The Progression of Immunization - Episode 4

Available Flu Vaccines, Choosing One, Adding Vaccines

Troy Trygstad, PharmD, MBA, PhD; John Beckner, BSPharm, RPh; and Brian Hille, BSPharm, RPh, talk about how to choose from the available influenza vaccine brands, based on patient factors.

Troy Trygstad, PharmD, MBA, PhD: So, we have the decision support—who’s eligible for what vaccines. Obviously, as you said, everybody walking in over the age of 6 months needs it. Then we have these subpopulations, which gives it a little bit of nuance, but then we have this concept also of knowing which to order. So, if we’ve got different types of flu vaccinations for different types of patient populations, I might need to think about a high dose if I’m in an area that’s Medicare heavy versus across the street from a pediatric clinic. John, what might go into the thinking of a wholesaler or an independent pharmacy out there, as far as preparing for a flu season from a supplier inventory perspective? It’s not just as simple as ordering the flu anymore, right? Or is it?

John Beckner, BSPharm, RPh: Not anymore. As I mentioned, the good thing is, vaccine typically is not in short supply. The challenge is what to order. Lately, it has become clear that the high dose is the flu vaccine of choice for those folks over the age of 65, which tends to be a good percentage of the folks who are vaccinated against the flu when you talk about independent community pharmacies. Knowing which other vaccines to order is a little bit more of a challenge. The independents tend to maybe pay a little bit more attention to inventory-carrying cost and may be a little reluctant to step out and try to expand their influence of vaccine portfolio. So, it’s really a continual educational effort to provide them with the information they need to make decisions year to year.

Troy Trygstad, PharmD, MBA, PhD: But at the simplest level, making sure you have a high dose for elderly populations is something every pharmacy should be thinking about, is that right?

John Beckner, BSPharm, RPh: Exactly, yes, for sure.

Troy Trygstad, PharmD, MBA, PhD: What other nuances are there associated with the inventory control, right? So, we talked about every patient coming in, identifying registry, workflow, nuances in different populations, order…but then we also have storage; we also have the recordkeeping and so on and so forth. If I’m one of those pharmacies that’s doing immunizations or just getting immunizations, what is the full breadth of activities that I need to be thinking about as I’m getting into immunizations?

John Beckner, BSPharm, RPh: Well, you mentioned inventory. Storage is important. Vaccines—not a lot but a number—require a freezer for them to be frozen. So, you carry a freezer, which is 1 reason I think pharmacies have become more important to vaccine administration, because physicians tend to be reluctant to invest in those types of equipment. And I think that may have been 1 of the reasons why they did not elect to carry certain vaccines, along with billing issues. So, billing is another important consideration—knowing how to bill. Typically, in a pharmacy, an immunization is treated just like a prescription in terms of billing. But it could be different, whether it’s Part B or Part D when it comes to Medicare.

Troy Trygstad, PharmD, MBA, PhD: As you were mentioning earlier, we’re not at the leading edge of the curve, and we’re not in the bell part of the curve. We’re waiting on the lagging part of the bell curve. So, it’s not if I go do these things now, I’ve got an advanced practice. If I’m not doing immunizations comprehensively, I’m actually getting behind.

John Beckner, BSPharm, RPh: You’re way behind, actually.

Troy Trygstad, PharmD, MBA, PhD: Way behind. If I were to ask you, Brian, if you think about the marketplace of products—FluQuadri, Fluarix Tetra, Influvac Tetra, Afluria Quad, Fluad, Fluzone—how do I make sense of all of that? We’ve got the ACIP guidelines, but then we’ve got all these different products that are out there. How do you distinguish and categorize in your mind? So, you’re the average pharmacist out there, there’s all these products. I’m thinking flu. How am I categorizing those in my mind?

Brian Hille, BSPharm, RPh: I can speak to my experience. I think John might have perspective on this, too, of looking at an independent pharmacy. Now, our pharmacists have a little bit of advantage, because we spoon-feed some of this to them. So, we give them information about different populations and which is the appropriate vaccination and why that is, and here’s the study that you can read that reinforces the direction that we’re providing to you. We preload each of our pharmacies based off of their patient population with the right kind of vaccines that they need for the patient population that they’re going to vaccinate that year. So, we take some of that off of them. I used to worry that it was going to be terribly complex, but it really is not that complex. When you think about it, for us now, we don’t use trivalent anymore; we’re quadrivalent 100%. And so, the base is, everybody should receive a quadrivalent vaccination now. If you’re between the ages of 50 and 65, you’ve got a specific vaccine that studies show have some additional benefit. If you’ve over the age of 65, here are the couple of brands that can actually be used for that population.

Troy Trygstad, PharmD, MBA, PhD: And the whole idea there with high dose is what?

Brian Hille, BSPharm, RPh: Well, you get a better immune response. Studies are showing that you actually get greater benefit from that high dose or an adjuvant vaccine that is made specifically for that over-65 population. Their immune system just doesn’t work quite as well, so giving more or giving a vaccine that has a better response…

Troy Trygstad, PharmD, MBA, PhD: Stimulates a larger response.

Brian Hille, BSPharm, RPh: It’s a benefit to that patient population. And so, it makes sense, and if you take it from the perspective of the pharmacist that you are doing the right thing for the patient and here’s why, you get buy-in very, very quickly.

Troy Trygstad, PharmD, MBA, PhD: What happens if you don’t have that person who’s sifting through that information in a pharmacy, John?

John Beckner, BSPharm, RPh: I was anticipating your question. They certainly don’t have that advantage, and that’s why it’s important for NCPA (National Community Pharmacists Association), as an organization, to provide them the tools and resources, whether it’s through webinars or whether it’s through our annual meetings on multiple occasions, which are increasing over the past several years. And I think the rates of members of immunizing have gone up, and I would like to think that that has something to do with the programming that we’ve been providing. There has been an emphasis on immunizations. Obviously, our independent members or owners have the autonomy to order what they want to. Hopefully, by virtue of the resources that we’re providing them through our various programs, they can select. And I think, obviously, the high dose is important for that population. When you consider the other vaccines and that there is a move toward quadrivalent, by and large, it’s not as important to drill down and pick a specific vaccine. I think the most important thing is to do the age-appropriate high dose, but with the others, it’s maybe not quite as important.

Troy Trygstad, PharmD, MBA, PhD: Let’s talk about gateway drugs. So, the concept of a gateway drug is, I experiment with 1 drug that leads me to a whole bunch of other drugs. Can we apply that concept to vaccinations? I’m giving the flu shot to everybody walking in the door. Is that a gateway drug to a bunch of other vaccinations that are needed by the patient?

John Beckner, BSPharm, RPh: That’s probably the biggest opportunity in the community pharmacy immunization world today, that a lot of people are candidates for other vaccines. For example, for people over the age of 65, if they come in for a flu shot, you probably ought to be thinking about pneumococcal or shingles vaccines. If you’ve got a grandparent who doesn’t want to run the risk of passing whooping cough to their grandchild, they can come in for the pertussis vaccine. So, there are lots of opportunities out there to expand beyond the flu.

Troy Trygstad, PharmD, MBA, PhD: There are a lot of diseases in a lot of patients we can help prevent. And we need to be thinking about those, because the mind-set of the patient walking in might be “I need to get my flu shot.”

John Beckner, BSPharm, RPh: Right.

Troy Trygstad, PharmD, MBA, PhD: That’s an opportunity to have them frame in their mind a broader array of vaccines and that they also need to consider them, because they’re in a state of readiness for a needle, right?

John Beckner, BSPharm, RPh: And because of the number of visits that patients pay to the pharmacy versus the number of visits that they pay to their physician, the pharmacist is really uniquely positioned to be able to offer those vaccines.