13 Deciphering immunization codes: making evidence-based recommendations

Introduction

According to the ‘Oath of the Pharmacist,’ pharmacists promise to devote their lives to others through the pharmacy profession. A major part of this oath is to consider the welfare of humanity and assure optimal outcomes in all patients.¹ Although pharmacists may work in different practice settings, each has the opportunity to be a key component of disease prevention by becoming a vaccine advocate.² Pharmacists can promote the use of vaccines by providing immunization administration services, screening patients in each practice setting, conducting patient counseling, and provide widespread public education regarding vaccine use.² Although pharmacists are immunizers in every state, it is important to review your state’s laws regarding pharmacist delivered immunization services. Up-to-date information can be found on the American Pharmacists Association’s website.³

There are many resources the pharmacist can turn to for vaccines schedules and patient education documents. The CDC’s website will link the pharmacist to many different materials for providers and patients regarding many different topics for vaccines.⁴ One of these documents that the pharmacist should always review are the immunization schedules that are available for children and adults. The CDC has different documents organizing the immunization schedules by age groups or comorbid conditions. They also include documents that outline contraindications, as well as a mobile phone application for quick access to the vaccine schedules.⁵ The CDC website also has links for more patient-friendly information (including an easy to read schedule) as well as a library of previous immunization schedules, specific changes for each year’s recommendations, and specific Advisory Committee on Immunization Practices’ recommendation.^6,7 An emerging role for pharmacists is in travel health, which include the administration of travel vaccinations. The CDC has a comprehensive resource for clinicians to identify the appropriate vaccines each patient needs depending on the country of travel.⁸

Another resource available to pharmacists is a website from the Immunization Action Coalition (IAC). The IAC works closely with the CDC to provide information and education to health care providers and the community to increase immunization rates.⁹ On this website are many documents for both health care providers and patients on many different vaccine related topics including documentation, vaccine hesitancy, temperature logs, promotional material, and much more. There are also educational resources for patients in other languages such as Spanish, Korean, Russian and French.¹⁰ A valuable resource included in the website is the ‘Ask the Experts’ section where experts from the CDC answer questions pertaining to each vaccine, as well as administration, billing, safety, and recommendations.¹¹

Case

CC: “This is my first time here.”

HPI: Michael Smith is a 57 year old male presenting to your clinic.

PMH: T2DM; hypertension; gastroesophageal reflux disease; seasonal allergies

FH:

• Mother: HTN, T2DM, died at 71 (NSTEMI)
• Father: HLD, COPD

SH:

• Tobacco: denies
• Alcohol: socially, one or two drinks weekly

Medications:

• Metformin 1000 mg PO BID
• Atorvastatin 40 mg PO daily
• Lisinopril 10 mg PO daily
• Cetirizine 10 mg PO daily
• Omeprazole 20 mg PO before breakfast

Allergies: NKDA

Vitals:

• BP 146/98 mmHg
• HR 88 bpm

Labs:

• BMP (fasting)
• Na 142 mmol/L
• K 4.5 mm/L
• Cl 102 mmol/L
• CO₂ 27 mmol/L
• Glucose 153 mg/dL
• BUN 18 mg/dL
• SCr 0.97 mg/dL
• Ca 8.8 mg/dL
• HgA1c 9.1%

Blood count:

• WBC 9.2 K/mcL
• RBC 4.03 M/mcL
• Hgb 14.3 gm/dL
• Hct 37.2%

Liver function:

• Alk Phos 80 U/L
• ALT 20 U/L
• AST 24 U/L

Other information:

• 10 year ASCVD Risk: 15.3%
• Vaccination history per state registry: none

Case Questions

1. One of the first items you evaluate in your clinic are the vaccinations each patient is eligible to receive. Using the most recent vaccine CDC schedule, which vaccines would the patient be eligible to receive?

2. What if the patient was 67 years old? What vaccines would you screen for?

3. The patient is interested in receiving the above vaccines, but states that he is concerned with overwhelming his immune system. How would you respond to this patient?

4. The patient found his immunization record from his previous primary care provider. According to his immunization record, he has received one dose of the hepatitis B vaccine two years ago. How should you proceed with finishing his vaccination series?

5. The patient reports that he will be traveling to Egypt with his family and is curious to what vaccines are recommended prior to his trip. Using the CDC’s travel health database, what vaccines would the pharmacists potentially recommend, depending on the activity of his trip?

6. A physician in your clinic asks you if patients taking methotrexate for rheumatoid arthritis are eligible to receive Zostavax^®. How would you answer this?

Author Commentary

Pharmacists are well respected and easily accessible, particularly those involved in community pharmacy. Hence, they often function as a first resource for many people and parents and serve, not only to counsel patients on current medications, but also to suggest over-the-counter products for common ailments such as fever and sore throat. Because some infectious diseases may initially present with mild symptoms common among many infections, it is imperative that pharmacists are aware of which diseases are endemic or circulating in the community, so they may ask relevant questions to assess disease exposure and vaccination status. Such conversations between the pharmacist and patient may result in patients receiving appropriate referrals and care to further prevent spread of vaccine-preventable diseases.

Patient Approaches and Opportunities

As pharmacists, it is important to consider the impact of infectious disease on the lives of our patients. Regardless of practice site, pharmacists can screen patients for immunizations for which they are eligible, recommend and counsel patients regarding the importance of immunization, educate on vaccine safety, and discuss concerns regarding myths related to vaccination. Pharmacists are uniquely positioned to provide immunization services within community pharmacies and outpatient clinics and should utilize opportunities to promote immunization and public health whenever possible.