The Pharmacist and

Public health: Screening

in Non-communicable
Disease

Elida Zairina, S.Si.,MPH.,PhD.,Apt

Departemen Farmasi Komunitas
Universitas Airlangga

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 Outcome yang diharapkan
setelah kuliah
• Setelah kuliah diharapkan mahasiswa
mampu memahami peran farmasis di
public health (pharmacy public health)
yang berfokus pada Promotif Preventif
terutama untuk mengurangi risiko penyakit
tidak menular di Indonesia salah satunya
memahami pelaksanaan Screening Faktor
Risiko penyakit tidak menular di
masyarakat.
 Outline
• Screening – Definition and Principles
• Screening – Assessing and the effectiveness of
screening
• Evidence for the effectiveness of screening
programs
• Screening – Non communicable diseases
(Diabetes, Cardiovascular)
• Screening – Asthma
• Sale of screening kits from community
pharmacies
• The future of pharmacy screening3
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Who is at risk of such
disease?
• People of all age groups, regions and countries
are affected by NCDs.

• These conditions are often associated with older

age groups, but evidence shows that 15 million of
all deaths attributed to NCDs occur between the
ages of 30 and 69 years.

• Children, adults and the elderly are all vulnerable

to the risk factors contributing to NCDs whether
from unhealthy diets, physical inactivity, exposure
to tobacco smoke or the harmful use of alcohol
Key FACTS of Non-communicable
disease
• Non-communicable diseases (NCDs) kill 40 million people
each year, equivalent to 70% of all deaths globally

• Cardiovascular diseases account for most NCD deaths, or

17.7 million people annually, followed by cancers (8.8
million), respiratory diseases (3.9million), and diabetes (1.6
million) - account for over 80% of all premature NCD deaths

• Tobacco use, physical inactivity, the harmful use of alcohol

and unhealthy diets all increase the risk of dying from a NCD

• Detection, screening and treatment of NCDs, as well as

palliative care, are key components of the response to NCDs
Countries with most NDC
programs

Pharmacist’s
Role?
The Ministry of Health and Family Welfare, Government of India, launched
the National Programme for Prevention and Control of Cancer, Diabetes,
Cardio-vascular diseases and Stroke (NPCDCS). Its objectives are to:

• Cegah dan kendalikan NCD umum melalui perubahan perilaku

dan gaya hidup

• Berikan diagnosis dini dan manajemen NCD secara umum

• Bangun kapasitas di berbagai tingkat perawatan kesehatan untuk

pencegahan, diagnosis, dan pengobatan NCD

• Melatih sumber daya manusia dalam pengaturan kesehatan

masyarakat, misalnya, dokter, paramedis, dan staf perawat untuk
mengatasi beban NCD yang terus meningkat

• Membangun dan mengembangkan kapasitas untuk perawatan

paliatif dan rehabilitasi
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Definition & Principles

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Screening??

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 Definition
• SCREENING :
– Suatu sistem aplikasi yang sistematis untuk mengidentifikasi
faktor resiko dari seseorang terhadap penyakit tertentu, sebagai
bahan pertimbangan untuk investigasi lebih lanjut
– Bukan merupakan service / pelayanan yang berdiri sendiri tetapi
meliputi diagnosis, dan plan of action dari health promotion
dan prevention / control dari penyakit
– The terms of screening:
•Laboratory / point of care test
•Risk assessment questionnaires
•Physical examination
•Observation alone or may combine methods
• SCREENING :
– Careful assessments of risk and benefits
– Can save lives or improve quality of life (early diagnosis)
– Can reduce the risk of developing condition / complications – but
cannot guarantee total protection!
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 Definition
• Screening:
– Subject to error!
– False positive results (wrongly reported as having the
condition)
– False negative results (wrongly reported as not having the
condition)
– E.g. False positive results in cancer screening have
produced high level of anxiety that do not resolve
immediately when subsequent testing shows no signs of the
diseases
• General principles:
– Screening harus menarget penyakit yang jika tidak
terdeteksi secara dini dapat menyebabkan penderitaan /
kesakitan yang signifikan, kecacatan atau kematian!

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Principles of screening
• Three basic principles of screening:
– Population based  high cost!
– Selective
– Opportunistic case detection
• Menurut WHO, population based screening akan
sesuai jika:
– Penyakit ini merupakan masalah kesehatan yang signifikan
– Riwayat alami penyakit ini bisa dipahami
– Ada tahapan praklinis yang dapat diidentifikasi dari penyakit ini
– Tes dapat diandalkan
– Manfaat pengobatan yang diperoleh setelah deteksi dini lebih
baik daripada jika pengobatan ditunda
– Prosesnya hemat biaya
– Penyaringan akan berlangsung secara sistematis
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Assessing the effectiveness of
screening
• Predictive value dipengaruhi oleh:
– Sensitivity – dapat mengidentifikasi orang yang mempunyai penyakit
– Specificity – dapat mengidentifikasi orang yang tidak mempunyai
penyakit (false positive)
– Prevalensi penyakit pada populasi yang di screening

• ↑ sensitivity - ↑ specificity - ↑ prevalence  higher positive predictive value

• ↓ prevalence  lower positive predictive value  needs ↑ specificity to

avoid false positive!

• Receiver Operating Characteristics (ROC) curve  a plot of the true

positive rate against the false positive rate for the different possible cut-
points of a diagnostic test. Value range from 0 – 1. An area of 1 represents
a perfect test; an area of 0.5 represents a worthless test
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Evidence of the effectiveness of
screening programmes
• Clinical trial – Randomised Controlled trial : dimana group
intervention dan control dibedakan berdasarkan exposure
dari screening test yang di evaluasi

• Robust evidence sulit dilakukan, karena:

– Aspek ethics dan feasibility : treatment pada satu group saja
pada pasien yang terdiagnosa
– Costly research – membutuhkan jumlah pasien yang tidak sedikit
– Jumlah pasien yang dibutuhkan sangat berpengaruh

• More opportunities present for community pharmacists to

provide screening tests on an opportunistic basis and to
become involved in national screening programs
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Screening programs
operating in England
Screening Target population/purpose Approved by UK
Program National Screening
Committee
Fetal Ultrasound for all pregnant women, to Yes
anomaly assess for physical anomalies and
offer Down’s syndrome screening

Infectious All pregnant women, offered Yes

diseases in screening for hepatitis B, HIV, Rubella
pregnancy susceptibility and syphilis

Sickle cell All pregnant women to identify sickle Yes

and cell disease
thalassemia
Newborn All babies within two weeks of birth, to Yes
hearing identify all children born with
moderate to profound permanent
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bilateral deafness
Screening programs
operating in England
Screening Target population/purpose Approved by UK National
Program Screening Committtee

Diabetic Annually, to people with diabetes aged 12 Yes

retinopathy or over, to reduce risk of sight loss

Breast Women aged 50 to 70 every three years, Yes

to detect and treat breast cancer early

Cervical Women aged 25 to 50 every three years, Yes

aged 50 to 64 every five years to detect
and treat cervical abnormalities

Bowel cancer People between 60 and 70 every two Yes

years, to detect and treat bowel cancer
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 Ethical aspects of screening –
criteria for adoption of screening for any
condition
• Kondisi yang di ‘screening’ harus menjadi salah satu yang penting
• Harus ada pengobatan yang dapat diterima untuk penyakit ini
• Fasilitas untuk diagnosis atau pengobatan harus tersedia
• Penyakit ini harus memiliki tahap gejala laten atau awal yang
diketahui
• Tes atau ujian yang sesuai harus ada
• Tes atau pemeriksaan harus diterima oleh populasi
• Riwayat alami kondisi ini, termasuk perkembangannya dari laten
ke penyakit yang sebenarnya, harus dipahami secara memadai
• Biaya ‘screening’, termasuk diagnosis dan pengobatan
selanjutnya, harus seimbang secara ekonomi dalam kaitannya
dengan manfaat potensial
• Penyaringan harus dilakukan secara terus-menerus dan bukan
proyek 'sekali jalan‘ atau one-off project! 24
Type 2 diabetes

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 Type 2 diabetes
• Methods of screening for diabetes:
– Risk assessment questionnaires
– Biochemical test in the form of blood glucose measurement
– Combination of those
• Most screening protocols recommend a follow-up screening
blood test for individuals identified to be at risk, by either a
laboratory test using venous plasma glucose or a capillary
blood glucose test using a point of care (POC) device
• POC: pemeriksaan laboratorium yang dilakukan di dekat
pasien di luar laboratorium sentral, baik pasien rawat jalan
maupun pasien rawat inap. Contoh: pemeriksaan kadar gula
darah, HbA1c,gas darah, kadar elektrolit, marker jantung,
marker sepsis, urine dipstik, koagulasi, tes kehamilan dan
ovulasi
• Keuntungan POC: convenience and accessibility of testing,
which may increase participation in screening and adherence
to follow-up diagnostic process

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Selected diabetes risk
screening tools
Risk scale
Danish diabetes risk score
Cambridge risk score (CRS)
Finnish diabetes risk score (FINDRISC)
The Australian type 2 Diabetes risk
assessment tool (AUSDRISK)
Factors included
Age, sex, family history of diabetes,
elevated blood pressure, BMI >25
kg/m2, insufficient physical activity
Age, gender, BMI, steroid,
antihypertensive medication, family
and smoking history
Age, BMI, waist circumference, physical
activity, daily consumption fruits,
history of antihypertensive
medication, family history of diabetes,
history of blood glucose
Age, sex, ethnicity, family history of
diabetes, hypertension, smoking, fruit
and vegetable consumption, history of
blood glucose, waist circumference,
physical activity
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Risk assessment factors for
diabetes – Australian NHMRC
I am over 55 years of age I have heart disease or have had a
heart attack

I am over 45 and overweight (BMI≥30) I am over 45 and have high blood

pressure

I am over 45 and one or more member I have had a borderline high blood
of my family has diabetes sugar test, i.e. fasting plasma glucose
5.5 – 6.9 mmol/L

I am over 35 and I am an Aboriginal or I am over 35 and I am of Chinese,

Torres Strait Islander Indian or Pacific Islander heritage

I have polycystic ovarian syndrome I had high blood sugar levels while I
and am overweight BMI≥30) was pregnant (gestational diabetes)
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 ≥ 1 Risk factor

Blood glucose test (fasting) Blood glucose test (random)

<5.5 mmol/L ≥5.5 mmol/L <5.5 mmol/L ≥11 mmol/L 5.5 – 11 mmol/L

Blood glucose Fasting blood

Blood glucose
level normal glucose test (8h)
level normal Retest (2h)
Lifestyle advice Lifestyle advice Refer to GP
and retest in and retest in
three years three years

Referral to GP
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 Opportunities for
pharmacy screening
• Community provides a logical site for this, with its established,
expansive and visible network of easily accessible health
professionals
• Community pharmacists can access a broad, apparently healthy,
population who rarely come into contact with GPs or nurses
• Consumers may consult a pharmacist without an appointment and
often with minimal waiting times
• Pharmacists can use their available information on medicines and
health conditions to identify people at possible risk who should be
screened, as well as providing education and referral
• opportunistic case detection  best options for type 2 Diabetes
in community pharmacies

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 Evidence for pharmacy
• screening
Community pharmacy-based diabetes screening programs:
– Australian community pharmacies (2002):
• Approximately 79000 screening tests for glucose with 22% of pharmacies
conducting at least one test per month
– Belgian community pharmacies (2005):
• Risk assessment questionnaires to customers who were advised to consult
their physician if they had more than one risk  20 patients needed to be
screened to diagnose one person with diabetes
– Swiss self care campaign “Stop-diabetes-test
now”
• Use a sequential screening approach in 530 community pharmacies (98258
patients)  6.9% were detected with possible diabetes and 74% received
targeted lifestyle advice
– American study in 577 community pharmacies
resulted in greater uptake of physician referral than
screening provided in non healthcare settings
• Studi-studi tersebut mendukung kelayakan skrining untuk diabetes di community
pharmacy dan menyoroti peluang tambahan bagi apoteker untuk31 terlibat dalam
promosi kesehatan dan konseling pencegahan
Cardiovascular disease

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 Methods of screening for
cardiovascular disease
•
risk
Banyak guideline merekomendasikan penilaian risiko untuk penyakit
kardiovaskular bagi yang berusia 40 tahun keatas atau 10 tahun lebih awal
untuk populasi berisiko

• Past: mengidentifikasi faktor-faktor risiko individu seperti tekanan darah

tinggi atau kolesterol dan menentukan ambang batas untuk pengobatan

• Now: pengembangan bagan prediksi risiko, berdasarkan kombinasi faktor

risiko individu untuk memperkirakan total risiko CVD (yaitu kemungkinan
kejadian CVD dalam 5 atau 10 tahun ke depan)

• Kebanyakan alat faktor risiko didasarkan pada serangkaian faktor risiko

yang serupa dan menggunakan persamaan prediksi risiko yang berasal
dari studi epidemiologi.

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CVD risk tool
Framingham (risk of a CVD
event over 10 years)
Joint British society
Guidelines (risk of a CVD
event over 10 years)
NZ risk calculator (5 year risk Age (50-65 years), gender,
of a CVD event)
Systematic Coronary Risk
Evaluation (SCORE) (10
year risk of a fatal CVD
event)
PROCAM (risk of a CVD
event over 10 years)
Factors Risks levels
Age (20-79 years), Gender, Males score:
Diabetes, Smoking, Systolic ≥12-10%
BP, TC, HDL 13-15-20%
16-25%
≥17 - ≥30%
Age (<50, 50-59, ≥60 years), <10% - low risk
Gender, Diabetes, Smoking, 10 – 20% - medium risk
Systolic BP, TC/HDL ratio >20% - high risk
Mild <10%
smoking, BP, TC/HDL ratio, Moderate 10-15%
Diabetes High 15 – 20%
Very high - >20%
Age (50-65 years), gender, Threshold for risk of death
smoking, systolic BP and is 5% or higher
TC/HDL ratio
Age (35-65 years), LDL, Score:
Smoking, HDL, Systolic BP, 0-20% < 1%
Family history of premature 21-44 <10%
myocardial infarction, 45-53 < 20%
diabetes, Triglycerides 54-61 <40%
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Opportunities for pharmacy
screening
• Pharmacies invited people for lipid screening who were at potential risk,
such as those taking antihypertensive, identified from patient medication
records

• Pharmacies themselves do not need to undertake the screening, or could

also combine it with medication review

• Pharmacist involvement through review and support positively impacts on

adherence to medicines and improved lipid levels

• Pharmacy delivery program that combine screening services with health

promotion interventions aimed at reducing risk factors in the targeted
population

• opportunistic case detection  best options for CVD in community

pharmacies
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EVIDENCE FOR PHARMACY
SCREENING
• New South Wales, Australia (9 rural pharmacies):
– Health promotion and screening service for CVD factors used a risk
assessment questionnaire plus measurement of weight, blood
pressure, total cholesterol and triglycerides  79% received lifestyle
advice (diet, physical activity, smoking cessation) and 21% required GP
referral
• Texas, USA (888 participants in 26 pharmacies):
– Achieved higher follow-up rates compared with screening in non-
healthcare settings
– 81% were referred for follow-up, 16% received one or more new
diagnoses and 42% therapy changes
• Iowa, USA:
– Pharmacies screened 265 people and calculated 10-years risk
– 1/3 half 10-20% risk
– 15% had greater than 20% with 2 or more risk factors
– Opportunity for pharmacist-led risk management
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ASTHMA
Screening within existing
conditions and in high risk
population: asthma
• Asthma : episodic disease, marked by exacerbations and
symptoms-free periods
• Characteristics: episodic shortness of breath, particularly at
night, and cough
• Factors that may influence: family history, obesity, gender,
exposure to allergens, early respiratory infection, tobacco
smoke exposure, indoor/outdoor pollution and diet
• Early diagnosis and use of medication can reduce the burden
on society, improve quality of life and reduce the risk of dying
the diseases cannot be cured!
• Although asthma is classified by severity, this may change
over time in response to treatment
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Methods for screening for poor
asthma control
• Measurement of lung function using spirometry and peak
flow Gold Standard!
• Instruments for measuring asthma control:
– Asthma score
– Asthma control questionnaire
• Very useful for screening patients for risk or poorly
controlled asthma  level of asthma control can be used to
make decisions on need for treatment

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 Opportunities and evidence
for pharmacy screening
• Pharmacists can easily identify potential patients with asthma whom
they care for on a regular basis using patient medication records, to
provide a service that screens for poor asthma control
• Evidence:
– Spirometry used in community pharmacy regularly
– Actively referred patient with poorly controlled asthma
– Algorithm based on pharmaceutical data for screening and
stratification of asthma patients
– Questionnaires designed for measuring poor asthma control
have been used regularly in community pharmacy
– These instruments can screen for patients at risk in terms of
asthma control as well as being sensitive to changes in control
following pharmacy interventions
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SCREENING KITS – YANG ADA DI
COMMUNITY PHARMACY
• Home diagnostic kits :
– Test kits: pasien mengumpulkan sample dan melakukan tes sendiri,
contoh:?
– Collection kits: pasien mengumpulkan sampel dan mengirimkan ke
laboratorium, contoh:?

• Contoh: Cholesterol testing kits  bisa mengukur kolesterol saja

atau full lipid profile termasuk HDL, LDL, dan trigliserida. Hasilnya
tergantung dari variability termasuk memperhatikan risk factor dari
CVD dan harus selalu diskusi dengan health professional!
• IMPORTANT:
– Meski relative mudah penggunaannya, hasil screening test yang akurat
tergantung dari variasi dan apakah direksi dari pembuat diikuti dengan
benar.
– Tidak bertujuan untuk menggantikan konsultasi dengan health
professionals
– Check expired date, mengikuti aturan pakai yang benar, dan pastikan
bahwa pasien paham cara penggunaan yang benar
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Screening and testing services
yang tersedia di community
pharmacy
• Pregnancy testing
• Ovulation testing
• Cholesterol and triglyceride measurement
• Blood pressure measurement
• Peak flow testing
• Blood / urine glucose testing
• Body weight / height measurement

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The future of pharmacy
screening
• Community pharmacies involve in public health activity 
recognized, legitimate and valuable role to play

• Proactive involvement in-store or outreach screening

programs linked to follow-up health promotion best
model for achieving significant impact on population
health outcomes

• Pharmacies must meet the requisite professional

standards of practice with respect of training, quality
assurance and testing equipment and procedures,
patient counselling, records, referral and follow-up

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 Key findings

• The nature and frequency of contact between

consumers and community pharmacists provide
significant opportunities for the provision of a wider
range of healthcare services through community
pharmacies
• Community pharmacists can play a key role in
population-based screening programs or in those
targeting population with risk behaviors and / or profiles
• A close collaboration with other primary health
professionals, particularly general practitioners, is
essential to avoid duplication of work and to ensure
continuity of patient care
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NON COMMUNICABLE DISEASE IN
DEVELOPING COUNTRIES…

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 REFERENCES

• Alison Blenkinsopp, Rhona Panton.

Screening and diagnostic testing in Health
Promotion for Pharmacists. Oxford University
Press, New York. 1992: 77 – 86
• Janet Krska. Preventing Disease: Screening in
The Pharmacy in Pharmacy in Public Health.
Pharmaceutical Press, London. 2011: 221-239
• Johnson George, Elida Zairina. The potential
role of pharmacists in chronic disease
screening. International Journal of Pharmacy
Practice, 2016: 3-5
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• Bagaimana Screening oleh Apoteker di
Komunitas di Indonesia?

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