Adult Immunizations: Are Your Patients Up-to-Date?
In the health-system setting, pharmacists must often prioritize their attention to treating the most acute medical condition a patient presents with; however, it is important to also consider opportunities to prevent disease.
In the health-system setting, pharmacists must often prioritize their attention to treating the most acute medical condition a patient presents with. However, it is important to also consider opportunities to prevent disease. Vaccines are life-saving medications that may prevent a disease before it ever occurs. This is particularly true for patients who require hospital admission, as they are typically at high risk for contracting these vaccine-preventable illnesses. Are the patients you care for up-to-date? Before your patient is discharged, consider the TIPS mnemonic to remember 4 key vaccines that all adult patients need: Tetanus, Influenza, Pneumococcal, and Shingles.
Tetanus, Diphtheria, and Acellular Pertussis Vaccine
Pertussis is a highly contagious disease caused by the bacterium Bordetella pertussis. More commonly known as whooping cough, pertussis is transmitted by respiratory droplets when coughing or sneezing in proximity to others.1 Pertussis most commonly affects infants younger than 1 year. It usually starts with cold-like symptoms such as a runny nose, low-grade fever, mild cough, and apnea. After 1 to 2 weeks, severe uncontrollable coughing with a loud “whooping” sound may emerge and continue for weeks. This cough is potentially lifethreatening because it may lead babies to stop breathing. Many patients who contract pertussis are infected by grandparents, parents, siblings, or caregivers.2
The best way to protect against pertussis is for adults to receive 1 dose of the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine. The vaccine takes 2 weeks to reach maximum effectiveness. Adults should use caution around young children during this time frame.3 The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommends a single Tdap dose for persons 19 to 64 years. Persons 65 years or older who have or who anticipate having close contact with an infant less than 12 months of age and who previously have not received Tdap should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission.4 Another vaccine called Td protects against tetanus and diphtheria, but not pertussis. A Td booster should be administered every 10 years. In individuals who have never received the Tdap vaccine, Tdap should replace 1 Td booster dose.2
Influenza, or the flu, is an acute respiratory illness caused by the influenza virus and is transmitted through respiratory secretions. In the United States, flu season spans from October to May each year, with peak infection rates occurring around January.5 The flu is responsible for significant morbidity and mortality. From October 2014 to April 2015, influenza resulted in approximately 65.5 hospitalizations per 100,000 persons and a mortality rate of 6.4%.6 To aid in the prevention of influenza epidemics, it is recommended that all persons 6 months and older receive the annual influenza vaccine, with rare exception. The only persons for whom influenza vaccination is not recommended are children who are less than 6 months of age or those who have a severe, life-threatening allergy to the influenza vaccine.5 Table 17,8 provides insight into the clinical use of available influenza vaccines.
Approximately 900,000 Americans contract pneumococcal pneumonia each year; 5% to 7% of these cases result in death. In addition, 400,000 hospitalizations are attributed to pneumococcal pneumonia annually in the United States.9 Streptococcus pneumoniae, the most common pathogen associated with pneumococcal pneumonia, is also a leading cause of invasive diseases such as bacteremia and meningitis. Risk factors that can increase a patient’s likelihood for pneumococcal disease include:
- Chronic illnesses (lung, heart, liver, or kidney disease; asthma; diabetes; or alcoholism)
- Weakened immune system (HIV/ AIDS, cancer, long-term steroid use, or damaged/absent spleen)
- Living in nursing homes or other longterm care facilities
- Cochlear implants or cerebrospinal fluid leaks
- Cigarette smoking
There are 2 vaccines available for protection against pneumococcal disease: pneumococcal conjugate vaccine (PCV13 [Prevnar 13]) and pneumococcal polysaccharide vaccine (PPSV23 [Pneumovax 23]). On September 4, 2015, the CDC ACIP updated its recommendations on the administration intervals between these 2 vaccines.10 Online Table 211 provides an overview of the use of these vaccines in adults.
Table 2: Current Recommendations for PCV13 and PPSV23 Use in Adults11
Ages 19 to 64 years
* If PPSV23 was given prior, wait 1 year before giving PCV13.
* If PPSV23 was given prior and group B (see below), wait at least 5 years before giving a second dose of PPSV23.
Timeline for Vaccine Administration
Long-term care facility resident
PCV13 → wait 8 weeks → PPSV23 → wait 5 years → PPSV23
Cerebrospinal fluid leaks
PCV13 → wait 8 weeks → PPSV23
Age 65 years or older
* If PCV13 was given before 65 years, no additional PCV13 is needed
Timeline for Vaccine Administration
No prior history
PCV13 → wait 1 year (8 weeks if Group B or Group C) → PPSV23
PPSV23 before age 65 years
Wait 1 year since last PPSV23 → PCV13 → wait 1 year AND 5 years from prior PPSV23 → PPSV23
PPSV23 at age 65 years and older
Wait 1 year since last PPSV23 → PCV13
PCV13 = pneumococcal conjugate vaccine 13; PPSV23 = pneumococcal polysaccharide vaccine 23.
Herpes zoster infection, or shingles, is the reactivation of the dormant varicella- zoster virus located in the sensory ganglia, which typically manifests as a painful, blister-filled rash wrapped around 1 side of the trunk; it can also appear on the face and scalp. Adults 50 years and older are at the greatest risk for shingles; at age 60, the risk sharply increases for developing post-herpetic neuralgia, defined as pain that persists for 90 days or more after the onset of shingles and can last for years.12,13 Post-herpetic neuralgia can severely limit the quality of life of the individual and affect all 4 health domains: physical, psychological, functional, and social.13
A shingles vaccine (Zostavax) is approved by the FDA for persons 50 years and older without contraindications to the vaccine. However, the CDC ACIP guidelines do not recommend the vaccine until a patient is at least 60 years of age. Contraindications include a severe allergy to gelatin, neomycin, or any other vaccine component; immunosuppression; and pregnancy. (Contact dermatitis to neomycin is not considered a contraindication.) Whereas the risk of shingles is increased at age 50, incidence is lower in the 50-to-59 age group than in adults older than 60 years.14 Factors that might lead a health care professional to immunize an individual at age 50 to 59 years include preexisting chronic pain, severe depression, or other comorbid conditions; inability to tolerate treatment medications because of hypersensitivity or interactions with other chronic medications; and occupational considerations.15
It can become increasingly challenging for pharmacists to stay current on proper vaccine use, as recommendations for current vaccines are improved or new vaccines become available to prevent disease. It is important that pharmacists rely on credible sources for vaccine information. The CDC is the “gold standard” resource for both pharmacists and patients (www.cdc .gov/vaccines). The Immunization Action Coalition provides a wide array of resources for pharmacists, physicians, nurses, and other public health professionals (www.immunize.org). The American Pharmacists Association maintains an immunization resource center (www.pharmacist.com/immunization-center) and provides a national certificate training program that is recognized by the CDC for meeting national standards in vaccine education.16 Online Table 317 notes select reputable applications available for download. Online Table 44,7,10,12 provides a snapshot of the adult immunizations covered in this article.
Table 3: Select Immunization-Related Apps17
ACP Immunization Advisor
American College of Physicians
CDC Vaccine Schedules
Centers for Disease Control and Prevention
Group on Immunization Education of the Society of Teachers of Family Medicine
Vaccines on the Go: What You Should Know
Vaccine Education Center of the Children’s Hospital of Philadelphia
Pharmacist involvement with immunizations spans over 2 decades.18,19 Numerous articles advocate for health-system pharmacists’ role in immunizations and document the improvements they have made in vaccination rates, particularly through use of standing orders or protocols.20-25 Health-system pharmacists are health care professionals on the frontline of patient care. Attention to a patient’s current immunization status can be an important, life-saving measure.
Table 4: Summary of Select Vaccine Recommendations for Adults4,7,10,12,a
Vaccines Available, Brand Name (Manufacturer)
Number of Doses Needed
Route of Administration
Not previously received and ≥18 years
Health care professionals or anyone having close contact with a child <12 months
Pregnant women between 27 and 36 weeks’ gestation
Booster dose when ≥18 years
1 dose every 10 years
Individuals who wish to reduce the likelihood of catching the flu, ≥18 years
High-risk individuals, ≥18 years
High-risk individuals include those with chronic health conditions or weak immune systems, pregnant women, and those ≥65 years
â— Afluria (bioCSL)
â— Fluvirin (Novartis)
â— Fluzone (Sanofi)
â— Fluarix (GSK)
â— FluLaval (GSK)
â— Fluzone or Fluzone Intradermal (Sanofi)
â— Flucelvax (Novartis)
â— Flublok (Protein Sciences)
â— Fluzone High-Dose (Sanofi)
1 dose annually
IM or ID
Healthy individuals 18 to 49 years of age
â— FluMist (MedImmune)
1 dose annually
Pneumococcal conjugate (PCV13)
Individuals ≥65 years
High-risk individuals b: 19 to 64 years of age
Individuals who smoke cigarettes or have asthma and are 19 to 64 years of age
Prevnar 13 (Wyeth/Pfizer)
Max 1 dose per lifetime
Pneumococcal polysaccharide (PPSV23)
Individuals ≥65 years
High-risk individuals,b 19 to 64 years of age
Individuals who smoke cigarettes or have asthma, 19 to 64 years of age
Max 3 doses per lifetime
IM or SC
FDA approval: ≥50 years
ACIP recommendation: ≥60 years
ACIP = Advisory Committee for Immunization Practices; GSK = GlaxoSmithKline; ID = intradermal; IM = intramuscular; PCV13 = pneumococcal conjugate vaccine 13; PPSV23 = pneumococcal polysaccharide vaccine 23; SC = subcutaneous; Td = tetanus and diptheria; Tdap = tetanus, diptheria, and pertussis.
aPlease note that although this table focuses on recommendations for adults, some of the vaccines discussed in this article are also recommended for persons younger than 18 years.
bHigh-risk individuals previously described in the body of this text.
Macary Marciniak, PharmD, BCACP, BCPS, FAPhA, is clinical associate professor and director of the PGY-1 community pharmacy residency program at the UNC Eshelman School of Pharmacy at the University of North Carolina at Chapel Hill (UNC). Laura Rhodes, PharmD, is a PGY-1 community pharmacy resident with UNC and Moose Professional Pharmacy. Jeannie Ong, PharmD, is a PGY-1 community pharmacy resident with UNC and Walgreens. Hannah Renner, PharmD, is a PGY-1 community pharmacy resident with UNC and Walgreens. Breanna Sunderman, PharmD, is a PGY-1 community pharmacy resident with UNC and Kroger.The authors would like to thank Jordan Ballou, PharmD; Desiree Gaines, PharmD; and Ryan Templeton, PharmD, for their suggestions regarding the content of this article.
- Centers for Disease Control and Prevention. Pertussis (whooping cough). www.cdc.gov/pertussis. Updated September 5, 2015. Accessed August 10, 2015.
- Centers for Disease Control and Prevention. Tdap (Tetanus, Diphtheria, Pertussis) vaccine information statements. www.cdc.gov/vaccines/hcp/vis/vis-statements/tdap.html. Published February 24, 2015. Accessed August 10, 2015.
- Centers for Centers for Disease Control and Prevention. Pertussis (whooping cough) Vaccination. www.cdc.gov/vaccines/vpd-vac/pertussis/default.htm. Accessed August 10, 2015.
- Centers for Disease Control and Prevention. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the advisory committee on immunization practices, 2010. MMRW Morb Mortal Wkly Rep. 2011;60(1):13-15. www.cdc.gov/mmwr/pdf/wk/mm6001.pdf.
- Centers for Disease Control and Prevention. What you should know for the 2015-2016 influenza season. www.cdc.gov/flu/about/season/flu-season-2015-2016.htm. Updated October 20, 2015. Accessed October 7, 2015.
- Centers for Disease control and Prevention. Situation update: summary of weekly FluView report. www.cdc.gov/flu/weekly/summary.htm. Updated October 16, 2015. Accessed October 7, 2015.
- Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder KR, Karron RA. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices, United States, 2015-16 influenza season. MMWR Morb Mortal Wkly Rep. 2015;64(30):818-825.
- PharmaJet. www.PharmaJet.com. Accessed October 7, 2015.
- Centers for Disease Control and Prevention. Pneumococcal disease: fast facts. www.cdc.gov/pneumococcal/about/facts.html. Updated June 10, 2015. Accessed October 11, 2015.
- Kobayashi M, Bennett NM, Gierke R, et al. Intervals between PCV13 and PPSV23 vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2015;64(34):944-947.
- California Department of Public Health, Immunization Branch. Pneumococcal vaccine timing tool for adults. http://eziz.org/assets/docs/IMM-1152.pdf. Accessed October 11, 2015.
- Hales CM, Harpaz R, Ortega-Sanchez I, Bialek SR. Update on recommendations for use of herpes zoster vaccine. MMWR Morb Mortal Wkly Rep. 2014;63(33):729-731.
- Johnson RW, Bouhassira D, Kassianos G, Leplege A, Schmader KA, Weinke T. The impact of herpes zoster and post-herpetic neuralgia on quality-of-life. BMC Medicine. 2010;8(37). doi: 10.1186/1741-7015-8-37.
- Le P, Rothberg MB. Cost-effectiveness of herpes zoster vaccine for persons aged 50 years. Ann Int Med. 2015;163(7):489-497. doi: 10.7326/M15-0093.
- Immunization Action Coalition. Ask the experts: diseases & vaccines: zoster (shingles). www.immunize.org/askexperts/experts_zos.asp. Accessed October 11, 2015.
- American Pharmacists Association. Pharmacy-based immunization delivery. http://pharmacist.com/pharmacy-based-immunization-delivery. Accessed October 13, 2015.
- Immunization Action Coalition. Apps: Immunization apps for healthcare providers and their patients. www.immunize.org/resources/apps.asp. Accessed October 13, 2015.
- Grabenstein JD. Pharmacists as vaccine advocates: roles in community pharmacies, nursing homes, and hospitals. Vaccine. 1998;16(18):1705-1710.
- Hogue MD, Grabenstein JD, Foster SL, Rothholz MZ. Pharmacist involvement with immunizations: a decade of professional advancement. J Am Pharm Assoc. 2006;46(2):168-182.
- Andrawis MA, Rehm SJ. Health-system pharmacists’ role in improving immunization rates. Am J Health-Syst Pharm. 2012;69(1):74-76. doi: 10.2146/ajhp110257.
- Bourdet SV, Kelley M, Rublein J, Williams DM. Effect of a pharmacist-managed program of pneumococcal and influenza immunization on vaccination rates among adult inpatients. Am J Health-Syst Pharm. 2003;60(17):1767-1771.
- Sokos DR. Pharmacists’ role in increasing pneumococcal and influenza vaccination. Am J Health-Syst Pharm. 2005;62(4):367-377.
- Robke JT, Woods M. A decade of experience with an inpatient pneumococcal vaccination program. Am J Health-Syst Pharm. 2010;67(2):148-152. doi: 10.2146/ajhp080638.
- Modrzejewski KA, Provost GP. Pharmacists’ involvement with vaccinations leads to preventative health care role. Am J Health-Syst Pharm. 2003;60(17):1724-1725.
- Thomas MC, Ademolu AO. Considerations for vaccine administration in the emergency department. Am J Health-Syst Pharm. 2014;71(3):231-236. doi: 10.2146/ajhp130163.