**1. Introduction**

Over a year has passed since the first declared case of COVID-19, a life-threatening infection, on 31st of December 2019, and all of our socio-economic life aspects have been affected while facing this worldwide pandemic [1–4]. Frontline health workers have reached

**Citation:** Turcu-Stiolica, A.; Bogdan, M.; Subtirelu, M.-S.; Meca, A.-D.; Taerel, A.-E.; Iaru, I.; Kamusheva, M.; Petrova, G. Influence of COVID-19 on Health-Related Quality of Life and the Perception of Being Vaccinated to Prevent COVID-19: An Approach for Community Pharmacists from Romania and Bulgaria. *J. Clin. Med.* **2021**, *10*, 864. https://doi.org/ 10.3390/jcm10040864

Academic Editor: Mauro Giovanni Carta

Received: 22 January 2021 Accepted: 17 February 2021 Published: 19 February 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

unprecedented anxiety levels, as information regarding contagiousness and pharmacotherapeutic management remains uncertain [1]. Long-lasting immense stress and panic, as well as physical exhaustion, could lead to post-traumatic disorders or depression, with a higher prevalence among healthcare workers [1]. Moreover, the performance of health care professionals could also be affected due to increased workload and fear of self-infection, social rejection, or even transmission to family members [5,6].

Inter-professional collaboration among healthcare settings, including community pharmacies, is highly recommended in order to face and manage the COVID-19 pandemic [2]. During the Ebola epidemics, for example, effective communication between physicians and community pharmacists was noted as a good control measure in avoiding the infection spread [7]. Pharmacists are exposed daily through face-to-face interactions with individuals [3], but are often neglected as frontline health care providers, although they represent accessible, essential health care workers [6–9]. Although pharmaceutical services cannot be offered from a remote location, little information about COVID-19 exposure and prevalence among community pharmacists is noted [9,10], which could be underestimated [7,10]. However, a higher risk of exposure to COVID-19-infected individuals involves a greater psychological impact [11]. Permanent fear of infection due to insufficient social distancing in pharmacies, aggressive patient behavior and higher stress levels could affect cognitive functioning in pharmacists and could weaken their attention [1,12]. Community pharmacists have also been involved in the screening and triage of COVID-19 patients (Figure 1), as well as in ensuring continuity of care for non-COVID-19 illnesses and promoting pharmacological adherence, which further increased the negative impact on their well-being [2,9]. However, pharmacists have shown a trustworthy attitude regarding the adoption of protective measures (Figure 1), despite the increased risk of burnout [8,10,12]. They even provided surveillance of suspicious cases, symptoms-related counselling and advice to patients on whether they should be quarantined or not, depending on their clinical manifestations (Figure 1) [7]. Community pharmacists also improved medical education among their patients by using telehealth consulting and new technologies [2]. Moreover, pharmacists maintained contact, through different and accessible smart mobile applications, e-mails, video calls and written text messages, with all individuals who requested pharmaceutical assistance (Figure 1) [2]. Continuous pharmaceutical monitoring and communication with patients not only supported rational medicine use, but also ensured constant clarification of various misconceptions regarding prophylactic or longterm curative treatments (Figure 1) [2]. Thereby, community pharmacists helped reduce unnecessary visits to health departments, which were already overwhelmed, ensuring a cost-effective approach to the COVID-19 pandemic [7]. A systematic review conducted in July 2019 underlined the importance and involvement of pharmacists in public threat recovery [6]; therefore, their proper mental health and quality of life are highly needed.

Community pharmacists are involved in pharmacovigilance activities and are able to educate and counsel individuals regarding both the pharmacotherapeutic approach of the COVID-19 infection and the proper use of personal protective equipment and sanitizers (Figure 1) [2,7,12]. Pharmacists are also able to communicate effectively in order to combat the flood of misinformation regarding COVID-19 and discourage dangerous self-medication [7,8,11–13]. Moreover, pharmacists could play a key role in the prevention and containment of COVID-19 pandemic, promoting patients' adherence to prophylactic immunomodulatory treatment (such as vitamins C and D); they could also promote vaccination and support vaccinovigilance (Figure 1) [2,7,8,13].

The European Medicines Agency (EMA) authorized Cominarty (developed by BioN-Tech and Pfizer) as the first vaccine used for prevention of COVID-19, in people aged over 16 years, in European countries, on 21st December 2020 [14]. Another conditional marketing authorization was given on 6th January 2021 for COVID-10 vaccine Moderna, recommended in individuals from 18 years of age [14]. The first two approved vaccines are based on the mRNA technique, preparing the human body to generate a proper immune response in case of infection. The most recent recommended vaccine for European

authorization was the one from AstraZeneca, on 29th January 2021, based on modified adenovirus. All three vaccines will be monitored in both European countries (Romania [15] and Bulgaria [16]) through pharmacovigilance online systems, and intensively supported and promoted by pharmacists.

**Figure 1.** Community pharmacy services during COVID-19 pandemic.

Vitamin C (ascorbic acid) cannot be synthesized by the human organism, but it is found in many fruits and vegetables [17–19] and is used as a supplement, alone or in combination with other vitamins and minerals [20]. Vitamin D exists in two forms: vitamin D2 (found in plants) and vitamin D3 (found in food and synthesized in the skin under sunlight ultraviolet-B ray exposure), both of which are available in dietary supplements [21,22]. An indoor lifestyle, sun avoidance for health or cultural reasons, and a modern diet based on highly processed food are significant contributors to the evolution of global vitamin D deficiency [23]. Even more, due to the long period of lockdown and following limitation of activities outside the home, vitamin D intake is beneficial during the pandemic. Both vitamin C and vitamin D supplementation has demonstrated positive effects on the immune system and on respiratory tract infections [24,25].

Pharmacists represent the first point of contact with individuals who need psychiatric assistance [12]. Robinson et al. emphasizes that in order to assist patients with behavioural health conditions (such as concern, fear, insomnia, fatigue, anger, frustration, intense anxiety, panic attacks, depression) and to help relieve the pandemic pressure, community pharmacists should be trained to first manage their own psychological disorders [3–6,9,12]. Nevertheless, self-care (physical activity, proper eating and sleep hygiene, mindfulness techniques) and resilience need greater promotion among pharmacists [11,12]. Multidisciplinary mental health services, such as training programs and careful evaluation of the pharmacy staff, should be initiated and provided for pharmacists as soon as possible [9,12].

Romania declared a COVID-19 lockdown from 16th March 2020 to 15th May 2020, whereas in Bulgaria the state of emergency was between 13th March 2020 and 13th May 2020. In both countries, it was followed by an alert period with many limitations and restrictions, which still continues. The reason we choose these two countries for the study

was because both are from the Central and Eastern European region and have similar drug policies and health legislation [26].

Our aim was to analyze the health-related quality of life (HRQoL) of community pharmacists from Romania and Bulgaria during the COVID-19 pandemic and to identify factors associated with perception of being vaccinated against COVID-19, in order to provide evidence-based interventions to community pharmacists to improve vaccine use. Associations between HRQoL, demographics, pharmacists' recommendations for vitamin C and D intake during the pandemic, and perception of being vaccinated against COVID-19 were evaluated. At the same time, based on multiple clinical trials about the vitamin C/vitamin D relation with COVID- 19, we aimed to assess the insight of the community pharmacists regarding the recommendation of over-the-counter drugs with vitamin C and D during the COVID-19 pandemic.
