Prescriptions for Flu Shots

We have started to get requests for pharmacists again this year to give flu vaccines to our patients.

THIS MAKES ME FURIOUS! (Can I be any more clear with this? I am not usually alarmist, but it really is frustrating.) Let me try to explain. I apologize in advance for complaining, but...

Risk

The pharmacy is essentially wanting to put the onus on me to verify that the child is healthy enough for the vaccine and doesn't have any contraindications. Of course this is getting very difficult to do even in my office now that walk in clinics are conveniently located everywhere, so continuity of care is lost. If I haven't seen the child in many months, I might not realize that he had a wheezing episode last week but went to another urgent care center to manage. The pharmacy wants me to spend the time looking at the child's chart to verify the health of the child without seeing the child, write the prescription, and have unused flu vaccine sitting in my office (or waiting to be shipped to my office) that I must pay for but not use. Really???

Cost of care

And all of this for free, since the patient is not coming to my office for a visit, but spending his money at the pharmacy. My time needs to be valued somehow in this. A lawyer would charge for the time spent, but I cannot get reimbursed for this. Pediatricians are famous for being nice and giving free advice and care.

Now don't get me wrong. I didn't go into pediatrics to get rich. Medical students who want to get rich don't go into primary care. But I do need to cover my costs and support my practice by earning income with patients who come into the office. Primary care offices are struggling to survive. Many are selling out to hospitals, which increases healthcare costs. 

Continuity of care in the medical home: special dosing for kids, live viruses, and chronic illness

Flu vaccines in kids, especially under 9 years of age, have different rules than older kids and adults. They must have two vaccines of the same strain once before getting a simple yearly booster. If we don't have proper documentation of previous flu vaccines, they need two doses. Until we have a nationwide vaccine database, the pharmacy is unlikely to have the complete vaccine record for these kids and if they give some of the vaccine, the primary care office might not have records of the vaccines.

Parents often don't remember which of their children have been vaccinated -- let alone the specific dates and which particular vaccines were given. If kids get live virus vaccines, they must be given at least 28 days apart from one another or on the same day. This can cause issues if a child gets the kindergarten vaccines at their doctor's office and then a FluMist at the pharmacy or other walk in center (or vice versa). It is easy to see how mom and dad might each take the child to one of the places and not realize the contraindication. If all vaccines are given in one location (or if a person transfers records to another physician for continuing care at a new location) then this type of mistake can be more likely avoided. I try to remember to warn parents to wait at least 28 days before giving the FluMist to their child at the well visit if they get the MMR and/or chickenpox vaccines around flu vaccine time, but sometimes I forget and parents often forget when the time comes at the pharmacy. These kids don't suffer from harm, but the vaccine is not effective and must be given again. I've seen more than one frustrated family suffering from this scenario...

Another issue with getting vaccines outside the medical home is when there is a chronic issue, such as asthma, and parents don't accurately remember the severity. Even in my office when I've talked to parents and given a written Asthma Action Plan, they sometimes tell my nurse the child doesn't have a history of asthma. The nurse can question further because it's in the chart. The pharmacist won't know to question in a different way, especially if the family hasn't filled medications for that child at that pharmacy.

Inventory issues

We have been ordering and giving flu vaccines for longer than the 16 seasons I have been a part of Pediatric Partners. Each year there has been some frustration with the flu vaccine season.

See here and here and here for some of our headaches -- I wasn't blogging at the time of the novel H1N1 outbreak, but you all remember that, I'm sure.

Now that some kids get vaccinated at the parent's workplace, others at pharmacies, and others not at all it is getting more and more difficult to predict how much flu vaccine to order. If we over order, we are stuck with vaccine that can't be used (in other words, we stand to lose a lot of money). If we under order, parents are upset that we run out. Some years we can get more, others we can't.

We offer flu vaccines in our office, or at least we do when we have the vaccine in our office. For the second year in a row we are experiencing shipping delays. This is frustrating because we love to take advantage of the school aged kids (especially college aged "kids") being in the office in late summer and getting the flu vaccine out of the way. We can't give it at well visits if we don't have it, so we must pay nurses for more overtime having more flu vaccine clinics when we finally get the vaccines in stock. It's much easier for all to get it at an already established visit, but we do not have control of when the vaccine arrives at our office.

Pharmacies giving vaccines is a relatively new thing. I am frustrated that they are getting their supplies before us and offering them to our patients before we even have a chance. We have more and more difficulty ordering flu vaccines because we have no idea how many kids will get them elsewhere versus our office. We must pre-order during the winter before the next season, often when we are still offering vaccine for the current season, so we don't know if we will run out early or have leftovers. That makes it really hard to predict use for the next season.

Prescription requests 

Thankfully when I get a faxed request for such a prescription, I have an easy answer: No.

Our malpractice carrier has advised us to not write prescriptions for over the counter medications unless we are seeing the child in person. We have interpreted vaccine prescriptions to be in a similar category. If we cannot assess how sick or well a child is, we should not make the decision for any medicine (or vaccine) to be given. If the pharmacist wants to do an evaluation and order it, great. Otherwise, we are more than happy to vaccinate our patients.

Another reason to get the vaccine at your doctor's office

I just saw in a Slate article that vaccines might be better covered by insurance by an in network provider: "Pediatrician Walter Orenstein of Emory University, who chairs the National Vaccine Advisory Committee and formerly was the country’s assistant surgeon general, notes that the Affordable Care Act now requires that insurers cover vaccines against flu and several other diseases with “no co-payments or other cost-sharing requirements,” but, again, the catch is “when those services are delivered by an in-network provider.”"

Getting the vaccine

Please be patient with us. It wasn't that long ago that it was recommended to hold off on giving flu vaccines until October, thinking that the vaccine wouldn't last the season if given too early. Now that we know it is okay to give it earlier, that doesn't mean we must give it earlier. It isn't even October yet and people are panicking that they won't be able to get the vaccine. As far as I know, there's plenty of vaccine. It just hasn't all shipped yet. We are getting small allotments and giving it to kids whenever possible if they're in the office when we have stock. Unfortunately we can't schedule any vaccine appointments yet because our stock is too limited and we might run out before that appointment. We will be getting more soon. When we have enough in stock to schedule flu vaccine clinics we will let our patients know.

We're not alone in this. Most pediatricians I've asked are in the same boat. Please be patient with us all.

Dr Mellick got a FluMist in a previous season

Flu Shots: First Update for 2015

Every year I have been a pediatrician there has been something that makes giving flu vaccine difficult. (I've previously written about that here, which also includes similar links.)

In recent years (last year being the exception) we have been able to at least start giving the vaccine over the summer, allowing us to vaccinate at least some of the school aged kids before school even starts. It is especially reassurring to vaccinate the college aged kids before they go back to school, because once they're at school it's hard to ensure that they'll get the vaccine. We missed the opportunity to offer shots at summer physicals last year and it did make a difference. Since schools in our area are starting back up less than a month from now and we haven't heard anything about vaccine shipments, it looks like we'll miss the majority of school aged kids this summer too.

This year we've heard that the FluMist will once again be delayed in shipments. FluMist will not be shipped to distributors until the end of September/beginning of October, and then the distributors will be able to ship the vaccine to everyone nationwide who has ordered it.

Why are the shipments delayed? 

 
There will be three new strains in this year's FluMist, including a more stable version of the type A H1N1. This strain is producing lower yields than expected which is causing the delay.

I have not heard any direct information about when our office should start getting the injectable flu vaccine, but after an online search I did find that Fluzone has been approved for shipment. When we have the vaccine in the office we will start offering it to eligible patients who are in the office. (Eligible means they of the appropriate age and health status for the vaccine.) Once we have enough in stock we will announce flu vaccine clinics. It is too soon to predict exactly when our flu clinics will be available, but hopefully we'll be able to share more soon. I know many of you are asking when they will be, but please be patient and we'll let you know!

What if the flu vaccine doesn't cover the right strains?

Recent news reported that the FluMist nasal spray might not cover the Influenza A H1N1 strain as well as the injectable might. I know this may cause concern for parents whose children have already gotten the FluMist vaccine this season.

Don't panic! (Gee, I've said that a lot this year with the delayed shipments of flu vaccine...)

Why not panic? 

First, this is a theoretical concern. It is based on the findings that the FluMist didn't cover the H1N1 well last season and it is the same vaccine this year.

Second, the main strains of influenza that are starting to circulate this year are NOT that H1N1 strain anyway.

I thought FluMist was preferred this year...

The CDC continues to state that the preferred vaccine for 2-8 year olds is the FluMist because it seems to be more effective than the injectable form against the other strains contained in the vaccines. (This is of course only if the child doesn't have contraindications to the FluMist and the FluMist is available. No one should delay vaccination if one form is available to wait for another form.)

Should we wait to get the shot? I know there are shipping delays...

Both the CDC and the AAP state to give whatever vaccine is available as appropriate and to not delay giving the vaccine to wait for another type. This makes sense. If you can be vaccinated with only one type due to the shipping delays, why risk being completely unprotected when you can get a vaccine that will most likely protect. No vaccine is 100% effective. With influenza we have the additional difficulty that the flu virus changes each year, but there is some protection across types when the flu vaccine is given.

Why doesn't the strain match?

Flu strains change every year and scientists predict what strains will be circulating. The vaccine companies all make vaccine against the predicted strains. This year the main strains that have been identified in people sick with the flu are Influenza A H3N2 and Influenza B. It is still early in the season, so findings might change, but so far both the FluMist and injectable vaccines seem to be effective against those strains. The FluMist appears to offer better protection than the injectable if the strains are not quite matched.

In short: 

Any age-appropriate influenza vaccine should be used as soon as possible to protect as many people as possible against the flu.

Do kids who got the FluMist need to be given a shot this year?

No. It is not recommended to do a second vaccination unless it is the first flu vaccine and a child needs a booster dose this season. It is appropriate to use either form of the vaccine for eligible children over 2 years, and mixing and matching is okay, but there is no recommendation specifically to do that.

The good news: 

We are starting to see shipments of flu vaccine! Hopefully we'll soon be able to vaccinate your children!

Flu Vaccine 2014-15 Season

Every year it's something.

Flu vaccine causes distress every year for physician offices around the country.

I wrote about some of the issues last year here and here.

This year's flu vaccine is identical to the trivalent and quadrivalent vaccines of last season, so it should be easier.

But as always, there's a hitch.

This year there is a delay in shipping but no one really knows why. I've heard pharmacies are starting to advertise they have flu vaccine. From a business standpoint, we start to worry when we hear people say "I'll just do it at the pharmacy." We've already ordered more doses than last year and don't want to get stuck with supplies we can't use. Bad for business...

How flu vaccine makers choose their shipping times to various offices around the country is unknown to me. We order nearly a year in advance so they can make the requested number of doses. We must project how many infant vs child injectable doses of vaccine we will need and how many nasal spray doses we will need. Some years we can add to our order, but other years there are shortages. There are several makers of various brands, but in pediatrics we are limited to what types we order based on the ages for which it can be used.

As soon as we start getting the vaccine we will begin to offer them in the office. Typically we start getting a few doses at a time, so we can't advertise with those first small shipments. It will simply be patients who are in the office and eligible for the type we have will be offered flu vaccine. When we get enough to hold a flu vaccine clinic, we will send out e-newsletters to patients who are registered, as well as post on our website and Facebook page. Our flu clinics run smoothly because parents sign up on line. We will send paperwork ahead of time for you to fill out at home. Bringing that really helps. You will need to have signed our financial policy before the flu vaccine. To keep things running smoothly, we encourage you to do that ahead of time if you have not already done so. We also ask that your child is current on well visits in order to use our flu clinic. If your child needs a well visit, simply schedule one and he can get the vaccine at that visit. We will always give flu vaccine to patients and their siblings who are in the office for a visit (but without significant illness, such as fever) as long as supply lasts.

Who needs a flu vaccine and when should it be given?

It is recommended that everyone over 6 months of age get a flu vaccine each year. As soon as the vaccine is available, it can be given. Ideally the vaccine is given before the influenza season starts. Flu season usually peaks in January, but influenza can occur at any time of the year. I must put a plug in for getting the vaccine in your medical home if at all possible. This keeps vaccine records all in one place and helps support your doctor's office.

Which vaccine should my child get?

Children 6 months to 2 years should get the injectable vaccine. They are not eligible for the nasal spray (FluMist).

Starting in 2014-2015, the CDC recommends use of the nasal spray vaccine (FluMist) in healthy children 2 - 8 years of age, when it is immediately available and if the child has no contraindications or precautions to that vaccine.

Contraindications to the FluMist are:

• Children younger than 2 years
• Adults 50 years and older
• People with a history of severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine
• Young children with asthma
• Children or adolescents on long-term aspirin treatment
• Children and adults who have chronic pulmonary, cardiovascular (except isolated hypertension), renal, hepatic, neurologic/neuromuscular, hematologic, or metabolic disorders
• Children and adults who have immunosuppression (including immunosuppression caused by medications or by HIV)
• Pregnant women
• Live virus vaccine (such as MMR or Varicella/chickenpox) within the past 4 weeks. The vaccines can be given together on the same day, but if not on the same day they must be given 28 days apart from one another.
• Most people with the above contraindications can still be vaccinated with the injectable vaccine - ask your doctor

Recent studies suggest that the nasal spray flu vaccine may work better than the flu shot in younger children. However, if the nasal spray vaccine is not immediately available and the flu shot is, children should get the flu shot. Don’t delay vaccination to find the nasal spray flu vaccine.

How many doses does my child need?

In young children who have never received a flu vaccine, two doses of the same strain should be given. If they've had two doses of the same strain previously, they only need one dose. In children over 9 years of age, regardless of previous vaccines, only one dose is needed. This is because it is presumed that by 9 years of age a child has been exposed to the influenza virus previously. Think of it as the first vaccine is the initial body's exposure to the virus in young children, then everyone needs a booster dose for the season, including the first season if a child has never had one before.

The CDC has put together a flow chart of how many doses are needed:

Can a person still get the flu even after getting the vaccine?

Each year experts pick the most likely strains of influenza virus that are expected. Some years they do a great job, other years it is not as accurate. There is some cross-reactivity among strains, so even in years that the wrong strains are in the vaccine, there is some protection against severe flu illness. So yes, it is possible to still get influenza, but usually the illness is mild.

Can a person get the flu from the vaccine?

No. I have heard many people say they get the flu from the vaccine, but this is not possible. People who get the nasal vaccine can get mild congestion (cold like symptoms), but they do not get the flu from the vaccine. It is possible that they were exposed to the actual flu virus and get sick before the vaccine has a chance to provide protection. Or they have a viral illness that isn't the flu. People with influenza often say they feel like they were run over by a train. They are sick. It is not just a cold.

Can I get the flu vaccine even though I have an egg allergy?

The following recommendations come from the Advisory Committee on Immunization Practices (ACIP):

People with a history of egg allergy who have experienced only hives after exposure to egg should receive the injectable influenza vaccine. Because there is limited data in the use of live attenuated influenza vaccine (FluMist) in egg allergic people, inactivated influenza vaccines (shots) either the IIV or trivalent recombinant influenza vaccine (RIV3) should be used.

Where can I get more information? 

Each year the CDC provides summary information about the current influenza vaccine season. You can read about the 2014-15 season, information on flu vaccine myths and misconceptions, and you can even see where the flu has hit.

 

Flu Shot Information 2013-14 Season

Dr. Mellick getting FluMist

Dr. Stuppy getting a flu shot

Many parents are already asking about this year's flu vaccine, which means we've done a great job in the past making them aware that they need to think about getting the vaccine before they start seeing people get sick!

We feel so strongly that the vaccine is effective at protecting not only the person vaccinated but also the community around them that our office requires all staff to get a vaccine. We made the Honor Roll for Patient Safety from the Immunization Action Coalition for this requirement!

What's new this year?

Every year scientists predict which strains of Influenza A and Influenza B will likely be prevalent. The World Health Organization makes the recommendations for the vaccine based on these predictions. The strains chosen are the same for every company that makes the vaccine. The difference this year is that some will have three strains (trivalent) with two A and one B, others will have four strains (quadrivalent) with two A and two B.

Flu shot season causes headaches for doctor's offices. 

We must anticipate our need many months in advance and get our orders in. Each year the vaccine demand varies (a lot based on press reports on how badly people are getting sick, which we don't know when ordering). As more places offer vaccines (such as offices and pharmacies) the numbers of people getting vaccines at their doctor's office might go down. (I am biased, but of course believe getting them at your doctor's office is superior since we keep all your medical records in one place.)

From a business perspective, no one wants to be stuck with thousands of dollars of unused vaccine-- we can't stay in business if we lose money. We also don't want to have kids at risk of disease because they're unprotected and unable to find an appropriate vaccine when we run out. We certainly don't want parents yelling at our staff because we run out. Sometimes we've ordered enough overall, but our shipping allotments don't come fast enough for the demand. Shortages have happened over the years, something beyond anyone's control.

Scheduling mass flu vaccine clinics is often the best way to vaccinate large numbers of patients, but they are fraught with complications: how many people will show up, what flu vaccine (injectable vs nose spray) will they need? How many doses do we need on hand to hold a clinic? In times of shortages or low stock, how do you prioritize who gets the vaccine -- or do you want to just keep giving to anyone until it is gone so the office isn't stuck with unused vaccine at the end of the season? Do you give one dose to a 6 month old who you know won't be able to get the 2nd dose due to your supply running out?

This year there's a new spin to the variety of headaches: different vaccines will be available. Not just injectable vs nose spray. There will be some with 3 strains of virus, others with 4 strains. (For a review of how strains get into vaccine and how this year is different, see Quadrivalent Flu Vaccines: Four Means More Protection.)

So this year we have new questions: How are we supposed to order the different types, who gets which type, and are they interchangeable? How will the public perceive the difference and will they demand one or the other? Will insurance companies reimburse the cost appropriately, given that one is more expensive than the other? While in health care our goal is to keep everyone as healthy as can be, no office can afford to lose money on vaccines and stay in business.

What kinds of vaccine will be available this season?

There are many companies that make influenza vaccine, each with their own indications. For a complete list, see the chart on the CDC website. Our office has pre-ordered the FluMist and the Fluzone products (both forms) in part because we didn't know which would be available at the start of the season. We do not purchase the brands that are only available for older children or adults. Ask your doctor what they order.

All FluMist will be quadrivalent (4 strains) and is for children over 2 years without high risk conditions, such as asthma (presumed based on previous recommendations, this year's statement has not been released yet). It is expected to start shipping in July or August, though any individual office may not receive their order with the first shipping dates.

Fluzone Quadrivalent (4 strains) is an injectable vaccine for everyone over 6 months of age. It has already sold out  based on pre-season orders and will be available in limited quantities. Shipping dates will begin in August or September.

Fluzone Trivalent (3 strains) is an injectable vaccine for everyone over 6 months of age. It is expected to begin shipping in July and August. I have not heard of shortages.

Is adding a new strain dangerous?

Based on the chaos in the year of H1N1, I know that many parents fear "new" strains added to a flu shot. In actuality, every year the vaccine changes with very rare exception. That is because the flu strains predicted to cause disease change year to year. Adding a new strain does not make the vaccine less safe, just more effective.

Who needs the flu vaccines and how will they be given?

As of today, the finalized recommendations have not been approved. The preliminary recommendations  continue to recommend flu vaccine for all people over 6 months of age. (The link should update to the final recommendations as they become available.)

Last year it was recommended to start giving the vaccine as soon as it was received (previously it was suggested to wait until October so it remained effective throughout the season, but the vaccine is effective longer than previously thought so earlier vaccine is effective.) I presume this will remain the same.

If a child under 9 years of age has not had flu vaccine before, they need 2 doses in the same season to "prime" and "boost" immunity. If only one vaccine was given, the next season the child needs 2 doses unless they have gotten 2 of the same strain before. (This was easier last year because it was a rare year that the vaccine didn't change, so they could have gotten one the season prior, and the booster last year.) For children over 9 years, only one dose is needed, even if never received previously. After that first year of 2 doses, each year everyone just needs one dose unless it dramatically changes (as in the H1N1 year). I suspect since 3 of the 4 strains are the same this year, if a child needs 2 doses because they have not had 2 doses of the same strains, the vaccines are interchangeable. We will all find out when the final recommendation is given.

At this point I have not heard if high risk people should get preference for the quadrivalent vaccine. I don't think this will be possible in many cases, since many of the high risk are under 2 years old, and not eligible for FluMist. The injectable quadrivalent vaccine is in short supply, and many offices are likely to not get it at all. I personally feel it would be bad to wait for the quadrivalent vaccine if we have the trivalent vaccine in stock and an eligible patient is in the office. I'd rather vaccinate than potentially miss the opportunity all together. I'm sure others will differ in opinion since the quadrivalent vaccine is better protection. Talk to your pediatrician about their preference.

Although we cannot require all patients to get vaccinated, we certainly encourage it and try to make it as painless as possible (though the kids who get shots don't always agree). We will once again allow any patient in the office to get a flu vaccine (even if just there with a sibling for an appointment) and we will offer on line sign up for our clinics. On line sign up has proved very popular, both among our nurses and the families who come. It has really made the process run much more smoothly. There will not be a co pay collected at those clinics. (After we submit the claim to your insurance company if they tell us differently we will send a bill, but do not expect that in most cases.) Be sure you have registered for our e-Newsletter so you will be among the first to know when sign ups are ready for our patients. (No dates are set yet because we have not gotten verification on shipping dates. Please don't call the office to ask-- staff have no idea.) We will put information on our website as it becomes available in addition to posting on our Facebook page and sending the e-Newsletter.

We will all have to wait to see how this plays out! Every year something is new with the flu vaccine. What will be next?