A panel of experts discuss those most at risk for complications from the flu, and how flu vaccines may benefit them.
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: Dr Welch, how do the adverse events profiles differ among the different types of flu vaccines? You might even want to delve into COVID-19 and flu vaccines.
Adam C. Welch, PharmD, MBA, FAPhA: We can expect any time we’re putting a needle into someone’s deltoid muscle, that there might be some pain at the injection site, some redness and swelling, [and] some reactogenicity events such as headache, chills, and maybe some mild fever. We can expect fatigue, as well, for example. When you’re looking at high-dose and adjuvanted vaccines, they were tested against a placebo in some of the clinical trials to get those products approved. [The event rate is] a little bit higher than [with] some of the placebos. Sixteen percent pain was [shown] in the packaging studies for the adjuvanted [vaccines]. Ten percent of patients experience headaches and 10% experience fatigue. You mentioned COVID-19: When you’re looking at the mRNA COVID-19 vaccines, about 80% of people had some sort of pain. It was much more pronounced from a frequency standpoint. About 40% had some sort of fatigue. So a little bit higher than what we [usually] see. To summarize, though, high-dose and adjuvanted [vaccines] may have a little bit more injection-site reactions and systemic reactions than the standard-dose injections that we’re seeing. But again, the efficacy, particularly in people 65 and older, makes that adverse effect tolerable, because typically these would last about a day or two and they would go away. The adverse events are usually mild. But having that protection against the complications from flu in that population makes them worth it. And that’s why they’re preferentially recommended by the ACIP [Advisory Committee on Immunization Practices].
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: It makes sense. The immune system’s reacting. So again, it’s that conversation with the public sometimes, and I know we’ll discuss this in a later segment around hesitancy issues and things like that but that conversation needs to occur, perhaps in the practice. Certainly when you’re talking to individuals about vaccination, is that “Guess what? When you get a vaccine, whether it’s shingles, flu, RSV [respiratory syncytial virus], whatever it is, you’re likely going to have at least some type of local reaction.” And then perhaps some light fever, perhaps some light fatigue, or more pronounced just because of that indication.
Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: And actually, when I talk to patients about that, I say, “That’s how you know it’s working.”
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: Yes, absolutely.
Adam C. Welch, PharmD, MBA, FAPhA: That’s the key. Tell them. Make them aware that this may happen so that they’re not feeling this and think it’s unexpected and then call you afterward.
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: Or aligning it with something else. Dr Worz, who is most at risk for complications from the flu and how can the flu vaccines benefit them?
Chad Worz, PharmD BCGP, FASCP: I think, again, you brought this up earlier with our experience with COVID-19. If we learned one thing from COVID-19, it is that our older, vulnerable patients are at higher risk of complications from infections. So we knew this. Dr Welch had mentioned immunosensitivity. Our immune system is weaker as we get older. When you’re fighting a battle on 2 fronts, whether it’s diabetes or cardiovascular disease or asthma, and you complicate that with an infection like influenza, you’re going to be at higher risk for harder complications and a more difficult path. So we look at those populations and identify them as higher risk. And our messaging might be different or more emphatic on why it’s important to get the flu vaccine when you’re in those populations. We also look at pregnancy; younger children, usually under 5 [years], particularly under 2, are at higher risk for complications from influenza. So vaccination becomes more important.
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: Yes, absolutely. And I know you gentlemen, all as pharmacists, often probably have to [inform] your patients and others that there are populations––again, this education piece––…however small they might be, that actually may not be able to receive a vaccine.
Chad Worz, PharmD, BCGP, FASCP: Absolutely. And I think, again, it gets to the conversation we’ve been having. We look at these things in population health and we look for a universal solution, but at the end of the day, it’s the person [who’s] in front of you that you’re making a decision about. Why is this important for you? Why do you need to do this? What complications might you have to make us think of a different direction on what to do here? And that’s important.
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: Absolutely.
Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: I can tell you, too, it changes for us every year. We put a new protocol together as we work with some of the physicians. Now we got a statewide protocol. But things change all the time. So that statewide protocol might be changing as well…. So make sure the pharmacists are aware of that and looking for the contraindications and other things with patients and having that discussion with them as well. Because sometimes they may think they have a contraindication when they actually don’t have a contraindication.
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: I think, again, what we’re doing here today and what we hope goes forward with all individuals in this area in health care and pharmacy and other aspects of health care, is that ultimately, it’s real-time, it’s changing every year, if not every day, and it’s our job to get that information, not just to the other health care providers but to our patients.
Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: I would say, too, if COVID-19 taught us anything, as a community pharmacist, it was the importance of having accessibility of pharmacists providing vaccinations. And if you look at the number of flu shots given annually, and the percentage of them being done in a community pharmacy because of the accessibility, that’s a perfect time for pharmacists to be having those discussions with patients. And as we’ve talked more about vaccine hesitancy, really it’s not those patients coming to you who are the hesitant ones, it’s those patients who are not coming to you. How do you reach out to those groups and then work with the public health departments and other support groups to get those patients in?
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: One of the exciting things––again, just a little tangent––is COVID-19 also taught us that getting out into the community is important. I mean, we’ve known this for decades, but I think we had to do it. And getting out there at drive-up vaccine clinics or going to maybe a mall or somewhere else. So just an interesting process that hopefully some of the lessons we learned, we’ll carry forward.
Chad Worz, PharmD, BCGP, FASCP: I think we learned that vaccines are relatively transportable. We can go places. There were mobile vehicles, there were places that set up clinics in malls and other public areas. And I think that’s important too. We have to go where the patient is, and we have to meet them where they are.
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: Absolutely.
Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: I think that’s an important component too. One of the most beneficial meetings I had during COVID-19 was with the Johnson County Public Health Department, the local public health department. It established a whole new relationship because they were actually the first ones to get the vaccine. We made a commitment to get the ultra-cold freezer, and they provided us with a portable ultra-cold freezer. We were able to meet patients where they were. That started this whole new relationship with them. So looking now, how can we work together with other aspects of health, including the flu vaccine?
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: It’s interesting. We all keep saying it: COVID-19 really did change things. I don’t know if we all expected to live through a pandemic in our lifetime, but I’ve been through several epidemics because of my public health background. But again, I think one of the interesting lessons that we’ve learned is not only meeting people where they are for that component, their protection, but also [for] their testing.
Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: Absolutely.
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: Because that was my world. I think and hope we carry this forward with respect to meeting people where they are in need.
Chad Worz, PharmD, BCGP, FASCP: I think it’s all circular. It’s hard to look at a pandemic and say what good came from it. But there was a lot of good that came from it in terms of how we approached it, how we created accessibility for…
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: Coalition.
Chad Worz, PharmD BCGP, FASCP: …people to get it. Identifying that there are different groups of people. I mean, in my world, the nursing home patient and the patient [who] lives in an assisted living environment, that's a different person than the one [who] walks into a community pharmacy. So how do we make sure we apply the right strategy to make sure that they are offered and can get the vaccine?
Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: I think the other important thing too is meeting the patient where they’re at. I look at it from a practice perspective and how we work within the community. It has to be more than just Towncrest Pharmacy making the solution. It has to be a community solution. How do we use the resources together? Because it’s not inexpensive to send someone to a single household with 1 person [to whom] you can give a vaccine, yet we realize these mobile clinics are extremely important, otherwise these patients are not going to be able to get that. So how do we work with the social services department? How do we work with the senior centers? How do we work with the transportation centers, so that we’re able to do this effectively?
Rodney E. Rohde, PhD, MS, SM(ASCP)CM, SVCM, MBCM, FACSc: Great conversation. I’m going to bring us back to what we had talked about before we went off a little bit on this tangent. And that’s really looking at those other types of management of different things around cardiovascular conditions, around chronic diseases. Dr McDonough, could you talk a little bit more about those other types of things chronically that might impact influenza immunizations? We kind of touched on it.
Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA: We have touched upon it. And obviously, being an older patient, you’re at more risk in making sure they’re getting the right dose of the shot or the right vaccine. But also, those patients who have chronic conditions. I look at cardiovascular [data] and if you look at the studies, it’s really pretty exciting to be looking at that information. Because it’s not just that it's preventing the flu, this might be preventing some of the complications for a patient who has other medical conditions. But it may have some other protective effects that we’re still trying to learn about with the influenza vaccine. So if you look at some of the patients with cardiovascular disease and whether or not they got the flu or not, they still [received] some benefit as far as its reducing morbidity or mortality as it relates to their condition. So I think that’s exciting. We don’t know enough about it right now to really understand that. But anybody who has a chronic medical condition, whether it be chronic lung disease, asthma, COPD [chronic obstructive pulmonary disease], type 2 or just…diabetes in general, these patients are chronic patients who have chronic conditions. And getting the flu may just take them over the edge [so] that they don’t have much reserve. We have to make sure that we protect them. So education is going to be extremely important for that patient population.
Transcript edited for clarity.