Philippine Pharmacists Association Immunization Training Manual: Public Health

Philippine Pharmacists Association (PPhA) Immunization Training Manual

• Edited by: Karen Grace Esteban Romero, RPh, MTM
• Contributors:
  • Christine Aileen Ching Benosa, RPh, MS
  • Francis R. Capule, RPh, MS
  • Imelda G. Pena, RPh, DrPH
  • Yolanda R. Robles, RPh, PhD
  • Gillbert Vargas, RPh

Module Overview: Pharmacists, Vaccines, and Public Health

• Goal: Enable pharmacists to participate in immunization advocacy.
• Rationale: Understanding rationale is crucial before investing time and resources into immunization programs.

Module Objectives

• Describe the health situation and public health issues in the Philippines.
• Explain the importance and benefits of immunization.
• Discuss pharmacist's role in preventive health via immunization.

Philippine Health Situation

• “Triple” Burden of Disease:
  • High incidence of communicable diseases (13 out of 17 WHO-recognized endemic diseases).
  • Rising non-communicable diseases (NCDs) and risk factors.
  • Third highest disaster-prone country.
• Stagnant Health Indicators: Despite being a lower-middle income country, health indicators show minimal improvement.
• Poverty: 50% of the population lives on less than $2 per day.
• Malnutrition: Significant child malnutrition (stunting, iron deficiency, iodine deficiency).
• Breastfeeding: Less than half of babies are exclusively breastfed for up to 6 months.
• Maternal Mortality: Little improvement in maternal mortality rates.
• Child Mortality: Inequities exist, with higher child mortality in Mindanao compared to Manila; 50% of under-five mortality are neonatal deaths.
• Medicine Prices: Remain among the highest in Asia (WHO, 2014).

Factors Contributing to Infectious Diseases

• Failure to meet measles elimination and Hepatitis B control targets.
• Measles Outbreak: Recent outbreak in the National Capital Region resulted in 40 deaths and required emergency vaccination.
• Other Diseases: Diphtheria, neonatal tetanus, and other vaccine-preventable diseases still occur.
• Tuberculosis: TB incidence decreasing but MDR-TB rising.
• HIV: Fastest growing HIV epidemic globally, with a 537% increase in reported cases in the past 5 years.

Emphasis Points Regarding Factors Contributing to Infectious Diseases

• Unaddressed inequities in the health system.
• Malnutrition and environmental factors due to poverty.
• Increased hospitalizations from NCDs leading to nosocomial infections (including antibiotic-resistant types).
• Disasters expose system weaknesses, impacting logistics and healthcare delivery.
• Financial Burden: Infectious Diseases and NCDs increase financial burden, with patients spending out-of-pocket.
• Government faces budget dilemmas balancing regular health programs and disaster mitigation.

Factors Contributing to Rise of Infectious Diseases & Disasters

• Increased immunocompromised patients due to NCDs.
• Increased hospitalizations predisposing patients to nosocomial infections.
• Emergency situations during disasters (lack of water, poor sanitation, malnutrition) increasing outbreak risks.
• Poverty and heavy burden on individuals and the health system highlighting the importance of preventive measures.

Immunization Program Benefits and Impact

• Benefits extend beyond individual disease prevention.
• Cost-effective investment, providing protection for vulnerable populations.
• WHO: Universal access to safe vaccines is a moral obligation and human right (World Health Organization, 2015).

Prevention of Infection and Infectious Diseases

• Vaccines vary in preventing disease and infection.
• Some vaccines prevent disease, while others protect against infection.
• Example: Hepatitis B vaccine provides protection against symptomatic disease and asymptomatic infections (Innis, et al., 1994).
• Sterilizing Immunity: Some vaccines can completely prevent persistent vaccine-type infection (Harper, et al., 2006).
• Immune Memory: Although sterilizing immunity may not be permanent, immune memory minimizes consequences of infection (Banatvala, Van Damme, & Oehen, 2000).

Control of Mortality, Morbidity, and Complications

• Vaccines protect individuals when good quality products are administered at the best time.
  • Pre-exposure administration
  • Post-exposure administration
  • Vulnerable groups (pregnant women, cancer patients, immunocompromised individuals) also benefit from vaccines (Succi & Farhat, 2006).
• Vaccines prevent almost 6 million deaths annually worldwide (Ehreth, 2003).
• Field trials show reduced mortality/morbidity for pneumococcal disease and rotavirus in Sub-Saharan Africa and Latin America.
• Failure to prevent infections may lead to complications like chronic hepatitis B (liver cirrhosis, cancer), congenital rubella syndrome, and neurological problems from measles/mumps.
• Hib meningitis may lead to life-long neurological defects in 40% of survivors (World Health Organization, 2006).

Examples of Vaccination Program Advantages

• Influenza vaccination in Finland and the USA exhibited vaccine efficiency greater than 30% for the prevention of acute otitis media in children (Moulton, Chung, Croll, Reid, Weatherholtz, & Santosham, 2005).
• Measles vaccines protect against multiple complications such as dysentery, bacterial pneumonia, keratomalacia and malnutrition (Strebel, Papania, & Halsey, 2004).
• Milder Disease: Vaccinated individuals experiencing disease usually have milder symptoms.
• Pertussis vaccine: Vaccinated individuals had shorter duration of chronic cough (Schmitt, et al., 1996).
• Varicella breakthroughs: Exhibited little fever, fewer skin lesions and fewer complications (Vasquez, et al., 2004).
• Rotavirus vaccines: Provided similar results.

Protection of the Unvaccinated Population

• Herd protection: Protecting unimmunized individuals.
• Mechanisms:
  • Reducing transmission of the pathogen via source drying (Anderson & May, 1991).
  • Transmitting the viral vaccine to others via contact.
• Hib disease elimination in Gambia achieved with less than 70% vaccine coverage (Adegbola, et al, 2005).
• Coverage Rate: Rate must be sufficient to provide herd protection (World Health Organization, 2015).
• Basic reproduction number (R_0): Average transmissions expected from a single primary case in a susceptible population.
• Measles has a higher R_0 than Rubella, Polio and Hib, requiring higher vaccination coverage.

Source Drying (Vaccination of Special Occupational Groups)

• Vaccination of food handlers to control typhoid and hepatitis A (Fiore, 2004).
• Administering pertussis vaccines to close contacts (parents, grandparents, nannies, siblings, nurses) to provide a “pertussis-free cocoon” (Crowcroft, et al,, 2003).

Societal and Economic Benefits of Immunization

• Investment required for infrastructure (cold-chain maintenance) and staffing (World Health Organization, 2015).
• Benefits translate to long-term cost savings and potential economic growth.
• Direct savings estimated at around 10 billion US dollars globally (Ehreth, 2003).
• Combination vaccines offer better compliance, coverage, and injection safety (Aristegui, et al., 2003).
• Economists emphasize reduction in indirect costs (lost productivity) (Bloom, Canning, & Weson, 2005).
• Savings on indirect costs seen in varicella compared to polio (Lieu, et al., 1994).
• Universal childhood vaccination more cost-effective than advice on smoking cessation (Chabot, Goetghebeur, & Gregoire, 2004).

Preventing Development of Antibiotic Resistance

• Slowing transmission slows proliferation of antibiotic-resistant microorganisms.
• Pneumococcal conjugate vaccine introduction in the US (2000) resulted in a:
  • 57% decline in invasive disease caused by penicillin-resistant strains.
  • 59% decline in strains resistant to multiple antibiotics by 2004 (Kyaw, et al, 2006).
• Vaccines reduce spread of multi-drug resistant strains (Parry, 2004).
• Vaccines are beneficial long-term choice for antibiotic resistance control (Liebermann, 2003).

Safe Travel and Mobility

• Travelers transmit and disseminate infectious diseases (observed in polio transmission).
• Vaccines can be administered on flexible accelerated schedules to ensure early protection.
• International travel, related to huge public gatherings pose greater risk.
• Pilgrims are required to be vaccinated against influenza and hepatitis B (Ahmed, Arabi, & Memish, 2006).
• Meningococcal ACWY vaccination prevents dispersal of meningococcal strains during the Muslim Hajj in Saudi Arabia (Klaber, Booy, El Bashir, Mifsud, & Taylor, 2002).

Protection Against Bioterrorism

• Surveillance and response systems are critical for identifying and responding to biological weapons (World Health Organization, 2015).
• Governments ensure adequate vaccine supply and logistics for potential threats (Hassani, Patel, & Pirofski, 2004).

Enhancing Equity

• Vaccination programs are seen as foundations of primary health-care services in developing countries (Martines, et al., 2005).
• Primary health care services focusing on infectious diseases enhances equity because the burden disproportionately falls on the disadvantaged.
• Vaccines benefit disadvantaged populations, as shown in the United States (pneumococcal immunization) and Bangladesh (measles vaccination).

Emphasis Points Summary

• Vaccinate to prevent diseases not only clinically but on the level of the population.
• Some vaccines can also prevent infections.
• Importance of vaccination extends to avoiding possible long-term complications.
• Even when breakthroughs may occur, vaccines lead to decreased disease severity.
• Vaccination targeted against the reservoir of infection can also be applied.
• Indirect costs further highlight the advantages particularly in more common infections.
• Greater benefits and savings from combination vaccines.
• Effective preventive measures reduces the transmission of both antibiotic susceptible and antibiotic resistant pathogens.
• Immunization is required to minimize risks for pilgrims and in events like the Hajj.
• Governments and systems must also include vaccination response as preparation for possible bioterror threats.

Main Targets of Immunization Programs

• Disease Eradication: Ideal goal, but difficult due to logistical challenges.
• Requires high immunity levels and adequate surveillance.
• Infectious diseases with no extrahuman reservoir can possibly be eradicated with effective vaccination.
• Polio: High coverage of Oral Polio Vaccine (OPV) has eliminated type 2 poliovirus globally.
• Monovalent type 1 and type 3 OPV and inactivated polio vaccine (IPV) may be required.

Local Elimination

• Feasible goal for most countries.
• Measles: Substantial progress achieving immunity in more than 95% of the population through a two-dose vaccination regimen.
• Combined measles, mumps and rubella (MMR) vaccine could also eliminate rubella and mumps.
• Reintroduction of infectious diseases poses a risk to countries that were previously successful in eliminating them.
• Global disease elimination may still be feasible by maintaining high levels of vaccination among humans.

Misconceptions and the Rise of the Anti-vaccination Movement

• Anti-vaccine lobby thrives despite evidence of benefits.
• Vaccine safety is getting more public attention than vaccination effectiveness and the collective benefits for the population.
• Vaccines are considerably safer than therapeutic medicines.
• Misguided safety concerns leading to decline in vaccination coverage.
• Effects of decline manifesting through re-emergence of pertussis and measles (World Health Organization, 2015).
• One underutilized opportunity is provided by pharmacists who can strategically interact with many members of the community to advocate for the benefits of vaccination.

Considerations in Establishing Pharmacy-Based Immunization Services

• Education and training
  Pharmacists in Immunization
• Pharmacists were able to utilize their practice to advocate for immunization
• Increase their interest in the area of immunization. Administering vaccines to patients
• The role of pharmacists and pharmacy in preventive health care is the integration of education. Academic institutions may opt to addition, continuing education programs and resources must be made available for practicing pharmacists to ensure quality, safe and effective immunization services.
• Where pharmacists are able to utilize their practices to advocate for immunizations (Modrzejewski, 2003).

American Pharmacists Association (APhA) Guidelines for Pharmacy-Based Immunization Advocacy

• Guideline 1 — PREVENTION: Pharmacists should protect their patient’s health by being vaccine advocates.
  • Pharmacists should adopt one of three levels of involvement in vaccine advocacy
    • Pharmacist advocate (motivating people to be Immunized);
    • Pharmacist coordinator (hosting others who Immunize);
      Pharmacy’s role: identify pt need of targeted vax, develop appropriate imm schedule
    • Pharmacist Immunizer (protect vulnerable people, consistent with state).
• Guideline 2 — PARTNERSHIP: Pharmacists should proactively participate in immunization programs.
  • Work with community prescribers, health departments (city, county, and state.) & assure pt maintain medical home
  • Assure appropriate vax is considered upon discharge hospitals, nursing homes & during drug reviews
• Guideline 3 — COMPETENCE: Pharmacies must achieve and maintain competence to administer immunizations.
  • Admin vax only after prop trained, evaluated disease epidemiology, vax characteristics, injection technique, & emergency responses
  • Question pt/ family about contraindications & inform specific terms risks & benefits of immunization. Ensure yearly additional ed & training
• Guideline 4 — DOCUMENTATION: Pharmacies must document immunizations fully and report clinically significant events appropriately.
  Maintain imm records to pt/ providers & to state immunization information registry
• Guideline 5 — EMPOWERMENT: Pharmacies Should Educate patients
  Encourage appropriate vax use - infocampaignpractitoner semployers, & hepuukm. Document any patient education & informed consent obtained, consistent with state law.
  Reference: American Pharmacist Association. Guidelines for Pharmacy-Based Immunization Advocacy. Adopted & Accessed November 20, 2015.

Expanded Program on Immunization to Achieve:

• FIC (Fully Immunized Child) covering at least 90% in provinces and cities
• Sustain global Polio-free status & eradicate Measles

Additional Considerations

• The government seeks to eliminate tetanus and measles in 2008
  *FDA advisory in 2014: hospitals/clinics not following proper Cold Chain Management

• Philippine gov't issued advisory FDA Advisory 2014~067 to Augment access & proper handling