By Cameron Bonell, BSc(Pharm), ACPR, Rph
The most recent survey of adult immunizations in Canada was done in 2016.1 This survey found that 88% of adults “believed that they received all of the vaccines recommended for someone their age”, yet only 3% reported having “received all of the recommended adult vaccines for their age/risk group”. This disconnect is putting adults at risk for preventable disease and putting society at risk for preventable transmission of disease and requires a concerted effort from physicians/practitioners, public health professionals and pharmacists2.
Identifying an immunization need is an actionable drug related problem and pharmacists need to make this a regular part of medication review.
Pharmacists are more accessible and see patients more often than any other health professional3. We can leverage our position in the health system to greatly improve immunization coverage. In addition, interactions with patients serve as ideal education touchpoints to improve vaccine uptake, correct misconceptions, and combat misinformation4. Completing a vaccine history can be frustrating; often no documentation exists, and memory of previous immunizations is fleeting. With a systematic approach we can and should begin constructing a vaccine history for each patient we review.
Identifying Patient Needs
It is always a pleasure when a patient brings in a logbook that shows their vaccine administration history. Unfortunately, this is a rare occurrence but one that pharmacists can strive to make more common. For those patients that do not have good documentation, we need to be systematic and organized. Start with disease susceptibility. Four important points to consider are:
- pregnancy status
- co-morbidities of the individual or their household contacts
- exposure risk owing to occupation, living circumstance, lifestyle factors or travel
Familiarity with BCCDC Immunization Manual (Part 4: Biological Products) and the NACI recommendations makes identifying immunization needs easier.
We should also consider:
- missed childhood vaccines7
- patients new to BC without record of immunization8
- previously immunized individuals that may benefit from newer vaccines (e.g. pneumococcal, polio, zoster, and others)
Which Vaccines To Focus On And Stock
Missing vaccines may be publicly funded or may require patients to pay—we need to think of both. Vaccines that are stocked routinely should be those for which we see consistent demand and/or need, including:
- Influenza (3 or 4 valent)
- Measles, mumps, rubella
- Pneumococcal vaccines
- Tetanus/diphtheria +/- pertussis
This year, high dose influenza vaccine (Fluzone® High-dose) will be publicly funded in BC for seniors of long-term care and assisted living facilities. Consider stocking this vaccine privately as NACI recommends it over standard dose influenza vaccine for those 65 years and older.10
We should also consider stocking other vaccines based on patient specific need or for pharmacy specific patient groups. Vaccines in this category include:
- Hepatitis A, B, A+B
- Meningococcal C and/or ACYW-135
- Travel vaccines (cholera/E. coli, Japanese encephalitis, meningococcal B, rabies, typhoid, yellow fever)
Some examples of groups that may have additional immunization needs are; first-nations individuals, persons with immunocompromising conditions, persons who are homeless, persons with substance use disorders, frequent travelers, and others as outlined in the manual/guidelines)5,6
Pharmacists are used to documenting on prescription hard copies and in our local software system, but we need to embrace additional documentation when providing immunizations. It is often frustrating to determine when or if a patient has received a recommended vaccine—it may be on a scrap of paper in the physicians’ or facilities’ chart or it may be some chicken scratch on a tiny immunization card. We should fill these documentation voids and make sure the next immunizer has better records to work with.
It is a sad reality that there is no provincial or national registry for adult immunizations and until one exists pharmacists can greatly improve documentation by considering these opportunities:
- Providing written record to the patient
- Documenting on Pharmanet in the clinical notes section
- Communicating with the patient’s practitioner for recording in chart or EMR
- Encouraging patients to consider a digital record such as the CANimmunze app9
Pharmacists can be patient advocates for improved immunization access, and we are ideally situated to provide immunization services and ensure education and documentation needs are met.
A vaccine reference document based on this article has been developed to help remind pharmacists which vaccines to recommend to adult patients, assuming they’ve received their routine childhood immunizations.
- Public Health Agency of Canada. Vaccine uptake in Canadian adults: results from the 2016 Adult National Immunization Coverage Survey (aNICs). July 2018. (updated on-line publication date August 31, 2018), survey conducted by Environics Research Group. Available: http://publications.gc.ca/collections/collection_2018/aspc-phac/HP40-222-2018-eng.pdf . This survey is updated every 5 years.
- Bach AT, Kang AY, Lewis J, Xavioer S, Portillo I, Goad JA. Addressing common barriers in adult immunizations: a review of interventions. Expert Rev Vaccines, 2019, Nov; 18(11) 1167-1185. Epub 2019 Dec 10.
- Tsuyuki RT, Beahm NP, Okada H, Al Hamarneh YN. Pharmacists as accessible primary healthcare providers: Review of the evidence. Can Pharm J (Ott). 2018 Jan-Feb; 15(1): 4-5. Published on-line 2018 Jan 2.
- Bragazzi NL. Pharmacists as Immunizers: The Role of Pharmacies in Promoting Immunization Campaigns and Counteracting Vaccine Hesitancy. Pharmacy (Basel), 2019 Dec; 7(4): 166. Published on-line 2019 Dec 5.
- BC Centre for Disease Control, Communicable Disease Manual. Chapter 2: Immunization. Part 4: Biologic Products. Available: http://www.bccdc.ca/health-professionals/clinical-resources/communicable-disease-control-manual/immunization/biological-products. This Chapter is updated on-line regularly.
- Public Health Agency of Canada. National Advisory Committee on Immunization (NACI). Canadian Immunization Guide. Available: https://www.canada.ca/en/public-health/services/canadian-immunization-guide.html. (Part 4: Active Vaccines, for specific recommendations on each vaccine)
- BC Centre for Disease Control, Communicable Disease Manual. Chapter 2: Immunization. Part 1 – Immunization Schedules. Available: http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%202%20-%20Imms/Part_1_Schedules.pdf. 2019 Oct.
- BC Centre for Disease Control, Communicable Disease Manual. Chapter 2: Immunization. Part 2: Immunization of Special Populations – Individuals New to Canada. Available: http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%202%20-%20Imms/Part2/NewToCanada.pdf. 2017 Mar.
- Wilson K et al. CANImmunize App. Available: https://www.canimmunize.ca/en/home.
- Summary of the NACI Seasonal Influenza Vaccine Statement for 2020–2021https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2020-46/issue-5-may-7-2020/naci-summary-influenza-2020-2021.html