Community, social & administrative pharmacy

1- Background & Definition

Historical background
Ancient ages:
 Sumerian pharmacological tablet So far, it is the first pharmacy recorded document
discovered. It contains prescriptions for diseases and descriptions of drugs. Recipes
included both internal and external preparations.
Important people of the Ancient Era:
 Hippocrates: Greek physician and pharmacist. Father of Medicine. Introduced scientific
thoughts and principles and described hundreds of drugs
 Theophrastus: Father of botany Experimented with many types of plants as medications.

 THE FIRST OFFICIAL PHARMACOPOEIA

 The idea of a pharmacopoeia with official status, to be followed by all apothecaries,
originated in Florence.
 The “Nuovo Receptario”, originally written in Italian, was published and became the
legal standard for the city- state in 1498.
 The first "United States Pharmacopoeia" (1820) was the work of the medical profession.
It was the first book of drug standards from a professional source to have achieved a
nation's acceptance
THE FATHER OF AMERICAN PHARMACY: William Procter, graduated from The
Philadelphia College of Pharmacy in 1837; operated a retail pharmacy.

Community Pharmacy Definition: A community pharmacy is a healthcare facility that

is able to provide pharmacy services to people in a local area. A community pharmacy
dispenses medicine under the supervision of registered pharmacist deliver professional service
to the community.
OR
A community pharmacy is a pharmacy that deals directly with the people in a local area. It has
responsibilities including dispensing, compounding, counseling, checking and dispensing of
prescription drugs to patients with care, accuracy and legality.
Scope of community pharmacy
 In processing prescriptions- The pharmacist verifies the legality, safety and
appropriateness of the prescription order, checks the patient medication record before
dispensing the prescription, ensures that the quantities of medication are dispensed
accurately, and decides whether the medication should be handed to the patient, with
appropriate counseling, by a pharmacist.
 Patient care- patient drug history, mode of administration, precautions, advices. 
Drug monitoring- to analyze prescriptions for the monitoring of adverse drug reactions

 Extemporaneous preparation- pharmacists engage in the small- scale preparation of

medicines.
 Checking symptoms of minor aliments- pharmacist can supply a non-prescription
medicine, with advice to consult a medical practitioner if the symptoms persist for more
than a few days. Alternatively, the pharmacist may give advice without supplying
medicine.
 Counselor- the pharmacist provides an advisory as well as a supply service to residential
homes for the elderly, and other long-term patients. In some countries, policies are being
developed under which pharmacists will visit certain categories of house-bound patients
to provide the counselling service that the patients would have received had they been
able to visit the pharmacy
 In prophylaxis and health promotion- The pharmacist can take part in health
promotion campaigns, locally and nationally, on a wide range of health- related topics,
and particularly on drug-related topics.
 Rational (reasonable) use of drugs– The irrational use of medicines is a major problem
worldwide. WHO estimates that more than half of all medicines are prescribed, dispensed
or sold inappropriately, and that half of all patients fail to take them correctly. The
overuse, underuse or misuse of medicines results in widespread health hazards.
2-Public health and community pharmacy
Epidemiology and its control
Definitions
 Health: A state of complete physical, mental and social wellbeing (WHO,1948)
 Disease: A physiological or psychological dysfunction

 Illness: A subjective state of not being well

 Sickness: A state of social dysfunction OR The role negotiated with society

 Endemic: a disease that exists permanently in a particular region or population. E.g.

Chicken pox and Malaria which is endemic to Africa.
 Epidemic: An outbreak of disease that attacks many peoples at same time and may
spread through one or several communities.
 Pandemic: When an epidemic spreads throughout the world
 Morbidity: Refers to the presence of disease in a population
 Mortality: Refers to the occurrence of death in a population
 Prevalence and incidence are two separate terms used in medicine to measure the
occurrence of a disease or condition in a population.
 Prevalence: Total number of existing cases of a particular disease or condition in a given
population during given time.
 Prevalence= New and existing case.
 It gives overall picture of the disease prevalence in population.
 PR = # existing cases during time period /population during same time period *100
 Prevalence is usually reported as % or given in form of number (like, ….. Cases per 1000
people, …… cases per 10000 people.
 Incidence: Incidence is the rate at which new cases of a particular disease or condition
emerge in a given population during a given time.
 IR = # new cases during time period / specified population at risk *100
  IR = Incidence rate

Relationship between prevalence and incidence

 There may be low incidence and a high prevalence – as for diabetes – or a high incidence
and a low prevalence – as for the common cold.
 Colds occur more frequently than diabetes but last only a short time, whereas diabetes is
essentially lifelong

 Example Of IR: During a six-month time period, a total of 53 fungal infections were
recorded by an infection control nurse at a hospital. During this time, there were 832
patients with a total of 1,290 population of that specified area which at risk. What is the
rate of fungal infections rate?
 IR = 53 X 100/1,290 = 4.1
 Reservoir: The habitat (place for living) where an infectious agent living, grows and
multiples. (human, animal and environmental sources)
 Carrier: Asymptomatic carrier, a person or organism infected with an infectious disease
agent, but displays no symptoms.
 Vector: Organism which transfer an infectious agent from an infected person to a healthy
person. (Mites, Lice, mosquito)
 Fomites: Objects or materials which are likely to carry infection such as clothes, utensils
and furniture.
 Incubation period: This is the time interval between the entry of disease agent into body
and appearance of first sign and symptom of the disease.
 Pathogenicity: Ability to cause the disease.
 Contagious: A disease that is transmitted through direct contact. (flu)
 Virulence: Measure the severity of disease.
  Isolation: Separate sick people (having contagious disease) from the people who are not
sick.
 Quarantine: Separates and restricts movement of people who were exposed to a
contagious disease to see if they become sick.

Epidemiology
 The term epidemiology is derived from the Greek word.
Definition:
It is the study of incidence, distribution, frequency and determinants of diseases and other health
related conditions in a human population. Application of this study to the prevention of disease
and promotion of health.
• Epidemiological thought emerged in 460 BC
• Epidemiology flourished as a discipline in 1940
Components of the Definition
∙ Study: Systematic collection, analysis and interpretation of data
∙ Frequency: the number of times a disease occurs
∙ Distribution: Circulation of a disease by person, place and time
∙ Determinants: Factors the presence/absence of which affect the occurrence and level
of an event
When disease outbreaks or other threats emerge, epidemiologists are on the scene to investigate.
Often called as “Disease Detectives”
 Originally, Epidemiology was concerned with investigation & management of epidemics
of communicable diseases.
 Lately, Epidemiology was extended to endemic communicable diseases and non
communicable infectious diseases.
 Recently, Epidemiology can be applied to all diseases and other health related events.
Scope of Epidemiology
1- To find out cause of diseases.
Diseases can arise from both external factors (pathogens) and internal dysfunctions within the
body.
2- Course and outcome of disease: How a disease progresses through subclinical changes,
clinical disease and recovery, disability or death.
3- Health status of population
Epidemiology is often used to describe the health status of population groups. Knowledge of the
disease burden in populations is essential for health authorities so that they can take action
accordingly.
Disease burden: The sum of mortality and morbidity is referred as burden of disease.
4- Evaluating interventions:

This study is also used to evaluate effectiveness and efficiency of health services.

Types of Epidemiological study

 Two major categories of Epidemiology
1-Descriptive Epidemiology: It defines frequency and distribution of diseases and other health
related events (4 questions: how many, who, where, and when?)
Study conduct on population or individual.

∙ Time distribution- When disease occur

∙ Place distribution- Where
∙ Person –Who is getting it
2. Analytic Epidemiology: Analyses determinants of health problems
Answers two other major questions: how? and why?

Epidemiology and disease control

Communicable diseases occur as a result of the interaction between:

∙ the infectious agent

∙ the transmission process
∙ the host
∙ the environment.
The control of such diseases may involve changing one or more of these components, the first
three of which are influenced by the environment. These diseases can have a wide range of
effects, varying from silent infection – with no signs or symptoms – to severe illness and death
Factors involves in disease control
Disease control involves:
1- Controlling the reservoir
2- Interruption of transmission
3- Preventive measures
1-Controlling the reservoir
(The habitat (place for living) where an infectious agent living, grows and multiples. E.g,
human, animal and environmental sources.
The reservoir can be controlled by:
i-Early diagnosis: Early diagnosis helps in:
 treatment of patient and to help the institution of prevention and control measures.
ii- Notification:

Once a infectious disease has been detected or suspected it should be notified to local health
authority.
iii- Epidemiological investigation: In epidemiological investigation factors which influencing the
spread of disease may be found out.
Factors:

∙ Geographical situations
∙ Climate condition, social and behavioral patterns
∙ The character of agent, reservoir, the vector and susceptible host population.
iv- Isolation

v- Quarantine
2- Interruption of transmission:
Means changing some components of environment to prevent the infective agent from a patient
or carrier from entering the body of susceptible person
e.g, simple chlorination to complex water treatment will prevent water borne
disease. 3- Preventive measures:

∙ Active immunization
∙ Passive immunization
Control and prevention of disease
Levels of Disease Prevention
1- Primordial prevention: Prevention of emergency or development of risk factors in countries
or population groups in which disease has not yet appeared.
Individual or mass education e.g national programs (like in news to spread awareness.
2- Primary prevention: Action taken prior to onset of disease, which removes the possibility
that a disease will ever occur.
Prepathogenesis of stage of disease
Health promotion and specific protection
3- Secondary prevention: Action which stop the progress of disease and prevents
complication. Early pathogenesis stage

Early diagnosis and adequate treatment.

4- Tertiary prevention
Measures or actions which reduce or limit impairments and disabilities and minimize
suffering. Late pathogenesis stage

Rehabilitation

Pharmaco-epidemiology
Definition: The application of epidemiologic reasoning methods and knowledge to the study
of uses and effects (beneficial and adverse) of drugs in human populations.
*Population: Large group of people, which may include thousands or even millions of people.
It is a new applied field bridging between clinical pharmacology and epidemiology. It creates the
relationship between drug exposure and health outcome in a defined population.

Clinical

pharmacologyEpidemiology

Need of pharmacoepidemiology:
1- Lack of alternative models to investigate some drug events. E.g, to evaluate teratogenic
effect of a new medicine.
2- Clinical trials are inadequate to answer to questions about drug safety as the sample size
are inadequate to detect less common ADR.
3- Clinical trials are conducted on highly selected patients without any co-morbity( without
any other disease) or who taking no other medications.
4- Clinical trials does not involve elderly , paediatric or pregnant patients.
Aims of pharmacoepidemiology:
WHO targets its pharmacoepidemiological efforts to ensure the quality, safety and efficacy of
drug. This studies concentrate on the period after the drug enters the market know as post
marketing survelliance (PMS)
Pharmacoepidemiological research in practice includes:

∙ Evaluation of specific drug use in certain conditions. ( Appropriate use of medicine) ∙

Patterns of drug use, that is, how it is being used how much, where, when and by whom. ∙
Drug taking behaviors in society.
∙ The study of adverse effects of drugs.
Signal generation: Case reports after the drug marketing is called as signal
generation. Signal is a reported information on an adverse effects event due to drug/
medicine.

Example: Minoxidil first indicated for hypertension but case report (Signal generation) soo
identified it causes hirsutism in a number of patients, side effects was investigated and now it is
marketed for the purpose of hair growth.
Aspirin first indicated for pain and anti-inflammation later it is used for in cardiac disease
because of its blood thinning property.
Application:
1- Risk involved in drug use can be quantified.
2- Benefits and risk of use for drug may be weighed.
3- Risk estimation also helps to identify risk situation. E.g, Case reprts of triazolam induced
psychiatric disturbance appeared soon after its introduction to market. The drug was
withdrawn in some countries. But later on, it was found that problem was due to dose
related. And the problem was abated by recommending a lower dose.
4- It also helps the policy makers to assess whether a drug should be withdrawn from the
market or allowed to remain.
5- Such studies also used in highlighting certain issues e.g, if an inappropriate prescribing is
observed among prescribers, regulatory agency may require educational intervention
(May conduct educational programs for prescriber) may impose restrictions on specific
drugs or on practitioners.
6- Such studies help to discover new indications of a drugs
7- Age based medicines use.

Drug utilization review (DUR)

In practice success of treatment largely depends on the ability of a physician to diagnose,
prescribe, then on pharmacy and nursing departments in dispensing and administering
drugs.
Definition: Drug utilization review (DUR) is defined as: “An authorized, structured, ongoing
program to review of prescribing, dispensing and use of medication.”
DUR focus on a drug review against predetermined criteria that results in changes to drug
therapy when these criteria are not met. It involves a comprehensive review of patients'
prescription and medication data before, during and after dispensing to ensure appropriate
medication use and positive patient outcomes.
Importance: DUR programs play a key role in management of health care systems to
understand, interpret, evaluate and improve the prescribing, administration and use of
medications. Pharmacists play a key role in this process, because of they are considered as drug
experts. Pharmacists, in collaboration with prescribers and other members of the health care
team, initiate action to improve drug therapy for patients.
Synonyms of DUR: Other terms considered synonymous with DUR include drug use evaluation
(DUE), medication use evaluation (MUE), and medication use management (MUM).

Classification: DUR is classified in three categories:

1. Prospective - evaluation of a patient's drug therapy before medication is dispensed
2. Concurrent - ongoing monitoring of drug therapy during the course of treatment 3.
Retrospective - review of drug therapy after the patient has received the medication

1- Prospective DUR: Prospective review involves evaluating a patient's planned drug therapy
before a medication is dispensed. This process allows the pharmacist to identify and resolve
problems before the patient has received the medication.
Issues Commonly Addressed by Prospective DUR:

∙ Clinical abuse/misuse
∙ Drug-disease contraindications (when a prescribed drug should not be used with certain
diseases)
∙ Drug dosage modification
∙ Drug-drug interactions (when two or more different drugs interact and alter their intended
effects, often causing adverse events)
∙ Drug-patient precautions (due to age, allergies, pregnancy, etc.)
∙ Inappropriate duration of drug treatment.
2. Concurrent DUR: Concurrent review is performed during the course of treatment (in patient)
and involves the ongoing monitoring of drug therapy to foster positive patient outcome. As
electronic prescribing becomes more widely adopted, the prescriber at the time of prescription
transmission to the hospital pharmacy, the concurrent DUR process may be performed by
pharmacist allowing interventions before the drug is dispensed.
Issues Commonly Addressed by Concurrent DUR:

∙ Drug-disease interactions
∙ Drug-drug interactions
∙ Drug dosage modifications
∙ Drug-patient precautions (age, pregnancy, etc.)
∙ Over and underutilization
∙ Duplicate therapy
∙ Therapeutic Interchange
Example: Concurrent DUR often occurs in institutional settings, where patients often receive
multiple medications. It can also alert the prescriber/pharmacist to the need for changes in
medications, such as antibiotics, or the need for dosage adjustments based on laboratory test
results.
3. Retrospective DUR: A retrospective DUR reviews drug therapy after the patient has received
the medication. Outcomes of this review may help prescribers in improving their prescribing
pattern.
Issues Commonly Addressed by Retrospective DUR:

∙ Appropriate generic use

∙ Clinical abuse/misuse
∙ Drug-disease contraindications
∙ Drug-drug interactions
∙ Inappropriate duration of treatment
∙ Incorrect drug dosage
∙ Use of formulary medications whenever appropriate
∙ Over and underutilization
∙ Therapeutic appropriateness and/or duplication
Example: An example of a retrospective DUR may be the identification of a group of patients
whose therapy does not meet approved guidelines. For example, a pharmacist may identify a
group of patients with asthma, who according to their medical and pharmacy history, should be
using orally inhaled steroids. Using this information, the pharmacist can then encourage
prescribers to utilize the indicated drugs.