The role of pharmacists in the delivery of influenza vaccinations

Racial and ethnic disparities in influenza vaccinations among community pharmacy patients and non-community pharmacy respondents

BACKGROUND

Since 2009, pharmacists in all 50 states in the U.S. have been authorized to administer vaccinations.

OBJECTIVES

This study examined racial and ethnic disparities in the reported receipt of influenza vaccinations within the past year among noninstitutionalized community pharmacy patients and non-community pharmacy respondents.

METHODS

The 2009 Medical Expenditure Panel Survey was analyzed. The sample consisted of respondents aged 50 years or older, as per the 2009 recommendations by the Advisory Committee on Immunization Practices. Bivariate and multivariate logistic regression analyses were conducted to examine the influenza vaccination rates and disparities in receiving influenza vaccinations within past year between non-Hispanic Whites (Whites), non-Hispanic Blacks (Blacks) and Hispanics. The influenza vaccination rates between community pharmacy patients and non-community pharmacy respondents were also examined.

RESULTS

Bivariate analyses found that among the community pharmacy patients, a greater proportion of Whites reported receiving influenza vaccinations compared to Blacks (60.9% vs. 49.1%; P < 0.0001) and Hispanics (60.9% vs. 51.7%; P < 0.0001). Among non-community pharmacy respondents, differences also were observed in reported influenza vaccination rates among Whites compared to Blacks (41.0% vs. 24.3%; P < 0.0001) and Hispanics (41.0% vs. 26.0%; P < 0.0001). Adjusted logistic regression analyses found significant racial disparities between Blacks and Whites in receiving influenza vaccinations within the past year among both community pharmacy patients (odds ratio [OR]: 0.81; 95% CI: 0.69-0.95) and non-community pharmacy respondents (OR: 0.66; 95% CI: 0.46-0.94). Sociodemographic characteristics and health status accounted for the disparities between Hispanics and Whites. Overall, community pharmacy patients reported higher influenza vaccination rates compared to non-community pharmacy respondents (59.0% vs. 37.2%; P < 0.0001).

CONCLUSION

Although influenza vaccination rates were higher among community pharmacy patients, there were racial disparities in receiving influenza vaccinations among both community pharmacy patients and non-community pharmacy respondents. Increased emphasis on educational campaigns among pharmacists and their patients, especially minorities, may be needed.

Examination of pneumococcal vaccination rates among U.S. adult smokers

PURPOSE

Pneumococcal vaccination rates among U.S. adult smokers in rural and nonrural areas were compared to determine the effect of federal vaccination recommendations.

METHODS

Using bivariate and multivariate techniques, 2005 and 2010 Behavioral Risk Factor Surveillance Survey data were analyzed for comparative purposes. The dependent variable for this analysis was receipt of pneumococcal vaccine. The population of interest was U.S. adults age 19-64 years who reported that they currently smoked. Covariates included sex, race and ethnicity, household income, educational attainment, geographic area (rural or nonrural location of last routine medical checkup), having a personal health care provider, having health insurance, deferring medical care because of cost, self-defined health status, and receipt of seasonal influenza vaccination in the past 12 months. Results In 2005, 15.5% of smokers reported that they had ever received a pneumonia vaccine; by 2010, this percentage increased to 20.8%. In 2005, rural adult smokers were more likely to receive a pneumococcal vaccine (odds ratio [OR], 1.357; 95% confidence interval [CI], 1.338-1.377) than their nonrural counterparts. In 2010, rural adult smokers were less likely to receive the vaccine (OR, 0.952; 95% CI, 0.938-0.966). In both years, men were more likely to receive pneumococcal vaccine, as were those with health insurance and a health care provider. Overall, receipt of a seasonal influenza vaccine was the strongest predictor of smokers receiving pneumococcal vaccine.

CONCLUSION

U.S. adult smokers were most likely to receive pneumococcal vaccine if they were men, had health insurance, had a health care provider, and received a seasonal influenza vaccination within the past year.

Injectable administration privileges among pharmacists in the United States

PURPOSE

Privileges for administering nonvaccine injectable medications among pharmacists in the United States were assessed.

METHODS

An e-mail inquiry on specific protocols for the administration of injectables was sent to the state boards of pharmacy (BOPs) for all 50 states and the District of Columbia that had a valid e-mail address listed on the National Association of Boards of Pharmacy website. Respondents were encouraged to include in their response a link to state regulations so that information from the BOP laws on privileges for administering injectables could be closely reviewed. State guidelines were reviewed online for all BOPs that did not respond to the first e-mail in order to complete the study. A follow-up e-mail was sent only to those respondents whose states granted pharmacists privileges for administering nonvaccine injectables in order to clarify the specific drugs allowed to be injected by pharmacists.

RESULTS

Responses received included either links to state regulations or explicit statements of the rules regarding pharmacists' injectable privileges. A total of 21 states currently grant pharmacists articulate written information or rules pertaining to the privilege of administering nonvaccine injectable products. Authority is provided through collaborative practice agreements for most states. Products administered by pharmacists vary by state.

CONCLUSION

Pharmacists in 21 states were found to have privileges for administering injectable medications other than vaccines. Pharmacists were authorized to administer these drugs through completion of training approved by the Accreditation Council for Pharmacy Education, collaborative practice agreements, valid prescription orders, board certification, or other broad privileges as specified in state regulations.

Pharmacy provision of influenza vaccinations in medically underserved communities

OBJECTIVE

To demonstrate the extent to which a community pharmacy can provide influenza immunizations in communities designated as medically underserved.

METHODS

This retrospective study examined the number of influenza immunizations administered and populations served in areas with limited access to health care by Walgreens pharmacies during the 2009-10 influenza season.

RESULTS

More than 43% of the U.S. population resides in medically underserved areas (MUAs), and our results show that Walgreens pharmacies served nearly one-half of this population. Nationwide, more than one-third of influenza immunizations were administered by pharmacies located in MUAs. In states with the highest proportion of their population in MUAs, the percentage of influenza vaccines provided in MUAs was much greater (up to 77.1%).

CONCLUSION

Community pharmacies are convenient and accessible venues at which patients can obtain seasonal influenza vaccines and other immunizations. They are well-positioned throughout the country, including in areas that are otherwise medically underserved. These factors help community pharmacists eliminate one of the most important barriers to vaccination: accessibility.

Hospital emergency preparedness: Push-POD operation and pharmacists as immunizers

OBJECTIVE

To describe Montefiore Medical Center's participation in a point-of-distribution (POD) exercise in which pharmacists were drilled on the ability to provide immunizations in the face of an emergency.

SETTING

New York City on October 9, 2007.

SUMMARY

Rapid and appropriate response to a terrorism event can limit morbidity and mortality. After the events of September 11, 2001, the New York City Department of Health and Mental Hygiene (DOHMH) recognized the need to develop a uniform procedure in the case of a potential health disaster. During the fiscal year occurring between September 1, 2006, and August 31, 2007, DOHMH requested that all citywide hospitals participate in a POD drill. All participating hospitals were required to have a team of five health professionals, including one pharmacist, one physician, two nurses, and another member of the institution. The drill was to be conducted within a 4-hour interval to simulate a situation of mass prophylaxis using influenza as a surrogate vaccine or pharmaceutical agent needed in the event of a public health emergency.

MAIN OUTCOME MEASURE

Number of health care workers immunized in 4-hour period.

RESULTS

During the 4-hour period, the team was able to immunize 942 heath care workers. Predicting a 24/7 operation in the event of a biological terrorism event, the Push-POD operation would have the capacity to immunize 12,000 health care workers-the approximate population of the hospital-in 48 hours. This exercise was replicated for the 2008 influenza program, and the results were identical.

CONCLUSION

By allowing pharmacists to expand their scope of practice, New York State will inevitably see a drastic improvement in its adult immunization rates for influenza and pneumococcal vaccinations through greater public awareness and expanded vaccine access.

The use of the health belief model to assess predictors of intent to receive the novel (2009) H1N1 influenza vaccine

OBJECTIVES: 1) Assess participants' perceptions of severity, risk, and susceptibility to the novel H1N1 influenza virus and/or vaccine, vaccine benefits and barriers, and cues to action and 2) Identify predictors of participants' intention to receive the novel H1N1 vaccine. DESIGN: Cross-sectional, descriptive study SETTING: Local grocery store chain and university in the central Virginia area PARTICIPANTS: Convenience sample of adult college students and grocery store patrons INTERVENTION: Participants filled out an anonymous, self-administered questionnaire based upon the Health Belief Model. MAIN OUTCOME MEASURES: Participants' predictors of intention to receive the novel H1N1 vaccine RESULTS: A total of 664 participants completed a questionnaire. The majority of participants were aged 25-64 years old (66.9%). The majority were female (69.1%), Caucasian (73.7%), and felt at risk for getting sick from the virus (70.3%). Most disagreed that they would die from the virus (68.0%). Participants received novel H1N1 vaccine recommendations from their physicians (28.2%), pharmacists (20.7%), and nurses (16.1%). The majority intended to receive the H1N1 vaccine (58.1%). Participants were significantly more likely to intend to receive the H1N1 vaccine if they had lower scores on the perceived vaccine barriers domain (OR= 0.57, CI: 0.35-0.93). Physicians' recommendations (OR=0.26, CI: 0.11-0.62) and 2008 seasonal flu vaccination (OR=0.45, CI: 0.24-0.83) were significant predictors of intention to receive the H1N1 vaccine. CONCLUSIONS: Most participants felt at risk for getting the novel H1N1 virus and intended to receive the novel H1N1 vaccine. Educating patients about vaccine benefits and increasing healthcare professionals' vaccine recommendations may increase vaccination rates in future pandemics.

Vaccinations in Older Adults: Focus on Pneumococcal, Influenza and Herpes zoster infections

Pneumococcal, influenza and herpes zoster infections cause significant morbidity and mortality in the aging population. Effective vaccines are available in Canada to prevent and minimize illnesses caused by these infections. The purpose of this review is to provide an overview of the epidemiology of pneumococcal, influenza and herpes zoster infections in older adults, as well as available vaccines and recommended immunization schedules. In addition, the benefits of these vaccines on patient outcomes and the role of pharmacists in improving immunization rates are highlighted.

A literature review was conducted to examine the clinical outcomes related to the use of pneumococcal, influenza and herpes zoster vaccines in adults 65 years and older. All 3 vaccines are beneficial in reducing complications of these infections and are well tolerated in older adults. Studies have shown that the uptake of these vaccines remains suboptimal and the burden of illness caused by these infections continues to affect the quality of life of older adults. Pharmacists are well positioned to screen seniors for vaccine indications during routine assessments, as well as provide education to improve patient awareness, vaccine uptake and health outcomes in older adults.

Individual- and neighborhood-level characteristics associated with support of in-pharmacy vaccination among ESAP-registered pharmacies: pharmacists' role in reducing racial/ethnic disparities in influenza vaccinations in New York City

New York State (NYS) passed legislation authorizing pharmacists to administer immunizations in 2008. Racial/socioeconomic disparities persist in vaccination rates and vaccine-preventable diseases such as influenza. Many NYS pharmacies participate in the Expanded Syringe Access Program (ESAP), which allows provision of non-prescription syringes to help prevent transmission of HIV, and are uniquely positioned to offer vaccination services to low-income communities. To understand individual and neighborhood characteristics of pharmacy staff support for in-pharmacy vaccination, we combined census tract data with baseline pharmacy data from the Pharmacies as Resources Making Links to Community Services (PHARM-Link) study among ESAP-registered pharmacies. The sample consists of 437 pharmacists, non-pharmacist owners, and technicians enrolled from 103 eligible New York City pharmacies. Using multilevel analysis, pharmacy staff who expressed support of in-pharmacy vaccination services were 69% more likely to support in-pharmacy HIV testing services (OR, 1.69; 95% CI 1.39-2.04). While pharmacy staff who worked in neighborhoods with a high percent of minority residents were less likely to express support of in-pharmacy vaccination, those in neighborhoods with a high percent of foreign-born residents were marginally more likely to express support of in-pharmacy vaccination. While educational campaigns around the importance of vaccination access may be needed among some pharmacy staff and minority community residents, we have provided evidence supporting scale-up of vaccination efforts in pharmacies located in foreign-born/immigrant communities which has potential to reduce disparities in vaccination rates and preventable influenza-related mortality.

Receipt of influenza and pneumonia vaccinations: the dual disparity of rural minorities

OBJECTIVES

To examine the receipt of age-appropriate influenza and pneumococcal polysaccharide vaccinations (PPV), with particular attention to rural minority persons.

DESIGN

Data were drawn from the 2005 Behavioral Risk Factor Surveillance System. The dependent variables were self-reported receipt of annual influenza immunizations in adults aged 50 and older (n=177,417) or lifetime pneumococcal immunizations in adults aged 65 and older (n=81,762). The main independent variables were residence and race.

MEASUREMENTS

All data are self-reported. Multivariate analysis controlled for selected personal and county-level characteristics. Analyses were conducted in 2009/10.

RESULTS

Forty-two percent of adults aged 50 and older reported an influenza vaccination; 31.1% of rural African Americans reported an influenza vaccination, and 64.6% reported a PPV. White and African-American rural residents reported lower vaccination rates. Adjusted analysis indicated an interaction between race and rurality. White rural residents were more likely to be vaccinated than other whites, whereas rural African Americans were less likely to be vaccinated than urban African Americans.

CONCLUSION

This study confirms previous findings while finding an interactive effect between rurality and race. The results indicated the importance of provider availability to delivery. Alternative delivery methods may be an effective solution to improve delivery rates.

Pharmacy characteristics, vaccination service characteristics, and service expansion: an analysis of sustainers and new adopters

OBJECTIVE

To compare earlier (sustainers) and later (new) adopters in terms of pharmacy characteristics and characteristics of in-house vaccination services and to identify how sustainers modified their in-house vaccination services over time.

DESIGN

Nonexperimental multistage study.

SETTING

Washington State during 2003, 2004, and 2006-2007.

PARTICIPANTS

Community pharmacies included in this study's analyses must have participated in all data collection stages and provided in-house vaccination services during the third stage. Based on key informants' self-reports, those who had provided in-house services before or since 2003 were sustainers and those who started their services after 2004 were new adopters.

INTERVENTION

Mixed-mode survey.

MAIN OUTCOME MEASURES

Pharmacy characteristics and characteristics of in-house vaccination services offered in 2003 and 2006 were measured in terms of service accessibility, scope, and supportive personnel.

RESULTS

A total of 37 sustainers and 27 new adopters met the inclusion criteria. The majority of independent and supermarket pharmacies were sustainers, whereas the majority of chain and mass merchant pharmacies were new adopters. In-house services offered by sustainers were broader in service accessibility and scope and involved a greater number of pharmacists trained in immunization delivery than services offered by new adopters in the same year. Further, when comparing sustainers' in-house services offered in 2003 and 2006, the 2006 services were expanded to provide year-round services, involved a greater number of settings, included services to adolescents, and involved a greater number of trained pharmacists.

CONCLUSION

Community pharmacies started their in-house vaccination services on a small scale and later expanded to a larger scale. Pharmacies with expanded in-house services can make greater contributions to their business, their patients, and the profession by bringing in additional revenues, improving vaccination rates among high-risk patients, and facilitating the growth of pharmacy-based services.

Daily versus single-day offering of influenza vaccine in community pharmacies

OBJECTIVE

To assess the cumulative number of influenza vaccinations delivered per pharmacy in relation to number of days of offering vaccination per season.

METHODS

Automated records of pharmacies involved in a cohort study were queried for number of influenza vaccinations delivered in each of three influenza vaccination seasons between 1996 and 1998. Eleven pharmacies in Washington State were compared with 13 pharmacies in Oregon, contrasting years when nurses offered influenza vaccine 1 day per season with years when pharmacists offered influenza vaccine daily for several months.

RESULTS

Pharmacies in which pharmacists offered influenza vaccination daily averaged 528 to 807 doses per pharmacy per season compared with 91 to 233 doses per pharmacy in seasons when nurses offered vaccination on a single day.

CONCLUSION

Professionals dedicated to providing adult vaccination on any given day outperformed professionals who attended to both vaccination and other clinical duties, but the cumulative effect of offering vaccinations on multiple days can achieve a greater number of vaccinations over a several-month interval.

Pharmacist-administered subcutaneous depot medroxyprogesterone acetate: a pilot randomized controlled trial

BACKGROUND

The objectives of this study were to assess the feasibility of administering subcutaneous depot medroxyprogesterone acetate (DMPA-SC) in a pharmacy setting and assess patient satisfaction.

STUDY DESIGN

Fifty women, at least 18 years of age, presenting to a family planning clinic to initiate, continue or restart any form of DMPA were randomized to receive two subsequent injections at a nearby pharmacy by trained pharmacists or at the clinic. Women completed two follow-up surveys to rate their satisfaction with DMPA-SC and their clinic/pharmacy experiences.

RESULTS

The relative risk of returning and receiving a second DMPA-SC injection of women randomized to the pharmacy compared with those randomized to the clinic was 0.73 (95% CI 0.42-1.27). The relative risk of returning and receiving a third DMPA-SC injection was 0.75 (95% CI 0.39-1.46). Most women found the pharmacy setting convenient (70%), private (100%), the providers respectful (100%) and were satisfied with DMPA-SC and the pharmacy as a clinical site (> or = 89%). No significant difference in patient satisfaction with location, convenience, privacy, and respect from providers was found between study groups (p>.05), nor were there significant differences in attitudes or satisfaction among women between their two follow-up injections.

CONCLUSION

Administration of DMPA-SC by pharmacists in a pharmacy setting is feasible. Continuation rates and patient satisfaction with DMPA-SC and the pharmacy setting were comparable to those who received DMPA-SC in a family planning clinic.

Impact of perceived innovation characteristics on adoption of pharmacy-based in-house immunization services

Objectives

An in-house immunization service in which staff pharmacists administer vaccines was conceptualized as an innovation. Prior to making adoption decisions, community pharmacies evaluated characteristics of in-house immunization services. This study examined the impact of three specific characteristics (perceived benefit, perceived compatibility and perceived complexity) of in-house immunization services on community pharmacies' adoption decisions.

Methods

A multi-stage mixed-mode survey design was used to collect data from key informants of community pharmacies in Washington State, USA. Key informants included pharmacy managers or pharmacists-on-duty who were able to answer questions related to immunization activities in their pharmacies. Perceived characteristics of in-house immunization services and pharmacy adoption decisions were measured in 2004 and in 2006–2007, respectively.

Key findings

Each perceived characteristic individually predicted adoption of in-house immunization services. When all three characteristics were included in logistic regression, perceived benefit was the only significant predictor of in-house immunization service adoption.

Conclusions

Appropriate strategies, particularly promoting the benefit of in-house immunization services, should be implemented. The proposed model and findings may be applicable to other pharmacy-based innovative practices or other public health initiatives. We recommend that organizational leaders, researchers and practitioners consider the impact of perceived benefit and incorporate it when they design strategies to foster adoption of innovative practices. Doing this may increase the number of adopters and also increase diffusion rates for innovative services.

Sustainability of pharmacy-based innovations: the case of in-house immunization services

OBJECTIVE

To examine the effect of organization-level factors on sustainability of pharmacy-based in-house immunization services.

DESIGN

Cross-sectional study.

SETTING

Washington State community pharmacies in 2006.

PARTICIPANTS

Key informants of 490 community pharmacies.

INTERVENTION

Mixed-mode survey; five mail and telephone contacts were used.

MAIN OUTCOME MEASURES

Effectiveness of champions (i.e., influential individuals within the host organization who actively and continuously promote the service), formal evaluation process, degree of modifications made to in-house services, degree of compatibility between in-house services and the host pharmacy, and sustainability of in-house immunization services were measured and included in the proposed model. Using survey responses, factor analysis and path analysis were performed to determine the relationships among these variables.

RESULTS

Of the 490 survey instruments sent, 1 was undeliverable, 2 were incomplete, and 206 were completed (42.1% response rate). A total of 104 pharmacies that reported offering immunization services in 2006 were included in the analysis. Compatibility, which was defined as the fit between in-house immunization services and the host pharmacy, was the key to sustainability of immunization services. To enhance compatibility between in-house services and the host pharmacy, two pathways were found. First, in-house services underwent formal evaluations and subsequent modifications were made to the services. The second pathway bypassed the adaptation process. Through the second pathway, an operational champion implemented in-house services in a way that was already compatible with the host pharmacy.

CONCLUSION

Organizational leaders and practitioners had the potential to sustain in-house services. The key factors included in the model should be incorporated as an integral part of programs planning to foster sustainability of in-house immunization services.

Forward and backward transitions in pharmacy-based immunization services

BACKGROUND

Community pharmacies can engage in immunization services by contracting with an external workforce (outsourced mechanism) or staff pharmacists (in-house mechanism) to deliver the services. Because an outsourced mechanism generally requires lower organizational commitment, pharmacies often start with an outsourced mechanism. Later, these pharmacies can have 1 of the following transitions: sit on a fence by continuing with an outsourced mechanism, move backward by abandoning any immunization services, or move forward by implementing an in-house mechanism.

OBJECTIVES

Using Rogers' Diffusion of Innovations model and Behavioral Theory of the Firm as guidance, this study identified the associations between perceived characteristics of immunization services and backward/forward transitions.

METHODS

A cross-sectional mail survey was conducted to collect data from key informants of Washington State community pharmacies during May-July 2004 (response rate=46.9%). A total of 106 pharmacies were included in the analysis. Based on pharmacy's immunization service transitions, these pharmacies were identified as Fence sitters, Backward movers, or Forward movers. Relationships between these transitions, pharmacy characteristics, and perceived characteristics of immunization services were analyzed using bivariate and multinomial logistic regression techniques.

RESULTS

Backward and Forward movers had less positive assessments of outsourced services when compared with Fence sitters. Backward and Forward movers differed in their perceptions of in-house services; Backward movers generally perceived no differences between these 2 services, whereas Forward movers generally perceived in-house services to be superior to outsourced services. Furthermore, the odds of being a Forward mover increased as perceived technical and social benefits of outsourced services decreased, perceived compatibility of in-house services increased, and perceived complexity of in-house services decreased.

CONCLUSIONS

Perceived characteristics of outsourced and in-house innovations were associated with backward and forward transitions. Findings can be used to guide the development of strategies for facilitating organizational change and preventing the abandonment of immunization services.

Prevalence and correlates of influenza vaccination among non-institutionalized elderly people: an exploratory cross-sectional survey

Background

Worldwide pandemics of influenza virus caused extensive morbidity and mortality around the world and influenza vaccination is the most effective method for preventing influenza virus infection and its potentially severe complications. A large proportion of the Hong Kong elderly population has not undergone influenza vaccination. An exploration of the correlates will provide significant information to help identify ways of improving vaccination uptake among Chinese elderly people.

Objectives

To explore the prevalence and correlates of influenza vaccination Hong Kong Chinese elderly people aged 65 or above. To investigate any differences in attitudes toward influenza vaccination among Hong Kong elderly people with different levels of cognitive and physical functioning.

Design

An exploratory cross-sectional survey with two objective assessments was employed. Settings: Fifteen elderly centers in Hong Kong Special Administrative Region. Participants: A total of 816 Hong Kong Chinese elderly participants were recruited.

Methods

Face-to-face interviews were adopted to explore the demographic characteristics, perceptions, health status, knowledge, and resources of, and the influence of disease outbreaks on, influenza vaccination. Two objective validated instruments, the Chinese Mini-Mental State Examination (CMMSE) and the Barthel Index-Modified Chinese Version (MCBI) were used to assess the cognitive status and physical functioning of the participants.

Results

Approximately two in three individuals (62.4%) had undergone influenza vaccination. Lower cognitive and physical functioning scores were found among the non-vaccinated participants. Multivariate logistic regression analyzes revealed the significant correlates associated with influenza vaccination to be consideration of vaccination in the subsequent years (aOR = 7.877; p < 0.001); consideration of vaccination if all people aged 65 or above were eligible to receive free vaccination (aOR = 3.024; p = 0.002); the belief that there is a need to receive influenza vaccination following the Severe Acute Respiratory Syndrome (SARS) and avian influenza (aOR = 2.413; p = 0.001); receiving advice from nursing staff of elderly centers (aOR = 7.161; p < 0.001); the medical staff of elderly centers (aOR = 3.771; p < 0.001) or family members or friends (aOR = 3.023; p = 0.001).

Conclusions

The prevalence of elderly Chinese people undergoing influenza vaccination remains suboptimal. The government can promote vaccination by educating the public about the advantages, by publicizing locations where vaccinations are available, and having nursing, other medical staff, family and friends encourage elderly people to be vaccinated. A high vaccination coverage rate must be ensured to achieve international goals.

Strategies for improving influenza immunization rates among hard-to-reach populations

Whereas considerable attention has been devoted to achieving high levels of influenza immunization, the importance of this issue is magnified by concern over pandemic influenza. Most recommendations for vaccine administration address high risk groups such as the elderly and those with chronic diseases, but coverage for hard-to-reach (HTR) populations has had less attention. HTR populations include minorities but also include other primarily urban groups such as undocumented immigrants, substance users, the homeless, and homebound elderly. Obstacles to the provision of immunization to HTR populations are present at the patient, provider, and structural levels. Strategies at the individual level for increasing immunization coverage include community-based educational campaigns to improve attitudes and increase motivation for receiving vaccine; at the provider level, education of providers to encourage immunizations, improving patient-provider interactions, broadening the provider base to include additional nurses and pharmacists, and adoption of standing orders for immunization administration; and at the structural level, promoting wider availability of and access to vaccine. The planning process for an influenza pandemic should include community engagement and extension of strategies beyond traditional providers to involve community-based organizations addressing HTR populations.

Pharmacist-Managed Vaccination Program Increased Influenza Vaccination Rates in Cardiovascular Patients Enrolled in a Secondary Prevention Lipid Clinic

STUDY OBJECTIVES

To determine whether a vaccination program in a pharmacist-managed secondary prevention lipid clinic increased influenza immunization rates in a high-risk population, and whether age or gender disparity existed among those vaccinated.

DESIGN

Retrospective chart review.

SETTING

Large, multispecialty, group practice.

PATIENTS

A total of 476 and 266 patients seen at clinic visits during the 2003-2004 and 2004-2005 influenza seasons, respectively.

MEASUREMENTS AND MAIN RESULTS

Immunization rates were compared before (2003-2004 influenza season) and after (2004-2005 influenza season) the implementation of the influenza vaccination program; chi2 analysis was used for all statistical inferences. Vaccination rates increased significantly from 39% to 76% (p<0.0001) after program implementation. No before-after difference in rates was noted based on gender. Before implementation, patients younger than 65 years were less likely versus those aged 65 years or older to receive the influenza vaccine (29% vs 58%, p<0.0001). Age disparity in vaccination rates was eliminated after initiation of the program.

CONCLUSION

The pharmacist-managed program increased influenza vaccination rates in high-risk patients with cardiovascular disease in advance of the newly published secondary prevention guidelines. Age-related differences in the vaccination rates were eliminated after program implementation.

Pandemics, avian influenza A (H5N1), and a strategy for pharmacists

Epidemics of influenza occur annually and account for more morbidity in the developed world than all other respiratory diseases combined. On average, 36,000 Americans die from influenza or its complications each year. Pandemics occur when influenza viruses undergo either antigenic drift or antigenic shift that results in a new viral strain that infects humans, when they are capable of sustained transmission from person-to-person, and when they are introduced in populations with little or no preexisting immunity. The influenza pandemic of 1918 caused an estimated 20-40 million deaths worldwide. An avian influenza A (H5N1) virus, currently circulating in Asia, has pandemic potential. However, no evidence currently exists that a pandemic is occurring. Pharmacists are uniquely positioned to initiate nearterm practice changes that may positively impact both seasonal and potential pandemic morbidity and mortality. Pharmacists must be immunization advocates and provide pharmaceutical care that includes evaluation of immunization status. Increasing immunization to prevent invasive pneumococcal disease, as well as seasonal influenza immunization, is encouraged. A pandemic vaccine represents the most effective strategy to mitigate the effects of a pandemic. Antiviral agents represent a treatment bridge until a pandemic-specific vaccine is available. The neuraminidase inhibitors oseltamivir and zanamivir are active against H5N1, although oseltamivir resistance has been reported. Advances in vaccine research, development, and production through the use of reverse-genetics systems represent the most effective technology to rapidly produce a pandemic influenza vaccine.

North Carolina family practice physicians' perceptions of pharmacists as vaccinators

OBJECTIVE

To determine whether family practice physicians are aware that pharmacists can administer vaccines and assess their support of pharmacists as vaccinators.

DESIGN

Cross-sectional study.

SETTING

North Carolina.

PARTICIPANTS

571 family practice physicians.

INTERVENTIONS

Mail survey.

MAIN OUTCOME MEASURES

Physician attitudes toward pharmacists' involvement with a variety of vaccines and patient populations.

RESULTS

A total of 25% of physicians correctly reported that pharmacists could administer vaccines in North Carolina, a state that had recently passed legislation permitting this practice. Almost 50% of the physicians supported pharmacists administering the influenza vaccine. Pharmacist administration of other vaccines received less support. Physicians who were newer to family practice had more positive attitudes than physicians who were in practice for longer periods of time.

CONCLUSION

While agreeing that the role of the pharmacist in patient care is becoming more important, physicians were neither very knowledgeable about nor supportive of pharmacists as vaccinators.

Pharmacist involvement with immunizations: a decade of professional advancement

OBJECTIVE

To review achievements in pharmacist-administered immunizations, emphasizing the period 1995 to 2004.

DATA SOURCES

Published articles identified through PubMed (1995-2004) using the search terms pharmacist, pharmacy, and vaccine, immunization, or shots. Additional sources were identified from personal bibliographies collected by the authors during this decade, as well as the bibliographies of the retrieved articles. The later two sources resulted in manuscripts of primarily historical significance.

STUDY SELECTION

More than 300 manuscripts were identified. The authors selected 15 studies that most clearly document the effect of pharmacist-administered immunizations for review.

DATA EXTRACTION

By the authors.

DATA SYNTHESIS

While pharmacists have been involved with vaccines dating back to the mid-1800s and the distribution of smallpox vaccine, only 10 years have passed since pharmacists began routinely immunizing patients in their communities as a standard practice activity. The Washington State Pharmacists Association initiated the first ongoing formalized training of pharmacists in vaccine administration in 1994. On November 1, 1996, the American Pharmaceutical (now Pharmacists) Association (APhA) began its nationally recognized training program for pharmacists, Pharmacy-Based Immunization DELIVERY: A National Certificate Program for Pharmacists. By 2004, an estimated 15,000 pharmacists and student pharmacists had been formally trained through recognized programs as vaccine experts, and the practice of pharmacist-administered immunizations, particularly for adult patients, has become routinely accepted as an important role of the pharmacist. Arguably, few initiatives have done more to move the pharmacy profession forward in direct patient care than the pharmacist-administered immunization movement.

CONCLUSION

Pharmacists have made significant strides in immunizations over the past decade. Limited activities in the hospital sector have been particularly well documented, as have the perceptions of patients regarding acceptance of pharmacists as immunizers. The activities of community pharmacists are less well documented. More research is needed into novel approaches to pharmacist involvement in public health-focused immunization initiatives, along with continued research evaluating the current practice of pharmacist-administered immunizations.

Keeping Up-to-Date on Immunizations: A Framework and Review for Pharmacists

OBJECTIVE

To provide a framework for keeping current in the immunizations field; an update on changes in adult and pediatric vaccine delivery since 2003; and an update on new immunization guidelines, new approved vaccines, and changes in uses for current vaccines.

DATA SOURCES

Published guidelines identified from the Centers for Disease Control National Immunization Program Web site. In addition, published articles were identified through Medline (January 2003-November 2005) using specific vaccine names as search terms. Additional sources were identified from the bibliographies of retrieved articles.

STUDY SELECTION

By the authors.

DATA EXTRACTION

By the authors.

DATA SYNTHESIS

To implement the immunization services now permitted under law in 44 states, many pharmacists receive initial training through the American Pharmacists Association Pharmacy-Based Immunization Delivery CERTIFICATE PROGRAM. To remain up-to-date in this field, pharmacists can apply the process described in this article, which includes regular monitoring of the Web site and publications of the Centers for Disease Control and Prevention and participation in one or more listservs. Specific information is presented on new vaccines marketed in the United States since 2003 along with updates on standards for adult and adolescent immunizations and changes in guidelines during this time frame.

CONCLUSION

As increasingly committed health professionals in the immunizations field, pharmacists are responsible for keeping updated on the constantly changing recommendations for vaccines and related products. By incorporating the recent information presented in this article and applying the process described for tracking changes in this field, pharmacists can fulfill their emerging vaccine-related roles on the health care team.

Where adults reported receiving influenza vaccination in the United States

BACKGROUND

Influenza vaccination coverage remains unacceptably low among persons aged > or =65 years and younger high-risk adults. This study assessed locations at which US adults receive influenza (flu) vaccinations and the relative roles that traditional and nontraditional vaccination settings play in influenza vaccine delivery.

METHODS

We analyzed data on types of settings at which last flu shot was received, reported by adult respondents to the 1999 Behavioral Risk Factor Surveillance System, stratified by age group and medical condition. We used multivariable logistic regression to identify factors associated with nontraditional vaccination settings.

RESULTS

In 1998-1999, reported influenza vaccination coverage was 19% for persons aged 18-49 years, 36% for persons aged 50-64 years, and 67% for persons aged > or =65 years. Seventy percent of flu shots received by persons aged > or =18 years were reportedly administered in doctors' offices and other traditional settings. Vaccination in nontraditional settings (eg, workplace, stores, community centers) was more likely for young, healthy, employed, white, college-educated adults who had not had a recent routine checkup.

CONCLUSION

Physicians should offer vaccination services at every opportunity. Increasing access to vaccination services in nontraditional settings should be considered as another strategy in pursuit of national vaccination coverage objectives.