One of the barriers to increasing adult vaccination rates and reasons for missed opportunities for vaccination is that many healthcare professionals do not routinely assess their patient’s vaccination status [1
]. Pharmacists across the United States (U.S.) have been vaccinating since the 1990s. However, pharmacists have traditionally been reactive vaccinators, waiting for patients to ask for a vaccine instead of proactively assessing them for vaccine needs. Pharmacists may also only promote a subset of vaccines that are commonly reimbursed for administration in the pharmacy by third party payers or prescription drug plans (e.g., zoster and pneumococcal vaccines) [2
]. The National Vaccine Advisory Committee and the Centers for Disease Control and Prevention (CDC) advocate that all healthcare professionals be proactive in assessing immunization and providing a “strong recommendation” to their patients for needed vaccinations, as this is the strongest predictor of patients getting vaccinated [1
]. Some interventions to identify and reduce missed opportunities for vaccination that have been published include education for patients and parents, electronic notices in the electronic medical records for providers, provider performance reports, patient outreach through postcards, phone calls and home visits, and manual screening of all patients’ vaccination records [4
In a pharmacy, before a vaccine is administered, a vaccine screening form is routinely completed by all patients to identify contraindications to vaccination [5
]. Screening forms contain demographic and health questions and are traditionally used by healthcare providers to determine if a patient is contraindicated to receive the requested vaccine. However, it is possible that a contraindication to one vaccine may be an indication for another. For example, a patient who checked they were immunocompromised would be contraindicated from receiving a live vaccine, but would likely be indicated for the pneumococcal vaccines. In addition, even when the requested vaccine is not contraindicated, the form may indicate there are still other vaccines that may be recommended for the patient. A standardized vaccine screening checklist from the Immunization Action Coalition (IAC) and endorsed by the CDC can be found here: http://www.immunize.org/catg.d/p4065.pdf
]. There are previous data on the successful use of proprietary forms developed by individual pharmacies to screen and assess patients for vaccination needs; however, to our knowledge, there are no published reports evaluating the use of standard CDC endorsed checklist questions on a pharmacy-based vaccine screening form to not only identify contraindications to vaccination, but also possible vaccination opportunities [7
]. The CDC has developed additional tools, separate from the screening questionnaire, to identify other indications, such as travel, health conditions, occupation, and lifestyle for vaccinations [9
We believe that vaccine screening forms can be used to identify potential opportunities to vaccinate and make proactive vaccine recommendations based on a uniform set of questions to be answered for every patient being vaccinated at the pharmacy. By retrospectively assessing the forms currently being used in a variety of community pharmacy practice settings, we hope to (1) create a standard set of recommendations based on questions on the screening form that are likely to yield a vaccine indication; and (2) categorize potential opportunities for vaccination, within the population that receive vaccines from the pharmacy, using the screening form questions.
Our study suggests that the vaccine indications that can be inferred from the vaccine contraindication screening form answers were based mostly on the patient’s age, obtained from the demographics section of the pharmacy screening form. For adults, these age-based vaccine indications are for the two pneumococcal vaccines and the zoster vaccines. According to key findings from the CDC’s 2015 Surveillance of Vaccination Coverage among Adult Populations in the United States (U.S.), although there was modest gain in the coverage for pneumococcal and zoster vaccinations compared to the previous year, the coverage is still low and many adults remain unvaccinated with recommended vaccines [13
]. In children and adolescents, the age-based vaccine indications that can be inferred from the screening form responses are for the HPV9, MCV4, MenB, and Tdap vaccines. In 2016, the CDC estimated that only 43.4% of teens had received the complete recommended HPV vaccination series and that among teens aged 13–17 years, coverage with two or more MenACWY doses was 39.1% [14
]. The CDC also recommends that clinicians consistently recommend and simultaneously administer Tdap, MenACWY, and HPV vaccines at age 11–12 years as a method to increase coverage of these vaccines. In both California and Michigan, state law allows pharmacists to administer all adult and adolescent vaccines without a prescription from a physician [15
]. For example, when teens present for influenza vaccination, reviewing the patient’s response to the vaccine contraindication screening form allows identification of other vaccination needs to discuss with the patient and parent.
When looking at actual questions on the screening forms, we were able to identify that 4 out of the 10 questions are likely to yield a vaccine recommendation. An answer of “yes” to three of these questions (#4, #5, or #6) elicits the possible need for one, or both, of the pneumococcal vaccines (Table 1
). These questions ask about the presence of comorbidities such as chronic illnesses (chronic heart, liver, kidney, lung, diabetes) and impaired immune function due to disease or medications. Although the intention of these three questions is to avoid administering a live vaccine to patients with these risk factors, the content of these three questions essentially also asks the patient to confirm if they have factors that increase their risk for getting pneumococcal disease, and therefore should be recommended pneumococcal vaccination. We were able to identify that 13.9% of our study sample with comorbidities (i.e., answering “yes” to questions #4, #5, or #6) would be indicated for the pneumococcal vaccine. However, in this high-risk group, national data suggest that only approximately 25% of adults less than 65 years of age with an indication for pneumococcal vaccination report ever having been vaccinated with pneumococcal vaccine [13
]. Using a patient’s response to the screening form questions that ask about comorbidities can identify these patients that often go unvaccinated. Even the CDC states that their screening questions are for precautions and contraindications to vaccines, not indications [6
]. In the pharmacies in our sample, only the screening form was used and not the CDC’s questionnaire to determine the recommended vaccines. Thus a large opportunity to identify patients potentially in need of recommended vaccines is lost.
The number of patients with comorbid conditions indicative of the need for immunization in our study is likely an underestimation due to several possible screening form discrepancies: (1) At one pharmacy, patients may have left the question blank because it asked it as a free-response question instead of a yes/no; (2) at another pharmacy in our study sample, they did not ask about comorbidities at all; and (3) some pharmacies had procedures that instructed patients not to complete the questions that ask about comorbidities because they were there for an inactivated vaccine and having a comorbidity would generally not be a contraindication to receiving inactivated vaccines. To increase the detection of comorbidities, pharmacies can also use inferred diagnoses (i.e., using the medications a patient takes to infer their diagnoses) from their pharmacy dispensing records. Obtaining an inferred diagnosis for comorbidities was not possible in our sample as a current medication list was not included in the pharmacy screening questionnaires.
The small number of pregnant women identified in our pharmacy population may be expected, as the literature suggests that the majority of pregnant women tend to receive their Tdap (96%) and influenza (97.3%) vaccine in a traditional healthcare setting, such as their OB/GYN or family doctor [16
]. However, pharmacists should still incorporate a vaccine needs assessment for pregnant women, as the U.S. maternal vaccination rate with Tdap and influenza vaccines is suboptimal. During the 2017–2018 influenza season, only 49.1% of pregnant women received influenza vaccination, 54.4% with a live birth received Tdap during pregnancy, and 32.8% received both recommended vaccines [18
]. Other vaccines may be indicated for patients of different ages, medical conditions, occupations, and lifestyles, but it would require the pharmacist to elicit more information from the patient.
Adult vaccination rates are still below the Healthy People 2020 target goals, and pharmacy-based immunization screening forms can identify opportunities to improve immunization rates. The zoster vaccine goal is set very low at 30% compared to the other vaccines (e.g., 90% for pneumococcal), and its coverage is currently only at 33.4% using the now non-preferred live zoster vaccine [19
]. Using pharmacy screening forms to infer indications for vaccinations is another method that can identify patients who should be vaccinated to increase coverage from vaccine-preventable diseases and help reach our Healthy People 2020 goals. The CDC and other organizations have developed additional tools for screening, which may increase the chances of identifying missed vaccine opportunities, but may also increase paperwork and workflow burden for pharmacists and patients [9
]. The additional CDC questionnaire asks about other risk factors, such as if they are a healthcare worker, a man who has sex with men, a college student, homeless, are planning travel, etc. Since the majority of the vaccinations that were administered by the pharmacies were influenza vaccines (74.5%), and influenza is recommended for everyone 6 months and older, this increases the pharmacists’ potential to identify and make recommendations on other vaccine needs on, at least, an annual basis.
Across the board for all vaccines that were identified as potentially indicated, only 20–37% of those indicated for the vaccine received that recommended vaccine during the pharmacy encounter (Table 4
). These results indicate that possibly 63–80% of the potential vaccine opportunities that are identified using the screening form are true opportunities for the pharmacist to initiate a conversation with the patient to assess for other needed vaccines.
While the age and pregnancy status of patients in CA and MI were similar, we did note a statistically significantly greater percentage of the sample in CA being 65 years or older compared to MI. This project, however, was not designed to detect and determine the reason for differences in the populations vaccinated between the two states.
Published studies have centered on the success pharmacists have had in targeted vaccine interventions to improve immunization rates, but all patients who come in for any vaccinations should be screened for all additional vaccine needs [21
]. Knowing the potential opportunities for vaccination allows for the pharmacist or provider to directly assess the status of that specific vaccine with the patient through open conversation or review of their records. A limitation of this study is that the patients included in this study were from a convenience sample of eleven pharmacies limited to Southern California and Michigan who agreed to participate. However, both chain and independent pharmacies were included. In addition, the screening forms used by the chain pharmacies in this project represent at least 13,378 pharmacies that use these forms across the United States, amplifying the impact of this opportunity.