Download Technician - Drug Store News CE

Technician CE LESSON
By Marsha Millonig, BPharm, MBA, consultant and associate fellow at the University of Minnesota College of Pharmacy,
center for leading healthcare change
Disclosures: Marsha Millonig and the
DSN editorial and continuing education
staff do not have any actual or potential
conflicts of interest in relation to this lesson.
Universal program number: 0401-0000-16-205-H01-T
CE Broker Tracking number: 20-572626
Activity type: Knowledge-based
Initial release date: Oct. 1, 2016
Planned expiration date: Oct. 1, 2018
This activity is worth 1.0 contact hour (0.1 CEU).
Target Audience
Technicians in community-based practice.
Program Goal
To improve the pharmacy technician’s ability to help patients with
the prevention and treatment of cough, cold and flu, including
triaging questions and recommendations between the patient and
the pharmacist.
Learning Objectives:
Upon completion of this program, the technician should be able to:
1.Recall symptoms associated with cough, cold and flu in adults
and children.
2.List non-pharmacologic and pharmacologic options available
for treating cough, cold and flu in adults and children.
3.Assist patients in locating non-pharmacologic treatment
options, including humidifiers and vaporizers, which
are appropriate.
4.Explain when to refer a patient with potential cough, cold and
flu symptoms to the pharmacist or other healthcare provider.
5.Identify opportunities to offer immunizations by screening
patients who present to the in window with prescriptions, refills
or questions.
To obtain credit:
Complete the learning assessment and evaluation questions
online at DrugStoreNewsCE.com. A minimum test score of 70%
is needed to obtain a statement of credit. Official statements of
credit will be available only at CPE Monitor (NABP.net). Please
verify that your correct personal NABP e-Profile ID and 4 digit
MMDD date of birth are included in your DSN CE profile before
completing the lesson to ensure accurate transmission of credit to
CPE Monitor.
Questions: Contact the DSN customer service team at
[email protected].
Drug Store News is accredited by the
Accreditation Council for Pharmacy Education as a provider
of continuing pharmacy education.
1 • OCTOBER 2016
This lesson is sponsored by Kaz
Cough, cold and flu
update for pharmacy
technicians
INTRODUCTION
Cough, cold and flu are among the
most commonly experienced conditions in adults and children, leading
them to seek medical care. 1,2 Patients
and caregivers frequently seek the
pharmacist’s advice for treating
symptoms associated with cough,
cold and flu, as well as preventing
their spread. As patients arrive at
the pharmacy, the technician is usually the first point of contact and can
assist by triaging questions; collecting additional information that may
help in targeting the pharmacist’s
education; advocating for and referring patients to the pharmacist
for education and services; and locating recommended products that
the patient would like to purchase.
Pharmacy technicians also can be
instrumental in asking about past
immunization status to identify patients who may benefit from immunizations available in the pharmacy.
COUGH
Cough is often a symptom of cold
and flu, but also can occur by itself.
It is the most common symptom for
which patients seek medical care.11
In 2015, Americans spent nearly $8
billion on cough, cold and related
products. Cough is an important
defensive reflex that helps the body
clear secretions, foreign particles
and irritants from breathing passages. Coughs may be voluntary or
involuntary as different areas of the
brain control each mechanism. There
are three phases in the cough reflex:
inhalation, followed by forced exhalation against a closed glottis and
violent air release from the lungs
after the glottis opens, usually accompanied by a distinctive sound.4
Cough is classified as acute, subacute or chronic, based on its duration. An acute cough is shorter than
three weeks in duration and can be
caused by a viral upper respiratory
infection, or URI; pneumonia; as-
pirating foreign bodies; asthma; or
acute left ventricular heart failure.
Because of cough variation and differing potential causes, it is important for the pharmacy technician to
offer the patient an opportunity to
talk with a pharmacist rather than
simply providing the location of
available over-the-counter products.
The pharmacist will need to assess
the patient by exploring the type of
cough the patient has, how long the
cough has been present, etc. By advocating for the patient and ensuring the counseling session, the pharmacist can conduct an appropriate
assessment and subsequent recommendation for management of
cough, including whether self-treatment is appropriate or if a referral
is necessary. When product recommendations are made, the pharmacy
technician plays a role in closing the
care loop by assisting the patient in
locating the product(s) that matches
the pharmacist’s recommendations.5
Symptomatology
Coughs are described as productive or nonproductive.6 Productive
coughs typically include secretions
to be expelled from the respiratory
tract and are often called “wet.”
These secretions can be clear or colored, and with or without odor. Colored secretions may be caused by an
underlying bacterial infection or inflammatory disorders, while odors
may result from anaerobic bacteria.6 Nonproductive, or dry, coughs
are not accompanied by secretions.
They are commonly associated with
viral respiratory infections, gastrointestinal reflux disease and cardiac
disease, or as a side effect of medications known as angiotensin-converting enzyme, or ACE, inhibitors. All
of this information will be important
as the pharmacist makes the best
recommendation for the patient.
Coughs that are accompanied
by a “whooping” sound may mean
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Technician CE LESSON
that a pertussis bacterial infection is present. Pertussis is a highly contagious bacterial disease that causes uncontrollable,
violent coughing and lasts for approximately six weeks. Symptoms of pertussis
are similar to the common cold for about a
week after bacterial exposure and progress
within another 10 to 12 days to the extreme
coughing episodes.7 Other symptoms include runny nose, slight fever and diarrhea. Because pertussis can be treated with
specific antibiotics, if caught early enough,
it is critical to arrange a consultation with
the pharmacist if symptoms suggesting
pertussis are present.
Pertussis is a disease for which immunizations are available, and the focus always
should be on prevention. The diphtheria,
tetanus and pertussis (i.e., DTaP) vaccines
are used for infants and children age 7 years
old and younger. The tetanus, diphtheria
and pertussis (i.e., Tdap) vaccine is used
for adults and children older than 7 years
old. After the initial childhood vaccination,
the Tdap vaccine should be given to adolescents near the age of 11 years old or 12
years old, and a tetanus and diphtheria (i.e.,
Td) booster should be given every 10 years
after.7 Tdap vaccination also is indicated in
women during each pregnancy to protect
the infant. Pertussis can be fatal in infants.
Technicians can engage patients by learning about past immunization status to identify candidates for pharmacist-delivered
vaccines, and to help identify situations
that may indicate existing infections that
need additional care from the pharmacist
and other providers. Current recommendations include maintaining up-to-date
immunization status for all people to prevent outbreaks. This is especially important
for family members, caregivers and others
who may come in contact with newborns.
The United States experienced a pertussis
outbreak recently, with more than 48,000
cases reported to the CDC in 2012.8 Pertussis cases declined in 2013 in all but 13 states
and the District of Columbia, but the number of cases reported in 2014 increased 15%
from 2013.8 The causes of the rise in pertussis have been attributed to lack of vaccination among a significant enough percentage
of the population, and to lower effectiveness of newer vaccines. “Herd” immunity
is important with pertussis to protect those
with no immunity.7
Prevention
There are a number of interventions that
the pharmacist can make in the prevention
and management of cough. These interventions are dependent upon the cause of the
cough and can offer opportunities for the
technician to advocate for the correct patient care. For example, some coughs may
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be caused by a specific class of medications that is widely known to cause a dry
cough. For a patient using an ACE inhibitor
but also reports a bothersome, persistent
cough, the pharmacist may be able to work
with the prescriber to identify another
medication that controls the patient’s illness and removes the cause of the cough.6
By recommending the consultation with
the pharmacist rather than simply showing
the patient the location of cough remedies,
the technician is positively impacting patient outcomes.6
In other situations, a discussion with
the pharmacist may uncover the presence
of causes that are linked to an infection or
the flu. Infections and viruses may spread
through direct contact, indirect contact
and/or airborne spread. For these types
of causes, the pharmacist may recommend
follow-up with a primary care provider, the
use of an over-the-counter medication to
cover the symptoms and/or a number of
non-pharmaceutical interventions or NPIs
to assist the patient. Viruses that cause
colds and other infections can live up to
three or four hours on contaminated skin
or surfaces, while the influenza virus may
survive up to 48 hours.9 NPIs are thought to
work by limiting this virus transmission in
a number of ways, including physical (e.g.,
filtration and dilution) and biological (e.g.,
humidity, disinfectants and UV light) decay
of the virus particles that may be emitted
when an infected person coughs, sneezes,
talks or breathes.9
Patients can use a number of NPIs that
prevent or slow the spread of infection, according to a published comprehensive literature review.9 Examples of NPIs include:
• Practicing healthy habits
• Maintaining hand hygiene
• Using masks
• Affecting air quality and ventilation
with the use of
• high-efficiency particulate air, or
HEPA, filtration
• -exhaust fans
• UV light
• household humidity/temperature control
Practicing healthy habits and good hygiene can help prevent the spread of infection, as can maintaining current vaccination. The primary, direct method of
contracting viral and other infections is
by allowing the virus to come into contact
with mucous membranes. Transmission is
often accomplished when hands that have
been in contact with surfaces that contain
the virus, such as door knobs, key boards,
writing utensils, etc., are used to rub the
eyes, nose or other mucous membrane.
By disinfecting surfaces and using proper
hand-washing techniques, these methods
of transmission can be interrupted. While
hand sanitizers often are used to help prevent the spread of infection, the CDC continues to recommend hand-washing with
soap and water as the preferred method of
reducing microbes, based on a review of
the science behind sanitizers.10 Available
hand sanitizers can contain a variety of ingredients, but alcohol is the primary active
antimicrobial ingredient. The CDC recommends using hand sanitizers with an alcohol content of 60% or more, if hand washing
with soap and water is not practical.10 The
pharmacy technician can help customers
select hand sanitizers with the appropriate
alcohol content by reviewing the label with
them. Research is available concerning the
use of hand sanitizers containing triclosan,
which has created controversy due to concerns about its use creating superbugs and
affecting human hormones.11 Triclosan is
commonly used in antibacterial soaps. The
FDA and Environmental Protection Agency
review its use on a regular basis.11 The FDA
recently published a ban on the use of antibacterial soaps. Evidence suggests a period
of 20 seconds of washing/sanitizing is a
suitable amount of time to reduce transmission risk.9 Face masks may provide protection against the spread of infection due to
limiting the potential of the ability of the
virus to come into contact with the mucous
membranes. Additionally, a mask worn by
a person with an infection may help block
aerosol transmission of the virus from an
infected person.
Studies have correlated higher infection
rates with poorly ventilated air.9 Airborne
virus concentration is reduced with the use
of filters and/or the entrance of fresh air.
HEPA filters used in home heating and air
conditioning systems can remove nearly
98% of particles that are very small (i.e.,
≥0.3 um). Portable air purifiers also can be
used and may be purchased with optional
UV lights, which also disinfect. Creating
negative pressure by using exhaust fans
also is effective in reducing particles in
the air. Bathrooms can pose a special risk
to infection spread. It is recommended that
bathroom windows be left partly open to
introduce fresh air and that exhaust fans
are used to create negative pressure. Additionally, in homes with more than one bathroom, infected individuals should use a
dedicated single bathroom to help prevent
spread of infection.9
Mounting evidence shows that humidity levels in an indoor environment can
impact the level of airborne influenza virus.12,13 A recent model showed the concentration of airborne influenza A virus
from cough would be reduced by 10% by
increasing relative humidity from 35% to
50% 10 minutes following the cough, and
OCTOBER 2016 •
2
Technician CE LESSON
by 40% in one hour.12 Another review of the
literature found supporting evidence that
showed low absolute humidity is a key
causal factor in during winter influenza
peaks in temperate climates.13 A humidity level of 40% to 60% is recommended to
minimize the survival of viruses in the air
and on surfaces.9, 14
See Table 1 for health habits and hygiene
practices that can be used. Patients or caregivers with questions should be referred to
the pharmacist for counseling.15 Guidelines
for home hygiene also have been developed by the International Scientific Forum
on Home Hygiene.16 The pharmacy technician may wish to download the guidelines,
which include broader hygiene practices, at
IFH-HomeHygiene.org/Resources-Guidelines and use them when appropriate.
NON-PHARMACOLOGIC TREATMENT OPTIONS
FOR COUGH
Treatment of cough includes both nonpharmacologic and pharmacologic options.
Non-pharmacologic options include nonmedicated lozenges, hydration and humidification. Pharmacologic options include
cough suppressants or antitussives for nonproductive coughs, and expectorants or protussives for patients with productive coughs.
Use of non-medicated lozenges with
adults and children old enough to avoid accidental swallowing can provide moisture
to a dry throat and reduce irritation and
coughing.6 Popsicles, preferably sugar-free,
may be used by children, as well. Hydration
with water may make mucus secretions less
sticky and more easily expelled. Most adults
should drink at least eight 8-oz. glasses of
water daily. The American Academy of
Pediatrics advises that children older than
three months old may be helped by drinking
warm, clear liquids, such as apple juice or
broth. The warm liquids may relax airways
and also loosen mucus. Honey should not
be added to liquids for children less than 1
year old because of the risk of botulism bacterial growth. Honey has been shown to be
beneficial in children older than 1 year for
acute cough.17 Infants and young children
up to 2 years old with congestion may require the use of a rubber nasal syringe or a
nasal aspirator to clear nasal passages, since
they cannot blow their noses. The nasal aspirator commonly used is the Nose Frida.
The aspirator allows the caregiver to suck
mucus from the child’s nose into a disposable filter. Aspirating mucus can reduce
cough caused by postnasal drip. Additionally, raising the head of the bed or propping
the infant or child upright during sleep can
help nasal secretion drainage.6
Humidification
Humidifiers may be used to increase the
3 • OCTOBER 2016
Table 1
Healthy habits and hygiene practices9, 11-12, 14-15
Medical identity theft
Eat a balanced diet.
Get enough sleep. The Sleep Foundation says seven to nine hours of sleep is a good rule of thumb, but individuals
need to assess their own situation.
Manage stress.
Exercise moderately.
Stop smoking or reduce frequency; avoid second-hand smoke.
Maintain adequate relative home humidity — 40% to 60%.
Use exhaust or ceiling fans to create circulation and negative pressure.
Use HEPA filters in furnace systems.
Use portable air filtration systems with or without UV lights.
Hygiene
Avoid contact with infected people.
Practice good hand-washing habits and techniques — at least 40 seconds to 600 seconds with hot water and soap,
or 20 seconds with alcohol — especially after shaking hands or coughing.
Use hand sanitizers when soap and water are not available.
Avoid touching the face with hands and potentially contaminated surfaces; consider using a face mask.
Disinfect surfaces.
Have infected individuals use only one bathroom in homes with multiple bathrooms.
amount of moisture in the air. Increasing air
humidity may clear secretions and soothe
irritated airways. However, care should be
taken not to over-humidify air, which may
increase mold and dust mite activity, worsening any existing allergies a patient has.
A humidity level of 40% to 60% is recommended to minimize the survival of airborne viruses and bacteria in the air and on
surfaces, yet remain nonoptimal for mold
and mites.9,14 This humidity level has been
shown to reduce the survival rate of infectious influenza A viruses in laboratory studies. No field studies have been reported.9,14
Different types of humidifiers and vaporizers, both cool and warm mist, are available. Vaporizers are humidifiers that have
a cup to place medicated liquids that create
medicated vapor.6 Regardless of type, humidifiers should be cleaned each day and
disinfected weekly. Some prefer cool mist
humidifiers and vaporizers because there is
less risk for injury if they are tipped over.
The majority of cool mist devices use distilled water, although some brands are now
designed for use of with regular water. Water should be changed daily.
Cool moisture
Evaporative humidifiers use a wick system to draw water from a reservoir, while
a fan blowing over the wick releases wa-
ter into the air. Because they use cool mist,
wicks may come treated with antibacterial
agents, or water may have antibacterial additives or use UV technology to inhibit bacterial growth.18 Impeller humidifiers use a
rotating disc to fling water at a comb-like
diffuser. The diffuser breaks the water into
fine droplets that float into the air. Ultrasonic humidifiers use a metal diaphragm,
vibrating at an ultrasonic frequency to create water droplets. These humidifiers usually are silent.
Warm moisture
Steam vaporizers work to boil water and
release the warm steam into the room. This
is the simplest and least expensive technology for humidification. However, their
use with children is not recommended because of the risk of injury should the unit
be tipped. Medicated inhalants may be
used with the unit to help reduce coughs.
Steam inhalers release the warm steam for
personal cough-cold relief. The amount
and temperature of the steam is controlled
by the amount of cool air that mixes with
the steam. There are two versions: one that
heats the water electrically and can be used
with medicated inhalant pads; and one that
requires adding hot water and can be used
with liquid medicated inhalant. Warm mist
humidifiers boil water in a small cup, us-
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Technician
CE LESSON
PATIENT SCENARIO
Mrs. Svendsen and her family are regular patients at the pharmacy. As she arrives at the in-window
to drop off new prescriptions for her husband’s blood pressure and cholesterol medications (changes
in strengths of products he has used previously), she lets the technician know that she would like to
wait for the medications. She needs to get home to her 7-year-old daughter, who was sent home early
with a neighbor because she had signs of the flu. She mentions that she will be shopping while the
prescriptions are prepared and has a list of items she needs to pick up. She asks the technician where
she can find hand sanitizer, disinfectant spray and the oral electrolyte products that her pediatrician
recommended. She also mentioned that she will be searching for anything else that could keep the rest
of the family from getting the flu as both she and her husband cannot afford lengthy periods of time
off work. Before Mrs. Svendsen leaves the in-window to complete her shopping, the technician quickly
checks her profile and notices that Mrs. Svendsen has not received a flu shot from the pharmacy. How
should the technician proceed with the situation?
Discussion: part one
The technician assures Mrs. Svendsen that he will put her husband’s medications in line and process
them as quickly as possible to allow her to get home to her daughter. He also shares the locations of
the items on her list. Before she leaves the in-window, the technician asks Mrs. Svendsen if she or
the other members of the family have received flu shots this season. Mrs. Svendsen sighs and states
that she has not had time to get herself and her children scheduled for flu shots with their doctor. Her
husband recently received the shot during his checkup. The technician lets Mrs. Svendsen know that
the pharmacist can give her a flu shot today, if she liked and could bring her children in whenever it
was convenient with no appointment necessary. Mrs. Svendsen happily accepts the offer to receive
her flu shot when she returns to pick up the prescriptions, as long as it can be done quickly. The
technician assures her that the pharmacist will take care of that when she returns and provides her
with the necessary paperwork, following the pharmacy’s protocol for immunization delivery. He then
processes the vaccine and pulls up the dose for the pharmacist’s verification.
Discussion: part two
The pharmacist is finishing an immunization with another patient when Mrs. Svendsen returns, and the
technician begins the check-out process to help her manage the time. He notices that she has selected
a number of cleaning and disinfecting products and seems very worried about the potential spread of
the flu within her home. The technician pulls out a pamphlet about handwashing and disinfecting and
shares the recommendation that if possible her daughter should use just one bathroom while she is ill
and the rest of the family use another bathroom to limit the possible exposure and the time that would
be needed to spend cleaning. The technician also shares the information he recently learned regarding
the effect of keeping household humidity between 40% and 60%, and the decreased ability of flu virus
survival. He suggests that Mrs. Svendsen ask the pharmacist if a humidifier might help her family. He
also tells her that if she decides to purchase a humidifier after consulting the pharmacist, he will be
happy to ring her up and explain how to use it so that she can be on her way quickly. Mrs. Svendsen
thanks the technician for his help and goes with the pharmacist into the consultation room to receive
her flu shot and discuss her questions about the flu.
ing an electrical heater element. This type
of heater produces steam that is usually
mixed with air in a cooling tower. Medicated inhalants may be used with the unit
to help reduce coughs.
Some humidifiers use a germ-free process that uses a patented ultraviolet light
technology to kill up to 99.999% of bacteria, mold and fungi in the unit’s water.
The technology is available in both cool
and warm moisture units. When using
medicated inhalants — usually those made
with menthol or camphor and are FDA approved — refer to product-specific directions for use. Use of these products is not
recommended with children younger than
2 years old. Commonly used inhalant examples are Vicks® VapoSteam® and Kaz®
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inhalant liquid, which contain camphor as
a cough suppressant, along with other essential oils. Commonly used inhalant pads
include Vicks® VapoPads® refills and Kaz®
Aromatic Inhalant Pads. Other products
may contain only aromatic oils, such as
lavender and rosemary. In addition, inhalant pads have been developed for use with
plug-in vaporizer nightlights (e.g., Vicks®
Soothing Vapors Plug In Waterless Vaporizer and nightlight). The pharmacy technician should refer patients who have questions about the humidifier or vaporizer
selection to the pharmacist for counseling.
PHARMACOLOGIC THERAPY FOR COUGH
Pharmacotherapy for cough consists of
oral and topical antitussives, oral expecto-
rants and antibiotics in cases where cough
is caused by an underlying bacterial infection. FDA-approved over-the-counter
systemic antitussives include codeine,
dextromethorphan,
diphenhydramine
and chlophedianol. Hydrocodone is approved for prescription use.18 Codeine,
dextromethorphan, diphenhydramine and
chlophedianol are indicated for the suppression of nonproductive cough caused
by chemical or mechanical respiratory
tract irritation. Guaifenesin is indicated
for symptomatic relief of acute, ineffective
productive cough. It should not be used
for chronic cough associated with chronic
lower respiratory tract diseases, such as
asthma, COPD, emphysema or smoker’s
cough. Authors of a 2014 Cochrane review
of OTC medications for acute cough in children and adults in ambulatory settings concluded that there is no good evidence for or
against the effectiveness of their use.19
The pharmacy technician may be aware
of the increasing use of dextromethorphan
for illicit purposes, particularly by adolescents. FDA panels considered moving
dextromethorphan to prescription status
due to its potential for abuse, but voted
against the recommendation in September
2010, citing lack of evidence that making
it prescription-only would curb abuse.20
Some states have restricted the sale of dextromethorphan to adults, or placed other
restrictions to its purchase similar to those
for pseudoephedrine.
Topical antitussives approved by the
FDA include camphor and menthol. These
products are rubbed on the throat or chest
in a thick layer up to three times a day. Examples include Vicks® VapoRub®, BabyRub
and Mentholatum® Chest Rub. The pharmacy technician should triage the patient
to the pharmacist for counseling on the appropriate use of these products.
Special considerations for children, pregnant
women and the elderly
The FDA’s Nonprescription Drugs Advisory and Pediatric Advisory committees
have recommended OTC cough-cold products not be used in children younger than
2 years old, as well as in children between
the ages of 2 years old to 6 years old. The
majority of manufacturers have voluntarily relabeled their products in the last five
years to reflect that they should not be used
in children younger than 6 years old.21 The
American Academy of Pediatrics, or AAP,
also recommends the use of fluids and humidity to control cough in children based
upon its determination that no well-controlled studies are available to support the
safety and efficacy of codeine and dextromethorphan in children.22 In May 2011, the
FDA released guidelines to address inaccu-
OCTOBER 2016 •
4
Technician CE LESSON
rate dosing issues of liquid OTC products
that contain any dispensing device.23 The
guidance requires that a dosing device be
included for all oral liquid OTC products,
that it be calibrated to the product’s dosage
directions, be used only with the product
it is packaged with and have visible markings, even if liquid is in the device. Parents
or caregivers with specific questions regarding OTC use in children, or appropriate
dosing, should be referred to the pharmacist. It is very important for the pharmacist
to educate the parent or caregiver on how
to determine the appropriate dose for the
child and how to correctly administer the
medication, including demonstrating the
use of the measuring device. The pharmacy
technician should be sure to maintain the
stock of dosing devices at the pharmacy,
including oral syringes and dosing spoons,
and provide them to parents and caregivers
when they receive oral medications at the
pick-up window.
There may be special considerations for
product use by pregnant women, nursing
women and the elderly. The pharmacy technician should refer questions from these patients directly to the pharmacist. There may
be opportunities for the pharmacist to provide medication management services with
these patients, as well.
Exclusions for self-treatment
Patients or caregivers with questions
about treatment options for cough should be
referred to the pharmacist for counseling. Patients should not self-treat, but rather should
seek medical treatment when the following
criteria are present: thick yellow, green or tan
mucus or pus, indicating possible bacterial
infection; fever higher than 103 degrees Fahrenheit (i.e., 39.4 degrees Celsius); unintended
weight loss; drenching nighttime sweats;
history or symptoms of underlying chronic
disease (e.g., asthma, COPD or GERD);
aspirating foreign object; drug-associated
cough; coughing for more than seven days;
cough that comes and goes or cough that
keeps coming back; cough accompanied by
“whooping;” worsening cough or development of new symptoms when self-treating;
or a bark-like cough, stridor or hoarseness in
an infant or child. Parents should call their
child’s physician if a fever is 101 degrees
Fahrenheit or higher in children between the
ages of 3 months to 6 months old, or if the
fever is 102 degrees Fahrenheit or higher in
children older than 6 months old.6
COLD
The common cold is an acute viral infection of the upper respiratory tract that is
self-limiting. More than a billion cases of
cold occur annually in the United States,
making it the most common illness.2 Colds
5 • OCTOBER 2016
are the most common in children. It’s estimated that they may have six to 10 colds
per year, with the number rising if they
are in daycare or school, where germs and
viruses can spread between children.2 Because children carry the rhinovirus during
off-peak cold seasons, they are the major
carriers of the common cold.24 The common cold is the second-most common diagnosis by pediatricians, and the incidence
is greatest among three-to-five year olds in
daycare.25 Colds are more common from
August to April, although they may occur
at any time.24
Symptomatology
Sore throat usually is the first symptom
of a cold. This is followed by nasal congestion, sneezing and runny nose within several days. Cough may follow, occurring in
about 20% of colds. A low-grade fever (i.e.,
lower than 101 degrees Fahrenheit) also
may occur. Cold symptoms usually last between one week and two weeks. While not
widespread, complications can result from
colds and include sinusitis, ear infections,
bronchitis and other respiratory infections.26 Other conditions may mimic cold
symptoms, so it is important for the pharmacy technician to triage the patient to the
pharmacist so as to determine appropriate
treatment recommendations.
adequate rest and nutrition, hydration and
humidification. Additionally, saline drops
and nasal sprays also can relieve congestion
by loosening encrusted mucus and drawing
fluid from the nasal passages, acting as decongestants. Because it has minimal side effects, saline can be used in children. Salinecontaining nasal sprays and drops do not
cause rebound congestion like decongestant
nasal sprays. The recommended dosage for
saline drops is one to two drops into each
nostril 15 to 20 minutes before feeding and
bedtime, with a repeated dose 10 minutes
later. For sprays, the dose should be two
sprays in each nostril as needed. Use of saline
nasal sprays or drops should be followed by
aspiration with a nasal bulb syringe to clear
the nasal passageways. The bulb should be
squeezed, while gently placing the tip into
the nostril and slowly releasing the pressure
to draw out the fluid. The bulb should be
disassembled and thoroughly cleaned with
warm, soapy water after each use.6 A nasal
aspirator also may be used.
Nasal rinses and nasal pots (e.g., netipots) also may be used to relieve nasal
symptoms associated with colds and flu.
They need to be used carefully to avoid bacterial contamination, however, and patients
should use distilled water with the devices.
The pharmacy technician should refer the
patient to the pharmacist for counseling
on how to use these devices safely. Nasal
strips also can be used in adults, and pediatric nasal strips in children aged 5 years
old and older. The strips consist of an adhesive-backed plastic band with a liner that is
removed. The strip is centered between the
bridge and the tip of the nose, just above
the flare of each nostril. Placement is important for the FDA-approved device to work
properly by exerting a gentle pressure on
the nostril, opening it and providing relief
of nasal congestion. Strips, which may be
used up to 12 hours per day, are singleuse. Patients allergic to latex should not
use them.28 Breathe Right® is the common
brand for nasal strips.
Prevention
There is no known cure for the common
cold, which may be caused by more than 200
viruses, the majority of which are rhinoviruses. It is transmitted most commonly by
touching mucous membranes with hands
that have touched the virus on other humans or objects. Preventing the spread of
the cold virus is the primary approach to
treatment. There are a number of healthy
habits and good hygiene practices that can
help prevent the spread of colds (see Table
1). The pharmacy technician may provide
these strategies to patients. Although adenovirus vaccines have been explored for use in
preventing colds, a Cochrane review of randomized controlled trials found no statistically significant evidence on the incidence of
colds in healthy people who receive the vaccine versus those who received placebo.27
Much attention has been paid to products
that claim to boost the immune system, and
many products are marketed as immune
boosters. Examples include high-dose vitamin C, echinacea and other botanicals, zinc
lozenges, combination products and probiotics. Refer patients with questions about these
products to the pharmacist for counseling.
PHARMACOLOGIC THERAPY FOR COLDS
Pharmacologic options for self-treatment
are limited and vary by age. Options primarily deal with treating each symptom
with single-entity products. While combination products are available, symptoms
appear at different times and with different
durations, so use of single-entity decongestants, antihistamines, cough suppressants,
expectorants and pain relievers are recommended.26 Use of cough suppressants and
expectorants was outlined earlier.
NONPHARMACOLOGIC TREATMENT OPTIONS
FOR COLDS
Nonpharmacologic treatment includes
Decongestants and antihistamines
For nasal congestion or runny nose, use
of topical or systemic decongestants and
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Technician CE LESSON
antihistamines may be considered. Pain
and fever associated with cold may be
treated with analgesics. These include aspirin, acetaminophen, ibuprofen and naproxen. Acetaminophen and ibuprofen are the
preferred analgesics for children. Liquid
OTC acetaminophen formulations for infants and children have been standardized
to contain 160 mg/5 mL. The pharmacy
technician may point this change out to patients, but also should refer the patient to
the pharmacist to provide counseling on
the dose change and the dosage devices.
This is especially important because acetaminophen can be toxic to the liver. The
recommended dose remains 10 mg/kg/
dose to 15 mg/kg/dose. Ibuprofen is restricted to children 6 months old and older.
The maximum duration of OTC acetaminophen therapy for all ages is three days for
fever; 10 days for pain in adolescents and
children 12 years old and older, five days
for children, three days for infants and two
days for children with sore throat. Aspirin
should not be used in a child younger than
18 years old with a fever, due to the risk of
Reye’s syndrome.
In addition to earlier recommendations
with treating throat irritation due to cough,
medicated lozenges may be used for sore
throats due to colds. Post-nasal drip often is
the cause of a sore throat, and treating nasal
congestion and runny nose may help reduce it. Medicated lozenges for sore throat
contain anesthetics and local antiseptics,
such as benzocaine, phenol and menthol.
The usual dosage regimen calls for their use
every two-to-four hours. Common brand
names include Cepacol®, Chloraseptic®,
Halls® and Sucrets®.
about preventing and treating colds should
be referred to the pharmacist for counseling. Patients should not self-treat, but rather
seek medical treatment when the following
criteria are present: fever higher than 101.5
degrees Fahrenheit (38.6 degrees Celsius);
history or symptoms of underlying chronic
disease (e.g., asthma, COPD, GERD, AIDS
or chronic immunosuppressant therapy);
chest pain or shortness of breath; unusual
fatigue/weakness; earache or tugging
on the ears; swollen glands in the neck or
severely painful sore throat; worsening
cough when self-treating or developing
new symptoms; frailty, elderly patients; infants younger than 9 months old; or infants
or children with a cold lasting longer than
seven days.26
Special considerations for children, pregnant
women and the elderly
Concerns about the use of cough-cold
products in children were addressed earlier in this activity. With colds, however,
analgesia for pain and fever creates an additional caution for children and adults
with regard to acetaminophen toxicity, and
care needs to be taken to avoid concomitant
use of combination products with singleingredient acetaminophen products. Additionally, sedating antihistamines can produce excitation in children and should be
avoided. As with cough, there may be special considerations for cold product use by
pregnant or nursing women, as well as the
elderly. The pharmacy technician should
refer questions from these patients to the
pharmacist. There may be opportunities to
provide medication management services
with older patients. as well.
FLU
The flu is caused by the influenza virus.
It is recommended to use the term “influenza” because sometimes patients can associate “flu” with illnesses other than influenza. The influenza virus is classified as type
A, B or C. Types A and B affect humans,
with type A having the most severe impact.
Influenza type A is subtyped, based upon
two surface protein antigens: hemagglutinin, or HA, and neuraminidase, or NA.
HA allows the virus into the cell, while NA
helps with cell-to-cell transmission of the
virus.29 Humans create antibodies to these
antigens when infected, producing an immune response.30 H1N1 and H3N2 are the
two types of influenza A viruses circulating in humans, with the latter being more
serious. Influenza is named according to
the type, the location of initial isolation, the
strain designation and the year of isolation.
For example, A/Texas/50/2012 (H3N2), or
H3N2, is influenza type A with an origin in
Texas, strain No. 50, isolated in 2012 and of
the H3N2 subtype.31
Influenza is a serious disease that can
lead to hospitalization and sometimes
even death. Influenza affects 5% to 20% of
Americans each year.32 More than 200,000
people are hospitalized from influenza
complications, and about 49,000 people die
based on annualized statistics from 1979
through 2006.32 Anyone can get sick from
influenza, but a number of populations are
at greater risk for serious complications,
including children, the elderly, pregnant
women and people with chronic lung diseases (e.g., asthma and COPD, diabetes,
heart disease, neurologic conditions and
certain other long-term health conditions).
These populations are very important for
the pharmacy technician to identify to provide vaccination.
Exclusions for self-treatment
Patients or caregivers with questions
Symptomatology
Fever, muscle weakness, body aches and
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fatigue are common symptoms associated
with the flu. Respiratory symptoms include
nasal congestion, rhinitis, sore throat and
nonproductive cough. Nausea and vomiting may occur, usually more often with
children. Onset is rapid, and the flu virus
can spread before symptoms occur. It is important to be able to distinguish the symptoms of flu from cold or other respiratory
conditions. Fever, headache and chills are
flu symptoms more often than cold symptoms. In flu, cough is nonproductive if present, fatigue and body aches are moderate to
severe and sore throats occur less often.
Prevention
Influenza vaccination is the most important method for preventing the virus and
its complications. In 2016, the Centers for
Disease Control and Prevention’s Advisory
Committee on Immunization Practices, or
ACIP, recommended routine influenza vaccination for all persons between the ages of
6 months old and older.33,34 The pharmacy
technician should ensure that vaccination is
available to groups considered high-risk for
contracting influenza. These include:
• children between the ages of 6 months
old to 18 years old35
• people age 50 years old and older35
• residents of nursing homes or other
chronic care facilities35
• adults and children who have chronic
pulmonary, cardiovascular or other
disorders35
• children and adolescents between the
ages of 6 months old to 18 years old on
long-term aspirin therapy35
• women who will be pregnant during
the flu season (i.e., indicated in all trimesters of pregnancy)35
• people who live with or care for persons at high risk for influenza-related complications, including healthy
household contacts and caregivers of
children younger than 5 years old and
adults older than 50 years old35
• healthy household contacts and caregivers of persons with medical conditions that put them at high risk for severe complications from influenza and
healthcare workers.35
Patients who think they do not need to
be vaccinated and who have not had a flu
shot should be referred to the pharmacist
for counseling and education.
Pharmacy technicians who are knowledgeable about vaccine design, production
and distribution play an important role in
dispelling common misunderstandings.
These include the myth that the flu vaccine
causes influenza and respiratory infection.
Randomized, blinded studies with people
who received inactivated flu shots versus
controls who received salt-water shots,
OCTOBER 2016
•6
Technician CE LESSON
found the only differences in symptoms
were increased soreness in the arm and redness at the injection site among those who
received the flu vaccine. No differences in
terms of body aches, fever, cough, runny
nose or sore throat were reported.36
There also is concern about health effects
of thimerosal, a vaccine preservative used
in multidose vials. ACIP recommendations
state that no scientific evidence exists indicating that thimerosal is a cause of adverse
events other than occasional local hypersensitivity reactions in vaccine recipients.37
Thimerosal also can be avoided by providing single-dose flu vaccine rather than using multidose vials.
Influenza vaccines may be of two types:
intranasal live attenuated influenza vaccine, or LAIV, and inactivated influenza
vaccine, or IIV. Vaccines may be trivalent or
quadrivalent influenza vaccines. If they are
inactivated trivalent, they may be abbreviated as IIV3. If they are inactivated quadrivalent vaccines, they may be abbreviated as
IIV4. For the 2016 to 2017 influenza season,
six inactivated quadrivalent influenza vaccines are available:
• One live attenuated influenza vaccine:
FluMist Quadrivalent = LAIV438
• Five inactivated influenza vaccines:
Fluarix Quadrivalent, FluLaval Quadrivalent, Fluzone Quadrivalent and
Fluzone Intradermal Quadrivalent =
IIV4, with one cell-culture based formulation, Flucelvax Quadrivalent =
ccIIV438
Four inactivated trivalent influenza vaccines are available:
• Three standard dose: Afluria, Fluvirin
= IIV3, adjuvanted Fluad = aIIV338
• One high-dose formulation: Fluzone
High-dose = IIV338
A recombinant influenza vaccine also is
available that is not made from the flu virus
— FluBlok = RIV3.38 More importantly, Fluzone Quadrivalent (LAIV) — or the nasal
spray vaccine — is not recommended for
use during the 2016 to 2017 season because
of concerns about its effectiveness.38
Influenza vaccine manufacturers receive
FDA approval for different age groups,
some beginning at six months old. Refer
to the individual vaccine product labeling
or the ACIP recommendations for more
specific information on each of the different vaccine brands at immunize.org/
acip. The FDA-approved 2016 to 2017 influenza vaccines include the following
three viruses: an A/California/7/2009
(H1N1)pdm09-like virus, an A/Hong
Kong/4801/2014 (H3N2)-like virus and a
B/Brisbane/60/2008-like virus (B/Victoria lineage). The quadrivalent vaccines also
contain a B/Phuket/3073/2013-like virus
(B/Yamagata lineage).39
7 • OCTOBER 2016
Flucelvax, the cell-cultured inactivated
influenza vaccine, is indicated for children
and adults age 4 years old and older.40 The
influenza virus for the vaccine is propagated in Madin Darby Canine Kidney, or
MDCK, cells as an alternative to traditional
fertilized chicken egg-based influenza vaccines. This vaccine would be an option for
patients who are allergic to eggs.
FluBlok, the recombinant influenza vaccine, uses DNA technology to produce
hemagglutinin,the exterior surface protein
on influenza viruses, and is indicated for
adults age 18 years old and older.41 No fertilized chicken eggs or influenza virus is
used in the production of the vaccine, and
it is another option for patients who are allergic to eggs.
Fluzone, the intradermal flu vaccine, is
a shot that is injected into the skin instead
of the muscle. The intradermal shot uses a
much smaller needle than the regular flu
shot, and it requires fewer antigens to be as
effective as the regular flu shot. It is recommended for adults age 18 years old to 64
years. There also is a Fluzone high-dose formulation indicated for adults age 65 years
old and older. Because human immune defenses become weaker with age, older people are at greater risk of severe illness from
influenza. Aging also decreases the body’s
ability to have a good immune response
after getting the influenza vaccine. The
higher dose of antigen in the vaccine is supposed to give older people a better immune
response and better protection against flu.39
Fluad, the adjuvanted trivalent in activated influenza vaccine, is manufactured
using an egg-based process, and is formulated with the adjuvant MF59. An adjuvant
is an ingredient added to a vaccine that
helps create a stronger immune response to
vaccination. It is indicated for adults age 65
years old and older.38
The ACIP modified recommendations
for influenza vaccination for people allergic to eggs, removing the recommendation
that these patients be observed for 30 minutes following vaccination and now recommending providers observe all patients for
15 minutes. For patients with a history of
severe egg allergy, the ACIP recommends
vaccination in an inpatient or outpatient
setting under the supervision of a health
professional, who is able to recognize and
manage severe allergic conditions.38 Complete 2016 to 2017 ACIP guidelines may
be found at: http://dx.doi.org/10.15585/
mmwr.rr6505a1.
In addition to flu vaccination, pharmacists and pharmacy technicians can recommend the healthy habits and hygiene
practices found in Table 1. Avoiding contact with people who already have the flu
is recommended since the virus can spread
through direct exposure from droplets expelled by infected persons. Persons with
the flu should be advised to stay home.
Humidification also is an important
strategy to prevent flu. Recent analyses
based on modeling and review of earlier
studies suggest that maintaining an indoor
humidity level between 40% and 60% can
reduce the survival of flu viruses on surfaces and in the air.9,14 This is because the
influenza virus survives best at humidity
levels lower than 40%.
Treatment approaches
Nonpharmacological treatment of flu
involves bed rest, proper nutrition and hydration. Flu symptoms may be addressed
with a variety of OTC medications (see
cold section).
Prescription antiviral medications with
influenza virus activity may be useful adjuncts in influenza prevention and are effective when used early in the course of illness
for treatment. They are considered a second
line of defense after vaccination.42 There are
five FDA-approved antiviral medications:
amantadine, rimatadine, oseltamivir (Tamiflu®), zanamivir (Relenza®) and peramivir
(Rapivab®). The first two are amantadines,
and the others are neuraminidase inhibitors. Inhibiting neuraminidase reduces the
release of virus from infected cells, viral aggregation and spreading within the respiratory tract.43 Peramivir is an intravenous
infusion and not commonly seen in the
community pharmacy setting.
Resistance may be a cause for concern,
and the CDC tracks the issue. For the 2015
to 2016 influenza season, data indicated that
the vast majority of currently circulating influenza virus strains were sensitive to these
medications, based upon viral surveillance
and resistance data from the influenza season summary.44 The pharmacist should stay
abreast of seasonal flu strains, flu recommendations and resistance. The flu area of
the CDC website — CDC.gov/Flu/Professionals — is an excellent resource. Another
helpful resource is the Immunization Action Coalition’s website: Immunize.org.
The CDC recommends use of either oseltamivir or zanamirvir for people at high
risk of developing complications, including:
• People with severe illness who have
been hospitalized;
• People younger than 19 years old who
are receiving long-term aspirin therapy; and
• People with suspected or confirmed
influenza who are at higher risk for
complications, such as the following:
• children younger than 2 years old;
• adults age 65 years old and older;
• pregnant women; and
• people with certain chronic medi-
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Technician CE LESSON
cal and immunosuppressive conditions
Antiviral medication may shorten the
duration of the flu by less than one day.45
Antiviral agents carry a C pregnancy rating, and there is limited data on their safe
use in pregnancy. For elderly patients, oseltamivir dosage should be adjusted based
on renal function. Zanamivir may be used
in children age 7 years old and older. Oseltamivir is indicated for children age 1 year
old and older.
Exclusions for self-treatment
Refer patients and caregivers with questions about influenza to the pharmacist for
counseling. Patients and parents/caregivers of children should consult a healthcare
provider if they develop symptoms associated with severe illness from the flu. The
CDC describes emergency warning signs as
difficulty breathing or shortness of breath;
pain or pressure in the chest or abdomen;
sudden dizziness; confusion; severe or persistent vomiting; flu-like symptoms that
improve but then return with fever; and
worsening cough.
Additional signs in children include
fast breathing or trouble breathing; bluish
skin color; and not drinking enough fluids.
Signs for infants include the use of fewer
wet diapers than normal; not waking up
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or not interacting; irritability to the extent
that they do not want to be held; diarrhea
lasting longer than two days; severe abdominal cramping; seizure and fever with
a rash.46
CONCLUSION
As cough, cold and flu season begin, it is
important for pharmacy technicians to be
aware of symptoms associated with these
conditions and understand when to refer
patients with symptoms or questions about
these conditions to the pharmacist for
counseling. There are many healthy habits and preventive strategies that can help
prevent the spread of cold and flu viruses.
The pharmacy technician can provide this
information to the patient, as well as show
them where hand sanitizers, cough-cold
medications, humidifiers, vaporizers and
other recommended products are available. Vaccinations are an important public
health service provided by the pharmacy
staff that can improve patients’ health and
quality of health care. These outcomes and
quality are increasingly being measured,
tracked and rewarded. The pharmacy
technician can contribute to the organization’s immunization goals by identifying
patients who may qualify for vaccination,
asking them their vaccination history, offering them the opportunity to be vaccinated and referring them to the pharmacist
to provide vaccination.
PRACTICE POINTS
• Patients or caregivers with questions about prevention or treatment of cough, cold and influenza
should be referred to the pharmacist for counseling.
• Pregnant, nursing women and older patients may have special needs and should be referred to
the pharmacist for assessment, counseling and medication management services.
• Practicing healthy habits and good personal and home hygiene can reduce the transmission of
cold and flu viruses.
• Maintaining home humidity between 40% and 60% is recommended to minimize the survival of
viruses in the air and on surfaces.
• Everyone older than 6 months of age should be vaccinated against influenza. Identify patients
appropriate for vaccine services when they ask questions or present to the in-window with
prescriptions or refills.
OCTOBER 2016
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Technician CE LESSON
1 Hsiao C-J, Cherry DK, Beatty PC, et al. National Ambulatory Medical Care Survey: 2007 Summary. Hyattsville, MD: National Center for Health Statistics; 2010. National Health
Statistics Reports; No. 27. http://www.cdc.gov/nchs/data/nhsr/nhsr027.pdf. Accessed September 2, 2016. 2 Common Cold. National Institute of Allergy and Infectious Diseases
Web site. February 8, 2016. http://www.niaid.nih.gov/topics/commoncold/Pages/default.aspx. Accessed September 2, 2016. 3 OTC sales by category 2012-2015. Consumer
Health Products Association website. http://www.chpa.org/PR_OTCsCategory.aspx. Accessed September 2, 2016. 4 Chung KF, Pavord ID. Prevalence, pathogenesis and
causes of chronic cough. Lancet. 2008; 371(9621):1364–74. 5 De Blasio F1, Virchow JC, Polverino M, Zanasi A, Behrakis PK, Kilinç G, Balsamo R, De Danieli G, Lanata L.
Cough management: a practical approach. Cough. 2011 Oct 10;7(1):7. doi: 10.1186/1745-9974-7-7. 6 Tietze KJ. Cough. “Handbook of Nonprescription Drugs.” 18th ed.
Washington, D.C.: American Pharmaceutical Association; 2015. Accessed online at pharmacylibrary.com [subscription required] September 3, 2016. 7 About Pertussis. CDC
Web site. September 8, 2015. https://www.cdc.gov/pertussis/about/index.html. Accessed September 3, 2016. 8 Pertussis Outbreak Trends. CDC Web site. September 8, 2015.
http://www.cdc.gov/pertussis/outbreaks/trends.html. Accessed September 3, 2016. 9 Finkelstein S, Prakas S, Nigmatulina K, et. al. A home toolkit for primary prevention of
influenza by individuals and families. Disaster Medicine and Public Health Preparedness. 2011;(5)4:266-271. 10 Show Me the Science: When to use Hand Sanitizers. CDC Web
site. February 22, 2016. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html. Accessed September 3, 2016. 11 Grisham L. Fact or Fiction: Can Hand
Sanitizers Create Super Bugs? USA Today Website. August 12, 2014. http://www.usatoday.com/story/news/nation-now/2014/08/12/five-facts-about-hand-sanitizers/13945273/
Accessed September 3, 2016. 12 Yang W, Marr LC (2011) Dynamics of airborne influenza A viruses indoors and dependence on humidity. PLoS ONE 6(6): e21481. doi:10.1371/
journal.pone.0021481 13 Metz JA, Finn A. Infuenza and humidity-Why a bit more damp may be good for you! J Infect. 2015;71:s54-S58. 14 Myatt TA, Kaufman MH, Allen JG,
MacIntosh DL, Fabian MP, McDevitt JJ. Modeling the airborne survival of influenza virus in a residential setting: The impacts of home humidification. Environmental Health
journal. 2010, 9:55doi:10.1186/1476-069X-9-55. Ehjournal.net/content/9/1/55. Accessed August 15, 2014. 15 Treating the common cold: An expert panel consensus
recommendation for primary care clinicians. Illinois Academy of Family Physicians. Npcentral.net/ce/colds/cold.references.shtml. Accessed September 3, 2016. 16 Guidelines
for the prevention of infection and cross-infection in the domestic environment. International Scientific Forum on Home Hygiene. 2004. http://www.ifh-homehygiene.org/bestpractice-care-guideline/guidelines-prevention-infection-and-cross-infection-domestic. Accessed September 3, 2016. 17 Oduwole O, Meremikwu MM, Oyo-Ita A, Udoh EE.
Honey for acute cough in children. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD007094. DOI: 10.1002/14651858.CD007094.pub4. http://summaries.
cochrane.org/CD007094/honey-for-acute-cough-in-children. Accessed September 3, 2016. 18 Schlesselman LS. Safe management of cough and cold in children. Drug Store
News Pharmacy Practice. September/October 2008; 22-27. 19 Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in
community settings. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub5. http://onlinelibrary.wiley.com/
doi/10.1002/14651858.CD001831.pub5/full. Accessed September 3, 2016. Accessed September 3, 2016. 20 Nordqvist C. FDA panel: Cough meds should stay over the counter.
Sept. 14, 2010. Medical News Today Web site. http://www.medicalnewstoday.com/articles/201227.php. Accessed September 3, 2016. 21 U.S. Food and Drug Administration.
Joint meeting of the Nonprescription Drugs Advisory Committee and the Pediatric Advisory Committee: Final report. http://www.fda.gov/ohrms/dockets/ac/07/minutes/20074323m1-Final.pdf Accessed September 3, 2016. 22 American Academy of Pediatrics Committee on Drugs. Use of codeine- and dextromethorphan-containing cough remedies
in children. Pediatrics Journal. 1997;99:918-920. 23 Food and Drug Administration. Guidance for Industry: Dosage Delivery Devices for Orally Ingested OVER-THE-COUNTER
Liquid Drug Products. Rockville, MD: U.S. Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; May 2011. http://
www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM188992.pdf, Accessed September 3, 2016. 24 Goldmann DA. Transmission of
viral respiratory infections in the home. The Pediatric Infectious Disease Journal. 2000;19(10) Suppl: S97-S102. 25 Katcher ML. Cold, cough, and allergy medications: Uses
and abuses. Pediatrics in Review. 1996;17:12–17. 26 Scolaro KL. Disorders related to colds and allergy. “Handbook of Nonprescription Drugs.” “Handbook of Nonprescription
Drugs.” 18th ed. Washington, D.C.: American Pharmaceutical Association; 2015. Accessed online at pharmacylibrary.com [subscription required] September 3, 2016. 27
Simancas‐Racines D, Guerra CV, Hidalgo R. Vaccines for the common cold. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD002190. DOI:
10.1002/14651858.CD002190.pub4. Accessed September 3, 2016. 28 FAQs. BreatheRight.com Web site. http://www.breatheright.com/faqs#reg1. Accessed September 3,
2016. 29 Cox RJ, et al. (2004). Influenza virus: Immunity and vaccination strategies. Comparison of the immune response to inactivated and live, attenuated influenza vaccines.
Scandinavian Journal of Immunology. 59(1), 1–15. 30 Michael M, et al. (2009). Influenza vaccination with a live attenuated vaccine. American Journal of Nursing. 109, 44–48.
2006;12:15-22. 31 Mandell GL, Bennett JE, Dolin R, eds. “Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases.” 7th ed. New York, NY: Churchill
Livingstone; 2010. 32 Seasonal influenza. CDC Web site. May 26, 2016. http://www.cdc.gov/flu/about/disease/us_flu-related_deaths.htm . Accessed September 3, 2016 33
Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0–18 years—United States, 2016. CDC Web site. http://www.cdc.gov/
vaccines/schedules/hcp/imz/child-adolescent.html. Accessed September 3, 2016. 34 Centers for Disease Control and Prevention. Recommended adult immunization
schedule—United States, 2016. CDC Web site. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. . Accessed September 3, 2016. 35 Who is at high-risk for developing flu
complications. CDC Web site. August 25, 2016. http://www.cdc.gov/flu/about/disease/high_risk.htm. Accessed September 3, 2016. 36 Misconceptions about Seasonal Flu and
Flu Vaccines. CDC Web site. August 31, 2016. http://www.cdc.gov/flu/about/qa/misconceptions.htm. Accessed September 3, 2016. 37 Frequently asked questions about
Thimerosol. CDC Web site. August 28, 2015. http://www.cdc.gov/vaccinesafety/concerns/thimerosal/thimerosal_faqs.html. Accessed September 3, 2016. 38 Grohskopf LA,
Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines. MMWR Recomm Rep 2016;65(No. RR-5):1–54. DOI: http://dx.doi.org/10.15585/
mmwr.rr6505a1. Accessed September 3, 2016. 39 What you should know about the 2016-2017 influenza season. CDC Website. August 25, 2016. http://www.cdc.gov/flu/about/
season/flu-season-2016-2017.htm. Accessed September 3, 2016. 40 Flucelvax [package insert]. Seqqirus, Inc. Holly Springs, NC. May 23, 2016. http://flu.seqirus.com/files/
us_package_insert_flucelvax.pdf. Accessed September 4, 2016. 41 Flublok [package insert]. Protein Sciences Corporation. Meriden, CT; 2013. https://www.flublok.com/media
/1009/18pluspackinsert-2016.pdf. Accessed September 4, 2016. 42 What you should know about flu antiviral drugs. CDC Website. Cdc.gov/flu/antivirals/whatyoushould.htm.
August 11, 2016. Accessed September 4, 2016. 43 McKimm-Breschkin JL. Resistance of influenza viruses to neuraminidase inhibitors — A review. Antiviral Research journal.
2000;47:1-17. 44 Influenza antiviral drug resistance. CDC Website. August 5, 2016. http://www.cdc.gov/flu/about/qa/antiviralresistance.htm Accessed September 4, 2016. 45
Jefferson T, Jones MA, Doshi P, Del Mar CB, Hama R, Thompson MJ, Spencer EA,Onakpoya IJ, Mahtani KR, Nunan D, Howick J, Heneghan CJ. Neuraminidase inhibitors for
preventing and treating influenza in adults and children. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD008965. DOI: 10.1002/14651858.CD008965.
pub4. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008965.pub4/full . Accessed September 4, 2016. 46 The flu: What to do if you get sick. CDC Web site. Cdc.gov/
flu/takingcare.htm. August 18, 2016. Accessed September 4, 2016.
9 • OCTOBER 2016
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Technician CE LESSON
Learning Assessment
Successful completion of “Cough, cold and
flu update for pharmacy technicians”
(0401-0000-16-205-H01-T) is worth one
contact hour of credit. To submit answers,
visit our website atwww.DrugStoreNewsCE.com. Please note: Assessment
questions submitted online will appear in
random order.
1.With regard to coughs, which statement
is false?
a. Coughs may be classified as acute,
subacute and chronic
b.Coughs with pertussis have colored
secretions
c. Coughs may accompany cold, flu or
present on their own
d.Coughs may be associated with
angiotensin-converting enzyme
inhibitors
2.Which statement is true regarding
cough treatment?
a. Hydration and humidification are
non-pharmacologic approaches to
treating cough
b.Non-productive coughs may be
treated with anti-tussives and
decongestants
c. Productive coughs should be
treated with both anti-tussives and
expectorants
d.The American Academy of
Pediatrics recommends codeine and
dextromethorphan as the primary
means to treat cough in children
3.Which of the following medications
is an ingredient in over-the-counter
cough and cold preparations that may
be abused, often by teenagers?
a. Phenylephrine
b.Chlorpheniramine
c. Diphenhydramine
d.Dextromethorphan
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4.Which of the following non-pharmacologic strategies can be recommended to
help prevent the spread of cough, cold
and flu?
a. Using good personal and home
hygiene practices to prevent viruses
from spreading
b.Practicing healthy habits, including
plenty of rest and good nutrition
c. Maintaining household humidity at
levels that inhibit viral spread — 40%
to 60%
d.All of the above
5.Which of the following statements is
not correct regarding vaporizers and
humidifiers?
a. Both vaporizers and humidifiers
can be used to maintain appropriate
humidification that can reduce viral
spread
b.Vaporizers allow the use of
medicated liquids or pads that create
medicated vapors
c. Warm mist humidifiers and
vaporizers are preferred for young
children and infants
d.Humidifiers and vaporizers may be
cold or warm mist
6.Which statement is true regarding the
onset of a cold?
a. Children are the primary carriers of
the common cold
b.Colds occur more often during June
to September
c. The first symptom of a cold is usually
a cough, followed by sore throat and
fever
d.Antivirals may be used to prevent the
spread of a cold
7.Regarding analgesics used to treat
cough, cold and flu, which of the following is correct?
a. Manufacturers are voluntarily
relabeling acetaminophen to indicate
a 4,000-g maximum daily dose
b.Infant and children’s acetaminophen
formulations have been standardized
to contain 160 ml/5 ml of
acetaminophen
c. The FDA has issued detailed
guidance about the dosing devices
used in all liquid over-the-counter
products that is voluntary
d.Children may be treated with either
ibuprofen or aspirin for fever
8.Patients with a cold should not selftreat, but rather seek medical treatment
when which of the following criteria
are present?
a. Fever higher than 102 degrees
Fahrenheit (38.9 degrees Celsius)
b.Earache or tugging on the ears
c. Children with a cold lasting longer
than five days
d.Cough associated with sore throat
9.The Centers for Disease Control and
Prevention’s Advisory Committee on
Immunization Practices recommends
that the following people be vaccinated
for flu in the 2016 to 2017 flu season:
a. High-risk individuals only and
healthcare workers
b.Infants 6 months old to 2 years old
who have not received prior vaccine
c. Children and adults age 6 months old
and older
d.Children and adults age 6 years old
and older
10.Which statement regarding antiviral
medications for flu is false?
a. May create resistance in some flu
strains
b.Are used only for treatment, not
prophylaxis
c. Can shorten flu symptoms
d.Are used for different durations
depending upon the reason they are
being used
OCTOBER 2016
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