Case one scenario

This educational activity was managed by PSA at the request of and with funding from GSK.

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 Objectives

After reading this article, pharmacists should be able to:

  • Describe vaccinations recommended for healthy aging
  • Discuss the effectiveness of the shingles and respiratory syncytial virus vaccinations
  • Discuss strategies pharmacists can employ to facilitate routine discussions about adult vaccination
  • Discuss critical factors for the delivery of an effective pharmacy-led vaccination program.

Competency standards (2016) addressed: 1.1, 1.3, 1.4,1.5, 2.1, 2.3, 3.6

Accreditation number: CAP2409SYPND

Accreditation expiry: 31/08/2026

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Vaccination and the role of the pharmacist

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.

Access

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

Alternative pathway to primary care

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 awareness

Perceptions 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 in adults

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.

  • Offer adults aged 50 years a booster dose of dTpa vaccine to protect against diphtheria, tetanus and pertussis, if their last dose was more than 10 years ago.
  • Offer adults aged ≥65 years a booster dose of dTpa vaccine if their last dose was more than 10 years ago.
Measles, mumps and rubella

  • If the person was born during or since 1966, check to see if they have received any MMR vaccines.
  • Offer 2 doses of MMR vaccine, 1 month apart, if they have not already received them.
Herpes zoster (shingles)

The incidence of shingles increases with age, as does the incidence of serious complications such as post-herpetic neuralgia.

  • Offer adults aged ≥50 years a 2-dose schedule of recombinant VZV vaccine, 2–6 months apart.
  • For people aged ≥18 years who are immunocompromised or shortly expected to be immunocompromised, a shorter 2-dose schedule of 1–2 months after the initial dose is recommended.
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.

  • For healthy non-Indigenous adults aged ≥70 years, give 1 dose of 13vPCV* if they have not already received a dose. Give 13vPCV* at least 12 months after any previous dose of 23vPPV.
  • For healthy Aboriginal and Torres Strait Islander adults aged ≥50 years, give
    1 dose of 13vPCV*, 1 dose of 23vPPV 12 months later, and a 2nd dose of 23vPPV at least 5 years later.

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

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

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. 

Conclusion

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 continued

After 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.’

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Key points

  • Older patients are at greater risk of complications and hospitalisation from VPDs, significantly impacting their quality of life.
  • Despite guidance from leading health organisations, vaccination rates among older adults continue to be inadequate.
  • Given the expansion of the NIPVIP Program to include various adult vaccines, pharmacists are in a unique position to broaden their vaccination service beyond seasonal vaccines.

References

  1. Morgan Poll. Roy Morgan image of professions survey. 2021. At: https://roymorgan-cms-dev.s3.ap-southeast-2.amazonaws.com/wp-content/uploads/2022/02/21014612/8691-Image-of-Professions-2021-April-2021.pdf  
  2. Australian Technical Advisory Group on Immunisation (ATAGI). Australian immunisation handbook. 2022. At: immunisationhandbook.health.gov.au  
  3. Breadon P, Burfurd I. A fair shot: how to close the vaccination gap. 2023. At: https://grattan.edu.au/wp-content/uploads/2023/11/A-fair-shot-How-to-close-the-vaccination-gap-Grattan-Institute-Report.pdf  
  4. Prodanovic D, Lapham K, Keenan R, et al. Enhancing adult vaccination coverage rates in Australia. 2021. At: www.immunisationcoalition.org.au/wp-content/uploads/2021/06/2021_06_28_Enhancing-adult-vaccination-coverage-rates-in-Aus_FINAL.pdf  
  5. Burson RC, Buttenheim AM, Armstrong A, et al. Community pharmacies as sites of adult vaccination: a systematic review. Hum Vaccin Immunother 2016;12(12):3146–59. 
  6. Healthengine. Australian Healthcare Index. 2023. At: https://australianhealthcareindex.com.au/australian-healthcare-index-june-2023-report/  
  7. Australian Institute of Health and Welfare (AIHW). 2009 Adult vaccination survey: summary results. Canberra, ACT: AIHW, 2011.  
  8. Menzies RI, Leask J, Royle J, et al. Vaccine myopia: adult vaccination also needs attention. Med J Aust 2017;206(6):238–39.  
  9. Raina MacIntyre C, Menzies R, Kpozehouen E, et al. Equity in disease prevention: vaccines for the older adults – a national workshop, Australia 2014. Vaccine 2016;34(46):5463–69. 
  10. Bach AT, Goad JA. The role of community pharmacy‐based vaccination in the USA: current practice and future directions. Integr Pharm Res Pract 2015;4:67. 
  11. Department of Health. National Immunisation Strategy for Australia 2019–2024. 2018. At: www.health.gov.au/sites/default/files/national-immunisation-strategy-for-australia-2019-2024_0.pdf  
  12. World Health Organization (WHO). Vaccines and immunization. 2024. At:  www.who.int/health-topics/vaccines-and-immunization#tab=tab_1  
  13. Doherty, TM, Del Guiudice G, Maggi S. Adult vaccination as part of a healthy lifestyle: moving from medical intervention to health promotion. Annals of Medicin 2019:5(2):128–40. 
  14. Esposito S, Principi N, Rezza G, et al. Vaccination of 50+ adults to promote healthy ageing in Europe: the way forward. Vaccine 2018;36(39):5819–24. 
  15. Australian Institute of Health and Welfare. The burden of vaccine preventable diseases in Australia – summary. 2019. At: www.aihw.gov.au/getmedia/ec9c16e9-970c-404e-9bfe-5e2541583f85/aihw-phe-242.pdf?inline=true  
  16. National Centre for Immunisation Research and Surveillance (NCIRS). Annual Immunisation Coverage Report 2021 Summary. 2022. At:  https://ncirs.org.au/annual-immunisation-coverage-report-2021-available-now   
  17. The Pharmaceutical Society of Australia. Pharmacist administered vaccinations. 2024. At: www.psa.org.au/state-vaccination-regulations/#1701652569667-898d6657-a4c6  
  18. Department of Health and Aged Care. Vaccination for healthy ageing. 2023. At: https://immunisationhandbook.health.gov.au/sites/default/files/2023-12/Infographic.%20Vaccination%20for%20healthy%20ageing.pdf  
  19. National Centre for Immunisation Research and Surveillance (NCIRS). Zoster (shingles) vaccines (Shingrix® [RZV] and Zostavax® [ZVL]) – frequently asked questions. 2022. At: https://ncirs.org.au/zoster-shingles/zoster-shingles-vaccines-shingrixr-rzv-and-zostavaxr-zvl-frequently-asked-questions  
  20. Cunningham AL, Lal H, Kovac M, et al. Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older. N Engl J Med 2016;375:1019–32. 
  21. Lal H, Cunningham A, Godeaux O, et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med 2015;372:2087–96. 
  22. Strezova A, Diez-Domingo J, Al Shawafi K, et al. Long-term protection against herpes zoster by the adjuvanted recombinant zoster vaccine: interim efficacy, immunogenicity, and safety results up to 10 years after initial vaccination. Open Forum Infect Dis 2022;9(10):ofac485.   
  23. Centers for Disease Control and Prevention (CDC). Respiratory syncytial virus (RSV) immunizations. 2024. At: www.cdc.gov/vaccines/vpd/rsv/index.html   
  24. National Centre for Immunisation Research and Surveillance (NCIRS). Respiratory syncytial virus (RSV): Frequently asked questions (FAQs). 2022. At: https://ncirs.org.au/ncirs-fact-sheets-faqs-and-other-resources/respiratory-syncytial-virus-rsv-frequently-asked   
  25. Recombinant respiratory syncytial virus (RSV) vaccines for older adults, and pregnant women to prevent disease in their infant. Aust Prescr 2024;47:100–1.  
  26. McClure CC, Cataldi JR, O’Leary ST. Vaccine hesitancy: where we are and where we are going. Clinical Therapeutics 2017;39(8):1550–62. 
  27. Attwell K, Dube E, Gagneur A, et al. Vaccine acceptance: science, policy, and practice in a ‘post-fact’ world. Vaccine 2019;29;37(5):677–82.   
  28. Pharmaceutical Society of Australia. Practice Guidelines for the provision of immunisation services. 2020. At: https://my.psa.org.au/s/article/immunisation-guidelines   
  29. Therapeutic Goods Administration. Arexvy® Product Information. 2024. At: www.tga.gov.au/resources/auspmd/arexvy  
  30. Therapeutic Goods Administration. Abrysvo® Product Information. 2024. At: www.tga.gov.au/resources/auspmd/abrysvo-rsv-vaccine  
  31. GSK. Shingrix® Product Information. 2022. At: https://au.gsk.com/media/6786/shingrix_pi_au.pdf  
  32. Le LM, Veettil SK, Donaldson D, et al. The impact of pharmacist involvement on immunization uptake and other outcomes: An updated systematic review and meta-analysis. J Am Pharm Assoc 2022;62(5):1499–1513.e16. 
  33. Australian Government Department of Health and Aged Care Therapeutic Goods Administration. Medicines shortage reports database. At: https://apps.tga.gov.au/Prod/msi/Search/Tradename/130229 

Our author

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.

Our reviewer

Sarushka Sritharan (she/her) BPharm(Hon) DipMgt MPS

Disclaimer

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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