161 Malaria Chemoprophylaxis Advice: Survey of South African Community Pharmacists Knowledge and Practices Stephen Toovey, MBBCh SAA-Netcare Travel Clinics at time of study. DOI: 10.1111/j.1708-8305.2006.00035.x Background. Over 3 million South African residents travel to malarious areas annually. Given pharmacists ready accessibility and travel clinics incapacity to service total potential demand, South African community pharmacists malaria chemoprophylaxis knowledge and practice were assessed. Methods. Covert survey. Pharmacies were approached at random and asked for malaria chemoprophylaxis re commendations. A standard questionnaire indicating a 3-day stay in either Maputo ( N = 43; malarious) or Harare ( N = 25; non-malarious) was used. Results. Maputo group: 41/43 (95%) pharmacists correctly identified need for chemoprophylaxis; 3/41 (7%) recommended an ineffective drug. Eight of 41 (20%) enquired about diving, and 6/41 (15%) enquired about epilepsy or mental illness; despite positive responses mefloquine, was nevertheless recommended. Harare group: 12/25 (48%) incorrectly advised chemoprophylaxis was necessary; 4/12 (33%) sought contraindications; all prophylaxis recommended was considered effective. Overall, 54/68 (79%) pharmacists correctly determined whether chemoprophylaxis was required or not; 6/53 (11%) of all recommended chemoprophylaxis included alternative antimalarials; 1/68 (1%) consulted external advice before making recommendations; 11/53 (21%) referred travelers to a physician; 1/68 (1%) referred to a travel clinic. Pharmacies were significantly more likely (Fisher exact, p < 0.0001) to recommend unnecessary prophylaxis (12/25; 48%) than to advise against necessary prophylaxis (2/43; 5%). Conclusions. Pharmacists are willing to give malaria chemoprophylaxis advice but appear to overprescribe; although unnecessary adverse events may result, this may be the preferred error in a falciparum-dominated region. Pharmacists knowledge of contraindications, willingness to consult external resources, and knowledge of antimalarials effectiveness could be improved. Pharmacists appear unwilling to refer to travel clinics. An effective intervention to improve the safety and accuracy of pharmacists advice might be the provision of a simple aid listing effective antimalarials and their contraindications, illustrated with a malaria risk map. Improving the safety and accuracy of pharmacists advice would increase significantly travelers access to reliable travel health information. Most of populated South Africa is malaria free, but travel by South Africans to malarious destinations within the greater southern African region, where Plasmodium falciparum is the dominant species, is common. Estimates derived from government statistics show approximately 3.28 Presented at the 9th Conference of the International Society of Travel Medicine, Lisbon, Portugal, May 1 to 5, 2005 Corresponding Author: Stephen Toovey, MBBCh, Burggartenstrasse 32, CH-4103 Bottmingen, Switzerland. E-mail: malaria@freesurf.ch million South African residents traveled to malarious destinations outside the country s borders in 2002. 1,2 This total excludes internal travel from nonmalarious to malarious areas. There are approximately 130 officially registered yellow fever vaccination centers or travel clinics in South Africa, but not all are active or dedicated full time to travel medicine. It is clear, given the above numbers, that South African travel clinics do not have the capacity to service the total possible malaria chemoprophylaxis demand. Additionally, the Johannesburg Airport Survey 3 revealed that over 40% of travelers departing by air 2006 International Society of Travel Medicine, 1195-1982 Journal of Travel Medicine, Volume 13, Issue 3, 2006, 161 165
162 Toovey to malarious African destinations through Johannesburg airport carried either no antimalarials or inappropriate antimalarials; this was despite many travelers having had predeparture contact with health care professionals. Interestingly, only 13 of 253 (5%) travelers in that study who were residents in South Africa had approached a pharmacy for their travel health advice, indicating that greater use could well be made of pharmacies. Three malaria chemoprophylaxis issues require addressing in South Africa: Improving travelers access to antimalarials, improving the quality of antimalarial prescribing, and increasing awareness amongst travelers of the need for chemoprophylaxis. This survey was intended to provide information on the ability of community pharmacies to assist in addressing the first two issues. Community pharmacies offer direct access to a health care professional and do not charge consultation fees; both are likely advantages in attracting travelers. Additionally, pharmacies are able to dispense medication (not all South African physicians are licensed to dispense). In theory at least, community pharmacists might be well placed to service at least part of the very large potential market in South Africa for malaria chemoprophylaxis. At the time this study was conducted, atovaquone/proguanil (Malarone, Malanil) was not registered in South Africa, being available on a named-patient basis only; mefloquine and doxycycline were considered first-line prophylaxis for chloroquine-resistant malaria areas. 4 Both mefloquine and doxycycline require a prescription for dispensing, while only proguanil and chloroquine, generally considered to offer inadequate protection, may be dispensed without a prescription. Previous noncovert studies of British and Swiss pharmacies revealed deficiencies in antimalarial knowledge, 5,6 and the question arises of whether South African pharmacists, given their closer proximity to malarious destinations, might offer better advice than their European counterparts. This study was undertaken to assess the knowledge and practices of South African community pharmacists with regard to the issuing of malaria chemoprophylaxis advice, to determine whether they might safely be able to service travelers requiring antimalarials. Anecdotal evidence supports the belief that community pharmacies will often supply prescription only medication without a valid prescription. The study sought to examine the extent of this practice with respect to antimalarials. Methods A covert survey of pharmacies in the greater Johannesburg and Pretoria area was conducted during the last quarter of 2003, ahead of the country s major holiday season and during the Southern Hemisphere s summer. Prominent pharmacies on high streets or in shopping malls in the relevant metropolitan areas were approached by survey personnel with one of two standard scripts. Only two personnel were used to conduct the survey, in an effort to maintain consistency: a male paramedic and a female medical student; both had firsthand clinical experience of malaria endemic areas. Rural pharmacies were not approached for logistic reasons, and also with the consideration in mind that they would be unlikely to service a high number of travelers. Scripts were written with the specific intention of being as realistic as possible; they were presented to lay personnel for an assessment of in-shop verisimilitude. One script presented the pharmacist with a scenario of a 3-day stay in malarious Maputo, Mozambique ( N = 43); the other script presented the pharmacist with the scenario of a 3-day stay in nonmalarious Harare, Zimbabwe ( N = 25). Scripts were designed to ask definite and clear questions, eg, Good morning/afternoon. I am going to Maputo/ Harare next week for a long weekend. Will I need to take malaria tablets? Survey personnel rehearsed their scripts until judged fluent. Researchers recorded responses to the standardized scripted questions immediately upon exiting the pharmacy. Results In the Maputo group, 41/43 (95%) pharmacists correctly identified the need for prophylaxis, but of those, 3/41 (7%) recommended an ineffective drug, despite Maputo being an area of high transmission and known chloroquine resistance. Six (14%) of the 43 pharmacists in this group either spontaneously offered or agreed to dispense prescription-only antimalarials without a prescription, although only 2/6 (33%) enquired about contraindications. With regard to history taking and seeking contraindications to mefloquine, only 8/41 pharmacists (20%) enquired about diving, and only 6/41 (15%) enquired about epilepsy or mental illness. Strangely, despite positive responses to these enquiries about contraindications, mefloquine was nevertheless recommended.
Malaria Chemoprophylaxis Advice 163 In the Harare group, 12/25 (48%) incorrectly advised that prophylaxis was necessary, and only 4/12 (33%) sought contraindications; all prophylaxis recommended for travel to Harare was considered effective for Southern Africa s malarious areas. Overall, 54/68 (79%) pharmacists correctly determined whether prophylaxis was required or not ( Figure 1 ), while 6/53 (11%) of all recommended prophylaxis included alternative medications of herbal, naturopathic, or homeopathic nature. Only 1/68 (1%) pharmacies consulted an external source of expert advice before making recommendations. While 11/53 (21%) pharmacies recommending prophylaxis spontaneously referred travelers to a physician to obtain further advice and a prescription, only 1/68 (1%) of all pharmacies suggested referral to a travel clinic ( Figure 2 ) ( 2 = 10.33, p = 0.0013). Pharmacies were significantly more likely (Fisher exact, p < 0.0001) to recommend unnecessary prophylaxis (12/25; 48%) than to advise against necessary prophylaxis (2/43; 5%). Discussion Unlike previous studies of pharmacists malaria knowledge, this study was covert, attempting to simulate and capture the real life interactions between travelers and community pharmacists. The survey was confined to Gauteng province, the commercial heart of South Africa. The pattern of pharmacy practice and organization is similar in the other major metropolitan areas in South Africa, and it is thought possible that similar results would have been obtained, although this remains unproven. Rural pharmacies, by virtue of their location, would see far fewer travelers and may possibly have provided different answers. The survey did show that community pharmacists are willing to give malaria chemoprophylaxis advice, making recommendations even in those cases where they referred the surveyor to a physician. Encouraging from the safety perspective was that pharmacists scored well overall on determining whether chemoprophylaxis was necessary or not. Noteworthy was the low referral rate to travel clinics and preference for referral to a physician; whether this is to be explained by ignorance of travel clinics, the fact that most travel clinics dispense and will deprive pharmacists of income, or some other reason, is unclear. In this regard, the Johannesburg Airport Survey 3 revealed travelers satisfaction with travel health advice given by pharmacists to be equal to that given by general practitioners but less than that given by travel clinics. Pharmacists appear to err on the side of overprescribing, recommending chemoprophylaxis when it is not indicated. The study was unable to determine the reason for this, but possible explanations include fear of litigation, profit motive, or simple lack of knowledge. There are ample sources of reference open to pharmacists in such situations, Figure 1 Community pharmacists knowledge of malaria risk.
164 Toovey Figure 2 Pharmacists malaria chemoprophylaxis practice. including telephonic advice from general practitioners, the National Department of Health, a malaria hot line, travel medicine specialists, and the medical departments of antimalarial manufacturers; guidelines on antimalarial use are published by the National Department of Health and are sent to pharmacies free of charge, and antimalarial manufacturers provide maps with chemoprophylaxis recommendations. Although recommending antimalarials when not indicated may result in unnecessary adverse events, it is probably the preferred error in a falciparum-dominated region. Of concern in this respect though were the inadequate histories taken by pharmacists before recommending particular antimalarials. Overall, although different methodologies make direct comparisons difficult, the impression is that South African pharmacists perform better than their British or Swiss counterparts when providing antimalarial advice. 5,6 This may well be a reflection of their proximity to malarious destinations. One area where South African pharmacy practice compares unfavorably with European practice is in readiness to consult external expert advice. Kodkani and colleagues noncovert study of Swiss pharmacists 5 found that more than 50% would refer to documentation, eg, the Bulletin of the Swiss Federal Office of Health, before issuing malaria chemoprophylaxis advice; only 1/68 (1%) South African pharmacists consulted an expert information source. This unwillingness by South African pharmacists to consult external advice is surprising, given that South African community pharmacies usually have close working relationships with the prescribing physicians in their vicinity. A possible weakness of this study is the limited number of pharmacists surveyed, although those surveyed worked in prominent and busy community pharmacies. A further possible weakness may be that the study depended upon the surveyor recording his responses after his consultation with the pharmacist. This was minimized by having standard scripts and answer sheets, and by having surveyor personnel record pharmacists responses immediately upon exiting the pharmacy. A focused education campaign addressing which antimalarials are effective, their contraindications, and malaria s geographic distribution might improve the safety and accuracy of pharmacists advice; an effective intervention might be the provision of a simple user friendly aid providing the above information, given that existing aids are not generally consulted. Given the apparent unwillingness of pharmacists to consult expert information sources, however, such an aid would need to be quick and easy to use. Declaration of Interests The author has been reimbursed by numerous manufacturers of antimalarials for attending conferences, speaking, and consulting. He is married to
Malaria Chemoprophylaxis Advice 165 a former Novartis employee who was closely associated with artemether-lumefantrine. He has testified as an expert witness in matters concerning antimalarials. References 1. Statistics South Africa. Advance releases of tourism statistics, February 2002. Statistical release P0352. Pretoria, South Africa : 2002. 2. Statistics South Africa. Tourism and migration 2003. Statistical release P0351. Pretoria, South Africa : 2004. 3. Toovey S, Jamieson A, Holloway M. Travelers knowledge, attitudes and practices on the prevention of infectious diseases: results from a study at Johannesburg International Airport. J Travel Med 2004 ; 11 : 16 22. 4. Centres for Disease Control. Malaria information for travelers to Southern Africa. Available at : http:// www.cdc.gov/travel/regionalmalaria/safrica.htm. (Accessed 2005 Mar 5) 5. Kodkani N, Jenkins JM, Hatz CF. Travel advice given by pharmacists. J Travel Med 1999 ; 6 : 87 93. 6. Goodyer LI, McNamara K. Pharmacists knowledge of malaria prophylaxis. British Travel Association annual conference. London: British Travel Health Association, 2002.