key: cord-0733441-23h8o970 authors: Erku, Daniel A.; Belachew, Sewunet A.; Abrha, Solomon; Sinnollareddy, Mahipal; Thomas, Jackson; Steadman, Kathryn J.; Tesfaye, Wubshet H. title: When fear and misinformation go viral: Pharmacists' role in deterring medication misinformation during the 'infodemic' surrounding COVID-19 date: 2020-05-01 journal: Res Social Adm Pharm DOI: 10.1016/j.sapharm.2020.04.032 sha: 64ba722f1c68baab29c03d17c4403e09d6f921a7 doc_id: 733441 cord_uid: 23h8o970 The world has faced an unprecedented challenge when coronavirus (COVID-19) emerged as a pandemic. Millions of people have contracted the virus and a significant number of them lost their lives, resulting in a tremendous social and economic shock across the globe. Amid the growing burden of the pandemic, there are parallel emergencies that need to be simultaneously tackled: the proliferation of fake medicines, fake news and medication misinformation surrounding COVID-19. Pharmacists are key health professionals with the required skills and training to contribute to the fight against these emergencies. Primarily, they can be a relevant source of accurate and reliable information to the public or other fellow health professionals thereby reducing the spread of COVID-19 medication misinformation. This can be achieved by providing accurate and reliable information based on recommendations given by relevant health authorities and professional associations to make sure the community understand the importance of the message and thus minimise the detrimental consequences of the pandemic. This commentary aims to summarise the existing literature in relation to the promising treatments currently under trial, the perils of falsified medications and medicine-related information and the role of pharmacists in taking a leading role in combating these parallel global emergencies. Our world has moved into uncharted territory as it fully succumbs to a novel coronavirus disease (COVID- 19) after it was initially reported in Wuhan, China in late December 2019. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), one of the most contagious and virulent viruses this world has witnessed in recent times. Although coronaviruses were responsible for the previous epidemics such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), COVID-19 is the first one to spread to the entire globe, putting the whole world into an unprecedented level of anxiety. Unlike the previous coronaviruses, and despite having a 79% genomic similarity with SARS CoV, COVID-19 seems to transmit very rapidly and efficiently, 1 contributing to its global occurrence. As of April 29, more than 3 million people have contracted the virus worldwide, with nearly 220,000 people lost their lives within just four months. As a result, several countries have now implemented aggressive public health measures -including the enforcement of social distancing and total lockdowns, aiming to limit the transmission of the disease. The clinical manifestations of COVID-19 include flu like symptoms, such as headache, fever and persistent dry cough, and atypical pneumonia that can lead to life-threatening acute respiratory distress. 2 While most patients with COVID-19 present with mild symptoms, this disease can cause hospitalisation, intensive care unit admission and death, particularly in older adults and those with comorbid conditions. 3 The case fatality rate of the disease is currently estimated at 2.7% and could be as high as 13% in older adults aged over 80 years. 4 https://doi.org/10.1016/j.sapharm.2020.04.032 Received 28 April 2020; Received in revised form 29 April 2020; Accepted 29 April 2020 Therapeutics for COVID -19 Research into potential vaccines and treatments for COVID-19 commenced immediately after the outbreak, with the aim to prevent infection, reduce the transmission and/or manage the severe outcomes of the disease. The usual process of vaccine development is a long, complex process typically takes about 6-10 years to reach the marketsbut currently researchers and regulators around the globe are working to accelerate this process. Nonetheless stopping this new virus may require a more aggressive approach. Repurposing existing drugs with good safety profiles and have activity against HIV, hepatitis C or similar virus strains might be the most feasible and timely approach. To this end, several clinical trials are currently underway, including in Australia, China, Japan, Europe and the USA to test the effectiveness of various drugs previously approved for other diseases for use against COVID-19. The drugs under investigation aim to do either of two things: kill the virus or limit the severity of the disease to increase chances of survival. Their antiviral activities are produced by targeting one or more of the proteins that are essential for SARS-CoV-2 to bind and cause infection. To have a greater understanding of these potential drugs, it is imperative to understand how the virus works and its mechanism of transmission. SARS-CoV-2 is a ribonucleic acid β-coronavirus and, like SARS and MERS, encodes non-structural proteins (such as 3-chemotrypsin-like protease, helicase, and RNA-dependent RNA polymerase), structural proteins like spike glycoprotein and other accessary proteins. 5 The spike proteins are responsible for host cell-surface binding via angiotensin converting enzyme 2 (ACE2). 6 Another human protein, TMPRSS2, cleaves the spike protein, allowing the virus to fuse with the cell and start to replicate inside it. 7 These proteins are among targets for promising drug candidates currently under investigation for COVID-19 treatment. Importantly, most of these proteins, including the drug binding pockets of this virus, have strong similarity with those observed in SARS and MERS, highlighting the potential use of previously developed small-molecule therapeutics for COVID-19. 8 Despite many pre-clinical and clinical studies on drugs against COVID-19, there is currently no evidence to make a definitive conclusion as to the most safe and effective COVID-19 treatment option. The ongoing large-scale trials on the potential treatments are hoped to reveal the most effective treatments for COVID-19. Available pre-clinical and clinical evidence on the drugs with potential activity against COVID-19 is summarized in Table 1 . Although there is no approved treatment for COVID-19, nearly 800 clinical trials have been registered by the World Health Organisation's (WHO) International Clinical Trials Registry Platform, with over 85% of the trials originated from China. 58 It is likely that 90% of new entrants into clinical trials never make it to the market. The drugs being investigated range from repurposed flu treatments to failed Ebola drugs, to antimalarial agents to immunosuppressants that have been developed decades ago. Coronavirus pandemic also fuelled a surge in counterfeit medicine sales -a parallel pandemic of fake "essential" medicines (including the COVID-19 candidate drug chloroquine and hydroxychloroquine) and other medical supplies. Since COVID-19 was declared as a pandemic, a global pharmaceutical crimes police unit has captured tens of thousands of counterfeit medicines and medical supplies claimed to cure the coronavirus. This is mainly attributed to a decline in the production capacities of world's two largest producers of medical supplies, China and India, following lockdown. After hydroxychloroquine was claimed effective for COVID-19 treatment, there was a surge in the demand for the drug and a decline in international supplies, 59 posing risk of drug shortages. The African nations will especially be affected if this trend continues because Indian companies supply up to 20% of all medical supplies to Africa, where the region carries a high share of global malaria burden (> 90% of global cases and deaths). 60 Also, reports of distribution of faulty coronavirus testing kits and substandard protective gears have dominated the news amid the COVID-19 pandemic. Another equally pressing and parallel emergency is medication information overload and misinformation surrounding COVID-19. The WHO has described that the outbreak of and response to COVID-19 "has been accompanied by a massive 'infodemic' -an over-abundance of information." An 'infodemic' refer to the perils of excessive volume of information in relation to COVID-19 (including false prevention measures or cures) that pose concerns for the public to distinguish fact from fiction, and for government agencies to conduct evidence-based policymaking. As COVID-19 turns into a full-fledged global public health crisis, several unsubstantiated claims regarding cures and transmission and/or exposure have taken hold on the internet and social media. Such misinformation and conjecture are of great concern as they represent a serious challenge in tackling the pandemic. Moreover, medication misinformation in the absence of scientific validation can potentially spread unnecessary fear and panic, undermining the public's willingness to follow legitimate public health advices and to take proven precautionary measures. 61 The current rush to search for the magic drug without adequate safety guarantees has already become a source of medication-related misinformation, causing public confusion and panic. A classic example is the recent media announcements that hydroxychloroquine and chloroquine are the "game changers" and potential cure for COVID-19, prompting inappropriate stockpiling and use by the public. Inappropriate stockpiling of hydroxychloroquine has also resulted in substantial shortages affecting arthritis or lupus patients-conditions for which it has been proven effective. 62 Moreover, people in many countries are being confused into taking unproven and at times poisonous "cures" for COVID-19 including ingesting methanol (which resulted in hundreds of deaths in Iran), using cocaine, taking Brazil's chloroform and ether based drug 'loló', exposure to the sun or to temperatures higher than 25°C, and widely circulated myths on social media around taking Ibuprofen (Advil, Motrin), naproxen (Aleve) and other non-steroidal anti-inflammatory drugs (NSAIDs), vitamins: C, D or a hot bath. 63 The emerging role of pharmacists in fighting the 'infodemic' Healthcare professionals are expected to be up to date with accurate and reliable information in order to provide information with utmost accuracy and clarity. Being located at the heart of the community and easy accessibility, community pharmacies can be a valuable source of reliable and evidence-based information for consumers. Pharmacies are also among essential business sectors that continue to serve the public despite the declaration of total lockdowns in several countries. Community pharmacists are vital part of the public health response and, in many instances, are the first point of contact given the nature of access to the pharmacies. They carry a shared responsibility to keep the public and other healthcare professionals informed on emerging evidence, especially in relation to potential treatments. In addition to their regular activities, pharmacists are well equipped to educate the community about the nature of the pandemic, symptoms, mode of transmission, promoting prevention and infection control procedures in line with the public health guidelines. Pharmacists are involved in identifying patients with symptoms and act as a point of referral at the community level. Adequate understanding of the symptoms of COVID-19 and being able to differentiate these symptoms from seasonal influenza is instrumental in early detection and referrals for further assessment, as required. This involves team-based care and proactively collaborating with other health workers within the pharmacist scope of practice whilst performing additional responsibilities. We have identified and discussed how pharmacists can serve the community during the fight against these global health emergencies, Table 1 Summary of preclinical and clinical evidence on drugs with potential activity against COVID-19. (continued on next page) Several randomised clinical trials evaluating the safety and efficacy of this drug are being conducted. Antibacterial agent A macrolide antibiotic with some in vitro activity against influenza A, H1N1, Zika viruses [25] [26] [27] and some immunomodulatory and anti-inflammatory effects. It may prevent bacterial superinfection. • It has been used as adjunct therapy in the treatment of viral respiratory tract infections such as influenza, 28 Hydroxychloroquine (hydroxyl analog of chloroquine) has similar antiviral mechanism as chloroquine. 37 This may include inhibition of viral enzymes or processes and ACE2 cellular receptor inhibition. • Hydroxychloroquine is also active against SARS- The media suggestions on the potential efficacy of certain drugs, such as chloroquine and hydroxychloroquine, have resulted in hoarding of the drugs in many countries. In Australia, this was accompanied by an increase in off-label prescribing and concerns about the potential shortage of hydroxychloroquine. Given the limited evidence on efficacy and safety of hydroxychloroquine, the Therapeutic Goods Administration (TGA) implemented restrictions on the medical specialists that can initiate hydroxychloroquine prescribing. Further to this, TGA has released a statement highlighting the absence of approved medicines for COVID-19 treatment, therefore prescribing of any drug for this indication is considered off-label use. 66 Pharmacists are in the front-line to act as stewards, and at the local level, they are involved in updating the prescribers with new legislative changes implemented by the TGA. In addition to hydroxychloroquine, there has been an increased demand in relation to adjunct treatments, such as salbutamol, ibuprofen, and paracetamol as well as pressure from the public to get more refills leading to shortages at various locations across Australia. This has resulted in enforcing new limits on dispensing of prescription and sales of over-the-counter medicines to one-month supply or one unit by the TGA in liaison with the Pharmacy Guild of Australia and the PSA. Again, pharmacists are on the front line enforcing these new restrictions whilst educating consumers the need for such changes during the pandemic in order to avoid medicine shortages. It is therefore imperative for pharmacists become aware of such developments to provide evidence-based information in a timely fashion. Pharmacists provide an essential public service in the supply of medicines and pharmaceutical care and continuing these services without interruption is even more important during the pandemic. In addition to continuing these essential services, pharmacists are empowered with extended capabilities to reduce the burden on general practitioners and support social distancing and self-isolation measures employed by the authorities. National, state and territory governments have put in place continued dispensing arrangements providing authority to pharmacists for the ongoing supply of medicines without a prescription until 30 June 2020. 67 This has increased responsibility of pharmacists to monitor and follow up patients, at times in liaison with their medical practitioner. In order to promote social distancing and self-isolation especially in vulnerable patients, home delivery services for Medicare subsidised medicines are implemented by the Department of Health. The Pharmacy Guild of Australia and the PSA in liaison with health authorities have provided guidance to pharmacies on how to set up these services. This programme has leveraged a previously existing payment process for pharmacy services. In addition, there is ongoing work in liaison with pharmacists, general practitioners, and state and territory authorities to enable therapeutic substitution by pharmacists in the event of a shortage. This will allow community pharmacists to substitute dose strength or form without prior approval from the prescriber, if a prescribed medicine is not available at the time of dispensing. These measures highlight the important role pharmacists can play in enabling and maintaining access to medicines for people in need throughout the COVID-19 outbreak. Given that Australia is entering the influenza season, health authorities are urging Australians to have the influenza vaccine to reduce the risk of doubling-up of seasonal influenza and COVID-19. Pharmacists in Australia are well placed with appropriate background knowledge and training to educate, encourage and provide vaccination Safe at a dose for anti-parasitic use, but from in vitro study and IC50 it is not possible to achieve the required SARS-CoV-2 IC50 (2μM) even with 3 times the highest dose approved for ivermectin. Clinical safety data at these doses is not available. Relatively safe from drug interactions point of view a Other antivirals active against influenza viruses such as baloxavir 56 and neuraminidase inhibitors (oseltamivir) 57 are currently under investigation for potential use in the treatment of COVID- 19. b Other drugs currently being evaluated for potential use in the management of patients hospitalised with severe COVID-19 include disease-modifying anti-rheumatic drugs such as sarilumab, immunosuppressive agents such as sirolimus, general corticosteroids, and high dose ascorbic acid. NB: The information contained in the table is emerging and rapidly evolving and reflects the evidence at the time of writing this piece (April 25, 2020). to the public. Provision of vaccinations by pharmacists 68 has increased the vaccination uptake and reduced the burden on general practitioners; in the current context, this reduces unnecessary visits to general practitioners and ensures their availability to focus on other important aspects of pandemic healthcare. In Australia, when a vaccine against SARS-COV-2 becomes available, pharmacists will be a key provider in the vaccination rollout. Pharmacists are acting as stewards on the frontline encouraging the public to get their annual immunisation on time so that the healthcare system will not be over-stretched in dealing with influenza cases during the pandemic period. In developing countries, pharmacists' responsibilities are beyond fighting medication misinformation. The International Pharmaceutical Federation (FIP) has prepared a guidance document for pharmacists on newly available evidence and recommendations, 69 including position statement on the safety concerns raised with some of the frequently mentioned drugs (such as non-steroidal anti-inflammatory drugs, ACEIs/ARBs and cotricosteroids). 70 These resources should be used along with locally relevant guidelines to provide sustainable benefis for the communties. Right now, people living in these settings are facing an extreme shortage of hand sanitizers or antiseptic hand-rub products. The pharmacist can play a key role through the formulation and supply of these products from local easily accessible chemicals and promoting their appropriate application and usage e.g. through social media. Depending on speciality and scope of practice, pharmacists can make substantial contributions in the fight against the pandemic including identifying, preventing and treating medication-related problems 71 managing minor ailments, 72 early detection and appropriate referral of possible cases of the COVID-19 73 , and in combating medication misinformation. 74 A summary of the potential role of pharmacists to fight against medication misinformation and other aspects around COVID-19 is provided below. • Provide updated and evidence-based scientific advice on vaccines or treatments under investigation to the community and other healthcare professionals. • Provide proper counselling and appropriate information through social media or other appropriate virtual platforms which can easily be accessed by the community and establish a conducive environment to encourage the public to seek advice or clarifications on COVID-19 preventive and therapeutic measures. • Counsel communities on therapy and medications for the treatment of minor symptoms associated with COVID-19. • Guide the public towards authorized national and local information distribution and dissemination channels within each country. • Participate actively in COVID-19 hygiene and infection control initiatives or strategies. • Conduct health-education campaigns that promote the appropriate use of medication information. • Collaborate with other health professionals, health-professional societies and associations to facilitate educational and behavioural interventions that will assist the community to comply with standards/procedures aimed at combating the spread of COVID-19 and misleading information. • Aid preventive measures through the preparation of sanitizers or antiseptic hand-rub products from locally available chemicals, and promote their appropriate application and usage. • Advise the community of risks with procuring drugs from unregistered internet retail shops, in particular with the risks of falsified medicines. • Examine products for suspicious appearance, and constantly monitor medicine product alerts. • Confirm the reliable sourcing of drugs with their respective National regulatory authorities (NRAs), e.g. drug registration with official NRAs, this is particularly important in resource limited communities, in the shadow of a global crisis. • Community education to reduce the risk of transmission of emerging pathogens from animals to humans in live animal markets or animal product markets including consumption of raw meat, milk or animal organs. Pharmacists around the globe are currently engaged in serving their communities and helping patients cope with COVID-19 pandemic. While they are faced with this unparalleled public health crisisfighting on multiple fronts, their authorities to test and treat are inconsistent across different jurisdictions. In addition to their routine roles, pharmacists are contributing significantly towards the overall COVID-19 pandemic control. These include rapid point of care tests for COVID-19 (varied depending on jurisdictions) and vigilant surveillance measures on suspected cases; procative steps in identifying, mitigating drug shortages, and ensuring the medicine quality; prioritized availability of up to date, reliable COVID-19 information to their communities via flyers and social media platforms; and ensuring education and home care for individuals, suspected patients, and related family members while in self isolation, including appropriate referrals for psychological support. 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A route proposal Community pharmacists and communication in the time of COVID-19: applying the health belief model All authors declare that there is no actual or potential conflict of interest.