Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Non-specific effect of vaccines wikipedia , lookup
Human mortality from H5N1 wikipedia , lookup
Influenza A virus subtype H5N1 wikipedia , lookup
Infection control wikipedia , lookup
Herpes simplex research wikipedia , lookup
Viral phylodynamics wikipedia , lookup
Transmission and infection of H5N1 wikipedia , lookup
Avian influenza wikipedia , lookup
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 WWW.DRUGSTORENEWSCE.COM 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 WWW.DRUGSTORENEWSCE.COM 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- WWW.DRUGSTORENEWSCE.COM 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® WWW.DRUGSTORENEWSCE.COM 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 WWW.DRUGSTORENEWSCE.COM 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 WWW.DRUGSTORENEWSCE.COM 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- WWW.DRUGSTORENEWSCE.COM 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 WWW.DRUGSTORENEWSCE.COM 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 •8 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 WWW.DRUGSTORENEWSCE.COM 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 WWW.DRUGSTORENEWSCE.COM 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 •8