of the pharmacist as a member of the patient’s health care team.

Exploring the History and Rise of Data Opportunity Systems

Immunization screening and provisions in the pharmacy setting often focus on initiatives for adults over 65 years of age. Yet the majority of the US population is between the ages of 18 and 64, with many of these individuals suffering from a chronic condition: The CDC estimates that 6 in 10 US adults have a chronic disease, and 4 in 10 have 2 or more.

 The most common chronic conditions, and the biggest drivers in annual health care costs for US adults, include heart disease, cancer, chronic lung disease, diabetes, and chronic kidney disease.

 Chronic health conditions with specific adult vaccination recommendations include those above, as well as HIV, chronic liver disease, iatrogenic immunosuppression, sickle cell anemia, and asplenia.

To better serve adults aged 19 to 64 years with chronic conditions, an easy-to-use vaccine guide, based on the CDC’s recommendations, is included below (see table).

 Additional resources to improve immunization screening practices for this patient population are also provided.

Current guidelines recommend that all adult patients aged 19 to 64 years—except those with allergies to components of the vaccine or contraindications&mdash; get an annual flu vaccine, a tetanus (or tetanus, diphtheria, and pertussis) booster every 10 years (assuming prior vaccination history), and the shingles vaccination series at 50 years or older.

Improving screening procedures for recommended vaccinations can be as simple as providing a vaccine screening questionnaire to patients to better identify chronic health conditions. The CDC offers an excellent questionnaire at 

cdc.gov/vaccines/hcp/adults/downloads/patient-intake-form.pdf

 This form can help explain to patients the importance of preventive health. After the patient fills out the form, the pharmacist can scan it into the computer charting system, analyze it, bill the patient’s insurance, and give recommended immunizations at the required intervals.

Resources for vaccine series follow-up are important yet often not discussed. Pharmacy staff can try to help patients set smartphone reminders at the end of their appointment to inform them when their next vaccine is due. Pharmacy staff can also provide appointment cards to remind patients when their next vaccine(s) are due and use technology means, such as text message reminders, to follow up with patients at appropriate intervals.

Using the aforementioned tools, pharmacists can better serve their adult patients with chronic condition immunization needs. 

, is a residency program director and student experiential coordinator at Albertsons Companies in Portland, Oregon. He is an alumnus of the Oregon State University College of Pharmacy. 

National Center for Chronic Disease Prevention and Health Promotion. Chronic diseases in America. CDC website. cdc.gov/chronicdisease/resources/infographic/ chronic-diseases.htm. Updated March 18, 2019. Accessed April 14, 2019.

Immunization schedules. CDC website. cdc.gov/vaccines/schedules/hcp/imz/ adult.html. Updated February 5, 2019. Accessed April 14, 2019.

Engerix-B [prescribing information]. Research Triangle Park, NC: GlaxoSmith- Kline; 2018. gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_ Information/Engerix-B/pdf/ENGERIX-B.PDF. Accessed April 14, 2019.

Twinrix [prescribing information]. Research Triangle Park, NC: GlaxoSmith- Kline; 2018. gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/ Prescribing_Information/Twinrix/pdf/TWINRIX.PDF. Accessed April 14, 2019.

FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old [news release]. Baltimore, MD: FDA; October 5, 2018. www.fda.gov/NewsEvents/ Newsroom/PressAnnouncements/ucm622715.htm. Accessed April 14, 2019.

Standards for practice: vaccine needs assessment. CDC website. cdc.gov/ vaccines/hcp/adults/for-practice/standards/assessment.html. Updated May 2, 2016. Accessed April 14, 2019.

Feature

The most common chronic conditions, and the biggest drivers in annual health care costs for US adults, include heart disease, cancer, chronic lung disease, diabetes, and chronic kidney disease.

Immunizing the 19- to 64-Year-Old Population With Chronic Disease

Immunizations are one of the biggest revenue growth opportunities for pharmacies, and learning to successfully navigate the world of vaccine billing can bring tremendous value to a business. Unfortunately, vaccine billing can be intimidating, which may cause many pharmacies to miss out on this revenue opportunity. Much of the confusion is because of the different ways that vaccines are covered by insurance; however, once the basics of vaccine billing are understood, pharmacists can easily take advantage of this growth opportunity.

PHARMACY COVERAGE VERSUS MEDICAL COVERAGE

Vaccines can be covered under the pharmacy benefit, medical benefit, or in some cases, both. Before reviewing vaccine coverage specifically, it is important to understand the differences between pharmacy coverage and medical coverage in general, including how claims are processed and reimbursed under each type of benefit.

Transactions covered under the pharmacy benefit are processed between the pharmacy and the pharmacy benefits manager (PBM). Claims submitted under the pharmacy benefit are adjudicated in real time, and the PBM provides paid responses based on their contracted rates with the pharmacy. Although the PBM may later apply clawbacks or direct and indirect remuneration (DIR) fees, the amount paid on a transaction will not change from what is shown during the claim adjudication.

Medical coverage accounts for a smaller percentage of a pharmacy’s overall transactions, but claims covered under the medical benefit are generally higher-value transactions such as specialty drugs, clinical services, durable medical equipment (DME), and, of course, certain vaccines. Medical benefit transactions occur between the pharmacy and the payer directly, as opposed to the pharmacy and the PBM. These claims must be submitted in batches and must use the required American National Standards Institute X12 837 batch standard or a CMS 1500 form. With medical claims, it is still possible to receive a denial days or weeks after a claim has been adjudicated, since the batch submission process does not occur in real time. A pharmacy can mitigate their denials by incorporating claim adjudication technology into their work- flow (see “Leveraging Technology”).

When it comes to vaccines, the simplest answer on how they are covered is that it depends on both the payer and the type of vaccine. Included above is a high-level summary of major payers, vaccines, and coverage types (see 

DISPELLING THE MYSTERY OF THE MEDICAL BENEFIT

There is a common misconception that not all pharmacies can bill vaccines under the medical benefit. Any pharmacy can bill medical benefit claims, but there is one important dependency. Because the relationship for medical coverage is between the pharmacy and the payer directly, the pharmacy must be contracted with the payer in order to bill under the medical benefit.

To bill claims to Medicare Part B, pharmacies must complete a CMS 855B application and be enrolled as a mass immunizer. The application approval process takes about 8 weeks, and once the application is complete, the pharmacy receives a Provider Transaction Access Number (PTAN) and is able to bill flu and pneumococcal vaccines covered under the medical benefit to Medicare Part B.

To bill claims to commercial payers, pharmacies must be contracted with each commercial payer that they wish to bill. For independent and smaller retail pharmacies, contracting with individual commercial payers can prove difficult, if not impossible. For those pharmacies that fall into this category, it is important not to be discouraged and abandon vaccines covered under the medical benefit altogether. There is still a lot of value in billing vaccines to Medicare Part B, and setting up to bill this way is worth the investment.

LEVERAGING TECHNOLOGY TO SIMPLIFY VACCINE BILLING

Good technology makes life easier, and the world of vaccine billing is no exception. Although claim submission under the pharmacy benefit is pretty straightforward, medical claim submission is more complex. A good medical claim billing solution will handle the complexities behind the scenes, automating the process and allowing operation within an existing workflow.

During the claim adjudication process, an effective technology solution will have a built-in set of rules (eligibility, coverage, etc) for each payer and apply those rules to the claim in real time. This reduces some of the risk around medical claim reimbursement by ensuring that the claim includes all of the required information and increasing the likelihood of receiving the expected reimbursement.

Technology should also allow providers to submit both pharmacy and medical benefit claims the same way, within the existing workflow of the pharmacy management system. If a technology solution requires an already busy pharmacist to change their workflow, it is not likely to be effective. Technology solutions should seamlessly integrate into an existing workflow and accounts receivable processes.

Navigating the world of vaccine billing is not as difficult as it may seem at first. Finding the right technology partner can help ensure success. Investing in a solid foundation for medical claim billing will have a positive impact beyond just immunizations. As provider status for pharmacists expands, a growing number of clinical services covered under the medical benefit (eg, oral contraceptive prescribing, health assessments, point-of-care diagnostic testing, smoking cessation counseling, etc) will create new ways for pharmacists to serve their patients and grow their business. Understanding how to effectively bill for these new services will be essential for pharmacies to differentiate their brand in today’s competitive market.

 is the chief executive officer of OmniSYS. He focuses on driving innovation and delivering high-impact solutions that enable customers to grow their businesses profitably.

Billing and Reimbursement

Once the basics of vaccine billing are understood, pharmacists can easily take advantage of this growth opportunity.

Navigating the World of Vaccine Billing

Academic detailing is an educational approach intended to create sustainable practice change and improve decision making.

 Through academic detailing visits, health care providers share tailored material with each other, with the goal of encouraging the use of evidence-based guidelines. The academic detailing model was developed by faculty from Harvard Medical School in the 1980s. For the model to be successful, there must be a focused problem that can be addressed through educational outreach and a well-defined target audience. Interactive learning is emphasized with repetition and reinforcement of key points.

For those interested in learning more about academic detailing, the National Resource Center for Academic Detailing (NaRCAD) is a useful guide.

 NaRCAD was founded in 2010 and operates as part of Brigham and Women’s Division of Pharmacoepidemiology and Pharmacoeconomics.

 This resource center supports clinical outreach education programs across the United States and internationally,

 offering information about live training programs, an online core toolkit, material created during previous successful academic detailing projects, and a blog written by health care providers actively engaged in providing detailing to address a variety of medical issues.

UTILIZING ACADEMIC DETAILING TO IMPROVE IMMUNIZATION RATES

Academic detailing has shown promise as a method for improving immunization rates. A national pneumococcal vaccination task force found that barriers to vaccination included provider vaccine knowledge gaps and failure to assume responsibility for patient vaccination.

 Academic detailing can be utilized to engage providers on both of these issues. According to the National Foundation for Infectious Diseases, there are 4 key barriers to vaccinating adults with chronic conditions

Addressing other competing priorities during patient visits

Difficulty determining vaccination status

Competing priorities during patient visits create difficulty in integrating adult vaccination screening, education, and administration.

 To address these issues, providers must become efficient at recognizing the vaccination needs of a patient, which is a task that can be addressed through academic detailing.

The results of a study to identify barriers and facilitators of pneumococcal vaccination in older adults demonstrate that of those patients who were not vaccinated for pneumococcal pneumonia, three-quarters believed their physician either did not think they should be vaccinated or they did not know their provider’s position on the vaccine.

 One of the major predictors of vaccination success is having a vaccination recommendation from a health care provider.

 Using academic detailing to enhance awareness of the current immunization guidelines and taking steps to ensure physicians and other patient-care providers will endorse vaccinations are crucial to improving immunization rates.

UTILIZING ACADEMIC DETAILING TO IMPROVE PROVIDER KNOWLEDGE

From November 2013 through June 2015, a pharmacist-led academic detailing team reached out to more than 400 practice sites in Rhode Island.

 The goal of this statewide education campaign was to increase knowledge and awareness of pneumococcal immunization recommendations. The results were measured using multiple metrics. After participating in the academic detailing, providers were asked to participate in an anonymous 6-question survey. The results showed 92% of providers agreed or strongly agreed to having improved knowledge of identifying patients needing a pneumococcal vaccine, 83% of participating providers intended to apply the knowledge in their clinical practice, and 73% expected to change their vaccination practices as a result of the academic detailing and education materials.

In addition to the survey, the research team compared state vaccination rates from 2013-2015. During this time, a statistically significant increase in pneumococcal immunization rates was seen in Rhode Island: The state had a 5.4% jump compared with 4.3% nationally. Additionally, a statistically significant decrease in the number of patients admitted to a hospital for pneumococcal disease was observed from the pre-intervention period to the postintervention period.

In a separate study in Washington state beginning in 2016, an interprofessional team comprising 5 faculty members from 2 universities (Washington State University and the University of Washington) and 3 health disciplines (medicine, nursing, pharmacy) collaborated to provide academic detailing. The goal of this project was to improve rural medical staff knowledge about pneumococcal immunization rates.

 The team developed academic detailing material to inform an interdisciplinary provider base about appropriate use of 2 adult pneumococcal vaccines.

 Two members of the project team attended a 2-day academic detailing training program at NaRCAD to gain skills with developing and presenting academic detailing material.

 Then the research team met with physicians from 2 local clinics, with the goals of learning about current pneumococcal immunization practices and inquiring about what educational materials would be useful to the clinic personnel. The interprofessional team created academic detailing materials using Avorn’s 3-step approach

Share material through academic detailing visits presented by trained providers

The results showed the detailing materials were well received at both clinic locations. One physician stated in an email, “What I have found is that if I advocate for [immunizations], most of my patients just do them—they say something like ‘Do you think I should?’; [and] I respond with ‘Yep’ and that is almost always the end of the conversation... Who would guess that is all it takes?”

Although more studies are needed to confirm the success of academic detailing in improving immunization practices and increasing immunization rates, this novel educational approach shows promise. Existing research demonstrates improvement in immunization rates and provider knowledge and a decrease in the prevalence of vaccine-preventable diseases.

is a clinical assistant professor in the department of pharmacotherapy at the Washington State University College of Pharmacy and Pharmaceutical Sciences.

Avorn J. Academic detailing; “marketing” the best evidence to clinicians. 

. 2017;317(4):361-362. doi: 10.1001/jama.2016.16036.

Soumerai SB, Avorn J. Principles of educational outreach (‘academic detailing’) to improve clinical decision making. 

About us. NaRCAD website. narcad.org/about-us.html. April 17, 2019.

Division of Pharmacoepidemiology and Pharmacoeconomics. Brigham and Women’s Hospital website. drugepi.org. Accessed April 17, 2019.

Rehm SJ, File TM, Metersky M, Nichol KL, Schaffner W; National Foundation for Infectious Diseases Pneumococcal Disease Advisory Board. Identifying barriers to adult pneumococcal vaccination: an NFID task force meeting. 

. 2012;124(3):71-79. doi: 10.3810/pgm.2012.05.2550.

National Foundation for Infectious Diseases. Call to action: preventing pneumococcal disease in US adults with chronic conditions. NFUD website. adultvaccination.org/professional-resources/pneumo/cta-chronic-conditions.pdf. Published July 2015. Accessed April 17, 2019.

Zimmerman RK, Santibanez TA, Fine MJ, et al. Barriers and facilitators of pneumococcal vaccination among the elderly. 

National Vaccine Advisory Committee. A pathway to leadership for adult immunization: recommendations of the National Vaccine Advisory Committee: approved by the National Vaccine Advisory Committee on June 14, 2011. 

Koch JA. Strategies to overcome barriers to pneumococcal vaccination in older adults: an integrative review. 

. 2012;38(2):31-39. doi: 10.3928/00989134-20110831-03.

Caffrey AR, DeAngelis JM, Ward KE, et al; Rhode Island Pharmacy Pneumococcal Vaccination Education Group. A pharmacist-driven academic detailing program to increase adult pneumococcal vaccination. 

. 2018;58(3):303-310. doi: 10.1016/j.japh.2017.08.010.

McKeirnan K, Colorafi K, Panther S, Potyk D, McCarthy J. Teaching the healthcare team about pneumococcal vaccination practices for older adults through academic detailing. 

Academic detailing is an educational approach intended to create sustainable practice change and improve decision making. Through academic detailing visits, health care providers share tailored material with each other, with the goal of encouraging the use of evidence-based guidelines.

Examining the Role of Academic Detailing in Improving Immunization Practices

Because of their impact on public health, immunizations are considered one of the greatest medical achievements of modern civilization.

 Since this vital medical intervention became available in the 18th century, there has been a significant decrease in the incidence, prevalence, morbidity, and mortality of vaccine-preventable diseases.

 Between 1924-2019, more than 103 million cases of smallpox, polio, measles, mumps, rubella, hepatitis A, diphtheria, and pertussis are estimated to have been prevented thanks to the introduction of vaccines. In recent years, immunizations have helped prevent between 2 and 3 million deaths annually in the United States.

 In addition, endemic transmission of polio and rubella has been eradicated from the United States, and smallpox has been eradicated worldwide.

Although childhood vaccination programs have helped contribute significantly to the positive impact of vaccines on public health, there are no formalized vaccination delivery programs for adults. As a result, vaccination rates are low among this patient population, increasing their susceptibility to serious illness and complications.

 Furthermore, vaccine-preventable diseases, including measles, have seen a resurgence over the last decade due to waning vaccination.

On average, 50,000 Americans die of vaccine-preventable diseases each year, of which more than 99% are adults.

 Therefore, it is crucial that pharmacists understand the barriers impacting immunization rates among adults and actively engage in strategies to improve vaccination rates not only among high-risk groups but also among non—health care consumers (ie, those who are otherwise healthy and do not regularly seek out health care services).

The US Public Health Service and multiple other stakeholders have identified barriers that impact adult immunization.

 Knowing these barriers is essential to creating strategies to engage adult patients and improve vaccination rates. These are the most common barriers to adult immunization:

 The importance of vaccination among adults is a low priority in the United States.

There is no formal vaccine delivery system for adults in the US health care system, and most employers—in contrast to schools that enroll children&mdash;do not require proof of vaccination for employment. Furthermore, there is a pervasive belief among American adults that if they are healthy, they do not need to receive immunizations or have wellness visits with their health care providers.

 A lack of information about vaccines is identified as a major contributor to the low vaccination rate among adults in the United States.

 The results of a survey of more than 2000 adults aged 19 to 74 years showed that 90% to 96% knew the tetanus vaccine existed but only 36% knew a booster dose was required every 10 years, and 74% thought a booster was only required after an injury.

 Similarly, 65% were aware of the pneumococcal vaccine, but 56% had not received it because their doctor had not recommended it.

 Myths and misinformation concerning vaccines and their potential adverse effects are prevalent.

 As a result, adults may not inquire about immunizations out of fear of adverse effects or due to a dislike of needles. Some patients also object to vaccines for religious principles or cite individual rights.

 The cost of vaccination, lack of transportation, language barriers, and incomplete records can all contribute to the lack of accessibility of vaccines.

 These include costs of immunizations, vaccine storage difficulties, and easily accessible immunization records.

For example, in 2012, only an estimated 31% of family physicians and 20% of internists stocked all routinely recommended adult vaccinations.

 As a result, patients may have difficulty obtaining certain vaccinations and may be unaware of alternative health care facilities, such as pharmacies, that can give them vaccines.

Pharmacists have been involved in vaccinations since the mid-1800s, with the procurement and distribution of smallpox vaccine for physicians.

 Today, pharmacists can not only distribute vaccines, they can also immunize patients in all 50 states, the District of Columbia, and Puerto Rico. Currently, 61% of community pharmacies offer immunizations as a service to their community.10 Furthermore, their accessibility and convenience for patients can increase immunization acceptance.

In addition, pharmacists have also created immunization programs that go beyond passive immunizing by actively identifying and administering vaccines to eligible patients.

 The majority of research evaluating the pharmacist’s impact on immunization rates has been for influenza and pneumococcal disease; however, most pharmacies who provide vaccines also provide the majority of the routinely recommended adult immunizations.

 Therefore, pharmacists can help bridge the gap for patients whose physicians do not regularly stock all the vaccines.

STRATEGIES TO ENGAGE NON—HEALTH CARE CONSUMERS

The accessibility of primary care in the United States is decreasing, in part, due to a rapidly aging population. US survey data show that the average wait time for an appointment with a primary care physician is about 20 days.

 Pharmacists are the most accessible health care provider and can help engage patients, who do not regularly seek out health care services, with the following strategies:

 Pharmacists interact with patients daily in their clinical practice regardless of the health care setting. They should assess a patient’s vaccination history at every encounter and educate patients on the importance of being up-to-date on any needed immunizations. A strong recommendation from a health care provider is a strong predictor of patient acceptance.

 For example, a 2016 systematic review found that increases in immunization rates resulting from a pharmacist recommendation were similar to those made by physicians or nurses.

 Pharmacies that offer immunizations can increase their accessibility by offering immunization services via walk-in visits and availability during extended hours. Immunization programs with these additional services have been shown to reach new patients (ie, individuals who do not currently utilize the pharmacy).

Utilize immunization information systems:

 Immunization registries can assist health care providers in consolidating immunization records for individuals who have multiple providers. As a result, pharmacists can utilize these registries (where available) to identify immunization gaps at the point of care or when patients are unsure of their immunization record.

Participate in community-based advocacy programs:

 Pharmacists can reach new patients and non—health care consumers via community outreach.

 Examples include partnering with local community centers to promote wellness and needed immunizations via clinics, brochures, posters, and educational seminars.

 Pharmacists can also partner with local businesses to provide immunization clinics to help keep patients healthy in the workplace.

 Pharmacists can participate in vaccine administrative programs offering immunizations to improve public health in their community. Regardless of the strategy that is used to engage new patients who are not regular health care consumers, it is essential that the pharmacy team is appropriately trained and has adequate supplies and sufficient space for offering immunizations.

 Vaccine administrative programs should also have protocols in place for immunization emergencies and the prevention of needlestick and sharps injuries.

Vaccines, as a medical intervention, have significantly decreased vaccine-preventable diseases; however, adult patient population immunization rates in the United States remain low, increasing the risk of serious illness and complications. The causes of these low immunization rates are multifactorial. Pharmacists are the most accessible health care provider; as such, they can help overcome these barriers. Employing strategies to reach not only high-risk individuals but also those who are non—health care consumers is essential to help improve immunization rates among the US adult population.

is a clinical pharmacist and the Founder and CEO of Banner Medical LLC, a medical communications company.

Ventola CL. Immunization in the United States: recommendations, barriers, and measures to improve compliance. part 2: adult vaccinations. P T. 2016;41(8):492-506.

Baroy J, Chung D, Frisch R, Apgar D, Slack MK. The impact of pharmacist immunization programs on adult immunization rates: a systematic review and meta-analysis.

 (2003). 2016;56(4):418-426. doi: 10.1016/j. japh.2016.03.006.

van Panhuis WG, Grefenstette J, Jung SY, et al. Contagious diseases in the United States from 1888 to the present. 

. 2013;369(22):2152-2158. doi: 10.1056/NEJMms1215400.

Isenor JE, Edwards NT, Alia TA, et al. Impact of pharmacists as immunizers on vaccination rates: a systematic review and meta-analysis. 

. 2016;34(47):5708-5723. doi: 10.1016/j.vaccine.2016.08.085.

Lutz CS, Kim DK, Black CL, et al. Clinicians’ and pharmacists’ reported implementation of vaccination practices for adults. 

. 2018;55(3):308- 318. doi: 10.1016/j.amepre.2018.05.011.

Porteous GH, Hanson NA, Sueda LA, et al. Resurgence of vaccine-preventable diseases in the united states: anesthetic and critical care implications. 

. 2016;122(5):1450-1473. doi: 10.1213/ANE.0000000000001196.

Anderson EL. Recommended solutions to the barriers to immunization in children and adults. 

Adult immunization schedule by vaccine and age group. CDC website. cdc.gov/vaccines/schedules/hcp/imz/adult.html. Updated April 4, 2019. Accessed April 14, 2019.

Hurley LP, Bridges CB, Harpaz R, et al. U.S. physicians’ perspective of adult vaccine delivery. 

. 2014;160(3):161. doi: 10.7326/M13-2332.

National Community Pharmacists Association. Immunizations. National Community Pharmacists Association. https://www.ncpanet.org/innovation-center/ diversified-revenue-opportunities/immunizations. Published 2019. Accessed 14 April 2019.

Figge H. Engaging the patient: tools and techniques. US Pharmacist. August 18, 2016. uspharmacist.com/article/engaging-the-patient-tools-and-techniques. Accessed April 14, 2019.

Engaging Patients

Improving Vaccination Rates Among Adult Non-Health Care Consumers

Pharmacists can put many safeguards into place to ensure patient safety when providing immunizations. Although patient safety is always crucial, pharmacists may not be doing enough to ensure their own safety during the immu- nization process. As immunizers, pharmacists can protect themselves in a number of ways. This article focuses on proper administration technique and safety-focused equipment that can keep both patient and immunizer safe.

Proper immunization technique is the most important aspect in protecting immunizers against both accidental finger sticks and exposure to bloodborne pathogens. Before preparing immunizations, pharmacists should clean their hands with soap and water or an alcohol-based hand sanitizer. During preparation, work in a clutter-free location that is as free from distraction as possible, and always maintain a keen focus on an uncapped needle, especially when recapping is necessary. To recap, scoop up the cap with the needle and secure it by applying pressure against a firm, clean, nonslip surface. Always use only 1 hand when scooping up the cap.

When administering an immunization, focus on these key steps:

Wear properly fitting gloves to protect against potential exposure to bloodborne pathogens. Gloves that are too large can get caught on the syringe, whereas those that are too tight can break during administration.

Never take eyes off an uncapped needle until the injection has been performed and the nee- dle has been safely discarded in a sharps con- tainer. The container should be on the same side as the hand that is holding the syringe. This will prevent the needle from passing over any part of the immunizer’s body on the way to the sharps container.

Put the needle into the sharps container immediately after withdrawing it from the patient. Any attempt to clean up blood or apply a bandage should come only after the needle has been properly discarded.

The immunizer should keep an adequate supply of sterile gauze and bandages nearby to minimize bleeding from the patient and reduce the risk of bloodborne pathogen exposure. Hold any material contaminated with blood in the palm of 1 gloved hand, and contain the material on the inside of the glove while removing it and turning it inside out with the opposite hand. This will form a pouch and contain the contaminated material, which can then be safely discarded. After the immunization, pharmacists should again wash their hands or use sanitizer to help eliminate any contaminants they might have touched.

Another important component of immunization administration is the use of safety-focused equipment or devices, in addition to properly fitting gloves. Use prefilled syringes whenever possible to reduce accidental finger sticks during preparation; this way, immunizers only need to attach the needle to the syringe. Prefilled syringes also cause less pain for the patient because the needle has not been previously inserted through a stopper in a vial, which could slightly dull the needle’s tip.

Pharmacists should use a safety syringe for all immunizations to also reduce the risk of finger sticks after the immunization. One type contains a spring-loaded retractable needle and a button on the end of the plunger or at the base of the needle. Press or squeeze the button to retract the needle into the barrel of the syringe, leaving no exposed tip to remove from the patient upon completion of the injection. Remember to activate the needle while it is still in the patient. The activation has an audible click that the immunizer should alert the patient to, but it does not cause any additional pain. If the device does not activate properly, withdraw the needle from the patient and place it directly into the sharps container. There is no need to activate the device after withdrawing it from the patient.

A second type of safety syringe features a sheath that the immunizer can slide over the needle tip after removing it from the patient. Using the thumb of the administration hand, simply push the sheath forward until it covers the needle. Immunizers should point the needle down and away from them before activation to prevent any residue from spraying onto them or the patient when the sheath is put into place. Do not involve the nonimmunizing hand in this process.

A newer piece of protective equipment is a barrier bandage that pharmacists can place on the patient before the immunization. This bandage has a membrane in its center that will allow the needle to be inserted through it and into the patient. The membrane will seal itself after the needle is removed and contain any blood if the patient bleeds. The immunizer should instruct patients to apply light pressure to the outside of the bandage if they are bleeding. With this safety bandage, the immunizer is never exposed to the patient’s blood.

Pharmacist safety is sometimes an afterthought when planning immunization best practices; however, during any immunization administration, both patient and pharmacist are at risk. By following proper techniques and using safety equipment, a diligent pharmacist can minimize the risks and help guarantee a successful immunization program.

, is pharmacy manager at Tom Thumb Pharmacy in Plano, Texas, and an active preceptor at Texas Tech University and the University of Houston. He is also the founder of the website Helpful Pharmacist (helpfulpharmacist.com).

Pharmacists can put many safeguards into place to ensure patient safety when providing immunizations.

Tips to Stay Protected During Immunization Administration

In the confusing and changing world of immunizations, the question of which tetanus vaccine to provide challenges a pharmacist’s ability to protect patients. Add to that the difficulty in obtaining accurate immunization records for adult patients, and the struggle is amplified. Questions that plague pharmacists include, “What does a provider do when a patient cannot recall infor- mation regarding their last dose of tetanus?” “Did the patient receive the Tdap (tetanus, diphtheria toxoids, and pertussis) vaccine or a Td (tetanus and diphtheria toxoids) booster?” “Was the vaccine given during pregnancy?” “When was the last time the patient received the vaccine?” These questions are even more difficult for a pharmacist to answer in the moment.

Even with registry access and provider consultations, last-dose information may still be unavailable. With immunization rates for adults being low

, it is critical that pharmacists be able to make confident recommendations to their patients. The purpose of this article is to clear up any confusion pharmacists have regarding tetanus vaccines in adults and enable them to make informed decisions when immunizing patients and stocking their pharmacies.

Clostridium tetani, the microorganism that causes tetanus, enters the body through an open wound. Tetanus is caused by the exotoxin produced by the bacterium, which is released into the bloodstream and lymphatic system. Because the bacterium is anaerobic, it germinates in low-oxygen conditions. The exotoxin leads to nervous system disruption and causes muscle contractions and spasms.

In the confusing and changing world of immunizations, the question of which tetanus vaccine to provide challenges a pharmacist's ability to protect patients.