Tag Archives: pharmacists

Adult Pneumococcal Recommendations in Practice

by Kerry Nolan, Oregon Immunization Program Pharmacy Intern

This is part one of our two part pneumococcal vaccination series. 

Update: This post was edited on 2/5/2015 for clarification.

Situation: A 65 year-old patient has come to our clinic today for a pneumococcal vaccination following her first dose of Pneumovax at age 62.

What vaccination should she receive today? If and when will she need another one? Will it be covered? Since the Advisory Committee on Immunization Practices (ACIP) introduced their latest pneumococcal recommendations for patients 65 and older, both providers and patients have been asking the right questions.

What are the new recommendations?

Adults aged 65 and older should now receive one dose each of Prevnar 13 and Pneumovax 23. Previously, a single dose of Pneumovax 23 alone was recommended for this age group. Although Prevnar 13 has been FDA approved for adults 50 years and over since 2011, it just earned the ACIP recommendation for adults age 65 and up last September. ACIP recommends that adults 19–64 years receive PCV13 if they have an identified health risk.  Healthy individuals age 50–64 may have a dose of Prevnar 13 per FDA approval, however, this dose may not be covered by insurance.  Sounds simple enough, but determining when and who should receive which vaccine gets a bit more complicated. The recommended pneumococcal vaccination schedule separates patients ≥65 years into those who have:
1. Never received any pneumococcal vaccine, and should receive Prevnar 13 first then Pneumovax 23 between 6 to 12 months later
2. Received one (or more) doses of Pneumovax 23, and should receive Prevnar 13 at least one year after their last Pneumovax 23 vaccination
3. Received Pneumovax 23 before turning 65, and should still wait at least one year since their last Pneumovax 23 vaccination to receive Prevnar 13, but must also wait at least 5 years between Pneumovax 23 doses to receive one final dose at ≥65.

In this diagram provided by the ACIP, the latest adult pneumococcal vaccination schedules are summarized:
Pneumococcal vaccine
Image: Sequential administration and recommended intervals for PCV13 and PPSV23 for adults aged ≥65 years — Advisory Committee on Immunization Practices, MMWR 2014

So- which should our patient receive and when? She received a dose of Pneumovax 23 prior to turning 65, which places her in the third category. It has been 3 years since Pneumovax was given, so she should receive Prevnar 13 today. However, when considering the best time for her to return for the final Pneumovax dose, we find that even in 12 months, only a total of four years (not the recommended five) will have passed since her last dose. What should we do? In this situation, the patient should wait the full five years since her Pneumovax dose before receiving the final one. In other words, she will receive Prevnar 13 today and a final Pneumovax 23 dose in about two years.

Will the new vaccine be covered?
On December 31st the Center for Medicaid and Medicare Services (CMS) released a statement announcing that an update to pneumococcal vaccine coverage requirements would be in effect as of September 19, 2014 to align with ACIP recommendations. Effective February 2nd, two pneumococcal vaccines and their administration will be covered under Medicare part B: the first for patients who have never received any pneumococcal vaccine and a second (different) vaccine one year after the first was administered. This coverage is not perfectly aligned with ACIP’s recommendations, but captures where vaccination schedules overlap at the one-year mark. Additionally, Medicare will adjust previously denied claims for qualifying pneumococcal vaccinations administered September 19th or later if the claim is resubmitted. Our patient is more likely to have her second vaccination covered if she is insured privately. As part of the Affordable Care Act, health plans are now required to cover ACIP-recommended vaccines without co-pays or cost-sharing.

As we become comfortable with the nuances of these recommendations, we are better able to provide vaccine protection and education. Tricky timing, different vaccines and varying coverage are each good reasons for giving pneumococcal vaccines in older adults your careful consideration.

References:

1. CDC. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine among Adults Aged ≥65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR 2014; 63 (37); 822-825. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm. Accessed 26 Jul 2015.
2. Centers for Medicare & Medicaid Services (CMS). Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations. MLN Matters 2014; p1-3. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9051.pdf. Accessed 26 Jan 2015.

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Alert on ALERT: All Pharmacists to use ALERT IIS

Alert

Pharmacists play an increasingly large role in immunizing Oregonians. People aged 11 years through the lifespan can be immunized by their pharmacists against diseases such as pertussis, shingles, and influenza.

Oregon’s online ALERT Immunization Information System (ALERT IIS) is an important tool for pharmacists and all vaccine providers. Most immunizations that are given in Oregon are stored in the system. As a result, the ALERT IIS provides authorized users access to millions of patient vaccination histories.

Many pharmacists, however, don’t take advantage of some very helpful ALERT IIS tools for looking up patient histories and forecasting needed vaccinations. By using the ALERT IIS, pharmacist can avoid immunizing patients unnecessarily with vaccines they’ve already received and also find out what vaccines patients need that day, and in the future. Pharmacy techs and other staff (and anyone who is an authorized ALERT user) can also access these tools.

The Oregon Board of Pharmacy and the Oregon Immunization Program (OIP) have worked together to include the use of these ALERT IIS functions in the Pharmacy Protocols. The effective date for this protocol change is no later than January 1, 2014, although pharmacies are encouraged to begin using the ALERT IIS as soon as possible.

The new language that appears in each protocol is as follows:
Effective no later than January 1, 2014, prior to administering vaccine, pharmacy personnel will look up each patient in the ALERT Immunization Information System (IIS) to determine the patient’s vaccine history and to forecast vaccines needed.

Exceptions:
• This is not required when administering only influenza vaccines, but will continue to be recommended to help increase pneumococcal vaccine rates.
• This is not required when the pharmacy/pharmacist conducts a remote vaccine clinic, but will continue to be recommended when remote connectivity is available.

The revised protocols are available here.

OIP’s ALERT IIS staff have begun working with some pharmacy chains to get pharmacists and staff enrolled and trained to access ALERT IIS. One pharmacy chain is also pilot testing a bidirectional query interface between their Electronic Health Record (EHR) and ALERT IIS; this may be an additional option other pharmacies could explore for requesting and submitting immunization information. For more information on how you and your staff can connect to ALERT, please contact Jenne McKibben at jenne.mckibben@state.or.us.

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