Standing Prescription Order to Administer …



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To: Immunizing Pharmacists

From: Anthony Pudlo, PharmD, MBA, BCACP

Vice President, Professional Affairs

Date: September 2013

Re: Sample Immunization Protocol and Policy & Procedures

On behalf of the Iowa Pharmacy Association, thank you for your interest in serving the patients of your community by establishing an immunization protocol in accordance with the Iowa Administrative Code (657 IAC 8.33 (155A)).

The following sample immunization protocol provides you with the opportunity to collaborate with a supervising prescriber to administer CDC recommended adult vaccines to patients 18 years and older, and child/adolescent influenza vaccinations to patients 6 years and older.

This document includes a sample policy and procedures to review with your supervising physician to handle emergency care for adverse events from a vaccination. In addition, this document provides a sample needle stick protocol to guide your pharmacy’s process for this emergency situation.

This document is provided to you as a framework to assist your pharmacy in providing immunizations in your community. You may alter this document to fit the needs of your pharmacy.

If you should have any questions or comments, please contact Anthony at apudlo@ or 515-270-0713.

Standing Prescription Order to Administer Immunizations

(Pharmacy Name)

The subsequent list of immunizing pharmacists have completed all training requirements and updated certifications required by the Iowa Board of Pharmacy pertinent to vaccine administration in Iowa and are authorized on the basis of this protocol to deliver vaccines in Iowa under the medical direction of (supervising prescriber), (prescriber’s title) for (prescriber’s practice name). Please note that the qualified trained pharmacists listed below may delegate administration of a vaccine to another qualified and trained pharmacist or student pharmacist that assist our pharmacy in our immunization services.

Registered Pharmacists:

|Last Name |First Name |License Number |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

Agreement Description:

To protect people from preventable infectious diseases that cause needless death and disease, the afore listed pharmacists may administer the following immunization to eligible patients within the state of Iowa, according to indications and contraindications recommended in current guidelines from the Advisory Committee on Immunization Practices (ACIP) of the U.S. Centers for Disease Control & Prevention (CDC) and in accordance with product labeling. Other vaccines may be added to or deleted from this list by written supplementary instruction from the undersigned.

• influenza inactivated virus vaccine 0.5 ml intramuscular

• influenza inactivated virus vaccine 0.1 ml intradermal

• influenza live attenuated vaccine 0.2ml intranasal

• recombinant influenza vaccine 0.5 ml intramuscular

• 23-valent pneumococcal vaccine polyvalent (Pneumovax 23) 0.5 ml intramuscular

• 13-valent pneumococcal conjugate vaccine (Prevnar 13) 0.5 ml intramuscular

• zoster vaccine live 0.65 ml subcutaneous

• varicella virus vaccine live 0.5 ml subcutaneous Injection in a 2-dose schedule at 0 and 4-8 weeks

• human papillomavirus vaccine 0.5 ml intramuscular in a 3-dose schedule at 0, 2, and 6 calendar months

• meningococcal conjugate vaccine quadrivalent (MCV4) 0.5 ml intramuscular

• meningococcal polysaccharide vaccine (MPSV4) 0.5 ml subcutaneous

• tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) 0.5 ml intramuscular

• tetanus toxoid, reduced diphtheria toxoid 0.5 ml intramuscular

• measles, mumps, rubella 0.5 ml subcutaneous

• hepatitis A 0.5-1.0 ml intramuscular

• hepatitis B 0.5-2.0 ml intramuscular in a 3-dose schedule at 0, 1, and 6 calendar months

Criteria:

Influenza Inactivated Virus Vaccine

The inactivated influenza vaccine (IIV) or influenza live, attenuated virus vaccine (ILAVV) may be given annually to all consenting individuals 6 years of age and older in whom the vaccine is not contraindicated. Priority will be given to high-risk populations during years of vaccine shortage and as directed by CDC. Specific intramuscular or the intradermal administrated IIV are also options for adults ages 18-64 years. Adults aged 65 years and older can receive the standard dose IIV or the high-dose IIV (Fluzone High-Dose).

High-risk populations are distinguished by the following:

• Persons aged 50 years and older

• Long-term care facility residents

• Children aged 6-59 months

• Healthcare workers

• Anyone 6 months or older with certain chronic illnesses

• People 6 months to 18 years old on chronic aspirin therapy

• Pregnant Women

• Morbidly obese (BMI >40)

• Caregiver of persons with medical condition with higher risks for complications

Chronic Illnesses Include:

• Pulmonary (e.g., emphysema, COPD, asthma)

• Cardiovascular (e.g., CHF, post-MI, heart anomalies)

• Metabolic (e.g., diabetes)

• Renal dysfunction, hemoglobinopathies (e.g., sickle cell)

• Immunosuppression (e.g., HIV infection)

• Any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or can increase the risk for aspiration

Contraindications / Ineligible Patients for Inactivated Virus Vaccine

• Allergy to eggs

• Persons with known severe allergic reaction (e.g., anaphylaxis) after previous dose or to a vaccine component

Precautions for Inactivated Virus Vaccine

• Moderate or severe acute illness with or without fever

• Previous paralysis by Guillain-Barre Syndrome

• Persons who experience only hives with exposure to eggs should receive vaccine with additional safety precautions

Influenza Live, Attenuated Virus Vaccine

The live, attenuated influenza vaccine may be given annually to all consenting individuals aged 6 to 49 years old in whom the vaccine is not contraindicated.

Contraindications/Ineligible Patients For Live, Attenuated Virus Vaccine

• Immunocompromised Individuals

• Close contacts and family members of severely immunocompromised individuals (i.e., patients with hematopoietic stem cell transplants who require care in a protected environment)

• Allergy to eggs

• Persons aged 10 years earlier and they have not previously received Tdap. Intervals shorter than 10 years since the last Td may be used for booster protection against pertussis.

Special Populations:

• Adults who have or who anticipate having close contact with an infant aged 200 cells/μl

• Men who have sex with men (MSM)

• Persons with Type I or Type II Diabetes

• Person with chronic liver disease

• Persons with kidney failure, end-stage renal disease (ESRD), or those who receive hemodialysis

• Persons with heart disease

• Persons with chronic lung disease including COPD and chronic bronchitis (emphysema)

• Persons with chronic alcohol abuse

• Persons with asplenia including those who have elective splenectomy and persistent complement component deficiencies

Contraindications:

• Individuals who have suffered a severe allergic reaction (e.g., anaphylaxis) after receiving their first dose or a component of the vaccine

• Women who are pregnant

• People who are severely immunocompromised, such as those with HIV and a CD4 T-lymphocyte count of ................
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