Role of private pharmacies in TB control in Egypt, 2009 Principal investigators Dr.Sherry Victor / NTP Logistic and DR-TB officer Dr. Magdy Fawzy/ Research & PAL coordinator, DR-TB consultant Technical assisstance: Dr Amal Bassili, TB Surveillance officer, STB/WHO/EMRO Focal point, Tropical Disease Research.

Egypt is a country in North Africa Area:1,010,000 square kilometers Population : 79,000,000

Objectives of the study: General objective: To describe the current pattern of TB treatment regimens used in the private pharmacies in Egypt

Specific objectives To determine the proportion of private pharmacies that have anti-TB treatment, ATT, in different geographical governorates; To evaluate the prescribing practices of the physicians referring cases to the private pharmacies for purchasing the drugs; To evaluate knowledge, attitudes and practices, KAP, of the private pharmacists towards TB; To evaluate the feasibility of engaging the private pharmacists in identifying TB suspects and their referral to the nearest TBMU for diagnosis.

Study area/Govenorates The study was carried out in a representative sample of all Egyptian governorates. Inclusion criteria - Pharmacies that have been working for at least 3 months whether registered or not - Consent to participate in the study

Study type Cross-sectional survey conducted in one quarter where pharmacists/pharmacists assistants in a representative sample of private pharmacies were interviewed using a questionnaire inquiring the following information: The presence of ATT, Their KAP regarding TB, Prescribing practices by the pharmacist (over the counter use of drugs), The prescribing practices of the referring physicians, and the extent of their adherence to the NTP guidelines.

 Pharmacists were requested to identify and collect information about TB suspects visiting their pharmacies during the study period and to refer them to the nearest TB management unit, TBMU.  They were subjected to every other week visits by the field supervisors in each district in order to:  ensure the quality of data collected  collect the completed forms  send them to the NTP central unit

Sample size The district is the primary sampling unit for the study. A sampling frame was developed from the list of pharmacies at the district level in the different governorates and 30 clusters in 20 governorates were selected using probability proportionate to size. The final sample size was 960 pharmacies. The cluster size was: 960/30= 32 pharmacy in each selected cluster. Only 866 responded in 17 governorates (27 clusters)

Participated pharmacies (866) Governorate (20) 32 6-Oct 68 Alexandria 32 Assuit 0 Aswan 32 Behira 32 Beni Sweif 128 Cairo 95 Daqahlia 32 Fayoum 96 Gharbia 32 Ismaeilia 32 Kafr Elsheikh 0 Luxor 32 Menia 32 Menofia 32 Port Saeid 32 Qaliobia 0 Qena 95 Sharqia 32 Sohag

Methodology Each district was covered by one pharmacist working at the governorates local authorities under the supervision of their heads. One day orientation was carried (TB overview, how to choose the selected sample, questionnaire overview) The study period was August, September and October 2009

Interviewed personnel by gender

Personnel by Job and Gender * Owners, directors and hired pharmacists

Knowledge about NTP with age group

Knowledge by governorate

Source of knowledge *Highest knowledge was from mass media. ** Others: Pharmacies inspectors, Government obligatory duty after graduation.

Willing to collaborate with NTP

Suggested collaboration activities

Collaboration barriers 75% responded that there are no barriers 19% mentioned that barriers could be time constraints, no cases being met, health status of the pharmacist, not the responsible personnel to decide……. 6% didn’t respond

Suggestions to strengthen notification to NTP 44 % suggested hot line 10% address 8 % others 38% didn’t offer suggestions

How the pharmacist deal with TB suspects

Anti-TB medications sold during the study period

TB treatment regimens prescribed for TB patients The referring sites were: Public hospitals other than NTP units (minority) Private hospitals and clinics (forming the highest percentage, 83%)

Regimens prescribed 446 regimen were prescribed: – 314 (70%) were mono-therapy either R, Z, E or S – 78 (17 %) were di-therapy mainly RH – 44 ( 10%) were treated with combination therapy. – 5 prescriptions (1%) were with Levofloxacin (Lfx) in addition to first line drugs.

Recommendations Orientation programs to pharmacists working in private sector concerning TB symptoms, and referral channels. Hot line to NTP aiming at case notifications. Distribution of IEC materials to the private sector. Strengthening collaboration with private doctors. Enhancing community orientation through mass media. Activation of legislation that ban the selling of anti-TB drugs over the counter.