Keeping up to Date: New Developments in Immunizations

Transcription

1 Keeping up to Date: New Developments in Immunizations Hannah Fish, PharmD, CPHQ, Associate Director, Strategic Initiatives John Beckner, RPh, Senior Director, Strategic Initiatives June 29, Disclosure John Beckner declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. Hannah Fish declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. 2 1

2 Learning Objectives Describe the advantages and disadvantages of new therapies compared to current therapies. Outline patient identification techniques and outreach. Identify practical ways to add non-flu immunization volume to your pharmacy. 3 Immunization Schedules 4 2

3 2018 Adult Schedule Child & Adolescent Schedule 6 3

4 2018 Adult Schedule: Condition Specific Recommendations 7 Influenza 8 4

5 FluView 9 Summary Influenza Vaccine Effectiveness Interim results for season (through February 3, 2018) indicate vaccination reduced influenza medically attended illness by 36% 25% (13 to 36) VE against A(H3N2) for all ages 51% (29 to 66) in children aged 6m 8 years No other age groups had statistically significant VE estimates 67% (54 to 76) VE against A(H1N1)pdm09 42% (25 to 56) VE against B (mostly B/Yamagata, not in IIV3) Final VE results at end of season will be used to calculate averted burden (cases, hospitalizations, deaths) Vaccination averts thousands of hospitalizations each year during , 47,000 (11, ,000) influenza hospitalizations averted H3N2 H1N1 B Antiviral Resistance Oseltamivir S R 1.0% S 10 Budd AP. Update: Influenza Activity United States, October 1, 2017 February 3, MMWR Morb Mortal Wkly Rep 2018;67: Zanamivir S S S Peramivir S R 1.0% S 5

6 Influenza Vaccine Composition A/Michigan/45/2015 (H1N1)pdm09-like virus A/Singapore/INFIMH /2016 (H3N2)-like virus Change A B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage) Change A B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage). Quad 2nd strain 11 Influenza Vaccine Sanofi Pasteur Fluzone Quad, Fluzone High Dose(trivalent), Fluzone Intradermal Seqirus Afluria, Afluria Quadravalent, Fluad, Flucelvax Quadravalent, Fluvirin GlaxoSmithKline Fluarix Quadravalent, Flulaval Quadravalent AstraZeneca Flumist Quadrivalent 12 6

7 Influenza Vaccine Updates Afluria(IIV3, IIV4) is approved for persons 5 years and older Flublok Quadravalent approved for persons 5 years and older Flulaval Quadravalent approved for 6 months and older Pregnant women may take any licensed, recommended, and age appropriate vaccine Flumist (LAIV4) is once again recommended for 2-49 years 13 LAIV 2003 LAIV3 Licensed 2 49 years 2012 LAIV4 Licensed Replace LAIV3 following season 2014 LAIV Preferred 2 8 years 2015 LAIV Preference Removed 2016 LAIV4 Not Recommended 2017 LAIV4 Not Recommended 2018 LAIV4 Recommended 2 49 years No preference 14 Adapted from APhA2018 Immunization Update 7

8 Influenza Recommendations Everyone 6 months and older without contraindication should get a flu shot every year Emphasis on certain groups at increased risk of effects of influenza Children 6-59 months Persons 50 years old Persons who are immunocompromised Persons with chronic diseases Pregnant women Extensive list of high-risk groups at cdc.gov/flu 15 Egg Allergy and Flu Vaccine 16 8

9 Different Pediatric Dosing > 6 months 17 Herpes Zoster 18 9

10 Epidemiology of Herpes Zoster (HZ) & Postherpetic Neuralgia (PHN) Approximately 1 million cases annually.1,2 4 cases per 1000 HZ incidence increases with age2,3 <1 case per 1000 children >15 cases per 1000 adults 80 years and older For adults 50 years and older with HZ, 10-18% go on to develop PHN Jumaan et al., JID, 2005, 191: Yawn et al., Mayo Clin Proc. 2007; 82: Insigna et al., J Gen Intern Med. 2005, 20: Shingles Vaccine Healthy People 2020 goal is 30% With pharmacists involvement we have surpassed the goal 20 10

11 Comparison of Zostavax (ZVL) and Shingrix (RZV) Zostavax (ZVL) Shingrix (RZV) Type of vaccine Live Inactivated Adjuvant None AS01 B Storage Frozen Refrigerate* Regimen 1 dose 2 doses (2 months apart) Efficacy against disease 51.3% (varies by age) 97.2% 50 years Duration 7 8 years 3.2years (modelpredicts19yrsto zero) SAE/ADR 1.9% / 48.3% 1.1% / 84.4% (17% Grade 3) 21 Lal H. et al. N Engl J Med. 2015;372: Shingles Vaccines Efficacy Comparison Percent Vaccine Efficacy ZVL(1,2) Vaccine RZV(3,4) yrs yrs yrs > 80 yrs Oxman M. NEJM. 2005;352: ; 2. Schmader KE. Clin Infect Dis. 2012;54: ; 3. Lal et al., NEJM 2015;372(22): (ZOE- 50); 4. Cunningham AL. NEJM. 2016;375: (ZOE-70) 11

12 ZVL vs RZV Against Post-Herpetic Neuralgia ZVL VE against PHN (95% CI) yrs Not studied yrs 65.7% ( ) >70 yrs 66.8% ( ) OVERALL 66.5% ( ) RZV VE* against PHN (95% CI) y 100.0% (40.8% 100.0%) y 100.0% ( 442.9% 100.0%) y 93.0% (72.4% 99.2%) 80 y 71.2% ( 51.6% 97.1%) OVERALL ( 70y) 88.8% (68.7% 97.1%) * Assumes two dose completion Harpaz et al. MMWR 2008;57(RR5) 2. Cunningham et al., NEJM 2016;375(11): (Pooled ZOE-50 and ZOE-70). Shingrix Incidence of Adverse Reactions 24 Shingrix PI,

13 Shingrix Vaccine Diluent is the adjuvant suspension Use same syringe to reconstitute and then administer Discard vaccine after reconstitution if not given within 6 hours 25 Shingrix FDA Package Insert: ACIP Zoster Recommendation 2018 Recombinant zoster vaccine (RZV) is preferred over ZVL for the prevention of herpes zoster and related complications. RZV is recommended for the prevention of herpes zoster and related complications for immunocompetent adults aged 50 years. RZV is recommended for the prevention of herpes zoster and related complications for immunocompetent adults who previously received zoster vaccine live (ZVL). 26 Dooling KL. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep 2018;67:

14 Need to Improve Vaccine Recall System RZV requires 60 day follow-up for second dose Reminder and recall systems Align with medication synchronization Electronic health records Prescription dispensing software Immunization information systems 1 dose uptake of ZVL : National immunization Survey (Lu et al, Vaccine 27:882-7); : NHIS (Am J Prev Med 40:e1-6 & MMWR February 5, 2016 / 65(1);1 36), 2016 CDC, unpublished Questions What if you ve already had an ZVL vaccine, can you get RZV? Can you give it if patient had HZ in the past? Can you give RZV if no history of VZV? How much protection do you get with only 1 dose of RZV? Is there any population where ZVL is recommended over RZV? What is the route of administration? How do you keep records to make certain patient is recalled? 28 14

15 Human Papillomavirus 29 Human Papillomavirus (HPV) Vaccine 31,000 women and men are diagnosed annually with cancer caused by HPV Cervical cancer accounts for 1 in 3 cancers Estimated nearly 80 million people in the US are infected About 14 million new infections yearly The other 2/3 are oral cancer, cancers of pharynx and cancers of anus and rectum HPV vaccination can prevent these unnecessary cancers as well as over 300,000 invasive tests and treatments for potential cancer causing lesions 30 15

16 HPV Vaccine Gardasil-9 and Gardasil-4 (Merck) Gardasil-4 strains: 6, 11, 16, 18 Gardasil-9 adds 5 more strains: 31, 33, 45, 52, 58 Highly immunogenic, near 100% Studies were done in individuals age 15 or 16 through 26 years Immunogenicity in individuals age 9 through 15 years was non-inferior 3 dose series at 0, 1-2 months and 6 months Later trials showed a 2 dose series in individuals age 9 to 14 years was noninferior 31 New Gardasil-9 Recommendation HPV vaccine should be administered to adolescents age 11 to 12 years to protect against cancers caused by Human Papillomavirus The series may be started at 9 years old Females through 26 years and males through 21 years Males 22 through 26 years may be vaccinated Newest recommendations for 11 to 12 years old is a 2 dose series Dose 2 should be 6 to 12 months after the first dose 32 16

17 Pneumococcal 33 Pneumococcal Conjugate Vaccine (PCV-13, Prevnar-13 ) ACIP recommendations All adults 65 years and older All persons 2 through 64 years old with certain medical conditions All babies and children under 2 years old 34 17

18 PVC-13 Certain Medical Conditions Anatomic or functional asplenia Sickle cell disease Cochlear implants CSF leaks Congenital or acquired immunodeficiencies Hodgkin disease Solid organ transplant HIV infection 35 Pneumococcal Polysaccharide Vaccine (PPSV-23, Pneumovax-23 ) ACIP recommendations All adults 65 years and older Persons 2 through 64 with certain medical conditions 36 18

19 PPSV-23 Certain Conditions Add to the PCV-13 list Diabetes Mellitus Chronic heart disease Chronic lung disease Including COPD, emphysema and asthma Chronic liver disease Alcoholism Smokers 19 years old and older 37 PCV/PPSV Intervals Immunocompetent persons 65 years old Pneumococcal naïve PCV-13 followed by PPSV-23 at 1 year Do not administer at the same time! PPSV-23 every 5 years thereafter Immunocompetent persons 65 years old Previous dose of PPSV-23 1 dose PCV-13 1 after last PPSV-23 Continue PPSV-23 on appropriate schedule At least 1 year after PCV-13 and 5 years after previous PPSV-23 dose 38 19

20 PCV/PPSV Interval Immunocompromised persons 19 years old Vaccine naïve PCV-13 followed by PPSV-23 8 weeks Additional PPSV should follow recommendations Previous PPSV PCV-13 should be administered 1 year after last PPSV-23 Additional PPSV-23 should follow recommendations 39 Meningococcal Disease 40 20

21 Meningococcal Disease Most commonly diagnosed in infants, adolescents and young adults Can be spread where large groups of people gather together Certain medical conditions can put people at increased risk International travel may put persons at risk 41 Risks for Meningitis A/C/Y/W Compliment component deficiency Taking eculizumab Asplenia HIV Traveling to a country where meningococcal disease is common Risk due to disease outbreak 42 21

22 Meningococcal ACYW Vaccine Recommendations ACYW Conjugate Vaccine (Menactra, Menveo ) All 11 to 12 year old should be vaccinated A booster dose should be administered at 16 years old If the first dose is administered at years old, a booster should be administered at If the first dose is administered at 16, no booster is required One dose to unvaccinated college students years old at their first year of college 43 Risk for Meningitis B Compliment component deficiency Taking eculizumab Asplenia Microbiologist routinely exposed to Neisseria meningitidis Persons that are part of a population at increased risk for meningitis B infection 44 22

23 Meningococcal B Vaccine Recommendations Meningitis B Vaccine (Trumenba, Bexsero ) All adolescents and adults aged 16 through 23 MAY be vaccinated Preferred years old Certain adolescents and adults SHOULD be vaccinated Compliment component deficiencies, asplenia, persons taking eculizumab Certain adults should be vaccinated Microbiologists that work with meningococcal bacteria are at risk Those at risk due to meningitis B outbreak 45 Meningococcal Vaccine Dosing Bexsero 2 doses Healthy or at risk teens 0, 1 month Trumenba 2 doses 0 and 6 months Healthy teens doses 0, 1-2 months, 6 months Adolescents 10 and older at increased risk or due to outbreak Bexsero and Trumenba are NOT interchangeable Men B and Men ACWY may be given at the same time 46 23

24 Measles, Mumps, Rubella (MMR) 47 Measles 48 24

25 Measles outbreaks Measles elimination documented in US Record 667 cases in 27 states 188 cases in 24 states 70 cases in 16 states Jan. 1 st to Jul. 15 th 177 cases in 13 states The majority of people who got measles were unvaccinated Majority of these cases are related to infection from international travel or exposure to a person just returned from travel 49 MMR Vaccine Recommendations All children should get 2 doses Dose 1 at months, Dose 2 at 4-6 years old Students at post-high school educational facilities that do not have evidence of immunity should get 2 doses Adults who do not have evidence of immunity should get 1 dose International travelers should be protected prior to travel Health care workers should have documentation of immunity or receive 2 doses of vaccine at least 28 days apart 50 25

26 MMR for International Travelers Infants 6 11 months should get 1 dose of MMR vaccine Children 12 months and older should get 2 doses at least 28 days apart Teenagers and adults without evidence of immunity should receive 2 doses at least 28 days apart 51 Evidence of Immunity is Written documentation of vaccination Laboratory evidence of immunity Laboratory confirmation of disease Birth before

27 Mumps 53 Mumps Cases 54 27

28 Third Dose of MMR Vaccine? 61-88% 3 MMRs vaccine effectiveness1,2,3 Studies had high percentage of patients with MMR2 Three studies ages 9 years through college age No serious adverse effects reported after 3 MMR2,3,4 3 MMRs appears to provide short-term boost in antibodies and seroconverts most seronegative persons Cardemil CV et al., NEJM 2017, 377(10): Nelson GE et al., Pediatr Infect Dis J 2013, 32(4): Ogbuanu IU et al., Pediatrics 2012, 130(6):e Albertson JP et al., MMWR 2016, 65(26): ACIP Mumps Recommendation Persons previously vaccinated with two doses of a mumpscontaining vaccine who are identified by public health as at increased risk for mumps because of an outbreak should receive a third dose of a mumps containing vaccine to improve protection against mumps disease and its complications 56 28

29 Hepatitis B 57 Hepatitis B Vaccine In the US: 850, million with chronic hepatitis B virus (HBV) since 2014 likely due to heroin and opioid epidemic 5,000 people die from HBV per year from chronic liver disease Hepatitis B Vaccine (Recombinant), Adjuvanted Heplisav-B (Dynavax) FDA licensed November 9, 2017 for 18 years and older Series of 2 doses, separated by 1 month Adjuvant stimulates TLR9, combined with HBsAg elicits anti-hbsag Ab Seroprotection 90.0%-100.0% 70.5%-90.2% with existing Hepatitis B vaccines Better response in diabetes, kidney disease than current Hep B vaccines Non-responders very small Local & systemic AEs similar to other Hep B vaccines Signal with CV disease will monitor in post-marketing studies 58 29

30 ACIP Workgroup Considerations 2 dose; minimum interval 4 weeks When a vaccine series initiated with one dose of a vaccine from a different manufacturer must be completed with Heplisav-B, 3 total Hepatitis B vaccine doses should be administered Fewer doses may mean better compliance with series completion and earlier protection ACIP to review more safety data and economic analysis in future ACIP Vote: Non-preferential Heplisav-B a hepatitis B vaccine that may be used to vaccinate persons aged 18 years and older against infection caused by all known subtypes of HBV. 59 Travel Vaccines 60 30

31 Cholera Cholera is a acute diarrheal illness caused by Vibrio cholerae found in contaminated water or food Profuse watery diarrhea, vomiting, leg cramps Dehydration, shock and death 3 to 5 million cases annually worldwide Cases have steadily increased worldwide since ,000 deaths annually worldwide Africa, Southeast Asia and Haiti 61 Cholera vaccine VaxChora (lyophilized CVD 103-HgR) - PaxVax Single dose, live vaccine ACIP approved for persons 18 to 64 years traveling to an area of active cholera transmission It is not recommended for travelers to areas that are not endemic or epidemic Vaccine is not required for entry or exit from any country 62 31

32 VaxChora Reported to reduce severe diarrhea by 90% if administered 10 days prior to exposure Side Effects include Headache, malaise Abdominal pain, N&V, diarrhea Unknown if protection lasts past 3-6 months To mix: 100ml purified water buffer stir active component stir cloudy 15 minutes 63 Dengue Fever 1/3 of the world s population lives in dengue fever risk areas Global incidence estimated by WHO million cases 50,000 cases of DHF 20,000 deaths, mostly of children Leading cause of death and illness in tropic and sub-tropic areas of the world 4 serotypes DEN-1, DEN-2, DEN-3 and DEN-4 There is no known cure only supportive treatment

33 Dengue Fever Sudden fever Headache Retro-orbital pain Flushing of face Nausea and vomiting Generalized myalgia and arthralgia Rash on the trunk, arms, legs, palms and soles of feet May have multiple episode with multiple serotypes Progression of DF to Dengue Hemorrhagic Fever can be fatal 65 Dengvaxia - dengue vaccine April 2016 World Health Organization endorsed Dengvaxia The first licensed dengue fever vaccine In Phase III efficacy studies Reduced all 4 serotypes of dengue in 2/3 of participants Prevented 9 of 10 cases of severe dengue fever Prevented 8 of 10 hospitalizations Showed consistent efficacy and long term safety in persons 9 years old Capeding M.R. et.al, Clinical efficacy and safety of a novel tetravalent dengue vaccine in healthy children in Asia: a phase 3, randomized, observer-masked, placebocontrolled trial ; Volume 384, Issue 9951, October 2014, Pages Villar L, Dayan GH, Arredondo-Garcia JL, Rivera DM, Cunha R, Deseda C et al. Efficacy of a tetravalent dengue vaccine in children in Latin America. N Engl J Med Hadinegoro, Sri Rezeki S., et al. Efficacy and Long-Term Safety of a Dengue Vaccine in Regions of Endemic Disease Integrated Analysis of Efficacy and Interim Long- Term Safety Data for a Dengue Vaccine in Endemic Regions. July 27, 2015DOI: /NEJMoa

34 Dengvaxia Live recombinant tetravalent vaccine 3 dose series Administered over 6 months Persons aged 9 45 years old Living in dengue endemic areas Vaccine efficacy is estimated at 65% against confirmed disease in those 9 years old Contraindications Severe allergic reaction to a previous dose or vaccine component Pregnancy or breast feeding Individuals with congenital or acquired immune deficiency Symptomatic or asymptomatic HIV infection with impaired immune function 67 Zika Cases in the US and D.C. 5,435 5,162 travelers returning from affected areas 224 presumed locally acquired mosquito borne 49 through other routes 2,155 pregnant women with any evidence of possible infection Cases in US territories 37, returning travelers 36,865 presumed locally acquired mosquito borne 0 through other routes 4,481 pregnant women with any evidence of possible infection 68 34

35 Zika Vaccine 2016 multiple entities were working on a vaccine 2016 FDA granted the first approval for human clinical trials 2017 Both subunit and inactivated vaccines are in Phase 2 clinical trials Estimates range from 18 months to 10 years to develop an effective vaccine 69 Yellow Fever Primarily found in Africa and South America WHO estimates of 2013 in Africa 80, ,000 cases of severe disease 29,000-60,000 deaths Sudden onset of fever, chills, severe headache, back ache, body aches, nausea, vomiting, fatigue and weakness Remission for a day 15% progress to severe disease High fever, jaundice, bleeding, multiple organ system failure, death (20-50%) 70 35

36 Yellow Fever Vaccine Yellow fever vaccination is recommended for travelers traveling to or live in areas of yellow fever risk. Yellow fever vaccine is required by some countries for entry and/or exit. Countries with yellow fever transmission are in Africa and South America 71 Yellow Fever (YF-Vax ) Vaccine Shortage YF-Vax is the only yellow fever vaccine approved for prevention of yellow fever in the US Sanofi-Pasteur announced the YF-Vax will not be available from mid 2017 to mid 2018 Sanofi-Pasteur applied and received approval under a investigational new drug (IND) program for another vaccine 72 36

37 Stamaril - Yellow Fever Vaccine Produced in France Used in more than 70 countries Comparable in safety and efficacy as YF-Vax To meet the IND requirements, Stamaril will only be available in a limited number of clinics To find a clinic go to /travel and access the yellow fever clinic search page 73 Other Vaccine Shortages 74 37

38 Td shortage Shortage is expected at least until mid-september Tdap is recommended for one dose in a lifetime, if Td is unavailable; As a booster, use Tdap whether the patient has had a previous dose or not Primary Series, use Tdap at the discretion of the HCP Wound management, use Tdap 75 Hepatitis B vaccine shortage Pediatric (Pediarix) and adult (Recombivax HB) formulations manufactured by Merck are unavailable through 2018 Engerix-B (GSK) in all formulations will remain available 76 38

39 Pharmacist Impact & Opportunities 77 Pharmacists Increase Vaccination Rates APhA Foundation, Project IMPACT Immunizations, pilot study in Washington state 8 pharmacies over a 6 month period Increased the number of vaccines administered by 41.1% Pharmacists had bidirectional access to immunization information system (IIS or registry) and clinical decision support at the point of care

40 Not only do we increase rates, but According to a paper published in JAPhA, almost 25% of adults received influenza vaccines in a pharmacy-based setting 37.8% of adults 65 years old received their influenza vaccine in a pharmacy-based setting Based on BRFSS data of 28,954 people in 8 states and Puerto Rico 79 Independent Pharmacy Immunization Growth Percent of Independent Pharmacies Providing Immunizations % 60% 61% 62% 71% 67% 76% Year 80 40

41 Independent Pharmacies Providing Immunizations The good news.76% of independent community pharmacies provide immunization services The bad news ONLY 76% of independent community pharmacies provide immunization services Yes No 81 Essential Strategies to Increase Immunization Levels Recordkeeping accurate and current Immunization Information Systems (IIS) Reminder to patients Computer generated telephone calls or text messages Mailers Reminder to providers Computer generated lists Reduce barriers and missed opportunities Standing orders Piggyback with other patient care services 82 41

42 Strengths and Opportunities Accessibility Pharmacists are most accessible health care provider with potential for greatest impact on public health Walk-in opportunity or appointment Community Connections Community pharmacists usually well-known and trusted leaders Pharmacies are trusted sources for medical care and advice Pharmacists are able to develop more connections with other health care professionals in the area by offering immunizations. Increased Revenue Providing immunizations is a sustainable diversified revenue stream Expansion of vaccine portfolio 83 ICN pdf Challenges Navigating State Laws and Regulations State variation on requirements regarding pharmacists as immunizers Competitive Market Most chain pharmacies now offer certain immunizations as a standard service in all of their stores, so independent pharmacies cannot focus only on common immunizations such as flu shots alone. Storage Requirements Vaccines must be stored under specific conditions and temperatures, which vary depending on the vaccine

43 Challenges Time and Workflow Evaluate and adjust workflow processes when considering addition of immunizations as a service. Use of ancillary personnel Billing Medicare Part B v. Part D vaccines American Patients First announcement Immunization Registries Bi-directional communication (reporting and querying) 85 Medicare Part B v. Part D Billing Part B Coverage Hepatitis B vaccine (for patients at high or intermediate risk) Influenza virus vaccine Pneumococcal pneumonia vaccine Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition Part D Coverage All commercially available vaccines as long as the vaccine is reasonable and necessary to prevent illness, except for vaccines covered under Medicare Part B 86 43

44 Value of Industry Partnership Pharmacist education New products Making the business case for expanded vaccine portfolio Patient education Employer education ROI of healthy workforce Supply Physician/pharmacist relationship - helping to forge a stronger bond 87 Training APhA Immunization Certificate Program APhA Travel Health Certificate Program 88 44

45 Operational Considerations: Initial Setup Research your state s immunization rules and regulations Establish immunization health policies, procedures, and protocols Identify a person or team to implement your program Role of the technician Administration?? Educate and train staff Physical layout (wellness center, counseling room, waiting area) 89 Operational Considerations (cont) Identify a partnering physician Collaborate with local/state health department Order vaccines Service listed on website Waiver and VIS 90 45

46 Opportunities to Expand Beyond Flu Adult vaccines Pneumo (2) Zoster Tdap Hepatitis Adolescents Meningitis (2) HPV (should market as a cancer preventative) Infants and Children check state regulations Travel Health (significant increase in international travel) 91 Marketing Your Service Social Media Website/Blog In-store signage Post card marketing campaign Physician communication Churches, schools, local businesses Referrals (state and local health departments) 92 46

47 Immunization Business Plan Considerations Competitive analysis Financial Modeling Patient forecasting Develop policies, procedures and protocols Training resources Vaccine purchasing Vaccine inventory, storage and shelf life Legislative and regulatory requirements (not all states are created equal) Marketing 93 Develop a Business Plan What can I charge for Rxs Consultation Ancillary supplies Budget 94 47

48 Community Pharmacy Enhanced Services Network (CPESN) All member pharmacies are capable of providing the following core services: Medication Reconciliation Clinical Medication Synchronization Immunizations Comprehensive Medication Reviews Personal Medication Record 95 Expanded Immunization Services: Practice Builder Preventative medicine Community need Lack of awareness Few access points Year-round immunization business Healthy revenue per patient Ability to position other pharmacy services Diabetes education Health and wellness services 96 48

49 Pharmacist Resources The Vaccine Handbook: A Practical Guide for Clinicians Available as an app for iphone and ipad Basic vaccinology Vaccine practice Diseases and vaccines Addressing concerns about vaccines CDC Vaccines app Child, Adolescent, Adult and Adult conditions schedules Contraindications Catch-up schedule 2018 CDC Health Information for International Travel (the Yellow Book)is available Epidemiology and Prevention of Vaccine-Preventable Disease The Pink Book Immunization Action Coalition (IAC) 97 Other Resources Travel specific software Travax ( Tropimed ( Scheduling software 12-month immunization marketing calendar 98 49

50 NCPA Working with Members to Increase % Diversified revenue section on website Member forum webinars CE articles in America s Pharmacist Educational sessions at Annual Meeting and MLC Re-Engineering Your Pharmacy Practice Boot Camp

51 Keeping up to Date: New Developments in Immunizations Hannah Fish, PharmD, CPHQ, Associate Director, Strategic Initiatives John Beckner, RPh, Senior Director, Strategic Initiatives June 29,