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Module 1: Overview of the Immunization NicheJonathan G. Marquess,

PharmD, CDE, CDM

Creating an Immunization Niche in the Community

Pharmacy

Learning ObjectivesAt the conclusion of this program the pharmacist will be able to:• Discuss various vaccine preventable diseases and their impact on

the community• List and describe five reasons why the community pharmacist can

improve vaccination resources in their community• Describe three methods for incorporating immunization outreach

in the community pharmacy• Discuss how to research vaccine administration requirements in

your state• List the various vaccination populations and their required

vaccines • Outline a step-by-step program for becoming involved in

improving immunization awareness and advancing the overall immunization rate in their community

• Discuss business and professional growth opportunities provided by offering an immunization program in their practice setting

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Pre-Assessment Questions

Pre-Assessment Question #1

According to research, what percentage of the population are likely to take action on the basis of the pharmacist’s vaccine recommendation? • a. 5%• b. 10%• c. 25-30%• d. 50-94% **

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Correct Answer

According to research, what percentage of the population are likely to take action on the basis of the pharmacist’s vaccine recommendation?

• d. 50-94% **

Pre-Assessment Question #2

Which of the following questions is the mostimportant one to ask a vaccine candidate?• a. How old are you?• b. Are you allergic to codeine?• c. Did you have any adverse reactions to earlier

doses of this vaccine? **• d. How will you be paying for your vaccine?• e. Which Medicare Part D plan to you have?

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Correct Answer

Which of the following questions is the most important one to ask a vaccine candidate?

• c. Did you have any adverse reactions to earlier doses of this vaccine? **

Pre-Assessment Question #3

Which of the following governs prescribing authority?• a. Federal Law• b. County Law• c. State Law **• d. State immunization registry• e. None of the above

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Correct Answer

Which of the following governs prescribing authority?

• c. State Law **

Introduction to Immunization

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Consider These Questions

1. Can the local pharmacist improve health care awareness and improve health care in the community?

Consider These Questions

2. Would establishing a patient-centered immunization program in your pharmacy setting serve your community?

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Consider These Questions

3. Should I consider becoming an immunizing pharmacist and have immunizations as part of my day-to-day practice?

Answer

YES!YES!

YES!

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Vaccinations are a Critical Need

• Vaccination coverage remains at less than 50% among – Young children– Adults with risk factors for influenza

complications– Health care personnel (HCP)– Pregnant women

Why Immunize?

Influenza• Annual prevalence: 5% to 20%• 36,000 deaths per year

– Mortality increased steadily since 1976-1977 season – 90% of influenza mortality (~32,000) greater than 65

years of age– 152 deaths in children less than 18 years of age

• 120,000 hospitalizations

1. Fact Sheet. Available at: http://www.cdc.gov/flu/keyfacts.htm.2. Sokos DR. Am J Health-Syst Pharm. 2005;62:367-377.

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Why Immunize?

Influenza• Influenza kills as many or more Americans than

breast cancer• Influenza kills 2 to 3 times more Americans than

HIV/AIDS• Annual impact of influenza in the United States

(US)– Infection – 82 million– Illness – 65 million– Medically attended – 30 million

Thompson WW, Shay DK, Weintraub E, et.al.Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003; 289:179-86

Influenza Related Deaths

• Influenza related pulmonary and circulatory deaths– 1976-1990 – Average 19,000– 1990-1999 – Average 36,000

• Rates of deaths/100,000– 0.4-0.6 aged 0-49– 7.5 aged 50-64– 98.3 aged 65 and older

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Nichol KL, et al, Vaccination and Reduction in Hospitalizations for Cardiac Disease and Stroke among the Elderly. NEJM 2003; 384:1322-32

Influenza VaccinationReduces Hospitalizations

• Vaccine was associated with– 19% reduction in hospitalization– 23% reduction of cerebrovascular disease– 29% reduction in pneumonia– 50% reduction of death from all causes

• These findings highlight the benefits of vaccination and supports efforts to increase the rates of vaccination among the elderly

Why Immunize?

Pneumonia• Every year, nearly 60,000 Americans die of

pneumonia • Mortality from pneumonia generally decreases

with age until late adulthood• Elderly individuals are at increased risk for

pneumonia and associated mortality

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Why Immunize?

Hepatitis B• Estimated 1.25 million chronically infected

Americans, of whom 20-30% acquired their infection in childhood– Over 6,000 new cases per year

• About 30% of persons have no signs or symptoms

• Death from chronic liver disease occurs in 15%–25% of chronically infected persons

Why Immunize?

Shingles• One million cases of shingles each year• Lifetime risk of 20 percent in the US• Generally associated with aging and reduced

immunocompetence (HIV/AIDS, cancer)• One in five patients develop postherpetic

neuralgia

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Why Immunize?

Tetanus• Tetanus infection causes painful tightening of

the muscles, usually all over the body• It can lead to "locking" of the jaw, which makes it

impossible to open your mouth or swallow• Death from suffocation is possible• The disease is rare in the US, with less than 100

cases of tetanus reported annually

Why Immunize?

Human Papillomaviruses (HPVs)• Approximately 20 million people are currently

infected with HPVs– 6.2 million new cases per year

• HPVs are now recognized as the major cause of cervical cancer

• 19 states, including the District of Columbia, have passed HPV-related laws or resolutions

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Why Immunize?

Meningococcal Disease• ~25,000 and 50,000 hospitalizations due to viral

meningitis yearly• College freshmen living in dormitories are at

higher risk

Why Immunize?Other Opportunities

• Travel vaccines• Rotavirus• Yellow fever• Rabies• Typhoid• Japanese encephalitis • Smallpox• Measles, mumps, rubella• Varicella• Diphtheria, pertussis

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Achievements in Public Health(Death Rate)

MMWR 1999;48(29):621-629

Healthy People 2010 Goals and Current Coverage

PPV23 65+, 56%PPV23 18-49

High Risk, 13% Flu 65+, 70%Flu 18-49

High Risk, 24% Hep B MSM, 9% Hep B HCW, 75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PPV23 65+ PPV23 18-49 HighRisk

Flu 65+ Flu 18-49 High Risk Hep B MSM Hep B HCW

90%

60%

90%

60% 60%

98%90% 90%

60% 60%

90% 90%

www.healthypeople.govNational Health Interview Survey (CDC, NCHS)

Healthy People 2010 Goal

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Interesting Fact• Percentage of persons age over 65 who received a

annual influenza shot 65.7% nationwide• Top ten states:

1. Minnesota 78.1%2. South Dakota 76.3%3. Colorado 74.2%4. Oklahoma 73.2%5. Wyoming 72.9% 6. Nebraska 72.6% 7. Hawaii 72.1%8. Wisconsin 71.8% 9. Iowa 71.7% 10. Connecticut 71.1%

Why a Pharmacy-based Immunization Niche?

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2007 ACIP Report –Pharmacist Recommendations

1. Schedule flu vaccine clinics throughout the flu season

2. Recommend and administer the proper flu vaccine dosage for children ages 6 months to 8 years old

3. Strongly recommend school age children through senior adults be vaccinated

4. Encourage health care professionals to be vaccinated for flu

Total Patient Care

• Change your practice to one that is concerned about the patient’s overall wellness and your service to the community will be even more valuable

• Educate your patients of the new service you will be offering

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Why Your Pharmacy as an Immunization Destination?

• Convenient hours • Extended evening and weekend hours• Less paperwork• No appointment needed• Vaccination given by someone who knows their health

history• Personal attention provided to answer concerns /

questions• Identification of high risk patients using the

pharmacy’s database • Most accessible health care professional• Trust!

PharmacyPharmacy

Medicaid AMP

Decreasing Third Party Reimbursement

Medicare Part D

PBMs Mail Order

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Current State of Community Pharmacy

Net operating income down 30%Gross profit down from 23.6% to 22.8%Overall and prescription sales stagnant

Independent Net Margin (Since 1997)

1997

1999

2001

2003

2005

“In the middle of difficulty lies opportunity”

Albert Einstein

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Immunizations

Medication Therapy

ManagementCompounding

Screening Programs

DME Provider

PharmacyPharmacy

Pharmacies Play a Growing Role in Immunization Efforts

Influenza vaccination accounted for majority of immunizations administered, which also included hepatitis A and B, Lyme disease, tetanus, and chicken pox.Kamal KM, et al. J Am Pharm Assoc. 2003;43:470-482.

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Immunization Promotion

Counseling About Adult Immunizations

Pharmacist-administeredAdult ImmunizationsPh

arm

acie

s R

epor

ting

Act

ivity

(%)

1998 2001

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Many of Your Colleagues are Already Providing this Service

• Over 43% of independent pharmacists offer immunizations

Nichol KL, et al. The effectiveness of vaccination against influenza in healthy, working adults. NEJM 1995; 333:889-893

Value of Vaccination in Working Adults

• Those who were immunized– 43% fewer days of sick leave– 44% fewer MD visits for upper respiratory

infection (URI)– 25% reduction of frequency of URI– 20% reduction of the duration of URI

• Net savings from vaccination was $4,685 per 100 employees or $46.85 per person

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Bottom Line

• Vaccinations are needed• Vaccination is a business opportunity

Benefits of a Immunization Niche

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Immunization Can Improve Your Pharmacy?

• Professional satisfaction• Improved community outreach• Financial opportunity

Professional Satisfaction

• Increased health care awareness • Proactive management of health risks

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Community Outreach

• Pharmacy as a community health center• Provide a needed service - professional

and convenient

Financial Opportunity

• Brings in new customers– Add-on sales– Word-of mouth advertising

• Creates a new profit center

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Return on Investment (ROI)

• Investment is relatively small– Staff training– Supplies– Documentation– Advertisement

• Payoff is proportionally large– Drug reimbursement– Administration fees– OTC companion sales– Increased foot traffic and customer base

How to Incorporate Immunization Outreach in

Your Pharmacy

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How to Incorporate Immunization Outreach in Your Pharmacy

• Level 1: Pharmacist as Advocate• Level 2: Pharmacist as Facilitator• Level 3: Pharmacist as Immunizer

Level 1: Pharmacist As Advocate

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Pharmacist As Advocate

• The pharmacist immunization advocate:– Determines patients immunization status– Identifies high-risk patients– Protects patients by becoming immunized

and having pharmacy staff do the same

Level 2: Pharmacist As Facilitator

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Immunization PartnershipsPharmacy Physician

Health Department Employer Groups

Increase Immunization Rates

Pharmacist As Facilitator

• The pharmacist facilitator– Assists patients in locating vaccine resources– Partners with providers (eg, visiting nurses,

clinics) to provide vaccinations in the pharmacy

– Refers to other health care providers

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Level 3 - Pharmacist As Immunizer

Complement the Physician

• Pharmacy and the physician or clinic need to be in a “partnership” relationship. Complement not compete

• Visit the physician or clinic and discuss your ideas/services and let them know of your desire to work with them in improving patient care in the community

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Considerations of the Pharmacy-Based

Immunization Niche

States Authorized to Administer Immunizationsa

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Legal and Regulatory

• After confirming legal eligibility to administer medications, make sure you have an authorization document (or other state requirement) to administer vaccines

Legal and Regulatory ex. Georgia• § 26-4-4. Definition of "practice of pharmacy.“ The

"practice of pharmacy" means the interpretation, evaluation, or dispensing of prescription drug orders in the patient's best interest; participation in drug and device election, drug administration, drug regimen reviews, and drug or drug related research; provision of patient counseling and the provision of those acts or services necessary to provide pharmacy care; performing capillary blood tests and interpreting the results as a means to screen for or monitor disease risk factors and facilitate patient education, and a pharmacist performing such functions shall report the results obtained from such blood tests to the patient's physician of choice; and the responsibility for compounding and labeling of drugs and devices

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Liability

• Legal issues vary state by state and are very complex in nature– Consult an attorney or insurance specialist – Coverage for pharmacy as well as pharmacist

to include “drug administration”• The best way to prevention against

liability claims is training and protocol

Which Vaccines Will You Administer?

• Start slow and grow your niche!– Choose two to four vaccines and become an

expert in administering those– Take a look at your patient population and

community– Incorporate vaccinations into your marketing

plan

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Who Should You Recommend for Immunizations?

• Children?– Eg, influenza, MMR, HPV

• Adults?– Eg, influenza, pneumonia, shingles

• Travel?– Eg, yellow fever, rotavirus, typhoid

Children• Many are not up to date on their

immunizations

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Child Catch-Up Schedule

Adults

• Adults are not getting the flu shot each year

• Newer vaccines were not available when they were children

• Immunity can fade over time

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ACIP Adult Schedule

Travel

• Vaccinated prior to overseas travel is highly recommended

• Travel season is year round • Publicize your service with travel

agencies, adoption agencies, travel clubs, etc.

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Myths/Facts about Immunizations

Immunization Myth #1

MYTH• "…I might catch the flu from the vaccine"

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Immunization Fact #1

FACT• Injectable influenza vaccines can't give

you influenza • Injectable influenza vaccines are made

from influenza viruses that have been killed, and a killed virus cannot give you influenza

Immunization Myth #2

MYTH• "…my friend had the influenza shot, but

still got the flu"

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Immunization Fact #2

FACT• There may be other factors involved • While it's true that getting an influenza

vaccination doesn't guarantee you won't become infected with influenza, the vaccine prevents influenza in about 70% to 90% of healthy people younger than age 65

Immunization Myth #3

MYTH• "…the flu is not that serious"

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Immunization Fact #3

FACT• Influenza can have serious results • Influenza is a contagious disease that can

lead to serious complications• Each year on average, in the US more

than 200,000 people are hospitalized and 36,000 die from influenza and its complications

Immunization Myth #4

MYTH• "…I never get the flu"

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Immunization Fact #4

FACT• Influenza strains change each year • The best way to help protect yourself

from new influenza strains is to get vaccinated each fall

Immunization Myth #5

MYTH• "…I'm willing to risk it"

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Immunization Fact #5

FACT• It’s not about you• Vaccination is recommended for people,

who want to reduce the likelihood of becoming ill with influenza or transmitting influenza to others, should they become infected

Immunization Myth #6

MYTH• "…it's for old people and young kids"

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Immunization Fact #6

FACT• The elderly and young children are just

two of the groups considered to be at increased risk for complications from influenza, but influenza vaccination can benefit anyone over the age of 6 months

• From 5% to 20% of the U.S. population develops influenza every year

Immunization Myth #7

MYTH• "…I may be allergic to the vaccine"

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Immunization Fact #7

FACT• Influenza vaccines are safe for most

people• However, the influenza vaccine is not

appropriate for those who have had a severe allergic reaction to eggs or to a previous influenza vaccination

• Vaccination may not be appropriate if you have a history of Guillain-Barré syndrome

Immunization Myth #8

MYTH• "…I've heard the side effects from the

shot are worse than the flu itself"

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Immunization Fact #8

FACT• Most people do not have any serious

problems from influenza vaccination• Most common side effects of the vaccine

include minor soreness or redness at the site of the shot and mild general symptoms

• May cause serious problems, such as severe allergic reactions

Immunization Myth #9

MYTH• "…I missed the vaccination season"

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Immunization Fact #9

FACT• You can still protect yourself after autumn • Getting vaccinated later in the season

(December through March) can still help protect you and your loved ones from influenza

Conclusion

• Vaccination provides a valuable health resource to the community

• The community pharmacy is an ideal location for this service

• There are three levels of pharmacist involvement in vaccination – advocate, facilitator, immunizer

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Please Proceed to the Post-Test