1. THE INAPPROPRIATE SALE OF MEDICATION FOR PEDIATRIC USE IN SIEM REAP PROVINCE, KINGDOM OF CAMBODIA
AUTHORS:
Sothearith Tiv Ph., Rathi Guhadasan MBBS MRCP DTM&H, Eliza Romey M.A.
INSTITUTION: Angkor Hospital for Children Siem Reap, Kingdom of Cambodia

2. Abstract
Problem Statement: In Cambodia, many people rely on unqualified drug sellers for their primary health care. Patients can buy medicine from pharmacies without a doctor’s prescription. It is estimated that a significant percentage of pharmacies in Siem Reap province are staffed by unqualified pharmacists. Drug sellers also operate in markets or from their homes. Medications, often unnecessary, are sold in combinations which are contraindicated, and children are regularly prescribed adult doses. In 2001, WHO estimated that there were at least 2800 illegal drug sellers in Cambodia.
Objectives: To reduce harm caused to children from inappropriate drug prescriptions; identify groups of drug sellers in Siem Reap for education about commonly prescribed drugs in children; identify areas of weakness in pharmaceutical knowledge for targeted education to different groups of drug sellers in Siem Reap; and identify common problem areas for targeted public health education at Angkor Hospital for Children (AHC).
Study Setting and Population: 50 consecutive AHC outpatients from Siem Reap province presenting at the AHC pharmacy, who have previously taken drugs from elsewhere for the same illness, will be selected. After verbal informed consent, the following data will be collected by AHC pharmacy staff using a standardized interview questionnaire.
Methods: Data to be gathered include demographic data including gender and age of the child, district and village of Siem Reap, which caregiver has bought the medicines, urban/rural status, family occupation; Location and type of drug seller; information given to drug seller by carer; advice given by drug seller; adverse effects; AHC doctor’s diagnosis; dose prescribed for each drug and length of prescription.
The study is planned for December because in that month there are no lengthy public holidays in Cambodia. The data will be analyzed using simple statistical tests.
Outcome Measures: Demographic data; percentage of non-hospital drug sellers; percentage of correct, partially correct and incorrect prescriptions and advice; percentage of drugs given at above the recommended dose; most common drugs prescribed; most common errors; percentage and types of adverse effects
Discussion: Most children presenting to our hospital have previously taken drugs from elsewhere for the same illness. These are often inappropriate and dangerous. Adult doses are often prescribed for children and infants; multiple preparations of paracetamol may be prescribed simultaneously as well as incomplete courses of antibiotics, which may lead to partially treated conditions such as meningitis and the development of antibiotic resistance. Many patients present late because the drug seller tried to treat them without referral to a hospital or health centre for proper diagnosis. It is hoped that this study will lead to plans for drug seller and public health education, thus leading to safer drug use in the community.

3. Background
In Cambodia, many rural inhabitants rely on unqualified drug sellers for their primary health care. Patients can buy medicine from pharmacies without a doctor’s prescription. It is estimated that 80% of pharmacies in Siem Reap province are staffed by unqualified pharmacists. Illegal Drug sellers also operate in markets or from their homes. Medications, often unnecessary, are sold in combinations which are contraindicated, and children are regularly prescribed adult doses.

4. Objectives
To reduce harm caused to children from inappropriate drug prescriptions.
To identify groups of drug sellers in Siem Reap for education about commonly prescribed drugs in children.
To identify areas of weakness in pharmaceutical knowledge for targeted education to different groups of drug sellers in Siem Reap.
To identify common problem areas for targeted public health education at Angkor Hospital for Children (AHC).

5. Study Setting
Collect information from 50 AHC outpatients from Siem Reap province presenting at the AHC pharmacy between 1st to 31st December 2003, who have previously taken drugs from elsewhere for the same illness. All questionnaires were administered AHC pharmacy staff using a standardized interview questionnaire.

6. Methods Data to be gathered including: gender and age of the child,
patient resident in Siem Reap province,
location and type of drug seller
information given to drug seller by carer
advice given by drug seller
adverse effect
AHC doctor’s diagnosis
dose and duration of prescribed medicine

7. Results < 5 years : 88% > 5years : 12% Males = Females
rural : 62%
urban : 38%
AHC doctor’s diagnosis:
47%: URI, Dysentery, Diarrhea
53%: others diseases
Sources of medicine previously purchased:
74%: clinic and pharmacy
26%: market

8. Table show the Incorrect Prescription according to Cambodia National guidelines and AHC guideline.
Pharmacy
Illegal Drug seller
Incorrect drugs
60%
84%
Incorrect dosage
62%
75%
Incorrect duration of use antibiotic
79%
92%
Toxicity multiple drugs
Toxicity over dosage
70%
Incorrect advice

9. Results Most Common Errors: Most Common of Adverse Effects:
Prescribed without indication: Chloramphenicol, Tetracycline, Loperamide, Promethazine
Poly pharmacy
Adult dose
Most Common of Adverse Effects:
Vomiting
Drowsiness
Dizziness
Extrapyramidal reaction

10. Summary 3cases received medicine from private clinic
Those drugs are often inappropriate and even dangerous.
Adult doses are often prescribed for children and infants.
Multiple preparation of Paracetamol may be prescribe simultaneously.
Incomplete courses of antibiotics, which may lead to partially treatment of conditions such as meningitis, are given. This may have serious medical sequences and also lead to development of antibiotic resistance.
Many patients present late because the drug sellers tried to treat them without referral to hospital or health center for proper diagnosis.

11. Conclusions and Policy implications
Education to drug sellers and pharmacists:
Common dangerous practices
Danger signs necessitating immediate referral to hospital
Public health education in appropriate health seeking behavior and use of medicines.
Strict enforcement of regulation relating to sale of drugs for children