Influenza in the Time of COVID-19: What Pharmacists Need to Know
Many measures that were concomitantly being instituted across the country to curtail the spread of COVID-19 also decreased the spread of the influenza virus.
Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, comparisons with seasonal influenza have been described because of their overlapping, nonspecific symptomatology and broad range of disease severity. However, there are important distinctions. COVID19 appears more transmissible and more virulent than influenza.1 The incubation period of COVID19 is longer and many individuals are asymptomatic, therefore leading to substantial community spread.1,2 Seasonal influenza has a tremendous impact on the pediatric population, whereas pediatric cases of COVID-19 are relatively infrequent.3 Postinfluenza bacterial superinfections occurring earlier in the disease course are well documented, but this remains controversial in COVID-19.4 Severe complications of COVID-19 have largely been hematologic (eg, thromboembolic events) and neurologic in nature which are not commonly observed with influenza virus.5,6 Mortality rates of COVID-19 seem to be higher than with influenza (3.0% to 4.0% vs 0.1%, respectively), although definitive numbers are not yet confirmed.7-9
As COVID-19 began to rapidly spread in the United States at the beginning of 2020, rates of influenza declined.10,11 This may have occurred because, although it was the end of influenza season, many measures that were concomitantly being instituted across the country to curtail the spread of COVID-19 (ie, social distancing, health-seeking behaviors, etc) also decreased the spread of the influenza virus.12 As a result, influenza surveillance data available for 2020 should be assessed with this information in mind.
With all these distinctions, it is important that pharmacists are aware of the latest developments regarding COVID-19 and the changes that will impact vaccination for influenza and other vaccinepreventable illnesses.
COVID-19 EPIDEMIOLOGY AND SYMPTOMATOLOGY
It is not yet completely known how severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), the virus that causes COVID-19, and influenza viruses will “coexist,” in terms of both epidemiology and symptomatology.13,14 Literature on coinfection is limited, although the results of a study by Kim and colleagues in March 2020 indicated that 24 of 116 patients who tested positive for SARS-CoV-2 also tested positive for another respiratory virus, including influenza.15
Many respiratory diagnoses have overlapping symptoms. The table describes the most common respiratory illnesses, most of which are caused by viruses.8,16-32 Patients who are immunocompromised, those who have underlying lung disease, older adults, neonates, and other special populations may develop severe manifestations of these infections. Influenza itself can cause severe infection in adults and children and in past years has led to considerable hospitalizations and mortality.33-35 It can be presumed that coinfection may lead to worse outcomes; therefore, vaccinating against influenza and other vaccine-preventable infections remains a high priority.
It is known that influenza virus is seasonal, but the seasonality of COVID-19 remains to be determined. Many community-based and institutionally based changes are often made at the start of influenza season that will also be helpful in curbing the spread of SARS-CoV-2 until a vaccine is available. In the United States, the season begins in October and peaks between January and March, although some years have longer-lasting seasons.36 Other respiratory viral infections, such as respiratory syncytial virus, show seasonality and recur with regular annual peaks, typically during winter months.37,38 Others, such as rhinoviruses, are found throughout the year.31
THE ROLE OF THE PHARMACIST DURING THE COVID-19 PANDEMIC
The pharmacist’s role is constantly evolving as the rates of COVID-19 continue to rise in the United States. The American Pharmacists Association (APhA) issued joint policy recommendations with 11 other pharmacy organizations to support the COVID-19 response, highlighting that pharmacists can serve as patient advocates, facilitators, and immunizers.39 It is estimated that 93% of Americans live within 5 miles of a pharmacy; therefore, pharmacists remain the most highly accessible health care providers, especially in underserved areas.40,41 As such, pharmacists can help support the health care workforce and ease the burden on the system during this pandemic.
The APhA Joint Policy recommends that the maximum number of pharmacists possible should be utilized to prevent, treat, and respond to the current coronavirus pandemic, and that pharmacists should be reimbursed for services performed. Specifically, the policy recommends that pharmacists be granted the authority to test for, treat, and immunize for COVID-19 as well as for influenza and strep pharyngitis, although this is currently allowed only in a few states.39
\On April 8, 2020, the Office of the Assistant Secretary for Health, under the guidance of the Public Readiness and Emergency Preparedness Act, issued a statement authorizing pharmacists to order and administer COVID-19 tests that have been approved by the FDA.42 Pharmacies enrolled in Medicare may also register as a temporary independent clinical diagnostic laboratories during the COVID-19 public health emergency.43 Furthermore, the Coronavirus Aid, Relief and Economic Security (CARES) Act provides health care resources to patients, including financial coverage of COVID-19 testing, treatment, and immunization when it becomes available.44
As the United States begins reopening, expanding COVID-19 testing to be administered by pharmacists may greatly increase testing capacity and rates. This action may help bridge the testing gaps in underserved areas where there are disparities in testing and poorer outcomes have been observed.45,46 It may also ease the burden on the health care system by minimizing patient visits to urgent care centers and emergency departments solely for the purpose of testing. Pharmacists can also assist with symptom management by providing patient education and medication recommendations for symptomatic relief.
THE ROLE OF THE PHARMACY TECHNICIAN DURING THE COVID-19 PANDEMIC
Pharmacy technicians can also play an integral role in battling the COVID-19 pandemic. The authors of the Joint Policy Statement recommend expanding technician authority by allowing technicians to transfer prescriptions, tech-check-tech for product verification, and administer rapid diagnostic tests under the supervision of the pharmacist.39 To date, the changes in technician regulations are mainly being handled by states; however, the National Association of Boards of Pharmacy (NABP) has initiated the NABP Passport, a temporary license that allows technicians and pharmacists to easily practice in other states.47 Changes to technician workflow will likely ease the burden for pharmacists as testing and immunizing responsibilities increase. (Also see “Prepping for Flu Season in 2020: Why the Vaccine Is More Important Than Ever” on page 8.)
A LOOK TO REIMBURSEMENT
Although a vaccine against SARS-CoV-2 is not yet available, APhA has proactively recommended that the CARES Act provide adequate reimbursement to pharmacists if they administer the vaccine, once it becomes FDA approved.39 Furthermore, the pharmacy organizations that issued the Joint Policy Statement recommended that Congress pass the Pharmacy and Medically Underserved Areas Enhancement Act into emergency legislation. This act would provide coverage for services provided to Medicare beneficiaries, as well as to the general population, by pharmacists in medically underserved areas, if such services were within their scope of practice. In addition, it would allow pharmacists to bill Medicare for telehealth services and expand the care and reimbursements for services provided to Medicare beneficiaries.48,49
According to CMS, pharmacists are supplementary, or additional, staff members who provide support to primary care providers. Under the new guidance, pharmacists can provide incident-to services via telehealth under the direct supervision of a physician or nonphysician practitioner, which under the new provisions can also be provided remotely.50 In the CMS interim final rule, pharmacists are able to provide medication management services covered under Medicare Part B and Part D and be reimbursed as long as the services are within the scope of practice and are under supervision by the billing physician. Although federal laws have expanded, state restrictions remain in effect.51
The COVID-19 pandemic, in the setting of known public health threats such as influenza, brings many challenges and unknowns to the health care system. Although the public remains focused on COVID-19, pharmacists must continue to prioritize vaccinations for their patients against vaccine-preventable illnesses, given that coinfection with potentially additive effects is possible. Providing patients with supportive care for symptomatic relief of many respiratory infections also is an important responsibility. As frontline health care providers, pharmacists must be prepared with the knowledge to tackle various respiratory illnesses, including COVID-19, in order to best serve their patients.
ALEXANDRA HANRETTY, PHARMD, is a clinical pharmacy specialist in infectious diseases at Cooper University Healthcare in Camden, New Jersey.LUCIA ROSE, PHARMD, is a clinical pharmacy specialist in infectious diseases at Cooper University Healthcare in Camden, New Jersey.
- Wu JT, Leung K, Bushman M, et al. Estimating clinical severity of COVID-19 from the transmission dynamics in Wuhan, China. Nat Med. 2020;26(4):506-510. doi:10.1038/s41591-020-0822-7
- Lauer SA, Grantz KH, Bi Q, et al. The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application. Ann Intern Med. Published online March 10, 2020. doi:10.7326/M20-0504
- Keep children healthy during the COVID-19 outbreak. CDC website. Updated June 14, 2020. Accessed June 29, 2020. https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children.html
- Morris DE, Cleary DW, Clarke SC. Secondary bacterial infections associated with influenza pandemics. Front Microbiol. 2017;8:1041. doi:10.3389/ fmicb.2017.01041
- Connors JM, Levy JH. Thromboinflammation and the hypercoagulability of COVID-19. J Thromb Haemost. Preprint posted online April 17, 2020. doi:10.1111/jth.14849
- Bridwell R, Long B, Gottlieb M. Neurologic complications of COVID-19. Am J Emerg Med. Published online May 16, 2020. doi: 10.1016/j.ajem.2020.05.024
- Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese center for disease control and prevention. JAMA. 2020;323(13):1239-1242. doi:10.1001/jama.2020.2648
- Coronavirus disease 2019 (COVID-19). CDC website. Published June 1, 2020. Accessed June 29, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/index. html
- Maragakis LL. Coronavirus disease 2019 vs. the flu. Johns Hopkins Medicine website. Updated June 28, 2020. Accessed June 29, 2020. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-disease2019-vs-the-flu
- Weekly U.S. influenza surveillance report. CDC website. Reviewed June 26, 2020. Accessed June 29, 2020. https://www.cdc.gov/flu/weekly/index.htm
- COVIDView: a weekly surveillance summary of U.S. COVID-19 activity. CDC website. Updated June 26, 2020. Accessed June 29, 2020. https://www.cdc. gov/coronavirus/2019-ncov/covid-data/covidview/index.html
- Considerations in adjusting public health and social measures in the context of COVID-19. WHO website. Published May 13, 2020. Accessed June 29, 2020. https://www.who.int/publications-detail/considerations-in-adjusting-publichealth-and-social-measures-in-the-context-of-covid-19-interim-guidance
- CDC COVID-19 Response Team. Geographic differences in COVID-19 cases, deaths, and incidence—United States, February 12—April 7, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(15):465-471. doi:10.15585/mmwr.mm6915e4
- Wu X, Cai Y, Huang X, Yu X, Zhao L, Wang F, et al. Co-infection with SARS-CoV-2 and influenza A virus in patient with pneumonia, China. Emerg Infect Dis. 2020;26(6):1324-1326. doi:10.3201/eid2606.200299
- Kim D, Quinn J, Pinsky B, Shah NH, Brown I. Rates of co-infection between SARS-CoV-2 and other respiratory pathogens. JAMA. 2020;323(20):2085-2086. doi:10.1001/jama.2020.6266
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- Pub L No. 116-136,H.R.748 — CARES Act. Modified March 27, 2020.
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- H.R. 592 — 115th Congress: Pharmacy and Medically Underserved Areas Enhancement Act. January 12, 2017. https://www.congress.gov/bill/ 115th-congress/senate-bill/109?q=%7B%22search%22%3A%5B%22Pharmacy+ and+Medically+Underserved+Areas+Enhancement+Act%22%5D%7D&r=2#:~:- text=This%20bill%20amends%20title%20XVIII,if%20furnished%20by%20a %20physician
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