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A window of opportunity?

Winter is on the way and with it an increase in common minor ailments such as cough, cold, sore throat and flu. With pressure on the NHS at unprecedented levels, driving home the self-care message has never been more important

Learning objectives

After reading this feature you should be able to:

  • Identify any changes made to the pharmacy flu vaccine service specification for the forthcoming season
  • Discuss current Public Health England guidelines regarding vitamin D
  • Appreciate the importance of reducing the prescribing of antibiotics.

As the colder weather brings in customers with stuffy noses, coughs and splutters, aches and pains, stressed skin and other troublesome winter ailments, it pays for pharmacies to stock up on the right products for their winter remedies fixtures and ensure their teams are confident and able to provide the best advice. 

Research by PAGB indicates that many people still do not know how to self-treat conditions such as coughs and colds and therefore visit their GP or A&E for advice. It is estimated that one-fifth of GP consultations concern minor ailments, including cold and flu symptoms, which costs the NHS around £370m a year.

So let’s look at some of the most common winter ailments we can expect to see once the temperature drops and the nights draw in, and consider how pharmacists can encourage customers to self care with good advice and appropriate product recommendations.

Armed with analgesics

Cold weather can exacerbate pain for many sufferers. “In cold weather people may stay in more and be less active, which can make the joints and muscles feel stiffer,” says LloydsPharmacy pharmacist Anshu Bhimbat. 

Some painful conditions are affected by temperature. Raynaud’s disease (when arteries supplying blood to the skin narrow) affects circulation to the extent that fingers and toes turn white. Reduced circulation can intensify pain caused by neurological conditions, such as multiple sclerosis and Parkinson’s disease.

Such customers should be advised to plan ahead to make sure they don’t run out of their regular medication if they have a condition that feels worse when it is cold and to stock up on suitable oral analgesics and any topical pain relief products they will need. 

Key facts

  • The provisional 2018/19 total for pharmacy flu vaccinations in England is 1,431,538
  • All primary school-aged children will now be offered the vaccine
  • The message for customers should be that antibiotics are of no use in colds and flu – self care is the preferred approach.

Coughs and colds

With everyone congregating indoors, winter is a prime time for the cold virus to spread. Adults get an average of two to five colds a year and children will suffer on average up to 10.

Cold and flu viruses can survive in water droplets for up to 24 hours after being released from an infected person when they sneeze or cough. These infected droplets can also settle on and contaminate household objects and surfaces, so when someone else touches these areas the virus can be transmitted through touching the nose or mouth. 

While it is not possible to avoid coming into contact with everyone who might be harbouring a cold or flu virus, there are plenty of ways customers can guard against infection through healthy living and hygiene measures. 

The best defence is a strong immune system, achieved through healthy diet and exercise or, for the times when this is simply not enough, taking a good quality, dedicated supplement.

Maintaining high hygiene standards is also important for avoiding winter bugs. A proper hand-washing technique is an important way to minimise transferring the viruses from hands to face, especially as the flu virus can live on surfaces for up to two days and cold viruses can survive for as long as seven days. Advise customers to wash their hands regularly with an antibacterial hand wash and warm water, especially after going to the toilet and before touching food, to minimise the spread of infection.

Colds are self-limiting conditions so pharmacists and their teams can reassure customers that a trip to their GP is usually not required. They can also help customers to deal with their winter ailments by stocking a comprehensive range of products that treat different/specific cold and flu symptoms, and keeping an eye out for new brand advertising and campaigns because this is likely to generate footfall into pharmacies as well as requests for these products.

Very few people buy winter remedies in advance when they are not ill, so encourage customers to stock up so they have them to hand when they are needed. Also link sell by offering additional products such as tissues, throat lozenges, a vapour rub/inhalant or vitamins and other supplements if appropriate. 

It is also worth being aware of health initiatives that coincide with this period. For example, the NHS ‘Stoptober’ campaign, which encourages people to give up smoking throughout October, comes at a time when the temperature starts to drop and is the perfect opportunity to target smokers who may be struggling with conditions such as asthma and COPD. 

When a customer is asking to purchase a cough linctus, use it as a chance to clarify their smoking status and, if appropriate, recommend a suitable nicotine replacement therapy product or smoking cessation service.

Sore throat test-and-treat expanded

A sore throat test-and-treat service is to be rolled out across half the community pharmacies in Wales over the coming winter, health minister Vaughan Gething has announced.

The scheme involves patients having their sore throat assessed in a pharmacy to determine whether it is being caused by a viral or bacterial infection and help them access advice and treatment without needing to see a GP.

Speaking in the Welsh Assembly on September 25, Mr Gething said a pilot of the service that has been running in Cwm Taf and Betsi Cadwaladr health boards since last November has led to 3,655 consultations, of which only 752 consultations – or 21 per cent – resulted in a prescription for antibiotics. The pilot had “roughly a 95 per cent positive patient response”, said Mr Gething.

The service is “part of the standard range of services we expect to see provided in community pharmacy locations,” he added, saying that it is “not just a winter pressure initiative”.

Antibiotics and the fight against AMR 

The upsurge in coughs and colds at this time of year will inevitably result in questions about antibiotics, despite public health campaigns explaining that they don’t work for these conditions, and the danger of inappropriate use leading to increasing antimicrobial resistance (AMR).

The key message for customers should be that antibiotics only work on bacterial infections and are ineffective against colds and flu, which are caused by viruses. Dr Diane Ashiru-Oredope, pharmacist lead for antimicrobial resistance and stewardship at Public Health England, says her research shows the “positive effect” that interactions with community pharmacy can have on patients.

“Thirty-eight per cent of patients expect to get an antibiotic from their GP or walk-in centre when they have a cough, flu or throat, ear, sinus or chest infection,” she says – so any advice that pharmacy teams can give that will reduce inappropriate prescribing is vital.

Online resources pharmacists and their teams can use to brush up on antimicrobial stewardship include:

A proper hand washing technique is an important way to minimise transferring viruses from hands to face

Flu vaccines in pharmacy for this season

Since September 2015, community pharmacies in England have been offering a flu jab service for those patients in at-risk groups as part of the NHS pharmacy flu vaccination service. 

The number of vaccinations administered has increased year on year, with the provisional 2018/19 figure reported as a record 1,431,538 – an increase of 87,076 on the 2017/18 flu season – despite the obstacles faced last year with the phased delivery of the adjuvanted trivalent flu vaccine.

Groups eligible for flu vaccination are based on the advice of the Joint Committee on Vaccination and Immunisation (JCVI) and include those who are at higher risk of flu- associated morbidity and mortality, such as older people, pregnant women and those with certain underlying medical conditions. 

This coming winter the only change to the eligibility criteria is the planned extension of the programme to school year six children. This means that, for the first time in England, all primary school children will be offered the vaccine. 

The public health messages surrounding this may well raise awareness of the availability of flu vaccination services in general and encourage more people to be vaccinated. However, Public Health England, and NHS England and NHS Improvement wrote to general practices and community pharmacy contractors warning about this year’s supply of quadrivalent flu vaccines, following alerts from the manufacturers that the delayed World Health Organization recommendation on vaccine strain had impacted on vaccine supplies.

Community pharmacies were able to order three different vaccine types for the 2019-20 season:

  • Egg-grown quadrivalent influenza vaccine (QIVe)
  • Cell-based quadrivalent influenza vaccine (QIVc)
  • Adjuvanted trivalent influenza vaccine (aTIV).

The pharmacy PGD does not include high-dose trivalent influenza vaccine (TIV-HD) or standard dose non-adjuvanted trivalent influenza vaccine (TIVe) as these vaccines are not eligible for reimbursement under the 2019/20 NHS influenza vaccination programme. 

Sanofi Pasteur has indicated it plans to phase some of the deliveries of the inactivated quadrivalent influenza vaccines for those at risk and under 65 years, with some vaccines being delivered by the end of November 2019.

PSNC’s advice to contractors is that if they have placed an order for quadrivalent influenza vaccines, they should contact the relevant manufacturer or supplier to confirm delivery dates in order to plan effectively for the season.

More information from the PSNC

Vitamin D

In the darker months, vitamin D is one of the most important potential deficiencies to avoid. Vitamin D has several important functions within the body, including regulating the amount of calcium and phosphate needed to keep bones and teeth healthy. Deficiency carries with it a whole host of health problems including rickets in children, and osteomalacia, the adult equivalent, which causes bone pain and tenderness.

Humans obtain vitamin D mainly from the action of sunlight on the skin, but in the UK the sun is only strong enough for vitamin D production in the summer months. So, although a small surplus is built up over the summer, most people are probably vitamin D deficient in the winter. Add to that the fact that vitamin D is only found in small amounts in food – such as eggs, oily fish and fortified foods such as breakfast cereals – and it becomes clear why taking a supplement is recommended for ‘at risk’ groups.

Public Health England guidelines recommend that everyone takes a 10mcg vitamin D supplement daily, particularly in autumn and winter. All babies and young children aged six months to five years should be given a daily supplement containing vitamin D in the form of drops to help them meet the requirement for this age group of 7-8.5mcg of vitamin D a day. 

Breastfed infants may need drops containing vitamin D from one month of age if the mother has not taken vitamin D supplements throughout pregnancy. However, babies fed infant formula will not need vitamin D drops until they are receiving less than 500ml a day, as these products are often fortified with vitamin D. 

Adults get an average of two to five colds a year, and children will suffer on average up to 10

 New Community Pharmacist Consultation Service 

Commissioned from October 29, the Community Pharmacist Consultation Service combines national NUMSAS and local DMIRS pilots in England into a single service, with the aim of driving patients to pharmacy as those who might have gone to other parts of the NHS with minor ailments are referred on. Pharmacies will initially receive referrals from NHS 111 (with those from GPs and A&E to be piloted later) and offer same-day appointments to patients with a minor illness. Patients will continue to have the option to see a GP if they prefer, but the Government estimates that eventually up to 6 per cent of all GP consultations could be safely transferred to community pharmacy – freeing up some 20 million GP appointments a year and helping manage demand during key pressure points such as winter.

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