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Original Research

Impact of COVID-19 of oncology pharmacy services: Results of 8-months survey

Bienert, Agnieszkaa; Meier, Klausb,∗; Kokisheva, Antoninac; Brambila, Rodrigo A. Gamad; Veraldi, Mariannae; Marques, Nuno Vilacaf; Kuzmanović, Majag; Andreianu, Dan Paulh; Badibouidi, Ferdinandi; Vallespin, Romina Moralesj

Author Information
European Journal of Oncology Pharmacy: January-March 2022 - Volume 5 - Issue 1 - p e00036
doi: 10.1097/OP9.0000000000000036
  • Open

Abstract

1 Introduction

The pandemic hit us almost unprepared in 2020. In many cases, after the first wave, the erroneous opinion prevailed that this pandemic could be brought under control relatively quickly. After we conducted a global survey in the first 13 weeks,[1] as we feared, after a short interim recovery, the next wave would appear.

Since the outbreak of SARS-CoV-2, pharmacists as well as other healthcare professionals, have been at the frontline of combating the disease. As community pharmacies have remained open, due to ease of access, pharmacists often became the first health-professional contact, especially in the times when hospitals and clinics were overloaded and patients, during the lockdown, had some difficulties with contacting their primary doctors. This also included the pharmaceutical care for community patients with cancer and other chronic diseases. On the other hand, pharmacists took direct part in pandemic prevention and control educating their patients as well as providing personal protective equipment (PPE) and detecting first COVID-19 symptoms.[2–4]

The professional responsibility of pharmacists has increased as they must have controlled the pandemic emergency and care for COVID-19 patients in hospitals.[5] Thus, SARS-CoV-2 pandemic has an impact on pharmacist profession in many aspects. To follow their development and to get an overview of the impact in individual parts of the world and regions, European Society of Oncology Pharmacy (ESOP) decided again, together with the European Association of Hospital Pharmacists (EAHP), to interview the employees in the health departments, but to focus on the consequences for the pharmacists to include reports for other health areas as well. During further development not only did we make the questionnaire available in 9 different languages to break down the barrier to participation, but also we developed additional questions after it became clear that testing and vaccination would bring important changes in all procedures in the hospitals as well. Because the scope of the survey has widened significantly, we decided to divide our outcome into two parts. In the first one the impact of SARS-CoV-2 pandemic on general situation in hospitals as well as hospital pharmacy, community pharmacy, and ambulatory care was presented and discussed.

2 Methods

Every month, a link to the survey based on LamaPoll (www.lamapoll.de) was sent by e-mail to all ESOP members (>3600 individuals in 66 countries). In addition, delegates from each country were asked to spread awareness of the survey among the members of their national oncology pharmacy societies. Participation was anonymous and voluntary.

The survey was endorsed by the European Cancer Organization, the European Association of Hospital Pharmacists, and the Oncology Pharmacy Associations from Chile and Egypt. A weekly newsletter with an update from the results of the survey was distributed via the e-mail service of ESOP and updates were also published on the ESOP website on a weekly basis.

Calculations were performed using Excel (Microsoft Office 2016, Microsoft, Redmond, USA).

Our first survey[1] consisted of three main sections of questions: general, hospital pharmacy, and community pharmacy. In the second survey, performed between August 2020 and April 2021, it was extended to 6 sections: general, hospital pharmacy, community pharmacy, ambulatory, vaccination, mental health, and additional questions for all respondents. General questions (about place of work, profession) have not been changed. Some questions were removed from the survey as they lost relevance. Also, for the convenience of respondents, we added options such as “data are not available” and “I do not work in this area,” but these answers have neither been presented in the manuscript nor taken into consideration due to their statistical insignificance.

We asked hospital and community pharmacy the same questions concerning medicine shortages or delays to compare the results with the first survey and make a conclusion about how the situation developed in the long-term. However, we included some new questions to follow the changing situation. As compared to the earlier 3-months survey,[1] we added questions addressed to community and hospital pharmacists concerning the ways they were preparing for the second pandemic wave (buying extra supplies of essential materials such as PPE and ventilators, extra stocks of drugs essential in the treatment of a disease pandemic or instruction of doctors / nurses to care for patients during a pandemic).

For community pharmacy, new relevant questions were also added according to patients’ behaviour in buying additional Over-The-Counter Drug (OTC) preparations. We also were interested in balance between personal and societal freedoms, negative impact lockdown on other illnesses and/or mental health, SARS-CoV-2 testing of health care workers.

According to ambulatory care, we mainly asked if there were any differences in chemotherapy production before Covid-19 pandemic, thinking in January 2020 as 100% production, and during the pandemic period, from February 2020 to March 2021.

Since December, the beginning of vaccination, we asked about the situation with the availability of vaccines and involvement pharmacists in vaccination, as well as their personal attitudes toward vaccination. Questions on vaccination and mental health were elaborated in the second part of the manuscript.

3 Results

3.1 Hospital general questions

Over 1000 colleagues from different health areas from 64 countries (Fig. 1) took part in the survey. The results are a snapshot, but the consequences described by other publications can be understood in various areas and evidence of their extent can be found. The consequences for cancer patients as well as for people in the healthcare system are of particular importance.

F1
Figure 1:
Respondents to the survey.

The distribution of professions and work places of the participants in our survey between August 2020 and March 2021 is presented in Figs. 2 and 3, respectively. The average percentage numbers of professions were: 89.43% for pharmacists, 6.08% for physicians, 1.45% for nurses and 4.40% for other professions.

F2
Figure 2:
Profession of respondents in survey from August 2020 to March 2021.
F3
Figure 3:
Working place of respondents in survey from August 2020 to March 2021.

3.2 Hospital pharmacy

According to hospital pharmacists, the drug shortage has concerned both drugs needed for the treatment of COVID-19 patients as well as drugs needed for the treatment of cancer patients. To the question about the shortage of drugs, in the second survey we offered 4 answer options: «No», «Up to 5 drugs», «Up to 10 drugs», «More than 10 drugs», but for comparison with the first survey, we combined all the positive answer options into one—«yes». Hospital pharmacists faced a drug shortage for corona patients, with the highest numbers in August 2020 (42.36%) where 4.71% indicated that shortage more than 10 drugs. According to the results of two surveys average shortage of corona drugs, in the period April 2020–March 2021, was detected by 32.51% of hospital pharmacists (range 25.28–42.36) (Fig. 4A).

F4
Figure 4:
Drug shortage for corona (A) and cancer (B) patients to Hospital Pharmacy (data of the first and second survey).

At the same time, many pharmacists also experienced a shortage of anticancer drugs. Overall, nearly half of the pharmacists had such deficiencies, with variations over the months of the survey. The highest shortage for cancer patients was also in August 2021 (54.76%). The average shortage of anticancer drugs, in the period April 2020–March 2021, was detected by 43.77% of hospital pharmacists (range 34.09–54.76) (Fig. 4B) which is much higher compared to shortage of drugs for corona patients (Fig. 4A).

As seen in Figure 4B, the situation of cancer patients has improved September 2020, where the trend for “yes” answer to drug shortage started to decrease whereas for “no” answer to increase. In March 2021, drug shortage for COVID-19 patients and for cancer patients appeared to be similar.

Hospitals were found to have an internal protocol for the new pandemic and/or the second wave of Covid-19. From August 2020 to January 2021, a positive trend was highlighted because over the months, 71.29% of the hospitals of the interviewees organized by themselves. Data for February and March are not available (Fig. 5), as this question was removed from the survey.

F5
Figure 5:
Availability of a protocol for a new pandemic and/or second wave of SARS-CoV-2 to Hospital Pharmacy.

Regarding the provision of extra supplies of essential materials, such as PPE and ventilators, extra supplies of essential drugs in the treatment of a pandemic disease and the training of additional doctors/nurses to care for patients during a pandemic in all months of the investigation, all hospital pharmacists tried to stock up.

The supply of extra stocks of essential materials such as PPE and ventilators/extra supplies of drugs essential in the treatment of a pandemic disease has not changed significantly during the survey period. The average number of respondents who noted extra stocks was 64.41% for essential materials and 66.61% for drugs (Fig. 6). Obviously, this solution was influenced by the delivery problems and shortage that we observed during the first wave of SARS-CoV-2.

F6
Figure 6:
Procuring extra stock of essential materials and essential drugs to Hospital Pharmacy.

Educating extra doctors/nurses for patient care during a pandemic has been found to be very important in preparing for a new pandemic and/or second wave of SARS-CoV-2. In fact, in January 2021, 57.00% of respondents declared that they had introduced this training method to better face a second wave or a new pandemic. Data for the months of February 2021 and March 2021 are not available because question was removed from survey (Fig. 7).

F7
Figure 7:
Educating extra doctors/nurses to care for patients during a pandemic to Hospital Pharmacy.

3.3 Ambulatory care

When comparing the production of chemotherapy based on the month of January 2020 with the pandemic months (from February 2020 to March 2021) we can emphasize the following—less production answer has two peaks: between March and May 2020 and then slighter one between November 2020 and January 2021. «More production» answer has a peak between April and October 2020. «No change» has the minimum between April 2020 and then in March 2021. Indeed, in March 2021 the situation stabilized and there is a big increase in production (Fig. 8).

F8
Figure 8:
Comparison number of available chemo preparations.

3.4 Community pharmacy

According to the community pharmacy the drug shortages were still noticed, however, to a slightly lesser extent. Due to some changes in the question structure in the community pharmacy section, to compare the first and second wave, we summarized “yes” and “mostly” questions from the first survey and “up to 5 drugs,” “up to 10 drugs,” and “more than 10 drugs” from the second survey. The mean drugs shortage was noticed by 72.50% of responders during the first survey (April 2020–May 2020) and by 57.37 ± 7.65% during the second survey (August 2020–March 2021)(Fig. 9).

F9
Figure 9:
Drug shortage according to Community Pharmacy (data of the first and second survey).

We also asked community pharmacists if their government has the protocol for the next wave prepared. Data for the months of February 2021 and March 2021 are not available because, by this time, the second wave was already behind (Fig. 10). Almost half of responders (mean 45.11%) answered “yes” about availability protocol for new pandemic and/or a second wave of SARS-CoV-2. The curve reached its minimum in November, situation was more confusing for health care workers during the second wave's peak.

F10
Figure 10:
Availability of a protocol for a new pandemic and/or a second wave of SARS-CoV-2 to Community Pharmacy.

According to the preparation for the second SARS-CoV-2 wave between August, 2020 and March, 2021 the need for self-preparation decreased among community pharmacists (Fig. 11). However, the responders more often answered that they needed to get prepared by themselves (mean 57.00 ± 9.33% in the period April 2020–January 2021) than that the government/local health authority procures extra central stock of essential materials such as PPEs (mean 36.50 ± 4.75% in the period April 2020–March 2021). Data for the months of February 2021 and March 2021 are not available because this option was removed from survey.

F11
Figure 11:
Preparations for a new pandemic and/or a second wave of SARS-CoV-2 to Community Pharmacy.

Additionally, the phenomenon of buying additional OTC preparations (e.g., immune-boosting preparations, acetylsalicylic acid, combination drugs with decongestants…) by patients was commonly observed by community pharmacists (mean 53.01%, summary «yes often» and «yes sometimes») during the whole survey period (Fig. 12).

F12
Figure 12:
Buying additional OTC preparations to Community Pharmacy. OTC, Over-The-Counter Drug.

3.5 Questions for all

From the very beginning of the pandemic, many hospitals have faced a shortage of PPE for their healthcare workers. In our research, it was noticed that 50.59% of health workers had enough protective equipment from beginning, and 30.40% of them answered «mostly later» (Fig. 13).

F13
Figure 13:
Availability of PPE for the pharmacists. PPE, personal protective equipment.

Only 31.42% of the respondents confirmed support of the government, while 37.55% of respondents answered that they did not have any support from the government (Fig. 14).

F14
Figure 14:
Governmental support to employer with PPE. PPE, personal protective equipment.

When asked whether the staff was tested for SARS-CoV-2, the largest number of participants answered that only those staff who showed symptoms (mean 58.06% ± 13.95%) were tested, while 12.99% were not tested at all (Fig. 15).

F15
Figure 15:
Staff tested for SARS-CoV-2.

During the SARS-CoV-2 pandemic mean 46.40% (from August 2020 to March 2021) of the respondents answered that their working hours remained the same as before the pandemic. Working hours increased in 43.37% of respondents, while 10.22% answered that their working hours were shortened (Fig. 16).

F16
Figure 16:
Increase or decrease in working time.

At the same time, about 63% of respondents answered that they did not have the opportunity to hire new workers and that they did not receive a lower salary than at the beginning of the pandemic (mean 83.33%) and of course everything was very emotionally stressful (mean 67.24%) (Fig. 17).

F17
Figure 17:
Emotional stress of employees during a pandemic.

Information placed in the media had a significant impact on the demand for medicines, medical equipment, and medical devices by patients in pharmacies (mean 48.34% ± 15.29% of respondents answered it continues to influence) (Fig. 18).

F18
Figure 18:
Effect of media information on demand.

When asked whether respondents directly participated in hospital plans to combat COVID-19, 23.26% answered «very often», 26.77% answered «sometimes» and 38.36% answered that they did not participate (Fig. 19).

F19
Figure 19:
Involvement in the hospital plans.

4 Discussion

The SARS-CoV-2 pandemic has been a threat to human health worldwide. Healthcare providers have been working tirelessly in the fight against COVID-19, extended hours, and extra shifts. Repeated donning and doffing of PPE undoubtedly have added to their physical fatigue and mental stress. The responsibilities of pharmacists have expanded significantly.

Hospital pharmacists supported pharmaceutical care services and participated in the COVID-19 medical collaboration team to facilitate pandemic control by developing strategies to address drug shortages and other problems. Our analysis found that hospital pharmacists have faced the emergence of drug shortages in terms of both COVID-19 and cancer treatments. PPE supplies were also impacted by the delivery problems and shortages we observed during the first wave of SARS-CoV2 disease. Their efforts also include drafting an internal protocol for hospitals and training additional doctors/nurses to assist patients during a pandemic.

In other studies, poor drug adherence among chronic disease patients and cancer patients has emerged as a downside to the COVID-19 pandemic. Cancer patients are immunocompromised and the critical hospital environment increases exposure to COVID-19 infection. The pharmacist's role in guiding cancer patients during the current pandemic is of great importance as most cancer patients need to visit the hospital for a routine check-up and chemotherapy.[6]

Pharmacy workflow has been redesigned in many hospitals.[7] The most challenging task has been to procure emergency and alternative medications, assess drug shortages, and book reused medications for the treatment of COVID-19.[8] Adequate pharmacovigilance was conducted by hospital pharmacists to identify and minimize serious adverse effects and drug interactions between various new COVID-19 drugs.[9] Initially, due to the limited availability of PPE in most hospitals, the existence of pharmaceutical services provided by hospital pharmacists often made them regularly vulnerable to infection. For example, a window dispensing method was adopted in many hospital pharmacies where the doors were closed and the helmet was used as a shield to cover the face to ensure adequate pharmaceutical care.[10] Furthermore, hospital pharmacists have played a crucial role in enrolling infected patients for clinical trials.[11] For this reason, their role cannot be overlooked as they directly contributed to the management protocols of COVID-19 together with nurses, doctors. They joined the collaborative multidisciplinary team to improve COVID-19 patient outcome and reduce mortality and facilitate pandemic control.[7]

As far as community pharmacists are concerned, as first contact health professionals they have met some immediate challenges during both first and second COVID waves. The results of our survey showed that one of them was excessive buying of immune boosting preparations, nonsteroidal anti-inflammatory drugs and other OTC drugs during whole pandemic period, including the second wave, which then decreased in the March 2021 (Fig. 12). One of the reasons was fear based on observed drugs shortage, which we also noticed in the second part of our survey (Fig. 9). Kostev and Lauterbach also reported panic buying of various drugs, that is, neurological, psychotropic, antihypertensives, directly before lockdown by patients under fear of extended quarantines.[12] Our survey also demonstrates that, although less than during the first pandemic wave, the need of self-preparation remained an issue during the second wave (Fig. 11). Additionally, confusion on health-authority protocol for second wave of COVID could be seen according to the results of our study (Fig. 10). Thus, like other health care providers, community pharmacists needed to modify their work system during SARS-CoV-2 pandemic to challenge the changing conditions and patients’ behaviour. Alhamad et al[13] studied public perceptions about pharmacist's educational and prescribing role, and the medication delivery service during SARS-CoV-2 outbreak and they found a positive endorsement for pharmacy services which may contribute to some updates in law regulations to allow extending pharmacy services and prescribing role. Due to the drug shortage and limited access to medical care during pandemics the collaboration between physicians and pharmacists should develop and can be of great importance, especially in the populations of patients where polypharmacy is a common issue.[7]

Cancer patients have been undoubtedly touched by the SARS-CoV-2 pandemic. During the first wave, we could observe a decreased in chemotherapy production between February and May 2020. In the following months, there were always reports in decreased chemotherapy production on a smaller scale than in the beginning.[1] This fact may be due to the initial situation of ignorance about pandemic, but also to changes in the access to diagnosis of cancer patients.[6] In March 2021, there is a big increased in chemotherapy production, and we could observe also a decreased in less production and in no change, probably due to a transformation in cancer care patients.

The SARS-CoV-2 pandemic has significantly affected almost every aspect of cancer care delivery and management worldwide. Social distancing, limited hospital visits, and isolation measures introduced by different governments have led to the cessation of continuous oncology treatments, including screening, diagnostic and prevention programs, treatments and monitoring services, and research and clinical trial programs. The research noted that pharmacists and pharmaceutical technicians had sufficient amounts of protective equipment (Fig. 13), but that the government, unfortunately, did not support employers in procuring them (Fig. 14). Different health systems in the countries have spoken differently about this pandemic. Presently, health-care workers are the most valuable resource of every country. Procurement and distribution of controlled and validated PPE is key to providing quality care while guaranteeing the safety of healthcare professionals.[14] Healthcare professionals were only tested for SARS-CoV 2 if they had symptoms (Fig. 15). Significant differences exist in the availability of healthcare workers SARS-CoV-2 testing between countries, and existing programs focus on screening symptomatic rather than asymptomatic staff. In their research, Gallasch et al emphasized the need to test healthcare workers with or without minimal symptoms of SARS-CoV-2 infection.[15] For most health workers, working hours remained the same as before the pandemic or increased (Fig. 16). At the same time, they were not able to hire new workers. They did not receive a lower salary, but it was very stressful for all of them (Fig. 17). The COVID-19 pandemic is an unprecedented challenge for society. Supporting the mental health of medical staff and affiliated healthcare workers (staff) is a critical part of the public health response. An earlier study found that health workers are more susceptible to depression, insomnia, anxiety than citizens. Their professional stress had a positive effect on their psychological stress.[16] It is very important to pay attention to workplace stress management, in order to reduce the risk of developing mental health problems during the COVID-19 pandemic.[16] The information published in the media significantly affects the demand for medicines and medical devices in pharmacies (Fig. 18). The main limitation of social media at the moment is the possibility of quickly spreading false information that can confuse and distract.[17] The Society relies on educated scientists and physicians to be leaders in providing evidence-based information to the public. For this reason, in times of crisis, it is important to be a leader in conversations on social networks in order to send correct and useful information and knowledge to the masses who are looking for answers.[18] Unfortunately, the policies of different countries in most cases did not allow participation in the design of hospital plans against COVID-19 (Fig. 19). Pharmacists, with their knowledge and skills, can play a key role during a pandemic.[19] They can provide reliable information for the prevention, detection and treatment of SARS-CoV-2 infection.[5,19]

5 Conclusions

In the pandemic period, the services of hospital pharmacists and pharmaceutical assistance have proved indispensable for the treatment and clinical management of hospitalized patients. Healthcare providers have been working tirelessly in the fight against COVID-19, extended hours, and extra shifts.

The hospital pharmacy has played an important role in the care framework of both corona patients and cancer patients, both hospitalized and non-hospitalized, such as coping with the emergency of the shortage of drugs and PPE, educating doctors and nurses about pharmacotherapy and, ultimately, provide enhanced care to special populations such as cancer patients. The SARS-CoV-2 pandemic has had a profound impact on cancer care and the management of cancer services and patients. Cancer patients should be more cautious and hospitals should have better management plans to mitigate the negative effects of the SARS-CoV-2 pandemic on vulnerable cancer populations.

The whole pharmaceutical market has become volatile during pandemic and patients often have acted under the influence of fear. For this reason, pharmaceutical care and interdisciplinary cooperation should be developed so that patients do not feel lost. Some law changes in the community pharmacists’ role can be taken into account.

References

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Keywords:

Covid-19; cancer; oncology pharmacy; professional protective equipment; global health emergency; Covid stress syndrome; pharmacists; drug shortages; survey; community pharmacy; medication adherence; pharmaceutical care; purchasing behaviour; Coronavirus infections

Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.