ENGAGINGTHEPHARMACYFORTBCONTROL

ThePharmacyDOTSInitiative

2014
ENGAGINGTHEPHARMACYFORTBCONTROL
ThePharmacyDOTSInitiative

PHARMACY
 A Global Perspective

22 High Burden Countries:

80% of Global TB Burden

The Philippines: A High TB Burden Country ranks 9th globally

Current 7th among 22 high TB burden
Status of countries worldwide (WHO Global Report on TB
2013)
TB in 4th in case notification rate (TB all
the forms) among Western Pacific
countries
Philippines (TB Control in the Western
Pacific Region, 2009 Report)

8th among 27 priority countries with

highest number of MDR TB cases
6th leading cause of morbidity and
mortality (DOH NTP, 2013)
 Philippine Morbidity Statistics
MORBIDITY:TENLEADINGCAUSESBYSEX
No.&Rate/100,000Population,PHILIPPINES,2004
MALE FEMALE BOTH SEXES
CAUSE
Rate** Rate** Number Rate*

1. Acute Lower RTI and Pneumonia 888.8 868.0 776,562 929.4

2. Bronchitis/ Bronchiolitis 651.8 817.1 719,982 861.6

3. Acute Watery Diarrhea 668.5 651.5 577,118 690.7

4. Influenza 400.7 444.6 379,910 454.7

5. Hypertension 338.2 442.1 342,284 409.6

6. TB Respiratory 137.7 93.9 103,214 123.5

7. Chickenpox 51.5 56.2 46,779 56.0

8. Diseases of the Heart 38.5 45.1 37,092 44.4

9. Malaria 24.0 20.0 19,894 23.8

10. Dengue Fever 17.8 17.1 15,838 19.0

Source:2004PhilippineHealthStatistics;**rate/100,000ofsexspecificpopulation
LastUpdate:February11,2008 5
 Philippine Mortality Statistics
MORTALITY:TENLEADINGCAUSESBYSEX
No.&Rate/100,000Population,PHILIPPINES,2004
MALE FEMALE BOTH SEXES

CAUSE Number %*

1. Heart Diseases 40,361 30,500 70,861 17.6

2. Vascular System Diseases 28,930 22,750 51,680 12.8

3. Malignant Neoplasms 21,395 19,129 40,524 10.1

4. Accidents** 28,041 6,442 34,483 8.6

5. Pneumonia 15,822 16,276 32,098 8.0

6. Tuberculosis, all forms 17,841 8,029 25,870 6.4

7. Ill-defined & unknown causes of mortality 10,916 10,362 21,278 5.3

8. Chronic Lower Respiratory Diseases 13,084 5,891 18,975 4.7

9. Diabetes Mellitus 7,970 8,582 16,552 4.1

10. Certain Conditions Originating in the Perinatal Period 7,809 5,371 13,180 3.6

Source:2004PhilippineHealthStatistics;*%sharefromalltotalcausesofdeaths;**externalcausesofmortality
In2010,TBisno.6
LastUpdate:February11,2008 Leadngcauseofdeath 6
 TB in the Philippines:
A National Burden

Alarming morbidity & mortality:

63% population infected

200,000 to 500,000 new cases infect 2

million to 10 million Filipinos annually

Source: 1997 National TB Prevalence Survey; FHIS

TB kills 63 Filipinos a day

Source:WHOGlobal
ReportonTB2013
 HealthSeekingBehaviorofPresumptiveTBCases

No
Action
Consulted
49.2% Consulted
24.5%
34.6%
NPS NPS
1997 2007
ReasonsforNoAction:
Symptomsareharmless45.0%
Financial:reasons39.1%
Proximity4.4% Patients who self-medicate buy their medicines from
Embarrasing:1.9% pharmacies
Others9.6% Pharmacists can play a big role in influencing behavior of
Source:PDI2005 these patients
CurrentTBSituation,2009
Treatment of
TB Treated with four to five
anti-TB drugs
With standard treatment
regimen; from 6 to 8 months
Coupled with a healthy
lifestyle E
E
FR
F RE
E
I
I SS AA N ND D
AAG
G N
N OOSS A
A TT
DII
D MEE
M NN TT
E
EAATT E
E R
R SS
TTRR
C
C EENN TT
ALLTTHH
HEEA
H
AN
A NDD
IIVV AATT EE
L
L I
ICC--PPRR
D
D ))
PPU
U BB ((PP P
P MM
O
O T
T SS
MMIIXXD D
I
ITT IIEESS
AC
FFA C IIL
L
 2015 Millennium Goal (WHO)
Baseline (1990
MDG Goal MDG Indicators Data Source
data)
MDG 2015 Target 2012
Goal 6: Combat HIV/AIDS, malaria,
and other diseases Target 6 C:
Prevalence and death rates associated Prevalence, TB all forms per
with tuberculosis are reduce by half 100,000 population WHO 800/100,000 400/100,000
from 1990 baseline

Mortality, TB all forms per

100,000 population WHO 87/100,000 44/100,000
Target 6 C: Proportion of
tuberculosis cases detected and
successfully treated under DOTS
(Directly Observed Treatment Short
Course)
NTP Annual 82% in 1996
Accomplishment (DOTS started in
Treatment Success Rate (%) Report Philippines) 85% or more 82%

NTP Annual 23% in 1996

Accomplishment (DOTS started in
Case Detection Rate (in %) Report Philippines) 70% or more 90%
The New Global Strategy to Stop
TB
 NTP Vision, Goals and Objectives

Vision: TB-free Philippines

Goal: Reduce TB mortality and morbidity
Targets by 2016:
Case detection rate, all forms 90%
Treatment success rate, all forms 90%
MDR-TB notification rate 62%
MDR-TB TSR 75%
 Objectives and Strategies
OBJECTIVE
Reduce local variation in TB
control program
performance
Scale up and sustain
coverage of DOTS
implementation
Ensure provision of quality
TB services
Reduce out-of-pocket
expenses related to TB care
STRATEGY
1. Localize implementation of TB control
2. Monitor health system performance
3. Engage both public and private health care providers
4. Promote and strengthen positive behaviour of the
communities
5. Address MDR-TB, TB/HIV, and needs of vulnerable
population
6. Regulate and make available quality TB diagnostic tests
and drugs
7. Certify and accredit TB care providers
8. Secure adequate funding and improve allocation and
efficiency of fund utilization
 Private Sector Involvement:

TheInnovationsandMultisectoralPartnershipstoAchieveControl
ofTuberculosis(IMPACT))isaprojectfundedbytheUnited
StatesAgencyforInternationalDevelopment(USAID),managed
bythePhilippineBusinessforSocialProgress(PBSP)andledby
theDepartmentofHealth(DOH).

ThePhilippinePharmacistsAssociationhad
beengivenasubgranttoimplementthe
PharmacyDOTSInitiativesin32sites
 Contextual Realities

Numerous, widely dispersed, and

strategically located

Commonly the first point of contact for health

concerns and information on drugs

Convenient and trusted for

health advice and other services
 PPHAPreviousInvolvementinPDI

PPHAfullsupporttothe2004PDI
implementedbyPhilTIPS
(7sites)

170Pharmacies
Source: PM and DOTS Clinic Data, Jul04-Jan06
 PPHAPreviousInvolvementinPDI

2010PDIimplementedbyPTSI/TBLINC
(12sites)

121Pharmacies
Sept2010June2011
 PPHAPreviousInvolvementinPDI

PPHAwasgivenasubgrantto
implementPDIin2012
(5sites)

122Pharmacies
Apr2012July2012
 PPHAPreviousInvolvementinPDI

PPHAwasoneof10countiresgivena
grantbyFIPTBChallengeRound1to
implementPDIinSurigaoCityin2012

25Pharmacies
JanMay2012
 TB Disease:
Transmission and Prevention
 TUBERCULOSIS

- an infectious disease caused by

a micro-organism called
Mycobacterium tuberculosis

Pulmonary Tuberculosis Extra -Pulmonary TB

 Transmission

Transmitted from an infected person through aerosolized droplets formed by

coughing, sneezing, talking, laughing, or singing

Infection is caused by inhalation of droplet nuclei

TB Infection: M. TB laden droplet must get past the mucociliary apparatus and
deposit at the alveolar level

Mucociliary Apparatus

M. Tb

Alveolar
Macrophage
 Infection vs. Disease
INFECTION DISEASE
Symptomatic
Asymptomatic Positive sputum smears
Negative sputum smears Positive chest x-ray
Negative chest x-ray Infectious
Not contagious Active infection
Quiescent or dormant infection

OnlyamedicaldoctorcandiagnoseTBdisease
 The TB Life
Index Case Cycle

Exposure A Tb patient infects 10-15 Only active TB pts

persons / yr
N (specially smear (+))
o can infect others
In 90-95% of
t infected patients, Infection 5-10%
M. tb remains lifetime risk
In dormant in the
f body 30% of un-treated
ec TB undergoes
t spont. re-mission Disease
Untreated, 70% will
ed die in 5 yrs
> 90% CURE
RATE (w/ DOTS) Death

Healthy Subjects
 Signs and Symptoms

Cough > 2 weeks

Sputum production which
may be blood-stained

chest pains,
shortness of breath

Fever, loss of appetite

& loss of weight, a
general feeling of
illness & tiredness

* If a patient has any of the following, consider him a TB Suspect

 Infectiousness
Patients are NOT considered infectious if:
Have received appropriate therapy for 2-3
weeks
Show favorable clinical response to therapy,
and
BASIC PRINCIPLES OF TREATMENT
 Not taking medication

In Loving Memory of
Did not take Did not take
medication medication

ubo! ubo! ubo!

(cough for 2 weeks or more)
Cough worsens DIED
(may be smear
positive)

Infects 10-20
persons
annually
 Incorrect treatment

Takes medication Not regularly taking

medication

ubo! ubo! ubo! Feels better but bacteria Coughing recurs &
(cough for 2 weeks or more) is still present in the lungs bacteria multiplies,
may be the drug
resistant strain
 First-Time TB vs MDR-TB

. TB MDR-TB

Treatment using regular anti- Treatment using special

Drug Used TB drugs drugs

Cost of Treatment P6,000 - 7000 P500,000

Accessibility Yes No

Treatment Outcome Good Poor

Treatment Centers for MDR TB Services
MMC-TDF De La Salle Treatment
LCP Center
Sorsogon Medical
PTSI-Tayuman
Missions Hospital
DJNRMH
Community of German
KASAKA Doctors
ITRMC Davao medical Center
Eversly Childrens Other Regional Treatment
Hospital Centers
Prevalence of Multi-Drug Resistant
TB
among new cases : 3.8% 2%
among previously treated: 20.9% 21%
combined: 5.7%

The Philippines ranked 9th among 27 countries that

account for 85% of global MDR-TB burden

(National Drug Resistance Survey, 2004 and

1012)
 Regularly taking medication

Takes medication Takes medication

(2 mos.) (4 mos.)

Feels better but bacteria

ubo! ubo! ubo!
(cough for 2 weeks or more) is still present in the lungs cured
TB is CURABLE.
And the best way to do it is

DOTS
with
WhatisDOTS?

DOTSistheWHOrecommended
strategyfordiagnosis,treatmentand
managementofTB.

ItstandsforDirectlyObserved
TreatmentShortCourse
 FIVEELEMENTSOFDOTS

Microscopes
Identify infectious TB patients
to confirm presence of TB
with smear microscopy bacilli

Medicines
Ensure that short-course anti-TB uninterrupted supply
drug are always available

Record Books
Monitor and record Standardized recording
progress of treatment and reporting system

Observers
Observe them swallow Ensures that no dose
each dose of medicine Is missed

! Funding
Sustain this effort with political sound policies
and financial commitment To support DOTS
 TB Disease Registration Group
Category of Type of TB Patient Treatment Regimen
Treatment

Pulmonary TB, new

Category I 2HRZE/4HR
Extra-pulmonary TB, new (except CNS/ bones or joints)

Category Ia Extra-pulmonary TB, new (CNS/ bones or joints) 2HRZE/10HR

Previously treated drug susceptible TB (pulmonary or

extrapulmonary)
Relapse
2HRZES/1HRZE
Category II Treatment After Failure
/5HRE
Treatment After Lost to Follow-up (TALF)
Previous Treatment Outcome Unknown
Other

2HRZES/1HRZE
Category IIa Previously treated drug susceptible EPTB (CNS/ bones or joints)
/9HRE
TB Disease Registration Group
Category of Treatment Type of TB Patient Treatment Regimen

ZKmLfxPtoCs
Standard Regimen Drug
RR-TB or MDRTB
Resistant (SRDR) Individualized once DST result is available
Treatment duration for at least 18 months

Individualized based on DST result and history of

Regimen for XDR XDR-TB
previous treatment
WhatistheAdvantageofReferringPatientstotheDOTS
Facilities?
Reduce possibility of
Reduce the delay in the diagnosis
infecting 15 20
and treatment of a TB case
persons per year

Ensure Continuity and Higher chance of cure.

compliance of treatment Prevents development of
MDR

Reduce out of pocket cost to

patients Ensures compliance

Ensure that TB patient is Assured case holding and

registered and notified to monitoring of treatment,
NTP contact tracing, MDR
reporting
 Pharmacy Interventions:

The Pharmacy DOTS Initiative

 Pharmacy DOTS Initiative:
Showcase of Good Antimicrobial Stewardship

A model developed by PhilTIPS

(2004)
Adopted by TB LINC in 20102012
Scale up by IMPACT (20142016)
With USAID support
The Pharmacy DOTS Initiative (PDI)
TRAINING/
Empower pharmacists and their
COMPETENCY- assistants to:
BUILDING Discourage the practice of self-
medication; encourage
adherence to NTP guidelines
Provide correct information on
TB and DOTS
Reinforce the No prescription
No dispensing of anti-TB drugs
policy
Support DOTS through
prescreening and referral to
DOTS facilities
NationalPoliciesandGuidelines
1.PharmacyBill
Sec.31:SaleofMedicinefollowingdispensingguidelines
Sec.32:Categorizationofpharmacyoutlets
Sec.35ProhibitionofthedistributionofPhysicianssamples
includingAntiTBdrugs
Sec.38:Recordbooksrequired,includingTBReferralLogbook
Sec.40:RegistrationofMedicineshandlerswiththePRCBOP
2. CHEDMemorandumOrder(CMO)onPolicies,StandardsandGuidelinesfor
PharmacyEducation
outcomesbasededucation
internshipguidelines
inclusionofPDIinPQFLevel1and2programs

3.InclusionofPDIintheTESDAstandardtrainingmoduleforpharmacyassistants
 PDI PROJECT OVER
VIEW

DOTS
PDI
PHARMACY CENTE
R

Customer OfferPDI Provide Customer

probablya Interventions DOTS curedof
presumptiveTB benefits TB
case
 DESIRED BEHAVIORAL
CHANGES AFTER PDI

DOTS
PDI CENTE
PHARMACY R

Willnow
Willnolonger Willnolonger
recognizethe
insistonself dispenseanti
pharmacyas
medication TBdrugwithout
asourceof
prescription
referrals
Componentsofthe2014PharmacyDOTSInitiativesScaleUp

1. Disseminationofinformationoncoughof2weeksormore
2. Prescreeningofcustomerswhocometothepharmacyfor
a.coughmedicationswithoutaprescription.
b.TBdrugswithoutaprescription
c.TBdrugswithaprescription
3.ReferraltoaDOTSfacility

 PHARMACY INTERVENTION

1. Who will be taking the

medication
2. Duration of cough
If < 2 If > 2
PHARMACY weeks: weeks:
3. Recommen 3. Informatio
d cough n
medication disseminat
4. Do not ion re
Clientaskingfor dispense cough
coughmedication antibiotic 4. Explain
withoutaprescription
5. If health
symptoms center
persist, benefit
come back 5. Issue
 PHARMACY INTERVENTION

1. Who will be taking the

medication
2. Reason for buying
3. Duration of cough
If < 2 If > 2
PHARMACY weeks: weeks:
4. Recommen 4. Information
d cough disseminati
medication on about
5. Do not TB.
Clientaskingforanti dispense 5. Explain
TBmedicinewithout
aprescription antibiotic need to see
6. If a doctor
symptoms 6. Explain
persist, health
 PHARMACY INTERVENTION

1. Explain importance of continuous

uninterrupted treatment
2. Give cost of treatment

3. 1. 3. If patient insists on
PHARMACY Explain buying, explain
DOTS again importance
benefit of continuous
uninterrupted
4. Issue
treatment
referral 4. Partial filling is
ClientaskingforTB slip allowed
drugwitha 5. Do not 5. Advice patient to go
prescription dispense back to doctor after
starter 2 months for follow
dose up
6. Log in names of
doctors prescribing
Phase1Sites

NCR Luzon VisMin

QuezonCity Pangasinan Cebu

CaloocanCity Pampanga SurigaoDelNorte
ValenzuelaCity NuevaEcija Bukidnon
MakatiCity Isabela ZamboangaDelNorte
MalabonCity Benguet MisamisOriental
Laguna
Batangas


Phase2Sites

NCR Luzon VisMin

LasPinasCity Bulacan NorthernLeyte

SanJuanCity Tarlac Aklan
MarikinaCity Cavite DavaoOriental
PasayCity Rizal Sarangani
MandaluyongCity Quezon Sibugay
TaguigCity


 PDI TARGET

EachPDIPharmacyshouldbeabletoreferatleast20
presumptiveTBpatientstothehealthcenterpermonth.
 Sustaining the Implementation of PDI through

CollaborationwithFDA,DSAP,PPHA

RepresentationofPPHA/DSAPinmultisectoralalliance
organizedinprojectsite

FDAnewAO56Requirements(tobereleasedJuly2014)
TBReferralLogbook
GoodPharmacyPracticeStandards
DispensingGuidelines
 The DOTS Referral Network

DOTS
Private
referring
Referring
MD
Hospital
PrivateTML
HM
O
PeripheralDOTS
Workplac
Facilities e
RHU,HealthCenter,PPMD
PublicDOTSprovidingHospital
PrivateDOTSprovidingHospital
Prison
Private
Pharmacy
Service
Delivery
Network
Pharmacists for a TB-Free Philippines

IrishBarrera09176230934
(globe)