Preventing and Managing Influenza

Pharmacists can provide vaccinations and help patients choose OTC products to provide symptomatic relief from the flu.

Yvette C. Terrie, BSPharm, RPh

The Centers for Disease Control and Prevention (CDC) recommends a yearly influenza vaccination as the most effective means of preventing the flu. For individuals who refrain from obtaining the vaccine and get the flu, there are a host of OTC medications marketed to manage the most common symptoms associated with the flu.

All 50 states provide pharmacists with certification training programs to administer vaccinations. As one of the most accessible health care professionals, pharmacists are in a pivotal position to encourage patients to obtain the yearly influenza vaccine as soon as it becomes available. Pharmacists can also provide pertinent medical information to patients who get sick, such as differentiating between the flu and a cold, the proper use and selection of nonprescription flu medications, and when to seek further medical care.

In the United States, flu season occurs between October and May, with the peak of the season occurring between late December and March.¹ An estimated 5% to 20% of the US population gets the seasonal flu, and more than 200,000 individuals are hospitalized for complications related to the influenza virus.^1-3 Although the majority of healthy individuals will recover from the influenza virus in a few days to a week, there are approximately 23,600 flu-related deaths annually.^3,4 Patient populations including individuals older than 65 years; those with chronic health conditions, such as diabetes, asthma, chronic obstructive pulmonary disease, cardiovascular disease, sickle cell anemia, renal disorders, and hepatic disorders; pregnant women; and young children are at an increased risk for developing complications associated with the influenza virus and should obtain yearly vaccinations.⁴ Possible flu-related complications include bacterial pneumonia, dehydration, and ear and sinus infections, as well as the exacerbation of certain chronic medical conditions, such as congestive heart failure, asthma, and diabetes.⁵ Certain populations should not be vaccinated without consulting a physician first (Table 1).

In 2009, an estimated 12,000 flu-related deaths were due to the H1N1 pandemic in the United States. In contrast to seasonal flu, approximately 90% of the deaths were among those younger than 65 years.^4,5 Individuals between the ages of 50 and 64 years were the most affected by the 2009 H1N1 virus, with an estimated 80% of this patient population having 1 or more medical conditions.⁴

Preventive Measures

On February 24, 2010, the CDC’s Advisory Committee on Immunization Practices agreed that all individuals 6 months and older should receive an annual flu vaccination and promoted “universal” flu vaccinations in the United States.^5,6 The 2010—2011 flu vaccine contains an A/ California/7/2009 (H1N1)-like virus, an A/Perth/16/2009 (H3N2)-like virus, and a B/Brisbane/60/2008-like virus.⁶ It is available as an injection or nasal spray. The nasal spray vaccination is indicated for use in healthy individuals between the ages of 2 and 49 years.

Despite the CDC’s recommendations, there are many individuals who elect not to be vaccinated. According to results from a telephone survey of more than 1000 individuals conducted by the National Foundation for Infectious Diseases, an estimated 43% of those surveyed reported that they would not be getting a vaccination. ⁷ The reasons included the belief that there are other ways of preventing the flu, concerns about side effects, and a lack of concern about getting the flu.⁷

Of those surveyed, 62% mistakenly believed that the vaccine only protected against 1 strain of the influenza virus and 34% perceived handwashing to be just as effective as the vaccine in flu prevention.⁷ Among mothers surveyed, an estimated 80% did not change their minds about vaccinations as a result of the 2009 H1N1 pandemic and 65% planned on getting their children vaccinated this flu season.⁷ Individuals surveyed reported that physician recommendation was the key factor in deciding to get vaccinated, followed by the desire to protect loved ones and not wanting to get sick.⁷ In addition, another survey from the same group found that one third of American mothers had no plans to get a flu shot for their children.⁷

Despite this survey’s findings, a report released in December 2010 by the CDC concluded that many lessons were learned from the 2009 H1N1 pandemic, such as the importance of vaccination.⁸ Data collected by the CDC in the second week of November 2010 reported that an estimated 33% of Americans reported already receiving the flu vaccine for the 2010—2011 flu season. The patient population with the highest vaccination rate was individuals older than 65 years, with a 64% vaccination rate.⁸ Vaccination rates among pregnant women and health care workers were reported as 45% and 56%, respectively.⁸

Managing Flu Symptoms

For those who get the flu, OTC medications are available to manage the common symptoms associated with the influenza virus (Table 2).

After exposure to the influenza virus, patients typically experience flu symptoms rapidly (within 1—2 days), and may present with a fever, feverish feeling, or chills. Not everyone with the flu will present with a fever, however. ⁴ Other symptoms include headache, general feeling of malaise, fatigue, muscle or body aches, dry cough, sore throat, and runny or stuffy nose.⁴ Some patients may experience diarrhea and vomiting, although this is more prevalent among pediatric patients than adults.⁴

OTC drugs marketed for symptomatic relief of flu symptoms include both singleentity and multiple-ingredient products, such as analgesics/antipyretics, cough suppressants, cough expectorants, decongestants, and antihistamines. Patients should be advised to use multiple ingredient products with caution to eliminate the unnecessary use of medications or therapeutic duplications.

In addition, there are a variety of alternative products available for the management of the influenza virus that are marketed to reduce the duration and severity of the flu. Examples include elderberry, echinacea, North American ginseng, Chinese medicinal herbs, oscillococcinum, green tea, vitamin D, vitamin C, N-acetylcysteine, and dehydroepiandrosterone. ⁹ Patients with other medical conditions should always consult their primary health care provider before taking any alternative products marketed for the flu.

According to the National Institutes of Health’s National Center for Complementary and Alternative Medicine, there is no conclusive scientific evidence that confirms that any alternative therapies are useful in reducing the duration or severity of the flu.⁹ Although the clinical evidence is limited, there are some studies that suggest a potential role for certain alternative therapies.⁹ Some studies report that vitamin C may have mild in vitro antiviral activity against the influenza virus and that a deficiency of vitamin C may impair effective immune response to influenza viral infections in male mice.¹⁰ However, there are a lack of clinical studies that support the use of vitamin C supplements to prevent or treat seasonal or atypical influenza, and more research is needed in this area.¹⁰ Some research has linked an increased risk for influenza with a vitamin D deficiency; however, more studies are needed.¹⁰

In some cases, physicians may prescribe the antivirals ostelamivir or zanamivir for those patients experiencing severe symptoms or those at high risk for flu-related complications in order to shorten the duration and severity of the virus.¹¹ Due to concern about emerging drug resistance, various medical experts recommend that the use of these agents should be reserved for severely ill patients or those at high risk for flu-related complications.¹¹

The Role of the Pharmacist

When encountering a patient seeking guidance about OTC drugs for the management of flu symptoms, pharmacists can utilize the opportunity to encourage patients, especially those in at-risk groups for flu-related complications, to obtain yearly influenza vaccinations. Pharmacists can also suggest various nonpharmacologic measures to reduce or prevent the transmission of the influenza virus to others. Patients with the flu should be advised to get plenty of rest and maintain adequate hydration. If patients elect to use OTC products marketed for the flu, pharmacists should screen patients for possible contraindications and drug interactions and ensure that the patient or caregiver clearly understands the proper use of the selected product. Patients with preexisting medical conditions should be advised to consult their primary health care provider prior to using any of these products to ensure appropriateness of use. The use of saline nose drops, humidifiers, and vaporizers may alleviate any nasal congestion.

Parents or caregivers should be advised to give children only those products marketed for pediatric use. If administering medication in liquid form, parents or caregivers should always use a calibrated medication delivery device and when in doubt always ask their primary health care provider about appropriateness of use and dosing. It is also important to avoid the use of aspirin or aspirin-containing products in children and teenagers with confirmed or suspected influenza or other viruses due to the risk of Reye’s syndrome.^12,13 Patients and caregivers should also be encouraged to seek emergency care if their child experiences symptoms that worsen, a fever above 103°F, trouble breathing, excessive fatigue, confusion, severe or persistent vomiting, or shows signs of dehydration.¹⁴

During counseling, pharmacists should always ask and remind patients, especially those at risk of developing flu-related complications, about the importance of obtaining yearly influenza vaccinations. It is important to note that the CDC also recommends that individuals in high-risk groups, such as children, seniors, and those with certain health conditions, also receive a pneumococcal vaccination.³

Annual influenza vaccinations are our best, safest, and most effective defense in preventing the flu, so as health care professionals, we should spread the word about the importance of prevention and encourage our patients to get vaccinated every year.

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

• Flu season. FluFACTS Web site. www.flufacts.com/about/season.aspx. Accessed January 17, 2011.
• Cold or flu. FluFACTS Web site. www.flufacts.com/know/what-is.jsp?SOURCE=GOOG&KEYWORD=p. Accessed January 18, 2011.
• Vaccination. Flu.gov Web site. www.flu.gov/individualfamily/vaccination/index.html. Accessed January 18, 2011.
• Flu symptoms and severity. Centers for Disease Control Web site. www.cdc.gov/flu/about/disease/symptoms.htm. Accessed January 18, 2011.
• Key facts about influenza. Centers for Disease Control Web site. www.cdc.gov/flu/keyfacts.htm. Accessed January 20, 2011.
• CDC’s Advisory Committee on Immunization Practices (ACIP) recommends universal annual influenza vaccination. Centers for Disease Control Web site. www.cdc.gov/media/pressrel/2010/r100224.htm. Accessed January 19, 2011.
• Many Americans plan to skip flu shot this year. United States Department of Health and Human Services Web site. www.healthfinder.gov/news/newsstory.aspx?docID=644083. Accessed January 18, 2011.
• National influenza vaccination week: updates on U.S. influenza activity. Centers for Disease Control Web site. www.cdc.gov/media/transcripts/2010/t101203.html. Accessed January 18, 2011.