the continuing professional - independent pharmacist...meningitis acw135y, japanese encephalitis,...

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CPD MODULE

module 227www.pharmacymag.co.uk

continuingprofessionaldevelopment

the

programmeThis module is suitable for use by pharmacists as part of their continuingprofessional development. After reading this module, complete the learningscenarios and post-test at www.pharmacymag.co.uk and include in your CPDportfolio. It should be read in conjunction with the Practice Focus on theLondon pharmacy flu scheme in the August issue of Pharmacy Magazine (p18).

pharmacy magazine

First in professional development

GOAL:To consider the role that communitypharmacy can play in providingimmunisation services.

OBJECTIVES:After completing this module you shouldbe able to:• Identify the range of immunisations that can bedelivered from community pharmacy

• Discuss how influenza immunisation services can be provided from community pharmacy

• Identify actions you need to take in order to develop and run an immunisation service.

forthismodule

Contributing author: Caroline Hind BPharm, PhD,MRPharmS, FFTM, RCPS (Glasgow), deputy directorof pharmacy and medicines management at NHSGrampian

Immunisation servicesin community pharmacy

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IntroductionHistorically, immunisation services havebeen provided by the nursing and medicalprofessions but, increasingly, there isevidence that pharmacists can play animportant role in disease prevention by advocating and administering certainimmunisations. While some may argue that the

administration of immunisations is not part of the traditional role of pharmacists, it should instead be viewed as a logicalextension to the activities of pharmacists inthe preventative aspects of pharmaceuticalcare and in the broader public health arena. Immunisation services initially started

in the US, where pharmacists were givenauthority to administer vaccines underindividual state laws and regulations.Initially, pharmacists were mainlyauthorised to administer influenza andpneumococcal vaccines but expansion of pharmacist-delivered immunisationsfollowed the 2009 H1N1 influenza pandemic,when the roles that pharmacists could playin improving this area of public health wereclearly highlighted.

WELCOME to the two hundred and twenty seventhmodule in the Pharmacy Magazine ContinuingProfessional Development Programme, which revisitsimmunisation services in community pharmacy.

Continuing professional development (CPD) is astatutory requirement for pharmacists. Journal-basededucational programmes are an important means of keeping up to date with clinical and professionaldevelopments and can form a significant element ofyour CPD. Completion of this module will contribute to the nine pieces of CPD that must be recorded a year, as stipulated by the GPhC.

Before reading this module, test your existingunderstanding of the topic by completing the pre-testat www.pharmacymag.co.uk. Then, after studying the module in the magazine, work through the sixlearning scenarios and post-test on the website.

Record your learning and how you applied it in yourpractice using the CPD report form available online and on pviii of this module.

Self-assess your learning needs:• How is the London pharmacy flu vaccinationservice being expanded in 2014-15?

•What are the premises criteria for the provisionof pharmacy immunisation services?

•What groups are eligible for a seasonal flu jab? Pharmacy immunisation in the UKWithin the UK, pharmacy immunisationservices are less well developed, althoughthey are growing rapidly. An early influenzaimmunisation service pilot1 wasset up in Aberdeen in 2002. In thisstudy, 55 patients in the under-65age group who wereclassified as ‘atrisk’ receivedinfluenza

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immunisation from a pharmacist and were askedto complete a patient acceptability questionnaire.The vast majority of patients thought that thevaccines had been administered as well as thosethey had received in the past from nurses anddoctors and indicated they would be happy to receive immunisation from pharmacists in the future. On the basis of this positive feedback, the

influenza immunisation service was expanded to other community pharmacies in Grampian. In the 2013/14 flu season, 47 (35.9 per cent)Grampian pharmacies delivered 1,962 influenzaimmunisations to NHS and local authority carers in support of the occupational healthimmunisation programme.As in the US, the 2009 H1N1 influenza pandemic

provided a further impetus to the development of immunisation services from communitypharmacies in the UK, both in terms of thenumbers of pharmacies involved and the range of vaccines administered. Indeed seasonalinfluenza immunisation is now provided in a variety of NHS settings. In 2005, pharmacists in City and Hackney PCT

were trained to administer influenza vaccine tohelp improve uptake in east London2. Accreditedcommunity pharmacists identified ‘at risk’patients bringing in prescriptions for dispensingand checked to see if they had received theinfluenza vaccine. If they hadn’t, the pharmacistoffered to administer the vaccine in a privateconsultation area in the pharmacy. NHS Isle of Wight commissioned a patient

evaluationof its community pharmacy influenzaimmunisation service, inviting feedback from over2,000 patients3. The 2010/11 influenza campaignaimed to integrate community pharmacists asservice providers working in collaboration withGP colleagues and occupational health. Seventeencommunity pharmacies vaccinated a total of2,903 patients (approximately 10 per cent of thetotal vaccinated through all services). Of these,36.6 per cent were under-65s with co-morbidities.The service was rated as excellent by 90.9 per centof patients and 92.8 per cent said they found theservice more accessible. Nearly all patients (98.4 per cent) said they would use the pharmacyservice again. NHS Wales has developed a national

community pharmacy seasonal influenza

vaccination service to provide flu vaccines on the NHS to patients aged 65 years and over, andthose under 65 years in other ‘at risk’ groups. In the 2012/13 influenza season, 81 pharmacies in Wales provided the service between October2012 and January 2013, representing 11 per centof the pharmacies in Wales. In total 1,537 peoplereceived vaccinations across the seven healthboards4.In December 2013, NHS England published

‘Community pharmacy – helping with winterpressures’5, which suggested ways localcommissioners could make better use ofcommunity pharmacy services to support

healthcare provision during the winter months. It detailed proposals for three services: influenzavaccination, emergency supplies of medicines andprovision of self-care support for winter ailments.The document has been influential in supportingthe commissioning of pharmacy influenzaimmunisation services. In the 2013/14 influenza season, Pharmacy

London (a forum of London local pharmaceuticalcommittees) worked with commissioners at NHS England London region to develop a pan-London community pharmacy influenzavaccination service6. Approximately 1,100 community pharmacies

in the capital were commissioned to support its seasonal influenza vaccination programme.Authorised pharmacies were able to provide aNHS influenza vaccination service for patientsaged 65 years and over and those under 65 yearsin other ‘at risk’ groups. This allowed patientswho lived, worked or accessed services in any ofthe London boroughs to access the service from a participating pharmacy. Almost 70,000 peoplewere vaccinated in these pharmacies7. (See alsoPractice Focus, PM August, p18.)

� new medicine service continues The NMS has been extended until April 2015 pending the results of an evaluation study, published thismonth

The 2009 swine flu pandemic was instrumental in the expansion of pharmacy immunisation services

Download the Health Protection Scotland ‘Guidance on vaccine handling and storage 2013’ fromwww.documents.hps.scot.nhs.uk/immunisation/general/vaccine-storage-handling-2013-09.pdf.• Consider what vaccine handling and storagerequirements are necessary to undertakeimmunisations within a community pharmacy

• How would your pharmacy do these?• What changes/improvements would be required?

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Reflection exercise 1


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As part of the flu plan for the 2014/15 winterseason, NHS England London region has agreed to continue to commission communitypharmacies to administer seasonal influenzavaccinations, expanding the range of eligiblepatients and including the use of Fluenz. A significant number of people who were eligible

for the seasonal influenza vaccination were alsoeligible for a number of other vaccines, such as pneumonia, shingles and pertussis vaccine. To make the most of the influenza vaccinationopportunity, pharmacists are now also able tooffer these vaccines to the appropriate eligiblegroups of patients.While the largest numbers of community

pharmacist services are for influenzaimmunisation, service commissioners are alsostarting to look at other areas where communitypharmacy can support public health campaigns,such as pneumococcal and hepatitis Bimmunisation.Both NHS Tayside and, at the time, Westminster

PCT looked to community pharmacy to provideadditional immunisation capacity to deliver thehuman papilloma virus (HPV) immunisationprogramme.A feasibility study was undertaken in 2007

in two community pharmacies in Grampian toprovide travel immunisations8. When patientswere asked to rate the overall service on a scale ofone to 10 – 10 being excellent – the medianresponse was 10. Ninety-eight per cent said theywould use the pharmacy service again and 81.4per cent thought the pharmacy service providedvalue for money.Community pharmacy immunisation

programmes are no longer only the remit of NHS commissioned services. In 2008, onepharmaceutical wholesaler, in conjunction withan influenza vaccine manufacturer, launched aprivate influenza vaccination service under theguidance of a private patient group direction.Now, non-NHS vaccination services are widelyavailable from community pharmacies in the UK. Seasonal flu immunisation is the vaccine most

frequently offered and customers are usuallycharged between £8 and £15 for the service. In 2011, the Co-operative Pharmacy group, inconjunction with the Muslim Council of Britain,offered meningococcal (ACWY135) vaccine toMuslims visiting Mecca as part of the Haj9.

In developing pharmacy immunisation services,almost all pharmacists will have started bydelivering seasonal influenza vaccinations. Once learnt, the key principles and techniques of providing influenza immunisation can betransferred to other similar services.

Vaccine preventable diseaseVaccine preventable diseases are targeted by a range of immunisation programmes, includingroutine childhood immunisations, vaccines for ‘at risk’ groups of patients, immunisations for the purpose of travel and seasonal influenzajabs. The overall aim of the routine childhood

immunisation programme is to protect allchildren against the preventable childhoodinfections of diphtheria, tetanus, whoopingcough, Haemophilus influenzae type B, polio,meningococcal serogroup C, measles, mumps,rubella and pneumococcus. The primarychildhood immunisations are usually delivered by nurses working within general practice;booster immunisations may also be provided byschool nurses. Human papillomavirus (HPV) isincluded in the routine immunisation programmefor girls aged 12-13 years.

Within the UK there are groups of patients for whom additional immunisations arerecommended – either due to the individual’soccupational risk or their own health status.These include pneumococcal, rabies, tuberculosisand hepatitis B vaccines. For example, hepatitis B vaccine is recommended for a wide range of individuals from injecting drug misusers tohealthcare staff. Immunisation for these groups of patients is available from a range of providersincluding GP practices, occupational healthdepartments and community pharmacists. Immunisations for the purpose of travel fall into

two groups, those that are allowable on the NHSand those that are provided as a private service.Hepatitis A, typhoid, diphtheria/tetanus/polio,hepatitis B in combination with hepatitis A andcholera (but only for those at absolute risk) areallowable on NHS prescriptions. MeningitisACW135Y, Japanese encephalitis, tick-borneencephalitis, yellow fever and rabies are usuallyprovided as a private service. A full risk assess-ment, based on destination and type of travel, isrequired to determine the individual’s need forimmunisation.Seasonal influenza immunisation will now be

dealt with in more detail.

� ‘Once learnt, the key principles andtechniques of providing influenzaimmunisation can be transferred toother immunisation services’

Consultation rate per 100,000 population

Scheme: RCGP (England) NPHS (Wales) HPS (Scotland)

Consultation for: Influenza & influenza-like

illnessInfluenza Influenza-like

illness

Baseline activity These levels reflect the situationfor the majority of the year whenthe consultation rate is low

0 - 30 <25 <50

Normal seasonalactivity

Observed each year and reflectsthe fact that some minimalinfluenza activity is expected each year

30 - 200 25 - 100 50 - 600

Higher thanaverage seasonalactivity

This is observed less frequently – >100 - 400 >600 - 1,000

Epidemic

This activity is reserved forperiods of unusually highinfluenza rates. In the past 10 years this level of activity has only been observed once in the UK

>200 >400 >1,000

�Figure 1: GP consultations for influenza

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Influenza infectionThe influenza virus was first identified in 1933.There are two main types of virus that causeinfection: influenza A and influenza B. Influenza A usually causes a more severe illness thaninfluenza B. Influenza occurs most often in winter and

usually peaks between December and March inthe northern hemisphere. Illnesses resemblinginfluenza that occur in the summer are usuallydue to other viruses (excluding the pandemic of 2009). The influenza virus is unstable and new strains

and variants are constantly emerging. For mostpeople influenza infection is just a nastyexperience, but for some it can lead to moreserious illnesses. The commonest complications

of influenza are bronchitis and secondarybacterial pneumonia. These illnesses may requiretreatment in hospital and can be life-threatening,especially in the elderly, asthmatics and those inpoor health.Influenza activity is monitored by Public Health

England (PHE), formerly the Health ProtectionAgency, through reports of new consultations forinfluenza-like illness from sentinel GP practices,combined with virological surveillance. The H1N1

(2009) ‘swine flu’ pandemic virus emerged inMexico in 2009 and spread around the worldcausing mild/asymptomatic disease in themajority of cases, but severe illness and death in a small proportion of cases, particularly inmore vulnerable groups. Severe epidemics were also recorded in 1975/76

and 1989/90, resulting in an estimated 29,646 and23,046 deaths respectively in England and Wales. Even in winters when incidence has beencomparatively low, 3,000-4,000 deaths have beenattributed to influenza.During the first influenza season after the

2009/10 H1N1 flu pandemic, the UK experiencedintense influenza activity. In 2013/14, low levels ofinfluenza activity were seen in the community in

the UK, with virological activity occurring late in the 2013/14 season. Outbreaks were initiallyreported in care homes (mainly resulting fromrespiratory viruses other than influenza) followedby influenza A H1N1 outbreaks primarily inhospital settings. With the 2009 pandemic A(H1N1) virus predominating, the impact waslargely seen in young adults as observed in2010/11, with little impact in the elderly. In order to provide the public and the press

with a simple and consistent statement regardingthe levels of clinical reports of influenza and flu-like illness, a set of common definitions wereagreed by PHE based on the rate of new GPconsultations per 100,000 population per week(see Figure 1). There are differences between the levels

for England, Scotland and Wales due to the three schemes employing slightly differentmethodologies, case definitions and guidelines,which means the consultation rates are notdirectly comparable.

Influenza vaccineChanges in the principal surface antigens of influenza A – haemagglutinin (H) andneuraminidase (N) – make these virusesantigenically labile. Minor changes (‘antigenicdrift’) occur progressively from season to season.Major changes (‘antigenic shift’) occur period-ically, resulting in the emergence of a new sub-type with a different haemagglutinin protein. A new sub-type can cause widespread epidemicsor even a pandemic if populations have little or no immunity. Three influenza pandemics occurredin the last century. NHS service and business continuity plans are

being updated and revised to cope with futureinfluenza pandemics. The lessons learned fromthe 2009 H1N1 pandemic are still high on theagenda as conditions continue to exist for theemergence of future strains with pandemicpotential. Influenza B viruses are subject to antigenic

drift but with less frequent changes. Due to thechanging nature of the influenza virus, the WorldHealth Organization (WHO) monitors influenzaviruses throughout the world. Each year the WHOmakes recommendations about the strains to beincluded in vaccines for the forthcoming winterseason.

Download the Health Protection Agency’s ‘NationalMinimum Standards for Immunisation Training’ fromwww.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1204100464376.• What should be included in an influenzaimmunisation training programme for pharmacists in order to develop the appropriate competencies?

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How might you use your pharmacy’s patient medicationrecord system to identify patients who may be in theNHS target groups to receive influenza immunisation?What medications might these patients be receiving?

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The influenza A virus is particularly virulent and can cause severe illness


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To provide continuing protection, annualimmunisation is necessary with a vaccine againstthe currently prevalent strains.The currently available influenza vaccines give

70-80 per cent protection against infection withinfluenza virus strains well matched with those inthe vaccine. Protection lasts for about one year.After immunisation, antibody levels may take upto 10 to 14 days to reach protective levels. Whileinfluenza activity is not usually significant beforethe middle of November, the influenza season can start early and therefore the ideal time forimmunisation is between September and earlyNovember. Manufacture of influenza vaccines is complex

and conducted to a tight schedule, constrained by the length of time available between the WHOrecommendations and the opportunity tovaccinate before the influenza season.Manufacturers may not be able to respond tounexpected demands for vaccine at short notice.This has caused problems in recent years whenmanufacturers have had production problems orthere has been an unexpected increase in uptake.Within the UK, influenza immunisation is

targeted at those individuals most at risk from thesequelae of influenza infection. They include: • All those aged 65 years and over • All those aged six months and over in thespecified ‘at risk’ groups (see Figure 2)

• All pregnant women, irrespective of their stageof pregnancy

• Those living in long-stay residential care homesor other long-stay care facilities where rapidspread is likely to follow introduction ofinfection and cause high morbidity andmortality

• Those in receipt of a carer’s allowance, or thosewho are the main carer of an elderly or disabledperson whose welfare may be at risk if the carerfalls ill

• Others involved directly in delivering healthcaresuch that they and vulnerable patients are atincreased risk of exposure to influenza

• Health and social care staff directly involved inthe care of their patients or clients.

In 2013/14, the universal childhood influenzavaccine programme with live attenuated influenzaintra-nasal vaccine commenced across the UK,targeting two to three-year-olds and varying pilotgroups by country. For the 2014/15 programme all

Pre-school children aged two tofive yearsAll primary school children in P1-7

All patients aged 65 years and over

Chronic respiratory disease (aged six months or older)

Chronic heart disease (aged six months or older)

Chronic kidney disease (aged six months or older)

Chronic liver disease (aged six months or older)

Chronic neurological disease (aged six months or older)

Diabetes (aged six months or older)

Immuno-suppression (aged six months or older)

Asplenia or dysfunction of thespleen

Pregnant women

People in long-stay residentialcare or homes

Unpaid carers and young carers

Health and social care staff

“65 years and over” is defined as those aged 65 years and over on March 31, 2015 (i.e. born on or before March 31, 1950)

• Asthma that requires continuous or repeated use of inhaled or systemic steroids or with previous exacerbations requiring hospital admission

• Chronic obstructive pulmonary disease (COPD) including chronic bronchitis andemphysema, bronchiectasis, cystic fibrosis, interstitial lung fibrosis,pneumoconiosis and bronchopulmonary dysplasia (BPD)

• Children who have previously been admitted to hospital for lower respiratory tractdisease

• Congenital heart disease, hypertension with cardiac complications, chronic heartfailure, individuals requiring regular medication and/or follow-up for ischaemicheart disease

• Chronic kidney disease at stage 3, 4 or 5, chronic kidney failure, nephroticsyndrome, kidney transplantation

• Cirrhosis, biliary atresia, chronic hepatitis, chronic hepatitis from any cause such ashepatitis B and C infections and other non-infective causes

• Stroke, transient ischaemic attack (TIA)• Conditions in which respiratory function may be compromised due to neurologicaldisease (e.g. polio syndrome sufferers)

Clinicians should consider on an individual basis the clinical needs of patientsincluding individuals with:• Cerebral palsy, multiple sclerosis and related or similar conditions • Hereditary and degenerative disease of the nervous system or muscles • Severe neurological or severe learning disability

• Type 1 diabetes, type 2 diabetes requiring insulin or oral hypoglycaemic drugs, diet-controlled diabetes

Immuno-suppression due to disease or treatment • Patients undergoing chemotherapy leading to immuno-suppression, bone marrowtransplant

• HIV infection at all stages, multiple myeloma or genetic disorders affecting theimmune system (e.g. IRAK-4)

• Individuals treated with or likely to be treated with systemic steroids for more thana month at a dose equivalent to prednisolone 20mg or more per day (any age) or adose of 1mg or more per kg per day for children under 20kg.

It is difficult to define at what level of immuno-suppression a patient could beconsidered to be at a greater risk of the serious consequences of flu and should beoffered flu vaccination. This decision is best made on an individual basis and left tothe patient’s clinician. Some immuno-compromised patients may have a sub-optimalimmunological response to the vaccine. Consideration should also be given to thevaccination of household contacts of immuno-compromised individuals – i.e.individuals who expect to share living accommodation on most days over the winterand therefore for whom continuing close contact is unavoidable. This may includecarers (see below)

• This also includes conditions such as homozygous sickle cell disease and coeliacsyndrome that may lead to splenic dysfunction

• Pregnant women at any stage of pregnancy (first, second or third trimesters)

• Vaccination is recommended for people in long-stay residential care homes or otherlong-stay care facilities where rapid spread is likely to follow the introduction ofinfection and cause high morbidity and mortality. This does not include, forinstance, prisons, young offender institutions, university halls of residence

• Someone who, without payment, provides help and support to a partner, child,relative, friend or neighbour, who could not manage without their help. This couldbe due to age, physical or mental illness, addiction or disability. A young carer is achild or young person under the age of 18 years carrying out significant caring tasksand assuming a level of responsibility for another person, which would normally betaken by an adult

• Health and social care workers who are in direct contact with patients/service usersshould be vaccinated by their employers as part of an occupational healthprogramme

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Figure 2: Groups eligible for seasonal flu vaccination 2014/15



pre-school children aged two to five years and all primary school children are eligible for immunisation.

Influenza vaccine uptake in 2013/14 in Englandwas similar to recent seasons in the elderly (73.2per cent), in under 65-year-olds in a pre-definedclinical risk group (52.3 per cent) and in pregnantwomen (39.8 per cent), while an increase wasseen in healthcare workers (54.8 per centcompared to 45.6 per cent in 2012/13). In England, an uptake of 42.6 and 39.6 per

cent was achieved in two and three-year-olds respectively and an overall uptake of 52.5 per centin the primary school age pilots targeting four to11-year-olds.

Pharmacy immunisation clinicsIn order to develop and set up communitypharmacy NHS immunisation clinics, local clinical commissioning groups, public healthcommissioners and health boards are likely totake the lead in identifying need and determiningthe level of provision required. Dialogue withlocal GPs is essential to ensure cohesive serviceplanning, recording arrangements and multi-disciplinary working. Decisions on which groupsof NHS patients will be targeted in any communitypharmacy scheme need to be agreed with clinical commissioning groups, public healthcommissioners or health boards. Remunerationarrangements also need to be decided and theseare likely to differ between different areas.

Legal authority to administer vaccinesAt present, if a pharmacist is not an independentprescriber, patient group directions (PGDs) will be

required if he/she is to make the autonomousdecision about who should receive vaccines. This is in order to comply with the Medicines Act1968. PGDs are already used as the basis for mostnurse-led immunisation services. In the future,once independent pharmacist prescribingbecomes more established, a PGD may no longerbe required. It is also good practice to use a PGD for the

administration of adrenaline in the event ofanaphylaxis, although the POM restriction doesnot apply to adrenaline injection 1mg/ml whereadministration is for saving life in an emergency.The legislation governing PGDs specifies that

a senior doctor, senior pharmacist or clinicalgovernance lead (or equivalent) should beinvolved in their development. Good practicerecommends that local drugs and therapeuticscommittees, area prescribing committees andsimilar advisory bodies should also be involved indrawing up the directions. The legislation furtherspecifies that each PGD must contain certaininformation (see Figure 3). A senior doctor and asenior pharmacist, both of whom should havebeen involved in developing the direction, mustsign all PGDs. For each profession required to operate within

the direction, a senior person must sign as beingresponsible for the competencies, qualificationsand training of the relevant authorisedprofessionals. In addition, the clinical governancelead or their equivalent (who must not be theauthor of the PGD) must sign on behalf of theauthorising NHS organisation.

Pharmacy premises criteria forimmunisation servicesFundamental to provision of a communitypharmacy immunisation service is the necessityfor a private clinical room. Minimumrequirements are:• Plumbed wash hand basin• Washable floors (not carpet)• Washable walls• Clinical workbench sufficient to prepare vaccineand lay out ancillaries

• Vaccine refrigerator• Chair(s)• Couch (preferable)• Wheelchair access

• Sufficient space to be able to access the patientfrom either side and to be able to lay the patienton the floor in the event of a faint.

• Seated waiting area available pre- and post-immunisation

• Filing cabinet for relevant documentation.More detailed specifications for communitypharmacy clinical rooms are listed in the 2007Scottish Health Planning Note 36 Part 310.

TrainingAlthough authority to administer vaccines may begranted by the preparation and signing of a PGD,pharmacists must achieve competency in allaspects of vaccine administration prior todelivering a service. Ideally, immunisation trainingshould take place at a local level and be led bylocal trainers. Involving experts like these indelivering training enables immunisers to raiselocal issues for further discussion. It is important to include the following when

devising training for pharmacists to administervaccines:• Principles of immunisations• Understanding of the disease(s) and nationaltarget groups for immunisation

• Current legal requirements for consent• Data protection • Documentation required• Professional accountability• Use of the PGDs• Knowledge of cold chain requirements• Assessment of fitness for vaccination• Identification of true contraindications tovaccination

• Practical vaccination skills including route,needle size and injection site for administration

• Dosage and presentation of vaccine• Preparation and disposal of vaccinationequipment

• Physiology of anaphylaxis and allergic reactions• Potential causes of anaphylaxis and ways ofdecreasing the risks

• Signs and symptoms of, and differencesbetween, anaphylaxis and fainting

• Treatment of anaphylaxis, equipment required,adrenaline dosages and sites for its administ-ration

• Recording of adverse events to vaccinations andusing the Yellow Card reporting system.

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• Department of Health. The Green Book – ImmunisationAgainst Infectious Disease: www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

• Health Protection Agency*. National MinimumStandards for Immunisation Training: www.hpa.org.uk

* now part of Public Health England

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Useful websites

• The name of the business to which the direction applies • The date the direction comes into force and the date it expires

• A description of the medicine(s) to which the directionapplies

• Class of healthcare professional who may supply oradminister the medicine

• Signature of a doctor and pharmacist• Signature by an appropriate health organisation• The clinical condition or situation to which the directionapplies

• A description of those patients excluded from treatmentunder the direction

• A description of the circumstances in which furtheradvice should be sought from a doctor and arrangementsfor referral

• Details of the appropriate dose and maximum totaldosage, quantity, pharmaceutical form and strength,route and frequency of administration, and minimum or maximum period over which the medicine should beadministered

• Relevant warnings, including potential adversereactions

• Details of any necessary follow-up action and thecircumstances; a statement of the records to be kept foraudit purposes

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Figure 3: Information required to beincluded in a PGD


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Usually this will require a full day’s training.Following on from a formal training session it isnecessary to undertake a number of supervisedadministrations, the number required dependingon the individual. Pharmacists need to beconfident in their own ability and the supervisorneeds be satisfied of their competency. The Health Protection Agency (now part of PHE)

has developed national minimum standards forimmunisation training and an accompanying corecurriculum has also been developed by anadvisory group led by the Centre for Infections’immunisation department.

Setting up a community pharmacyimmunisation serviceThe development of standard operatingprocedures and appropriate documentation willassist in the smooth running of any immunisationservice. Utilising support staff to help patientscomplete elements of the documentation prior toseeing the pharmacist can streamline the process.While the occasional walk-in immunisation can

be accommodated during quiet periods, it is goodpractice to schedule specific appointment times.This will allow pharmacies to ensure that there is a second pharmacist on duty to coverroutine dispensary duties and other aspects ofpharmaceutical care provision. Providing clinicappointments at times that are convenient for the patient (e.g. evenings and weekends) has been one of the strengths of communitypharmacy immunisation services.Combined record forms that include the key

information required and space for written patientconsent can simplify the paperwork. Patients willbe required to stay for at least 10 to 15 minutesafter their immunisation in order to be observedfor immediate adverse effects post-vaccination.Patients should therefore be seated in an areawhere they can be observed by a member of staffat all times. Good organisation involving allmembers of pharmacy staff will be required inorder to run successful immunisation services.

The publicity developed to promote apharmacist-led immunisation service needs toensure that the public get the right messagesconcerning the target group of patients and the service they can expect from pharmacy. NHS communications teams can play a vital role in supporting a new pharmacy service. Appropriate patient information leaflets will

also need to be developed, not only to informpatients about the scheme, but also to provide thespecific information about the immunisation inorder for the patient to give informed consent.Support from other healthcare professionals,

such as nurses, experienced in the running ofimmunisation clinics is essential in the earlystages of service development.

Evaluation of new and innovative services is important for the improvement and develop-ment of future services. It is therefore valuable to build an element of audit/evaluation into theservice design from the outset.

ConclusionImmunisation services from communitypharmacies are growing steadily in the UK andthere is clear potential for pharmacists to beinvolved both in identifying patients requiringimmunisation and administering the relevantvaccine itself.Pharmacist-led influenza immunisation services

across various parts of the country have beenboth successful and feasible. The accessibility ofcommunity pharmacies has proved popular withpatients wishing to use these services. A collaborative approach to service delivery

across the NHS, such as utilising the pharmacynetwork, gives greater options and increasedchoice for patients, both of which are likely toimprove uptake of immunisation services.

How can community pharmacy support parents andcarers with advice on childhood immunisations? What advice can you provide to encourage uptake and how can you provide support post-immunisation?

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1. Hind CA, Peterkin G, Downie G, Michie C and Chisholm E. Successful provision of influenza vaccine from a communitypharmacy in Aberdeen. Pharmaceutical Journal 2004; 273:194-196

2. Anonymous. Pharmacists trained to give flu vaccines. Pharmaceutical Journal 2005; 275:3283. Isle of Wight seasonal pharmacy flu evaluation – an end-of-service evaluation report for the NHS service includingcohort analysis and patient reported outcomes. 2011 Pinnacle Health Partnership LLP.www.psnc.org.uk/data/files/seasonal_flu_community_pharmacy_service_report_2010__v1.4c__final.pdf

4. Welsh Government. Community pharmacy influenza vaccination 2012-13: a summary of the results of the national community pharmacy seasonal influenza vaccination service. 2013.http://wales.gov.uk/docs/dhss/publications/131009pharmacyflureporten.pdf

5. Community pharmacy – helping with winter pressures. NHS England December 2013. www.england.nhs.uk/wp-content/uploads/2013/12/comm-pharmacy-winter-pressures.pdf

6. Pharmacy London. London Community Pharmacy Seasonal Flu Vaccination Enhanced Service. 2013-2014 ServiceGuidance. http://psnc.org.uk/city-and-hackney-lpc/wp-content/uploads/sites/69/2013/08/Pharmacy-London-Community-Pharmacy-Seasonal-Flu-Vaccination-Enhanced-Service-v31.pdf

7. Commissioning of Community Pharmacies in London to Deliver Vaccinations in 2014/15 – A Briefing on TrainingRequirements – June 2014. Accessed 28 July 2014. http://nellpc.org.uk/wp-content/uploads/2013/10/Training_Requirements_ for_2014_15_CP_Vaccination_Service-FINAL.pdf

8. Hind CA, Bond CB, Lee AJ and van Teijlingen E. Travel medicine services from community pharmacy: evaluation of apilot service. Pharmaceutical Journal 2008; 28:625-628

9. Co-operative offers Haj pilgrims meningococcal vaccine. Pharmaceutical Journal online July 201110. Scottish Health Planning Note 36 Part 3. Health Facilities Scotland. 2007 www.communitypharmacy.scot.nhs.uk

�References


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IMMUNISATION SERVICES IN COMMUNITY PHARMACIES CPD recordUse this form to record your learning and action points from this module on Immunisation services in community pharmacies and include it in your

CPD portfolio and record online at www.uptodate.org.uk

Activity completed. (Describe what you did to increase your learning. Be specific)(ACT)

Date: Time taken to complete activity:

What did I learn that was new in terms of developing my skills, knowledge and behaviours? Have my learning objectives been met?*(EVALUATE)

Do I need to learn anything else in this area? (List your learning action points. How do you intend to meet these action points?)(REFLECT & PLAN)

How have I put this into practice? (Give an example of how you applied your learning) Why did it benefit my practice? (How did your learning affect outcomes?)(EVALUATE)

* If as a result of completing your evaluation you have identified another new learning objective, start a new cycle. This will enable you to start at Reflect and then go on to Plan, Act and Evaluate.

This form can be photocopied to avoid having to cut this page out of the module. Complete the learning scenarios at www.pharmacymag.co.uk

September2014

Pharmacy Magazine

ENTER YOUR ANSWERS HERE Please mark your answers on the sheet below by placing a cross in the box next to the correct answer. Only mark one boxfor each question. Once you have completed the answer sheet in ink, return it to the address below together with your payment of £3.75. Clear photocopies areacceptable. You may need to consult other information sources including the August edition of Pharmacy Magazine to answer the questions.

Processing of answers Completed answer sheets should besent to Precision Marketing Group,Precision House, Bury Road, Beyton,Bury St Edmunds IP30 9PP (tel: 01284 718912; fax: 01284 718920; email: [email protected]), together withcredit/debit card/cheque details tocover administration costs. Thisassessment will be marked and youwill be notified of your result and senta copy of the correct answers. The assessors’ decision is final andno correspondencewill be entered into. 227

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viii CPD SEPTEMBER 2014 PHARMACY MAGAZINE PULL OUT AND KEEP

1. Which of the following is included as part of the routine childhoodimmunisation programme?

a. Diphtheriab. Tuberculosis c. Hepatitis Bd. Rabies

2. Pregnant women areoffered a dose of pertussisvaccine:

a. Before they reach 28 weeks of pregnancy

b. From 28 weeks of pregnancyc. Directly after they havedelivered the baby

d. In the first trimester ofpregnancy

3. Which group is the UKinfluenza 2014/15immunisation programmeNOT targetting?

a. All those aged 65 years and overb. All pregnant women c. All children over two years andup to less than 18 years

d. Health and social care staffdirectly involved in the care of their patients or clients

4. Which statement is TRUE?Shingles vaccine isroutinely offered to:

a. All people over 80 years of age b. People aged 79 years of age c. People aged 65 years of aged. People aged 60 years of age

5. Which does NOT have to beincluded in immunisationtraining?

a. Assessment of fitness forvaccination

b. Knowledge of UK pandemicinfluenza plan

c. Practical vaccination skills d. Preparation and disposal ofvaccination equipment

6. A patient has just receivedan immunisation in acommunity pharmacy.Which statement is TRUE?

a. Patients should be providedwith written information ontheir immunisation

b. The site of the immunisationshould be rubbed to ensurethe vaccine in absorbed intothe muscle

c. Patient should be asked toremain on the premises for at least five minutes post-immunisation but arefree to walk around

d. Patient can leave the premisesimmediately

7. Which respiratory conditionis NOT on the JCVI list of ‘at risk’ conditions?

a. Cystic fibrosisb. COPD c. Stable asthma and receivingonly a salbutamol inhaler

d. All pregnant women

8. Which MUST be included in a PGD?

a. A description of thecircumstances in whichfurther advice does not haveto be sought from a doctor

b. Details of the proprietary/brand of the medicine that can be administered

c. A description of those patientswho cannot be treated underthe PGD

d. The name(s) of the patient(s)receiving the medicine via thePGD from your pharmacy


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