101
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Proof-of-Concept of Detection of Counterfeit Medicine through Polymeric Materials Analysis of Plastics Packaging. Polymers (Basel) 2021; 13:polym13132185. [PMID: 34209331 PMCID: PMC8271851 DOI: 10.3390/polym13132185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 11/16/2022] Open
Abstract
The detection of counterfeit pharmaceuticals is always a major challenge, but the early detection of counterfeit medicine in a country will reduce the fatal risk among consumers. Technically, fast laboratory testing is vital to develop an effective surveillance and monitoring system of counterfeit medicines. This study proposed the combination of Attenuated Total Reflectance Fourier Transform Infrared (ATR-FTIR) and Differential Scanning Calorimetry (DSC) for the quick detection of counterfeit medicines, through the polymer analysis of blister packaging materials. A sample set containing three sets of original and counterfeit medicine was analyzed using ATR-FTIR and DSC, while the spectra from ATR-FTIR were employed as a fingerprint for the polymer characterization. Intending to analyze the polymeric material of each sample, DSC was set at a heating rate of 10 °C min-l and within a temperature range of 0- 400 °C, with nitrogen as a purge gas at a flow rate of 20 ml min-an. The ATR-FTIR spectra revealed the chemical characteristics of the plastic packaging of fake and original medicines. Further analysis of the counterfeit medicine's packaging with DSC exhibited a distinct difference from the original due to the composition of polymers in the packaging material used. Overall, this study confirmed that the rapid analysis of polymeric materials through ATR-FTIR and comparing DSC thermograms of the plastic in their packaging effectively distinguished counterfeit drug products.
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102
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Emgård M, Mwangi R, Mayo C, Mshana E, Nkini G, Andersson R, Msuya SE, Lepp M, Muro F, Skovbjerg S. Tanzanian primary healthcare workers' experiences of antibiotic prescription and understanding of antibiotic resistance in common childhood infections: a qualitative phenomenographic study. Antimicrob Resist Infect Control 2021; 10:94. [PMID: 34176486 PMCID: PMC8237496 DOI: 10.1186/s13756-021-00952-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/17/2021] [Indexed: 11/30/2022] Open
Abstract
Background Antibiotic resistance is a threat to global child health. Primary healthcare workers play a key role in antibiotic stewardship in the community, but few studies in low-income countries have described their experiences of initiating antibiotic treatment in children. Thus, the present study aimed to describe primary healthcare workers’ experiences of antibiotic prescription for children under 5 years of age and their conceptions of antibiotic resistance in Northern Tanzania. Methods A qualitative study involving individual in-depth interviews with 20 prescribing primary healthcare workers in Moshi urban and rural districts, Northern Tanzania, was performed in 2019. Interviews were transcribed verbatim, translated from Kiswahili into English and analysed according to the phenomenographic approach. Findings Four conceptual themes emerged during the analysis; conceptions in relation to the prescriber, the mother and child, other healthcare actors and in relation to outcome. The healthcare workers relied mainly on clinical examination and medical history provided by the mother to determine the need for antibiotics. Confidence in giving advice concerning non-antibiotic treatment varied among the participants and expectations of antibiotic treatment were perceived to be common among the mothers. Antibiotic resistance was mainly perceived as a problem for the individual patient who was misusing the antibiotics. Conclusions To increase rational antibiotic prescription, an awareness needs to be raised among Tanzanian primary healthcare workers of the threat of antibiotic resistance, not only to a few individuals, but to public health. Guidelines on childhood illnesses should be updated with advice concerning symptomatic treatment when antibiotics are not necessary, to support rational prescribing practices and promote trust in the clinician and mother relationship. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-00952-5.
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Affiliation(s)
- Matilda Emgård
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden. .,Department of Paediatrics, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Rose Mwangi
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Sokoine Road, Moshi, Tanzania
| | - Celina Mayo
- Department of Community Health, Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
| | - Ester Mshana
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Sokoine Road, Moshi, Tanzania
| | - Gertrud Nkini
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Sokoine Road, Moshi, Tanzania
| | - Rune Andersson
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Microbiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Sia E Msuya
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Sokoine Road, Moshi, Tanzania
| | - Margret Lepp
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Østfold University College, Fredrikstad, Norway.,School of Nursing and Midwifery, Griffith University, Gold Coast, QLD, Australia
| | - Florida Muro
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Sokoine Road, Moshi, Tanzania.,Department of Community Health, Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
| | - Susann Skovbjerg
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Centre for Antibiotic Resistance Research (CARe), University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Microbiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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103
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Hasnida A, Kok MO, Pisani E. Challenges in maintaining medicine quality while aiming for universal health coverage: a qualitative analysis from Indonesia. BMJ Glob Health 2021; 6:bmjgh-2020-003663. [PMID: 34049935 PMCID: PMC8166595 DOI: 10.1136/bmjgh-2020-003663] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/11/2020] [Accepted: 10/21/2020] [Indexed: 01/15/2023] Open
Abstract
Introduction Indonesia, the world’s fourth most populous nation, is close to achieving universal health coverage (UHC). A widely-publicised falsified vaccine case in 2016, coupled with a significant financial deficit in the national insurance system, has contributed to concern that the rapid scale-up of UHC might undermine medicine quality. We investigated the political and economic factors that drive production and trade of poor-quality medicines in Indonesia. Methods We reviewed academic publications, government regulations, technical agency documents and news reports to develop a semi-structured questionnaire. We interviewed healthcare providers, policy-makers, medicine regulators, pharmaceutical manufacturers, patients and academics (n=31). We included those with in-depth knowledge about the falsified vaccine case or the pharmaceutical business, medicine regulation, prescribing practice and the implementation of UHC. We coded data using NVivo software and analysed by constant comparative method. Results The scale-up of UHC has cut revenues for physicians and pharmaceutical manufacturers. In the vaccine case, free, quality-assured vaccines were available but some physicians, seeking extra revenue, promoted expensive alternatives. Taking advantage of poor governance in private hospitals, they purchased cut-price ‘vaccines’ from freelance salespeople. A single-winner public procurement system which does not explicitly consider quality has slashed the price paid for covered medicines. Trade, industrial and religious policies simultaneously increased production costs, pressuring profit margins for manufacturers and distributors. They reacted by cutting costs (potentially threatening quality) or by market withdrawal (leading to shortages which provide a market for falsifiers). Shortages and physician-promoted irrational demand push patients to buy medicines in unregulated channels, increasing exposure to falsified medicines. Conclusion Market factors, including political pressure to reduce medicine prices and healthcare provider incentives, can drive markets for substandard and falsified medicines. To protect progress towards UHC, policy-makers must consider the potential impact on medicine quality when formulating rules governing health financing, procurement, taxation and industry.
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Affiliation(s)
- Amalia Hasnida
- Health Care Governance, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, Netherlands .,Migunani Research Institute, Yogyakarta, Indonesia
| | - Maarten Olivier Kok
- Health Care Governance, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, Netherlands.,Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Elizabeth Pisani
- Health Care Governance, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, Netherlands.,Policy Institute, King's College London, London, London, UK
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104
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Small-scale dissolution test screening tool to select potentially substandard and falsified (SF) medicines requiring full pharmacopoeial analysis. Sci Rep 2021; 11:12145. [PMID: 34108529 PMCID: PMC8190288 DOI: 10.1038/s41598-021-91443-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 05/26/2021] [Indexed: 11/08/2022] Open
Abstract
The purpose of this study was to design a convenient, small-scale dissolution test for extracting potential substandard and falsified (SF) medicines that require full pharmacopoeial analysis. The probability of metronidazole samples complying with the US Pharmacopoeia (USP) dissolution test for immediate-release tablet formulations was predicted from small-scale dissolution test results using the following criteria: (1) 95% confidence interval lower limit (95% CIlow) of the average dissolution rate of any n = 3 of n = 24 units of each sample, and (2) average and minimum dissolution rates for any n = 3 of n = 24 units. Criteria values were optimized via bootstrap sampling with Thinkeye data-mining software. Compliant metronidazole samples in the USP first-stage and second-stage dissolution test showed complying probabilities of 99.7% and 81.0%, respectively, if the average dissolution rate of n = 3 units is equal to or greater than the monograph-specified amount of dissolved drug (Q; 85% of labeled content for metronidazole). The complying probabilities were 100.0% and 79.0%, respectively, if the average dissolution rate of n = 3 units is 91% or higher and the minimum dissolution rate is 87% or higher. Suitable compliance criteria for the small-scale dissolution test are: average dissolution rate of n = 3 units is Q + 6% or more and minimum dissolution rate is Q + 2% or more.
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105
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Hauk C, Hagen N, Heide L. Identification of Substandard and Falsified Medicines: Influence of Different Tolerance Limits and Use of Authenticity Inquiries. Am J Trop Med Hyg 2021; 104:1936-1945. [PMID: 33788775 PMCID: PMC8103440 DOI: 10.4269/ajtmh.20-1612] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/05/2021] [Indexed: 11/21/2022] Open
Abstract
Substandard and falsified medicines have severe public health and socioeconomic effects, especially in low- and middle-income countries. The WHO has emphasized the need for reliable estimates of the prevalence of such medicines to efficiently respond to this problem. In the present study, we used 601 medicine samples collected in Cameroon, the DR Congo, and Malawi to assess the rates of substandard and falsified medicines based on different criteria. Based on the specifications of the U.S. Pharmacopoeia for the amount of the active pharmaceutical ingredients, the rate of out-of-specification medicines was 9.3%. By contrast, this rate ranged from 3.3% up to 35.0% if the tolerance limits of other pharmacopoeias or recently published medicine quality studies were used. This shows an urgent need for harmonization. Principal methods to assess the rate of falsified medicines are packaging analysis, chemical analysis, and authenticity inquiries. In the present study, we carried out an authenticity inquiry for the aforementioned medicine samples, contacting 126 manufacturers and 42 distributors. Response rates were higher for samples stated to be manufactured in Asia (52.4%) or Europe (53.8%) than for samples manufactured in Africa (27.4%; P < 0.001). One sample had been identified as falsified by packaging analysis by the local researchers and two additional ones by chemical analysis. Notably, seven additional falsified samples were identified by the authenticity inquiries. The total rate of falsified medicines resulted as 1.7%. Considerations are discussed for assessing the rates of "substandard" and "falsified" medicines in future medicine quality studies.
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Affiliation(s)
| | | | - Lutz Heide
- Address correspondence to Lutz Heide, Pharmaceutical Institute, Eberhard Karls University Tuebingen, Auf der Morgenstelle 8, Tuebingen 72076, Germany. E-mail:
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Comparative Quality Evaluation of Selected Brands of Cefuroxime Axetil Tablets Marketed in the Greater Accra Region of Ghana. ScientificWorldJournal 2021; 2021:6659995. [PMID: 33927582 PMCID: PMC8049799 DOI: 10.1155/2021/6659995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/18/2021] [Accepted: 03/29/2021] [Indexed: 11/29/2022] Open
Abstract
The ever-growing commercialization of poor-quality and substandard medicines, especially anti-infectives characterized by inadequate postmarket surveillance by stakeholders remains a major global health challenge, particularly in developing countries, where antibiotic drug resistance and its repercussions on human health remain dominant. This research sought to evaluate the pharmaceutical quality of six randomly selected brands of cefuroxime axetil tablets (250 mg) marketed in the Greater Accra region of Ghana. The selected brands were coded and subjected to both compendial and noncompendial tests. Statistical analysis and model-independent parameter (similarity factor, f2) were employed in analyzing the dissolution profiles of all the brands. All brands including the reference brand conformed to the pharmacopeial specifications for both compendial and noncompendial tests, indicating that they were of good quality. However, there were significant variations (p < 0.05) in the disintegration time amongst the various brands. All the brands had ƒ2 values > 50 indicating similarity of their drug release profiles with the innovator. Hence, all the sampled cefuroxime axetil brands can be considered as pharmaceutical equivalents to the innovator drug. These brands can, therefore, be used as a substitute for the innovator drug by physicians to patients in cases of unaffordability or unavailability of the innovator brand.
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107
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Shiferie F, Kassa E. The scourge of substandard and falsified medical products gets worse with COVID-19 pandemic. Pan Afr Med J 2021; 37:344. [PMID: 33738032 PMCID: PMC7934180 DOI: 10.11604/pamj.2020.37.344.26322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/15/2020] [Indexed: 11/23/2022] Open
Abstract
Although health professionals, communities, governments and global institutions work closely to halt the spread of COVID-19 and mitigate its societal impact, COVID-19 remains a challenge to many countries around the world. In addition to its direct health, economic and social consequences, the pandemic has also resulted in unforeseen consequences in Africa especially in East African countries. COVID-19 might increase the demand and consumption of Substandard and Falsified (SF) medical products in three major ways. The first way is due to the inability of vulnerable segment of the population to access healthcare services as they used to do before. The second way people get exposed to SF medical products is due to fear of being quarantined, isolated and traced. Yet another way is related to import permits for medical products. Concerned regulatory bodies shall intervene aggressively in ensuring the safety, quality and effectiveness of medical products before we face a parallel pandemic from SF medical products.
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Affiliation(s)
- Fisseha Shiferie
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Eden Kassa
- Defense Health Science College, Debre Zeit, Ethiopia
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108
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Dos Santos Ribeiro HS, Dagnino D, Schripsema J. Rapid and accurate verification of drug identity, purity and quality by 1H-NMR using similarity calculations and differential NMR. J Pharm Biomed Anal 2021; 199:114040. [PMID: 33836463 DOI: 10.1016/j.jpba.2021.114040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/24/2021] [Accepted: 03/23/2021] [Indexed: 12/24/2022]
Abstract
The illegal trade in counterfeit and fake drugs is a worldwide multi-billion dollar industry, not only generating enormous economic losses, but health problems for the general population, through direct toxicity, treatment failure and the increased generation of antibiotic resistance. Techniques for high-throughput testing of suspect medicines are needed to face the challenges of the problem. In this study we show that with nuclear magnetic resonance spectroscopy (NMR) drug compliance can be verified in a few minutes, providing data on drug identity, purity and quality without the necessity to develop a specific methodology and using a direct extraction with deuterated solvent. The evaluation of the data is facilitated by similarity calculations and differential NMR spectroscopy. The viability and limitations of this method were assessed, with the application on five different drugs, namely sertraline hydrochloride, alprazolam, vitamin D3, enalapril maleate and paracetamol, in which the individual dosage quantity of the active ingredient ranged from 750 mg down to 0.25 mg. The appropriate sample weight, solvent and internal standard were determined for each drug and quantification was carried out by choosing the most adequate NMR signals for each compound and the internal standard. With the method the accuracy of the quantification is somewhat sacrificed for increased speed in the analysis, but the measurements offer excellent precision and offer the possibility of external calibration. Spectral similarity calculations and differential NMR spectroscopy were used to compare different generic brands and detect eventual undeclared constituents and contaminants. In one brand of alprazolam tablets the undeclared constituent tristearin was found, while in paracetamol tablets the contaminant para-aminophenol was found at a level above the allowed by the legislation. The applicability and limitations of the method are discussed.
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Affiliation(s)
- Helen Sant'Ana Dos Santos Ribeiro
- Grupo Metabolômica, Laboratório de Ciências Químicas, Universidade Estadual do Norte Fluminense, Av. Alberto Lamego, 2000, Campos dos Goytacazes, 28013-602, Brazil
| | - Denise Dagnino
- Grupo Metabolômica, Laboratório de Biotecnologia, Universidade Estadual do Norte Fluminense, Av. Alberto Lamego, 2000, Campos dos Goytacazes, 28013-602, Brazil.
| | - Jan Schripsema
- Grupo Metabolômica, Laboratório de Ciências Químicas, Universidade Estadual do Norte Fluminense, Av. Alberto Lamego, 2000, Campos dos Goytacazes, 28013-602, Brazil.
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Rolfe R, Kwobah C, Muro F, Ruwanpathirana A, Lyamuya F, Bodinayake C, Nagahawatte A, Piyasiri B, Sheng T, Bollinger J, Zhang C, Ostbye T, Ali S, Drew R, Kussin P, Anderson DJ, Woods CW, Watt MH, Mmbaga BT, Tillekeratne LG. Barriers to implementing antimicrobial stewardship programs in three low- and middle-income country tertiary care settings: findings from a multi-site qualitative study. Antimicrob Resist Infect Control 2021; 10:60. [PMID: 33766135 PMCID: PMC7993456 DOI: 10.1186/s13756-021-00929-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 03/19/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Antimicrobial resistance has been named as one of the top ten threats to public health in the world. Hospital-based antimicrobial stewardship programs (ASPs) can help reduce antimicrobial resistance. The purpose of this study was to determine perceived barriers to the development and implementation of ASPs in tertiary care centers in three low- and middle-income countries (LMICs). METHODS Interviews were conducted with 45 physicians at tertiary care hospitals in Sri Lanka (n = 22), Kenya (12), and Tanzania (11). Interviews assessed knowledge of antimicrobial resistance and ASPs, current antimicrobial prescribing practices, access to diagnostics that inform antimicrobial use, receptiveness to ASPs, and perceived barriers to implementing ASPs. Two independent reviewers coded the interviews using principles of applied thematic analysis, and comparisons of themes were made across the three sites. RESULTS Barriers to improving antimicrobial prescribing included prohibitively expensive antimicrobials, limited antimicrobial availability, resistance to changing current practices regarding antimicrobial prescribing, and limited diagnostic capabilities. The most frequent of these barriers in all three locations was limited drug availability. Many physicians in all three sites had not heard of ASPs before the interviews. Improved education was a suggested component of ASPs at all three sites. The creation of guidelines was also recommended, without prompting, by interviewees at all three sites. Although most participants felt microbiological results were helpful in tailoring antibiotic courses, some expressed distrust of laboratory culture results. Biomarkers like erythrocyte sedimentation rate and c-reactive protein were not felt to be specific enough to guide antimicrobial therapy. Despite limited or no prior knowledge of ASPs, most interviewees were receptive to implementing protocols that would include documentation and consultation with ASPs regarding antimicrobial prescribing. CONCLUSIONS Our study highlighted several important barriers to implementing ASPs that were shared between three tertiary care centers in LMICs. Improving drug availability, enhancing availability of and trust in microbiologic data, creating local guidelines, and providing education to physicians regarding antimicrobial prescribing are important steps that could be taken by ASPs in these facilities.
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Affiliation(s)
- Robert Rolfe
- Duke University, Durham, NC, USA.
- Duke Global Health Institute, Durham, NC, USA.
| | - Charles Kwobah
- Moi University/Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Florida Muro
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Furaha Lyamuya
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Champica Bodinayake
- Duke Global Health Institute, Durham, NC, USA
- University of Ruhuna, Galle, Sri Lanka
| | - Ajith Nagahawatte
- Duke Global Health Institute, Durham, NC, USA
- University of Ruhuna, Galle, Sri Lanka
| | | | | | | | - Chi Zhang
- Duke Global Health Institute, Durham, NC, USA
| | | | - Shamim Ali
- Moi University/Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Richard Drew
- Duke University, Durham, NC, USA
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | | | - Deverick J Anderson
- Duke University, Durham, NC, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
| | - Christopher W Woods
- Duke University, Durham, NC, USA
- Duke Global Health Institute, Durham, NC, USA
| | | | - Blandina T Mmbaga
- Duke Global Health Institute, Durham, NC, USA
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - L Gayani Tillekeratne
- Duke University, Durham, NC, USA
- Duke Global Health Institute, Durham, NC, USA
- University of Ruhuna, Galle, Sri Lanka
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Ippolito MM, Moser KA, Kabuya JBB, Cunningham C, Juliano JJ. Antimalarial Drug Resistance and Implications for the WHO Global Technical Strategy. CURR EPIDEMIOL REP 2021; 8:46-62. [PMID: 33747712 PMCID: PMC7955901 DOI: 10.1007/s40471-021-00266-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Five years have passed since the World Health Organization released its Global Technical Strategy for Malaria (GTS). In that time, progress against malaria has plateaued. This review focuses on the implications of antimalarial drug resistance for the GTS and how interim progress in parasite genomics and antimalarial pharmacology offer a bulwark against it. RECENT FINDINGS For the first time, drug resistance-conferring genes have been identified and validated before their global expansion in malaria parasite populations. More efficient methods for their detection and elaboration have been developed, although low-density infections and polyclonality remain a nuisance to be solved. Clinical trials of alternative regimens for multidrug-resistant malaria have delivered promising results. New agents continue down the development pipeline, while a nascent infrastructure in sub-Saharan Africa for conducting phase I trials and trials of transmission-blocking agents has come to fruition after years of preparation. SUMMARY These and other developments can help inform the GTS as the world looks ahead to the next two decades of its implementation. To remain ahead of the threat that drug resistance poses, wider application of genomic-based surveillance and optimization of existing and forthcoming antimalarial drugs are essential.
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Affiliation(s)
- Matthew M. Ippolito
- Divisions of Clinical Pharmacology and Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
- The Johns Hopkins Malaria Research Institute, Johns Hopkins University School of Public Health, Baltimore, MD USA
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Kara A. Moser
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC USA
| | | | - Clark Cunningham
- School of Medicine, University of North Carolina, Chapel Hill, NC USA
| | - Jonathan J. Juliano
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina, CB#7030, 130 Mason Farm Rd, Chapel Hill, NC 27599 USA
- Curriculum in Genetics and Molecular Biology, School of Medicine, University of North Carolina, Chapel Hill, NC USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC USA
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Chen HH, Higgins C, Laing SK, Bliese SL, Lieberman M, Ozawa S. Cost savings of paper analytical devices (PADs) to detect substandard and falsified antibiotics: Kenya case study. MEDICINE ACCESS @ POINT OF CARE 2021; 5. [PMID: 33834120 PMCID: PMC8026160 DOI: 10.1177/2399202620980303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Over 10% of antibiotics in low- and middle-income countries (LMICs) are
substandard or falsified. Detection of poor-quality antibiotics via the gold
standard method, high-performance liquid chromatography (HPLC), is slow and
costly. Paper analytical devices (PADs) and antibiotic paper analytical
devices (aPADs) have been developed as an inexpensive way to estimate
antibiotic quality in LMICs. Aim: To model the impact of using a rapid screening tools, PADs/aPADs, to improve
the quality of amoxicillin used for treatment of childhood pneumonia in
Kenya. Methods: We developed an agent-based model, ESTEEM (Examining Screening Technologies
with Economic Evaluations for Medicines), to estimate the effectiveness and
cost savings of incorporating PADs and aPADs in amoxicillin quality
surveillance in Kenya. We compared the current testing scenario (batches of
entire samples tested by HPLC) with an expedited HPLC scenario (testing
smaller batches at a time), as well as a screening scenario using PADs/aPADs
to identify poor-quality amoxicillin followed by confirmatory analysis with
HPLC. Results: Scenarios using PADs/aPADs or expedited HPLC yielded greater incremental
benefits than the current testing scenario by annually averting 586 (90%
uncertainty range (UR) 364–874) and 221 (90% UR 126–332) child pneumonia
deaths, respectively. The PADs/aPADs screening scenario identified and
removed poor-quality antibiotics faster than the expedited or regular HPLC
scenarios, and reduced costs significantly. The PADs/aPADs scenario resulted
in an incremental return of $14.9 million annually compared with the
reference scenario of only using HPLC. Conclusion: This analysis shows the significant value of PADs/aPADs as a medicine quality
screening and testing tool in LMICs with limited resources.
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Affiliation(s)
- Hui-Han Chen
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Colleen Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Sarah K Laing
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Sarah L Bliese
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN, USA
| | - Marya Lieberman
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN, USA
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA.,Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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Ncube BM, Dube A, Ward K. Establishment of the African Medicines Agency: progress, challenges and regulatory readiness. J Pharm Policy Pract 2021; 14:29. [PMID: 33685518 PMCID: PMC7938385 DOI: 10.1186/s40545-020-00281-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/01/2020] [Indexed: 12/15/2022] Open
Abstract
Insufficient access to quality, safe, efficacious and affordable medical products in Africa has posed a significant challenge to public health for decades. In part, this is attributed to weak or absent policies and regulatory systems, a lack of competent regulatory professionals in National Medicines Regulatory Authorities (NMRAs) and ineffective regional collaborations among NMRAs. In response to national regulatory challenges in Africa, a number of regional harmonisation efforts were introduced through the African Medicines Regulatory Harmonisation (AMRH) initiative to, among others, expedite market authorisation of medical products and to facilitate the alignment of national legislative frameworks with the AU Model Law on Medical Products Regulation. The goals of the model law include to increase collaboration across countries and to facilitate the overall regional harmonisation process. The AMRH initiative is proposed to serve as the foundation for the establishment of the African Medicines Agency (AMA). The AMA will, as one of its mandates, coordinate the regional harmonisation systems that are enabled by AU Model Law domestication and implementation. In this paper, we review the key entities involved in regional and continental harmonisation of medicines regulation, the milestones achieved in establishing the AMA as well as the implementation targets and anticipated challenges related to the AU Model Law domestication and the AMA's establishment. This review shows that implementation targets for the AU Model Law have not been fully met, and the AMA treaty has not been ratified by the minimum required number of countries for its establishment. In spite of the challenges, the AU Model Law and the AMA hold promise to address gaps and inconsistencies in national regulatory legislation as well as to ensure effective medicines regulation by galvanising technical support, regulatory expertise and resources at a continental level. Furthermore, this review provides recommendations for future research.
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Affiliation(s)
- Bakani Mark Ncube
- Department of Pharmacy Practice, School of Pharmacy, University of the Western Cape, Private Bag X17, Bellville, 7535, South Africa
| | - Admire Dube
- Department of Pharmacy Practice, School of Pharmacy, University of the Western Cape, Private Bag X17, Bellville, 7535, South Africa
| | - Kim Ward
- Department of Pharmacy Practice, School of Pharmacy, University of the Western Cape, Private Bag X17, Bellville, 7535, South Africa.
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113
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Ciapponi A, Donato M, Gülmezoglu AM, Alconada T, Bardach A. Mobile apps for detecting falsified and substandard drugs: A systematic review. PLoS One 2021; 16:e0246061. [PMID: 33539433 PMCID: PMC7861418 DOI: 10.1371/journal.pone.0246061] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/12/2021] [Indexed: 11/19/2022] Open
Abstract
The use of substandard and counterfeit medicines (SCM) leads to significant health and economic consequences, like treatment failure, rise of antimicrobial resistance, extra expenditures of individuals or households and serious adverse drug reactions including death. Our objective was to systematically search, identify and compare relevant available mobile applications (apps) for smartphones and tablets, which use could potentially affect clinical and public health outcomes. We carried out a systematic review of the literature in January 2020, including major medical databases, and app stores. We used the validated Mobile App Rating Scale (MARS) to assess the quality of apps, (1 worst score, 3 acceptable score, and 5 best score). We planned to evaluate the accuracy of the mobile apps to detect SCM. We retrieved 335 references through medical databases and 42 from Apple, Google stores and Google Scholar. We finally included two studies of the medical database, 25 apps (eight from the App Store, eight from Google Play, eight from both stores, and one from Google Scholar), and 16 websites. We only found one report on the accuracy of a mobile apps detecting SCMs. Most apps use the imprint, color or shape for pill identification, and only a few offer pill detection through photographs or bar code. The MARS mean score for the apps was 3.17 (acceptable), with a maximum of 4.9 and a minimum of 1.1. The 'functionality' dimension resulted in the highest mean score (3.4), while the 'engagement' and 'information' dimensions showed the lowest one (3.0). In conclusion, we found a remarkable evidence gap about the accuracy of mobile apps in detecting SCMs. However, mobile apps could potentially be useful to screen for SCM by assessing the physical characteristics of pills, although this should still be assessed in properly designed research studies.
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Affiliation(s)
- Agustín Ciapponi
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
- Centro de Investigaciones Epidemiológicas y Salud Pública (CIESP-IECS), CONICET, Buenos Aires, Argentina
- * E-mail:
| | - Manuel Donato
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
- Centro de Investigaciones Epidemiológicas y Salud Pública (CIESP-IECS), CONICET, Buenos Aires, Argentina
| | - A. Metin Gülmezoglu
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Tomás Alconada
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
- Centro de Investigaciones Epidemiológicas y Salud Pública (CIESP-IECS), CONICET, Buenos Aires, Argentina
| | - Ariel Bardach
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
- Centro de Investigaciones Epidemiológicas y Salud Pública (CIESP-IECS), CONICET, Buenos Aires, Argentina
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114
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Twesigye G, Hafner T, Guzman J. Making the investment case for national regulatory authorities. J Pharm Policy Pract 2021; 14:16. [PMID: 33478590 PMCID: PMC7818051 DOI: 10.1186/s40545-021-00299-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/12/2021] [Indexed: 11/12/2022] Open
Abstract
Well-functioning national regulatory authorities (NRAs) ensure access to safe, effective, quality-assured, and affordable medical products. However, the benefits of their work are often unseen and difficult to attribute, thereby making NRAs undervalued and under-resourced, particularly in low- and middle-income countries. This paper offers three key arguments NRAs and other stakeholders can use to advocate for greater investment in regulatory systems strengthening-medical products regulation effectively safeguards public health; effective regulation improves health system's efficiency by increasing access to affordable medical products, contributing to universal health coverage; and robust regulation strengthens local pharmaceutical manufacturing and bolsters pharmaceutical trade. NRAs' critical role in health systems is indisputable, yet they need to better promote their value to receive the requisite resources to function effectively.
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Affiliation(s)
- Gloria Twesigye
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Arlington, VA USA
| | - Tamara Hafner
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Arlington, VA USA
| | - Javier Guzman
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Arlington, VA USA
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115
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Abebe K, Beressa TB, Yimer BT. In-vitro Evaluations of Quality Control Parameters of Paracetamol Tablets Marketed in Gondar City, Northwest Ethiopia. DRUG HEALTHCARE AND PATIENT SAFETY 2020; 12:273-279. [PMID: 33376411 PMCID: PMC7762764 DOI: 10.2147/dhps.s282420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/09/2020] [Indexed: 11/23/2022]
Abstract
Background The aim of this research was to evaluate quality control parameters of available brands of paracetamol tablets in Gondar city since standard quality parameters are essential for a better quality of the product. The different brands of paracetamol tablets were obtained from local pharmacies in Gondar town and the University of Gondar (UOG) hospital pharmacies. Methods Five brands of paracetamol, from each, 102 tablets were collected from private pharmacies, government health centers, and UOG pharmacies. The popular brands in the city, Panadol, Para-denk, Paramol, Paracetamol (EPHARM), and Cadimol, conventional tablets of 500 mg strength were chosen and the tablets were assessed for different quality parameters: weight variation, hardness, friability, disintegration, dissolution, and drug content (assay) using compendial methods. The tablets were evaluated to check if they comply with the specifications of USP (United States Pharmacopeia). Results From the results, it was observed that all the brands of paracetamol have passed the tests and met the specifications of USP. Results of weight variation, hardness, friability, and disintegration time ranged from 0.46 to 1.11%, 117.0 to 174.70 N, 0.07 to 0.63%, and 01 to 08 minutes for all the tablets, respectively. The dissolution profiles of all the brands are within the acceptable label claim. The assay results showed that the drug content of the paracetamol brands ranged from 95.04% to 106.81%. The dissolution rate was significantly different (p < 0.05) as compared to code 1 with all brands tested at 30 minutes. The disintegration time of different brands was also significantly different from the comparator (code 1) except code 2. Conclusion Based on the finding from this study, there were no significant deviations from pharmacopeia standards and specifications. The brands studied were safe enough and could be used to achieve the desired therapeutic effect.
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Affiliation(s)
- Konjit Abebe
- School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tamirat Bekele Beressa
- Department of Pharmacy, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Bilal Tessema Yimer
- School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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116
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Majumder MAA, Rahman S, Cohall D, Bharatha A, Singh K, Haque M, Gittens-St Hilaire M. Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health. Infect Drug Resist 2020; 13:4713-4738. [PMID: 33402841 PMCID: PMC7778387 DOI: 10.2147/idr.s290835] [Citation(s) in RCA: 182] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/17/2020] [Indexed: 12/18/2022] Open
Abstract
Antimicrobial resistance (AMR) is a serious threat to global public health. It increases morbidity and mortality, and is associated with high economic costs due to its health care burden. Infections with multidrug-resistant (MDR) bacteria also have substantial implications on clinical and economic outcomes. Moreover, increased indiscriminate use of antibiotics during the COVID-19 pandemic will heighten bacterial resistance and ultimately lead to more deaths. This review highlights AMR's scale and consequences, the importance, and implications of an antimicrobial stewardship program (ASP) to fight resistance and protect global health. Antimicrobial stewardship (AMS), an organizational or system-wide health-care strategy, is designed to promote, improve, monitor, and evaluate the rational use of antimicrobials to preserve their future effectiveness, along with the promotion and protection of public health. ASP has been very successful in promoting antimicrobials' appropriate use by implementing evidence-based interventions. The "One Health" approach, a holistic and multisectoral approach, is also needed to address AMR's rising threat. AMS practices, principles, and interventions are critical steps towards containing and mitigating AMR. Evidence-based policies must guide the "One Health" approach, vaccination protocols, health professionals' education, and the public's awareness about AMR.
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Affiliation(s)
- Md Anwarul Azim Majumder
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Sayeeda Rahman
- School of Medicine, American University of Integrative Sciences, Bridgetown, Barbados
| | - Damian Cohall
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Ambadasu Bharatha
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Keerti Singh
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Mainul Haque
- Faculty of Medicine and Defence Health, Universiti Pertahanan, Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, Malaysia
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117
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Mosoro E, Wilson AN, Homer CSE, Vogel JP. Assessing the quality of antenatal corticosteroids in low- and middle-income countries: A systematic review. PLoS One 2020; 15:e0243034. [PMID: 33270682 PMCID: PMC7714108 DOI: 10.1371/journal.pone.0243034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/15/2020] [Indexed: 11/26/2022] Open
Abstract
Background The World Health Organization (WHO) recommends the administration of intramuscular antenatal corticosteroids to women at risk of preterm birth to prevent preterm-associated neonatal mortality and morbidity. Poor quality medicines are a major problem for health services in low- and middle-income countries (LMICs), however the quality of antenatal corticosteroids is not well understood. We aimed to conduct a systematic review of available studies describing the quality of recommended injectable antenatal corticosteroids (dexamethasone or betamethasone) in LMICs. Methods Structured search strategy was applied to six databases (MEDLINE, EMBASE, CINAHL, International Pharmaceutical Abstracts, Global Index Medicus, WHO Medicines Quality Database), without year or language restrictions. Any primary study reporting any medicine quality parameter (Active Pharmacological Ingredient, pH and sterility) for injectable dexamethasone or betamethasone was eligible. Two authors independently screened studies for eligibility, extracted data on included studies and applied Medicine Quality Assessment Reporting Guidelines tool to assess study quality. Results were reported narratively, stratified by country of manufacture, organisation type and level of care. Results In total, 15,547 citations were screened with two eligible studies identified that focussed on dexamethasone quality (no studies of betamethasone were identified). One study included 19 samples from 9 LMICs, and the other included “less than 100 samples” from India. The prevalence of failed dexamethasone samples ranged from 3.14% to 32.2% due to inadequate Active Pharmacological Ingredient. A higher prevalence of failed dexamethasone samples were seen at the point of care and the public sector. Conclusions Poor quality maternal and newborn health medicines can endanger women and newborns. Though available evidence on antenatal corticosteroids quality in LMICs is limited, results suggested poor quality dexamethasone may be prevalent in some countries. More primary studies are required to confirm these findings and guide policymakers on procurement of good-quality maternal and newborn health medicines.
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Affiliation(s)
- Euodia Mosoro
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Alyce N. Wilson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Caroline S. E. Homer
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Joshua P. Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
- * E-mail:
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118
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Vian T. Anti-corruption, transparency and accountability in health: concepts, frameworks, and approaches. Glob Health Action 2020; 13:1694744. [PMID: 32194010 PMCID: PMC7170369 DOI: 10.1080/16549716.2019.1694744] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: As called for by the Sustainable Development Goals, governments, development partners and civil society are working on anti-corruption, transparency and accountability approaches to control corruption and advance Universal Health Coverage. Objectives: The objective of this review is to summarize concepts, frameworks, and approaches used to identify corruption risks and consequences of corruption on health systems and outcomes. We also inventory interventions to fight corruption and increase transparency and accountability. Methods: We performed a critical review based on a systematic search of literature in PubMed and Web of Science and reviewed background papers and presentations from two international technical meetings on the topic of anti-corruption and health. We identified concepts, frameworks and approaches and summarized updated evidence of types and causes corruption in the health sector. Results: Corruption, or the abuse of power for private gain, in health systems includes bribes and kickbacks, embezzlement, fraud, political influence/nepotism and informal payments, among other behaviors. Drivers of corruption include individual and systems level factors such as financial pressures, poorly managed conflicts of interest, and weak regulatory and enforcement systems. We identify six typologies and frameworks that model relationships influencing the scope and seriousness of corruption, and show how anti-corruption strategies such as transparency, accountability, and civic participation can affect corruption risk. Little research exists on the effectiveness of anti-corruption measures; however, interventions such as community monitoring and insurance fraud control programs show promise. Conclusions: Corruption undermines the capacity of health systems to contribute to better health, economic growth and development. Interventions and resources on prevention and control of corruption are essential components of health system strengthening for Universal Health Coverage.
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Affiliation(s)
- Taryn Vian
- School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, USA
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119
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Bliese SL, Berta M, Lieberman M. Involving Students in the Distributed Pharmaceutical Analysis Laboratory: A Citizen-Science Project to Evaluate Global Medicine Quality. JOURNAL OF CHEMICAL EDUCATION 2020; 97:3976-3983. [PMID: 33840832 PMCID: PMC8026146 DOI: 10.1021/acs.jchemed.0c00904] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The distributed pharmaceutical analysis laboratory (DPAL) is a collaboration between 30 academic institutions around the world, whose goal is to determine the quality of medicines collected from partner organizations in low- and middle-income countries (LMICs). Institutions complete system suitability for a high-performance liquid chromatography (HPLC) system using United States Pharmacopeia (USP)-traceable reference standards, and are then approved to analyze batches of samples that are collected in LMICs by covert shoppers. Open Science Framework (OSF) allows DPAL participants access to resources for the program including an HPLC methodology manual, a wiki with HPLC troubleshooting information, detailed checklists and Excel templates for system suitability and sample assay, as well as steps for reporting results. Participants incorporate the DPAL program into their academic curriculum as undergraduate research or via lab activities for analytical chemistry or instrumental analysis courses. Over a thousand samples have been analyzed through DPAL in the last three years, and 168 samples with quality problems have been discovered, including falsified acetaminophen, adulterated amoxicillin-clavulanate and doxycycline, and substandard losartan. These quality problems are reported to the medicine regulatory agencies in the countries of origin and the WHO Rapid Alert System for further action. This real-world program gives students a hands-on opportunity to see the importance of analytical metrics taught in the classroom.
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Affiliation(s)
- Sarah L. Bliese
- Chemistry and Biochemistry Department, University of Notre Dame, Notre Dame, Indiana, USA, 46556
| | - Margaret Berta
- Chemistry and Biochemistry Department, University of Notre Dame, Notre Dame, Indiana, USA, 46556
| | - Marya Lieberman
- Chemistry and Biochemistry Department, University of Notre Dame, Notre Dame, Indiana, USA, 46556
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120
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Kiguba R, Ndagije HB, Nambasa V, Manirakiza L, Kirabira E, Serwanga A, Olsson S, Speybroeck N, Mukonzo J. Pharmacovigilance of suspected or confirmed therapeutic ineffectiveness of artemisinin-based combination therapy: extent, associated factors, challenges and solutions to reporting. Malar J 2020; 19:389. [PMID: 33143714 PMCID: PMC7640656 DOI: 10.1186/s12936-020-03463-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/26/2020] [Indexed: 11/30/2022] Open
Abstract
Background Therapeutic ineffectiveness of artemisinin-based combination therapy (ACT) increases the risk of malaria-related morbidity and mortality, and raises healthcare costs. Yet, little has been done to promote the pharmacovigilance (PV) of ACT ineffectiveness in sub-Saharan Africa, particularly in Uganda. This study aimed to determine the extent and associated factors of the past 6 months reporting of suspected or confirmed ACT therapeutic ineffectiveness by healthcare professionals (HCPs), and difficulties and potential solutions to the PV of ACT therapeutic ineffectiveness. Methods Survey of 685 HCPs conducted using a self-administered questionnaire from June to July 2018 in a nationally representative sample of public and private health facilities in Uganda. HCPs disclosed if they had spontaneously reported ACT therapeutic ineffectiveness to appropriate authorities in the previous 6 months. Multivariable logistic regression models were used to identify determinants of past 6-months, HCP-reported ACT therapeutic ineffectiveness. Results One in five (20%, 137/685; 95% CI 17–23%) HCPs reported ACT therapeutic ineffectiveness to an appropriate authority in the previous 6 months. HCPs commonly reported ACT therapeutic ineffectiveness to immediate supervisors (72%, 106/147), mostly verbally only (80%, 109/137); none had ever submitted a written report of ACT therapeutic ineffectiveness to Uganda’s National Pharmacovigilance Centre. Common difficulties of reporting ACT therapeutic ineffectiveness were: unavailability of reporting procedures (31%, 129/421), poor follow-up of treated patients (22%, 93/421) and absence of reporting tools (16%, 68/421). Factors associated with reporting ACT therapeutic ineffectiveness in the past 6 months were: hospital-status (vs other; OR = 2.4, 95% CI 1.41–4.21), HCPs aged under 25 years (OR = 2.2, 95% CI 1.29–3.76), suspicion of ACT therapeutic ineffectiveness in the past 4 weeks (OR = 2.3, 95% CI 1.29–3.92), receipt of patient-complaint(s) of ACT therapeutic ineffectiveness in the past 4 weeks (OR = 2.9, 95% CI 1.62–5.12) and HCPs from northern (vs central; OR = 0.5, 95% CI 0.28–0.93) and western (vs central; OR = 0.4, 95% CI 0.17–0.77) parts of Uganda. Conclusion One in five HCPs reported ACT therapeutic ineffectiveness, mostly verbally to supervisors. The existing adverse drug reaction (ADR)-reporting infrastructure could be leveraged to promote the PV of ACT therapeutic ineffectiveness.
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Affiliation(s)
- Ronald Kiguba
- Department of Pharmacology and Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda.
| | | | - Victoria Nambasa
- National Pharmacovigilance Centre, National Drug Authority, Kampala, Uganda
| | - Leonard Manirakiza
- National Pharmacovigilance Centre, National Drug Authority, Kampala, Uganda
| | - Elijah Kirabira
- National Pharmacovigilance Centre, National Drug Authority, Kampala, Uganda
| | - Allan Serwanga
- National Pharmacovigilance Centre, National Drug Authority, Kampala, Uganda
| | - Sten Olsson
- Pharmacovigilance Consulting, Uppsala, Sweden
| | - Niko Speybroeck
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - Jackson Mukonzo
- Department of Pharmacology and Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda
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121
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Rathmes G, Rumisha SF, Lucas TCD, Twohig KA, Python A, Nguyen M, Nandi AK, Keddie SH, Collins EL, Rozier JA, Gibson HS, Chestnutt EG, Battle KE, Humphreys GS, Amratia P, Arambepola R, Bertozzi-Villa A, Hancock P, Millar JJ, Symons TL, Bhatt S, Cameron E, Guerin PJ, Gething PW, Weiss DJ. Global estimation of anti-malarial drug effectiveness for the treatment of uncomplicated Plasmodium falciparum malaria 1991-2019. Malar J 2020; 19:374. [PMID: 33081784 PMCID: PMC7573874 DOI: 10.1186/s12936-020-03446-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/10/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Anti-malarial drugs play a critical role in reducing malaria morbidity and mortality, but their role is mediated by their effectiveness. Effectiveness is defined as the probability that an anti-malarial drug will successfully treat an individual infected with malaria parasites under routine health care delivery system. Anti-malarial drug effectiveness (AmE) is influenced by drug resistance, drug quality, health system quality, and patient adherence to drug use; its influence on malaria burden varies through space and time. METHODS This study uses data from 232 efficacy trials comprised of 86,776 infected individuals to estimate the artemisinin-based and non-artemisinin-based AmE for treating falciparum malaria between 1991 and 2019. Bayesian spatiotemporal models were fitted and used to predict effectiveness at the pixel-level (5 km × 5 km). The median and interquartile ranges (IQR) of AmE are presented for all malaria-endemic countries. RESULTS The global effectiveness of artemisinin-based drugs was 67.4% (IQR: 33.3-75.8), 70.1% (43.6-76.0) and 71.8% (46.9-76.4) for the 1991-2000, 2006-2010, and 2016-2019 periods, respectively. Countries in central Africa, a few in South America, and in the Asian region faced the challenge of lower effectiveness of artemisinin-based anti-malarials. However, improvements were seen after 2016, leaving only a few hotspots in Southeast Asia where resistance to artemisinin and partner drugs is currently problematic and in the central Africa where socio-demographic challenges limit effectiveness. The use of artemisinin-based combination therapy (ACT) with a competent partner drug and having multiple ACT as first-line treatment choice sustained high levels of effectiveness. High levels of access to healthcare, human resource capacity, education, and proximity to cities were associated with increased effectiveness. Effectiveness of non-artemisinin-based drugs was much lower than that of artemisinin-based with no improvement over time: 52.3% (17.9-74.9) for 1991-2000 and 55.5% (27.1-73.4) for 2011-2015. Overall, AmE for artemisinin-based and non-artemisinin-based drugs were, respectively, 29.6 and 36% below clinical efficacy as measured in anti-malarial drug trials. CONCLUSIONS This study provides evidence that health system performance, drug quality and patient adherence influence the effectiveness of anti-malarials used in treating uncomplicated falciparum malaria. These results provide guidance to countries' treatment practises and are critical inputs for malaria prevalence and incidence models used to estimate national level malaria burden.
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Affiliation(s)
- Giulia Rathmes
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Susan F Rumisha
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- Telethon Kids Institute, Perth, Australia.
| | - Tim C D Lucas
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Katherine A Twohig
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Andre Python
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Center for Data Science, Zhejiang University, Hangzhou, 310058, China
| | - Michele Nguyen
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anita K Nandi
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Suzanne H Keddie
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emma L Collins
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jennifer A Rozier
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Harry S Gibson
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Elisabeth G Chestnutt
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Katherine E Battle
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Georgina S Humphreys
- WorldWide Anti-Malarial Resistance Network (WWARN), Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Punam Amratia
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rohan Arambepola
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Amelia Bertozzi-Villa
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Institute for Disease Modeling, Bellevue, WA, USA
| | - Penelope Hancock
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Justin J Millar
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tasmin L Symons
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Ewan Cameron
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Telethon Kids Institute, Perth, Australia
- Curtin University, Perth, Australia
| | - Philippe J Guerin
- WorldWide Anti-Malarial Resistance Network (WWARN), Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Peter W Gething
- Telethon Kids Institute, Perth, Australia
- Curtin University, Perth, Australia
| | - Daniel J Weiss
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Telethon Kids Institute, Perth, Australia
- Curtin University, Perth, Australia
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122
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Bandyopadhyay S, Samanta I. Antimicrobial Resistance in Agri-Food Chain and Companion Animals as a Re-emerging Menace in Post-COVID Epoch: Low-and Middle-Income Countries Perspective and Mitigation Strategies. Front Vet Sci 2020; 7:620. [PMID: 33195500 PMCID: PMC7581709 DOI: 10.3389/fvets.2020.00620] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/30/2020] [Indexed: 01/08/2023] Open
Abstract
Antimicrobial resistance (AMR) leads to enormous financial losses from issues such as high morbidity, mortality, man-days lost, hospital length of stay, health-care, and social costs. In humans, over prescription of antimicrobials, which is presumably higher during COVID, has been identified as the major source of selection for antimicrobial resistant bacteria; however, use of antimicrobials in food and companion animals, fish, and vegetables, and the environmental resistance gene pool, also play important roles. The possibilities of unnecessary use of antibiotics as prophylaxis during and after COVID in livestock and companion animals exist in low-and middle-income countries. A considerable loss in gross domestic product (GDP) is also projected in low-and middle-income countries (LMICs) due to AMR by the year 2050, which is further going to be reduced due to economic slowdown in the post-COVID period. Veterinary hospitals dedicated to pets have cropped up, especially in urban areas of LMICs where use of antimicrobials has also been increased substantially. The inevitable preventive habit built up during COVID with the frequent use of hand sanitizer might trigger AMR due to the presence of cross-resistance with disinfectants. In LMICs, due to the rising demand for animal protein, industrial food animal production (IFAP) is slowly replacing the small-scale backyard farming system. The lack of stringent regulations and monitoring increased the non-therapeutic use of antimicrobials in industrial farms where the persistence of antimicrobial resistant bacteria has been associated with several factors other than antimicrobial use, such as co-resistance, cross-resistance, bacterial fitness, mixing of new and old animals, and vectors or reservoirs of bacterial infection. The present review describes types of antimicrobials used in agri-food chains and companion animals in LMICs with identification of the gap in data, updated categories of prevalent antimicrobial resistant bacteria, the role of animal farms as reservoirs of resistant bacteria, and mitigation strategies, with a special focus on the pivotal strategy needed in the post-COVID period.
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Affiliation(s)
| | - Indranil Samanta
- Department of Veterinary Microbiology, West Bengal University of Animal and Fishery Sciences, Kolkata, India
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123
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Rojas-Cortés R. Substandard, falsified and unregistered medicines in Latin America, 2017-2018. Rev Panam Salud Publica 2020; 44:e125. [PMID: 33033498 PMCID: PMC7537817 DOI: 10.26633/rpsp.2020.125] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/10/2020] [Indexed: 11/24/2022] Open
Abstract
Objective To assess all the incidents of substandard, falsified and unregistered medicines in 2017 and 2018 in Latin America, determining the types of products affected, stages of the supply chain in which incidents were detected, quality deviations identified in tested samples, and regulatory measures taken by authorities. Methods A comprehensive search of the websites of the Latin American national regulatory authorities was conducted, identifying all eligible incidents during 2017-2018. Standardized values were collected from each incident for pre-determined variables: country, year, type of incident, therapeutic group, supply chain, regulatory measures and laboratory data. Results A total of 596 incidents in 13 countries were included (236 substandard, 239 falsified, 116 unregistered and 5 stolen). The therapeutic categories with the highest incidents were: anti-infectives, medicines for pain/palliative care, hormones/contraceptives, medicines for the respiratory tract, and medicines for mental/behavioural disorders. The most common places where incidents were detected were commercial establishments, pharmacies, health services and manufacturers. The most recurrent quality deviations were failure in parameters (appearance or physicochemical), incorrect labelling, different quantity of active pharmaceutical ingredient, presence of unknown particles, and microbiological contamination. The most frequent regulatory measures identified were alerts, withdrawals, seizures, and prohibition of marketing/distribution/use. Conclusions In Latin America, substandard, falsified and unregistered medicines persist as a highly prevalent problem. An advanced degree of regulatory development in countries is associated with higher incident detection/reporting rates and a more comprehensive set of measures. The pharmaceutical supply chain is more vulnerable in its final node. Quality deviations identified in tested samples pose serious risks to public health.
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Affiliation(s)
- Robin Rojas-Cortés
- Regional Network for the Prevention, Detection and Response to Substandard and Falsified Medical Products in the Americas Washington DC United States of America Regional Network for the Prevention, Detection and Response to Substandard and Falsified Medical Products in the Americas, Washington, DC, United States of America
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124
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Hassan IA, Adegbola AJ, Soyinka JO, Onyeji CO, Bolaji OO. Post-Marketing Surveillance of Quality of Artemether Injection Marketed in Southwest Nigeria. Am J Trop Med Hyg 2020; 103:1258-1265. [PMID: 32588802 PMCID: PMC7470523 DOI: 10.4269/ajtmh.20-0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/14/2020] [Indexed: 11/07/2022] Open
Abstract
Access to good-quality medicines remains a contentious issue in developing countries. This development is worrisome, particularly in a setting with a high incidence of malaria. Monitoring of antimalarial drugs in the commercial domain becomes necessary; thus, we evaluated the quality of artemether injection marketed in Southwest Nigeria. A cross-sectional survey was conducted to obtain 22 different brands of artemether injections within Southwest Nigeria. The samples were examined for their sources, lot numbers, containers for injection, oil base used for preparation, and dates of expiration. Further analysis involved visual inspection, assessment of extractable volume, identity tests, and an assay of active pharmaceutical ingredient. The pharmaceutical quality of each sample was determined according to the criteria set in the International Pharmacopoeia 2019. None of the products had any particulate matter, but there were certain irregularities in their presentation. Eighteen of the 22 products (81.7%) were packaged in plain instead of amber-colored ampoules, and 77.3% (17/22) did not indicate the oil base used as the vehicle on the label as against the pharmacopoeial standard. Sixteen products (72.7%) passed the extractable volume test, although the remaining 22.3% did not conform to the extractable volume per unit dose. Artemether was present in all the samples, although only 40.9% (9/22) met the recommended percentage content of 90-110% of artemether. The study revealed the presence of a high percentage of substandard artemether injection products marketed in Nigeria. Further surveillance is warranted to confirm the quality of artemether injection circulated in other regions within Nigeria.
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Affiliation(s)
- Ibrahim A. Hassan
- Department of Pharmacy, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria
| | - Adebanjo J. Adegbola
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile Ife, Nigeria
| | - Julius O. Soyinka
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile Ife, Nigeria
| | - Cyprian O. Onyeji
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile Ife, Nigeria
- Department of Pharmaceutical and Medicinal Chemistry, University of Nigeria, Nsukka, Nigeria
| | - Oluseye O. Bolaji
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile Ife, Nigeria
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125
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Kirchhelle C, Atkinson P, Broom A, Chuengsatiansup K, Ferreira JP, Fortané N, Frost I, Gradmann C, Hinchliffe S, Hoffman SJ, Lezaun J, Nayiga S, Outterson K, Podolsky SH, Raymond S, Roberts AP, Singer AC, So AD, Sringernyuang L, Tayler E, Rogers Van Katwyk S, Chandler CIR. Setting the standard: multidisciplinary hallmarks for structural, equitable and tracked antibiotic policy. BMJ Glob Health 2020; 5:e003091. [PMID: 32967980 PMCID: PMC7513567 DOI: 10.1136/bmjgh-2020-003091] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 01/16/2023] Open
Abstract
There is increasing concern globally about the enormity of the threats posed by antimicrobial resistance (AMR) to human, animal, plant and environmental health. A proliferation of international, national and institutional reports on the problems posed by AMR and the need for antibiotic stewardship have galvanised attention on the global stage. However, the AMR community increasingly laments a lack of action, often identified as an 'implementation gap'. At a policy level, the design of internationally salient solutions that are able to address AMR's interconnected biological and social (historical, political, economic and cultural) dimensions is not straightforward. This multidisciplinary paper responds by asking two basic questions: (A) Is a universal approach to AMR policy and antibiotic stewardship possible? (B) If yes, what hallmarks characterise 'good' antibiotic policy? Our multistage analysis revealed four central challenges facing current international antibiotic policy: metrics, prioritisation, implementation and inequality. In response to this diagnosis, we propose three hallmarks that can support robust international antibiotic policy. Emerging hallmarks for good antibiotic policies are: Structural, Equitable and Tracked. We describe these hallmarks and propose their consideration should aid the design and evaluation of international antibiotic policies with maximal benefit at both local and international scales.
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Affiliation(s)
- Claas Kirchhelle
- School of History, University College Dublin, Dublin, Ireland
- Oxford Martin School, University of Oxford, Oxford, Oxfordshire, UK
| | - Paul Atkinson
- Department of Public Health and Policy/ Institute of Infection and Global Health, University of Liverpool, Liverpool, Merseyside, UK
| | - Alex Broom
- School of Social and Political Sciences, Faculty of Arts and Social Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Jorge Pinto Ferreira
- Antimicrobial Resistance and Veterinary Products Department, World Organisation for Animal Health, Paris, Île-de-France, France
| | - Nicolas Fortané
- Irisso, Paris-Dauphine University, PSL, INRAE, Paris, Île-de-France, France
| | - Isabel Frost
- Center for Disease Dynamics Economics and Policy, Washington, DC, USA
- Department of Infectious Disease, Imperial College London, London, UK
| | - Christoph Gradmann
- Institute for Health and Society, Dept. of Community Medicine and Global Health, University of Oslo, Oslo, Norway
| | - Stephen Hinchliffe
- Geography, College of Life and Environmental Sciences and Wellcome Centre for Cultures and Environments of Health, University of Exeter, Exeter, Devon, UK
| | - Steven J Hoffman
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, Toronto, Ontario, Canada
| | - Javier Lezaun
- Institute for Science, Innovation and Society, School of Anthropology and Museum Ethnography, University of Oxford, Oxford, Oxfordshire, UK
| | - Susan Nayiga
- Infectious Diseases Research Collaboration, Kampala, Central Region, Uganda
| | - Kevin Outterson
- School of Law, Social Innovation on Drug Program, Boston University, Boston, Massachusetts, USA
| | - Scott H Podolsky
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie Raymond
- School of Social and Political Sciences, Faculty of Arts and Social Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Adam P Roberts
- Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Andrew C Singer
- Pollution, UK Centre for Ecology & Hydrology, Wallingford, UK
| | - Anthony D So
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Innovation + Design Enabling Access (IDEA) Initiative, ReAct - Action on Antibiotic Resistance, Baltimore, Maryland, USA
| | | | - Elizabeth Tayler
- Global Coordination and Partnerships, AMR Division, World Health Organisation, Geneva, Switzerland
| | - Susan Rogers Van Katwyk
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, Toronto, Ontario, Canada
- Global Strategy Lab, York University, Toronto, Ontario, Canada
| | - Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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126
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Connor S, Forrister D, Karir V, Kauffman Y, Sochacki M. Improving equitable access to essential medicines: Learning from the experience of pharmacists within Médecins Sans Frontières (Doctors Without Borders). JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Sharon Connor
- University of Pittsburgh School of Pharmacy Pittsburgh PA
| | - Daniel Forrister
- Social Solutions International (USAID Institutional Contractor), Office of U.S. Foreign Disaster Assistance, Preparation, Strategic Planning, and Mitigation Division Washington DC
| | - Veena Karir
- Doctors Without Borders (Médecins Sans Frontières), Operational Center Amsterdam (OCA) Amsterdam Netherlands
| | - Yardlee Kauffman
- Doctors Without Borders (Médecins Sans Frontières) Operational Center Brussels (OCB) Brussels Belgium
| | - Marisa Sochacki
- Doctors Without Borders (Médecins Sans Frontières) Operational Center Paris (OCP) Paris France
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127
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McManus D, Naughton BD. A systematic review of substandard, falsified, unlicensed and unregistered medicine sampling studies: a focus on context, prevalence, and quality. BMJ Glob Health 2020; 5:e002393. [PMID: 32859648 PMCID: PMC7454198 DOI: 10.1136/bmjgh-2020-002393] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023] Open
Abstract
Substandard and falsified (SF) medicines are a global issue contributing to antimicrobial resistance and causing economic and humanitarian harm. To direct law enforcement efficiently, halt the spread of SF medicines and antimicrobial resistance, academics, NGOs and government organisations use medicine quality sampling studies to estimate the prevalence of the problem. A systematic review of medicine quality studies was conducted to estimate how the methodological quality of these studies and SF prevalence has changed between 2013 and 2018. We also aimed to critique medicine sampling study methodologies, and the systematic review process which generates prevalence estimates. Based on 33 studies, the overall estimated median (Q1-Q3) prevalence of SF medicines appears to have remained high at 25% (7.7%-34%) compared with 28.5% in 2013. Furthermore, the methodological quality of prevalence studies has improved over the last 25 years. Definitive conclusions regarding the prevalence of SF medicines cannot be drawn due to the variability in sample sizes, consistency of design methods, and a lack of information concerning contextual factors affecting medicine quality studies. We contend that studies which present cumulative average prevalence figures are useful in a broad sense but could be improved to create more reliable estimates. We propose that medicine quality studies record the context of the study environment to allow systematic reviewers to compare like with like. Although, the academic rigour of medicine quality studies is improving, medicine sampling study limitations still exist. These limitations inhibit the accurate estimation of SF medicine prevalence which is needed to support detailed policy changes.
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Affiliation(s)
- Dominic McManus
- School of Pharmacy (Formerly of), University College London, London, UK
| | - Bernard David Naughton
- Saïd Business School, University of Oxford, Oxford, UK
- Pharmacy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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128
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Bolla AS, Patel AR, Priefer R. The silent development of counterfeit medications in developing countries - A systematic review of detection technologies. Int J Pharm 2020; 587:119702. [PMID: 32736015 DOI: 10.1016/j.ijpharm.2020.119702] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 01/17/2023]
Abstract
Drug counterfeiting detection is very important for the safety of patients around the world. Counterfeit pharmaceutical products can be referred to the production and distribution of mislabeled medications in which the identity, authenticity, and/or effectiveness is altered. Drugs are often counterfeited to reduce manufacture costs, while still marketing it at as an authentic product. Increased incidence of drug counterfeiting is most noticeable in developing countries, which may not have the resources to supply counterfeit detection devices at a large scale. It is important to consider the direct problems that it may cause and to propose options for controlling and reducing the prevalence of counterfeit medications. Certain counterfeit detection devices have been successfully used for qualitative and quantitative assessment to differentiate counterfeit medications from the reference product. Different technologies are needed to identify the chemical properties of a questioned drug product, which can then be used to determine its authenticity. This review examines the implications of counterfeit medications and the current technological approaches that are able to detect counterfeited pharmaceuticals.
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Affiliation(s)
- Anmole S Bolla
- Massachusetts College of Pharmacy and Health Sciences University, Boston 02115, USA
| | - Ashwani R Patel
- Massachusetts College of Pharmacy and Health Sciences University, Boston 02115, USA
| | - Ronny Priefer
- Massachusetts College of Pharmacy and Health Sciences University, Boston 02115, USA.
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129
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Hanboonkunupakarn B, White NJ. Advances and roadblocks in the treatment of malaria. Br J Clin Pharmacol 2020; 88:374-382. [PMID: 32656850 PMCID: PMC9437935 DOI: 10.1111/bcp.14474] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/11/2020] [Accepted: 05/15/2020] [Indexed: 12/12/2022] Open
Abstract
The deployment of artesunate for severe malaria and the artemisinin combination therapies (ACTs) for uncomplicated malaria has been a major advance in antimalarial therapeutics. These drugs have reduced treated mortality, accelerated recovery and reduced treatment failure rates and transmission from the treated infection. Artemisinin derivatives remain highly effective against falciparum malaria in most malaria endemic areas, but significant resistance has emerged in the Greater Mekong subregion of Southeast Asia. Resistance to artemisinins was followed by resistance to the ACT partner drugs, and fit multidrug resistant parasite lineages have now spread widely across the region. ACTs remain highly effective against P. vivax and the other malaria species. Recent studies have shown that radical curative regimens of primaquine (to prevent relapse) can be shortened to 7 days, and that the newly introduced single dose tafenoquine is an alternative, although the currently recommended dose is insufficient in Southeast Asia and Oceania. Targeted malaria elimination using focal mass treatments with dihydroartemisinin-piperaquine have proved safe and effective malaria elimination accelerators, but progress overall towards malaria elimination is slow. Indeed since 2015 overall malaria case numbers globally have risen. As new drugs will not become widely available in the near future, active measures to preserve the current antimalarials should be given the highest priority.
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Affiliation(s)
| | - Nicholas J White
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, UK
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130
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Jackson KD, Higgins CR, Laing SK, Mwila C, Kobayashi T, Ippolito MM, Sylvia S, Ozawa S. Impact of substandard and falsified antimalarials in Zambia: application of the SAFARI model. BMC Public Health 2020; 20:1083. [PMID: 32646393 PMCID: PMC7350731 DOI: 10.1186/s12889-020-08852-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 05/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many countries are striving to become malaria-free, but global reduction in case estimates has stagnated in recent years. Substandard and falsified medicines may contribute to this lack of progress. Zambia aims to eliminate their annual burden of 1.2 million pediatric malaria cases and 2500 child deaths due to malaria. We examined the health and economic impact of poor-quality antimalarials in Zambia. METHODS An agent-based model, Substandard and Falsified Antimalarial Research Impact (SAFARI), was modified and applied to Zambia. The model was developed to simulate population characteristics, malaria incidence, patient care-seeking, disease progression, treatment outcomes, and associated costs of malaria for children under age five. Zambia-specific demographic, epidemiological, and cost inputs were extracted from the literature. Simulations were run to estimate the health and economic impact of poor-quality antimalarials, the effect of potential artemisinin resistance, and six additional malaria focused policy interventions. RESULTS We simulated annual malaria cases among Zambian children under five. At baseline, we found 2610 deaths resulting in $141.5 million in annual economic burden of malaria. We estimated that elimination of substandard and falsified antimalarials would result in an 8.1% (n = 213) reduction in under-five deaths, prevent 937 hospitalizations, and realize $8.5 million in economic savings, annually. Potential artemisinin resistance could further increase deaths by 6.3% (n = 166) and cost an additional $9.7 million every year. CONCLUSIONS Eliminating substandard and falsified antimalarials is an important step towards a malaria-free Zambia. Beyond the dissemination of insecticide-treated bed nets, indoor residual spraying, and other malaria control measures, attention must also be paid to assure the quality of antimalarial treatments.
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Affiliation(s)
- Kathryn D Jackson
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Colleen R Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, CB#7574, Beard Hall, 115H, Chapel Hill, NC, 27599, USA
| | - Sarah K Laing
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Chiluba Mwila
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Tamaki Kobayashi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Matthew M Ippolito
- Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Division of Clinical Pharmacology and Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sean Sylvia
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.,Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, CB#7574, Beard Hall, 115H, Chapel Hill, NC, 27599, USA. .,Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
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131
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Ozawa S, Higgins CR, Yemeke TT, Nwokike JI, Evans L, Hajjou M, Pribluda VS. Importance of medicine quality in achieving universal health coverage. PLoS One 2020; 15:e0232966. [PMID: 32645019 PMCID: PMC7347121 DOI: 10.1371/journal.pone.0232966] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/24/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To assess the importance of ensuring medicine quality in order to achieve universal health coverage (UHC). METHODS We developed a systems map connecting medicines quality assurance systems with UHC goals to illustrate the ensuing impact of quality-assured medicines in the implementation of UHC. The association between UHC and medicine quality was further examined in the context of essential medicines in low- and middle-income countries (LMICs) by analyzing data on reported prevalence of substandard and falsified essential medicines and established indicators for UHC. Finally, we examined the health and economic savings of improving antimalarial quality in four countries in sub-Saharan Africa: the Democratic Republic of the Congo (DRC), Nigeria, Uganda, and Zambia. FINDINGS A systems perspective demonstrates how quality assurance of medicines supports dimensions of UHC. Across 63 LMICs, the reported prevalence of substandard and falsified essential medicines was found to be negatively associated with both an indicator for coverage of essential services (p = 0.05) and with an indicator for government effectiveness (p = 0.04). We estimated that investing in improving the quality of antimalarials by 10% would result in annual savings of $8.3 million in Zambia, $14 million in Uganda, $79 million in two DRC regions, and $598 million in Nigeria, and was more impactful compared to other potential investments we examined. Costs of substandard and falsified antimalarials per malaria case ranged from $7 to $86, while costs per death due to poor-quality antimalarials ranged from $14,000 to $72,000. CONCLUSION Medicines quality assurance systems play a critical role in reaching UHC goals. By ensuring the quality of essential medicines, they help deliver effective treatments that lead to less illness and result in health care savings that can be reinvested towards UHC.
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Affiliation(s)
- Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, United States of America
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - Colleen R. Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, United States of America
| | - Tatenda T. Yemeke
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, United States of America
| | - Jude I. Nwokike
- Promoting the Quality of Medicines (PQM) Program, United States Pharmacopeial Convention (USP), Rockville, MD, United States of America
| | - Lawrence Evans
- Promoting the Quality of Medicines (PQM) Program, United States Pharmacopeial Convention (USP), Rockville, MD, United States of America
| | - Mustapha Hajjou
- Promoting the Quality of Medicines (PQM) Program, United States Pharmacopeial Convention (USP), Rockville, MD, United States of America
| | - Victor S. Pribluda
- Promoting the Quality of Medicines (PQM) Program, United States Pharmacopeial Convention (USP), Rockville, MD, United States of America
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132
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Mavungu Landu DJ, Frédérich M, Manzambi Kuwekita J, Bongo-Pasi Nswe C, Mbinze JK, Liégeois S, Kalenda Tshilombo N, Kwete Minga M, Ciza Hamuli P, Hubert P, Marini Djang'eing'a R. Quality of antimalarials in Kinshasa peri-urban areas with regard to local pharmaceutical legislation and regulation. Int Health 2020; 12:253-263. [PMID: 31613326 PMCID: PMC7322209 DOI: 10.1093/inthealth/ihz070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In the context of old pharmaceutical legislation and regulations not adapted to current realities, the aim of the present study was to evaluate the existing pharmaceutical system in peri-urban areas of Kinshasa. METHODS A prospective study was carried out during the period 2016-2018. The most used antimalarial medicines were identified through household and pharmaceutical establishment surveys. The samples of the obtained medicines were assayed with generic separation methods using the high-performance liquid chromatography technique coupled to a diode array detector. The registration status was checked for 126 antimalarial brand names. A characterization was carried out in 196 pharmaceutical establishments on the basis of standards set out by the Ministry of Health. RESULTS Of the 75 samples assayed, 19% (14/75) were non-compliant. Of the 124 brand names, 46.0% (57/124) were unlicensed and 14.5% (18/124) had an expired licence. Of the 196 pharmaceutical establishments, only 2 (1.0%) had an authorization to practice, none met all the Ministry of Health minimum standards and 24.5% (48/196) met the World Health Organization Guidelines for the Storage of Essential Medicines and Other Health Commodities. CONCLUSIONS More resources should be mobilized to apply regulator sanctions.
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Affiliation(s)
- Don Jethro Mavungu Landu
- Laboratory of Pharmacognosy, CIRM, Department of Pharmacy, Liège University, Liège 4000, Belgium.,Ecole Régionale Postuniversitaire d'Aménagement et de Gestion intégrée des Forêts et Territoires tropicaux, University of Kinshasa, Kinshasa 10, Democratic Republic of Congo
| | - Michel Frédérich
- Laboratory of Pharmacognosy, CIRM, Department of Pharmacy, Liège University, Liège 4000, Belgium
| | - Joseph Manzambi Kuwekita
- Department of Public Health Sciences, Liège University, Liège 4000, Belgium.,Community Health Section, Institut Supérieur des Techniques Médicales de Kinshasa, Kinshasa 10, Democratic Republic of Congo
| | - Christian Bongo-Pasi Nswe
- Faculty of Public Health, Université des Sciences et des Technologies de Lodja, Sankuru 83, Democratic Republic of Congo
| | - J K Mbinze
- Laboratory of Drug Analysis, Department of Galenic Pharmacy and Drug Analysis, University of Kinshasa, Kinshasa 10, Democratic Republic of Congo
| | - Sophie Liégeois
- Laboratory of Analytical Pharmaceutical Chemistry, CIRM, Department of Pharmacy, Liège University, Liège 4000, Belgium
| | - Nicodème Kalenda Tshilombo
- Laboratory of Analytical Pharmaceutical Chemistry, CIRM, Department of Pharmacy, Liège University, Liège 4000, Belgium.,Laboratory of Chromatography, Faculty of Pharmaceutical Sciences, University of Kinshasa, Kinshasa 10, Democratic Republic of Congo
| | - Mineze Kwete Minga
- Advanced School of Translation and Interpretation, Université Pédagogique Nationale, Kinshasa 10, Democratic Republic of Congo
| | - Patient Ciza Hamuli
- Laboratory of Drug Analysis, Department of Galenic Pharmacy and Drug Analysis, University of Kinshasa, Kinshasa 10, Democratic Republic of Congo.,Laboratory of Analytical Pharmaceutical Chemistry, CIRM, Department of Pharmacy, Liège University, Liège 4000, Belgium
| | - Philippe Hubert
- Laboratory of Analytical Pharmaceutical Chemistry, CIRM, Department of Pharmacy, Liège University, Liège 4000, Belgium
| | - Roland Marini Djang'eing'a
- Laboratory of Analytical Pharmaceutical Chemistry, CIRM, Department of Pharmacy, Liège University, Liège 4000, Belgium
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Koech LC, Irungu BN, Ng'ang'a MM, Ondicho JM, Keter LK. Quality and Brands of Amoxicillin Formulations in Nairobi, Kenya. BIOMED RESEARCH INTERNATIONAL 2020; 2020:7091278. [PMID: 32685520 PMCID: PMC7306854 DOI: 10.1155/2020/7091278] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 01/04/2020] [Indexed: 11/17/2022]
Abstract
Antibiotics are among the most counterfeited anti-infectious medicines in developing countries. Amoxicillin is one of the commonly prescribed, affordable, and easily accessible antibiotic in Kenya. It is a broad-spectrum antibiotic hence commonly used in chemotherapy. This study sought to determine the quality and identify the various brands of amoxicillin and its combination amoxicillin/clavulanic acid marketed in Nairobi County. Nairobi is the capital city of Kenya, gateway for imports and exports, and the headquarters to most of the pharmaceutical distributors. Ten wards in Nairobi County representing different socioeconomic settings were purposively sampled for the study. A detailed questionnaire was used to collect background data on brands of amoxicillin and amoxicillin/clavulanic acid in the market. A total of 106 different brands were found in the market: 85 were imports while 21 were locally manufactured. Fifty-three samples were analyzed with reference to the United States Pharmacopoeia. Amoxicillin and clavulanic acid contents for oral suspensions were determined immediately after reconstitution and 7 days thereafter to determine their stability during the prescription period. On day seven, 23.1% (3 out of 13) of amoxicillin and 66.7% (8 out of 12) amoxicillin/clavulanic acid oral suspensions presented levels below recommended limits. Uniformity of weight for amoxicillin capsules noted 13.6% (3 out of 22) failure rate, while amoxicillin/clavulanic acid tablets complied. Potency determination for all amoxicillin capsules analyzed were within required limits, but amoxicillin/clavulanic acid tablets showed 33.3% (2 out of 6) noncompliance. For amoxicillin capsule and amoxicillin/clavulanic acid tablet dissolution tests, there was 10.5% (2 out of 19) and 50% (2 out of 4) noncompliance, respectively. Overall, 37.7% of the drugs analyzed failed to comply with the Pharmacopoeia. These results highlight the presence of poor-quality amoxicillin formulations in Nairobi County, affirming the need for regular postmarket surveillance to inform on the situation of antibiotic quality in the Kenyan market.
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Affiliation(s)
- Lilian C. Koech
- Department of Chemistry, School of Pure and Applied Sciences, Kenyatta University, P.O. Box 43844-00100, Nairobi, Kenya
- Center for Traditional Medicine and Drug Research, Kenya Medical Research Institute, P.O. Box 54840-00200, Nairobi, Kenya
| | - Beatrice N. Irungu
- Center for Traditional Medicine and Drug Research, Kenya Medical Research Institute, P.O. Box 54840-00200, Nairobi, Kenya
| | - Margaret M. Ng'ang'a
- Department of Chemistry, School of Pure and Applied Sciences, Kenyatta University, P.O. Box 43844-00100, Nairobi, Kenya
| | - Joyce M. Ondicho
- Center for Traditional Medicine and Drug Research, Kenya Medical Research Institute, P.O. Box 54840-00200, Nairobi, Kenya
| | - Lucia K. Keter
- Center for Traditional Medicine and Drug Research, Kenya Medical Research Institute, P.O. Box 54840-00200, Nairobi, Kenya
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134
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Newton PN, Bond KC. Global access to quality-assured medical products: the Oxford Statement and call to action. LANCET GLOBAL HEALTH 2020; 7:e1609-e1611. [PMID: 31708137 DOI: 10.1016/s2214-109x(19)30426-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/15/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Research Unit, Vientiane, Laos; Centre for Tropical Medicine and Global Health and Infectious Diseases Data Observatory, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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135
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Nadimpalli ML, Marks SJ, Montealegre MC, Gilman RH, Pajuelo MJ, Saito M, Tsukayama P, Njenga SM, Kiiru J, Swarthout J, Islam MA, Julian TR, Pickering AJ. Urban informal settlements as hotspots of antimicrobial resistance and the need to curb environmental transmission. Nat Microbiol 2020; 5:787-795. [PMID: 32467623 DOI: 10.1038/s41564-020-0722-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/07/2020] [Indexed: 12/24/2022]
Abstract
Antimicrobial resistance (AMR) is a growing public health challenge that is expected to disproportionately burden lower- and middle-income countries (LMICs) in the coming decades. Although the contributions of human and veterinary antibiotic misuse to this crisis are well-recognized, environmental transmission (via water, soil or food contaminated with human and animal faeces) has been given less attention as a global driver of AMR, especially in urban informal settlements in LMICs-commonly known as 'shanty towns' or 'slums'. These settlements may be unique hotspots for environmental AMR transmission given: (1) the high density of humans, livestock and vermin living in close proximity; (2) frequent antibiotic misuse; and (3) insufficient drinking water, drainage and sanitation infrastructure. Here, we highlight the need for strategies to disrupt environmental AMR transmission in urban informal settlements. We propose that water and waste infrastructure improvements tailored to these settings should be evaluated for their effectiveness in limiting environmental AMR dissemination, lowering the community-level burden of antimicrobial-resistant infections and preventing antibiotic misuse. We also suggest that additional research is directed towards developing economic and legal incentives for evaluating and implementing water and waste infrastructure in these settings. Given that almost 90% of urban population growth will occur in regions predicted to be most burdened by the AMR crisis, there is an urgent need to build effective, evidence-based policies that could influence massive investments in the built urban environment in LMICs over the next few decades.
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Affiliation(s)
- Maya L Nadimpalli
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA, USA.,Center for Integrated Management of Antimicrobial Resistance (CIMAR), Tufts University, Boston, MA, USA
| | - Sara J Marks
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Dübendorf, Switzerland
| | | | - Robert H Gilman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA.,Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Monica J Pajuelo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA.,Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Mayuko Saito
- Department of Virology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Pablo Tsukayama
- Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru.,Instituto de Medicina Tropical 'Alexander von Humboldt', Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - John Kiiru
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Jenna Swarthout
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA, USA
| | - Mohammad Aminul Islam
- Paul G. Allen School for Global Animal Health, Washington State University, Pullman, WA, USA.,International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh
| | - Timothy R Julian
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Dübendorf, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Amy J Pickering
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA, USA. .,Center for Integrated Management of Antimicrobial Resistance (CIMAR), Tufts University, Boston, MA, USA.
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Khurelbat D, Dorj G, Sunderland B, Sanjjav T, Bayarsaikhan E, Damdinjav D, Dorj G, Jigjidsuren A, Lkhagvasuren O, Erdenetsetseg B. A cross-sectional analysis of falsified, counterfeit and substandard medicines in a low-middle income country. BMC Public Health 2020; 20:743. [PMID: 32434489 PMCID: PMC7240934 DOI: 10.1186/s12889-020-08897-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/11/2020] [Indexed: 01/26/2023] Open
Abstract
Background High prevalence of falsified, counterfeit and substandard medicines pose a threat to public health and treatment failure. This study aimed to investigate the quality of selected essential medicines available in Mongolia. Methods A cross-sectional study collected essential medicines from pharmacy outlets in Mongolia, during June and July, 2017. These products were then submitted for pharmacopoeial analysis and registration status. Results A total of 1770 samples from 118 pharmacy entities were purchased from wholesalers in urban and rural areas. Pharmacopoeial analysis found 179 (10.1%) samples or eleven product groups were unacceptable. The prevalence of substandard locally produced medicines (n = 105, 5.9%) was higher than imported equivalents [(n = 74, 4.17%, p = 0.0001)]. Approximately one-third of all unacceptable tests were related to assay (n = 73, 30.8%) and weight variation. Of 1770 samples, 76 (4.3%) were unregistered and the prevalence of unregistered samples was 3.8% in Ulaanbaatar city and 5.8% in rural areas, respectively. Conclusions This study has indicated that falsified and substandard medicines are prevalent in Mongolia. Considerable effort is required by regulatory authorities, private manufacturers, as well as importers to increase the quality of essential medicines in Mongolia.
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Affiliation(s)
- Daariimaa Khurelbat
- School of Pharmacy, Mongolian National University of Medical Sciences, S. Zorig street, Ulaanbaatar, Sukhbaatar District, 14210, Mongolia
| | - Gereltuya Dorj
- School of Pharmacy, Mongolian National University of Medical Sciences, S. Zorig street, Ulaanbaatar, Sukhbaatar District, 14210, Mongolia.
| | - Bruce Sunderland
- School of Pharmacy, Curtin University of Technology, GPO Box U1987, Perth, 6845, Western Australia
| | - Tsetsegmaa Sanjjav
- School of Pharmacy, Mongolian National University of Medical Sciences, S. Zorig street, Ulaanbaatar, Sukhbaatar District, 14210, Mongolia
| | - Enkhtuul Bayarsaikhan
- School of Pharmacy, Mongolian National University of Medical Sciences, S. Zorig street, Ulaanbaatar, Sukhbaatar District, 14210, Mongolia
| | - Davaadagva Damdinjav
- School of Pharmacy, Mongolian National University of Medical Sciences, S. Zorig street, Ulaanbaatar, Sukhbaatar District, 14210, Mongolia
| | - Gantuya Dorj
- School of Public Health, Mongolian National University of Medical Sciences, S. Zorig street, Ulaanbaatar, Sukhbaatar District, 14210, Mongolia
| | - Altantuya Jigjidsuren
- Asian Development Bank, Mongolia Resident Mission, Ulaanbaatar, Sukhbaatar District, 14210, Mongolia
| | - Oyun Lkhagvasuren
- Asian Development Bank, Mongolia Resident Mission, Ulaanbaatar, Sukhbaatar District, 14210, Mongolia
| | - Baasandorj Erdenetsetseg
- School of Pharmacy, Mongolian National University of Medical Sciences, S. Zorig street, Ulaanbaatar, Sukhbaatar District, 14210, Mongolia
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137
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Olliaro E, Olliaro P, Ho CWL, Ravinetto R. Legal Uncertainty-The Gray Area around Substandard Medicines: Where Public Health Meets Law. Am J Trop Med Hyg 2020; 102:262-267. [PMID: 31746313 PMCID: PMC7008313 DOI: 10.4269/ajtmh.19-0645] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
A vicious circle links lack of equitable access to health to the supply of poor-quality medicines, which amount to one-tenth of medicines available in low- and middle-income countries. The WHO introduced a new, public health–focused definition of substandard and falsified (SF) medicines, which offers opportunities for governments to broaden the scope of interventions to combat poor-quality medicines. At the same time, translating it into legal and regulatory measures may be challenging because this definition is not free of ambiguity (in that, there is a gray area between intentionally falsified and unintentional substandard medicines), and some countries may not have appropriate regulatory mechanisms/jurisdictions in place. The focus of the article is to consider what a public health–informed legal and regulatory environment could look like in light of WHO’s SF definition and propose appropriate measures to put it into effect. We present a “legal levers matrix” that may assist legislators and policymakers evaluate the adequacy of measures (i.e., criminal, civil, and administrative mechanisms) to address the problem of poor-quality medicines, particularly in terms of their configuration. In addition, this matrix underscores the importance of fostering dialogue between medical/public health and the legal/regulatory communities and to develop alternative/complementary solutions, including regulatory strengthening and nonpunitive actions. Substandard and falsified medicines arise from the interplay between societies, economies, and behaviors: effective regulation is necessary to disincentivize the production and/or supply of SF medicines, whereas health systems should strive to provide affordable medicines to all levels of society.
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Affiliation(s)
| | - Piero Olliaro
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Calvin W L Ho
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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138
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Lambert P, McIntosh MP, Widmer M, Evans L, Rauscher M, Kuwana R, Theunissen F, Yeager B, Petach H. Oxytocin quality: evidence to support updated global recommendations on oxytocin for postpartum hemorrhage. J Pharm Policy Pract 2020; 13:14. [PMID: 32467764 PMCID: PMC7227300 DOI: 10.1186/s40545-020-00205-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/05/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The use of quality injectable oxytocin effectively prevents and treats postpartum hemorrhage, the leading cause of maternal death worldwide. In low- and middle-income countries (LMICs), characteristics of oxytocin-specifically its heat sensitivity-challenge efforts to ensure its quality throughout the health supply chain. In 2019, WHO, UNFPA and UNICEF released a joint-statement to clarify and recommend that oxytocin should be kept in the cold chain (between 2 and 8 °C) during transportation and storage; however, confusion among stakeholders in LMICs persists. OBJECTIVES AND METHODS To further support recommendations in the WHO/UNFPA/UNICEF joint-statement, this paper reviews results of oxytocin quality testing in LMICs, evaluates product stability considerations for its management and considers quality risks for oxytocin injection throughout the health supply chain. This paper concludes with a set of recommended actions to address the challenges in maintaining quality for a heat sensitive pharmaceutical product. RESULTS Due to the heat sensitivity of oxytocin, its quality may be degraded at numerous points along the health supply chain including: At the point of manufacture, due to poor quality active pharmaceutical ingredients; lack of sterile manufacturing environments; or low-quality manufacturing processesDuring storage and distribution, due to lack of temperature control in the supply chain, including cold chain at the end user health facilitySafeguarding the quality of oxytocin falls under the purview of national medicines regulatory authorities; however, regulators in LMICs may not adhere to good regulatory practices. CONCLUSIONS Storing oxytocin from 2 to 8 °C throughout the supply chain is important for maintaining its quality. While short temperature excursions may not harm product quality, the cumulative heat exposure is generally not tracked and leads to degradation. National and sub-national policies must prioritize procurement of quality oxytocin and require its appropriate storage and management.
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Affiliation(s)
- Peter Lambert
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Michelle P McIntosh
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Mariana Widmer
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Lawrence Evans
- Promoting Quality of Medicines Plus Program, U.S. Pharmacopeial Convention, Rockville, MD USA
| | - Megan Rauscher
- Global Health Supply Chain Program-Procurement and Management Project, Chemonics International, 251 18th Street South, Suite 1200, Arlington, VA 22202 USA
| | - Rutendo Kuwana
- Regulatory Systems Support, World Health Organization, Geneva, Switzerland
| | | | - Beth Yeager
- Promoting Quality of Medicines Plus Program, U.S. Pharmacopeial Convention, Rockville, MD USA
| | - Helen Petach
- Office of Maternal and Child Health and Nutrition, Bureau for Global Health, United States Agency for International Development, Washington, DC USA
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139
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Chan AHY, Rutter V, Ashiru-Oredope D, Tuck C, Babar ZUD. Together we unite: the role of the Commonwealth in achieving universal health coverage through pharmaceutical care amidst the COVID-19 pandemic. J Pharm Policy Pract 2020; 13:13. [PMID: 32426144 PMCID: PMC7218554 DOI: 10.1186/s40545-020-00214-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The world currently faces unprecedented health challenges as COVID-19 poses a huge threat to health systems, economies and societies as we know it. The events of the current COVID-19 pandemic have further emphasised existing issues within our health systems. There is no better time than now to come together in global solidarity to tackle these evolving threats of COVID-19 pandemic. The Commonwealth is an ideally placed network to tackle these global health challenges, with its wide-reaching networks of governmental, non-governmental and civil society organisations across all continents. Although the biennial Commonwealth Heads of Government Meeting (CHOGM) originally scheduled to take place in Kigali in Rwanda 22-27 June 2020 has been postponed in view of COVID-19, Commonwealth country discussions are continuing, centred on the CHOGM key theme of 'Delivering a Common Future: Connecting, Innovating, Transforming', and five subthemes of Information and Communications Technology (ICT) and Innovation; Trade; Environment; Governance and the Rule of Law; and Youth. The planned CHOGM and Commonwealth itself provides all members a timely platform to consider innovative ways to connect, innovate and transform healthcare to meet the needs of their populations. This commentary considers these five CHOGM subthemes and how member nations can be supported to achieve universal health coverage through optimising medicines use and outcomes, in the midst of a global pandemic in line with the global health agenda.
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Affiliation(s)
- Amy Hai Yan Chan
- Commonwealth Pharmacists Association, London, UK
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Level 3, Building 505, 85 Pard Road, Grafton, Auckland, 1023 New Zealand
| | - Victoria Rutter
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Level 3, Building 505, 85 Pard Road, Grafton, Auckland, 1023 New Zealand
| | - Diane Ashiru-Oredope
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Level 3, Building 505, 85 Pard Road, Grafton, Auckland, 1023 New Zealand
| | - Chloe Tuck
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Level 3, Building 505, 85 Pard Road, Grafton, Auckland, 1023 New Zealand
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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140
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Orubu ESF, Ching C, Zaman MH, Wirtz VJ. Tackling the blind spot of poor-quality medicines in Universal Health Coverage. J Pharm Policy Pract 2020; 13:40. [PMID: 32670594 PMCID: PMC7350647 DOI: 10.1186/s40545-020-00208-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/08/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Universal Health Coverage (UHC) is challenged by the prevalence of poor-quality medicines, those that either do not meet required specifications (substandard) or are outrightly fraudulent (falsified), especially in Low- and Middle-Income Countries, LMICs. Whereas poor-quality medicines are a significant burden in these countries, medicine quality still remains a neglected component of UHC programs. This article describes key barriers to quality medicines and presents five select approaches leveraging the scale-up of UHC for medicine quality assurance. MAIN BODY Barriers to medicine quality assurance, while numerous, are described in five key inter-related domains as: low political priority, weak regulatory systems capacity, poor access to accredited facilities and licensed outlets, medicine manufacturing and other supply-chain challenges, and lack of public awareness. Five select approaches for leveraging the scale-up of UHC for medicine quality assurance in LMICs are (1): political commitment (2) strengthening the capacity of regulatory authorities and investment in detection technologies as part of national security (3); licensing of medicines outlets and expanding pharmacovigilance (4); strengthening the supply-chain; and (5) public awareness and participation. CONCLUSIONS Unchecked, poor-quality medicines can jeopardize UHC. National governments in LMICs need to prioritize medicine quality assurance through enforcing policies, regulatory strengthening and investments in technologies. Healthcare facilities and insurance schemes under UHC also play critical roles through incorporating medicine quality assurance into procurement practices and by promoting awareness among beneficiaries. Tackling medicine quality with a committed systems approach will enhance progress towards UHC implementation.
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Affiliation(s)
- E. S. F. Orubu
- Institute for Health System Innovation & Policy, Boston University, Boston, MA USA
- Department of Biomedical Engineering, Boston University, Boston, MA USA
| | - C. Ching
- Department of Biomedical Engineering, Boston University, Boston, MA USA
| | - M. H. Zaman
- Department of Biomedical Engineering, Boston University, Boston, MA USA
| | - V. J. Wirtz
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
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141
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Schäfermann S, Hauk C, Wemakor E, Neci R, Mutombo G, Ngah Ndze E, Cletus T, Nyaah F, Pattinora M, Wistuba D, Helmle I, Häfele-Abah C, Gross H, Heide L. Substandard and Falsified Antibiotics and Medicines against Noncommunicable Diseases in Western Cameroon and Northeastern Democratic Republic of Congo. Am J Trop Med Hyg 2020; 103:894-908. [PMID: 32394884 PMCID: PMC7410427 DOI: 10.4269/ajtmh.20-0184] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Falsified and substandard medicines may undermine the progress toward the Sustainable Development Goals. The present study investigated the quality of 13 essential medicines in Cameroon and the Democratic Republic of Congo (DR Congo). Five hundred six medicine samples were collected from the government and faith-based health facilities, private pharmacies, and informal vendors (total 60 facilities). Collected samples were analyzed according to the U.S. Pharmacopeia (USP) for identity, content, and dissolution of their active pharmaceutical ingredients (APIs) and for uniformity of dosage units. Three samples (0.6%) were identified as falsified. Overall, 8.5% of the samples failed USP specifications for the content of the API and 11.7% failed dissolution testing. Medicines from informal vendors showed a higher out-of-specification rate (28.2%) than other types of drug outlets (12.3%; P < 0.0001). All three falsified medicines had been sold by informal vendors. The failure rate of medicines stated to be produced in Europe (5.1%) was lower than that for medicines from Asia (17.7%; P = 0.0049) and Africa (22.2%; P = 0.0042). Medicines against noncommunicable diseases showed a higher failure rate than antibiotics (25.3% versus 12.1%; P = 0.0004). Four hundred fifty-one of the samples were analyzed in Cameroon and the DR Congo with the Global Pharma Health Fund Minilab (thin-layer chromatography and disintegration testing). The three falsified medicines were readily detected in Minilab analysis. However, substandard samples were detected with low sensitivity. A well-enforced ban of medicine sales by informal vendors and increased attention to supplier qualification in the procurement process may reduce the prevalence of substandard and falsified medicines.
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Affiliation(s)
- Simon Schäfermann
- Pharmaceutical Institute, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Cathrin Hauk
- Pharmaceutical Institute, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Emmanuel Wemakor
- Pharmaceutical Institute, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Richard Neci
- Le Dépôt Central Médico-Pharmaceutique de la 8e CEPAC (DCMP), Bukavu, Democratic Republic of Congo
| | - Georges Mutombo
- Le Dépôt Central Médico-Pharmaceutique de la 8e CEPAC (DCMP), Bukavu, Democratic Republic of Congo
| | - Edward Ngah Ndze
- Cameroon Baptist Convention (CBC), Central Pharmacy, Mutengene, Cameroon
| | - Tambo Cletus
- Cameroon Baptist Convention (CBC), Central Pharmacy, Mutengene, Cameroon
| | - Fidelis Nyaah
- Presbyterian Church in Cameroon (PCC), Central Pharmacy, Limbe, Cameroon
| | - Manyi Pattinora
- Presbyterian Church in Cameroon (PCC), Central Pharmacy, Limbe, Cameroon
| | - Dorothee Wistuba
- Institute of Organic Chemistry, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Irina Helmle
- Pharmaceutical Institute, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | | | - Harald Gross
- Pharmaceutical Institute, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Lutz Heide
- Pharmaceutical Institute, Eberhard Karls University Tuebingen, Tuebingen, Germany
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142
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Schiavetti B, Wynendaele E, Melotte V, Van der Elst J, De Spiegeleer B, Ravinetto R. A simplified checklist for the visual inspection of finished pharmaceutical products: a way to empower frontline health workers in the fight against poor-quality medicines. J Pharm Policy Pract 2020; 13:9. [PMID: 32377348 PMCID: PMC7193355 DOI: 10.1186/s40545-020-00211-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 04/15/2020] [Indexed: 11/10/2022] Open
Abstract
Background Substandard and falsified medicines, mainly prevalent in low and middle-income countries (LMICs), cause avoidable morbidity and mortality, and put at stake the performance of health systems. They may be prevented by an adequate implementation of pharmaceutical Quality Assurance (QA) guidelines, but unfortunately, most guidelines address upstream stakeholders and specialized staff in the supply chain. A multi-layered approach is needed, in order to empower the health workers at the point-of-care to proactively contribute to the fight against poor-quality medicines. Visual inspection is a simple technique, suitable for field screening. The findings of a survey conducted in the Democratic Republic of the Congo (DRC) suggested that it might be a fairly good (yet partial) predictor of poor-quality, when compared to full laboratory tests. Methods and results Starting from the 68-questions checklist originally used in the survey in the DRC, we developed a simplified checklist, specifically designed to guide health workers at the point of care to rapidly identify suspect poor-quality medicines. We selected those medicines’ attributes the assessment of which does not require technical expertise, or access to regulatory information. Attributes were categorized according to a 3-level risk scale, to guide decision-making on suspect poor-quality medicines, based on an informed risk assessment. The simplified checklist contains 26 binary questions (YES/NO), grouped into four themes: packaging, identification, traceability, and physical appearance. Each non-conformity corresponds to a level of risk for patients. The user is guided towards three possible actions: A) reasonably safe for dispensing; B) dispense with explanation; C) quarantine and make a risk-benefit evaluation before dispensing. Conclusion The simplified checklist should now be implemented in real-life setting in LMICs. If proven useful in guiding health workers at the point-of-care to take rapid, transparent, patient-centred actions when facing a suspect poor-quality medicine, it could be further extended to address specific formulations. Digitalization for linkage with pharmacovigilance programs could also be considered.
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Affiliation(s)
- B Schiavetti
- 1Institute of Tropical Medicine Antwerp, Nationalestraat 155, B-2000 Antwerp, Belgium
| | - E Wynendaele
- 2Department Pharmaceutical Analysis, DruQuaR (Drug Quality & Registration), Ghent University, Ottergemsesteenweg 460, B-9000 Ghent, Belgium
| | | | - J Van der Elst
- Centre for Adult Education CVO COOVI, Emile Grysonlaan 1, 1070 Brussels, Belgium
| | - B De Spiegeleer
- 2Department Pharmaceutical Analysis, DruQuaR (Drug Quality & Registration), Ghent University, Ottergemsesteenweg 460, B-9000 Ghent, Belgium
| | - R Ravinetto
- 5Department of Public Health, Institute of Tropical Medicine Antwerp, Nationalestraat 155, B-2000 Antwerp, Belgium
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143
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Ozawa S, Shankar R, Leopold C, Orubu S. Access to medicines through health systems in low- and middle-income countries. Health Policy Plan 2020; 34:iii1-iii3. [PMID: 31816069 PMCID: PMC6901066 DOI: 10.1093/heapol/czz119] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2019] [Indexed: 12/15/2022] Open
Abstract
Nearly 2 billion people globally have no access to essential medicines. This means essential medicines are unavailable, unaffordable, inaccessible, unacceptable or of low quality for more than a quarter of the population worldwide. This supplement demonstrates the implications of poor medicine access and highlights recent innovations to improve access to essential medicines by presenting new research findings from low- and middle-income countries (LMICs). These studies answer key questions such as: Can performance-based financing improve availability of essential medicines? How affordable are cardiovascular treatments for children? Which countries’ legal frameworks promote universal access to medicines? How appropriately are people using medicines? Do poor-quality medicines impact equity? Answers to these questions are important as essential medicines are vital to the Sustainable Development Goals and are central to the goal of achieving Universal Health Coverage. Access to affordable, quality-assured essential medicines is crucial to reducing the financial burden of care, preventing greater pain and suffering, shortening the duration of illness, and averting needless disabilities and deaths worldwide. This supplement was organized by the Medicines in Health Systems Thematic Working Group of Health Systems Global, a membership organization dedicated to promoting health systems research and knowledge translation. The five studies in the supplement further our understanding by showcasing recent successes and challenges of improving access to quality-assured medicines through health systems in LMICs.
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Affiliation(s)
- Sachiko Ozawa
- Medicines in Health Systems Thematic Working Group, Health Systems Global, Geneva, Switzerland.,Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA.,Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Raja Shankar
- Medicines in Health Systems Thematic Working Group, Health Systems Global, Geneva, Switzerland.,Consulting Services, IQVIA, London, UK
| | - Christine Leopold
- Medicines in Health Systems Thematic Working Group, Health Systems Global, Geneva, Switzerland.,Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Samuel Orubu
- Medicines in Health Systems Thematic Working Group, Health Systems Global, Geneva, Switzerland.,Institute for Health System Innovation and Policy, Boston, MA, USA.,Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Niger Delta University, Wilberforce Island, Bayelsa State, Nigeria
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144
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Evans DR, Higgins CR, Laing SK, Awor P, Ozawa S. Poor-quality antimalarials further health inequities in Uganda. Health Policy Plan 2020; 34:iii36-iii47. [PMID: 31816072 PMCID: PMC6901073 DOI: 10.1093/heapol/czz012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/13/2018] [Accepted: 02/13/2019] [Indexed: 12/16/2022] Open
Abstract
Substandard and falsified medications are a major threat to public health, directly increasing the risk of treatment failure, antimicrobial resistance, morbidity, mortality and health expenditures. While antimalarial medicines are one of the most common to be of poor quality in low- and middle-income countries, their distributional impact has not been examined. This study assessed the health equity impact of substandard and falsified antimalarials among children under five in Uganda. Using a probabilistic agent-based model of paediatric malaria infection (Substandard and Falsified Antimalarial Research Impact, SAFARI model), we examine the present day distribution of the burden of poor-quality antimalarials by socio-economic status and urban/rural settings, and simulate supply chain, policy and patient education interventions. Patients incur US$26.1 million (7.8%) of the estimated total annual economic burden of substandard and falsified antimalarials, including $2.3 million (9.1%) in direct costs and $23.8 million (7.7%) in productivity losses due to early death. Poor-quality antimalarials annually cost $2.9 million to the government. The burden of the health and economic impact of malaria and poor-quality antimalarials predominantly rests on the poor (concentration index −0.28) and rural populations (98%). The number of deaths among the poorest wealth quintile due to substandard and falsified antimalarials was 12.7 times that of the wealthiest quintile, and the poor paid 12.1 times as much per person in out-of-pocket payments. Rural populations experienced 97.9% of the deaths due to poor-quality antimalarials, and paid 10.7 times as much annually in out-of-pocket expenses compared with urban populations. Our simulations demonstrated that interventions to improve medicine quality could have the greatest impact at reducing inequities, and improving adherence to antimalarials could have the largest economic impact. Substandard and falsified antimalarials have a significant health and economic impact, with greater burden of deaths, disability and costs on poor and rural populations, contributing to health inequities in Uganda.
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Affiliation(s)
- Daniel R Evans
- Duke University School of Medicine, DUMC 3710 Durham, NC 27710, USA
| | - Colleen R Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA
| | - Sarah K Laing
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA
| | - Phyllis Awor
- Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Mulago Hospital Complex, Mulago Hill, P.O. Box 7072, Kampala, Uganda
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, NC 27599, USA
- Corresponding author. Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA. E-mail:
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145
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Mauri D, Kamposioras K, Tzachanis D, Tolia M, Valachis A, Dambrosio M, Alongi F, De Mello RA, Lövey J, Anthoney A, Christopoulos C, Saraireh HH, Kountourakis P, Kampletsas E, Tsali L, Tsakiridis T, Kosovitsas I, Soukovelos A, Lymperatou D, Polyzos N, Zarkavelis G. Patient and family support in the era of fake e-medicine: food for thought from an international consensus panel. ESMO Open 2020; 5:e000696. [PMID: 32340999 PMCID: PMC7204800 DOI: 10.1136/esmoopen-2020-000696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/02/2020] [Accepted: 03/07/2020] [Indexed: 12/24/2022] Open
Affiliation(s)
- Davide Mauri
- Department of Medical Oncology, University Hospital of Ioannina, Ioannina, Greece
- Oncology, EMEKEN, Ioannina, Greece
| | | | | | - Maria Tolia
- Department of Radiotherapy/Radiation Oncology, University of Thessaly Faculty of Medicine, Larissa, Greece
| | - Antonis Valachis
- Department of Oncology, Örebro Universitet Institutionen för Medicinska Vetenskaper, Orebro, Sweden
| | - Mario Dambrosio
- Division of Medical Oncology, Clinica San Carlo, Paderno Dugnano, Lombardia, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, University of Brescia, Verona, Italy
| | - Ramon Andrade De Mello
- Medicine, Univ Porto, Porto, Portugal
- Medical Oncology / Research Center, Jorge Valente Hospital, Institute of Oncology, Salvador, Brazil
| | - Jozsef Lövey
- Center of Radiotherapy, National Institute of Oncology, Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Alan Anthoney
- Department of Medical Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christos Christopoulos
- Service de Radiothérapie Oncologique, Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, Île-de-France, France
| | - Haytham Hamed Saraireh
- Radiation Oncology Department, King Hussein Medical Center, Jordanian Royal Medical Services, Amman, Jordan
| | | | | | | | | | | | | | | | - Nikolaos Polyzos
- Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
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146
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Rahman MS, Yoshida N, Tsuboi H, Sokchamroeun U, Keila T, Sovannarith T, Kiet HB, Dararath E, Akimoto Y, Tanimoto T, Kimura K. A Cross-Sectional Investigation of the Quality of Selected Medicines for Noncommunicable Diseases in Private Community Drug Outlets in Cambodia during 2011-2013. Am J Trop Med Hyg 2020; 101:1018-1026. [PMID: 31516106 PMCID: PMC6838583 DOI: 10.4269/ajtmh.19-0247] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Although the issue of substandard and falsified medicines is quite well known, most research has focused on medicines used to treat communicable diseases, and relatively little research has been carried out on the quality of medicines for noncommunicable diseases (NCDs). This study was designed to assess the quality of seven widely used medicines for NCDs in Cambodia during 2011–2013. Medicines were collected from private community drug outlets in Phnom Penh (urban area), by stratified random sampling and in Battambang, Kandal, Kampong Speu, and Takeo (rural areas) by convenience sampling. Samples were subsequently analyzed by visual inspection, authenticity investigation, and pharmacopoeial analysis by high-performance liquid chromatography. Various discrepancies were observed in visual inspection of packages and medicines. Of 372 tablet/capsule samples from 64 manufacturers in 16 countries, the manufacturers confirmed 107 (28.8%) as authentic; the authenticity of other samples could not be verified. Three hundred sixty-four (97.8%) samples were registered in Cambodia. Among all samples, 23.4% (95% CI 19.2–28.0) were noncompliant in one or more of the quality tests: 12.9% (95% CI 9.7–16.7) contained an amount of active pharmaceutical ingredient outside the permitted range, including some showing extreme deviations, 14% (95% CI 10.6–17.9) failed because of content variation, and 10.8% (95% CI 7.8–14.4) failed to meet pharmacopoeial reference ranges in dissolution tests. Pharmaceutical quality appeared to be unrelated to storage conditions. Although no sample was obviously falsified, there is a high prevalence of substandard medicines for NCDs in Cambodia, indicating the need for focused regulatory action, including collaborative initiatives with manufacturers.
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Affiliation(s)
- Mohammad Sofiqur Rahman
- Medi-Quality Security Institute, Kanazawa University, Kanazawa, Japan.,Department of Pharmacy, University of Asia Pacific, Dhaka, Bangladesh
| | - Naoko Yoshida
- Department of Clinical Pharmacy and Healthcare Sciences, Kanazawa University, Kanazawa, Japan
| | - Hirohito Tsuboi
- Department of Clinical Pharmacy and Healthcare Sciences, Kanazawa University, Kanazawa, Japan
| | - Uy Sokchamroeun
- National Health Product Quality Control Center, Ministry of Health, Phnom Penh, Cambodia
| | - Tep Keila
- National Health Product Quality Control Center, Ministry of Health, Phnom Penh, Cambodia
| | - Tey Sovannarith
- National Health Product Quality Control Center, Ministry of Health, Phnom Penh, Cambodia
| | - Heng Bun Kiet
- Department of Drugs and Food, Ministry of Health, Phnom Penh, Cambodia
| | - Eav Dararath
- Department of Drugs and Food, Ministry of Health, Phnom Penh, Cambodia
| | - Yoshio Akimoto
- Medi-Quality Security Institute, Kanazawa University, Kanazawa, Japan
| | - Tsuyoshi Tanimoto
- Pharmaceutical and Medical Device Regulatory Science Society of Japan, Osaka, Japan
| | - Kazuko Kimura
- Medi-Quality Security Institute, Kanazawa University, Kanazawa, Japan
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147
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Tawil S, Sacre H, Sili G, Salameh P. Patients’ perceptions regarding pharmacists’ healthcare services: the case of Lebanon. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Samah Tawil
- Drug Information Center Lebanese Order of Pharmacists Beirut Lebanon
- Continuing Education Department Lebanese Order of Pharmacists Beirut Lebanon
| | - Hala Sacre
- Drug Information Center Lebanese Order of Pharmacists Beirut Lebanon
- Continuing Education Department Lebanese Order of Pharmacists Beirut Lebanon
- INSPECT‐LB: Institut National de Santé Publique Epidémiologie Clinique et Toxicologie Beirut Lebanon
| | - Georges Sili
- Continuing Education Department Lebanese Order of Pharmacists Beirut Lebanon
| | - Pascale Salameh
- Continuing Education Department Lebanese Order of Pharmacists Beirut Lebanon
- INSPECT‐LB: Institut National de Santé Publique Epidémiologie Clinique et Toxicologie Beirut Lebanon
- Faculty of Pharmacy Lebanese University Hadath Lebanon
- Faculty of Medical Sciences Lebanese University Hadath Lebanon
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148
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Ndagije HB, Kiguba R, Manirakiza L, Kirabira E, Sserwanga A, Nabirye L, Mukonzo J, Olsson S, Spinewine A, D'Hoore W, Speybroeck N. Healthcare professionals' perspective can guide post-marketing surveillance of artemisinin-based combination therapy in Uganda. Malar J 2020; 19:63. [PMID: 32041619 PMCID: PMC7011371 DOI: 10.1186/s12936-020-3148-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Efficient testing to identify poor quality artemisinin-based combination therapy (ACT) is important to optimize efforts to control and eliminate malaria. Healthcare professionals interact with both ACT and malaria patients they treat and hence could observe, first-hand, suspect poor quality artemisinin-based combinations linked to poor malaria treatment outcomes and the factors associated with inappropriate use or treatment failure. METHODS A cross-sectional study of 685 HCP perspectives about the efficacy of ACT between June and July 2018 at selected health facilities in Uganda. Medicine samples were obtained from the seven regions of Uganda and tested for quality using the Germany Pharma Health Fund™ minilabs. RESULTS The average age of the 685 respondents was 30 (SD = 7.4) years. There was an almost equal distribution between male and female respondents (51:49), respectively. Seventy percent (n = 480) were diploma holders and the nurses contributed to half (49%, n = 334) of the study population. Sixty-one percent of the HCPs reported having ever encountered ACT failures while treating uncomplicated malaria. Nineteen percent of HCPs thought that dihydroartemisinin/piperaquine gave the most satisfactory patient treatment outcomes, while 80% HCPs thought that artemether/lumefantrine gave the least satisfactory patient treatment outcomes, possibly due to dosing schedule and pill burden. Healthcare professionals from the Central region (OR = 3.0, CI 0.3-1.0; P = 0.0001), Eastern region (OR = 5.4, CI 2.9-9.8; P = 0.0001) and Northern region (OR = 5.3, CI 2.9-9.9; P = 0.0001) had a higher chance of encountering ACT failure in 4 weeks prior to the survey as compared to those from the western region. Healthcare professionals from private health facilities also had higher chances of encountering ACT failures in past 4 weeks as compared to those from public health facilities (OR = 2.7, CI 1.7-3.9; P = 0.0001). All 192 samples passed the quality screening tests. The random sample of 10% of all samples randomly obtained by the laboratory staff also passed the chemical content analysis and dissolution tests. CONCLUSION ACT medicines are widely available over-the-counter to the public and it is very difficult to report and monitor a decrease in efficacy or treatment failure. The perspectives of HCPs on treatment failure or lack of efficacy may potentially guide optimization efforts of sampling methodologies for the quality survey of ACT medicines.
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Affiliation(s)
| | - Ronald Kiguba
- Department of Pharmacology and Therapeutics, Makerere University, Kampala, Uganda
| | - Leonard Manirakiza
- National Pharmacovigilance Centre, National Drug Authority, Kampala, Uganda
| | - Elijah Kirabira
- National Pharmacovigilance Centre, National Drug Authority, Kampala, Uganda
| | - Allan Sserwanga
- National Pharmacovigilance Centre, National Drug Authority, Kampala, Uganda
| | - Leah Nabirye
- Department of Pharmacology and Therapeutics, Makerere University, Kampala, Uganda
| | - Jackson Mukonzo
- Department of Pharmacology and Therapeutics, Makerere University, Kampala, Uganda
| | - Sten Olsson
- Pharmacovigilance Consulting, Uppsala, Sweden
| | - Anne Spinewine
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - William D'Hoore
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - Niko Speybroeck
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
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149
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Ozawa S, Haynie DG, Bessias S, Laing SK, Ngamasana EL, Yemeke TT, Evans DR. Modeling the Economic Impact of Substandard and Falsified Antimalarials in the Democratic Republic of the Congo. Am J Trop Med Hyg 2020; 100:1149-1157. [PMID: 30675851 DOI: 10.4269/ajtmh.18-0334] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Substandard and falsified medicines pose significant risks to global health, including increased deaths, prolonged treatments, and growing drug resistance. Antimalarials are one of the most common medications to be of poor quality in low- and middle-income countries. We assessed the health and economic impact of substandard and falsified antimalarials for children less than 5 years of age in the Democratic Republic of the Congo, which has one of the world's highest malaria mortality rates. We developed an agent-based model to simulate patient care-seeking behavior and medicine supply chain processes to examine the impact of antimalarial quality in Kinshasa province and Katanga region. We simulated the impact of potential interventions to improve medicinal quality, reduce stockouts, or educate caregivers. We estimated that substandard and falsified antimalarials are responsible for $20.9 million (35% of $59.6 million; 95% CI: $20.7-$21.2 million) in malaria costs in Kinshasa province and $130 million (43% of $301 million; $129-$131 million) in malaria costs in the Katanga region annually. If drug resistance to artemisinin were to develop, total annual costs of malaria could increase by $17.9 million (30%; $17.7-$18.0 million) and $73 million (24%; $72.2-$72.8 million) in Kinshasa and Katanga, respectively. Replacing substandard and falsified antimalarials with good quality medicines had a larger impact than interventions that prevented stockouts or educated caregivers. The results highlight the importance of improving access to good quality antimalarials to reduce the burden of malaria and mitigate the development of antimalarial resistance.
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Affiliation(s)
- Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Deson G Haynie
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Sophia Bessias
- Enterprise Analytics and Data Sciences, University of North Carolina Health Care, Chapel Hill, North Carolina
| | - Sarah K Laing
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Emery Ladi Ngamasana
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Tatenda T Yemeke
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Daniel R Evans
- Duke University School of Medicine, Durham, North Carolina
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150
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Nayyar GML, Breman JG, Mackey TK, Clark JP, Hajjou M, Littrell M, Herrington JE. Falsified and Substandard Drugs: Stopping the Pandemic. Am J Trop Med Hyg 2020; 100:1058-1065. [PMID: 30860016 DOI: 10.4269/ajtmh.18-0981] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Falsified and substandard medicines are associated with tens of thousands of deaths, mainly in young children in poor countries. Poor-quality drugs exact an annual economic toll of up to US$200 billion and contribute to the increasing peril of antimicrobial resistance. The WHO has emerged recently as the global leader in the battle against poor-quality drugs, and pharmaceutical companies have increased their roles in assuring the integrity of drug supply chains. Despite advances in drug quality surveillance and detection technology, more efforts are urgently required in research, policy, and field monitoring to halt the pandemic of bad drugs. In addition to strengthening international and national pharmaceutical governance, in part by national implementation of the Model Law on Medicines and Crime, a quantifiable Sustainable Development Goal target and an international convention to insure drug quality and safety are urgent priorities.
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Affiliation(s)
| | - Joel G Breman
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Tim K Mackey
- School of Medicine, University of California, San Diego, La Jolla, California
| | - John P Clark
- Pfizer Pharmaceuticals, Pfizer Global Security, New York, New York
| | - Mustapha Hajjou
- Global Health Impact Programs, United States Pharmacopeial Convention, Rockville, Maryland
| | - Megan Littrell
- Public Affairs, Program for Appropriate Technology in Health (PATH), Seattle, Washington
| | - James E Herrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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