With pockets of measles outbreaks throughout the country, we discuss the reasons and strategize ways pharmacy can impact vaccination rates in their communities.
The GameChanger
Measles was essentially eliminated from the US in 2000. Now, we are seeing a resurgence of outbreaks that have prompted the CDC to issue warnings and reminders of the importance of proper vaccination.
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health
Elizabeth Skoy, PharmD
Professor
North Dakota State University
Lacy Epperson, PharmD
Clinical Pharmacist
Mitchell’s Drug Store
Reference
https://www.usatoday.com/story/news/health/2024/01/26/cdc-issues-alert-measles-global/72365871007/
Pharmacist Members, REDEEM YOUR CPE HERE!
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)
CPE Information
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe the CDC warning about the increased incidence of measles
2. Discuss ways pharmacy can have an impact on increasing vaccination rates and decreasing measles outbreaks
0.05 CEU/0.5 Hr
UAN: 0107-0000-24-057-H01-P
Initial release date: 2/19/2024
Expiration date: 2/19/2025
Additional CPE details can be found here.
With pockets of measles outbreaks throughout the country, we discuss the reasons and strategize ways pharmacy can impact vaccination rates in their communities.
The GameChanger
Measles was essentially eliminated from the US in 2000. Now, we are seeing a resurgence of outbreaks that have prompted the CDC to issue warnings and reminders of the importance of proper vaccination.
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health
Elizabeth Skoy, PharmD
Professor
North Dakota State University
Lacy Epperson, PharmD
Clinical Pharmacist
Mitchell’s Drug Store
Reference
https://www.usatoday.com/story/news/health/2024/01/26/cdc-issues-alert-measles-global/72365871007/
Pharmacist Members, REDEEM YOUR CPE HERE!
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)
CPE Information
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe the CDC warning about the increased incidence of measles
2. Discuss ways pharmacy can have an impact on increasing vaccination rates and decreasing measles outbreaks
0.05 CEU/0.5 Hr
UAN: 0107-0000-24-057-H01-P
Initial release date: 2/19/2024
Expiration date: 2/19/2025
Additional CPE details can be found here.
These E plan members from CE Impact. This is Game Changers. I'm Jen Moulton and this week we're talking about the recent measles outbreak in at least four states, I think, as of this recording since the beginning of the year. So with me today we have two experts who will help us dive into how we got here and what's next for this disease that was essentially eliminated in the United States a little over 20 years ago. So with us today we have Elizabeth Skoy and Lacey Epperson, so welcome to you both. Thank you so much. Lacey. Can you just kind of introduce yourself, maybe tell us a little bit about your pharmacy practice and the perspective that you bring to this conversation today?
Speaker 3:Yeah, thank you so much, Jen. Thanks for having me. I serve as the director of clinical services at Mitchell's Drug Stores in Neosho, Missouri. We're in a rural town so we serve a lot of not just our county but neighboring counties as well, neighboring towns as well. So I would say that we do have a high population of vaccine hesitant individuals. Additionally, I spend a lot of time in work with CPSN Missouri and we're actually working on a vaccine gap hesitancy project right now. So this has been a really hot topic for us recently. And how do we close those gaps in care? And I'm a huge advocate for closing those gaps in care related to work that can be done not just by the pharmacist we can use that clinical knowledge but also through an extension of community health workers, who I spend a lot of time training as well. So that's a little bit of a brief look into my life and a lot of where I spend my time recently.
Speaker 1:Awesome. Well, I'm excited to dig into that a little bit. So thank you so much for being with us today, and Elizabeth Skoy also we have with us. And, elizabeth, you're a regular faculty member with us here at CE Impact and do a lot in the immunization space. So for those of you who don't, or are listeners I guess that don't know you can you tell us a little bit about you and your practice?
Speaker 2:Yeah, so I'm also a community pharmacist, I'm practicing community pharmacist and I do do a lot of work in the vaccination space, and so I collaborate a lot with the center here at where I'm a faculty member, at North Dakota State University, and that center is the Center for Immunization Research and Education. So then some statewide, national, regional projects. Just looking at increasing vaccine acceptance, immunization rates. I've been a creator for some of the programs for technician and pharmacist delivery of immunizations, and then more recently, I was named as the pharmacist representative from the American Pharmacy Association on the ACIP work group for adult RSV vaccine. So send a lot of time and space in the vaccine world, which I love.
Speaker 1:Yeah, oh, that's awesome. I didn't even know that you were on the ACIP committee, so that's a big one right now.
Speaker 2:Yeah, yeah, we're busy.
Speaker 1:Yeah, lots of time, I'm sure. Well, thank you, thank you both for being here today and, as I was saying, like before we started, you know the great thing about Game Changers is we try to keep up with, you know, what's hot and what's new. And the bad thing is I emailed you both this week and said, hey, can we do this real quick Because this is a hot topic. So, thank you, I know you didn't have a ton of time to prepare, but that's also the beauty of this is, you know, just kind of talking about your expertise and sort of, in the moment, what's happening. So I'd like to start by just looking back at the history of measles, at least in the United States. And, dr Skoie, what did our world look like before we had a measles vaccine?
Speaker 2:Yeah.
Speaker 2:So I think sometimes, especially since you had mentioned, jen, that measles has technically been eradicated from the United States, I think we sometimes forget about measles because, if you think about it, most of us growing up, and maybe even our parents, never really experienced measles.
Speaker 2:It's one of those things that's an easy disease, I guess, to forget that it has serious consequences. And so just to kind of understand, really before the vaccine came into play and so before the mid-1960s, there was usually endemics every two to three years. That happened worldwide with measles, and so typically there was anywhere between like two to three million deaths annually worldwide from measles. And so really even in, and even though we say that it's been eradicated in the United States, which technically it has, although we're having these pockets and these outbreaks which we'll talk about, there are still over 100,000 people, usually children, which is usually under the age of five or so, that die from measles worldwide annually. So this is still a disease that's active around the globe and has severe consequences. We've come a long way, obviously, since the introduction of the vaccine, but still recognizing that it can still be a really severe and deadly disease.
Speaker 1:Yeah, and so what are the reasons that we're having this resurgence? I mean, I know like when I was looking at some of the tables online, you could see that there are times where it increases. I think 2019 was one of those, or there were quite a few, but already in January we've had I guess it's February now, but in the first month of the year we're already reporting a good number, which is a great outlook for the rest of the year. So I know there's CDC warnings about this increase in incidence. So what do you think are the reasons that this is happening?
Speaker 2:Yeah. So really, the only major and logical explanation of this is under vaccination and reduction in vaccination and rates. And so when we think of herd immunity right, so, meaning that as a group and as a population, we get vaccinated, and so that we prevent that endemic status and the spreading of a disease for, maybe, individuals that haven't been vaccinated, or for individuals that maybe the vaccine wasn't effective for or they can't get vaccinated, then that prevents the spreading of the disease. And so for herd immunity for measles, and it's argued, if it's like 93%, 96%, but we say on average, about 95% of the population needs to be vaccinated. And what we've been seeing ever since, really like 2020, is we've been seeing the national vaccination rates for measles decreasing slightly. And so as a whole, as a country, we're still technically above, you know, but you know the the herd immunity rate, but we're getting close. So when you go from a 98%, you start dropping and you know you need about 95%, 96% to be herd immunity.
Speaker 2:It can be a little scary, and then I think it also depends upon the pockets that this is happening in. And so a lot of the data I haven't personally dug down into the county level specific data, but if you look at some of the ones that we've heard more recently with, like Georgia and Missouri, they're definitely below, like as a state. They're published vaccination rates against measles, you know, accepting the measles mumps rebeller MMR vaccine, they're below the herd immunity threshold and so you know, that's that's kind of the scary. It's showing that as a community, as a population, if you are not vaccinated, you're going to have these diseases come back and research.
Speaker 1:Yeah, well, and you referenced kind of at the county level. I know, lacey, you have been working with a project in Missouri and so maybe you could address that kind of more at that county level. And you know what, what are you hearing from patients about? You know why they're not being vaccinated? You know, I know there's a lot of since COVID I think, we've had a lot of conversations about vaccines, which is so interesting to me.
Speaker 1:I feel like you know, we've been kind of doing well, we have been doing training since 1999. And I, you know, in the beginning it was like when we were doing that it's like this is kind of I don't mean to say like a no-brainer, but, like you know, everybody gets vaccinated. You know we always have had people that have said you know, I don't, I want to change the schedule, or you know, you have kind of some of those rogue people, but I feel like it's becoming more and more, which is scary when we think about. You know, some of you know measles, back and MMR, and you know what that can mean for other diseases that have essentially been out of our lives. You know, all of us as adults.
Speaker 3:Yeah. So I think, just like what you alluded to Jen, with a lot of sources of misinformation and gaps in education surrounding the safety of vaccination, there are higher instances of vaccine hesitancy in general, which results in no protection against preventable diseases like measles. I think a huge thing that we're seeing a lot with parents trying to make decisions is they're doing research on what they believe to be reputable sources and they're trying to determine risk-versed benefit. This is the conversation I have with RCHWs all the time is risk-versed benefit and unfortunately I believe that there are a lot of individuals that believe the vaccine to not be as safe. But when you do this, the research in the studies like what Dr Skoy was saying this is deadly. So it kind of surprises me.
Speaker 3:But I'm wondering if we're hearing of these one-off instances and it's just like everything you're hearing in the news. People want to pull the information that catches someone's eye or that pops up on the first article whenever you're googling something. So I do think that that can be really challenging to try to put on a front of. We care about your health as a whole and so whenever I'm talking to you about eating healthy and exercise and supplements, vaccines are part of that prevention as well, and so it gets very challenging. But I think it's kind of changing that mindset surrounding how we educate patients, as there has been a push recently which is great for whole foods and natural ways and preventable measures. But vaccination is a preventable measure, so I think it's important to remind patients of that as well.
Speaker 1:Yeah, for sure. So talk a little bit, either one of you, about the safety of the MMR vaccine.
Speaker 2:So again, this is a vaccine that's been given since the 1960s right, and millions and millions of doses have been delivered. And we also see the prevention, that the number of cases and deaths that have dramatically decreased since the vaccination. So we know what's and we see that safety and we see that efficacy, just like getting medicine and we say this with vaccines too that there is rare occurrences that you could have a side effect. The MMR vaccine is a live vaccine and so sometimes people get especially children are giving to them. They might not, they might get a fever a couple of days later, and so you might still see some of those side effects. But there again, the side effects that you're experiencing with the vaccine are far, far less than what it is that you would experience if you actually got measles itself or mumps or rubella. In addition, if we can think back to the first claim that vaccines caused autism that fake paper, remember that has all been published false and the research has been shown to be not ethical and false information that was fabricated but that was on the MMR vaccine. So they were making a false claim against the MMR vaccine. So I think that's kind of part of that too.
Speaker 2:And one other thing, just to go back a little bit to measles, is just the again, since we haven't experienced this disease or most of us haven't we forget how incredibly dangerous that particular virus is and the fact that it's so incredibly contagious. And that's why you see these crazy outbreaks, because it's this weird virus that you know in for with spreading and I think Dr Offit's made this analogy before. Dr Paul Offit and I use it even when I'm talking with my students is the droplets hang out. They hang out like little ghosts in the air, like they can literally leave, like be suspended and left in the air for hours. And so we always say that any infectious disease is a plane right away, right?
Speaker 2:So if you think, if you go through an airport and somebody had just been to a country, that is, the measles isn't eradicated or it's, you know that are they went and traveled somewhere, or they went through an airport where somebody had measles and it stays in that they're there. They don't even know they have measles because you're contagious for seven days before you present with it. Plus, it's highly contagious. They just could walk through the same security line that somebody did recently and you can get measles. And so I think like that there's a combination of that too that we have this false like oh, we're eradicating the US, we don't have to worry about it. Well, you know, we have international and global travel, and anyone can be exposed to the disease.
Speaker 1:Yeah, so, and you mentioned you know a lot of us well, most of us haven't seen it. So what does it look like? I mean, I know that you know there are these pockets, but that doesn't make any of you know any other state immune If you're not in. What is it like? Pennsylvania, Georgia, new Jersey and Lacey, it's in Missouri as well. Right, was there a little outbreak there too? So what does it look like? Like what do you know? What do we look for if we have patients that come in? And I mean, I know it's a rash, but you know what are the? What are the differentiators?
Speaker 2:Yeah, so I can talk a little bit to that.
Speaker 2:So a lot of times it you know, it can come on, as of course, like there's usually a rash associated with it, and then you can have you'll usually see like a high fever, cough, runny nose.
Speaker 2:So those are things that we see sometimes, even with other besides the rash, which is sometimes the telltale sign of measles, the other symptoms can be really similar to what we would see with other respiratory issues. However, I think that you have to also realize that the complications from measles can be really high, and so, on average, of those that can track measles, one in five are hospitalized, and so you can have some really severe complications of measles. And those that are really most at risk are pregnant women or are really young children. Those are the ones that you also children less than five, which I already mentioned. Those are some of those, and so some of the complications might just be as like a, you know, developing onto an ear infections, but others can lead to pneumonia or encephalitis or swelling of the brain, and so there again, I think recognizing that, you know, can be a really severe illness.
Speaker 1:Lacey, can you talk a little bit about? I know that in your pharmacy you're working on a vaccine hesitancy project, and so what are you talking to patients about and what do you? You know, what can we do as pharmacists and technicians to continue to close this vaccine gap, so that you know we can have an impact. You know the CDC warning was loud and clear, and so what can we do to advance that?
Speaker 3:Yeah. So the way I like to compare how we're operating these things is in two buckets. So I believe that we have two really great opportunities to routinely capture these patients, one of which is through education and outreach in the community, so whenever we're at community events, which we make an effort to attend and intentionally orchestrate. But the second is through utilizing adherence programs, which we very much lean on and regiment, which allows us to provide care for the patient in ways outside of medication optimization that include follow up and monitoring. So at our pharmacy, we utilize I mentioned our community health workers previously, who have gone through this specialized training, but what they do is they administer a COH screening.
Speaker 3:So social determinants of health I'm a very much a believer in how this process works. So social determinants of health essentially are the conditions and environments where the person lives, is born, works and plays that contribute to and influence their health outcomes. So examples of these social determinants of health might include health literacy, housing insecurity and consistent transportation and financial barriers as well. So all of these factors that I just mentioned and there are many others, by the way, but all these factors that I just mentioned contribute to the buzzword health equity, which ensures that individuals have an equal and fair opportunity to achieve high levels of health outcomes. So I think, as community pharmacies, we can. There are a lot of ways for us to contribute to and ensure health equity, but ultimately, when we eliminate and alleviate some of these barriers that I mentioned. So, whether it is transportation, that's a common one. Whenever we're making a phone call at the end of our adherence calls and a patient says, well, but I don't have a way of getting there because they're used to us delivering well, is there a way for us to take this to the patient's home? So and that's just like I said, that's a one off example If it's a financial barrier, we likely have resources in the community where we can refer these patients to. And when we're able to eliminate some of these barriers by being intentional with these interventions and educational opportunities, we're able to ensure that we're delivering these equitable services.
Speaker 3:So our community health workers, just to kind of take a step back, they are local individuals who live and work in the communities that they are serving.
Speaker 3:So the primary basis of their work is a referral system where they're utilizing their developed resources in the community to enhance this access to care.
Speaker 3:So another example of how this may look in our community specifically and it will look different to every community, but there might that might be some overlap is through various connections with local child centers, parent programs, a local pregnancy and parenting center there, outreach through the schools and partnering with the local health department and other health centers.
Speaker 3:Through those connections we're able to reach patients that are unreachable through resources that allow us to deliver services to their places of residence and places of work. So I just think I guess I would really encourage and empower community pharmacies to really take a look at your own community first and start with your community, because these are the people that are coming to you because they trust you as their local pharmacy and, instead of them trying to read information online or listen to what they're hearing on the news or talking to their friend that they heard this from, they trust us, they've become friends with us, they know they can call us and we're one of the most accessible healthcare providers. So I just would encourage you to also do your research, find your way of being able to communicate with patients, and I think it's appropriate to be consistent and frequent with these messages. So I hope that answered that yeah.
Speaker 1:so as it relates to vaccines, then do you have specific messages that you're constantly asking patients if they're up to date on their vaccines, or what are the ways that you're making inroads in that space?
Speaker 3:specifically, yeah, so that's a great question. So I've tried to differ a couple of different approaches of this One. I've made a theme for our pharmacy each quarter, so I focus on I can't remember exactly what I did last year, but one quarter maybe we focus on ammonia, the next quarter maybe we focus on shingles, and so through that effort I'm able to talk to my staff. First, I also talked to them about billing and what that looks like as far as what we're allowed to do in our state and the legislature behind that. And here's how we develop protocols so that they're learning the pharmacy side as well. Then how do we talk to patients is step two. I do utilize our pharmacy management system to automate a lot of these reminders for our staff, and so they can't really get around it, and if they do, I know. So that's one way to make sure that we're all being consistent. And then, whenever we're talking to patients, there is a fine line. My community health workers are there for the initial outreach, the referral process, but the pharmacist ultimately it's their clinical discretion. So I think it's important to define these parameters as well, and one way that I've done that is by really making a push. So we try to focus marketing around whatever that vaccine was Including hey, did you know that your part D now covers the shingleshot, for example? We try to just be really intentional during that phase.
Speaker 3:The second part of that is maybe focusing on relevance to what's occurring. So if I'm going to capture someone for a flu shot, I usually, ironically, don't get a lot of people when the flu shot. When it first comes in my door, when I start seeing people requesting the flu shot is when they've started being exposed to people with the flu. So I think just kind of taking it where you can as well. And so I've been focusing a lot recently on different respiratory preventable measures, including RSV, pneumonia, covid, flu. Those have been our most recent pushes, and so I kind of want my staff to cherry pick those first as their high priority in my mind as well.
Speaker 3:If I'm going to vaccinate my family for that right now, then what do we need to be? Talking about patients and just putting ourselves in their shoes, and I also try to think about what questions I may ask as a parent as well. So that's kind of our approach for right now, but, like I said, we mostly lean on tacking this onto the end of their call. We're caring for their whole health. So, yes, we're reviewing your medicines, but we're also asking you about over-the-counter medicines. We're also asking you if you're up to date on your labs. We're also checking on. We've got this whole slew of things that we're doing while we're already having that patient touch point, so why can't we also check in on this preventable measure as well?
Speaker 1:Yeah, well, it's a great way to build trust, and so then, when things like this come up, where it's like, ok, you need to do this, then they have some trust with you that what they're reading is maybe not science-based. Elizabeth, do you have anything else that you do in your pharmacy, specifically as it relates to vaccine, particularly with with the mmr as well?
Speaker 2:Yeah, you know, to be honest with you, we haven't really needed to target mmr vaccine. So I think one thing just on a you know some of the work I've done in collaboration nationally and pharmacy networks is that one thing we can do as pharmacists is we can just be involved in our advocacy for a profession and vaccine legislation within our states. A lot of some of the national buzz has been just the. A lot of this comes from like kindergarten exemptions and so not getting vaccinated against against mmr and having the mmr vaccine Typically that's a required vaccine for kindergarten entry but every state's different and what they allow for an exemption status, and so states that actually have really hard to get exemptions are have a lot better rates than states that you know anyone can really sign an exemption and you know. So I think that's that's one thing.
Speaker 2:For other vaccines, we do a lot with vaccine in general of. One thing we've been doing now and you know something that people could consider doing in their own state Is we do look at our county level data and so we work really closely with our department of health and human services and we look at our county level data and we've actually been doing some targeting county level data with particularly looking at influenza rates. But I mean, even in our state. I'll be honest, and you know, sometimes it has to do with access and populations. I'm from North Dakota, we're a rural state, but there's some, even some, mmr rates in counties that are pretty scary.
Speaker 2:I think to myself oh my gosh, I hope nobody travels to any of these countries, you know, and so the other thing that you know, just looking at I think that pharmacists can do, when we were trying to do a bigger push for pharmacy to be involved in pediatric vaccine, and so a lot of times I think we've just been targeting the adult population, which is fantastic, we've done an phenomenal job at that and keep up that great work. But if we haven't, if our state allows it in our you know protocols and things like that. But to consider, you know, vaccinating, that you know, potentially, with the prep act it was three and up, so a lot of states are allowing for that now. So, looking at that three and up range for vaccination and getting some of our you know, making sure that our pediatric patients are up to date.
Speaker 1:Yeah, well, and I think too, as people see this in the news, you know, because that's like you know, everything is media driven, and so you see it in the media and I can imagine, you know, if you had a patient or a parent who was, you know, potentially vaccine hesitant. Now they're like oh, this is real, Like you know, I maybe need to think about this, and that opens the door for pharmacy to play a role. You know where we, where we didn't before, where you relied on those you know well, child checkups and all of that. But if you just have that, and now this comes up, then you have an opportunity in pharmacy to close that gap. So there's definitely, you know, I think those conversations are so important, even when we think they might not be, you know there's things like this that happen that really bring us back into the fold.
Speaker 1:So, staying current on you know what those guidelines are and ACIP guidelines I know new ones just came out, mostly as a result of that. So, being a really good adult, I think the the beginning of the year changes and nothing related specifically to MMR, but a lot with RSV. So, to your point being on that committee, there's a lot, of, lot of lot in that space right now. So being current on that, I think, is really important. So things like this come up, you can be a really good resource and be a trusted resource. So yeah, that's awesome.
Speaker 1:Yeah, do either one of you have anything else to add? This was a great conversation. You know you think, when things are are eliminated or eradicated, that we're not dealing with this again, but you know these things always happen, so it's it's good to get a little refresher on on where we were and where we don't want to be again. So anything, any last words, either one of you.
Speaker 2:Not necessarily, but I mean one thing again, just kind of reiterating your pharmacy. This is also a really great way for you know, lacey mentioned a lot of options, are opportunities for outreach. I think this is a really great opportunity for pharmacies to do outreach or just checking keto, especially if you're in one of those states that have the lower, the lower vaccination rates. You know, thinking of ways that you can do, or is there outreach events or things like that you can do to try to help get individuals aware, like what the great work that Lacey and her team is doing, or even, you know, providing the vaccine itself.
Speaker 1:Yeah, absolutely.
Speaker 3:Yeah, I don't have a lot to add either. I appreciate that and I appreciate Dr Squays expertise, I think. I think the point that she mentioned about being intentional with pediatrics I think is a is a really important piece as well, and it kind of has me thinking with with how do we make those connections so kind of tying that back to being intentional with your resources in your community. And so if you can, if you can make those those right connections and catch parents at the right time and catch the appropriate individuals that are talking to parents and individuals that are ultimately making these decisions for the candidates that need to be, need to be screened for vaccination, I think that can be be really influential in in how we can can help change this thing around.
Speaker 1:Yeah, yeah, absolutely Well. Thank you both so much for being with me today and especially on you know, kind of a quick notice I appreciate that and being able to pivot quickly so that we can address what's happening in the world. So it's been a pleasure talking to both of you. Thank you for all the work you're doing in your communities and it is making a difference. So thank you and all of our listeners as always, have a great week and keep learning. We'll talk soon.