Preparing for the 2024 ‘tripledemic’

Now is the time to arm Australians with vaccines, respiratory disease advice, testing and essential medicines to get ahead of respiratory ailment season.

The trifecta of respiratory viruses, influenza, respiratory syncytial virus (RSV) and COVID-19, hit Australia hard last year. Influenza peaked 2 months early in June for the second year in a row, with those under 16 making up the largest hospitalised group (72%).¹

This season, pharmacists should get their ducks in a row early to protect the community, particularly those most vulnerable, against severe disease. 

Vaccines 

Ahead of respiratory illness season, pharmacists should ensure they are up to date with the latest available vaccines, says Sherri Barden MPS, a member of PSA’s Respiratory Care Community of Specialty Interest (CSI), and owner of Asthma and Hay Fever Clinic Training, APlus Pharmacy. 

‘Making sure we’re aware of immunisation schedule changes when new vaccines become available is important to uphold patient safety, facilitate informed decision making, contribute to disease prevention and control, and play an active role in promoting community health,’ she says. 

A new quadrivalent influenza vaccine is formulated each year to protect patients aged 6 months and over against the dominant strains, with recommendations on the composition of the 2024 vaccine issued by the World Health Organization in September 2023.² 

This year, patients will benefit from the RSV vaccine, approved for use in Australia by the Therapeutic Goods Administration on 8 January and available to patients aged 60 years and over via private prescription.³

With the introduction of the new monovalent Omicron XBB.1.5 vaccine at the end of 2023, pharmacists should also ensure they’re up to date with recommendations by the Australian Technical Advisory Group on Immunisations (ATAGI) for the vaccine, which provides a ‘modest’ increase in protection, and is now the preferred COVID-19 vaccine in patients aged 5 years and older.⁴  

Pharmacists should also refer to ATAGI, Australian Immunisation Handbook advice and the federal Department of Health and Aged Care website on who can or should get a booster.^4–6 

Safety considerations 

As new vaccines become available, it’s also important for pharmacists to keep up to speed with safety protocols. 

‘As with any vaccine, pharmacists should familiarise themselves with storage and handling, administration procedures, screening for contraindications, monitoring and observation requirements, and recording adverse effects,’ Ms Barden says. 

Patients expect pharmacists to be up to date with this information, and to have it at their fingertips, even if the vaccines are new.

New adverse effects might also crop up. ‘First and foremost, we should look for contraindications, including hypersensitivity to the active substance or excipients within the vaccine,’ she warns. 

Counselling tips 

When patients are considering a vaccine they haven’t had previously, it’s essential to provide accurate information, address any concerns and foster open communication, according to Ms Barden. 

‘This includes going back to basics through techniques such as listening actively without interrupting and asking open-ended questions to understand the patient’s concerns and reasons for considering the new vaccine,’ she says. 

‘Pharmacists should then discuss the vaccine schedule, provide clear, evidence-based information, assess the benefits versus the risks and personalise the information to patients’ age, lifestyle or health conditions. If the patient is still uncertain, alternative options can be discussed. Always offer supportive evidence-based materials,’ Ms Barden counsels.  

‘You could also schedule a follow-up to address any further questions or concerns that may arise.’ 

Chronic respiratory conditions

Patients with chronic respiratory conditions should be well equipped to manage their condition, including preventing exacerbations and maintaining good disease control, says Professor Sinthia Bosnic-Anticevich FPS, Chair of the Respiratory Care CSI.

‘This includes a review of their asthma or chronic obstructive pulmonary disease (COPD) with their GP before winter to ensure their Action Plan is up to date.’ 

Asthma Action Plans can improve lung function while reducing hospital admissions and emergency or general practice visits.⁷ 

Care plans should address the unique triggers and challenges for patients with chronic respiratory conditions to optimise medication management and promote patient engagement.

‘Personalised care plans should take patient preferences into consideration, fostering a sense of ownership, increasing adherence to prescribed treatments, and knowing what to do when they start to lose control,’ says Ms Barden.

Some people with asthma might have winter-associated triggers, such as smoke from wood fires and cold air, said Prof Bosnic-Anticevich.

‘During winter it’s important to remind individuals with respiratory problems to either select a different form of exercise, which they can do indoors during winter, or if they still prefer to exercise outside, to do so during the warmest part of the day. Ensuring correct inhaler technique and continuing (or starting) preventer medication(s) regularly are also important factors for pharmacists to consider,’ Prof Bosnic-Anticevich stresses. 

Early counselling 

Ahead of the season, pharmacists should equip patients who live with chronic respiratory conditions with advice to prevent exacerbations. As viruses can trigger exacerbations of underlying chronic respiratory conditions, this includes promoting vaccination, says Prof Bosnic-Anticevich. 

‘Pharmacists have an important role in both administering vaccinations and education and supporting patients in their decision to get vaccinated in a timely manner. There has been a focus on COVID-19 vaccinations over the last couple of years,’ she acknowledges, ‘but we mustn’t forget the annual influenza virus continues to add risk to patients with chronic respiratory conditions such as asthma and COPD.’ 

Pharmacists should also ensure patients are up to date with pneumococcal vaccination, which, while routine in infants and children, is also recommended for at-risk patient groups.⁸  

Ms Barden adds: ‘When reviewing patients’ vaccination status on the Australian Immunisation Register (AIR), pharmacists should ensure pneumococcal vaccination is considered for those eligible.’ 

The tetanus, diphtheria and pertussis vaccine is also recommended as a routine booster vaccination for people with COPD or asthma.⁹

Stocktake 

Preparing for respiratory illness season requires having the right Rapid Antigen Tests (RATs), vaccinations and appropriate medicines in stock, and knowing when they should be offered. 

Vaccines 

Cases of respiratory illnesses such as COVID-19 and influenza began to climb in early April 2023.¹⁰  

It takes up to 2 weeks to develop an immune response post-influenza vaccination, with optimal protection lasting 3–4 months. To help ensure protection through peak influenza season, patients need vaccination against influenza before this (usually June – September). 

COVID-19 vaccines can be co-administered, so pharmacists should check AIR, check when their last COVID-19 vaccine dose was, and consider alongside current ATAGI/Australian Immunisation Handbook recommendations to determine eligibility. 

Tests 

Combined triple Rapid Antigen Tests (COVID-19, influenza and RSV) should be kept in stock and recommended when patients present to the pharmacy with respiratory symptoms, said Ms Barden. 

‘Rapidly identifying which virus a patient has is important to assist with current management and treatment options, so we get the best patient outcomes, less spread of disease and reduced hospital admissions.’ 

This is particularly important for patients at risk of severe disease who will most benefit from antivirals. Combined tests can help to ensure patients receive antivirals within the treatment window to prevent severe disease, which is 5 days from symptom onset for COVID-19 antivirals and 2 days from symptom onset for oseltamivir,¹¹ although, Ms Barden adds, it may be commenced up to 4 days after symptom onset in some high-risk individuals.¹² 

Essential medicines 

Given COVID-19 is present year-round, with case numbers rising in August 2023 and peaking in an 8th wave during summer, Ms Barden warns that it’s always pertinent to have COVID-19 antivirals such as nirmatrelvir/ritonovir and/or molnuviripir on hand.¹³ 

And while oseltamivir supplies should be replenished ahead of influenza season, pharmacists should prepare for a change in demand. 

‘Combined RATs will provide earlier diagnoses of influenza, so we could experience an increase in demand for oseltamivir,’ Ms Barden says. 

‘Pharmacists should also consider having the suspension paediatric formulation of oseltamivir in stock.’ 

Oseltamivir could also be used as a prophylactic treatment in those at risk of severe disease, including patients with chronic respiratory symptoms, she says.¹⁴ 

‘For example, if a patient has COPD and someone in their household has been diagnosed with influenza via a RAT test, oseltamivir could be prescribed as a preventive measure’ – although Ms Barden warns this will not always prevent infection.  

Pharmacists should also ensure they have essential medicines in stock to facilitate emergency treatment in the event of adverse vaccination events or respiratory exacerbations in the pharmacy. 

‘This includes adrenaline (EpiPens and Anapens),and salbutamol and spacers for asthma first aid, which all pharmacy staff should know how to administer.’ 

References

1. Fitzgerald Hughes D, O’Neill E. The Conversation. Flu season started early in Australia – countries in the Northern Hemisphere took note. 2023. At: https://theconversation.com/flu-season-started-early-in-australia-countries-in-the-northern-hemisphere-took-note-207967
2. World Health Organization. Recommended composition of influenza virus vaccines for use in the 2024 Southern Hemisphere influenza season. 2023. At: www.who.int/publications/m/item/recommended-composition-of-influenza-virus-vaccines-for-use-in-the-2024-southern-hemisphere-influenza-season
3. GlaxoSmithKline. January 2024. Australia’s first RSV (Respiratory Syncytial Virus) vaccine, Arexvy, approved by TGA. At: https://au.gsk.com/en-au/media/press-releases/australia-s-first-rsv-respiratory-syncytial-virus-vaccine-arexvy-approved-by-tga/
4. Australian Government Department of Health and Aged care. ATAGI recommendations on use of the Moderna and Pfizer monovalent Omicron XBB.1.5 COVID-19 vaccines. 2023. At: www.health.gov.au/news/atagi-recommendations-on-use-of-the-moderna-and-pfizer-monovalent-omicron-xbb15-covid-19-vaccines
5. Australian Government Department of Health and Aged Care. Australian Immunisation Handbook. 2023. At: https://immunisationhandbook.health.gov.au/
6. Australian Government Department of Health and Aged Care. COVID-19 booster vaccine advice. 2024. At: www.health.gov.au/our-work/covid-19-vaccines/getting-your-vaccination/booster-doses#:~:text=A%20booster%20dose%20is%20recommended,significant%20or%20complex%20health%20needs
7. National Asthma Council Australia. Asthma action plans. 2017. At: www.nationalasthma.org.au/health-professionals/asthma-action-plans
8. Australian Government Department of Health. Pneumococcal immunisation service. 2022 At: www.health.gov.au/topics/immunisation/vaccines/pneumococcal-immunisation-service
9. International Pharmaceutical Federation. Discussing vaccination with patients living with asthma or COPD. 2023.At: https://prevention.fip.org/wp-content/uploads/2023/12/SC_COPD.pdf
10. Flutracking. Weekly Interim Report: Australia Week ending 02 April 2023. At: https://info.flutracking.net/reports/australia-reports/
11. Roche. Taking Tamiflu. 2024. At: www.tamiflu.com/taking-tamiflu.html
12. Rossi S, ed. Australian medicines handbook. Adelaide: Australian Medicines Handbook; 2024. At: https://amhonline.amh.net.au/chapters/anti-infectives/antivirals/neuraminidase-inhibitors/oseltamivir
13. Wood j, Liu B, Flanagan KL, et al. University of New South Wales. 2023. We’re in a new COVID wave: What can we expect this time? At: www.unsw.edu.au/news/2023/11/we-re-in-a-new-covid-wave–what-can-we-expect-this-time-
14. New South Wales Ministry of Health. Antiviral treatments and prophylaxis in residential aged care facilities. 2023. At: www.health.nsw.gov.au/Infectious/factsheets/Pages/racf-antiviral-treatments-and-prophylaxis.aspx#:~:text=Oseltamivir%20(Tamiflu%C2%AE)%20can%20be,higher%20risk%20of%20severe%20disease).
15. Richards B. Pharmacists report low stocks of rapid antigen tests. The Mercury. 2024. At: www.themercury.com.au/subscribe/news/1/?sourceCode=TMWEB_WRE170_a_GGL&dest=https%3A%2F%2Fwww.themercury.com.au%2Fnews%2Ftasmania%2Fpharmacists-report-low-stocks-of-rapid-antigen-tests%2Fnews-story%2Fd3c282bbc216d8eab1d19f1325f7af35&memtype=anonymous&mode=premium