Addressing common barriers in adult immunizations: a review of interventions.

Introduction: Low levels of adult vaccination have been documented in the United States and globally. Research has been conducted to identify reasons for low immunization rates; however, the most useful studies are those that implemented interventions for identified barriers to evaluate their impact on rates of immunization. Identifying successful interventions provides immunization providers with evidence-based methods that can be utilized to increase the uptake of recommended vaccines.Areas covered: This review focuses on known barriers to adult immunizations and the interventions available in the literature to overcome these barriers. It outlines interventions that may increase vaccine uptake in the adult population through addressing barriers related to lack of vaccine knowledge, cost, access, provider and practice-based challenges, and racial and ethnic disparities.Expert opinion: Improving adult immunization rates is critical to protecting a population against vaccine-preventable diseases. Those interventions that appeared to increase immunization rates in the adult population included education and reminders about vaccination using text and telephone calls, low-cost or subsidized vaccines, easy access to immunization services, and understanding the cultural and social needs of different racial and ethnic populations. It is likely that an evidence-based multimodal approach using different categories of interventions is necessary to significantly improve adult immunization rates.

Using Community Pharmacy Immunization Screening Forms to Identify Potential Immunization Opportunities.

Immunization screening forms are completed for each patient that is to be vaccinated in the pharmacy. Screening forms contain demographic and health questions, which are used to determine if a patient is contraindicated to receive a vaccine. The objective is to determine if patient responses to questions on these forms can be used to identify potential vaccine indications. De-identified data was retrospectively collected from 11 community pharmacies in California and Michigan that included basic demographics, answers to immunization screening questions, and vaccine(s) administered during that visit. The Advisory Committee on Immunization Practices (ACIP) recommendations were used to forecast vaccine needs using the limited demographic and health history available from the screening forms. Descriptive statistics are presented, characterizing patient demographics and health condition-based recommendations, and the percentage of patients in a pharmacy population that may have potential indications for additional vaccines. Data were collected from 8669 pharmacy vaccine screening forms. Using the patient's date of birth on the screening form, 10% (n = 759) and 34.6% (n = 2615) of patients receiving vaccines at the pharmacy may be indicated for the zoster, or both the zoster and pneumococcal vaccines, respectively. Screening form questions that inquire about medical history are also able to identify 13.9% (n = 977) of patients with a potential need for pneumococcal vaccines. Our data indicate that pharmacists can identify potential immunization opportunities proactively by using their immunization screening form, not only to identify contraindications, but also indications.

Pharmacy-Based Travel Health Services in the United States.

The aim of this paper is to review pharmacy laws and regulations, pharmacist training, clinic considerations, and patient care outcomes regarding pharmacy-based travel health services in the United States. Pharmacists and pharmacies in the United States are highly visible and accessible to the public, and have long been regarded as a source for immunization services. As international travel continues to increase and grow in popularity in this country, there is a pressing need for expanded access to preventative health services, including routine and travel vaccinations, as well as medications for prophylaxis or self-treatment of conditions that may be acquired overseas. In the United States, the scope of pharmacy practice continues to expand and incorporate these preventable health services to varying degrees on a state-by-state level. A literature review was undertaken to identify published articles on pharmacist- or pharmacy-based travel health services or care in the United States. The results of this paper show that pharmacists can help to increase access to and awareness of the need for these services to ensure that patients remain healthy while traveling abroad, and that they do not acquire a travel-related disease while on their trip. For those pharmacists interested in starting a travel health service, considerations should be made to ensure that they have the necessary training, education, and skill set in order to provide this specialty level of care, and that their practice setting is optimally designed to facilitate the service. While there is little published work available on pharmacy or pharmacist-provided travel health services in the United States, outcomes from published studies are positive, which further supports the role of the pharmacist in this setting.

Topical Ketamine in the Treatment of Complex Regional Pain Syndrome.

The purpose of this study was to evaluate the effectiveness and adverse effects of topical ketamine in the treatment of complex regional pain syndrome. Retrospective charts were reviewed of patients 18 years or older diagnosed with complex regional pain syndrome and treated with topical ketamine during the study period of May 2006 to April 2013 in an academic medical center specialty pain clinic. Exclusion criteria consisted of subjects who 1) were treated with topical ketamine for pain syndromes other than complex regional pain syndrome, 2) initiated other pain therapies concurrently with topical ketamine, 3) had less than two documented visits, 4) began use of topical ketamine prior to the start of the study period, 5) were under 18 years of age. Subjects with ICD-9 diagnoses codes complex regional pain syndrome-1 or complex regional pain syndrome-2 were identified from encounter-based data and billing records. Data collected for each subject included demographics, description of complex regional pain syndrome, concurrent medications and medical conditions, type of ketamine compound prescribed, duration of therapy, side effects, reasons for discontinuation (if any), and pain scores (numerical pain rating scale; 0 to 10). Data were analyzed using descriptive statistics. Institutional Review Board approval was obtained prior to initiating the study. Sixteen subjects met the inclusion/exclusion criteria for the study, 69% of which were female with an average age of 46 years (range: 24 to 60). Subjects took an average of 3.7 other pain medications (range: 2 to 8), had an average of 2.7 other co-morbid pain conditions (range: 1 to 5), and 1.6 other co-morbid non-pain conditions (range: 0 to 4). Eight (50%) reported that their pain had improved, while 7 (44%) reported a worsening of pain. One reported no change in pain score. No subjects reported adverse effects. Based on the findings in this study, the use of topical ketamine in the treatment of complex regional pain syndrome shows promise due to the overall limited options available to treat this condition, as well as the favorable safety profile of topical agents. Future prospective controlled studies are needed to demonstrate a clear benefit.

The role of community pharmacy-based vaccination in the USA: current practice and future directions.

Community pharmacy-based provision of immunizations in the USA has become commonplace in the last few decades, with success in increasing rates of immunizations. Community pharmacy-based vaccination services are provided by pharmacists educated in the practice of immunization delivery and provide a convenient and accessible option for receiving immunizations. The pharmacist's role in immunization practice has been described as serving in the roles of educator, facilitator, and immunizer. With a majority of pharmacist-provided vaccinations occurring in the community pharmacy setting, there are many examples of community pharmacists serving in these immunization roles with successful outcomes. Different community pharmacies employ a number of different models and workflow practices that usually consist of a year-round in-house service staffed by their own immunizing pharmacist. Challenges that currently exist in this setting are variability in scopes of immunization practice for pharmacists across states, inconsistent reimbursement mechanisms, and barriers in technology. Many of these challenges can be alleviated by continual education; working with legislators, state boards of pharmacy, stakeholders, and payers to standardize laws; and reimbursement design. Other challenges that may need to be addressed are improvements in communication and continuity of care between community pharmacists and the patient centered medical home.

Vaccinations administered during off-clinic hours at a national community pharmacy: implications for increasing patient access and convenience.

PURPOSE: Approximately 50,000 adults die annually from vaccine-preventable diseases in the United States. Most traditional vaccine providers (eg, physician offices) administer vaccinations during standard clinic hours, but community pharmacies offer expanded hours that allow patients to be vaccinated at convenient times. We analyzed the types of vaccines administered and patient populations vaccinated during off-clinic hours in a national community pharmacy, and their implications for vaccination access and convenience. METHODS: We retrospectively reviewed data for all vaccinations given at the Walgreens pharmacy chain between August 2011 and July 2012. The time of vaccination was categorized as occurring during traditional hours (9:00 am-6:00 pm weekdays) or off-clinic hours, consisting of weekday evenings, weekends, and federal holidays. We compared demographic characteristics and types of vaccine. We used a logistic regression model to identify predictors of being vaccinated during off-clinic hours. RESULTS: During the study period, pharmacists administered 6,250,402 vaccinations, of which 30.5% were provided during off-clinic hours: 17.4% were provided on weekends, 10.2% on evenings, and 2.9% on holidays. Patients had significantly higher odds of off-clinic vaccination if they were younger than 65 years of age, were male, resided in an urban area, and did not have any chronic conditions. CONCLUSIONS: A large proportion of adults being vaccinated receive their vaccines during evening, weekend, and holiday hours at the pharmacy, when traditional vaccine providers are likely unavailable. Younger, working-aged, healthy adults, in particular, a variety of immunizations during off-clinic hours. With the low rates of adult and adolescent vaccination in the United States, community pharmacies are creating new opportunities for vaccination that expand access and convenience.

Global TravEpiNet: a national consortium of clinics providing care to international travelers--analysis of demographic characteristics, travel destinations, and pretravel healthcare of high-risk US international travelers, 2009-2011.

BACKGROUND: International travel poses a risk of destination-specific illness and may contribute to the global spread of infectious diseases. Despite this, little is known about the health characteristics and pretravel healthcare of US international travelers, particularly those at higher risk of travel-associated illness. METHODS: We formed a national consortium (Global TravEpiNet) of 18 US clinics registered to administer yellow fever vaccination. We collected data regarding demographic and health characteristics, destinations, purpose of travel, and pretravel healthcare from 13235 international travelers who sought pretravel consultation at these sites from January 2009 through January 2011. RESULTS: The destinations and itineraries of Global TravEpiNet travelers differed from those of the overall population of US international travelers. The majority of Global TravEpiNet travelers were visiting low- or lower-middle-income countries, and Africa was the most frequently visited region. Seventy-five percent of travelers were visiting malaria-endemic countries, and 38% were visiting countries endemic for yellow fever. Fifty-nine percent of travelers reported ≥1 medical condition. Atovaquone/proguanil was the most commonly prescribed antimalarial drug, and most travelers received an antibiotic for self-treatment of travelers' diarrhea. Hepatitis A and typhoid were the most frequently administered vaccines. CONCLUSIONS: Data from Global TravEpiNet provide insight into the characteristics and pretravel healthcare of US international travelers who are at increased risk of travel-associated illness due to itinerary, purpose of travel, or existing medical conditions. Improved understanding of this epidemiologically significant population may help target risk-reduction strategies and interventions to limit the spread of infections related to global travel.

A comparison of pharmacist travel-health specialists' versus primary care providers' recommendations for travel-related medications, vaccinations, and patient compliance in a college health setting.

BACKGROUND: Pretravel medication and vaccination recommendations and receipt were compared between primary care providers (PCPs) without special training and clinical pharmacists specializing in pretravel health. METHODS: A retrospective chart review of patients seen for pretravel health services in a pharmacist-run travel clinic (PTC) compared to PCPs at a University Student Health Center. Vaccine/medication recommendations were assessed for consistency with national/international guidelines. Medical/pharmacy records were queried to determine the receipt of medications/vaccinations. RESULTS: The PTC recommended antibiotics for travelers' diarrhea were given more often when indicated (96% vs 50%, p < 0.0001), and patients seen in the PTC received their medications more often (75% vs 63%, p = 0.04). PCPs prescribed more antibiotics for travelers' diarrhea that were inconsistent with guidelines (not ordered when indicated 49% vs 6%, p < 0.0001 and ordered when not indicated 21% vs 3%, p < 0.0001). The PTC prescribed antimalarials more often when indicated (98% vs 81%, p < 0.0001), while PCPs prescribed more antimalarials that were inconsistent with guidelines (not ordered when indicated 15% vs 1%, p < 0.0001 and ordered when not indicated 19% vs 2%, p < 0.0001). The PTC ordered more vaccines per patient when indicated (mean = 2.77 vs 2.31, p = 0.0012). PTC patients were more likely to receive vaccines when ordered (mean = 2.38 vs 1.95, p = 0.0039). PCPs recommended more vaccines per patient that were inconsistent with guidelines (not ordered when indicated: mean = 0.78 vs 0.12, p < 0.0001, ordered when not indicated: mean 0.18 vs 0.025, p < 0.0001). CONCLUSIONS: A pharmacist-run pretravel health clinic can provide consistent evidence-based care and improve patient compliance compared to PCPs without special training. Pretravel health is a dynamic and specialized field that requires adequate time, resources, and expertise to deliver the best possible care.

Mosquito-borne illnesses in travelers: a review of risk and prevention.

In 2008, residents of the United States made 12 million visits to developing countries in Asia, South America, Central America, Oceania, the Middle East, and Africa. Due to the presence of Anopheles, Aedes, and Culex mosquitoes, travel to these destinations poses a risk for diseases such as malaria, yellow fever, and Japanese encephalitis that cause significant morbidity and mortality. To gain a better understanding of the major emerging and established travel-related infectious diseases transmitted principally by mosquitoes and the measures for their prevention in U.S. residents who travel to these developing countries, we performed a literature search of the PubMed and MEDLINE databases (January 1950-February 2010). Information from the Centers for Disease Control and Prevention and the World Health Organization and relevant references from the publications identified were also reviewed. Vaccines for the prevention of Japanese encephalitis and yellow fever are commercially available to U.S. travelers and should be administered when indicated. However, the prevention of malaria, dengue fever, chikungunya, and West Nile virus relies on personal insect protection measures and chemoprophylaxis for malaria. As the rate of international travel continues to rise, individuals traveling overseas should be made aware of the risk of various infectious diseases and the importance of prevention. Physicians, pharmacists, nurses, and other practitioners can play a vital role in disease education and prevention, including the administration of vaccines and provision of chemoprophylactic drugs.

Intravenous artesunate for the treatment of severe malaria.

OBJECTIVE: To review the pharmacodynamics and pharmacotherapeutic use of intravenous artesunate for the treatment of severe malaria. DATA SOURCES: Literature was retrieved through PubMed (1999-March 2010), MEDLINE (1996-March 2010), and the Centers for Disease Control and Prevention (CDC), using the search terms artemisinin, artesunate, malaria, and severe malaria. In addition, reference citations from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: All articles in English that were identified from the data sources were reviewed. Focus was placed on postmarketing trials examining the safety and efficacy of artesunate in comparison with other regimens. DATA SYNTHESIS: The treatment of severe malaria requires prompt, safe, and effective intravenous antimalarials. Many oral and intravenous agents are available worldwide for the treatment of malaria; however, quinidine has been the only option for parenteral therapy in the US. Furthermore, this product's lack of availability as well as its adverse safety profile have created a treatment option gap. Recently, intravenous artesunate was approved by the Food and Drug Administration (FDA) for investigational drug use and distribution by the CDC. Three major studies regarding the use of intravenous artesunate are reviewed, in addition to the World Health Organization's malaria treatment guidelines. While there are no published head-to-head trials of intravenous artesunate versus intravenous quinidine for severe malaria, several international studies comparing intravenous quinine and artesunate concluded that artesunate has the highest treatment success, with lower incidence of adverse events. In addition, other literature is reviewed regarding counterfeit and other issues associated with artesunate. CONCLUSIONS: Artesunate, a new antimalarial currently available through the CDC, appears to be highly effective, better tolerated than quinidine, and not hampered by accessibility issues. If it were to be FDA approved and commercially available, it would be the preferred agent for the treatment of severe malaria in the US.

Vaccination delivery by chain pharmacies in California: Results of a 2007 survey.

OBJECTIVE: To better understand the practice standards and scope of pharmacist-administered vaccination services at chain pharmacies in California. DESIGN: Cross sectional. SETTING: California in 2006-2007. PARTICIPANTS: Eight state-level immunization coordinator corporate liaisons to chain pharmacies' immunization programs. INTERVENTION: Key informant phone survey with follow-up written survey. MAIN OUTCOME MEASURES: Policies, procedures, and vaccine usage. RESULTS: All eight chains provided immunization services to adults; four chains also vaccinated adolescents. More than 1,000 California pharmacists employed at chain pharmacies have been trained to vaccinate; more than 500 locations participate with evening, weekend, and walk-in hours. Influenza and pneumococcal vaccines were the most common vaccines administered. Other vaccines were used less frequently. Respondents expressed interest in partnering with public health to improve record sharing, build awareness, receive vaccine news updates, and explore other activities. CONCLUSION: Chain pharmacies in California have started to vaccinate adults and adolescents--two commonly undervaccinated age groups. To date, patients seeking vaccination at pharmacies are most likely to receive influenza and pneumococcal vaccines. Community locations and extended hours offer patients convenience, although out-of-pocket fees may be a barrier to some patients. Opportunities exist to build and strengthen partnerships among public health, the medical community, and pharmacists in order to vaccinate and protect patients not vaccinated in traditional settings.

Isoniazid completion rates for latent tuberculosis infection among college students managed by a community pharmacist.

OBJECTIVE: The authors' objective was to document 9-month and previously recommended 6-month treatment completion rates for latent tuberculosis infection (LTBI) in a pharmacist-managed LTBI clinic in a community pharmacy on a college campus, and to describe patient characteristics. PARTICIPANTS: Participants were university students diagnosed with LTBI. METHODS: The authors conducted a retrospective review of pharmacy records from 2000 to 2006. Main outcome measures included 6-month and 9-month LTBI treatment completion rates, total isoniazid (INH) tablets taken, characteristics of completers versus noncompleters, average time to treatment completion, and reported adverse drug events. RESULTS: The 9-month completion rate was 59%, and the 6-month completion rate was 67%. Among those not completing treatment, 15.2% experienced fatigue and 2.2% experienced a rash (p=.04 and p=.03, respectively). CONCLUSION: LTBI clinics are a unique niche for community pharmacies and can provide individualized patient care to ensure LTBI treatment adherence, monitoring for disease progression, and safety of INH.

New options in herpes management.

Herpesviruses in the alpha group--HSV-1, HSV-2, and VZV (i.e., HSV-3)--are ubiquitous in American society. HSV-1 is associated primarily with herpes labialis, while HSV-2 is involved in about 70% of cases of genital herpes. Varicellazoster virus causes chickenpox in unvaccinated children and others, and latent virus produces shingles later in life. Since many patients with HSV-1 and HSV-2 infections are asymptomatic, testing is important in determining presence of the viruses. Several antiviral agents effective against HSV have been marketed. While the infection cannot be cured, the available medications are effective for reducing the duration of outbreaks, recurrences, and possibly viral transmission.