Establishment of clinical pharmacy services: evidence-based information from stakeholders

High morbidity and mortality related to the use of drugs resulted in demand for clinical pharmacy services (CPS) globally. In developed countries, the evolution of pharmacists' role in direct patient care started in the 1960s. The participation of pharmacists in CPS has resulted in positive clinical, economic, and humanistic outcomes. In developing countries, efforts have started to ensure pharmacists are engaged in the provision of CPS. However, the efforts are hampered by poorly defined pharmacist career paths, financial constraints, and a lack of political willingness. In Tanzania, efforts started in 2008, in which CPS was introduced into the Bachelor of Pharmacy curriculum, followed by the initiation of a postgraduate program on hospital and clinical pharmacy in 2013. A regulation was released by the Tanzania Ministry of Health in 2020 to enforce pharmacists' engagement in providing CPS. In 2021, a project was launched in the country, aiming to strengthen the provision of CPS in public and faith-based hospitals by training on-job pharmacists. The project was implemented in phases, including stakeholders' engagement, baseline survey, training, and supportive supervision of the trained pharmacists. Therefore, this commentary aims to share what we experienced during project implementation, the achievements, challenges, and key lessons learned.

Antenatal corticosteroid therapy, delivery intervals and perinatal mortality in low-resource settings

BACKGROUND

Uncertainty exists regarding the ideal interval between the administration of antenatal corticosteroids (ACS) and delivery. The study's objective was to assess the risks of perinatal mortality and respiratory distress syndrome (RDS) among preterm neonates whose mothers gave birth within 48 h of the administration of ACS and those whose mothers gave birth between 48 h and 7 days.

METHODS

The study design was a secondary analysis of data from an observational prospective chart review study that was carried out in Tanzania in 2020. Preterm infants born to mothers who got at least one dose of ACS between 28 and 34 weeks of pregnancy were included.

RESULTS

A total of 346 preterm neonates (294 singletons and 52 twins) were exposed to ACS. Compared to infants born 48 h following the first dose of ACS, those exposed to the drug between 48 h and 7 days had significantly decreased rates of perinatal mortality and RDS. Multivariable analysis revealed that infants exposed ACS between 48 h and 7 days prior to delivery had lower risk of perinatal mortality (aRR 0.30, 95% CI 0.14-0.66) and RDS (aRR 0.27, 95% CI 0.14-0.52).

CONCLUSION

The first dose of ACS given between 48 h and 7 days before delivery was associated with a lower risk of perinatal mortality and RDS than when the first dose was given <48 h before delivery. To improve neonatal outcomes, healthcare providers should consider administering ACS to mothers at the appropriate time.

Access to essential cancer medicines for children: a comparative mixed-methods analysis of availability, price, and health-system determinants in east Africa

BACKGROUND

Access to essential childhood cancer medicines is a core determinant of childhood cancer outcomes. Available evidence, although scarce, suggests that access to these medicines is highly variable across countries, particularly in low-income and middle-income countries, where the burden of childhood cancer is greatest. To support evidence-informed national and regional policies for improved childhood cancer outcomes, we aimed to analyse access to essential childhood cancer medicines in four east African countries-Kenya, Rwanda, Tanzania, and Uganda-by determining the availability and price of these medicines and the health system determinants of access.

METHODS

In this comparative analysis, we used prospective mixed-method analyses to track and analyse the availability and price of essential childhood cancer medicines, investigate contextual determinants of access to childhood cancer medicines within and across included countries, and assess the potential effects of medicine stockouts on treatment. Eight tertiary care hospitals were included, seven were public sites (Kenyatta National Hospital [KNH; Nairobi, Kenya], Jaramogi Oginga Odinga Referral and Teaching Hospital [JOORTH; Kisumu, Kenya], Moi University Teaching and Referral Hospital [MTRH; Eldoret, Kenya], Bugando Medical Centre [BMC; Mwanza, Tanzania], Muhimbili National Hospital [MNH; Dar es Salaam, Tanzania], Butaro Cancer Centre of Excellence [BCCE; Butaro Sector, Rwanda], and Uganda Cancer Institute [UCI; Kampala, Uganda]) and one was a private site (Aga Khan University Hospital [AKU; Nairobi, Kenya]). We catalogued prices and stockouts for 37 essential drugs from each of the eight study siteson the basis of 52 weeks of prospective data that was collected across sites from May 1, 2020, to Jan 31, 2022. We analysed determinants of medicine access using thematic analysis of academic literature, policy documents, and semi-structured interviews from a purposive sample of health system stakeholders.

FINDINGS

Recurrent stockouts of a wide range of cytotoxic and supportive care medicines were observed across sites, with highest mean unavailability in Kenya (JOORTH; 48·5%), Rwanda (BCCE; 39·0%), and Tanzania (BMC; 32·2%). Drugs that had frequent stockouts across at least four sites included methotrexate, bleomycin, etoposide, ifosfamide, oral morphine, and allopurinol. Average median price ratio of medicines at each site was within WHO's internationally accepted threshold for efficient procurement (median price ratio ≤1·5). The effect of stockouts on treatment was noted across most sites, with the greatest potential for treatment interruptions in patients with Hodgkin lymphoma, retinoblastoma, and acute lymphocytic leukaemia. Policy prioritisation of childhood cancers, health financing and coverage, medicine procurement and supply chain management, and health system infrastructure emerged as four prominent determinants of access when the stratified purposive sample of key informants (n=64) across all four countries (Kenya n=19, Rwanda n=15, Tanzania n=13, and Uganda n=17) was interviewed.

INTERPRETATION

Access to childhood cancer medicines across east Africa is marked by gaps in availability that have implications for effective treatment delivery for a range of childhood cancers. Our findings provide detailed evidence of barriers to access to childhood cancer medicine at multiple points in the pharmaceutical value chain. These data could inform national and regional policy makers to optimise cancer medicine availability and affordability as part of efforts to improve childhood cancer outcomes specific regions and internationally.

FUNDING

American Childhood Cancer Organization, Childhood Cancer International, and the Friends of Cancer Patients Ameera Fund.

Barriers and facilitators of integration of pharmacists in the provision of clinical pharmacy services in Tanzania

BACKGROUND

Collaboration between medical doctors and nurses in the provision of healthcare services has been there for decades. The concept of clinical pharmacy services as a main goal for pharmacy practice is relatively new and is yielding more positive results for healthcare providers (HCPs), patients, and the health system. This study assessed barriers and facilitators toward the integration of pharmacists in the provision of CPS in Tanzania.

METHODS

A qualitative study was conducted in five tertiary hospitals representing Tanzania mainland. Ten (10) focus group discussions (FGDs) with 83 HCPs and 14 in-depth interviews (IDIs) with hospital administrators in referral hospitals were conducted between August and September 2021. The experienced qualitative researchers moderated the IDIs and FGDs, and all discussions were audio-recorded. Finally, the audios were transcribed verbatim, and analysis was done using a thematic approach.

RESULTS

Limited skills, lack of confidence, poor communication, inferiority, and superiority behaviors among HCPs were among the mentioned barriers. Shortage of pharmacists, lack of in-job training, standard operating procedures (SOPs), and guidelines were also mentioned. The study noted the high acceptability of CPS by other HCPs, the positive perception of pharmacists, and the recognition of CPS by the Tanzania Pharmacy Act and regulation.

CONCLUSION

The facilitators and barriers to the integration of pharmacists in the provision of CPS lie at the individual, health facility, and health system levels. Therefore, the study recommends in-job pharmacists training, fostering teamwork among HCPs, and development of CPS SoPs, and guidelines.

The magnitude of prescribing medicines by brand names in a tertiary hospital, Mwanza, Tanzania

Background:

Globally, one of the most common causes of irrational use of medicines is brand-name prescribing. The consequence of prescribing medicines using brand names is an economic burden on patients and society. Thus, this study aimed to investigate the magnitude of prescribing medicines by brand names in a tertiary hospital in Mwanza, Tanzania.

Methods:

A retrospective cross-sectional study was conducted between April 2020 and March 2021 at the Bugando Medical Centre. Data were collected from electronic prescriptions (outpatients) and medical files (inpatients). The data were analyzed using STATA version 14. A Chi-square test was conducted to examine the relationship between different categorical variables. p-Values of less than 0.05 were considered statistically significant.

Results:

Of 851 prescriptions analyzed, 416 (48.9%) contained medicines prescribed using brand names. Compared to outpatient units, the proportion of prescriptions with medicines prescribed by brand names in inpatient units was significantly higher (58.5% vs 39.1%), p < 0.001. The most frequently prescribed medicines by brand names were Ampiclox (ampicillin + cloxacillin), 35.2%, Buscopan (hyoscine butylbromide), 8.7%, and Amoxyclav (amoxicillin + clavulanic acid), 7.7%.

Conclusion:

Prescriptions written with brand names were found to be common, especially among fixed-dose combinations (FDCs), according to the current study. Governments, institutions, and other stakeholders should support and encourage the use of generic names in prescription writing because it saves money for patients and health care systems. This calls for Tanzania’s government to prioritize the development and implementation of generic prescribing policies.

Impact of coronavirus of 2019 on the delivery of pharmacy services to patients with cancer: An international survey of oncology pharmacy practitioners

INTRODUCTION

The coronavirus of 2019 pandemic has necessitated vast and rapid changes in the way oncology pharmacy services are delivered around the world.

METHODS/AIMS

An international survey of oncology pharmacists and technicians was conducted via the International Society of Oncology Pharmacy Practitioners and collaborating global pharmacy organisations to determine the impact that the coronavirus of 2019 has had on pharmacy service delivery, pharmacy practitioners and oncology practice.

RESULTS

The survey received 862 responses from 40 different countries from September to October 2020. The majority of respondents were pharmacists (n = 841, 97.6%), with 24% involved in the direct care of patients with the coronavirus of 2019. Of the survey participants, 55% increased their time working remotely, with remote activities including dispensing, patient assessment/follow-up and attending multi-disciplinary rounds. Respondents reported a 72% increase in the use of technology to perform remote patient interaction activities and that participation in educational meetings and quality improvement projects was reduced by 68% and 44%, respectively. Workforce impacts included altered working hours (50%), cancelled leave (48%) and forced leave/furloughing (30%). During the pandemic, respondents reported reduced access to intensive care (19%) and anti-cancer (15%) medications. In addition, 39% of respondents reported reduced access to personal protective equipment, including N95 masks for chemotherapy compounding. Almost half of respondents (49%) reported that cancer treatments were delayed or intervals were altered for patients being treated with curative intent. A third of practitioners (30%) believed that patient outcomes would be adversely impacted by changes to pharmacy services. Sixty-five percent of respondents reported impacts on their mental health, with 12% utilising support services.

CONCLUSION

The coronavirus of 2019 pandemic has altered the way oncology pharmacy services are delivered. These results demonstrate the adaptability of the oncology pharmacy profession and highlight the importance of formal evaluation of the varied practice models to determine the evidence-based practices that enhance pharmacy services and, thus, should be reinstated as soon as practical and reasonable.

Reducing neonatal mortality and respiratory distress syndrome associated with preterm birth: a scoping review on the impact of antenatal corticosteroids in low- and middle-income countries

BACKGROUND

The most common cause of death among preterm infants in low- and middle-income countries is respiratory distress syndrome. The purpose of this review was to assess whether antenatal corticosteroids given to women at risk of preterm birth at ≤ 34 weeks of gestation reduce rates of neonatal mortality and respiratory distress syndrome in low- and middle-income countries.

METHODS

Two reviewers independently searched four databases including MEDLINE (through PubMed), CINAHL, Embase, and Cochrane Libraries. We did not apply any language or date restrictions. All publications up to April 2020 were included in this search.

RESULTS

The search yielded 71 articles, 10 of which were included in this review (3 randomized controlled trials, 7 observational studies, 36,773 neonates). The majority of studies reported associations between exposure to antenatal corticosteroids and lower rates of neonatal mortality and respiratory distress syndrome. However, a few studies reported that antenatal corticosteroids were not associated with improved preterm birth outcomes.

CONCLUSIONS

Most of the studies in low- and middle-income countries showed that use of antenatal corticosteroids in hospitals with high levels of neonatal care was associated with lower rates of neonatal mortality and respiratory distress syndrome. However, the findings are inconclusive because some studies in low-resource settings reported that antenatal corticosteroids had no benefit in reducing rates of neonatal mortality or respiratory distress syndrome. Further research on the impact of antenatal corticosteroids in resource-limited settings in low-income countries is a priority.

Disposal practices of expired and unused medications among households in Mwanza, Tanzania

BACKGROUND

The community practice towards disposal of expired and unused medications in spite of its adverse impact have been widely neglected in many developing countries. The available guidelines in Tanzania focus on the disposal of expired medications and cosmetics in hospitals and community pharmacies only.

AIM

The aim of this study was to assess the disposal practice of expired and unused medications at household level in Mwanza city, north-western Tanzania.

METHODOLOGY

The household based cross-sectional study was conducted among 359 randomly selected household members. Semi-structured questionnaires were used for interview during data collection and while STATA® version 13 was used for analysis.

RESULTS

Out 359 households visited, 252 (70.19%) had medications kept in their houses at the time of data collection. Among them, 10 (4.0%) households had kept medications at their houses because they were still continuing with treatment while 242 (96.0%) kept unused medications which were supposed to be discarded. The main reason for keeping unused or expired medications at home was uncompleted course of treatment (199 (82.20%) after feeling that they had recovered from illness. The main reason for discarding medications were recovering from illness (141(48.7%) and expiry (136 (46.9%). The major discarding practices for medications were disposing into domestic trashes (219 (75.5%) and pit latrines (45 (15.5%). Majority of respondents (273 (76%) were aware that improper disposal of expired medications are detrimental to human health and environment in general.

CONCLUSION

Improper disposal of unused and expired medications at household level was a common practice in the study area. Tailor-made interventions by the Food and Drugs Authority (FDA) and other national as well as local stake holders are urgently needed to address the situation.

Magnitude and factors associated with anti-malarial self-medication practice among residents of Kasulu Town Council, Kigoma-Tanzania

Background

Anti- malarial self-medication practice in Africa is very common. It is considered as an alternative way for people who cannot afford the cost of health care services. This study was conducted to assess the magnitude and factors associated with anti-malarial self-medication practice among residents of Kasulu Town Council.

Materials and methods

The study was a descriptive cross sectional study. Two hundred and eighty consenting respondents were selected by systematic random sampling and interviewed with the aid of a semi structured questionnaire to assess anti-malarial self- medication practice. A p value of less than 0.05 was considered statistically significant, at 95% confidence interval.

Results

Prevalence of anti-malarial self-medication was (69.6%). Majority of the respondents (83.1%) reported that, they did not get better after self- medication. About 36% of the respondents metioned time taken in health facilities as the main factor for self-medication.

Conclusion

This study revealed that, self-medication practice is very common among community members in Kasulu district. The main reasons identified for self-medication was long time taken to get treatment in health facilities.

Self-medication among pregnant women attending antenatal clinic at Makongoro health centre in Mwanza, Tanzania: a challenge to health systems

BACKGROUND

Self-medication is a universal challenge that requires attention because of the potential threat not only to the pregnant women but also to unborn child. Data on self-medication practice and predictors among pregnant women is lacking in Tanzania. Information on the effects of this practice to the pregnant woman and the foetus globally is also scanty.

METHODS

This was a cross sectional study which was conducted using face to face interview with 372 pregnant women at Makongoro health centre. Semi-structured questionnaires were used. Data were analysed using STATA 13 (Statistical Corporation, College Station, Texas, US).

RESULTS

A total of 372 pregnant women participated in the study. The prevalence of self-medication among pregnant women was 172 (46.24%). There was a significant statistical association between self-medication and occupation (P value =0.01), gestation age (P < 0.01) and education (P < 0.01). Age, marital status and gravidity were not associated with self-medication (P = 0.809, P = 0.243 and P = 0.922) respectively. When bivariate logistic regression was performed, occupation and education were the only determining factors for self-medication. Pregnant women who were unemployed, doing business and house wife were most likely to practice self-medication than employed pregnant women (P = 0.03; OR = 2.33; 95% CI, 1.06-5.31, P = 0.01; OR = 2.31; CI 1.21-4.41, P = <0.01, OR = 2.73, 95% CI 0.52-2.43) respectively. Pregnant women with no formal education, incomplete primary education, primary education and secondary education were most likely to practice self-medication than pregnant women with college or university education (P < 0.01, OR = 6.37 95% CI 2.37-19.03, P < 0.01, OR = 6.58, 95% CI 2.36-18.25, P < 0.01, OR = 3.78, 95% CI 1.89-7.56, P < 0.01, OR = 2.59 95% CI = 1.30-5.17). The leading illness/symptoms which led to self-medication among pregnant women attending clinic were malaria 56 (32.56%, morning sickness 44 (25.55%) and headache 33(19.19%). Drugs commonly used in self-medication among pregnant women were ant malarial 42 (24.42%), antiemetics 59 (34.30%) and analgesics 33 (19.19%).

CONCLUSION

Prevalence of self-medication among pregnant women is high in Tanzania. This is a threat to the safety of the developing foetus and the pregnant woman. Therefore there is a need of interventions to minimize the practice among pregnant women.

Vitamin D receptor polymorphisms or serum levels as key drivers of breast cancer development? The question of the vitamin D pathway

As total vitamin D levels are often lower in black than in white Americans, the former are frequently classified as vitamin D-deficient. To fully understand African vitamin D (25(OH)D) status, other factors should be considered, e.g. vitamin D blood carrier, vitamin D-binding protein (DBP), vitamin D receptor (VDR) and DBP polymorphisms. A prospective study on an indigenous black Tanzanian and a Caucasian Italian population was performed on 50 healthy donors from both populations and 35 Caucasian and 18 African breast cancer patients. 25(OH)D and DBP serum levels were analyzed by ELISA. A1012G, Cdx2 and Fok1 VDR polymorphisms and DBP polymorphisms rs4588 and rs7041 were genotyped by real-time PCR. Vitamin D and DBP levels were lower in healthy African donors than in Caucasians. Africans had a significantly higher frequency of AA and CC for Cdx2 and Fok1 polymorphisms, respectively. These allelic variants were related to a higher transcription of VDR gene and a higher activity of VDR receptor. With regard to polymorphism distribution, Africans showed innate higher levels and activity of VDR. We conclude that a strengthening of the vitamin D pathway could have a protective role against the development of breast cancer in the African population.