By: Yao Jiang, PharmD Candidate c/o 2019

–

While each flu season comes and goes, the 2017-2018 flu season caught health care professionals by surprise.  According to the Centers for Disease Control and Prevention (CDC), this season’s flu activity was the most widespread since the 2009 influenza pandemic caused by the influenza A (H1N1) virus, or the swine flu. The agency also reported that this year’s hospitalization and mortality rates reached and surpassed those during the severe 2014-2015 flu season. To put things in perspective, the flu vaccine is only thirty percent effective against the influenza A (H3N2) strain. The influenza A (H3N2) strain was the most predominant strain this year and is often associated with severe illness in pediatric and geriatric populations.¹ To gauge the severity, there were 142 influenza-associated pediatric deaths and 731 pediatric hospitalizations during this past flu season.²

On January 25, 2018, New York State Governor Andrew M. Cuomo signed executive order No. 176 declaring an influenza disaster emergency in New York.³ This executive order allowed pharmacists who are already licensed immunizers to also administer the influenza vaccine to children between ages 2 to 18.⁴ While this executive order had been set to expire February 23, 2018, it was extended once on February 22, 2018 and again on March 27, 2018. The executive order was active until April 22, 2018 with no further extensions.^5,6

While the executive order seemed to expand the pharmacist’s scope of practice, it also introduced more training and liabilities in that it was only applicable to pharmacists who are certified in pediatric CPR. Pharmacists should be careful regarding which flu vaccines they choose to administer to their pediatric patients. Only three vaccines, Fluarix®, FluLaval®, and Fluzone® are indicated for those ≥6 months. There are other flu vaccines available, but the lower age limit is 3 years and older. Pharmacists should also be aware that they are not to administer vaccines with more than trace amounts of thiomersal, a mercury containing preservative, to children less than 3 years old. More than trace amounts of thiomersal is defined as more than 0.625 µg of mercury per 0.25 ml of vaccine. All influenza vaccines in prefilled syringes or single-dose vials comply with the thiomersal trace limit. However, multi-dose influenza vials do contain excess thiomersal. Pharmacists should keep in mind that the dosage of all flu vaccines are not uniform at 0.5 ml. Fluzone®, when given to patients aged 6 to 35 months, should be administered at 0.25 ml. If given to patients older than 3 years of age, it’s administered at 0.5 ml. ^{7, 8}

In an effort to support pediatric immunizations, New York State Commissioner of Health Howard A. Zucker also published non-standing orders for epinephrine and diphenhydramine to be administered to children during an anaphylactic reaction to the flu shot.⁸

To further expand vaccination to children, the New York State Vaccines for Children (VFC) Program is also available to provide vaccines at no cost to eligible children. A child is eligible for this program if he or she is younger than 19 years old and is enrolled in New York State Child Health Plus or Medicaid, is uninsured, underinsured, or is an American Indian or Alaska Native.⁸

During the 2017-2018 flu season, there was also a shortage of oseltamivir (Tamiflu®) capsules and suspensions. Oseltamivir is a neuramidase inhibitor that is FDA-approved for the prophylaxis and treatment of influenza. Pharmacists are eligible to compound the liquid form of the medication under the permission of the State Board of Pharmacy. The pharmacist can annotate on the prescription that an emergency exists and commercial preparation is unavailable. A separate prescription is not required.⁸

Since the passage of executive order no. 176, more than 8,000 New Yorkers aged 2 to 18 have been vaccinated. After the order’s passage, there was a nine percent increase in lab confirmed flu. A trend of decline in hospitalizations was seen two weeks after the order was passed.⁵

While all this may be daunting for the typical community pharmacist, we must not forget our responsibilities as patient educators. To prevent contracting the flu, educate your patients to wash their hands with soap and water for at least 20 seconds. If soap and water are not available, have patients use hand sanitizers containing at least sixty percent alcohol. Advise patients to not cough and sneeze into their hands and use a tissue instead. If tissues are not available, advise them to cough into the fold of their arms.⁵ Recommend the flu vaccine to patients even if they have already caught the flu. Patients are often infected with only one strain, but the flu vaccine covers 3 to 4 different strains depending on the vaccine received. Recommend the vaccine even if its efficacy is low. Patients who catch the flu after receiving the flu vaccine experience a less severe course of illness.⁹ As future community pharmacists, our roles have moved beyond standard dispensing. We also serve as educators and immunizers for the good of public health. How will you serve your population next flu season?

SOURCES:

1. Nguyen H, Bronze M. Influenza. Medscape. https://emedicine.medscape.com/article/219557-overview. Published 02/28/2018. Assessed 04/08/2018.
2. U.S. Department of Health and Human Services. Situation update: Summary of weekly FluView report. Centers for Disease Control and Prevention. https://www.cdc.gov/flu/weekly/summary.htm. Published 04/06/2018. Assessed 04/08/2018.
3. New York State Governor Press Office. Governor Cuomo signs executive order to combat widespread flu epidemic in New York. New York State Governor. https://www.governor.ny.gov/news/governor-cuomo-signs-executive-order-combat-widespread-flu-epidemic-new-york. Published 01/25/2018. Assessed 04/08/2018.
4. Zucker H. Non-patient specific order for the administration of influenza vaccine (2017-2018 season). New York State Department of Health. https://www.health.ny.gov/prevention/immunization/providers/docs/2018_standing_order.pdf. Published 01/27/2018. Assessed 04/08/2018.
5. New York State Governor Press Office. Governor Cuomo extends emergency executive order to promote vaccination as flu epidemic continues. New York State Governor. https://www.governor.ny.gov/news/governor-cuomo-extends-emergency-executive-order-promote-vaccination-flu-epidemic-continues. Published 02/22/2018. Assessed 04/08/2018.
6. New York State Governor Press Office. No. 176.2: declaring a disaster emergency in the state of New York and expanding access to immunize children against seasonal influenza. New York State Governor. https://www.governor.ny.gov/news/no-1762-declaring-disaster-emergency-state-new-york-and-expanding-access-immunize-children. Published 03/27/2018. Assessed 04/08/2018.
7. New York State Department of Health. Questions and answers for pharmacists regarding influenza vaccine and antivirals. New York State Department of Health. https://www.health.ny.gov/prevention/immunization/providers/faq_for_pharmacists.htm. Published 02/01/2018. Assessed 04/08/2018.
8. New York State Department of Health. Influenza update for pharmacists. New York State Department of Health. https://www.health.ny.gov/prevention/immunization/providers/docs/2018_influenza_update_for_pharmacists.pdf. Published 02/01/2018. Assessed 04/08/2018.
9. U.S Department of Health and Human Services. Vaccine effectiveness – how well does the flu vaccine work? Centers for Disease Control and Prevention. https://www.cdc.gov/flu/about/qa/vaccineeffect.htm. Published 10/03/2018. Assessed 04/08/2018.

Published by Rho Chi Post