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2/5/2018
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Pharmacy-based Immunizations: Current Best Practices and Novel Strategies to Increase Vaccination Rates
Joy Fakhouri, Pharm.D.Pharmacy Team Leader
Meijer PharmacyLivonia, MI
Joe Fava, Pharm.D.Clinical Assistant Professor
Wayne State UniversityDetroit, MI
An application-based continuing education program
Friday February 23, 2018
Michigan Pharmacists Association2018 Annual Convention & Exposition
Learning Objectives: Pharmacists
1. Understand the most up-to-date evidence on the safety, efficacy, and indications for current influenza, pneumococcal, herpes zoster, and tetanus/diphtheria/pertussis vaccines in adolescents and adults.
2. Evaluate patient vaccination status and make strong vaccine recommendations using efficient communication skills and electronic resources
3. Create a comprehensive annual vaccination plan that engages multiple stakeholders, starting with your pharmacy staff and including pharmacy students, community leaders, and public health representatives.
Learning Objectives: Technicians
1. Understand the indications and vaccine schedules of current influenza, pneumococcal, herpes zoster, and tetanus/diphtheria/pertussis vaccines in adolescents and adults.
2. Apply patient communication methods that are both efficient and effective - to recruit eligible patients for vaccinations.
3. Create a comprehensive annual vaccination plan that engages multiple stakeholders, starting with your pharmacy staff and including pharmacy students, community leaders, and public health representatives.
At your table
Presentation summary (one-page Key Points) and references
During-presentation active learning case studies
2017* ACIP/CDC Immunization Schedules
Listing of Influenza Vaccine Products for 2017-2018 Season
CDC MMWR August 2017
Adult Pneumococcal Vaccination Clinical Reference Chart Courtesy of California Department of Public Health (CDPH)
Immunization Update – Early 2018
Influenza Pneumococcal
Herpes ZosterTetanus,
Diphtheria & Pertussis
https://www.cdc.gov/flu/images/influenza-virus-fulltext.jpg
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Influenza Viruses: Four Types A: human, drifter + shifter, capable of pandemics or epidemics
Subtypes: based on surface proteins Hemagglutinin (H) 18 different (H1-H18)
Neuraminidase (N) 11 different (N1-N11)
Strains H1N1, H3N2
B: not divided into subtypes, does NOT shift Yamagata or Victoria lineage
C: mild, usually not associated w/ epidemics D: cattle, not known to infect humans
https://www.cdc.gov/flu/about/viruses/types.htm
Influenza: This Season
https://www.cdc.gov/flu/weekly/index.htm
Vaccine Efficacy Good match: 40-60% efficacy overall 2016-2017: 39% (32% against H3N2)
2017-2018: preliminary estimate against H3N2 in Australia: 10% U.S. vaccines have same composition (chosen September 2016 for release Summer 2017)
Hypotheses for poor vaccine efficacy Prior influenza exposure variable vaccine response Egg adaptation (changes in surface proteins during replication) Intra- or Inter-season drift
Vaccine Benefit Prevention of severe illness and decreased QOL in elderly
Decreases risk for flu-associated death by 65% in children
Influenza Vaccine: This Season
http://www.nejm.org/doi/full/10.1056/NEJMp1714916https://shotofprevention.com/2017/12/11/flu-vaccine-benefits-go-beyond-effectiveness-of-one-strain/?blm_aid=18693
Influenza VaccinationEligibility ALL patients aged 6 months and older*
INCLUDES: pregnant, immunosuppressed, and egg-allergic patients!!!
Formulations • Trivalent (IIV3) A types: H1N1 and H3N2, B type: Victoria lineage• Quadrivalent (IIV4) additional B type: Yamagata lineage
• Recombinant (RIV3 and RIV4) EGG-FREE• Cell culture-based (ccIIV4)
• Adjuvanted (aIIV3)• High dose (IIV3)
High Risk Groups (9)3-age4-disease states2-residence/race
Adverse Events • Injection-site reactions (soreness, redness, swelling) Up to 65%• Systemic flu-like symptoms (headache, fever, nausea, muscle aches) similar to placebo
Precautions (2)
Contraindications (1)
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5908a1.htmGrohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 Influenza Season. MMWR Recomm Rep 2017;66(No. RR-2):1–20. DOI: http://dx.doi.org/10.15585/mmwr.rr6602a1.
• < 5 years• > 50 years• < 18 years on ASA or salicylate-containing meds• Chronic pulmonary, CV**, renal, hepatic,
neurologic, hematologic, or metabolic disorders
• Immunocompromised• Pregnancy• BMI > 40 kg/m2
• Nursing Home/Long Term Care Residents• American Indians/Alaska Natives
• Moderate-to-severe acute illness w/ or w/out fever• History of Guillain-Barré syndrome within 6 weeks of receipt of influenza vaccine
• History of severe allergic reaction to any component of the vaccine or after previous dose of any influenza vaccine
Influenza Vaccination: Age 6 months – 8 years
Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 Influenza Season. MMWR Recomm Rep 2017;66(No. RR-2):1–20. DOI: http://dx.doi.org/10.15585/mmwr.rr6602a1.
Influenza Vaccination: Egg Allergy
https://www.cdc.gov/flu/protect/vaccine/egg-allergies.htm
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Influenza: Vaccine Product SelectionPatient Appropriate Vaccine
73 YOWM
32 YOAAF with latex allergy12 YOWF with egg allergy (hives)
28 YOAAF who is 20 weeks pregnant
Any age-appropriate IIV3/IIV4 EXCEPT Fluvirin®
High Dose IIV3 (Fluzone® HD) or aIIV3 (FluadTM)*
Any AGE-APPROPRIATE IIV3 or IIV4 Why not RIV3/4?
Any age-appropriate IIV3/IIV4Pregnancy Category B: Fluzone® Quadrivalent (ID and IM), Flucelvax Quadrivalent®, Afluria® Trivalent, Fluvirin® TrivalentNo Pregnancy Category: Afluria® Quadrivalent, Fluarix® Quadrivalent, Flulaval® Quadrivalent
CDC NOTES: • Less experience with IIV4 and ccIIV4 formulations• Data for RIV3/4 very limited**
Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 Influenza Season. MMWR Recomm Rep 2017;66(No. RR-2):1–20. DOI: http://dx.doi.org/10.15585/mmwr.rr6602a1.Highlights of Prescribing Information for all influenza vaccines listed above. Accessed 1 Feb 2018 – URLs available upon request.
Immunization Update – Early 2018
Influenza Pneumococcal
Herpes ZosterTetanus,
Diphtheria & Pertussis
Pneumococcal Disease Etiology: Streptococcus pneumoniae
90 different serotypes
10 common types cause 62% of invasive disease
Not just pneumonia! Two major clinical syndromes: bacteremia and meningitis
Pneumonia is most common disease caused by S. pneumoniae 25-30% will get bacteremia
Vaccines Pneumovax®23 (PPSV23)
Serotypes: 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19A, 19F, 20, 22F, 23F, and 33F
Prevnar 13® (PCV13) Serotypes: 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F
http://www.immunize.org/askexperts/experts_pneumococcal_vaccines.asphttps://www.merck.com/product/usa/pi_circulars/p/pneumovax_23/pneumovax_pi.pdfhttp://labeling.pfizer.com/showlabeling.aspx?id=501
Pneumococcal Vaccination
Case Study 1DL is a 67 YOWF who comes to your
pharmacy asking for a pneumonia ‘booster.’ Her MCIR profile shows she received one dose of PPSV23 at age 63 years. What are your recommendations?
Pneumococcal Vaccination
From “Pneumococcal Vaccine Timing – For Adults.” California Department of Public Health; Immunization Branch – September 2015
Pneumococcal Disease
Case Study 1 DL is a 67 YOWF who comes to your pharmacy asking for a pneumonia
‘booster.’ Her MCIR profile shows she received one dose of Pneumovax®23 (PPSV23) at age 63 years. What are your recommendations? PMH: T2DM, HTN
Case Study 1 Answer: Prevnar 13® (PCV13) today
Pneumovax®23 (PPSV23) 1 year later (5 total years since last PPSV23)
What if you’re < 65 YO?
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Pneumococcal Vaccination
From “Pneumococcal Vaccine Timing – For Adults.” California Department of Public Health; Immunization Branch – September 2015
Pneumococcal Vaccination Safety and Efficacy
Prevnar 13® Pneumovax®23
Efficacy • Against CAP: 45%*• Against Invasive Pneumococcal
Disease: 75%*
• Against invasive infection: 57%*; • 75%* in immunocompetent patients > 65
YO
Adverse Events (in adults)
• Injection site reactions (pain in >50%, redness and swelling in >10%)
• Fatigue (>30%)• Headache, muscle pain (>20%)• Joint pain, ↓ appetite, limitation of
arm movement (>10%)• vomiting, fever, chills, rash (>5%)
• Injection-site pain/soreness/tenderness (60.0%)
• Injection-site swelling/induration (20.3%) • Headache (17.6%)• Injection-site erythema (16.4%)• Asthenia and fatigue (13.2%)• Myalgia (11.9%)
https://www.merck.com/product/usa/pi_circulars/p/pneumovax_23/pneumovax_pi.pdfhttp://labeling.pfizer.com/showlabeling.aspx?id=501
*Against vaccine-type pneumococcal disease (serotypes contained in vaccine)
Immunization Update – Early 2018
Influenza Pneumococcal
Herpes ZosterTetanus,
Diphtheria & Pertussis
Herpes Zoster
http://www.nejm.org/doi/full/10.1056/NEJMct066061
Herpes Zoster
http://www.nejm.org/doi/full/10.1056/NEJMct066061
Herpes ZosterZostavax® (ZVL) SHINGRIX (RZV)
Vaccine Type • Live-attenuated• Oka/Merck strain VZV
• Inactive, recombinant, adjuvanted• VZV surface glycoprotein E antigen
component + AS01B adjuvant
How Supplied • Single-dose vial of lyophilized vaccine (powder)
• Separate package of diluent (clear)
• Single-dose vial of lyophilized vaccine (powder)
• Accompanying vial adjuvant suspension component (opalescent, colorless to pale brown)
Dosing and route of administration
• 0.65 ml (reconstituted) subcutaneously(1 dose)
• *Within 30 minutes of reconstitution
• 0.5 ml (reconstituted) IM at 0 and 2-6 months (2 doses)
• Administer immediately or store refrigerated and use w/in 6 hours
Storage and Handling
• Protect From light• Vaccine: frozen (-58oF to 5oF) • Diluent: Room temperature or
refrigerated (36oF to 46oF)
• Protect From light• Lyophylized gE antigen component AND
adjuvant suspension: (36oF to 46oF)
https://www.merck.com/product/usa/pi_circulars/z/zostavax/zostavax_pi2.pdfhttps://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Shingrix/pdf/SHINGRIX.PDF
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Herpes ZosterZostavax® (ZVL) SHINGRIX (RZV)
Schedule (FDA/ACIP)
• FDA: 1 dose in > 50 YO• ACIP: 1 dose in > 60 YO
• FDA and ACIP: 2 doses (0 and 2-6 months) in > 50 YO
Efficacy • Overall: 51.3%• 50-59 YO: 69.8%• 60-69 YO: 63.9%• 70+ YO: 37.6%
• 50+ YO: 97.2%• 70+ YO: 89.8%
Adverse Effects Local:• Pain (34.3-53.9%)• Erythema (35.6-48.1%)• Swelling (26.1-40.4%)• Pruritus (6.9-11.3%), warmth (1.6-3.7%),
hematoma (1.6%), induration (1.1%)
Systemic: headache (1.4-9.4%), pain in extremity (1.3%)
Local• Pain (78%)• Erythema (38.1%)• Swelling (25.9%)
Systemic: myalgia (44.7%), fatigue (44.5%), headache (37.7%), shivering (26.8%), fever (20.5%), gastrointestinal symptoms (17.3%)
Pricing • ~$250-300• Medicare Part D Benefit w/ variable copays
• ~$280 for two doses• Coverage?
https://www.merck.com/product/usa/pi_circulars/z/zostavax/zostavax_pi2.pdfhttps://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Shingrix/pdf/SHINGRIX.PDF
• Reduces PHN by 66.5%
Oxman, et al. NEJM 2005 352(22):2271-84 Cunningham et al. NEJM 2016;375(11):1019-32Schmader, et al. CID 2012;54(7):922-8 Chlibek et al. Vaccine 2016;34(6):863-8Lal et al. NEJM 2015;372(22):2087-96
• 88.8-91.2% effective against PHN
Herpes Zoster
https://www.gsksource.com/pharma/content/gsk/source/us/en/brands/shingrix/pi/acip.html
Herpes Zoster New Recommendations: Key Reminders
Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep 2018;67:103–108. DOI: http://dx.doi.org/10.15585/mmwr.mm6703a5
Can you give SHINGRIX to patients who are immunosuppressed?
Can you give SHINGRIX to patients w/ history of Shingles?
Can you give SHINGRIX to someone who previously received Zostavax®?
How long do I have to wait after someone has gotten Zostavax to give SHINGRIX?
Can I give SHINGRIX at the same time as other vaccines?
NO (not yet: no data, studies ongoing)
YES
YES
When acute phase of illness is over and no symptoms present
Only available data: > 5 yearsExpert opinion: > 2 months
Fluarix Quadrivalent: data says YESPPSV23, TdAP: studies ongoing but CDC says YES*
Immunization Update – Early 2018
Influenza Pneumococcal
Herpes ZosterTetanus,
Diphtheria & Pertussis
Tetanus, Diphtheria, & Pertussis
Children: DTaP at 2, 4, 6, and 15-18 months, followed by last dose at 4-6 years
https://www.cdc.gov/vaccines/schedules/index.html
Adults: Tdap ONCE, Td every 10 years
Pregnancy: Tdap with EVERY pregnancy – ideally early in gestational weeks 27-36
Tetanus, Diphtheria, & Pertussis Case Study 2
GQ is a 68 YOAAM at your pharmacy requesting a tetanus shot booster. You check his MCIR and reveal that his last tetanus shot was in 2004 and he received TdaP. You check your vaccine stock for Td and notice you only have Boostrix® (TdaP) in stock. GQ has two infant grandchildren. What should you do?
A) Give him nothing. His caught up on his tetanus shots.
B) Give 1 dose of Boostrix® (Tdap) today
C) Refer him to another pharmacy or provider for the Td vaccine
D) Order Tenivac (Td) and tell him to come back when it arrives
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Tetanus, Diphtheria, & Pertussis Immunity to pertussis from vaccination is estimated to last only ~4-7 years
Can vary from person to person
Intervals of 5 and 10 years between TdaP vaccinations have been shown to be well-tolerated and immunogenic in adolescents and adults
Per Immunization Action Coalition panel of experts: If a person who previously received Tdap needs a Td booster and Td is not available it IS
acceptable to administer Tdap
Kilgore PE et al. Clin Microbiol Rev. 2016;29(3):449-86. van Twillert I et al. Pathogens and disease. 2015;73(8):ftv071.
McGirr A etl al. Pediatrics. 2015;135(2):331-43. Halperin SA et al. Vaccine. 2011;29(46):8459-65.
Halperin SA,et al. Vaccine. 2012;30(5):974-82. Epub 2011/11/26. doi: 10.1016/j.vaccine.2011.11.035. PubMed PMID: 22115634.http://www.immunize.org/askexperts/experts_per.asp
Tetanus, Diphtheria, & Pertussis
Case Study 2 GQ is a 68 YOAAM at your pharmacy requesting a tetanus shot booster. You
check his MCIR and reveal that his last tetanus shot was in 2004 and he received TdAP. You check your vaccine stock and notice you only have Boostrix® in stock. GQ has two infant grandchildren. What should you do?
A) Give him nothing. His caught up on his tetanus shots.
B) Give 1 dose of Boostrix® today
C) Refer him to another pharmacy or provider for the Td vaccine
D) Order Tenivac (Td) and tell him to come back when it arrives
Check your CPA first!
Novel Strategies to Boost your Immunization Numbers
Education
Annual education for both pharmacists and technicians
CEBloodborne PathogensCPR/AED TrainingReview Immunization SchedulesUnderstand State laws and Collaborative
Agreements and Protocols
Education
Flu + 1 or 2Use a state immunization registry (MCIR)
Check before giving flu shots to see which other vaccines are indicated.
Adult records complete??Educate technicians on who to offer certain
vaccines
“Flu + 1” Triggers
Vaccine TriggerPneumonia Age >65
Metformin/Insulin prescriptionAlbuterol inhalersNicotine replacement therapyNitroglycerinImmunosuppressive injectables
Shingles Age >50Medicare Part D.
Tdap Prenatal vitaminsPregnant patients, spouses, and grandparents
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Case #3
Overcoming Barriers
Myths/Misconceptions“I am sick. I can’t get my flu shot.”“I have an egg allergy.”“The flu shot will give me the flu. ““I never get the flu.”“I don’t want to be injected with Mercury.”
Overcoming Barriers
Fear of NeedlesTell patients side effects (local reactions)
upfront. Children- having suckers/stickers, distraction,
help from parentsHow to handle syncope
Overcoming Barriers
Financial Barriers
Financial Barriers Indigent patientsHigh copays
Pharmacy Barriers
Staffing- call offs during winter months
Busiest time of the year
Let’s take advantage of our increased volume to make a bigger impact in our community!
Making a Strong Recommendation
Research indicates that most adults believe that vaccines are important and are likely to get them if recommended by their healthcare professionals. “My pharmacist strongly recommends getting
your flu shot.” “My pharmacist recommends that all diabetics
get their pneumonia vaccine.”
https://www.hhs.gov/blog/2017/11/07/healthcare-providers-strong-vaccination-recommendation-can-be-game-changer-this-flu-season.html
Making a Strong Recommendation
1. Tailor reasons to that individual.2. Discuss how vaccination prevents illness.3. Outline the consequences of getting sick.4. Explain how vaccines work.5. Answer questions with compassion.
https://www.hhs.gov/blog/2017/11/07/healthcare-providers-strong-vaccination-recommendation-can-be-game-changer-this-flu-season.html
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Motivational Interviewing
Roll with resistance
1Express empathy
2Avoid argumentation
3Develop discrepancy
4Support self-efficacy
5
SHARE
SHARE the tailored reasons why the recommended vaccine is right for the patient
HIGHTLIGHT positive experiences with vaccines
ADDRESS patient questions and any concerns about the vaccine, including side effects, safety, and vaccine effectiveness
REMIND patients that vaccines protect them and their loved ones from many common and serious diseases
EXPLAIN the potential costs of getting the disease, including serious health effects, time lost
https://www.cdc.gov/vaccines/hcp/adults/downloads/standards-immz-practice-recommendation.pdf
Creating a Plan
Having a game plan in early summer will be a great help.
Stock up on supplies at beginning of season. Don’t have to worry about basic supplies
going on back order. Adequate supply of vaccines and
checking stock on a weekly basis.Epi-pens on hand and in date?
Creating a Plan
SpacePrivate area for vaccination in
case clothing needs to be removed
Clean area clutter and food free.
Avoid patient information disclosures.
Incorporating into the Workflow
Technicians and Pharmacist offering vaccines at every patient interaction!
Technicians collecting patient information via screening questionnaire. Calling PCP if MCIR incomplete. Checking personal immunization card.
Incorporating into the Workflow
Bill vaccines while patient shops/waits for their prescription.Triage as “Urgent” to increase
convenience. Tech provides vaccine in basket for
pharmacist to check, allowing vaccine to warm up.
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Use your Interns!
Lessen the labor burden.• Pharmacist
stays in workflow.
• Hours charged off.
Technician education about vaccines/how to
overcome patient barriers
Part of their
Education
Increasing Visibility Sending letters with pre-filled questionnaires to patients
that you gave flu shots the year before.
In-store advertisementsSigns, overhead announcements, greeters giving
flyers to customers.Setting up a table or having a technician on the
busiest entrance of the store to offer/advertise.
Off-site clinicsBusinesses with >100 employeesChurches, Schools, Community health fairs/events
Motivating Your Team
Ask at every patient interaction Weekly or monthly competitions Games Poster that shows progress Create a theme for your pharmacy Rewarding via gift cards/food
Geographical OutbreaksHepatitis A
Outbreak from August 2016. Michigan has 677 current cases and had 22 deaths as of Jan 12,
2018. Shortage of Hep A vaccine Prevention:
HAVRIX (HepA Vaccine) given at 0 and 6-12 monthsVAQTA® (HepA Vaccine) given at 0 and 6-18 monthsTWINRIX (HepA + HepB Vaccine) given at 0, 1, and 6 months
Childhood vaccine but most adults have not received yet.http://www.michigan.gov/mdhhs/0,5885,7-339-71550_2955_2976_82305_82310-447907--,00.html
https://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Havrix/pdf/HAVRIX.PDFhttps://www.merck.com/product/usa/pi_circulars/v/vaqta/vaqta_pi.pdf
https://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM110079.pdf
Geographical Outbreaks
Pertussis Vaccine-preventable disease Rise in cases in Michigan, peaking in 2010 with
over 1,500 cases reported. 2014- over 1,400 cases reported. Target pregnant patients 27-36 weeks and
those who are in close contact with a newborn.
http://www.michigan.gov/mdhhs/0,5885,7-339-73971_4911_4914-240419--,00.html
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More ways to increase vaccination rates
CMRs
Asses vaccination status during every CMR encounter.
MCIR patients
Travel Vaccines
Azithromycin or Metronidazole prn diarrhea.
Yellow Book Foreign
population?
Back-to-School Vaccines
11 year old vaccines-Tdap, HPV, and MenACWY
College Freshman
Flu shot
Follow-up Reminders Notify patients due for their boosters.
Ex. Run reports of Prevnar 13 given more than a year ago.
Others- SHRINGRIX HPV Hep A and B
More ways to increase vaccination rates
Why Vaccinate?
Protecting your community (herd immunity) Convenience of pharmacy hours and no
appointments needed. Doctors are too busy to assess vaccination status
and often do not stock all vaccines. Economic Benefit
Less work-days missed, hospitalizations, inappropriate prescribing of antibiotics, etc.
Why Vaccinate?
Increased profitability when reimbursement rates are low.
Building up your business! Annual Flu Vaccine is part of Medicare Part C
star ratings.Will pharmacies be measured by their rate of
vaccinations next?
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-12.html
Make it Fun! It’s our time to shine. Just have a plan and start
early. Team building and competition Increases our patient contact
Offer more services Show that Pharmacists do more than prepare
prescriptions.
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