this presentation is based on national health program in india in relation to tuberculosis and malaria as these are mostly occuring disease in india so national program are organised to irradicate the spread of vector borne disease by various methods like controlling the vector (mosquitos) from spreading role of community pharmacist in educating and monitoring of patients for infection and counselling and educating them regarding the control of malaria and tb.

1. National Health Program:
Role Of Community Pharmacist In TB and Malaria Control Program
Presented By :Arbeena Shakir
Presented to :Dr. Sayed Ehtashamul haque sir

2. 1. Tuberculosis

3. Definition:
Tuberculosis (TB) is a highly infectious bacterial disease caused by Mycobacterium tuberculosis.
TB can affect any part of the body. When it affects the lungs it is called pulmonary TB. The
commonest form of TB is pulmonary TB. TB in any other part of the body (i.e. other than lungs)
is called extra pulmonary TB
Mode of infection :
TB germs usually spread through air. When a patient with pulmonary tuberculosis coughs or
sneezes, TB germs are spread in the air in the form of tiny droplets. When these droplets are
inhaled by a healthy person s/he gets infected with tuberculosis. This infected person will have
a 10% lifetime risk of developing tuberculosis.

4. Risk of developing disease :
All those who get infected do not necessarily develop TB disease. The life time risk of
breaking down to disease among those infected with TB is 10–15%, which gets increased to
10% per year amongst those co-infected with HIV. Other determinants such as diabetes
mellitus, smoking tobacco products, malnutrition and alcohol abuse also increase the risk of
progression from infection to TB disease.

5. Extent of TB problem in the world
Every year, more than 9 million new cases of tuberculosis (TB) occur and nearly 2 million
people die of the disease. Nearly half a million cases have the multidrug-resistant form of the
disease. While Asia bears the largest burden of the disease, sub-Saharan Africa has the highest
incidence of drug-susceptible TB and Eastern Europe has the highest incidence of multidrug-
resistant TB (MDR -TB).
Extent of TB problem in india
The extent of the TB problem is generally described in terms of incidence, prevalence and
mortality.
Incidence is the number of new events (infection or disease) that occur over a period of one year
in a defined population.
Prevalence is total of new and existing events (infection or disease) at a given point of time in a
defined geographical population.
India accounts for 26% of the total global TB burden i.e. 2.0-2.5million new cases annually.

6. HIV Co infection among TB patients
Tuberculosis is the most common opportunistic infection amongst HIV-infected individuals. It
is a major cause of mortality among patients with HIV and poses a risk throughout the course of
HIV disease, even after successful initiation of antiretroviral therapy (ART). In India 55-60% of
AIDS cases reported had TB, and TB is one of the leading causes of death in 'People living with
HIV/AIDS' (PLHA)

7. Revised National TB Control Programme (RNTCP)

8. National strategic plan for TB elimination (2017-25)
Goal: To achieve a rapid decline in burden of TB, morbidity and mortality while working
towards elimination of TB in India by 2025.
World Tuberculosis Day, observed on 24 March each year, si designed to build public
awareness about the global epidemic of tuberculosis and efforts to eliminate the disease.
RNTCP has released a 'National strategic plan for tuberculosis 2017-2025' (NSP) for the
control and elimination of TB in India by 2025.
According to the NSP TB elimination has been integrated into the four strategic pillars
of"Detect- Treat- Prevent- Build" (DTPB).
•Detect: Find all DS - TB and DR - TB cases with an emphasis on reaching TB patients
seeking care from private providers and undiagnosed TB in high - risk populations.
• Treat: Initiate and sustain all patients on appropriate anti - TB treatment wherever they
seek care, with patient friendly systems and social support

9. •Prevent: Preventing the emergence of TB in susceptible populations.
• Build: It strengthen enabling policies, empowered institutions and human resources with
enhanced capacities.
Key services of programme
•Free diagnosis and treatment for TB patients.
•Provision of rapid diagnostics Testing of all TB patients for drug resistance and HIV.
•Management of associated diseases.
•Treatment adherence support .
•Nutrition assistance to TB patients.
• Preventive measures.
• Ministry of Health and Family Welfare (MoHFW) will evolve a scheme to address the patients
seeking care in private sector. The scheme will have suitable incentives for the private doctors and
patients to report TB cases coupled with another scheme to provide free of cost medicines to TB
patients going to a private doctor/ institute.

10. DIAGNOSIS OF TUBERCULOSIS :

11. Following are some of the special investigations which are helpful in diagnosing extra
pulmonary tuberculosis. These may be radiological, cytological/ pathological, biochemical
and immunological.
(a) Fine Needle Aspiration Cytology (FNAC) and direct smear examination
(b) Excision / Biopsy of specimen for histo-pathological examination
(c) Fluid for cytology, biochemical analysis and smear examination
(d) X-ray of the involved region
(e) Ultra Sonography for Abdominal Tuberculosis
(f) Culture for Mycobacterium tuberculosis (M.Tb)
• Sputum smear microscopy
• Chest X-ray
• Sputum culture
• Newer diagnosis ,including Molecular diagnosis, GeneXpert etc
Diagnostic test for extra-pulmonary TB

12. Treatment of TB :
Provision of free TB drugs in the form of daily fixed dose combinations (FDCs) for all TB cases is
advised with the support of directly observed treatment (DOT)
For drug sensitive TB, daily fixed dose combinations (FDCs) of first-line anti-tuberculosis drugs
in appropriate weight bands for all forms of TB and in all ages should be given.
For new TB cases, the treatment ni intensive phase (IP) consists of eight weeks of
Isoniazid(INH), Rifampicin, Pyrazinamide and Ethambutol (HRZE) in daily doses as per four
weights band categories and in continuation phase three drug FDCs- Rifampicin, Isoniazid, and
Ethambutol (HRE) are continued for 16 weeks.
for previously treated cases of TB, the Intensive Phase is of 12 weeks, where injection
streptomycin si given for 8 weeks along with four drugs (INH, Rifampicin, Pyrazinamide and
Ethambutol) and after 8weeks the four drugs (INH, Rifampicin, Pyrazinamide and
Ethambutol)ni daily doses as per weight bands are continued for another four weeks. In
continuation phase Rifampicin, INH, and Ethambutol are continued for another 20 weeks as
daily doses.

13. Role Of Community Pharmacist :
1. Community Awareness
• Distribution of TB information leaflets to TB patients, TB suspects as well as to any other
patient who wish to know/need to know more about TB
• Creating awareness about DOTS programme by displaying posters/boards/stickers in the
Pharmacy.
• Arrange and conduct group awareness activities
• TB and DOTS awareness sessions among schools, community etc

14. 2. Patient Counselling
During first meeting with a patient, one has to find out whether the patient has previously
been treated for tuberculosis. A patient should be made aware that tuberculosis is a
life-threatening disease and tuberculosis treatment is only effective if all prescribed drugs
are taken regularly for the entire prescribed duration.
Then he has to be explained about the following about tuberculosis:
• What is tuberculosis, and how it spreads.
• Symptoms of tuberculosis.
• Treatment of tuberculosis. either from private or public sector
• Information about Directly Observed Treatment (DOT).
• Importance of contact examination and chemoprophylaxis of children below 6 yrs of age.
• Taking some of the drugs or irregular taking of drugs is dangerous and makes the disease
incurable.
• Motivation of the patient with respect to treatment requirements and expected duration of
the treatment .

15. 3 Case detection and referral of TB suspects
When to refer a patient to TB Clinics (or to any Doctor for TB evaluating) and how to
identify chest symptomatic cases:
• Any patients with cough more than two weeks
• Greet the patient, asking the patients who are seeking cough medication about how
long the patient has the cough.
• Asking for other symptoms if the cough has persisted for a long time.
• Asking for specific TB symptoms i.e. persistent cough, sputum or blood in cough,
chest pain, fever, night sweats, weight loss, loss of appetite, etc.
• Asking whether the suspect has consulted a doctor.
• Telling the patients about the importance of TB diagnosis and effective TB
treatment which is free in government hospitals & also can be made available from
the pharmacy.

16. 4.Referral Form

17. 5.Patient activities related to DOTS
• Swallowing of drugs during the intensive phase of treatment in the presence of
DOT Provider.
• Swallowing of the first dose of the weekly course of the continuation phase under
direct observation of the health functionary and bringing the empty blister-pack
during the next weekly collection of drugs.
• Going for follow up sputum test
• Bringing all symptomatic contacts to the nearest heath unit for a checkup.
6. Patient Communication
The skills involved in good interpersonal communication include:
• Listening and Understanding
• Demonstrating caring, concern and commitment
• Problem solving and Motivating

18. 7.Management of patients in special situations

19. 2. MALARIA

20. Definition:
Malaria is a life-threatening disease. It's typically transmitted through hte bite of an infected
Anopheles mosquito. Infected mosquitoes carry the Plasmodium parasite. Five species of
Plasmodium (single-celled parasites) can infect humans and cause illness: a) Plasmodium
falciparum (P. falciparum) b) Plasmodium malariae (P. malariae) c) Plasmodium vivax (P. vivax)
d) Plasmodium ovale (P. ovale) e) Plasmodium knowlesi (P. knowlesi)
Mode of infection :
Malaria is transmitted by the infective bite of Anopheles mosquito. Man develops disease after
01 ol 41 days of being bitten by an infective mosquito. There are two types of parasites of
human malaria, Plasmodium vivax, P. falciparum, which aer commonly reported from India.
Inside the human host, the parasite undergoes a series of changes as part of its complex life
cycle. (Plasmodium is a protozoan parasite). The parasite completes life cycle in liver cells (pre-
erythrocytic schizogony) and red blood cels (erythrocytic schizogony Infection with P. falciparum
is the most deadly form of malaria.

21. Malaria control in India :

22. Diagnosis of malaria :
1 Microscopy
Microscopy of stained thick and thin blood smears remains the gold standard for confirmation
of diagnosis of malaria.
The advantages of microscopy are:
• The sensitivity is high. It is possible to detect malarial parasites at low densities. It also helps
to quantify the parasite load.
• It is possible to distinguish the various species of malaria parasite and their different stages.
2 Rapid Diagnostic Test
Rapid Diagnostic Tests are based on the detection of
circulating parasite antigens. Several types of RDTs are available. Some of them can only
detect P. falciparum, while others can detect other parasite species also. The latter kits are
expensive and temperature sensitive.

23. Chemoprophylaxis :
Chemoprophylaxis is recommended for travellers, migrant labourers and military personnel
exposed to malaria in highly endemic areas. Use of personal protection measures like
insecticide-treated bednets should be encouraged for pregnant women and other vulnerable
populations.
-For short-term chemoprophylaxis (less than 6 weeks) Doxycycline: 100 mg daily in adults
and 1.5 mg/kg for children more than 8 years old. The drug should be started 2 days before
travel and continued for 4 weeks after leaving the malarious area.
.
-For long-term chemoprophylaxis (more than 6 weeks) Mefloquine: 5 mg/kg bw (up to 250
mg) weekly and should be administered two weeks before, during and four weeks after
leaving the area.

24. Treatment of malaria :
1- Treatment of uncomplicated malaria
(As per ministry of health and family welfare
guidelines 2009)

25. 2. Treatment of severe malaria :
Severe manifestations can develop in P. falciparum infection over a span of time as short as
12 – 24 hours and may lead to death, if not treated promptly and adequately. Severe
malaria is characterized by following features :
• Impaired consciousness/coma
• Repeated generalized convulsions
• Renal failure (Serum Creatinine >3 mg/dl)
• Jaundice (Serum Bilirubin >3 mg/dl)
• Severe anaemia (Hb <5 g/dl)
• Pulmonary oedema/acute respiratory distress syndrome
• Hypoglycaemia (Plasma Glucose <40 mg/dl)
• Metabolic acidosis
• Circulatory collapse/shock (Systolic BP <80 mm Hg, <70 mm Hg in children)

26. Parenteral artemisinin derivatives or quinine should be used irrespective of
chloroquine sensitivity
• Artesunate: 2.4 mg/kg i.v. or i.m. given on admission (time=0), then at 12 hours
and 24 hours, then once a day (Care should be taken to dilute artesunate powder
in 5% Sodium bi-carbonate provided in the pack).
• Quinine: 20 mg quinine salt/kg on admission (i.v. infusion in 5%
dextrose/dextrose saline over a period of 4 hours) followed by maintenance dose
of 10 mg/kg 8 hourly; infusion rate should not exceed 5 mg/kg per hour. Loading
dose of 20 mg/kg should not be given, if the patient has already received quinine.
NEVER GIVE BOLUS INJECTION OF QUININE. If parenteral quinine therapy needs
to be continued beyond 48 hours, dose should be reduced to 7 mg/kg 8 hourly.
• Artemether: 3.2 mg/kg i.m. given on admission then 1.6 mg/kg per day.
• αβ Arteether: 150 mg daily i.m. for 3 days in adults only (not
recommended for children).

27. NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME
• The National Vector Borne Diseases Control Programme (NVBDCP) is an umbrella
programme for prevention and control of vector borne diseases viz. Malaria, Japanese
Encephalitis (JE), Dengue, Chikungunya, Kala-azar and Lymphatic Filariasis.
• Malaria, Filaria, Japanese Encephalitis, Dengue and Chikungunya are transmitted by
mosquitoes.
• The transmission of vector borne diseases depends on prevalence of infective vectors and
human-vector contact, which is further influenced by various factors such as climate, sleeping
habits of human, density and biting of vectors etc.

28. STRATEGIES FOR PREVENTION AND CONTROL OF VECTOR
BORNE DISEASES :
1. Integrated Vector Management including Indoor Residual Spraying (IRS) in selected high
risk areas; Long Lasting Insecticidal Nets (LLINs), use of larvivorous fish, anti - larval measures
in urban areas including bio-larvicides and source reduction.
2. Disease Management including early case detection with active, passive and sentinel
surveillance and complete effective treatment, strengthening of referral services.
3. Supportive Interventions including Behaviour Change Communication (BCC), Inter-sectoral
Convergence, Human Resource Development through capacity building.
4. Vaccination only against J.E.(Japanese Encephalitis)
5. Annual Mass Drugs Administration (only against Lymphatic Filariasis)

29. Control Strategy for Malaria
1. Parasite Control: Treatment is done through passive agencies hospitals, dispensaries both
in private & public sectors. In mega cities malaria clinics are established by each health
sector/malaria control agencies via Municipal Corporations, Railways, Defence services.
2. Vector Control: Source reduction, use of larvicides, use of larvivorous fish, space spray.

30. Role Of Community Pharmacist :
Community pharmacists appear to be the most accessible
health care professionals, for the prevention, control, and
treatment of malaria.
• Pharmacists are experts in the use of medications.
• They possess the knowledge and skills required to ensure
the safe and effective use of medicines.
• Also, community pharmacists are becoming increasingly
involved in health promotion and education.

31. PHARMACIST COUNSELLING FOR MALARIA PREVENTION
•Offer advice, particularly around prevention, to patients through effective
• communication. Identify complicated malaria in patients by being aware of the signs and
symptoms to ensure timely and appropriate care.
•Supply treatment and prophylaxis to patients, according to guidelines, in hospitals or
community pharmacies.
•Adhere to treatment guidelines by staying aware of local policies and developing action
plans to implement.
•Monitor response to treatment in patients by being aware of signs and symptoms and
reactions to antimalarials.
•Raise awareness in patient communities by using your knowledge.