At the pointy end

The 2017 flu season is nearly upon us, but this time pharmacy is ready to play a greater role than ever before. Megan Haggan investigates

This year follows the two worst flu seasons in Australia’s history… but more than ever, it looks like Australia may be well prepared, increasingly thanks to the contribution of pharmacy.

Dr Paul Van Buynder, Chairman of the Australian Immunisation Coalition, told the APP Conference in March that “last year we had our second biggest ever influenza season”.

“We had 90,000 notifications,” he told delegates. “The year before was the biggest ever Australian influenza season, an influenza B year – more than 100,000 notifications.

“Both of those were actually more than what we saw in the [“swine flu” H1N1] pandemic back in 2009.”

Dr Van Buynder told delegates that the Northern Hemisphere’s most recent flu season was “not particularly dramatic” but cautioned that the Northern Hemisphere’s experience is not always a reliable barometer of what’s expected to happen in the following Australian season.

“This year it’s been a mixed season in the north,” he said.

“In the United States there was only really some of the middle areas of the country that had a very high flu season, and the areas in fact that were closest to the Canadian border had a relatively low flu season this year, but it was a patchy picture which was the same in Europe. The data [from the US] suggests that it wasn’t as big as some of the other years they’ve had, although we’ve rarely been able to say because this happened in America, this is what’s going to happen in Australia.”

Europe did not have an intense year for flu over its latest season, he said.

“There was only two or three countries, France being one of them, that had a heavy flu season this year, the rest of Europe’s been relatively mild.”

The quadrivalent vaccines for use in the 2017 southern hemisphere influenza season include an H1N1 strain and a H3N2 strain as well as two B strains (see box).

The changing face of vaccination

Earlier this year, the Pharmacy Guild conducted a study to find out how Australian adults felt about flu vaccination in pharmacy, their intentions regarding flu vaccination in 2017, and whether the availability of flu vaccination in pharmacy would influence their likelihood of seeking a flu shot.

The Guild found that 93% of Australian adults recognised the benefits of flu vaccination in pharmacy, citing access, cost and convenience as the biggest motivators for protecting against seasonal influenza.

The research also showed that more than seven million Australians were planning to have a flu shot this year, with the number of adults seeking vaccination climbing by about a million on top of previous years.

More than six million would be more likely to have a flu shot if it could be administered at a local pharmacy.

“Out of that six million, there are about two million people who have never previously had a flu shot, so we’re expecting a reasonably big uptake,” said Guild NSW Branch President Rick Samimi.

“Once you consider accessibility, convenience and cost you’re looking at a lot of healthy adults who wouldn’t necessarily have time to go to the doctor.”

Mr Samimi said that with 2017 the first year in which all jurisdictions permit pharmacist vaccination, it’s natural to expect uptake to continue to grow.

“As a profession, we should be very proud of the fact that a lot of people are saying that they’re more inclined to go to the pharmacy and get vaccinated.”

The tension between GPs and pharmacists over the provision of vaccination appears to be easing, for the most part.

In March, Professor Robert Booy, head of the clinical research team at the National Centre for Immunisation Research and Surveillance and spokesperson for the Influenza Specialist Group, told MJA InSight that people who are eligible for free flu vaccination should not go to a pharmacy for the jab, but wait until it became available from their GP in April.

There was some controversy over the article as it originally claimed that pharmacies were selling 2016 vaccine stock; this incorrect statement was later corrected by MJA.

“There is supply already available in the private market, and someone mistakenly thought it was last year’s product. It’s this year’s product that’s currently available. That was the issue that got scrambled,” Prof Booy told the AJP.

He said it was convenient for healthy people to get vaccinated as soon as stock became available in pharmacy, particularly if they were a contact of an at-risk person.

“So if there’s someone in their household, or a close workmate, or if they’re a health care worker, or if they’re otherwise in contact with someone with a chronic medical condition, or who is pregnant, or Indigenous, they can protect themselves and others at risk by getting vaccinated,” he said.

“What I say is that for at-risk people whose care is coordinated by the GP, the GP will know if they’ve been vaccinated if they have the jab at the GP practice. But if the pharmacist gives a jab, it behoves them to make sure the GP knows, because the GP has to coordinate the care.

“So pharmacists and GPs can live very nicely together if they talk to each other.”

Lucy Walker, of the Lucy Walker Chemmart Pharmacy in Goondiwindi, Queensland, agrees. The pharmacy is this year’s Guild Pharmacy of the Year and also won the Award’s Community Engagement category.

“We see people who don’t want to annoy the doctors, because they’re not sick,” says Lucy Walker. “In our town we have a really great medical centre with a lot of doctors, but they’re really busy and hard to get in to see.

“So people don’t want to annoy them for a flu shot, but they’re happy to come and see us.

“When we started doing this a few years ago, we went to the doctors and said, ‘We’re going to do vaccinations.’ There were a variety of feelings about that: some thought it was fantastic, one less job for them to do and that any vaccination is great for the community.

“Some doctors were concerned about how they’d know who was vaccinated or not. We told them that we’d send them the details, and we do. Others were concerned about how junior doctors would gain experience doing vaccination.

“But now that we’ve been going for a few years, they’ve realised the service helps the community. Everyone who’s on the schedule can go to the GP and get the vaccine for free, though they may come to the pharmacy instead because it’s convenient.”

She says that patients do assume that the pharmacy should have access to the vaccines in the Immunisation Program for free, and that the pharmacy is able to input the vaccination to their National Immunisation Record and My Health Record, however.

Vaccination in action

“We were involved in the second stage of the QPIP trial, so this is our third year vaccinating,” says Ms Walker.

She says that significant amounts of paperwork generated during the QPIP trial have now been streamlined through GuildCare, and that the flu service in her pharmacy is “going from strength to strength”.

The pharmacy has already vaccinated former Queensland Health Minister Lawrence Springborg, under whose auspices QPIP was commenced; the local mayor; and all the local Council.

“We love doing the flu shots – the customers love it, they love the convenience and they like that it’s quick and easy,” she told the AJP. “We do encourage bookings, but we also take walk-ins as well.

“Every year we keep doing more and more: in the first year we might have done about 150 vaccinations, last year it was 450 and this year [as at mid-April] we’ve already done about 250.”

Ms Walker says that in general, consumers are becoming more aware of different aspects of influenza, and that the accessibility of vaccination in community pharmacy is helping drive this.

Fewer are likely to seek antibiotics to treat the flu, for example, she says.

“Our customers are getting more knowledgeable about the availability of the vaccine, and we now also have local businesses coming to us and saying, ‘Can you vaccinate our staff members?’

“And what we find is that it sparks a conversation. The first question is, ‘What’s the difference between the flu and a cold?’ People also ask whether the flu vaccine will give them the flu.

“We’re able to tell them that there are four strains of the flu in the vaccine, and they’ve all been inactivated: so no, you can’t get sick from it. We also tell people that they still have to look after themselves for a couple of days, because they will have an immune response to the vaccine and may feel off colour for a day or two afterwards. And if they do get flu later in the year, it won’t be as bad as it otherwise would have been.

“So we spend a lot of time educating them about the flu vaccination. And then they go home and talk to their family and their friends – so awareness that we do it, and about the flu, is definitely spreading.

“We found that we weren’t just seeing customers who might not have had the flu shot at all, but also people who weren’t our customers – some were new people.”

Vaccination is also helping improve customer understanding of the services available in the pharmacy.

“They were able to see our consulting rooms, they could see that we do Impromy weight loss, and that we have sleep apnoea products. So it helped them become aware of the other services we provide in our pharmacy.”

Pandemic looming?

If a new study by UNSW researchers is anything to go by, the emergence of pharmacist vaccination in Australia could be very timely.

A worrying increase in the number of new influenza viruses infecting humans means the risk of pandemic is higher than ever, says PhD student Dr Chau Bui, who earlier this year published research in the Archives of Public Health showing that in the past five years alone, four novel subtypes and three novel variant strains of influenza have emerged in humans.

With recent unprecedented changes in avian influenza as well, there is an increased risk that a bird flu strain will emerge that can cause a human pandemic, says Dr Bui, a veterinarian who works within the UNSW-led NHMRC Centre for Research Excellence, Integrated Systems for Epidemic Response (ISER), which focuses on controlling epidemics.

“This urgency needs to be acknowledged by national and international pandemic planning organisations,” she says.

The increase in new flu viruses in the past 10 years is unprecedented, she says, citing concerns that new avian influenza viruses will obtain the ability to transmit easily from human to human and cause a major global pandemic.

It took almost 40 years after the 1918 Spanish flu for the next novel influenza virus to emerge, and then more than 10 years for the next. In contrast, in the five years between 2011 and 2015 alone, seven new strains have emerged in humans and they have appeared all over the world − China, Egypt, the US and Europe, Dr Bui says.

The reasons behind this escalation are unknown, but could be due to changes in climate, urbanisation and agricultural practices as well as better diagnostics. However, these factors have not changed as quickly as the escalation of new viruses.

Dr Bui says pandemic preparedness measures need to focus on preventing disease in birds, particularly poultry.

This includes better control efforts to reduce introductions of new viruses into poultry populations, and reducing the risk of virus transmission where humans interact with animals.

Co-author and director of ISER Professor Raina MacIntyre says it’s not possible to predict which virus will cause the next pandemic, as witnessed in 2009.

“Efforts in pandemic planning globally had focused on avian flu H5N1, but the pandemic which emerged (in 2009) was a completely different virus, unrelated to H5N1,” she says.

Raising awareness

There are still several myths, misconceptions and knowledge gaps amongst the general public, stakeholders say, including about methods for treating flu.

Prof Booy says that too many people still use the word “flu” to describe the common cold, though the 2009 pandemic helped raise awareness “somewhat”.

“But it’s eight years since swine flu.

“They [pharmacists] can simply help by raising awareness about the severity of flu. If you’re an older adult, 65 and above, or you have a chronic illness, flu can be quite severe; however there are even plenty of severe flu cases in healthy people too.

“Raising awareness of the potential seriousness of the disease is important, especially for at risk groups: Indigenous adults, Indigenous children under five, pregnant women, people with chronic disease and people aged 65 and above.”

Rick Samimi said that more and more Australians understand that antibiotics do not help to combat the flu virus, only any secondary bacterial infections which may arise, and that pharmacists have played a part in raising this awareness.

“Now that pharmacists on a national basis can act to provide the vaccination service, it gives us an expanded way to explain that to patients,” he said.

There’s low awareness of antivirals, however.

“There’s very little promotion amongst even doctors these days, let alone patients,” he said. “My understanding of oral antiviral agents is that you must start them as soon as possible, and if they’re not taken quickly they’re not as effective.

“So again, the best way of countering the flu infection is to get the flu shot.”

And Paul van Buynder warned against Australians’ tendency not to take “sickies” when actually sick.

“One of the key winter strategies for the community is good respiratory hygiene and staying home when you are sick,” he told the AJP. “Wash your hands frequently, cough into a tissue and dispose of it carefully. Don’t infect your co-workers by going to work or school.”

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