Transcript the inappropriate sale of medication for pediatric use in siem reap

THE INAPPROPRIATE SALE OF
MEDICATION FOR PEDIATRIC
USE IN SIEM REAP PROVINCE,
KINGDOM OF CAMBODIA
AUTHORS:
Sothearith Tiv Ph., Rathi Guhadasan MBBS
MRCP DTM&H, Eliza Romey M.A.
INSTITUTION: Angkor Hospital for Children
Siem Reap, Kingdom of Cambodia
Abstract
Problem Statement: In Cambodia, many people rely on unqualified drug sellers for their primary health care. Patients can buy medicine
from pharmacies without a doctor’s prescription. It is estimated that a significant percentage of pharmacies in Siem Reap province are
staffed by unqualified pharmacists. Drug sellers also operate in markets or from their homes. Medications, often unnecessary, are sold in
combinations which are contraindicated, and children are regularly prescribed adult doses. In 2001, WHO estimated that there were at
least 2800 illegal drug sellers in Cambodia.
Objectives: To reduce harm caused to children from inappropriate drug prescriptions; identify groups of drug sellers in Siem Reap for
education about commonly prescribed drugs in children; identify areas of weakness in pharmaceutical knowledge for targeted education
to different groups of drug sellers in Siem Reap; and identify common problem areas for targeted public health education at Angkor
Hospital for Children (AHC).
Study Setting and Population: 50 consecutive AHC outpatients from Siem Reap province presenting at the AHC pharmacy, who have
previously taken drugs from elsewhere for the same illness, will be selected. After verbal informed consent, the following data will be
collected by AHC pharmacy staff using a standardized interview questionnaire.
Methods: Data to be gathered include demographic data including gender and age of the child, district and village of Siem Reap, which
caregiver has bought the medicines, urban/rural status, family occupation; Location and type of drug seller; information given to drug
seller by carer; advice given by drug seller; adverse effects; AHC doctor’s diagnosis; dose prescribed for each drug and length of
prescription.
The study is planned for December because in that month there are no lengthy public holidays in Cambodia. The data will be analyzed
using simple statistical tests.
Outcome Measures: Demographic data; percentage of non-hospital drug sellers; percentage of correct, partially correct and incorrect
prescriptions and advice; percentage of drugs given at above the recommended dose; most common drugs prescribed; most common
errors; percentage and types of adverse effects
Discussion: Most children presenting to our hospital have previously taken drugs from elsewhere for the same illness. These are often
inappropriate and dangerous. Adult doses are often prescribed for children and infants; multiple preparations of paracetamol may be
prescribed simultaneously as well as incomplete courses of antibiotics, which may lead to partially treated conditions such as meningitis
and the development of antibiotic resistance. Many patients present late because the drug seller tried to treat them without referral to a
hospital or health centre for proper diagnosis. It is hoped that this study will lead to plans for drug seller and public health education,
thus leading to safer drug use in the community.
Background
In Cambodia, many rural inhabitants rely on
unqualified drug sellers for their primary health
care. Patients can buy medicine from
pharmacies without a doctor’s prescription. It is
estimated that 80% of pharmacies in Siem
Reap province are staffed by unqualified
pharmacists. Illegal Drug sellers also operate in
markets or from their homes. Medications, often
unnecessary, are sold in combinations which
are contraindicated, and children are regularly
prescribed adult doses.
Objectives
 To reduce harm caused to children from
inappropriate drug prescriptions.
 To identify groups of drug sellers in Siem
Reap for education about commonly
prescribed drugs in children.
 To identify areas of weakness in
pharmaceutical knowledge for targeted
education to different groups of drug sellers
in Siem Reap.
 To identify common problem areas for
targeted public health education at Angkor
Hospital for Children (AHC).
Study Setting
Collect information from 50 AHC
outpatients from Siem Reap province
presenting at the AHC pharmacy between
1st to 31st December 2003, who have
previously taken drugs from elsewhere for
the same illness. All questionnaires were
administered AHC pharmacy staff using a
standardized interview questionnaire.
Methods
Data to be gathered including:
 gender and age of the child,
 patient resident in Siem Reap province,
 location and type of drug seller
 information given to drug seller by carer
 advice given by drug seller
 adverse effect
 AHC doctor’s diagnosis
 dose and duration of prescribed medicine
Results
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< 5 years: 88%
> 5years : 12%
Males = Females
rural
: 62%
urban
: 38%
AHC doctor’s diagnosis:
 47%: URI, Dysentery, Diarrhea
 53%: others diseases
 Sources of medicine previously purchased:
 74%: clinic and pharmacy
 26%: market
Table show the Incorrect Prescription according to
Cambodia National guidelines and AHC guideline.
Pharmacy
Illegal Drug seller
Incorrect drugs
60%
84%
Incorrect dosage
62%
75%
Incorrect duration of use
antibiotic
79%
92%
Toxicity multiple drugs
75%
92%
Toxicity over dosage
70%
84%
Incorrect advice
70%
92%
Results
 Most Common Errors:
 Prescribed without indication:
Chloramphenicol, Tetracycline, Loperamide,
Promethazine
 Poly pharmacy
 Adult dose
 Most Common of Adverse Effects:




Vomiting
Drowsiness
Dizziness
Extrapyramidal reaction
Summary




3cases received medicine from private clinic
Those drugs are often inappropriate and even dangerous.
Adult doses are often prescribed for children and infants.
Multiple preparation of Paracetamol may be prescribe
simultaneously.
 Incomplete courses of antibiotics, which may lead to partially
treatment of conditions such as meningitis, are given. This
may have serious medical sequences and also lead to
development of antibiotic resistance.
 Many patients present late because the drug sellers tried to
treat them without referral to hospital or health center for
proper diagnosis.
Conclusions and Policy
implications
 Education to drug sellers and pharmacists:
 Common dangerous practices
 Danger signs necessitating immediate referral to
hospital
 Public health education in appropriate
health seeking behavior and use of
medicines.
 Strict enforcement of regulation relating to
sale of drugs for children