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ENGAGING THE PHARMACY FOR TB CONTROL The Pharmacy DOTS Initiative 2014
ENGAGING THE PHARMACY FOR TB CONTROL The Pharmacy DOTS Initiative
PHARMACY
A Global Perspective
22 High Burden Countries: 80% of Global TB Burden
The Philippines: A High TB Burden Country ranks 9th globally
Current Status of TB in the Philippines
• 7th among 22 high TB burden countries worldwide (WHO Global Report on TB 2013)
• 4th in case notification rate (TB all forms) among Western Pacific countries (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: TEN LEADING CAUSES BY SEX No. & Rate/100,000 Population, PHILIPPINES, 2004 MALE
FEMALE
Rate**
Rate**
BOTH SEXES
CAUSE 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: 2004 Philippine Health Statistics; ** rate/100,000 of sexspecific population Last Update: February 11, 2008
5
Philippine Mortality Statistics MORTALITY: TEN LEADING CAUSES BY SEX No. & Rate/100,000 Population, PHILIPPINES, 2004 MALE
FEMALE
CAUSE
BOTH SEXES
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: 2004 Philippine Health Statistics; * % share from all total causes of deaths; ** external causes of mortality Last Update: February 11, 2008
In 2010, TB is no. 6 Leadng cause of death
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: WHO Global Report on TB 2013
Health Seeking Behavior of Presumptive TB Cases
NPS 1997
Consulted 24.5%
Reasons for No Action: Symptoms are harmless 45.0% Financial: reasons 39.1% Proximity 4.4% Embarrasing: 1.9% Others 9.6%
Source: PDI 2005
No Action 49.2%
Consulted 34.6%
NPS 2007
Patients who self-medicate buy their medicines from pharmacies Pharmacists can play a big role in influencing behavior of these patients Current TB Situation, 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 ►
E RE F FR
D N ND A A S S I I O OSS N N TT G G A A A A T T D DII N N M MEE T T SS A A R R E E E E R T T TTR N EEN C C H H ALLTT H HEEA D EE ND T T A AN A A V V I I R PPR C C )) I I L L D D B B M M U U P P PP ((PP S S T T O O D XD IIEESS M MIIX T T I I L L I I C AC FFA
2015 Millennium Goal (WHO) MDG Goal Goal 6: Combat HIV/AIDS, malaria, and other diseases Target 6 C: Prevalence and death rates associated with tuberculosis are reduce by half from 1990 baseline
MDG Indicators
Data Source
Baseline (1990 data)
MDG 2015 Target
2012
Prevalence, TB all forms per 100,000 population
WHO
800/100,000
400/100,000
Mortality, TB all forms per 100,000 population
WHO
87/100,000
44/100,000
Treatment Success Rate (%)
NTP Annual Accomplishment Report
82% in 1996 (DOTS started in Philippines)
85% or more
82%
Case Detection Rate (in %)
NTP Annual Accomplishment Report
23% in 1996 (DOTS started in Philippines)
70% or more
90%
Target 6 C: Proportion of tuberculosis cases detected and successfully treated under DOTS (Directly Observed Treatment Short Course)
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 Treatment success rate, all forms MDR-TB notification rate MDR-TB TSR
90% 90% 62% 75%
Objectives and Strategies OBJECTIVE
STRATEGY
Reduce local variation in TB control program performance
1. Localize implementation of TB control 2. Monitor health system performance
Scale up and sustain coverage of DOTS implementation
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
Ensure provision of quality TB services
6. Regulate and make available quality TB diagnostic tests and drugs 7. Certify and accredit TB care providers
Reduce out-of-pocket expenses related to TB care
8. Secure adequate funding and improve allocation and efficiency of fund utilization
Private Sector Involvement: The Innovations and Multisectoral Partnerships to Achieve Control of Tuberculosis (IMPACT) ) is a project funded by the United States Agency for International Development (USAID ), managed by the Philippine Business for Social Progress (PBSP ) and led by the Department of Health (DOH).
The Philippine Pharmacists Association had been given a subgrant to implement the Pharmacy DOTS Initiatives in 32 sites
Contextual Realities
•
Numerous, widely strategically located
dispersed, and
• Commonly the first point of for health concerns and information on drugs
• Convenient and trusted for health advice and other services
PPHA Previous Involvement in PDI PPHA full to the 2004 PDI implemented by PhilTIPS (7 sites)
170 Pharmacies Source: PM and DOTS Clinic Data, Jul’04-Jan’06
PPHA Previous Involvement in PDI 2010 PDI implemented by PTSI/TBLINC (12 sites)
121 Pharmacies Sept 2010 – June 2011
PPHA Previous Involvement in PDI PPHA was given a subgrant to implement PDI in 2012 (5 sites)
122 Pharmacies Apr 2012 – July 2012
PPHA Previous Involvement in PDI PPHA was one of 10 countires given a grant by FIPTB Challenge Round 1 to implement PDI in Surigao City in 2012
25 Pharmacies Jan – May 2012
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 • • • • •
Asymptomatic Negative sputum smears Negative chest x-ray Not contagious Quiescent or dormant infection
DISEASE • • • • •
Symptomatic Positive sputum smears Positive chest x-ray Infectious Active infection
Only a medical doctor can diagnose TB disease
The TB Life Cycle
Index Case Exposure N o t In f ec t ed
In 90-95% of infected patients, M. tb remains dormant in the body
A Tb patient infects 10-15 persons / yr
Infection 30% of un-treated TB undergoes spont. re-mission
Only active TB pts (specially smear (+)) can infect others 5-10% lifetime risk
Disease > 90%
CURE
RATE (w/ DOTS)
Healthy Subjects
Untreated, 70% will die in 5 yrs
Death
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 medication
“ubo! ubo! ubo!” (cough for 2 weeks or more)
Did not take medication
Cough worsens (may be smear positive)
Infects 10-20 persons annually
DIED
Incorrect treatment
Not regularly taking medication
Takes medication
“ubo! ubo! ubo!” (cough for 2 weeks or more)
Feels better but bacteria is still present in the lungs
Coughing recurs & bacteria multiplies, may be the drug resistant strain
First-Time TB vs MDR-TB .
TB
MDR-TB
Drug Used
Treatment using regular anti- Treatment using special 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 L PTSI-Tayuman DJNRMH KASAKA ITRMC Eversly Children’s Hospital
• De La Salle Treatment Center • Sorsogon Medical Missions Hospital • Community of German Doctors • Davao medical Center • Other Regional Treatment Centers
Prevalence of Multi-Drug Resistant TB • among new cases : 3.8% • among previously treated: 20.9% • combined: 5.7%
2% 21%
The Philippines ranked 9th among 27 countries that
for 85% of global MDR-TB burden
(National Drug Resistance Survey, 2004 and 1012)
Regularly taking medication
Takes medication (2 mos.)
“ubo! ubo! ubo!” (cough for 2 weeks or more)
Takes medication (4 mos.)
Feels better but bacteria is still present in the lungs
cured
TB is CURABLE. And the best way to do it is with
DOTS
What is DOTS? DOTS is the WHOrecommended strategy for diagnosis, treatment and management of TB. It stands for Directly Observed Treatment Short Course
FIVE ELEMENTS OF DOTS Identify infectious TB patients with smear microscopy
Microscopes
Ensure that short-course anti-TB drug are always available
Medicines
Monitor and record progress of treatment
Observe them swallow each dose of medicine
!
Sustain this effort with political and financial commitment
to confirm presence of TB bacilli
uninterrupted supply
Record Books Standardized recording and reporting system
Observers Ensures that no dose Is missed
Funding sound policies To DOTS
TB Disease Registration Group Category of Treatment
Type of TB Patient
Treatment Regimen
Pulmonary TB, new Category I
2HRZE/4HR Extra-pulmonary TB, new (except CNS/ bones or ts)
Category Ia
Category II
Category IIa
Extra-pulmonary TB, new (CNS/ bones or ts) Previously treated drug susceptible TB (pulmonary or extrapulmonary) Relapse Treatment After Failure Treatment After Lost to Follow-up (TALF) Previous Treatment Outcome Unknown Other
Previously treated drug susceptible EPTB (CNS/ bones or ts)
2HRZE/10HR
2HRZES/1HRZE /5HRE
2HRZES/1HRZE /9HRE
TB Disease Registration Group Category of Treatment
Type of TB Patient
Treatment Regimen
ZKmLfxPtoCs Standard Regimen Drug Resistant (SRDR)
Regimen for XDR
RR-TB or MDRTB
XDR-TB
Individualized once DST result is available Treatment duration for at least 18 months
Individualized based on DST result and history of previous treatment
What is the Advantage of Referring Patients to the DOTS Facilities? Reduce the delay in the diagnosis and treatment of a TB case
Reduce possibility of infecting 15 – 20 persons per year
Ensure Continuity and compliance of treatment
Higher chance of cure. Prevents development of MDR
Reduce out of pocket cost to patients
Ensures compliance
Ensure that TB patient is ed and notified to NTP
Assured case holding and monitoring of treatment, 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
The Pharmacy DOTS Initiative (PDI)
TRAINING/ COMPETENCYBUILDING
Empower pharmacists and their assistants to: ►Discourage the practice of selfmedication; encourage adherence to NTP guidelines ►Provide correct information on TB and DOTS ►Reinforce the No prescription – No dispensing of anti-TB drugs policy ► DOTS through prescreening and referral to DOTS facilities
National Policies and Guidelines 1. Pharmacy Bill Sec. 31: Sale of Medicine following dispensing guidelines Sec. 32: Categorization of pharmacy outlets Sec. 35 Prohibition of the distribution of Physician’s samples including AntiTB drugs Sec. 38: Record books required, including TB Referral Logbook Sec. 40: Registration of Medicines handlers with the PRC BOP 2. CHED Memorandum Order (CMO) on Policies, Standards and Guidelines for Pharmacy Education outcomes based education internship guidelines inclusion of PDI in PQF Level 1 and 2 programs 3. Inclusion of PDI in the TESDA standard training module for pharmacy assistants
PDI PROJECT OVER VIEW
PDI PHARMACY
Customer probably a presumptive TB case
Offer PDI Interventions
DOTS CENTE R Provide DOTS benefits
Customer cured of TB
DESIRED BEHAVIORAL CHANGES AFTER PDI
PDI PHARMACY
Will no longer insist on self medication
Will no longer dispense anti TB drug without prescription
DOTS CENTE R Will now recognize the pharmacy as a source of referrals
Components of the 2014 Pharmacy DOTS Initiatives Scale Up 1. Dissemination of information on cough of 2 weeks or more 2. Prescreening of customers who come to the pharmacy for a. cough medications without a prescription. b. TB drugs without a prescription c. TB drugs with a prescription 3. Referral to a DOTS facility
PHARMACY INTERVENTION
PHARMACY
Client asking for cough medication without a prescription
1. Who will be taking the medication 2. Duration of cough If < 2 If > 2 weeks: weeks: 3. Recommen 3. Informatio d cough n medication disseminat 4. Do not ion re dispense cough antibiotic 4. Explain 5. If health symptoms center persist, benefit come back 5. Issue
PHARMACY INTERVENTION
PHARMACY
Client asking for anti TB medicine without a prescription
1. Who will be taking the medication 2. Reason for buying 3. Duration of cough If > 2 If < 2 weeks: weeks: 4. Recommen 4. Information disseminati d cough on about medication TB. 5. Do not 5. Explain dispense need to see antibiotic a doctor 6. If 6. Explain symptoms health persist,
PHARMACY INTERVENTION 1. Explain importance of continuous uninterrupted treatment 2. Give cost of treatment
PHARMACY
Client asking for TB drug with a prescription
3. 1. Explain DOTS benefit 4. Issue referral slip 5. Do not dispense starter dose
3.
4. 5.
6.
If patient insists on buying, explain again importance of continuous uninterrupted treatment Partial filling is allowed Advice patient to go back to doctor after 2 months for follow up names of doctors prescribing
Phase 1 Sites NCR
Luzon
VisMin
Quezon City Caloocan City Valenzuela City Makati City Malabon City
Pangasinan Pampanga Nueva Ecija Isabela Benguet Laguna Batangas
Cebu Surigao Del Norte Bukidnon Zamboanga Del Norte Misamis Oriental
Phase 2 Sites NCR
Luzon
VisMin
Las Pinas City San Juan City Marikina City Pasay City Mandaluyong City Taguig City
Bulacan Tarlac Cavite Rizal Quezon
Northern Leyte Aklan Davao Oriental Sarangani Sibugay
PDI TARGET
Each PDI Pharmacy should be able to refer at least 20 presumptive TB patients to the health center per month.
Sustaining the Implementation of PDI through Collaboration with FDA, DSAP, PPHA Representation of PPHA/DSAP in multisectoral alliance organized in project site FDA new AO 56 Requirements (to be released July 2014) TB Referral Logbook Good Pharmacy Practice Standards Dispensing Guidelines
The DOTS Referral Network Private Referring MD
DOTS referring Hospital Private TML
Peripheral DOTS Facilities
•RHU, Health Center, PPMD •Public DOTSproviding Hospital •Private DOTSproviding Hospital
Private Pharmacy
HM O Workplac e Prison
Service Delivery Network
Pharmacists for a TB-Free Philippines
Irish Barrera – 09176230934 (globe)
ENGAGING THE PHARMACY FOR TB CONTROL The Pharmacy DOTS Initiative
PHARMACY
A Global Perspective
22 High Burden Countries: 80% of Global TB Burden
The Philippines: A High TB Burden Country ranks 9th globally
Current Status of TB in the Philippines
• 7th among 22 high TB burden countries worldwide (WHO Global Report on TB 2013)
• 4th in case notification rate (TB all forms) among Western Pacific countries (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: TEN LEADING CAUSES BY SEX No. & Rate/100,000 Population, PHILIPPINES, 2004 MALE
FEMALE
Rate**
Rate**
BOTH SEXES
CAUSE 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: 2004 Philippine Health Statistics; ** rate/100,000 of sexspecific population Last Update: February 11, 2008
5
Philippine Mortality Statistics MORTALITY: TEN LEADING CAUSES BY SEX No. & Rate/100,000 Population, PHILIPPINES, 2004 MALE
FEMALE
CAUSE
BOTH SEXES
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: 2004 Philippine Health Statistics; * % share from all total causes of deaths; ** external causes of mortality Last Update: February 11, 2008
In 2010, TB is no. 6 Leadng cause of death
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: WHO Global Report on TB 2013
Health Seeking Behavior of Presumptive TB Cases
NPS 1997
Consulted 24.5%
Reasons for No Action: Symptoms are harmless 45.0% Financial: reasons 39.1% Proximity 4.4% Embarrasing: 1.9% Others 9.6%
Source: PDI 2005
No Action 49.2%
Consulted 34.6%
NPS 2007
Patients who self-medicate buy their medicines from pharmacies Pharmacists can play a big role in influencing behavior of these patients Current TB Situation, 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 ►
E RE F FR
D N ND A A S S I I O OSS N N TT G G A A A A T T D DII N N M MEE T T SS A A R R E E E E R T T TTR N EEN C C H H ALLTT H HEEA D EE ND T T A AN A A V V I I R PPR C C )) I I L L D D B B M M U U P P PP ((PP S S T T O O D XD IIEESS M MIIX T T I I L L I I C AC FFA
2015 Millennium Goal (WHO) MDG Goal Goal 6: Combat HIV/AIDS, malaria, and other diseases Target 6 C: Prevalence and death rates associated with tuberculosis are reduce by half from 1990 baseline
MDG Indicators
Data Source
Baseline (1990 data)
MDG 2015 Target
2012
Prevalence, TB all forms per 100,000 population
WHO
800/100,000
400/100,000
Mortality, TB all forms per 100,000 population
WHO
87/100,000
44/100,000
Treatment Success Rate (%)
NTP Annual Accomplishment Report
82% in 1996 (DOTS started in Philippines)
85% or more
82%
Case Detection Rate (in %)
NTP Annual Accomplishment Report
23% in 1996 (DOTS started in Philippines)
70% or more
90%
Target 6 C: Proportion of tuberculosis cases detected and successfully treated under DOTS (Directly Observed Treatment Short Course)
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 Treatment success rate, all forms MDR-TB notification rate MDR-TB TSR
90% 90% 62% 75%
Objectives and Strategies OBJECTIVE
STRATEGY
Reduce local variation in TB control program performance
1. Localize implementation of TB control 2. Monitor health system performance
Scale up and sustain coverage of DOTS implementation
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
Ensure provision of quality TB services
6. Regulate and make available quality TB diagnostic tests and drugs 7. Certify and accredit TB care providers
Reduce out-of-pocket expenses related to TB care
8. Secure adequate funding and improve allocation and efficiency of fund utilization
Private Sector Involvement: The Innovations and Multisectoral Partnerships to Achieve Control of Tuberculosis (IMPACT) ) is a project funded by the United States Agency for International Development (USAID ), managed by the Philippine Business for Social Progress (PBSP ) and led by the Department of Health (DOH).
The Philippine Pharmacists Association had been given a subgrant to implement the Pharmacy DOTS Initiatives in 32 sites
Contextual Realities
•
Numerous, widely strategically located
dispersed, and
• Commonly the first point of for health concerns and information on drugs
• Convenient and trusted for health advice and other services
PPHA Previous Involvement in PDI PPHA full to the 2004 PDI implemented by PhilTIPS (7 sites)
170 Pharmacies Source: PM and DOTS Clinic Data, Jul’04-Jan’06
PPHA Previous Involvement in PDI 2010 PDI implemented by PTSI/TBLINC (12 sites)
121 Pharmacies Sept 2010 – June 2011
PPHA Previous Involvement in PDI PPHA was given a subgrant to implement PDI in 2012 (5 sites)
122 Pharmacies Apr 2012 – July 2012
PPHA Previous Involvement in PDI PPHA was one of 10 countires given a grant by FIPTB Challenge Round 1 to implement PDI in Surigao City in 2012
25 Pharmacies Jan – May 2012
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 • • • • •
Asymptomatic Negative sputum smears Negative chest x-ray Not contagious Quiescent or dormant infection
DISEASE • • • • •
Symptomatic Positive sputum smears Positive chest x-ray Infectious Active infection
Only a medical doctor can diagnose TB disease
The TB Life Cycle
Index Case Exposure N o t In f ec t ed
In 90-95% of infected patients, M. tb remains dormant in the body
A Tb patient infects 10-15 persons / yr
Infection 30% of un-treated TB undergoes spont. re-mission
Only active TB pts (specially smear (+)) can infect others 5-10% lifetime risk
Disease > 90%
CURE
RATE (w/ DOTS)
Healthy Subjects
Untreated, 70% will die in 5 yrs
Death
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 medication
“ubo! ubo! ubo!” (cough for 2 weeks or more)
Did not take medication
Cough worsens (may be smear positive)
Infects 10-20 persons annually
DIED
Incorrect treatment
Not regularly taking medication
Takes medication
“ubo! ubo! ubo!” (cough for 2 weeks or more)
Feels better but bacteria is still present in the lungs
Coughing recurs & bacteria multiplies, may be the drug resistant strain
First-Time TB vs MDR-TB .
TB
MDR-TB
Drug Used
Treatment using regular anti- Treatment using special 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 L PTSI-Tayuman DJNRMH KASAKA ITRMC Eversly Children’s Hospital
• De La Salle Treatment Center • Sorsogon Medical Missions Hospital • Community of German Doctors • Davao medical Center • Other Regional Treatment Centers
Prevalence of Multi-Drug Resistant TB • among new cases : 3.8% • among previously treated: 20.9% • combined: 5.7%
2% 21%
The Philippines ranked 9th among 27 countries that
for 85% of global MDR-TB burden
(National Drug Resistance Survey, 2004 and 1012)
Regularly taking medication
Takes medication (2 mos.)
“ubo! ubo! ubo!” (cough for 2 weeks or more)
Takes medication (4 mos.)
Feels better but bacteria is still present in the lungs
cured
TB is CURABLE. And the best way to do it is with
DOTS
What is DOTS? DOTS is the WHOrecommended strategy for diagnosis, treatment and management of TB. It stands for Directly Observed Treatment Short Course
FIVE ELEMENTS OF DOTS Identify infectious TB patients with smear microscopy
Microscopes
Ensure that short-course anti-TB drug are always available
Medicines
Monitor and record progress of treatment
Observe them swallow each dose of medicine
!
Sustain this effort with political and financial commitment
to confirm presence of TB bacilli
uninterrupted supply
Record Books Standardized recording and reporting system
Observers Ensures that no dose Is missed
Funding sound policies To DOTS
TB Disease Registration Group Category of Treatment
Type of TB Patient
Treatment Regimen
Pulmonary TB, new Category I
2HRZE/4HR Extra-pulmonary TB, new (except CNS/ bones or ts)
Category Ia
Category II
Category IIa
Extra-pulmonary TB, new (CNS/ bones or ts) Previously treated drug susceptible TB (pulmonary or extrapulmonary) Relapse Treatment After Failure Treatment After Lost to Follow-up (TALF) Previous Treatment Outcome Unknown Other
Previously treated drug susceptible EPTB (CNS/ bones or ts)
2HRZE/10HR
2HRZES/1HRZE /5HRE
2HRZES/1HRZE /9HRE
TB Disease Registration Group Category of Treatment
Type of TB Patient
Treatment Regimen
ZKmLfxPtoCs Standard Regimen Drug Resistant (SRDR)
Regimen for XDR
RR-TB or MDRTB
XDR-TB
Individualized once DST result is available Treatment duration for at least 18 months
Individualized based on DST result and history of previous treatment
What is the Advantage of Referring Patients to the DOTS Facilities? Reduce the delay in the diagnosis and treatment of a TB case
Reduce possibility of infecting 15 – 20 persons per year
Ensure Continuity and compliance of treatment
Higher chance of cure. Prevents development of MDR
Reduce out of pocket cost to patients
Ensures compliance
Ensure that TB patient is ed and notified to NTP
Assured case holding and monitoring of treatment, 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
The Pharmacy DOTS Initiative (PDI)
TRAINING/ COMPETENCYBUILDING
Empower pharmacists and their assistants to: ►Discourage the practice of selfmedication; encourage adherence to NTP guidelines ►Provide correct information on TB and DOTS ►Reinforce the No prescription – No dispensing of anti-TB drugs policy ► DOTS through prescreening and referral to DOTS facilities
National Policies and Guidelines 1. Pharmacy Bill Sec. 31: Sale of Medicine following dispensing guidelines Sec. 32: Categorization of pharmacy outlets Sec. 35 Prohibition of the distribution of Physician’s samples including AntiTB drugs Sec. 38: Record books required, including TB Referral Logbook Sec. 40: Registration of Medicines handlers with the PRC BOP 2. CHED Memorandum Order (CMO) on Policies, Standards and Guidelines for Pharmacy Education outcomes based education internship guidelines inclusion of PDI in PQF Level 1 and 2 programs 3. Inclusion of PDI in the TESDA standard training module for pharmacy assistants
PDI PROJECT OVER VIEW
PDI PHARMACY
Customer probably a presumptive TB case
Offer PDI Interventions
DOTS CENTE R Provide DOTS benefits
Customer cured of TB
DESIRED BEHAVIORAL CHANGES AFTER PDI
PDI PHARMACY
Will no longer insist on self medication
Will no longer dispense anti TB drug without prescription
DOTS CENTE R Will now recognize the pharmacy as a source of referrals
Components of the 2014 Pharmacy DOTS Initiatives Scale Up 1. Dissemination of information on cough of 2 weeks or more 2. Prescreening of customers who come to the pharmacy for a. cough medications without a prescription. b. TB drugs without a prescription c. TB drugs with a prescription 3. Referral to a DOTS facility
PHARMACY INTERVENTION
PHARMACY
Client asking for cough medication without a prescription
1. Who will be taking the medication 2. Duration of cough If < 2 If > 2 weeks: weeks: 3. Recommen 3. Informatio d cough n medication disseminat 4. Do not ion re dispense cough antibiotic 4. Explain 5. If health symptoms center persist, benefit come back 5. Issue
PHARMACY INTERVENTION
PHARMACY
Client asking for anti TB medicine without a prescription
1. Who will be taking the medication 2. Reason for buying 3. Duration of cough If > 2 If < 2 weeks: weeks: 4. Recommen 4. Information disseminati d cough on about medication TB. 5. Do not 5. Explain dispense need to see antibiotic a doctor 6. If 6. Explain symptoms health persist,
PHARMACY INTERVENTION 1. Explain importance of continuous uninterrupted treatment 2. Give cost of treatment
PHARMACY
Client asking for TB drug with a prescription
3. 1. Explain DOTS benefit 4. Issue referral slip 5. Do not dispense starter dose
3.
4. 5.
6.
If patient insists on buying, explain again importance of continuous uninterrupted treatment Partial filling is allowed Advice patient to go back to doctor after 2 months for follow up names of doctors prescribing
Phase 1 Sites NCR
Luzon
VisMin
Quezon City Caloocan City Valenzuela City Makati City Malabon City
Pangasinan Pampanga Nueva Ecija Isabela Benguet Laguna Batangas
Cebu Surigao Del Norte Bukidnon Zamboanga Del Norte Misamis Oriental
Phase 2 Sites NCR
Luzon
VisMin
Las Pinas City San Juan City Marikina City Pasay City Mandaluyong City Taguig City
Bulacan Tarlac Cavite Rizal Quezon
Northern Leyte Aklan Davao Oriental Sarangani Sibugay
PDI TARGET
Each PDI Pharmacy should be able to refer at least 20 presumptive TB patients to the health center per month.
Sustaining the Implementation of PDI through Collaboration with FDA, DSAP, PPHA Representation of PPHA/DSAP in multisectoral alliance organized in project site FDA new AO 56 Requirements (to be released July 2014) TB Referral Logbook Good Pharmacy Practice Standards Dispensing Guidelines
The DOTS Referral Network Private Referring MD
DOTS referring Hospital Private TML
Peripheral DOTS Facilities
•RHU, Health Center, PPMD •Public DOTSproviding Hospital •Private DOTSproviding Hospital
Private Pharmacy
HM O Workplac e Prison
Service Delivery Network
Pharmacists for a TB-Free Philippines
Irish Barrera – 09176230934 (globe)
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