the United States, the most common infectious cause of death is pneumonia.
1 While pneumonia occurs in individuals of all ages, the most severe
clinical manifestations are seen in the elderly, the very young, and those
with special health conditions such as alcoholism, diabetes, heart or lung
disease, kidney failure, HIV infection, or certain types of cancer. In
otherwise healthy adults, Streptococcus pneumoniae(pneumococcus) and
Mycoplasma pneumoniae are the most prominent pathogens causing
community-acquired pneumonia (CAP).1 In the U.S., pneumococcus is
considered the most common cause of bacterial pneumonia in all age categories,
accounting for approximately 70% of all acute bacterial pneumonias.1
Pneumococcal disease is a
serious condition that may result in considerable morbidity causing pneumonia,
bacteremia, or meningitis. It is known to kill more people in the U.S. each
year than all other vaccine-preventable diseases combined.2,3
Pneumococcal morbidity statistics identify death in approximately one out of
every 20 people with pneumococcal pneumonia, two out of 10 with bacteremia,
and three out of 10 with meningitis; death from these conditions is even more
likely in patients with the special health conditions identified above.2,3
Pneumococcal infection accounts for approximately 66% of all fatal cases of
CAP of unknown etiology.4 Prevention of pneumococcal pneumonia is
particularly important because this infection, once commonly treated with
penicillin, has become more difficult to treat due to antibiotic resistance.
According to the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO), pneumonia is
a core performance measure; additionally, one related quality indicator
measure for JCAHO and the Centers for Medicare and Medicaid Services (CMS) is
the screening for and administration of the pneumococcal polysaccharide
vaccine (PPV) in individuals 65 and older.5
immunization, considered more specific than the term vaccination,
refers to the process of inducing or providing immunity artificially by
administering an immunobiologic agent.6 The PPV provides protection
against 23 types of pneumococcal bacteria. TABLE 1 outlines those
individuals who should receive the PPV. Most healthy adults develop protection
to all or the majority of these various types within two to three weeks
following injection of the vaccine. Those who may not respond as well or at
all include the very old, individuals with long-term illnesses, and children
younger than 2. The PPV is administered intramuscularly or subcutaneously as a
single 0.5-mL dose.
In general, one dose of the
PPV is usually all that is needed. Under some circumstances, however, a second
dose may be necessary and is recommended for individuals 65 and older if they
were vaccinated 5 or more years earlier and were younger than 65 at the time
of the primary vaccine injection. A second dose is also recommended for
individuals with special conditions (e.g., damaged spleen or no spleen,
sickle-cell disease, HIV or AIDS, etc.) or those who are taking
immunosuppressant medication (e.g., chemotherapy or long-term
corticosteroids). Additionally, the PPV may be less effective in some people,
particularly those with lower resistance to infection (see TABLE 1).
These patients should still be immunized, however, since they are more
susceptible to increased morbidity secondary to pneumococcal disease.
While a suppressed response to
vaccines may occur in patients receiving glucocorticoids, there is no
contraindication to immunization in patients receiving the following
glucocorticoid therapy: up to two weeks of low- to moderate-dose, long-term,
alternate-day therapy with short-acting agents; topical; aerosol; maintenance
physiologic doses; intra-articular, bursal, or tendon injections.6
Caution is advised, however, in all patients receiving immunosuppressant
Risks and Allergic
Reactions Associated with the PPV
While the PPV is a
very safe vaccine, approximately half of individuals who receive it experience
very mild side effects, including pain or redness at the injection site; less
than 1% develop muscle aches, fever, or more severe local reactions.2,3
Although very rare, severe allergic reactions have been reported
following vaccine administration, and there is a very small risk that serious
complications, including death, may ensue. Taking all of this into account,
coming down with pneumococcal disease is significantly more likely to cause
serious problems than receiving the vaccine.2,3
Patients receiving vaccines
may respond with allergic reactions, not only to the immunobiologic agent
itself, but also to other components of the vaccine preparation. These would
include suspending agents (e.g., complex fluids containing proteins such as
albumin) and additives to help maintain sterility such as preservatives,
stabilizers, and antibiotics.6 Formulations may vary from
manufacturer to manufacturer. A severe allergic reaction requires immediate
medical attention. Patients should report to the physician exactly what
occurred, including the date and time it transpired, and when the vaccine was
administered. A physician, nurse, pharmacist, or health department should file
a Vaccine Adverse Event Reporting System form, or if necessary, the patient
can self-report the event (see RESOURCES SIDEBAR).2,3,7
Statements (VISs) are information sheets produced by the CDC that explain to
vaccine recipients, their parents, or their legal representatives both the
benefits and risks of a vaccine. Federal law requires that a VIS be handed out
whenever (before each dose) certain vaccines are administered. VISs are
available in a variety of languages (see RESOURCES SIDEBAR).2,3
It is recommended that health care providers consult their state requirements
pertaining to immunization, since the federal requirement to provide the
vaccine information materials supplements any applicable state laws.2,3
Pharmacist's Role as
Educator, Facilitator, and Immunizer
According to the
American Pharmacists Association, pharmacists have an important role in
immunizations--one of educator (motivating people to be immunized), facilitator
(hosting others who immunize), and immunizer (protecting vulnerable people,
consistent with state law).7 It has been reported nationally that
the availability of vaccines that are administered by pharmacists increases
immunization rates and can lead to a larger number of physician-administered
vaccinations.8,9 Furthermore, physician associations (e.g., the
American College of Physicians and the American Society of Internal Medicine)
have supported the pharmacist acting as an immunization information source,
host of immunization sites, and immunizer, as allowed by state law. Research
has shown that in states that allow pharmacist immunizations versus those
states that do not, a statistically significantly greater percentage of
patients 65 and older were vaccinated and pharmacist-managed programs can
substantially increase compliance.10,11
Vaccine Standing Orders
Programs and Collaborative Agreements
Standing orders for
vaccines reduce and eliminate missed opportunities to immunize and have proven
to be effective in improving immunization rates.12 In many states,
through the establishment of a collaborative practice arrangement with a
physician, a pharmacist is able to obtain a standing order for vaccines that
remains in place for administration by the pharmacist as a service offered by
a pharmacy immunization practice. Vaccine standing order programs were
developed to avoid the labor-intensive process of requiring pharmacists to
contact a physician for a verbal order to vaccinate each time a patient is
identified as a candidate for immunization (see TABLE 2).
Once a patient is screened and
identified as a candidate, a vaccine may be offered and administered by the
pharmacist. Documentation of the screening process (e.g., indication
appropriateness and contraindications) and the reporting process (e.g.,
informing primary care provider of vaccine administration), for example, would
be formally addressed in the collaborative practice agreement to ensure
completeness of the medical record. In order to sustain the vaccination
program and allow pharmacists to focus on patient risk assessment and
evaluation of vaccine contraindications, pharmacy students and technicians are
employed, providing a formalized structure of workflow (see TABLE 2).
5 This general strategy may be utilized, and modified appropriately, for
a variety of practice settings, such as a community pharmacy, hospital
pharmacy, or consultant pharmacy practice.
The 2002 CMS regulation does
allow for the use of standing orders with regard to billing of pneumococcal
immunization.5 It is recommended that pharmacists
familiarize themselves with the specific requirements for the periodic review
of collaborative agreements and/or standing orders by the board of pharmacy or
medicine in their state.5 The CMS reimbursement fees for the PPV
vary by state or locality, with coverage provided as a Medicare Part B benefit.
Pneumococcal disease is considered a
serious condition that may result in considerable morbidity and mortality.
Pharmacists, as advocates, hosts, and immunizers for the PPV, can assist with
the overall prevention of morbidity and mortality associated with this
1. Glover ML, Reed
MD. Lower respiratory tract infections. In: DiPiro JT, Talbert RL, Yee GC, et
al., eds. Pharmacotherapy: A Pathophysiologic Approach. 5th ed. New
York, NY: McGraw-Hill; 2002:1849-1867.
2. Pneumococcal polysaccharide
vaccine: what you need to know. Centers for Disease Control and Prevention.
Available at: www.cdc.gov/nip/publications/VIS/vis-ppv.pdf. Accessed June 8,
3. At a glance: Vaccine Information
Statements (VISs), Centers for Disease Control and Prevention. Available at:
www.cdc.gov/nip/publications/vis. Accessed May 18, 2007.
4. Beers MH, Porter RS, Jones TV, et
al. The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse
Station, NJ: Merck Research Laboratories; 2006:424-430.
5. Sokos DR, Skledar SJ, Ervin KA,
et al. Designing and implementing a hospital-based vaccine standing orders
program. Am J Health-Syst Pharm. 2007;64:1096-1102.
6. Bertino JS Jr , Hayney MS.
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GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 5th ed.
New York, NY: McGraw-Hill; 2002:2123-2145.
7. Guidelines for pharmacy-based
immunization advocacy. American Pharmacists Association. Available at:
Accessed June 8, 2007.
8. Field RI. Pharmacists set to
become more active clinicians in Pennsylvania. P & T.
9. Jelesiewicz E. Pennsylvania
pharmacists could soon be "calling the shots." Temple Times
(online edition). March 17, 2005. Available at: www.
temple.edu/temple_times/3-17-05/pharmacy.html. Accessed April 10, 2006.
10. Steyer TE, Ragucci KR, Pearson
WS, Mainous AG III. The role of pharmacists in the delivery of influenza
vaccinations. Vaccine. 2004;22:1001-1006.
11. Van Amburgh JA, Waite NM, Hobson
EH, Migden H. Improved influenza vaccination rates in a rural population as a
result of a pharmacist-managed immunization campaign. Pharmacotherapy.
12. Hogue MD, Grabenstein JD, Foster
SL, Rothholz MC. Pharmacist involvement with immunizations: a decade of
professional advancement. J Amer Pharm Assoc. 2006;46:168-182.
13. Medicare Preventive Services:
adult immunizations. Centers for Medicare and Medicaid Services. Available at:
Accessed June 8, 2007.
14. Semla TP, Beizer JL, Higbee MD.
Geriatric Dosage Handbook. 12th ed. Ohio: Lexi-Comp, Inc;
15. Recommended adult immunization
Schedule–United States, October 2005-September 2006. Morb Mortal Wkly
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