‘’Pharmacists: an untapped potential in TB care and control’’

India has the world’s largest population of TB-infected individuals and MDR TB is on the rise. What role can pharmacists in India play to tackle this problem?

Manjiri Gharat

TB has been our major public health problem. Pharmacists who come in direct contact with the patients , i.e. community (retail) pharmacists, have a tremendous role to play in TB care and control. Being the first point of contact for patients, they come across several undiagnosed, untreated TB patients. Thus, it provides great opportunity to detect the people with symptoms of TB, counsel them to go for diagnosis and try to bring them on  treatment. One untreated case of Pulmonary (Lung) TB can infect 10 to 15 individuals in a year. So when a pharmacist detects even one such case, he is safeguarding the life of 10 to 15 individuals. This is a tremendous opportunity for early case detection. The Government of India has the Revised National Tuberculosis Control Programme (RNTCP) to fight against TB and under RNTCP, diagnosis and treatment is given free of charge under direct observation. This is known as DOTS (Directly Observed Treatment, short course) which is mainly delivered through Government hospitals, health posts and through some private providers. But till recently, retail pharmacies were never roped in this programme or rather in any national health programme. If DOTS is made available through pharmacies, it can certainly  increase the access to free anti-TB medicines. The long opening hours of pharmacies and convenient location makes it a perfect patient-centric DOTS setup.

Another important point to be noted is that 50 to 60 per cent TB patients go to private sector even though there is free treatment available in the public sector. One of the several reasons is lack of awareness about DOTS.

Also, an important issue is TB treatment is a lengthy process which takes a minimum of six to eight months or more. Many patients from the private sector leave the treatment halfway. This non-adherence is one of the major contributors to drug resistant TB. There is no monitoring mechanism in private sector treatment. Thus, counselling the patients and monitoring treatment is very important to improve the adherence. And pharmacists are in the best position to offer such services.

Thus, with this background,you realise that pharmacists can play a very important role. Community awareness about TB and about DOTS, case referral of TB symptomatic cases, provision of DOTS medicines through pharmacies, supervision of treatment, patient counselling and rational use of antibiotics are some of the key areas where pharmacists can contribute effectively.

Through Indian Pharmaceutical Association-Community Pharmacy Division (IPA CPD), you have spearheaded initiatives to engage pharmacists in the Revised National TB Control Programme (RNTCP). What are the goals and objectives of these initiatives?

At IPA, we realised that pharmacists’ potential has largely remained untapped and the situation in India urgently demands that this unutilised human resources be engaged in TB services. We should not leave any stone unturned when it comes to fight against TB. With this objective, from 2006, we started training pharmacists in Mumbai with the support of RNTCP and Maharashtra State Chemists and Druggists Association (MSCDA). Pharmacists were trained for the roles and responsibilities discussed earlier. Starting with seven pharmacists in 2006, now there are 350 plus pharmacists in Mumbai, Thane district, Nagpur in Maharashtra who are working for this social cause. Central TB Division, MoH, GoI took note of this DOTS TB Pharmacists project work and in April, 2012, CTD signed a MoU with IPA, AIOCD, SEARPharm Forum and PCI for engaging pharmacies in RNTCP pan India. This was a great satisfying milestone for us at IPA to see that a small initiative went to the national scale to benefit thousands of TB patients in the country. Also, this marked the first footprints of pharmacists in any national health programme. This project has turned out to be an innovative public private partnership model and Indian pharmacists’ work is appreciated world over.

IPA is invited to share these experiences in several of international conferences. Also, some high TB burden countries are in touch with us for this purpose. Recently; delegates from Ministry of Health, Vietnam visited DOTS pharmacies in Mumbai and as per the latest news, now they are replicating this model back home.

Central TB Division and IPA jointly have developed training module for community pharmacists. It has been uploaded on the www.tbcindia.nic.in/ website. On February 18, Director General of Health Services Dr Jagdish Prasad released this module. This module is for the pharmacists, as well as for the trainers. So using this module, the project will be implemented in Jharkhand, Delhi, Madhya Pradesh, Gujarat and West Bengal and later on to other states.

Have these initiatives resulted in any changes by way of better patient compliance, better public awareness of TB prevention and control, etc?

Yes, we have some data. Pharmacists have reached out to more than 7,000 people to create awareness. In the last two years, more than 400 patients have been cured at DOTS pharmacies under the supervision of the pharmacists.10 to 15 per cent of the cases referred by the pharmacists have been positive TB cases. Thus they are very well contributing to RNTCP and are strengthening the programme.

Apart from the statistics, I can give you some real life examples by which we can understand how significant the pharmacist’s contribution is. This is a case from Mulund, Mumbai. A pharmacist displayed the board outside the pharmacy about free anti-TB medicines (DOTS) appealing to enquire about TB diagnosis and free treatment at the pharmacy. The very next day, one patient approached the pharmacist after reading this board. The patient was recently diagnosed in the private sector and had just started the treatment. The patient was poor and was very unlikely to complete the full course of treatment. After interacting with the pharmacist, he went back to his physician and informed that he wished to switch to DOTS. He went to the nearby Corporation hospital as guided by the pharmacist where his diagnosis was confirmed by RNTCP TB authorities and DOTS treatment was started and his DOTS box was kept at the pharmacy. Now the patient has completed the treatment under the supervision of the pharmacist.

See, such patient would have been possibly a likely case of DR TB later as he would have left the treatment in a few days or few months, because of unaffordability. Pharmacists’ intervention proved to be very useful to get such patient under the purview of DOTS. There are several such case studies and pharmacists are doing a wonderful job.

Let me tell you that there are no much financial incentives for the pharmacists to do this work. I really appreciate and salute the socio-professional work of the pharmacists.

What remains to be achieved and implemented? (future plans, roadmap on this project)

Well, there is a lot to do. As I said earlier, now RNTCP will be expanding this pharmacist’s model in other states. IPA will extend support for this roll out. I see that it will take around next three to five years of efforts for this roll out and we have a clear road map for the same.

With support of all stakeholders, we wish to sensitise all the pharmacists in the country for this public health issue. Every pharmacist should be aware of TB symptoms and should be able to detect as many TB cases as possible from the community.

Is IPA CPD engaging with pharmaceutical companies as well? If so, what is the scope of this engagement and which pharma companies are involved?

Lilly MDR TB Partnership (of Eli Lilly and Company Foundation) is the one who is supporting us throughout this journey. In fact with Lilly’s support, we were able to expand our work in Maharashtra since 2010. Apart from funding, Lilly always provides support for work such as, follow up for some work with Govt TB authorities. So it is a true collaborative partnership that we have with Eli Lilly for this pharmacists TB work. Participating in the annual Lilly Summit is also an excellent opportunity to showcase our work, network with other stakeholders and to know the latest happenings in the globe. Lilly MDR-TB Partnership is further expanding this engagement with pharmacists by supporting partners /NGOs to implement the initiative in other states of India.

The RNTCP has announced its National Strategic Plan (NSP), for the period 2012 – 2017, with its new objective of ‘universal access’ for quality diagnosis and treatment for all TB patients in the community. What are the broad contours of the NSP and how is IPA CPD planning to be part of it?

I would say that we will offer all our services for this noble cause. In NSP, we can see that retail pharmacies will play a crucial role in Universal access plan. Things are yet to become clear but IPA CPD is always there wherever RNTCP needs us.

What are IPA CPD’s plans for World TB Day 2013?

Every year, CPD conducts TB awareness programme for the community through pharmacists. Also IPA Students Forum conducts awareness campaigns all over the country. We will continue the same. We also felicitate the DOT provider pharmacists on the TB day.

Are there any alignment/ partnerships with WHO, global initiatives like the Stop TB Partnership, etc.?

I have been enrolled by TB TEAM Expert in public-private mix (PPM) for TB care and control by WHO STOP TB Partnership. We have also worked with Partnership to develop draft tool for ‘Engaging pharmacies in TB care and Control’ for PPM tool-kit and participated in 8th PPM subgroup meeting of WHO. The draft is being finalised and once it is included in the tool-kit, the pharmacist’s model will more easily spread across the globe. It is always a great  feeling and great opportunity to work with WHO.