Pharmacist Administration of Vaccines to Prevent Diphtheria, Tetanus and Pertussis

Policies

Tdap Vaccine Formulations

  1. BOOSTRIX® vaccination is licensed for patients ages 10 and older.
  2. ADACELTM vaccination is licensed for patients 11 through 64 years of age.

Note: The ACIP recommends that either preparation may be used for patients 65 years and older.

Recommended Schedule

  1. If a patient 18 years or older has not received a dose of Tdap, or if vaccine status is unknown, the patient should receive a one-time dose of Tdap as soon as feasible.
  2. Tdap can be administered regardless of the interval since the last tetanus or diphtheria toxid-containing vaccine.

Indications for Use

  1. Adults
  2. Upon request, administer a single dose of Tdap to any adult 18 years and older to replace a single dose of Td
  3. Upon request, those adults with close contact to children, who are healthcare personnel, or are parents who are at a high risk of pertussis
  4. Pregnancy
  5. Any patient who might become pregnant
  6. Pregnant women who have not received a Tdap vaccine, should receive a dose after 20 weeks gestation
  7. Notes
  8. If the patient has completed the recommended childhood DTap/DTP/DT vaccination series and has not yet received a Td booster, then either Tdap vaccine can be administered.
  9. Tdap may be administered to other high-risk individuals at the recommendation of the Immunization Section Medical Director

Administration

  • Age- 18 years of age or older
  • Dosage- 0.5 mL
  • Route- Intramuscular (IM)
  • Site- Preferably into the deltoid muscle

Side Effects

  1. Local reactions (pain, redness, swelling)

Precautions/Contraindications

Note: Patients with possible precautions/contraindications who have NOT received a Tdapvaccine in previous years or who have developed precautions/contraindications since their last Tdapvaccine will be referred to PCP/specialist

  1. History of Guillian-Barre syndrome within 6 weeks after a previous dose of toxoid-containing vaccine
  2. Progressive or unstable neurologic disorders, e.g., uncontrolled epilepsy, encephalopathy cerebrovascular events and acute encephalopathic condition
  3. History of a severe local reaction (Arthus reaction) following a prior dose of a tetanus and/or diphtheria toxoid-containing vaccine
  4. Syncope can occur in association with administration of injectable vaccines. Procedures should be in place to avoid falling injury and to restore cerebral perfusion following syncope
  5. Moderate or severe acute illness
  6. Refer to the package insert to determine if latex is contained in the product
  7. Severe allergic reaction to vaccine component or following a prior dose
  8. Encephalopathy not due to another identifiable cause occurring within 7 days after vaccination with a pertussis-containing vaccine

Storage and Handling

  1. Tdap vaccines should be stored between 35o-46o F (2o-8o C) at all times
  2. Tdap vaccines should never be frozen
  3. Vaccines exposed to temperature outside of the specified range must not be administered
  4. Contact the vaccine manufacturer for guidance if temperatures exceed recommended range

Documentation

  1. Provide VIS
  2. Counsel patient regarding vaccines needed
  3. Report doses to registry per store protocol
  4. Providepatient with an immunization record

Exposure to Disease/Recovery from Disease

  1. Patients 18 years of age and older with a history of pertussis generally should receive Tdap according to routine recommendations.
  2. History of tetanus or diphtheria may not confer immunity. Active immunization should be initiated at the time of recovery and the remaining doses administered as early as possible.

Pharmacist Administration of Vaccines to Prevent Influenza

Policies

Influenza Vaccine Formulations

  1. The trivalent influenza vaccine in the United States for the 2012-2013 influenza season contains an A/California/7/2009 (H1N1)pdm09-like virus, an A/Victoria/361/2011 (H3N2)-like virus, and a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses).
  2. An inactivated trivalent influenza vaccinemay also be administered. It contains killed viruses and thus cannot cause influenza.
  3. A live, attenuated influenza vaccine (LAIV), Flu Mist ©, may be administered. It is a nasal spray and indicated for healthy, non-pregnant patients. Pharmacists may administer Flu Mist© to ages 7 to 49.

Recommended Schedule

  1. All patients ≥ 7 years of age
  2. Patients 7 years and older who have never received a flu shot will be referred to their PCP
  3. Patients between 7 and 8 years old who have not received 2 doses in one season should refer to their PCP
  4. Patients at higher risk for influenza-related complications
  5. When vaccine supplies are limited, vaccination efforts should focus on delivering vaccination to the following patients
  6. Women who are or will be pregnant during the influenza season
  7. Patients ≥ 50 years of age
  8. Adults and children who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus)
  9. Patients who are immunosuppressed (including immunosuppression caused by medications or by human immunodeficiency virus)
  10. Children and adolescents (aged 7 years through 18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye Syndrome after influenza virus infection
  11. Residents of nursing homes and other chronic-care facilities
  12. American Indians/Alaskan Natives
  13. Patients who are morbidly obese (BMI ≥ 40)
  14. Health-care personnel
  15. Household contacts and caregivers of children aged < 5 years and adults aged ≥ 50 years, with particular emphasis on vaccinating contacts of children aged < 6 months
  16. Household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza

Indications for Use

  1. Influenza vaccine is recommended for all persons aged ≥ 6 months who do not have contraindications to vaccination.
  2. TIV can be used for any person aged ≥ 6 months, including those with high-risk conditions
  3. LAIV may be used for healthy non-pregnant persons aged 2 through 49 years.
  4. The safety and effectiveness of LAIV has not been established in patients with underlying medical conditions that confer a higher risk for influenza complications; these patients should be vaccinated only with TIV
  5. One dose is adequate for patients 9 through 49 years of age
  6. Children 7 through 8 years of age may need two doses of LAIV administered at least 4 weeks apart

Administration

  1. TIV
  2. For adults and older children, administer 0.5 mL intramuscularly in the deltoid muscle.
  3. Vaccine from a previous influenza season must not be used.
  4. LAIV
  5. LAIV is intended for intranasal administration only and should not be administered by the intramuscular, intradermal or intravenous route. LAIV is not licensed for vaccination of children < 2 year or adults > 49 years.
  6. Vaccine from a previous influenza season must not be used.
  7. LAIV is supplied in prefilled, single use sprayer containing 0.2 mL of vaccine. Administer the vaccine according to the following directions:
  • Insert the tip of the sprayer just inside the nose and rapidly depress the plunger until the dose-divider stops the plunger which administers approximately 0.1 mL (half of the total sprayer contents) into the first nostril while the recipient is in the upright position.

Side Effects

  1. TIV
  2. Soreness around vaccination site for up to 1-2 days
  3. Fever, malaise or myalgia beginning 6-12 hours past injection and lasting 1-2 days
  4. Severe local allergic response and anaphylaxis
  5. LAIV
  6. Runny nose or nasal congestion
  7. Fever > 100o F
  8. Sore throat
  9. Headache
  10. Vomiting
  11. Abdominal pain
  12. Myalgias

Precautions/Contraindications

Note: Patients with possible precautions/contraindications who have NOT received a flu vaccine in previous years or who have developed precautions/contraindications since their last flu vaccine will be referred to PCP/specialist

  1. TIV
  2. Moderate or severe acute illness with or without fever
  3. Guillian-Barre Syndrome within 6 weeks following a previous dose of influenza vaccine
  4. If administering to an immunocompromised patient, their immune response may be diminished
  5. Vaccination may not protect all recipients
  6. Serious allergic reaction to latex (the tip cap of the pre-filled syringes may contain natural rubber latex)
  7. Anaphylactic reactions to components of the vaccine
  8. A serious reaction to a previous dose of influenza vaccine
  9. Severe allergic reaction (anaphylaxis) to eggs
  10. LAIV
  11. Patients with a history of hypersensitivity, including anaphylaxis, to eggs, egg proteins, gentamicin, gelatin or arginine or life-threatening reaction to previous influenza vaccination
  12. Patients > 49 years of age
  13. Patients with any of the underlying medical conditions that serve as an indication for routine influenza vaccination, including asthma, reactive airways disease, or other chronic disorders of the pulmonary or cardiovascular systems; other underlying medical conditions, including such metabolic diseases as diabetes, renal dysfunction, and hemoglobinopathies; or known or suspected immunodeficiency diseases or immunosuppressed states
  14. Children or adolescents receiving aspirin or other salicylates (because of the association of Reye Syndrome with wild-type influenza virus infection)
  15. Patients with a history of Guillain-Barre̕ Syndrome after a prior influenza vaccination
  16. Pregnant women

Storage and Handling

  1. TIV
  2. Vaccines should be stored between 35o F to 46o F (2o C to 8o C) and should not be frozen
  3. Vaccine placed in coolers for use during influenza clinics should be packaged with enough frozen packs to maintain the cold chain. Be sure to place an insulating barrier (e.g., bubble wrap, crumpled brown packing paper, styrofoam peanuts) between the frozen packs and the vaccines to prevent accidental freezing. A layer of toweling is not sufficient as a barrier.
  4. LAIV
  5. Store between 35o F to 46o F (2o C to 8o C) upon receipt and maintain at that temperature until the expiration date is reached.
  6. Discard sprayer according to standard procedures for disposal of medical waste (e.g., sharps container or biohazard container)

Drug Interactions with LAIV

  1. If not simultaneously administered, FluMist can be administered 4 weeks after another live vaccine such as MMR or varicella.
  2. Do not administer FluMist until 48 hours after antiviral cessation.
  3. Antiviral agents should not be administered until 2 weeks after FluMist administration unless medically necessary.

Documentation

  1. Provide VIS
  2. Counsel patient regarding vaccines needed
  3. Report doses to registry per store protocol
  4. Providepatient with an immunization record

Factor / LAIV / TIV
Route of Administration / Intranasal spray / Intramuscular injection
Type of vaccine / Live virus / Killed virus
Number of included virus strains / 3 (2 influenza A, 1 influenza B) / 3 (2 influenza A, 1 influenza B)
Approved age for Pharmacist administration / Patients aged 7 through 49 years / Patients aged ≥ 7 years
Can be given to persons with medical risk factors for influenza-related complications / No / Yes
Can be administered to family members or close contacts of immunosuppressed persons not requiring a protected environment / Yes / Yes
Can be administered to family members or close contacts of immunosuppressed persons requiring a protected environment (e.g., hematopoietic stem cell transplant recipient) / No / Yes
Can be administered to family members or close contacts of persons at higher risk including pregnant women / Yes / Yes
Can be administered simultaneously with other vaccines / Yes / Yes

Pharmacist Administration of Vaccines to Prevent Pneumonia

Policies

Pneumococcal Vaccine Formulations

  1. Pneumococcal polysaccharide vaccine is composed of purified preparations of pneumococcal capsular polysaccharide. PPSV23 contains polysaccharide antigen from 23 types of pneumococcal bacteria. The polysaccharide vaccine currently available in the United States (Pneumovax 23, Merck) contains 25 mcg of each antigen per dose and contains 0.25% phenol as a preservative.

Recommended Schedule

  1. Most recipients need only a single lifetime dose of PPSV23. Patients with uncertain or unknown vaccination status should be vaccinated.
  2. Routine revaccination of immunocompetent patients previously vaccinated with 23-valent polysaccharide vaccine is not recommended. Only one PPSV23 revaccination dose is recommended for high-risk patients.
  3. The following patients are eligible for revaccination with PPSV23
  4. Patients ≥ 18 years of age with:
  5. Functional or anatomic asplenia (from sickle cell disease or splenectomy)
  6. Immunosuppression (from disease, chemotherapy or long term corticosteroids)
  7. Transplant
  8. Chronic renal failure
  9. Nephrotic syndrome
  10. Patients vaccinated at < 65 years of age
  11. The second dose should be administered 5 or more years after the first dose.

Indications for Use

  1. Adults ≥ 65 years of age
  2. Patients ≥ 18 years of age with chronic illness to include cardiovascular disease, pulmonary disease, diabetes, alcoholism, cirrhosis, cerebrospinal fluid leak, cochlear implant, or immunocompromised patients
  3. Adults ≥ 18 years with asthma or cigarette smoking

Administration

  1. PPSV23 is 0.5 mL to be administered either by intramuscular injection or subcutaneously. The preferred sites would be the deltoid muscle or anterior lateral thigh if administered IM.

Side Effects

  1. Pain, swelling or erythema at site of injection
  2. Fever and myalgia (most frequently following a second dose of PPSV23)

Precautions/Contraindications

Note: Patients with possible precautions/contraindications who have NOT received a pneumonia vaccine in previous years or who have developed precautions/contraindications since their last pneumonia vaccine will be referred to PCP/specialist

  1. Severe allergic reaction to vaccine component or following a prior dose of vaccine
  2. Moderate or severe acute illness
  3. Use caution and appropriate care for individuals with severely compromised cardiovascular and/or pulmonary function in whom a systemic reaction would pose a significant risk

Storage and Handling

  1. Store between 35o F to 46o F (2o C to 8o C)
  2. Vaccine should be shipped in an insulated container with cool packs

Documentation

  1. Provide VIS
  2. Counsel patient regarding vaccines needed
  3. Report doses to registry per store protocol
  4. Providepatient with an immunization record

Pharmacist Administration of Vaccines to Prevent Shingles

Policies

Herpes Zoster Vaccination Formulations

  1. ZOSTAVAX®is a lyophilized preparation of the Oka/Merck strain of live, attenuated VZV, the same strain used in the varicella vaccines (VARIVAX®, PROQUAD®).

Recommended Schedule

  1. A single dose of zoster vaccine is recommended for adults age 60 years and older regardless of whether they report a prior episode of herpes zoster. Although the vaccine is licensed by the FDA for use among, and can be administered to, patient’s age 50 years and older, ACIP recommends that vaccination begins at age 60.

Indications for Use

  1. Patients 60 years and older regardless of whether they report a prior episode of herpes zoster

Administration

  1. Administer a 0.65 mL dose subcutaneously in the deltoid muscle
  2. Reconstitute only with the diluent supplied
  3. Administration must be within 30 minutes of reconstitution. Ensure all screening and paper work is complete before reconstituting.

Side Effects

  1. Pain, erythema and swelling around the injection site
  2. Headache

Precautions/Contraindications

Note: Patients with possible precautions/contraindications who have NOT received a zoster vaccine in previous years or who have developed precautions/contraindications to the vaccine will be referred to PCP/specialist

  1. Moderate or severe acute illness with or without fever
  2. Receipt of specific antivirals (i.e., acyclovir, famciclovir or valacyclovir) 24 hours before vaccination, if possible; avoid use of these antiviral drugs for 14 days after vaccination
  3. Hypersensitivity reactions including anaphylaxis have occurred with ZOSTAVAX
  4. Transmission of vaccine virus may occur between vaccines and susceptible contacts
  5. Severe allergic reaction (anaphylaxis) to neomycin, gelatin or any other vaccine component
  6. Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, or long-term immunosuppressive therapy or patients with HIV infection who are severely immunocompromised)
  7. Pregnancy
  8. Avoid pregnancy for 3 months following vaccination

Storage and Handling

  1. Vaccine must be frozen between -58°F and +5°F (-50°C and -15°C) until reconstitution.
  2. It may be stored and/or transported at refrigerator temperature between 36°F and 46°F (2°C to 8°C) for up to 72 continuous hours prior to reconstitution. If the vaccine is not used within the 72 hours, it must be discarded.
  3. The vaccine should be reconstituted immediately upon removal from the freezer.
  4. The diluent should be stored separately at room temperature (68°F to 77°F, 20°C to 25°C), or in the refrigerator (36°F to 46°F, 2°C to 8°C).

Documentation

  1. Provide VIS
  2. Counsel patient regarding vaccines needed
  3. Report doses to registry per store protocol
  4. Providepatient with an immunization record

Adapted from Immunization Polices of the Arkansas Department of Health and respective drug package inserts