The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on all aspects of life around the world. By August 11, 2020, more than 20 million confirmed cases had been identified globally, including more than 730,000 deaths. In the United States, this includes more than 5 million confirmed cases and more than 163,000 deaths.1 Despite these staggering statistics, parts of the world are seeing an ebbing in deaths and infections and an easing of lockdown and quarantine restrictions. Restrictions and viral activity remain widespread in the United States, and state-by-state variations in virus activity necessitate a local response to ensure public health and well-being during this time.2,3

The current pandemic serves as an important reminder of basic recommendations for ensuring health and wellness and protecting oneself against communicable disease transmission. As schools wrestle with planning for the upcoming academic year, these reminders remain as true today as they were in March 2020, at the onset of viral activity in the United States. Health care providers continue to advocate those basic principles of infection prevention—washing one’s hands often, covering coughs and sneezes, staying home if feeling ill, disinfecting high-touch surfaces, and being immunized appropriately—to mitigate the spread of disease, prevent secondary infections, and reduce the burden of illness.4 This article discusses the latest immunization guidelines from the CDC during this time of the COVID-19 pandemic and provides an update on a vaccine against severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2), the virus that causes COVID-19.

INTERIM GUIDANCE ON IMMUNIZATION SERVICES, TRAVEL, AND HIGH-RISK PATIENTS
The CDC recently published interim guidance on provision of immunization services during the time of COVID-19.5 It is evident that the global pandemic and response have resulted in a decline in use of preventive health services, including the number of individuals seeking routine immunization services that ultimately serve to prevent disease, thereby reducing health care resource usage and the associated strain on the health care system. There is much hope that strategies such as the adoption of social distancing, masking in public, and use of frequent sanitizing practices will have a collateral effect on reducing transmission of influenza during the upcoming fall and winter months.4 However, advocating for influenza vaccination and ensuring public health by following national guidance documents on how to safely administer vaccines during this time represents a critical service for addressing those who may be reluctant to become immunized in the coming months. Important points from the CDC’s guidance document are highlighted in TABLE 1.5



The CDC also has issued a number of other recommendations to reduce the spread of infection and maintain nonurgent health services. Telehealth and the use of virtual care for routine health care delivery have seen widespread adoption since the pandemic began. Although rules and restrictions governing telehealth services vary from state to state, the CDC has issued national guidance on optimizing the uptake and usage of these services.6 Telehealth supports social distancing and the maintenance of continuity of health care and management of chronic health conditions or provision of routine care during this time; however, it does not allow for the remote provision of vaccination services.6

Providers who engage with their patients via telehealth instead must be creative and use the opportunity to reinforce, advocate for, and provide encouragement for immunization. Reviewing vaccination recommendations, addressing and allaying patient fears or concerns, helping to establish a plan for how one can become immunized, and exploring which vaccines could be combined during a single encounter are just some of the strategies clinicians can use to bolster patients’ immunization confidence and promote immunization during a telehealth encounter.7 Additional resources for supporting immunization and empowering pharmacists and other health care professionals can be found in TABLE 2.



For individuals traveling during this time, pharmacists can advocate for following guidance from the CDC on current travel restrictions and recommended vaccines. Current recommendations can be found on the CDC’s Travelers’ Health webpage (https://wwwnc.cdc.gov/travel).

In an effort to protect older adults and those at high risk of complications of COVID-19, the Centers for Medicare & Medicaid Services issued visitation restrictions on all nonessential health care personnel or visitors at long-term care facilities and nursing homes this past spring.8 As current local viral activity varies, facilities in different phases of response may be relaxing restrictions and permitting visitation. Individuals who may be visiting spouses or relatives in nursing homes should be educated on COVID-19 and the facility’s response and precautions implemented, along with actions they should take to protect themselves. These include, at a minimum, emphasizing the importance of hand hygiene, practicing source control via required cloth face coverings while in the building or facility, and issuing reminders to avoid visitation if otherwise ill.9

PHARMACY MANAGEMENT GUIDELINES
The CDC continues to update its guidance for pharmacy management during the COVID-19 pandemic, which underscores the fact that pharmacies and pharmacy personnel represent a vital component of the health care system.10 Implementing and enforcing infection control strategies, including universal face covering requirements, encouraging sick or symptomatic staff to stay home, practicing social distancing during direct patient care activities, and reducing risk when conducting COVID-19 testing or other close-contact encounters are paramount.10 Installing physical barriers such as plexiglass shields at drop-off and will-call areas, along with reconfiguring waiting areas and other measures intended to prevent the spread of illness, have become necessary during this time.10 It is also not uncommon for pharmacies without drive-through access to encourage patients who are ill to call ahead and use curbside pickup to minimize the potential transmission of infectious particles by exposing other individuals at a location.10

The CDC has suggested that pharmacy-based immunization services continue, if appropriate personal protective equipment (PPE) is available and no additional risks to the patient or provider exist.10 Patients should be screened for COVID-19 symptoms prior to vaccine provision, and pharmacy personnel should follow all recommendations for PPE, use of eye protection, and appropriate hand hygiene.5 Encouraging patients to become immunized via curbside or drive-up influenza clinics represents another option for ensuring public health during this unprecedented time.10

AN UPDATE ON THE COVID-19 VACCINE
Finally, it is imperative that pharmacists keep current with the status of the development of a COVID-19 vaccine and be prepared to field patients’ questions and concerns regarding this product. According to the World Health Organization, as of August 11, 2020, there were 28 candidate vaccines in various phases of clinical evaluation and 139 undergoing preclinical evaluation.11 The global race to develop 1 or more vaccines against COVID-19 is a sprint; however, which vaccine will receive initial approval in the United States remains unknown.

The absence of a vaccine provides another opportunity to educate patients about the relationship between COVID-19 and influenza and dispel misperceptions and myths about the relationship between these 2 viral illnesses.12 For example, remind individuals that the influenza vaccine does not confer immunity or protection against contracting COVID-19 and emphasize that it is possible to have influenza and COVID-19 simultaneously, thus making vaccination with the influenza vaccine more important than ever.5,13

Importantly, a COVID-19 vaccine work group of the CDC’s Advisory Committee on Immunization Practices has been formed to develop US policy around prioritization of vaccine delivery.14 It is likely that highest-priority groups will include health care workers and those at highest risk of severe disease, but evidence and expert opinion will provide such clarity only when such a product is available.14 
 
MARY BARNA BRIDGEMAN, PHARMD, BCPS, BCGP, FASCP, is a clinical professor at Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital, also in New Jersey.


REFERENCES
  1. COVID-19 data in motion. Johns Hopkins University & Medicine. Updated August 11, 2020. Accessed August 11, 2020. https://coronavirus.jhu.edu/
  2. When and how is New Jersey lifting restrictions? what does a responsible and strategic restart of New Jersey’s economy look like? New Jersey COVID-19 Information Hub. Updated August 3, 2020. Accessed August 4, 2020. https:// covid19.nj.gov/faqs/nj-information/reopening-guidance/when-and-how-is-newjersey- lifting-restrictions-what-does-a-responsible-and-strategic-restart-of-newjerseys- economy-look-like
  3. COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Johns Hopkins University & Medicine. Updated August 3, 2020. Accessed August 4, 2020. https://coronavirus. jhu.edu/map.html
  4. How to protect yourself & others. CDC. Updated July 31, 2020. Accessed August 3, 2020. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting- sick/prevention.html
  5. Vaccination guidance during a pandemic. CDC. Updated June 9, 2020. Accessed July 24, 2020. https://www.cdc.gov/vaccines/pandemic-guidance/index. html
  6. Using Telehealth to expand access to essential health services during the COVID-19 pandemic. CDC. Updated June 10, 2020. Accessed July 24, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html
  7. Make a strong flu vaccine recommendation. CDC. Updated July 30, 2020. Accessed August 3, 2020. https://www.cdc.gov/flu/professionals/vaccination/ flu-vaccine-recommendation.htm
  8. Guidance for infection control and prevention of coronavirus disease 2019 (COVID-19) in nursing homes. Centers for Medicare & Medicaid Services. March 13, 2020. Accessed July 27, 2020. https://www.cms.gov/files/document/ qso-20-14-nh-revised.pdf
  9. Preparing for COVID-19 in nursing homes. CDC. Updated June 25, 2020. Accessed July 27, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/longterm- care.html
  10. Guidance for pharmacies. CDC. Updated June 28, 2020. Accessed July 25, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/pharmacies.html
  11. Draft landscape of COVID-19 candidate vaccines. World Health Organization. August 10, 2020. Accessed August 11, 2020. https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines
  12. Similarities and differences between flu and COVID-19. CDC. Updated August 4, 2020. Accessed August 6, 2020. https://www.cdc.gov/flu/symptoms/flu-vs-covid19.htm
  13. Frequently asked questions. CDC. Updated August 1, 2020. Accessed August 3, 2020. https://www.cdc.gov/coronavirus/2019-ncov/faq.html
  14. Lee GM, Bell BP, Romero JR. The Advisory Committee on Immunization Practices and its role in the pandemic vaccine response. JAMA. Published online July 22, 2020. doi:10.1001/jama.2020.13167