Back-to-school season offers a great opportunity to make sure children, teens and college students are up-to-date on their vaccines. Immunizations are a crucial part of public health because they can prevent the spread of vaccine-preventable diseases. They are also a source of controversy: The anti-vaccination movement fueled the recent measles outbreak through misinformation and disrupted the sound science that consistently demonstrates the safety and effectiveness of vaccines. That’s where pharmacists come in: These health care professionals can play an important role in vaccine education and administration, helping to protect children against infectious diseases that can spread easily through a classroom.
Measles: Recent Outbreaks and a Rising Movement
The global spread of measles can largely be attributed to the growing anti-vaccination movement. According to the Centers for Disease Control and Prevention (CDC), there have been 1,095 confirmed cases of measles across 28 states this year alone as of June 27.1 This is the largest number in the United States reported since 1992 and since measles was declared eliminated in 2000.1
Total Pharmacy interviewed Andrea Levin, Pharm.D., an assistant professor in the department of pharmacy practice at Nova Southeastern University College of Pharmacy, in Fort Lauderdale, Florida. Levin, who is board certified in ambulatory care, is an immunizing pharmacist who also educates and trains pharmacy students about the importance of vaccines. She noted that some parents who choose not to immunize their children were vaccinated themselves and may not realize the severity of measles. “I educate parents about the CDC facts that if unvaccinated children are in a room where someone with measles was within a two-hour time frame, then about 90% of them will become infected with the disease,” Levin said. Pharmacists can educate the community through health fairs and outreach programs, she added.
The harsh reality is that proven scientific evidence usually will not sway the decision of anti-vaxxers, who tend to focus on misinformation and conspiracy theories. Nevertheless, it is important to continue educating these patients. The World Health Organization named vaccine hesitancy as one of the 10 global threats of 2019.2 Pharmacists should target vaccine-hesitant patients who are on the fence about immunizations. Social media is a powerful tool, and platforms such as Facebook are taking steps to counter vaccine misinformation. Pharmacists, too, can use social media to educate the public on the importance of vaccines, which may help increase immunization rates.
Messages can warn parents about just how serious measles is — the disease can lead to complications such as pneumonia, encephalitis, permanent hearing loss, hospitalization and even death. In one study, researchers successfully altered vaccine attitudes by using pictures and written personal perspectives to highlight the dangerous consequences of not immunizing children.3
The measles, mumps and rubella (MMR) vaccine offers the best protection against measles. The first dose is recommended at 12 to 15 months of age and the second at 4 to 6 years, or at least 28 days after the initial dose.4 Pharmacists should talk with parents of children about to begin school to ensure that both doses have been given. Children who were not previously vaccinated can receive two doses separated by at least 28 days.4 One dose is approximately 93% effective at preventing measles; two doses, about 97% effective.4 The mumps component appears to wane over time, so a third dose of MMR is recommended for certain patients during mumps outbreaks.
Other Back-to-School Vaccinations
Depending on state laws (see below), many pharmacists may be able to perform a dual role, both discussing important back-to-school vaccines with parents and administering those immunizations to children. The free CDC vaccine schedules app can help pharmacists access up-to-date immunization information — schedules, catch-up charts and patient counseling services — right at the point of care. The app includes immunization schedules, catch-up vaccine charts and patient counseling resources. Here’s a rundown of key vaccines to check on with parents.
Varicella (chickenpox): The second dose should be given at 4 to 6 years of age.4 Pharmacists should ensure that individuals ages 7 to 18 have received the twodose varicella series.
Diphtheria, tetanus and acellular pertussis (DTaP): The fifth dose should be given at 4 to 6 years of age.4
HPV: Recommended for all adolescents ages 11 to 12, the HPV vaccine can be administered as a 2-dose series if started at 9 to 14.4 If the series is initiated at 15 years or older, it is administered as a 3-dose series.4 Pharmacists should let parents know that the HPV vaccine is safe and effective and protects against cervical cancer, precancerous lesions and genital warts. The findings of a new systematic review of 65 studies showed that the vaccine decreased HPV infections and genital warts in both women and men.8
Meningococcal: Children should receive their first dose at 11 to 12 years and the booster dose at 16. Tetanus, diphtheria and pertussis (Tdap): Pharmacists should ensure that children receive one dose of Tdap at 11 to 12 years.4
Influenza: The influenza vaccine should be given as soon as it becomes available before flu season starts in October. Neither the ACIP nore the American Academy of Pediatrics will have a preference between the inactivated influenza vaccine and the live attenuated influenza vaccine (LAIV) for the upcoming season.6 However, FluMist nasal spray, a live attenuated type, will be limited during the 2019-20 season because of manufacturing constraints.6 Children age 6 months to 8 years who did not receive at least two doses of the influenza vaccine before July 1, 2018, should receive two doses separated by at least four weeks.4 Pharmacists should inform parents that there were 119 pediatric deaths during the 2018-19 flu season, which underscores the importance of annual vaccination.9
Hepatitis A: An Increasing Infection Rate
Pharmacists should also be sure to alert parents that the CDC’s Advisory Committee on Immunization Practices (ACIP) made a new recommendation for hepatitis A vaccination.6 Hepatitis A infections in the United States have increased dramatically, so the ACIP voted to strengthen its guidelines for catch-up vaccination. Children and teens ages 2 to 18 years should receive the vaccine if they missed the recommended window at 12 to 23 months.6 These recommendations will be considered official once they are published in the CDC’s Morbidity and Mortality Weekly Report.
Hepatitis A infections in the United States increased by 294% from 2016-18 compared with 2013-15. Outbreaks have been associated with contaminated food, among men who have sex with men, and with individuals reporting drug use or homelessness.7
Because the vaccine provides long-term coverage, immunizing children early, before they have risk factors for hepatitis A, may prevent infections. By updating parents about these new recommendations, pharmacists can help ensure that children are up-to-date on the vaccine before the start of the school year. The hepatitis A vaccine consists of two doses separated by at least six months.
Legal Considerations and Regulations
Vaccine exemptions vary by state and have sparked controversy amid the measles outbreaks. All school immunization laws grant exemptions to children for medical reasons.10 Forty-five states and Washington, D.C., grant religious exemptions, and 15 states permit philosophical exemptions for individuals who object to immunizations based on personal, moral or other beliefs. New York recently enacted legislation that bans religious exemptions for public school immunization requirements.10 Pharmacists should actively work to strengthen school immunization laws.
All 50 states, the District of Columbia and Puerto Rico authorize pharmacists to administer vaccines.11 The laws and regulations regarding which vaccines and age groups vary by state. Because pharmacists are considered among the most accessible health care professionals, they can make a large impact on increasing immunization rates and decreasing outbreaks of vaccine-preventable diseases. Pharmacists can administer vaccines without age restrictions in 27 states, and 17 have no age restrictions for the MMR vaccine.11 However, some states limit pharmacist administration to certain vaccines and may require a prescription.
Jennifer Gershman, Pharm.D., CPh, received her Pharm.D. degree from Nova Southeastern University (NSU) College of Pharmacy in 2006 and completed a two-year drug information residency. She served as a pharmacy professor at NSU’s College of Pharmacy for six years, managed the drug information center and conducted medication therapy management reviews. She has published research on prescription drug abuse, regulatory issues and drug information in various scholarly journals.
- Measles cases and outbreaks. CDC website. https://www.cdc.gov/measles/cases-outbreaks.html. Last reviewed July 1, 2019. Accessed July 1, 2019.
- Ten threats to global health in 2019. WHO website. https://www.who.int/emergencies/ten-threats-to-global-health-in-2019. Accessed June 30, 2019.
- Horne Z, Powell D, Hummel JE, Holyoak KJ. Countering antivaccination attitudes. Proc Natl Acad Sci USA. 2015;112(33): 10321-4. doi: 10.1073/pnas.1504019112.
- Robinson CL, Bernstein H, Romero JR, Szilagyi P. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger — United States, 2019. MMWR Morb Mortal Wkly Rep 2019;68:112–114. DOI: http://dx.doi.org/10.15585/mmwr.mm6805a4.
- Marin M, Marlow M, Moore KL, Patel M. Recommendation of the Advisory Committee on Immunization Practices for Use of a Third Dose of Mumps Virus-Containing Vaccine in Persons at Increased Risk for Mumps During an Outbreak. MMWR Morb Mortal Wkly Rep 2018;67:33-38. DOI: http://dx.doi.org/10.15585/mmwr.mm6701a7.
- ACIP approves recommendations on MenB, HepA, flu vaccines. AAP website. https://www.aappublications.org/news/2019/06/28/acip062819. Published June 28, 2019. Accessed July 1, 2019.
- Foster MA, Hofmeister MG, Kupronis BA, et al. Increase in Hepatitis A Virus Infections-United States, 2013-2018. MMWR Morb Mortal Wkly Rep 2019;68:413-415. DOI: http://dx.doi.org/10.15585/mmwr.mm6818a2.
- Drolet M, Benard E, Perez N, Brisson M; HPV Vaccination Impact Study Group. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet. Published online June 26, 2019. pii: S0140-6736(19)30298-3. doi: 10.1016/S0140-6736(19)30298-3.
- Weekly U.S. influenza surveillance report. CDC website. https://www.cdc.gov/flu/weekly/index.htm. Accessed July 2, 2019.
- States with religious and philosophical exemptions from school immunization requirements. National Conference of State Legislatures website. http://www.ncsl.org/research/health/school-immunization-exemption-state-laws.aspx. Accessed July 2, 2019.
- Pharmacist administered vaccines. APhA website. https://media.pharmacist.com/practice/IZ_Authority_012019_corrected_April_2019.pdf. Updated January 2019. Accessed July 2, 2019.