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5 Medicine And Vaccine Distribution
Key Points
- NHS Board plans for the distribution of antivirals should be flexible, responsive and capable of ensuring timely access.
- NHS Boards will need to set aside resources for home delivery of antiviral medication.
- Strain-specific pandemic flu vaccine is unlikely to be available in the first wave of a pandemic, but may be ready for use in subsequent waves.
5.1 Antiviral medication
NHS Boards plans should specify local distribution arrangements for the national antiviral stockpile. The following discussion outlines the main considerations in developing local arrangements.
5.1.1 The time factor
A key parameter which will determine the best means for distributing antiviral medication is the recommended minimum duration of time from identification of symptoms to receiving the medication. Current advice is that antivirals should preferably be taken within 12 hours of the onset of influenza symptoms.
5.1.2 The risks to core community pharmacy services
Distributing antivirals via community pharmacies may increase the exposure of pharmacy staff to flu infection and will bring an associated additional workload. The relative risks to and consequences of disruption to core pharmacy services will need to be carefully considered in a local context and local arrangements made explicit in operational plans.
5.1.3 Centralised or decentralised distribution
In developing plans for the local distribution of antivirals a key consideration for territorial Boards will be whether to adopt centralised distribution, with some combination of pick up and home delivery services for individual patients, or to have a decentralised distribution mechanism which is integrated with existing community pharmacy services.
Centralised distribution would probably be managed directly by the Board and would involve a number of specifically planned distribution points per Board area. These would manage antiviral stocks, and have the necessary resources in place to make deliveries to individuals. As the pandemic develops, this model might cease to be sustainable and home delivery might have to be restricted to a minimal number of patients with no other means of acquiring antiviral treatment. To compensate, the number of centres through which antivirals are distributed would need to increase correspondingly.
Advantages of centralised distribution include:
- ensuring strong centralised control over the stock of antivirals, particularly if stocks run low
- reducing the potential for transmission of influenza by home delivery
- avoiding adding to the existing workload of community pharmacies
- reducing the impact which failures in business continuity at pharmacy level will have upon antiviral distribution
- avoiding public order issues if patients try to demand antiviral medicines from community pharmacies.
However, centralised distribution with home delivery is clearly dependent upon the Board being able to provide a workforce and fleet of vehicles which can undertake such a task. This may not be feasible under the pressures of a pandemic, when many staff will themselves be affected by influenza or other factors such as shortage of fuel.
Decentralised distribution would involve providing supplies of antiviral medication to community pharmacies and relying upon patients to pick up medicines from pharmacies via friends and relatives who are well enough to visit the pharmacy. Boards would need to provide, exceptionally, some level of home delivery to support those who have nobody to collect their antivirals on their behalf e.g. those who live alone with no immediate family in the locale and no social care support.
An important advantage of decentralised distribution is that while it may be affected at a small scale by the closure of individual pharmacies, the business continuity and local coordination functions which will occur at local level will work to ensure that at least some degree of function is maintained. A further advantage of decentralised distribution is that it builds upon a routine process for distributing medications, so that patients will not be expected to make any change from their usual behaviour.
Between the extremes of centralisation or decentralisation there will be specific arrangements that are appropriate to each locale. These should reflect the prevailing clinical consensus about the best use of antivirals, the specific circumstances of the local population and geography and include arrangements to reduce or mitigate the potential for adverse impact on infection control and core community pharmacy services.
5.1.4 Antiviral record keeping
A record will have to be kept of who has been authorised to receive and who has actually received antiviral medication via a central database and identified through their unique CHI number. This will ensure that distribution is taking place equitably, will make sure that stocks can be controlled by central planners and will make sure that records of antiviral use are available to GP's and all workers who may be involved in patient care. Antiviral collection points will need to have access to appropriate IT for accessing and updating the planned national antiviral database.
5.2 Medicine supply
Demand for antibiotics, other medicines and over-the-counter remedies is likely to be high in a pandemic and the supply chain may be disrupted. The Department of Health and the Scottish Government are reviewing available stock levels and working with the pharmaceutical sector and others to improve supply chain resilience and consider options for meeting demand and maintaining supply.
Further guidance will be issued on the prescribing and use of medicines during a pandemic outbreak and there will be consultation on proposed changes to medicines legislation and related regulations, with a view to implementing those changes in the event of a pandemic.
5.3 Vaccinations
A specific vaccine for the strain of pandemic influenza is unlikely to be generally available early in the first wave of a pandemic. However, there is a possibility of vaccine becoming available in the recovery period between waves or in subsequent waves, and the UK has secured manufacturing capacity for the production of the vaccine if required. Once production starts it will take an estimated 44 weeks for the total volume of vaccine to be manufactured.
A small amount of H5N1 vaccine has also been purchased for healthcare workers. Immunisation with this vaccine before the first wave may offer some limited, but useful protection. Decisions on the use of this vaccine will need to be made following assessments of the likely degree of cross-protection afforded (if any) and balance of risks against benefits as the pandemic phases change.
Guidance is being prepared for health planners about the model for delivery of these vaccines and issues to be considered in the development of local vaccination plans. While there will be flexibility in the approach taken to reflect local circumstances, the proposed models will be for H5N1 vaccine to be delivered through local occupational health services and for the pandemic specific vaccine to be delivered through Primary Care.
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