Engaging Community Pharmacies in Early Detection of Missing Tuberculosis Patients through Public–Private Mix Intervention in Pakistan

Abstract

Globally, Pakistan ranks fifth in terms of missing tuberculosis (TB) patients' burden. Missed TB cases are either undiagnosed or diagnosed but not notified to the national TB database. Public-private mix interventions are contributing significantly to the case detection, diagnosis, and treatment of TB in Pakistan. However, it is estimated that many cases of infected TB patients go undetected. It is likely that these "undiagnosed" active TB cases seek treatment from community pharmacies, among other venues. This study aimed at assessing the feasibility of community pharmacy-based TB case detection. Case detection protocol implementation in three Pakistani districts in a nonrandom selection of pharmacies was followed by a review of routinely maintained prospective records of patients referred from these private community pharmacies to general practitioner (GP) clinics. The study engaged 500 community pharmacies for referring presumptive TB patients to GP clinics. In total, 85% of the engaged pharmacies remained active in providing referrals during the study period. The community pharmacy-referral network achieved an annual referral rate of 3,025 presumptive TB patients and identified 547 active TB cases for the period January-December 2017. Every fifth referral among presumptives presenting and counseled at pharmacies was diagnosed with TB at GP clinics. This contribution was 9% of all new TB cases identified in these districts through all other private venues linked with the Greenstar Social Marketing setup. Identified barriers and facilitators to implementation and cost effectiveness of pharmacy models for TB case detection should be considered if the model were to be scaled up.

Barriers and motivation for presumptive tuberculosis case referral: qualitative analysis among operators of community medicine outlets in Ghana

“…Their motivation was also to ensure they or their families do not fall victims to the TB disease. This could explain why in studies in Pakistan [8] and Cambodia [10], most pharmacy staff show no hesitation in signing to participate in the PPM contract.…”

“…Supports in the form of training, provision of TB referral forms and sputum containers, feedback on referred cases and financial support are key motivation factors for TB referral in our study. Many studies with success stories on referral by pharmacies emphasized the need to provide training for pharmacy staff [29] and support services including incentives as avenues for sustenance [8,32]. Participants are motivated when they received clients who are open to the suggestions of pharmacists and who have some basic knowledge on TB.…”

“…Community pharmacies and over-thecounter medicine outlets do not require prescriptions for most of their medications and have short or no waiting time, hence their services are highly frequented by community members including individuals presenting with cough [7]. International studies have shown that operators of community medicine outlets in other countries largely support the public-private mix (PPM) strategy, which also includes referral of individuals with presumptive TB to public health facilities as shown in studies from Pakistan [8,9], Cambodia [10] and India [11].…”

Knowledge, attitude and practice of community pharmacy personnel in tuberculosis patient detection: a multicentre cross-sectional study in a high-burden tuberculosis setting

“…[3][4][5][6][7][8] Other evidence from India, Pakistan and Tanzania also supported that community pharmacies can help in detecting patients with TB in the community. [37][38][39] However, a comprehensive strategy is required to follow up on this study to implement TBPD activities among pharmacy personnel.…”

Role of small private drug shops in malaria and tuberculosis programs in Myanmar: a cross-sectional study

“…Mixed findings about the performance of drug shop referral service were seen in previous studies. While these drug shops could not provide promising outcomes in some countries [ 11 , 12 ], some worked well in referring presumptive TB cases, and therefore, sustainability should be considered for the longer term and collaborative actions were suggested [ 13 ]. Great opportunities of these providers from TB case finding to treatment completion were reported [ 14 – 17 ].…”