In addition to supporting the rollout of the most ambitious flu vaccination programme ever seen in this country, pharmacies are playing a key role in helping customers manage common winter ailments against the ever-present backdrop of Covid-19. It’s a tough ask

Earlier this year, the health secretary Matt Hancock set out a vision to deliver the “biggest flu vaccination programme in history”, rolling out to a wider group of patients than ever before with the ultimate aim of vaccinating over 30 million people in England.^1,2 

In addition to the traditional target groups (the elderly, people aged 18-65 years with qualifying medical conditions and pregnant women), eligibility for vaccination this year was extended to include the ‘shielded’ list for coronavirus as well as members of their households; all school groups up to year seven; and health and social care workers employed through direct payment and/or personal health budgets.^1,3 

People aged 50-64 years not in an at-risk group were also earmarked for vaccination this winter and community pharmacy contractors were given the go-ahead to start vaccinating this group on December 1, contingent on vaccine supply.¹ 

So far this flu season, pharmacists have already surpassed the number of patients vaccinated in previous years, having administered nearly 1.9 million doses, with demand for flu vaccination from eligible patients still being very high.

Pharmacists help to deliver England’s annual flu vaccination programme under a nationally commissioned service – but with the second wave of coronavirus still dominating the healthcare agenda, this year presents a unique set of challenges. 

As already mentioned, community pharmacies are seeing surging demand from customers seeking flu vaccinations but there are also ongoing issues with the supply and delivery of the vaccines. On November 2, in what many felt was a long overdue announcement, the Department of Health and Social Care (DHSC) finally published guidance for community pharmacies on how to access supplies of flu vaccines from the Government’s central stockpile.⁵ 

To meet its ambitious flu vaccination targets this year, the DHSC secured an additional supply of vaccines from four manufacturers.⁴ Most of these supplies represented stock that would not ordinarily be available in the UK and are the result of vaccine suppliers running their production cycles for longer than originally intended.4 Expectation is that the majority of these extra vaccines will be available for delivery to pharmacies through to the end of this month. 

The PSNC has worked with the DHSC to iron out the process for accessing the vaccine stock, taking into account the usual pharmacy supply route and potential business impacts. A trio of different vaccines (QIVe, QIVc and aTIV) are now available from pharmaceutical wholesalers although supply is still patchy. Pharmacies are required to complete a declaration and pay for their flu vaccines in the usual way. 

The DHSC advises which wholesalers have been allocated stock via the NHSBSA website. Wholesalers themselves are charged with alerting pharmacy customers when the stock is available to order and advise on delivery times, ordering limits and pricing information.⁵ 

“We are pleased that a process for pharmacy access to the DHSC flu vaccination stock has been put in place, but it is regrettable that DHSC took much longer than expected to publish the details,” says Alastair Buxton, director of NHS services at PSNC. 

“In addition to NHS use, the stock will also be available for use within occupational health schemes for frontline health and social care workers. Where there is sufficient DHSC stock available later in the season, the agreed process may also allow use of that stock for wider occupational health and non-NHS services.” ⁵

The DHSC guidance splits potential vaccine recipients into three groups, with initial use of pharmacy stocks restricted to those in group A. This includes patients and frontline social care workers as set out in Appendix A of the Community Pharmacy Seasonal Influenza Vaccination Advanced Service specification, and frontline health and social care workers through locally agreed occupational health schemes. 

People in the 50-64-year age group were not vaccinated until the December 1 start date. The decision to begin rolling out vaccination to this younger cohort was driven by the availability of vaccine stocks and progress made with vaccinating the other target groups. 

As well as overcoming obstacles of supply and demand, pharmacies had the additional burden this year of ensuring flu vaccines are delivered in a Covid-secure manner. As such, the PSNC agreed specific changes to the community pharmacy flu vaccination service for the 2020/2021 season that reflect the need for social distancing, limitation of patient numbers in pharmacy and enhanced infection control. Comprehensive guidance and a checklist to help pharmacy teams deliver this year’s service are available via the PSNC website. 

Despite the challenges, the importance of maximising population coverage with the influenza vaccine this year of all years is abundantly clear. As the PSNC points out: “The impact of Covid-19 on the NHS and social care has been visible to all, and this coming winter we may be faced with co circulation of Covid-19 and flu. 

“Those most at risk from flu are also most vulnerable to Covid-19, so flu vaccination is one of the most effective interventions the NHS has to reduce pressure on the health and social care system this winter. As a sector, we must do all we can to help protect those at risk of serious illness or death from the complications of influenza this winter.”¹

Key symptoms

As winter arrives, pharmacy teams will have other important roles to play beyond the delivery of flu vaccinations. With people reporting ongoing difficulties in accessing GPs and clear evidence that many were afraid to seek healthcare advice in the traditional settings of local surgeries and A&E departments during the first Covid wave, the position of pharmacy as the accessible frontline of primary healthcare has never been more critical. 

So one of the key responsibilities falling on pharmacy this winter is identifying customers with potentially serious health issues and encouraging them to seek medical attention where necessary. 

The Government has been at pains to stress that the NHS remains ‘open for business’ and is particularly keen to ensure cancer sufferers, potential heart attack/stroke victims, mental health patients and pregnant women do not fall through the cracks.6 Pharmacy staff should be alert for key symptoms that warrant immediate action including those indicating: 

• Potential heart attack: heavy or tight chest pain that may spread to the arms, neck or jaw and may be associated with breathlessness, sickness, sweating and light headedness
• Stroke: Face – is the face drooping/fallen on one side? Can the person smile? Arms – can they raise both arms and keep them there? Speech –  is it slurred? Time to call 999 if any of the above signs are noted (FAST). 

Pregnant women should be advised to continue attending routine antenatal appointments and seek advice if they have any concerns. Similarly, cancer patients should be encouraged to consult their GP if they experience any worrying symptoms or wish to discuss their ongoing treatment. 

Mental health is a particularly challenging area, exacerbated by both the pandemic itself and the ensuing lockdowns and restrictions. Customers who are struggling can check self-referral options for psychological therapies at nhs.uk/conditions/stress-anxiety-depression or contact their GP or keyworker. Anyone facing a mental health crisis should use the NHS 111 online service or call 111. 

Cold or Covid?

A key aspect of this winter will be helping pharmacy customers to differentiate the signs of symptoms of coronavirus from those of regular cold and flu. Pharmacists and their teams have a key role here.

According to the Covid-19 Symptom Study, 82 per cent of patients who tested positive for the virus experienced one or more of three hallmark symptoms: 

• A high temperature
• A new continuous cough (defined as coughing a lot for more than an hour or three or more coughing episodes in 24 hours)
• A loss or change to sense of smell or taste.

Any customer presenting with one or more of these symptoms should be encouraged to return home and get tested immediately. All members of their household and support bubble should also remain at home until the test results are known. 

Differential diagnosis becomes more difficult when a person is suffering from more traditional cold symptoms such as sore throat and runny nose or more nebulous symptoms such as tiredness, headaches and malaise. 

The Covid-19 Symptom Study describes headache and fatigue as the ‘dark horses’ of coronavirus symptoms. These rank among the most common early signs of the disease for all age groups, with over 90 per cent of positive patients reporting one or the other. However, the study cautions that headache and fatigue are common symptoms of a myriad of other conditions, so either or both alone – in the absence of other symptoms – is very unlikely to be indicative of Covid-19 (only around 3 per cent of positive patients reported just these two symptoms) 

The most predictive symptom of Covid-19 appears to be loss of smell, which occurred in 55 per cent of positive patients aged 18-65 years. Fever was reported by around 40 per cent of all age groups but tended to occur only in the early phases of infection. Although sore throat was reported by nearly half of Covid-19 patients, sneezing and runny noses are rarely seen and probably act as one of the best indicators of a cold versus Covid. 

The Covid-19 Symptom Study has also revealed some interesting differences in the way coronavirus affects different age groups. Adults were more likely to experience loss of smell than children (in which it often goes unnoticed) or the elderly, while over 65s also reported confusion, disorientation and severe shortness of breath more often than other age groups. 

For pharmacies, the most important action is to encourage anyone with Covid-19 symptoms to seek a test. However, customers will also require guidance on effective OTC medications to manage their symptoms – whether due to coronavirus or other typical winter infections – and appropriate self-care advice. 

Despite its well-publicised association with Covid-19, colds and flu still remain the most common causes of cough, which can persist for up to three to four weeks. For dry coughs (the type also caused by Covid-19), demulcents such as glycerol, liquid glucose, syrup and honey (available as cough sweets or syrups) can provide short-term relief. Cough medicines containing suppressant agents such as dextromethorphan can also be recommended for those aged 12 years and over. 

Expectorants are preferred for productive chesty coughs as they increase bronchial secretions and reduce the stickiness of the mucus, making it easier to cough up. 

For any type of cough, the NHS recommends trying a hot lemon and honey drink first-line – ahead of other OTC options. Customers should be advised to sit upright or lie on their side, rather than flat on their back, which can exacerbate cough. The NHS website also provides important tips for anyone suffering from breathlessness, which include keeping the room cool, breathing in slowly through the nose and out through the mouth, and trying not to panic. 

OTC options for customers with sore throat include pastilles, lozenges and throat sprays. Many of these products contain antiseptic and/or local anaesthetic ingredients that help to numb the throat and relieve pain. Gargling with warm salty water can also be beneficial although hot drinks should be avoided as they can exacerbate throat pain. Customers should be reassured that sore throats are typically self-limiting and ease within three to seven days with no need for antibiotics. 

For the treatment of any pain (including sore throat), muscle aches and fever, standard OTC analgesics such as paracetamol and ibuprofen can also be recommended. Despite the furore at the start of the pandemic, the Commission on Human Medicines has now confirmed there is no evidence that using ibuprofen makes coronavirus worse.8 Paracetamol is still preferred first-line due to its more favourable tolerability profile.8 

It should be remembered that aspirin should not be used by children under 16 years of age and it is important to always ask customers about any concomitant medications and/or comorbid conditions before selling or dispensing NSAIDs. 

Recognition of vitamin D   

Important self-care advice for any customer with cold or flu symptoms is to rest, stay warm and take plenty of fluids. Evidence is also growing for the role of vitamin D in both reducing the chance of contracting Covid-19 and lessening the likelihood of serious illness or death for those who do become infected. 

Such is the strength of the data (with close to 30 supportive studies) that the Government is sending out free doses of vitamin D to care home residents and those who are shielding.⁹ A total of four months’ supply of the ‘sunshine’ vitamin will be dispatched, enough to last elderly and vulnerable individuals through the winter. 

In addition to its impact on Covid-19, research has also shown that vitamin D supplementation plays a critical role in preventing other respiratory infections – including flu – and reducing antibiotic use, especially in older adults. In one study, the risk of chest infections was cut by half in those taking vitamin D supplements.¹⁰ 

Given this body of evidence, advice on vitamin D supplementation would seem prudent for all pharmacy customers – particularly the older demographic. The NHS currently recommends taking 10mcg (400 IU) of vitamin D daily between the months of October and early March but there is increasing consensus among researchers that higher doses (up to 5000 IU) may be optimal. 

References

1. PSNC Briefing 026/20: Guidance on the influenza 2020/21 seasonal influenza vaccination advanced service. September 2020
2. PoliticsHome. Matt Hancock vows ‘most comprehensive’ flu vaccine programme ever as Britain prepares for coronavirus winter pressure. 24 July 2020
3. NHS. National Seasonal Influenza Immunisation Programme 2020/21: primary care frequently asked questions 23 October 2020
4. PSNC. Flu vaccination service
5. PSNC. Guidance published on accessing DHSC flu vac stock. 2 November 2020
6. NHS ‘Open for business’ campaign materials. Updated 01.05.2020 
7. PAGB. PAGB survey suggests coronavirus will change attitudes to NHS use
8. NHS
9. Sixty seconds on….vitamin D. BMJ 2020; 371:m3872
10. Vitamin D deficiency in Ireland - implications for Covid-19. Results from the Irish Longitudinal Study on Ageing (TILDA). April 2020.