key: cord-312904-875s0md1
authors: Badreldin, Hisham A.; Raslan, Shahad; Almudaiheem, Hajar; Alomari, Bedor; Almowaina, Sahar; Joharji, Hala; Alawagi, Mohammad; Al-jedai, Ahmed
title: Pharmacists Roles and Responsibilities During Epidemics and Pandemics in Saudi Arabia: An Opinion Paper from the Saudi Society of Clinical Pharmacy
date: 2020-07-07
journal: Saudi Pharm J
DOI: 10.1016/j.jsps.2020.07.002
sha: 
doc_id: 312904
cord_uid: 875s0md1

Abstract On the 2nd of March 2020, Kingdom of Saudi Arabia confirmed its first case of the coronavirus's newly emerging strain, causing coronavirus disease 2019 (COVID-19). Soon after, the number of confirmed cases started to increase nationally. In light of the emerging outbreak, all healthcare professionals, including pharmacists, began to function with maximum capacity and efforts. The Saudi Society of Clinical Pharmacy (SSCP) acknowledges the substantial impact pharmacists can play during outbreaks. Based on the existing scientific knowledge during this outbreak, the SSCP established an expert writing task force to conceptualize and draft the proposed recommendations that highlights the roles and responsibilities of pharmacists during epidemics and pandemics. The SSCP writing task force issued 28 recommendations. In addition to the national and institutional guidelines, these recommendations could serve as guidance for the impacted entities.

In December 2019, an alarming epidemic of unexplained etiology occurred in Wuhan City, Hubei Province, China (Cucinotta and Vanelli, 2020) . The World Health Organization (WHO) described the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as the infective agent, causing the coronavirus disease 2019 . The WHO classified COVID-19 as a pandemic on the 11th of March 2020. (Cucinotta and Vanelli, 2020) . Kingdom of Saudi Arabia (KSA) took several proactive preemptive measures to limit the spread of the outbreak (Yezli and Khan, 2020). For instance, on the 27th of February 2020, KSA declared that it would immediately the role of pharmacists is important during circumstances such as epidemics and pandemics.

The writing task force was selected by the SSCP to conceptualize the first draft of the recommendations. These recommendations were drafted based on the currently available evidence that highlights the best practices regarding pharmacist's roles during emergency situations. Following that, these recommendations were shared with pharmacy profession stakeholders via the society social media platforms. The writing task force issued 28 recommendations after receiving the feedback from the stakeholders.

These recommendations aim to provide the pharmacy profession community with several insights regarding the pharmacist's roles and responsibilities in the community, supply chain, and healthcare settings based on existing scientific knowledge during this outbreak. It also reinforces to the other healthcare providers and national organizations the importance of pharmacists' participation and role in decision making during these circumstances. 

Recommendation 1: We urge the Saudi Center for Disease Prevention and Control (CDC) and the Ministry of Health (MoH) to continue to utilize pharmacists' expertise in prevention and treatment during epidemic and pandemic situations. The World Health Organization (WHO) recommends including pharmacists in the infection prevention and control of epidemics and pandemics (Sakeena et al., 2018) . Pharmacists receive extensive education and training in appraising emerging evidence, and the Saudi CDC and MOH could utilize their expertise in conceptualizing, appraising, and drafting prevention and treatment protocols. Their role is integral in analyzing national and international therapeutic options for the management of any emerging outbreak due to their rapidly advancing clinical experience.

Recommendation 2: We urge all healthcare institutions to involve pharmacists in emergency preparedness and disaster planning during epidemic and pandemic situations. Pharmacists can play an integral role in providing patient-focused services such as developing comprehensive care plans, therapeutic drug monitoring, and provide evidence-based recommendations. (Song et al., 2020) . Due to the diverse nature of the pharmacy profession, pharmacists are working in different healthcare sectors such as the MoH, Saudi Food and Drug Administration (SFDA), pharmaceutical industry, community pharmacies, primary healthcare centers and hospitals. Their involvement in the emergency planning during an emerging epidemic or pandemic situations is essential and integral. Recommendation 3: Pharmacists should take a proactive role in the development, implementation, and adherence to institutional and national guidelines related to the emerging outbreak such as COVID-19. As stated previously, pharmacists play a fundamental role in the development and implementation of institutional and national guidelines, protocols, and clinical pathways (Thompkins et al., 2019) . Previous evidence showed that 50% of the published clinical practice guidelines between January 1, 2010, and December 31, 2016, had at least one pharmacist as a member of on its writing panel (Thompkins et al., 2019) . Pharmacist's interventions and involvement are associated with higher rates of adherence to these clinical practice guidelines (Horning et al., 2007) .

Recommendation 4: We urge pharmacy department directors to ensure that pharmacy practice settings are capable of maintaining full functionality during epidemic and pandemic situations. It is the responsibility of pharmacy directors to ensure that all patients are receiving adequate pharmaceutical care services during epidemics and pandemics. This includes setting cost-effective plans to ensure the quality of care delivered to all patients, including infected and uninfected patients. One of the suggested modalities to ensure adequate functionality is to change the staffing shifts to 12 hours shifts instead of short staffing hours and have all staff only enter through separate entrances to the facility, separate from the public entrances. Reducing the frequency of shift changes or turnover of staff would limit the spread of infection to a smaller number of individuals if exposures were to occur. Pharmacy directors should ensure the continuity of pharmacy business and consider the need for the following: 

In addition to changing short staffing hour shifts to 12 hours shifts, would it also be optimal to have all staff only enter through separate entrances to the facility, separate from the public entrances. Response: The authors have made this edit as suggested.

: "this may reduce the chance of contracting the disease or interaction with any potentially infected individuals" (would it also be helpful to include the mechanics of this by adding)... by reducing the frequency of shift changes or turnover of staff which would limit the spread of infection to a smaller number of individuals if exposures were to occur. Response: The authors have made this edit as suggested.

antipyretics and decongestants as these create artificial supply shortages. Moreover, in both inpatient and outpatient settings, pharmacists are urged to adhere to the national rules of dispensing any prescriptive medications without a valid prescription. They can also suggest therapeutic substitutions and modify the patients' treatment plan in collaboration with their primary care providers when the need arises in case of a shortage of certain medications. Recommendation 7: Community pharmacists should be trained to screen pharmacy customers for signs and symptoms of infections such as COVID-19 and provide the most appropriate action plan in suspicious cases as per the Saudi CDC guidance. In order to reduce the risk of exposure to and transmission of infections such as COVID-19, community pharmacies should develop a screening system to screen customers/patients before entering into the pharmacy. medications, encouraging electronic prescriptions, and extending the refilling period for patients with chronic disorders. This should not impact the counseling service, which is integral in preventing hospitalization due to patient's lack of sufficient information regarding their medications. We urge all pharmacists to use virtual platforms to conduct patient counseling and medication reconciliation. 

In the time since this draft was written, HCQ has fallen out of favor with new evidence that points to its benefit being unproven or lacking. I know this is a great example of a drug that had shortages since it was the first "go-to" drug for COVID-19 that also experienced classic cases of shortages due to demand, however it is now perhaps not the best to use as an example. Perhaps delete this as an example and just let the rest of the sentence stand on its own. Response: The authors have made this edit as suggested.

WhatsApp and even Facebook is great, however as big technology evolves and changes with the apps we use to communicate, it can change in a few years and then date this guideline document. Other apps may become better that have more security or are organized by healthcare systems. I think best to call this as the broader category of "online and group messaging apps" since you are also using social media (broad category) in place of naming Facebook or others. Response: The authors have made this edit as suggested.

another way to proceed with meetings as it is an easy and convenient modality, and it enforces the concept of social distancing. Creating disease registries can be a beneficial way to understand the nature of the disease across different geographic locations as they can aid in recognizing risk factors and prognosis of diseases and identify the impact of therapeutic management on diverse patient populations (Akazawa et al., 2018) .

These 28 recommendations establish safety goals for pharmacists and protect the integrity of the healthcare system. They direct pharmacists to the best optimal use of resources, time, and shared information with the ultimate goal of ensuring the optimal access to and quality of care for everyone living in Saudi Arabia.

The authors would like to thank the SSCP board members and all pharmacists and policymakers who provided feedback regarding these recommendations prior to drafting the final manuscript.

This conclusion is a quick summary of the document, is there an overall goal or message that should be stated here as well? Here are some of my thoughts to add...such as how these 28 recommendations allow pharmacists to reduce their contact with others (to reduce spread of infection) allowing the protection of the supply of available pharmacists in the healthcare system. (elaborate further based on some of the other 28 recs)... Also assessment of the use of pharmacists as resources, optimization of this resource to ensure necessary care is guaranteed for all Saudis even with strains on the resources, protection of drug resources; organization of pharmacists into a more collaborative group to increase the spread of clinical information and education during epidemic and pandemic which would protect the quality of care. The goals of the 28 recs are sometimes stated clearly and individually, but how do all of the goals combined serve the country? I think if I had to write a quick conclusion on that point it would be "These 28 recommendations establish safety goals for pharmacists and protect the integrity of the healthcare system. They direct pharmacists to the best optimal use of resources, time, and shared information with the ultimate goal of ensuring the optimal access to and quality of care for all Saudis." Response: The authors have made this edit as suggested.

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