Preparing for the flu season during the COVID-19 outbreak
With detailed planning, timely ordering and an effective system for our vaccination clinics, a simultaneous flu epidemic and potential COVID-19 resurgence is avoidable
Imagine heading towards the flu season unprepared amidst a global coronavirus pandemic. After insufficient organisation, hospitals could be flooded with patients with one of two respiratory illnesses, needless to say, no one knows which, and with little to distinguish between them, we would be left with an even bigger pandemic... it's not a very great stretch, is it?
The pandemic is straining the whole population enormously, whatever our occupation or pursuit.1 Whether sporting sore facial indentations from masks,2 despairingly counting pennies after closing small businesses’ doors,3 or attempting to both teach and entertain children at home day after day,4 substantial adjustments have had to be made. This will be no different for general practice staff in the coming flu season, which is a frightfully hectic time of year to say the least, even without current uncertainty.5 But catastrophes can be averted. We know what could go wrong, so preventative measures can be taken. With detailed planning, timely ordering and an effective system for our vaccination clinics, a simultaneous flu epidemic and potential COVID-19 resurgence is avoidable.6
SUPPLY AND DEMAND
A fall in infectious disease deaths in the developed world has led to nonchalance when it comes to vaccination.7 Thanks to antimicrobial breakthroughs, major advances in sanitation and sewage systems, and vaccination development itself, horrors such as treating syphilis with mercury, the consumption of cholera-contaminated water, and dependence on iron lungs for polio victims have become distant memories.8-12 Without the personal experience of these tragedies, without visibly being able to see the impact of vaccines, people have begun to question their validity, and misinformation is gaining more traction, aided by anti-vaxxer propaganda on social media platforms.13
As a result of the coronavirus pandemic, it is thought that infectious disease and vaccine awareness are currently at a higher level,14 and so more people are expected to seek a seasonal influenza vaccine compared with previous years.15 In the southern hemisphere we have seen evidence of this. In Australia, by 7 April 2020, pharmacists were reporting that they had given more influenza vaccine doses in 3 weeks than the entire 2019 season,16 and current evidence suggests that influenza activity there seems to be at lower levels than expected for the time of year.17 However, after an initial surge of vaccination, providers in the southern hemisphere experienced vaccine shipment delays associated with the pandemic, caused by air traffic disruption and border closures.18
NHS England urges us to review vaccine orders in time for our coming season.19 But are pharmaceutical companies prepared for these obstacles? Manufacturers such as Seqirus have confirmed extended production,20 but even with higher production levels, demand may still exceed supply and concerns are growing over vaccine shortages.21 Efforts must be made to prioritise clinical risk groups carefully, and keep up to date with ongoing information from manufacturers and suppliers.
COVID 19 – PRESENTATION, ANTIBODIES AND VACCINES
Clinically, COVID-19 and influenza have similar presentations.22 Fever, cough, headaches, chills, myalgia, fatigue and sore throat can be present in both conditions.23 Shortness of breath is common in COVID-19 but less so with influenza.24 Flu tends to start abruptly whereas COVID-19 typically has a gradual onset.25 Those most vulnerable to COVID-19 are also the most vulnerable to flu and we must go above and beyond to protect those most at risk. It is also worth considering that the pandemic may well have caused members of these at-risk groups to comprehend their vulnerability more than they had before, and as a result seek out a flu vaccination when they haven’t in previous years – a study in the Netherlands examined changes in the public perception of COVID-19 between February and May 2020, by asking participants at weekly intervals how concerned they felt about the virus. The percentage of people feeling concerned rose with each round of the survey.26
Nationally, the COVID-19 antibody test remains available only to healthcare sector workers and those living with them.27 With the travel and tourism industry slowly resuming, one wonders if research into antibody testing needs to be accelerated. The World Health Organization (WHO) is currently recommending against ‘Immunity Passports’ due to uncertainty regarding the degree of protection afforded by past infection,28 so further scientific understanding of COVID-19 antibody serology is urgently needed.
Around the world there are currently 25 vaccines in clinical evaluation. Of these, six have so far reached phase 3 trials.29 In the UK, the University of Oxford and AstraZeneca’s ChAdOx1-S vaccine candidate showed promising results in phase 1/2 trials with neutralising antibody activity demonstrated in all study participants.30 Phase 3 is ongoing, with over 10,000 study participants. The study is scheduled to complete in August 2021.31
Influenza eligibility criteria remain the same as last season with the same vaccines being offered to the same age groups and risk categories. Reimbursement arrangements also remain the same – the NHS will reimburse adult vaccines, but not the high dose trivalent vaccine (TIV-HD) due to its continuing high list price.32 Furthermore, three key areas of expansion to the programme have been announced: later in the season a free vaccine will be made available to 50-64 year olds; households of those on the COVID-19 shielded patient list are eligible for a free vaccine, and the school vaccine programme has been expanded up to the first year of secondary schools. Surgeries will receive information in due course regarding the exact point at which the programme will roll out to 50-64 year olds.33 Protecting more people by broadening the availability of flu vaccination ought to reduce the winter pressure in hospitals, but practices require further assurance from the Government guaranteeing adequate supply of vaccines.34
Preparing reports of categorised lists of patients well in advance would help the organisation of clinics to come. Invitations sent out in general practice will need to ensure they match pharmaceutical company supply, and NHS England’s annual flu letter says we should aim to complete vaccination by the end of November.19 However, with social distancing limits probably still in place, and more time required for decontaminating clinical areas, this may be a stretch. Bearing this in mind, prioritising our most clinically vulnerable groups becomes even more crucial.
With regards to communication with patients, it may be worth considering sending out a ‘Preparation for the upcoming flu season’ letter to eligible patients as soon as possible, highlighting the added importance of seasonal flu vaccination this year, and sharing the practice’s plan for delivering clinics in a safe and efficient manner. Perhaps something along the lines of: ‘Dear Patient, influenza season 2020-2021 starts from September. I’m sure you’ll agree a flu epidemic as well as another potential wave of COVID-19 would certainly not be welcome, so this year it’s more important than ever to get your vaccination. We’re working hard at the surgery to establish safe and effective clinics while ensuring social distancing measures are maintained.’ And then, depending on how clinics are running in individual practices, the next section of the letter should go on to give a rough idea about what to expect on the day of a clinic, including information about the flu vaccine they will receive, the procedure and layout of the surgery, instructions to attend on time and with the correct PPE, and not to attend if they feel unwell.35 Perhaps the initial letters should go to the most vulnerable patients, those in the ‘shielding’ cohort – this will depend on each surgery’s preferences and the characteristics of the local population.
Use leaflets and posters around surgeries to provide easily understood, key information, remind patients of the value of vaccination, and reawaken seasonal flu awareness.36 While we fight against the digital spread of misinformation each day, it is hoped that media sources will also help to counteract this problem. Facebook is already taking measures such as disrupting economic incentives for traffickers of misinformation.37 With COVID-19 still regularly being discussed on news programmes, the dialogue between news presenter, health professionals and lay people about the importance of protecting against flu and preventable infectious diseases in general will also help.38
The practical management of flu clinics will require both significant preparation, leadership, and frequent assessments of efficiency so ongoing changes can be made if need be. Considering the layout of a surgery, if a one-way system can be created this would immediately lower the risk of face to face contact, and allow for a consistent flow of patients.39 Comparable to a production line system, at the entrance patients would be recorded on medical systems as ‘arrived’, screened for COVID-19 symptoms and given hand sanitiser, and the same member of staff can ensure the patient is wearing a mask. This patient would then continue to see the clinician, where consent would be sought, their eligibility would be checked and they would be vaccinated. Post vaccine advice could be laminated and pinned to a wall near to where patients would exit. If patients belong to the same household, they could go through the one-way system as one party, otherwise a ‘one being screened, one being seen’ policy would be necessary. If the screener and vaccinator can see each other the process would run more smoothly, therefore each one-way system would ideally cover a relatively small scale. Larger surgeries may find they can replicate this pattern in another part of the building. Furthermore, practices operating over multiple sites should make use of all branches for flu clinics, assuming adequate staff availability. As in many establishments that have reopened with increased safety measures, arrows on the ground will help direct people – a downstairs location for clinics would be ideal but if an upstairs location is unavoidable, arrows on the ground can also be beneficial on stairs to guide people to keep to the correct side.
Clear, simple signage will be imperative.40 Examples of helpful instructions visible to all patients may include advice not to ask about any other medical problem; to ensure their jacket is removed and sleeve rolled up ready for their vaccine; and simply to maintain the one-way system through the surgery. When it comes to the flu vaccination consultation itself, some surgeries may choose to allow patients to only enter a small way into the room. Privacy is then provided, but needless contamination avoided. There may be a case for clear, wipeable screens to be used – a screen with a small window to vaccinate through. The installation of such barriers is highly effective in protecting staff.41 However, while creative proposals such as this can help in uncertain times, preparation is often then required to gather and assemble the materials, and questions may be raised over available funding.
The number of patients that can be booked into one clinic will naturally depend on the size of surgery, and walk in clinics have of course become a thing of the past. Special care should be taken so that patients, when booking their appointment, receive strict advice about arrival at the exact time of the appointment – neither early, nor late – as a queue of patients, even outside the surgery, could promote infection.40 Such instructions could be given in the form of a letter, text or, if the appointment is booked face to face, a useful flyer, emphasising importance of attending precisely at appointment time along with what kind of procedure to expect at clinics.
In the various surgeries I’ve had experience with, flu clinics of 2 to 3 hours often take place once or twice in a day. Perhaps in current circumstances we need to consider little and often, bursts of short clinics, throughout the day – 20-minute blocks of 10 patients for example. If patients are kept moving there may not be a need for gaps between flu appointments booked.39 Then, normal, clinics would resume for, let’s say an hour, then there could be another 20-minute block. Perhaps with even more diligent planning, vaccination clinics may be able to be longer. This would cause more disturbance to the running of normal clinics, but this degree of forethought and conscientiousness not only aids in the running of the clinics themselves, but reassures patients that their safety takes precedence. If, as previously mentioned, patients don’t fully enter a consultation room and instead enter as far as a ‘vaccinating station’, appointments may not need to be longer. However, if patients are required to fully enter the clinical consultation room, then perhaps one extra member of staff helping with decontamination would be wise. If efficient templates on medical systems are used for recording, and those vaccinating document whilst another decontaminates, appointments still may only need to be a minute longer than in the past.40
Another idea circulating is the potential of ‘drive-through’ clinics. Risk of contamination in the surgery is lowered and contact between patients eliminated. Some GP surgeries are already offering ‘drive-through’ childhood vaccination and blood test clinics, and feel confident about using the same model for the flu season. Perhaps this solution would work well for surgeries with purpose-built premises, with the space for cars to drive in a one-way system around the building, however many do not have this luxury.42 Patients would still need to arrive at a precise time, to prevent gridlock. Furthermore, some patients do not drive; only 65% of over-65s hold a full driving licence,43,44 and some may simply want to attend the surgery for an appointment – this must remain an option.
There is no doubt that, in whatever way a clinic operates, more staff will be required. Partnerships between surgeries will be more important than ever.40 The upcoming flu season may be the perfect opportunity to capitalise on Primary Care Network (PCN) relationships, of which over 98% of practices are now signed up as members.45 With bigger teams, it is possible that larger external venues may be a viable approach for carrying out clinics. The ‘production line’ system mentioned previously would still certainly be applicable, with parallel queues and multiple teams working at a time.40
During flu clinics it has often been appropriate to offer the pneumococcal (PPV) vaccine simultaneously,46 and sometimes the shingles vaccine as well.47 In order to maximise efficiency this may not be possible this season, particularly as the shingles vaccine is a live vaccine and there are additional clinical considerations before vaccinating.48 It may be pertinent to provide a poster informing patients that only their flu vaccine should be expected at the appointment. Perhaps strictly scheduled clinics for PPV and shingles vaccines could be offered outside the flu season.
So, it is time to start scrupulously planning our clinics, now. The UK consistently achieves some of the highest vaccination rates in Europe,49 so let’s ensure this continues. This coming season we will be required to think laterally in order to protect our most vulnerable patients. Health education must never be overlooked – now is a more relevant time than ever to remind people of the absolute necessity of prevention in medicine. Routine vaccinations, diabetes medication compliance and low glycaemic index diet, accurate inhaler technique – the simplest of measures can yield great results, alleviate pressure on our health services, and keep our patients safe.50-54
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BA (Hons) MSc RGN FRSPH
Nurse Practitioner, Immunisation Lead, North Manchester
Practice Nurse 2020;50(7):10-15
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