Health service and policy Division (Collaborative Works)

/Health service and policy Division (Collaborative Works)
Health service and policy Division (Collaborative Works)2022-07-23T09:32:31+00:00
1107, 2022

National TB Control Program of Bangladesh: System Failure and Loss of Effectiveness

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Publication status: Published
Brief description: The National Tuberculosis Control Program (NTP) is one of the largest programs run by the state with many successes. However, underreporting is considered a real flaw of the current program. To report the characteristics and outcomes of TB patients registered in an upazila health complex in Kazipur, Sirajganj district, Bangladesh between September 2018 and February 2019 under the control of NTP was the objective of the study. This retrospective cohort study was conducted using routinely collected program data from the aforementioned site. Data retrieved from the hospital record form. Formal permission was obtained from the local authority. Consent statements and ethical aspects were waived due to the retrospective nature of the study. Analysis was performed using SPSS 20.0. A total of 207 tuberculosis cases were included with an average age of presentation of 43 years. Approximately 82.0% had pulmonary tuberculosis (PTB) and the rest had extrapulmonary tuberculosis (EPTB). PTB was more common in males, whereas EPTB was common in females (p=0.01). Of all cases, 84.0% were diagnosed by a positive sputum smear and 16.0% were diagnosed clinically with a negative sputum smear. Attendance at follow-up was 82.12%, 70.04% and 68.59% at months 2, 5 and 6 following index admission respectively. Overall, the cure rate was higher in PTB than EPTB [146 (85.9%) vs. 5 (13.5%), p<0.001). The rate of treatment completion was 25.1% (n=52) and the death count was 1.4% (n=3) [PTB-1.2 (n=2) vs. EPTB-2.7% (n=1)]. A gradual decline in reporting or completion of treatment was observed in this setting. However, a nationwide study is warranted to explore this issue in detail.

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607, 2022

Medicine promoting marketing factors: Survey among medical representatives in Bangladesh

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Publication status: Published
Brief description: Introduction: This study was aimed at gaining marketing insight by analysis of factors that influence medical representatives’ drug promotion and thus the prescription preparation of physicians. Methods: A descriptive cross-sectional study was conducted from February to October, 2013 among medical representatives by purposive convenient sampling. A structured questionnaire with measurements on 5-point Likert Scale was provisioned. Data input, format, transformation and analysis were performed using SPSS version 22 and Microsoft Excel 2010. Results: A total of 245 medical representatives were enrolled who were affiliated with a pharmaceutical company. Representatives’ improvisation, easy brand availability, regular promotion and company image are the factors having most influence. Easy brand name, low price and international certification of the company were on lower side. Conclusion: This study contains a brief summary of experience of medical representatives and insights of this paper will be helpful for marketers to ensure greater effectiveness and economic efficiency from drug prescribing.

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607, 2022

Prescription Modifying Marketing Factors: A Survey among the Clinicians in Bangladesh

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Publication status: Published
Brief description: It was aimed at finding out the important factors those influence the prescription preparation of doctors during their daily life consultancy. It was a descriptive, cross-sectional survey conducted by purposive, convenient sampling. 200 registered practicing doctors from different regions of Bangladesh were interviewed with the prepared self reporting questionnaire from February 2013 to October 2013. Questionnaire was prepared and finalized after pretesting. The measurement was made on the basis of 5 point Likert scale and data were analyzed by using SPSS 16 version and Microsoft Excel®. It was found that doctors consider company image, brand availability, regular promotion, easy brand name, scientific information, and personal experience related confidence with high preference. Promotional tools and representatives’ improvisation, low price of brands are relatively less sensitive to doctors. This study provides only selected aspects on pharma marketing; larger study may reveal the scenario more precisely.

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607, 2022

Use and Abuse of Anti-Ulcerants: A Perspective from Bangladesh

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Publication status: Published

Brief Description: Proton pump inhibitors (PPIs) is a time-tested drug for effective suppression of gastric acid and is indicated in several upper gastrointestinal disorders . These drugs irreversibly inhibit the gastric H+, K+ ATPase pump and reduce both basal and stimulated gastric acid output . They are shown to be effective in the treatment of gastro-esophageal reflux disease (GERD), peptic ulcers, and dyspepsia . Along with antibacterial, they are used for the  eradication of Helicobacter pylori . PPIs are also prescribed as a concomitant medication to prevent non-steroidal anti-inflammatory drug (NSAID) associated ulcers in high-risk patients and also patients who receive Glucocorticoid for prolonged duration . There are two main indications for long-term use of PPIs are reflux disease and use of maintenance non-steroidal anti-inflammatory drugs (NSAIDs), which puts patients at risk for non- steroidal gastropathy. Except for hyper secretory states, which are very rare disorders, most other indications for acid suppression do not require years and years of PPI exposure . The National Institute for Health and Clinical Excellence (NICE) published its guidelines on proton pump inhibitors in 2000. Its recommendations for using these drugsparticularly in the long termare relatively selective. In spite of limited  prescribing recommendation, rise of PPI usage is far beyond a change in morbidity. These are frequently prescribed without a clear indication and for a longer period than recommended. Although it might be assumed that overprescribing occurs mainly in primary care but inappropriate use of PPI in secondary care is also abundant. In hospital inpatients taking proton pump inhibitors in Australia, Ireland, and the UK, 63%, 33%, and 67% of patients did not meet their country’s criteria for taking the drug. In a series of hospital inpatients in Michigan, USA, 20% of patients were taking a proton pump inhibitor on admission and another 40% were prescribed the drug during their hospital stay (mostly for prophylaxis). At discharge, half the patients were taking a proton pump inhibitormore than double the number who were taking the drug when admitted [15]. Another study from New Zealand found that 40% of hospital inpatients were taking proton pump inhibitors inappropriately. Two thirds of these patients were still taking the drugs on discharge and moswere still taking them six months later. In a Swedish cohort of patients who had been taking proton pump inhibitors for four years, 27% were able to discontinue the drug altogether. A prospective audit of a series of patients admitted as a medical emergency to a hospital in Wales found that a quarter of patients were taking a proton pump inhibitor. In only half of the patients was the indication for the drug  deemed appropriate. Though fewer data is available to our country it can be assumed that situated is almost same in Bangladesh. PPI are relatively safe and less toxic in comparison to other drugs but it is not free from side effects and cannot be overlooked. The long-term use of PPIs is associated with a higher risk of community acquired pneumonia, osteoporosis and hip fractures. Another important recognized consequence  of prolonged use is acute interstitial nephritis and pseudomembranous colitis. An increase in the prevalence of pneumonia and Campylobacter  enteritis is reported, as well as a doubling of the risk of infection with Clostridium difficile. Investigators around the world have published many studies looking at longer-term exposure among patients may increase the risk of hepatotoxicity, nephrotoxicity, or other unusual side effects but fortunately incidence is not so common. More common potential adverse effects relating to the two known class effects of PPIs: Hypochlorhydria and Hypergastrinemia. Rebound secretion of Hydrochloric acid after discontinuation of drug may potentiate increase sensation of burning and lead to further consumption of PPI22. Moreover, several investigations had shown the strong association of iron deficiency anemia with prolonged use of PPI which may be fatal if untreated. Besides side effect profile it causes enormous burden of health expenditure throughout the world. In United Kingdom, they constitute the largest expenses for any single drug group. In 2006, expenditure on these drugs was £425m (€595m; $872m) in England. Germany has resulted in an annual spend of € 927 million (i.e. $ 1.2 billion) in 2010 and £7bn globally. Bangladesh is a densely-populated country with significant health related Millennium Development Goals (MDGs) with progressive pharmaceuticals sector mostly driven by anti-ulcerants . The current market size is about 14 billion with having almost persistently double-digit growth. There are 267 licensed pharmaceutical companies and the market is almost self-sufficient in meeting local demand as 97% of the drugs are manufactured locally. Anti-Ulcerants are significantly dominating the huge volume sells with marked impact on company revenue. Recent tradition shows, anti-ulcerants as a therapeutic class tops the whole market with having about 15% of the total market share. Moreover, brand wise ranking based on sales volume shows among the top 25 brands, there are 11 anti-ulcerant brands with the top 4 anti-ulcerant brands. Yet studies consistently show that proton pump inhibitors are being overprescribed worldwide in both primary and secondary care. Between 25% and 70% of patients taking these drugs have no appropriate indication. This means that, at the very least, £100m from the National Health Service (NHS) budget and almost £2 bn worldwide is being spent unnecessarily on proton pump inhibitors each year and it could be saved if proper utilization can be maintained.

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2106, 2022

Health System Resilience for a Concurrent Outbreak of Coronavirus Disease 2019 and Dengue: A Response From Bangladesh

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Publication status: Published
Brief description: Bangladesh, a tropical country, has been facing periodic outbreaks of dengue since 2000. The country suffered its largest outbreak last year, with >100 000 confirmed cases and 120 deaths. These outbreaks usually reach the peak during monsoon and last till December and cause a considerable burden on our low-budgeted health care delivery system in terms of increased bed occupancy, higher outdoor and indoor consultations, and increased workload on health service providers. Even the diagnostic kits might fall short, as evident from previous outbreaks.1 Besides, this makes hospitals preoccupied with noncritical patients, which hampers the critical patients’ timely management. This year, 792 dengue cases were reported until November 11, 2020, with an expected spike in the number to follow.2 On the other hand, the existing health care facilities are already overburdened with coronavirus disease 2019 (COVID-19) patients. A total of 393 000 confirmed COVID-19 cases and 5723 deaths had been identified so far. Historically, concurrent outbreaks are not uncommon. The coincidence of dengue with chikungunya as well as influenza A H1N1 pandemic were previously documented. Concurrent infections of COVID-19 and dengue was already reported in Bangladesh3 and also in few other dengue-endemic countries.4 Although COVID-19 shows a classic respiratory symptom, it shares some common characteristics and laboratory profile with dengue as both can elicit a similar immune response in the body.5 As a result, a concurrent infection may spread insidiously among the general population while the nation focuses on COVID-19 alone. The simultaneous presence of both diseases in a person might cause diagnostic and management difficulty leading to fatal consequences. The coincident outbreak of dengue on top of the COVID-19 pandemic may cause havoc on the health care delivery system of Bangladesh if the preparation is not carried out in advance. To prevent increased dengue incidence on top of the COVID-19 pandemic, Bangladesh needs to take immediate action. Policymakers should collaborate with epidemiologists, entomologists, virologists, infectious disease specialists, health care professionals, and nongovernmental organizations in this regard. Public health measures in reducing the spread of COVID-19, such as social distancing or lockdown strategy, have been ineffective in our setting. Prevention strategies involving mosquito control and bite reduction failed in the past. Hence, the health care facilities should be ready to tackle the concomitant surge in dengue and COVID-19 cases. An organized effort of both public and private health care is therefore warranted. Bangladesh’s health care authority has already recommended testing all patients with fever for both COVID-19 and dengue and opened the dedicated COVID-19 hotlines for receiving dengue-related calls at district and upazila levels. Despite those measures, the recent escalating number of patients causes fearful apprehension about the health system’s preparedness. Therefore, authorities should increase testing facilities, designate COVID plus wards in the hospitals, and increase the number of beds in critical and intensive care units as early as possible. Intensified surveillance should be prioritized. A combination of these extraordinary measures is expected to strengthen the existing health system against this dual outbreak and could be applied in other countries sharing a similar social context.

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