Self-Care for Immunizations

SEPTEMBER 25, 2017
Rupal Patel Mansukhani, PharmD, and Mary Bama Bridgeman, PharmD, BCPS, CGP
Case 1: Immune Boosters
Q: BF, a 22-year-old woman, comes to the pharmacy seeking something to help boost her immune system. She says she always gets colds during the year and wants to use zinc daily to prevent colds. Her friend has been using zinc for the past few years and has not gotten sick at all. BF was thinking about using zinc lozenges daily to help prevent colds for the upcoming cold and flu season. She said that she has tried to increase the number of times she washes her hands and is willing to try other nonpharmacologic techniques to prevent the spread of germs. BF has no medical conditions and no drug allergies, but she takes a multivitamin daily. What recommendations about zinc do you have for BF?

A: Zinc is an essential nutrient, which can help with growth and immunity. BF should be told that the evidence that zinc prevents colds is conflicting, and many of the clinical studies have poor designs. One study evaluated patients who used daily zinc lozenges, and the results showed that the number of colds per year and antibiotic use decreased.1 However, the results of most studies show that zinc does not help prevent colds. BF should also be told that zinc lozenges appear to help treat the common cold. Most trials have had patients use zinc lozenges every 2 hours while awake as soon as symptoms begin. Most of the studies show a symptom reduction of 3 days.2,3 Therefore, BF should start zinc lozenges as soon as her symptoms begin to help decrease the length of illness. But based on the data, it appears that taking zinc daily will not help prevent a cold. In addition to her nonpharmacologic way of preventing infection, BF should ensure that all her vaccinations are up to date, which can prevent any vaccine-preventable illnesses. 

Case 2: Influenza Vaccine
Q:
MR, a 48-year-old woman, visits the pharmacy asking for something to help prevent influenza. She says that a distant family member recently died from influenza. MR was surprised to learn that the flu can be fatal because she always thought that people recover. Since she heard the news, she has been thinking about getting a flu vaccination. As the pharmacist, you recommend that MR get the vaccine today because it is flu season. She says that she is allergic to eggs and has never received the vaccine before. Upon questioning, MR says that her normal reaction to eggs is to break out in hives. She has never used epinephrine and has never needed to seek urgent medical attention for her allergy. What recommendations do you have for MR?

A: MR should be told that the recommendation for flu vaccination for those with an egg allergy changed last season. It is now recommended that a patient who breaks out in hives after contact with eggs receive any licensed flu vaccine, whether it is the inactivated influenza vaccine or the recombinant influenza vaccine. Therefore, MR should receive the vaccination either at the pharmacy today or at her physician's office, as it is the best way to protect against influenza. Patients with egg allergies, who have symptoms such as angioedema, respiratory distress, lightheadedness, or recurrent emesis, or who in the past required epinephrine or another emergency medical intervention, may also receive any licensed influenza product. However, these patients should receive the vaccine at an inpatient or outpatient medical facility. In addition, the vaccine is contraindicated for anyone who has had a previous severe allergic reaction.4MR should also be told that the influenza vaccine is not 100% effective. However, if she does get the flu, it will be a milder version. MR should be told that the vaccine takes up to 14 days to kick in, so if she comes in contact with the influenza virus before then, it could have no benefit during that time. 

Case 3: Whooping Cough

Q:
TA, a 28-year-old woman, comes to the pharmacy to inquire about whooping cough. She is 30 weeks pregnant and was advised by a friend to get the vaccine for whooping cough, which is also known as pertussis. There is currently an outbreak of pertussis in the state where she lives. She says she does not want to harm her baby, so she would like to wait until she gives birth. TA does not understand why she needs to get the vaccine while she is pregnant. In addition, she does not want a combination vaccine but one for pertussis only. What recommendations do you have for TA?

A: TA should be told that whooping cough is a contagious respiratory disease that can be deadly for babies younger than 12 months.  It is caused by bacteria, and symptoms include an uncontrollable cough that makes is difficult to breathe. The best way to help TA’s baby is by getting vaccinated during the third trimester of pregnancy. When the vaccine is given during pregnancy, some of the antibodies pass to the baby before birth, offering protection until the baby can get his or her own pertussis vaccination at 2 months. Because TA is already 30 weeks pregnant, she can get a one-time dose of Tdap today. The pertussis vaccine only comes as a combination vaccine of DTaP for children and Tdap for adolescents and adults. It is recommended that pregnant women get vaccinated between weeks 27 and 36. The recommendations only recommend Tdap post-pregnancy if the mother has never received the vaccination before or if her vaccination status is unknown.

Case 4: Echinacea

Q:
RM, a 35-year-old woman visits the pharmacy looking for something to prevent colds. She works in a daycare center and over the past month has had 3 colds. Every time RM has gotten a cold, she cannot go to work and does not get paid. Although she has tried to increase her vitamin C intake and now takes a multivitamin, it has not helped. RM is looking for an immune booster. She heard that echinacea can help prevent colds. RM does not take any other prescription medication and has no other medical conditions. What recommendations do you have for RM?

A: RM should be told that though echinacea is a natural supplement, strong randomized clinical trials are lacking. Data on the use of echinacea is conflicting, though some research suggests that it may help prevent and treat the common cold. The results of a study showed that echinacea taken on the first day of a cold and continued for 6 days can reduce symptom scores by 23% compared with a placebo. Results of another study showed that it could decrease cold symptoms by day 4, compared with day 7 with a placebo.6,7  Some research also suggests that echinacea can reduce the incidence of colds by 45% to 58%.8,9 Although some of the data show that echinacea may be beneficial, there is also conflicting research suggesting that there is no benefit over a placebo. Therefore, RM should be told that she can try echinacea, but it may not benefit her. Depending on the product she selects, she should follow the package directions. In addition, RM may benefit from good hand-washing techniques. She should wash her hands frequently and keep the soap on her hands for 20 to30 seconds before rinsing with water. In addition, RM should make sure that her immunizations are up to date. 
 
Dr. Mansukhani is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and a transitions-of-care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey.

Dr. Bridgeman is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.


References
  1. McElroy BH, Miller SP. An open-label, single-center, phase IV clinical study of the effectiveness of zinc gluconate glycine lozenges (Cold-Eeze) in reducing the duration and symptoms of the common cold in school-age subjects. Am J Ther. 2003;10(5):324-39. 
  2. Hemila H, Petrus EJ, Fitzgerald JT, Prasad A. Zinc acetate lozenges for treating the common cold: an individual patient data meta-analysis. Br J Clin Pharmacol. 2016 ;82(5):1393-1398. doi: 10.1111/bcp.13057.
  3. Zinc lozenges reduce the duration of common cold symptoms. Nutr Rev. 1997;55(3):82-5.
  4. CDC. Flu vaccine and people with egg allergies. https://www.cdc.gov/flu/protect/vaccine/egg-allergies.htm. Updated September 2, 2016.Accessed August 7, 2017.
  5. CDC. Tdap (tetanus, diptheria, pertussis) VIS. cdc.gov/vaccines/hcp/vis/vis-statements/tdap.html. Updated October 16, 2016. Accessed August 7, 2017.
  6. Goel V. Lovlin R, Barton R, et al.  Efficacy of a standardized echinacea preparation (Echinilin) for the treatment of the common cold: a randomized, double-blind, placebo-controlled trial. J Clin Pharm Ther. 2004;29(1):75-83. 
  7. Goel V, Lovlin R, Chang C, et al. A proprietary extract from the echinacea plant (Echinacea purpurea) enhances systemic immune response during a common cold. Phytother Res. 2005;19(8):689-94.
  8. Shah SA, Sander S, White CM, et al. Evaluation of echinacea for the prevention and treatment of the common cold: a meta-analysis. Lancet Infect Dis. 2007;7:473-80.
  9. Schoop R, Klein P, Suter A, Johnston SL. Echinacea in the prevention of induced rhinovirus colds: a meta-analysis. Clin Ther. 2006;28(2):174-83.


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