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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"]
Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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[post_content] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve patient health and safety.
As the 2024 FIP World Congress continues, Australian Pharmacist reports from Cape Town on some innovative services presented which are improving health across the globe.
South Africa: Improving access to HIV treatment and prevention
There are 7.9 million people in South Africa between the ages of 15 and 49 years living with HIV. Despite strides in treatments and preventative therapies, the rate of new infections remains high.
One project driven by pharmacists is aiming to change this, allowing community pharmacists to initiate high-risk young women and men onto HIV Pre-Exposure Prophylaxis (PrEP). In this implementation study, 10 pharmacies in Gauteng and the Western Cape (Cape Town) initiated high-risk individuals on combination tenofovir and lamivudine/emtricitabine for a period of 13 months. Patients were recruited inside and outside of the pharmacy.
Of the 838 potential participants, 88% (n = 737) were initiated on PrEP between June 2023 and January 2024. Risk assessment found most were sexually active, and more than three quarters (n = 595) engaged in sexual activity without a condom. Initial results from the study were positive, with further analysis to explore patient perceptions of PrEP initiation in community pharmacy.
Spain: Pharmacy reporting of stock shortages helps detect shortages sooner
The General Council of Pharmacists of Spain has developed two systems to prevent and mitigate medicine shortages.
The first is CisMED, a system that generates real-time information on supply incidents at a pharmacy level.
Over 10,000 pharmacies participated in this initiative in 2023 – over half of all pharmacies. CisMED reported a 30% increase in medicines that could not be supplied, with over half the alerts generated being for medicines not listed by their regulator, the Spanish Medicines Agency.
The second initiative, FarmaHelp, is a communication system which allows pharmacists to communicate with nearby pharmacies when a request for a medicine cannot be fulfilled. From the 10,000 pharmacies connected to the system, the number of medicines ‘found’ increased from 106,925 to 389,364. This meant 73.5% of the time, the pharmacist was able to offer a solution to the patient due to the FamraHelp system.
In combination, these digital systems have helped pharmacists both contribute to a more accurate and complete medicine shortage database, and allowed pharmacists to find more options to support access to scarce medicines to their patients more often.
The Netherlands: Palliative care kit improves access to care at end-of-life
The decision to initiate palliative care is often a time where medicines need to be prescribed and initiated at short notice, with a new and often complex regimen of medicines.
A project in The Netherlands led by the Royal Dutch Pharmacists Association, is trying to make this a smoother process for patients and their families through the introduction of a ‘palliative care kit’.
Based on the concept of a first-aid kit, the ‘palliative care kit’ contains everything patients will need to facilitate administration of medicines at end-of-life. This includes morphine and midazolam ampoules, syringes, needles, bandages and a urinary catheter with insertion set.
The kit is supplied by a pharmacy, which receives reimbursement for the medicines, and a professional fee for facilitating the supply of the kit.
The kit contains a permission document from the GP to use the supplies when necessary. The kit is delivered to the home of palliative patients when they enter the terminal phase at a time that can be planned. This allows a nurse to immediately use that kit when necessary.
The kit has reduced unnecessary time spent by community nurses, GPs and pharmacists in facilitating palliative care, particularly during evenings, nights and on weekends. Families report the presence of the kit reassuring because they know their loved one will be able to access the medicines they need instantly, should they experience acute deterioration.
Thailand: Medicine reviews for high-risk CKD patients
In Thailand, 30% of people with chronic kidney disease (CKD) use NSAIDs or other herbal medicines which may accelerate the progression of CKD. A pilot project has shown pharmacists can help reduce this.
In this pilot, a nurse at the CKD clinic referred patients (n = 23) with medicine problems to a pharmacy for medicine reconciliation, adherence checks and to review for potential causes of acute kidney injury. Importantly, the pharmacist also managed any problems identified and monitored kidney function for at least 3 months.
Half (52%) of patients stopped using NSAIDs, and kidney function improved from Stage 3 to Stage 2 in five patients within 3 months. While not statistically significant, the small pilot concluded the model of care appeared to reduce costs associated with medicines and CKD management.
Australian pharmacist on SA TV!
Meanwhile, Australian pharmacist and FIP President Paul Sinclair AM MPS has appeared on South African breakfast television to talk about the important role of pharmacists. Paul told SABC’s Expresso Show he was excited about the opportunities around the world for pharmacists.
[caption id="attachment_27480" align="aligncenter" width="507"]
FIP President Paul Sinclair AM MPS (left)[/caption]
‘Health care across the world is changing very quickly. It’s being driven by innovation, and pharmacists historically have embraced innovation and technology,' he said.
‘What excites me most about our profession at the moment is that we have the chance to do more. Our scope of practice is expanding rapidly, and with that comes opportunities to help more people deliver more outcomes and improve the health system.'
[post_title] => What are pharmacists doing in other countries?
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[post_content] => Syphilis cases have tripled in the last 10 years in Australia, leading to an ‘avoidable and unacceptable’ reemergence of congenital syphilis. This World Sexual Health Day (4 September), Australian Pharmacist explores pharmacists’ role in addressing this escalating issue.
When syphilis infections began to rise in Australia in 2011, the cases were primarily among men with male sexual partners, and young heterosexual persons in remote Aboriginal and Torres Strait Islander communities. However, there was a 500% increase in the rate of infectious syphilis among women aged 15 to 44 between 2011 and 2021, according to a report from the University of New South Wales’ Kirby Institute.
That means parent-to-child transmission is also on the rise - this is called congenital syphilis. There was a median of 4 cases per year in Australia between 2011 and 2019, skyrocketing to 17 cases in 2020, and 15 in 2021 and 2022. For the birthing parent of babies with congenital syphilis, the report’s authors found less than 40% were tested for syphilis during pregnancy.
Left untreated, congenital syphilis can lead to serious complications in more than 50% of cases, including miscarriage, stillbirth, neonatal death and permanent disability. Of all the cases of congenital syphilis in Australia between 2011 and 2021, 25% of babies were stillborn.
In Queensland, where cases of infectious syphilis have increased by 600% in 15 years, five babies contracted the disease in the womb in 2023, leading to 4 deaths. This is the largest number of Queensland deaths from congenital syphilis in a single year this century.
As a preventable and curable disease, Queensland Minister for Health Shannon Fentiman said the deaths ‘shouldn’t be happening’. It’s a message echoed by Australia’s Chief Medical Officer Professor Paul Kelly, who said health professionals need to ensure they’re up to date on information about syphilis testing and management.
‘Any baby losing its life is a tragedy. Any baby losing its life to a preventable illness is a responsibility for us all in our health system,’ he said in a video (below) recorded for the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM).
https://vimeo.com/912435688
‘We must ensure everyone is tested for syphilis during pregnancy. All pregnant people should be tested at least once, and in many cases more … Once diagnosed, treatment is simple and effective.’
High-risk populations
In 2022, syphilis rates among Aboriginal and Torres Strait Islander peoples were more than five times higher than in non-Indigenous populations. Of the 15 congenital syphilis cases across the country in the same year, eight were among Aboriginal and Torres Strait Islander peoples.
‘Congenital syphilis diagnoses are 14 times as high among Aboriginal and Torres Strait Islander infants compared with non-Indigenous infants,’ said researcher Dr Skye McGregor, who led the Kirby Institute report.
‘All pregnant people should be tested for sexually transmitted infections (STIs) as part of pre- and antenatal health screening, but antenatal care is not always accessible. It is vital that comprehensive services are in place to ensure appropriate care is accessible for all pregnant people.’
Other high-risk populations include men who have sex with men and babies of mothers who have not had proper syphilis testing and treatment during pregnancy. However, ASHM Deputy CEO Jessica Michaels said it is important to recognise that syphilis can affect anyone.
‘In order to curb the rising syphilis epidemic, it is important that we take a “no wrong door’’ approach to testing,’ she said.
What to look out for
People presenting at a pharmacy with signs or symptoms of syphilis should be encouraged to test, Ms Michaels said, especially if the symptoms are otherwise unexplained.
‘Other instances when pharmacists can encourage patients to test for syphilis include people presenting with symptoms of any STI or an STI diagnosis, those asking about testing for STIs and/or blood-borne viruses, when people are assessed for post-exposure prophylaxis, and pregnant people who are not engaged in antenatal care.’
Symptoms and/or signs of syphilis can include:
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[post_content] => Case one scenario
[caption id="attachment_27445" align="alignright" width="173"]
This educational activity was managed by PSA at the request of and with funding from GSK.[/caption]
Anne comes in for her prescription and, in conversation, informs you she has just celebrated her 60th birthday. Unfortunately, some of her family couldn't attend as her grandchild was recovering from chickenpox. She recalls her own childhood infection as being relatively mild.
Case two scenario
Ron, aged 67 years, is a regular patient of yours. He comes to the pharmacy to have his prescriptions filled for high blood pressure, heart failure and hyperlipidaemia. He mentioned he just got over a cold and seeks your advice as he has since developed conjunctivitis. Given his history, you check his vaccination records on the Australian Immunisation Register (AIR) and noted he is up to date with his COVID booster, influenza, herpes zoster and pneumococcal vaccinations.
Learning ObjectivesAfter reading this article, pharmacists should be able to:
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Pharmacists, consistently regarded as one of the most highly trusted groups of healthcare professionals, are in a unique position to promote and support the uptake of vaccination in older adults.1 However, despite clinical recommendations by the Australian Technical Advisory Group on Immunisation (ATAGI), there remains a significant gap in adult vaccination coverage in Australia.2,16 With the expanded scope of vaccination practice and the launch of the National Immunisation Program Vaccinations in Pharmacy (NIPVIP) program in pharmacy since 1 January 2024, pharmacists have a key role in providing vaccinations in primary care. Pharmacists are well placed to help improve adult vaccination rates by addressing some of the key barriers outlined in the table below, the ‘Five A’s’ of vaccination.3 Pharmacists can improve adult vaccination rates by addressing key barriers such as improving access and improving the awareness and understanding of vaccines.4
The 'Five A's' of vaccination3
The ‘Five A’s’ of vaccination are a framework for understanding why some people voluntarily get vaccinated, while others do not.
| Awareness | Whether people know about vaccines, where to get them, and their benefits and risks. |
| Acceptance | Whether people want to get vaccinated, subject to access and affordability. |
| Affordability | Whether people can afford the price of getting vaccinated and other costs of getting vaccinated, such as time off work if they have an adverse reaction to the vaccine. |
| Access | Whether people can safely and easily get vaccines, including physical and psychological safety. |
| Activation | Whether people who are aware of and accepting of vaccines are motivated to get the vaccine. |
Pharmacists are among the most consistently accessible healthcare professionals to patients. Compared to other healthcare professionals, pharmacists typically have longer hours of operation, including weekends, in which to offer vaccination services.5 These added conveniences facilitate greater flexibility and increased opportunities for individuals to access vaccination services in their local community.5
Community pharmacists continue to rate higher satisfaction and referral with patients than doctors or dentists, according to the 2023 Australian Healthcare Index (AHI) survey.6 With the rising out of pocket costs for general practice consultations, pharmacists are being sought by some patients as the first point of care before booking a general practitioner consult. There is also increased awareness of pharmacy services beyond the provision of prescription and over-the-counter medications, with 1 in 4 AHI survey participants reporting a visit to the pharmacy for vaccination service.6
Understanding and awarenessPerceptions about disease severity, vaccine effectiveness and safety, along with low provider confidence in the effectiveness of adult vaccination, contribute to low immunisation rates in older adults.3,7–9 Additionally, older adults’ knowledge of vaccines and vaccination guidelines varies.9 Pharmacists are well positioned to bridge knowledge gaps, increase awareness, dispel myths, and reduce complacency regarding vaccination.10
Vaccination remains a key preventative strategy in public health.11 Vaccines prevent 3.5–5 million deaths a year, and drastically reduce the morbidity and disability rates due to vaccine preventable diseases (VPDs).12 Older adults share a disproportionately high burden of VPD, which may be prevented or attenuated by vaccination.13 Despite recommendations from peak health organisations, vaccination rates among older patients remain suboptimal.14,15 Of people in their 70s, less than half are vaccinated against shingles, and only 1 in 5 is vaccinated against pneumococcal disease.16
Vaccination for adults2,16
Adults aged ≥50 years are at increased risk of some VPDs and of serious complications from these diseases, even if they are otherwise healthy. Check to see if your patients need any of the following.
dTpa booster
Immunity to some diseases can start to wane in older people, and they may need booster doses of some vaccines.
|
Measles, mumps and rubella
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Herpes zoster (shingles)
The incidence of shingles increases with age, as does the incidence of serious complications such as post-herpetic neuralgia.
|
| Influenza Annual influenza vaccination is recommended for everyone ≥6 months of age. As Influenza-associated mortality rates are highest among older adults and Aboriginal and Torres Strait Islander peoples, influenza vaccination is particularly recommended for adults aged ≥65 years and for Aboriginal and Torres Strait Islander adults of any age. |
Pneumococcal disease
Pneumococcal disease is more prevalent in older adults.
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Adapted from: Department of Health and Aged Care. Vaccination for healthy ageing. 2023.18 See the Australian Immunisation Handbook for more details. dTpa, diphtheria, tetanus and acellular pertussis–containing vaccine; MMR, measles, mumps and rubella; VZV, varicella zoster virus.
*15vPCV and 20vPCV are available as alternatives to 13vPCV but are not currently NIP-funded.With the recent expanded scope of vaccination practice as part of the NIPVIP Program to include a number of adult vaccines, including those against shingles (nationally)17 and RSV (selected states, not funded),17 there is a need for pharmacists to upskill around delivering vaccines outside of the usual seasonal vaccines, like influenza. So how can pharmacists be equipped to have proactive conversations on all recommended vaccinations? What are the key critical success factors that will help drive high quality vaccination care?
Topline information for shingles and RSV
|
Herpes zoster (shingles) |
Respiratory syncytial virus (RSV) |
|
What is shingles? Shingles is a reactivation of the varicella-zoster virus (VZV) in someone who has previously had chickenpox (varicella) disease. Shingles commonly presents as a painful rash of fluid-filled blisters on one side of the face or body, often in a strip or band-like pattern. Other symptoms can include headache, malaise, itching, tingling or severe pain.19 Post-herpetic neuralgia (PHN) is defined as neuropathic pain at the site of the rash that can persist for >3 months after an outbreak of shingles.2 It can have a substantial impact on the quality of life in those affected and can be refractory to treatment. |
What is RSV? How do you get RSV? RSV is a respiratory virus that usually causes mild, cold-like symptoms, but can also lead to more severe conditions like bronchiolitis, bronchitis or pneumonia, and exacerbations of existing lung conditions such as asthma and heart disease. Transmission most commonly occurs through respiratory contact with infected secretions from sneezing and coughing.23,24 |
|
Who can get shingles, and how common is it? People are at risk of developing shingles if they have previously had chickenpox (i.e. VZV infection). In Australia, most adults will be at risk even if they don’t remember having had chickenpox in the past. Around 20–30% of people will have shingles in their lifetime – most after the age of 50 years – and around half of all people who live to 85 years of age will develop shingles.19 |
Who can get RSV, and how common is it in adults? RSV can infect people of all ages; however, infants and older adults are more likely to develop severe RSV.24 Since RSV disease was historically regarded as a disease that affects infants and children, testing for the virus in adults was previously uncommon and data in adults are limited.24 |
|
Who should receive a shingles vaccine and why? There have been two vaccines available in Australia for the prevention of herpes zoster and associated complications — Shingrix® and Zostavax®. As of 31 October 2023, the manufacturers of Zostavax® have discontinued supply in Australia.33 Unless otherwise contraindicated, the Australian Immunisation Handbook recommends shingles vaccination with Shingrix® – the recombinant Varicella Zoster Virus Glycoprotein E Antigen/ ASO1B adjuvanted vaccine (recombinant VZV vaccine) for people aged ≥18 years who are immunocompromised, and immunocompetent adults aged ≥50 years and household contacts of a person who is immunocompromised aged ≥50 years who have not previously received a dose.2 |
Which adults are at greatest risk of requiring hospitalisation with RSV disease? The risk of severe RSV disease is higher among adults with medical risk conditions (such as chronic cardiac, respiratory and neurological conditions, immunocompromising conditions, chronic metabolic disorders, chronic kidney disease), older adults (with the risk increasing with age), and Aboriginal and Torres Strait Islander peoples.24 There are two RSV vaccinations registered to protect against RSV-related lower respiratory tract disease in adults aged ≥60 years.2 |
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What is the efficacy and tolerability of recombinant VZV vaccine? Vaccination with recombinant VZV vaccine resulted in a high level of protection against shingles and PHN in adults aged ≥50 years. In two large clinical trials against placebo, the recombinant VZV vaccine demonstrated over 90% vaccine efficacy against shingles in adults aged ≥50 years (p<0.001).20,21 Vaccine efficacy of the recombinant VZV vaccine against PHN was 91% in immunocompetent people ≥50 years of age and 89% in immunocompetent people ≥70 years of age (p<0.001).20,21 From the long-term follow-up study, protection against shingles with recombinant VZV vaccine remained high in adults aged ≥50 years, with a vaccine efficacy of 81.6% (vs placebo or historical control), (mean 5.6 - 9.6 +/- 0.3 years post-vaccination).22 The most frequently reported local adverse reactions was pain at the injection site; myalgia, fatigue and headache were the most frequently reported systemic reactions. The majority of reactions, both local and systemic, were mild to moderate in intensity and of short median duration (1–3 days).20,21 |
How effective is RSV vaccination at preventing RSV-related lower respiratory tract disease in older adults? Vaccine efficacy of the adjuvanted recombinant RSV vaccine through one RSV season (median 6.7 months follow-up) against RSV-related lower respiratory tract disease in adults ≥60 years was 82.6%. Vaccine efficacy of the recombinant RSV vaccine (without adjuvant) in adults ≥60 years through one RSV season (mean 7 months follow-up) against RSV-related lower respiratory tract disease with ≥2 symptoms was 66.7%, and 85.7% with ≥3 symptoms.2,25 |
Implementing pharmacy-led vaccination programs requires careful planning, adherence to regulations, and a commitment to patient safety. Critical factors to consider are shown in Box 4. By addressing these critical factors, pharmacists can help ensure the success and effectiveness of pharmacy-led vaccination programs, including those focusing on shingles and RSV vaccinations.
Critical factors for pharmacy-led vaccination [for more information please refer to the PSA's Practice Guidelines for the provision of immunisation services]28
| Regulatory compliance: Ensure that your pharmacy and staff comply, and are up to date with, all relevant regulations set forth by the Department of Health and Aged Care and NIPVIP Program and local state legislation. Staff training and certification: Ensure that pharmacists administering vaccines are properly trained and certified in administration techniques, handling and storage, and managing adverse reactions, including general first aid and cardiopulmonary resuscitation. Patient education and counselling: Provide patients with accurate information about vaccine benefits, potential adverse effects, and any necessary precautions. Vaccine storage and handling: Follow strict protocols including monitoring and recording refrigerator temperatures, proper storage in designated areas and vaccine rotation to prevent expiration. Documentation and record-keeping: Maintain accurate records, including the type of vaccine administered, lot number, expiration date, administration date, and patient information as part of the patient’s personal records and relevant registers (Australian Immunisation Register [AIR] or Australian Q Fever Register). Collaboration with healthcare providers: Collaborate with other healthcare providers to ensure continuity of care and appropriate patient referrals and establish clear communication channels for sharing information. Adverse event monitoring and reporting: Develop protocols for monitoring and managing adverse events. Educate staff on recognising and responding to adverse reactions and reporting adverse events to regulatory agencies as required. Continuous quality improvement: Regularly review your vaccination program, solicit feedback from patients and staff and stay updated on best practices to ensure high-quality care. |
Vaccination is a national priority in Australia.11 In-pharmacy vaccination programs have expanded access to vaccines, making preventive health care more convenient and accessible. These programs leverage the widespread presence of pharmacies in communities, allowing individuals to have a greater choice around where and when they can receive vaccinations in primary care. By offering vaccinations for various VPDs, these programs have the potential to play a crucial role in increasing vaccination rates and reducing the burden of vaccine preventable illnesses.32 Their success lies in their ability to reach diverse populations, promote health equity, and contribute to overall public health outcomes. While older adults may encounter many barriers to vaccination, pharmacists are positioned to address many of these barriers by providing a convenient point of access, building confidence in vaccination, and actively increasing awareness to reduce complacency.
Case scenario one continued'Speaking of chickenpox, Anne, did you know that this is the same virus (varicella) that causes shingles? Shingles is a painful and debilitating condition, that can occur in people who have previously had chickenpox. The risk of getting shingles increases with age, especially from the age of 50. As you are in the age group where vaccination against shingles is recommended, would you like to receive it now? I have the vaccine in stock.* Let me get the vaccination information sheet and consent form and discuss further.' *Note the recombinant VZV shingles vaccine is the only shingles vaccine available. It is accessible privately or via the NIP for eligible cohorts.Case scenario two continuedAfter responding to the management of Ron's conjunctivitis, you take the opportunity to discuss RSV. 'I’m glad your cold has resolved. Actually, there is another respiratory virus that commonly circulates mostly in the colder months called RSV that can lead to quite severe conditions like bronchitis or pneumonia. Due to your age and heart condition, you are at a greater risk of hospitalisation. Vaccinating now could ensure you only have mild symptoms if infected and could keep you out of hospital. If you’re interested in getting it, I can get it ready while we take your blood pressure.' |
Natasha Dean (she/her) BSc(Hon) is a Senior Medical Writer with over 20 years’ experience in medical education and medical communications. She is a CPD representative with the RACGP CPD Program and regularly accredits activities for other organisations including ACCRM, PSA and ACN.
Sarushka Sritharan (she/her) BPharm(Hon) DipMgt MPS
Vaccine administration should be in accordance with relevant legislation, the Australian Immunisation Handbook, and State-based conditions specific to the vaccine.
[post_title] => The essential role of the pharmacist in adult vaccination [post_excerpt] => Pharmacists, consistently regarded as one of the most highly trusted groups of healthcare professionals, are in a unique position to promote and support the uptake of vaccination in older adults. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => role-of-the-pharmacist-in-adult-vaccination [to_ping] => [pinged] => [post_modified] => 2024-09-10 09:17:52 [post_modified_gmt] => 2024-09-09 23:17:52 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=27438 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => The essential role of the pharmacist in adult vaccination [title] => The essential role of the pharmacist in adult vaccination [href] => https://www.australianpharmacist.com.au/role-of-the-pharmacist-in-adult-vaccination/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 27465 [authorType] => )td_module_mega_menu Object
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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"] Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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[post_content] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve patient health and safety.
As the 2024 FIP World Congress continues, Australian Pharmacist reports from Cape Town on some innovative services presented which are improving health across the globe.
South Africa: Improving access to HIV treatment and prevention
There are 7.9 million people in South Africa between the ages of 15 and 49 years living with HIV. Despite strides in treatments and preventative therapies, the rate of new infections remains high.
One project driven by pharmacists is aiming to change this, allowing community pharmacists to initiate high-risk young women and men onto HIV Pre-Exposure Prophylaxis (PrEP). In this implementation study, 10 pharmacies in Gauteng and the Western Cape (Cape Town) initiated high-risk individuals on combination tenofovir and lamivudine/emtricitabine for a period of 13 months. Patients were recruited inside and outside of the pharmacy.
Of the 838 potential participants, 88% (n = 737) were initiated on PrEP between June 2023 and January 2024. Risk assessment found most were sexually active, and more than three quarters (n = 595) engaged in sexual activity without a condom. Initial results from the study were positive, with further analysis to explore patient perceptions of PrEP initiation in community pharmacy.
Spain: Pharmacy reporting of stock shortages helps detect shortages sooner
The General Council of Pharmacists of Spain has developed two systems to prevent and mitigate medicine shortages.
The first is CisMED, a system that generates real-time information on supply incidents at a pharmacy level.
Over 10,000 pharmacies participated in this initiative in 2023 – over half of all pharmacies. CisMED reported a 30% increase in medicines that could not be supplied, with over half the alerts generated being for medicines not listed by their regulator, the Spanish Medicines Agency.
The second initiative, FarmaHelp, is a communication system which allows pharmacists to communicate with nearby pharmacies when a request for a medicine cannot be fulfilled. From the 10,000 pharmacies connected to the system, the number of medicines ‘found’ increased from 106,925 to 389,364. This meant 73.5% of the time, the pharmacist was able to offer a solution to the patient due to the FamraHelp system.
In combination, these digital systems have helped pharmacists both contribute to a more accurate and complete medicine shortage database, and allowed pharmacists to find more options to support access to scarce medicines to their patients more often.
The Netherlands: Palliative care kit improves access to care at end-of-life
The decision to initiate palliative care is often a time where medicines need to be prescribed and initiated at short notice, with a new and often complex regimen of medicines.
A project in The Netherlands led by the Royal Dutch Pharmacists Association, is trying to make this a smoother process for patients and their families through the introduction of a ‘palliative care kit’.
Based on the concept of a first-aid kit, the ‘palliative care kit’ contains everything patients will need to facilitate administration of medicines at end-of-life. This includes morphine and midazolam ampoules, syringes, needles, bandages and a urinary catheter with insertion set.
The kit is supplied by a pharmacy, which receives reimbursement for the medicines, and a professional fee for facilitating the supply of the kit.
The kit contains a permission document from the GP to use the supplies when necessary. The kit is delivered to the home of palliative patients when they enter the terminal phase at a time that can be planned. This allows a nurse to immediately use that kit when necessary.
The kit has reduced unnecessary time spent by community nurses, GPs and pharmacists in facilitating palliative care, particularly during evenings, nights and on weekends. Families report the presence of the kit reassuring because they know their loved one will be able to access the medicines they need instantly, should they experience acute deterioration.
Thailand: Medicine reviews for high-risk CKD patients
In Thailand, 30% of people with chronic kidney disease (CKD) use NSAIDs or other herbal medicines which may accelerate the progression of CKD. A pilot project has shown pharmacists can help reduce this.
In this pilot, a nurse at the CKD clinic referred patients (n = 23) with medicine problems to a pharmacy for medicine reconciliation, adherence checks and to review for potential causes of acute kidney injury. Importantly, the pharmacist also managed any problems identified and monitored kidney function for at least 3 months.
Half (52%) of patients stopped using NSAIDs, and kidney function improved from Stage 3 to Stage 2 in five patients within 3 months. While not statistically significant, the small pilot concluded the model of care appeared to reduce costs associated with medicines and CKD management.
Australian pharmacist on SA TV!
Meanwhile, Australian pharmacist and FIP President Paul Sinclair AM MPS has appeared on South African breakfast television to talk about the important role of pharmacists. Paul told SABC’s Expresso Show he was excited about the opportunities around the world for pharmacists.
[caption id="attachment_27480" align="aligncenter" width="507"] FIP President Paul Sinclair AM MPS (left)[/caption]
‘Health care across the world is changing very quickly. It’s being driven by innovation, and pharmacists historically have embraced innovation and technology,' he said.
‘What excites me most about our profession at the moment is that we have the chance to do more. Our scope of practice is expanding rapidly, and with that comes opportunities to help more people deliver more outcomes and improve the health system.'
[post_title] => What are pharmacists doing in other countries?
[post_excerpt] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve health and safety.
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[post_content] => Syphilis cases have tripled in the last 10 years in Australia, leading to an ‘avoidable and unacceptable’ reemergence of congenital syphilis. This World Sexual Health Day (4 September), Australian Pharmacist explores pharmacists’ role in addressing this escalating issue.
When syphilis infections began to rise in Australia in 2011, the cases were primarily among men with male sexual partners, and young heterosexual persons in remote Aboriginal and Torres Strait Islander communities. However, there was a 500% increase in the rate of infectious syphilis among women aged 15 to 44 between 2011 and 2021, according to a report from the University of New South Wales’ Kirby Institute.
That means parent-to-child transmission is also on the rise - this is called congenital syphilis. There was a median of 4 cases per year in Australia between 2011 and 2019, skyrocketing to 17 cases in 2020, and 15 in 2021 and 2022. For the birthing parent of babies with congenital syphilis, the report’s authors found less than 40% were tested for syphilis during pregnancy.
Left untreated, congenital syphilis can lead to serious complications in more than 50% of cases, including miscarriage, stillbirth, neonatal death and permanent disability. Of all the cases of congenital syphilis in Australia between 2011 and 2021, 25% of babies were stillborn.
In Queensland, where cases of infectious syphilis have increased by 600% in 15 years, five babies contracted the disease in the womb in 2023, leading to 4 deaths. This is the largest number of Queensland deaths from congenital syphilis in a single year this century.
As a preventable and curable disease, Queensland Minister for Health Shannon Fentiman said the deaths ‘shouldn’t be happening’. It’s a message echoed by Australia’s Chief Medical Officer Professor Paul Kelly, who said health professionals need to ensure they’re up to date on information about syphilis testing and management.
‘Any baby losing its life is a tragedy. Any baby losing its life to a preventable illness is a responsibility for us all in our health system,’ he said in a video (below) recorded for the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM).
https://vimeo.com/912435688
‘We must ensure everyone is tested for syphilis during pregnancy. All pregnant people should be tested at least once, and in many cases more … Once diagnosed, treatment is simple and effective.’
High-risk populations
In 2022, syphilis rates among Aboriginal and Torres Strait Islander peoples were more than five times higher than in non-Indigenous populations. Of the 15 congenital syphilis cases across the country in the same year, eight were among Aboriginal and Torres Strait Islander peoples.
‘Congenital syphilis diagnoses are 14 times as high among Aboriginal and Torres Strait Islander infants compared with non-Indigenous infants,’ said researcher Dr Skye McGregor, who led the Kirby Institute report.
‘All pregnant people should be tested for sexually transmitted infections (STIs) as part of pre- and antenatal health screening, but antenatal care is not always accessible. It is vital that comprehensive services are in place to ensure appropriate care is accessible for all pregnant people.’
Other high-risk populations include men who have sex with men and babies of mothers who have not had proper syphilis testing and treatment during pregnancy. However, ASHM Deputy CEO Jessica Michaels said it is important to recognise that syphilis can affect anyone.
‘In order to curb the rising syphilis epidemic, it is important that we take a “no wrong door’’ approach to testing,’ she said.
What to look out for
People presenting at a pharmacy with signs or symptoms of syphilis should be encouraged to test, Ms Michaels said, especially if the symptoms are otherwise unexplained.
‘Other instances when pharmacists can encourage patients to test for syphilis include people presenting with symptoms of any STI or an STI diagnosis, those asking about testing for STIs and/or blood-borne viruses, when people are assessed for post-exposure prophylaxis, and pregnant people who are not engaged in antenatal care.’
Symptoms and/or signs of syphilis can include:
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[post_content] => Case one scenario
[caption id="attachment_27445" align="alignright" width="173"] This educational activity was managed by PSA at the request of and with funding from GSK.[/caption]
Anne comes in for her prescription and, in conversation, informs you she has just celebrated her 60th birthday. Unfortunately, some of her family couldn't attend as her grandchild was recovering from chickenpox. She recalls her own childhood infection as being relatively mild.
Case two scenario
Ron, aged 67 years, is a regular patient of yours. He comes to the pharmacy to have his prescriptions filled for high blood pressure, heart failure and hyperlipidaemia. He mentioned he just got over a cold and seeks your advice as he has since developed conjunctivitis. Given his history, you check his vaccination records on the Australian Immunisation Register (AIR) and noted he is up to date with his COVID booster, influenza, herpes zoster and pneumococcal vaccinations.
Learning ObjectivesAfter reading this article, pharmacists should be able to:
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Pharmacists, consistently regarded as one of the most highly trusted groups of healthcare professionals, are in a unique position to promote and support the uptake of vaccination in older adults.1 However, despite clinical recommendations by the Australian Technical Advisory Group on Immunisation (ATAGI), there remains a significant gap in adult vaccination coverage in Australia.2,16 With the expanded scope of vaccination practice and the launch of the National Immunisation Program Vaccinations in Pharmacy (NIPVIP) program in pharmacy since 1 January 2024, pharmacists have a key role in providing vaccinations in primary care. Pharmacists are well placed to help improve adult vaccination rates by addressing some of the key barriers outlined in the table below, the ‘Five A’s’ of vaccination.3 Pharmacists can improve adult vaccination rates by addressing key barriers such as improving access and improving the awareness and understanding of vaccines.4
The 'Five A's' of vaccination3
The ‘Five A’s’ of vaccination are a framework for understanding why some people voluntarily get vaccinated, while others do not.
| Awareness | Whether people know about vaccines, where to get them, and their benefits and risks. |
| Acceptance | Whether people want to get vaccinated, subject to access and affordability. |
| Affordability | Whether people can afford the price of getting vaccinated and other costs of getting vaccinated, such as time off work if they have an adverse reaction to the vaccine. |
| Access | Whether people can safely and easily get vaccines, including physical and psychological safety. |
| Activation | Whether people who are aware of and accepting of vaccines are motivated to get the vaccine. |
Pharmacists are among the most consistently accessible healthcare professionals to patients. Compared to other healthcare professionals, pharmacists typically have longer hours of operation, including weekends, in which to offer vaccination services.5 These added conveniences facilitate greater flexibility and increased opportunities for individuals to access vaccination services in their local community.5
Community pharmacists continue to rate higher satisfaction and referral with patients than doctors or dentists, according to the 2023 Australian Healthcare Index (AHI) survey.6 With the rising out of pocket costs for general practice consultations, pharmacists are being sought by some patients as the first point of care before booking a general practitioner consult. There is also increased awareness of pharmacy services beyond the provision of prescription and over-the-counter medications, with 1 in 4 AHI survey participants reporting a visit to the pharmacy for vaccination service.6
Understanding and awarenessPerceptions about disease severity, vaccine effectiveness and safety, along with low provider confidence in the effectiveness of adult vaccination, contribute to low immunisation rates in older adults.3,7–9 Additionally, older adults’ knowledge of vaccines and vaccination guidelines varies.9 Pharmacists are well positioned to bridge knowledge gaps, increase awareness, dispel myths, and reduce complacency regarding vaccination.10
Vaccination remains a key preventative strategy in public health.11 Vaccines prevent 3.5–5 million deaths a year, and drastically reduce the morbidity and disability rates due to vaccine preventable diseases (VPDs).12 Older adults share a disproportionately high burden of VPD, which may be prevented or attenuated by vaccination.13 Despite recommendations from peak health organisations, vaccination rates among older patients remain suboptimal.14,15 Of people in their 70s, less than half are vaccinated against shingles, and only 1 in 5 is vaccinated against pneumococcal disease.16
Vaccination for adults2,16
Adults aged ≥50 years are at increased risk of some VPDs and of serious complications from these diseases, even if they are otherwise healthy. Check to see if your patients need any of the following.
dTpa booster
Immunity to some diseases can start to wane in older people, and they may need booster doses of some vaccines.
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Measles, mumps and rubella
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Herpes zoster (shingles)
The incidence of shingles increases with age, as does the incidence of serious complications such as post-herpetic neuralgia.
|
| Influenza Annual influenza vaccination is recommended for everyone ≥6 months of age. As Influenza-associated mortality rates are highest among older adults and Aboriginal and Torres Strait Islander peoples, influenza vaccination is particularly recommended for adults aged ≥65 years and for Aboriginal and Torres Strait Islander adults of any age. |
Pneumococcal disease
Pneumococcal disease is more prevalent in older adults.
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Adapted from: Department of Health and Aged Care. Vaccination for healthy ageing. 2023.18 See the Australian Immunisation Handbook for more details. dTpa, diphtheria, tetanus and acellular pertussis–containing vaccine; MMR, measles, mumps and rubella; VZV, varicella zoster virus.
*15vPCV and 20vPCV are available as alternatives to 13vPCV but are not currently NIP-funded.With the recent expanded scope of vaccination practice as part of the NIPVIP Program to include a number of adult vaccines, including those against shingles (nationally)17 and RSV (selected states, not funded),17 there is a need for pharmacists to upskill around delivering vaccines outside of the usual seasonal vaccines, like influenza. So how can pharmacists be equipped to have proactive conversations on all recommended vaccinations? What are the key critical success factors that will help drive high quality vaccination care?
Topline information for shingles and RSV
|
Herpes zoster (shingles) |
Respiratory syncytial virus (RSV) |
|
What is shingles? Shingles is a reactivation of the varicella-zoster virus (VZV) in someone who has previously had chickenpox (varicella) disease. Shingles commonly presents as a painful rash of fluid-filled blisters on one side of the face or body, often in a strip or band-like pattern. Other symptoms can include headache, malaise, itching, tingling or severe pain.19 Post-herpetic neuralgia (PHN) is defined as neuropathic pain at the site of the rash that can persist for >3 months after an outbreak of shingles.2 It can have a substantial impact on the quality of life in those affected and can be refractory to treatment. |
What is RSV? How do you get RSV? RSV is a respiratory virus that usually causes mild, cold-like symptoms, but can also lead to more severe conditions like bronchiolitis, bronchitis or pneumonia, and exacerbations of existing lung conditions such as asthma and heart disease. Transmission most commonly occurs through respiratory contact with infected secretions from sneezing and coughing.23,24 |
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Who can get shingles, and how common is it? People are at risk of developing shingles if they have previously had chickenpox (i.e. VZV infection). In Australia, most adults will be at risk even if they don’t remember having had chickenpox in the past. Around 20–30% of people will have shingles in their lifetime – most after the age of 50 years – and around half of all people who live to 85 years of age will develop shingles.19 |
Who can get RSV, and how common is it in adults? RSV can infect people of all ages; however, infants and older adults are more likely to develop severe RSV.24 Since RSV disease was historically regarded as a disease that affects infants and children, testing for the virus in adults was previously uncommon and data in adults are limited.24 |
|
Who should receive a shingles vaccine and why? There have been two vaccines available in Australia for the prevention of herpes zoster and associated complications — Shingrix® and Zostavax®. As of 31 October 2023, the manufacturers of Zostavax® have discontinued supply in Australia.33 Unless otherwise contraindicated, the Australian Immunisation Handbook recommends shingles vaccination with Shingrix® – the recombinant Varicella Zoster Virus Glycoprotein E Antigen/ ASO1B adjuvanted vaccine (recombinant VZV vaccine) for people aged ≥18 years who are immunocompromised, and immunocompetent adults aged ≥50 years and household contacts of a person who is immunocompromised aged ≥50 years who have not previously received a dose.2 |
Which adults are at greatest risk of requiring hospitalisation with RSV disease? The risk of severe RSV disease is higher among adults with medical risk conditions (such as chronic cardiac, respiratory and neurological conditions, immunocompromising conditions, chronic metabolic disorders, chronic kidney disease), older adults (with the risk increasing with age), and Aboriginal and Torres Strait Islander peoples.24 There are two RSV vaccinations registered to protect against RSV-related lower respiratory tract disease in adults aged ≥60 years.2 |
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What is the efficacy and tolerability of recombinant VZV vaccine? Vaccination with recombinant VZV vaccine resulted in a high level of protection against shingles and PHN in adults aged ≥50 years. In two large clinical trials against placebo, the recombinant VZV vaccine demonstrated over 90% vaccine efficacy against shingles in adults aged ≥50 years (p<0.001).20,21 Vaccine efficacy of the recombinant VZV vaccine against PHN was 91% in immunocompetent people ≥50 years of age and 89% in immunocompetent people ≥70 years of age (p<0.001).20,21 From the long-term follow-up study, protection against shingles with recombinant VZV vaccine remained high in adults aged ≥50 years, with a vaccine efficacy of 81.6% (vs placebo or historical control), (mean 5.6 - 9.6 +/- 0.3 years post-vaccination).22 The most frequently reported local adverse reactions was pain at the injection site; myalgia, fatigue and headache were the most frequently reported systemic reactions. The majority of reactions, both local and systemic, were mild to moderate in intensity and of short median duration (1–3 days).20,21 |
How effective is RSV vaccination at preventing RSV-related lower respiratory tract disease in older adults? Vaccine efficacy of the adjuvanted recombinant RSV vaccine through one RSV season (median 6.7 months follow-up) against RSV-related lower respiratory tract disease in adults ≥60 years was 82.6%. Vaccine efficacy of the recombinant RSV vaccine (without adjuvant) in adults ≥60 years through one RSV season (mean 7 months follow-up) against RSV-related lower respiratory tract disease with ≥2 symptoms was 66.7%, and 85.7% with ≥3 symptoms.2,25 |
Implementing pharmacy-led vaccination programs requires careful planning, adherence to regulations, and a commitment to patient safety. Critical factors to consider are shown in Box 4. By addressing these critical factors, pharmacists can help ensure the success and effectiveness of pharmacy-led vaccination programs, including those focusing on shingles and RSV vaccinations.
Critical factors for pharmacy-led vaccination [for more information please refer to the PSA's Practice Guidelines for the provision of immunisation services]28
| Regulatory compliance: Ensure that your pharmacy and staff comply, and are up to date with, all relevant regulations set forth by the Department of Health and Aged Care and NIPVIP Program and local state legislation. Staff training and certification: Ensure that pharmacists administering vaccines are properly trained and certified in administration techniques, handling and storage, and managing adverse reactions, including general first aid and cardiopulmonary resuscitation. Patient education and counselling: Provide patients with accurate information about vaccine benefits, potential adverse effects, and any necessary precautions. Vaccine storage and handling: Follow strict protocols including monitoring and recording refrigerator temperatures, proper storage in designated areas and vaccine rotation to prevent expiration. Documentation and record-keeping: Maintain accurate records, including the type of vaccine administered, lot number, expiration date, administration date, and patient information as part of the patient’s personal records and relevant registers (Australian Immunisation Register [AIR] or Australian Q Fever Register). Collaboration with healthcare providers: Collaborate with other healthcare providers to ensure continuity of care and appropriate patient referrals and establish clear communication channels for sharing information. Adverse event monitoring and reporting: Develop protocols for monitoring and managing adverse events. Educate staff on recognising and responding to adverse reactions and reporting adverse events to regulatory agencies as required. Continuous quality improvement: Regularly review your vaccination program, solicit feedback from patients and staff and stay updated on best practices to ensure high-quality care. |
Vaccination is a national priority in Australia.11 In-pharmacy vaccination programs have expanded access to vaccines, making preventive health care more convenient and accessible. These programs leverage the widespread presence of pharmacies in communities, allowing individuals to have a greater choice around where and when they can receive vaccinations in primary care. By offering vaccinations for various VPDs, these programs have the potential to play a crucial role in increasing vaccination rates and reducing the burden of vaccine preventable illnesses.32 Their success lies in their ability to reach diverse populations, promote health equity, and contribute to overall public health outcomes. While older adults may encounter many barriers to vaccination, pharmacists are positioned to address many of these barriers by providing a convenient point of access, building confidence in vaccination, and actively increasing awareness to reduce complacency.
Case scenario one continued'Speaking of chickenpox, Anne, did you know that this is the same virus (varicella) that causes shingles? Shingles is a painful and debilitating condition, that can occur in people who have previously had chickenpox. The risk of getting shingles increases with age, especially from the age of 50. As you are in the age group where vaccination against shingles is recommended, would you like to receive it now? I have the vaccine in stock.* Let me get the vaccination information sheet and consent form and discuss further.' *Note the recombinant VZV shingles vaccine is the only shingles vaccine available. It is accessible privately or via the NIP for eligible cohorts.Case scenario two continuedAfter responding to the management of Ron's conjunctivitis, you take the opportunity to discuss RSV. 'I’m glad your cold has resolved. Actually, there is another respiratory virus that commonly circulates mostly in the colder months called RSV that can lead to quite severe conditions like bronchitis or pneumonia. Due to your age and heart condition, you are at a greater risk of hospitalisation. Vaccinating now could ensure you only have mild symptoms if infected and could keep you out of hospital. If you’re interested in getting it, I can get it ready while we take your blood pressure.' |
Natasha Dean (she/her) BSc(Hon) is a Senior Medical Writer with over 20 years’ experience in medical education and medical communications. She is a CPD representative with the RACGP CPD Program and regularly accredits activities for other organisations including ACCRM, PSA and ACN.
Sarushka Sritharan (she/her) BPharm(Hon) DipMgt MPS
Vaccine administration should be in accordance with relevant legislation, the Australian Immunisation Handbook, and State-based conditions specific to the vaccine.
[post_title] => The essential role of the pharmacist in adult vaccination [post_excerpt] => Pharmacists, consistently regarded as one of the most highly trusted groups of healthcare professionals, are in a unique position to promote and support the uptake of vaccination in older adults. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => role-of-the-pharmacist-in-adult-vaccination [to_ping] => [pinged] => [post_modified] => 2024-09-10 09:17:52 [post_modified_gmt] => 2024-09-09 23:17:52 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=27438 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => The essential role of the pharmacist in adult vaccination [title] => The essential role of the pharmacist in adult vaccination [href] => https://www.australianpharmacist.com.au/role-of-the-pharmacist-in-adult-vaccination/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 27465 [authorType] => )td_module_mega_menu Object
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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"] Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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[post_content] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve patient health and safety.
As the 2024 FIP World Congress continues, Australian Pharmacist reports from Cape Town on some innovative services presented which are improving health across the globe.
South Africa: Improving access to HIV treatment and prevention
There are 7.9 million people in South Africa between the ages of 15 and 49 years living with HIV. Despite strides in treatments and preventative therapies, the rate of new infections remains high.
One project driven by pharmacists is aiming to change this, allowing community pharmacists to initiate high-risk young women and men onto HIV Pre-Exposure Prophylaxis (PrEP). In this implementation study, 10 pharmacies in Gauteng and the Western Cape (Cape Town) initiated high-risk individuals on combination tenofovir and lamivudine/emtricitabine for a period of 13 months. Patients were recruited inside and outside of the pharmacy.
Of the 838 potential participants, 88% (n = 737) were initiated on PrEP between June 2023 and January 2024. Risk assessment found most were sexually active, and more than three quarters (n = 595) engaged in sexual activity without a condom. Initial results from the study were positive, with further analysis to explore patient perceptions of PrEP initiation in community pharmacy.
Spain: Pharmacy reporting of stock shortages helps detect shortages sooner
The General Council of Pharmacists of Spain has developed two systems to prevent and mitigate medicine shortages.
The first is CisMED, a system that generates real-time information on supply incidents at a pharmacy level.
Over 10,000 pharmacies participated in this initiative in 2023 – over half of all pharmacies. CisMED reported a 30% increase in medicines that could not be supplied, with over half the alerts generated being for medicines not listed by their regulator, the Spanish Medicines Agency.
The second initiative, FarmaHelp, is a communication system which allows pharmacists to communicate with nearby pharmacies when a request for a medicine cannot be fulfilled. From the 10,000 pharmacies connected to the system, the number of medicines ‘found’ increased from 106,925 to 389,364. This meant 73.5% of the time, the pharmacist was able to offer a solution to the patient due to the FamraHelp system.
In combination, these digital systems have helped pharmacists both contribute to a more accurate and complete medicine shortage database, and allowed pharmacists to find more options to support access to scarce medicines to their patients more often.
The Netherlands: Palliative care kit improves access to care at end-of-life
The decision to initiate palliative care is often a time where medicines need to be prescribed and initiated at short notice, with a new and often complex regimen of medicines.
A project in The Netherlands led by the Royal Dutch Pharmacists Association, is trying to make this a smoother process for patients and their families through the introduction of a ‘palliative care kit’.
Based on the concept of a first-aid kit, the ‘palliative care kit’ contains everything patients will need to facilitate administration of medicines at end-of-life. This includes morphine and midazolam ampoules, syringes, needles, bandages and a urinary catheter with insertion set.
The kit is supplied by a pharmacy, which receives reimbursement for the medicines, and a professional fee for facilitating the supply of the kit.
The kit contains a permission document from the GP to use the supplies when necessary. The kit is delivered to the home of palliative patients when they enter the terminal phase at a time that can be planned. This allows a nurse to immediately use that kit when necessary.
The kit has reduced unnecessary time spent by community nurses, GPs and pharmacists in facilitating palliative care, particularly during evenings, nights and on weekends. Families report the presence of the kit reassuring because they know their loved one will be able to access the medicines they need instantly, should they experience acute deterioration.
Thailand: Medicine reviews for high-risk CKD patients
In Thailand, 30% of people with chronic kidney disease (CKD) use NSAIDs or other herbal medicines which may accelerate the progression of CKD. A pilot project has shown pharmacists can help reduce this.
In this pilot, a nurse at the CKD clinic referred patients (n = 23) with medicine problems to a pharmacy for medicine reconciliation, adherence checks and to review for potential causes of acute kidney injury. Importantly, the pharmacist also managed any problems identified and monitored kidney function for at least 3 months.
Half (52%) of patients stopped using NSAIDs, and kidney function improved from Stage 3 to Stage 2 in five patients within 3 months. While not statistically significant, the small pilot concluded the model of care appeared to reduce costs associated with medicines and CKD management.
Australian pharmacist on SA TV!
Meanwhile, Australian pharmacist and FIP President Paul Sinclair AM MPS has appeared on South African breakfast television to talk about the important role of pharmacists. Paul told SABC’s Expresso Show he was excited about the opportunities around the world for pharmacists.
[caption id="attachment_27480" align="aligncenter" width="507"] FIP President Paul Sinclair AM MPS (left)[/caption]
‘Health care across the world is changing very quickly. It’s being driven by innovation, and pharmacists historically have embraced innovation and technology,' he said.
‘What excites me most about our profession at the moment is that we have the chance to do more. Our scope of practice is expanding rapidly, and with that comes opportunities to help more people deliver more outcomes and improve the health system.'
[post_title] => What are pharmacists doing in other countries?
[post_excerpt] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve health and safety.
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[post_content] => Syphilis cases have tripled in the last 10 years in Australia, leading to an ‘avoidable and unacceptable’ reemergence of congenital syphilis. This World Sexual Health Day (4 September), Australian Pharmacist explores pharmacists’ role in addressing this escalating issue.
When syphilis infections began to rise in Australia in 2011, the cases were primarily among men with male sexual partners, and young heterosexual persons in remote Aboriginal and Torres Strait Islander communities. However, there was a 500% increase in the rate of infectious syphilis among women aged 15 to 44 between 2011 and 2021, according to a report from the University of New South Wales’ Kirby Institute.
That means parent-to-child transmission is also on the rise - this is called congenital syphilis. There was a median of 4 cases per year in Australia between 2011 and 2019, skyrocketing to 17 cases in 2020, and 15 in 2021 and 2022. For the birthing parent of babies with congenital syphilis, the report’s authors found less than 40% were tested for syphilis during pregnancy.
Left untreated, congenital syphilis can lead to serious complications in more than 50% of cases, including miscarriage, stillbirth, neonatal death and permanent disability. Of all the cases of congenital syphilis in Australia between 2011 and 2021, 25% of babies were stillborn.
In Queensland, where cases of infectious syphilis have increased by 600% in 15 years, five babies contracted the disease in the womb in 2023, leading to 4 deaths. This is the largest number of Queensland deaths from congenital syphilis in a single year this century.
As a preventable and curable disease, Queensland Minister for Health Shannon Fentiman said the deaths ‘shouldn’t be happening’. It’s a message echoed by Australia’s Chief Medical Officer Professor Paul Kelly, who said health professionals need to ensure they’re up to date on information about syphilis testing and management.
‘Any baby losing its life is a tragedy. Any baby losing its life to a preventable illness is a responsibility for us all in our health system,’ he said in a video (below) recorded for the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM).
https://vimeo.com/912435688
‘We must ensure everyone is tested for syphilis during pregnancy. All pregnant people should be tested at least once, and in many cases more … Once diagnosed, treatment is simple and effective.’
High-risk populations
In 2022, syphilis rates among Aboriginal and Torres Strait Islander peoples were more than five times higher than in non-Indigenous populations. Of the 15 congenital syphilis cases across the country in the same year, eight were among Aboriginal and Torres Strait Islander peoples.
‘Congenital syphilis diagnoses are 14 times as high among Aboriginal and Torres Strait Islander infants compared with non-Indigenous infants,’ said researcher Dr Skye McGregor, who led the Kirby Institute report.
‘All pregnant people should be tested for sexually transmitted infections (STIs) as part of pre- and antenatal health screening, but antenatal care is not always accessible. It is vital that comprehensive services are in place to ensure appropriate care is accessible for all pregnant people.’
Other high-risk populations include men who have sex with men and babies of mothers who have not had proper syphilis testing and treatment during pregnancy. However, ASHM Deputy CEO Jessica Michaels said it is important to recognise that syphilis can affect anyone.
‘In order to curb the rising syphilis epidemic, it is important that we take a “no wrong door’’ approach to testing,’ she said.
What to look out for
People presenting at a pharmacy with signs or symptoms of syphilis should be encouraged to test, Ms Michaels said, especially if the symptoms are otherwise unexplained.
‘Other instances when pharmacists can encourage patients to test for syphilis include people presenting with symptoms of any STI or an STI diagnosis, those asking about testing for STIs and/or blood-borne viruses, when people are assessed for post-exposure prophylaxis, and pregnant people who are not engaged in antenatal care.’
Symptoms and/or signs of syphilis can include:
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[post_content] => Case one scenario
[caption id="attachment_27445" align="alignright" width="173"] This educational activity was managed by PSA at the request of and with funding from GSK.[/caption]
Anne comes in for her prescription and, in conversation, informs you she has just celebrated her 60th birthday. Unfortunately, some of her family couldn't attend as her grandchild was recovering from chickenpox. She recalls her own childhood infection as being relatively mild.
Case two scenario
Ron, aged 67 years, is a regular patient of yours. He comes to the pharmacy to have his prescriptions filled for high blood pressure, heart failure and hyperlipidaemia. He mentioned he just got over a cold and seeks your advice as he has since developed conjunctivitis. Given his history, you check his vaccination records on the Australian Immunisation Register (AIR) and noted he is up to date with his COVID booster, influenza, herpes zoster and pneumococcal vaccinations.
Learning ObjectivesAfter reading this article, pharmacists should be able to:
|
Pharmacists, consistently regarded as one of the most highly trusted groups of healthcare professionals, are in a unique position to promote and support the uptake of vaccination in older adults.1 However, despite clinical recommendations by the Australian Technical Advisory Group on Immunisation (ATAGI), there remains a significant gap in adult vaccination coverage in Australia.2,16 With the expanded scope of vaccination practice and the launch of the National Immunisation Program Vaccinations in Pharmacy (NIPVIP) program in pharmacy since 1 January 2024, pharmacists have a key role in providing vaccinations in primary care. Pharmacists are well placed to help improve adult vaccination rates by addressing some of the key barriers outlined in the table below, the ‘Five A’s’ of vaccination.3 Pharmacists can improve adult vaccination rates by addressing key barriers such as improving access and improving the awareness and understanding of vaccines.4
The 'Five A's' of vaccination3
The ‘Five A’s’ of vaccination are a framework for understanding why some people voluntarily get vaccinated, while others do not.
| Awareness | Whether people know about vaccines, where to get them, and their benefits and risks. |
| Acceptance | Whether people want to get vaccinated, subject to access and affordability. |
| Affordability | Whether people can afford the price of getting vaccinated and other costs of getting vaccinated, such as time off work if they have an adverse reaction to the vaccine. |
| Access | Whether people can safely and easily get vaccines, including physical and psychological safety. |
| Activation | Whether people who are aware of and accepting of vaccines are motivated to get the vaccine. |
Pharmacists are among the most consistently accessible healthcare professionals to patients. Compared to other healthcare professionals, pharmacists typically have longer hours of operation, including weekends, in which to offer vaccination services.5 These added conveniences facilitate greater flexibility and increased opportunities for individuals to access vaccination services in their local community.5
Community pharmacists continue to rate higher satisfaction and referral with patients than doctors or dentists, according to the 2023 Australian Healthcare Index (AHI) survey.6 With the rising out of pocket costs for general practice consultations, pharmacists are being sought by some patients as the first point of care before booking a general practitioner consult. There is also increased awareness of pharmacy services beyond the provision of prescription and over-the-counter medications, with 1 in 4 AHI survey participants reporting a visit to the pharmacy for vaccination service.6
Understanding and awarenessPerceptions about disease severity, vaccine effectiveness and safety, along with low provider confidence in the effectiveness of adult vaccination, contribute to low immunisation rates in older adults.3,7–9 Additionally, older adults’ knowledge of vaccines and vaccination guidelines varies.9 Pharmacists are well positioned to bridge knowledge gaps, increase awareness, dispel myths, and reduce complacency regarding vaccination.10
Vaccination remains a key preventative strategy in public health.11 Vaccines prevent 3.5–5 million deaths a year, and drastically reduce the morbidity and disability rates due to vaccine preventable diseases (VPDs).12 Older adults share a disproportionately high burden of VPD, which may be prevented or attenuated by vaccination.13 Despite recommendations from peak health organisations, vaccination rates among older patients remain suboptimal.14,15 Of people in their 70s, less than half are vaccinated against shingles, and only 1 in 5 is vaccinated against pneumococcal disease.16
Vaccination for adults2,16
Adults aged ≥50 years are at increased risk of some VPDs and of serious complications from these diseases, even if they are otherwise healthy. Check to see if your patients need any of the following.
dTpa booster
Immunity to some diseases can start to wane in older people, and they may need booster doses of some vaccines.
|
Measles, mumps and rubella
|
Herpes zoster (shingles)
The incidence of shingles increases with age, as does the incidence of serious complications such as post-herpetic neuralgia.
|
| Influenza Annual influenza vaccination is recommended for everyone ≥6 months of age. As Influenza-associated mortality rates are highest among older adults and Aboriginal and Torres Strait Islander peoples, influenza vaccination is particularly recommended for adults aged ≥65 years and for Aboriginal and Torres Strait Islander adults of any age. |
Pneumococcal disease
Pneumococcal disease is more prevalent in older adults.
|
Adapted from: Department of Health and Aged Care. Vaccination for healthy ageing. 2023.18 See the Australian Immunisation Handbook for more details. dTpa, diphtheria, tetanus and acellular pertussis–containing vaccine; MMR, measles, mumps and rubella; VZV, varicella zoster virus.
*15vPCV and 20vPCV are available as alternatives to 13vPCV but are not currently NIP-funded.With the recent expanded scope of vaccination practice as part of the NIPVIP Program to include a number of adult vaccines, including those against shingles (nationally)17 and RSV (selected states, not funded),17 there is a need for pharmacists to upskill around delivering vaccines outside of the usual seasonal vaccines, like influenza. So how can pharmacists be equipped to have proactive conversations on all recommended vaccinations? What are the key critical success factors that will help drive high quality vaccination care?
Topline information for shingles and RSV
|
Herpes zoster (shingles) |
Respiratory syncytial virus (RSV) |
|
What is shingles? Shingles is a reactivation of the varicella-zoster virus (VZV) in someone who has previously had chickenpox (varicella) disease. Shingles commonly presents as a painful rash of fluid-filled blisters on one side of the face or body, often in a strip or band-like pattern. Other symptoms can include headache, malaise, itching, tingling or severe pain.19 Post-herpetic neuralgia (PHN) is defined as neuropathic pain at the site of the rash that can persist for >3 months after an outbreak of shingles.2 It can have a substantial impact on the quality of life in those affected and can be refractory to treatment. |
What is RSV? How do you get RSV? RSV is a respiratory virus that usually causes mild, cold-like symptoms, but can also lead to more severe conditions like bronchiolitis, bronchitis or pneumonia, and exacerbations of existing lung conditions such as asthma and heart disease. Transmission most commonly occurs through respiratory contact with infected secretions from sneezing and coughing.23,24 |
|
Who can get shingles, and how common is it? People are at risk of developing shingles if they have previously had chickenpox (i.e. VZV infection). In Australia, most adults will be at risk even if they don’t remember having had chickenpox in the past. Around 20–30% of people will have shingles in their lifetime – most after the age of 50 years – and around half of all people who live to 85 years of age will develop shingles.19 |
Who can get RSV, and how common is it in adults? RSV can infect people of all ages; however, infants and older adults are more likely to develop severe RSV.24 Since RSV disease was historically regarded as a disease that affects infants and children, testing for the virus in adults was previously uncommon and data in adults are limited.24 |
|
Who should receive a shingles vaccine and why? There have been two vaccines available in Australia for the prevention of herpes zoster and associated complications — Shingrix® and Zostavax®. As of 31 October 2023, the manufacturers of Zostavax® have discontinued supply in Australia.33 Unless otherwise contraindicated, the Australian Immunisation Handbook recommends shingles vaccination with Shingrix® – the recombinant Varicella Zoster Virus Glycoprotein E Antigen/ ASO1B adjuvanted vaccine (recombinant VZV vaccine) for people aged ≥18 years who are immunocompromised, and immunocompetent adults aged ≥50 years and household contacts of a person who is immunocompromised aged ≥50 years who have not previously received a dose.2 |
Which adults are at greatest risk of requiring hospitalisation with RSV disease? The risk of severe RSV disease is higher among adults with medical risk conditions (such as chronic cardiac, respiratory and neurological conditions, immunocompromising conditions, chronic metabolic disorders, chronic kidney disease), older adults (with the risk increasing with age), and Aboriginal and Torres Strait Islander peoples.24 There are two RSV vaccinations registered to protect against RSV-related lower respiratory tract disease in adults aged ≥60 years.2 |
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What is the efficacy and tolerability of recombinant VZV vaccine? Vaccination with recombinant VZV vaccine resulted in a high level of protection against shingles and PHN in adults aged ≥50 years. In two large clinical trials against placebo, the recombinant VZV vaccine demonstrated over 90% vaccine efficacy against shingles in adults aged ≥50 years (p<0.001).20,21 Vaccine efficacy of the recombinant VZV vaccine against PHN was 91% in immunocompetent people ≥50 years of age and 89% in immunocompetent people ≥70 years of age (p<0.001).20,21 From the long-term follow-up study, protection against shingles with recombinant VZV vaccine remained high in adults aged ≥50 years, with a vaccine efficacy of 81.6% (vs placebo or historical control), (mean 5.6 - 9.6 +/- 0.3 years post-vaccination).22 The most frequently reported local adverse reactions was pain at the injection site; myalgia, fatigue and headache were the most frequently reported systemic reactions. The majority of reactions, both local and systemic, were mild to moderate in intensity and of short median duration (1–3 days).20,21 |
How effective is RSV vaccination at preventing RSV-related lower respiratory tract disease in older adults? Vaccine efficacy of the adjuvanted recombinant RSV vaccine through one RSV season (median 6.7 months follow-up) against RSV-related lower respiratory tract disease in adults ≥60 years was 82.6%. Vaccine efficacy of the recombinant RSV vaccine (without adjuvant) in adults ≥60 years through one RSV season (mean 7 months follow-up) against RSV-related lower respiratory tract disease with ≥2 symptoms was 66.7%, and 85.7% with ≥3 symptoms.2,25 |
Implementing pharmacy-led vaccination programs requires careful planning, adherence to regulations, and a commitment to patient safety. Critical factors to consider are shown in Box 4. By addressing these critical factors, pharmacists can help ensure the success and effectiveness of pharmacy-led vaccination programs, including those focusing on shingles and RSV vaccinations.
Critical factors for pharmacy-led vaccination [for more information please refer to the PSA's Practice Guidelines for the provision of immunisation services]28
| Regulatory compliance: Ensure that your pharmacy and staff comply, and are up to date with, all relevant regulations set forth by the Department of Health and Aged Care and NIPVIP Program and local state legislation. Staff training and certification: Ensure that pharmacists administering vaccines are properly trained and certified in administration techniques, handling and storage, and managing adverse reactions, including general first aid and cardiopulmonary resuscitation. Patient education and counselling: Provide patients with accurate information about vaccine benefits, potential adverse effects, and any necessary precautions. Vaccine storage and handling: Follow strict protocols including monitoring and recording refrigerator temperatures, proper storage in designated areas and vaccine rotation to prevent expiration. Documentation and record-keeping: Maintain accurate records, including the type of vaccine administered, lot number, expiration date, administration date, and patient information as part of the patient’s personal records and relevant registers (Australian Immunisation Register [AIR] or Australian Q Fever Register). Collaboration with healthcare providers: Collaborate with other healthcare providers to ensure continuity of care and appropriate patient referrals and establish clear communication channels for sharing information. Adverse event monitoring and reporting: Develop protocols for monitoring and managing adverse events. Educate staff on recognising and responding to adverse reactions and reporting adverse events to regulatory agencies as required. Continuous quality improvement: Regularly review your vaccination program, solicit feedback from patients and staff and stay updated on best practices to ensure high-quality care. |
Vaccination is a national priority in Australia.11 In-pharmacy vaccination programs have expanded access to vaccines, making preventive health care more convenient and accessible. These programs leverage the widespread presence of pharmacies in communities, allowing individuals to have a greater choice around where and when they can receive vaccinations in primary care. By offering vaccinations for various VPDs, these programs have the potential to play a crucial role in increasing vaccination rates and reducing the burden of vaccine preventable illnesses.32 Their success lies in their ability to reach diverse populations, promote health equity, and contribute to overall public health outcomes. While older adults may encounter many barriers to vaccination, pharmacists are positioned to address many of these barriers by providing a convenient point of access, building confidence in vaccination, and actively increasing awareness to reduce complacency.
Case scenario one continued'Speaking of chickenpox, Anne, did you know that this is the same virus (varicella) that causes shingles? Shingles is a painful and debilitating condition, that can occur in people who have previously had chickenpox. The risk of getting shingles increases with age, especially from the age of 50. As you are in the age group where vaccination against shingles is recommended, would you like to receive it now? I have the vaccine in stock.* Let me get the vaccination information sheet and consent form and discuss further.' *Note the recombinant VZV shingles vaccine is the only shingles vaccine available. It is accessible privately or via the NIP for eligible cohorts.Case scenario two continuedAfter responding to the management of Ron's conjunctivitis, you take the opportunity to discuss RSV. 'I’m glad your cold has resolved. Actually, there is another respiratory virus that commonly circulates mostly in the colder months called RSV that can lead to quite severe conditions like bronchitis or pneumonia. Due to your age and heart condition, you are at a greater risk of hospitalisation. Vaccinating now could ensure you only have mild symptoms if infected and could keep you out of hospital. If you’re interested in getting it, I can get it ready while we take your blood pressure.' |
Natasha Dean (she/her) BSc(Hon) is a Senior Medical Writer with over 20 years’ experience in medical education and medical communications. She is a CPD representative with the RACGP CPD Program and regularly accredits activities for other organisations including ACCRM, PSA and ACN.
Sarushka Sritharan (she/her) BPharm(Hon) DipMgt MPS
Vaccine administration should be in accordance with relevant legislation, the Australian Immunisation Handbook, and State-based conditions specific to the vaccine.
[post_title] => The essential role of the pharmacist in adult vaccination [post_excerpt] => Pharmacists, consistently regarded as one of the most highly trusted groups of healthcare professionals, are in a unique position to promote and support the uptake of vaccination in older adults. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => role-of-the-pharmacist-in-adult-vaccination [to_ping] => [pinged] => [post_modified] => 2024-09-10 09:17:52 [post_modified_gmt] => 2024-09-09 23:17:52 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=27438 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => The essential role of the pharmacist in adult vaccination [title] => The essential role of the pharmacist in adult vaccination [href] => https://www.australianpharmacist.com.au/role-of-the-pharmacist-in-adult-vaccination/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 27465 [authorType] => )td_module_mega_menu Object
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While Australians are taking fewer antibiotics overall, there are concerns that antimicrobial prescribing is steadily increasing in aged care.
Each year, the Australian Commission on Safety and Quality in Health Care’s Antimicrobial use in the community (AURA) report analyses antimicrobials supplied under the Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS (RPBS) – featuring both antimicrobial use in aged care and by local area.
The latest report, AURA 2023 found that although there has been a small increase of 1.3% in overall antimicrobial use in the community from 2022 to 2023, use is still 24.4% lower than in 2015.
Alarmingly, there has been a stark 11.1% increase in antimicrobial use in residents of aged care homes from 2022 to 2023.
Antimicrobial use is also considerably higher for older Australians who reside in aged care homes than for those living in the community. While just over a third of Australians had at least one antimicrobial dispensed, almost three-quarters of residential aged care facility (RACF) residents received at least one antimicrobial prescription last year.
Australian Pharmacist looks at which antibiotics are most commonly prescribed in aged care, the impacts of high antimicrobial use, and what pharmacists can do to help.
Why is antibiotic prescribing in aged care so high?
There are several reasons why RACF antimicrobial prescribing is higher than in the rest of the community.
[caption id="attachment_24236" align="alignright" width="216"] Professor John Turnidge AO[/caption]
According to infectious diseases physician and microbiologist Professor John Turnidge AO, Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care, these include:
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[post_content] => Sleep is a hot topic for Anousheh Page MPS, Director of Pharmacy at Brisbane’s only 24-hour pharmacy.
Why did you choose pharmacy?
Becoming a pharmacist was actually one of three options on my university application. At the time, all I really knew was that I enjoyed science-based subjects at school and also helping people (natural Virgo at heart, of course!). When it came to the pros and cons list, pharmacy felt like the best option. And I don’t have any regrets.
I absolutely love being a pharmacist. I completed a Bachelor of Pharmacy at the University of Sydney and can honestly say my university experience was the best of all time, which reinforced my choice to become a pharmacist.
What led you to your current role?
I knew whilst completing my pharmacy degree that I always wanted to work within a hospital environment. My pharmacy career in hospital began after completing my internship at the Children’s Hospital, Westmead, in Sydney. In 2007, I was moving back from a hospital role on the South Coast of New South Wales when I saw a Pharmacist In Charge role advertised for Kareena Private Hospital (God’s country, aka the Sutherland Shire in southern Sydney). I was fortunate enough to be offered the role. Working within any Ramsay Health Care facility never feels like work. The hospital staff become your adopted family and you work within a well-supported multidisciplinary team. I gained experience within multiple Ramsay Hospitals and eventually landed Director of Pharmacy at Greenslopes Private Hospital.
How do you and your staff cope with the late-night and overnight hours?
In general, staff cope very well and have an amazing ability to adapt to the various hours. There is a good balance of work which flows through the hospital inpatient stream but is also complemented by the variety of community patients that come through. I personally would sleep a few hours before a shift if I knew I had to cover an overnight. Like most, I would stay awake and try and get back to a normal sleep routine for the next shift.
What are common requests from patients who visit in the wee small hours?
Patients do often come in for sleep issues at night, however what stands out the most are patients who request salbutamol inhalers. Every night can be different depending on the day of the week, but the most consistent request is salbutamol. We have had patients coming from areas like the Gold Coast or even Mount Barney (130 kilometres south-east of Brisbane, population less than 50). This really highlights the opportunity pharmacists have to be able to deliver full-scope activities such as improved asthma management – including developing an asthma action plan – particularly outside standard business hours. The second-most common would be the management of acute illnesses to treat gastroenteritis or flu-like symptoms. We have many local public facilities surrounding Greenslopes, including our own emergency department, so we service lots of patients requiring after-hours medicines.
What are your strategies to deal with barriers to overnight care?
In most scenarios we would just use our experience and clinical judgment when helping patients. Working an overnight shift is similar to working a weekend shift in some respects, so we are very accustomed to managing or referring when necessary. We are also fortunate to work in an area with late-opening medical centres and local emergency centres. This allows us to refer patients who require further review. QScript (Queensland’s real-time prescription monitoring system) has also been a game changer in helping provide better support and clinical judgement for dispensing high-risk medicines; this had often been a challenge when working outside normal hours in pharmacy.
If you could change anything about your 24-hour pharmacy, what would it be?
Coffee is the gift that keeps on giving. A barista-made coffee on hand at any hour wouldn’t be too much to ask, would it?
What’s your advice for ECPs?
It’s important to work in an environment you love. Surrounded by the right team and environment can absolutely make the difference on how you approach work. If you dread work or feel anxious before the work week, you’re not in the right job.
A day in the life of Anousheh Page MPS, Director of Pharmacy, Greenslopes Private Hospital, QLD
| 4.30 am |
Up and at it Never in my life did I think I would be one of those early morning risers to hit the gym, but the pandemic forced a change and that schedule gets me mentally prepared for the day. |
| 7.30 am |
Handover time A double-shot of cappuccino in hand, my day begins with a handover between the 24-hour retail pharmacy and hospital dispensary team. Urgent action might be needed on alteplase orders to replace stock used overnight for a stroke patient in ED, or ensuring discharge medicines that were completed are given to that ward’s pharmacist for patient counselling. |
| 8.30 am |
Hospital bed managers’ meeting Meeting daily with the ward and other multidisciplinary hospital team managers helps me reallocate pharmacy staff to areas that need support i.e. for timely discharges or immediate communication if a regular pharmacy staff member is on leave. On Thank You Thursdays, meetings end by nominating a team member deserving of recognition, who later receives a card and lunch voucher from the hospital executive team. |
| 9.30 am |
Current shortages Next meeting addresses state shortages – this time its fluids. This entails direct contact with other Ramsay Queensland hospitals via the state procurement manager who organises a consistent supply of fluids, such as saline. |
| 10 am – 4 pm |
Daily challenges Every work day is different. Overseeing a 24-hour pharmacy that never closes requires being prepared for anything, and problem-solving is a strong skill set in my role. If I have multiple staff on leave with the spread of colds and flu, I actively help cover an area, (which has helped me be a better manager with greater knowledge of what shifts entail or how wards operate). Urgent deliveries of home IV antibiotics for patients and expensive IV anti-fungals at short notice are part of it. |
| 4.00 pm |
Home time I start my second job, which could ideally be a paid Uber driver, but is actually driving my children to their various daily extracurricular activities. At least I’m off my feet! |
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[post_content] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve patient health and safety.
As the 2024 FIP World Congress continues, Australian Pharmacist reports from Cape Town on some innovative services presented which are improving health across the globe.
South Africa: Improving access to HIV treatment and prevention
There are 7.9 million people in South Africa between the ages of 15 and 49 years living with HIV. Despite strides in treatments and preventative therapies, the rate of new infections remains high.
One project driven by pharmacists is aiming to change this, allowing community pharmacists to initiate high-risk young women and men onto HIV Pre-Exposure Prophylaxis (PrEP). In this implementation study, 10 pharmacies in Gauteng and the Western Cape (Cape Town) initiated high-risk individuals on combination tenofovir and lamivudine/emtricitabine for a period of 13 months. Patients were recruited inside and outside of the pharmacy.
Of the 838 potential participants, 88% (n = 737) were initiated on PrEP between June 2023 and January 2024. Risk assessment found most were sexually active, and more than three quarters (n = 595) engaged in sexual activity without a condom. Initial results from the study were positive, with further analysis to explore patient perceptions of PrEP initiation in community pharmacy.
Spain: Pharmacy reporting of stock shortages helps detect shortages sooner
The General Council of Pharmacists of Spain has developed two systems to prevent and mitigate medicine shortages.
The first is CisMED, a system that generates real-time information on supply incidents at a pharmacy level.
Over 10,000 pharmacies participated in this initiative in 2023 – over half of all pharmacies. CisMED reported a 30% increase in medicines that could not be supplied, with over half the alerts generated being for medicines not listed by their regulator, the Spanish Medicines Agency.
The second initiative, FarmaHelp, is a communication system which allows pharmacists to communicate with nearby pharmacies when a request for a medicine cannot be fulfilled. From the 10,000 pharmacies connected to the system, the number of medicines ‘found’ increased from 106,925 to 389,364. This meant 73.5% of the time, the pharmacist was able to offer a solution to the patient due to the FamraHelp system.
In combination, these digital systems have helped pharmacists both contribute to a more accurate and complete medicine shortage database, and allowed pharmacists to find more options to support access to scarce medicines to their patients more often.
The Netherlands: Palliative care kit improves access to care at end-of-life
The decision to initiate palliative care is often a time where medicines need to be prescribed and initiated at short notice, with a new and often complex regimen of medicines.
A project in The Netherlands led by the Royal Dutch Pharmacists Association, is trying to make this a smoother process for patients and their families through the introduction of a ‘palliative care kit’.
Based on the concept of a first-aid kit, the ‘palliative care kit’ contains everything patients will need to facilitate administration of medicines at end-of-life. This includes morphine and midazolam ampoules, syringes, needles, bandages and a urinary catheter with insertion set.
The kit is supplied by a pharmacy, which receives reimbursement for the medicines, and a professional fee for facilitating the supply of the kit.
The kit contains a permission document from the GP to use the supplies when necessary. The kit is delivered to the home of palliative patients when they enter the terminal phase at a time that can be planned. This allows a nurse to immediately use that kit when necessary.
The kit has reduced unnecessary time spent by community nurses, GPs and pharmacists in facilitating palliative care, particularly during evenings, nights and on weekends. Families report the presence of the kit reassuring because they know their loved one will be able to access the medicines they need instantly, should they experience acute deterioration.
Thailand: Medicine reviews for high-risk CKD patients
In Thailand, 30% of people with chronic kidney disease (CKD) use NSAIDs or other herbal medicines which may accelerate the progression of CKD. A pilot project has shown pharmacists can help reduce this.
In this pilot, a nurse at the CKD clinic referred patients (n = 23) with medicine problems to a pharmacy for medicine reconciliation, adherence checks and to review for potential causes of acute kidney injury. Importantly, the pharmacist also managed any problems identified and monitored kidney function for at least 3 months.
Half (52%) of patients stopped using NSAIDs, and kidney function improved from Stage 3 to Stage 2 in five patients within 3 months. While not statistically significant, the small pilot concluded the model of care appeared to reduce costs associated with medicines and CKD management.
Australian pharmacist on SA TV!
Meanwhile, Australian pharmacist and FIP President Paul Sinclair AM MPS has appeared on South African breakfast television to talk about the important role of pharmacists. Paul told SABC’s Expresso Show he was excited about the opportunities around the world for pharmacists.
[caption id="attachment_27480" align="aligncenter" width="507"] FIP President Paul Sinclair AM MPS (left)[/caption]
‘Health care across the world is changing very quickly. It’s being driven by innovation, and pharmacists historically have embraced innovation and technology,' he said.
‘What excites me most about our profession at the moment is that we have the chance to do more. Our scope of practice is expanding rapidly, and with that comes opportunities to help more people deliver more outcomes and improve the health system.'
[post_title] => What are pharmacists doing in other countries?
[post_excerpt] => Pharmacists present to the International Pharmaceutical Federation (FIP) on unique services in their country to improve health and safety.
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[post_content] => Syphilis cases have tripled in the last 10 years in Australia, leading to an ‘avoidable and unacceptable’ reemergence of congenital syphilis. This World Sexual Health Day (4 September), Australian Pharmacist explores pharmacists’ role in addressing this escalating issue.
When syphilis infections began to rise in Australia in 2011, the cases were primarily among men with male sexual partners, and young heterosexual persons in remote Aboriginal and Torres Strait Islander communities. However, there was a 500% increase in the rate of infectious syphilis among women aged 15 to 44 between 2011 and 2021, according to a report from the University of New South Wales’ Kirby Institute.
That means parent-to-child transmission is also on the rise - this is called congenital syphilis. There was a median of 4 cases per year in Australia between 2011 and 2019, skyrocketing to 17 cases in 2020, and 15 in 2021 and 2022. For the birthing parent of babies with congenital syphilis, the report’s authors found less than 40% were tested for syphilis during pregnancy.
Left untreated, congenital syphilis can lead to serious complications in more than 50% of cases, including miscarriage, stillbirth, neonatal death and permanent disability. Of all the cases of congenital syphilis in Australia between 2011 and 2021, 25% of babies were stillborn.
In Queensland, where cases of infectious syphilis have increased by 600% in 15 years, five babies contracted the disease in the womb in 2023, leading to 4 deaths. This is the largest number of Queensland deaths from congenital syphilis in a single year this century.
As a preventable and curable disease, Queensland Minister for Health Shannon Fentiman said the deaths ‘shouldn’t be happening’. It’s a message echoed by Australia’s Chief Medical Officer Professor Paul Kelly, who said health professionals need to ensure they’re up to date on information about syphilis testing and management.
‘Any baby losing its life is a tragedy. Any baby losing its life to a preventable illness is a responsibility for us all in our health system,’ he said in a video (below) recorded for the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM).
https://vimeo.com/912435688
‘We must ensure everyone is tested for syphilis during pregnancy. All pregnant people should be tested at least once, and in many cases more … Once diagnosed, treatment is simple and effective.’
High-risk populations
In 2022, syphilis rates among Aboriginal and Torres Strait Islander peoples were more than five times higher than in non-Indigenous populations. Of the 15 congenital syphilis cases across the country in the same year, eight were among Aboriginal and Torres Strait Islander peoples.
‘Congenital syphilis diagnoses are 14 times as high among Aboriginal and Torres Strait Islander infants compared with non-Indigenous infants,’ said researcher Dr Skye McGregor, who led the Kirby Institute report.
‘All pregnant people should be tested for sexually transmitted infections (STIs) as part of pre- and antenatal health screening, but antenatal care is not always accessible. It is vital that comprehensive services are in place to ensure appropriate care is accessible for all pregnant people.’
Other high-risk populations include men who have sex with men and babies of mothers who have not had proper syphilis testing and treatment during pregnancy. However, ASHM Deputy CEO Jessica Michaels said it is important to recognise that syphilis can affect anyone.
‘In order to curb the rising syphilis epidemic, it is important that we take a “no wrong door’’ approach to testing,’ she said.
What to look out for
People presenting at a pharmacy with signs or symptoms of syphilis should be encouraged to test, Ms Michaels said, especially if the symptoms are otherwise unexplained.
‘Other instances when pharmacists can encourage patients to test for syphilis include people presenting with symptoms of any STI or an STI diagnosis, those asking about testing for STIs and/or blood-borne viruses, when people are assessed for post-exposure prophylaxis, and pregnant people who are not engaged in antenatal care.’
Symptoms and/or signs of syphilis can include:
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[post_content] => Case one scenario
[caption id="attachment_27445" align="alignright" width="173"] This educational activity was managed by PSA at the request of and with funding from GSK.[/caption]
Anne comes in for her prescription and, in conversation, informs you she has just celebrated her 60th birthday. Unfortunately, some of her family couldn't attend as her grandchild was recovering from chickenpox. She recalls her own childhood infection as being relatively mild.
Case two scenario
Ron, aged 67 years, is a regular patient of yours. He comes to the pharmacy to have his prescriptions filled for high blood pressure, heart failure and hyperlipidaemia. He mentioned he just got over a cold and seeks your advice as he has since developed conjunctivitis. Given his history, you check his vaccination records on the Australian Immunisation Register (AIR) and noted he is up to date with his COVID booster, influenza, herpes zoster and pneumococcal vaccinations.
Learning ObjectivesAfter reading this article, pharmacists should be able to:
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Pharmacists, consistently regarded as one of the most highly trusted groups of healthcare professionals, are in a unique position to promote and support the uptake of vaccination in older adults.1 However, despite clinical recommendations by the Australian Technical Advisory Group on Immunisation (ATAGI), there remains a significant gap in adult vaccination coverage in Australia.2,16 With the expanded scope of vaccination practice and the launch of the National Immunisation Program Vaccinations in Pharmacy (NIPVIP) program in pharmacy since 1 January 2024, pharmacists have a key role in providing vaccinations in primary care. Pharmacists are well placed to help improve adult vaccination rates by addressing some of the key barriers outlined in the table below, the ‘Five A’s’ of vaccination.3 Pharmacists can improve adult vaccination rates by addressing key barriers such as improving access and improving the awareness and understanding of vaccines.4
The 'Five A's' of vaccination3
The ‘Five A’s’ of vaccination are a framework for understanding why some people voluntarily get vaccinated, while others do not.
| Awareness | Whether people know about vaccines, where to get them, and their benefits and risks. |
| Acceptance | Whether people want to get vaccinated, subject to access and affordability. |
| Affordability | Whether people can afford the price of getting vaccinated and other costs of getting vaccinated, such as time off work if they have an adverse reaction to the vaccine. |
| Access | Whether people can safely and easily get vaccines, including physical and psychological safety. |
| Activation | Whether people who are aware of and accepting of vaccines are motivated to get the vaccine. |
Pharmacists are among the most consistently accessible healthcare professionals to patients. Compared to other healthcare professionals, pharmacists typically have longer hours of operation, including weekends, in which to offer vaccination services.5 These added conveniences facilitate greater flexibility and increased opportunities for individuals to access vaccination services in their local community.5
Community pharmacists continue to rate higher satisfaction and referral with patients than doctors or dentists, according to the 2023 Australian Healthcare Index (AHI) survey.6 With the rising out of pocket costs for general practice consultations, pharmacists are being sought by some patients as the first point of care before booking a general practitioner consult. There is also increased awareness of pharmacy services beyond the provision of prescription and over-the-counter medications, with 1 in 4 AHI survey participants reporting a visit to the pharmacy for vaccination service.6
Understanding and awarenessPerceptions about disease severity, vaccine effectiveness and safety, along with low provider confidence in the effectiveness of adult vaccination, contribute to low immunisation rates in older adults.3,7–9 Additionally, older adults’ knowledge of vaccines and vaccination guidelines varies.9 Pharmacists are well positioned to bridge knowledge gaps, increase awareness, dispel myths, and reduce complacency regarding vaccination.10
Vaccination remains a key preventative strategy in public health.11 Vaccines prevent 3.5–5 million deaths a year, and drastically reduce the morbidity and disability rates due to vaccine preventable diseases (VPDs).12 Older adults share a disproportionately high burden of VPD, which may be prevented or attenuated by vaccination.13 Despite recommendations from peak health organisations, vaccination rates among older patients remain suboptimal.14,15 Of people in their 70s, less than half are vaccinated against shingles, and only 1 in 5 is vaccinated against pneumococcal disease.16
Vaccination for adults2,16
Adults aged ≥50 years are at increased risk of some VPDs and of serious complications from these diseases, even if they are otherwise healthy. Check to see if your patients need any of the following.
dTpa booster
Immunity to some diseases can start to wane in older people, and they may need booster doses of some vaccines.
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Measles, mumps and rubella
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Herpes zoster (shingles)
The incidence of shingles increases with age, as does the incidence of serious complications such as post-herpetic neuralgia.
|
| Influenza Annual influenza vaccination is recommended for everyone ≥6 months of age. As Influenza-associated mortality rates are highest among older adults and Aboriginal and Torres Strait Islander peoples, influenza vaccination is particularly recommended for adults aged ≥65 years and for Aboriginal and Torres Strait Islander adults of any age. |
Pneumococcal disease
Pneumococcal disease is more prevalent in older adults.
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Adapted from: Department of Health and Aged Care. Vaccination for healthy ageing. 2023.18 See the Australian Immunisation Handbook for more details. dTpa, diphtheria, tetanus and acellular pertussis–containing vaccine; MMR, measles, mumps and rubella; VZV, varicella zoster virus.
*15vPCV and 20vPCV are available as alternatives to 13vPCV but are not currently NIP-funded.With the recent expanded scope of vaccination practice as part of the NIPVIP Program to include a number of adult vaccines, including those against shingles (nationally)17 and RSV (selected states, not funded),17 there is a need for pharmacists to upskill around delivering vaccines outside of the usual seasonal vaccines, like influenza. So how can pharmacists be equipped to have proactive conversations on all recommended vaccinations? What are the key critical success factors that will help drive high quality vaccination care?
Topline information for shingles and RSV
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Herpes zoster (shingles) |
Respiratory syncytial virus (RSV) |
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What is shingles? Shingles is a reactivation of the varicella-zoster virus (VZV) in someone who has previously had chickenpox (varicella) disease. Shingles commonly presents as a painful rash of fluid-filled blisters on one side of the face or body, often in a strip or band-like pattern. Other symptoms can include headache, malaise, itching, tingling or severe pain.19 Post-herpetic neuralgia (PHN) is defined as neuropathic pain at the site of the rash that can persist for >3 months after an outbreak of shingles.2 It can have a substantial impact on the quality of life in those affected and can be refractory to treatment. |
What is RSV? How do you get RSV? RSV is a respiratory virus that usually causes mild, cold-like symptoms, but can also lead to more severe conditions like bronchiolitis, bronchitis or pneumonia, and exacerbations of existing lung conditions such as asthma and heart disease. Transmission most commonly occurs through respiratory contact with infected secretions from sneezing and coughing.23,24 |
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Who can get shingles, and how common is it? People are at risk of developing shingles if they have previously had chickenpox (i.e. VZV infection). In Australia, most adults will be at risk even if they don’t remember having had chickenpox in the past. Around 20–30% of people will have shingles in their lifetime – most after the age of 50 years – and around half of all people who live to 85 years of age will develop shingles.19 |
Who can get RSV, and how common is it in adults? RSV can infect people of all ages; however, infants and older adults are more likely to develop severe RSV.24 Since RSV disease was historically regarded as a disease that affects infants and children, testing for the virus in adults was previously uncommon and data in adults are limited.24 |
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Who should receive a shingles vaccine and why? There have been two vaccines available in Australia for the prevention of herpes zoster and associated complications — Shingrix® and Zostavax®. As of 31 October 2023, the manufacturers of Zostavax® have discontinued supply in Australia.33 Unless otherwise contraindicated, the Australian Immunisation Handbook recommends shingles vaccination with Shingrix® – the recombinant Varicella Zoster Virus Glycoprotein E Antigen/ ASO1B adjuvanted vaccine (recombinant VZV vaccine) for people aged ≥18 years who are immunocompromised, and immunocompetent adults aged ≥50 years and household contacts of a person who is immunocompromised aged ≥50 years who have not previously received a dose.2 |
Which adults are at greatest risk of requiring hospitalisation with RSV disease? The risk of severe RSV disease is higher among adults with medical risk conditions (such as chronic cardiac, respiratory and neurological conditions, immunocompromising conditions, chronic metabolic disorders, chronic kidney disease), older adults (with the risk increasing with age), and Aboriginal and Torres Strait Islander peoples.24 There are two RSV vaccinations registered to protect against RSV-related lower respiratory tract disease in adults aged ≥60 years.2 |
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What is the efficacy and tolerability of recombinant VZV vaccine? Vaccination with recombinant VZV vaccine resulted in a high level of protection against shingles and PHN in adults aged ≥50 years. In two large clinical trials against placebo, the recombinant VZV vaccine demonstrated over 90% vaccine efficacy against shingles in adults aged ≥50 years (p<0.001).20,21 Vaccine efficacy of the recombinant VZV vaccine against PHN was 91% in immunocompetent people ≥50 years of age and 89% in immunocompetent people ≥70 years of age (p<0.001).20,21 From the long-term follow-up study, protection against shingles with recombinant VZV vaccine remained high in adults aged ≥50 years, with a vaccine efficacy of 81.6% (vs placebo or historical control), (mean 5.6 - 9.6 +/- 0.3 years post-vaccination).22 The most frequently reported local adverse reactions was pain at the injection site; myalgia, fatigue and headache were the most frequently reported systemic reactions. The majority of reactions, both local and systemic, were mild to moderate in intensity and of short median duration (1–3 days).20,21 |
How effective is RSV vaccination at preventing RSV-related lower respiratory tract disease in older adults? Vaccine efficacy of the adjuvanted recombinant RSV vaccine through one RSV season (median 6.7 months follow-up) against RSV-related lower respiratory tract disease in adults ≥60 years was 82.6%. Vaccine efficacy of the recombinant RSV vaccine (without adjuvant) in adults ≥60 years through one RSV season (mean 7 months follow-up) against RSV-related lower respiratory tract disease with ≥2 symptoms was 66.7%, and 85.7% with ≥3 symptoms.2,25 |
Implementing pharmacy-led vaccination programs requires careful planning, adherence to regulations, and a commitment to patient safety. Critical factors to consider are shown in Box 4. By addressing these critical factors, pharmacists can help ensure the success and effectiveness of pharmacy-led vaccination programs, including those focusing on shingles and RSV vaccinations.
Critical factors for pharmacy-led vaccination [for more information please refer to the PSA's Practice Guidelines for the provision of immunisation services]28
| Regulatory compliance: Ensure that your pharmacy and staff comply, and are up to date with, all relevant regulations set forth by the Department of Health and Aged Care and NIPVIP Program and local state legislation. Staff training and certification: Ensure that pharmacists administering vaccines are properly trained and certified in administration techniques, handling and storage, and managing adverse reactions, including general first aid and cardiopulmonary resuscitation. Patient education and counselling: Provide patients with accurate information about vaccine benefits, potential adverse effects, and any necessary precautions. Vaccine storage and handling: Follow strict protocols including monitoring and recording refrigerator temperatures, proper storage in designated areas and vaccine rotation to prevent expiration. Documentation and record-keeping: Maintain accurate records, including the type of vaccine administered, lot number, expiration date, administration date, and patient information as part of the patient’s personal records and relevant registers (Australian Immunisation Register [AIR] or Australian Q Fever Register). Collaboration with healthcare providers: Collaborate with other healthcare providers to ensure continuity of care and appropriate patient referrals and establish clear communication channels for sharing information. Adverse event monitoring and reporting: Develop protocols for monitoring and managing adverse events. Educate staff on recognising and responding to adverse reactions and reporting adverse events to regulatory agencies as required. Continuous quality improvement: Regularly review your vaccination program, solicit feedback from patients and staff and stay updated on best practices to ensure high-quality care. |
Vaccination is a national priority in Australia.11 In-pharmacy vaccination programs have expanded access to vaccines, making preventive health care more convenient and accessible. These programs leverage the widespread presence of pharmacies in communities, allowing individuals to have a greater choice around where and when they can receive vaccinations in primary care. By offering vaccinations for various VPDs, these programs have the potential to play a crucial role in increasing vaccination rates and reducing the burden of vaccine preventable illnesses.32 Their success lies in their ability to reach diverse populations, promote health equity, and contribute to overall public health outcomes. While older adults may encounter many barriers to vaccination, pharmacists are positioned to address many of these barriers by providing a convenient point of access, building confidence in vaccination, and actively increasing awareness to reduce complacency.
Case scenario one continued'Speaking of chickenpox, Anne, did you know that this is the same virus (varicella) that causes shingles? Shingles is a painful and debilitating condition, that can occur in people who have previously had chickenpox. The risk of getting shingles increases with age, especially from the age of 50. As you are in the age group where vaccination against shingles is recommended, would you like to receive it now? I have the vaccine in stock.* Let me get the vaccination information sheet and consent form and discuss further.' *Note the recombinant VZV shingles vaccine is the only shingles vaccine available. It is accessible privately or via the NIP for eligible cohorts.Case scenario two continuedAfter responding to the management of Ron's conjunctivitis, you take the opportunity to discuss RSV. 'I’m glad your cold has resolved. Actually, there is another respiratory virus that commonly circulates mostly in the colder months called RSV that can lead to quite severe conditions like bronchitis or pneumonia. Due to your age and heart condition, you are at a greater risk of hospitalisation. Vaccinating now could ensure you only have mild symptoms if infected and could keep you out of hospital. If you’re interested in getting it, I can get it ready while we take your blood pressure.' |
Natasha Dean (she/her) BSc(Hon) is a Senior Medical Writer with over 20 years’ experience in medical education and medical communications. She is a CPD representative with the RACGP CPD Program and regularly accredits activities for other organisations including ACCRM, PSA and ACN.
Sarushka Sritharan (she/her) BPharm(Hon) DipMgt MPS
Vaccine administration should be in accordance with relevant legislation, the Australian Immunisation Handbook, and State-based conditions specific to the vaccine.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
