Timothy Rennie

Patient choice promotes adherence in preventive treatment for latent tuberculosis

The aim of the present study was to compare the effect of patient choice on completion rates and adverse drug reactions for patients treated for latent tuberculosis infection (LTBI) using 3-month rifampicin and isoniazid treatment (3RH) or 6-month isoniazid treatment (6H). Data for all patients treated using 3RH or 6H for LTBI between 1998 and 2004 were analysed. In total, 675 patients attended for chemoprophylaxis. Of these, 314 received 3RH and 277 received 6H. From April 1, 2000, patients were offered a choice of regimen; 53.5% completed the regimen successfully, a further 10.3% potentially completed it successfully and 36.2% failed to complete treatment. Logistic regression analysis suggested that successful completion was more likely in patients who were younger (an association that was lost after removing all patients aged <16 yrs), were offered a choice of regimen and attended all clinic visits before commencing treatment. Treatment was discontinued due to adverse reactions in 16 (5.1%) patients who were prescribed 3RH and 16 (5.8%) who were prescribed 6H. Treatment failure was most likely during the first 4 weeks of treatment for both regimens. At 13 weeks of treatment, more patients taking 6H had stopped compared with those completing the 3RH regimen. Drug costs were greater using 6H compared with 3RH. In conclusion, offering a choice of regimen improves completion. Most patients chose the 3-month rifampicin and isoniazid treatment over the 6-month isoniazid treatment. Adverse drug reaction rates between the two regimens were similar.

Needs-Based Education in the Context of Globalization

While opinion leaders in developed countries are calling for curricula to prepare students for specialized areas of pharmacy,1-4 developing countries are seeking patient-centered curricula and public health pharmacy to meet their changing health environments.5 In addition, there may be specific needs, especially in settings where tertiary pharmacy education has not been in place previously.6

Data mining of tuberculosis patient data using multiple correspondence analysis.

The aim of this study was to demonstrate the epidemiological use of multiple correspondence analysis (MCA), as applied to tuberculosis (TB) data from North East London. Data for TB notifications in North East London primary care trusts (PCTs) between the years 2002 and 2007 were used. TB notification data were entered for MCA allowing display of graphical data output (n=4947); MCA analyses were performed on the whole dataset, by PCT, and by year of notification. Graphical MCA output displayed variance of data categories; clustering of variable categories in MCA output signified association. Clustering patterns in MCA output demonstrated different associations by year of notification, within PCTs and between PCTs. MCA is a useful technique for displaying association of variable categories used in TB epidemiology. Results suggest that MCA could be a useful tool in informing commissioning of TB services.

Reflecting on interprofessional education in the design of space and place:lessons from Namibia

Abstract Education at the University of Namibia, School of Medicine and School of Pharmacy relies on a community-centred curriculum. The aim is to nurture “7-star” doctors and pharmacists that will address the current social and health needs within the country. A sound understanding of the interplay between learning and the learning environment is said to improve interprofessional educational activities. This relationship is dependent on constrictive alignment of not only the aspects of pedagogy, but also that of educational leadership in context of the current and social health needs. In this report, we reflect on the interprofessional-learning environment that was created out of necessity within a Namibian context.

Liver enzyme elevations in a cohort of HIV/AIDS patients on first-line antiretroviral therapy in Namibia: Findings and implications

Highlights • All antiretroviral therapies (ARTs) are potentially toxic to the liver. The rising incidence of ART induced adverse events has led to guideline revision.• The rising incidence of ART induced adverse events has led to guideline revision. Limited studies to date evaluating ART induced liver injury in these countries. This need to be addressed to guide future clinical practice.• Majority of patients developed significant ALT elevation within 3 months of ART initiation. No significant difference between mean ALT levels at baseline and month 6.• Patients with high risk of hepatocellular damage, female sex, and > grade 2 ALT elevations, and patients who test positive for HBV/HCV, should be monitored for at least 6 months after initiation of NVP and EFV based ART. Abstract Introduction All antiretroviral therapies (ARTs) are potentially toxic to the liver. In sub-Saharan Africa, the rising incidence of ART induced adverse events has complicated treatment leading to recent revisions of Namibian ART guidelines. Unfortunately there have been limited studies to date evaluating ART induced liver injury in Namibia to guide further revisions if needed. Objective Determine the current patterns and grades of ALT elevation in Namibia’s HIV/AIDS. Methods Retrospective cohort analysis. Patterns of alanine amino transferase (ALT) liver enzyme elevation were determined in a cohort of ART naïve HIV patients on firstline ART regimen in a referral hospital in Namibia over a 1 year treatment period. Patterns of ALT changes at baseline, 3 months and 6 months were analyzed using ANOVA and Bonferroni test for pairwise comparisons. Results Of 79 eligible patients, 72 developed significant ALT elevation within 3 months of ART initiation (F (3, 76) = 6.4, p = 0.002, η2 = 0.193). Four 4 (5.6%) and 1 (1.38%) patient respectively developed grade 2 and grade 3 ALT elevation by month 3. There was no significant difference between mean ALT levels at baseline and month 6. A CD4 count of <350 cells/mm3; female gender and age over 40 years were the main factors associated with moderate or severe ALT elevation. Conclusions First line ART commonly induces mild self-limiting liver enzyme elevation in Namibian HIV patients especially in the first 3 months. Consequently, there is a need to monitor ALT levels for at least 3 months after initiation mainly in high risk patients to reduce side-effect concerns. This is already happening.

Highlights From the FIPEd Global Education Report

The International Pharmaceutical Federation Education Initiative (FIPEd) launched the 2013 FIPEd Global Education Report (available at: www.fip.org/educationreports) in September 2013. This is the first publication of its kind to provide a baseline on the current status and transformation of pharmacy and pharmaceutical science education worldwide. A foundation of scientific and professional education and training is a key factor for pharmacists to develop the capability to improve therapeutic outcomes, enhance patients’ safety and quality of life and help people to stay healthy, as well as advance science and practice. For pharmacy, contemporary forms of initial education and training are vital for the profession to meet the increasingly complex pharmaceutical and public health care demands of populations. The 2013 FIPEd Global Education Report was conducted using surveys in English, French, Portuguese, Arabic, Japanese, Chinese, and Spanish. This resulted in education and workforce data for 109 countries and territories representing around 175,000 pharmacy students and 2,500 education institutions worldwide. Data indicate that education, in both capacity and infrastructure, varies considerably between countries and World Health Organization (WHO) regions, and generally correlates with a country’s population size and economic development indicators. Those countries and territories with lower economic indicators tend to have relatively lower educational capacity and pharmacist production. African countries tend to have lower educational capacity and supply pipelines for pharmacists. This has implications for future parity for access to medicines and medicines expertise. There needs to be an ongoing effort to ensure capacity building linked with initial education and training to meet the health needs of populations. Initial education is key in the development of the health care workforce for the future; better science, better practice, and better health care are all linked to the responsible use of medicines. The proportion of the female undergraduate population is a majority globally, with some regions having an average female pharmacy student enrolment of more than 70%. The relative costs of pharmacy and pharmaceutical education also varies across countries and territories. Fourteen countries in this sample reported no direct student tuition fees (including Afghanistan, Austria, Czech Republic, Denmark, Estonia, Greece, Hungary, Malta, Poland, Serbia, Slovenia, Sweden, Turkey and Uruguay). For those countries in the sample that do charge a direct tuition fee (for domestic students in public universities) the correlation of direct tuition fee payments with gross national income (per capita) is significant. Similarly with the total student costs (ie, direct tuition fee plus public capitation contribution) there are strong positive correlations with gross national income. There is an associated variation in the relative contributions of direct (individual) and public contributions for initial undergraduate education in the higher education sectors. Respondents provided high-level information on quality assurance. Information was sought to characterize whether quality assurance and accreditation was in place within the country and the accrediting body responsible. Sixteen percent of respondents claimed to have no accreditation mechanisms. Of the 64 countries and territories who supplied data in this section, 38 (59%) indicated the existence of a national core curriculum or syllabus for initial education. Forty-seven countries and territories provided data on the proportion of time spent on science-based laboratory learning in the core curriculum, which ranged from 6% to 70%, with a sample mean of around 36% (one third) of curriculum time spent on laboratory-based learning. Degree titles and lengths vary, which suggests differences in content and education provision models between countries and regions. This variance suggests that additional research is needed to examine similarities and differences in the educational outcomes associated with differing degree titles and lengths. The 14 case studies included in the report provide an overview of the transformation that is occurring in pharmacy and pharmaceutical science education globally. Fourteen countries, Chile, Great Britain, Japan, Jordan, Malaysia, Namibia, Philippines, Portugal, Saudi Arabia, Switzerland, Thailand, UAE – Abu Dhabi, USA and Zimbabwe, were purposively sampled based on existing knowledge and asked a series of questions about pharmacy education, relating to current drivers, trends, innovations, transformation and links with national strategy for health care services. The case studies provide an overview of the transformation that is occurring in pharmacy and pharmaceutical science education globally. Notably, there is a shift to patient-centered, team-based practice and to clinically focused, integrated curricula with increasing opportunities for patient and practice-centered and interprofessional learning. Nonetheless, there is still a shortage of pharmacist academics and of clinical preceptors worldwide. The understanding of education and the factors that influence it are essential for human resource planning and for achieving universal access to medicines (Figure 1). We need to provide quality education that meets national and global standards and engage in a socially accountable manner to serve the needs of individual patients and society as a whole. Moreover, there needs to be a strong alignment between the outcomes of pharmacy education and the overall health needs of nations. Figure 1. Needs-based professional educational model.

Adverse events and patients’ perceived health-related quality of life at the end of multidrug-resistant tuberculosis treatment in Namibia

Purpose The health-related quality of life (HRQoL) of patients completing multidrug-resistant tuberculosis (MDR-TB) treatment in Namibia and whether the occurrence of adverse events influenced patients’ rating of their HRQoL was evaluated. Patients and methods A cross-sectional analytic survey of patients completing or who recently completed MDR-TB treatment was conducted. The patients rated their HRQoL using the simplified Short Form-™ (SF-8) questionnaire consisting of eight Likert-type questions. Three supplemental questions on the adverse events that the patients may have experienced during their MDR-TB treatment were also included. Scoring of HRQoL ratings was norm-based (mean =50, standard deviation =10) ranging from 20 (worst health) to 80 (best health), rather than the conventional 0–100 scores. We evaluated the internal consistency of the scale items using the Cronbach’s alpha, performed descriptive analyses, and analyzed the association between the patients’ HRQoL scores and adverse events. Results Overall, 36 patients (20 males, 56%) aged 17–54 years (median =40 years) responded to the questionnaire. The median (range) HRQoL score for the physical component summary was 58.6 (35.3–60.5), while the median score for the mental component summary was 59.3 (26.6–61.9), indicating not-so-high self-rating of health. There was good internal consistency of the scale scores, with a Cronbach’s alpha value of >0.80. In all, 32 (89%) of the 36 patients experienced at least one adverse drug event of any severity during their treatment (median events =3, range 1–6), of which none was life-threatening. The occurrence of adverse events was not related to HRQoL scores. For patients reporting zero to two events, the median (range) HRQoL score was 56.8 (44.4–56.8), while for those reporting three or more events, the median score was 55.2 (38.6–56.8); P=0.34 for difference between these scores. Conclusion Patients completing treatment for MDR-TB in Namibia tended to score moderately low on their HRQoL, using the generic SF-8 questionnaire. The occurrence of adverse events did not lead to lower HRQoL scores upon treatment completion.

Oversupply and under-resourced: the global context of pharmacy education.

There are growing concerns over the oversupply of pharmacists amid continued growth in the pharmacy education sector in the United States.1 Brown predicts that 21 US states will increase the number of pharmacy graduates by 100% or more from 2001 to 2016, with no sign of a slowdown and a declining demand in the market.2 The author paints a bleak picture and argues that the profession should not simply allow market forces of survival of the fittest to correct the imbalance. However, there appear to be encouraging signs of expansion of the profession. For example, the broadened and well-defined role of the clinical pharmacist, not just in the hospital setting but in the community; the range of the profession in seeking traditionally hard-to-reach communities and less desired nightshift work; task-shifting from the medical profession; and a comeback of the compound pharmacist.3 The US situation does not appear to be unique, with a proliferation of both pharmacy schools and pharmacy graduates reported in other countries such as the United Kingdom and Canada. In response to this, the United Kingdom is examining a cap on student numbers.4 There are, however, vast differences in the pharmacy workforce globally. The International Pharmaceutical Federation Global Pharmacy Workforce Report (2009)5 identified sub-Saharan Africa as the area with the smallest proportion of pharmacists. Although the report did not include an analysis of schools of pharmacy or other pharmacy education programs, there appears to be a similar trend in the educational output. For example, the southern African countries Botswana, Namibia, and Swaziland are creating pharmacy programs for the first time.6 These countries share similarities besides their geography and disease profiles in that they are all low-population countries. They also all neighbor the Republic of South Africa where pharmacy education has long been established with a relatively healthy pharmaceutical industry sector. This might also explain why pharmacy education has been slow to take off given the huge investment required to initiate such programs when it may make more economical sense to train pharmacists in neighboring or wider countries. A report by Brock et al, 7 for example, suggested that an increase of 50% of pharmacists to steady state may be sufficient to meet the pharmaceutical care demand in Namibia. While this may seem a significant challenge, with the number of registered pharmacists in Namibia hovering at about 200 (a professional group less than the number of pharmacy graduates predicted for 2016 in 25 US States), an output of 20-30 pharmacy graduates per year over a decade may be all that is necessary. In this setting, there is little room for competition and little room for significant growth in the education sector except to consider international students, postgraduate programs, continuing professional development, and other educational programs such as technician training. This trend between oversupply in the “developed” setting and undersupply in continents such as Africa is not truly a dichotomy. In Ethiopia, for example, there were reported to be upwards of 12 pharmacy education programs, 8 some of which with support from US institutions.9 With a population of over 90 million people, this may not be surprising but could also result in government initiated rationalization to avoid oversupply and/or a loss of quality in the profession. While there are some stark differences between pharmaceutical care needs in different settings and the resultant educational strategies (for example, the clinical emphasis of North American education vs the emphasis on the pharmaceutical industry in some South African courses), there are also some lessons to be learned by policymakers and educationalists from the global trends observed in pharmacy education. Observing how educational output can change the profession might call some to question whether the tail wags the dog.

A pragmatic approach ensuring accuracy in language translation in tuberculosis research

BACKGROUND To research patient perceptions of medicines and illness in a multicultural setting, it is appropriate to translate research materials. However, the translation procedures should be valid and reliable to assure accuracy. OBJECTIVES To translate into 3 languages-Turkish, Urdu, and Bengali-a research questionnaire investigating illness and medicines perceptions of tuberculosis patients and to validate the translation. METHODS A 4-stage protocol for the translation and validation of research questionnaires investigating illness and medicines perceptions was designed and implemented. This involved forward and back-translation, group-validation, and post hoc conceptual equivalence rating in 3 different languages. RESULTS The translation protocol was found to be very useful in identifying discrepancies between original and translated versions; a total of 83 amendments were required. Post hoc evaluations also demonstrated improvements for 2 of the 3 language translations. Some redundancy was apparent and an improved protocol was suggested by the authors. CONCLUSIONS This study demonstrated that including a protocol for translation and validation of the translation is crucial to assure accuracy in multicultural research.

Implementing clinical pharmacy within undergraduate teaching in Namibia

Clinical pharmacy is currently not practised in Namibia. To introduce the concept and skills pertinent to this area of practice, pharmacy undergraduates at Namibia’s new School of Pharmacy are introduced to clinical pharmacy from their second year, and progress from theory to practical application on the wards. This approach has led to students having a greater understanding of clinical pharmacy and how it can be applied in practice. Introducing clinical pharmacy progressively at an undergraduate level may help to stimulate interest in the speciality for future career progression.