 Dr. Diane Ashiru-Oredope In December 2021, the UCL PharmAlliance Medication Safety team were fortunate enough to meet with Dr. Diane Ashiru-Oredope - Pharmacist Lead for Antimicrobial Resistance and Stewardship and Healthcare Associated Infections (HCAI) at the UK Health Security Agency (UKHSA) and Global AMR Lead for the Commonwealth Pharmacists Association. The Medication Safety team collaborated with the UCL Fight the Fakes team to prepare questions which were then posed to Dr. Diane Ashiru-Oredope. It was a truly insightful and inspiring interview, which covered numerous topics - from the impact of the COVID-19 pandemic on antimicrobial resistance, to her day-to-day role. 1. Why is antimicrobial resistance a global health issue?  The World Health Organization (WHO) declared antimicrobial resistance (AMR) as one of the top 10 global public health threats against humanity, making it a major global health issue. AMR is concerning due to the speed at which it can spread, which is accelerated because of open borders, with people travelling often for business or leisure reasons, as well as the fact that it is possible for resistance to spread between humans (and note that as we see now with SARS-Cov-2 virus, healthy people can carry resistant bacteria and pass it on to others). Transmission of resistance from animals to humans can also occur.
High rates of resistance against antibiotics frequently used to treat common infections have been observed worldwide. For example, the rate of resistance to ciprofloxacin, an antibiotic commonly used to treat urinary tract infections, varied from 8.4% to 92.9% in countries reporting to the Global Antimicrobial Resistance and Use Surveillance System (GLASS). There are also high rates of drug resistance reported for fungi, viruses and parasites globally. A report released in 2016 predicted that AMR could cause 10 million deaths each year by 2050 if adequate action is not taken. Inaction can also cause a significant economic burden, as it is estimated that AMR could cost 100 trillion dollars (also by 2050) if it is not controlled. Challenges in tackling AMR include lack of sanitation and clean water in some areas of the world, which can cause increased instances of microbial infections. The misuse and overuse of antimicrobials to treat infections are also important drivers of AMR, as it allows mechanisms of resistance to spread more easily. There is also a limited pipeline of new antimicrobials, with the last discovery of a new class of antimicrobials being more than 30 years ago. Antimicrobials being developed today are combinations of existing classes. In 2020, WHO revealed that “none of the 43 antibiotics that are currently in clinical development sufficiently address the problem of drug resistance in the world’s most dangerous bacteria”. In addition, highly resistant infections called ‘superbugs’ are on the rise, a common one being methicillin-resistant Staphylococcus aureus (MRSA). These infections are resistant to several types of antimicrobials, making them even more difficult to treat. In relation to the pandemic we are currently facing, the COVID-19 pandemic has shown us a real-life experience of what infections can do when untreatable. 2. Has the COVID-19 pandemic affected antimicrobial resistance in any way (both positively and negatively)? In England, there is the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) - an annual report which includes data on antibiotic prescribing and resistance, as well as antimicrobial stewardship. The ESPAUR report 2021 (data to end-2020) showed that the overall incidence of infection dropped between 2019 and 2020. This can be attributed to the fact that people stayed at home more often during this time and measures such as social distancing and masks were in place, making infections less likely to spread. There were also lower rates of antimicrobial prescribing. In contrast, the proportion of bloodstream infections resistant to one or more antibiotics has increased, suggesting we are likely to see a rise in antibiotic-resistant infections as pandemic-related restrictions are discontinued. People are mixing more now in England and many places have opened up, so we have to be alert and continue to exercise caution. There have been challenges in maintaining many antimicrobial stewardship activities including audits and quality improvement activities, especially in hospitals, where resource has been allocated to dealing with the acute impact of COVID-19. However, in a recent survey of infection pharmacists, some positive impacts were noted, including the use of technology to support meetings, for example virtual ward rounds have become possible, as well as the acceptance of biomarker tests (e.g., procalcitonin). We are also seeing primary care general practitioners (GPs) continue to access and utilise antimicrobial stewardship resources. 3. What has the UK Health Security Agency (UKHSA) implemented to tackle antimicrobial resistance? The UKHSA is proactive in implementing the UK AMR strategy and leads on national surveillance of antimicrobial resistance, prescribing, and stewardship in England. The ESPAUR report is published annually. The UKHSA also highlight key behavioural change strategies and leads on public awareness campaigns such as Keep Antibiotics Working. We work in partnership with NHS England and NHS Improvement and other government organisations to tackle antimicrobial resistance. There are also several Antimicrobial stewardship (AMS) activities that we lead on in the form of education and training opportunities for healthcare professionals (HCPs) and the public. For example, the Antibiotic Guardian campaign, where people can pledge to make better use of antibiotics to help tackle antimicrobial resistance. We currently have more than 147,000 pledges in more than 80 countries. It is a global support system. Antimicrobial stewardship for primary and secondary care is also provided by the UKHSA, examples of which are the TARGET Antibiotics toolkit for primary care and the ‘Treating Your Infection Respiratory Tract Infection (TYI-RTI)’ which includes information leaflets for patients. The latter is available in more than 20 languages so more people can benefit. These resources are also free of charge. There are also online interactive and fun teaching materials on infections and AMR resistance and stewardship through the eBug website for educating children and young people, and the Antibiotic Guardian platform runs a ‘schools ambassadors’ campaign. Professionals in public health and healthcare provide teaching sessions in local schools around tackling AMR – largely supported by the excellent eBug materials. The UKHSA leads World Antimicrobial Resistance Awareness Week for England, a campaign to raise awareness of AMR. The week runs from 18-24 November each year and this year focused on disseminating digital resources, including digital ‘sticky notes’, teleconference backgrounds, screensavers and promoting social media activity, including Twitter polls and videos from senior leads in partner organisations, pledging their ongoing support of tackling AMR. Lastly, we publish data on AMR openly, and to my knowledge I believe England is still the only country which does so to a locality level (GP practice, CCG, hospital). The data published includes AMR and antibiotic prescribing data for Clinical Commissioning Groups (CCGs). 4. Can you tell us a bit more about your research/day to day work? I have two roles, my main role is as the Lead Pharmacist for Antimicrobial Resistance, Stewardship and healthcare associated infections (HCAI) at UKHSA, I also have a role as the Global AMR lead for the Commonwealth Pharmacist Association (CPA). I am also an honorary lecturer at the UCL School of Pharmacy, and I am currently leading a UK wide evidence review on pharmaceutical public health on behalf of the 4 UK Chief Pharmaceutical Officers. I focus most of my time on AMS projects at UKHSA, such as developing a new stewardship workstream to consider surveillance for COVID-19 antivirals. I am also currently focused on developing the strategy and planning for the coming year, commenting and providing feedback on a range of documents including policy, guidance and Patient Group Directions (PGDs). It can be challenging but it is actually really fun, rewarding and I love my role. For my global AMR role, this week I have been on teleconferences with colleagues in Sierra Leone, Nigeria, Uganda and other African countries, to support AMS initiatives to tackle AMR. I have also been focused on the UK-wide pharmaceutical public health research, by drafting the final report and writing a presentation to the Chief Pharmaceutical Officer for England (Prof Keith Ridge) and the Pharmacy Advisory Group (PAG). Something else that I do is support and mentor trainee pharmacists as a General Pharmaceutical Council (GPhC) report found that Black trainee pharmacists perform less well in the registration assessments. This week I have discussed clinical academic career pathways for pharmacists and met with colleagues at Imperial College London to collaborate on a Patient and Public Engagement Strategy on AMR and health inequalities. I've also had discussions around advanced clinical practice in public health for healthcare professionals, as well as meetings on AMR campaigns. I also lecture/contribute to sessions at universities such as Schools of Pharmacies at UCL and Aston University. At Aston University, over the last few weeks I have been supporting one of their elective modules on AMR. 5. Out of the many global health issues, why was it important for you to focus on antimicrobial resistance? My journey with antimicrobial resistance started when I was an AMR pharmacist in hospital, after which I got a role in the Health Protection Agency as it was then. AMR became more than a day job for me when I watched a documentary about an 11-year-old girl who got a simple scratch. She started to complain about hip pain, and soon after was admitted to hospital. She did not come out until 5 months later, and when she did, she was in a wheelchair, blind in one eye and had survived double lung transplants due to an untreatable infection. What had happened was that resistant organisms had caused an infection, and the doctors could not treat this infection, which meant the infection wreaked havoc on her body. I watched another documentary where another child had cut the cuticle of their finger, and due to a resistant infection, ended up having to have their finger cut off. At the time my children were very young, and I thought to myself this could happen to anyone, and realised AMR was something I wanted to help address. I wanted to do more to raise awareness and increase public engagement. One of the main things I focused on was the development of what is now called the Antibiotic Guardian campaign, as well as join the CPA, to support and learn from the CPA and other organisations as well as colleagues in other countries. 6. How do falsified and substandard medicines contribute to antimicrobial resistance? The WHO in 2017 released a report on the burden of substandard and falsified Antimicrobials where their global analysis highlighted that 11% of antimicrobials contained subtherapeutic concentrations of active ingredient. Of course, these will not adequately treat an infection. This can lead to an increase in antimicrobial resistance. It is bad enough that we have effective medicines for which resistance develops, falsified and substandard antimicrobials pose an even greater risk of resistance developing and spreading. If infections cannot be treated adequately, it will lead to increased mortality rates, an increase in morbidity and increased risk of resistance spreading to other people. 7. What measures can be put in place in pharmacy practice to ensure the impact of antimicrobial resistance is reduced? Infection prevention and control - pharmacy practice can put measures in place to prevent infections happening in the first place, reduce the risk of resistant organisms developing and reduce the need to use antimicrobials. Vaccination reduces the burden of infection, and so can reduce the risk of AMR, so pharmacies can provide vaccination services and/or promote vaccination We can also optimise the use of antimicrobials. For example, if a patient presents with a self-limiting infection, we can give support without suggesting antimicrobials. Like I said before, there are resources such as the TARGET Antibiotics toolkit for primary care and the ‘Treating Your Infection Respiratory Tract Infection (TYI-RTI)’ which includes information leaflets for patients. We can inform patients how long infections will last for, when to worry or talk to a HCP, basically safety netting and giving self-care advice. When patients come in with prescriptions, pharmacists should assess prescriptions for appropriateness and provide adequate counselling. The Pharmacy Antibiotic Checklist is a useful resource. We can assess how we are doing in terms of supporting tackling AMR by conducting audits and quality improvement projects. Finally, we have a key role in raising awareness of AMR to the public and educating other healthcare professionals. 8. What can university students and student organisations such as PharmAlliance and Fight the Fakes do to raise awareness on antimicrobial resistance? What you are doing right now. Educating yourselves on this important global health issue and engaging in discussions around AMR. Public engagement is another way to raise awareness on antimicrobial resistance - university students have a key role in lobbying within their university, for example through leading campaigns during World Antimicrobial Awareness Week. Students can also start simply with talking to family and friends, educating them on AMR and what we can do as individuals to mitigate its impact. Students can also organise activities such as workshops to ensure the engagement of their peers in tackling AMR. Some examples are Vaccination Champion and Antibiotic Guardian. You can also raise awareness of AMR by posting on social media. Using the hashtags #AntibioticGuardian and #KeepAntibioticsWorking is encouraged, as we can see what excellent awareness activity you are engaging in throughout the year. I hope one day I may work alongside some of your readers in taking the fight forward together. For more information on antimicrobial resistance, we recommend you watch this video explainer where Dr Diane Ashiru-Oredope explains what role microbes have on our planet, how antimicrobials work, what the origins of antimicrobial resistance are and more importantly, what can you do to help reduce it: https://www.youtube.com/watch?v=MENdrA8B0N4 Authors: Dorothea Tang, Nusayba Ali and Janice Wong Acknowledgments: Yasna Nasrollahi and UCL Fight the Fakes
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 Addiction and health Substance use disorder (SUD), commonly referred to as ‘addiction’, can be perceived as ‘taboo’ and surrounded by stigma. But the fact of the matter is, SUD is complex and there are so many forms it can take — a single blog would not do the topic justice. As pharmacy students and future pharmacists, it is likely that we will meet patients with SUD, so it is of paramount importance that we have knowledge of the condition. This blog will focus on SUD in relation to the following substances: opioids, alcohol and tobacco. Substance use disorder The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) — the handbook used by health care professionals in the United States and around the world as the authoritative guide for the diagnosis of mental disorders — describes SUDs as a part of a class of disorders known as substance-related disorders. Substance-related disorders include 10 separate classes of drugs, 9 of which have been attributed to SUD.¹,² The British Medical Association (BMA) defines SUD as the repeated use of a psychoactive substance/s, such that the user tends to be periodically or chronically intoxicated, displays a compulsion to take the substance/s and finds it extremely difficult to cease taking the substance/s; demonstrating a determination to acquire the psychoactive substance/s by ‘almost any means’.³ Substance use disorder can often stem from drug misuse, whether intentional or unintentional.³ Drug misuse is the ‘use of a substance for a purpose that is not consistent with legal or medical guidelines’.³ In other words, the use of a drug that goes against medical advice or the law. The term ‘drug use’ is sometimes used instead of ‘drug misuse’ by healthcare professionals as it is perceived to be less judgmental and will be the term used in this blog.³ SUD related to drug use is the compulsive need to take a drug that can be difficult to control, despite the person being aware of the negative consequences of its usage.⁴ When a person takes a psychoactive drug, the reward circuit of the brain releases dopamine and produces feelings of elation.⁴ The dopamine release reinforces the feelings of pleasure, which gives the drug the ability to be addictive.⁴ SUD can even be initiated by as-prescribed use of a drug, as repeated drug use can change the brain’s biochemistry such that the brain’s ability to resist compulsion for the drug is challenged, resulting in a harsh cycle of recovery and relapse.⁴ The impact of drugs use is significant. It has been associated with poor physical and mental health, as well as death, unemployment, homelessness, family breakdown and criminal activity.⁵ In fact, drug use is the third most common cause of death for those aged 15 to 49 in England.⁵ This reveals the pressing need to help people quit drug use in an effort to improve and preserve the lives of these individuals and better society as a whole. Opioid use disorder Opioid use disorder (OUD), also known as ‘opioid dependence’ is defined in the DSM-V as “…a problematic pattern of opioid use leading to clinically significant impairment or distress…”² A joint paper by the World Health Organization (WHO), The United Nations Office on Drugs and Crime (UNODC) and the United Nations AIDS division (UNAIDS) states that: ‘substitution maintenance therapy is one of the most effective treatment options for opioid dependence.’⁷ The type of substitution maintenance therapy can vary between countries and even between patients. In the United Kingdom (UK), The Royal Pharmaceutical Society (RPS) supports methadone treatment as a maintenance treatment to recover from and overcome OUD, stating that methadone is ‘not a cure for addiction’ but is a ‘safer alternative’ to the use of illicit opioids such as heroin.⁸ However, the RPS recognises the limits of methadone treatment in the long-term, and so supports a holistic approach where methadone or newer therapies such as buprenorphine are combined with other interventions such as psychosocial interventions to help drug users recover from OUD.⁸ In the United States (US), OUD has been linked to the misuse of prescription opioids.⁶ In fact, in 2016, 11.5 million Americans self-reported that they had personally misused prescription opioids in the previous year.⁶ Medication-assisted treatment (MAT) is considered the Gold Standard treatment option for OUD in the US.⁶ MAT for OUD is the use of one of three medications, namely buprenorphine, naltrexone, or methadone in combination with psychosocial and/or behavioural therapy.⁶ OUD is also a concern in Australia, with heroin the 4th most common principal drug of concern in 2016–17.⁹ One of the main treatment types used for OUD in Australia is opioid pharmacotherapy which involves regular use of a legally obtained, longer-lasting opioid, examples of which are methadone, buprenorphine or buprenorphine-naloxone.⁹ Tobacco use disorder When we think of the long-term effects of smoking tobacco, people may immediately jump to lung cancer as the major condition- and they aren’t wrong. Smoking is the cause of 7 out of 10 lung cancer cases, and it can also cause or worsen other lung conditions like asthma and chronic obstructive pulmonary disease (COPD).¹⁰ But what many people don’t realise is that it can cause a whole array of other conditions, including many cancers like liver and pancreatic cancer, and also increase the risks of heart attack and stroke in otherwise healthy individuals.¹⁰ Smoking causes around 100,000 deaths in the UK alone each year.¹⁰ With these facts in mind, it’s understandable that 50% of smokers try to quit each year.¹¹ Despite this, only 6% of smokers manage to quit smoking in a given year.¹¹ When a person smokes a cigarette, nicotine binds to cholinergic receptors to release dopamine, causing an elated sensation while reducing stress.¹¹,¹² Over time, the receptors become desensitised and nicotine levels in the body decline, causing the person to feel withdrawal symptoms like irritability and anxiety.¹¹,¹² These symptoms, alongside other factors like environmental stressors and smoking cues, add to the craving urges the person experiences to continue smoking.¹² Although the number of smokers continue to drop annually due to the decreasing appeal of smoking and improvements in health education, there is still a substantial subset that smokes regularly (14% for the UK in 2019).¹³ As future pharmacists, we will be in a position to help people quit smoking and lower the number of people with tobacco use disorder further. Smoking cessation programmes are offered by some pharmacies in the UK. One key service is the promotion of nicotine replacement therapy, where nicotine formulations like patches and gums are offered to patients in the event that they are considering or trying to quit. In addition, an important campaign that pharmacies promote in the UK is Stoptober, where smokers are encouraged to quit smoking for 28 days during the month of October.¹³ In 2019, 25% of smokers nationwide attempted the challenge, with 8% continuing to abstain after the four weeks, suggesting that this campaign does have an impact on the smoking population.¹³ In North Carolina the programme QuitlineNC is also available as a free smoking cessation service, which provides 24/7 telephone and online coaching.¹⁴ In Victoria, the programme Quit offers a hotline where smokers can access a trained counsellor to speak to for advice and support, as well as access to regular texts that offer encouragement in their journey.¹⁵ Alcohol use disorder Alcohol is often portrayed by the media as a ‘glamorous’ or an ‘exciting’ thing to have on a night out with friends. It is possible that due to this association, people don’t usually link its consumption with addiction. When people drink alcohol, they tend to feel more fun, confident or relaxed, as alcohol stimulates dopamine release.¹⁶ However, this can also cause people to become psychologically dependent on alcohol, where they feel that they need a drink- this is the basis of alcohol use disorder (AUD), also called ‘alcohol dependence’.¹⁷ Another sign of AUD is worrying about when the next drink will be available and wanting a drink in the morning.¹⁷ This psychological reliance also results in physical dependence where people develop shakes, sweats and feel nauseous and anxious without a drink.¹⁷ Over time, this leads to long term effects like hypertension, heart disease or liver disease, so identifying when a patient needs treatment is essential in helping them avoid these effects.¹⁸ The Alcohol Use Disorders Identification Test developed by the World Health Organisation is available for people worldwide to use to identify if an intervention is needed, with a score of 8 or more indicating hazardous alcohol use.¹⁹ Many UK pharmacies display educational posters explaining that adults should not drink more than 14 units of alcohol a week, with half a pint of beer being equivalent to 1 unit and a small glass of wine being 1.5 units.²⁰ There are also many leaflets available with the contact details of support groups such as Alcohol Change UK, Alcoholics Anonymous in the US and SMART Recovery in Australia. Patients identified as heavy drinkers are encouraged to cut back by having several alcohol-free days per week, and to set a limited budget per week to spend on drinks.²⁰ If the addiction is severe enough to warrant an intervention by a healthcare professional, inpatient treatment is offered at licensed treatment centres.²¹ Monitored detoxification treatment is given to the patient, after which patients recover in residential treatment centres. This is where they can be put on medication-assisted therapy in order to stay sober and avoid relapsing.²¹ The most common drugs used are disulfiram, which stops the body from metabolising alcohol, acamprosate, which prevents alcohol cravings, and naltrexone, an opioid antagonist, which also prevents cravings.²² Disulfiram, a carbamate derivative, interacts with the acetaldehyde found in alcohol and causes it to build up in the patient’s body if alcohol is consumed, causing them to experience symptoms like nausea and vomiting, sweating and headaches.²² Other drugs which can be used include antipsychotics, where the alcohol use is associated with mental illness, and clonidine, an antihypertensive which helps by reducing the side effects caused in the detoxification process such as hot flashes. Anticonvulsants and beta blockers can also be used off-label in treating alcohol use disorder.²² SUD is difficult to define, and even more difficult to treat. Although drug therapies are available to help treat this condition, these are typically offered in conjunction with other therapies (such as counselling) for a more holistic treatment. Pharmacists and pharmacy teams have a role to play in helping individuals overcome the types of SUD described in this blog, and as pharmacy students, we will come across patients battling this condition - if not now than in the future as qualified pharmacists - and the more informed we are about the condition, the better help we will be. Written by: Nusayba Ali and Amelia Ryan References:
 As the semester winds down with finals and the holiday break on the horizon, it’s safe to say that students are feeling all kinds of stress right now. Whether it’s worries about grades, waiting to hear about something you applied for, or whatever else, this time of year can be overwhelming for many. In this blog post, I hope to offer some helpful tips for taking care of yourself and ending the semester strong.
First things first, I want you to pause, take a deep breath in, and exhale. I want you to take a second to think about this past semester and where you are in this present moment. We should be incredibly proud of ourselves for how far we’ve come in the semester! Yes, we still have to make it through finals, and you probably feel a sense of impending doom or like you’re going through a mid-midlife crisis right now but rest assured, YOU GOT THIS. Without further ado, here are some ways to engage in self-care and avoid burnout as you close out the rest of this semester. -Try to stick to a schedule or routine that works for you. You don’t have to account for every minute of your day but having a simple outline of what you want to accomplish on a given day can make things more manageable and reduce how overwhelmed or anxious you may feel. -Try to get an adequate amount of sleep. This ties in with making a schedule – if you try to wake up and sleep around the same time each day, you’re more likely to have better quality of sleep and achieve the recommended 7-9 hours of sleep. This is easier said than done but also try to limit screen time before bed, and avoid caffeine later in the day. Remember, sleep affects learning and memory so it is more important to get as much sleep as you can, rather than stay up pulling an all-nighter. -Take breaks. Give yourself short breaks between blocks of studying to refresh your mind and cut down on screen fatigue. You can use the time to grab a snack, take a walk to get the blood pumping, or even watch a little bit of TV. Whatever you’re doing, be sure to take your mind off studying for the time being and enjoy your break. This will help keep you more focused and motivated during those chunks of studying. -Make sure you’re eating properly and staying hydrated. It can be easy to sit for hours studying and forget to eat or drink anything during that time. You have to feed the body to power the mind. Try to get adequate nutrition and avoid things like eating a bag of chips and calling that dinner (guilty!). -Don’t be afraid to ask for help. It’s okay to lean on your support network for help, and if you don’t this kind of support available, there are resources such as Counseling and Psychological Services (CAPS) that can help. Hopefully some of these tips can help you with finding and maintaining ways to take care of yourself. Self-care is not something that you should just do during finals. It is important to take care of yourself the rest of the year as well, and building healthy habits and taking just a little bit of time out of the day to check-in with yourself can do wonders. I wish you all the best with finals and hope you enjoy your winter break! Written by: Natalie Ly  Dean Carla White is highly regarded as a confidant by BIPOC students at the UNC Eshelman School of Pharmacy (ESOP). As Associate Dean for Organizational Diversity and Inclusion, Dean White is a champion for equity and inclusion. She leads by example, allowing humility and transparency to guide her everyday actions. She shared her story with me via Zoom interview on February 8, 2021.
Christian Brown: How did being Black impact your studies? Carla White: I’ve always loved being Black. The diverse intellect, creativity, and perspectives within Black culture truly enriched my life experiences. This started with my grandmother. Everyone in the community respected her. She was a relentlessly regal individual that was proud of her Black culture and an advocate for social justice in Pennsylvania. At only 18 years old, she was one of the first and youngest people to testify before Congress [for Civil Rights]. She was my example. I knew nothing else but to love myself. CW: In undergrad [at WVU], my roommate and I were the only Black girls in the dorm, and everyone would come to our room to hangout. I believe most people enjoy learning about various cultures. While in pharmacy school at the University of Pittsburgh, there was only one other black student in my class, and I believe no more than 4 in the entire School of Pharmacy. CW: Reflecting back on that, I did not feel connected as a student. Pharmacy school felt more like a process rather than an experience. It’s interesting that, currently, I sit on the School’s Board of Visitors, and feel more connected now as an Alum. CB: How has being Black impacted your career? CW: After a few years in community pharmacy in Pittsburgh, I moved to Oregon in the early 90s. There were so few people of color that customers would knock over displays while staring at me behind the counter. CW: I started with WRAL-TV Raleigh [NC] in 1999. In the media, people would address news anchors and reporters by name and say, “Wow, it’s this person,” but about me they would say, “Wow! That’s the Black pharmacist at WRAL.” To others, being Black was more important than my knowledge or expertise. It’s the first thing that people would say. It was absolutely crazy. CW: It was a consistent theme across every area of my professional career. When I was a pharmacy manager and a district manager, colleagues would have to frequently point out what my role was. Bias is prevalent and hard to mitigate without a commitment to acknowledge and educate. It leaves you seeing the world through a narrow lens. CB: That’s powerful. And you’ve been a leader in so many different roles from founding a consulting group to working in women’s health and infectious disease to directing pharmaceutical care labs at ESOP. Will you share how you came into your most recent position as Associate Dean for Organizational Diversity and Inclusion? CW: Oh, I’m so ashamed! I said “no” twice! I didn’t want my career to be aimed in the direction of D&I. I was afraid that the work would be further marginalized. People would think, “Of course the Black faculty member would do this,” and “Of course this kind of work would be important to her.” I was also concerned that this could potentially be a window dressing measure and not a real commitment. To add to that, I wasn’t an expert in the field- personal experiences bring tremendous insights, but they don’t make you an expert or necessarily mean that you have an interest in DEI. CW: Then the [former] Dean sent in reinforcements- someone else to ask me to take the position, and I started to give it some thought. The Dean expressed that he was deeply committed to improving D&I. So I accepted the position. And now, I’m delighted that he pressed the issue. It is one of the most fulfilling aspects of my career, and it’s amazing to see the value that our investment in strategy development has brought. The great teamwork with my colleagues has led to tremendous progress and opportunity. It’s really cool to see former students in leadership roles! CW: There’s certainly more work to do. Faculty are realizing that it’s everyone’s responsibility to contribute towards cultural transformation to produce a diverse pharmacy workforce. This is a priority for the School, and we are leading in this space. CB: Thank you so much for your candor and honesty. How did it feel to be the only Black faculty member for so long? CW: We get used to being the only one. When there is no representation, profound loneliness and isolation can be experienced. It’s also a challenge recruiting BIPOC faculty. They want to wait until we are a diverse faculty. I am often asked “Carla, how do you do it?” Community and advocacy are critical. CW: It’s also important to realize that singular interventions aren’t going to fit for the whole BIPOC “group.” For example, when I was a SNPhA advisor, the African students and Black students members would often gravitate into separate groups based on their cultures. There are differences in these cultures that should be celebrated and respected as such. Often, people think these cultures are interchangeable through composition diversity metrics. CW: In conversations with some Latinx students, I listened to their frustrations on hearing about extracurriculars. As a School, we, as well as our accrediting body, promote extracurricular engagement. However, for some, taking care of their families was top priority, even while in pharm school. Perhaps there is an opportunity to broaden our communication and priorities, and certainly increasing societal equity has a role in this. All this to say, that dimensions of diversity are multifaceted and diverse strategies are needed to build an inclusive community. CB: You’re right. Celebrating BIPOC differences is important. Thank you so much for taking the time to share your story. You’re an inspiration! CW: Thank you for the opportunity. Introduction written by: Christian Brown, UNC Class of 2023; PharmAlliance Student Ensuring equity is an active process, particularly when the world is falling apart. In Black communities, it seems like we are always teetering on the edge- reaching out for support from backs turned. There is an uncommon resilience that is, fortunately or not, common to Black people. This force commands us to find our balance and strengthens us to lend a helping hand. We return to our roots; we give back; we come full circle. Future pharmacist Jodelie Bellot knows what it is like to feel the earth give way, and she is committed to helping others pick themselves up and dust themselves off. “I was born in Haiti and spend most of my childhood there; however, this childhood was abruptly cut short on the afternoon of January 12th, 2010. That afternoon, my once home in Port-au-Prince was ravaged by a devastating earthquake of a magnitude of 7.4. The whole country was plagued with ruin; everywhere I looked was in a state of emergency. Experiencing and witnessing such destruction at a young age really shifted something in me. This gave me a great push to be involved in the healthcare field, and after much reflection, I decided to become a pharmacist. As a pharmacist, I would be able to contribute to my community if something like this would’ve happened again. This journey wasn’t easy: I faced many challenges and setbacks, but I am dedicated to meet my end goal. I am currently a 3rd-year student serving the community through a similar crisis such as the COVID-19 pandemic. I worked all throughout the pandemic from staffing at my local pharmacy to procuring COVID tests and administering the COVID vaccine. I am so glad that I am in the position where I can serve my community in such disasters and I will continue to do so once I complete my studies for my PharmD in 2022.”  Jodelie Bellot, PharmD Candidate in NY Introduction written by: Christian Brown, UNC Class of 2023; PharmAlliance Student
Why is being Black a problem? As a Black woman and a Black future pharmacist, I constantly surprise people. I talk like I have an education; I walk like I have a purpose; and I live like I have a right. Unfortunately, this is not true for many patients who look like me.
We’ve been demonized and ignored and treated as less than human. We are locked out of mainstream society- told to swim against the current and “better ourselves,” only to meet the dam of double standards. This is not a model for health. What we need are role models, such as Dr. Blaise Ndukwe of Kalamazoo, Michigan, to show Black patients that we, too, can wear white coats. “As the only black pharmacist employed with Gull Pointe Pharmacy at the time, I felt a duty from the first day I stepped into that pharmacy to advocate for black and brown patients. While I enjoyed my interactions with all of the patients I assisted, my interactions with black and brown patients, specifically, always felt more special. The way they looked at me, the way they spoke with me. There was always some level of respect and awe there. To be the only young, black, male pharmacist at that pharmacy and one of the only black pharmacists in the city of Kalamazoo, MI. That duty to represent weighed heavily on my shoulders and I fully embraced it. My most memorable encounter was with a black patient who had come through the drive-thru for his monthly refill. The cashiers noted him as a “problem patient” because he never “knew what medications he needed to pick up.” Instead, I saw him as someone who needed more devoted time from a pharmacist. I offered to sit down with him to review all of his medications and he accepted. A few days went by, and I never heard from him again. Then one day, he walked in unexpectedly and asked for me. Sitting down with him to review his medications was an opportunity for me to not only educate him, but for him to open up to me about his experiences at the pharmacy. He talked to me about the personal struggles he faced in his life as a black man and the things he does now to give back to his community. As I listened to him speak, I realized how important it was for him to finally see a pharmacist who looked like him. I realized just how important it was for him to finally see a pharmacist he could be unapologetically black with. Our conversation meant a lot to him, not just from an educational perspective, but also a personal one. He left the pharmacy that day knowing that he had an advocate, someone who would have his back when the other employees labeled him as “difficult” and “drug seeking.” He left that day knowing that he had an advocate who looked like him. He never let me forget just how much our interaction meant to him. Whenever he called he would ask to speak to me, and if I was unavailable, he would let the technician know to tell me how grateful he was for my help. We developed a friendly relationship, and sometimes he would show me pictures of his garden. I always enjoyed my interactions with him. Those moments truly made me feel as though I was fulfilling the duty I gave myself when I first stepped into Gull Pointe Pharmacy.” -Blaise Ndukwe, PharmD Introduction written by: Christian Brown, UNC Class of 2023; PharmAlliance Student  February in America is Black History Month. In the annals of pharmacy history, there is precious little concerning Black pharmacists. Leo Butts of Wisconsin wrote the first scholarly work compiling the contributions of Black pharmacists in 1920. He chose the topic for his Degree of Graduate in Pharmacy thesis and was encouraged to pursue this work by his mentor, Nellie Wakeman, the first woman instructor at the University of Wisconsin School of Pharmacy (1). Still today, we see minorities supporting minorities to reach their full potential. Throughout his writing process, however, Butts expressed his disappointment that there was “scarcely a reference to the Negro in pharmacy” in the greatest pharmacy history library in the US (2).
In his thesis, Butts acknowledges a truth that characterizes the Black experience: “it is absolutely necessary for the colored druggists to give not only as good but better services than his white competitors, if he is to be even moderately successful (2).” His work predates the National Pharmaceutical Association by 27 years (3). The only national option for the 1400 Black pharmacists at the time was to join the physicians and dentists in the National Medical Association (2,3). Only in the American South were state organizations available, and their main focus was improving sanitation in Black neighborhoods. In only 16 pages, Butts recounts the most complete history of Black pharmacists to date. Five years later, another student pharmacist writes on the subject. Mozella E. Lewis, likewise, bemoans the lack of Black recognition, and seeks to fill the gaps: “Mention has not been made…because our people have been timid and no other people have thought enough of us to give us serious thought (4).” Even so, Lewis’s words are tainted with the Eurocentric disdain of her African roots as, after extolling the progress of Greeks and Hebrews, she complimentarily concedes that her ancestor, “in his savage way, was a great pharmacist.” Her thesis contains lists of names, cities, and achievements of Black pharmacists beginning with James T. Wormeley, the first graduate of the Pharmaceutical College of Howard University. He graduated in 1870 from the program started three years prior. Following the list of Howard graduates, Lewis lists Black graduates from White institutions, approximately 100 in total, along with their successes. She closes with this: These statistics give us an idea of what the Negro has done in pharmacy, and should encourage the young Negroes interested in this work to improve the many branches of this science in which the Negro has become famous and further develop those phases in which he seemingly has not yet entered to any great extent, so that the Negro will be an outstanding light in the development of pharmaceutical science (4). Written by: Christian Brown Bibliography 1. Bond G. Leo Butts, UW Pharmacy Pioneer . UW Madison School of Pharmacy Historical Alumni Information. https://pharmacy.wisc.edu/alumni-friends/events-awards-programs/historical-information/leo-butts-uw-pharmacy-pioneer/. Accessed January 13, 2021. 2. Butts LV. The Negro in Pharmacy. 1920. 3. NPhA - Home. https://nationalpharmaceuticalassociation.org/. Accessed January 14, 2021. 4. Lewis ME. History of the Negro Pharmacist. Am Drug. 1925.  With roughly 71 million COVID-19 vaccine doses administered worldwide, 24.5 million doses given in the United States alone, humanity is experiencing one of the largest-scale global health efforts in history. There are dozens of different COVID-19 vaccines in various stages of development throughout the world that have the potential to be approved. As of writing this article, the World Health Organization (WHO) has identified 63 vaccine candidates in the clinical phase. Currently, the vaccines authorized for emergency use in the United States are the Pfizer-BioNTech and Moderna mRNA vaccines. These vaccines are a great first step into widespread vaccination, but there are several barriers limiting their use.
One of the biggest challenges for mRNA vaccines is their extremely strict storage requirements for stability, which are not unique to the Pfizer or Moderna formulations. The Pfizer vaccine is supplied as a frozen, 5-dose vial that is stored between -80ºC to -60ºC and has to be thawed and diluted prior to administration. After dilution, they have to be stored between 2ºC to 25ºC and used or discarded within 6 hours from the time of dilution. The Moderna vaccine also comes in multi-dose vials but has slightly less strict temperature requirements. They are stored frozen between -25ºC to -15ºC, but can be stored refrigerated between 2ºC to 8ºC up to 30 days prior to first use. Another limitation is that the Pfizer vaccine is recommended for people aged 16 years and older, while the Moderna vaccine is approved for people aged 18 years and older. If these mRNA vaccines have so many drawbacks, what other options will there be in the future? Despite the fact that the only COVID-19 vaccines currently available are mRNA vaccines, this vaccine type is actually relatively new and uncommon. To date, there are no other approved mRNA vaccines on the market. According to the WHO’s novel coronavirus vaccine landscape, only 7 of the 63 vaccines in development are RNA based. An additional 9 vaccines under development are DNA-based. In contrast, there are 20 protein subunit vaccines in clinical development. Another 16 vaccines in the viral vector class as either replicating or non-replicating varieties with or without additional antigen presenting cells are also identified. In the whole virus vaccine category, there are 9 inactivated virus vaccines and 1 live attenuated vaccine. The latest vaccine that has been approved in the UK is a viral vector vaccine developed by AstraZeneca and the University of Oxford. The vaccine has a reported efficacy of 90% and is stable for refrigeration. Their clinical trials, which involved over 11,000 people, found the vaccine’s 90% efficacy figure in those that received a low dose followed by a standard dose. Surprisingly, in participants that received two standard doses the efficacy of the vaccine was only 62.1%. One of the major benefits of the vaccine is its price of $4 per dose, much lower than the $20 of the other available vaccines. However, there have been problems with supply and pricing. The UK has ordered 100 million doses, Australia has ordered 53 million, and the EU has a contract with AstraZeneca to provide up to 400 million doses in total, around 80 million of which were due this quarter. Unfortunately, AstraZeneca reported on January 22 that they will only be able to deliver 31 million doses to the EU and supply chain issues likely affect their other agreements as well. The U.S. still has not approved the vaccine due to delays in clinical trials. Some other major viral vector vaccines production includes Jannsen/Johnson&Johnson’s vaccine, which also has an agreement for 400 million doses with the EU once its year-long clinical trial is finished. They launched their phase 3 trials in Latin America and the UK in fall of 2020. The Ganekaya Research institute in Russia is also developing a viral vector, called Sputnik V, that has just entered phase 3 trials. It has a reported effectiveness of 92% and can be stored at normal fridge temperatures. Another U.S. based biotech company, Novavax, has recently finalized an agreement with Canada to purchase 52 million doses and concluded talks with the EU for up to 200 million doses for their fridge-stable protein subunit vaccine. The French company Sanofi and England-based GSK also have a protein subunit vaccine that is stable at refrigerator temperatures and can even be stored at room temperature for a short amount of time. The EU has already confirmed the purchase of 300 million doses of their vaccine. Additionally, Sanofi has just finished settling an agreement to assist in producing 100 million doses of the Pfizer/BioNTech vaccine just hours before writing this article. Information on vaccines in development in China is more difficult to obtain, but Sinovac’s inactivated vaccine is currently approved for emergency use in China. The country currently has the second highest number of vaccines given in the world at 15 million in total. Other countries have already reached agreements with Sinovac, such as Turkey approving 10 million doses of the vaccine. The latest figures of its effectiveness put it at around 50.4%, making it an unlikely contender at its reportedly $60/dose price tag. Sinopharm, which is a state-run company, is also developing two inactivated vaccines of its own. Reports of its efficacy are a little inconsistent but hover around 80% effectiveness. Regardless, the United Arab Emirates has already approved the Sinopharm vaccine earlier this month. The vaccines mentioned in this article are nowhere near an exhaustive list of all the potential vaccines that may come out to protect against COVID-19, which is great news. As the effort to push for global immunity to the virus that turned the world on its head continues, it’s reassuring to know that several different options will eventually become available for the public in the coming years. More than likely, a set of gold-standard vaccines will be developed in the years to come that will join the likes of influenza on the list of regularly scheduled vaccinations. Written by: Kervin Novido References: ● https://www.gavi.org/vaccineswork/covid-19-vaccine-race ● https://www.gavi.org/vaccineswork/there-are-four-types-covid-19-vaccines-heres-how-they-work ● https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines ● https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/ ● https://www.fda.gov/media/144245/download ● https://www.fda.gov/media/144637/download ● https://www.novavax.com/covid-19-coronavirus-vaccine-candidate-updates ● https://clinicaltrials.gov/ProvidedDocs/60/NCT03681860/Prot_SAP_000.pdf ● https://ourworldindata.org/covid-vaccinations ● https://pubmed.ncbi.nlm.nih.gov/33306989/ ● https://fortune.com/2021/01/25/astrazeneca-covid-vaccines-europe-deliveries-south-africa-price/ ● https://www.news.com.au/world/coronavirus/australia/doctors-in-australia-will-bulk-bill-covid19-vaccinations-making-it-free-for-members-of-the-community/news-story/1e7beed205791af4fd60f45cfc56fe93 ● https://www.bbc.com/news/world-europe-55822602 ● https://www.bbc.com/news/world-asia-china-55212787 ● https://www.fiercepharma.com/pharma/despite-pfizer-s-high-efficacy-expectations-other-covid-vaccines-may-have-a-logistics-edge#:~:text=Pfizer's%20vaccine%20must%20be%20kept,35.6%20and%2046.4%20degrees%20Fahrenheit. ● https://www.cnn.com/2021/01/27/europe/sanofi-vaccine-doses-intl/index.html With the Rapid Development of Several COVID-19 Vaccines, is Coronavirus Finally on its Way Out?1/12/2021  As of 11 March 2020, the world has been in the midst of a pandemic. A once meaningless word to many, ‘coronavirus’ has taken the world by storm. In fact, Google revealed last December that ‘coronavirus’ was the top trending search for the UK in 2020. Coronaviruses are a family of viruses that cause infection in humans and animals. The one that led to the pandemic is called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) but is more commonly referred to as simply ‘coronavirus’. When an individual is infected with the virus, they may display mild symptoms or no symptoms at all. Consequently, if the individual displays more severe symptoms and potentially need to be hospitalised, they are said to have coronavirus disease or COVID-19. An insidious infectious disease, the impact of COVID-19 has been catastrophic. Since the beginning of the pandemic, one clear solution to eliminate this disease and aid in the return to normal life has been the development of an effective vaccine. With COVID-19 vaccines having been approved for use in the UK and worldwide, is the pandemic finally over?
Vaccines are chemically weakened or dead forms of a pathogen, whereby a pathogen is a microorganism which results in disease. Once a person is treated with a vaccine i.e. they are vaccinated, their immune system is stimulated. This stimulation leads to destruction of the pathogen and the production of memory cells. This means that if a person was infected with the same pathogen in the future, the body remembers how to fight the pathogen. There are several types of vaccines which exist. The four main types of vaccines are live vaccines, inactivated vaccines, subunit vaccines and nucleic acid-based vaccines. The first type, live vaccines, include commonly administered injections such as MMR and tuberculosis vaccines. As the name suggests, they contain the actual microorganism which causes the disease. However, they don’t make people ill due to attenuation, which is a process whereby the microorganisms are reduced in virulence (capability to cause severe disease). This is possible as vaccine developers only use the mutated strains of the organism that have a lower toxicity. However, as they still contain the actual disease-causing microorganism, they cause the body to produce many antibodies. This results in lifelong immunity against the disease. The second type, inactivated vaccines, are made from dead microorganisms. They are safer compared to the live ones, but a higher dose is often needed as the bacteria and viruses don’t replicate inside the body. This makes them more expensive compared to live vaccines. An example of an inactivated vaccine is the polio vaccine. The third vaccine type are subunit vaccines, such as the hepatitis B vaccine. As the name suggests, they only include the antigen parts of the microorganism, which is the part that stimulates our body’s immune system. The final vaccine type is the nucleic acid vaccine, which contains plasmid DNA or mRNA from the bacteria/virus that codes for the antigens that cause an immune response. These mRNA vaccines are considered safe and very effective, which is why they are increasingly being developed. The current vaccines against COVID-19 encompass the second, third and fourth vaccine types; for example, Sinopharm has produced an inactivated virus vaccine, AstraZeneca/Oxford has produced a subunit vaccine and Pfizer has produced an mRNA vaccine. Currently in the UK, the Pfizer, Moderna (another mRNA vaccine) and AstraZeneca/Oxford vaccines have all been approved for use. A report published by Imperial College London’s Institute of Global Health Innovation (IGHI) and YouGov in November 2020 looks at people’s attitudes towards COVID-19 vaccines across 15 countries, including the UK. This report was based on survey responses from around 13,500 people and gives an insight into behaviours related to COVID-19. 65% of respondents in the UK reported being willing to get vaccinated in 2021 if a COVID-19 vaccine became available to them, which made respondents from the UK the most willing to be vaccinated among the countries surveyed. Overall, of all those surveyed, around half (51%) were willing to get a COVID-19 vaccine in 2021. This also reveals how half of those asked, the other 49%, would be hesitant in getting a COVID-19 vaccine if it was available to them. This is not a new concept when it comes to vaccines; vaccine hesitancy has existed for many years and is in fact a global issue. The World Health Organization (WHO) recently listed vaccine hesitancy as one of their top 10 biggest threats to global health. Vaccine hesitancy is the scientific term for anti-vaccination; it is when people with access to vaccines delay or refuse vaccination. Vaccination is one of the most effective ways of eliminating disease across the world, with a staggering 2 to 3 million deaths prevented by vaccination every year. Nonetheless, vaccine hesitancy has grown in popularity in recent years, fuelled by misconceptions and misinformation. This could have potentially devastating consequences on public health. The biggest concern people have regarding the COVID-19 vaccines is whether they are safe. Many are hesitant to be vaccinated as they feel the vaccine was developed too quickly, with the time taken from initial development to the deployment of the vaccines being approximately a year or less. Thus, people are concerned that long-term studies of the vaccines have not been conducted, and so are afraid of the potential long-term implications of a COVID-19 vaccine. An article published by the COVID Symptom Study addresses this concern. The COVID Symptom Study is the world’s largest ongoing study of COVID-19. The study is based on data provided by over 4 million people globally through the COVID Symptom Study app. It is a non-profit initiative launched by health science company ZOE in collaboration with King’s College London. The article explains that the global health emergency created by the pandemic led to billions of pounds being committed to global COVID-19 vaccine research, as well as tens of thousands of people volunteering for the clinical trials of the vaccine. The level of funding for the vaccine meant that scientists all over the world were working on a vaccine and had the means to do so, making the process of vaccine development much faster. In addition, the large number of volunteers for clinical trials further increased the rate of vaccine development, as it can take many months or years to obtain enough volunteers. Furthermore, the genetic code of SARS-CoV-2 was identified quite quickly relative to the spread of disease (January 2020), so scientists were able to begin working on a vaccine immediately. The vaccines were not developed from scratch, rather they were developed based on existing safe and effective vaccine delivery systems. These were adapted to work against COVID-19. For example, the AstraZeneca/Oxford vaccine had been in development and testing for 15 years, having been previously developed to work against other related coronaviruses that cause SARS and MERS. In addition, compared to the past vaccines can be manufactured at a much quicker rate due to modern technology. It is a culmination of these factors which led to the fast development of COVID-19 vaccines. If faced with vaccine hesitant members of the public, it is important to inform them that the safety precautions, clinical trials and tests for the COVID-19 vaccines were conducted as thoroughly as with any other vaccine. The spread of misinformation is especially worrying now as vulnerable patients who see or hear it may refuse the COVID-19 vaccine, thus endangering their life and the health of those around them. Ensuring we are fully educated about the history and development of this virus and its treatment can be what saves them in the future. Authors: Amelia Ryan and Nusayba Ali References:
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