Covid 8
Covid 8
A R T I C L E I N F O A B S T R A C T
Keywords: Pharmacies have been practicing innovative infection control measures during COVID-19. This article seeks to
Pharmacy practice explore the current activities undertaken across various community pharmacy settings in relation to the safety of
Infection control the workplace environment for staff and patients.
Sanitation
Methods: An online cross-sectional survey was conducted in Australia during the COVID-19 outbreak from 1st to
Hygiene
COVID-19
30th April 2020, addressing community pharmacist’s awareness and response to infection and sanitation control.
SARS-CoV-2 Results: A total of 137 pharmacists took part in the survey. Regular cleaning took place in the pharmacy, but the
Pharmacists use of gloves while cleaning was not regularly practice (48.18%). In addition, only 46.72% of respondents re
Public health ported observing script baskets being cleaned and disinfected. About one-third (37.96%) of pharmacists were
Workplace safety aware of the two-step cleaning and disinfecting process, with only 18.98% of pharmacist practicing such cleaning
OHS procedures. More than half of surveyed pharmacists reported having difficulty keeping up with pharmacy
practice and infection control guidelines during the pandemic.
Conclusion: This study demonstrates that the majority of pharmacists are not fully aware of the proper infection
control measures needed in a community pharmacy setting. Pharmacists must play a bigger role in infection
control measures to ensure staff and public health safety.
Introduction globally.8
The source and etiology of COVID-19 is still unknown. As of current
The first case of the novel coronavirus was first reported in Wuhan, in evidence, COVID-19 is caused by the severe acute respiratory syndrome
the Hubei Province of China in December 2019, with links to a source coronavirus 2 (SARS-CoV-2) virus that is spread via droplet transmission
from a seafood wholesale market in Huanan, Wuhan.1 The spread of the of between 5 and 10 μm.9 Such transmission can occur via an infected
novel coronavirus was uncontainable and spreading rapidly, leading to person’s sneeze or cough that results in expulsion of infectious respira
the Chinese central government imposing a lockdown in Wuhan and tory droplets into the air and surfaces.10 Transmission can occur via two
other cities in Hubei province as of 23 January 2, 020.2 This was done in different modes: 1) direct, and 2) indirect contact.11 In direct contact, an
effort to quarantine the epicentre of the outbreak, which on the day prior infectious individual can transfer the virus to susceptible host via actions
the lockdown 444 positive cases were reported3 with 25 deaths within such as a handshake from a contaminated hand or inhalation of a droplet
the Hubei province.4 from an infected person’s sneeze. On the other hand, indirect contact
On 13 January 2020 saw the first coronavirus case outside of China consist of an infectious individual transferring viral content on a fomite
in Thailand. A few weeks later, the first death outside of China was re such as a frequently touched surface in the form of door handles,
ported in the Philippines.5 On 11 February 2020, the World Health elevator buttons and via money transactions. Both contact methods can
Organization (WHO) changed the name of the novel coronavirus from lead to COVID-19 infection when susceptible individuals unknowingly
the 2019 novel coronavirus (2019-nCoV) to coronavirus disease 2019 come in contact with viral contents on their oral, nasal, or eye mucous
(COVID-19).6 On March 11, 2020, the World Health Organization membranes, or touching these areas with their contaminated hands.12
labeled COVID-19 to be a pandemic.7 As of 1 April 2020, WHO officially As it is not known definitely if COVID-19 is an airborne virus, America’s
reported more than 823,626 confirmed cases with 40,598 deaths Centres for Disease Control and Prevention (CDC) has recommended
* Corresponding author.
E-mail addresses: [email protected] (Z.Z. Sum), [email protected] (C.J.W. Ow).
https://doi.org/10.1016/j.sapharm.2020.06.014
Received 11 June 2020; Accepted 11 June 2020
Available online 17 June 2020
1551-7411/© 2020 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Z.Z. Sum and C.J.W. Ow Research in Social and Administrative Pharmacy 17 (2021) 1845–1852
that healthcare workers and teams ensure adequate environmental categorized as retail workplaces, pharmacist and their employers must
sanitation, sound infection prevention practices and routine droplet use their professional judgment to determine their pharmacy’s risk
barrier precautions.13 exposure, and provide staff with the necessary PPE such as masks,
The virus that causes COVID-19 disease is the Severe Acute Respi goggles, gowns and gloves.27
ratory Syndrome Coronavirus 2 (SARS-CoV-2).6 A recent study has With community pharmacy an essential healthcare service in
shown that SARS-CoV-2 virus can remain viable on various surfaces for Australia, the health and safety of the pharmacy workforce is of high
different lengths of time, and can be a factor in human-to-human priority. While some pharmacies have reported providing novel and
transmission via indirect contact.14 The study published in the New extra measures on top of professional infection control guidance,28
England Journal of Medicine demonstrated that aerosols (<5 μm) of leaders in each community pharmacy must ensure adequate hygiene
SARS-CoV-2 strain was detectable in the air for up to 3 h, 4 h on copper, measures are practiced as per their situation. Professional oversight and
24 h on cardboard and up to two to three days on plastic and stainless leadership are essential to preserve the health and safety of pharmacy
steel surfaces.14 SARS-CoV-2 also has a longer half-life on cardboard staff and ensure continuity in supply of essential health services to the
than SARS-CoV-1 (the virus strain that causes SARS in 2003). With that, public.29 In addition, leaders in the workplace should be made aware of
SARS-CoV-2 has a higher propensity for both community transmissions individual worker’s pre-existing health conditions that may put them at
in the public and healthcare setting due to the handling of external a higher risk of severe infections and complications should they contract
cardboard packaging as compared to SARS-CoV-1. This places commu COVID-19, and redeploying these susceptible workers to non-patient
nity pharmacies at an increased risk due to its unique overlap as a pri facing roles where the risk of contracting COVID-19 is lower.
mary healthcare facility and placement in the community encountering Published research has been focusing on the extent of pharmaceu
high foot traffic (i.e. shopping centres, medical clinics, hospitals). tical care being provided by pharmacists in all clinical settings.27,28 No
Pharmacist can play wide-ranging roles in disaster management previous study has looked into pharmacist and/or pharmacy’s response
across four key phases in 1) prevention, 2) preparedness, 3) response, to their role in sanitation implementation management in the COVID-19
and 4) recovery.15 In community pharmacies, the provision of accurate pandemic.
public health education and knowledge on infection control and disease Pharmacists are one of the most highly trusted profession in
transmission are important across these four phases during an infectious Australia,30 and it is of utmost importance that they provide sound
diseases outbreak.16 public health recommendations21 and implement adequate sanitation
As highly assessable healthcare professionals,17 the community and infection control measures that can support the ever-evolving levels
pharmacist will often be the first point of contact within the Australian of an infectious disease outbreak emergency.31
health system for individuals who require advice on COVID-19-related The aim of this study was to investigate pharmacies and pharmacists’
information, health advice and medication access during the current preparedness level and their awareness of important information
pandemic.18 With physicians cancelling non-urgent consultations and regarding the occupational health and safety of their workplaces in
Australian government ceasing non-essential elective surgery to free up infection control during this emergent situation.
human and capital resources to manage COVID-19,19 the community
pharmacist is now one of the sole point of contact in the primary Methods
healthcare system. To respond to the crisis, pharmacies extended their
opening hours and services, and is supported by the Australian Gov Study period
ernment in delivering medicines to vulnerable populations to ensure
continuity of medicine supply and treatments.20 Early accounts from Australia’s positive COVID-19 case numbers started to increase at the
Chinese community pharmacist showed that pharmacists played sig start of March 2020 and peaked towards the end of March 2020. On 1
nificant roles in educating the public on personal and environmental April 2020, Australia has a total of 4707 COVID-19 confirmed cases and
hygiene during COVID-19.21 Therefore it is imperative that community 20 deaths from COVID-19.8 The month of April 2020 was the start of
pharmacist possess the right knowledge needed to help limit the impacts strict restrictions in public gatherings to curb the spread of the virus.32 A
of COVID-19 in the community.22 survey conducted during this period of highest social restrictions will
The total positive COVID-19 cases vary across Australian states and demonstrate community pharmacy’s response to the pandemic.
territories.23 Community pharmacies are in an environment where staff
are not advised to routinely wear masks and personal protective Study design
equipment (PPE). A mixture of clinical staff (pharmacist), non-clinical
staff (pharmacy assistants and dispensary technicians) and patients A quantitative cross-sectional survey was undertaken during the
utilize common areas and devices such as communal pens, blood pres month of April 2020. An online survey was directed at Australian
sure monitors, script counters, product shelves, furniture and keyboards. registered pharmacist practicing in the community setting or in a
As community pharmacies do not commonly have dedicated environ pharmacy that includes a retail section. The survey consists of 23 mul
mental service workers in cleaning its premises, the responsibilities of tiple choice questions formulated based on guidance from the Interna
cleaning and disinfecting frequently touched surfaces rests on individual tional Pharmaceutical Federation (FIP) health advisory,18 New South
pharmacies and their management team. Good infection prevention and Wales (NSW) health advice for community pharmacies on COVID-19,33
control practices can reduce direct virus transmission between people, websites from non-Australian pharmacy society and medical society,
and indirectly through contact with frequently touched items in the media networks, and observations of the rapid changes taking place
pharmacy. It is therefore important that pharmacy staff are practicing around retail companies in infection control measures. Questions
meticulous hand hygiene with readily available hand hygiene prod included steps taken for staff and patient safety, understanding of
ucts,24 and keeping workspaces clean and disinfected regularly to sanitation requirements, and steps taken by each individual pharmacies
eliminate potential source of infection.25 Providing a set of measures in in maintaining hygiene standards.
decontamination not only minimizes the spread of COVID-19, but also
provides extra assurance to stressed and concerned pharmacy staff and Questionnaire administration
their patients during the pandemic.26
Community pharmacists in Australia are in a unique position where Pharmacists were invited to participate via informal pharmacist-only
they are neither classified front-line health workers in the COVID-19 groups on social media website Facebook. These informal groups are a
pandemic but may be considered to be at medium risk of exposure to mix of employed pharmacist working either as full time, part-time, lo
the SARS-CoV-2 virus.18 Given that community pharmacies are cums, managers, and employer pharmacist proprietors. The survey was
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Z.Z. Sum and C.J.W. Ow Research in Social and Administrative Pharmacy 17 (2021) 1845–1852
provided via an online link onto a Survey Monkey website. Pharmacists In terms of staff safety precaution, there were more than 70% uptake
were informed prior participation in the survey that their participation of social distancing and hygiene measures in the areas of employing
is made anonymous, voluntary, and their inputs will be treated as clear physical Plexiglas shields, social distancing at cash registers,
confidential. The names of pharmacists and their professional registra encouragement of contactless payment, visible floor markings for safe
tion numbers were not recorded in any part of the survey. Consent was distancing in high traffic areas, and removing of communal pens.
obtained from participants’ prior the start of the survey. The survey was However reassigning of job task for immunocompromised or high health
opened from 1 April 2020 to 31 April 2020. risks staff (such as moving away from patient-facing roles) was least
practiced in pharmacies, with only an uptake of 34.31% of total re
Data analysis spondents (see Fig. 1). In addition, temperature checks prior starting
work was not heavily practiced, with only 42 out of 137 participants
The data from the online survey were exported into Microsoft Office being involved in such measures.
Excel and into IBM SPSS Statistic 25. Frequency analysis was performed A small number of pharmacies (35.04%) provided restricted sections
to create a demographic profile of our participants. of the pharmacy for COVID-19 suspected patients, while 65.69% of
pharmacies were actively involved in limiting the amount of patients in
Results the pharmacy premises at any one time according to the 4 square meters
per person guidelines.34
In this section, a pharmacist’s response is assumed to be synonymous When assessing the awareness and status of sanitation and infection
to their own actions or the actions taken at their primary workplace. control in the workplace, 94.89% of pharmacists observed regular
cleaning occurring in their workplace. However only 48.18% of cleaning
was performed using gloves (see Fig. 2). Frequently touched surfaces
Participant’s demographics
such as countertops were cleaned regularly as reported by 95.62% of
respondents, but only 46.72% of respondents reported observing script
A total of 137 pharmacists took part in the survey, with 71.53% fe
baskets (a frequently touched item) being cleaned and disinfected (see
males and 28.47% males. Almost half (45.26%) of pharmacist surveyed
Fig. 3).
belonged to the age group of 25–34 years. Community pharmacy rep
Out of the 137 pharmacists surveyed, only 49 pharmacists (35.77%)
resented 89.05% of participant’s primary place of practice, with 9.49%
worked in pharmacies that provided hand sanitizer for patient use as a
practicing at private hospitals with a retail section, and 1.46% at public
pre-requisite before entry into the premises. Only 44.53% of pharmacies
hospitals with retail sections.
provided hand sanitizers around the pharmacy premises for public use.
In Australia, community pharmacies are categorized into three main
About one-third (37.96%) of pharmacists were aware of the two-step
groups. Discount chains, non-discount chains, and independent phar
cleaning and disinfecting process of using detergent and water followed
macies. Half of our study’s participants belong to non-discount chains
by a chemical disinfectant (see Fig. 4). When surveyed, a majority of
(47.45%), followed by independents (34.31%), then discount chains
pharmacist (34.31%) observed that their workplace only used a chem
(18.25%).
ical disinfectant as a cleaning process on frequently touched surfaces,
Full/part-time employed pharmacist formed half of our study’s
while 24.09% observed the usage of a combination of chemical disin
participants (55.47%), with pharmacist manager at 18.25%, pharmacist
fectant and natural disinfectant such as eucalyptus oil and tea tree oil
proprietor at 15.33%, and locum/casual pharmacist at 10.95% (see
(see Table 2). Only 18.98% of pharmacies were practicing the correct
Table 1).
two-step cleaning and disinfecting process.
With the need to practice physical distancing, more than half of all
Overall health & safety activities pharmacists responded that medication advice and clinical services
could be achieved. However 38.69% of pharmacist found the provision
When surveyed on whether they are asked to wear face masks at of clinical services and medication counseling to be challenging due to
work, 82.48% of pharmacist were not asked to wear face masks, while distancing measures (see Fig. 5).
the remaining 17.52% of pharmacist chose or were asked to wear face More than half of surveyed pharmacists reported difficulty in keep
masks during work periods. ing up with evolving changes in pharmacy practice guidelines during
this period of time. Only 9.49% of pharmacist found it easy to keep up-
Table 1 to-date to new guidelines.
Participant’s demographics.
Demographic Type Percentage Discussion
(%)
Sex Male 28.47 The majority of pharmacists surveyed did not observe or practice
Female 71.53 wearing face mask at work. This was in line with the guidance provided
Age 18–24 6.57
by the Australian Department of Health.35 Unless pharmacists are in
25–34 45.26
35–44 16.79 direct contact with confirmed cases of COVID-19 patients, they will then
45–54 18.98 be required to put on full Personal Protective Equipment (PPE) including
55–64 12.41 P2/N95 respirators, disposable gowns, aprons, goggles, visors and
65þ 0.00 gloves.35 The split decision to wear surgical mask despite guidance is
Primary Place of Community pharmacy 89.05
Practice Private hospital pharmacy with 9.49
similar to pharmacist in the United Kingdom.36 In Australia, local pri
community retail section mary health networks have provided community pharmacies with sur
Public hospital pharmacy with 1.46 gical mask and some PPE, only to be used in situations where pharmacist
community retail section are in direct contact with a confirmed COVID-19 case or to be given to a
Pharmacy Groups Discount chains 18.25
suspected patient.37
Non-discount chains 47.45
Independents 34.31 The death of a community pharmacist in the United Kingdom made
Pharmacist Roles Full/Part-time 55.47 certain that community pharmacies are susceptible to COVID-19 despite
Pharmacist Manager 18.25 their position as a retailer.38 Community pharmacies are a mix of pri
Pharmacist Proprietor 15.33 mary healthcare service with a retail section, and therefore may come in
Locum/Casual 10.95
contact with patients who are asymptomatic or are displaying cold and
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Z.Z. Sum and C.J.W. Ow Research in Social and Administrative Pharmacy 17 (2021) 1845–1852
Fig. 1. The uptake of activities undertaken by pharmacists and their pharmacies in ensuring staff and workplace safety.
Fig. 2. Awareness and status of sanitation and infection control practices undertaken by pharmacists and their pharmacies.
flu-like symptoms similar to that of COVID-19. Pharmacists play an infrastructure requirements to isolate and monitor patients with highly
important role in triaging these patients and directing suspected patients contagious infectious diseases.39 Due to limited floor space re
to COVID-19 testing centres. Therefore the risk of close contact with a quirements; the provision of an isolated area is least likely to occur in a
true positive COVID-19 case is still probable. Hence stringent measures community pharmacy. A snapshot survey performed in the United
must be taken to ensure staff safety is of utmost importance in com Kingdom showed that 94% and 40% of pharmacist were unable to
munity pharmacies. maintain a physical distance of 2 m from their colleagues, and patients
The data obtained in this survey showed that pharmacies are not respectively.40
practicing reassigning at-risk staff members to non-patient facing roles. Only half of pharmacist respondents reported the use of hand gloves
In addition, temperature checks prior commencement of the days work worn by themselves or staff during the cleaning and disinfecting process
was not regularly conducted. This poses a risk for staff and patients, as in the pharmacy. Gloves are meant to protect the individual performing
precautions are not put in place to ensure the safety of both pharmacy the sanitation process. It preserves hand skin integrity by forming a
teams and their patients. Stricter compliance to guidance provided by physical barrier against the irritant and hazardous nature of some
local professional pharmacy organization and government documents cleaning chemicals, and also provides protection against cuts and
could mitigate the risks of community transmission of COVID-19 in the punctures to skin membranes when cleaning contaminated sharp ob
compounds of the community pharmacy.29 jects.41 As community pharmacies do not regularly employ professional
The nature of community pharmacy premise is the absence of environmental cleaning professionals to maintain hygiene standards in
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Z.Z. Sum and C.J.W. Ow Research in Social and Administrative Pharmacy 17 (2021) 1845–1852
Fig. 3. Types of fomites cleaned and disinfected by pharmacists and their pharmacies.
Fig. 4. Pharmacist’s awareness of two-step cleaning and disinfecting process in Australian healthcare setting.
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Z.Z. Sum and C.J.W. Ow Research in Social and Administrative Pharmacy 17 (2021) 1845–1852
pandemic. Similar results were obtained in non-healthcare workplaces safety requirements, including proper sanitation and infection protocols
around Australia where employees were reasonably knowledgeable to ensure staff and patients feel safe. A recent media release showed that
about basic infection prevention measures (such as good hand hygiene patient visits to their general practitioner have dropped due to fear of
and equipment cleaning), but were unaware of its true effectiveness and contracting COVID-19 in the clinic.49 Community pharmacists and
appropriateness in their specific workplaces.44 pharmacies must aim to quell fear by setting high standards in hygiene
In contrast, pharmacists in China were heavily involved in ensuring management such that patients continue to visit their pharmacist and/or
public safety by ensuring high standards of infection control measures.45 community pharmacy regularly thus not putting themselves at risk of
Therefore more attention should be given to pharmacists around infec not being able to access essential healthcare items.
tion control measures to ensure the continuity of their role as an Infection control management strategies are more likely to be
essential service provider. developed in higher infection risk organizations (e.g. aged care facility
Social and physical distancing may compromise the quality of and hospitals), where exposure of biohazard waste and bodily fluids to
medication counseling provided by a pharmacist, especially when staff are higher as compared to those working in lower risk areas.50
community pharmacies do not regularly have a private room to conduct Regardless, most non-healthcare business independent of size reported a
counseling of private and confidential health matters. However the lack of formalized policy plans in infection prevention strategies even
safety of patients and staff are crucial during this period of time. Phar for the annual influenza virus.51 In addition, infection control strategies
macists who are unable to relay private health message across to a pa adopted in workplaces were not backed by evidence, but rather based on
tient during a physical distancing consultation could utilize telehealth assumption to be more effective than other infection control strategies.51
methods to deliver quality care as soon as practicable. A systematic re In the uncertainty of COVID-19, the maintenance of a hygienic and
view demonstrated positive patient satisfaction in receipt of telehealth sanitary environment in community pharmacies must be prioritized. A
consultations, but its effectiveness and efficiency are still debated.46 In systematic review on hand hygiene programs in the office setting
Australia, general practitioners and accredited consultant pharmacists showed increased staff morale and confidence at work when such pro
have been given the ability for reimbursement for telehealth during the grams are put in place.52 Despite the ever-evolving work health and
COVID-19 pandemic as a means of ensuring the continuity of quality safety requirements in different industry types may have influenced the
medical and healthcare.47,48 This provision offers incentives to results, pharmacy management teams must take initiatives and plan
accredited pharmacist to conduct telehealth for their patients, however ahead to enact adequate evidence-based protection measures for the
non-accredited pharmacist are not able to get reimbursed for such tel safety and morale of their staff and patients.53
ehealth consultations, and may hinder the quality of consultations that
requires more privacy while trying to maintain physical and social Conclusions
distancing in a community and/or retail setting.
During the course of COVID-19 pandemic, the large influx of guid During times of crisis, community pharmacists are required to adapt
ance changes to sanitation and hygiene protocols may create some to and respond with new ideas to safeguard the profession and their
confusion and anxiety among non-clinical pharmacy staff. As commu community. Community pharmacists are given a huge responsibility of
nity health leaders, pharmacists must uphold sanitation measures so as accurately informing their local community about ways to reduce
to reduce anxiety among staff and the public. Carico Jr et al. discussed community spread of the SARS-CoV-2 virus.
the possible benefits of pharmacists applying the Health Belief Model to This article is not exhaustive, but serve to illustrate the range of
reinforce COVID-19 limiting behaviours to patients,22 and this construct activities undertaken by community pharmacists in infection control
could be helpful for adopting better infection control practices amongst and environmental hygiene risk management measures in response to
staff. It is crucial that continuous feedback sessions are conducted, the public health crisis of COVID-19. These measures are currently
including the dissemination of transparent information in a clear and implemented to varying extents across pharmacy settings; and show
concise manner so that teams can practice safely. As the only clinical pharmacists commitments and response to protect their staff and the
member of a community pharmacy, pharmacists must continue to keep local community. Although most pharmacies were implementing an
up-to-date with the ever-evolving changes to workplace health and adequate range of infection control and prevention strategies, a majority
1850
Z.Z. Sum and C.J.W. Ow Research in Social and Administrative Pharmacy 17 (2021) 1845–1852
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