Ask the average person whether it feels like we are starting to get out of the woods on COVID-19 and most everyone would respond in the affirmative, despite some worrying trends in vaccine hesitancy and hospitalizations of young adults. It sure feels like we’ve been hunkered down for quite a long time now. Remember the flu? It’s practically nonexistent this year. The latest data show substantially fewer than 1000 lab-confirmed cases, with only 1 pediatric death nationwide directly coded to the flu for the 2020-2021 season.

 The CDC has chosen to track Pneumonia-Influenza-COVID-19 (PIC) as a bundle of coded conditions for death and will likely continue to do so. From the January 1, 2021, through June 12, 2021, there have been 256,915 PIC deaths.

 In a normal year, between 6% and 8% of all deaths are from influenza- or pneumonia-coded illness; at our peak earlier this year, PIC produced more than 25% of our nation’s deaths.

Mitigating COVID-19 Spread has Taught Us Something (That We Already Knew) About Influenza

Social distancing, wearing masks, washing hands, and getting the flu vaccine are all great ways to avoid getting influenza, at least until another strain comes around. Of course, doing the same for COVID-19 clearly had the same effect, and the evidence supporting behavior-driven mitigation of spread is now overwhelming. There is some ongoing debate about the effectiveness of this year’s influenza match up against the advantage of these behavior changes, but together they are clearly successful in reducing the spread of influenza. Notably, Pacific Rim and East Asian countries have largely figured this out already, and mask wearing during outbreaks is commonplace in countries like South Korea and Japan.

Seasonal and Infectious, But Only One Remains Elusive (For Now)

I quite enjoyed not getting any symptoms or sickness from the flu this year, and I’d like to keep it that way. Unlike for COVID-19, we don’t get nearly perfect coverage and effectiveness rates in the 90%-plus range for the influenza vaccine.

 Rather, we are generally quite happy with rates between 40% and 60%.

 Assuming we get to a manageable, steady state, or a low rate of COVID-19 with booster management, will influenza roar back? Or has COVID-19 changed our therapeutic prowess and social behaviors?

The More Powerful Influence: Lessons Learned or Vaccine Fatigue?

Habits are a powerful influence. We are more than 14 months now into handwashing, wearing masks, avoiding the other person walking down the aisle at the grocery store, and holding our breath. (Admit it. You’ve done it in an elevator.) These habits and front-of-mind awareness will persist. Will I wear a mask everywhere I go? Will I avoid live concerts? Doubtful. Will I get an influenza vaccination? Of course. But what’s the view from the non–health care professional? We still regularly fail to hit 50% of adults vaccinated against the flu most years.

 Will that rate go up or down? It’s so hard to predict: Will COVID-19 mitigation and behavior continue after case rates drop, and will flu again become the principal threat each fall?

Brazil, India, and the Realization That COVID-19 Isn't Going Away

Then there is the worldview. While we begin to have an embarrassment of abundance of vaccine supplies,

 much of the world is still struggling with COVID-19. India can’t keep up with cremations, while Brazil is still in denial.

 If the world’s rate of COVID-19 infections doesn’t come down, herd immunity will get harder as trade and international travel scream to move on. The cruise industry and the CDC are locked in a bitter battle,

 and airline CEOs are grappling with how to treat international travel differently than domestic travel

 as our own “bubble” now eclipses 60% vaccinated with at least 1 dose.

What if a basal rate of COVID-19 infections persists, despite widespread vaccine availability with near 100% effectiveness against severe disease and death,

 especially in the face of an opening up of society that lets us experience a typical flu season? Well, lots of testing would result, one might surmise. Unlike spring allergies, where the differential between COVID-19 and sneezing is more distinct, flu and COVID-19 are remarkably similar in their presentation, although not necessarily in their treatment

—especially in light of oral agents for influenza versus some of the emerging treatment options for patients with COVID-19, with early but potentially progressive infections.

 Testing for influenza with COVID-19 ruled out may become the new normal, for the sake of both patients and surveillance.

2022 Could Be Watershed Year If We Are Prepared, Keep Public Trust

It’s entirely possible for us to vaccinate most Americans against COVID-19; continue testing efforts; and sustain noninfringing, nonimposing, and easy-to-implement behavior change—and still have influenza vaccination rates above 50% this fall. With nearly half a million PIC deaths this year—and the 3 prior years producing roughly 100,000, 80,000, and 80,000 PIC deaths, respectively, inclusive of baseline pneumonia (and the earlier 2 having no COVID-19 deaths)

—might we end up with far fewer overall PIC deaths next year and set a new baseline with our new behaviors and vaccine technologies? Or will we slide back into complacency? Much of that has to do with pharmacist-led preparedness, patient counseling, public communication, and action. Oh, and by the way, maybe now we’ll be better about promoting and administering pneumonia vaccines as well.

 is vice president of pharmacy and provider partnerships for Community Care of North Carolina, which works collaboratively with more than 2000 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.

FluView summary ending on June 18, 2021. Influenza (flu). CDC. Accessed June 24, 2021. https://www.cdc.gov/flu/weekly/

Thompson MG, Burgess JL, Naleway AL, et al. Interim estimates of vaccine effectiveness of BNT162b2 and mRNA-1273 COVID-19 vaccines in preventing SARS-CoV-2 infection among health care personnel, first responders, and other essential and frontline workers - eight U.S. locations, December 2020-March 2021. MMWR Morb Mortal Wkly Rep. 2021;70(13):495-500. doi:10.15585/mmwr.mm7013e3

Vaccine effectiveness: how well do the flu vaccines work? CDC. Accessed May 17, 2021. https://www.cdc.gov/flu/vaccines-work/vaccineeffect.htm 

Flu vaccination coverage, United States, 2019-20 influenza season. CDC. October 1, 2020. Accessed May 17, 2021. https://www.cdc.gov/flu/fluvaxview/coverage-1920estimates.htm

Olsen H. Opinion: The U.S.’s massive vaccine supply could become a diplomatic headache for Biden. Washington Post. April 7, 2021. Accessed May 17, 2021. https://www.washingtonpost.com/opinions/2021/04/07/uss-massive-vaccine-supply-could-become-diplomatic-headache-biden/

Hallal PC, Victora CG. Overcoming Brazil’s monumental COVID-19 failure: an urgent call to action. Nature Medicine. May 6, 2021. Accessed May 17, 2021. https://www.nature.com/articles/s41591-021-01353-2

Norton T. Cruise industry frustrated by ‘burdensome’ CDC requirements. TravelPulse. Updated April 5, 2021. Accessed May 5, 2021. https://www.travelpulse.com/news/cruise/cruise-industry-frustrated-by-burdensome-cdc-requirements.html

Richter F. Aviation industry suffers ‘worst year in history’ as COVID-19 grounds international travel. World Economic Forum. February 18, 2021. Accessed May 5, 2021. https://www.weforum.org/agenda/2021/02/covid19-coronavirus-tourism-aviation-industry-decline

COVID-19 vaccinations in the United States. CDC. May 17, 2021. Accessed May 17, 2021. https://covid.cdc.gov/covid-data-tracker/#vaccinations

Jang A, Ogurchak J. Emergency medications for inpatient treatment of COVID-19 patients. Pharmacy Times®. September 11, 2020. Accessed May 5, 2021. https://www.pharmacytimes.com/view/emergency-medications-for-inpatient-treatment-of-covid-19-patients

Tan Q, Duan L, Ma Y, et al. Is oseltamivir suitable for fighting against COVID-19: in silico assessment, in vitro and retrospective study. Bioorg Chem. 2020;104:104257. doi:10.1016/j.bioorg.2020.104257

Articles

Uncertainty and preparedness make strange bedfellows.

Into the Unknown: What Might a Combined Influenza/COVID-19 Season Look Like This Fall?

Recently, an editor from Pharmacy Timessat down with Kevin Day, PharmD, president of Day’s Miami Heights Pharmacy in Cincinnati, Ohio, to discuss how his independent pharmacy is gearing up for influenza season while continuing to deliver COVID-19 vaccines safely.

How have pharmacy staff helped to streamline the immunization programs at your pharmacy?

In our pharmacy we have a clerk who works at the front register, right inside the door when someone walks in. That person is responsible for starting the process and identifying that a customer is there for a vaccine, whether they have an appointment or just walk in. There is a notification process for us in the pharmacy to know there’s a vaccine appointment or a vaccine walk-in ready for us. Then we generally use either a technician or a pharmacy intern to check in the person and complete any required paperwork or documentation, which varies by vaccine. With COVID-19 vaccines, the process is online; with most of the other vaccines, it’s still a paper process.

[With this process,] all the paperwork is completed by a team member; the pharmacist goes into the vaccine room exclusively to answer any questions and to administer the vaccine. This helps keep the pharmacist in workflow and allows customers to build relationships with other staff members.

Could that process be easily extrapolated to a [retail] chain pharmacy?

I think it can certainly be. It’s probably harder in a busy chain because it depends on how many [customers] are in that space. The person toward the front of the store—the patient services advocate—tends to be free [at our facility]. It’s not [often] that they have 6 people waiting in line. They can step away momentarily to welcome someone. I can see at a large chain pharmacy where that same person might regularly have 4 or 5 people in line, and their job is to get those people through the line efficiently so stepping away might not be an option. And in a supermarket, where someone coming through the front door might be 300 yd away from where [they are] going to get the vaccine, that conversation is going to be a little bit different. But the mentality of getting other people involved in doing some of the steps that have to get done for every person, using more than the pharmacist, is critical to scaling up a vaccine program [without putting] more pressure on the pharmacist.

How do you disseminate information to both patients and pharmacy staff about the available vaccination options?

At my store, the pharmacist is the one who provides information to the patient. We have a de facto system where the pharmacist counsels every patient. Ninety-plus percent of the time, the pharmacists are the ones handing the medication to the patient at the counter and dispensing, and we use that opportunity to talk with the patient, [not only when there’s a] dedicated campaign.

When there is a campaign—for example, [when] we were promoting the shingles vaccines—we identified everyone over the age of 50 and asked them if they had received a shingles vaccine. We’re in that same mode right now, in early May, about the COVID-19 vaccines; we are checking to ensure that the people who are standing in front of us have been vaccinated. Then we are able to answer [any] questions because we have the licensure and the training to do so. It’s just part of a natural flow for us as pharmacists.

For staff training, the advantage we have as a small team is that we can meet regularly and [use] team emails to talk about what is going on and what’s available. We communicated a lot about the COVID-19 vaccines because information was updated week after week.

Do you have a designated education champion or someone who is providing the information to the patient services advocates?

That is one difference between a small pharmacy vs a big one: I am the pharmacist in charge of providing education to the team. My pharmacy [has] 14 or 15 different names on payroll—that includes the patient services advocates, delivery drivers, everyone. A large, busy chain pharmacy location may have 30 to 50 people, so they may need more infrastructure around what the education model looks like, in addition to making sure everyone is on the same page.

I was at my pharmacy earlier today, on an off day, to see a few people whom I do not generally interact with on my team and ensure that they are on the same page as far as what we are doing for COVID-19 vaccines for this week and next. On Thursdays, when I am scheduled [to work] as a pharmacist, that just becomes part of my process: to ensure that the people who are around me are on the same page. If I were in a much bigger location, I would be doing this with a combination of online communication, …such as an email or a message board, and a team huddle, such as a 5-minute discussion on where we are right now. Especially with COVID-19–specific learning, it makes sense [to have this type of training] when information changes on a weekly basis. People on your team need to have the most up-to-date information, particularly now that we are moving into flu season, too.

I love those 5-minute huddle models. They can feel forced early on, but oftentimes, once you get a couple weeks into it, they become a useful and usual part of the process, to get that quick check-in to see what’s going on.

How have the responsibilities or time management of pharmacy staff shifted to accommodate the new tasks?

Not much has changed for the patient services advocates. Welcoming the person who walks in the door and helping them find what they need or pointing them in the right direction has always been a part of their responsibilities. In this case, they are identifying that the person walked in the door for a vaccine. We have 3 waiting areas for social distancing purposes, so they can run that process pretty easily. If a person walks in and drops off a few prescriptions and wants to wait for them, the time management shifts a little bit. Filling those prescriptions takes priority over whatever else has to be done in the pharmacy over the next hour. If the person who walks in has a vaccine appointment or someone walks in for a vaccine without an appointment, then they are next in line. It takes about the same amount of time to check a few scripts as it does to give a vaccine, especially if you have a process in place [and] someone else is helping take care of the paperwork.

The process is similar if we have pharmacy technicians or pharmacy interns and others on the team. If the data entry technician is typing out of an autofill queue, they are going to stop that process and take over to type for the vaccinator; that becomes top priority. Similarly, if the tech is the one who is responsible in that moment to check in that vaccine, they are going to stop what they’re doing and check in that person for the vaccine. The process fits fairly naturally into that workflow that exists in most pharmacies, in my experience.

 You talked about spacing needs for social distancing requirements. What spacing and equipment needs must a pharmacy take into account to ensure the safe storage and delivery of vaccines?

Social distancing definitely made the process more difficult. We took down almost 20 ft of shelving units in the pharmacy to create new areas where patients can wait and to add tables and chairs. Many pharmacies have waiting areas already: that was part of how they were built. However, ours was not built that way. That’s a feature of being a small pharmacy that tends not to have a lot of people waiting around very often, [but with] social distancing that has to be a consideration.

It can be simple: if there are 3 chairs in a waiting area, take out the middle one and move the other 2 chairs 6 ft apart. We use a lot of signage to help keep people separated. For the vaccine administration itself, it was really important that we had a private space to do that and so we built it ourselves. It is not terribly hard to put up a few walls, and I promise you that you have someone in your life who owns a nail gun, or you can rent one and learn how to use it. Two-by-fours are still fairly cheap, and drywall is relatively easy and cheap. You can manage this if you want to. For a few hundred dollars we were able to create a private space with a door that patients feel comfortable in.

As a pharmacy, you have commitments to suppliers and the signage required for some products. How did you decide to remove some to create more space?

That is another advantage to owning my own pharmacy: I didn’t have to ask for permission from anyone about what I was doing. It was about making smart choices, though. If there is no inventory on the shelves, you cannot sell as much. However, in every pharmacy there is inventory that never sells. Learning what that is, running reports to identify it, and making decisions can be challenging.…We used to have almost 200 running feet—or 20 linear feet—of shelving of greeting cards and 45 running feet of school and office supplies. We only have about 500 to 600 running feet of total shelf space. For a long time, about 30% to 40% of our pharmacy housed school and office supplies and greeting cards. When I bought the store, I made a conscious choice that I wanted it to be a health care destination and not an “everything store.” I had the ability to make that choice.

Obviously, though, there are many environments [in which] people do not have the ability to make the choice themselves. However, I would challenge any of them to look into it. As pharmacies get bigger, they also get better data from sales and inventory management. I would challenge them to run those reports and identify the 4-ft, 8-ft, 12- and 16-ft sections that aren’t making any money. If they’re not paying the rent, then you should push [them] out. If you think about the pharmacy or a retail space as an apartment complex, you have penthouse suite locations: Some of the products just move quickly. Those 4-ft sections are paying rents double or triple what the going “rent” might be. Conversely, there are also [locations] that haven’t paid rent in 25 years....Put on your landlord hat and kick those [products] out! You have better things to do with [that space], including either putting out new products that can pay rent or, in our case, taking the shelves down to create more space where everyone is more comfortable.

It also makes the store feel bigger. We have had an incredible response to it. Do people sometimes ask for a hot glue gun? Absolutely. But if you sell hot glue guns twice in a 2-year period and make $1 each time, [it doesn’t come close to] your inventory costs.

 Could this model theoretically be utilized in either a parking lot-extended pharmacy or an off-site vaccination clinic? How would that look?

We’ve done quite a few vaccine clinics off site. I know pharmacies have been doing that for a long time. If the pharmacy is located in a part of the country [where it’s] doable, with ample parking spaces outside, great! There is an opportunity to administer many vaccines in a short period of time if you do leave the 4 walls of the pharmacy. An off-site model can be designed around the flow you need for vaccines, whereas inside the pharmacy you must adapt to the space you have.

Some pharmacies have a board requirement that prohibits leaving the pharmacy with vaccines. For example, some of the COVID-19 vaccines are in that [category]. There are also some logistical aspects, [such as] items that are easy to access inside the pharmacy that might not be easily accessible outside. These items include things as simple as trash cans and sharps containers, as well as more complex aspects such as what to do with documentation and tasks that are normally done in real time, electronically. If you’re taking computers [off site], consider how they are going to be powered and how you are ensuring HIPAA [Health Insurance Portability and Accountability Act] and HITECH [Health Information Technology for Economic and Clinical Health Act] protections. In addition, we almost exclusively offer a single [type of] vaccine, such as influenza vaccines, pneumonia, or COVID-19; we do not take multiple vaccine [types].

Generally, when we go off site, we have a “check-in” person and multiple vaccinators. The check-in process off site is different from in the pharmacy. We already know this person has come to receive a vaccine. The off-site process is to ensure we have the right information on the person, such as their demographic information, allergies, and insurance.

For COVID-19 vaccines, we also take a person who will monitor patients for 15 minutes after they have been vaccinated, which occurs after any vaccination. The monitoring person helps direct traffic to go from the checkin to the vaccinator.

The vaccinator is responsible for any screening questions and answering any questions the patient might have and then administering the vaccine and giving instructions about follow-up, if there are any. All that happens at the point of vaccination, and the patient moves from that spot. That’s really important from a flow perspective, to keep them moving somewhere else. That’s where gyms, churches, and parking lots are helpful.

 How do you keep track of the patients? Is it done on paper or through a web portal?

If you were to have asked me that question a year and a half ago, I would have said it was all paper. Sometimes we had the information in advance from the patients and had profiles built the morning of, say, an afternoon vaccine clinic. Then we brought the paper back to the pharmacy and performed the data entry at that point. That task does not have to be completed immediately. It might take several days to get all the information uploaded, which can work, as long as all the forms are dated on the day the vaccine was administered, in addition to the billing date, and ensuring that the origin code dates are all the same for the date the vaccine was administered.

At our pharmacy, we do not yet take enough technology with us to be able to bill or document on-site; however, for COVID-19 vaccines, our state has a system for scheduling first and second doses. Thus, all the documentation goes into that site.

How does a pharmacy account for the cost of vaccination supplies and inventory?

That is going to be pharmacy specific. At our pharmacy, we have a store-use document to track all the things we use in the store, from supplies for reconstitutions to paper towels, Lysol wipes, and hand sanitizer. We try to [do the same for] vaccine supplies. For my business, we performed a projection model: For example, for every 100 vaccines these are the associated costs, such as a Band-Aid for each one, which equals a box of Band-Aids, and then alcohol swabs, etc. There’s a syringe, and for shingles vaccines, for example, there are 2 different needles as we change needles in between. From there you calculate that out to say, "For every 100 vaccines, this is what the cost is to the pharmacy side." We know if we make on a revenue perspective or on gross profit perspective, X number of dollars on 100 vaccines, that the hard costs associated with that are a certain number.

In terms of billing, what channels are available to pharmacists regarding vaccination reimbursement and insurance coverage?

For most small pharmacies and community pharmacies, it is likely either an all-pharmacy benefit model or potential cash pay. The cash pay model for vaccines is fairly small because most vaccines are fairly expensive, other than maybe flu shots. You’re not likely to convince someone to pay out of pocket for a shingles vaccine at about $400 for a 2-shot series. For my pharmacy, and many pharmacies like mine, we do not have access to medical billing outside of Medicare Part B; we’re exclusively billing on the pharmacy side of the benefit, which makes it easy because it’s the exact same way that you bill everything else. Overall it just becomes very routine.

There are many pharmacies that do have medical billing contracts; some are built into the pharmacy dispensing system. It’s fairly similar to typing a regular prescription, but adjudication is going somewhere else. Diagnosis codes are needed, but those are often built into the system. Medicare tends to [pay for] flu vaccines, pneumonia vaccines, and COVID-19 vaccines under Medicare Part B; however, the pharmacy needs to have an accreditation for that. Again, most [chain] pharmacies have that already within the system. Independent pharmacies likely have one too; whether they use it or not, it’s likely assigned to them. They need to make sure they know what this is and that it’s built into their system. However, Medicare Advantage plans, third-party insurance plans for commercial insurance, and Medicaid plans for the most part all [pay for vaccines as] a normal prescription, and it is fairly simple to take advantage of that.

The cash pay model is competitive. It’s less how about how to do it and more about how to set the pricing. For example, travel vaccines, which regularly are not covered by insurance, may be cash pay. If a person is going to go spend a month in South America, they might need 5 or 6 different vaccines and they may be willing to pay directly for that as part of their travel expenses. The competitor for those vaccines is unlikely to be the pharmacy across the street. The real competitor is a travel-specific company, which may offer those vaccines at a higher cost compared with the acquisition costs of vaccines. If you are in a position where you can choose how much you bill for a vaccine, especially for travel, then those are the places to compare with.

How can pharmacies review their location demographics to determine which vaccines to stock?

That’s a great question. The pharmacy is embedded in the community it’s located in. To me, every pharmacy across the country can succeed with flu, pneumonia, shingles, and tetanus vaccines. If the pharmacy offers anything beyond that, it is going to get a bit subjective as to what you’re interested in, who your relationships are with, and the providers in your area as well as within the community itself.

For example, our pharmacy did well offering hepatitis A vaccines about a year and a half ago because there was a hepatitis A outbreak in our neighborhood. It was [therefore] easy to articulate the value of the vaccine. If you don’t have hepatitis A in your county, then you’re never going to get someone to agree to pay for a vaccine to reduce their very small risk.

For me the decision stems from relationships. The pediatricians on my side of town are incredible. They take really good care of the community. I don’t want to step on their toes, so we’ll work collaboratively with them in building a plan for pediatric vaccines so that we’re helpful for their practices and the families.

The same goes for meningitis if you are located in a town with a private college, for example. [That provider visit] at 17 years of age may be the last time a student sees a health care provider until they turn 30. You don’t want to take away that last doctor’s visit. We have to recognize the ways we can bring value in addition to what others may bring to the team.

At this point in 2021, pharmacies have been giving vaccines broadly for almost 15 years. Providers in the area are going to expect pharmacies to give vaccines. If you do not have a relationship with a doctor, you’re possibly stepping out of line. Don’t step on toes that you don’t need to step on.

 How do you reach all the members of a certain age group for a given vaccine? Are you doing phone calls, text alerts, emails?

A program we did for shingles vaccination was very successful: We would place little paper flags on prescriptions for pickup with a patient over 50, and that would transition at various times [to talking about] a vaccine. We do have programs to send text messages or to send automated voice calls as well; however, our business model is built on personal relationships, and an automated phone call does not fit into the brand that we live and breathe. Thus, we have conversations at the point of dispensing and on the phone. And we encourage patients to tell their friends, particularly after every COVID-19 vaccination.

Pharmacists are masters at building a good rapport. Asking patients to tell their friends is important for encouraging vaccine-hesitant individuals. We want people to be vocal about it and say, ‘Yes, I got my vaccine today. It was a great experience, it was super easy, and it didn’t even hurt!’ That is wonderful, because the person who they said that to might be on the fence about getting a vaccination. [Hearing something positive from their friend] might be the trigger that gets them to change their mind. That worked at our pharmacy with shingles vaccines. The friends came from all over; no amount of text messages or phone call campaigns would ever have found those people.

How are you handling vaccine fatigue, both for patients and pharmacy staff?

[Vaccine fatigue] has the potential to be a fairly big problem coming into this fall, and a lot of it’s going to have to do with what happens around the success of the COVID-19 vaccines and the durable immune response to them. A situation [in which] a person is trying to get a flu shot while also thinking about getting a COVID-19 booster can be difficult. We are going to learn how to approach this from experience and talking to patients and seeing what resonates and what doesn’t. Many patients likely will try to skip flu shots this fall if they have to get a COVID-19 booster. From the pharmacy and pharmacy team’s perspective, if we get instruction that we need to use COVID-19 vaccine boosters in a November to February time frame, it’s going to be really hard to get through the flu shot frenzy of September and October and directly into COVID-19 and organizing the two. That’s a challenge we don’t have the answer to yet.

What else should pharmacies be thinking about going forward?

If you look across all the vaccines and vaccine percentages, pneumonia vaccine percentages are pretty dismal across the country, and they have not really changed for a while. A program to improve that makes sense. Similarly, HPV [human papillomavirus] is estimated to cause more than 40,000 cancer cases a year.

 It’s not a small cancer, yet only about half of teens have been fully vaccinated against HPV.

 The first step…is getting you and your team educated about the vaccine and the virus that can cause it so you can speak eloquently about the benefits of vaccination. To have it in stock, to know what the schedules are, to be able to speak about the benefits, and then to build relationships with providers about how to target those populations, that makes a ton of sense. There’s so much opportunity in that regard from a public health perspective. 

1. HPV-associated cancer statistics. CDC. Updated September 3, 2020. Accessed June 10, 2021. https://www.cdc.gov/cancer/hpv/statistics/index.htm

2. Elam-Evans LD, Yankey D, Singleton JA, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years — United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(33):1109-1116. doi:10.15585/mmwr.mm6933a1

Kevin Day, PharmD, president of Day’s Miami Heights Pharmacy in Cincinnati, Ohio, discusses how his independent pharmacy is gearing up for influenza season while continuing to deliver COVID-19 vaccines safely.

Leveling Up for Flu Season in the COVID-19 Era: How One Pharmacy Is Rising to the Challenge

The beginning of the 2020-2021 influenza season brought much anticipation about how the cocirculation of influenza and SARS-CoV-2 might affect the health care system. Social distancing measures and mask wearing were likely to lower the influenza rates, as was seen at the start of the SARS-CoV-2 pandemic, but it was unclear by how much. Ensuring individuals were up-to-date on vaccine-preventable illnesses was a CDC priority that could help preserve the health care system's capacity and prevent influenza-related visits.

Throughout the 2020-2021 season, influenza rates were noticeably low, and at the end of the season, rates were at an historic low. Between September 27, 2020, and June 19, 2021, the proportion of patient visits for influenza-like-illness remained between 0.8% and 1.6%, which is well below the national baseline of 2.6%.

This is compared with 38 million cases of influenza during the 2019-2020 influenza season with percentages around 6%—which had been described as being moderately severe.

 The low influenza rate in the 2020-2021 season was likely attributable to social distancing measures and mask wearing.

Since the start of the pandemic, politicization and misinformation campaigns have led to vaccine hesitancy about the COVID-19 vaccine. However, vaccine hesitancy is not a new behavior. For example, there is still a substantial amount of vaccine hesitancy surrounding the influenza vaccine, though it was developed in the 1940s.

 During the 2018-2019 influenza season, just 45.3% of adults aged 18 and older in the United States received a seasonal influenza vaccine.

 The Strategic Advisory Group of Experts (SAGE) established the SAGE Working Group on Vaccine Hesitancy in March 2012 because of concerns about hesitancy and the effect it can have on vaccine uptake rates and national immunization programs.

 The decision was based on declining immunization rates among individuals from developing and developed countries.

 The working group defined vaccine hesitancy as a "...delay in acceptance or refusal of vaccines despite availability of vaccine services....It is influenced by factors such as complacency, convenience, and confidence."

Vaccine hesitancy is a global issue, despite considerable evidence that vaccines are safe and effective.

 In 2019, the World Health Organization (WHO) stated that vaccine hesitancy was a global health threat,

 and in the United States there has been an uptick in vaccine-preventable diseases, such as measles, along with growing vaccine hesitancy.

 The COVID-19 pandemic has been associated with vaccine skepticism. The results of a recent survey on COVID-19 and vaccine hesitancy in the United States found that during the first 6 months of the pandemic there was an increase in vaccine hesitancy and a decrease in the intention to get the anticipated COVID-19 vaccination and the seasonal influenza vaccine.

On December 11, 2020, the FDA authorized the use of the first COVID-19 vaccine, from Pfizer-BioNTech, under an emergency use authorization (EUA).

 Since that time, the FDA has also granted EUAs to the Moderna and Johnson & Johnson COVID-19 vaccines.

 As of June 30, 2021, 179 million individuals (54.2%) in the United States have received at least 1 dose of a COVID-19 vaccine and 154 million (46.4%) are fully vaccinated.

 As adult COVID-19 vaccination rates continue to increase and with the recent FDA authorization of the Pfizer COVID-19 vaccine for emergency use in children aged 12 to 15 years, there likely will be continued easing or social distancing and mask-wearing restrictions.

 Therefore, for the 2021-2022 season, influenza vaccinations will remain a priority.

REDUCING INFLUENZA BURDEN THROUGH VACCINATIONS

Throughout the pandemic, pharmacists have stood out as frontline vaccinators. Going into the 2021-2022 influenza season, pharmacists will likely encounter patients with some degree of vaccine hesitancy or vaccine fatigue. Pharmacists should encourage patients to get not only a COVID-19 vaccine but also an annual influenza vaccine.

Influenza can cause significantly morbidity and mortality and is associated with an economic burden from lost work productivity.

 To reduce the burden of influenza-related illness, the Advisory Committee on Immunization Practices recommends an annual influenza vaccine for individuals 6 months or older without medical contraindications.

 Vaccination is especially important in individuals at increased risk for medical complications from influenza, including individuals 50 years or older, children aged 6 months to 8 years, pregnant women, and those with underlying health conditions.

 An influenza vaccine can reduce the risk of illness, hospitalization, and death.

 Vaccine efficacy varies yearly and is dependent on patient-specific factors such as age and immune status, the type of vaccine administered, and how well matched the vaccine is between circulating viruses and those in the vaccine. Nonetheless, vaccination protects against influenza and reduces the severity of illness in vaccinated individuals who become infected.

VACCINE ACCESS IN HEALTH CARE, PHARMACY DESERTS

Health care providers cite patient deliberation about the pros and cons of vaccinations and distrust of the health care system as reasons individuals of racial minorities may choose not to be vaccinated.

 However, limited access to vaccines also can lead to lower vaccination rates. Vaccines need to be available not only at clinics but also in pharmacies and other locations in more isolated communities, with more flexibility of hours for those who have to work during business hours.

Influenza vaccination is offered at most community pharmacies nationwide. Because pharmacists are accessible individuals may feel comfortable talking with them about vaccine-related fears. As described in a recent 

 article, many individuals live in health care deserts where access to care is limited

 and pharmacies are the closest locations to access vaccines. Nine out of 10 Americans live within 5 miles of a pharmacy, with the average distance being 1.6 miles for those living in a region based around an urban center and 5.6 miles for those not near an urban center.

 Even then, if a patient lives in this health care desert or a rural area outside of urban centers, it might be difficult for them to travel every year for the vaccine. Those who live in cities also may not be able to easily access a pharmacy or clinic. Areas where the average distance to a pharmacy is 1 mile or more have been classified as pharmacy deserts, and in low-income neighborhoods where 100 households or more have no vehicle, the distance to be classified as a pharmacy desert is 0.5 miles.

 Studies evaluating the proximity of individuals to pharmacies have shown that these distances and circumstances can be challenging, particularly if the individual is elderly or relies on walking or public transportation.

 Getting to the bus or directly walking to a pharmacy may be nearly impossible.

CVS corporate leaders discussed the role of pharmacies in equitable vaccine distribution and announced in February 2021 that they will be working with nonprofits, such as the YMCA, to increase vaccine access. They also will partner with the ride-sharing company Lyft to help those in lower-income areas with free rides or discounts.

 This initiative will increase access to vaccines for those who may have difficulty getting to their regular clinic.

It is important to distinguish between vaccine hesitancy and refusal, as the approach to each is different. Patients who are hesitant may only need questions answered before choosing to vaccinate, whereas it may be more challenging to persuade someone who outright refuses vaccines.

 There is no one-size-fits all way to overcome vaccine hesitancy, as the reasons behind each individual's fears and concerns are different. Health care providers need to listen to their patients and address their unique concerns rather than simply trying to explain the science behind vaccines.

American Journal of Pharmaceutical Education

 in 2018 discussed vaccine hesitancy and how to prepare pharmacy students for vaccinating patients and providing information about vaccines. Student pharmacists and doctors were evaluated on how they spoke with multiple "standardized patients" and were assessed on rhetoric, communication skills, and social-emotional competence.

 Studies evaluating parents' acceptance of influenza vaccines for their children have noted that it works well when pharmacists use presumptive phrasing such as "Today we are going to give your child the recommended vaccines to keep your child healthy."

Displaying empathy toward patient concerns while dispelling myths and describing benefits of vaccination also has been shown to be effective. For example, if a patient argues that it is still possible to become infected with influenza after receiving a vaccine, providers can explain that, yes, this is true, but the symptoms are milder and outcomes are better after receiving a vaccine.

 Scientists and physicians estimate the prevalent influenza strains each year to the best of their ability,

 but, it is not possible to know which strains will be the most common. A universal influenza vaccine, one that can protect against multiple subtypes of influenza, is being investigated by National Institute of Allergy and Infectious Diseases' influenza research program. This vaccine would protect more individuals against influenza without the need to investigate and predict which strains will be most common each year.

The SAGE working group suggests a communication plan for health care providers to use when addressing patients who are vaccine hesitant.

anticipating antivaccine remarks or behaviors and planning responses in advance,

understanding the population and considering determinants of vaccine hesitancy to deliver a tailored and persuasive message,

providing knowledge but also identifying underlying issues and taking action based on those issues, and 

using a variety of methods to deliver information. Marketing and social media campaigns have been effective in improving vaccine uptake in some places, but using multiple delivery methods focusing on the population in question is ideal.

Although using a script may sound insincere to patients, having a few notes to use as a guide for fielding patient concerns is reasonable. Providers should consider addressing concerns that cannot be answered with statistics. For example, sometimes patients need time to process information, so expecting them to receive a vaccine at that moment may not be logical. Offering the patient options to come back and receive a vaccine may allow them to feel more in control of their health. Conversely, if it would be difficult for a patient to return, the vaccine should be provided that visit.

The WHO puts vaccine hesitancy into 3 categories: complacency, confidence, convenience. Many factors can affect each of these, including misinformation spread on social media or through word of mouth. If the perceived risk is lower than the perceived benefit, patients become complacent. Effective and safe vaccines, reliable and competent health services delivering the vaccines, and policy-making motivations affect patient confidence. Convenience is measured by physical availability, affordability, willingness to pay, accessibility, ability to understand, and appeal of immunization services.

However, access to vaccines and vaccine affordability remain a challenge. For patients without insurance, vaccines may be cost prohibitive. For others, travel to a health care facility may not be an option. In addition, patients may not be confident about the vaccine or health care providers in general, based on prior experiences with the health care system.

It is important for health care providers to be prepared to address patient concerns. Examples of common concerns are stated next and in the table.

For patients who think they receive too many shots, it is important to empathize with their concern, be understanding if they are more fearful of pain or adverse effects from vaccines, and reiterate that administering multiple vaccines at once is safe and effective.

"How will a flu shot interact with the COVID-19 vaccination?"

Initially, there were limited data regarding the interaction of an influenza vaccine with a COVID-19 vaccine, and the CDC recommended a 14-day interval between any vaccinations. However, with more data becoming available, the CDC now says that COVID-19 vaccines can be administered simultaneously with other vaccines, such as the influenza vaccine, and coadministration within 14 days is also permissible. There have been no reported interactions between the COVID-19 and influenza vaccines.

With the development of COVID-19 vaccines, there has been an increase in hesitancy and fatigue surrounding vaccines. Hesitancy surrounding a COVID-19 vaccine also seems to have increased hesitancy toward influenza vaccines. As the 2021-2022 influenza season approaches, health care providers should prepare to overcome vaccine hesitancy and fatigue. Science alone is often not enough to alleviate patients' fears and concerns, and there are many cultural and societal inequities that influence patients' beliefs. All of these factors should be taken into consideration when addressing vaccine hesitancy and fatigue.

is a clinical pharmacy specialist in infectious diseases at Cooper University Health Care in Camden, New Jersey.

is an assistant professor of clinical pharmacy at the Philadelphia College of Pharmacy in Pennsylvania. King also is an infectious disease clinical pharmacist at Cooper University Hospital in Camden, New Jersey.

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Feature

Since the start of the pandemic, politicization and misinformation have led to hesitancy about the COVID-19 vaccine. However, vaccine hesitancy is not a new behavior.

Just One More Shot: Influenza Vaccine Hesitancy During a Pandemic

Since the advent of the global COVID-19 pandemic, the health care community has experienced an increased demand on services. In the United States, the health care system continues to be pushed to its breaking point with rising workload demands on health care providers. These demands include preparing for the implementation of pandemic-related services and delivering those services (eg, point-of-care testing, vaccinations, increased inpatient census, triaging of care).

As essential businesses on the front lines, pharmacies have continued to demonstrate their value during the pandemic by remaining open to the community for vital prescription services, evolving into COVID-19 point-of-care testing sites, and becoming COVID-19 vaccine administration sites. Pharmacies are essential in achieving the end goal of herd immunity

 in the global battle against SARS-CoV-2, the virus that causes COVID-19.

Now pharmacies will have the opportunity to take the lessons learned during the COVID-19 vaccination rollout to prepare for the 2021-2022 influenza season.

With many people remaining to be vaccinated against COVID-19 and everyone 6 months and older needing an annual influenza vaccine for the 2021-2022 season, many pharmacies are turning to pharmacy technicians to assist in the process.

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Just One More Shot: Influenza Vaccine Hesitancy During a Pandemic

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Equal but Not the Same—2021 Update on Influenza Vaccines