Management of the Tuberculosis

Drug Supply

Module 13 – March 2010

Project Partners

Funded by the Health Resources and Services Administration (HRSA)

Module Overview

Determining appropriate quantities

Ensuring quality

Financing and procurement

Distributing and storing

Learning Objectives

At the end of this presentation, participantswill be able to:

Describe the basic principles of TB drug supply management

Identify areas in the drug supply management process that they can impact

Drug Supply

Management of TB medicines is critical to the success of a TB Program

Interruptions in drug supply can result in misuse, treatment default and the development of drug resistance

Nurses play an important role in ensuring an uninterrupted supply of TB drugs by monitoring stock supplies and advising those in charge of ordering of the TB medicine needs

Drug Supply (2)

Selection, distribution and management of the anti-TB drug supply is an important responsibility of the NTP

WHO and IUATLD recommend that use of fixed-dose combinations be restricted to combinations whose bioavailability has been demonstrated by laboratories that are independent from the manufacturers

Drug Quality

National TB control programs should ensure that anti-tuberculosis drugs are of good quality by making sure that the drugs:

• Are produced following the good manufacturing practices recommended by WHO

• Are imported with a PAHO/WHO certificate

• When bought by competitive tender, are ordered with the appropriate specifications

• Are stored properly following good storage practice and the first expiry, first out (FEFO) principle

Appropriate Quantity: Stock Control

Advantages of an effective stock control system include:• Ensures efficient use of financial resources

• Prevents under-stocking and “stock outs”

• Prevents overstocking and wastage

• Prevents shortages in case of delays in delivery

• Keeps medicine stores going even when there are staff shortages

• Allows identification of security problems

Medicine Distribution & Supply

Keeping stock records up-to-date is important for real time assessment of available stock

Steps include the ordering, receiving and issuing of medications and related supplies (includes the removal of expired or damaged items from stock)

Ordering Principles Order at regular intervals• Know when orders are to be placed and get order

in on time

Anticipate changes in demand• Quantity is directly related to number of TB

patients registered at the facility

Be systematic• Perform a physical stock count

• Decide whether or not an item needs to be ordered

• Complete order for items under the minimum stock

Terminology

Order interval is the time between two orders

Minimum stock level is the level of an item that is twice what is generally used during an order interval

Maximum usage is the average consumption of an item during order cycle x. This number should be documented on the stock card

Terminology (2)

Lead time is the time it takes between the first step in the procurement process until the supplies arrive in the country’s central medical stores

Both minimum and maximum stock levels can change over time depending on consumption. For TB medications, these levels will change as the number of TB patients change

Calculating Minimum Stock Level

Minimum lead time = 1 time per month

Maximum Usage = 3 units per month

Minimum Stock Level = 3 units X 2 X 1 = 6 units of isoniazid

=2 X Maximum lead time in

months

2 X Maximum lead time in

monthsX Maximum

UsageMaximum

UsageMinimum

Stock LevelMinimum

Stock Level

Re-order when stock reaches minimum stock level

Re-order when stock reaches minimum stock level

Receiving Supplies

When supplies are received, the following steps should be taken:

• Check that the number of items received matches the number of items ordered

Right item

Right unit size

Right quantity

Receiving Supplies (2)

Check that all boxes/containers are sealed and intact

Check medicine expiry dates

Document and report any problems noted

Storage of TB Medications

Good storage and management procedures are particularly important for medications• Keep drugs safe – should be in a cabinet or

room that can be locked/secured when not in use Store high security/high value products in

appropriate security zones

• Temperature, light, and humidity should be kept moderate in area where medications are stored

• No food, drink or smoking should be allowed in the storage area

Storage of TB Medications (2)

Place liquid products on the lower shelves or bottom of stacks

Separate damaged or expired products from the usable stock without delay and dispose of, using established disposal procedures

Arrange cartons so arrows point up and identification labels, expiry dates, and manufacturing dates are visible

Stock Records

Product name/description

Stock on hand/beginning stock balance

Receipts

Issues

Losses/adjustments

Closing/ending balance

Transaction reference (e.g., issue voucher number or name of supplier or recipient)

Distribution of Supplies

Each time supplies are issued/distributed, it should be recorded on the _________

Issuing supplies involves:• Moving stock from shelf to dispensing areas,

treatment rooms, outreach teams

• Ensuring medications issued to peripheral sites match the order sheet

• Removing stock of fast-moving items for pre-packaging

• Removing expired supplies or damaged items

Methods to Avoid Stock Wastage

FEFO Rule = First Expiry First Out

Clearly mark containers with close expiry dates (less than 12 months) and place at the front of the shelf

Return excess stock to hospital or medical stores as soon as you are aware of it

Summary

Ensuring a secure, uninterrupted drug supply is essential to an effective National TB Control Program

Staff at all levels can positively impact the national drug supply through:

• Appropriate use of TB medications

• Trouble-shooting supply problems

• Ensuring that guidelines for management of anti-TB drugs are fully implemented