Framing public health and

pharmacy
Dr.Hiwa Abas
Bsc.pharmacy
Msc.Community Medicine
The Essential Public Health services
The Essential Public Health services
1.Assess and monitor population health.
2.Investigate, diagnose and address health hazards and root causes.
3.Communicate effectively to inform and educate.
4.Strengthen, support and mobilize communities and partnerships.
5.Create, champion and implement policies, plans and laws.
6.Utilize legal and regulatory actions.
7.Enable equitable access.
8.Build a diverse and skilled workforce.
9.Improve and innovate through evaluation, research and quality
improvement.
10.Build and maintain a strong organizational infrastructure for public
health.
Role of the Pharmacist in public health
• In 1981, the role of the pharmacist in public health is defined by the
American Public Health Association (APHA).
• This association outlined that the role of the pharmacist is now
escalating beyond the dispensation and distribution of medicines,
and health supplies.
The administrative, and public health functions are also included in
the services of pharmacists.
Now, it becomes more patient-oriented . A pharmacist can provide many
services to public health that may include pharmacotherapy, provide
care, and prevention measures.
A pharmacist has an available resource for health and medication
information apart from dispensing medicine.
• The public health services that an individual pharmacist performs will
depend on the abilities, experience, training, and work
methodology.
• APHA believes that all pharmacists can contribute to the promotion of
public health by working alone or in cooperation with health care
colleagues and administrators.
The activities where pharmacists can play an important role to promote
public health:

1. Population-based Care
2. Prevention of Disease and Medication Safety
3. Health Education
4. Public Health Policy
5. Research and Training
1. Population-based Care:
The Center for Advancement in Pharmaceutical education (CAPE)
Educational Outcomes suggested that pharmacists should involve in
both patient-based and population-based care.
In the past twenty years, the health-system pharmacists can support
public health efforts using designing and providing disease
management programs.
Disease management programs are designed to improve the health of
persons with chronic conditions and reduce associated costs from
avoidable complications by identifying and treating chronic conditions
more quickly and more effectively, thus slowing the progression of
those diseases.
The health-system pharmacists with their health care colleagues can
contribute to population health care using tools such as medication-use
evaluation, evidence-based disease management programs that are
planned according to the needs of the served institutions and
communities.
Health-system pharmacists can involve in quality reviews by which they
assure that evidence-based treatments are used for all patients to help
assuage (improve) population health care.
2. Prevention of Disease and Medication Safety:

A pharmacist can be indulged in the prevention and control of disease

in a many ways.
They can help in the establishment of some screening programs to
check out the status of immunization, and identification of some
undiagnosed medical conditions.
The role of health-system pharmacists in medication safety and error
prevention.
These practices can reduce the number of hospital admissions due to
reasons for drug therapy mismanagement and counterfeit
medications.
Medication reconciliation programs are one of the vital tools with
which pharmacists can achieve these goals.
3. Health Education:
The development of programs on the safe and effective use of
medication, and other public health-related topics, such as exercise,
healthy nutrition and tobacco cessation, is also an important area
where pharmacists play their role.
The Education and training programs are beneficial for public health
care if they start on at an early age, such as school health programs,
which help in the development of good health behaviors in children that
can continue into adulthood also.
Pharmacists should support these types of school health programs.
health-system pharmacists can educate their health care colleagues
about the safe and effective use of medication that further improves
use of medications.
The pharmacists can also educate community leaders like public office
holders, legislators, school officials, regulators, and religious leaders
who involve in public health customs.
4. Public Health Policy:
• Health-system pharmacists can participate in the development of
public health policy concerned with local boards of health as well as
national programs.
• Drugs are the central part of health systems. Hence, the health policy,
especially policy targeted for chronic disease, must be prepared with
better consideration of drug therapy as well as factors affecting the
disease outcomes.
• The role of Health-system pharmacists in emergency planning and
service delivery of specialized pharmaceuticals like antidotes,
vaccines, and antibiotics is critical.
APHA also outlined the role of health system pharmacists as assistant
in procuring, distributing and dispensing emergency supplies of
pharmaceuticals, medications and immunization products and managing
the drug therapy of individual victims with National Disaster Medical
System assistance teams.
Pharmacists, as medication-use experts, should also work in the
assistance of health-system administrators to develop policies for the
best management practices in the proper handling and disposal of
hazardous drugs.
5. Research and Training:
A health-system pharmacist must get adequate education and training to
carry out his responsibility in public health.
Health-system pharmacists should be expertise in
pharmacoepidemiology, research methodology, and biostatistics
with their applications in decision related to public health.
He should have an understanding of the design, conduct, and
interpretation of clinical studies.
Health-system pharmacists should participate in collaborative research
and serve on data monitoring and safety committees, institutional
review boards, and expert medication advisory committees.

Moreover, the research fellows need exposure to research in public

health policy, Pharmacoeconomics, pharmacoepidemiology, and
evidence-based medicine for experimental and instructive training.
Health-system pharmacists should also work in collaboration with
public health policymakers, governmental agencies, medical
centers, and academic institutions to promote optimal
pharmacotherapy.
• Future Aspects
• New technology and practices such as population genetics and
pharmacogenomics will allow reduction in failures of treatment and
prevent adverse drug reactions using the proper appliance of
pharmacogenetic principles.
• Health-system pharmacists will need to apply these new tools not to
get better patient-specific pharmacotherapy but to progress public
health.
 Antibiotic resistance
• Antibiotic resistance is a subset of antimicrobial resistance that
specifically refers to bacteria becoming resistant to antibiotics
(medicines that act against bacteria).

Antimicrobial resistance (AMR)

• AMR is the ability of bacteria, viruses, fungi and parasites to resist the
effects of antimicrobial medicines that kill susceptible organisms or
keep them from growing.
• Infection with antimicrobial-resistant pathogens makes infections
harder to treat and increases the risk of disease spread, severe illness
and death.
• Healthy patients with mild common infections can be treated without antibiotics
as these infections are frequently self-limiting and the potential medicine- related
adverse events outweigh the clinical benefits.

• The risks of taking antibiotics when they are not needed should always be
considered, such as side-effects, allergic reactions, Clostridioides difficile
infection and selection of resistant bacteria.
Clostridioides difficile
• Clostridioides difficile (klos-TRID-e-oi-deez dif-uh-SEEL) C. difficile is a bacterium that causes
an infection of the colon, the longest part of the large intestine. Symptoms can range from diarrhea
to life-threatening damage to the colon..
• Illness from C. difficile often occurs after using antibiotic medicines.
• The antibiotics that most often lead to C. difficile infection include:
Clindamycin ,Cephalosporins ,Penicillins ,Fluoroquinolones.
• Taking a proton pump inhibitor (PPI), a type of medicine used to cut stomach acid, also may
increase the risk of C. difficile infection.
• AWaRe
• The AWaRe book gives guidance on first- and second-choice antibiotics for common infections in
line with the recommendations in the EML and EMLc .
• WHO has classified antibiotics into four groups, Access, Watch, Reserve (AWaRe) and a fourth –
Not Recommended – group (which are rejected for use in clinical practice.).
• As well as the antibiotics in the EML and EMLc, more than 200 other antibiotics have now been
classified into AWaRe groups to help inform local and national policy development and
implementation .
Access antibiotics have a narrow spectrum of activity, lower cost, a good safety profile and
generally low resistance potential. They are often recommended as empiric first- or second-choice
treatment options for common infections .
• Watch antibiotics are broader-spectrum antibiotics, generally with higher costs and are
recommended only as first-choice options for patients with more severe clinical presentations or
for infections where the causative pathogens are more likely to be resistant to Access antibiotics,
such as upper urinary tract infections (UTIs).
• Reserve antibiotics are last-choice antibiotics used to treat multidrug-resistant infections.
• Essential medicines are those that satisfy the priority health care needs of a population.
• They are selected with due regard to disease prevalence and public health relevance, evidence
of efficacy and safety and comparative cost-effectiveness.
• They are intended to be available in functioning health systems at all times, in appropriate
dosage forms, of assured quality and at prices individuals and health systems can afford.
• The WHO Model List of Essential Medicines (EML) and Model List of Essential Medicines for
Children (EMLc) are updated and published every two years
Principles of the AWaRe framework
• Maximizing clinical effectiveness
• Minimizing toxicity
• Minimizing unnecessary costs to patients and health care systems
• Reducing the emergence and spread of antibiotic resistance (i.e. prioritizing
antibiotics that are less likely to lead to antibiotic resistance in an individual
patient and the community)
• Parsimony (i.e. avoiding the inclusion of many similar antibiotics)
• Simplification (i.e. same Access antibiotic recommended for multiple indications)
• Alignment with existing WHO guidelines
Points to always consider when prescribing
• Diagnose – what is the clinical diagnosis? Is there evidence of a significant bacterial infection?
• Decide – are antibiotics really needed? Do I need to take any cultures or other tests?
• Drug (medicine) – which antibiotic to prescribe? Is it an Access or Watch or Reserve antibiotic?
Are there any allergies, interactions or other contraindications?
• Dose – what dose, how many times a day? Are any dose adjustments needed, for example, because
of renal impairment?
• Delivery – what formulation to use? Is this a good quality product? If intravenous treatment is
needed, when is step down to oral delivery possible?
• Duration – for how long? What is the stop date?
• Discuss – inform the patient of the diagnosis, likely duration of symptoms, any likely medicine
toxicity and what to do if not recovering.
• Document – write down all decisions and the management plan.

• The great majority of common infections in primary health care can be treated without any
antibiotics or with Access antibiotics.
• Reducing the inappropriate use of Watch antibiotics is key to control antibiotic resistance.
The five objectives of the global action plan
1.Improve awareness and understanding of antimicrobial resistance.
2.Strengthen surveillance and research.
3.Reduce the incidence of infection.
4.Optimize the use of antimicrobial medicines.
5.Ensure sustainable investment in countering antimicrobial resistance.
Responsibility of Antibiotic Resistance
• All prescribers and dispensers have a responsibility to improve the use of antibiotics.
• Patients also have responsibilities and efforts should be made to ensure they know basic principles
of appropriate antibiotic use (e.g. taking antibiotics as prescribed and not using leftover antibiotics
for a later illness) and symptomatic care.
• The wide use of fixed-dose combinations (FDC )of antibiotics that are not compatible with the
EML and not approved by the major regulatory agencies is of concern. Their use should be reduced
as these combinations may result in increased toxicity and selection of resistance.
• WHO has developed a list of fixed-dose combinations of antibiotics whose use is strongly
discouraged(prevent). (amoxicillin and clavulanic acid)
• Prescribers should always consult local and national dosing guidelines, where available.
• The dosing guidance provided in the AWaRe book is for the most common clinical infections in
patients with normal kidney and liver function but the need for dose adjustments should always
be considered.
• The guidance on duration of treatment is generally the shortest suggested duration
for specific infections.
• Severe infections or patients with underlying conditions or immunosuppression may require
longer courses of treatment than suggested in the AWaRe book.
• True severe allergy to antibiotics is rare and allergies are often over-reported
• Beta-lactam antibiotics (penicillins and cephalosporins) of the Access group are among the most
effective and safe medicines for many infections, and they should only be avoided when there is a
high suspicion of true allergy.
• Cephalosporins and carbapenems can be safely used in most cases of non-severe penicillin
allergy.