The first confirmed case of the coronavirus disease 2019 (COVID-19) was reported in December 2019, and the contagion has since spread across international borders, leading to a widespread global pandemic that will likely define our modern times.

As of May 1, 2020, more than 5.2 million cases had been confirmed worldwide with more than 337,000 deaths due to the sequelae of the disease.

 On January 30, 2020, the World Health Organization declared COVID19 a public health emergency, because of the reproduction number and communicability of the disease.

The United States alone accounts for more than 1.59 million total cases and more than 96,000 deaths.

Questions regarding the impact that COVID-19 will have on our economy, education system, mental and physical health, and overall well-being are fervently being explored worldwide.

As health care providers, this pandemic provides an opportunity to rise and stand at the front line to care for patients while we adjust to a new sense of normalcy and rebuild our society.

In addition to the deleterious effects of the infection, COVID-19 has disturbed every facet of our daily living.

In April 2020, the number of unemployed individuals rose to a staggering 18.1 million from 1.4 million before the pandemic took hold, according to the US Bureau of Labor Statistics.

 Additionally, the closing of educational institutions has left many US families in desperate need of childcare and some without a means to feed children who depend on school lunches for nutrition.

 The US Department of Agriculture National School Lunch Program, School Breakfast Program, and Child and Adult Care Food Program assist more than 35 million children in receiving adequate nutrition, and without access to school systems, more than two-thirds of US children’s nutritional needs may be compromised.

School closures will also add to rising economic decline and unemployment rates.

In 2009, the Brookings Institution estimated that the cost of school closures for 1 week would lead to $142 lost per student and projected that a nationwide closure of just 4 weeks could cost 1% of the gross domestic product.

 The full economic impact of COVID-19 has not yet been seen. However, as much of the nation and world remain in quarantine, economic instability is predicted to rise.

Historically, times of economic depression, natural disaster, and world wars have left the US health care system relatively unscathed in regard to economic stability.

 COVID-19 presents a new challenge. On 1 hand, hospitals in heavily affected states such as New York are facing shortages in all directions, from manpower to personal protective equipment.

 Although acute care institutions are bracing for heavy impact, ambulatory care practices are at risk of closing their doors because of the decline of billable hours and patient visits.

 Subsequently, a decrease in work hours, furloughs, and loss of jobs for many health care workers may ensue. Michigan provides an example, with health care businesses accounting for the second largest source of unemployment insurance claims at the end of March.

Although the US Federal Government’s Coronavirus Aid, Relief, and Economic Security Act, passed on March 27, 2020, is providing more than $2 trillion in aid to US families and loans for small businesses, as well as $100 billion in aid to hospitals, resources are quickly being depleted. A sustained closure is predicted to decrease health care resources, availability of care to vulnerable populations, and further attrition of the health care workforce.

The national decline in economic expenditure and increase in the US unemployment rate have also disproportionally affected the vulnerable and weak and have led to a loss of adequate health care coverage for many.

 Patients displaced from the health care system, because of an inability to afford care and poor insurance coverage may be inequitably affected by this pandemic, while the country remains at a standstill.

The Centers for Disease Control and Prevention said that individuals with chronic health conditions, such as asthma, diabetes, and heart, liver, and kidney disorders, as well as the immunocompromised and adults 65 years and older are at an especially high risk of suffering poor outcomes if infected with COVID-19.15 A reduction in chronic disease management because of an inability to afford health care costs poses an additional risk of succumbing to the negative outcomes of the virus for individuals in this population.

Social distancing poses yet another challenge that is unprecedented in modern times. The increasing uncertainty surrounding the reopening of society and a shift to “normalcy” may have an impact far greater than the pandemic alone.

 The question of how individuals and communities at large will respond to mandatory social distancing and sheltering-in-place orders is a question yet unanswered.

In many ways, society is better prepared for a socially distant world by comparison to historical periods of quarantine, such as during the 1918 Spanish Flu.

 A readily accessible online consumer market and widespread access to virtual social platforms has temporarily softened the blow of isolation for many.

 However, even with the availability of a “virtual reality,” the psychological impact of quarantining should not be minimized.

Historical evidence has demonstrated that levels of anxiety, depression, posttraumatic stress disorder, and substance use disorder all rise following natural disasters, wars, and other traumatic world events.

 Literature regarding the aftermath of pandemics is scarce. However, even the short period following the 2009 SARS epidemic saw a rise in anxiety and depression for both patients and providers.

 Additionally, stay-at-home orders may be accompanied by increased rates of child abuse and domestic violence.

 Furthermore, reduced access to mental health providers and support groups during social isolation may make it more difficult for at-risk populations to seek appropriate care. Health care providers must take extra caution to stay attuned to their patients’ emotional well-being to prevent chronic mental health issues that may affect our society for generations to come.

Pharmacists’ role in the COVID-19 pandemic is paramount. Community pharmacists are working on the front line as some of the few health care providers who remain accessible in an increasingly virtual world.

 Given the risk that uncontrolled chronic diseases can play in leading to poor COVID-19 outcomes, pharmacists must ensure that medication accessibility and adherence is maintained during these uncertain times. Additionally, a need for widespread national testing remains, and local pharmacies provide a safe and trusted location for individuals to get tested for the virus. With the US Department of Health and Human Services authorizing licensed pharmacists to order and administer COVID-19 tests, pharmacists are able to help ensure the safety of communities and serve as essential providers during this pandemic.

 Additionally, counseling on appropriate medication use and encouraging stringent management of chronic conditions will be increasingly necessary during this time. Pharmacists should take this opportunity to engage with health professional colleagues to ensure that patients are not lost to follow-up and are able to receive medications in a timely manner.

The COVID-19 pandemic has undoubtedly shaken our society and world in ways we cannot yet understand. From a sudden economic recession to worldwide isolation, the effects of this disease will likely define our era. Historical references of social quarantine provide us with valuable lessons regarding the short- and long-term effects of social distancing and closure of our brick-and-mortar institutions. Amid social isolation, pharmacists offer refuge to the sick and vulnerable by serving as frontline providers and remaining accessible during these uncertain times. As the COVID-19 pandemic continues to unfold, health care providers can respond to those in need by donning our white coats and advocating for patients to help maintain the health and well-being of our society.

, is an assistant professor of pharmacy practice at the Chapman University School of Pharmacy in Irvine, California.

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The crisis affects our economy, education system, and mental and physical health, but pharmacists have a key role to play advocating for patients

COVID-19 Is More Than a Pandemic

The World Health Organization announced a global pandemic on March 11, 2020, in response to the severe acute respiratory syndrome coronavirus 2,

the cause of the coronavirus disease 2019 (COVID-19).

The socioeconomic impact of the virus has led to a major economic crisis with worldwide record unemployment, lack of transportation, social isolation, and an overwhelming demand for specialized health care services. Health care providers have shifted their efforts to prioritize acute care, and coincidentally, some have been forced to close their businesses or furlough workers in response to state practice provisions.

The economic situation has forced many patients to make difficult decisions about which maintenance medications they will continue to take. Adherence, or even worse, self-discontinuation, may have also been affected as the pharmaceutical industry has been overwhelmed by increased demand.

More than half of patients already do not take their medications as prescribed because of costs.

 Medication adherence barriers can also include transportation.

 Unemployed patients who once could afford their copays are now compelled to prioritize other essential items over their health needs. Now more than ever, pharmacists are in a unique position to increase awareness about medication adherence and offer alternative patient solutions to prevent nonadherence.

PrescribeWellness, a national pharmacy network, investigated prescription fill data to provide a preliminary descriptive summary. In 2019, 5,802,679 chronic condition prescriptions were filled. Refill statistics comparing fill data for March and April 2020 showed that maintenance medication adherence in 2020 decreased from 2019 (Figure 1). Prior to COVID-19, the mean volume of fills for maintenance medications was much higher (1,545,291 for oral antidiabetics, 1,978,085 for antilipidemic agents, and 2,279,303 for renin-angiotensin system agents). From March and April 2019 to March and April 2020, a decrease of 2% (n = 31,307) in fills among a consistent population of patients with diabetes, a 6% decline (n = 1 22,959) in patients taking antilipidemics, and a 5.5% decrease (n = 124,810) in fills among a consistent population of patients with hypertension were observed. In total, these numbers represent 279,076 prescriptions that were not filled among patients with chronic conditions, compared to last year. In total, these numbers represent 279,076 chronic condition prescriptions that were not filled compared with last year.

Interestingly, the volume of filled oral antidiabetic agents and renin-angiotensin system agents in 3452 patients coprescribed a repurposed medication (eg, hydroxychloroquine, tocilizumab, or lopinavir/ritonavir) for COVID-19 increased by 3.5% (n = 55) and 6% (n = 166), respectively (Figure 2). However, the mean fill volume for these patients (n = 2449) taking antilipidemic medications fell from the previous year. It is speculated that patients who are being treated for COVID-19 are receiving more attentive and personalized health care services during the pandemic, resulting in improved acute and chronic condition management.

Pharmacists are in a unique position as frontline responders to improve medication adherence in such dire times to preserve expected positive outcomes in patients with chronic diseases. As health care providers, pharmacists can relay findings from professional agencies and scientific publications to diffuse speculation from social media and provide scientifically valid information on multidrug interactions and risk of adverse drug events or reactions. Furthermore, pharmacists can provide guidance on cost-effective alternatives and educate patients on the health ramifications of medication nonadherence.

Editor's Note: Jennifer M. Bingham, PharmD, BCACP, discloses an outside interest in Tabula Rasa Op-Co. Conflicts of interest resulting from this interest are being managed by the University of Arizona in accordance with its policies. The other authors did not receive any specific grant from funding agencies in the commercial, not-for-profit, or public sectors for this study. All authors receive salary from Tabula Rasa HealthCare (TRHC) and own TRHC shares. 

, is the director of ambulatory care residency programs and research at Tabula Rasa Op-Co in Tucson, Arizona.

, is the manager of pharmacy business intelligence, and 

, is executive vice president of the pharmacy provider division, at Tabula Rasa HealthCare PrescribeWellness, in Moorestown, New Jersey.

, is the chief operating officer of the Tabula Rasa HealthCare Precision Pharmacotherapy Research and Development Institute, in Orlando, Florida.

, is the chief scientific officer at Tabula Rasa HealthCare in Orlando. 

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Resulting economic decline Is forces many to make hard choices about medications, but pharmacists can increase awareness and offer solutions.

Adherence Takes Hit During Pandemic

Vaccinations are some of the most cost-effective preventive health care tools available and have significantly contributed to the steady rise in life expectancy.

Despite this, adult vaccination rates in the United States remain below Healthy People 2020 goals, leaving individuals vulnerable to otherwise preventable diseases, as illustrated by recent outbreaks of hepatitis A, measles, and mumps.

 As a result, there is a continuing need to maintain high vaccination rates to prevent future outbreaks of vaccine-preventable diseases (VPDs). In light of the coronavirus disease 2019 (COVID-19) pandemic, pharmacists face the challenge of keeping patients and staff members safe from this new infectious disease while continuing to provide patient care. Pharmacists should consider several factors when deciding to vaccinate during this pandemic.

Worldwide, the COVID-19 pandemic has affected more than 4.3 million people and counting, with about 1.4 million confirmed cases in the United States alone as of May 13, 2020.

 The coinfection rate with other bacterial, viral, and/or fungal pathogens and a coinfection’s impact on patient outcomes remain unknown. Recent reports of coinfection with influenza and other pathogens suggest that coinfection may be more prevalent than thought, perhaps as high as 21%.

 Given the unknown coinfection rate and because influenza and pneumococcal disease have historically been leading causes of US deaths, hospitalizations, and office visits,

 it is important that patients continue receiving routine vaccinations to decrease their risk of VPDs, which may potentially increase the risk of complications with COVID-19.

Recognizing vaccines’ positive impact, the National Committee for Quality Assurance, National Vaccine Advisory Committee, and Centers for Medicare & Medicaid Services have incorporated vaccination quality measures into their standards that incentivize vaccination activities during emergency department or routine provider visits and during hospital discharge.

 After the implementation of adult vaccination programs in clinics, hospitals, and nursing homes, influenza and pneumococcal vaccination rates have increased by as much as 83% and 78%, respectively, in some institutions.

 However, with recent reports about the pandemic-related closure of many outpatient clinics, low hospital censuses, and the temporary halt of vaccination activities in some community pharmacies, the United States may see vaccination rates fall over time, resulting in increased VPD-related morbidity and mortality.

Ninety percent of the US population lives within 5 miles of a pharmacy, and it is estimated that during any given week, almost the entire US population will walk through a pharmacy.

 This makes pharmacists the most accessible health care providers in the United States. Pharmacists have become widely accepted as vaccinators, as pharmacy law authorizes pharmacists to administer vaccines in all 50 states. However, the extent of this authority varies from state to state with regard to patient age and/or vaccine type.

Community pharmacies have become the second most common destination for administration of the seasonal influenza vaccine, just behind physician offices. Consequently, millions more adults have been vaccinated against influenza, resulting in an estimated 81,000 to 134,000 fewer cases because of pharmacist involvement.

 Pharmacies’ extended hours of operation, particularly when other health care settings are closed, further improves the public’s access to vaccines and could greatly contribute to strengthening our nation’s vaccination rates during this pandemic.

 Therefore, continuing vaccination activities in community pharmacies during the COVID-19 pandemic may help maintain vaccination rates of common VPDs. Pharmacists played a crucial role in providing patient education and vaccinating during previous pandemics, such as the 2009 H1N1 influenza pandemic.

 In a simulation model of the H1N1 pandemic, including pharmacists as vaccinators shortened the time to achieve an 80% vaccination rate at the population level by increasing administration to 25 million doses per week.

Should the decision be made to vaccinate during the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) suggests combining these services with others for which a patient must be seen in person or when the benefits of the vaccine outweigh the risk of exposure.

 For example, patients picking up medications for chronic conditions could be offered an influenza vaccine at the point of dispensing. However, presenting to the pharmacy solely for a vaccine should be discouraged, because this may unnecessarily increase the risk of exposure to COVID-19 for patients and/or staff members.

 In addition, the CDC recommends that personal protective equipment, such as face masks and shields and gowns, be made available and used by both the patient being vaccinated and staff members. All these recommendations are in addition to the administrative and engineering controls that the CDC recommends to minimize such contact (see Table).

Although a vaccine for COVID-19 is not yet available, significant research is under way, with several candidates in the pipeline.

 Once a commercial vaccine is available, pharmacists should be legally authorized to administer it to help improve national vaccination coverage levels.

 Considering the unknown coinfection rate with other infections and possible complications from such coinfections, it is crucial to maintain vaccination activities to protect the public from VPDs. Given their accessibility and expertise in vaccines and vaccine administration, pharmacists have the potential to greatly contribute to improving vaccination rates and herd immunity during this pandemic.

KARL HESS, PHARMD, APH, CTH, FCPHA, FAPHA, AFTM, RCPS (GLASG)

, an associate professor, are both in the Department of Pharmacy Practice at Chapman University School of Pharmacy in Irvine, California. 

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. 2020;13:8. doi:10.1186/s40545-020-00210-w

Pharmacists can greatly contribute to herd immunity during this unprecedented health crisis.

Vaccinating Adults Amid Crisis Poses Challenges

Editor's Note: The FDA revoked Emergency Use Authorization for chloroquine and hydroxychloroquine on June 15, 2020, and no longer recommends related dosing regimens for treatment of COVID-19. This article was printed in Pharmacy Times prior to the revocation.

Although there are no FDA-approved medications for treating coronavirus disease 2019 (COVID-19), more than 405clinical studies are underway to evaluate potential treatments, according to a search of ClinicalTrials.gov.

In April, the National Institutes of Health (NIH) published treatment guidelines for managing patients with COVID-19 based on disease severity, and recommendations will be updated as new evidence becomes available.

 Pharmacists practicing in community and hospital settings play a vital role as part of the frontline health care team in managing patients with COVID-19 by staying up-to-date with the latest drug information.

There is insufficient evidence to recommend for or against antiviral or immunomodulatory therapies in patients with mild, moderate, or severe COVID-19, according to the NIH guidelines.

Patients with mild COVID-19 symptoms without shortness of breath can be managed in an ambulatory setting or at home through telemedicine consults.

Those with mild symptoms and other health conditions should be monitored closely, as symptoms can progress. Patients with moderate COVID-19 should be admitted to the hospital because pulmonary disease can progress quickly. Individuals who may have bacterial pneumonia or sepsis should receive empiric antibiotic treatment for community-acquired pneumonia and be reassessed daily. Patients with severe COVID-19 symptoms should be hospitalized and receive oxygen therapy and empiric antibiotics if bacterial pneumonia or sepsis are suspected. Outside of clinical trials, the guideline panel recommends against using lopinavir/ritonavir or other protease inhibitors for COVID-19 treatment, because of negative study results.²

Chloroquine and hydroxychloroquine (Plaquenil) have gained much media attention and controversy for the treatment of COVID-19, especially because of the risks of heart-related adverse effects (AEs).

Insufficient evidence is available to recommend for or against their use, according to the NIH guidelines.

Additionally, the FDA recently issued a drug safety communication emphasizing the importance of using chloroquine or hydroxychloroquine (whether alone or in combination with azithromycin) for COVID-19 only in a clinical trial setting or for treating certain hospitalized patients, because of the risk of heart rhythm problems, such as QT prolongation.

 The American College of Cardiology, the American Heart Association, and the Heart Rhythm Society recently released guidance regarding possible serious health risks associated with azithromycin and hydroxychloroquine and recommended baseline evaluations, drug interaction assessments, and monitoring.

 The NIH also does not recommend using the combination of hydroxychloroquine and azithromycin, because of potential toxicities, unless it is part of a clinical trial.

The FDA issued an emergency use authorization (EUA) for the use of chloroquine and hydroxychloroquine for the treatment of hospitalized adolescent and adult patients with COVID-19 who weigh 50 kg or more and who are unable to participate in a clinical trial.

 The dosage of hydroxychloroquine recommended by the EUA is 800 mg on the first day of treatment, followed by 400 mg daily for 4 to 7 days of total therapy based on clinical evaluation.

 Chloroquine’s EUA recommends 1 gram on day 1, followed by 500 mg daily for 4 to 7 days of total treatment based on clinical evaluation.

Evidence suggests that patients with COVID19 may have an increased risk of venous thromboembolism (VTE) characterized by elevated D-dimer and fibrinogen levels, which is being studied further.

No FDA-approved treatments exist, but the future is promising, with many clinical trials underway.

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