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Pharmacists Impacting Immunization Rates in Ohio

Pharmacists Impacting Immunization Rates in Ohio
Christine Murphy, R.Ph.
Coordinator of Year III Experiential Rotations
OSU College of Pharmacy

Why should patients get immunized?
•Pneumonia and influenza combined are the sixth leading cause of death and the most common cause of death due to infectious disease.[1]
•The flu vaccine can prevent 50 to 60 percent of hospitalizations and 80 percent of deaths from influenza-related complications among the elderly.2
•30,000 to 60,000 or more people die each year from pneumococcal disease, influenza, hepatitis B and other vaccine-preventable diseases.[3,4]

Are the immunization rates really that low in the U.S.? In Ohio?
•In 2001, 22.7 percent of Ohio’s children aged 19 to 35 months did NOT complete the vaccine series as recommended, i.e., they had not received Hib (Haemophilus influenzae type b) or Hepatitis B vaccine. [5]

•In 2001, 21.5 percent of Ohio’s children did not receive their fourth DTP (diphtheria/tetanus/pertussis) booster. [6]

•In 2001, 30.3 percent of people > 65-years-old did not receive their flu shot.[7]

Why are these immunization levels so low?
Sociologists list a number of barriers related to a person’s perception.
•“They” won’t get infected.
•These diseases are not as serious as they used to be.
•Side effects or access are perceived barriers.
•Why should they get vaccinated?
•Sometimes lack of positive reinforcement by health professionals, such as pharmacists, deters persons from becoming immunized.

For example, the primary reason some patients don’t get a pneumonia vaccine is because they don’t know they need it and the recommended schedule is somewhat confusing.[8] See Table 1.

Goals for improving the immunization rates.
The U.S. Department of Health and Human Services has defined the goal for improving the immunization rates in the Healthy People 20109 document. (Healthy People 2010 is a comprehensive set of disease prevention and health promotion objectives for the nation to achieve over the first decade of the new century.) The goal is to immunize 90 percent of individuals > 65-years-old. In order for Ohio to reach that goal, at least 430,000 more Medicare beneficiaries will need to receive the flu vaccine, and over 500,000 will have to receive the pneumococcal vaccine! Other goals include:

•90 percent routine vaccination coverage for adolescents (13 to 15 years);
•90 percent coverage for recommended vaccines for young children (19 to 35 months), achieve and maintain;
•80 percent coverage for young children and adolescents for all vaccines, maintain for at least five years.

The recommended schedule for influenza vaccine is presented in Table 2.

Pharmacists’ Activities.
What are pharmacists, one of the most accessible healthcare professionals,10 doing to help reach Healthy People 2010 goals which will decrease the alarming morbidity and mortality statistics stated earlier?

Denver pharmacists were the first to take the lead in this arena in 1984. Over time, the efforts of 400 community pharmacies, both independent and chains, increased the immunization rates from 100,000 per year to 700,000 per year.11 While some of these doses were administered in pharmacies, many were not. The increased awareness of the pharmacists’ efforts increased the number of immunizations at other sites, such as doctors’ offices and clinics.

Pharmacist activities included:
1. educating patients about the importance of immunizations for adults and children;
2. providing patients with information about available immunization locations;
3. encouraging high-risk patients to get recommended immunizations either at their physician’s office or immunization clinics; and
4. holding flu shot days and/or more comprehensive immunization clinics in community pharmacies. Either certified pharmacists or nurses could administer immunizations.

More than 300 Ohio pharmacists have completed the Ohio Pharmacists Association Pharmacist Training Program for Adult Immunizations. Kroger pharmacists in southwest Ohio have set up immunization clinic days in their pharmacies. Max Peoples, R.Ph. and Andrea Lawrence, Pharm.D. at Uptown Pharmacy in Westerville; Tom Lamb, R.Ph., Meg Lamb, R.Ph., and Kathy Karas, R.Ph. at Sand Run Pharmacy in Akron; and Andy DeHoff, R.Ph. at Northland Medical Pharmacy in Columbus are a few independent pharmacists providing adult immunizations throughout the year.

What are the Colleges of Pharmacy doing to promote immunizations?
In September 2002, The Ohio State University College of Pharmacy decided to frontload the pool of immunization certified pharmacists. An immunization certification course and related activities were integrated into the Fall Quarter experiential rotation for third-year entry-level Pharm.D. students. The CDC/APhA Pharmacy-Based Immunization Delivery, a national certificate program for pharmacists, certifies each student to be an immunization advocate upon completion. When licensed in Ohio, they can administer certain adult immunizations12, i.e., influenza, pneumonia, tetanus, hepatitis A and hepatitis B. The first class of students to complete this course will graduate in June 2004.

•Course. The course consists of eight hours of self-study, a pre-test, 12 hours of class, post-test, training in and observation of intramuscular and subcutaneous injections. In addition to this course work, each student must complete an Adult CPR/AED13 class.

After the coursework is completed, the students participate in a series of activities where they apply their knowledge to patients in the community.

•Adult and Childhood Immunization

Advocacy. Students triage patients at the Columbus Health Department’s Immunization Clinics to determine which immunizations are needed that day and answer patient/family member’s questions about the immunizations and adverse effects. The students also encourage patients or parents to return for additional recommended immunizations. Students also phone parents to remind them to catch up on missed immunizations for their children.

•Flu Shot Days at Community Pharmacies, Senior Centers, OSU Staff and Faculty Wellness Events. Students help patients with paperwork, answer questions, suggest that adult patients consider other immunizations that day or in the future, e.g., pneumococcal, tetanus/diphtheria. Students also provide brochures that include both adult and childhood immunization schedules and information about the location of nearby immunization clinics.

The other three colleges of pharmacy in Ohio are now training students in immunization practices as well.

How can pharmacists gain the necessary knowledge to administer adult immunizations and/or become an immunization advocate?
Licensed Ohio pharmacists can become advocates of immunization or become qualified to administer certain adult vaccines by any or all of the following.

•Completing an Ohio State Board of Pharmacy approved pharmacist immunization training program. Information about the Ohio Pharmacists Association Pharmacist Training Program for Adult Immunizations is available on the OPA web site, This program is offered once a year, or on demand when a sufficient number of pharmacists are interested. The program consists of a home-study program, a live training session including hands-on experience with IM, SC and now the intranasal administration of vaccines, and basic life-support training by the American Red Cross.

•Providing adult immunizations in their community pharmacy by qualified pharmacists or nurses; e.g., sponsoring a flu shot day at the pharmacy between mid-October and early December to prevent flu January through March.

•Targeting high risk patients (i.e., patients > 50 years old, those with diabetes, cancer, or lung disease, or those who are immunocompromised) for an annual flu shot and pneumonia shot as recommended. Establish a policy to distribute a flu shot flyer to each patient receiving certain disease-specific medications, such as oral hypoglycemics, insulin, or inhalers.

•Targeting parents of preschoolers to be sure they know the current immunization schedule for children. Distribute childhood immunization schedules to parents when they pick up a prescription filled for their preschooler.

There are a many web sites that provide useful information, reproducible documents and free brochures that can be used to advocate immunizations (Table 3). The OPA web site provides links to some of these sites. Go to the OPA home page,, click on the Related Sites button, click on Immunization Resources.

By increasing the number of “immunization advocates,” i.e., pharmacy students and licensed pharmacists, Ohio can better meet the Healthy People 2010 immunization goals and, thereby, decrease the incidence of and deaths from vaccine-preventable diseases in Ohio.


1. National Immunization Project Prevention of Influenza and Pneumococcal Disease, Ohio KePRO, Publication No. 1004-OH-026-11/20/02
(The original articles providing this information are:
•Butler JC, Shapiro ED, Carlone GM. Pneumococcal vaccines: history, current status, and future directions. AM J Med. 1999;107(1A):69S-76S

•Centers for Disease Control and Prevention. Influenza and pneumococcal vaccination levels among adults aged > 65 years – United States. MMWR Morb Mortal Wkly Rep. 2001;51(45):1019-1024

•Farr BM, Johnston BL, Cobb DK, et al. Preventing pneumococcal bacteremia in patients at risk. Results of a matched case-control study. Arch Intern Med. 1995;155:2336-2340

•Sisk JE, Moskowitz AJ, Whang W, et al. Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA. 1997;278:1333-1339)

2. Ibid.

3. Grabenstein JD. Immunofacts: Vaccines & Immunologic Drug. St. Louis: Facts and Comparisons, Revision 26, May 2002

4. Advisory Committee on Immunization Practices. Update on adult immunization: Recommendation of the Immunization Practices Advisory Committee. MMWR 1991;40 (rr4-12):1-94

5. Centers for Disease Control and Prevention, National Immunization Program, National Immunization Surveys, 1996-2001

6. Ibid.

7. Medicare Consumer Assessment of Health Plan Study Survey (CAHPS), 2001

8. National Immunization Project Prevention of Influenza and Pneumococcal Disease, Ohio KePRO, Publication No. 1004-OH-026-11/20/02

9. Healthy People 2010, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services,

10. Arledge S. Influenza immunization: An opportunity for effective patient advocacy. Consult Pharmacist 1996;11:894,896,898

11. Debrovner D. Beyond Chicken Soup. Am Druggist 1994; 209(Dec):21-4

12. The Ohio Board of Pharmacy permits only licensed pharmacists to administer immunizations

13. AED = Automated External Defibrillator

14. Advisory Committee on Immunization Practices (ACIP) guidelines 2003

Table 1
Recommended Schedule for Adult Pneumococcal Vaccine

Highest risk population:
The first vaccination is recommended for people who are at highest risk, i.e., spleen removed, sickle cell, HIV, immunocompro-mised, receiving immunosuppressive chemotherapy. A second dose may be given after 65 years of age, if it has been more than five years since the first vaccine. Only one revaccination dose (total of two doses) is recommended since the risk of adverse effects increases significantly.14

Persons 65 years of age or older:
If a person has not received a pneumococcal vaccine before the age of 65, a single dose of the vaccine is recommended. If the person received a dose of vaccine before the age of 65, he should receive a second dose five years after the first dose.

Note: for both the highest risk population and the over 65 group, some physicians may give a high risk patient a third dose, but they must consider the related benefit-to-risk ratio.

Adapted from: CDC Pink Book 2002

Table 2
Recommended Schedule for Adult Influenza Vaccine

•Adults 50 year of age or older

•Persons 6 months to 50 years with chronic illness such as heart disease, lung disease, diabetes, renal dysfunction, hemoglobinopathies, immunosuppression and/or people living in chronic care facilities

•Persons (>6 months) working or living with at-risk persons

•Pregnant women with underlying medical conditions

•Healthy pregnant women in second or third trimester during influenza season

•All health care workers and those who provide key community services

•Travelers in areas of influenza activity or those with persons from those areas

•Anyone who wishes to reduce the likelihood of becoming ill with influenza

Adapted from the Advisory Committee on Immunization Practices (ACIP) recommendations by the Immunization Action Coalition, June 2002

Table 3
Selected Immunization Resources
CDC National Immunization Program includes adult immunization schedules and vaccine information statements (VIS), and much more.
Ohio KePRO (Keystone Peer Review Organization) is a diversified healthcare information company that offers quality improvement to physicians in providing care and preventative health maintenance, with a current focus on immunizations, diabetes and mammography through a contract with the Centers for Medicare & Medicaid Services (CMS).
Ohio Department of Health includes educational materials for health care providers under Health Resources, up-to-date alerts and advisories on threats and concerns to public health in Ohio, etc.
Local Health Districts contact information to obtain vaccine immunization program schedules in your area, etc. are included.
Ohio Immunization Registry is a web-based registry to record immunizations. Pharmacists who administer vaccines can participate in this registry.
Healthcare workers’ information and materials is available from Aventis Pasteur.
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