Addressing the unique challenges of each influenza season: An in-depth pharmacy operations perspective

Sponsored by Sanofi

Written by Ajit Johal, featuring Linda Gutenberg 

Pharmacist and BCPhA board member Linda Gutenberg supported the Heart Pharmacy group in administering over 12,000 influenza vaccinations during the 2022-2023 season.  In a candid, in-depth interview with pharmacist Ajit Johal, Linda provides her operational expertise to support pharmacies in navigating another challenging influenza season.  Ajit has been providing immunizations and clinical education since 2012, he champions community pharmacist as leaders of immunization services through his vaccine centre of excellence program.

It was recently stated that “nothing had advanced the pharmacy profession more than the ability to administer vaccinations.”  Do you think BC pharmacists' ability to provide influenza vaccinations since 2009 has built a strong case for our role as knowledgeable and accessible healthcare providers?  

For pharmacists, our advocacy for expanded scope has always materialized when there is a “great need” for us to support in a larger capacity. For influenza vaccination, the great need was additional immunization providers to support vaccinating the population during the H1N1 pandemic. Providing vaccinations had been advocated for a long time before this, but it was a protected service held on to very tightly by public health. The advocacy laid the foundation for our profession to step up when needed and deliver excellent results. We expect pharmacists' strong track record and growing healthcare needs in our province will continue to yield opportunities for expanded scope.  

This past influenza season during the pandemic was undoubtedly a challenging one; how did you mobilize your team to deliver a successful campaign? 

Two critical mobilizations for our pharmacy group to prepare for the 2022-2023 influenza season were assigning a dedicated staff member to logistics and leveraging allied healthcare professionals to increase vaccination capacity. 

Managing the staffing, clinic schedule, appointments, and vaccine inventory was nothing short of a full-time job. One dedicated staff member attended to all the above responsibilities across all stores. They set the scheduler on ImmsBC, booked all staff at the clinic locations, carefully monitored inventory, and adjusted based on vaccination delivery.  

With the ability to have registered and licenced practical nurses administer influenza and COVID-19 in the community pharmacy, our pharmacists could be mobilized as clinical specialists.  With “vaccine administration” duties supported by allied health, our pharmacists were better suited to answer patient questions and provided the necessary education on available influenza and COVID-19 products.  

One unique operational change this past season was including influenza vaccination within “ImmsBC”, which was previously only used for COVID-19 vaccinations. What challenges did you experience, and how did your team adapt to this new workflow? 

Our pharmacy team had to adapt our workflow with the ImmsBC system for both our community pharmacy vaccination clinics and our offsite clinics at long-term care facilities.  

Within the pharmacy, it was essential to “monitor” booked appointments on the ImmsBC system to ensure our team could best service our patients. Screening for age, for example would allow us to flag appointments for patients who were 65+ to ensure we had enough of the publicly funded adjuvanted vaccine. Similarly, we would also screen for patients less than 12 to ensure that they were booked for influenza vaccination and not COVID-19 since pharmacies do not carry inventory for this age demographic. When a patient booked an appointment, we did not know if they were coming for one vaccine or two (both COVID-19 and influenza), so it was a challenge to anticipate the time each appointment would take.  Juxtaposed on top of this was the fluctuating inventory of multiple COVID-19 mRNA, non-mRNA, and influenza products for different age groups.   Our staff member in charge of logistics had to carefully monitor inventory and appointments to ensure everyone who booked received the vaccinations they had selected.   Inevitably, there were cases where patients would want COVID-19 and influenza vaccinations, and we would not have the latter in the fridge. We tried our best to ensure these patients got immunized by calling them back for priority “walk-in appointments” to make this as convenient as possible. 

For offsite clinics at long-term care homes and assisted living facilities, laptops needed to be purchased to administer vaccinations using ImmsBC.  To ensure quality and secure access to ImmsBC, stable and secure internet access was needed to the facility's protected network.  To ensure smooth operations for an offsite clinic, the pharmacy team arrived 35-40 minutes before the first vaccination appointment at the facility. Once again, our central administration person organized all offsite clinics, and a “checklist” for offsite clinics helped to standardize the procedure across all locations. Pharmacies administering vaccinations through ImmsBC at the pharmacy and offsite on the same day should plan accordingly.  Especially if the facility requests a report of those residents and staff vaccinated. In that case, it is very difficult as ImmsBC cannot filter out patients vaccinated at the facility versus at the pharmacy.  

Another programmatic change to this past influenza season was delineating an influenza vaccination program for community-dwelling seniors 65 and older. Specifically, the allocation of adjuvanted trivalent inactivated influenza vaccination for this group. Historically, no product has been specifically allocated to community-dwelling seniors, with seniors in LTC and assisted living receiving the high-dose quadrivalent inactivated influenza vaccine since 2020. Since community-dwelling seniors may opt to purchase the high-dose vaccine, or receive a publicly funded adjuvant vaccine, what tips do you have for pharmacists to help older adults 65+ understand which vaccine is best for them? 

The terminology “enhanced” was very confusing for seniors, and our pharmacist would be called in to clarify the difference between the government-funded adjuvanted vaccine and the high-dose vaccine available for private pay.  Since our location offers both vaccinations, we have an independent booking system for those who want to pay privately for the high-dose vaccine. Administering a private “unfunded vaccine” is not currently done through ImmsBC, so this vaccine, once administered, is adjudicated through pharmanet via the pharmacy software.   Many patients booked through ImmsBC and wanted to pay for the high-dose vaccine. We established a workflow to let all immunizers know to ask their patients 65 and older which vaccine they wanted.  If the immunizer was a nurse working at the pharmacy, they were provided clear instructions to defer all questions about the difference between the two products to the clinical pharmacist.  

Some tips for pharmacists to sort out which vaccine is best for their older adult patients while being conscious of the long lineup waiting to be vaccinated are as follows

1. Start by asking the patient what they want.  Almost 90 per cent of patient queries regarding selecting vaccination products for those 65+ could be clarified by asking which one they wanted and whether they wanted to pay for it.
2. About 10 per cent of queries fell into the “I’m not sure what I should get” category.  In these cases, when it was deferred to the pharmacist, patients were advised that despite a lack of head-to-head comparator studies between the high dose and adjuvanted product, the high dose vaccine has the most evidence showing its superiority over the standard dose in RCT and RWE settings.  

Many pharmacies do not opt to order private inventory of influenza vaccinations. What advice would you give to support pharmacists in offering influenza vaccinations that are not part of the public program?  

It is important to differentiate your community pharmacy; offering additional influenza vaccination services for high-risk older adult groups is undoubtedly one way to do this. Create a demand for the product before influenza season and build a following of patients who opt for the unfunded vaccination product every season. Screening for high-risk patients, such as older adults with multiple medical conditions, can be part of your pharmacy's medication review services program.  

As we gear up for another fall respiratory disease season, what key operational insights should BC pharmacists know to have a successful 2023-2024 campaign considering the expanded scope of MACS? 

A gradual approach to refining the workflow will help ramp things up for September. Our pharmacy group aims to build upon the successful workflow from last season and accommodate the additional demand for minor ailment prescribing in addition to vaccinations. Some of the things we are looking at include multiple areas within the stores offering vaccination and minor ailment services. Again, screening your appointments will be necessary. For MACS, for example, building a patient profile into the pharmacy dispensing software and ensuring inventory for potential medications your pharmacist may prescribe are meaningful investments to ensure a high-quality patient experience at the pharmacy.  

¹Both the Adjuvanted trivalent influenza vaccination and the high dose quadrivalent vaccine are indicated for use in adults 65+^1,2.  The 2023-2024 NACI Influenza statement recommends for adults 65+ the high-dose vaccination should be used instead of the standard-dose vaccine with grade-A evidence.³  The 2022 ACIP analysis stated that there is no strong evidence favoring either high dose or adjuvanted vaccine over one another among studies providing direct comparators. However, according to the analysis the most evidence is for high dose with high quality evidence favouring high-dose over standard-dose from 1 RCT, and the largest quantity of data available for high dose⁴. Pharmacists are expected to provide individual level recommendations based on their knowledge, assessment, and product availability of the patient at the time of vaccination. 

Ajit has been providing immunizations and clinical education since 2012. As a community pharmacist, he is an accessible provider of immunizations to patients in the community. In 2018, he started an organization called immunize.io with a mission statement of “taking our best shot at immunizing the world”. Through “immunize.io” he has worked with numerous organizations and communities to address “vaccine hesitancy” and improve access to vaccines. 

He champions community pharmacists as leaders of immunization services, in recommended but “unfunded” vaccines. Ajit is also a clinical assistant professor for the University of British Columbia Faculty of Sciences program. At UBC he has coordinated an elective course for UBC pharmacy students in travel health and immunizations.