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Unusual complications (e.g., severe bacterial superinfections, Reye syndrome,

encephalopathies) are markedly reduced with an immunization program.

103 Before the

vaccine was available, approximately 4 million cases of chickenpox were reported

annually, with 4,000 to 9,000 hospitalizations and 100 deaths.

103 Historically, 55% of

varicella-related deaths occurred in adults, many of whom were infected by exposure

to unvaccinated preschool-aged children with typical cases of varicella.

106

Despite high vaccine coverage rates and 85% vaccine efficacy with the previous

single dose vaccination, outbreaks of breakthrough varicella continued to occur in the

United States.

107 As a result, current guidelines recommend a two-dose series for all

children, adolescents, and adults without evidence of immunity.

1

,

27

,

107 The first

varicella vaccine dose should be administered at 12 to 15 months of age, followed

by the second dose at 4 to 6 years of age. For persons 7 to 12 years of age who have

not received varicella vaccine, two doses of varicella vaccine should be

administered at least 3 months apart. For persons older than 13 years of age,

administer two doses of varicella vaccine at least 4 weeks apart.

107

Postexposure varicella vaccination should be considered for J.T. Chickenpox

infection can be prevented or symptoms reduced if varicella vaccine is administered

within 3 days of exposure and may provide some protection within 5 days.

105

,

107

If

J.T. also needs MMR vaccination, the quadrivalent combination vaccine ProQuad

containing measles, mumps, rubella, and varicella antigens may be considered. A

second dose of varicella vaccine in 3 months should be recommended to ensure longterm protection.

The most common adverse effect associated with varicella vaccine administration

is rash. Transmission of the virus from the vaccine has been documented in only 3 of

15 million doses administered, all of which occurred in the presence of a vesicular

rash after vaccination.

103 Caution should be used when patients exhibit a rash

postvaccination to avoid contact with immunocompromised individuals until rash

resolution.

107

Although varicella vaccine might not entirely prevent the occurrence of chickenpox

in an immunocompromised patient, it can modify the disease. In the National

Institutes of Health’s Collaborative Varicella Vaccine Study, a seroconversion rate

of only 85% was observed after a single dose in adults, compared with 95% in

healthy children and 90% in children with leukemia.

108 Varicella vaccine is generally

not recommended in children who have cellular immunodeficiencies, but it can be

used in those with impaired humoral immunity.

107 The vaccine should be avoided in

children with symptomatic HIV, but it may be considered in asymptomatic or mildly

symptomatic patients.

103

,

107

CASE 64-16, QUESTION 2: If the varicella vaccine is now universally recommended, what is the role of the

herpes zoster vaccine?

After a primary infection with varicella, 15% to 30% of the population

experiences a latent infection in the sensory nerve ganglia that reactivates, causing

herpes zoster (HZ).

107

,

109 HZ typically occurs decades after initial varicella infection.

This reactivation can result in post-herpetic neuralgia or dissemination which results

in skin eruptions (“shingles”) and potential CNS, pulmonary, or hepatic

complications.

107

,

109 Although some have theorized that universal varicella

vaccination should eventually reduce the incidence of HZ because it prevents

primary infection, others debate that the attenuated virus may have greater potential

for becoming latent and reactiving.

107

,

109 Still others argue that with the elimination of

wild-type virus in the community, the exposure of individuals with latent wild-type

varicella to help boost immunity and prevent HZ is reduced. In this situation, the risk

of HZ may be increased.

107

,

109 Routine varicella immunization began in 1995 and only

long-term studies of vaccinated individuals will answer the questions about the

impact of the varicella vaccination upon the incidence of HZ. However, currently the

majority of adults are not immunized against varicella (unless required as a health

care worker) and have previously acquired wild-type varicella infections. Therefore,

most adults in the United States are at risk for exhibiting HZ as they age.

The zoster vaccine (Zostavax) is a live attenuated varicella zoster vaccine that

uses the same strain and antigens as the varicella vaccines (Varivax and ProQuad);

however, it is 14 times more potent and contains additional antigenic components. It

was initially recommended for all individuals older than 60 years of age as a single

subcutaneous injection to prevent HZ.

28–30,109,110

In 2011, FDA approval was given to

use HZ vaccine in individuals 50 years of age or older; however, ACIP

recommendations remain for patients 60 years and older.

110

It may be given to

patients with a previous history of HZ, but it is not indicated to treat acute zoster or

prevent further complications during an acute episode.

109

It is not recommended for

routine immunization for anyone who has previously received the varicella vaccine.

The zoster vaccine was shown in the Shingles Prevention Study to reduce the

incidence of HZ by more than 50% and resulted in reductions in the severity and

duration of pain, in addition to preventing the development of post-herpetic

neuralgia.

111

ADMINISTRATION TECHNIQUES

Vaccines or other biological agents are typically administered as either an

intramuscular (IM) or subcutaneous injection.

Because appropriate administration by the correct route and technique is critical to

the effectiveness of the specified vaccine, it is essential to consult the prescribing

and administration information for each specific vaccination administered to a patient

(see also Table 64-1). The technique of vaccine administration by either route should

include sterilizing the skin surface, drawing up the vaccine from the vial into a

syringe using sterile technique, protecting the patient and health care provider

regarding biological hazards, performing proper disposal of biohazardous/sharps

materials (needles and blood-borne products), observing for adverse effects after

administration, and reassuring the patient postvaccine administration. Table 64-3

includes general guidelines for safe and effective parenteral administration.

CASE 64-17

QUESTION 1: B.D., a nurse from a family medicine clinic, frantically calls you because she mistakenly

administered a Pneumovax vaccination subcutaneously. How to you respond to B.D.’s call?

The majority of vaccines, including Pneumovax, specify IM administration. This

technique involves penetration of the appropriate muscle at a 90-degree angle. For

graphical illustration of intramuscular vaccine administration, see

http://www.immunize.org/catg.d/p2020.pdf. Site of IM injections include the

anterolateral thigh muscle in infants and toddlers, and the deltoid (upper arm) muscle

for children and adults.

1

,

112 The typical needle used to administer an IM injection is 1

inch long and 22 to 25 gauge. A shorter needle (e.g., 5/8 inch) may be used for

newborns, whereas a 1 to 1/2-inch needle may be needed for adults weighing greater

than 90 kg for women and 118 kg for men.

112

,

113 Multiple IM injections given in the

same extremity during the same time period should be placed at least 1 inch apart.

1

Although most vaccine products specify the route of administration, Pneumovax may

be administered either IM or into subcutaneous tissue.

114 Therefore, B.D. should be

reassured that she has administered the Pneumovax correctly because it is acceptable

to administer this vaccination by either route.

p. 1363

p. 1364

Table 64-3

Subcutaneous and Intramuscular Vaccine Administration Techniques

Patient Age Site Injection Area

Typical Needle

Length (inch)

Needle

Gauge

Birth to 12 months Subcutaneous Fatty tissue over the

anterolateral thigh muscle

5/8 23–25

12 months and older Subcutaneous Fatty tissue over anterolateral

thigh or fatty tissue over triceps

5/8 23–25

Newborn (0–28

days)

Intramuscular Anterolateral thigh muscle 5/8 22–25

Infant (1–12 months) Intramuscular Anterolateral thigh muscle 1 22–25

Toddler (1–3 years) Intramuscular Anterolateral thigh muscle OR

Deltoid muscle of arm if muscle

mass is adequate

1–1¼

5/8–1

22–25

Children (3–18

years)

Intramuscular Deltoid muscle OR

Anterolateral thigh muscle

5/8–1

1–1¼

22–25

Adults ≥19 years Intramuscular Deltoid muscle OR

Anterolateral thigh muscle

1–1½ 22–25

Sources: National Center for Immunization and Respiratory Diseases. General recommendations on

immunizations-recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR

Recomm Rep. 2011;60:1–61; Immunization Action Coalition. How to Administer Intramuscular (IM) Vaccine

Injections. http://www.immunize.org/catg.d/p2020.pdf. Accessed May 27 2015; Immunization Action Coalition.

Administering Vaccines: Dose, route, site, and needle size. http://www.immunize.org/catg.d/p3085.pdf.

Accessed May 27 2015.

Subcutaneous vaccinations involve injection of vaccine into fatty subcutaneous

tissue between the layer of skin and the layer of muscle.

1

,

112 Subcutaneous

vaccinations are administered with a 5/8-inch needle, 23 to 25 gauge, inserted at a

45-degree angle to the skin, while pinching up on the subcutaneous tissue to prevent

injection into the muscle. For graphical illustration of subcutaneous vaccination

administration, see http://www.immunize.org/catg.d/p2020.pdf. Sites of

subcutaneous injections include the fatty tissue over the anterolateral thigh muscle in

children newborn to 1 year old, and fatty tissue over the triceps in children 1 year old

to adults. Multiple subcutaneous injections given in the same extremity during the

same time period should be placed at least 1 inch apart.

Other routes of administration for vaccinations include the oral, intranasal, and

intradermal routes. Rotavirus and oral typhoid are the only orally administered

vaccines in the United States.

1

Inactivated influenza is the only intranasal vaccine,

administered via a nasal sprayer with a dose divider. Intradermal influenza is the

only intradermally administered vaccine, and it is administered in the area of the

deltoid at a 90-degree angle into the skin.

113

LEGAL REQUIREMENTS

CASE 64-18

QUESTION 1: What are the requirements necessary to become a pharmacist immunizer? How are

pharmacists advocates for improving population immunization rates?

Pharmacists have varying authority to administer vaccinations within the United

States based on each state’s Pharmacy Practice Act. The rationale for pharmacists to

deliver immunizations to the public includes pharmacist accessibility in every

community and overall low vaccination rates throughout the population.

115 The

Department of Health & Human Services and Centers for Disease Control and

Prevention recognized pharmacist’s unique position to promote vaccines and also

influence vaccination in diverse populations through a letter from the Assistant

Surgeon General.

116 This letter also acknowledged pharmacist’s contribution to

increase immunization awareness in the past, but it also requested continued

assistance in this endeavor through the following:

Increasing vaccine awareness in the adult and adolescent population

Ensuring patient’s vaccine requirements are assessed when they visit pharmacies

Offering vaccinations to patients with certain medical conditions (high risk)

Entering adult immunizations into vaccine registries where possible

Partnering and collaborating with local and state health departments, immunization

coalitions, medical providers, and other vaccination outreach programs

The American Pharmacist’s Association has developed a national competencybased certificate training program for pharmacists, and most schools of pharmacy

across the country contain or provide an opportunity to learn immunization

administration within their curriculum.

117 These programs include both didactic and

hands-on training and prepare the learners to be public health educators regarding

immunizations, to promote vaccinations within their community, and to administer

vaccines at their practice sites.

Although each state’s requirements regarding necessary training, protocols, and

notification systems may differ, there are some standardized requirements a

pharmacist immunizer must follow. Current cardiopulmonary resuscitation

certification is a common requirement for pharmacist immunizers. Immunization

administration curricula typically contain information regarding basic immunology,

specifics regarding vaccine information, practice implementation, legal and

regulatory issues, and administration techniques.

117 Each state stipulates the statutes

on patient age that

p. 1364

p. 1365

may receive a pharmacist-administered vaccination; what types of vaccinations

pharmacists are able to administer; and the mechanism by which pharmacists are

authorized to administer vaccines by physicians, such as through a prescription,

collaborative drug therapy management agreement, protocol, or standing order.

118

Some states require continuing-education credit maintenance specific to

immunizations or vaccinations for pharmacists who immunize; some states are very

specific in their requirements, and others are more general. It is important to check

with the state licensing board regarding specific statutes and regulations relating to

pharmacist immunization practices. In addition, a growing number of states have

passed legislation allowing pharmacy interns with the necessary training to

administer immunizations. Currently, 44 states and territories have adopted

legislation allowing pharmacy interns to administer vaccines, given the student has

completed an immunization certificate program and operates only under supervision

of an immunizing pharmacist.

118

Patient consent forms for immunization and vaccine information sheets are

important aspects for patient safety that pharmacists are required to use as part of an

approved immunization program. Consent forms should include screening

questionnaires specific for each vaccine, should be signed prior to vaccine

administration, and should be reviewed by the pharmacist with the patient present.

Vaccine information sheets are patient information developed by the CDC providing

specific individual vaccine information benefits and risks, and they are required to

be distributed to the patient with each vaccine by the National Childhood Vaccine

Injury Act of 1986. Resources for pharmacists are available through the CDC,

Immunization Action Coalition, and American Pharmacists Association.

119–121

KEY REFERENCES AND WEBSITES

A full list of references for this chapter can be found at

http://thepoint.lww.com/AT11e. Below are the key references and websites for this

chapter, with the corresponding reference number in this chapter found in parentheses

after the reference.

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