Stephan L. Foster

Pharmacist Involvement with Immunizations: A Decade of Professional Advancement

OBJECTIVE To review achievements in pharmacist-administered immunizations, emphasizing the period 1995 to 2004. DATA SOURCES Published articles identified through PubMed (1995-2004) using the search terms pharmacist, pharmacy, and vaccine, immunization, or shots. Additional sources were identified from personal bibliographies collected by the authors during this decade, as well as the bibliographies of the retrieved articles. The later two sources resulted in manuscripts of primarily historical significance. STUDY SELECTION More than 300 manuscripts were identified. The authors selected 15 studies that most clearly document the effect of pharmacist-administered immunizations for review. DATA EXTRACTION By the authors. DATA SYNTHESIS While pharmacists have been involved with vaccines dating back to the mid-1800s and the distribution of smallpox vaccine, only 10 years have passed since pharmacists began routinely immunizing patients in their communities as a standard practice activity. The Washington State Pharmacists Association initiated the first ongoing formalized training of pharmacists in vaccine administration in 1994. On November 1, 1996, the American Pharmaceutical (now Pharmacists) Association (APhA) began its nationally recognized training program for pharmacists, Pharmacy-Based Immunization DELIVERY: A National Certificate Program for Pharmacists. By 2004, an estimated 15,000 pharmacists and student pharmacists had been formally trained through recognized programs as vaccine experts, and the practice of pharmacist-administered immunizations, particularly for adult patients, has become routinely accepted as an important role of the pharmacist. Arguably, few initiatives have done more to move the pharmacy profession forward in direct patient care than the pharmacist-administered immunization movement. CONCLUSION Pharmacists have made significant strides in immunizations over the past decade. Limited activities in the hospital sector have been particularly well documented, as have the perceptions of patients regarding acceptance of pharmacists as immunizers. The activities of community pharmacists are less well documented. More research is needed into novel approaches to pharmacist involvement in public health-focused immunization initiatives, along with continued research evaluating the current practice of pharmacist-administered immunizations.

Glycine-based oral rehydration solution: Reassessment of safety and efficacy

We evaluated the safety and efficacy of a glycine-based orally administered rehydration solution by comparing it with a standard oral rehydration solution (ORS) without glycine in a randomized double-blind trial in United States infants (age less than 15 months) given treatment for acute gastroenteritis as inpatients or outpatients. The response to therapy (stool volume and duration of illness) was similar in the two groups, except that in four (13%) of 31 hospitalized infants receiving glycine-ORS hypernatremia developed, (one had symptoms) compared with none of 35 receiving ORS (P less than 0.04). Among the 77 outpatients there were no differences between the groups. This study demonstrates that glycine-ORS did not provide any therapeutic advantage over standard ORS, and hypernatremia developed in some patients receiving glycine-ORS. We suggest that caution be used with this type of solution until further safety studies have been done.

Vaccine administration: Preventing serious shoulder injuries

Erroneous administration of intramuscular vaccines, particularly above the deltoid muscle, can result in serious shoulder injuries and diminished vaccine efficacy.1 With few studies published addressing injection technique before 2002, inconsistencies arose regarding optimal vaccine administration, thus causing variations in current practice.2 We will examine cases of serious shoulder injuries as a result of incorrect technique and provide a step-by-step guide to the proper administration of intramuscular injections. In 2006, Bodor and Montalvo3 reported two cases of vaccine-related shoulder dysfunction. One patient received the 23-valent pneumococcal vaccine and the other an influenza vaccine. Both patients reported receiving injections high into the deltoid muscle, within 1 to 2 cm of the acromion. Both patients noticed severe shoulder pain and loss of range of motion within 2 days and increasing pain during a period of 2 to 5 months. One patient was diagnosed with subacromial bursitis that later progressed to adhesive capsulitis or frozen shoulder; the other was diagnosed with bicipital tendonitis, subacromial bursitis, and a mild C6 sensory radiculopathy. The authors recommended that guidelines specify avoiding vaccine injections in the upper third of the deltoid muscle. They recommended that health professionals consider vaccine-related shoulder dysfunction in patients presenting with shoulder pain and weakness following a vaccine injection. Atanasoff et al.4 reported a series of 13 cases submitted to the Vaccine Injury Compensation Program between 2006 and 2010, in which patients experienced shoulder injury related to vaccine administration. Of the cases, 62% received influenza vaccine and the remainder received tetanus–diphtheria toxoids, Td– acellular pertussis, or human papillomavirus vaccine. The proposed mechanism of injury was that vaccine, an antigenic substance, injected into synovial tissue resulted in an immune-mediated inflammatory response. Of patients, 46% stated that the vaccine was injected “too high” into the deltoid muscle. Magnetic resonance images revealed fluid collections in the deep deltoid or overlying the rotator cuff tendons, bursitis, fluid buildup within the bursa, or rotator cuff tears. About one-third of patients (31%) required surgery, with one-half of those requiring a Vaccine administration: preventing serious shoulder injuries

Annual Influenza Vaccination: Offering Protection Beyond Infection

Abstract Cardiovascular disease (CVD), the leading cause of death in the world, is largely preventable. An increasing amount of evidence suggests that annual vaccination with inactivated influenza vaccine reduces morbidity and mortality associated with CVD; however, immunization rates in patients with CVD fall consistently below the goals established by Healthy People 2020. This review outlines the importance of vaccination and summarizes the available literature on the role of seasonal influenza vaccination and the incidence of coronary artery disease and stroke.

Outpatient use of oral rehydration solutions in Apache population: effect of instructions on preparation and contamination.

Oral Rehydration Solutions (ORS) containing 90 and 50 mmol/L sodium have recently been recommended for use in ambulatory children in the U.S. These solutions are now marketed in powder form by some commercial companies. However, few data are available in the U.S. on the accuracy with which the solutions are mixed at home or on the bacterial contamination that may occur during mixing. We evaluated the effect of various forms of instructions on the occurrence of bacterial contamination and accuracy of mixing ORS at home by mothers of patients who were dispensed the dry ingredients of an ORS containing 90 mmol/L sodium at the U.S. Public Health Service Hospital, Whiteriver, Arizona. Patients were randomized to one of the four following groups: group I (23 patients) was given written instructions for mixing the solution along with a pre-marked container; group II (22 patients) was given written instructions only; group III (22 patients) was given a premarked container only; and group IV (19 patients) was given neither. All patients were given oral instructions in the preparation of ORS and were asked to refrigerate the reconstituted ORS. We collected samples of ORS at the patients home 1 day after the clinic visit, to measure their electrolyte content and to identify any bacterial contamination. Mean Na+ concentrations were significantly lower in the ORS prepared by mothers/guardians in groups that were not given a premarked container [82 +/- 13 (II) and 79 +/- 21 (IV) mmol/L vs. 88 +/- 13 (I) and 92 +/- 14 (III) mmol/L; p less than 0.01].(ABSTRACT TRUNCATED AT 250 WORDS)

The Use of Capacity Ratios in Introductory Pharmacy Practice Experiences

Objective. To describe the use of capacity ratios following the assignment of introductory pharmacy practice experiences (IPPEs) to a rising third-year pharmacy (P3) class. Methods. Practice experience availability for IPPEs was collected by means of preceptor response to requests. Following assignment of IPPEs to the rising P3 class, capacity ratios from the IPPEs available across the entire state and within each of 4 geographic zones were calculated. Capacity ratios for both community pharmacy and institutional pharmacy also were calculated. Results. The capacity ratio for IPPEs across the entire state was 2.11, which documents solvency. When the capacity ratios were calculated individually for community pharmacy and institutional pharmacy, solvency was also achieved. Likewise, IPPE capacity ratios were solvent in all 4 geographic zones. Conclusions. Capacity ratios are helpful in evaluating IPPE availability as they can be used to determine practice experience need in either type of practice experience or geographic zone.

Nicotine conjugate vaccines: A novel approach in smoking cessation

Tobacco use remains the numberone preventable cause of death in the United States despite current pharmacologic and behavioral approaches in smoking cessation.1 Approximately 5 million deaths worldwide each year are attributed to tobacco use, 443,000 of which occur in the United States.2 Lung cancer is the leading cause of U.S. cancer deaths in both men and women, and tobacco use accounts for 87% of these cases. In addition, from 2000 to 2004, smoking caused more than

2010 pertussis outbreak and updated Tdap recommendations

193 billion in health care expenditures including direct medical costs and loss of job productivity. However, 47 million Americans continue to smoke despite the negative economic and health-related costs.3 Recent surveys estimate that 70% of current smokers want to quit and about one-half of them will be successful at an initial quit attempt.2 Unfortunately, fewer than 5% of these individuals will stay abstinent for longer than 3 months to 1 year without counseling or pharmacologic interventions.4

Influenza vaccination administration: When is it too early?

clinical presentation Pertussis, also known as whooping cough, is an acute, highly contagious respiratory disease caused by the bacterium Bordetella pertussis.4 The incubation period of pertussis generally is 7 to 10 days, and the infection is divided into three phases: catarrhal, paroxysmal, and convalescent. Pertussis is most readily transmitted during the catarrhal stage and the first 2 weeks after cough onset. The catarrhal stage is characterized by nonspecific symptoms such as mild cough, low-grade fever, and coryza and lasts around 1 to 2 weeks.4–6 The cough gradually worsens as the patient progresses to the paroxysmal stage, which typically lasts from 1 to 6 weeks but may persist up to 10 weeks.4 The paroxysmal stage is characterized by numerous spasmodic coughs during a single expiration, followed by a labored inspiration that may result in the classic high-pitched “whoop,” especially in children.4–6 Posttussive emesis and exhaustion also are common. As the patient progresses from the paroxysmal to convalescent stage, the cough gradually decreases in frequency and severity during 2 to 3 weeks. The convalescent stage can last weeks to months. Infants are at highest risk of serious pertussisrelated complications, such as seizures, encephalopathy, and bacterial pneumonia, which is the most common cause of pertussis-related death.4 Other complications include otitis media, anorexia, dehydration, pneumothorax, epistaxis, hernias, and rectal prolapse. Difficulty sleeping, urinary incontinence, pneumonia, and rib fracture are pertussis-related complications that may be experienced by adolescents and adults.

High-dose influenza vaccination in the elderly.

Eachyear, the Advisory Committee on Immunization Practices (ACIP) publishes recommendations on the appropriate use of influenza vaccine. Over the years, there have been concerns about the optimal time when the vaccine should be given owing to the possibility of waning immunity if administered too early in the influenza season. The ACIP recommendations for the 2015-2016 influenza season state that the vaccine should be given before the onset of influenza activity in the community and should be offered by October if possible. 1