Prepping for Flu Season in 2020: Why the Vaccine Is More Important Than Ever

In preparation for the upcoming 2020-2021 influenza season, pharmacists are ideally positioned to educate patients about the utility of the influenza vaccine in helping to “flatten the curve” and prevent illness. Because of the coronavirus disease 2019 (COVID-19) pandemic, many patients may be hesitant to venture to the pharmacy to receive an influenza vaccine for fear of possible exposure to severe acute respiratory syndrome coronavirus 2, the virus that causes the disease. As such, pharmacy staff have an opportunity to engage in outreach efforts to educate patients about the measures the pharmacy has put in place to help ensure their safety while continuing to promote the importance of receiving an annual influenza vaccine.

To learn how pharmacy staff can prepare for the 2020-2021 influenza season and discuss the changes that pharmacy staff may be anticipating, Pharmacy Times spoke with David P. Zgarrick, PhD, FAPhA, professor in the Department of Pharmacy and Health Systems Sciences in the School of Pharmacy at Northeastern University’s Bouvé College of Health Sciences in Boston, Massachusetts, and Shane Desselle, PhD, RPh, FAPhA, professor of social & behavioral pharmacy at Touro University California in Vallejo, California.

Pharmacy Times: How can pharmacy staff start to prepare for the upcoming influenza in the summer, and what might be different this year (2020)?

Zgarrick: We are going into a very unique influenza season this coming year. Everyone has COVID-19 on their minds; but, it is important to remember that we are still going to have a 2020-2021 flu season. The flu is still going to be out there, and it needs to be something that people are concerned about. Thousands of individuals die of the flu every year, and just because we arefocusing on COVID-19 right now does not mean that the influenza virus is going to go away. If anything, there will be an added challenge to help patients realize they still need their annual regular influenza vaccine.

Of course, there is the anticipation of the need for vaccines and supplies using pharmacy data, which is used to anticipate the number of [people] who may request vaccines, the total amount per vaccine type, and supplies that are needed. In addition, there [should] be consideration of the marketing activities...to encourage patients to receive vaccinations and when these activities will launch. Some of that planning already starts at the end of the previous flu season, but [as summer begins], we are starting to move into that full-court press to prepare for the fall. Decisions are being made regarding the aforementioned questions right now [in July].

Pharmacy Times: What advice would you give pharmacy staff on how they can ensure they are effectively commu- nicating the importance of the influenza vaccine at this time?

Zgarrick: It goes back to leveraging the fact that pharmacists are the most accessible health care professionals. In light of COVID-19, more patients are coming into the pharmacy with questions. This provides an opportunity for the phar- macist to get the message out that influenza [remains] an illness of concern, and patients should be prepared for the 2020-2021 influenza season. Pharmacists can ensure they are having those conversations with patients, and they need to be having those conversations now, to be ready for when the time comes to really start the push toward flu season—which, honestly, in many places starts in August. This brings up the question of when pharmacists should typically start thinking about influenza vaccines. As the new [seasonal] influenza vaccine becomes available, the message will quickly turn to reminding patients, “It isn’t too early to get your influenza vaccine” or “Don’t wait for a COVID-19 vaccine to get your influenza vaccine.” Pharmacy staff are increasingly getting into this mindset that immunizations are a year-round activity rather than seasonal.

Pharmacy Times: How can pharmacists help to flatten the curve?

Zgarrick: [As frontline health care providers] we recognize the importance of educating people about health and what they can do to protect not only their health, but that of those they love. [There is much talk about] social distancing and all the things we did to flatten the curve with COVID-19 and getting an influenza vaccine should also be thought of as another form of flattening that curve. The recommended actions to stay healthier overall are going to help not only individual patients, but also the health care system. This is certainly a message that pharmacists can put out there: We all play a part in keeping not just ourselves healthy, but also our communities, and getting an influenza vaccine is a really important component. Just like social distancing was an important part of lowering the COVID-19 curve, getting your immunization and keeping yourself healthy is also going to play a role moving forward.

Pharmacy Times: Should pharmacy staff expect a percentage increase in influenza vaccinations in fall 2020?

Zgarrick: That is a really good question, and I think the answer is still unknown. On one hand, there may be an uptick in people requesting immunizations because they are more tuned into their health as a result of COVID-19. [Many people] recognize that the healthier they are, the better their chances of effectively dealing with COVID-19 should they become infected. That is certainly a message I would want to get out there as a health leader and health professional.

On the other hand, demand for immunizations could be challenged because many people are unemployed right now and may have depended on their employment-based insurance for healthcare. Many people may not have the resources to be able to pur- chase a vaccine or immunization as they have had in previous years. Or, patients may be so tuned in to focus on COVID-19 only that they do not pay attention to other aspects of their health that require attention.¹

Pharmacy Times: How can pharmacy staff prepare in case there is an influx of people demanding vaccines, in terms of routing patients, having extra personal protective equipment, designated areas to vaccinate, etc?

Zgarrick: This is a good point. Pharmacies have already had to change their ways [because of COVID-19] and are already focused on appropriate use of personal protective equipment (PPE). However, pharmacies also are tasked with emphasizing [to the public] that it will still be safe to go to a pharmacy. And, when administering an influenza vaccine, pharmacists will take certain precautions to not only protect themselves but also to protect patients from any undue exposure to COVID-19—or anything else for that matter.

How to effectively communicate that it is safe to travel to a pharmacy to receive a vaccine is a challenge. On one hand, people could latch onto the message that it is important to stay healthy through this [current health crisis], and pharmacies could receive more influenza vaccine business as a result. On the other hand, patients could be worried about the risk of exposure to COVID-19 [and stay away from the pharmacy].

Many pharmacies have already transitioned some daily tasks to be performed through telemedicine, telepharmacy, and online orders. Reminding patients that if they do not have to go to the pharmacy [to pick up their medications] is important, but receiving vaccines is still a task that requires an in-person visit. The message we will have to get out is that: you can still come to the pharmacy to get your influenza vaccine, it’s more important than ever that you do, and we can do it safely.

Pharmacy Times: What can a pharmacy technician do if they are faced with a customer who is unwilling to adhere to recommended safety precautions (ie, wear a mask)?

Desselle: That relates back to communication. Each situation is somewhat different, yet they all share things in common; for example, patients might be recalcitrant [when it comes to] quitting smoking or not taking their medications properly. These are all potential barriers to effective treatment: If you do not take your medication or quit smoking, ultimately, you are not going to achieve the expected therapeutic outcomes.

There is no communication [strategy] that works 100% of the time, and there always will be some communication failures. If a patient is going to be belligerent, they will not necessarily open up to you, and you might not find the underlying reason for that belligerence. If a patient comes into the pharmacy and is not wearing a mask, there could be some political aspects involved, but although we might be quick to assume so, that may not be the reason at all (ie, the patient may have simply forgotten their mask at home). We will not always be able to talk a patient down if they are angry, belligerent, or bellicose, but utilizing empathy, asking open-ended questions, and providing rationale [can help]. If patients are allowed to express themselves and air their concerns, oftentimes, they will calm down.

It is important to remember that even after using empathy and asking open-ended questions, you might not get the result that you are looking for right then and there, and think the conversation was a failure. That’s the big mistake people make. They think, “I tried this communication strategy and it didn’t work because the patient left without doing what I wanted them to do, and they still left [angry].” However, if you were able to encourage the patient to talk things out, you probably planted a seed [in their minds] and at some point, maybe next time they come into the pharmacy, you will have success. Maybe at home or on the way there, they may reflect on the conversation: “The technician made a good point, and although I did not get my vaccinations today or I did not bring my mask today, I am going to think about this [situation] a little bit more.”

Communication is an ongoing, longitudinal process, and it may take several encounters for it to be successful.

Pharmacy Times®: In light of COVID-19, if more people request vaccinations, there will be more responsibilities on the pharmacist. As such, the role of pharmacy technicians may be evolving, and some tasks may be delegated. How can the pharmacy as a whole help to prepare technicians for a potential increase in their responsibilities?

Zgarrick: That has been a big issue. At the onset of the COVID-19 crisis, a number of states put forward emergency orders [to increase technician responsibilities].² In many cases, these will ultimately transition into permanent orders, thereby enabling pharmacy technicians to do more and enabling pharmacists to delegate more activities. Pharmacists are still ultimately responsible for what happens in their pharmacies, regardless of how tasks might be delegated and completed, especially as there is more ability now to do that with the technicians. Nevertheless, something incumbent upon pharmacists at this time is the need to recognize [that] we still need to educate and train our technicians. Just because the laws and regulations have changed, that does not necessarily mean it is acceptable to delegate [new tasks and/or responsibilities] to pharmacy technicians without training. Instead, we need to prepare them to be able to perform these new roles. Pharmacies need to take that step back and say, “Let’s train our technicians. Let’s make sure they are prepared to be able to do these things.” This includes going so far as considering compensation, to ensure technicians are effectively and appropriately compensated for what that they are doing, because their work is very much in demand right now.

Desselle: In the past couple of years, we’ve seen quite an [array] of diverse roles for technicians evolve, but even more so moving forward.^3,4 In the states where technicians can administer vaccinations, I don’t necessarily see much difference [than in states where] they cannot. Obviously, that is an added task technicians can do, but when you look at the whole process of vaccinations, there is an entire gambit of responsibilities that technicians can take up. There are also administrative components, such as keeping track of vaccinations that were provided. Additionally, there are a number of supply chain issues for vaccinations, so technicians can make sure to keep monitoring the amount of supply and work with pharmacists to not only anticipate the supply needs in the future, but also maintain contact with distributers of the vaccine to ensure vaccine lots are not expired. Even beyond the supply chain, technicians can work with pharmacists to help with administrative tasks, such as ensuring that vaccinations have been recorded into the patient’s medical record.

Given that they are on the proverbial front lines, technicians can also focus on communication with patients. In states where they do not [administer vaccinations], technicians are not prohibited from speaking to patients about vaccination. They can use motivational interviewing techniques to speak with patients and encourage them to receive the vaccinations.⁵ Although many patients come to the pharmacy who are willing to be vaccinated, they might have friends, family, and so forth who are not [or] who have doubts about it. These patients [may] want to know some tips and strategies to use when talking to the other individuals in their life to convince them to not only get vaccinated, but to do so here at this pharmacy. Technicians can elicit information about the patients themselves, as well as about the patient’s caregivers, family, and social support network to discover the patient’s logic behind wanting to get vaccinated [and where]. The technician can collect this information, record it, and share everything with the pharmacist.

In addition to coordinating the gathering of vaccination-related information from patients, technicians can also help with scheduling. For example, some pharmacies might use a first-come-first-served model for their vaccinations, whereas some might use an appointment-based structure, and some might use a hybrid of those 2 [arrangements]. The technician can help the pharmacist design an implementation strategy for vaccinations. For example, a pharmacy without an appointment-based system still might consider instituting such a system for patients who would prefer having a scheduled time rather than wait in a line. The technician can help by using that strategy and setting up appointments as needed, even though the pharmacy’s primary system is not appointment based.

This is an exciting time for the growth and advancement of the technician as a profession. Technician roles and responsibilities are evolving and continually changing and growing to meet different needs.

Pharmacy Times: Are roles for pharmacy technicians going to change in light of COVID-19?

Desselle: Unquestionably, and we have already seen [it] in a few states. Some states call it a suspension of rules, others call it an expansion of scope, some are calling it temporary. Some [states] are not necessarily labeling it as temporary, but under the current situation, boards of pharmacy are allowing different scopes of practice for technicians.^6,7 As with anything else, when an organization, a person, or an entity tries something out and it works, then it is likely to stay.

Pharmacy Times: What are some examples of how the scope of work for pharmacy technicians could be changing?

Desselle: There are specific things, but I might consider it in more of a generalist manner. For example, in Idaho—which is one of the more progressive states in terms of boards of pharmacy—regarding technician “deregulation,” what that state did was to say, “Rather than write a definitive list of what technicians can do, let’s just state what they can’t do.”⁸ Then, everything else is up to the pharmacist in terms of delegating. As a result of COVID-19—and certainly not solely due to COVID-19—certain things will speed up, [particularly] pharmacists having greater delegatory authority. Therefore, this change will not necessarily start with the technician, but rather with the pharmacist: An empowered pharmacist is the one who has greater delegatory authority.

Boards of pharmacy are going to leave more and more dis- cretion up to the pharmacist regarding what technicians can do, as opposed to [the Board] delineating all the [tasks]. With the advent of COVID-19 and the associated drug shortages, supply chain issues, and increased demand on pharmacy staff to help patients who are having difficulty navigating the health care system, or who are confused and/or frustrated, states are looking to one another to learn from the success of what’s happening in locations that have already expanded technicians’ scope of practice (ie, being able to immunize), to learn how to follow suit. Centralization is key here. Within certain limits and parameters that can be defined, it will be more up to the pharmacists and their organization to expand the technicians’ scope of practice.

Pharmacy Times®: What can pharmacy technicians do now to prepare themselves for this potential increase in responsibilities?

Desselle: Among the first things that technicians can do is to be proactive and talk to pharmacists. Most, if not all, technicians are aware that the landscape is changing. They know their duties and responsibilities are being expanded and that changes are coming. This [change] manifests in a great opportunity for technicians. Just as any employee should approach their supervisor or employer in saying, “In light of these changes that are coming, let me offer my services. Let me offer you what I would like to do in the future.” I think this is something more technicians should be doing—being proactive and talking to the pharmacist on their own behalf and having the pharmacist even talk to their supervisor, if need be, about the roles technicians can take on.

A technician can say, “My understanding is that beginning this fall, we are going to be able to do this and that. Let me speak on behalf of at least myself to say that I am very interested in doing that. Let me put my name in the hat as someone who wants this. Can you provide me with any suggestions on any education and training that I might need to better prepare myself?” Then, based on the response they receive, at least to some degree, technicians can seek out more education and training, and not just in the technical sense. For example, when it comes to immunization, technicians can take any number of nationally accredited courses on vaccinations or immunizations.

[I should mention,] however, there are also the issues of time management and stress management: How will [technicians] handle these new roles? How will they take on the stress of these now roles? How will they manage their time to effectively incorporate these new roles perhaps into the roles that they are already doing?⁹ Technicians may be asked to perform even more tasks. Oftentimes, people volunteer their services, but the employer or supervisor may say, “Great, but we’re not taking away these other responsibilities. They’re going to be added to what you are doing, and maybe later on, we might think about relieving you of some of your current duties, but first you’re going to have to do both.” With this in mind, there are issues of stress management, time management, organization, organizational skills, etc, that need to be considered.

We are beginning to see mentorship programs for pharma- cists in some of the professional organizations. For example, in California in the Sacramento Valley chapter of the California Pharmacists Association, there is a mentoring program that actually includes technicians.¹⁰ Technicians seeking to receive encouragement and aid with stress management may want to seek out mentorship for guidance, education, and training not just in the technical aspects, but in more humanistic aspects as well.

Pharmacy Times®: Would this additional training be provided onsite, online, or a mix of both, and how can pharmacies incorporate this training into their busy workflow?

Zgarrick: Likely a mix of both. [Additional training] is cer- tainly in the nature of the work of a pharmacy technician, and onsite training is key for tasks that are very specific to a particular pharmacy. Although there are online [training] options, much of what needs to be done requires hands-on, in-person training. That is the role of pharmacists and pharmacies to train technicians to do tasks such as intake interviews and to be more involved in the process of immunizations, or, especially now, to have pharmacies transition into places where COVID-19 testing occurs. And although the pharmacist may be the one who is doing [the actions of] swabbing and handling the sample, there is a role for the pharmacy technician in this process as well, such as taking the initial intake and other tasks. Ultimately, it comes down to the pharmacist and the pharmacy providing that technician with the training they need...to effectively do the things they are being asked to do.

This is where pharmacists have to recognize that [larger] pharmacies often have people with more expertise in some areas or topic than others and there is an entire staff of people whose job it is to help enable pharmacies to effectively provide immunizations and ensure there is a team of individuals with that expertise. It is essentially their job to educate technicians on what they need to do in order to help make these things happen. This is probably abit more of a challenge for an independent pharmacy where the staff have to figure out how to do that on their own. Nevertheless, [when it comes to training,] it can help to tap into the expertise of a relatively small number of trained staff who are expected to have skills in these areas, rather than simply telling every single pharmacist that they have to [personally] train their own technicians to do everything.

Desselle: Pharmacy Times recently published several articles on communication strategies, motivational interviewing, and the like.¹¹ Effective communication is the first area where technicians might seek additional education and training. Many people are under the false assumption that communication is easy, given that we communicate every day and we begin speaking between the ages of 1 and 2. Many people think communication means just people talking, but it is much more than that. Effective communication involves eliciting a feeling of mutual understanding. By being empathetic and using more advanced communication strategies, it becomes easier to learn from the patient any necessary [personal] history, disease history, and vaccination history.

Pharmacy Times: What else can pharmacy staff do to keep themselves and their patients safe during the upcoming 2020-2021 influenza season?

Zgarrick: One action would be to help people understand that flattening the curve is not just about social distancing and what we are doing specifically for COVID-19. Instead, it is about the actions we are taking to keep ourselves healthy and getting an influenza vaccine is very much part of that. Every time a patient comes into the pharmacy to get a prescription filled for something else, pharmacists have a role in getting the message out about how it is more important than ever to consider an influenza vaccine, and all their recommended vaccinations for that matter. The visit can become a point of interaction where you the pharmacist (or technician) can ask the patient whether they received an influenza vaccine this year, and remind the patient that staying healthy is going to increase the chances of being able to protect themselves and others.

Having that personal conversation is going to be especially important this year because patients are going to have questions about the influenza vaccine and COVID-19. [The conversation] needs to be about prompting the patient to get the influenza vaccine not only to stay protected themselves, but also to keep their family protected as well. And, we know COVID-19 is still out there and that we are going to be dealing with it for some time into the future. Although our natural inclination is to focus on COVID-19, we cannot lose sight of other illnesses as well.

Pharmacy staff are in the same boat as any essential worker or anyone who has to be in a store and exposed to people to providea service. Some pharmacies are providing PPE and other resources to their personnel, whereas others are redesigning how patients interact with staff.^12,13

Desselle: Come fall 2020, obviously, we are going to have a flu season. Many [public health experts] are predicting that we will have another wave of COVID-19 [infections], so individuals will have symptoms.¹⁴ Patients are going to be worried and overly anxious—more anxious than they were before. For example, some patients who [only] have cold-like symptoms [may] think they do not have the flu at all, and those with influ- enza might think that they have COVID-19. On the other hand, patients who have COVID-19 might think they have something else, such as influenza or just a bad cough. This increased uncertainty may lead to an added need for the coordination of administering vaccines. Communication will be the key in determining whether patients are infected with the influenza virus, and effective triage will be necessary to prepare for the potential increase in patient load at the pharmacy.

Technicians are in a tough spot. It is challenging because they cannot always procure PPE on their own. Again, communication is the key. If technicians feel unsafe or unprotected, they can [speak up] if the pharmacist has not already done so, by approaching the pharmacist and saying, “Flu season is coming up, [and] we are going to have patients [coming into the pharmacy] with allergic rhinitis, cold, flu, and COVID-19, etc. We will not necessarily know ‘who’s who’ and ‘what’s what’ right at the very beginning when they present themselves. What should we be doing to protect ourselves?” Pharmacies should be proactive and already have a plan.

Pharmacy Times: Is there anything that pharmacy staff might not be thinking about to prepare for this upcoming flu season?

Zgarrick: [As pharmacy staff,] we think a lot about equipment supplies and resources; however, an areas of focus that does not come into the conversation as often is it could is the costs of taking these additional prevention measures, especially at the pharmacy level. There are real financial costs [associated with] having to buy PPE to keep pharmacy staff and customers safe. Because PPE and other supplies meant to keep a pharmacy’s staff and patients safe are not something we are “selling to our patients” like a prescription or an OTC product, it does not generate revenue. PPE isn’t free; it is a pure cost and somehow, pharmacies need to figure out a way to incorporate it into the everyday costs of doing business and evaluate the impact.

There are also costs associated with additional marketing. To get the message out [to the public] that we want to keep people healthy and safe, it takes resources, which cost time and money. It is an investment most pharmacies should want to make because it brings in business, but they need to make that investment first.

One thing I have not heard or seen is pharmacies having an honest conversation with their clientele or patients and helping them understand that there are costs involved with the extra steps being taken to keep everyone safe. We need to get that same message out to our patients and pharmacies as well. For community pharmacies in particular, in many cases they will need to increase their price points on items because that is really the only way they can generate the revenue to be able to cover these extra costs. A big challenge is that much of the revenue pharmacies generate from prescriptions is based on contracts they have with pharmacy benefit managers and other third-party payers. In the short term, that limits the ability of a pharmacy to recoup any extra costs associated with the PPE and other supplies needed to keep pharmacy personnel and patients safe. Long term, pharmacies may look to renegotiate these contracts because they can make the argument that their costs are going up as a result of what is needed to keep patients, clients, and our personnel safe.

Desselle: The employer has an enormous role. The organizational culture of the employer is a primary driver behind the extent to which pharmacists will implement services and the success of those services. With that in mind, it all goes back to communication. Employers need to effectively communicate [with their staff]. They need to reconcile the difference between where they are now and what their company’s mission statement and goals are because there is likely to be a gap. They need to effectively communicate with pharmacy staff and pharmacy organizations and help facilitate education for the staff. There is a considerable amount of free education available from credible sources. Employers can identify sets of documents from both the professional and lay literature, the sources that are freely available online like Pharmacy Times, as well as peer-reviewed sources. For example, employers can create a repository on the company website or the company intranet where employees can find articles on promoting communication skills and various resources on time management. These actions can be accomplished with very little cost, but with maximum results to improve communication and the support provided to pharmacist staff with the goal of elevating the level of practice for everyone.

Pharmacy Times: Do you envision that because costs may be increasing, there will be an increase in the number of programs offered for low-income patients to be able to afford an influenza vaccine (or their medications)?

Zgarrick: It’s challenging. Not every customer in a pharmacy is fortunate enough to be able to afford higher costs; however, they still need the services that a pharmacy provides. [The solutions] can come from different sources. Some unemployed patients may be able to [look to] their state Medicaid program, as well as other charitable and public assistance programs that provide influenza and immunization coverage.

On the other hand, we are likely to be dealing with more people in the future who have to pay for their health care themselves. We [have to] help our patients understand what options they have in these situations. Pharmacists do such a good job with this because they understand the costs of medications and vaccines. A pharmacist is a great resource for helping a patient find options so that they can more effectively make those choices; ultimately, it is the patient’s choice what care they receive, how much care they receive, and [to some extent] what they pay for it.

Pharmacy Times: How can pharmacy staff stay positive during this time?

Zgarrick: One of the positive takeaways [of this challenging time] is that pharmacies and pharmacy staff have been put front and center in ways they haven’t been before. Furthermore, whether it be policy makers at the government level, or among individual patients, there is a realization that pharmacies are an essential business in our communities. This has been a positive thing for pharmacies and pharmacists to relish this role—it’s what we do and what we want to do. We want to be there for people to be able to help them get the most out of their medica- tions and [learn] how to live the healthiest life possible. There is recognition that pharmacy staff are providing vitally important services, and will continue to do so.

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