: Case Discussion and Administration Technique Miranda Wilhelm, Pharm.D. Clinical Associate Professor Department of Pharmacy Practice Southern Illinois University Edwardsville, School of Pharmacy 1
Disclosure Miranda Wilhelm, Pharm.D. reports she is a speakers bureau member for Merck Vaccines. CEI has taken appropriate action for conflict resolution, including external peer review by an unconflicted reviewer. Learning Objectives Upon successful completion of this activity, pharmacists should be able to: Recommend immunizations for patients based on their ages, concurrent illnesses or conditions, and lifestyle. Implement knowledge of immunization recommendations through patient cases. Based on the immunization and patient, determine anatomic site and needle size. Describe the process to administer an immunization, including patient preparation and infection control. Accurately prepare a vaccine for administration. 2
In this module, the presenter will outline 5 individual cases and ask for your recommendations. As the activity pauses each time, take a moment to consider the case. You may wish to print a copy of the current CDC Immunization Schedules as a reference. You may wish to print a copy of the handout associated with this program as a reference. Case 1 KS, a 12 year-old female, presents to her PCP with her mother for management of an asthma exacerbation while getting over a cold. While waiting in the exam room for the physician to return with a new prescription (Prednisone 40 mg PO Daily X 5 days), her mother notices a flyer for the annual influenza clinic and wonders if her daughter is up-to-date with immunizations. What is the first question that you should ask KS and her mother about immunizations? 3
KS s Immunization Record Up-to-date at 4 to 6 year-old well child visit No immunizations since Screening Questionnaire Screening Question Response 1. Is the child sick today? YES 2. Does the child have allergies to medications, food, a vaccine component, or latex? No 3. Has the child had a serious reaction to a vaccine in the past? No 4. Has the child had a health problem with lung, heart, kidney or metabolic disease (e.g. diabetes), YES asthma, or a blood disorder? Is he/she on long-term aspirin therapy? 5. If the child to be vaccinated is 2 through 4 years of age, has a healthcare provider told you that N/A the child had wheezing or asthma in the past 12 months? 6. If your child is a baby, have you ever been told he or she has had intussusception? N/A 7. Has the child, a sibling, or a parent had a seizure; has the child had brain or other nervous No system problems? 8. Does the child have cancer, leukemia, HIV/AIDS, or any other immune system problem? No 9. In the past 3 months, has the child taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn s disease, or psoriasis; or had radiation treatments? NEW RX 10. In the past year, has the child received a transfusion of blood or blood products, or been given No immune (gamma) globulin or an antiviral drug? 11. Is the child/teen pregnant or is there a chance she could become pregnant during the next No month? 12. Has the child received vaccinations in the past 4 weeks? No What vaccinations are recommended for KS? 4
Schedule for Birth to 18 Years Case 1 Summary Inactivated influenza vaccine (IIV3 or IIV4) Meningococcal conjugate vaccine (MCV4) Tetanus-diphtheria-acellular pertussis vaccine (Tdap) Human papillomavirus vaccine (HPV9) 5
Case 2 LV is a 23 year-old male who presents to campus Health Services. He is a pharmacy student and current smoker. The School of Pharmacy requires a physical and documentation of vaccinations prior to the start of Advanced Pharmacy Practice Experiences (APPE), which he will begin next summer. What is the first question that you should ask LV about immunizations? LV s Immunization Record Influenza (IIV3) yearly x2 DTaP complete series Td x1 last given at 12 years Varicella x2 last given at 5 years MMR x2 last given at 5 years PCV x4 last given at 1 year Hepatitis A x2 last given at 5 years Hepatitis B x1 given 1 year ago MCV4 x2 last given at 16 years Hib complete series 6
Screening Questionnaire What vaccinations are recommended for LV? Schedule for Adults by Medical and Other Indications 7
Case 2 Summary Inactivated influenza vaccine (IIV3 or IIV4) OR live attenuated influenza vaccine (LAIV) Tetanus-diphtheria-acellular pertussis vaccine (Tdap) Pneumococcal polysaccharide vaccine (PPSV23) Hepatitis B vaccine (HBV) Case 3 PG, a 30 year-old female with Type 2 diabetes, reports to the community pharmacy for a refill on her prenatal vitamin prescription. She is 28 weeks pregnant. She asks if the pharmacy is giving flu shots because her OB/GYN recommended she get one. What is the first question that you should ask PG about immunizations? 8
PG s Immunization Record Influenza (IIV3) yearly X5 Td x1 last given 9 years ago Varicella physician documented case of chicken pox at age 7 MMR complete series PPSV23 x1 last given 5 years ago Hepatitis A complete series MCV4 complete series HIB complete series Screening Questionnaire What vaccinations are recommended for PG? 9
Schedule for Adults by Medical and Other Indications Schedule for Adults by Medical and Other Indications 10
Case 3 Summary Inactivated influenza vaccine (IIV3 or IIV4) Tetanus-diphtheria-acellular pertussis vaccine (Tdap) Upon delivery, prior to hospital discharge: Hepatitis B vaccine (HBV) Immunization and Pregnancy 11
Case 4 AW is a healthy 66 year-old male presenting to the community pharmacy seeking your advice regarding immunizations. He recently recovered from a shingles rash and wants to get the vaccine so this will never happen again. What is the first question that you should ask AW about immunizations? AW s Immunization Record Influenza (IIV3) yearly No other vaccinations since childhood 12
Screening Questionnaire What vaccinations are recommended for AW? Neomycin Allergy - What do we do? Pink Book Appendix B (Vaccine Excipient & Media Summary) Zostavax Package Insert 13
Blood Transfusion What do we do? Schedule for Adults - by Age 14
Case 4 Summary Inactivated influenza vaccine (IIV3 or IIV4) Tetanus-diphtheria-acellular pertussis vaccine (Tdap) Zoster vaccine Pneumococcal conjugate vaccine (PCV13) Pneumococcal polysaccharide vaccine (PPSV23) 1 year after PCV13 Case 5 NS is a healthy 75 year-old female presenting to the community pharmacy for an annual influenza vaccine. What is the first question that you should ask NS about immunizations? 15
NS s Immunization Record Influenza (IIV3) yearly X25 Pneumonia shot at 65 years Unsure of childhood immunizations Screening Questionnaire Screening Question Response 1. Are you sick today? No 2. Do you have allergies to medications, food, a vaccine component, or latex? No 3. Have you ever had a serious reaction after receiving a vaccination? No 4. Do you have a long-term problem with heart disease, lung disease, asthma, kidney disease, No metabolic disease (e.g. diabetes), anemia, or other blood disorder? 5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? No 6. In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn s disease, or psoriasis; or have you had radiation treatments? No 7. Have you had a seizure or a brain or other nervous system problem? No 8. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug? 9. For women: Are you pregnant or is there a chance you could become pregnant during the next month? No No 10. Have you received any vaccinations in the past 4 weeks? No What vaccinations are recommended for NS? 16
Schedule for Adults - by Age Case 5 Summary Inactivated influenza vaccine (IIV3 or IIV4) Tetanus-diphtheria-acellular pertussis vaccine (Tdap) Zoster vaccine Pneumococcal conjugate vaccine (PCV13) 17
Vaccine Administration The following video is a production of the California Department of Public Health Immunization Branch. This 25 minute program demonstrates appropriate vaccine administration technique and serves as the final phase of the self-study portion of your training. Needle-free Injector Technology FDA approved PharmaJet Stratis for use with Afluria August 15, 2014 Indicated for 18 to 64 years old Needle-free Eliminates risk of needle stick Reduce anxiety for patients with fear of needles 18
Needle-free Injector Technology Needle-free Injector Technology Immunogenicity and safety trial published in Lancet 2014, Aug 23;384(9944):674-81. Immune response to influenza given by jet injector was non-inferior to needle and syringe Higher frequency of injection site reactions Needle injection Needle-free injection 19
Conclusion Congratulations! You have completed the self-study portion of Immunization Administration Training for Pharmacists. Prior to attending the live session, please return to My Profile Claim CPE within the CEI website. Then click on the green tab TO DO ACTIVITIES and complete the exam and evaluation associated with the self-study. Questions regarding next steps? Contact us at admin@gotocei.org 20
MODULE 7 - Self-Assessment Questions The self-assessment questions below address the information contained in Modules 7. The questions will be the same questions as what will appear in the final, self-assessment examination required to obtain your CE Statement of Credit upon completion of Modules 1-7. Because there are 100 questions and you have a time limit, it is suggested that you print these questions, answer them on your own, and save them to refer to when you are completing the final, self-assessment examination. 1. Which of the following are inactivated vaccines? a) IIV4, PPSV23, Tdap b) MMR, Tdap, IIV3 c) LAIV, PCV13, Zoster d) Hepatitis B, Hib, Zoster 2. For which of the following individuals is Tdap recommended? a) A 12 year old female who completed the childhood DTaP series b) A 30 year old pregnant female at 32 weeks gestation c) A 65 year old female caring for her newborn granddaughter d) All of the above 3. Joseph, a healthy 55 year old male, is employed as a pharmacist at a chain pharmacy. The chain pharmacy will be implementing a corporate immunization program this October. Joseph wants to make sure he is upto-date on his immunizations before the program begins. He has received no vaccinations since childhood. Which of the following vaccines are recommended for this patient? a) Zoster, Td, PPSV23, Hepatitis A b) IIV3, Tdap, Hepatitis B c) Zoster, LAIV, Hepatitis B d) Td, HPV9, PPSV23 4. A 13 year old male and his mother go to the community pharmacy counter for a refill on his ADHD medication. His mother notices the pharmacy s immunization clinic sign and realizes her son has not seen the PCP for several years. She wonders if he is up-to-date with immunizations. He was up-to-date at his 4 to 6 year-old well child visit and has received no immunizations since. Which of the following vaccines are recommended for this patient? a) Tdap, HPV9, MCV4, IIV3 b) PCV13, IPV, MMR, Tdap c) LAIV, HPV9, Varicella, Td d) IIV3, DTaP, Hepatitis B, MMR 5. Martha is a 68 year old female seeking your advice regarding immunization. Her son and daughter in-law are expecting their first child in the next few months. She has no medical conditions and has received no vaccinations since childhood. Which of the following vaccines would you recommend she receive today? a) Zoster, IIV3, Tdap, PCV13 b) LAIV, Zoster, Hepatitis B c) Td, HPV9, PPSV23 d) IIV3, MMR, MCV, Hepatitis A 6. Which of the following vaccines is administered via the subcutaneous route? a) Zoster b) IIV4 c) Td d) Hepatitis B
MODULE 7 - Self-Assessment Questions 7. For patients 65 years of age and older who are indicated to receive both PCV13 and PPSV23, what is the recommended time period for separation of administration of the two vaccines? a) No separation needed, simultaneous administration recommended b) 6 months c) 1 year d) 5 years 8. Which of the following describes the procedure for intramuscular administration of a vaccine to an adult patient? a) Select a site on the outer aspect of the upper arm b) Use a 22 gauge, 1 inch needle c) Insert the needle at a 45 degree angle to the skin d) Aspirate before injection of the vaccine 9. For which of the following individuals is Live Attenuated Influenza Vaccine (LAIV) recommended? a) A 6 month-old healthy infant b) A 10 year-old patient with a fear of needles c) A 35 year-old pregnant patient d) A 52 year-old patient with asthma 10. Following the ACIP guidelines, for which of the following individuals is Zoster vaccine recommended? a) A 65 year old patient who had chicken pox at 7 years of age b) A 45 year old patient recovering from shingles rash c) A 55 year old patient with active shingles rash lesions d) A 58 year old patient with an anaphylactic reaction to neomycin