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Open season for cold and flu

Pharmacies should gear up for another busy – to say the least – cold and flu season

Last year’s cold and flu season was a hectic one for community pharmacy, with high levels of circulating winter viruses, severe pressures on the NHS, and shortages of several common OTC and prescription medicines.

This year, the Government originally pushed the start date of the flu and Covid vaccinations back to October. But with the sudden rise of the new BA.2.86 Covid-19 variant, it announced at the end of August that the flu vaccination and Covid booster would start in September, after all. 

The vaccination changes and new Covid variant could lead to another challenging season for community pharmacy teams. With Pharmacy First expected to launch in England by the end of the year, rising numbers of customers are likely to be seeking advice from community pharmacies rather than from their GP surgery.

“It’s unlikely to be a less dramatic winter,” says Ade Williams, lead prescribing pharmacist at Bedminster Pharmacy in Bristol. “The expected launch of the common ailments scheme in England may mean more people see value in community pharmacy services, but problems may occur if pharmacies can’t cope with the demand.”

Eoghan O’Brien, community pharmacist at Bannside Pharmacy in Portglenone, Northern Ireland, says that in Northern Ireland, the situation is still uncertain. “We normally have a Pharmacy First service in Northern Ireland over the winter, but this didn’t run last year, which put a spanner in the works,” he says. “We don’t yet know if it will be running this year either. It’s important to have a consistent, ongoing funded service each year to take the pressure off the GPs.”

According to a Community Pharmacy Scotland (CPS) spokesperson: “In winter 2022/23, community pharmacy teams undertook over 1.5 million consultations with patients suffering from common clinical conditions, delivering care where it is needed and making a major contribution to the delivery of the primary care workload. It’s anticipated that the service will deliver even more consultations and care through winter 2023/24.”

Jakemans senior brand manager Elizabeth Hughes-Gapper adds: “It’s important to look at growing consumer trends for pharmacists to fully prepare themselves for cold and flu season. As the NHS continues to be under pressure from increased demand, the organisation recommends that patients experiencing winter ailments – such as a cough or sore throat – can be self-medicated or treated by seeing their local pharmacist.”

Virus surges

Last winter saw a surge in strep A infections and scarlet fever, as well as being a strong flu season. According to the UK Health Security Agency (UKHSA) and Health Protection Surveillance Centre in Ireland in June 2023, cases of scarlet fever and invasive group A streptococcal infection in England still remain higher than normal. 

Further data released from the UKHSA in June indicated that excess deaths in England last year associated with flu were higher (14,500) than the average figure (13,500) for the five years before the pandemic – the highest figure since the 2017-2018 season, when there were 22,500 excess flu deaths. Last year’s flu season started relatively early, but also peaked quickly. Influenza A(H3N2), which was the predominant subtype in 2022-2023, is known to be more severe in older age groups, but other factors were involved as well. 

“Flu returned at scale last winter after being locked out by Covid-19 control measures,” says Dr Conall Watson, consultant epidemiologist at the UKHSA. “Lower population immunity following flu’s absence played a part in the season starting relatively early and led to lots of people catching flu in a short timeframe. Many people needed advice from NHS 111 services, and there were high numbers of severe flu episodes that required hospital care, placing pressure on the health system.”

There isn’t enough data yet to show whether the new Covid-19 variant will lead to increased hospital admissions. “Covid has not gone away, and with the colder months fast approaching, cases are likely to increase as people start to congregate inside as temperatures drop,” says Karen Baker, expert pharmacist for Care at Thornton & Ross, although she adds that because it is no longer being tracked as closely, its spread is harder to monitor. 

This is a vital category for our pharmacy and the early autumn is especially important this year with the new Covid variant around, so we are even busier than usual. Lots of our customers are asking for Covid tests and we can barely keep up with demand as suppliers are only giving us a limited amount. The coughs and colds season seems to have started early, despite the warm weather in September. People are really worried about the new Covid variant. Typical questions are: ‘What treatment should I use for my symptoms?’ and ‘Do I need antibiotics?’ It’s important that as pharmacists we are explaining to customers why they don’t usually need antibiotics for a minor illness.

Vaccination push

According to Alastair Buxton, director of NHS services at Community Pharmacy England, the changing start dates of the vaccination services caused unnecessary work and hassle for pharmacy owners and their teams. “The public can and will be relying on community pharmacies again this year to do what they do best: providing valuable services such as vaccinations to prevent flu and Covid, recommending OTC products to ease cold symptoms, and giving wider advice on how to stay healthy this winter,” he says, urging pharmacists to review all available guidance and resources for autumn/winter NHS services. 

The UK Government is recommending that, where possible, patients should be able to have flu and Covid-19 vaccinations at the same time. However, the changes in vaccination eligibility may have caused some confusion and frustration. “People have been coming into the pharmacy since August asking if they will be eligible for NHS flu vaccinations this year,” says Richard Evans, community pharmacist in Wales and member of the RPS Welsh Pharmacy Board. 

“Eligibility in Wales is the same as in England. Flu vaccinations are not available for free on the NHS for the under 65s this year, unless they are in an at-risk category, and there have been many last-minute changes to the vaccination schedule. If customers are not in the eligible categories but feel they still need the flu jab, it’s an opportunity to promote the pharmacy’s private service if this is available.”

Some community pharmacies are part of the NHS Vaccination Programmes in Scotland at a local level, but there isn’t a national service delivered through community pharmacy. Community pharmacies provide NHS flu vaccinations as part of the public health service. “This service offers opportunistic contributions to the preventative health agenda and includes the promotion and support of a pro-active approach to self-care for patients,” says a CPS spokesperson.

Williams says it’s important to encourage customers to have the flu vaccination and dispel any worries or concerns. “Look at how the vaccination programme can be further targeted to protect the vulnerable,” he says. “This may mean reaching out and engaging with certain groups in the community. Different parts of society and different people have a different mindset about vaccinations. But ultimately, they invest trust in pharmacists to help them make the right choices.” 

There are concerns that university students may be at an increased risk of meningitis due to low vaccination coverage. According to the UKHSA in August 2023, vaccine coverage data shows around one in eight new students going to college and university this year remain unprotected against the four strains of meningococcal bacteria. 

Managing pharmacy supplies

Evans says that last year’s strep A surge caused significant problems with supplies of cold and flu medicines. “There were also breaks in the supply chains, so these couldn’t cope with the demand,” he says. “Common medicines such as Lemsip and cough syrup were very difficult to order in. Many people wanted popular cold and flu remedies to ease their symptoms, but we couldn’t supply them.”

Williams stresses that the resilience of the supply chain shouldn’t be the responsibility of community pharmacies, but pharmacies can still plan ahead. “It’s important to make sure the right systems are in place within the pharmacy, bearing in mind that stock management can easily be technology-led,” he says. “We need to stock a range of products in line with the needs of the community and help people to access the care they need, while avoiding the temptation to stockpile. Make sure there is something for every type of patient, such as those with existing medical conditions, sugar-free formulations for those with diabetes, and also medicines for children.”

The cost-of-living crisis continues to escalate, which means customers are likely to be looking for affordable, effective cold and flu medicines – even more so than in previous years. Because certain brands weren’t available last year, some customers may have already switched to generic or cheaper versions.

“Around half of customers will ask for products by the brand name,” says Evans. “Obviously, there’s a big price difference between branded and unbranded versions. It’s important to explain to customers that they can buy an unbranded version at a fraction of the price and that these are the same products and have the same effects. In the past, if customers couldn’t get the brand they wanted, they didn’t want anything else, but many have become more aware of generics over the last few years.”

Baker says the cold and flu season provides an ideal opportunity for link selling. “Customers are more likely to test for illnesses since Covid-19 and also wear masks to protect others, so keeping tests and masks in stock will help to maximise sales,” she says. 

This category has become even more important since Covid and since last winter’s step A outbreak. Common questions we get asked are ‘Can you prescribe antibiotics for me?’ (I’m planning to hopefully do the strep A PGD this year) ‘What is the best all in one product?’ Best selling brands for us include Night Nurse liquid, Lemsip, and Beechams. (Day Nurse will no doubt be requested to some disappointment following the recent pholcodine containing medicines withdrawal). Our colleagues’ best way of increasing sales is by increasing awareness of the flu vaccine and highlighting link sales (e.g. benefits of sore throat spray – this works well if their GP has only prescribed an antibiotic).

Healthcare advice

According to Baker, being able to distinguish between cold, flu and Covid-19 symptoms will be particularly important over the coming months.

Williams says this is the ideal time to make sure the whole pharmacy team is up to speed and to look for any gaps in their knowledge. “The new variant of Covid has emerged before we get back into the full winter season,” he says. “Successful training will mean fewer referrals to the pharmacist. We need to explain to customers that most people don’t need antibiotics for their symptoms, while identifying those who do need them.” 

The cold and flu season provides an opportunity to discuss general health issues with customers, such as sleeping well, looking after their weight, and smoking cessation. “Going into the winter months, evidence shows that people find it more difficult, physically and emotionally, as it gets darker and the weather seems less appealing,” says Williams. “Covid and flu vaccinations are a great way to get messages across, beginning with the question, ‘How are you planning to look after yourself this winter?’ 

“We are running two winter programmes this year: one involving referral for social isolation, and the other about keeping warm in the cold weather.”

O’Brien has noticed that more customers are asking for advice on keeping their immune system healthy. “People are realising there’s so much they can do themselves,” he says. “Vitamin D supplements should be taken from September until March. Higher doses of 4,000 to 5,000 units per day show the best results, as long as there are no contraindications, such as sarcoidosis. It takes around six weeks for vitamin D levels to build up, so it’s important to start taking the supplements early on, from when summer stores start depleting.”

Other dietary supplements are important for the immune system as well, but it’s important to take budget into consideration. 

“Vitamin C can also be helpful to treat a cold or flu, but again this needs to be in high doses – around 1,000 mg of vitamin C every two or three hours while the infection is present,” says O’Brien. “It’s expensive to take it four to five times a day, so I recommend a budget brand. Zinc is another useful supplement, but needs to be taken with copper as it can deplete copper stores.”

Eating well is important too. “Reducing sugar in the diet helps the immune system,” says O’Brien. “Sugar depletes many essential nutrients, such as magnesium, zinc and B vitamins. It also leads to a drop in energy levels, which encourages people to then eat more sugar. 

“There’s concern about how many and how quickly antibiotics are prescribed for cold and flu symptoms. Research shows that taking probiotics alongside antibiotics helps to reduce antibiotic resistance and the frequency of antibiotic prescribing.”

This is always an important topic and, surprisingly, it’s a year-round issue. Coughs, colds and flu can happen during the summer months. We always get asked what is the best treatment for their symptoms. Night Nurse liquid is always a top seller for our pharmacy. Other brands that do well for our pharmacy include Sudafed, Olbas and Benylin. Stock issues are becoming all too common these days. I have noticed more people seem to be getting unwell and/or repeated symptoms this year. This could be related to the reduced strict hygiene measures and social distancing that we abided by for so long during the Covid pandemic.

Product News

TORQ aTAC contains vitamin C, glutamine and echinacea – micronutrients proven to reduce the severity and duration of cold and flu symptoms – plus carbohydrate and fluid for energy and hydration. It should be taken at the first signs of infection and followed by doses as per the ‘mega-dosing’ protocol – typically 28 doses over five days. A daily dose can also be used as a pre-emptive measure.

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