Review Article PHARMACY PRACTICE & PRACTICE-BASED RESEARCH

Role of Pharmacist in Disaster Management: A Quantitative Content Analysis Approach

Muhammad Ahmer Raza, MS, PharmD1,2; Shireen Aziz, MS, Pharm3,4; Misbah Noreen, MPhil, PharmD1;
Shahid Masood Raza, PhD, MPhil, BPharm 1, 4,5
1
Faculty of Pharmacy, The University of Faisalabad, Punjab, Pakistan
2
Department of Pharmacy Practice, University of Lahore, Punjab, Pakistan
3
School of Pharmacy, Zhengzhou University, Henan, China
4
Faculty of Pharmacy, University of Sargodha, Punjab, Pakistan
5
School of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Hubei, China

Abstract
Background: Little attention has been given to characterizing the roles of pharmacists in disasters even though the importance of
pharmacists’ involvement is widely acknowledged. Objective: We amid to review a broad range of pharmacists roles in disasters and
their response by numerous reports in the literature. Method: A quantitative content analysis technique was used to gather data
consisting of words and phrases from literature regarding pharmacists’ roles and their response in disasters. Results: A total of 106
reports were reviewed and screened based on titles and abstracts. Of these, only 20 studies were determined to meet the eligibility
criteria for discussion. A total of 7 natural disasters (pandemics, tornadoes, fires, earthquakes, floods, hurricanes and storms) were
found in the literature. Roles were classified using the Setlak classification scheme, which includes descriptors such as pharmaceutical
supply, patient management, policy coordination, and response integration. Pharmaceutical supply was remains the pharmacists’
preferred role. Conclusion: It is evident from the literature that pharmacists are uniquely positioned during disasters to provide
healthcare continuity and medication.

Keywords: Pharmacist, natural disasters, disaster management

Introduction Disasters present unique challenges and opportunities to the

Disasters — natural or man-made — occurring since the medical community [5]. During a disaster, health can be affected
existence of human beings lead serious and negative outcomes severely for various reasons, including the performance of
in terms of health. Disaster consider a public health problem healthcare professionals and their responses to unexpected
has been defined by World Medical Association as “A disaster challenges. Pharmacists or other pharmaceutical personnel
is the sudden occurrence of a calamitous, usually violent, event have a history of their role in disasters. Over the years,
resulting in substantial material damage, considerable pharmacists have become known as prescription checkers and
displacement of people, a large number of victims and/or medication dispensers. As critical these roles are, however, the
significant social disruption or a combination thereof”[1]. United unique situations disaster create require pharmacists to play
Nations’ of International Strategy for Disaster Reduction nontraditional roles involving decision-making in therapeutic
(UN/ISDR) defines a disaster as “calamity” or a “catastrophic” protocols; extended authority for clinical pharmacists in
event that causes serious destruction in the functioning of a hospitals; and additional services provided in community
community or society with widespread human, material, pharmacies such as administering vaccinations, medication
economic, and/or environmental loss [2]. According to World mail delivery, and pharmaceutical care for people affected by
Health Organization (WHO), natural hazards from emergencies the disaster [6].
impact approximately 190 million people directly, leading to
more than 77,000 deaths annually. Furthermore, the WHO Pharmacists are serving for meeting the needs for drugs of the
recorded 1200 outbreaks in 168 countries during the period society and are trying to sustain such services in the events of
2012–2017, taking into account new or reappearing infectious disasters. They are uniquely positioned during disasters to
diseases [3]. In 1918, the H1N1 virus caused an influenza provide healthcare continuity and medication management to
pandemic that the Centers for Disease Control and Prevention affected communities. Pharmacists play a very important role
(CDC) described as the harshest and most severe pandemic in in the accurate determination, provision, and use of drugs
recent history. It is estimated that this virus infected which are of particular importance in terms of medical care
approximately one-third of the world’s population and caused used by disaster victims. It has been acknowledged that
more than 50 million deaths worldwide [4]. pharmacists are the most widely distributed healthcare
professional, being more accessible than supermarkets, banks,
or medical centers [7].
Corresponding author:
Shahid Masood Raza, PhD, MPhil, BPharm The role of pharmacists in community pharmacies and hospital
School of Pharmacy, Tongji Medical College, settings can be seen during the current ongoing coronavirus
Huazhong University of Science and Technology disease 2019 (COVID19) disaster around the globe. An
Hubei, China; Email: shahipharmacist@gmail.com extensive range of new responsibilities has been introduced in

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Europe and the U.S to expand the legal roles of pharmacists to research findings that met the above keywords. The reviewers
fight an ongoing COVID19 disaster. Pharmacists in Australia are agreed to exclude articles that did not meet the
receiving prescriptions through mails/faxed/email, and phone aforementioned eligibility criteria, whereas those that met the
messages for home delivery services. Pharmacists promoted eligibility criteria based on reviewers’ assessments were
social distancing by organizing pharmacies in such a way as to included for full paper review. Full articles were reviewed
make it difficult for the virus to spread. They designed independently by each reviewer against the inclusion and
temporary barriers to limit the number of patients in the exclusion criteria. In case of disagreement between the three
pharmacy at any given time and to increase the distance reviewers, a fourth reviewer (SMR) who was an expert in
between patients. They played an important role in educating pharmacy practice and practice based research was asked to
people and patient on how to behave in the pharmacy and, how review the disagreement between the authors. However, there
patients can protect themselves from infection. Pharmacists were no disagreements between the reviewers during the
worked with other members of the healthcare team and refer review process.
patients’ chronic disease-related issues to them. They also
provided additional information to patients having associated Data items extraction and studies quality assessment
chronic diseases and educate them to perform self-monitoring We extracted and recorded data on a Microsoft Excel data
[8-10]
. extraction sheet. We reviewed the following information in the
full-text records: authors and year of publication, the country
The purpose of this article was to review a broad range of where the study was conducted, study design, nature of
pharmacists’ functions in disasters and their response by disasters, and pharmacist role and response to the disaster
numerous reports in the literature. management. Study qualities were evaluated using the Critical
Appraisal Skills Program (CASP) checklist [12]. (See table 4)
Methods
Search strategy Data analysis
The units of analysis and observation were journal articles. Data Natural disasters and pharmacists’ roles were examined using
for this review were identified by a structured review of the nonparametric Kruskal-Wallis test, and a follow-up multiple
‘PubMed’ ‘Medline’, ‘Cumulative Index to Nursing and Allied comparison procedure (Dunn’s test) was run using an online
Health Literature (CINAHL), ‘International Pharmaceutical macro compatible with the statistics software [13]. Statistical
Abstracts (IPA), ‘Sociological Sources’ including sociINDEX and analysis was performed using SAS and descriptive statistics,
Social Work Abstracts. The following keywords were used: including counts and percentages, were run using Microsoft
‘Pharmacist’ ‘Pharmacist roles’ ‘Natural Disasters’ ‘Pharmacist Excel. Descriptive statistics such as pie chart and bar chart were
and Natural Disasters’ ‘Pharmacist and Disaster Management’. used for cumulative percentages of disasters referenced in the
All papers reviewed were written in the English language. The literature and cumulative percentage of pharmacist roles in
included papers were quantitative studies that analyzed disaster management. Goodness-of-fit analysis was used to
pharmacists’ roles and classified using the Setlak classification calculate the differences between pharmacists’ roles and
scheme[11] across the areas related to pharmaceutical supply, functions in disaster management.
patient management, response integration and policy
coordination during disasters. The last search was performed in Results
July 2020 which was based on COVID19. All studies were The electronic search based on the screening of titles yielded a
screened based on titles and abstracts to exclude irrelevant total of 106 reports from ‘PubMed’ ‘Medline’, ‘CINAHL’, ‘IPA’,
articles and the remaining full-text reports were further ‘Sociological Sources’ including sociINDEX and Social Work
examined to determine whether they met the inclusion criteria. Abstracts. A total of 106 articles were identified as relating to
pharmacists’ roles during natural disasters; after removing
Eligibility criteria for inclusion duplicate and non-English articles, 96 articles were screened for
Studies conducted to examine or report the role of pharmacists eligibility. In total, 80 articles were related to the topic, but only
in natural disasters were included and considered eligible for 20 fit the inclusion criteria. In the first screening process, 35
this review. The studied population was community articles were excluded because they were not related to
pharmacists, hospital pharmacists, and regulatory pharmacists, pharmacist role, natural disasters, and pharmacist response to
those involved in the field of disaster and health, or any disaster management. In the next step, 25 articles including
combination of the above. Only English studies were included non-peer-reviewed articles (n=13), review articles (n=2),
in the review. Studies that did not directly address pharmacists’ reports, editorial and commentaries (n=3), and inaccessible
roles in disasters response and management were excluded. online articles (n=7) were also excluded. All the included articles
Commentary articles were excluded because these depend on had clear aims and objectives, and describing data sources. The
the author or authors’ point of view. Partially available reported study selection process is illustrated in Figure 1.
studies (e.g., abstracts, forms, or articles that were inaccessible
online) were also excluded. The three authors (MAR, SA and
MN) independently reviewed the titles and abstracts of the

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Studies quality assessment

Overall, the studies were generally of a reasonable quality. An important consideration is the shortage of manpower during
However, some limitations were noted among the studies, and a disaster and the need for medical personnel, particularly
higher quality studies that contribute to existing knowledge are pharmacists, to be pre-trained to perform an array of duties
needed. In some studies, neither the relationship between the assumed by other disciplines. Such roles include providing basic
researcher and the participants nor their influence on the cardiac life support and cardiopulmonary resuscitation (CPR)
research was stated explicitly. (See table 4) functioning and in the absence of a physician offering medical
aid and assisting medical personnel in front-line response
Disasters and pharmacist role referenced in the literature activities [21-24]. During the sudden acute respiratory syndrome
Numerous references to disasters have appeared in the (SARS) epidemic in 2003 that closed many hospitals, emergency
literature since the early 1960s. A total of 7 natural disasters clinics, and medical offices in Toronto, Canada, pharmacies that
[pandemics (36%), hurricanes, tornadoes and storms (47%), remained open became the city’s healthcare centers and
flood and fires (8%) and earthquakes (9%)] were found in the pharmacists were the primary care providers. Pharmacists
literature. Table 1 shows the summary of the natural disasters begin to assume duties beyond their traditional scope of
classification. Figure 2 shows the total percentages of disasters practice and done well at the time of crisis with allied health
referenced in the literature. Table 2 shows the summary of professionals before an event occurred to maximize role
natural disasters in literature with bibliographical references. A flexibility [25].
broad range of pharmacist roles in disaster is described by
numerous reports in the literature and organized according to Pharmacists also assumed several therapeutic and outcomes
a scheme described by Setlak (2004)[11]: pharmaceutical supply, management roles during disasters. Pharmacists as toxicology
patient management, response integration, and policy consultants and poison specialists managed poisonings and
coordination. Table 3 shows the summary of pharmacist roles drug overdoses by identifying offending substances and
in disaster management. Pharmaceutical supply (44%), patient providing antidotal and therapeutic management information
management (20%), response integration (15%) and policy to physicians. Specifically, pharmacists obtained a detailed
coordination (13%) remained the pharmacists’ preferred role. patient history; determine the patient’s general medical
Bar-chart with goodness-of-fit analysis of the weighted counts condition before and after the disaster and the potential for
suggests very significant differences between pharmaceutical patient education, and document physician approval or
supply, patient management, response integration and policy unauthorized (non-approved) refills or therapeutic
coordination roles. Figure 3 shows the cumulative percentage substitutions. A major component of managing therapeutic
of pharmacist role in disasters referenced in the literature. outcomes involves the basic and widely recognized role of
distributing or dispensing medications [21, 26, 27]. Two dramatic
Discussion accounts of the effects of Hurricane Iniki in 1993 describe
A broad range of pharmacist roles and responsibilities in pharmacists improvising distribution efforts due to lack of
disasters is described by numerous reports in the literature. electricity by handwriting prescription labels for patients,
Pharmaceutical supply has been the primary focus of pharmacy documenting activities for insurance reimbursement, and
services. Ford et al. (2013) stated that pharmaceutical supply delivering medications to hospitals due to blown windows and
outweighs other roles among roles reported [14]. Pharmacists water damage inpatient rooms [23, 28]. An interesting account of
have played significant roles in medication inventory, and pharmacists duties during the anthrax attacks in October 2001
coordinating drug transportation and drug wholesaler support shown how pharmacists were integral in the development and
in disasters. Pharmacists’ efforts to deliver medications in a implementation of a mass anthrax prophylaxis clinic as they
snowstorm in the Spokane, Washington area necessitated using provided logistical support by repackaging and relabeling bulk
snowmobile teams to deliver medications to homebound medications for dispensing, and dispensed antibiotics to people
residents [15-17]. Similarly, the medicine shortage was one of the at risk for developing anthrax-related complications [29]. During
main challenging problems during the start of the currently the SARS crisis in Canada in 2004, community pharmacists
ongoing COVID-19 pandemic. Pharmacists played an important served as primary care providers, some diagnosing and
role in overcoming this problem by ensuring the availability of prescribing in the absence of physicians. Interviews with
essential medicines by changing the same medicine with pharmacists who maintained health system continuity by
different strengths, generic substitution, therapeutic keeping their pharmacies open (while physician offices and
substitution, preparing compounded formulation, and emergency departments closed) revealed a common theme:
importing the medicine from another country or by purchasing non-traditional roles increased considerably, and pharmacists’
the same medicine from alternative authorized sources cross-train with other health professionals (i.e., response
(nationally). Pharmacists also played an important role in integration) before disasters occurs to better prepare the
managing the temporal shortage of antiseptics by health system when human resources are scarce. Pharmacists
compounding antiseptics. This additional responsibility would in Birmingham, Alabama performed a variety of non-traditional
be a novel step towards minimizing the further spread of roles after receiving a large influx of Hurricane Katrina
pandemic [8, 18-20]. evacuees. In addition to meeting an increased demand for

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Ethics approval and consent to participate: Not applicable. social and administrative pharmacy, 2021. 17(1): p.
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Availability of data and materials: Not applicable 11. Setlak, P., Bioterrorism preparedness and response:
Competing interests: All authors declare no competing emerging role for health-system pharmacists.
interests
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Funding: None
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the literature, designing the model, drafting and writing the System Pharmacists, 2004. 61(11): p. 1167-1175.
manuscript. MN and SMR were responsible for the conception 12. Critical Appraisal Skills Programme, 2018. CASP
and critical revision of the manuscript. All authors have read qualitative checklist. [cited 2021 6 October];
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Acknowledgment: We are thankful to our colleagues to content/uploads/2018/03/CASP-Qualitative-
address the attention to this issue.
Checklist-2018_fillable_form.pd.

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Figure 1: Study selection process

Identification

PubMed, Medline, CINAHL, IPA, sociINDEX: n = 106

Records after duplicate removed: n = 80

Screening

Records screened: n = 65

excluded: n = 35
not about pharmacist role in disasters
Eligibility

Full text articles assessed for eligibility: n = 30

Excluded after reading full text: n = 25

Non-peer reviewed articles: n = 13
Review articles: n = 2
Inaccessible online: n = 7
Commentaries: n = 3
Included

Selected articles: n = 20

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Figure 2: Cumulative percentages of disasters referenced in literature

Cumulative percentage of disasters referenced in literature

9%

8%

36%
Pandemics
Hurricanes, Tornados, Storms
Fires
Earthquacks

47%

Figure 3: Cumulative percentage of pharmacist role in disasters

Cumulative percentage of pharmacist role in disasters referenced in the

literature
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Pharmaceutic Patient Response Policy
Others
al supply Management Integration Coordination
Series1 44% 20% 15% 13% 8%

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Table 1: Natural disaster classification

Pandemics (H1N1, MERS, COVID19)

Floods
Natural disaster Hurricanes
Fires
Earthquake
Tornados
Storms (rainstorms, windstorms, tropical storms, snowstorms)
H1N1: Hemaglutinin1 Neuramidases 1, MERS: Middle East Respiratory Syndrome, COVID19: Corona virus disease in 2019

Table 2: Summary of natural disaster appearing in literature

Year Month Event Bibliographical reference

1966 March, April Tornado in Jackson, Mississippi and Florida Pharmacother. 2002; 22(3):271-81.
1979 September Anthrax release from Sverdlovsk, USSR Am J Health-Syst Pharm. 2004; 61:756-58.
1984 August Salmonella typhmurium release in Dalles Hosp Pharm. 1990; 25:523-526.
1989 September Hurricane Hugo Am J Health-Syst Pharm. 2008; 65:904
1989 November Tornado in Huntsville, Alabama Am Pharm. 1995; NS35 (10):33-34.
1992 August Hurricane in Andew and Iniki Hosp Pharm. 1993; 28(5):393,394,400.
Ann Pharmacother. 2000; 34:112-18
2001 October Anthrax attack in Washington D.C Am J Health-Syst Pharm. 2004; 61:1167-75.
2002 March SARS outbreak in China Pharmacother. 2004; 24(6):705-12.
2003 --- SARS outbreak in Toronto, Canada Res Soc Adm Pharm. 2007; 3:320-35.
2005 August, Hurricane in Katrina and Rita J Am Pharm Assoc. 2008; 48(6):702,707.
September Ann Pharmacother. 2002; 36:1282-86.
2008 --- Tornado and flooding in Lowa Am J Health-Syst Pharm. 2007; 64:1998-99.
2008 February Snowstorm in Washington, D.C J Am Pharm Assoc. 2008; 48(6):702,707.
2008 July Hurricane in Dolly and Ike J of the Am Pharm Assoc, 48(6), 702,707
2008 --- Flood in Lowa Hosp Pharm. 1989; 24:697-99.
2009 --- H1N1 outbreak Am J Health Syst Pharm. 2005; 62:220216.
2012 April MERS outbreak in Middle East https://doi.org/10.1016/j.jiph.2017.05.005
2019 November COVID19 in China http://m.news.cctv.com/2020
COVID19; Corona virus Disease in 2019, SARS; Severe Acute Respiratory Syndrome, MERS; Middle East Respiratory Syndrome

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Table 3: Summary of pharmacist role in disasters

Collaborate on medication management

Educate public about therapies
Patient Management Act to prevent panic and fear
Discourage personal drug stockpiles
Monitor disease progression
Engage in one-on-one patient counseling
Ensure proper deployment of drugs
Response Integration Become well-informed about relevant topics
Develop and maintain first-aid skills
Assist in patient triage and cardiopulmonary resuscitation (CPR)
Select therapies for stockpiles and inventories
Pharmaceutical Supply Maintain effective system of distribution and control
Ensure proper packaging, storing, labeling, etc.
Compile patient records
Develop guidelines for diagnosis and treatment of disease
Policy Coordination Coordinate with state and local boards to avoid redundancy
Incorporate drug expertise in policy decisions at state and local level
Prevention
Tele-pharmacy and tele-health
Other
Patient counseling and education at community level
Vaccination and immunization

Table 4 Critical Appraisal Skills Program (CASP) checklist

Studies quality assessment checklist Yes No

1. Was there a clear statement of the aims of the research? 20 0

2. Was a quantitative methodology appropriate? 20 0

3. Was the research design appropriate to address the aims of the research? 20 0

4. Was the recruitment strategy appropriate to the aims of the research? 15 05

5. Has the relationship between researcher and participants been adequately considered? 09 11

6. Have ethical issues been taken into consideration? 12 08

7. Was the data analysis sufficiently rigorous? 17 03

8. Was there a clear statement of findings? 16 04

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