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1. Community Pharmacy ASMA GHULAM MUSTAFA Faculty of pharmacy University of Lahore 1

2. Definition A   community pharmacy  is a healthcare facility that emphasizes providing pharmaceutical services to a specific community. It dispenses medicine and typically involves a registered pharmacist. or Community Pharmacy is a community based pharmacy. Community pharmacy, all of those establishments that are privately owned and whose function is to serve the society needs for both drug products and the pharmaceutical services. 2

3. Background of Community Pharmacy The concept of community pharmacy has evolved over centuries. Initially, pharmacists were medicine preparers and compounders, but today, they are integral health care providers ensuring rational drug use and patient safety. Historical Development Ancient Era (Before 1000 AD) Early apothecaries prepared herbal medicines and remedies. Pharmacists worked closely with physicians to formulate medicines . Medieval and Renaissance Period (1000–1700 AD) Establishment of pharmacy as a separate profession from medicine . The first community pharmacies (separate from physicians) were established in Baghdad in the 9th century. Development of official pharmacopeias and drug standards. 3

4. Background of Community Pharmacy Industrial Revolution (1700–1900 AD ) The first pharmacy schools were established in Europe and the U.S. 1820: The U.S. Pharmacopeia (USP) was created to standardize drug quality. Mass production of drugs began, reducing the need for extemporaneous compounding . Pharmacists started focusing on dispensing and patient care. The Expansion of Community Pharmacy 20th Century (1900–2000 AD) Introduction of modern drug regulation and pharmacy education programs . Emergence of clinical pharmacy services beyond dispensing . 21st Century (2000–Present) Focus on patient-centered care, medication therapy management (MTM), and public health initiatives. Integration of digital health, telepharmacy , P oint of care testing and electronic prescribing. 4

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6. Pharmaceutical Care “ Pharmaceutical care is a co-operative , patient- centered system for achieving specific and positive patient outcomes from the responsible provision of medicines . ” Pharmaceutical Care is a component of pharmacy practice which entails the direct interaction of pharmacist with patient for the purpose of caring for the patient’s drug related needs “The responsible provision of drug therapy for the purposes of achieving definite outcomes that improve a patients quality of life ” 6

7. Desired outcomes of PC Cure of patient disease Reduction or elimination of disease symptoms. Arresting or slowing progression of disease . Preventing a disease or symptoms 7

8. Community vs Retail Pharmacy Community Pharmacy Retail Pharmacy A community pharmacy is a healthcare-focused facility that provides pharmaceutical care, including medication therapy management, disease prevention, and patient counseling. A retail pharmacy is a business-oriented establishment primarily focused on the sale of prescription and over-the-counter (OTC) medicines, along with health-related products. The primary objective is to enhance patient health and well-being through proper medication use, chronic disease management, and preventive care. The primary focus is on profitability and efficient distribution of medicines and healthcare products. Pharmacists play a important role in patient education, medication adherence, and public health initiatives such as vaccinations and health screenings. Pharmacists mainly dispense medications and provide limited counseling , with less emphasis on direct patient care. 8

9. Community Pharmacy and Public Health Community pharmacy in the Public Health service include Rational use of drugs Poisoning prevention Epidemiological control Smoking cessation services Prevention and management of drug abuse, misuse and addiction Healthy eating and lifestyle advice Chronic Disease Management Infection control and prevention Minor Ailments Schemes 9

10. Community Pharmacist A Community Pharmacist is a healthcare professional who works in a community pharmacy and provides medication-related services, patient counseling, and health promotion to the general public. 10

11. Role of Community Pharmacist Following are the areas where a community pharmacist can be actively involved to serve the community Drug related problems (DRPs)  Counseling on proper use of OTC and prescribed medicines, recording of drug and medical problem histories, immunization schedules, refer patients to specific healthcare professionals. Pharmacoepidemiology  post marketing phase of clinical trial of a drug that concerns the safety or risk assessment of a new drug coming in market. Control of serious communicable diseases  making community aware through counseling e.g. Dengue, syphilis, gonorrhea, herpes genitals, AIDS, hepatitis etc. Prevention of chronic diseases  using various proven techniques of preventions e.g. prevention of stroke by control of high blood pressure, lowering cholesterol and promoting regular intake of prescribed medicines and physical exercise (life-style modifications. Patient health education  use of pamphlets and bulletins 11

12. Role of Community Pharmacist Following are the areas where a community pharmacist can be actively involved to serve the community Woman and child health  counseling to pregnant ladies about personal hygiene and child health on diet and other diseased or sub nutritional states and proper immunization schedules. Family planning  control of population. Nutritional advice  guide patients about nutrition intake according to the requirement of the patient and their disease states. Weight control program  to control the obesity. Environmental Health  make aware community about food born diseases, local hazards, carcinogens etc. Prevention of drug abuse  provide counseling to patients involved in alcoholism and drug abuse about the hazards and side-effects or draw backs. May refer the patient for treatment to an appropriate health care professional. 12

13. Disease Terminologies 13

14. Disease Terminologies An “ Acute disease " is a condition that develops suddenly, has severe symptoms, and typically lasts for a short period of time, like a common cold. A “Chronic disease" is a long-term condition that develops gradually and may worsen over time, like diabetes, heart disease, or arthritis A “Communicable disease" is a disease that can be transmitted from one person to another, typically caused by infectious agents like bacteria or viruses. E.g COVID-19 A “Non-communicable disease" cannot be passed between people and is often linked to lifestyle factors like diet and exercise, including conditions like cancer, heart disease, and diabetes 14

15. Disease Terminologies Infection: Infection is the entry and development or multiplication of an infectious agent in the body of man or animals. Contamination: The presence of an infectious agent on a body surface, on or in clothes, beddings, toys, surgical instruments or dressings, or other articles or substances including water and food. Infestation: It is the lodgment, development and reproduction of arthropods on the surface of the body or in the clothing, e.g. lice, itch mite. Contagious disease: A contagious disease is the one that is transmitted through contact. Examples include scabies: is a contagious skin infestation by the mite Sarcoptes scabiei 15

16. Disease Terminologies Mortality rate , or death rate , is a measure of the number of death (in general, or due to a specific cause) in a particular population, scaled to the size of that population, per unit of time. Morbidity (from Latin morbidus , meaning "sick, unhealthy") is a diseased state, disability, or poor health due to any cause Incidence of an infectious disease: number of new cases in a given time period expressed as percent infected per year (cumulative incidence). Prevalence of an infectious disease: number of cases at a given time expressed as a percent at a given time. 16

17. Disease Terminologies 17

18. Disease Terminologies Zoonosis is an infection that is transmissible under natural conditions from vertebrate animals to man, e.g. rabies Nosocomial (hospital acquired) infection is an infection originating in a patient while in a hospital or another health care facility. It has to be a new disorder unrelated to the patient’s primary condition. Examples include infection of surgical wounds, hepatitis B and urinary tract infections . Eradication: Termination of all transmission of infection by the extermination of the infectious agent through surveillance and containment. Eradication is an absolute process, an “all or none” phenomenon, restricted to termination of infection from the whole world . Elimination: The term elimination is sometimes used to describe eradication of a disease from a large geographic region . Disease which are amenable to elimination in the meantime are polio, measles and diphtheria. 18

19. Epidemiology and its control 19

20. Epidemiology It is the study of frequency , distribution , and determinants of diseases and other health-related conditions in a human population and the application of this study to the prevention of disease and promotion of health Study : Systematic collection, analysis and interpretation of data Frequency : the number of times an event occurs Distribution : Circulation of an event by person, place and time Determinants: Factors the presence/absence of which affect the occurrence and level of an event Diseases & other health related events Human population Application 20

21. Disease Transmission Cycle (Epidemiologic Triangle) Reservoir : The place where the pathogen survives and multiplies (e.g., humans, animals, soil, water). Portal of Exit : The way the pathogen leaves the infected host (e.g., respiratory droplets, feces, blood). Mode of Transmission : The process of disease spread, either through direct contact (e.g., touching, sneezing) or indirect contact (e.g., contaminated surfaces, vectors like mosquitoes). Portal of Entry : The route through which the pathogen enters a new host (e.g., inhalation, ingestion, open wounds). Susceptible Host : A person who lacks immunity or resistance and can get infected. 21

22. Aim of Epidemiology According to the International Epidemiological Association (IEA) , the aim of epidemiology includes: Describing Health and Disease Patterns – Understanding how diseases and health conditions vary by time, place, and person. Identifying Causes of Diseases – Investigating risk factors and determinants of diseases to establish causality. Developing and Evaluating Public Health Interventions – Informing policies, programs, and strategies for disease prevention and health promotion. Providing Evidence-Based Recommendations – Supporting healthcare planning, policy-making, and resource allocation. 22

23. Types of Epidemiology THREE major categories of Epidemiology 1. Descriptive Epidemiology Focuses on the distribution of diseases in terms of time, place, and person. Used to generate hypotheses about possible causes . Defines frequency and distribution of diseases and other health related events (4 questions: how many, who, where, and when?) 2. Analytic Epidemiology Investigates the causes and associations between risk factors and diseases. Aims to test hypotheses generated from descriptive studies . Analyses determinants of health problems Answers two other major questions: how? and why? 3. Experimental (Interventional) Epidemiology Involves actively testing interventions to assess their effectiveness. Used in clinical and public health research. 23

24. Uses of Epidemiology 1. Study of Disease Pattern in Population Describes the distribution of diseases based on time, place, and person. Helps identify disease trends, outbreaks, and disparities among different populations. Example: Tracking the rise of diabetes in urban vs. rural populations. 2. Community Diagnosis Determines the health status and disease burden of a community. Helps assess the needs for healthcare services and interventions. Example: Conducting a survey on thyroid disease awareness in Lahore to identify gaps in knowledge and prevention . 3. Planning and Evaluation of Health Services Provides data for health policy development and resource allocation. Helps evaluate the effectiveness of vaccination programs, screening tests, and disease control measures. Example: Assessing the impact of polio eradication programs in Pakistan. 24

25. Uses of Epidemiology 4. Evaluation of Individual Risk Identifies risk factors and predicts the likelihood of developing diseases. Helps in preventive strategies and lifestyle modifications. Example: Estimating the risk of heart disease based on cholesterol levels, smoking, and family history. 5. Completing the Natural History of Disease Studies the progression of diseases from preclinical stages to recovery or death. Helps in identifying critical intervention points for disease prevention. Example: Understanding the progression of cervical cancer from HPV infection to invasive cancer. 6. Search for Risk Factors Identifies modifiable and non-modifiable factors contributing to disease development. Supports public health interventions to reduce disease burden. Example: Linking tobacco use to lung cancer and promoting anti-smoking campaigns. 25

26. Prevention The goals of medicine are to promote health, to preserve health, to restore health when it is impaired, and to minimize suffering and distress. Successful prevention depends upon: a knowledge of causation, dynamics of transmission, identification of risk factors and risk groups, availability of prophylactic or early detection and treatment measures, an organization for applying these measures to appropriate persons or groups, and continuous evaluation of procedures applied 26

27. Level of Prevention Primordial Prevention Primordial prevention is the earliest level of disease prevention, aimed at eliminating risk factors and creating conditions that prevent the development of risk factors. It focuses on modifying social, environmental, and economic factors that contribute to disease before they even arise . E.g Banning trans fats in food to prevent heart disease . Primary Prevention (Preventing Disease Before It Occurs) Primary prevention aims to prevent the onset of disease or injury by reducing risk factors and promoting health . Primary prevention may be accomplished by measures of “ Health promotion ” and “ specific protection . ” Examples Vaccination against polio, Promoting healthy eating and exercise to prevent obesity and diabetes.. 27

28. Level of Prevention Secondary Prevention (Early Detection & Treatment) Secondary prevention focuses on early disease detection and intervention to prevent progression or complications. The specific interventions are: early diagnosis (e.g. screening tests, and case finding programs….) and adequate treatment. It thus protects others from in the community from acquiring the infection and thus provide at once secondary prevention for the infected ones and primary prevention for their potential contacts . Examples Mammograms for early detection of breast cancer. Pap smears for cervical cancer screening. 28

29. Level of Prevention Tertiary Prevention (Managing and Reducing Complications of Disease) Tertiary prevention focuses on managing established diseases to reduce complications, disability, and improve quality of life . Intervention that should be accomplished in the stage of tertiary prevention are disability limitation , and rehabilitation . Examples Rehabilitation for stroke patients to improve mobility and speech . Insulin therapy and lifestyle management for diabetes to prevent complications like kidney failure . Palliative care for terminal illnesses (e.g., cancer) 29

30. Level of Prevention Quaternary Prevention (Preventing Overmedicalization & Harm ) Quaternary prevention aims to protect patients from unnecessary medical interventions, overdiagnosis , or overmedication . The action taken to identify patient at risk of over- medicalisation , to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable. Examples Stopping unnecessary antibiotic prescriptions to prevent antimicrobial resistance. Reducing polypharmacy in elderly patients to avoid side effects. Avoiding excessive diagnostic tests (e.g., unnecessary CT scans exposing patients to radiation ). 30

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32. Pharmacoepidemiology 32

33. Pharmacoepidemiology Pharmacoepidemiology is the study of the use of and the effects of medicines in large numbers of people. New applied field bridging between clinical pharmacology and epidemiology. Pharmacoepidemiology started with increasingly frequent accusations about adverse drug reactions, often arising out of spontaneous reporting system, followed by formal studies proving or disproving those associations. One of the most pressing problems facing public health providers and administrators in many countries is ensuring the rational use of drugs. 33

34. Pharmacoepidemiology In practice, success of treatment largely depends on the ability of a physician to diagnose, prescribe, foresee probable adverse reactions and prevent unnecessary or dangerous duplication therapy. Further success depends on performance of the pharmacy and nursing departments in preparing and administering drugs. However, the existence of a rationally derived list of drugs approved for procurement and health care consultants performance does not ensure that they are prescribed and used correctly. One mechanism to ensure correct prescribing and use is the Drug Utilization Review. 34

35. Drug Utilization Review (DUR)/ Drug Use Evaluation (DUE)  "DUR" (Drug Utilization Review) and "DUE" (Drug Use Evaluation) are often used interchangeably, the key difference is that  DUR focuses on a broader, systematic review of medication usage patterns across a population to identify potential issues, while DUE usually refers to a more targeted evaluation of a specific drug or patient's medication therapy to assess its appropriateness and effectiveness;  B oth processes aim to improve medication use and patient outcomes, but DUR tends to be more focused on identifying trends and patterns, whereas DUE is more individual-patient centered.  35

36. Drug Utilization Evaluation (DUE) DUE is an ongoing, systematic process designed to maintain the appropriate and effective use of medicines . It involves a comprehensive review of patients' prescription and medication data before, during, and after dispensing in order to assure appropriate therapeutic decision making and positive patient outcomes. Pharmacists participating in DUE programs can directly improve the quality of care for patients, individually and as populations, by preventing the use of unnecessary or inappropriate drug therapy and by preventing adverse drug reactions. 36

37. Drug Utilization Review (DUR) DUR is defined as an authorized, structured, ongoing review of practitioner prescribing, pharmacist dispensing, and patient use of medications. The purpose of a DUR is to ensure that drugs are used appropriately, safely, and effectively to improve patient health status. DUR is typically classified in three different categories: prospective, concurrent, and retrospective 37

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39. Steps In Conducting A Drug Use Evaluation Identify or Determine Optimal Use: Criteria are defined to allow for comparisons of optimal use with actual use. Criteria should focus on relevant outcomes. For example, if the use of a drug prescribed to treat a patient with diabetes is being evaluated, then set standards should be determined to evaluate its effectiveness, such as a decrease in blood glucose or HbA1c (glycosylated hemoglobin) levels. Measure Actual Use: This step is where data is gathered to measure the actual use of medications. This data can be obtained from medical and prescription records or electronic claim forms. 39

40. Steps In Conducting A Drug Use Evaluation Compare : This involves the comparison between optimal or appropriate and actual use. During this process, the evaluator determines whether findings are expected and causes for any discrepancies. In this process, patterns or aberrations can be interpreted. Intervene : This is the step where corrective action is implemented. Action should be targeted to areas of concern such as prescribing patterns, medication misadventures, the quality of drug therapy, or economic consideration. Evaluate the DUE Program : The last step is to assess the effectiveness of the DUE program. Efforts should be made to evaluate the outcomes and document reasons for positive and negative results. Implementing appropriate changes to the DUE program and continued observation should be undertaken 40

41. Scope of Drug Use Evaluation DUE programs play a key role in helping a health organization to understand, interpret, and improve the prescribing, administration, and use of medications. This is often accomplished by using DUE programs to provide physicians with feedback on their performance and prescribing behaviors as compared to pre-set criteria or treatment protocols. DUE information also assists health policy makers in designing educational programs that improve rational prescribing, formulary compliance, and patient compliance. 41

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43. CDC ( Centers For Disease Control & Prevention) 43

44. CDC The centers for disease control and prevention (CDC) is an agency of the United States Department of Health and Human Services based in the small building of Atlanta, Georgia. It works to protect public health and safety by providing information to enhance health decisions and it promotes health through partnerships with state health departments and other organizations . The CDC focuses national attentions on developing and applying disease prevention and control (especially infectious diseases), environmental health, occupational safety and health , health promotion, prevention and education activities designed to improve the health of people of the United States. 44

45. Present and future Today, CDC is the nation’s premiere health promotion , prevention and awareness agency and a global leader in public health. It helps in public health efforts to prevent and control infectious and chronic diseases, injuries, workplace hazards, disabilities and environmental health threats . CDC works with states and other partners to provide a system of health surveillance to monitor and prevent Disease outbreaks implement disease prevention strategies and maintain national health statistics. CDC also guards against international disease transmission , with personnel stationed in more than 25 foreign countries. CDC is one of the 13 major operating components of the Department of Health and Human Services(HHS). 45

46. CDC Mission To promote health and quality of life by preventing and controlling disease, injury and disability. CDC seeks to accomplish its mission by working with partners through out the nation and the world to Monitor health, Detect and investigate health problems , Conduct research to enhance prevention , Develop and advocate sound public health policies, Implement prevention strategies, Promote healthy behaviors, Provide training. 46

47. CDC Organization The CDC is one of the major operating components of the Department Of Health and Human Services. CDC’s top organizational components include Office of the Director , National Institute for Occupational Safety and Health 6 Coordinating Centers / Offices 47

48. Office of the director CDC Organization 48

49. National Centers Coordinating center for Environmental health and injury prevention Coordinating center for Health information and Services Coordinating center for Health Promotion Coordinating center for Infectious Diseases 49

50. Coordinating Center for Environmental Health and Injury Prevention National center for environmental health / Agency for Toxic Substances and Disease Registry (NCEH/ATSDR ) It provide national leadership in preventing and controlling disease and death resulting from the interaction b/w people and their environment . National Center for Injury prevention and control (NCIPC ) It prevent death and disability from non occupational injuries , including those that are unintentional and those that result from accidents or violence . 50

51. Coordinating Center for Health Information & Services National Center for Health Marketing (NCHM) It provide national leadership in health marketing science and in its application to impact public health . National Center For Health Statistics (NCHS) It provides statistical information that guides actions and policies to improve the health of the American people . National Center for Public Health Informatics (NCPHI ) It provides national leadership in the application of information technology in the pursuit of public heath . 51

52. Coordinating Center for Health Promotion National Center on Birth Defects and Developmental Disabilities (NCBDDD) It provide national leadership for preventing birth defects and developmental disabilities and for improving the health and wellness of people with disabilties . National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) It prevents premature death and disabilities from chronic diseases and promotes healthy personal behaviors. National Office for Public Health Genomics (NOPHG) It focuses on how genetic information can be used to prevent, detect, and manage diseases at a population level. 52

53. Coordinating Center for Infectious Diseases National Center for immunization and Respiratory Diseases (NCIRD) It is an immunization program that brings together vaccine preventable disease science and research with immunization program activities . National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) It focuses on preventing, detecting, and responding to zoonotic, vector-borne, and enteric diseases . National Center for HIV/ AIDS,Viral Hepatitis and TB Prevention (NCHHTP) It integrates epidemiology and prevention initiatives related to human immunodeficiency virus(HIV),acquired immunodeficiency syndrome (AIDS),viral hepatitis and tuberculosis(TB) to enhance opportunities in to develop and implement collaborative public health interventions. National Center for Preparedness, Detection, and Control of Infectious Diseases (NCPDCID) It focuses on emerging and re-emerging infectious diseases, public health preparedness, and disease control strategies . It plays a vital role in preventing, detecting, and responding to infectious disease threats at national and global levels. 53

54. CDC Bioterrorism Agents The CDC has different categories for diseases posing a threat to the US: Category A Diseases/Agents High priority agents include organisms that pose a risk to national security because they: Can be easily disseminated or transmitted from person to person. Result in high mortality rates and have the potential for major public health impact. Might cause social disturbance and Require special action for public health awareness. Agents/ Diseases: Small pox ( Variola major ), Plague (Yersinia pestis ) 54

55. CDC Bioterrorism Agents The CDC has different categories for diseases posing a threat to the US: Category B Diseases/Agents Second highest priority agents include those that are moderately easy to disseminate ; result in moderate morbidity rates and low mortality rates; and require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance. Agents / Diseases: Food safety threats (e.g., Salmonella species, Escherichia coli) 55

56. CDC Bioterrorism Agents The CDC has different categories for diseases posing a threat to the US: Category C Diseases/Agents Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of Availability ease of production and dissemination potential for high morbidity and mortality rates and major health impact. Agents / Diseases: Emerging infectious diseases such as Nipah virus and hantavirus 56

57. MDGs ( Millennium Development Goals) 57

58. MDGs The Millennium Development Goals (MDGs) were eight global goals established by the United Nations (UN) in 2000 to address major global challenges, including poverty, education, gender equality, health, and environmental sustainability. These goals were set to be achieved by 2015 . These goals were based on commitments made in the UN Millennium Summit (2000) and were endorsed by 189 countries, including Pakistan. 58

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60. Pakistan’s Progress on MDGs Pakistan signed the MDGs commitment in 2000 but faced several challenges in achieving them by 2015 . Pakistan did not fully achieve the MDGs by 2015, the UN introduced the Sustainable Development Goals (SDGs) 2016–2030, a more detailed and ambitious framework. 60

61. SDGs ( Sustainable Development Goals) 61

62. SDGs The Sustainable Development Goals (SDGs) were adopted by the United Nations (UN) in 2015 as a follow-up to the Millennium Development Goals (MDGs). The SDGs are a set of 17 global goals designed to address major challenges like poverty, inequality, environmental sustainability, and economic growth . 62

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64. Pakistan’s Progress on SDGs Pakistan was one of the first countries to adopt the SDGs as a National Development Agenda in 2016. The Pakistan Vision 2025 aligns with the SDGs, focusing on poverty reduction, health, education, and economic growth. Pakistan established SDG Units in all provinces for policy implementation. 64

65. EPI ( Expanded Programme on Immunization) 65

66. Immunization Also called vaccination or inoculation, A method of stimulating resistance in the human body to specific diseases using microorganisms—bacteria or viruses—that have been modified or killed . It is a process whereby a person is made immune or resistant to an infectious disease, typically by the administration of vaccine. Vaccine stimulates the body defense system against the respective infectious agent or disease . Prevention of the disease is the need of the day. The morbidity and mortality caused by a disease and rising cost of treating them requires us to focus more on their prevention. It is the effective public health intervention that had the greatest impact on the health of public. Every year millions of children are saved just because of immunization. 66

67. What Is EPI? Expanded program on Immunization (EPI) is World Health Organization’s program, with the goal to make vaccines available to all children throughout the world. “ Expanded” Means? Expanding the number of diseases to be covered Expanding the number of children and target population to be covered Expanding coverage to all corners of the country and spreading services to reach the less privileged sectors of the society. AIM: To reduce morbidity and mortality of diseases Goal : To make vaccines Available to all children 67

68. History of EPI Experience with smallpox eradication program showed the world that immunization was the most powerful and cost-effective weapon against vaccine preventable diseases. In 1974, the WHO launched its “ Expanded program of Immunization” (EPI) against six most common preventable diseases (diphtheria, pertussis, tetanus, polio, tuberculosis, measles and recently added pneumococcal vaccine) with the objective to vaccinate children throughout the world. Ten years later, in 1984, the WHO established a standardized vaccination schedule for the original EPI vaccines: Bacillus Calmette Guérin (BCG), diphtheria-tetanus-pertussis (DPT), oral polio, and measles. Later on new vaccines being developed and added to the EPI’s list of recommended vaccines: these include Hepatitis B ( Hep -B) and Haemophilus influenza meningitis (Hib) conjugate vaccine in countries with high burden of disease. 68

69. History of EPI In 1999, the Global Alliance for Vaccines and Immunization (GAVI) was created with the sole purpose of improving child health in the poorest countries by extending the reach of the EPI. In 2006, combination Tetravalent combo vaccine was introduced replacing separate DPT and Hepatitis B vaccine which was later in 2008 switched to the Pentavalent (DPT- Hep B-Hib) vaccine with addition of the new Hib vaccine. EPI also adopted new technology to make immunization safer and more client compliant. Since 2002, to prevent the risk of blood borne diseases, EPI is using Auto-disable (AD) Syringes for all its immunization injections for all clients and safety box for proper disposal of the sharp wastes. 69

70. EPI in Pakistan The Expanded Programme on Immunization (EPI) was launched in Pakistan in 1978 to protect children by immunizing them against childhood tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus and measles . Later, with the support of development partners, a number of new vaccines e.g. hepatitis B, haemophilus influenzae type b (Hib) and pneumococcal vaccine (PCV10) were introduced in 2002, 2009 and 2012, and inactivated polio vaccine in 2015, respectively. It also aims to protect mothers and newborn against tetanus. Immunizing children with these vaccines may avert up to 17% of childhood mortality in Pakistan and thus help contribute towards achieving Sustainable Development Goal (SDG) 3, on reducing child morbidity and mortality. The programme also plans to introduce rotavirus vaccine in 2017, which will prevent one cause of fatal diarrhea due to rotavirus. 70

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72. EPI in Pakistan The national immunization programme has contributed to significantly decreasing childhood morbidity and mortality due to vaccine preventable diseases. A child needs only 5 visits during the first year and one visit during the second year of his/her life to complete the vaccination with 6 visits against 9 dreadful diseases. 72

73. Types of Vaccines Live Attenuated Vaccines It Contain weakened (attenuated) forms of the pathogen that can replicate but do not cause disease in healthy individuals. Examples: Measles, Mumps, and Rubella (MMR) vaccine Varicella (chickenpox) vaccine Bacillus Calmette-Guérin (BCG) vaccine for tuberculosis Oral Polio Vaccine (OPV) 73

74. Types of Vaccines Inactivated (Killed) Vaccines It Contain pathogens that have been killed or inactivated, preventing replication while still triggering an immune response. Examples: Inactivated Polio Vaccine (IPV) Hepatitis A vaccine Rabies vaccine 74

75. Types of Vaccines Subunit, Recombinant, Polysaccharide, and Conjugate Vaccines It Use specific parts of the pathogen (e.g., protein, sugar, or capsid) to trigger immunity without using the whole virus or bacteria. Examples: Hepatitis B vaccine (recombinant) Human Papillomavirus (HPV) vaccine Pneumococcal vaccine (polysaccharide/conjugate) Meningococcal vaccine 75

76. Types of Vaccines Toxoid Vaccines It Contain inactivated bacterial toxins (toxoids) to build immunity against the toxin rather than the bacteria itself. Examples: Diphtheria vaccine Tetanus vaccine 76

77. Types of Vaccines mRNA Vaccines It Uses messenger RNA (mRNA) to instruct cells to produce a viral protein, triggering an immune response. Examples: Pfizer- BioNTech COVID-19 vaccine Moderna COVID-19 vaccine Viral Vector Vaccines It Uses a modified virus (vector) to deliver genetic instructions for making a viral protein, stimulating an immune response. Examples: AstraZeneca COVID-19 vaccine 77

78. Components of EPI 78

79. ▪Children 0-23 months – immunization with 8 EPI antigens ▪Pregnant ladies by TT Regular Immunization 79

80. NIDs & SIAs NIDs = National Immunization Days SIAs = Supplementary Immunization Activities NIDs / SIAs: children < 5 years receive polio drops (3-days campaign) house to house strategies for NIDs. Routine immunization does not ensure 100% coverage of the mobile population i.e. hard to reach areas / missed areas. So SIAs are scheduled to ensure coverage of this population / areas. Some time these SIAs also include Vitamin-A drops campaign in their schedule 80

81. This network system has been established by Designating District Surveillance Coordinator (DSC) in each district to detect suspected cases of EPI diseases by Continuous monitoring of vaccine-preventable diseases to detect outbreaks and evaluate immunization program effectiveness. Disease Surveillance 81

82. Special campaigns 5-8 km around the infected locality to localize the disease and stop its transmission. It is house-to-house immunization with OPV in high risk districts. It consists of two to three rounds 4-6 weeks apart . High risk districts are those: Where the wild polio virus is still circulating ( polio case in the last 36 months) . With low immunization coverage. Transient population, with overcrowding poor sanitary environment and low access to health services. Mopping up 82

83. References Remington, J. P. (2006). Remington: the science and practice of pharmacy (Vol. 1). Lippincott Williams & Wilkins. Winfield, A. J., Rees, J., & Smith, I. (Eds.). (2009). Pharmaceutical practice e-book. Elsevier health sciences. Bonita, R., Beaglehole , R., & Kjellström , T. (2006).  Basic epidemiology . World Health Organization . https://www.cdc.gov/about/organization/index.html https://www.emro.who.int/pak/programmes/expanded-programme-on-immunization.html 83