Evaluating The Effectiveness Of Anti-Smoking Messages On Knowledge About Health Effects, Negative Thinking And Behaviour Among Malaysians

Tobacco use has been identified as the leading cause of death and disability in the world. In Malaysia, overall (age ≥15 years) smoking prevalence of 23.2%, with male smoking rate is 44.6%. Among teenagers, 15% indicated as experimenters, another 8% confessed to being regular smokers. Smoking-related diseases had caused 35% of the death in Government hospitals in 2006. The Malaysian government launched a comprehensive national anti-smoking media campaign called “Tak Nak” in targeting at children, youth, women as well as smokers and the non-smokers

Assessing knowledge, perception and attitudes about antibiotics among final year pharmacy undergraduates in Sri Lanka

Objective: Anti-microbial resistance has become a global problem especially in developing countries. The aim of the study was to evaluate the effect of socio-demographic predictors amongst final year pharmacy undergraduates in Sri Lanka on their knowledge, perception and attitudes regarding antibiotic use.Methods: A questionnaire-based study involved final year pharmacy students from four public universities in Sri Lanka. Data on knowledge, attitudes and perception about the appropriate use of antibiotics were analysed. Ethics approval was granted by the university of Ruhuna Sri Lanka.Results: There was good general knowledge of antibiotics (mean=15.57), however, 46% said metronidazole is not an antibiotic, 82% said that the use of antibiotics speed-up the recovery from the common cold. Perception (p=0.033) and attitudes (p=0.028) of respondents from urban area were significantly higher than that of those from rural area.Conclusion: Clinical education for pharmacy undergraduates should have an in-depth focus on the rational of antibiotics use in Sri Lanka

ANTIBIOTICS UTILIZATION PATTERNS AND DIRECT COST IN AN EMERGENCY TREATMENT UNIT IN SRI LANKA

Objective: Anecdotal evidence suggested that antibiotics are frequently used in the Emergency Treatment Units in Sri Lanka, mostly for the respiratory tract, soft tissue or urinary tract infections. This study aimed to describe the utilization patterns of antibiotics in terms of most common type, indication and associated direct cost in ETU at the Teaching Hospital Karapitiya, Sri Lanka. Methods: In this study, utilization patterns and the direct cost of antibiotics in an emergency treatment unit was evaluated by checking the bed-head tickets of all patients admitted to the unit from 1/5/16 to 15/5/16. Out of the 414 bed-head tickets checked 156 patients were receiving antibiotic treatment. Socio-demographic characteristics were analyzed. The prices of antibiotics in SriLankan government hospitals were taken from the hospital medical supply division price list. Data were analyzed by Microsoft Excel™. Results: In this study, 45.5% (out of 156 patients) were aged between 61-80years. The most used antibiotic was amoxicillin/clavulanic acid (18.1%) and clarithromycin (15.5%). Generic antibiotics were used for most patients (95.58%). Fixed-dose combinations were used in 18.5% of cases, including amoxicillin/clavulanic acid and piperacillin/tazobactam. The common indications for prescribing antibiotics were respiratory tract infections (31.2%) and soft tissues injuries (12.1%). Conclusion: This study revealed that there is apparent overuse of antibiotics and reveals that antibiotic stewardship programme could reduce antibiotic use, antibiotic resistance, and cost. Improved understanding of the rationale for antibiotic use would contribute optimising their use. Further studies are needed to establish the extent of sub-optimal prescribing of antibiotics in Sri Lankan hospitals

ANTIBIOTICS UTILIZATION PATTERNS AND DIRECT COST IN AN EMERGENCY TREATMENT UNIT IN SRI LANKA

Objective: Anecdotal evidence suggested that antibiotics are frequently used in the Emergency Treatment Units in Sri Lanka, mostly for the respiratory tract, soft tissue or urinary tract infections. This study aimed to describe the utilization patterns of antibiotics in terms of most common type, indication and associated direct cost in ETU at the Teaching Hospital Karapitiya, Sri Lanka. Methods: In this study, utilization patterns and the direct cost of antibiotics in an emergency treatment unit was evaluated by checking the bed-head tickets of all patients admitted to the unit from 1/5/16 to 15/5/16. Out of the 414 bed-head tickets checked 156 patients were receiving antibiotic treatment. Socio-demographic characteristics were analyzed. The prices of antibiotics in SriLankan government hospitals were taken from the hospital medical supply division price list. Data were analyzed by Microsoft Excel™. Results: In this study, 45.5% (out of 156 patients) were aged between 61-80years. The most used antibiotic was amoxicillin/clavulanic acid (18.1%) and clarithromycin (15.5%). Generic antibiotics were used for most patients (95.58%). Fixed-dose combinations were used in 18.5% of cases, including amoxicillin/clavulanic acid and piperacillin/tazobactam. The common indications for prescribing antibiotics were respiratory tract infections (31.2%) and soft tissues injuries (12.1%). Conclusion: This study revealed that there is apparent overuse of antibiotics and reveals that antibiotic stewardship programme could reduce antibiotic use, antibiotic resistance, and cost. Improved understanding of the rationale for antibiotic use would contribute optimising their use. Further studies are needed to establish the extent of sub-optimal prescribing of antibiotics in Sri Lankan hospitals

Clinical pharmacy in Galle Sri Lanka, collaboration and friendship

Pharmacy undergraduate courses in Ruhuna, while is more practice focus than many of the other courses in Sri Lanka, it is still missing clinical pharmacy elements. Collaboration between academic staff from Ruhuna University and two international clinical pharmacy academics was established in 2014. The aim of this paper is to report on a clinical pharmacy training program, delivered by the international academics and supported by the Sri Lankan academics to pharmacy students in 2015-2016. After short conceptualisation lecture on each topic, there was a workshop which was structured as team case-based learning progressive case studies. Topics included mental health, pharmacokinetics, interpreting laboratory results, parenteral drug compatibility, special hospital compounding and medication review, of which all were assessed in the final examination. Student found team based learning to be engaging and enabled them to independently and critically think in a safe environment and preferable over the traditional lectures

Antibiotics utilization patterns and direct cost in an emergency treatment unit in Sri Lanka

Objective: Anecdotal evidence suggested that antibiotics are frequently used in the Emergency Treatment Units in Sri Lanka, mostly for the respiratory tract, soft tissue or urinary tract infections. This study aimed to describe the utilization patterns of antibiotics in terms of most common type, indication and associated direct cost in ETU at the Teaching Hospital Karapitiya, Sri Lanka. Methods: In this study, utilization patterns and the direct cost of antibiotics in an emergency treatment unit was evaluated by checking the bed-head tickets of all patients admitted to the unit from 1/5/16 to 15/5/16. Out of the 414 bed-head tickets checked 156 patients were receiving antibiotic treatment. Socio-demographic characteristics were analyzed. The prices of antibiotics in SriLankan government hospitals were taken from the hospital medical supply division price list. Data were analyzed by Microsoft Excel™. Results: In this study, 45.5% (out of 156 patients) were aged between 61-80years. The most used antibiotic was amoxicillin/clavulanic acid (18.1%) and clarithromycin (15.5%). Generic antibiotics were used for most patients (95.58%). Fixed-dose combinations were used in 18.5% of cases, including amoxicillin/clavulanic acid and piperacillin/tazobactam. The common indications for prescribing antibiotics were respiratory tract infections (31.2%) and soft tissues injuries (12.1%). Conclusion: This study revealed that there is apparent overuse of antibiotics and reveals that antibiotic stewardship programme could reduce antibiotic use, antibiotic resistance, and cost. Improved understanding of the rationale for antibiotic use would contribute optimising their use. Further studies are needed to establish the extent of sub-optimal prescribing of antibiotics in Sri Lankan hospitals

Acute Human Self-Poisoning with Imidacloprid Compound: A Neonicotinoid Insecticide

Background: Deliberate self-poisoning with older pesticides such as organophosphorus compounds are commonly fatal and a serious public health problem in the developing world. The clinical consequences of self-poisoning with newer pesticides are not well described. Such information may help to improve clinical management and inform pesticide regulators of their relative toxicity. This study reports the clinical outcomes and toxicokinetics of the neonicotinoid insecticide imidacloprid following acute self-poisoning in humans. Methodology/Principal Findings: Demographic and clinical data were prospectively recorded in patients with imidacloprid exposure in three hospitals in Sri Lanka. Blood samples were collected when possible for quantification of imidacloprid concentration. There were 68 patients (61 self-ingestions and 7 dermal exposures) with exposure to imidacloprid. Of the self-poisoning patients, the median time to presentation was 4 hours (IQR 2.3–6.0) and median amount ingested was 15 mL (IQR 10–50 mL). Most patients only developed mild symptoms such as nausea, vomiting, headache and diarrhoea. One patient developed respiratory failure needing mechanical ventilation while another was admitted to intensive care due to prolonged sedation. There were no deaths. Median admission imidacloprid concentration was 10.58 ng/L; IQR: 3.84–15.58 ng/L, Range: 0.02–51.25 ng/L. Changes in the concentration of imidacloprid in serial blood samples were consistent with prolonged absorption and/or saturable elimination. Conclusions: Imidacloprid generally demonstrates low human lethality even in large ingestions. Respiratory failure and reduced level of consciousness were the most serious complications, but these were uncommon. Substitution of imidacloprid for organophosphorus compounds in areas where the incidence of self-poisoning is high may help reduce deaths from self-poisoning

Standardised patient study to assess tuberculosis case detection within the private pharmacy sector in Vietnam.

BACKGROUND: Of the estimated 10 million people affected by (TB) each year, one-third are never diagnosed. Delayed case detection within the private healthcare sector has been identified as a particular problem in some settings, leading to considerable morbidity, mortality and community transmission. Using unannounced standardised patient (SP) visits to the pharmacies, we aimed to evaluate the performance of private pharmacies in the detection and treatment of TB. METHODS: A cross-sectional study was undertaken at randomly selected private pharmacies within 40 districts of Vietnam. Trained actors implemented two standardised clinical scenarios of presumptive TB and presumptive multidrug-resistant TB (MDR-TB). Outcomes were the proportion of SPs referred for medical assessment and the proportion inappropriately receiving broad-spectrum antibiotics. Logistic regression evaluated predictors of SPs' referral. RESULTS: In total, 638 SP encounters were conducted, of which only 155 (24.3%) were referred for medical assessment; 511 (80·1%) were inappropriately offered antibiotics. A higher proportion of SPs were referred without having been given antibiotics if they had presumptive MDR-TB (68/320, 21.3%) versus presumptive TB (17/318, 5.3%; adjusted OR=4.8, 95% CI 2.9 to 7.8). Pharmacies offered antibiotics without a prescription to 89.9% of SPs with presumptive TB and 70.3% with presumptive MDR-TB, with no clear follow-up plan. CONCLUSIONS: Few SPs with presumptive TB were appropriately referred for medical assessment by private pharmacies. Interventions to improve appropriate TB referral within the private pharmacy sector are urgently required to reduce the number of undiagnosed TB cases in Vietnam and similar high-prevalence settings

Pharmacists’ provision and public’s use of antibiotics for common infections in Sri Lanka

Background: Antibiotic resistance (ABR) is a major and complex preventable global problem which transcends international boundaries. It makes infections more difficult to treat or even untreatable as well as contributing to a shrinking range of effective antibiotics available. Transmission of bacteria which are resistant to antibiotics between developed and developing countries is two-way, however it has been rarely explored in developing countries because of inadequate resources. There is evidence suggesting that the emergence and spread of ABR, especially the appearance of multidrug-resistant bacterial strains which are resistant to many antibiotic classes, has raised a major global public health concern, including in Sri Lanka, and has been linked to inappropriate antibiotic supply and use. ABR is also associated with increased morbidity, mortality and treatment costs. It appears that the greatest burden occurs in low and middle-income countries (LMICs) where common infections are higher in rate, particularly diarrhoea, upper respiratory tract infections, and urinary tract infections (UTIs). If no actions are taken, it has been estimated that antimicrobial resistance will lead to 10 million deaths annually by 2050, and a loss of US$100 trillion of the world economic output. Hence, it is important to understand antibiotic supply and use, and factors that contribute to such practices in a country and to develop country specific interventions to promote appropriate practices. Currently, there is a scarcity of research in this area, particularly in LMICs, and none has been conducted in Sri Lanka. Factors which contribute to inappropriate provision and use of antibiotics may be geographically linked and influenced by human behaviour, health literacy, economy, and legislation. Thus, findings in one geographic location may not be generalisable to other areas. Hence, it is imperative to generate local data in order to plan effective country and region-specific interventions. xxi The overall aims of this thesis were to (i) evaluate the supply of antibiotics without a prescription by Sri Lankan community pharmacy staff; their knowledge about, and attitudes towards, antibiotics; and factors that may be associated with the supply for common infections. (ii) investigate how the public in Sri Lanka use antibiotics, including their knowledge about, attitudes to, self-medication with, and requests for, antibiotics from pharmacies; and factors that may be associated with the self-medication and antibiotic request without prescription from pharmacies for common infections. Methods: Antibiotics supply for infections, such as the common cold, acute sore throat, acute diarrhoea and UTIs was measured using three approaches among an estimated sample of 369 community pharmacies in Sri Lanka from Dec. 2016 to Sept. 2017: a self-reported survey, including pharmacy staff’s knowledge and attitudes related to antibiotic supply and two simulated client (SC) visits. SCs visited consenting pharmacies twice, approximately two weeks to six months apart. One SC visit involved directly requesting one of four antibiotics (direct product request or DPR): erythromycin, metronidazole, or ciprofloxacin tablets, or amoxicillin syrup. The other SC visit involved presenting symptoms of one of the four infections (symptoms based request or SBR) and requesting a medicine for the symptoms. The interactions in the pharmacy during the SC visits were covertly audio-recoded with prior permission. The public’s knowledge, attitudes and antibiotic use and self-medication for common infections were assessed using a cross-sectional interviewer-administered household survey among a random sample (n=1100) of the Sri Lankan public. This was conducted in a similar xxii geographical area as where the pharmacies were surveyed. Informed written consent was obtained from each eligible participant prior to the interview. Data were analysed using descriptive statistics including mean and standard deviation (SD), median and interquartile range (IQR), frequencies (%), factor analysis and reliability tests, and inferential statistics including t-test, one-way ANOVA or chi-square test, and binary and multiple logistic regression. Results: Across the four infections – acute sore throat, the common cold and cough, diarrhoea and UTI, the proportion of pharmacy staff who provided an antibiotic without a prescription was found to be 61% (147/242) in the DPR SC study compared to 41% (99/242) in the SBR SC study. These were markedly higher than the findings from the self-reported survey of the identical pharmacy staff 19.4% (47/242). The SBR study revealed that 66% (65/99) of SCs with viral infections were supplied antibiotics inappropriately for reported symptoms of viral infections. Though the availability of a pharmacist reduced the likelihood of unlawful antibiotic supply (OR = 0.53, 95% CI: 0.31–0.89; p = 0.016), it did not impact on appropriate antibiotic supply. The self-reported survey found that the overall knowledge about antibiotics was poor among pharmacy staff. Pharmacists with higher ABR knowledge were less likely to supply antibiotics without a prescription for viral infections in adults (Adj. OR=0.73, 95% CI: 0.55-0.96; P=0.027) and children (Adj. OR=0.55, 95% CI: 0.38-0.80; P=0.002). Pharmacy staff who had knowledge about the legal aspects of antibiotic supply were less likely to provide antibiotics (Adj. OR=0.47, 95% CI: 0.30-0.75; P=0.001), and specifically less likely to give an antibiotic for bacterial infections in adults (Adj. OR=0.45, 95% CI: 0.20-0.99; P=0.047). Knowledge xxiii about antibiotic use and misuse reduced the likelihood of dispensing an antibiotic without a prescription for the common cold (Adj. OR=0.75, 95% CI: 0.60-0.94; P=0.011) and acute diarrhoea (Adj. OR=0.76, 95% CI: 0.58-0.99; P=0.048). Pharmacy staff with more positive beliefs about their professional competency to supply and monitor antibiotic use, and their beliefs that antibiotics are effective against different conditions, were more likely to dispense antibiotics without a prescription for common infections. The public survey revealed that half of the public had used an antibiotic in the three months prior to the survey, and nearly all of them (98%, 974/998) reported that they had used an antibiotic in the past. Eighty-seven percent (866/998) of the respondents had obtained their antibiotic (in the past) on a physician’s prescription. About 11% (108/998) had self-medicated with antibiotics in the past, and the main source for self-medication was a community pharmacy (89/108). Overall, 68% (678/998) of the participants requested antibiotics from pharmacies without prescriptions for common infections. The common cold (26%, 258/998), sore throat (14%, 143/998) and wound infections (16%, 163/998) were the most common infections for which the public self-medicated and requested antibiotics from pharmacies without a prescription. The public’s knowledge regarding antibiotics, ABR and use of antibiotics for common infections was poor and most did not know about antibiotic resistance. The public’s knowledge about antibiotic prescription requirements was statistically significantly associated with self-medication with antibiotics (Adj. OR=0.37, 95% CI: 0.19- 0.72; p=0.004). Factor analysis of the attitudinal items resulted in three factors, explaining 56.1% of the variance: ease of access to antibiotics from pharmacies (factor 1), appropriate use of antibiotics (factor 2) and situational use of antibiotics (factors 3). Overall, participants demonstrated positive attitudes (median score was 4/5 for almost every attitude item) towards xxiv appropriate use of antibiotics. Those participants who did not support ease of access to antibiotics from pharmacies (Adj. OR=0.38, 95% CI: 0.27-0.54; p<0.001) and situational use of antibiotics (Adj. OR=0.55, 95% CI: 0.38-0.79; p=0.001); and those who supported appropriate use of antibiotics (Adj. OR=0.64, 95% CI: 0.47-0.86; p=0.003) were less likely to self-medicate with antibiotics. Overall 68% of the public requested antibiotics from pharmacies without prescriptions for the examined common infections (listed in the questionnaire), with the highest request for the common cold and cough where about 26% of the public expected to receive antibiotics from pharmacies without prescriptions for the common cold and cough. Participants who had experienced receiving antibiotics with physicians’ prescriptions, expected antibiotics from pharmacy staff and physicians, and those who self-medicated with antibiotics were more likely to request antibiotics from pharmacies without prescriptions for common infections. Conclusions: These were the first studies which assessed the public’s knowledge about, attitudes to, and use of antibiotics at the same time as community pharmacy staff’s knowledge about, attitudes to, and supply of antibiotics in Sri Lanka for common infections. The findings from this research using four methodological approaches revealed that despite the law prohibiting provision, illegal and inappropriate antibiotic supply is common in Sri Lanka for common infections. Antibiotic supply was primarily associated with a low level of pharmacists’ legal and clinical knowledge about antibiotics. Staff’s beliefs associated with higher level of professional competency and the effectiveness of antibiotics for common infections were predictors of antibiotics supply without a prescription for common infections. xxv Although antibiotic use for common infections is high among the Sri Lankan public, specifically for the common cold and cough, their knowledge about appropriate antibiotic use for common infections was poor. The main source of the public’s antibiotic use for common viral infections was via physicians’ prescriptions; and for self-medication with antibiotics, via pharmacies. The factors such as easy access, appropriate use of antibiotics and situational use of antibiotics were associated with self-medication, the public’s experience strongly predicted antibiotic request from pharmacies. Recommendations: From the findings of this research we recommend development of multifaceted interventions, including for health professionals, policy makers and consumers, which can address the educational gaps and therefore improve antibiotics-related knowledge among the pharmacy staff and the public in Sri Lanka. It is also recommended that the legislation for antibiotic supply is firmly enforced in community pharmacies and national antibiotic prescribing guidelines are implemented for physicians

ASSESSING KNOWLEDGE, PERCEPTION AND ATTITUDES ABOUT ANTIBIOTICS AMONG FINAL YEAR PHARMACY UNDERGRADUATES IN SRI LANKA

Objective: Anti-microbial resistance has become a global problem especially in developing countries. The aim of the study was to evaluate the effect of socio-demographic predictors amongst final year pharmacy undergraduates in Sri Lanka on their knowledge, perception and attitudes regarding antibiotic use.Methods: A questionnaire-based study involved final year pharmacy students from four public universities in Sri Lanka. Data on knowledge, attitudes and perception about the appropriate use of antibiotics were analysed. Ethics approval was granted by the university of Ruhuna Sri Lanka.Results: There was good general knowledge of antibiotics (mean=15.57), however, 46% said metronidazole is not an antibiotic, 82% said that the use of antibiotics speed-up the recovery from the common cold. Perception (p=0.033) and attitudes (p=0.028) of respondents from urban area were significantly higher than that of those from rural area.Conclusion: Clinical education for pharmacy undergraduates should have an in-depth focus on the rational of antibiotics use in Sri Lanka