up to CPD Credits GROUP 3 Immunisation Health promotion & professional services workbook Print Post approved PP

Transcription

1 up to 22 CPD Credits GROUP 3 Immunisation Health promotion & professional services workbook Print Post approved PP

2 Pharmaceutical Society of Australia Ltd., 2013 This handbook contains material that has been provided by the Pharmaceutical Society of Australia (PSA), and may contain material provided by the Commonwealth and third parties. Copyright in material provided by the Commonwealth or third parties belong to them. PSA owns the copyright in the handbook as a whole and all material in the handbook that has been developed by PSA. In relation to PSA owned material, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968 (Cth), or the written permission of PSA. Requests and inquiries regarding permission to use PSA material should be addressed to: Pharmaceutical Society of Australia, PO Box 42, Deakin West ACT Where you would like to use material that has been provided by the Commonwealth or third parties, contact them directly.

3 Professional services are a vital part of pharmacy practice today. PSA is leading the profession by supporting you in the delivery of new professional services. This ACTION kit provides you with a step by step workbook, education, personalised resources and tools to assist you to implement an in store promotion and host an influenza immunisation service. I urge you to take ACTION today to secure your future. Kind regards Liesel Wett Chief Executive Officer

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5 Contents Part one: In-store promotion 7 Plan 9 1. Choose a theme 9 2. Choose a target audience Choose the timing of our activity Consider the scope of our promotion 11 Design Appoint a champion What are we actually going to do? Order posters, Fact Cards and other resources Hold a staff meeting to inform the whole team Engage with external contributors 14 Implement Conduct staff training Set up displays, posters, windows Go! Talk to customers, give out Fact Cards 16 Evaluate Conduct team and customer evaluations Do our own evaluation 17 Part two: Service delivery 19 Plan 22 Do a needs assessment Current situation analysis Demographic analysis Desired situation and pharmacy vision 24 Build a business case SWOT analysis Identify our target audience Set our aim and objectives Brainstorm what could be offered in the service Calculate costs and formulate a financial plan Establish the timeframe for rollout 29 Design 32 Team involvement Appoint a champion Plan whole team involvement 29 Service elements What the service will include the scope 35

6 13. Summarise the scope of the service Which tools will we use? Document the consultation process Plan the physical area where the service will take place Plan our promotional and collaboration activities Plan the evaluation of the service 44 Implement Negotiate and sign a service agreement Conduct staff training Collate all documents (tools) and material required Prepare the service area Start promotional activity Host the immunisation service 45 Evaluate Conduct team and customer evaluation Do our own evaluation Please give PSA your feedback 47 Part three: Education 49 Clinical evidence brief 50 Facts Behind the Fact Card article 54 Counter Connection article 60 Staff training presentation 64 Community group presentation 69 Part four: Tools 75 Guide to documenting Group 3 CPD credits 76 PSA Group 3 CPD documentation template 79 National Immunisation Program Schedule 81 State and Territory drugs and poisons legislation 83 Immunisation service checklist for pharmacies 84 Service agreement template 85 Pre-immunisation screening checklist 89 Consumer vaccination statement template 90 Post-vaccination procedures checklist 91 Emergency response protocol 92 Referral letter 93 Health column 94 Order form 95 Customer feedback form 96 Team feedback form 97 ACTION kit evaluation form 98

7 ACTION In-store promotion 1

8 8ACTION1 Part one In-store promotion An immunisation in-store promotion aims to increase the awareness of the benefits of immunisation and the need to maintain full and up to date immunisation coverage. The promotion may include information about immunisation schedules, types of vaccines and the risk of side effects. Allaying the fears of customers about the perceived dangers of immunisation is an important aspect of the pharmacist s role. A promotion should focus on the modifiable risk factor of under-immunisation. This step by step workbook will enable you to run a successful in-store promotion. To host an influenza vaccination service and offer your customers a new professional service refer to Part 2: Service delivery in addition to undertaking the in-store promotion. In-store promotion checklist Plan Design Implement Evaluate 1. Choose a theme 2. Choose a target audience 3. Choose the timing of our activity 4. Consider the scope of our promotion 5. Appoint a champion 6. What are we actually going to do? 7. Order posters, Fact Cards and other resources 8. Hold a staff meeting to inform the whole team 9. Engage with external contributors 10. Conduct staff training 11. Set up displays, posters, windows 12. Go! Talk to customers, give out Fact Cards 13. Conduct team and customer evaluations 14. Do our own evaluation Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. Tick once complete

9 PLAN Plan 1. Choose a theme Choose an in-store promotion that will have the maximum impact in your area. The focus of your immunisation promotion could be on promoting immunisation at a population level rather than at an individual level. To achieve this, closely review your community s demographics and decide what focus will be most beneficial. For example, if you have an older customer or community demographic you could promote the influenza vaccination. There are various components to an immunisation in-store promotion such as: window displays and posters in the pharmacy in-store activities providing presentations to community groups or at an event providing an advertorial column to local media. Select a theme for your in-store promotion and decide upon the components. Your promotion could have some of the following objectives: increase awareness of the need for seasonal influenza vaccination encourage customers to consider the need for immunisation and the risks associated with being under-immunised assist customers to understand the safety profiles of immunisation raise awareness of the importance of childhood immunisation, reporting immunisations to the Australian Childhood Immunisation Register (ACIR) and completion of the National Immunisation Program (NIP) schedule provide information to the community on the human papillomavirus vaccine that will also be given to boys from 2013 via the NIP (see NIP Schedule on page 79) raise awareness of the need for all carers of newborn babies to have a pertussis booster raise awareness of the need to have tetanus booster vaccinations raise awareness of the need to consider vaccinations prior to travel Our theme is:... Please note: the above suggested themes link with established health promotion campaigns currently available from national and state-based organisations such as the Australian Government Immunise Australia Program, immunisation programs in each state and territory and the National Council for Immunisation Research and Surveillance (NCIRS).These organisations have developed key resources which can be obtained for use in a health promotion campaign. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 9

10 Your promotion should have some objectives, such as: Health promotion objective To increase immunisation coverage in the community To raise awareness of the benefits of immunisation To ensure all members of the community have access to immunisation information Explanation Complete immunisation coverage protects the individual as well as the community from vaccine preventable diseases (VPDs) Pharmacists can raise awareness of the health benefits of immunisation and avoid a gap in the customer s immunisation coverage. Pharmacists also have a role providing information to customers about the different types of vaccines and addressing customer concerns regarding vaccine safety Lifestyle factors such as beliefs, health literacy, socioeconomic factors can impede a customer from actively pursuing immunisation services Our objectives are: Choose a target audience Defining a target group allows you to provide the most appropriate activities/services and this will align with your chosen theme. Your target group may be customers who are: between 18 and 65 years of age who do not qualify for free NIP vaccinations potentially under-immunised and at risk due to chronic disease such as diabetes, respiratory and cardiovascular disease or mental health issues from selected cultural groups and/or linguistically-diverse backgrounds who may be under immunised commencing a new school year are likely to be in contact with a newborn baby planning to travel overseas. Our target audience is: Choose the timing of your activity When, you hold your health promotion may be influenced by the theme you have decided on. For example, if you are going to promote influenza vaccinations then the most appropriate timing of the promotion will be late summer or early autumn as this is when influenza vaccinations tend to take place. This may not be a consideration for other themes but you could consider timing your promotion to coincide with a national or state promotion on immunisation. The other aspect of timing is how long will your promotion run in your pharmacy? How long will you continue to offer additional or new services or consultations that you have started during the promotion? Our promotion will run from:...to:... Notes 10 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

11 display posters and make Fact Cards available 4. Consider the scope of your promotion The breadth and depth of what you do may include: display posters and make Fact Cards available commit to counsel all customers purchasing certain products during the promotion e.g. travel medicines give a talk to a local community group, utilising the customer presentation enclosed involve suppliers, other organisations or health professionals in your promotion offer an influenza vaccination service in your pharmacy see the next section for implementing this service. e.g. You could work with a local travel agent and arrange a night where you speak to their customers (e.g. those going on a tour of Vietnam) about travel health and vaccinations. This could include a talk by the GP from the travel clinic. e.g. You could order and display the influenza vaccination posters throughout the pharmacy and in a window display. In addition you could hand out customer pamphlets relating to annual influenza vaccination, available from your supplier of influenza vaccine. Plan when you will inform the pharmacy team and provide training so that the entire team is on message. This aspect is vital as team members are often the ones talking to customers and they should be empowered to promote and implement the promotion. The scope of our promotion is:... Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 11

12 DESIGN Design 5. Appoint a champion The champion is responsible for ensuring that all planned activities and required resources are available a pharmacy team member may achieve this better than the pharmacist, whose priorities are determined by professional obligations. Our champion is: What are we actually going to do? These actions could be brainstormed with the team or at least with the designated champion. Display posters Give out Fact Cards Counsel every customer purchasing travel medicines Give a talk to a group yes / no yes / no yes / no yes / no Which group:... Contact who and when:... Involve other providers yes / no If yes, who will be involved:... Other: Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

13 7. Order posters Fact Cards and other resources The champion is responsible for ensuring that all required resources are ordered and arrive before the promotion starts. Resources required: Posters (use order form) Size Number PSA immunisation poster (Influenza) PSA immunisation poster (General) Fact Cards (use order form) Travel health Childhood Immunisation Chickenpox Cold and Flu Appointment cards (use order form) PSA appointment cards Other Number (packs of 20) Number Number Other resources: Hold a staff meeting to inform the whole team The whole team needs to be aware of the promotion, what the objectives of the activity are and how they will contribute. This may include up skilling and providing them with information at the same time or at a later date use the inpharmation articles and the staff training presentation that are included. The training presentation: outlines immunity and the role of vaccines discusses immunisation schedules, customers who may be at risk from a gap in their immunisation coverage and types of vaccines dispels common myths about immunisation highlights the role of the pharmacist in promoting immunisation. We will use the staff training presentation provided yes / no The date of our staff meeting is:... Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 13

14 9. Engage with external contributors Contact external contributors to get their co-operation and involvement. These may be supplier companies, health care organisations, or other health care professionals. e.g. Plan to host an evening where you present to a community group or group of your customers (using the presentation included) on influenza vaccination and you have a nurse immuniser presenting to give their perspective and experience. The community presentation: outlines immunity and the role of vaccines discusses immunisation schedules, customers who may be at risk from a gap in their immunisation coverage and types of vaccines dispels common myths about immunisation highlights the role of the pharmacist in promoting immunisation. We will use the community presentation provided yes / no You can also approach local media in your area. The provided health column can be used as a media release or placed on your website as a promotion activity. The following table lists some of the resources available from organisations for use in an immunisation health promotion campaign. It also lists a suggested format for use of these resources to assist you with the design of your campaign. Suggested theme Suggested Association and campaign format Seasonal influenza vaccines Fact sheets Brochures and posters NPS Influenza vaccine what is it for? National Centre for Immunisation (NCIRS) Influenza Influenza Specialist Group How safe are vaccines? Fact sheets homeopathy-vaccination-fact-sheet.pdf Are you fully covered? Fact sheets Catch up immunisation for Tasmania for people with no documentation of previous vaccines NCIRS - Adult vaccination Pertussis and newborns Brochure Fact Card Immunise Australia Whooping cough NCIRS Pertussis Immunisation and Poster Health ACT Immunised Children children Immunisation for Aboriginal People Posters Fact Sheets SA Health Immunisation for Aboriginal People posters SA Health Immunisation for Aboriginal People factsheets Immunise Australia Aboriginal and Torres Strait Islander People HPV for boys Fact Sheet Immunise Australia HPV vaccination for boys Get covered before you travel Brochure Smart Traveller Travelling Well 14 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

15 List the external contributors you will use and what action is to be taken by whom and by when: EXTERNAL CONTRIBUTOR ACTION (phone or meeting) RESPONSIBILITY (WHO WILL ORGANISE) WHEN (DATE THIS WILL BE DONE BY) Go! contact external contributors to get their co operation and involvement. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 15

16 IMPLEMENT Implement 10. Conduct staff training All team members should have the required educational background to talk on the subject to customers. The inpharmation articles and the staff training presentation (available for download from the Education section) are ideal for this purpose. The clinical evidence brief provides a snapshot of key points. The team should also know exactly what is expected from them for the promotion to run successfully. Further action required is: Set up displays, posters, windows The champion should ensure that on the launch day all in-store displays and posters are set up and that all required material (e.g. Fact Cards) are available for use. We will setup our displays, posters, windows and have our resources ready by: Go! Talk to customers, give out Fact Cards On launch day the whole team should undertake the roles assigned to each so that the promotion has maximum impact. As the promotion progresses the champion should ensure that all aspects of the promotion are running effectively. If required, adjust certain elements, order more resources and keep encouraging team members to play their part. Our promotion will start on: Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

17 EVALUATE Evaluate 13. Conduct team and customer evaluations It is important to measure the success of your in-store promotion and this can be done as frequently as required, but should at least involve an evaluation in the middle of the promotion and at the end. The assessment during the activity allows a snapshot to be taken so that adjustments can be made if required. It is too late to wait to the end and then decide that it hasn t worked, when there could be adjustments made along the way to give a better result. The final evaluation should be a formal assessment so that you can record what worked and what didn t to inform your next health promotion. There are evaluation tools provided for the team and your customers (available for download from the Tools section). Finally send back the ACTION kit evaluation to PSA to inform the development of our next ACTION kit. We will conduct staff evaluations on:... We will conduct customer evaluations on:... We will conduct the ACTION kit evaluation on:... Evaluation examples Team feedback NOT AT ALL VERY MUCH Were the resources in this kit helpful when planning your activity? Were you able to use the resources in this kit? Would you like to offer an influenza vaccination service? Do you consider that your activities were successful? Do you have any suggestions on improving these activities in the future? Customer assessment NOT AT ALL Did staff offer you information about immunisation? Was the information offered helpful? Did the pharmacist offer you appropriate support? Were staff helpful when you spoke to them about immunisation? Would you come back to this pharmacy for help with immunisation? VERY MUCH Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 17

18 14. Do our own evaluation What worked?... What could be improved?... What should we do next time?...

19 ACTION Service delivery 2

20 20ACTION 2 Part one Service delivery Immunisation has been demonstrated to be one of the most effective public health interventions for preventing disease. The overarching goal of immunisation is to protect individuals and populations from vaccine-preventable diseases (VPD). Over the last 15 years in Australia, immunisation coverage, especially of infants and children, has reached very high levels; the incidence of VPDs has diminished greatly and these diseases now rarely occur. 1 Programs such as Immunise Australia have helped in maximising immunisation coverage. Immunise Australia aims to increase national immunisation rates by funding free vaccination programs according to the National Immunisation Program (NIP) Schedule and communicating information about immunisation to the general public and healthcare professionals. 1 However despite the success of these immunisation programs, there are certain population groups in Australia that remain at-risk of VPD. Customers, who do not proactively seek out immunisation may have a gap in their immunisation coverage. Customers who have no firsthand knowledge of the consequences of these diseases may not see the need for immunisation. Unlike most healthcare initiatives, immunisation programs tend to target the healthy population who may not seek out healthcare services. Some customer groups object to immunisation because of concerns regarding the safety of immunisation leading to a fall in vaccination rates in some areas. Language difficulties and cultural differences may also reduce access to immunisation services, leaving some communities at-risk of VPD. 1 Pharmacists have an important role in health promotion and customer education with regard to immunisation, particularly in addressing customer concerns about the safety and efficacy of immunisation. Pharmacists can also have a role in increasing the public s access to immunisation services by hosting authorised immunisers to provide immunisations in the pharmacy setting. Internationally, the provision of immunisation services through pharmacy is well established, and significant experience exists from the United States of America (USA), Canada, the United Kingdom (UK), Portugal and New Zealand. The National Flu Survey reported that almost 20% of Americans over the age of 18 who were immunised against influenza were vaccinated in the pharmacy setting. International studies have concluded that immunisation services can be provided safely through community pharmacy, that customers support pharmacy based immunisation and that pharmacy-based immunisation services increase vaccination coverage within communities. 3 Pharmacy, in collaboration with other healthcare providers, is in an ideal position to deliver information about immunisation and vaccines to the customer and maintain their confidence in the immunisation process. High levels of immunisation coverage depend on the confidence of individuals and communities in the safety, efficacy and effectiveness of vaccines and immunisation services. The customer must understand the need for immunisation, recognise the value of immunisation in protecting the population from serious disease, and have a realistic appreciation of the risks of vaccines in relation to the benefits of immunisation. Through the supply of vaccine products, health promotion and targeted risk assessment and pharmacy hosted immunisation services, pharmacists can provide preventative and public health services. 1 Many pharmacies and pharmacists provide advice and assistance to customers wanting information on immunisation for travel purposes, annual influenza vaccination and the NIP Schedule. Ideally these services should be provided in a consistent, structured and systematic manner. This step by step workbook will enable you to host a successful influenza vaccination service. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

21 To complement your professional service consider undertaking an in-store promotion on influenza vaccination as this may be leveraged to make appointments for customers wanting to receive an influenza vaccination from your pharmacy. This activity should form part of the promotional plan for the service. For the step by step guide to undertaking an in-store promotion please refer to section one of this workbook. Service delivery checklist Plan Do a needs assessment 1. Current situation analysis 2. Demographic analysis 3. Desired situation and pharmacy vision Build a business case 4. SWOT analysis 5. Identify our target audience 6. Set our aim and objectives 7. Brainstorm what could be offered in the service 8. Calculate costs and formulate a financial plan 9. Establish the timeframe for rollout Tick once complete Design Team involvement 10. Appoint a champion 11. Plan whole team involvement Service elements 12. What the service will include the scope 13. Summarise the scope of the service 14. Which tools will we use? 15. Document the consultation process 16. Plan the physical area where the service will take place 17. Plan our promotional and collaboration activities 18. Plan the evaluation of the service Implement 19. Negotiate and sign a service agreement with our chosen authorised immuniser 20. Conduct staff training 21. Collate all documents (tools) and material required 22. Prepare the service area 23. Start promotional activity 24. Host the immunisation service EVALUATE 25. Conduct team and customer evaluation 26. Do our own evaluation 27. Please give PSA your feedback Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 21

22 Plan Do a needs assessment PLAN At present legislation does not allow pharmacists to administer vaccines in Australia, in the future appropriately trained pharmacists may be permitted to offer immunisation services themselves. Currently pharmacy may host an immunisation service which is delivered by an authorised immuniser, recognised as such, in the State or Territory in which the service will be conducted. Before introducing a new professional service, such as an influenza immunisation service, it is recommended that the pharmacy undertake a needs assessment to identify existing gaps and barriers to customer care that support the need for the service. Needs assessment involves measuring the health needs of a population. 5 Understanding the needs and expectations of customers, and targeting services towards these is a key factor in ensuring the success of new services and programs Current situation analysis The first part of the needs assessment is to establish a base line of what is being done now in relation to influenza immunisation and product sales in the pharmacy. This baseline assessment will assist with the evaluation of the service. What do we do now? (e.g. Do you currently provide influenza vaccines to patients with a doctor s prescription? Do you currently encourage your patients to be immunised each autumn/winter?) How many influenza vaccinations have we dispensed each year over the past 3 years? Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

23 2. Demographic analysis The next consideration is the demographic of your customers. Do we have enough eligible customers to warrant hosting an influenza vaccination service? (e.g. healthy adults between the ages of 18 and 65 who do not qualify on the NIP for free vaccinations) Approximately how many of our customers may be eligible? (an estimation is sufficient) How can we identify or target them?... What are the current services or treatment pathways for our customers wishing to have an annual influenza vaccination? (e.g. Do your customers go to their GP, have it done by mobile vaccination service providers in their workplace or do they simply not have an annual vaccination because they do not think about it or can t be bothered to go to their doctor?) Determining the answers to these questions can help determine the viability of hosting the service, and help you to target and promote the service to relevant customers. The Medicare Local in your area may have already completed a population needs assessment that may provide some of these answers. To find your Medicare Local visit An in-store promotion addressing the risks of influenza may also help you identify your customers who are suitable for and interested in this service. PLAN WHAT DO YOU DO NOW? Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 23

24 3. Desired situation and pharmacy vision How would we like our pharmacy to be perceived by our customers, in relation to being a health destination? (e.g. A supportive environment that helped me to ) What benefits can we provide to our customers, that they are currently not receiving? (e.g. remaining unimmunised each winter.) Having a vision for the business will provide guidance for every decision you make. Do we have an overall vision for our pharmacy? yes / no What is our vision? vision What is your vision? 24 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

25 Build a business case 4. SWOT analysis When implementing a new service, it is important to consider the impact on the business and existing services. A SWOT (strengths, weaknesses, opportunities, threats) analysis assists businesses to evaluate whether they have the internal means and capabilities to withstand threats and to exploit opportunities in their external environment. 7 In the healthcare setting, there are four important areas of consideration for SWOT analysis: Expectations of stakeholders including demand for services, standards of performance and cost expectations. Contextual factors such as healthcare initiatives e.g. workplaces providing employees with an annual influenza vaccination at the local clinic or via mobile service providers. Resources including people, financial means and capabilities to conduct the service and provide information resources. Strategies things you can do to address weaknesses and threats. Undertaking a SWOT analysis for hosting this service 1. Consider the expectations of relevant stakeholders, such as customers, the pharmacy s owners, other healthcare professionals, and the authorised immuniser; plus the threats and opportunities for the pharmacy that are associated with these expectations. What do your customers expect or want in relation to annual influenza vaccinations? Possible threats include the availability of influenza immunisation services through local immunisation clinics and at doctor surgeries, and customer beliefs that they do not need to be immunised against influenza. Possible opportunities exist for the pharmacy where customers have not identified the need for influenza vaccination, for example customers who have not had the flu in previous years so do not think they need to be vaccinated. 2. Evaluate any contextual factors that may influence the expectation of stakeholders. A key contextual opportunity that can be leveraged by the pharmacy as a business opportunity is the opportunity to offer influenza vaccination either in the pharmacy or directly in the customer s workplace. Offering vaccination in a readily accessible location for the customer may motivate them to be immunised; an increase in the number of customers requesting immunisation services can be leveraged by the pharmacy as a business opportunity. 3. Assess the resources such as staff, finance and the current capabilities of your pharmacy, and classify as strengths or weaknesses. A key strength for your pharmacy may be the availability of a motivated staff member to drive the program. Declining financial performance or failure of previous professional services may be regarded as weaknesses. 4. Identify strategies for maximising strengths and opportunities, while overcoming weaknesses and threats associated with the new service. e.g. If your customers do not believe they need to be immunised against influenza, how can the pharmacy change these beliefs? In Australia, there are, on average, 85 deaths and over 4,000 hospitalisations recorded as being due to influenza illness each year 8. By promoting the benefits of annual influenza vaccination, and targeting customers who are at risk of contracting influenza such as the elderly, healthcare workers, those with chronic disease as well as healthy customers between the ages of 18 and 65 who do not receive the vaccine free under the NIP, it may be possible to change customer expectation and beliefs. With regards to maximising opportunities, leveraging the desire for employers to minimise sick leave may increase your customer base for the service. Consider approaching local businesses to promote your pharmacy s service both in the pharmacy and potentially in their workplace. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 25

26 If your pharmacy has not been successful in offering professional services in the past, consider why this has been the case? Contracting external support from PSA s Pharmacy Support Program may help overcome these barriers. For further information on the Pharmacy Support Program, visit supporting-practice/pharmacy-support-program. For free telephone advice or to discuss your specific situation call Simon Carroll (PSA Senior Professional Practice Pharmacist) on A SWOT analysis template with examples is provided to assist you to perform your SWOT analysis. Fill in your own SWOT notes: SWOT analysis template EXPECTATIONS CONTEXTUAL FACTORS RESOURCES STRATEGIES STRENGTHS e.g. Large target audience currently under immunised e.g. Motivated staff member e.g. Run a health promotion on risks of influenza and promote the service to be offered WEAKNESSES e.g. Staff not convinced of the value of influenza vaccinations e.g. Space to conduct the service in the pharmacy OPPORTUNITIES e.g. Local offices do not currently offer employees an annual vaccination THREATS e.g. Local GPs may get upset if you do not sell them the health benefits for the community 26 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

27 5. Identify your target audience Pharmacies may wish to target specific customer groups, i.e. customers who are aged between 18 and 65 who are currently in the workforce. The customer s beliefs about immunisation are of particular importance; customers who have previously had influenza may clearly identify immunisation as an important preventative health measure, while customers who have never had the flu may be more likely to think they do not need to be vaccinated. Another important consideration when targeting services to a particular group is consideration of the customer s need to be vaccinated. Younger adults are less likely to appreciate the need for vaccination as they may have rarely been ill or may not have a chronic disease. However, older adults will tend to be more likely to accept the need for vaccination as a preventative healthcare strategy and want to be vaccinated. You need to identify who you are targeting, some possibilities are: local business owners who are wanting to reduce staff sick days in winter customers between 18 and 65 years of age who do not qualify for free NIP influenza vaccinations customers who may be eligible for free NIP influenza vaccinations but who do not receive them e.g. working people too busy to see their doctor selected cultural groups and/or linguistically-diverse backgrounds who may be under immunised customers who have chronic diseases, respiratory illness or are immunocompromised and would have an increased health risk if they contracted influenza customers who are likely to be in contact with a newborn baby customers planning to travel overseas. Our target audience is: Set our aim and objectives An effective plan for hosting an influenza vaccination service, requires a strategy that clearly defines the goal that the pharmacy is wanting to achieve. 9 A goal or aim describes what you would like to achieve at a general level, and should include clearly specified improved healthcare outcomes (objectives) for customers, as well as outcomes (objectives) that strengthen the business. 9 Establishing aims and objectives can assist in defining and shaping the delivery of services, and provides a target to measure performance against. Objectives must be SMART (specific, measurable, achievable, realistic and time framed), so that meaningful evaluation of the service can be made. For example: Aim: To immunise customers against influenza by hosting an immunisation service. Objective 1: Achieve a gross profit from hosting this service of $X. Objective 2: Successfully facilitate the vaccination of 100 customers. Objective 3: Increase customer loyalty measured by an increase in prescription numbers over time. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 27

28 Our aim is:... Our objectives are: Brainstorm what could be offered in the service Brainstorm with the team, or at least with your champion, the various possibilities of what you may offer in the service in the design phase you will put down specific activities, but here it is more about allowing discussion and ideas to be raised. Consider if any layout changes are required to host the authorised immuniser and to ensure that you adhere to the physical requirements of providing immunisation. See page 41. What physical changes will need to be made? Which authorised immuniser will be contracted? Which and whose vaccines will be used? What costs will you have, what is the authorised immuniser s expectation of you and your team? What times are available for the service provider to be in your pharmacy? Notes: Calculate costs and formulate a financial plan Service payments and remuneration The decision on what to charge customers for the immunisation service will depend upon the financial arrangement that you have with your authorised immuniser and on the cost and supply of influenza vaccines. It is essential that all customers are informed of any charges before agreeing to the service. What costs will be incurred?... What will we charge for the service? (Note you will need to make this decision following your negotiation with an authorised immuniser. Currently pharmacies are charging between $20 and $35). 28 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

29 Pharmacy practice incentives (PPI) and programs At present, immunisation services are not eligible for claiming under 5CPA PPI because they do not meet the requirements of the program. However, conducting a health promotion for immunisation can meet the Primary Health Care PPI relating to health promotion. Information on 5CPA programs, including eligibility and payment information, is available online at The financial objectives of the service must relate to your objectives above. Note: There are associated potential financial returns from: sales made to the customer when they attend their appointment for the vaccination increased customer loyalty; leading to the lifetime value of the customer to the pharmacy. Keeping a record of these additional transactions will allow a more complete analysis of the benefits. 9. Establish the timeframe for rollout An effective plan for implementing a new service requires the establishment of a specific timeframe. 9 Within this timeframe, it is important to identify phases or stages of the implementation process; will the service be implemented incrementally, perhaps with a certain group of customers first. Each stage of the plan should include milestones with dates for completion. 5 Consider the objectives of your influenza immunisation service How will you achieve these given you have not hosted an immunisation service before? What resources (e.g. protocols) and training will be required to deliver the service? In particular, a shortage of capable staff able to speak to customers appropriately about the immunisation service can limit the rate of adoption. The time taken to contract an authorised immuniser, up skill staff, make required changes in the pharmacy and create resources will influence how soon you can deliver your influenza immunisation service. Consider scheduling a review of the booking/appointment phase e.g. Have a target number of bookings at various timeframes prior to the actual week of vaccinations so that you can assess how you are progressing towards your target number of customers. ESTABLISH THE TIMEFRAME FOR ROLLOUT Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 29

30 1. Consider your anticipated date for the hosting of your service. The time taken to up skill your team, create the required physical space and create resources will influence how soon you can host your immunisation service. Considering the resources (e.g. contracted immuniser, policy and procedures, documents and marketing material) that will be required to host the service, how long will it take to be fully prepared? Considering the physical layout changes that will be required to host the service, how long will it take to be fully prepared? In particular a shortage of available and capable staff can limit the rate of adoption of a new pharmacy service. How long will it take to up skill staff? 2. Consider the scope of the service Do you plan to target specific customer groups first? The bigger the scope, the longer it may take to implement the service. For example, while it may be relatively easy to identify customers who ask about influenza vaccinations, developing processes to identify other customers who will benefit from having an influenza vaccination may take longer. Will it be a staged targeting? If so which target audience is first, second etc? (e.g. Will you target every customer or will you concentrate on talking to and handing out fliers explaining the service, to prescription customers only, or those on chronic medications or those buying salbutamol puffers OTC?) What are the timeframes for each stage? What target number of appointments would we like at the end of each stage? 30 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

31 3. Consider when you will make contact with potential authorised immunisers to establish a service agreement with one. Be aware that you may need to fit in with the available timeframes nominated by the authorised immuniser. When will we contact the potential authorised immunisers? When would we like to have a contracted authorised immuniser s service agreement in place? 4. Consider when and how you will evaluate the service. Will we conduct a customer evaluation on all customers at the time of their vaccination appointments? Consider when to conduct the review of the service yes / no We will review the service on:... You should use data from the evaluation to make decisions on either repeating the service this year or hosting it again next year. 5. Having considered all aspects, decide on a hosting date (you probably cannot finalise this date at this stage). Our launch date is:... Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 31

32 DESIGN Design Team involvement 10. Appoint a champion Appointing a leader or champion to manage the changes and the process associated with the implementation of a new service has been shown to contribute to success. 9 You are strongly encouraged to identify an innovative staff member to oversee and drive the service in the pharmacy your champion. The champion can take responsibility for the project management process, and help to educate and motivate other team members to adopt any new work practices associated with the service, such as encouraging customers to be vaccinated. The champion is also responsible for ensuring that all planned activities and required resources are available a pharmacy team member may achieve this better than the pharmacist, whose priorities are dictated by professional obligations. Our champion is: Plan whole team involvement The whole team approach Research has established the importance of taking a whole team approach when implementing new services. Even where services are to be delivered primarily by pharmacists, involving other staff members in the service and communicating the goals of the service is a determinant of success. 9 In particular, it is important to consider the values and motivation of staff, as it is these factors that often drive an individual s behaviour. 10 e.g. You may experience resistance if staff members are not themselves convinced of the benefits of annual influenza vaccinations. Aligning aims and objectives of the service to these values and motivations and clearly explaining the reasons for change may increase the participation and enthusiasm of staff. Role of the pharmacist and pharmacy staff All pharmacy staff involved should have clearly defined roles and responsibilities. The assessment and provision of clinical information and clinical decisions should always include the involvement of a pharmacist. 11 However, with appropriate training and supervision, staff may be suitable to advocate for the service with customers. You can delegate non-professional tasks to pharmacy staff to improve workflow practices and have pharmacists involved only in roles requiring a pharmacist to make professional decisions. Therefore you are encouraged to consider how the service fits within existing workflow processes, and what components of the service, if any, are suitable to be managed by your team. These may include booking customer appointments, administrative duties and promotion and marketing of the service. Which team members will have key roles and what are their skills? 32 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

33 Team education and training To provide a consistent and high quality service, it is important that all team members involved in the delivery of the service are competent and confident in their roles. Of particular importance when determining training and education needs is consideration of how components of the service differ from existing practice and staff roles and responsibilities. 10 For example many pharmacists will not require clinical education on the principles of immunisation if they regularly counsel customers. However they may require training on how the immunisation service will operate and how to document the service appropriately. The pharmacy team may require assistance with the front end delivery, e.g. introducing and promoting the service, determining eligibility of customers etc. Group 3 CPD credits * CPD credits are available for undertaking this education as specified. These points can be converted into Group 3 points if you start a new service or improve the service you currently provide and evaluate the change in practice over time see the Guide to documenting Group 3 CPD Credits and the Group 3 CPD recording template with a worked example in this kit. Resource Who will do it? By when? Pharmacist education CPD credits available* Clinical evidence brief (Group 1 CPD credit available for self-recording if read) inpharmation Facts Behind the Fact Card Immunisation (2 Group 2 CPD credits available if the questions are answered) PSA Motivational Interviewing online (2 Group 2 CPD credits available if the questions are answered) PSA Collaboration online (2 Group 2 CPD credits available if the questions are answered) PSA Immunisation an overview online (2 Group 2 CPD credits available if the questions are answered) PSA Implementing an in-pharmacy influenza immunisation service online (2 Group 2 CPD credits available if the questions are answered) PSA Immunisation services in pharmacy guidelines (Group 1 CPD credit available for self-recording if read) PSA ACTION kit immunisation (Group 1 CPD credit available for self-recording if read) The Australian Immunisation Handbook (Group 1 CPD credit available for self-recording if read) Available at immunise/publishing.nsf/content/handbook10-home Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 33

34 Staff education Resource Who will do it? By when? inpharmation Counter Connection Immunisation Staff training presentation Self Care Fact Cards Travel health, Childhood immunisation, Chicken pox, Cold and flu Service specific training 34 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

35 Service elements 12. What the service will include the scope Responsibility for customer clinical needs assessment and pre-vaccination screening lies with the authorised immuniser. However, such activities may be supported by the pharmacist and pharmacy staff. In collaboration with the authorised immuniser, pharmacists should work with the customer to establish immunisation status and confirm immunisation needs. When planning new services, such as an influenza vaccine service, it is important to clearly define the scope and parameters of the service, in the context of an in-pharmacy influenza immunisation service, this includes consideration of which customer groups to target for participation in the service. Defining the scope of your influenza vaccine service Spend time considering the following information and familiarising yourself with the various practice tools and documents available to assist you to host an influenza immunisation service and then in section 13 summarise the actual activities to be undertaken by your pharmacists, your staff and the authorised immuniser. Note: you will have to initiate conversations with potential authorised immunisers to establish the scope of each of their offers to you. Consider your chosen target audience and their needs and expectations. Consistency in the promotion is important to ensure that your customer s experience is professional and consistent. The key elements and actions you should undertake as part of a comprehensive service are detailed below. You should familiarise yourself with and adhere to the PSA practice guidelines for the provision of immunisation services within pharmacy. The guidelines and practice tools may be accessed at Pharmacies can facilitate the provision of vaccinations by hosting immunisation services delivered by other healthcare professionals authorised to administer vaccines. Pharmacists should satisfy themselves that any person administering vaccines is an authorised immuniser that is, either a registered medical practitioner, or an appropriately qualified, competent and authorised registered nurse. Registered medical practitioners and registered nurses are listed in the Australian Health Practitioner Regulation Agency registers, and should provide evidence of professional indemnity insurance. Pharmacists should note that nurses working for service providers or in general practice may be covered under their employer s insurance, while independent contractors must hold their own indemnity insurance. In either case, pharmacists should ensure that the authorised immuniser has cover appropriate to their immunisation activities. One of the first steps is to choose an authorised immuniser. Your negotiations with the authorised immuniser will determine what roles and which tools the pharmacy is responsible for and what the authorised immuniser will provide and be responsible for. For example authorised immunisers are AusVax, Corporate Medical Options, MediMobile and Revive. Some of the tools available from PSA are: PSA practice guidelines for the provision of immunisation services within pharmacy immunisation service checklist for pharmacies service agreement template pre-immunisation screening checklist Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 35

36 customer vaccination statement template post-vaccination procedures checklist emergency response protocol referral letter template. PSA practice guidelines for the provision of immunisation services within pharmacy The guidelines are available at The guidelines are an educational resource for pharmacists to promote best practice and the delivery of high quality immunisation services in pharmacy. This includes descriptions of appropriate and effective processes, how the duties and professional responsibilities of pharmacists may be best fulfilled, and expected outcomes. Nonetheless, pharmacists are expected to exercise professional judgement in applying the guidance provided to specific presenting circumstances. Guidelines developed by the PSA are not definitive statements of correct procedure but usually reflect agreement by experts in the field. PSA guidelines are underpinned by available clinical evidence, and encourage the application of theoretical concepts shown to facilitate changes in practice and implementation of new services. PSA guidelines can be used as a support tool for balanced, professional decision-making in the context of the customer s needs, beliefs and preferences, can contribute to quality assurance processes and may assist in the resolution of legal disputes or ethical dilemmas. They are not intended to provide clinical information; it is the responsibility of individual pharmacists to maintain their clinical skills, knowledge and competence. Certain aspects with regard to the implementation of pharmacy-hosted immunisation services are considered outside the scope of these national guidelines. Pharmacists must, at all times, meet all legislative requirements, which may not be detailed in these guidelines. Pharmacists should refer to the legislation detailing the administration of drugs, poisons and controlled substances in their respective State or Territory (see page 81), or contact their State or Territory Department of Health for specific guidance on jurisdictional requirements. Other issues not covered within the guidelines include models of supply or practice and funding arrangements for pharmacy-hosted immunisation services. The guidelines should be read and considered in conjunction with information and recommendations provided in the current edition of the Australian Immunisation Handbook. The Australian Immunisation Handbook provides clinical guidelines for health professionals to support the safest and most effective use of vaccines in their practice; recommendations in the handbook have been developed by the Australian Technical Advisory Group on Immunisation (ATAGI) and endorsed by the National Health and Medical Research Council (NHMRC). The handbook is available for download or free to order as a hardcopy book at Pharmacists and pharmacy staff are also encouraged to use this document in conjunction with existing operating procedures in their pharmacy. 6 Immunisation service checklist for pharmacies (see page 82) This checklist provides a logical, stepwise process for the provision of an immunisation service in pharmacy. The checklist refers to the Australian Immunisation Handbook and you should always refer to the current edition of the handbook which may be accessed at 36 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

37 Service agreement template (see page 83) Pharmacy-hosted immunisation services must be delivered through collaboration between the pharmacist and the authorised immuniser. Pharmacists are strongly encouraged to consider entering a service agreement with the authorised immuniser that outlines the roles and responsibilities of each party. Pharmacists are also encouraged to consult guideline 6, Allied health, and complementary and alternative therapy when practised by other persons in the pharmacy in the Pharmacy Board of Australia s Guidelines on practice specific issues. 12 (Available at Specific State and Territory legislation may require that a medical officer be contactable for the time in which immunisations are provided. Pharmacists are also strongly encouraged to formalise such arrangements using a service agreement. Pre-immunisation screening checklist (see page 87) Responsibility for customer clinical needs assessment and pre-vaccination screening lies with the authorised immuniser. However, such activities may be supported by the pharmacist. In collaboration with the authorised immuniser, pharmacists should ensure the correct processes are in place to allow the authorised immuniser to establish immunisation status and confirm immunisation needs. Where possible, the customer s immunisation record, Indigenous status and relevant medical history should be referred to and considered as part of the clinical needs assessment. The accuracy of all information must be confirmed verbally with the customer, or where appropriate, the customer s carer. The pharmacist should satisfy themselves that appropriate pre-vaccination health screening is in place to identify contraindications or precautions to vaccines that are to be administered. Customer consent must be obtained and documented prior to the provision of immunisation services. Consent must be obtained by the authorised immuniser before each vaccination, after it has been established that there are no conditions that contraindicate immunisation. Customer consent must be informed by the provision of appropriate and reliable information regarding immunisation procedures, including the risks and benefits associated with specific vaccines. Customers must also be informed of any fees associated with the service, and consent to such costs. Customers participating in pharmacy-hosted immunisation services must also be specifically asked if they have a regular primary healthcare provider, and if, in the interest of ensuring continuity of care, they consent to that provider being provided with a copy of their vaccination statement. Pharmacists should satisfy themselves that appropriate processes to obtain and document customer consent are in place before immunisation services are delivered. The Pre-immunisation screening checklist can be used to obtain and record customer consent prior to the provision of immunisation services. For further information regarding valid consent, including how to obtain consent in special populations (i.e. children or people with impaired decision-making ability), see Valid consent in the current edition of the Australian Immunisation Handbook. Customer vaccination statement template (see page 88) Customers should be provided with a statement of vaccinations received following each appointment. With the customer s consent, a copy of the customer vaccination statement, along with any relevant customer consent and screening documents, should be stored according to the pharmacy s information management system. Documents should be stored in a format and location that allows timely access and easy retrieval. Patient information should be stored in a secure system, and access and disclosure processes should comply with the relevant privacy legislation. If the customer consents, the administration of all vaccinations should be reported to their nominated primary healthcare provider. 12 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 37

38 Post-vaccination procedures checklist (see page 89) Pharmacists hosting immunisation services may support the authorised immuniser in encouraging and enabling customers to remain in the vicinity for at least 15 minutes following vaccination. Customers should be offered seating in an area near the immunisation service area to enable assistance to be given and treatment to be provided if necessary. Pharmacies hosting immunisation services should have procedures in place to refer customers experiencing adverse events following immunisation for appropriate medical advice and care. Pharmacists may be consulted by customers at a later time for advice and treatment to manage delayed adverse events or to confirm information provided to them by the authorised immuniser. As such pharmacists should be suitably informed to be able to provide an appropriate referral to the authorised immuniser, the customer s primary healthcare provider or to an emergency care facility, depending on the severity of the adverse event. This Post vaccination procedures checklist, includes the immediate aftercare procedures required. Emergency response protocol Pharmacies hosting immunisation services must have a written protocol for responding to emergencies. Pharmacy staff, as well as the authorised immuniser, must be familiar with the pharmacy s emergency procedures. Pharmacists hosting immunisation services are strongly encouraged to have current CPR certification to enable them to assist in an emergency. For further information on the management of serious adverse events following immunisation (AEFI) and medical emergencies, see Post vaccination procedures in the current edition of the Australian Immunisation Handbook. Policy and procedure Pharmacies should develop a policy and procedure manual for immunisation services in collaboration with the authorised immuniser or service provider. Pharmacies may choose to use the template provided by the Quality Care Pharmacy Program (QCPP) 6 to develop this document. An immunisation service policy and procedure manual should include: A clearly defined aim or purpose for the service that will enable pharmacy staff to understand the role the service has in the delivery of primary and preventive health care. A checklist or flow chart of the service, including how it works and how it is integrated into the established functioning of the pharmacy. A clearly defined description of the roles and responsibilities of all staff and authorised immunisers involved in the service. A training schedule for pharmacy staff to educate them about their roles and responsibilities within the immunisation service. Roles and responsibilities should match the existing defined roles of staff members in the delivery of pharmacy services (e.g. discussion of the immunisation service with customers and the referral process to the pharmacist and/or authorised immuniser). Guidelines and procedures for the development and maintenance of the consultation area, including (as necessary) screening, furniture, equipment for storing and administering vaccines, and facilities for sharps and medical waste disposal. A vaccine management policy or protocol for ensuring compliance to cold chain storage and monitoring requirements, including the identification of persons responsible for ensuring vaccine potency, contingency plans in the event of mechanical or power failure, and reporting of cold chain breaches. A protocol for responding to medical emergencies following the administration of vaccines, including the management of anaphylaxis, the use of emergency response equipment, 38 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

39 and the roles and responsibilities of pharmacy staff and the authorised immuniser. See page 90 for an example Emergency response protocol). The contact details for the medical officer who has agreed to be contactable during periods in which immunisations are administered, if required by State or Territory legislation. A policy or procedure for referring customers for appropriate medical advice and care if presenting with an adverse event following immunisation. A workplace health and safety protocol, with specific reference to minimising the risk of needle stick injury, exposure to blood and bodily fluids and the transmission of infectious diseases, including a process for post exposure prophylaxis. A process for the removal of sharps and medical waste from the pharmacy premises as per the pharmacy s waste management policy. The process and requirements for documenting immunisation services, including the creation and maintenance of customer records, addition of details to the customer s electronic health record where possible, and processes for ensuring authorised immunisers report vaccinations to appropriate immunisation registers. A policy for documentation and storage of customer records (with customer consent) that ensures customer confidentiality is maintained. A policy for communication and provision of service information to local healthcare providers and customers. Details of the responsibilities for maintenance of the service and associated documentation (e.g. access, storage, security, backups). A process for maintaining access to, and currency of, relevant health information for customers. A process for the development and update of relevant forms and templates (i.e. screening and needs assessment tools, and customer immunisation history statements). Appointments An appointment system will ensure that the authorised immuniser s time and the number of available vaccine doses are co-ordinated to allow for maximum efficiency on the days that the authorised immuniser is present in the pharmacy. Appointment reminder cards can be provided to customers see enclosed order form. Ad hoc appointments on the day may be possible, and the process of pre-screening etc must still be followed. Consider what our service will include the scope (e.g. use of PSA Immunisation guidelines and tools etc from brainstorm at point 7) Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 39

40 13. Summarise the scope of the service Your service agreement and negotiated arrangements with the authorised immuniser will dictate the roles and responsibilities of each party, so it is worth summarising these so that you are clear on the service delivery. The authorised immuniser will:... The pharmacist will:... The pharmacy staff will: Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

41 14. Which tools will we use? We will use the PSA practice guidelines We will use PSA Immunisation service checklist for pharmacies We will use the PSA Service agreement template We will use the PSA Pre-immunisation screening checklist We will use the PSA Customer vaccination statement template We will use the PSA Post-vaccination procedures checklist We will use the PSA Emergency response protocol We will use the PSA Referral letter template QCPP template policy and procedure manual We will use the PSA appointment cards We will use the PSA posters We will provide customers with relevant Fact Cards Other notes yes / no yes / no yes / no yes / no yes / no yes / no yes / no yes / no yes / no yes / no yes / no yes / no 15. Document the consultation process Documentation of services Documentation provides a means of accountability, promotes continuity of care and is a source of information to use for customer follow up and after care. Documentation used and storage of records will be dependant on your service agreement with the authorised immuniser, however be sure that appropriate records are maintained by the pharmacy. We will use the PSA tools or we will document using:... Referral Following vaccination, it will sometimes be preferable or necessary to refer the customer for further advice and management. Customers can be referred for further medical investigation via the PSA Referral Form on page 91. We will use the PSA Referral letter template yes / no Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 41

42 16. Plan the physical area where the service will take place Pharmacies hosting immunisation services should ensure services are provided in a screened area or room separate from the public area of the pharmacy, so that the privacy and confidentiality of customers is protected. As customers will be advised to remain in the general vicinity for at least 15 minutes following vaccination, pharmacies should provide adequate seating adjacent to the immunisation services area to accommodate multiple customers as necessary. Pharmacies are also encouraged to use discreet identifiers to enable the quick identification of customers who have received vaccinations should they require further assistance. The immunisation service area must be appropriately furnished, with facilities to allow customers to sit or lie and receive treatment as necessary. The area should be of sufficient size and appropriate layout to accommodate efficient workflow, including adequate room for the customer, their carer and the authorised immuniser, as well as all the consumables, equipment and documentation required for the service. Of particular consideration is the need for sufficient space and appropriate surfaces for the authorised immuniser to treat potential adverse events. Appropriate handwashing facilities should also be available to meet relevant State or Territory government health authority requirements. Pharmacies hosting immunisation services must have appropriate equipment for storing vaccines and vaccine products as required, including a reliable and stable refrigerator compliant with cold chain requirements. 14 Such equipment may be available in the immunisation service area or within the dispensary; however, pharmacists need to ensure that access to vaccines and vaccine products is restricted as per the relevant State or Territory legislation governing the storage of controlled substances. Equipment for the appropriate disposal of sharps and medical waste must be available in the immunisation service area, as outlined in the current edition of the Australian Immunisation Handbook. Appropriate resources to treat customers in case of an emergency, including a displayed emergency response protocol and emergency response kit, should also be readily available in the immunisation service area, whether provided by the authorised immuniser or the pharmacy. For further information regarding preparation of an emergency response kit, pharmacists should refer to the Immunisation service checklist for pharmacies on page 82, or the current edition of the Australian Immunisation Handbook. An example Emergency response protocol is available on page 90. A copy of the National Vaccine Storage Guidelines: Strive for 5 14 and the current edition of the Australian Immunisation Handbook 5 should be available in the immunisation service area. Pharmacists should satisfy themselves that appropriate procedures are in place to verify that all resources are available and in date prior to each immunisation session. Immunisation services must not proceed unless the above requirements are met. What changes do we need to make to create a professional service area? Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

43 17. Plan your promotional and collaboration activities Promotion Promotion of a new service is important; the service needs to be recognisable to the customer so that they request it. In addition, awareness and the consequent expectation of customers to receive a particular service can help drive its implementation by your pharmacy and team. 9 Raising awareness Your promotion plan should include both active and passive promotion methods. While displaying posters and brochures advertising a service can be effective in raising customer awareness, evidence from the UK has demonstrated that active promotion of a service results in greater levels of participation. 5 Passive display of posters and brochures alone is not enough; your team should be trained to approach customers, discuss and explain the service and encourage participation. Providing your team with some key messages including the benefits of participating in the immunisation service may increase staff confidence in promoting the service. You may also consider linking your immunisation service to an in-store promotion activity. You can use local media to promote your service. For a comprehensive in-store promotion plan refer to part 1 of the workbook. Collaboration with other healthcare professionals The relationship between pharmacist and physician is a key facilitator in the shift towards a greater focus on services in pharmacy. 14 Research has shown that building rapport with local physicians can be integral to the success of customer centred services in the pharmacy setting, 15 and that inter professional relationships are of great importance in pharmacy delivered minor ailment schemes. 17 Indeed, experience from the UK advocates the importance of a collaborative multidisciplinary approach and improved understanding of the roles and relationships between healthcare professionals when implementing professional services. 5 When implementing an immunisation service you are strongly encouraged to approach local GPs and other local healthcare providers, and explain the aims and objectives of the service. You may find it helpful to explain that the aim of the service is to increase the number of people who receive the seasonal influenza vaccine and provide vaccine advice, rather than encroach upon the roles and responsibilities of other healthcare professionals. In particular, you should establish agreed lines of communication of customer issues, including referral of customers who are eligible and desire to receive an influenza vaccine under the NIP for free from their local GP or clinic. External support The ability to implement change is directly related to an organisation s capacity for action. 9 When considering implementing professional services, such as an immunisation service, you should be prepared to seek assistance with the implementation process. There is evidence demonstrating that pharmacies can benefit from targeted, on-site support to assist their preparation for change and to build the capacity to integrate new professional services over time. 9,16,17 PLAN YOUR PROMOTIONAL ACTIVITIES Pharmacy support program PSA s Pharmacy Support Program can provide assistance to pharmacies wanting to establish an immunisation service. The program is a consultancy service offered to pharmacies in every State and Territory of Australia. Practice support pharmacists provide in-pharmacy support for the implementation and delivery of professional services, as well as other elements of practice change. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 43

44 Pharmacies can purchase a package that provides them with in-pharmacy visits from a practice support pharmacist as well as phone and support. Practice support pharmacists will provide practical advice and examples, and tailor the program to suit the pharmacy s individual needs and unique circumstances. For further information on the Pharmacy Support Program, visit For free telephone advice or to discuss your specific situation call Simon Carroll (PSA Senior Professional Practice Pharmacist) on Plan the evaluation of the service Service evaluation It is important to measure the success of your immunisation service. This should be done at pre determined intervals prior to the actual days that the authorised immuniser will be present to ensure adequate uptake of the service. Your team and customers of the service should be encouraged to formally evaluate the service after the vaccination days. Template forms are available in this kit. We will use the staff evaluation forms We will use the customer evaluation forms The information gathered will assist you when planning the immunisation service in subsequent years. yes / no yes / no 44 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

45 IMPLEMENT Implement 19. Negotiate and sign a service agreement with your chosen authorised immuniser Our authorised immuniser is Conduct staff training In the design phase you documented the required staff training for both pharmacists and pharmacy staff. The pharmacist training will be completed by:... The staff training will occur by: Collate all documents (tools) and material required All documents (tools) and other material will be ready by: Prepare the service area The changes to the service area will be complete by: Start promotional activity Once you and your champion have all elements in place and the appropriate staff training has occurred it is time to promote the new service. Approach customers and book appointments. Date of promotion launch: Host the immunisation service On launch day the whole team should undertake the roles assigned to each so that the service meets the scope and objectives that have been planned. As the service progresses the champion should ensure that all aspects are running effectively and if required, adjust certain elements, order more resources and keep encouraging team members. Date that service will be offered:... Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 45

46 EVALUATE Evaluate 25. Conduct team and customer evaluation It is important to measure the success of your service and this can be done as frequently as required, but should at least involve an evaluation soon after commencement and again at regular intervals. The assessment soon after commencement allows a snap shot to be taken so that adjustments can be made if required. It is too late to wait to the end and then decide that certain aspects are not working, when there could be adjustments made earlier to give better results. There are evaluation tools provided for the team and your customers (available for download from the Tools section). Date of initial staff evaluation:... Subsequent staff evaluations:... Adjustments to the service made:... We will conduct customer evaluations on the day of vaccination yes / no 26. Do our own evalutation What worked? 46 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

47 What could be improved? What should we do next? 27. Please give PSA your feedback Please give us your feedback on this workbook and the resources so that we improve our service to you. Contact Self Care on or References 1. Communicable Diseases Information. Available at : internet/main/publishing.nsf/content/health-pubhlth-strateg-communicvpd.htm 2. Australian Government. National Immunisation Program Schedule. At: nips2 3. PSA Practice guidelines for the provision of immunisation services in pharmacy February Daniels A. In-pharmacy flu immunisations are happening. Australian Pharmacist. April 2012; 31(04): What is Health Promotion? Centre for health promotion. Women and Children s Health Network. At: Content.aspx?p= Australian Government and the Pharmacy Guild of Australia. Primary health care basics factsheet. 7. The National Pharmaceutical Association Implementing a community pharmacy minor ailment scheme: A practical tool kit for primary care organisations and health professionals 2003 UK 8. National Centre for Immunisation, Immunisation Fact Sheet. edu.au/immunisation/fact-sheets/influenza-fact-sheet.pdf 9. Roberts, A. Practice change in community pharmacy: the implementation of cognitive services 2005 University of Sydney 10. van Wijngaarden, J., Scholten, G., & van Wijk, K. (2012). Strategic analysis for health care organisations: the suitability of SWOT-analysis. International Journal of Health Planning and Management, 27, Allied health, and complementary and alternative therapy when practiced by other persons in the pharmacy. In: Pharmacy Board of Australia Guidelines on practice-specific issues. Melbourne Pharmacy Board of Australia; At (accessed 16 Feb 2013). 12. Australian Medical Association. Position statement on vaccinations outside of general practice. At: vaccinations-outside-general -practice-2011 (accessed 16 Feb 2013). 13. Australian Government Department of Health and Ageing. National Vaccine Storage Guidelines: Strive for 5. Canberra: Commonwealth of Australia; At: publishing.nsf/content/provider-store (accessed 16 Feb 2013). 14. Cavaco, A., & Pereira, P. (2012). Pharmacists counselling protocols for minor ailments: A structure-based analysis. Research in Social and Administrative Pharmacy, 8, Roberts, A. S., Benrimoj, S. I., Chen, T. F., Williams, K. A., & Aslani, P. (2006). Implementing cognitive services in community pharmacy: a review of facilitators of practice change. Int J Pharm Pract, 14, Baker, R. a. (2010). Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 17. Jamtvedt, G. e. (2006). Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 47

48 48 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

49 ACTION Education 3 Copies of these resources available for download from the Education section.

50 Clinical evidence brief 2013 Immunisation Immunisation is the process of obtaining immune status through vaccination. 1. Public health benefits The public health benefits of immunisation include: reduction in illness, disability and death control, prevention and eradication of disease protection of both the individual and the community from vaccine preventable diseases (VPD) a cost effective health strategy. 2. Herd immunity Herd immunity is the effect achieved when a significant portion of a population is vaccinated providing a measure of protection for individuals who do not have immunity. Only a small fraction of the population can be left unvaccinated for this method to be effective. Unvaccinated individuals may include those who cannot safely receive vaccines for various reasons such as impaired immunity, failure to respond adequately to vaccination, or egg allergies. 1,2 The control of highly infectious diseases, such as measles, requires 95% of the population to be vaccinated to prevent the transmission of the disease. Diphtheria, a less infectious disease, requires a lower percentage of the population to be vaccinated and as a result there have been no cases of diphtheria in Australia since the 1970s. The pneumococcal vaccine which was introduced to protect children against diseases caused by the bacterium, Streptococcus pneumoniae, has also been shown to provide protection for susceptible unvaccinated elderly people due to a reduction in circulation of the bacterium in the community National immunisation program To ensure immunisation rates remain at a high level, Australia has a comprehensive National Immunisation Program (NIP). The NIP Schedule includes 16 vaccines for mass childhood immunisation programs and influenza and Hepatitis A for at-risk adults. 3. Vaccines 4,5 Vaccines contain active components such as attenuated live viruses, inactivated viruses, modified or partial forms of the virus or bacteria or the toxin produced by the bacteria. The antigen in the vaccine is altered from its original form so it no longer causes disease but produces an immune response. Active components used in a vaccine are: Live viruses used in vaccines are weakened (or attenuated) limiting the virus ability to replicate and are able to induce an immune response without causing severe disease. The advantage of live, attenuated vaccines is that only one or two doses usually provide whole of life immunity. However, these vaccines cannot be given to people with severely impaired immunity, as a greatly weakened immune system may not be able to limit reproduction of the vaccine virus. Women receiving live viral vaccines must be advised against falling pregnant within 28 days of vaccination. Inactivated viruses are inactivated by formaldehyde so the pathogenic effects are rendered inactive but the antigenicity is preserved. The virus is incapable of replication after vaccination but it is still recognised by the body s immune system. These vaccines can be given to people with impaired immunity. Several doses may need to be given to achieve long-term immunity, and persons with impaired immunity may not respond to even multiple doses. Part of the virus or bacteria is used in certain vaccines to induce immunity e.g. hepatitis B vaccine is composed of a protein from the surface of the virus, haemophilus influenzae type b (Hib) vaccine only the outer coating or polysaccharide is used and joined to a protein so that the immune system responds to it. These vaccines can be administered to people with weakened immunity, although, if the person s immune system is too weak, they may not develop a satisfactory immune response. Toxins produced by the bacteria are chemically inactivated to produce a vaccine that is known as a toxoid. E.g. diphtheria and tetanus-containing vaccines. Tetanus vaccination stimulates the production of antitoxin, which protects against the toxin produced by the organism. Having tetanus infection does not induce a long-term immune response and nonimmune individuals who contract tetanus must be fully vaccinated to protect against future exposure. References 1 National Prescribing Service. Why be vaccinated. At: www. nps.org.au/medicines/immune-system/vaccines-andimmunisation/for-individuals/why-be-vaccinated 2 Understanding childhood immunisation booklet (revised June 2010). Immunise Australia Program. At: gov.au/internet/immunise/publishing.nsf/content/imm52-cnt 3 The Science of immunisation. Australian Academy of Science November At: AAS_Immunisation_FINAL_LR_v3.pdf 4 The Australian Immunisation Handbook 9th Edition. At: www. health.gov.au/internet/immunise/publishing.nsf/content/ Handbook-home 5 Vaccine and its Components Fact Sheet. National Council for Immunisation Research and Surveillance. At: immunisation/fact-sheets/vaccine-components-fact-sheet.pdf 50 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

51 Practice points These practice points are taken from the Immunisation inpharmation, Facts Behind the Fact Card article. Discussing childhood immunisation with parents 4,12 It has been estimated that immunisation currently saves three million lives per year throughout the world while remaining one of the most cost effective health interventions. When immunisation rates in the community are very high the number of cases of certain diseases can be reduced. For example, Haemophilus influenzae type b (Hib) vaccine was introduced into the Australian NIP schedule for all children in In 1992, there were 560 cases of Hib disease notified but in 2006, only 22 cases were notified. Despite a very good record of effectiveness and safety, there are still people who have reservations about immunisation. To make informed decisions, parents need to understand the benefits and risks of vaccination, or not vaccinating, their children. Parents do not usually understand how immunisation protects the child, and the diseases are often not seen as serious. When discussing concerns about immunisation with parents or adults, it is important to recognise that a logical demonstration of the weaknesses in arguments against immunisation needs to be combined with listening and other good communication skills. Two useful resources to assist pharmacists in discussing immunisation issues with parents are Immunisation Myths & Realities, A Guide for Providers and Understanding childhood immunisation, accessible at health.gov.au Onset, extent and duration of immunity 2 Immunity does not occur immediately after vaccination. Activation of the normal immune response takes approximately two weeks. Many vaccines require several booster doses to be given for full immune response to occur and, even when all the doses of a vaccine have been given, not everyone will be immune. Measles, mumps, rubella, tetanus, polio, hepatitis B and Hib vaccines protect more than 95% of children who have completed the recommended immunisation course. Three doses of whooping cough vaccine will protect about 85% of children immunised, and will reduce the severity of the disease in the other 15% of children if they do catch whooping cough. One dose of meningococcal C vaccine at 12 months of age will protect more than 90% of children immunised. 1,8 The protective effect of immunisation is not always lifelong. Some vaccines, such as tetanus, can last up to 30 years, then a booster dose may be required. (Note: A booster dose may be required earlier (e.g. after 10 years) in the presence of a tetanus prone wound.) Other vaccines, such as whooping cough, give protection for about five years after a full course. 1,8 A two-dose course of hepatitis A vaccine given 6 12 months apart is thought to give protection for about 20 years. 1,2 Contraindications to vaccines 2,8 There are only two absolute contraindications applicable to all vaccines: a known anaphylactic sensitivity to any component of the relevant vaccine anaphylaxis following a previous dose of the relevant vaccine. Further contraindications to live attenuated vaccines are: immunosuppressed people regardless of whether the suppression is caused by disease or treatment adults treated with systemic corticosteroids in excess of 60 mg of prednisolone (or equivalent) per day (vaccination should be postponed until at least three months after treatment has stopped) pregnancy. For further explanation, see the Australian Immunisation Handbook 9th edition. If a child has an acute febrile illness (current temperature 38.5 C) the vaccination should be postponed for 2 3 days until the child is well. The following are NOT contraindications to any of the vaccines in the NIP Schedule: family history of any adverse events following immunisation family history of convulsions previous pertussis-like illness, measles, rubella, mumps or meningococcal infection prematurity (vaccination should not be postponed) neurological conditions including cerebral palsy and Down s syndrome contact with an infectious disease asthma, eczema, atopy, hayfever or snuffles treatment with antibiotics treatment with locally acting (inhaled or low-dose topical) steroids child s mother is pregnant child to be vaccinated is being breastfed woman to be vaccinated is breastfeeding history of neonatal jaundice low weight in an otherwise healthy child recent or imminent surgery. Late adverse effects of vaccines 2 Long term surveillance of vaccines is conducted to ensure unanticipated adverse effects are detected. Through the systematic collection of data and analysis of reports, some vaccines have been shown to cause serious late events, although the rate is always hundreds to thousands times less frequent than the disease complication. For example: Approximately one in 1,000,000 doses of MMR vaccine among children causes acute encephalitis occurring 8 9 days after vaccination. In comparison, one in 500 cases of naturally-acquired measles results in severe acute encephalitis. 5 Vaccines containing diphtheria and tetanus have been implicated in causing brachial neuritis with an incidence of approximately one in 100,000 (adults). One additional case of Guillain-Barre syndrome has been detected in every one million people vaccinated against influenza. 5 Although late adverse effects have been reported following immunisation, there is strong epidemiological evidence that there is no causal association between: sudden infant death syndrome (SIDS) and any vaccine autism and MMR vaccine multiple sclerosis and hepatitis B vaccine inflammatory bowel disease (IBD) and MMR vaccine diabetes and Hib vaccine asthma and any vaccine. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 51

52 Practice points Seasonal influenza vaccine 3 Seasonal influenza vaccines normally contain three strains of virus; two current influenza A subtypes, H1N1 and H3N2, and influenza B, representing recently circulating viruses. The H1N1 influenza A strain (known as swine flu) is incorporated in the 2013 seasonal influenza vaccines. However, the current influenza vaccines will not give protection against the H5N1 (avian) virus. Although seasonal influenza vaccines contain minimal amounts of egg protein, they can be used in certain egg-sensitive individuals. Referral to a specialist immunologist is recommended in such cases, however. 5,6 It is important that people in at-risk groups continue to have annual influenza vaccines. If a child under the age of nine years is receiving the vaccine for the first time, they will require two doses at least one month apart. 2 Vaccination is best given in autumn; however, it can be given as early as February. Influenza vaccine can be administered concurrently with other vaccines, including pneumococcal polysaccharide vaccine and all the scheduled childhood vaccines. Annual influenza vaccination is recommended for the following groups: 13 all people aged 65 years and older Aboriginal and Torres Strait Islander people over 15 years of age children ( six months of age) and adults with chronic illnesses including: heart conditions lung/respiratory conditions including asthma diabetes (and other chronic metabolic diseases) kidney disease impaired immunity chronic neurological conditions including multiple sclerosis and seizure disorders haemoglobinopathies (a range of genetically inherited disorders of red blood cell haemoglobin) pregnant women residents of nursing homes and other long-term care facilities. In addition, it is important that people who care for, or who are in close contact with, people who are at particular risk, also avoid spreading the infection. Annual influenza vaccination is also strongly recommended for travellers and people providing essential community services. The National Health and Medical Research Council (NHMRC) also recommends that influenza vaccination can be given to any person aged 6 months or more who wishes to reduce the chance of becoming ill with influenza. Influenza vaccination should be delayed when a person has a high fever or a moderately severe illness, but can generally be given once the illness is resolved. Avian flu 14 There are many different subtypes of type A influenza viruses. Influenza A viruses are constantly changing, and it is possible for viruses that infect birds to adapt over time to infect and spread among humans. Influenza A (H5N1) virus is a highly pathogenic influenza A virus subtype that occurs mainly in birds. It does not usually infect people, but about 160 human cases have been reported by the World Health Organization since January Most of these cases have occurred as a result of people having direct or close contact with infected poultry or contaminated surfaces. So far, the spread of H5N1 virus from person-to-person has been rare and has not continued beyond one person. There is currently no commercially available vaccine to protect humans against the H5N1 virus that is emerging in Asia and Europe. However, vaccines are being developed. Studies to test a vaccine to protect humans against H5N1 virus began in April 2005, and a series of clinical trials is in progress. As a pandemic vaccine needs to be a close match to the actual pandemic virus, commercial production cannot begin prior to emergence and characterisation of the pandemic virus. On current trends, it appears likely that most developing countries will have no access to a vaccine during the first wave of a pandemic and perhaps throughout its duration. PSA Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

53 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 53

54 John Facts Bell says Behind the Fact Card inpharmation Immunisaton Pharmacist CPD Module number 235 Immunisation UP TO 2 CPD CREDITS GROUP 2 By Jill Malek This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed. Immunisation is a simple, safe and effective way of protecting children and adults against certain diseases. The risks of these diseases are far greater than the very small risks of immunisation. 1 Pharmacists can play an important role in promoting nationwide immunisation by providing information on available vaccines and the recommended immunisation schedule, giving advice on adverse effects and their management, allaying parent s fears about the perceived dangers of immunisation, and offering in pharmacy immunisation services. Learning objectives After reading this article, the pharmacist should be able to: describe the public health benefits of immunisation and vaccines discuss the aims of the National Immunisation Program (NIP) Schedule in providing nationwide immunisation describe the role of the pharmacist in promoting immunisation within their community discuss the different types of vaccines available advise consumers on immunisation and vaccines and any adverse effects of vaccines. Competencies addressed (2010):1.3, 1.5, 2.1, 2.2, 2.3, 6.1.1, 6.1, 6.2, 6.3, 7.1. Immunisation has prevented the deaths of hundreds of millions of people. Immunisation is the process of obtaining immune status through vaccination. Vaccines, which contain inactivated or weakened viruses or bacteria (or parts of them), stimulate the body s immune system to protect itself against subsequent infection or disease. 2 Public health benefits Immunisation has prevented the deaths of hundreds of millions of people. It is one of the greatest scientific advances. The public health benefits of immunisation include: reduction in illness, disability and death control, prevention and eradication of disease protection of both the individual and the community from vaccine preventable diseases (VPD) a cost effective health strategy. Infected individuals can travel anywhere in the world within 24 hours, so as long as a disease remains endemic in some parts of the world, it is important for vaccination programs to be maintained worldwide. Once global vaccination programs eliminate the infectious agent (as in the case of the smallpox virus), vaccination against that antigen is no longer necessary. 2 Although mass immunisation programs are aimed at all members of a community not everyone will become immunised due to medical reasons and/or personal choice. The percentage of non-immunised or under-immunised people can pose a public health threat and can put currently high vaccination levels at risk. National immunisation programs aim to vaccinate a significant portion of a population to provide a measure of protection for individuals who do not have immunity. This effect is known as herd immunity. Unvaccinated individuals are indirectly protected by vaccinated individuals, as the latter will not contract and transmit the disease to susceptible individuals. Since only a small fraction of the population can be left unvaccinated for this method to be effective, only those who cannot safely receive vaccines for reasons such as impaired immunity, failure to respond adequately to vaccination, or egg allergies should be left unimmunised. 3,4 54 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

55 inpharmation Immunisaton Pharmacist CPD Module number 235 Facts Behind the Fact Card People who are under-immunised have a gap in their immunisation schedule. It has been shown that when vaccination rates drop the re-emergence of some infectious diseases occur. Under-immunisation may be a result of a person s: attitudes, beliefs, and behaviours based around vaccine safety difficulty accessing healthcare services to receive vaccines and immunisation education socio-economic situation such as cultural differences, language problems, financial issues. The control of highly infectious diseases, such as measles, requires 95% of the population to be vaccinated to prevent the transmission of the disease. Diphtheria, a less infectious disease, requires a lower percentage of the population to be vaccinated and as a result there have been no cases of diphtheria in Australia since the 1970s. The pneumococcal vaccine which was introduced to protect children against diseases caused by the bacterium, Streptococcus pneumoniae, has also been shown to provide protection for susceptible unvaccinated elderly people due to a reduction in circulation of the bacterium in the community. 5 Therefore, protection afforded by immunisation is two-fold. Firstly, it protects the individual through direct vaccination. Secondly, when a large proportion of the population is immunised, there is a subsequent disease reduction in the unimmunised segment. National immunisation program To ensure immunisation rates remain at a high level, Australia has a comprehensive National Immunisation Program (NIP). The NIP Schedule includes mass childhood immunisation programs for hepatitis B, poliomyelitis, pertussis, diphtheria, tetanus, measles, mumps, rubella, chicken pox, gastroenteritis, pneumococcal infections, meningitis, epiglottis and cervical cancer. It also recognises the risk from influenza and Hepatitis A for at-risk adults. The NIP Schedule details recommended vaccines by age group that are provided free to eligible groups. Currently 16 vaccines are recommended. A person or group in the states and territories will choose a combination of vaccines from those listed on the Designated Vaccines list to best suit the needs of the geographic and demographic conditions in their region. It is important to refer to each state or territory for the most current, state-appropriate schedule. 1,6 See Table 1. Immunisation schedules are constantly being updated and developed in an attempt to combat emerging worldwide disease patterns. The latest additions to national immunisation schedules are: Aboriginal and Torres Strait Islander children living in the Northern Territory, Queensland, South Australia and Western Australia will receive a fourth dose of pneumococcal vaccine (Prevenar 13) which will be listed on the NIP from 1 October HPV vaccine (Gardasil) will be given to 12 and 13 year old boys through school-based programs under the National Immunisation Program from Year 9 boys will also be able to get the vaccine at school under a catch-up program for the next two years. 1 For further information on vaccination and to view the current NIP schedule go to Vaccines 2,7 Vaccines contain active components such as attenuated live viruses, inactivated viruses, modified or partial forms of the virus or bacteria or the toxin produced by the bacteria. The antigen in the vaccine is altered from its original form so it no longer causes disease but produces an immune response. Vaccines may also contain additional components such as preservatives, additives, adjuvants and traces of other components. See Table 2. Active components used in a vaccine are: Live viruses used in vaccines are weakened (or attenuated) limiting the virus ability to replicate and are able to induce an immune response without causing severe disease. The advantage of live, attenuated vaccines is that only one or two doses usually provide whole of life immunity. However, these vaccines cannot be given to people with severely impaired immunity, as a greatly weakened immune system may not be able to limit reproduction of the vaccine virus. Women receiving live viral vaccines Practice point 1 Discussing childhood immunisation with parents 4,12 It has been estimated that immunisation currently saves three million lives per year throughout the world while remaining one of the most cost effective health interventions. When immunisation rates in the community are very high the number of cases of certain diseases can be reduced. For example, Haemophilus influenzae type b (Hib) vaccine was introduced into the Australian NIP schedule for all children in In 1992, there were 560 cases of Hib disease notified but in 2006, only 22 cases were notified. Despite a very good record of effectiveness and safety, there are still people who have reservations about immunisation. To make informed decisions, parents need to understand the benefits and risks of vaccination, or not vaccinating, their children. Parents do not usually understand how immunisation protects the child, and the diseases are often not seen as serious. When discussing concerns about immunisation with parents or adults, it is important to recognise that a logical demonstration of the weaknesses in arguments against immunisation needs to be combined with listening and other good communication skills. Two useful resources to assist pharmacists in discussing immunisation issues with parents are Immunisation Myths & Realities, A Guide for Providers and Understanding childhood immunisation, accessible at Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 55

56 John Facts Bell says Behind the Fact Card inpharmation Immunisaton Pharmacist CPD Module number 235 Practice point 2 Onset, extent and duration of immunity 2 Immunity does not occur immediately after vaccination. Activation of the normal immune response takes approximately two weeks. Many vaccines require several booster doses to be given for full immune response to occur and, even when all the doses of a vaccine have been given, not everyone will be immune. Measles, mumps, rubella, tetanus, polio, hepatitis B and Hib vaccines protect more than 95% of children who have completed the recommended immunisation course. Three doses of whooping cough vaccine will protect about 85% of children immunised, and will reduce the severity of the disease in the other 15% of children if they do catch whooping cough. One dose of meningococcal C vaccine at 12 months of age will protect more than 90% of children immunised. 1,8 The protective effect of immunisation is not always lifelong. Some vaccines, such as tetanus, can last up to 30 years, then a booster dose may be required. (Note: A booster dose may be required earlier (e.g. after 10 years) in the presence of a tetanus prone wound.) Other vaccines, such as whooping cough, give protection for about five years after a full course. 1,8 A two-dose course of hepatitis A vaccine given 6 12 months apart is thought to give protection for about 20 years. 1,2 Related Fact Cards Childhood Immunisation Chickenpox Shingles Table 1. National Immunisation Program (NIP) Schedule (as at May 2012 )1,2 Age Vaccine Disease Birth Hepatitis B (hepb) a Hepatitis B 2, 4, and 6 months Hepatitis B (hepb) b Hepatitis B Diphtheria, tetanus and acellular pertussis infant/child formulation (DTPa) Diphtheria, tetanus and whooping cough Haemophilus influenzae type b (Hib) c,d Meningitis Epiglottitis Inactivated poliomyelitis (IPV) Polio Pneumococcal conjugate (13vPCV) Pneumococcal infections Rotavirus b Gastroenteritis 12 months Haemophilus influenzae type b (Hib) Meningitis Epiglottitis Measles, mumps and rubella (MMR) Measles, mumps and rubella Meningococcal C (MenCCV) Meningococcal infections 12 months at risk individuals Pneumococcal conjugate (13vPCV) f,g Pneumococcal infections Hepatitis B (HepB) h Hepatitis B months Hepatitis A (Aboriginal and Torres Strait Islander children in high risk areas) i Hepatitis A Pneumococcal conjugate(13vpcv) (12 18 months from 1 October 2012) (Aboriginal and Torres Strait Islander children in high risk areas) or Pneumococcal polysaccharide (23vPPV) (18-24 months)(aboriginal and Torres Strait Islander children in high-risk areas) Pneumococcal infections 18 months Varicella-zoster (VZV) Chicken pox 4 years Diphtheria, tetanus and whooping cough (acellular pertussis)(dtpa) Diphtheria, tetanus and whooping cough Measles, mumps and rubella (MMR) Measles, mumps and rubella Polio (inactivated poliomyelitis) (IPV) Polio Pneumococcal polysaccharide (23vPPV) (at risk individuals) f Pneumococcal infections years Hepatitis B (hepb) c Hepatitis B Varicella (VZV) d Chicken pox years Human papillomavirus (HPV) e Cervical cancer years Diphtheria, tetanus and whooping cough (acellular pertussis) adult/ adolescent formulation (dtpa) 15 years and over Influenza (Aboriginal and Torres Strait Islander people) Influenza Pneumococcal polysaccharide (23vPPV) (Aboriginal and Torres Strait Islander people medically at-risk) 50 years and over Pneumococcal polysaccharide (23vPPV) (Aboriginal and Torres Strait Islander people) Diphtheria, tetanus and whooping cough Pneumococcal infections Pneumococcal infections Pregnant women Influenza Influenza 65 years and over Influenza Influenza Pneumococcal polysaccharide (23vPPV) Pneumococcal infections a. Hepatitis B vaccine should be given to all infants as soon as practicable after birth. The greatest benefit is gained if given within 24 hours, and it must be given within seven days. b. Third dose of vaccine is dependent on the vaccine brand used. Contact State or Territory Health Department for details. c. Contact State or Territory Health Departments for details. d. These vaccines are for one cohort only within this age range, and should only be given if there is no prior history of disease or vaccination. Dose schedules may vary between jurisdictions. e. This vaccine is for one cohort only within this age range. Contact State or Territory Health Department for details. f. Medical at-risk children require a fourth dose of 13vPCV at 12 months of age, and a booster dose of 23vPPV at four years of age. g. Pneumococcal vaccination at 12 months for: children with medical conditions placing them at risk of serious complications; and all infants born at less than 28 weeks gestation. h. Hepatitis B vaccination at 12 months of age is for children born less than 32 weeks gestation or weigh less than 2,000 g at birth. i. Two doses of hepatitis A vaccine are required for Aboriginal and Torres Strait Islander children living in areas of high risk (Queensland, Northern Territory, Western Australia and South Australia). Contact State or Territory Health Department for details. 56 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

57 inpharmation Immunisaton Pharmacist CPD Module number 235 Facts Behind the Fact Card must be advised against falling pregnant within 28 days of vaccination. Inactivated viruses are inactivated by formaldehyde so the pathogenic effects are rendered inactive but the antigenicity is preserved. The virus is incapable of replication after vaccination but it is still recognised by the body s immune system. These vaccines can be given to people with impaired immunity. Several doses may need to be given to achieve long-term immunity, and persons with impaired immunity may not respond to even multiple doses. Part of the virus or bacteria is used in certain vaccines to induce immunity e.g. hepatitis B vaccine is composed of a protein from the surface of the virus, haemophilus influenzae type b (Hib) vaccine only the outer coating or polysaccharide is used and joined to a protein so that the immune system responds to it. These vaccines can be administered to people with weakened immunity, although, if the person s immune system is too weak, they may not develop a satisfactory immune response. Toxins produced by the bacteria are chemically inactivated to produce a vaccine that is known as a toxoid. E.g. diphtheria and tetanus-containing vaccines. Tetanus vaccination stimulates the production of antitoxin, which protects against the toxin produced by the organism. Having tetanus infection does not induce a long-term immune response and non-immune individuals who contract tetanus must be fully vaccinated to protect against future exposure. Adverse effects of immunisation 2,4,8,9 Common adverse effects following immunisation are generally mild and transient and treatment is not usually required. Examples include: pain, redness, swelling, itching or burning at the injection site for one to two days development of a small, hard nodule at the injection site, which may persist for some weeks or months low grade fever ( C) which may last up to two or three days. Practice point 3 Contraindications to vaccines 2,8 There are only two absolute contraindications applicable to all vaccines: a known anaphylactic sensitivity to any component of the relevant vaccine anaphylaxis following a previous dose of the relevant vaccine. Further contraindications to live attenuated vaccines are: immunosuppressed people regardless of whether the suppression is caused by disease or treatment adults treated with systemic corticosteroids in excess of 60 mg of prednisolone (or equivalent) per day (vaccination should be postponed until at least three months after treatment has stopped) pregnancy. For further explanation, see the Australian Immunisation Handbook 9th edition. If a child has an acute febrile illness (current temperature 38.5 C) the vaccination should be postponed for 2 3 days until the child is well. The following are NOT contraindications to any of the vaccines in the NIP Schedule: family history of any adverse events following immunisation family history of convulsions previous pertussis-like illness, measles, rubella, mumps or meningococcal infection prematurity (vaccination should not be postponed) neurological conditions including cerebral palsy and Down s syndrome contact with an infectious disease asthma, eczema, atopy, hay fever or snuffles treatment with antibiotics treatment with locally acting (inhaled or low-dose topical) steroids child s mother is pregnant child to be vaccinated is being breastfed woman to be vaccinated is breastfeeding history of neonatal jaundice low weight in an otherwise healthy child recent or imminent surgery. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 57

58 John Facts Bell says Behind the Fact Card inpharmation Immunisaton Pharmacist CPD Module number 235 Practice point 4 Late adverse effects of vaccines 2 Long term surveillance of vaccines is conducted to ensure un-anticipated adverse effects are detected. Through the systematic collection of data and analysis of reports, some vaccines have been shown to cause serious late events, although the rate is always hundreds to thousands times less frequent than the disease complication. For example: Approximately one in 1,000,000 doses of MMR vaccine among children causes acute encephalitis occurring 8 9 days after vaccination. In comparison, one in 500 cases of naturally-acquired measles results in severe acute encephalitis. 5 Vaccines containing diphtheria and tetanus have been implicated in causing brachial neuritis with an incidence of approximately one in 100,000 (adults). One additional case of Guillain-Barre syndrome has been detected in every one million people vaccinated against influenza. 5 Although late adverse effects have been reported following immunisation, there is strong epidemiological evidence that there is no causal association between: sudden infant death syndrome (SIDS) and any vaccine autism and MMR vaccine multiple sclerosis and hepatitis B vaccine inflammatory bowel disease (IBD) and MMR vaccine diabetes and Hib vaccine asthma and any vaccine. Table 2. Components of vaccines Active component of vaccines Attenuated live viruses Inactivated virus Part of the virus or bacterium Toxin produced by the bacteria (toxoid) 4, 8-11 Management strategies include: giving extra fluids to drink ensuring the child does not overheat holding a cold wet cloth against the injection site. Routine use of paracetamol at the time of vaccination is no longer recommended. Paracetamol may be required if an infant or child has a high fever following vaccination. The recommended dose in children less than 10 years is 15 mg/kg every 4 6 hours. Maximum daily dose for a medically unsupervised child is 60 mg/kg (not exceeding 4 g) daily for Example of vaccines Varicella, rotavirus and measles-mumps-rubella Poliomyelitis, influenza, hepatitis A Hepatitis B, Haemophilus influenzae type b, Human papillomavirus Diphtheria, tetanus up to 48 hours. For an adult and child over 10 years, the recommended dose is 0.5 1g every 4 6 hours with a maximum daily dose of 4 g. If a reaction is severe or persistent, the patient should be taken to a doctor, immunisation clinic or hospital. Other adverse effects can be vaccine specific. For example: 2,4 DTPa vaccine may cause crying, irritability and drowsiness. The booster dose (fourth dose) may cause swelling of the arm or thigh in approximately 2% of patients, which subsides within 2 7 days. IPV and HepB may cause myalgia (muscle aches). Hib vaccine may cause irritability, drowsiness, vomiting and prolonged crying. MMR vaccine may cause faint red rash (not infectious) about 1 3 weeks after vaccination. The rash is usually transient. Swelling of facial glands may occur three weeks after vaccination. Influenza vaccine may cause malaise, headache and myalgia lasting one or two days. MenCCV may cause irritability, anorexia, headache (more common in adolescent/adults). VZV may cause a mild pustular rash (2 5 lesions) at the injection site but it may cover other parts of the body, 5 26 days after vaccination. In rare cases, more serious adverse reactions to vaccination can occur. The most serious immediate reaction to vaccination is anaphylaxis. Most life-threatening adverse events begin within 10 minutes of vaccination. It is therefore recommended that patients remain in the surgery/clinic for at least 15 minutes following vaccination. In adults and older children, the most common immediate adverse event is fainting. Most faints following 58 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

59 inpharmation Immunisaton Pharmacist CPD Module number 235 Facts Behind the Fact Card immunisation occur within 5 30 minutes. Adults should be warned of the risk of driving or operating machinery after vaccination. Many serious adverse events can be prevented by screening. The screening process should ensure that each person to be vaccinated does not have a condition that either increases the risk of an adverse event or is a contraindication to vaccination. (See The Australian Immunisation Handbook 9th Edition for details of Pre-vaccination screening for conditions that may preclude vaccination.) For further information see The Australian Immunisation Handbook 9th Edition Adverse events following immunisation. Role of the pharmacist 15 Pharmacists should opportunistically remind customers, particularly those with young children, as well as those with chronic diseases, of the benefits of immunisation, encouraging them to participate in the nationally established programs that offer vaccines free of charge to eligible customers. If immunisation doses have been missed, pharmacists should refer customers to their local doctor or immunisation clinic for catch up vaccines to complete their immunisation schedule. The reduction in incidence of vaccine preventable disease (VPD) depends on maximal coverage of eligible people. Pharmacists can: establish and maintain a commitment to maintaining high vaccination rates. Customers should be encouraged to complete immunisation schedules address patient concerns about vaccines and immunisation. Concern about vaccine safety is a potential barrier to immunisation. Customers may be concerned about possible reactions or adverse effects of vaccines. Pharmacists can provide information on how adverse effects should be treated and who to contact if something of concern is observed Practice point 5 Seasonal influenza vaccine 3 Seasonal influenza vaccines normally contain three strains of virus; two current influenza A subtypes, H1N1 and H3N2, and influenza B, representing recently circulating viruses. The H1N1 influenza A strain (known as swine flu) is incorporated in the 2013 seasonal influenza vaccines. However, the current influenza vaccines will not give protection against the H5N1 (avian) virus. Although seasonal influenza vaccines contain minimal amounts of egg protein, they can be used in certain egg-sensitive individuals. Referral to a specialist immunologist is recommended in such cases, however. 5,6 It is important that people in at-risk groups continue to have annual influenza vaccines. If a child under the age of nine years is receiving the vaccine for the first time, they will require two doses at least one month apart. 2 Vaccination is best given in autumn; however, it can be given as early as February. Influenza vaccine can be administered concurrently with other vaccines, including pneumococcal polysaccharide vaccine and all the scheduled childhood vaccines. Annual influenza vaccination is recommended for the following groups: 13 all people aged 65 years and older Aboriginal and Torres Strait Islander people over 15 years of age children ( six months of age) and adults with chronic illnesses including: - heart conditions - lung / respiratory conditions including asthma - diabetes (and other chronic metabolic diseases) - kidney disease - impaired immunity - chronic neurological conditions including multiple sclerosis and seizure disorders - haemoglobinopathies (a range of genetically inherited disorders of red blood cell haemoglobin) - pregnant women - residents of nursing homes and other long-term care facilities. In addition, it is important that people who care for, or who are in close contact with, people who are at particular risk, also avoid spreading the infection. Annual influenza vaccination is also strongly recommended for travellers and people providing essential community services. The National Health and Medical Research Council (NHMRC) also recommends that influenza vaccination can be given to any person aged 6 months or more who wishes to reduce the chance of becoming ill with influenza. Influenza vaccination should be delayed when a person has a high fever or a moderately severe illness, but can generally be given once the illness is resolved. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 59

60 Immunisation strengthens the body s immune system its natural defence system helping it to resist particular infections. Immunisation is a simple, safe and effective way of protecting children (and adults) against disease. Vaccines are injections or oral doses of live but weakened virus, dead bacteria or virus, parts of bacteria or weakened bacterial toxins. Immunisation with a vaccine (vaccination) strengthens the body s immune system against a particular bacteria or virus, before contact with that microorganism. It gives people increased protection against serious and life-threatening infection. Chicken pox (varicella) a viral infection that causes an itchy, blistering skin rash and can lead to severe complications. It may reappear later in life as shingles. Child Health Diphtheria a bacterial infection that causes a membrane to grow in the throat, leading to breathing difficulties. It can also cause heart and nerve damage, and can lead to death. Haemophilus influenzae type B (Hib) a bacterial infection that can affect the brain, throat, lungs, joints or skin and can lead to death. It occurs mostly in children under 2 years. Hepatitis B a viral infection that affects the liver and can lead to liver failure or cancer. Human papillomavirus (HPV) a sexually transmitted viral infection that can lead to cervical cancer and genital warts. John Bell Counter says Connection inpharmation Immunisation Pharmacy assistant s education Module 235 Immunisation By Jill Malek This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed. Immunisation uses the body s natural defence mechanism to build resistance to specific infections. It is a simple, safe and effective way of protecting people against certain diseases. The risks of these diseases are far greater than the very small risks of immunisation. Immunisation not only protects individuals, but also the community as a whole, by increasing the general level of immunity and minimising the spread of infection. It is important for the public to be made aware immunisation save lives and prevents serious illness. Immunisations currently save around three million lives per year throughout the world. Childhood Immunisation Some infections that immunisation can prevent Self Care is a program of the Pharmaceutical Society of Australia. Self Care is committed to providing current and reliable health information. Related Fact Cards Childhood Immunisation Chickenpox Shingles If enough people in the community are immunised, infection can no longer be spread from person to person and the disease dies out altogether. This is how smallpox was eliminated from the world, and why polio has disappeared from many countries too. What is immunisation? Immunisation describes the process whereby people are protected against illness caused by infection with micro organisms by administering a vaccine. To cause immunity, a vaccine that the body recognises as foreign is given. This results in an immune response. The vaccine may be a whole killed organism, a weakened live organism, or a specific protein from an organism. When someone is injected with a vaccine their body produces an immune response in the same way that it would following exposure to a disease, but without them getting the disease. If the person comes in contact with the disease in the future, their body recognises the disease and is able to make an immune response fast enough to prevent them developing it. A number of immunisations are required in the first few years of a child s life to protect them from the most serious childhood infectious diseases. Young children s immune systems are not as developed as those of older children and adults. In the first months of life, a baby is protected from most infectious diseases by antibodies from their mother which they receive through the placenta and through breast milk. The baby s immune system needs to be activated or they will be at risk of serious infections. The protection received from the placenta and breast milk only lasts for a few months, so the first immunisations are given before these antibodies have gone. To ensure the immunisation rate remains at a high level in Australia the childhood National Immunisation Program (NIP) provides vaccines against 14 preventable infectious diseases. These diseases are: diphtheria, tetanus and pertussis (whooping cough) poliomyelitis (polio) measles, mumps and rubella (German measles) 60 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

61 inpharmation Immunisation Pharmacy assistant s education Module 235 Counter Connection meningitis and epiglottitis hepatitis B pneumococcal infections gastroenteritis chicken pox (varicella) meningococcal C infections. All of these diseases can cause serious complications and sometimes death. Combination vaccines are now available to protect against up to six different diseases in one vaccine. This has reduced the number of injections a child needs to become fully immunised. Vaccines against these diseases are provided free for all children in Australia. See Table 1 on page 6. Several other diseases can be prevented by vaccinating people who are at risk of infection, e.g. people with chronic diseases, travelling to other countries, working in certain occupations, or living in high risk areas. These diseases include: influenza cholera hepatitis A Japanese encephalitis tuberculosis (TB) typhoid yellow fever rabies. Effectiveness of vaccines The normal immune response takes about two weeks to work; therefore immunity does not occur immediately after vaccination. Many vaccines require several booster doses to produce full immunity and even when all the doses of a vaccine have been given, not everyone will be immune. Measles, mumps, rubella, tetanus, polio, hepatitis B and Hib vaccines protect more than 95% of children who are immunised. Whooping cough vaccine protects about 85% of children who are immunised, and will reduce the severity of the disease in the other 15% of children if they do catch whooping cough. Meningococcal C vaccine protects over 90% of children who are immunised. Immunity acquired through vaccination does not always last for life. Some vaccines, such as tetanus, can last up to 30 years, and then a booster dose may be required. (Note: A booster dose may be required earlier (e.g. after 10 years) in the presence of a tetanus prone wound.) Other vaccines, such as whooping cough, give protection for about five years after a full course. A two dose course of hepatitis A vaccine gives protection for about 20 years. For vaccines to provide maximum protection against infectious diseases, a person must be fully immunised. Most of the childhood vaccines are made up of a number of doses given at scheduled intervals. Full immunisation means that a person has had all the recommended doses of a vaccine e.g. polio has three doses at 2, 4 and 6 months. The importance of immunisation Immunisations currently save around three million lives per year throughout the world. They are also cost effective. When the immunisation rates in the community are very high, the number of cases of these diseases can be reduced. For example, Haemophilus influenzae type b (Hib) vaccine was introduced into the NIP Schedule for all children in In 1992, there were 560 cases of Hib disease but in 2006, only 22 cases were notified. Hepatitis B is a serious disease caused by a virus that affects the liver. Babies that get this disease may only have mild symptoms, or have no symptoms at all. Babies are at much higher risk than adults of becoming lifetime carriers of the virus. A carrier may then pass the virus on to other people. Up to 25% of hepatitis B carriers may develop liver cancer or liver failure later in life. Children now receive Hepatitis B vaccine at birth, 2, 4 and 6 months and a booster dose is given between years. Haemophilus influenzae type b (Hib) was the most frequent cause of meningitis (infection around the brain) and epiglottitis (swelling in the throat which can block breathing) in children under five years of age before the introduction of Hib vaccines in the early 1990s. It is not related in any way to influenza. Hib may also cause pneumonia, joint infection or infection of the tissue under the skin (cellulitis). Both meningitis and epiglottitis can develop quickly and if left untreated, can rapidly cause death. A full course of Hib vaccine is three doses given at 2, 4 and 6 months. Measles is a highly contagious viral illness causing fever, rash, runny nose, cough and conjunctivitis (infection of the eyes). Complications following measles can be very dangerous, and pneumonia occurs in 4% of cases. Approximately one child in every 500 with measles will develop encephalitis (inflammation of the brain). For every 10 of these children, one will die and up to four will have permanent brain damage. A very serious but rare illness called subacute sclerosing panencephalitis (SSPE), which rapidly destroys the brain and always results in death, can occur in children several years after a measles infection. Measles is still a leading cause of death worldwide; in 1998, it caused 888,000 deaths. Measles vaccine is combined with mumps and rubella vaccine and is given to children at 12 months and four years. Tetanus is an often fatal disease caused by bacteria present in soil and manure. The bacteria enter the body through a wound that may be as small as a pinprick and attack the nervous system, causing severe muscle spasms, first felt in the neck and jaw muscles (lockjaw). The effects spread, causing breathing difficulties, painful convulsions and abnormal heart rhythms. Older people need to have a tetanus vaccine booster at around 50 years to make sure they are fully protected against tetanus. Pertussis (whooping cough) is a highly contagious disease causing severe coughing spasms. Between these spasms, the child gasps for breath causing the characteristic whoop sound. The cough may last for months. Whooping cough is most serious in babies under 12 months of age, often requiring admission to hospital. Complications include convulsions, pneumonia, coma, encephalitis, permanent brain damage and long term lung damage. Around one in every 200 children less than six months of age who catches whooping cough will die. Carers of very young babies and women planning a pregnancy should be encouraged to have the whooping cough vaccine to make sure they don t spread the infection. Mumps is a viral disease that causes fever, headache and inflammation of the salivary glands. Five in every 1,000 patients with mumps can develop encephalitis. It can also cause permanent deafness. About one in five adolescent or adult males who contract mumps will develop painful inflammation and swelling of the testes, and this may sometimes cause infertility. Mumps vaccines Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 61

62 John Bell Counter says Connection inpharmation Immunisation Pharmacy assistant s education Module 235 are given in two doses at 12 months and four years of age. Diphtheria can cause a membrane to grow around the inside of the throat which can lead to difficulty in swallowing, breathlessness and suffocation. A powerful toxin is produced by the diphtheria bacteria and this may spread throughout the body, causing serious complications such as paralysis and heart failure. About 7% of people who contract diphtheria die from it. There are four doses of diphtheria vaccine and all must be given to ensure full immunisation. The other common childhood diseases can also cause serious complications and, sometimes, death. Polio can affect the nerves and cause permanent paralysis; it can paralyse the breathing and swallowing muscles, leading to death. Pneumococcal disease can cause meningitis, blood poisoning (septicaemia) and pneumonia. Rubella, if contracted during the first 20 weeks of pregnancy, can cause abnormalities in the newborn baby, such as deafness, blindness, heart defects and mental retardation. Meningococcal disease can rapidly cause meningitis and/or blood poisoning (septicaemia), which may be fatal. Chickenpox in children with other medical conditions may cause lifethreatening complications such as pneumonia or encephalitis. If a woman develops chickenpox during pregnancy, there is a small chance of damage to the unborn baby and if she is close to delivery, the chicken pox may result in severe infection in the newborn baby. Children and immunisation Some children may have a fear of needles. To help reduce pain and distress in a child receiving a vaccination, the skin may be numbed by applying a local anaesthetic before the injection. EMLA, is a local anaesthetic patch or cream that can be used prior to the vaccination. Side effects of immunisation Common side effects following immunisation are generally mild and short lived and treatment is not usually required. Examples include: pain, redness, swelling, itching or burning at the injection site a small, hard lump that may develop at the injection site and remain for some weeks or months low grade fever ( C). Some vaccines may have additional side effects such as: DTPa and Hib may cause crying, irritability and drowsiness booster doses of DTPa may cause extensive swelling of the arm or thigh, which usually goes away within a few days MMR vaccine may cause fever, a faint red rash (not infectious), runny nose, cough, puffy eyes, drowsiness and swelling of salivary glands seven to 10 days after injection influenza and MenCCV vaccines may cause headache five to 26 days after a varicella vaccine, a few chickenpox like spots may appear at the injection site and sometimes on other parts of the body IPV and influenza vaccines may cause aching muscles (myalgia). Occasionally a patient will have a more serious reaction to a vaccination, such as fainting. The most serious reaction to vaccination is anaphylaxis (a possibly fatal hypersensitivity reaction). Because serious reactions usually begin within about 10 minutes of receiving the vaccination, patients are advised to stay in the surgery/ clinic/pharmacy for at least 15 minutes after being vaccinated. Some people have suggested that vaccinations can cause certain disorders, such as autism, asthma and diabetes, or contribute to the risk of sudden infant death syndrome (SIDS). These theories have been investigated and no evidence has been found to indicate that they are true. Managing side effects Reactions usually do not last for more than 48 hours, and the following strategies may help to relieve symptoms: Place a cold cloth on the injection site if it is red or swollen (do not place ice directly onto the skin). Give extra fluids (breast milk, formula or water). Do not allow babies to become overheated e.g. by overdressing. Many children need extra cuddling and comforting for a day or so. If a reaction is severe or persistent, the child should be taken to a doctor or hospital. Paracetamol Routine use of paracetamol at the time of vaccination is no longer recommended and should be only given if an infant or child has a high fever following vaccination. The recommended dose in children is 15 mg/kg every four to six hours. Paracetamol should be given strictly according to the dose and frequency instructions on the label. When to refer Depending on the request of the customer, you may need to refer them to the pharmacist. Using the WHAT STOP GO or CARERS protocols will help to guide your questioning. If the customer requests any of the following, refer them to the pharmacist: information about immunisation, certain vaccines or their eligibility to receive an influenza immunisation information about and management of adverse effects of immunisation management of symptoms relating to adverse effects of immunisation such as a red and swollen area at the injection site or raised temperature. If the pharmacy is conducting and immunisation service, you may be asked for information about this. Such as: cost to customer and date and time service will be provided. inpharmation March 2013 I Pharmaceutical Society of Australia Ltd. 62 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

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64 Staff training presentation What you should know The difference between immunisation and vaccination Benefits of immunisation National Immunisation Program Myths and realities about immunisation Influenza vaccine and its benefit and effectiveness Your role 2 Immunisation and vaccination Immunisation process of making a person immune or resistant to infectious disease Vaccination administration of a vaccine Vaccine material used for immunisation inactivated or weakened virus or bacteria interacts with the body s immune system We often hear the words vaccination and immunisation and use them interchangeably but they do not mean exactly the same thing. Immunisation is the process whereby a person is made immune or resistant to an infectious disease. Immunisation is the obtaining of immune status through vaccination. Vaccination is the administration of a vaccine. Vaccine refers to the material used for immunisation. It contains inactivated or weakened viruses or bacteria (or parts of them), provide immunity by interacting with the body s immune system which is actively stimulated into developing the antibodies needed to fight infection (or respond to immunisation) by an antigen (toxin or foreign substance). Benefits of immunisation Protects the individual the community Reasons reduces illness, disability and death controls, prevents and eradicates disease cost effective health strategy accessible health strategy Immunisation offers benefits to the community on two levels. Firstly, it offers protection to the individual from vaccine-preventable diseases such as influenza, measles, hepatitis B through direct vaccination. Secondly, through large scale immunisation programs, it offers benefits to the entire community by reducing the potential exposure to vaccine preventable diseases by people who are unimmunised and susceptible to infection. Immunisation s many public health benefits include: reduction in illness, disability and death control, prevention and eradication of disease protection of both the individual and the community from vaccine preventable diseases (VPD) a cost effective health strategy an accessible health strategy 64 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

65 National Immunisation Program To ensure the immunisation rate remains at a high level, Australia has implemented long-standing mass childhood immunisation programs for poliomyelitis, pertussis, diphtheria, tetanus, measles, mumps, rubella, meningitis, gastroenteritis, hepatitis B chicken pox and cervical cancer as well as influenza and hepatitis A at-risk adults. This is known as the National Immunisation Program (NIP) which has a schedule detailing recommended vaccines by age group. These vaccines are provided free to the groups listed on the schedule. Currently 16 vaccines are recommended. It is updated regularly. For a person to be fully immunised they must receive all the vaccines in the schedule. For example for a child to be immune against chickenpox they must receive a vaccine at 18 months and another between 10 and 13 years. Under immunisation Individual immunisation levels are incomplete Reasons for under immunisation: vaccine safety concerns difficulty accessing healthcare services socioeconomic situation Can put high community vaccination levels at risk Outbreaks of vaccine-preventable diseases, such as measles which has occurred recently, can occur if people are not completely immunised that is they have not receive all or any of the vaccines to protect them from a disease. People who are underimmunised have a gap in their immunisation schedule. There are many reasons why a person may not be fully immunised. It may be due to a person s: attitudes, beliefs, and behaviours based around vaccine safety difficulty accessing healthcare services to receive vaccines and immunisation education socioeconomic situation such as cultural differences, language problems, financial issues. Pharmacists and pharmacy staff should remind consumers, particularly those with young children, as well as those with chronic diseases, of the benefit of immunisation and encourage them to participate in the nationally established programs which offer vaccines free of charge to eligible consumers. If immunisation doses have been missed, refer consumers to their local doctor for catch up vaccines so they can achieve maximum protection. Missing out on immunisation Family unit consisting of: parents under 25 years a single parent more than one child parents who are unemployed, on low income or with very high or very low education levels Migrant families Families who move frequently Young adults Healthy adults People in rural and urban areas In the pharmacy, you may be able to identify consumers who may be missing out on immunisation. Such groups may include: families with young parents (under age 25 years) single-parent families and families with more than one child families where the parents are unemployed, on low incomes or have very high or very low education levels migrant families (particularly in the first years of their arrival in Australia, or if a language other than English is spoken at home) families who move frequently young adults and healthy adults who may not appreciate the need for immunisation people in rural and urban areas. Pharmacy staff can identify these groups who are typically under-immunised or non immunisation and give additional education about immunisation and reinforce the importance of immunisation in protecting the whole community from certain disease. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 65

66 Effectiveness of vaccines No vaccine is 100% effective Risk from disease is much higher than risk from vaccine Depends on age of the person receiving the vaccine person s ability to form an immune response similarity between circulating virus strains and the vaccine Consumers may ask how effective is a vaccine in preventing disease. The answer is that no vaccine is 100% effective and although vaccines may cause some adverse effects such as an allergic reaction, the risk of a vaccine causing serious harm or death is extremely small. The effectiveness of vaccine depends mainly on: the age of the person receiving the vaccine if the person is able to develop an immune response after receiving the vaccine how closely the virus strains in the vaccine match those circulating in the community. Myths and realities about vaccines Vaccines aren t safe Children get too many vaccines Adults don t need vaccines My child has a cold, so they shouldn t get immunised Vaccines have too many side effects Immunisation causes autism 66 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. There are many myths about vaccines. Pharmacy staff may need to need to discuss these myths with consumers and provide accurate and current information about vaccines. Consumers may say the following. Vaccines aren t safe. No vaccine is 100% safe. All vaccines currently available in Australia are tested and approved for use by the Therapeutic Goods Administration. In addition, the safety of vaccines is monitored once they are in use, by the Adverse Drug Reactions Advisory Committee (ADRAC) and other organisations. Vaccines may cause side effects such as redness at the injection site and a possibly a feeling of unwellness. These symptoms are usually quickly resolved. Children get too many immunisations National immunization schedules are designed to provide protection at the earliest possible time against serious diseases that may affect children early in life. Due to the immune system in a young child being not fully developed they are more susceptible to infection. Therefore, more doses of vaccine are needed. Although a baby receives antibodies from their mother and through breast milk, these are not long lasting and the benefit decreases. Adults don t need vaccines If fully immunised as children then there are some vaccines that adults do not need to have again, however there are some that require adults to have booster vaccines and some like the influenza vaccine change annually so that an annual vaccine is required to give the highest possible level of immunity.my child has a cold so shouldn t get immunised A child who has a runny nose, but is not ill can be immunised, as can a child who is on antibiotics and obviously recovering from an illness. If a child is sick with a high temperature (over 38ºC) then immunisation should be postponed until the child is recovering. Vaccines have too many side effects All vaccines cause an immune response. Some of these responses can include a mild fever and headache, amounting to flu-like symptoms. Redness, soreness and swelling at the site of an injection may also occur but most resolve quickly. Immunisation and autism Some researchers have proposed that vaccinations can cause certain disorders, such as autism and diabetes, or contribute to the risk of sudden unexpected death in infancy (SUDI), which includes sudden infant death syndrome (SIDS) and fatal sleep accidents. These theories have been extensively investigated and dismissed. Immunisation reactions are generally mild and resolve by themselves without needing medical treatment. Reactions may include fever and soreness at the injection site. Serious immunisation reactions are exceptionally rare.

67 Influenza vaccine 3 strains of virus swine flu (H1N1) is included 2 weeks for protection to develop Require yearly vaccine Available free on NIP schedule for certain groups Myth: I can get the flu from the vaccine. Influenza vaccines normally contain three strains (or types) of viruses, 2 current influenza A subtypes, H1 and H3, and influenza B, representing recently circulating viruses including the H1N1 swine flu. It takes up to 2 weeks for protection to develop. Since the viruses are constantly changing, the consumer must have an influenza vaccine each year to make sure they are immunised against the season s current influenza strains. Seasonal influenza vaccines contain minimal amounts of egg protein and they can be used in certain egg-sensitive individuals. However, it is recommended that these people are referred to a specialist immunologist. Annual influenza vaccination is provided free under the NIP schedule for people who are most at-risk of developing influenza. Those people are: all people over 65 years of age Aboriginal and Torres Strait Islander people over 15 years of age children with underlying medical conditions to receive annual influenza vaccination pregnant women. Myth buster: Influenza vaccine does not contain any live viruses and therefore cannot cause the illness. The vaccines used are either split-virus or inactivated vaccines, which only contain theb surface structures of the virus, not infectious particles. Benefits of influenza vaccine Protects individual against influenza Reduces the chance of spreading influenza to others the number of deaths and hospital admissions due to influenza the risk of complications from influenza in at-risk people illness in healthy people workplace absenteeism Consumers may be unaware of the benefits of having an influenza vaccine. They may be healthy and very rarely get sick. They may say they don t need to have one. Here are some influenza facts: Influenza is extremely contagious and is easily spread by coughing, sneezing and nasal secretions. So it is easy to catch. Getting vaccinated against influenza protects the individual from influenza and reduces the risk of spreading influenza to others. Outbreaks of influenza occur every year usually starting in autumn and vary from mild random outbreaks to serious epidemics; it is estimated that between 5 and 20% of the population may be infected annually. In Australia, there were 101 influenza-related deaths reported between 2002 and 2005 and over 9000 hospitalisations and it is likely that influenza notifications are underestimated. Annual vaccination is the single most effective measure to prevent influenza. Influenza poses the most risk of complications to those with pre-existing medical conditions, such as chronic lung and heart disease, the elderly and pregnant women. People with a chronic disease have a 40 times increased risk of death from influenza yet only 42 per cent of this at risk group under 65 years of age are being vaccinated annually. Healthy people can also get influenza with illness due to influenza accounting for 10 per cent of all workplace absenteeism. Less than 50 per cent of healthcare workers, who are at a greater risk of contracting and spreading influenza, are being vaccinated against influenza annually. When there is a good match between the influenza strains in the vaccine and those causing current disease, the vaccine can prevent illness in about 70 90% of healthy children and adults. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 67

68 In-pharmacy influenza vaccine service Conducted in-pharmacy Vaccine administered by a trained immuniser Pharmacist unable to provide vaccinations Pre-vaccine screening Require consumer consent Provided in a private screened area Wait 15-minutes after vaccine Provide information PSA immunisation services in pharmacy - guidelines Many pharmacies are starting to offer seasonal influenza vaccines services in the pharmacy. An in-pharmacy influenza vaccine service: Vaccine administered by a trained immuniser - Influenza vaccines offered in Australian pharmacies are provided by a trained immuniser, usually a nurse practitioner. Pharmacist unable to provide vaccinations - Currently Australian state legislation prevents pharmacists from giving vaccinations. Pre-vaccine screening before a consumer can receive a vaccine, they must be screened to determine the person s medical fitness to receive the vaccine. See the PSA pre-vaccine screening guide. Require consumer consent the consumer must sign a consent form before having the vaccine after they have received information about the risks and benefits of vaccination and the risk of vaccine-preventable diseases. Provided in a private screened area the vaccine must be given in a private area that is screened from the main pharmacy area. Wait 15-minutes after vaccine after the vaccine, the consumer is required to wait 15 minutes in case they have any reaction to the vaccine. Provide information consumers should be provided with information about the influenza vaccine as well as how to treat any possible side effects to the vaccine. For a reference guide to the influenza vaccine service refer to PSA immunisation services in pharmacy guidelines Immunisation your role Maintain a commitment to immunisation Answer consumer concerns vaccine safety reactions and side effects current immunisation issues Provide consumers with educational material Identify high-risk individuals Collaborate with other healthcare providers Pharmacists and pharmacy staff play an important role in reducing the impact of vaccine-preventable diseases in the community. All pharmacy staff can: establish and maintain a commitment to maintaining high vaccination rates in the community. Consumers should be encouraged to complete immunisation schedules. answer patient concerns about vaccines and immunisation. Concern about vaccine safety is a potential barrier to immunisation. Consumers may be concerned about possible reactions or side effects of vaccines. Pharmacy staff can provide information on how they should treat side effects and who to contact if they observe something they are concerned about. provide parents with educational materials and/or direct them to reputable immunisation websites identifying individuals (e.g. through MedsCheck, HMRs) who are at high risk for certain illnesses such as influenza. Such interventions can have a significant impact on a person s decision to be immunised. work collaboratively with other health care professional by holding clinics where another healthcare professional, usually a nurse immuniser, administers the vaccine. 68 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

69 Community group presentation Immunisation and vaccination Immunisation process of making a person immune or resistant to infectious disease Vaccination administration of a vaccine Vaccine interacts with the body s immune system We often hear the words vaccination and immunisation and use them interchangeably but they do not mean exactly the same thing. Immunisation is the process whereby a person is made immune or resistant to an infectious disease. It is a simple and effective way of protecting children from serious diseases. It not only helps protect individuals, it also protects the broader community by minimising the spread of disease. Vaccination is the administration of a vaccine. Vaccines work by triggering the immune system to fight against certain diseases. If a vaccinated person comes in contact with these diseases, their immune system is able to respond more effectively, preventing the disease developing or greatly reducing its severity. Benefits of immunisation Protects the individual the community Reasons reduces illness, disability and death controls, prevents and eradicates disease cost effective health strategy accessible health strategy Immunisation offers benefits to the community on two levels. Firstly, it offers protection to the individual from vaccine preventable diseases such as influenza, measles, hepatitis B through direct vaccination. Secondly, through large scale immunisation programs, it offers benefits to the entire community by reducing the potential exposure to these vaccine preventable diseases of people who are unimmunised and susceptible to infection. Immunisation s many public health benefits include: reduction in illness, disability and death control, prevention and eradication of disease protection of both the individual and the community from vaccine preventable diseases (VPD) a cost effective health strategy an accessible health strategy Childhood vaccines Whooping cough (pertussis) Measles German measles (rubella) Meningococcal C Pneumococcal disease Chickenpox (varicella) Tetanus Mumps Polio Diphtheria Rotavirus Hepatitis 4 All children are encouraged to be immunised against many serious childhood diseases including: Whooping cough (pertussis) Tetanus Measles Mumps German measles (rubella) Polio meningococcal C diphtheria Pneumococcal disease Rotavirus Chickenpox (varicella) Hepatitis These diseases can cause hospitalisation, serious ongoing health conditions (including cancer, brain damage and deafness) and are sometimes fatal. High immunisation rates in the community have led to many of these diseases becoming rare such as diphtheria and polio. However, some of these diseases still exist. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 69

70 Under immunisation Individual immunisation levels are incomplete Reasons for under immunisation: vaccine safety concerns health access problems socioeconomic situation Can put community high vaccination levels at risk Outbreaks of vaccine-preventable diseases, such as measles which has occurred recently, can occur if people are not completely immunised that is they have not receive all or any of the vaccines to protect them from a disease. People who are underimmunised have a gap in their immunisation schedule. There are many reasons why a person may not be fully immunised. It may be due to a person s or their carer s: attitudes, beliefs, and behaviours based around vaccine safety difficulty accessing healthcare services to receive vaccines and immunisation education socioeconomic situation such as cultural differences, language problems, financial issues. National Immunisation Program The National Immunisation Program Schedule recommends certain vaccinations at certain times. These vaccines are available free of charge for all Australian children. Childhood immunisations are recommended at birth, two months, four months, six months, 12 months, 18 months and four years. Immunisation continues with school based programs between 10 and 17 years. For a person to be fully immunised they must receive all the vaccines in the schedule. For example for a child to be immune against chickenpox they must receive a vaccine at 18 months and another between 10 and 13 years. Adult vaccines Depends on: age lifestyle medical conditions travel plans workplaces NIP for special groups influenza pneumococcal Vaccines for adults are just as important as for children in protecting adults from certain diseases. The vaccines you need as an adult depend on everything from your age and lifestyle to high-risk medical conditions, travel plans, and which vaccines you ve had in the past. Please discuss your vaccine needs with your doctor Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

71 Effectiveness of vaccines No vaccine is 100% effective Risk from disease is much higher than risk from vaccine Depends on age of the person receiving the vaccine person s ability to form an immune response similarity between circulating virus strains and the vaccine Consumers may ask how effective is a vaccine in preventing disease. The answer is that no vaccine is 100% effective and although vaccines may cause some side effects such as severe allergic reaction, the risk of a vaccine causing serious harm or death is extremely small. The normal immune response takes about two weeks to work; therefore immunity does not occur immediately after vaccination. For vaccines to be fully effective and to achieve maximum protection against infectious diseases, a person must be fully immunised. Full immunisation means that they have had all the doses of a vaccine e.g. polio has three doses at 2, 4 and 6 months. Most of the childhood vaccines are made up of a number of doses given at scheduled intervals. Children must receive all the doses to be fully protected against the disease. The effectiveness of vaccine depends mainly on: the age of the person receiving the vaccine if the person is able to develop an immune response after receiving the vaccine how closely the virus strains in the vaccine match those circulating in the community. There are many myths about vaccines. Let s look at a few of the common myths. Myths and realities Vaccines aren t safe Children get too many vaccines Adults don t need vaccines My child has a cold, so they shouldn t get immunised Vaccines have too many side effects Immunisation causes autism Vaccines aren t safe. No vaccines is 100% safe. All vaccines currently available in Australia are tested and approved for use by the Therapeutic Goods Administration. In addition, the safety of vaccines is monitored once they are in use, by the Adverse Drug Reactions Advisory Committee (ADRAC) and other organisations. Vaccines may cause side effects such as redness at the injection site and possibly a feeling of unwellness. These symptoms are usually quickly resolved. Children get too many immunisations National immunization schedules are designed to provide protection at the earliest possible time against serious diseases that may affect children early in life. Due to the immune system in a young child being not fully developed they are more susceptible to infection. Therefore, more doses of vaccine are needed. Although a baby receives antibodies from their mother and through breast milk, these are not long lasting and the benefit decreases with time. Adults don t need vaccines Vaccination is just as important for adults as it is for children, and yet many adults are not optimally vaccinated. The vaccines you need as an adult depend on everything from your age and lifestyle to high-risk medical conditions, travel plans, and which vaccines you have had in the past. My child has a cold so shouldn t get immunised A child who has a runny nose, but is not ill can be immunised, as can a child who is on antibiotics and obviously recovering from an illness. If a child is sick with a high temperature (over 38ºC) then immunisation should be postponed until the child is recovering. Vaccines have too many side effects All vaccines cause an immune response. Some of these responses can include a mild fever and headache, amounting to flu-like symptoms. Redness, soreness and swelling at the site of an injection may also occur but most resolve quickly. Immunisation and autism Some researchers have proposed that vaccinations can cause certain disorders, such as autism and diabetes, or contribute to the risk of sudden unexpected death in infancy (SUDI), which includes sudden infant death syndrome (SIDS) and fatal sleep accidents. These theories have been extensively investigated and dismissed. Immunisation reactions are generally mild and resolve by themselves without needing medical treatment. Reactions may include fever and soreness at the injection site. Serious immunisation reactions are exceptionally rare. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 71

72 Homeopathy and vaccination Homeopathic vaccines made by diluting disease, tissue or plant extracts claim to reduce the incidence or severity of disease no scientific basis to claims Australian Register of Homeopaths advises people to receive conventional vaccines Several homoeopathic substances marketed as vaccines are available. Most of these preparations are made by repeatedly diluting disease, tissue or plant extracts. Homoeopathic immunisation programs consist of a number of different oral preparations which are supposed to reduce the incidence or severity of childhood diseases such as pertussis (whooping cough), tetanus, diphtheria, measles, mumps and rubella (German measles). There is no scientific basis to support the use of any homoeopathic preparation in preventing diseases targeted by conventional vaccines. Australian Register of Homoeopaths recommend that people should receive conventional immunisations unless a medical condition precludes this. Although homoeopathic preparations and schedules have been developed claiming to prevent childhood infectious diseases such as pertussis (whooping cough), tetanus, diphtheria, measles, mumps and rubella (German measles), many homoeopaths appear to support the need for children to be vaccinated conventionally. Homeopathy Side effects and vaccination Homeopathic Generally mild vaccines and short-lived Treatment made by diluting not required disease, tissue or plant extracts Examples: claim to reduce the incidence or severity of disease at injection site no scientific basis to claims pain, redness, itching Australian small, Register hard lump of Homeopaths advises people to receive low conventional grade fever vaccines Stay in the surgery/clinic for 15 minutes after being vaccinated 11 Vaccines may cause some side effects such as severe allergic reaction, the risk of a vaccine causing serious harm or death is extremely small. Common side effects following immunisation are generally mild and short-lived and treatment is not usually required. Examples include: pain, redness, swelling, itching or burning at the injection site. A small, hard lump may develop at the injection site and remain for some weeks or months. Low grade fever ( C) Occasionally a patient will have a more serious reaction to a vaccination, such as fainting. The most serious reaction to vaccination is anaphylaxis (a possibly fatal hypersensitivity reaction). Because serious reactions usually begin within about 10 minutes of receiving the vaccination, patients are advised to stay in the surgery/clinic/ pharmacy for at least 15 minutes after being vaccinated. Some vaccines may have additional side effects. The doctor or nurse immuniser will talk to you about these vaccine-specific side effects. Managing side effects Relieve symptoms: Cold cloth at injection site Give extra fluids Keep babies cool Extra comforting Paracetamol only use if there is a high fever give exactly according to the label recommended dose: 15mg/kg every 4-6 hours See a doctor or go to hospital if the reaction to the vaccine is severe 12 Reactions usually do not last for more than 48 hours, and the following strategies may help to relieve symptoms: Place a cold cloth on the injection site if it is red or swollen (do not place ice directly onto the skin). Give extra fluids (breast milk, formula or water). Do not allow babies to become overheated e.g. by overdressing. Many children need extra cuddling and comforting for a day or so. If a reaction is severe or persistent, the child should be taken to a doctor or hospital. Paracetamol: Routine use of paracetamol at the time of vaccination is no longer recommended and should be only given if an infant or child has a high fever following vaccination. The recommended dose in children is 15mg/kg every four to six hours. Paracetamol should be given strictly according to the dose and frequency instructions on the label. 72 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

73 Pharmacist s role Answer your concerns and questions vaccine safety reactions and side effects current immunisation issues Provide you with educational material Your pharmacist is here to assist by answering your questions and concrens and providing you with information so that you can make informed choices. NB: Pharmacists and pharmacy staff play an important role in reducing the impact of vaccine-preventable diseases in the community. All pharmacy staff : establish and maintain a commitment to maintaining high vaccination rates in the community by encouraging consumers to complete immunisation schedules. answer questions about vaccines and immunisation. Concern about vaccine safety is a potential barrier to immunisation. Consumers may be concerned about possible reactions or side effects of vaccines. Pharmacy staff can provide information on how they should treat side effects and who to contact if they observe something they are concerned about. provide parents with educational materials and/or direct them to reputable immunisation websites talk with other health care providers such as nurse immunisers, doctors and local health clinics about current vaccines. Resources - consumers Listed on the slide are reference sources about immunisation that you can access on the internet. They are reputable sites that contain current information on vaccines and immunisation. Australian Immunisation Handbook 9 th edition Immunise Australia Program Better Health Channel National Prescribing Service Healthinsite All state health services Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 73

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75 ACTION Tools 4 Available for download from the Tools section.

76 Guide to documenting Group 3 CPD credits This guide is designed to help you understand the concept of Group 3 CPD credits. It is accompanied by the PSA Group 3 CPD Recording Template, which is where you can record your Group 3 CPD information. Introduction Group 3 CPD credits are defined as quality or practice improvement facilitated credits. 1 The following diagram details processes involved in gaining all types of CPD credits. Group 3 credits are obtained when an assessment of existing practice (as an individual or within a pharmacy practice), and the needs and barriers to changes in this practice is undertaken prior to the development of a particular activity. As a result, the activity addresses identified learning needs with a reflection post-activity to evaluate practice change or outcomes resulting from the activity. Such an activity will likely extend over a number of weeks or months. 1 Group 1 Information accessed (without assessment) To self assess against the Competency Standards you will need to: Identify the competencies required for your role or service. Make an honest self assessment of where improvements could be made to your practice within the required competencies. Document required learning needs and how they were identified. Identify learning activities to address gaps or make improvements to your practice. Learning needs can be identified outside of self-assessment against the Competency Standards, but you will need to document how these learning needs were identified. Examples of how to document this are provided in the tables below: Part A. Learning needs identified: Example 1 Area of need How did you identify this as being an area of need? Information accessed through an activity One CPD credit per hour for the activity Group 2 Knowledge or skills improved (with assessment) Information accessed through an activity Two CPD credits per hour for the activity Group 3 Quality or practice improvement facilitated Structured reflection on (or self-assesment of) practice to identity learning needs Information accessed through an activity Three CPD credits per hour for the activity Demonstration of knowledge or skills gained eg. through succesful completion of assessment, role play etc Demonstration of knowledge or skills gained eg. through succesful completion of assessment, role play etc Reflection on (or self-assessment of) practice to identify learning needs Application in practice and evaluation to reflect on practice improvement and outcomes relating to activity The Pharmacy Board of Australia s Continuing Professional Development Registration Standard states that Pharmacists will be expected to self assess their individual needs with reference to the 2010 Competency Standards for Pharmacists in Australia. Performance management need to develop a complaints management process, and a standard performance review process Supervise personnel need to improve delegation of tasks and how I communicate Example 2 Area of need Implementation of a diabetes MedsCheck service in the pharmacy Through self assessment using competency standards (3.2) Identified through staff survey feedback was that I could improve in this area How did you identify this as being an area of need? Many patients are presenting at the pharmacy with complex and unmet needs in relation to their diabetes medication and management. Implementing a service where patients can book a consultation to discuss this will allow the pharmacist the time to spend with patients and facilitate better health outcomes and may allow the pharmacy to record certain PPIs. PSA Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

77 Guide to documenting Group 3 CPD credits Further resources: Using standards to guide your CPD Competency Standards Framework for Pharmacists in Australia. Professional Practice Standards Version 4. Information accessed through an activity and demonstration of knowledge In this section, you are required to describe what you will actually do (your strategies and learning activities you will undertake) to improve upon your identified area of need and make an impact and change to your practice. In this section of the template, record what learning you will engage in to make changes/improvements to practice. The Pharmacy Board s Guidelines on Continuing Professional Development state that Group 3 credit learning activities will likely extend over a number of weeks or months 1, so you may choose to undertake a series of activities over a period of time. As you complete each activity, record the date of completion and the number of hours the activity required. Examples of the kind of activities that you may choose to participate in to meet learning needs: face-to-face workshop conferences lectures online presentation podcast webinar journal articles with assessment courses. Examples of how this could be documented are provided in the tables below: Part B. CPD to address learning needs: Example 1 CPD activity Performance development training course: au/performance-management.htm Online module on communication for managers communicationideas.com/manageremployee-communication.html> Example 2 CPD activity Attended lecture on managing type 2 diabetes refresher Attended MedsCheck workshop Prepared and delivered presentation about the diabetes and the diabetes MedsCheck service to pharmacy staff Date Completed 2 November November 2012 Date Completed 17 August September September 2012 Time taken (hours) Time taken (hours) 1.5 Evaluate and reflect on changes to your practice After completing the activities you identified in Part B, complete a follow-up evaluation to identify what impact this learning has had on your practice and the changes/improvements that you have made as a result of this process. You will need to leave an appropriate amount of time between completing the CPD activities and evaluating outcomes. You can evaluate the impact on your practice in a number of ways (e.g. provide patients or staff with evaluation questionnaires, measure tangible goals). 5 6 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 77

78 Guide to documenting Group 3 CPD credits Examples of how this could be documented are provided in the tables below: Part C: Evaluate and reflect on changes to your practice Upon evaluation, there may be more areas of needs identified, therefore creating a cycle of continuous improvement. The process can then begin again, with the evaluation of practice being your means of identifying further learning needs. Example 1 Activity/area of need Performance management Example 2 Activity/area of need Diabetes service in the pharmacy Resulting change to practice/outcomes Reviewed policy for performance management, amended performance management forms and developed new complaints management process which has now been appropriately communicated to all staff. Staff feedback has been positive, they feel comfortable that we now have the appropriate processes in place for managing complaints. The pharmacy now meets requirements for QCPP. Resulting change to practice/outcomes Implementation of the diabetes service is still continuing. The pharmacy has registered as a Diabetes MedsCheck provider and we have made changes to the layout for private consultations with patients. Education has been delivered to the whole pharmacy team and they are now equipped to start communicating to patients about the service. Other comments/ further learning needs identified This process has now highlighted that other managers in the pharmacy require further training around performance management. Other comments/ further learning needs identified Further learning needs will be identified as the service is implemented. Education around communicating effectively with patients would be beneficial. Recording Group 3 CPD credits Upon completion of this process, you may then count all of the activities completed in Part 2 as Group 3 activities, which attract 3 CPD credits per hour. Keep a copy of the completed documentation template as evidence that the activities qualify for Group 3 CPD credits. You should record each activity separately with the following details: Date of activity. Source or provider details (e.g. PSA). Type of activity (e.g. conference, workshop, journal article). Topics covered during activity. Accreditation status (and if accredited the accreditation number). Number and type of CPD credits (e.g. 3 Group 3). You may record these activities using your PSA CPD record. To self-record CPD activities log-in to the PSA Website with your member details and click on My PSA > CPD self recording. If you wish to change the Group or credit value of a PSA CPD activity that has automatically been recorded by PSA as Group 1 or 2 activity, you will need to request this by ing education@psa.org.au. References: 1. Pharmacy Board of Australia 2010, Guidelines on Continuing Professional Development. 78 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

79 PSA Group 3 CPD Documentation Template This form can be completed to record your Group 3 CPD credits. For assistance with this form, please refer to the PSA Guide to Documenting CPD credits. All parts of this form must be completed for the activity to qualify for Group 3 credits. Please click here to view a worked example of this template. Retain this form as evidence of CPD activities qualifying for Group 3 CPD credits. Name PSA Member Number Pharmacy or practice area Date Part A. Learning needs identified: Area of need How did you identify this as being an area of need? e.g. Learn how to host an influenza immunisation service - Competency Standards 6.1; 6.2; 6.3 e.g. Learn how to conduct a health promotion for influenza vaccination - Competency Standard 2.1 e.g. My pharmacy has a large number of customers who are potentially eligible to receive an annual influenza vaccine, but are currently not eligible for the NIP free vaccination Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 79

80 Part B. CPD to address learning needs: CPD activity Completed? Time taken (hours) e.g. Read InPHARMation FBFC immunisation and completed MCQs e.g. Read PSA immunisation guidelines e.g. Undertake PSA ONL modules immunisation overview and implementing influenza service 10 March March March Part C: Evaluate and reflect on changes to your practice Date of evaluation Learning need addressed Resulting change to practice Example of outcome e.g. 6.1; 6.2; 6.3; 2.1 Ran our first health promotion Commenced an influenza vaccination health promotion for our customers, so that each customer identified was offered a booking for our hosted influenza vaccination service 105 customers were vaccinated with 2013 influenza vaccine by our immunisation provider You must now record each individual CPD activity (from part 2) on your CPD&PI record. Please see the PSA Guide to Documenting Group 3 CPD Credits for information on the Pharmacy Board of Australia s CPD recording requirements. 80 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

81 National Immunisation Program Schedule From 1 July 2013 Child programs Age Vaccine Birth Hepatitis B (hepb) a 2 months Hepatitis B, diphtheria, tetanus, acellular pertussis (whooping cough), Haemophilus influenzae type b, inactivated poliomyelitis (polio) (hepb-dtpa-hib-ipv) Pneumococcal conjugate (13vPCV) Rotavirus 4 months Hepatitis B, diphtheria, tetanus, acellular pertussis (whooping cough), Haemophilus influenzae type b, inactivated poliomyelitis (polio) (hepb-dtpa-hib-ipv) Pneumococcal conjugate (13vPCV) Rotavirus 6 months Hepatitis B, diphtheria, tetanus, acellular pertussis (whooping cough), Haemophilus influenzae type b, inactivated poliomyelitis (polio) (hepb-dtpa-hib-ipv) Pneumococcal conjugate (13vPCV) Rotavirus b 12 months Haemophilus influenzae type b (Hib) Meningococcal C (MenCCV) Measles, mumps and rubella (MMR) 18 months Measles, mumps, rubella and varicella (chickenpox) (MMRV) 4 years Diphtheria, tetanus, acellular pertussis (whooping cough) and inactivated poliomyelitis (polio) (DTPa-IPV) Measles, mumps and rubella (MMR) (to be given only if MMRV vaccine was not given at 18 months) School programs years Hepatitis B (hepb) c (contact your State Varicella (chickenpox) c or Territory Health Human papillomavirus (HPV) d Department for details) Diptheria, tetanus and acellular pertussis (whooping cough) (dtpa) At-risk groups 6 months and over Influenza (flu) (people with medical conditions placing them at risk of serious complications of influenza) 12 months Pneumococcal conjugate (13vPCV) e (medically at risk) months Pneumococcal conjugate (13vPCV) (Aboriginal and Torres Strait Islander children in high risk areas) e months Hepatitis A (Aboriginal and Torres Strait Islander children in high risk areas) f 4 years Pneumococcal polysaccharide (23vPPV) e (medically at risk) 15 years and over Influenza (flu) (Aboriginal and Torres Strait Islander people) Pneumococcal polysaccharide (23vPPV) (Aboriginal and Torres Strait Islander people medically at risk) 50 years and over Pneumococcal polysaccharide (23vPPV) (Aboriginal and Torres Strait Islander people) Pregnant women Influenza (flu) 65 years and over Influenza (flu) Pneumococcal polysaccharide (23vPPV) * Please refer to reverse for footnotes Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 81

82 Footnotes to the National Immunisation Program (NIP) Schedule a. Hepatitis B vaccine: should be given to all infants as soon as practicable after birth. The greatest benefit is if given within 24 hours, and must be given within 7 days. b. Rotavirus vaccine: third dose of vaccine is dependent on vaccine brand used. Contact your State or Territory Health Department for details. c. Hepatitis B and Varicella vaccine: contact your State or Territory Health Department for details on the school grade eligible for vaccination. d. HPV vaccine: is for all adolescents aged between 12 and 13 years. A catch-up program for males aged between 14 and 15 years is available until December Contact your State or Territory Health Department for details on the school grade eligible for vaccination. e. Pneumococcal vaccine: i. Medically at risk children require: a fourth dose of 13vPCV at 12 months of age; and a booster dose of 23vPPV at 4 years of age (but less than 6 years of age). ii. Infants born at less than 28 weeks gestation require: a fourth dose of 13vPCV at 12 months of age. iii. Aboriginal and Torres Strait Islander children require: a fourth dose of pneumococcal vaccine (13vPCV) at 12 months of age (but not more than 18 months) for children living in high risk areas (Queensland, Northern Territory, Western Australia and South Australia). Contact your State or Territory Health Department for details. f. Hepatitis A vaccine: two doses of Hepatitis A vaccine for Aboriginal and Torres Strait Islander children living in high risk areas (Queensland, Northern Territory, Western Australia and South Australia). Contact your State or Territory Health Department for details. Further information Further information and immunisation resources are available from the Immunise Australia Program website at or by contacting the infoline on You should contact your State or Territory Health Department for further information on the program specific to your State or Territory: State/Territory Contact Number Australian Capital Territory (02) New South Wales Northern Territory (08) Queensland 13 HEALTH ( ) South Australia Tasmania Victoria Western Australia (08) Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

83 Appendix 1: State and Territory drugs and poisons legislation DRUG AND POISONS LEGISLATION FOR THE STATES AND TERRITORIES ACT NSW NT QLD SA TAS VIC WA Medicines, Poisons and Therapeutic Goods Act At: Medicines, Poisons and Therapeutic Goods Regulation At: Poisons and Therapeutic Goods Act At: Poisons and Therapeutic Goods Regulation At: subordleg first+0+n Poisons and Dangerous Drugs Act. At: Medicines, Poisons and Therapeutic Goods Act At: Poisons and Dangerous Drugs Regulations. At: dangerous%20drugs%20regulations?opendocument Health Act At: Health (Drugs and Poisons) Regulations At: Controlled Substances Act At: Controlled Substances (Poisons) Regulations At: (POISONS)%20REGULATIONS% aspx Poisons Act At: Poisons Regulations At: ;histon=;prompt=;rec=;term= Drugs, Poisons and Controlled Substances Act At: Drugs, Poisons and Controlled Substances Regulations At: LTObject_Store/LTObjSt6.nsf/DDE300B846EED9C7CA A3571/CBB80677A53FB2B4CA2578B ED/$FILE/06-57sra010%20authorised.pdf Poisons Act At: Poisons Regulations At: Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 83

84 Appendix 5: Immunisation service checklist for pharmacies Note: the checklist below refers to the Australian Immunisation Handbook. 5 You should always refer to the current edition of the handbook, which may have changed since the time of writing. The latest edition of the handbook is available at: internet/immunise/publishing.nsf/content/handbook-home Immunisation service checklist for pharmacies hosting immunisation services delivered by other health professionals CHECKLIST FOR IMMUNISATION SERVICE DELIVERY Contact an authorised immuniser who can provide immunisation services in the pharmacy. An authorised immuniser must: be a registered nurse or medical practitioner listed on the Australian Health Practitioners Regulation Agency (AHPRA) register of health practitioners have completed an approved program of study and maintained recency of practice to immunise have a current statement of proficiency in cardiopulmonary resuscitation (CPR) be permitted under State or Territory legislation to administer vaccines independently of supervision have professional indemnity insurance appropriate to their immunisation activities. Ensure specific State or Territory legislative requirements s have been met. Contact the health authorities in your relevant State or Territory in regard to the legislative requirements (contact information is listed in Appendix 4). Ensure the pharmacy s insurance policies are appropriate for the delivery of immunisation services. Ensure a service agreement is signed between the pharmacy and the authorised immuniser outlining the roles and responsibilities of each party. Develop a policy and procedure manual for the service. Establish a screened area or room separate from the public area that meets the following requirements: The area is sufficient to accommodate the consumer, their carer if appropriate, and the authorised immuniser, as well as all equipment required to store and administer vaccines. Provide appropriate space and furnishings to allow consumers to sit or lie and receive treatment as necessary. Allow for space, surfaces and equipment to respond to any adverse events and medical emergencies as necessary. Provide equipment for the appropriate disposal of sharps and medical waste. Make available appropriate handwashing facilities. Ensure adequate seating is available adjacent to the immunisation service area for all consumers and their carers who will be advised to remain in the general area for at least 15 minutes following vaccination. Ensure appropriate equipment for storing and administering vaccines is available (e.g. a reliable and stable refrigerator with adequate capacity to store vaccines appropriately). For more information about appropriate equipment for storing and administering vaccines, refer to: Effective cold chain: transport, storage and handling of vaccines in the Australian Immunisation Handbook 5 Basic principles for safe vaccine management in National vaccine storage guidelines: Strive for 5 47 (available at: health.gov.au/internet/immunise/publishing.nsf/content/provider-store). Ensure an emergency response kit is available and in date, whether provided by the authorised immuniser or the pharmacy (see current edition of the Australian Immunisation Handbook 5 ). An anaphylaxis response kit should be on hand at all times and should contain: adrenaline 1:1000 (minimum of 3 ampoules check expiry dates) minimum of three 1 ml syringes and 25 mm length needles (for intramuscular injection) cotton wool swabs pen and paper to record time of administration of adrenaline a laminated copy of Recognition and treatment of anaphylaxis from the quick guides in the Australian Immunisation Handbook (available at: Ensure immunisation service identifiers (i.e. consumer stickers) are available and used to enable the quick identification of consumers who have received vaccinations should they require further assistance. Ensure an emergency response protocol is displayed (an example Emergency response protocol is available in Appendix 6). Show Adverse events following immunisation from the quick guides in the Australian Immunisation Handbook displayed as a poster (available at: DATE COMPLETED 84 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

85 Parties Agreement for the provision of influenza vaccination services between: and Address: Representative: Contact number: ACN: ABN: Address: Representative: Contact number: ACN: ABN: Definitions Client - the pharmacy contracting influenza immunisation services Consumer/s - includes all customers of the client participating in the service Premises - the address of the client Services - the provision of the influenza vaccination clinic Service provider - the company or individual providing influenza immunisation services This sample service agreement has been provided in conjunction with the Pharmaceutical Society of Australia s Practice guidelines for the provision of immunisation services within pharmacy. Pharmacists should refer to the full guidelines for further information. This sample service agreement does not replace the need for specific legal advice. PSA accepts no responsibility for consequences, legal or otherwise, from the use or adaption of the sample service agreement by pharmacists or pharmacies. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 85

86 Service The Service provider will provide the Client with influenza vaccination services in accordance with this Agreement. Location The Service provider agrees to provide Services at the premises on the agreed dates/s and time/s. Confirmation The date/s and time/s of Services must be agreed and confirmed by both Parties in writing. The Client will confirm the exact number of consumers with the Service provider days prior to Services. The minimum number of consumers required is. If the minimum number of consumers is not met, the Service provider may cancel or reschedule Services at their discretion and the Client will need to notify any booked consumers of the cancellation or change. Cancellations The Client must give days notice for the cancellation of Services without penalty. Cancellations made within this time of the scheduled booking will attract a cancellation fee of $ plus GST. Once the date and time for Services has been agreed, changes to the booking may attract a fee of $ plus GST at the discretion of the Service provider. Vaccines The service provider will provide one vaccine for each confirmed consumer. Extra vaccines may be available on the day however the Service provider cannot guarantee that a vaccine will be available for any consumer that was not confirmed by the agreed date. The Service provider is responsible for maintaining the viability of all vaccines through appropriate cold chain procedures. Approvals, licences and permits The Client is responsible for obtaining any approvals, licences or permits necessary for the performance of Services in accordance with this Agreement. By signing this Agreement the Client warrants that it holds or has obtained the necessary approvals, licences or permits to allow the Service provider to consult with consumers on the premises. Standard of performance The Service provider will perform Services in accordance with the highest degree of care, diligence, foresight, prudence and skill exercised by skilled and experienced professionals providing similar services, including complying with all jurisdictional legislation and industry standards. The Service provider warrants that it possesses and will deploy the specific skills and experience relevant to deliver Services according to this Agreement. Consent The Service provider requires documented consent to receive the influenza vaccine from each consumer prior to vaccination. Consent must include agreement from the consumer to meet the cost of any medical treatment required in connection with vaccination. Consent forms will be provided by This sample service agreement has been provided in conjunction with the Pharmaceutical Society of Australia s Practice guidelines for the provision of immunisation services within pharmacy. Pharmacists should refer to the full guidelines for further information. This sample service agreement does not replace the need for specific legal advice. PSA accepts no responsibility for consequences, legal or otherwise, from the use or adaption of the sample service agreement by pharmacists or pharmacies. 86 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

87 Eligibility and screening The Service provider is responsible for conducting pre-vaccination screening to determine the eligibility of each consumer to receive the influenza vaccine. Pre-vaccination screening forms will be provided by The Service provider reserves the right to refuse vaccination to any consumer at their discretion. Observation The Service provider or representative administering the vaccine will remain on site for 15 minutes post vaccination. In the unlikely event of a medical emergency, the Service provider will not be liable for the costs of any required medical treatment. Privacy and confidentiality All information contained within the consumer records is classified as sensitive information under the Privacy Act 1988 and as such cannot be disclosed to a third party without the consumer s consent. Indemnity insurance The Service provider holds indemnity insurance appropriate for delivery of Services in accordance with this agreement. The Service provider indemnifies the Client from and against all actins, claims, demands, costs and expenses made, sustained, brought or prosecuted against the Client by consumers based on any loss or damage to themselves which may arise in connection with any act or omission of the Service provider or representative in the delivery Services. The Client holds indemnity insurance appropriate for hosting of the Service provider on the premises and indemnifies the Service provider against all liability, claims and damages associated with the use of the premises. Payment Price The Client will collect payment of $ from each consumer on or before the day of vaccination. The Service provider will invoice the Client $ plus GST per consumer vaccinated. Terms of payment The invoice for Services provided is payable within days. At the discretion of the Service provider, failure to make payments in accordance with this Agreement may be treated as a repudiation of this Agreement. At the discretion of the Service provider, interest shall be paid by the Client on overdue accounts calculated on the daily balances from the day after payment was due, at the rate of % per annum and without any demand being necessary. Payment made by the Client shall be allocated first to the interest then to the unpaid invoices in the order of issue. Dispute resolution Parties to this Agreement must attempt to settle any dispute in relation to this Agreement by negotiation before resorting to external dispute resolution mechanisms. It the dispute is not settled by Parties within days of one party providing written notice of the dispute to the other party, the dispute must be submitted to an alternative dispute resolution mechanism. If Parties cannot agree on the alternative dispute resolution mechanism within days the mechanism will be chosen by the President of the relevant State Law Society. Each party will pay its own costs associated with the dispute resolution process. Costs incurred for mediation /arbitration will be shared equally. Parties agree that the decision of the mediator /arbitrator will be final. This clause survives the expiration or termination of this Agreement. This sample service agreement has been provided in conjunction with the Pharmaceutical Society of Australia s Practice guidelines for the provision of immunisation services within pharmacy. Pharmacists should refer to the full guidelines for further information. This sample service agreement does not replace the need for specific legal advice. PSA accepts no responsibility for consequences, legal or otherwise, from the use or adaption of the sample service agreement by pharmacists or pharmacies. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 87

88 Agreement period This Agreement is effective up to and including the date of Services. Authority to sign The person/s signing this Agreement warrants that they are duly authorised to enter into the Agreement. Declaration Executed as an Agreement. Client Signed for on behalf of: Service provider Signed for on behalf of: Full name:... Full name:... Position:... Position:... Signed:... Signed:... Date:... In the presence of Full name of witness:... Date:... In the presence of Full name of witness:... Signed:... Signed:... Date:... Date:... This sample service agreement has been provided in conjunction with the Pharmaceutical Society of Australia s Practice guidelines for the provision of immunisation services within pharmacy. Pharmacists should refer to the full guidelines for further information. This sample service agreement does not replace the need for specific legal advice. PSA accepts no responsibility for consequences, legal or otherwise, from the use or adaption of the sample service agreement by pharmacists or pharmacies. 88 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

89 Appendix 7: Pre-immunisation screening checklist Note: This pre-immunisation screening checklist was adapted from the Australian Immunisation Handbook. 5 You should always refer to the current edition of the handbook, which may have changed since the time of writing. The latest edition of the handbook is available at: PRE-VACCINATION SCREENING AND CONSENT TOOL FOR PHARMACY HOSTED IMMUNISATION SERVICES Consumer details Name:... DOB:... Address:... Phone:...Medicare No.:... Allergies:... Primary healthcare provider details Name:... Address:... Phone: Vaccination(s) I expect to be vaccinated against the following infectious diseases (list all):... at today s visit on... I have not received vaccines for the following infectious diseases before (list all that apply): OR I have received these vaccines for the following infectious diseases before (list disease and last date of vaccination for all that apply): General health and suitability for vaccination Please tell your nurse or doctor if you answer yes to any of the following statements, as vaccination may not be suitable for you today if you: are unwell today have a disease which lowers immunity (eg. Leukaemia, cancer, HIV/ AIDs) are having treatment which lowers immunity (oral steroid medicines such as cortisone or prednisolone, radiotherapy, chemotherapy) have had a severe reaction following any vaccine have any severe allergies (to anything) have had any vaccine in the past month have had an injection of immunoglobulin, or received and blood products or a whole blood transfusion within the past year are pregnant have a history of Guillain-Barré syndrome were a pre-term infant have a chronic illness have a bleeding disorder Vaccination needs assessment Please tell your nurse or doctor if you answer yes to any of the following statements, as a different vaccination schedule may be recommended for you if you: are of Aboriginal or Torres Strait Islander origin do not have a functioning spleen are planning pregnancy or anticipating parenthood are a parent, grandparent or carer or a newborn Consent I have been provided with, read and understood information regarding the possible side effects of the vaccine, and if I have any further questions I will ask the nurse or doctor prior to being vaccinated. I request to have this vaccine and understand that it is completely voluntary. I have been informed of and agree to paid any fees or charges associated with this service. I consent to the pharmacy or service provider issuing a copy of my vaccination statement to my nominated primary healthcare provider. live with someone who has a disease which lowers immunity (eg. Leukaemia, cancer, HIV/AIDs) live with someone who is having treatment which lowers immunity (oral steroid medicines such as cortisone or prednisolone, radiotherapy, chemotherapy) I agree to remain in the general vicinity of the pharmacy for 15 minutes following vaccination, to enable the provision of medical assistance or treatment if required. I consent to the provision of emergency care if required, and authorise the pharmacy or service provider to access medical care on my behalf as required. I understand that I am responsible for any costs associated with emergency care provided. Name:... Signature:... Date:... Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 89

90 Appendix 9: Consumer vaccination statement template Note: This consumer vaccination statement template was adapted from the Australian Immunisation Handbook. 5 You should always refer to the current edition of the handbook, which may have changed since the time of writing. The latest edition of the handbook is available at: Pharmacy logo CONSUMER VACCINATION STATEMENT Consumer details Name Date of birth Phone Address Medicare no. Authorised immuniser Name Contact details Signed Date Vaccination(s) Infectious disease Brand name Dose Batch number Site of administration Right arm Left arm Right leg Left leg Date of vaccination Time Date of next vaccination (if required) Infectious disease Brand name Dose Batch number Site of administration Right arm Left arm Right leg Left leg Date of vaccination Time Date of next vaccination (if required) Infectious disease Brand name Dose Batch number Site of administration Right arm Left arm Right leg Left leg Date of vaccination Time Date of next vaccination (if required) Infectious disease Brand name Dose Batch number Site of administration Right arm Left arm Right leg Left leg Date of vaccination Time Date of next vaccination (if required) Pharmacy details Name Address Phone 90 Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

91 Appendix 8: Post-vaccination procedures checklist Note: the checklist below refers to the Australian Immunisation Handbook. 5 You should always refer to the current edition of the handbook, which may have changed since the time of writing. The latest edition of the handbook is available at: internet/immunise/publishing.nsf/content/handbook-home POST-VACCINATION PROCEDURES CHECKLIST For pharmacists Be familiar with the authorised immuniser s post-vaccination care procedures including: the disposal of used needles, syringes and vaccine vials or ampoules in accordance with standard infection control guidelines provision of comfort and the use of distraction techniques to alleviate any distress and pain felt by the consumer (note: paracetamol is not used routinely at the time of vaccination but may be recommended as required for fever or pain) the provision of appropriate consumer information regarding the vaccination and possible adverse events. Refer to Post-vaccination procedures in the latest edition of the Australian Immunisation Handbook. 5 For authorised immuniser Provide immunisation information to consumers. COMPLETED (Y/N) See Appendix 3 for a list of appropriate consumer information resources about vaccines and immunity to support and reinforce the information provided by the authorised immuniser. Inform the vaccinated person and/or their parent or carer about the possible common adverse events following immunisation and how to recognise and manage them. Provide appropriate consumer information on adverse events following immunisation and give advice on when to seek medical attention. The following resources could be given: Adverse events following immunisation from the quick guides in the Australian Immunisation Handbook (available at: Victorian Department of Health s Common reactions to vaccines leaflet (available at: doc/common-reactions-to-vaccines-). Advise the vaccinated person and/or their parent or carer to remain in a nearby area for a minimum of 15 minutes after the vaccination. The area should be close enough to the authorised immuniser so the vaccinated person can be observed and medical treatment can be readily obtained if needed. Remind the vaccinated person and/or their parent or carer to promptly report any significant adverse event following immunisation to the authorised immuniser or their primary healthcare provider, so that it can be reported to the Therapeutic Goods Administration (TGA), and to the relevant State or Territory Department of Health, or any other body as mandated by jurisdictional requirements. For more on how to report an adverse event to a medicine to the TGA, see An adverse event following immunisation report form is available at: infectious/diseases/pdf/adverse_event_form.pdf Provide consumers with a statement of vaccinations received following each appointment (see Appendix 9). With the consumer s consent, forward a copy of the consumer s vaccination statement to their nominated healthcare provider. Report all National Immunisation Program (NIP) and private vaccinations given to children under 7 years of age to the Australian Childhood Immunisation Register (ACIR). Refer to The Australian Childhood Immunisation Register in the latest edition of the Australian Immunisation Handbook. 5 Report all Human Papillomavirus vaccinations to the HPV register. Record the consumer s vaccination details in pharmacy immunisation records, and on the consumer s personally controlled electronic healthcare record as available. Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 91

92 Appendix 6: Emergency response protocol Note: this emergency response protocol was adapted from the Australian Immunisation Handbook. 5 You should always refer to the current edition of the handbook, which may have changed since the time of writing. The latest edition of the handbook is available at: EMERGENCY RESPONSE PROTOCOL Signs of anaphylaxis Anaphylaxis causes respiratory and/or cardiovascular signs or symptoms AND involves other organ systems, such as the skin or gastrointestinal tract. Signs include: skin signs, such as the rapid development of urticarial lesions or erythaema signs of upper airway obstruction, such as hoarseness and stridor indications of lower airway obstruction, such as subjective feelings of retrosternal tightness, dyspnoea or wheeze limpness and pallor, which are signs of severe anaphylaxis in children profound hypotension in association with tachycardia, and/or other signs of cardiovascular disturbance, such as sinus tachycardia or severe bradycardia abdominal cramps, diarrhoea and/or vomiting. Management of anaphylaxis If the consumer is unconscious, place them on their left side and position them to keep the airway clear. If the consumer is conscious, place them supine in head down and feet up position (unless this results in breathing difficulties). Give adrenaline by intramuscular injection (see below for dosage) for any signs of anaphylaxis with respiratory and/or cardiovascular symptoms or signs. Adrenaline is not required for generalised non-anaphylactic reactions (such as skin rash or angiooedema). If in doubt, intramuscular adrenaline should be given. The time and dose of adrenaline administered should be noted in the consumer s record. If there is no improvement in the consumer s condition by 5 minutes, repeat the dose of adrenaline every 5 minutes until improvement occurs. If oxygen is available, administer by facemask at a high flow rate. Call for professional assistance and call an ambulance. Never leave the consumer alone. Begin expired air resuscitation for apnoea, and check for a central pulse. If a central pulse not palpable, commence external cardiac massage (ECM). All cases should be admitted to hospital for further observation and treatment. Adrenaline dosage The recommended dose of 1:1000 adrenaline is 0.01 ml/kg body weight (equivalent to 0.01 mg/kg up to a maximum of 0.5 ml or 0.5 mg) given by deep intramuscular injection into the thigh (not the deltoid region). Adrenaline 1:1000 must not be administered intravenously. Adrenaline 1:1000 contains 1 mg of adrenaline per ml of solution in a 1 ml glass vial. The use of 1:1000 adrenaline is recommended because it is universally available. Use a 1 ml syringe to improve the accuracy of measurement when drawing up small doses. Doses of 1:1000 (one to one thousand) adrenaline for children The following table lists the doses of 1:1000 adrenaline to be used for children if the exact weight of the child is not known. AGE DOSES OF 1:1000 (one to one thousand) adrenaline Less than 1 year ml 1 2 years (approx. 10 kg) 0.1 ml 2 3 years (approx. 15 kg) 0.15 ml 4 6 years (approx. 20 kg) 0.2 ml 7 10 years (approx. 30 kg) 0.3 ml years (approx. 40 kg) 0.4 ml 13 years and over (over 40 kg) 0.5 ml Roles and responsibilities to be assigned The person who will administer the adrenaline is the authorised immuniser. The person who will call the ambulance is.... The person who will meet and direct the paramedics to the consumer is... They should meet the paramedics at.... The person who will provide clinical handover to the paramedics is the authorised immuniser. The person who will record the details of treatment provided, including time and dose of adrenaline administered, is... The person who will manage other customers in the pharmacy is.... The person who will report the adverse event following immunisation to the relevant State or Territory health authorities is the authorised immuniser and/or Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

93 Referral letter 2013 Healthcare provider:... Pharmacist:... Address:... Address: Phone:... Date:... Re: Consumer s name:... Consumer s address... Date of intervention:... Discussed via phone: I have referred... to you for review, following the identification of a potential issue concerning their care. Potential issue (DRP, medications and/or medical conditions involved): Recommendations (e.g. drug change recommended): Advice given (e.g. dose administration aid recommended): Additional notes: References: Yours sincerely,... PSA3885 Pharmacist s name:... Post nomimals:... Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 93

94 Health column Give vaccination your best shot 2013 By John Bell When it comes to medical interventions, vaccination is arguably the greatest single public health strategy ever developed. It is rivalled only by access to potable water, good nutrition and the introduction of sanitation and hygiene procedures. The terms vaccination and immunisation are often used interchangeably; in fact vaccination is the process by which our immune system becomes fortified and thus develops immunity to a particular disease causing pathogen (we can sometimes develop natural immunity to some conditions). Despite the obvious benefits of vaccines, some people are unnecessarily apprehensive about having their children immunised. There are probably a number of reasons. Immunisation has been so successful over recent decades that most young parents today would never have seen the horrendous effects of diphtheria, pertussis and polio, or realise that measles can kill or cause brain damage and mumps can cause male sterility. Also misguided and misinformed anti vaccine advocates and conspiracy theorists have caused unnecessary alarm. No doubt, the greatest desire parents have is to make sure their children remain healthy and avoid serious illness. No parent would knowingly put their child s life at risk. However, according to leading scientists and medical specialists, this is what is happening as a result of misleading and inaccurate claims (to get an idea on just how emotion can cloud a sensible debate, read the book The Panic Virus by Seth Mnookin). The number of Australian babies not fully immunised is now one in 12 with the number of parents registering a conscientious objection rising from around 4,000 in 1999 to more than 30,000 this year. Professor Ian Frazer, who developed the cervical cancer vaccine, has warned of the dangerous fall in immunisation rates for diseases such as whooping cough which has now reached epidemic levels. More than 13,000 cases were recorded last year in NSW alone. Australia wide there were over 7,000 cases in the first three months of Clearly, pharmacists and pharmacy assistants have a major role to play in promoting immunisation. The benefits accrue not only to the individual who is immunised but also by way of so called herd immunity to everyone in the community and especially to all those who themselves cannot be safely immunised. This inpharmation outlines the benefits and the risks of immunisation (of course there are some potential adverse effects no medical procedure is 100% safe and effective); and it also details how to explain these issues to parents. Remember too, the Self Care Fact Card on Childhood immunisation is a great resource to use in these discussions. As well, up to date, objective and evidence based information has recently been produced by the Australian Academy of Science in its booklet The Science of Immunisation: Questions and Answers (You can download a copy or order free hardcopies for your customers at: PSA Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd.

95 1 Street Crescent Suburb STATE P: F: E: Order form 2013 Make the most of your health promotion. Order your personalised resources today. Please fax completed form to PSA Pharmacy name: (this name will be printed on your personalised resources)... Contact name:... Delivery address:... Suburb/Town:...State:... Post Code:... Phone:...Mobile: Special delivery instructions:... (Please allow 7 working days for delivery) Posters Influenza (red) Poster size (mm) Quantity Unit price Total A3 (297w x 420h) $3.20 $ A2( (420w x 594h) $25.60 $ A1 (594w x 841h) $48.00 $ Posters Generic (blue) Poster size (mm) Quantity Unit price Total A3 (297w x 420h) $3.20 $ A2( (420w x 594h) $25.60 $ A1 (594w x 841h) $48.00 $ Appointment cards Quantity Unit price Total 50 $47.00 (94 cents per card) $ 100 $53.00 (53 cents per card) $ 250 $64.00 (26 cents per card) $ 500 $80.00 (16 cents per card) $ Give yourself an edge this winter Are your vaccinations up to date? Personalise with your pharmacy s name! Fact Cards (pack of 20) Free for Self Care members. $30 per pack for PSA members. Title Total Travel health $ Childhood immunisation $ Chickenpox $ Cold and flu $ Talk to your pharmacy name about your flu injection. PSA3945 Talk to your pharmacy name about your vaccination status. Pharmacy name Name... Your appointment is on... at... PSA3945 PSA3806 Payment details I authorise PSA to debit my/our account Please charge my Mastercard Visa AMEX Freight for the first item $14 Plus $4 per item thereafter $... Total $... Card Number: Cardholders name:... Expiry Date: / PSA4007 Signature:... Immunisation: Health promotion & professional services workbook I Pharmaceutical Society of Australia Ltd. 95