Questions Answered: Immunization in the Community Setting

December 2014, Vol 2, No 6 - Inside Patient Care

In a recent interview with Inside Patient Care: Pharmacy & Clinics, Jonathan L. Temte, MD, PhD, Chair of the US Advisory Committee on Immunization Practices, discusses the role of the committee and the importance of pharmacists and retail clinicians in immunization.

What is the role of the committee?

A: The US Advisory Committee on Immunization Practices (ACIP) evaluates vaccines and other closely related biologic products (eg, immune globulin preparations and/or antimicrobial agents) for the best deployment or best use in the civilian population of the United States.

In doing so, we primarily look at vaccines—either existing vaccines or newly licensed vaccines—licensed through the US Food and Drug Administration, and consider their safety, efficacy, and disease burden.

We also consider the cost-effectiveness of a vaccine program, as well as the practicality of implementing a recommendation. We are also concerned about equity, feasibility, and acceptability. By and large, we are the people who make the recommendations for patients across the United States in terms of use of standard immunizations.

How did you become the Committee Chair?

A: It began when I was asked to represent the American Academy of Family Physicians in March 2000 during a meeting at the Centers for Disease Control and Prevention (CDC) that dealt with the elimination of measles in the United States.

We were impaneled to review all the evidence available for the transmission of measles in the United States and had to reach a consensus on whether it met the criteria for pathogen elimination in our country. We were able to conclude that it was.

That was my very first activity dealing specifically with vaccines. I had initial training within family medicine in terms of infectious disease and immunology. From there, it just blossomed. I was also involved in the rubella elimination meeting in 2004. Also that year, I was asked to be the liaison between the American Academy of Family Physicians and the Advisory Committee on Immunization Practices. That’s a role that I held for approximately 4 years.

At that point, I was nominated to serve on the ACIP and was approved as a voting member. As it turned out, that is an appointment by the US Secretary of Health & Human Services. I was appointed to a 4-year term in 2008 and reappointed for a second term in 2012, as the incoming Chair.

I became the chair of ACIP in 2012. My term goes through next summer, at which point I will be rotating off ACIP.

How are recommendations made?

A: The 15 voting members of the committee hold a vote and a recommendation requires a majority of votes. Most of the time, we do so with a fairly high level of consensus. It is most common that we have a unanimous decision. The most recent recommendation we made was for the use of live attenuated influenza vaccine for children 2 to 8 years of age, in preference to the inactivated form of the vaccine, if the live attenuated vaccine is immediately available. If it’s not, then we recommend the use of whichever vaccine is available. That was not a new vaccine and it was for a limited group of people, but it maximized the benefit of a vaccine policy.

Keep in mind that we review and update the routinely recommended immunization schedules for 2 population groups on an annual basis: children and adolescents, 0 through 18 years of age; then we have a second recommendation or several recommendations for adults 19 years and older. Each year, ACIP and the CDC cojointly review and approve any modifications to the 2 immunization schedules; it is also harmonized with a number of professional organizations.

For example, the child and adolescent schedule is a product not only of ACIP and the CDC but also the American Academy of Pediatrics and the American Academy of Family Physicians.

The adult schedule is cosponsored and co-approved by the CDC, the American Academy of Family Physicians, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives.

The recommendations are the standard of practice in medicine and are a product of ACIP, but also approved and endorsed by our stakeholder organizations as well.

Why are these recommendations important in the community setting?

A: The recommendations that we make and the schedules we produce provide a blueprint of good medical practice in terms of the preventive services associated with vaccinations. ACIP does not express any strong opinion as to who should vaccinate and who should provide the vaccines.

Rather, it is a road map to achieve good coverage. Traditionally, we do an excellent job of providing immunization in children, especially the routine vaccines from birth through age 6 years. Those are largely done in the offices of pediatricians and family physicians. As we get into older age groups, however, I think we see much more opportunity for retail pharmacies to be involved. The coverage that we have with some of the adolescent vaccines, particularly the human papillomavirus vaccine, really has a lot of room for improvement.

We just are not at our target in terms of good coverage. The situation is even more critical for adults. For example, Tdap—tetanus, diphtheria, and acellular pertussis vaccine—and the pneumococcal vaccine for high-risk individuals are far from meeting our goals in terms of appropriate coverage.

We find that retail pharmacies oftentimes have much more generous hours than clinical practices. Most clinical practices require an appointment for vaccinations, whereas many pharmacies allow walk-in visits and are able to administer immunizations relatively easily. I think it certainly is a method to fill in the gap.

The ability for retail pharmacies to provide vaccinations to children is highly variable from state to state. No real generic comment can be made about child vaccinations—especially through age 6 years— other than that it has always been a very important component of routine clinical care.

There is a need for an expanding role of retail pharmacies in providing vaccination. Every year, we have the need to immunize several million individuals for influenza, and, oftentimes, there is no capacity within clinical practice to do so. We rely and benefit from our colleagues in the pharmacies.

From my point of view, there is also a need for very good communication between pharmacies and the medical homes so we know what immunizations are being provided. Vaccine administration needs to be documented appropriately, and reported in an immunization registry.

One of the things we have for any retail pharmacy, in a statement, is immunization registry—that registry should be used with every vaccine.

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