Protecting the Circle of Life: Adult Immunizations

by Amy Groom, MPH andCDR Ann Gorman, PharmD,

BCPS, NCPS, NCPS-I

IHS Clinical RoundsJanuary 10, 2013

hosted by Susan Karol, MDIHS Chief Medical Officer

Objectives:

1. Understand the rationale and current recommendations for adult immunizations

2. Be familiar with tools and strategies they can implement in their facilities to help improve adult immunization coverage.

3. Understand the rationale for and how to set up a pharmacy based immunization clinic.

Accreditation

• The Indian Health Service (IHS) Clinical Support Center is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The IHS Clinical Support Center designates this live educational activity for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

• The Indian Health Service Clinical Support Center is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

• This activity is designated 1.0 contact hours for nurses.

Disclaimer

Accreditation applies solely to this educational activity and does not imply approval or endorsement of

any commercial product, services or processes by the CSC, IHS, the federal

government, or the accrediting bodies.

Upcoming Clinical Rounds

• IHS TBHCE Training Calendar

• January 17th –• Northwest Portland Area IndianHealth Board’s

WeRNative website presentation

• February 14th – Management of Chronic Pain in Primary Care

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Meet the Presenters:Amy Groom, MPH

• Amy Groom is a CDC assignee to IHS, and has served as the IHS immunization Program Manager since 2001.

• She oversees the development of the RPMS immunization software and serves as a liaison between IHS, CDC and state immunization programs on issues affecting the American Indian and Alaska Native population.

• She has a Master in Public Health from Boston University.

Meet the Presenters:CDR Ann Gorman, PharmD

• CDR Ann Gorman was co-director of Phoenix Indian Medical Center's Pharmacy Immunization Services from 2006-2012.

• With 2 providers her first year and 30 providers her final year, the pharmacy was able to offer an array of immunization services in the outpatient and inpatient settings.

• CDR Gorman has transferred to Santa Clara Health Clinic in Espanola, NM for a new adventure.

Guidelines for Receiving Continuing Education Credit

• To receive a certificate of continuing education or certificate of attendance, you must attend the educational event in its entirety and successfully complete an on-line evaluation of the seminar within 15 days of the activity. At the end of the evaluation, click on the appropriate line to obtain your certificate, fill in your name and print the certificate.

• If you need assistance, please contact Dr. Chris Fore (chris.fore@ ihs.gov) or Mollie Ayala (mollie.ayala@ihs.gov).

Protecting the Circle Of Life: Adult Immunizations

Amy Groom, MPHIHS Immunization Program Manager

Overview of the Presentation

• Provide rationale for emphasis on adult vaccination

• Review current adult vaccine recommendations• Review current adult vaccine coverage estimates• Describe strategies and best practices to increase

adult vaccine coverage• Describe the process for implementing a

pharmacy-based immunization clinic

BackgroundHigh burden of illness from infectious diseases among adults in the United States for which vaccines are available • From 3,000 to about 49,000 influenza-related deaths per year

– ~90% among adults 65 years and older • 9,419 cases of acute hepatitis B in 2009 • 43,500 cases invasive pneumococcal disease (IPD) in 2009, including

~5,000 deaths – 85% of IPD and nearly all IPD deaths among adults

• Over 27,000 reported cases of pertussis in US in 2010 – 6,640 among adults, 4% of which are hospitalized

• About 1 million cases of zoster annually U.S 1.CDC. Active Bacterial Core Surveillance. http://www.cdc.gov/abcs/reports-findings/survreports/spneu09.pdf 2.Huang et al . Vaccine 2011 3.2009 NNDSS 4.Thompson AJPH 2009 5.CDC. Prevention of Herpes Zoster. MMWR 2008. 57(RR-5): p. 1-30

Slide courtesy of Dr. Carolyn Bridges, presented at the 2012 National Adult Immunization Summit

VACCINE RECOMMENDATIONS

Vaccine Recommendations

CDC 2012 Recommended Adult Vaccine Schedule

Vaccine Recommendations

CDC 2012 Recommended Adult Vaccine Schedule

Changes/New Recommendations

• Hepatitis B vaccine for all unvaccinated diabetics 19 –59 years (Dec. 2011)– Can be considered for those 60 yrs and older

• Routine Tdap for all adults, including those 65 years and older (June 2012)

• Tdap during EVERY pregnancy (Dec. 2012)– To protect the infant through passive antibody transfer– Optimal window is 27 – 36 weeks gestation

• 13-valent Pneumococcal Conjugate vaccine (PCV13) for adults with immunocompromising conditions (Oct. 2012)

Source: CDC/ACIP Vaccine Recommendations: http://www.cdc.gov/vaccines/pubs/ACIP-list.htm

PCV13 Recommendation for Immunocompromised Adults

• Pneumococcal Naïve persons:– PCV13 first, followed by a dose of 23-valent Pneumococcal

Polysaccharide Vaccine (PPSV23) at least 8 weeks later. – Re-vaccination with PPSV23 5 years after PPSV23 dose if indicated

• Previous vaccination with PPSV23: – PCV13 dose ≥1 year after the last PPSV23 dose was received.– For those who require additional doses of PPSV23, the first such dose

should be given no sooner than 8 weeks after PCV13 and at least 5 years after the most recent dose of PPSV23.

Source: Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine for Adults with Immunocompromising Conditions: Recommendations of the Advisory Committee on Immunization Practices (ACIP)

Risk group Underlying medical condition PCV13Recommended

PPSV23 Recommended Revaccination 5 yrs after1st dose

Immunocompetent persons Chronic heart disease† ✔

Immunocompetent persons Chronic lung disease§ ✔

Immunocompetent persons Diabetes mellitus ✔

Immunocompetent persons Cerebrospinal fluid leak ✔ ✔

Immunocompetent persons Cochlear implant ✔ ✔

Immunocompetent persons Alcoholism ✔

Immunocompetent persons Chronic liver disease, cirrhosis ✔

Immunocompetent persons Cigarette smoking ✔

Persons with functional or anatomic asplenia Sickle cell disease/other hemaglobinopathy ✔ ✔ ✔

Persons with functional or anatomic asplenia Congenital or acquired asplenia ✔ ✔ ✔

Immunocompromised persons Congenital or acquired immunodeficiency¶ ✔ ✔ ✔

Immunocompromised persons Human immunodeficiency virus infection ✔ ✔ ✔

Immunocompromised persons Chronic renal failure ✔ ✔ ✔

Immunocompromised persons Nephrotic syndrome ✔ ✔ ✔

Immunocompromised persons Leukemia ✔ ✔ ✔

Immunocompromised persons Lymphoma ✔ ✔ ✔

Immunocompromised persons Hodgkin disease ✔ ✔ ✔

Immunocompromised persons Generalized malignancy ✔ ✔ ✔

Immunocompromised persons Iatrogenic immunosuppression** ✔ ✔ ✔

Immunocompromised persons Solid organ transplant ✔ ✔ ✔

Immunocompromised persons Multiple myeloma ✔ ✔ ✔

TABLE. Medical conditions or other indications for administration of 13-valent pneumococcal conjugate vaccine (PCV13), and indications for 23-valent pneumococcal polysaccharide vaccine (PPSV23) administration and revaccination for adults aged ≥19 years,* by risk group - Advisory Committee on Immunization Practices, United States, 2012

* All adults aged ≥65 years should receive a dose of PPSV23, regardless of previous history of vaccination with pneumococcal vaccine.† Including congestive heart failure and cardiomyopathies, excluding hypertension. § Including chronic obstructive pulmonary disease, emphysema, and asthma.¶ Includes B- (humoral) or T-lymphocyte deficiency, complement deficiencies (particularly C1, C2, C3, and C4 deficiencies), and phagocytic disorders (excluding chronic granulomatous disease). ** Diseases requiring treatment with immunosuppressive drugs, including long-term systemic corticosteroids and radiation therapy.

ADULT VACCINE COVERAGE

U.S. Adult Vaccine Coverage Rates 2010

18.5%

59.7%

30.8%

66.4%

8.2%14.4%

20.7%

0%10%20%30%40%50%60%70%80%90%

100%

Coverage Estimate

Source: National Health Interview Survey, 2010. CDC. Adult Vaccination Coverage — United States, 2010. MMWR 2012; 61(04);66-72.

Challenges for Vaccinating Adults –General Population

• Dispersed/diverse sources of medical care– Adult vaccination less integral to adult medical practices

• Vaccination of adults not “required” or routinely assessed • Fewer formal relationships between adult providers and

immunizations programs • High out of pocket costs No “Vaccines for Adults” program

to provide vaccine for uninsured – Even for insured persons, e.g. costs for Medicare Part D vaccines

(non-flu or pneumococcal vaccines) • Vaccination of adults of substantial health benefit, but

lower effectiveness especially in older adults and immune compromised

Slide Courtesy of Dr. Carolyn Bridges, CDC. Presented at the 2012 National Adult Immunization Summit.

Vaccinating Adults in IHSChallenges• Patients may access care infrequently, or only use ER/Urgent Care services• Competing priorities, limited time• Limited funding for vaccine purchase• Patient education• Provider buy in?

Advantages• Integrated care• EHR and provider reminders• No financial barriers for patients• Relationships with the community

– PHNS, CHRs

STRATEGIES TO IMPROVE ADULT VACCINATION COVERAGE

Evidenced-based Strategies• Standing Orders

– The most consistently effective method for increasing adult vaccination rates

• Computerized Record Reminder• Chart Reminder • Performance Feedback • Home Visits • Mailed/Telephoned Reminders

– Most useful in settings with low baseline coverage• Expanding Access in Clinical Settings

– Recommended as part of a multi-component intervention • Patient Education • Personal Health Records

– Recommended as part of a multi-component intervention

Meta-Analysis of interventions to Increase use of Adult Immunization

Intervention Odds Ratio

Organizational Change (e.g. standing orders, separate clinics)

16.0

Provider Reminder 3.8

Patient Financial Incentive 3.4

Provider Education 3.2

Patient Reminder 2.5

Patient Education 1.3

Source: Stone E. Interventions That Increase Use of Adult Immunization and CancerScreening Services: A Meta-Analysis. Ann Intern Med. 2002;136:641-651.

BEST PRACTICES IN IHS

System Changes

– Policy • All vaccines on IHS Core Formulary• Establishing provision of routinely recommended ACIP

vaccines as a standard of care for IHS – Memo from IHS Chief Medical Officer, July 11, 2012

– IPC initiative– Expanding Access

• Standing Orders• Walk-in immunization clinics, extended hours• Pharmacy-based immunization

Electronic Provider Reminders - Current

• Immunization reminders for adults currently in RPMS:– Influenza– PPSV23 for 65 years+– PPSV23 for adults with high risk condition (Optional)– Tdap for everyone 19 yrs+– HPV (Optional)

• Females 19 – 26 years• Males 19 – 21 years

– Zoster for 60 yrs + (Optional)– Hepatitis A and B for patients who receive first dose

Electronic Provider Reminders In development

• Hepatitis B – Diabetics 19 – 59 years– Patients with Sexually Transmitted Infection (STI) diagnosis– Patients with chronic renal failure– Patients with chronic liver disease– Patients with hepatitis C

• Hepatitis A– Patients with chronic liver disease– Patients with hepatitis C

• Meningococcal– Patients with immune-compromising conditions

• PCV13– Adults with immune-compromising conditions

Assessment and FeedbackRPMS reports – run them regularly!

– Adult Immunization Report– Influenza Report

• Provide vaccine coverage estimates• Can be run by designated provider

– Performance feedback• Provide list of patients who are not current with

recommended vaccines– Can be used for Reminder/Recall

• National Quarterly Reports – Based on collection of data from all sites

CRS reports for some adult immunization measures– Flu , Pneumo and Tdap

Assessment and FeedbackIHS Adult Vaccine Coverage, FY 2012 Quarter 4

61.8%

40.0%

23.6%

5.0% 1.1%

22.5%

73.8%

0%10%20%30%40%50%60%70%80%90%

100%

Coverage

Source: Indian Health Service, Quarterly Vaccine Coverage Reports.

Influenza Vaccine Coverage Dec. 29th, 2012

0%10%20%30%40%50%60%70%80%90%

100%

All adults 18yrs+

18-49 years 50-64 years 65 years+

% Vaccinated

% Vaccinated

Source: IHS Influenza Awareness System (IIAS) Week 52 Report

Summary

• Provision of ALL recommended vaccines is a Standard of Care

• Nationally, adult vaccine coverage rates are sub-optimal

• In IHS, adult vaccine coverage rates are much higher, but many adults remain unvaccinated

Resources

• CDC Immunization Recommendations• Adult Immunization Guide from the American

College of Physicians – Includes examples of incorporating immunizations

into the Chronic Care Model• CDC Adult Immunization Resources • Immunization Action Coalition

– Adult Immunization Resources– Examples of Standing Orders

Pharmacy Based Immunization Services

Presented by:CDR Ann Gorman

Santa Clara Health Clinic Pharmacy Manager

Brief Background• Graduated from Duquesne University 2000• Gallup Indian Medical Center 2000-2006

– PharmPAC Immunization Workgroup 2006-2007• Phoenix Indian Medical Center 2006-2012

– APhA Immunization Cert at COA 2007– Pharm Based Imz Clinic 2007-2012– APhA Faculty Training 2008– IHS Point of Contact for APhA Imz Cert – Trained 177 IHS RPH

• Santa Clara Health Clinic 2012-??– Pharmacy Manager

IMPORTANT REMINDER:ALL Vaccines are on the IHS Core Formulary

As of September 2011, all vaccines recommend for children, adolescents and adults by the Advisory Committee for Immunization Practices (ACIP) for routine use will be automatically included on the IHS Core FormularyRationale: • Ensures portability

– Some vaccines require multiple doses (e.g. Hepatitis A, Hepatitis B, HPV)

• Ensures parity • Under the Affordable Care Act (ACA), private health insurance plans and Medicaid/Medicare

programs will be REQUIRED to offer first dollar coverage for ALL ACIP recommended vaccines• If IHS does NOT cover these vaccines, we risk a two-tiered system

• AI/AN Children < 19 years have coverage for recommended vaccines (VFC)• Adults with private insurance or Medicaid/Medicare have coverage for recommended

vaccines• Adult IHS patients who are uninsured may not have coverage for recommended vaccines

if the facility chooses to/cannot not provide the vaccine

Where?

• Walk-in/Urgent Care• Emergency Room• Primary Care• Specialty Clinics• Pharmacy• Inpatient

Who?

• Reception• Nursing and Nursing Aides• Midlevel providers• Medical Staff• Pharmacists

Why Pharmacy?

• Patients Trust Us• Increase Patient

Awareness• Increase Provider

Awareness• Catch Missed

Opportunities• Different Focus• Augment Current Services• Extended Hours

• Frequent Encounters• Increased Access• Cocooning Effect• New Recommendations• Generate Revenue• Cost Savings• Sub-optimal Coverage

Rates

HOW?Outpatient Pharmacy

• Part of normal prescription process– Screening– Prescriptions– Counseling

• Improving Patient Care (IPC) Model– Healthcare Team– Clinical Focus– Highest Level of Licensure

• Administer vaccines

PIMC Flu Clinic Model• Workflow Example: • 10-15 minutes per patient

Patient arrives at pharmacy -> Checked in as walk-in appointment in RPMS -> Given an influenza VIS-> Asked to answer 4 screening questions (yes/no only)-> Sent to the waiting room-> Assigned pharmacist calls patient into room in order of check-in -> Reviews screening questions/education -> Computer documentation -> Pharmacist gives shot(s) -> Checks patient out -> Next patient

HOW?Inpatient Pharmacy

• Admission– Screen

• Daily Contact– Remind provider to order– Order independently

• Discharge– Ensure immunizations received

PIMC Inpatient Model• Admission

– Flag those in need of vaccines• During Stay

– Interview & educate patient• Screening questions

– Verify and enter any historical shots– Order per protocol (Flu, pneumococcal, Td/Tdap, &

Hepatitis B)– Obtain provider order for others

• Discharge– Ensure patient received needed vaccines– Inform of any additional vaccines needed

Determine Level of Need

– Advocate– Facilitate

• Educate/Inservices/Rounds• Host or organize immunization events

– Vaccinate • Maintenance Vaccines

– Influenza– Pneumoccoccal– Td/Tdap

• Comprehensive Clinic– All Vaccines

PIMC Model• Outpatient Walk-in Immunization Clinic

Monday – Friday 10am-5pm– During Flu Season:

• 10am-2pm all shots • 2-6pm flu (and pneumococcal) shots only

– “Expert” Immunizers – “Flu only” Immunizers

• Inpatient Prescribing Protocol– “Inpatient” Immunizers

• Mass Vaccination Drills• Flu Planning Committee• Immunization of non-beneficiaries who have contact with

high risk patient • Pharmacists & technicians advocate during medication

counseling• Educators

State Laws: Pharmacist ImmunizersVaccine Type StateAny Vaccine - 38 AL,AK,AZ,AR,CA,CO,DC,DE,

GA,HI,ID,IL,IN,IA,KS,KY,LA,MI,MN,MS,MT,NE,NV,NJ,NM,NC,ND,OK,OR,PA,RI,SC,TN,TX,VT, VA,WA,WI

Influenza Only - 3 FL,MA,PR

Influenza and Pneumo - 2 NY,WV

Other Combos - 9 OH,CT,MD,ME,MO,NH,SD,UT,WY

Source: APhA survey, updated Oct. 2011.

Pharmacist Administered Vaccines: Protocols vs Prescriptions

Type State

Protocol or Standing Order (22)

AK,AZ,CA,CO,CT,FL,ID,KS,KY, MN,MS,MT, ND, NH, NM, NV,NY,OK,OR,UT, WI, WY

RX (1) AL

Protocol, Standing Order OR RX (29)

AR,DC,DE,GA,HI,IL,IN,IA,LA,ME,MD,MA,MI,MO,NE,NJ,NC,OH,PA,PR,RI,SC,SD,TN, TX, VT, VA,WA,WY

Source: APhA survey, updated Oct. 2011

Determine Target Population

– Outpatient vs Inpatient– Pediatrics– Adolescents– Adults

Pharmacist Administered Vaccines:Patient Age Limitations

Age State

Any age (13) AL, AK, CA, CO, MI,MS,NE,NM,OK,TN,TX,VA,WA

Adults (1) FL

> 19 yrs (1) WY

> 18 yrs (15) CT,DC,HI,IA,MA,NC,NH,NJ,NY,PA,PR,SC,SD,VT,WV

>14yrs (4) IL,IN,NV,OH

>13 yrs (2) GA,UT

>12 yrs (3) ID,MO,MT

> 11 yrs (1) OR

> 10 yrs (1) MN

>9 yrs (5) DE,KY,ME,MD,RI

>7 yrs (3) AR,LA,TX

>6 yrs (2) KS,WI

>5 yrs (1) ND

Source: APhA survey, updated Oct. 2011.

Details

• Walk-in vsAppointment

• Hours of Operation• Private Area• Computer Access• Vaccine Info Sheets• State Registries• Advertise• Supplies

– Vaccines– Needles & Syringes– Sharps Container– Bandaids– Gauze– Alcohol Wipes

• Manage• Monitor

Training

• Initial – Pharmacy Schools– APhA– State/local

• Continuing Education– Live– Online

Pharmacy Immunization Services

• Mentor• Provider Support• Administration Support• Approved Protocol• Advertise• Vaccinate• Monitor• Improve and Expand

Policies, Procedures, & Protocols

• Standing Orders

• Collaborative Practice Agreements

• Clinical Protocols

National Clinical Pharmacy Specialists (NCPS)

• A credentialing system for IHS, Tribal, & Urban (I/T/U) & Bureau of Prisons (BOP) pharmacists

• IHS Pharmacy Program– History– Applications– Critical Elements in designing Collaborative Practice

Agreements (CPA) / Clinical Protocols– Sample protocols, including PIMC’s Immunization Clinic

• New NCPS-I designation for comprehensive immunization clinics

Comprehensive Immunization Services

• Reading and interpreting immunization schedules• Ordering and interpreting laboratory studies• Making clinical decisions based on the patient’s

history, disease states, immunization schedules and current vaccine recommendations

• Prescribing all appropriate vaccines independently

• Beyond following standing orders

Summary

• Ensuring our patients have access to all ACIP recommended vaccines is imperative

• Pharmacists can play an important role in increasing patient access to vaccines

• The purpose of pharmacy-based immunization is not to replace current immunization activities, but to augment them

Additional Resources

– APhA Pharmacist Immunization Center– Imunize.org, standing orders, education materials,

handouts, and vaccine information statements (VIS)

– Vaccine Schedules, ACIP recommendations– NCPS-i Immunization Clinic P & P