33 Staying on track: reducing missed immunization opportunities in the pediatric population

Autumn Stewart-Lynch, PharmD, BCACP

Craig Kimble, PharmD, MBA, MS, BCACP

Michelle DeGeeter Chaplin, PharmD, BCACP, CDCES

Andrew Helmy, PharmD, MPH

Introduction

Current immunization recommendations are published by the Centers for Disease Control and Prevention (CDC) based on recommendations from Advisory Committee on Immunization Practices (ACIP). Recommendations are based on several criteria including age, risk factors, and chronic diseases.¹ Pharmacists must be familiar with the immunization schedules as well as strategies for catching up on missed doses. The CDC’s Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger identifies the vaccines routinely recommended by age and when catch-up immunizations are considered appropriate, should a dose be delayed. The catch-up schedule provides users with vaccine specific guidance on minimum intervals between doses, maximum ages for administration, and conditions under which additional doses may not be necessary.² The American Academy of Pediatrics (AAP) also publishes schedules and the CDC publishes best practices guidelines.^3,4

Despite the many opportunities to receive immunizations at primary care offices, pharmacies, health departments, and employer programs that exist, overall immunization rates remain below Healthy People 2030 goals for most communities.⁵ Although pharmacists are trusted resources for provision of immunizations in adults, they have not traditionally had a large role in providing pediatric immunizations, with most given in a pediatrician’s office. Across various pharmacy practice settings, a pharmacist could recognize a child as not up-to-date on immunizations, but due to scope of practice limitations, children either went unimmunized or relied on pharmacist referral, which constitute missed opportunities. Additionally, the decrease in childhood wellness visits as a result of the COVID-19 pandemic placed constraints on the usual opportunities for immunizations for pediatric patients.⁶

Before the COVID-19 pandemic, some states had already expanded pharmacist practice for pediatric immunizations as a solution to care access issues. In response to declining rates of pediatric immunizations and to reduce barriers to immunizations, the US Department of Health and Human Services issued a directive on August 19, 2020 (the Third Amendment to the declaration under the Public Readiness and Emergency Preparedness Act) to allow all pharmacists and supervised qualified pharmacy interns and technicians to administer any CDC approved immunization to individuals three to 18 years of age without a collaborative practice agreement or protocol.⁷ This effectively expanded ability for pharmacists in all 50 states to immunize pediatric patients. The amendment was subject to various requirements, including:

• Only using FDA-approved or emergency use authorized vaccines
• Ordering/administration according to CDC ACIP immunization schedules
• Compliance with jurisdictional recordkeeping and reporting requirements
• Informing patients/caregivers the importance of a well-child visit with a pediatrician
• Completion of at least 20 hours of practical training, current cardiopulmonary resuscitation certification and (for licensed pharmacists) a minimum of two hours of Accreditation Council for Pharmacy Education approved, immunization-related continuing pharmacy education during each state licensing period

Delays in immunizations can be tied to individual factors such as cost or vaccine hesitancy; however, others are more structural, including access to care, vaccine distribution, misinformation, or more recently, the COVID-19 global pandemic. With patients or their caregivers, it is important to have discussions on why immunizations are not up-to-date to identify and reconcile any barriers as needed. From a public health perspective, increasing the access to care, such as allowing pharmacists to immunize children, or marketing campaigns directed at vaccine education, can help to fight barriers at a population level. Providing clinics at local schools, libraries, community centers, or other organizations that are centrally located and providing vaccines or education may be an effective strategy to reduce access barriers.^7,8

Case

CC: “My grandson hasn’t been able to get into his pediatrician in a while and I’m concerned that he is falling behind on his shots.”

Patient: AP is a 15-month-old (32 in, 10.9 kg) white male who is brought in to establish care as a new patient. His grandmother is his legal guardian and accompanies him today.

HPI: unremarkable

PMH: unremarkable

FH:

• Mother OUD
• Father (deceased) suicide; AUD
• Maternal grandmother T2DM

SH: Second-hand tobacco exposure (grandfather smokes 10 cigarettes per day)

Medications: None

Allergies: NKDA

Labs: unremarkable

ROS: unremarkable

SDH: AP lives with his grandparents (both in their 50s) and his four-year-old sister. He has medical and prescription coverage through the state Medicaid program. His grandfather works full-time for a utility company and his grandmother recently quit her retail job to care for the grandchildren. AP’s mother has weekly supervised custody visits.

Additional context: AP’s grandmother reports that while AP was scheduled for a 12-month-old well child visit with his previous provider, this appointment was canceled due to COVID-19. She does not have his immunization records but reports his last vaccines were received prior to her gaining custody two months ago. She is concerned about the costs for this visit as the family is on a fixed income and has spent much of their savings on legal fees related to custody of their grandchildren.

Case Questions

1. What are the long-term implications of missed childhood immunizations upon a community?

2. What role could the pharmacist in AP’s primary care setting play in bringing his immunizations up to date? What role might a pharmacist have in bringing immunizations up to date in the following practice settings: (1) community; (2) acute care; or (3) managed care?

3. What tools are available to healthcare professionals to determine a patient’s immunization record when the patient or caregiver is not able to provide one?

4. You manage to track down the following records from AP’s previous pediatric provider. Using the CDC Pediatric Immunization catch-up schedule, which vaccines would you recommend for AP’s visit today?

5. AP requires multiple vaccines at today’s visit. Explain how you will ensure that he will be brought up to date while avoiding unnecessary clinic visits.

6. Referring to the CDC’s Pink Book, how will you address each of the following special considerations for pediatric immunizations specific to AP: (1) education; (2) site selection; (3) needle length/gauge; and (4) comfort measures and after-care?

7. What strategies would you suggest to address the cost barriers identified by AP’s grandmother?

8. What strategies could you consider if the following barriers were present: (1) safety/vaccine hesitancy; (2) transportation to the physician’s office; or (3) lack of a PCP?

9. How would you ensure the continuity of care between you and the other members of AP’s healthcare team?

Author Commentary

Pharmacists are respected immunizers. Because many children missed vital doses in their recommended immunization schedules due to the COVID-19 pandemic, pharmacists were given expanded ability to immunize in the pediatric population age three and over in all 50 states. Therefore, it is the responsibility of the pharmacist or student pharmacist to stay current and to develop competency in pediatric immunizations through additional training or completing a continuing education program on pediatric immunizations.⁹

As regulations on obtaining childhood immunizations have loosened, patients require assistance to understand the importance of and pathway to catching up on missed immunizations. Oftentimes, patients present as part of a family to the pharmacy, and this is an opportunity to assess patients for missed doses. Depending on state regulations, pharmacists can also consider becoming a Vaccine For Children (VFC) program provider, which enables delivery of no-cost vaccines to children who are uninsured, under insured, Medicaid-eligible or American Indian or Alaska Native.¹⁰ Regardless of practice settings, pharmacists should be an active participant of the “immunization neighborhood” by sharing immunization records, making referrals, and providing information and professional advice to raise immunization rates. The COVID-19 pandemic and associated issues it has created an all-hands-on deck approach to care and children should be included in the pharmacist’s approach to immunization completion where possible.^9,11

Patient Approaches and Opportunities

It is widely known that pharmacists are the most accessible healthcare professionals. With expanding pharmacist roles in pediatric immunizations, barriers such as vaccine hesitancy, transportation to the pediatrician, and access issues can be overcome. The CDC Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger and the catch-up schedule are key resources in determining what immunizations a child requires and how to bring delayed immunizations up-to-date. The pharmacist ensures continuity of care by recording vaccinations administered in the pharmacy in the pharmacy’s immunization system, and the state registries or Immunization Information Systems (IIS), and by communicating this information with the patient’s healthcare team. Additionally the pharmacist should inform parents/caregivers on the importance of a well-child visit with their pediatrician or family medicine provider to assess growth and developmental milestones to ensure the optimal physical, mental, and social health of the child.