Consider the following case scenario at your community pharmacy:

As you are working through a stack of red baskets, a noticeably distressed elderly patient approaches the dispensary and asks…

Chief Complaint (CC)

“I’m due for my 2nd dose of Shingrix, but my family doctor’s clinic is closed. What do I do?”

History of Presenting Complaint (HPC)

MM, a 68-year-old female, tells you she’s been largely homebound for the past 2 months and only leaves the house for essential errands. She lives with her husband and manages his medications at home. Their children live far away, but because of the pandemic, they drop off groceries at the door every 2 weeks. MM explains that her family doctor has mostly been offering virtual visits and delaying routine vaccination services. Today, she decides to come into the pharmacy to pick up her husband’s medication and is hoping to receive her overdue Shingrix injection as soon as possible.

Vaccination Framework for Pharmacy

Let’s apply this step-by-step decision framework to help address MM’s chief complaint.
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Step 1: COVID-19 Screening

• MM does not present with any concerning symptoms such as dry cough, tiredness, or fever
• Mostly stays at home—no known contact to anyone with a probable or confirmed case of COVID-19

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Step 2: Gathering Relevant Information

Upon a quick review of MM’s patient file:

Medical Conditions:

• Type 2 diabetes (T2DM) x 15 years

Medications:

• Blood glucose levels controlled by 4 oral antihyperglycemic agents

• 1st Shingrix dose (dispensed 7 months ago)

Social History:

MM has been homebound for the past few months. This may potentially result in: 

• Lack of social interactions (e.g. with friends/other family members)
• Reduced physical activity
• Dietary changes — grocery is largely done by her children 
• Increased stress — she takes care of her husband alone  
  
  

Step 3: Assessment of Risks

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Remember to consider the nature of the vaccine-preventable disease (VPD) and the patient’s behavioural risk factors:

• Shingles outbreaks may be triggered at unpredictable times.
• Patients may already be infected with the varicella-zoster virus, which remains latent in the body
• Viral reactivation may occur at any time without warning‍
• In elderly patients, shingles may be the triggering event that forces them into the vicious cycle of frailty
• Dietary changes and reduced physical activity due to social isolation may result in uncontrolled T2DM and disease progression

Step 4: Confirm Vaccine Schedule

Shingrix is given as 2 doses with a recommended interval range of 2-6 months apart

• According to NACI’s Interim Guidance on Immunizations, the 2nd dose may be delayed to 6-12 months after the 1st dose
• However, the patient would have suboptimal protection for a prolonged period of time, therefore remaining at increased risk for VPD

Step 5: Safety Evaluation

Ensure timely access to:

• Recommended PPE (e.g. surgical masks/gloves)
• Hand sanitizer and alcohol for thorough disinfection/cleaning of contaminated surfaces

Step 6: Establishing a Standard Protocol

In the event that you decide to administer:

For patients already at the pharmacy, establish strategies to minimize additional risk of COVID-19 exposure at the pharmacy and to protect pharmacy staff as well.

• Examples: maintain physical distancing until time of vaccine administration, ask patients to wear face masks and turn their heads away from the pharmacist during vaccination

If a patient is on the phone, establish strategies to minimize the exposure risk to COVID-19 by coming to the pharmacy.

• Examples: limit specific time(s) of the day to provide vaccinations, schedule a time for patients to come in, ask patients to wait in their vehicles until the pharmacist is ready for vaccine administration
  

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Step 7: Decision Making

The final decision:     ☐ Administer     ☐ Postpone — if it’s safe to do so     ☐ Refuse & refer

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Step 8: Follow-up Process

If vaccine dose can be safely delayed:

• Consider scheduling a follow-up date to reassess any changes in patient’s level of risk
• Establish a reminder system to ensure that patient receives the postponed dose when vaccination services resume
  

If vaccination is refused:

• Refer patient to another healthcare provider who can safely administer the vaccine

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Vaccination Patient Case Discussion Summary

We have synthesized a concise summary of the patient case discussion:

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References & Recommended Readings: 

1. NACI Interim Guidance on Continuity of Immunization Programs: https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/interim-guidance-immunization-programs-during-covid-19-pandemic.html
2. Risk Factors for Herpes Zoster: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5631994/
3. COVID-19 Risk Factors for Severe Disease and Death: https://www.bmj.com/content/368/bmj.m1198
4. CDC COVID-19: Groups at Higher Risk for Severe Illness: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html
5. Herpes Zoster and Diabetes Mellitus: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6104256/
6. Diabetic Neuropathy and PostHerpetic Neuralgia: https://www.openaccessjournals.com/articles/two-much-pain-a-patient-with-painful-diabetic-neuropathy-and-post-herpetic-neuralgia-a-case-report-and-review.html

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Graphics: Michelle Yee
Editors: Rui Su and Yifan Zhou

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Disclaimer: The contents of this blog is to be used for informational purposes only and is not intended to replace clinical guidelines or the advice of a health professional. Patients should contact a health professional for appropriate advice.

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