The Progression of Immunization - Episode 5

Patient-Specific Flu Vaccine & Side Effects

Troy Trygstad, PharmD, MBA, PhD; John Beckner, BSPharm, RPh; and Brian Hille, BSPharm, RPh, review the selection of flu vaccines for the patient and association of adverse effects with the vaccine, as well as identify the packaging options available.


Troy Trygstad, PharmD, MBA, PhD: John, let’s revisit the selection of flu vaccine. So, we were talking with Brian earlier about how there’s more nuance, there are more options available, rather than just a single type of a shot for every population and subpopulation. When I get into flu season, I’m a practitioner behind the counter. What am I thinking about when somebody is coming up to the counter? What types of patients and what types of categories of flu vaccinations am I thinking about when they approach the counter?

John Beckner, BSPharm, RPh: I think probably the main differentiation is the recommended high dose for folks over the age of 65. That’s going to be your main demographic. I think as we discussed earlier, there’s really a move toward the quadrivalent, which offers more coverage. The CDC has recommended a reduction in the manufacture of trivalent, so I think you need to be thinking in terms of quadrivalent. There are a couple of other different types of vaccine. It used to be there was a major concern about egg allergy. I think that’s dissipated to a degree. And I think the recommendation is that unless you’ve had a severe allergic reaction, you probably shouldn’t get that immunization in the pharmacy; it ought to be done at a specialist such as an allergist or a physician. So, there are a couple of vaccines; 1 in particular does not have an egg component. And I think the main thing that they need to be thinking about is really the high dose versus the other, and the other tends to gravitate toward the quadrivalent these days.

Troy Trygstad, PharmD, MBA, PhD: We’ve got extremely low instances of harm caused by administration of vaccines in this setting of care. It doesn’t mean that there aren’t adverse effects associated with vaccinations or adverse effects that are perceived to be associated with vaccinations. So, Brian, speaking to this issue that I’m a frontline pharmacist out there, and although all the numbers tell us that my activities improve health, help the care team, improve outcomes, move measures, and are safe and effective, it doesn’t mean that folks aren’t going to have an experience or perceived experience of an adverse effect associated with a vaccination. What’s the best way to handle that in that practice environment?

Brian Hille, BSPharm, RPh: First, we just have to recognize the fact that there are going to be some adverse effects associated with administering immunizations. Most of them are just simply local reactions, and so getting a sore arm after an immunization is expected. And, actually, when I was training our pharmacists, I’d always talk to them about how that’s actually a good thing. That means the vaccine is actually having a reaction that is causing antibodies to be produced, so having a little soreness in the arm is a good thing. Now, sometimes you get a little bit of fever or malaise that’s associated with some of these vaccines. That’s different depending upon the type of vaccine. But as long as patients are informed before they receive a vaccine, so they know what to expect, then they’re fine. It’s when they are not informed that there’s a problem.

Troy Trygstad, PharmD, MBA, PhD: So, put yourself behind the counter. A patient comes up and says, “Oh, I don’t want to get a flu vaccine this year. I got a flu vaccine last year, and it gave me the flu.” What’s your talk trap?

Brian Hille, BSPharm, RPh: Yes, right. That’s always a difficult one, because they’ve already convinced themselves that they got the flu as a result of getting the flu shot. And you can say that that is impossible until you’re blue in the face, but they believe what they want to believe. But we should always, as health care providers, represent the truth. And the truth is, it is not possible to get the flu from getting the flu shot. You might have come in contact with somebody that had a cold or the flu at the same time that you’re getting your flu vaccine, and you ended up getting sick as a result of that. Now, there are certain things that happen that are by coincidence, but you can’t get the flu as a result of getting the flu shot.

John Beckner, BSPharm, RPh: And it could actually be your immune system kicking in after you got the flu shot.

Troy Trygstad, PharmD, MBA, PhD: Getting back to the variation of different products that are available to us, which is a good thing now: It’s more complex but allows us to have better offerings and more selective offerings for select populations. When we get back to the inventory question, John—multidose vials, single-dose vials, prefilled syringes, etc, etc—what am I thinking about as a pharmacy owner, as a pharmacy practitioner, and as a technician with respect to these various forms of the vaccine?

John Beckner, BSPharm, RPh: I’m going to touch on technicians first because we really haven’t covered that. But I think that when it comes to patient engagement and the technician oftentimes being the first person the patient comes in contact with, the technicians play a vital role in a community pharmacy’s immunization program from an ancillary standpoint, from a patient engagement standpoint. But back to your initial question: If I’m a pharmacy owner and I’m trying to decide what to buy for this coming year, obviously the multidose vials are probably the most economical. Single-dose vials are probably not very prevalent these days. Also, if I’m a community pharmacist and I go out into the community and offer flu shot clinics at employer groups, the prefilled syringes are really a pretty efficient way to go. Everything is self-contained: the vaccine, the syringe, the needle—typically, a very sharp needle that works very well. So, I’m probably thinking in those terms if I do a lot of flu clinics and off-site immunizations.

Brian Hille, BSPharm, RPh: Yes, and I think from our perspective of buying and determining, obviously price is always a big consideration there. But you are exactly right, pharmacists really like that prefilled syringe because it makes it efficient. It’s quick and easy. Put on a needle and you can give a shot, and it’s a fresh needle that hasn’t been stuck in to the top of a stopper. So, there are some advantages to the prefilled syringe, but a multidose vial is still a great product. It has been the staple for years and years, but I do see the marketplace moving more toward that prefilled syringe.

Troy Trygstad, PharmD, MBA, PhD: And is that related more to ease of work flow or more related to economics? What might be driving that trend?

Brian Hille, BSPharm, RPh: I think a combination of both of those. The prefilled syringes economically can compete with a multidose vial and then, of course, preference by the health care provider.

John Beckner, BSPharm, RPh: Pharmacists are always concerned about how long it takes to do it and work flow. The prefilled syringe kind of takes that out of the equation. I don’t have to worry about that.