My employer sent out the marching orders recently like many other community pharmacies. The email said something to the effect “if you’ve got them, shoot them.”
I’m not trying to single out my employer. Other pharmacy chains started their flu shot programs for this season weeks before we did. My question today is this: are we properly serving our patients by giving flu shots in August?
First let me qualify my reservations about giving flu shots this early in the season. Certainly, vaccination rates are important. We want everyone to protect themselves. If the choice is between getting the dose early or not getting it, I’ll gladly administer the shot as soon as I can.
But I couldn’t help but wonder a couple of things. Is there compelling data against flu shot administration this early? What does the Center for Disease Control (CDC) say on the matter?
I think the information I’ve found might cause one to wonder if we are not properly serving the public by offering flu shots this early. What if there is a drop off in effectiveness after a certain period of time? When are the months that are critical to be covered?
The CDC has a nice report on the flu. It tracks data such as confirmed cases by week in previous years as well as peak monthly data. The following is a graph that looks at the peak of the flu seasons from the 1982-1983 season through the 2013-2014 season.
Peak Month of Flu Activity
1982-83 through 2013-14
“*During 2008-2009, flu activity peaked twice because of the 2009 H1N1 pandemic. Activity in the United States peaked once in in February due to seasonal influenza activity and then again in the Spring (June), with the first wave of 2009 H1N1 viruses A second, larger peak of 2009 H1N1 activity occurred in October, the peak of the 2009-2010 season.” CDC (CDC Flu Season Data Report)
As you can see above when we talk about recent flu seasons the hardest hit months are later. There’s a spike of activity starting in December but the most likely month for the most cases is February.
If we examine the last flu season in greater detail based on reported cases, you will see a similar pattern. This indicates that coverage needs to last until at least March of a given flu season for optimal protection.
Graph is courtesy of the CDC’s Weekly Surveillance Report (CDC FluView Weekly Surveillance Report)
But what about the duration of coverage for people who do get a flu shot this time of year? Is there evidence suggesting that flu shots lose effectiveness? The data to support the flu shot not lasting an entire season is not solid. The following statement was part of the CDC’s 2012-2013 Prevention and Control Recommendations from the Advisory Committee. (Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2013–2014)
“A case-control study conducted in Navarre, Spain during the 2011–12 season revealed a decline in vaccine effectiveness from 61% (95% CI = 5–84) in the first 100 days post-vaccination, to 42% (95% CI = -39–75) for days 110–119 days post-vaccination, to -35% (95% CI = -211–41) thereafter. This decline primarily affected persons aged ≥65 years, among whom effectiveness declined from 85% (95% CI = -8–98) to 24% (95% CI = -224–82) to -208 (95% CI = -1,563–43) over the same time intervals. However, most viruses isolated among infected vaccines did not match the vaccine strains.” The report concluded that more studies are needed. It also points out that mismatches between the strains covered and cases seen could account for the decline in effectiveness.
There are lots of factors that impact the spread of the flu including school calendars, weather, and sanitation. But when you have twenty plus years of data revealing late season spikes in flu cases, doesn’t the medical community need to take a closer look at the duration of vaccine protection?
The data suggests the peak time to protect yourself is later in the season. There is a much higher risk for flu cases in the February and March months than in the August to October period.
So what would I recommend to patients? Given the 14 days it takes for full protection, I’d probably tell a patient to get the shot sometime in mid-September. That way you would be fully protected at the beginning of October and be covered through the six month period ending in March.
The only qualifiers I’d include is if one was traveling sooner or if they were attending a large event where there will be lots of people in close contact. I would not want to go to something like a large concert or state fair without first protecting myself.
If someone wants to get a flu shot today, I won’t stop them. But based on the data, we should be more concerned with these late season peaks in flu activity. Whether or not those late peaks are a result of vaccine content or duration of coverage is yet to be determined.
What about you? Do you think August flu shot administration is appropriate? Should we wait longer before administering these vaccines to our patients? Or should we focus more on the overall vaccination rate?
The Redheaded Pharmacist
I have a piece of advice for all pharmacists and technicians that may be difficult to follow. Please, just go home.
I’ve worked with many pharmacists and technicians over the years. The vast majority of them have been hard working and dedicated employees. They care about their job and they care about the people they serve. In fact, they might care a little too much.
How many of you have stayed late or come in early to get work done? It can seem like we are all playing an endless game of catch up. And there is a tendency by many to simply put in extra time off the clock to help keep things calm.
The problem with staying late or coming in early is that it becomes a habit. Before you know it, you are working 45-50 hours or more per week. And as far as your employer knows, everything is fine. Your numbers look good. And to them, that is how community pharmacy is summed. Numbers on pages or email attachments define pharmacy for the big employers.
I’ve stayed well past the end of my shift to help coworkers get through busy times. I’ve stayed well past closing time to “catch up” and get things as calm as possible for whomever is showing up the next morning to work. I don’t like to leave messes, even for myself.
But working extra becomes a bad habit that is hard to break. And dedication to your patients aside, your employer simply doesn’t care that you do all of this extra work.
Putting in all of this extra time can contribute to severe burnout. Our work is physically and mentally exhausting enough without adding extra burdens. It’s just not worth it.
I think in many cases large community pharmacy chains punish those who go the extra mile. It’s as if we are treated worse for taking it upon ourselves to do whatever it takes to get the job done. This leads to further hour cuts and extra responsibilities that simply push us beyond our limits.
We’d benefit from a policy of doing what we can for our shift and trusting that our coworkers can handle the rest. And that means going home when you are supposed to and leaving those extra prescriptions to be finished by someone else. It also means working hard to catch up workflow so others can leave on time.
I can think of pharmacists I work with now who you practically have to push out the door at the end of their shift. I’ve yelled out “go home” to a few of them on more than one occasion. They will stay well past their scheduled time even when they have families at home and other commitments.
I’ve learned that I can only do what I can and that has to be enough. Pushing myself needlessly beyond my limits only hurts myself.
Our profession has become so hectic that it encourages pharmacists and technicians to go the extra ten miles. But where does all that extra dedication end? When is enough finally enough?
We’ve got to learn to accept our limitations instead of constantly pushing limits higher. We need to trust others and know that they can handle doing whatever work we thought was important enough to stay to complete.
So please, I’m telling you one little piece of advice that will help you have a longer and happier career. When it’s time for you to go, just go home. It’s that simple!
The Redheaded Pharmacist
Truth be told, it’s not easy to stay positive when you’re discussing the current state of the profession of pharmacy. Getting lost in all of the negatives is just a step or two short of inevitable it seems.
Occasionally though there are glimmers of hope that can get you through the tough times. I’m thankful that I’ve recently received one of those glimmers.
If I’m brutally honest, I’ll tell you that my lack of updating this blog wasn’t simply a need for a break from writing. The truth is I love to write. It’s in my blood like some sort of happy disease.
What I really needed was a break from the subject matter of my musings: the profession of pharmacy. My work stresses and frustrations were building inside me like some sort of terrible mental skyscraper. It was crushing my interest in this blog and my profession.
I guess working long days with all of its associated challenges was getting to be too much. I didn’t want to come home and write about work during my off time. Off time is supposed to be an escape isn’t it?
But I can’t run from the problems this profession faces. And I can’t ignore myself the joys and challenges of writing about them. I just needed a little bit of hope to direct me back to where I thought I needed to go.
As it so happens, hope came to me in the form of a thick first class envelope. The contents inside were a couple of issues of what is known as The Guerrilla Pharmacist. It’s a bold and in your face publication brought to all of us by Jim Plagakis and The Pharmacy Alliance. It’s worth a read for anyone with any involvement in the profession of pharmacy.
I’ve always had a great deal of respect for JP. He’s cared more than most pharmacists ever will and he doesn’t give up. The Guerrilla Pharmacist is a collection of many great writers that have strong opinions regarding the profession of pharmacy.
I’ve read the first two installments of The Guerrilla Pharmacist nearly straight through. The articles are honest and in your face. But considering what we face as pharmacists, someone needs to write to us this way. And if they are brave enough to do it, we need to read those words and take them to heart.
I told my wife about this publication. She turned to me and said “He’s really a one-man machine taking on the big chain pharmacy world isn’t he?”
My response was “yes he is, unless of course he has backup.” She responded “And that’s were you come in right?” Yes indeed, along with a host of others.
There are those of us not satisfied with the status quo. After all, things could be better right? But if you think you can sit back and wait for improvements to simply happen I have bad news for you. You will be waiting your entire career.
That leaves a directive for those of us that care enough to try and impact change. The directive is to stand up and fight. And one way to do that is to support efforts like The Guerrilla Pharmacist and The Pharmacy Alliance.
If the advice and articles I’ve seen in the first two issues are any indication of the future of this publication, it’s worth your time and money to get a subscription for yourself. Support those that are working hard to fight an uphill battle against very big and powerful opponents.
Thanks JP and everyone involved in the production, content creation, and distribution of The Guerrilla Pharmacist. That one piece of mail provided just the right amount of hope I needed to get motivated. And of all places to find true hope, I just had to check my mail. Who would have thought?
The Redheaded Pharmacist
Maybe I’m just getting to be an older and more cynical pharmacist? Maybe I can’t see the merits of certain decisions? Maybe there is value to changing hydrocodone combination products (HCPs) to C2 status? Or maybe, I have a valid concern that this is the wrong way to handle a real problem.
Starting October 6th, 2014 chronic pain patients and pharmacists will notice a significant change that will impact both groups. The decision has been made to change the status of hydrocodone combination products from C3 to C2 status. The move will further restrict legal access to this group of medications and put them on the same level of control as other C2 medications such as oxycodone.
The natural question to ask is will this do any good? Will it make an impact on the abuse problems we now face in the United States? Or worse, will it become a burden for chronic pain sufferers who need access to these medications?
I think the idea needed to be considered. The drug abuse problem in America has gotten that bad. Even bad ideas that might address the problem should be considered. But again, I am referencing “bad ideas” to describe this change. That should clear up how I personally feel on the matter.
I would have looked to see if the idea was already working anywhere in the country already. The problem, only New York previously changed HCPs to C2 status on their own and that just happened last year. If there is any significant data showing it’s impact on the abuse problems of HCPs in New York, I can’t find it. If New York had years of data proving it helps, I might feel differently.
One can only look at the abuse problems a drug like oxycodone has despite it’s C2 status and wonder if drug classification is the root problem. Of course, you can’t exactly determine how much worse things might be for a drug like oxycodone if it were C3 status. But it’s not a good sign to look at the peers in this classification group to validate this decision.
Unless prescribers really start to evaluate their own prescribing habits things will not significantly change. Unless we look at our drug culture that actively promotes “a pill is the answer” mentality for anyone with a problem, things will not change.
And what is worse, the law of unintended consequences suggests that legitimate chronic pain sufferers will be impacted more by this change than anyone else. The last thing we need is to make it more difficult for people who are actually suffering from pain to get relief.
It will be interesting to see what impact this change will have on HCPs in the near future. Will those products be avoided now by prescribers? Will patients ask for alternatives?
I wonder if prescribers will try tramadol or codeine combination products more often now to avoid the new C2 restriction on HCPs? Will prescribers that normally would have considered hydrocodone combination products simply bump some patients up to oxycodone products?
I have seen anecdotal evidence in my area that there has been an uptick of HCP scripts in recent weeks. I wonder if pain patients are “stocking up” before the switch in status? I’d be curious to hear if anyone else has noticed similar trends recently.
I’d like to be on board with this idea. I’d like to say that everything will be fine starting 10/6/14 and that hydrocodone abuse will start a nice gradual decline after it become C2.
But the reality is I can’t help but feel that this will not do what it intended to do. We will continue to have a serious drug abuse problem even after early October. This will not change that fact. And that leaves us with the real question of the day: what can be done that will actually work?
The Redheaded Pharmacist
It all started with an email I received from another pharmacist. That email left me wondering about questions I felt I couldn’t answer.
Someone who has been a pharmacist for a lot longer than I have sent me an email with some comments and questions about the state of our profession. His concerns and frustrations have been echoed here and elsewhere by many other pharmacists.
He wrote about the idea of the unionization of pharmacists and his personal reservations with unionizing. But he did mention that something needed to be done.
He also voiced his frustration with the organizations that represent our profession. He said that we needed to unite in some meaningful way as pharmacists. Sound familiar? It should.
I sat on this email for several days without responding. I didn’t know what I could say. I felt a lot of the same concerns he did. And sadly, I have fewer answers than questions.
I showed the email to my wife and I told her I didn’t know how to respond. “What do I need to tell him?” I asked the question as if I was completely lost. In some ways, I am.
She looked at what this pharmacist wrote and then she said to me “sometimes, you just have to get angry!” She knows my frustations. She knows the challenges I face at work. I couldn’t have said it better myself.
Her comment got me thinking. Anger is a good motivator. It spurs action like no other human emotion.
The problem with anger is that it can lead to irrational behavior. We don’t need irrational behavior pushing our profession forward. We need organized and thoughful responses to any problem we might face.
Sometimes it does seem like the organizations that are supposed to have our backs don’t really care or are focused on non-essential issues. They want to push us towards the future. But sometimes we just need help with the present.
I’ve explained before that I don’t think unionization is the answer for the profession of pharmacy. I won’t bore you with my reasoning. Let’s just assume I’d vote no if it came to that.
But the fact that so many pharmacists entertain the idea tells me something is wrong. Power and control are important. And many pharmacists feel like they’ve lost both at work.
I also think the big organizations like the APhA do more for our behalf than they get credit. But having said that, couldn’t they do more? Couldn’t they voice our concerns a little louder?
I think a code of conduct for retail pharmacy operators is in order. It could include a basic set of standards for working conditions, staffing, and expectations. The big organizations could become involved in this.
But we all as individual pharmacists need to get more involved ourselves. And that might even include joining the organizations that we sometimes question. They can’t be expected to be the strong voice we need if we aren’t there to support them.
I’d also lean harder on politicians. Like it or not, they have power. And if they don’t understand how bad working conditions in retail pharmacies might endanger the public, they won’t be pressed to address the issue.
I don’t know exactly what it’s going to take to make things better for the profession of pharmacy. I do know that something needs to be done.
As my wife said “sometimes, you just have to get angry.” For many of us, that time has already arrived. The question then remains: what are you going to do about it?
The Redheaded Pharmacist