Addressing gaps in pharmacovigilance practices in the antiretroviral therapy program in the Eastern Cape Province, South Africa

Perceptions, practices and barriers to reporting of adverse drug reactions among HIV infected patients and their doctors in 3 public sector hospitals of the Ethekwini Metropolitan, Kwa-Zulu Natal: a cross sectional and retrospective analysis

BACKGROUND

Adverse drug reactions (ADRs) remain a global public health concern. Pharmacovigilance practises are essential in ensuring patients safety and post drug marketing surveillance. This study aimed to describe practices, perceptions and barriers towards ADR reporting practices amongst People Living with HIV/AIDS (PLWHA), who are on Highly Active Anti-Retroviral Therapy (HAART) and their doctors.

METHODS

The study took place at 3 public sector hospitals. The first phase of the study was a quantitative cross-sectional study using a closed ended questionnaire that was given to PLWHA. Phase two was a retrospective analysis of these patients' medical files, whilst phase 3 included a descriptive statistics to determine the frequencies and percentages for variables such as ADR reporting practices by doctors.

RESULTS

Spontaneous reporting, was evident with 202 patients (48%) indicating that they reported experiencing ADRs to their doctors. Ten doctors (77%) indicated that they received PV training. Eight (62%) doctors indicated that the completed ADR reporting forms were submitted to the pharmacy manager in the hospital for forwarding to the regulatory authority, with 2 (15%) indicating that they submitted directly to the South African Health Products Regulatory Authority. Four (31%) doctors stated that the system of reporting ADRs is ineffective with the majority of the doctors 12 (92%) responding that the reporting of ADRs is very important/critical. A barrier cited by 4 patients (0.9%) for non-reporting of their ADRs was transport cost. Whilst doctors' barriers included reporting being time consuming (31%), and a lack of availability of reporting forms (31%).

CONCLUSION

Patients and doctors are reporting ADRs but more education and easier reporting process should be available to strengthen the knowledge and reporting of ADRs. Doctors agree that it is critical to report ADRs. Electronic reporting should be encouraged to lessen the time it takes to report ADRs.

The comparative assessment of awareness, perspective, and basic practice skills about the Saudi pharmacovigilance system among students of different health-care professionals of a Saudi Female University

INTRODUCTION

The low reporting of adverse drug reactions (ADRs) in Saudi Arabia is prevalent among health-care professionals and is responsible for poor ADR signal detection. Therefore, all healthcare institutes connected with patient concern require joint and sustained efforts to strengthen ADR reporting by providing harmless and efficient medication.

OBJECTIVES OF THE STUDY

The current study was performed to estimate the awareness corresponding to the knowledge, perspective, and basic practice skills about the Saudi pharmacovigilance system among students of different health-care professionals of a Saudi Female University.

MATERIAL & METHODS

A questionnaire was planned and standardized by a thorough literature review. Questions were classified: Group 1 had ten knowledge-based, group 2 five attitude-based, and group 3 four basic practice skills-based questions of pharmacovigilance (PV). Also, determinants that hindered them from becoming part of the pharmacovigilance program were reported. Such 600 questionnaires were distributed among the interns, final and prefinal year students of different health care professionals of Princess Nourah bint Abdulrahman University, Riyadh. The participants' awareness and practice skills were graded in 3 categories as unacceptable, inadequate, and adequate, depending upon the mean score along with identification of their type of perception towards PV. The data was interpreted by calculating the frequencies, one-way ANOVA, and by post-hoc Tukey-Kramer HSD multiple comparison test.

RESULTS

Five hundred ninety-two questionnaires were statistically investigated. Students' awareness and basic practice skills of pharmacovigilance were found to be inadequate, but positive perception towards PV.

CONCLUSION

Our study showed that awareness and practice skills of PV among students of different health care professionals stand insufficient but favourable perceptions towards PV. Regular educative interventions can increase these parameters of pharmacovigilance.

Reporting of adverse drug events in the Veterans Health Administration for patients whose treatment with empagliflozin or apixaban was discontinued

PURPOSE

To examine the reporting rates of adverse drug events (ADEs) with apixaban and empagliflozin as reports move up to the next level of spontaneous reporting.

METHODS

This was a retrospective cohort study of outpatients who discontinued apixaban or empagliflozin within 3 years of Food and Drug Administration (FDA) approval. We enriched the sample using an active surveillance strategy to identify subsets of patients with International Classification of Diseases (ICD) codes possibly associated with an ADE. Stratified random samples of charts were reviewed to determine if patients discontinued the medication due to an ADE. If so, we ascertained whether these were uploaded into the Veterans Administration (VA) electronic health record reporting system (Adverse Reaction Tracking System [ARTS]), VA national Web-based system (VA Adverse Drug Event Reporting System [VA ADERS]), and FDA MedWatch.

RESULTS

From the cohort of 2,973 patients who discontinued apixaban, 321 patients (10.8%) were randomly sampled for chart review (including 61 patients with relevant ICD codes). During chart review, 88 ADEs were identified, with 40/61 (65.6%) from the subset with ICD codes. Of the total of 88 ADEs, 18.2%, 10.2%, and 6.8% were reported in ARTS, VA ADERS, and MedWatch, respectively. Of the 1,555 patients who discontinued empagliflozin, 179 patients (11.5%) were randomly sampled for chart review (40 patients with relevant ICD codes). During chart review, 78 ADEs were identified, with 19/40 (47.5%) from the subset with ICD codes. Of the 78 ADEs, 28.2%, 19.2%, and 7.7% were reported in ARTS, VA ADERS, and MedWatch, respectively.

CONCLUSION

We found substantial underreporting of apixaban and empagliflozin ADEs that became worse at each higher level of spontaneous reporting.

Effective integration of pharmacovigilance systems at public health facilities in resource-limited settings: A qualitative study

BACKGROUND

Pharmacovigilance systems increase access to safe medicines and healthcare, but their integration in public healthcare remains a challenge in many countries. The main barriers to pharmacovigilance integration are attributed to high patient load and limited capacities.

OBJECTIVE

To explore the challenges associated with the effective integration of pharmacovigilance systems in public healthcare in a developing country such as Namibia.

METHODS

A nationwide qualitative assessment of integration of pharmacovigilance systems particularly spontaneous adverse drug reaction (ADR) reporting at public health facility level was conducted. Key informant interviews were conducted among pivotal healthcare professionals involved in pharmacovigilance. The main outcomes were themes on challenges and strategies for effective integration of PV services at the facility level. Qualitative data were collected over a one-month period (i.e., March 2019), and thematically analysed.

RESULTS

Eight (8) key informants were recruited; the majority were pharmacists (n = 7) and male (n = 5). The main challenges affecting the effective integration of pharmacovigilance systems reporting at public health facilities were "weak pharmacovigilance policies and structures", "negative attitude of healthcare workers towards pharmacovigilance", and "limited capacity and support for implementation of pharmacovigilance activities". The main strategies for effective integration of PV systems at facilities included local capacity-building through continuing profession education and support, advocacy, stakeholder engagement, facility/region based pharmacovigilance champions, and facility-based policies for universal and inclusive reporting, (i.e. patients and health workers at all levels) as well as development of workable standard operational procedures.

CONCLUSIONS

The pharmacovigilance systems at healthcare facilities in Namibia were observed to have sub-optimal policies, structures and support systems, and lack health care worker buy-in. There is a need for a policy framework to ensure effective and sustainable integration of pharmacovigilance activities at public healthcare facilities.

Knowledge, attitudes and practices of nurses and pharmacists towards adverse drug reaction reporting in the South African private hospital sector

Background

Pharmacovigilance (PV) is an important tool in monitoring the quality, efficacy and safety of medicines, with spontaneous reporting being the mainstay system of reporting adverse drug reactions (ADRs) worldwide. ADRs are largely underreported in South Africa.

Aim

This study aimed to evaluate the knowledge, attitudes and practices of pharmacists and nurses in the private hospital sector towards ADR reporting.

Setting

This study was conducted in six private hospitals and clinics within a single hospital group in Johannesburg, South Africa.

Method

A cross-sectional survey was conducted amongst healthcare professionals using a structured multiple-choice questionnaire containing 20 close-ended questions. Both electronic and paper questionnaires were used to obtain as many responses as possible.

Results

A total of 233 healthcare professionals participated in the study. Of these, 78.5% were registered nurses and 21.5% were hospital pharmacists. Although three-quarters of participants believed ADR reporting to be important, most had received no previous PV training (76.2%) and did not know how to report an ADR (54.5%). The majority of participants (87.1%) believed that all ADRs should be reported, with 75.5% of participants believing they would report all ADRs they encountered in the future provided they had sufficient training and knowledge. The major factors discouraging participants from reporting was a lack of awareness with respect to the process of reporting as well as a lack of access to the ADR reporting form.

Conclusion

The majority of participants require further training regarding ADR reporting. Although the knowledge of most participants was acceptable, the transition into practice needs to be improved.

Active Surveillance versus Spontaneous Reporting for First-Line Antiretroviral Medicines in Namibia: A Cost-Utility Analysis

INTRODUCTION

Active surveillance pharmacovigilance is a systematic approach to medicine safety assessment and health systems strengthening, but has not been widely implemented in low- and middle-income countries. This study aimed to assess the cost effectiveness of a national active surveillance pharmacovigilance system for highly active antiretroviral therapy (HAART) compared with the existing spontaneous reporting system in Namibia.

METHODS

A cost-utility analysis from a governmental perspective compared active surveillance pharmacovigilance to spontaneous reporting. Data from a sentinel site active surveillance program in Namibia from August 2012 to April 2013 was projected to all HIV-infected adults initiating HAART in Namibia. Costs (pharmacovigilance program, HAART, adverse event [AE] treatment), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs, dollars/QALY) were evaluated. Analysis was completed for (i) cohort analysis: a single cohort beginning HAART in 1 year in Namibia followed over their remaining lifetime, and (ii) population analysis: patients continued to enter and leave care and treatment over 10 years.

RESULTS

For the cohort analysis, totals were US$21,267,902 (2015 US dollars) and 116,224 QALYs for care and treatment under active surveillance pharmacovigilance versus US$15,257,381 and 116,122 QALYs for care and treatment under spontaneous reporting pharmacovigilance, resulting in an ICER of US$58,867/QALY for active surveillance compared with spontaneous reporting pharmacovigilance. The population analysis ICER was US$4989/QALY. Results were sensitive to quality of life associated with AEs.

CONCLUSION

Active surveillance pharmacovigilance was projected to be highly cost effective to improve treatment for HIV in Namibia. Active surveillance pharmacovigilance may be valuable to improve lives of HIV patients and more efficiently allocate health resources in Namibia.

Knowledge, attitudes and perspective on adverse drug reaction reporting in a public sector hospital in South Africa: baseline analysis

OBJECTIVE

Adverse drug reactions (ADRs) can cause significant harm in patients; however, ADRs are under-reported in many countries, including South Africa, where evidence of a pharmacovigilance (PV) system to monitor and manage ADRs is a requirement for compliance with norms and standards for quality healthcare delivery. We conducted an analysis amongst health care professionals (HCPs) at Sebokeng Hospital to assess the situation there and make recommendations.

METHODS

Data were collected using a structured self-administered questionnaire, targeting all medical practitioners, nurses, pharmacists and pharmacist assistants in the hospital. Current procedures for reporting of ADRs were documented. Records were reviewed to determine the number of ADR reports submitted for the 18-month period prior to the study. Data were analysed with SAS. Ethical clearance was obtained.

RESULTS

The questionnaire was completed by 132 HCPs (nurses: 58.3%; medical practitioners: 23.5%; pharmacist assistants: 11.4%; pharmacists: 6.8%). The vast majority indicated ADR reporting is necessary (96.2%) and their professional obligation (89.4%). Only 18.9% were aware of an existing PV system in the hospital, 15.2% had an ADR form available and 18.9% knew to whom the form should be submitted. The vast majority had never reported an ADR, had never received training in PV, but wanted training on ADR reporting. Factors discouraging ADR reporting included not knowing how to report them (53.8%), lack of time (37.1%), additional work load (22.0%), uncertainty about the outcome of reporting (32.6%), and lack of confidence to discuss ADRs with colleagues (22.0%). Only 2.3% knew how many ADRs were reported, that ADRs are discussed by a committee (6.1%) and that internal feedback is received on reported ADRs (6.1%).

CONCLUSION

There is an extensive need in Sebokeng Hospital for training on ADR reporting and implementation of systems to facilitate relevant processes; a need which may also exist in other public hospitals in South Africa.

A qualitative exploration of the major challenges facing pharmacovigilance in Saudi Arabia

Objectives:

To explore the challenges facing pharmacovigilance in Saudi Arabia and formulate recommendations to improve it from the perspective of healthcare professionals in Saudi Arabia.

Methods:

This was a qualitative study of 4 focus group discussions with pharmacists, physicians, and academicians held under the auspices of the King Saud University School of Pharmacy and the Center for Medicine in the Public Interest, Riyadh, Saudi Arabia. A total of 29 eligible healthcare professionals were invited to participate in the discussion. The predefined themes of the study were the current practice and major challenges facing pharmacovigilance in regulatory bodies, hospitals, the community, and academia, as well as recommendations to improve pharmacovigilance practice.

Result:

Of the 29 participants invited, 27 attended the discussion. Challenges facing regulatory bodies included complicated adverse drug reactions (ADR) reporting forms, lack of feedback on ADRs submitted to the Saudi Food and Drug Authority, lack of decisions from the local authority to withdraw medications, and lack of data on pharmacovigilance. The challenges to pharmacovigilance in hospitals included the lack of knowledge of the significance of ADR reporting, workload, blaming culture, and lack of collaboration between regulatory bodies and hospitals. However, challenges facing pharmaceutical industries included the lack of drug manufacturers in Saudi Arabia and lack of interest in pharmacovigilance. Recommendations to improve pharmacovigilance included the need for communication, stronger regulatory requirements, the need for research, the need for unified ADRs reporting, and continuous education and training.

Conclusion:

The study has identified the challenges facing pharmacovigilance in Saudi Arabia and made certain recommendations to overcome them. These recommendations might be helpful for regulatory bodies to enhance spontaneous reporting and promote pharmacovigilance.

Adverse Drug Reaction Reporting in Africa and a Comparison of Individual Case Safety Report Characteristics Between Africa and the Rest of the World: Analyses of Spontaneous Reports in VigiBase®

Introduction

Following the start of the World Health Organization (WHO) Programme for International Drug Monitoring (PIDM) by 10 member countries in 1968, it took another 24 years for the first two African countries to join in 1992, by which time the number of member countries in the PIDM had grown to 33. Whilst pharmacovigilance (PV), including the submission of individual case safety reports (ICSR) to VigiBase^®, the WHO global ICSR database, is growing in Africa, no data have been published on the growth of ICSR reporting from Africa and how the features of ICSRs from Africa compare with the rest of the world (RoW).

Objective

The objective of this paper was to provide an overview of the growth of national PV centres in Africa, the reporting of ICSRs by African countries, and the features of ICSRs from Africa, and to compare ICSRs from Africa with the RoW.

Methods

The search and analysis interface of VigiBase^®—VigiLyze^®—was used to characterise ICSRs submitted by African countries and the RoW. The distribution of ICSRs by African countries was listed and characterised by anatomic therapeutic chemical (ATC) code, Medical Dictionary for Regulatory Activities (MedDRA^®) system organ class (SOC) classification, and patient age and sex. The case-defining features of ICSRs between Africa and the RoW were also compared.

Results

The number of African countries in the PIDM increased from 2 in 1992 to 35 at the end of September 2015, and African PIDM members have cumulatively submitted 103,499 ICSRs (0.88 % of global ICSRs) to VigiBase^®. The main class of products in African ICSRs are nucleoside and nucleotide reverse transcriptase inhibitors (14.04 %), non-nucleoside reverse transcriptase inhibitors (9.09 %), antivirals for the treatment of HIV infections (5.50 %), combinations of sulfonamides and trimethoprim (2.98 %) and angiotensin-converting enzyme (ACE) inhibitors (2.42 %). The main product classes implicated in ICSRs from the RoW are tumour necrosis factor-α (TNFα) inhibitors (5.29 %), topical nonsteroidal anti-inflammatory preparations (2.26 %), selective immunosuppressants (2.08 %), selective serotonin reuptake inhibitors (2.04 %) and HMG CoA reductase inhibitors (1.85 %). The main SOCs reported from Africa versus the RoW include skin and subcutaneous tissue disorders (31.14 % vs. 19.58 %), general disorders and administration site conditions (20.91 % vs. 30.49 %) and nervous system disorders (17.48 % vs. 19.13 %). The 18–44 years age group dominated ICSRs from Africa, while the 45–64 years age group dominated the RoW. Identical proportions of females (57 % Africa and the RoW) and males (37 % Africa and the RoW) were represented.

Conclusions

As at the end of September 2015, 35 of 54 African countries were Full Member countries of the PIDM. Although the number of ICSRs from Africa has increased substantially, ICSRs from Africa still make up <1 % of the global total in VigiBase^®. The features of ICSRs from Africa differ to those from the RoW in relation to the classes of products as well as age group of patients affected. The gender of patients represented in these ICSRs are identical.

[Nursing role in reporting adverse drug reactions]

BACKGROUND

The spontaneous report system, in which suspected adverse drug reaction (ADR) are reported by healthcare workers, is currently one of the primary methods to prevent and discover new and serious ADR to marketed medicinal products. The collaboration of nursing professionals with this task makes it possible to improve patient safety and to reduce ADR costs. Although a total of 781 cases of ADR cases were reported in Navarra in 2011, only 7.33% were reported by nurses. The objectives werw to determine the factors that influence nurses in reporting of ADR, and second, to devise strategies which help to increase reporting.

MATERIAL AND METHODS

A bibliographic search for articles that included the words: reacciones adversas medicamentosas (adverse drug reactions), notificación (reporting) and enfermería (nursing) was conducted using the PubMed and Cinhal databases. A total of 107 articles were retrieved, of which 27 were selected according to inclusion and exclusion criteria.

RESULTS

The conclusion learned by reading and analyzing the selected articles was that the factors that affect the notification depend on the attitude of the notifier, as well as personal and professional factors. The main strategies to encourage notification are education and training, motivation, and the availability of facilitating tools.

CONCLUSIONS

The main factors that have an influence on under-notification are the lack of knowledge and motivation among professionals. To solve the problem of under-notification, the main actions and strategies to undertake are education, motivation and persistence.

Knowledge of HIV and its treatment among health care providers in South Africa

BACKGROUND

In South Africa, availability of antiretroviral (ARV) drugs has increased largely in the public sector since it became available in 2004. Follow-up of stabilized patients on ARV drugs are done in primary health care (PHC) facilities run by nurses, often without specialized training. This has deep impact on the patients' drug adherence.

OBJECTIVE

To investigate health care providers' (HCPs) knowledge about human immunodeficiency virus (HIV) and antiretroviral therapy (ART) in the Eastern Cape Province, South Africa. The aim was also to investigate nurses' knowledge and experience regarding adverse drug reaction (ADR) reporting.

SETTING

Public PHC clinics in one district of the Eastern Cape Province.

METHOD

Personal interviews, using a structured questionnaire, were conducted with 102 HCPs (nurses and auxiliary staff) working at six PHC facilities, one community health centre and one health post.

MAIN OUTCOME MEASURE

Knowledge about HIV and ART among nurses and auxiliary staff.

RESULTS

Both nurses and auxiliary staff had some basic knowledge about symptoms of HIV and modes of transmission, but great uncertainty was seen regarding specific topics including ARV drugs, ADRs and HIV complications. The PHC staff were uncertain about how to administer ARV drugs--with or without food--and some of them would advice their patients not to take ARV drugs at times when food was lacking. Both nurses and auxiliary staff knew that HIV was treated with ARV drugs. Only 60 % of the HCPs claimed that ART was the only effective treatment for HIV, whereas 39 % claimed that nutritious food also could treat HIV. Nurses showed lacking ability to manage ADRs. They also had very little knowledge about ADR reporting, and very few had ever submitted a report at all.

CONCLUSION

The study shows that both nurses and auxiliary staff are unable to provide the patients with adequate advice about administration of the ARV drugs and management of ADRs. Serious lack of knowledge among HCPs regarding the treatment of HIV presents structural barriers to the patients' adherence.

Recent advances in pharmacovigilance of antiretroviral therapy in HIV-infected and exposed children

PURPOSE OF REVIEW

Antiretroviral therapy (ART) has greatly improved the survival of HIV-infected children. However, ART is associated with immediate and long-term adverse events. Pharmacovigilance systems, although imperfect, have been developed in many high-income countries (HICs), but coverage in low- and middle-income countries (LMICs) is poor and uneven. This review covers the recent advances in the understanding of adverse events following perinatal ART exposure, including surveillance from birth cohorts; we also describe the adverse events of antiretroviral drugs among HIV-infected children, focussing particularly on those relevant to LMICs, where more than 90% of HIV-infected children live.

RECENT FINDINGS

ART is largely safe in both HIV-infected and HIV-exposed uninfected children, in whom no significant increase in birth defects has been noted. Among HIV-infected children, toxicity to some drugs may be less frequent than in adults, possibly related to immature immune systems in younger children. As per WHO guidelines, many countries are moving from stavudine-based to zidovudine-based or abacavir-based fixed-dose combination (with nevirapine/lamivudine) paediatric mini-pills. However, reassuring data are emerging about short-term stavudine use in LMICs, as this remains an important first-line regimen for young children, as well as an alternative to zidovudine for anaemic children. Zidovudine appears to be well tolerated in young children living in nonmalarious areas, and, among African children, concerns about abacavir hypersensitivity have not been substantiated.

SUMMARY

Optimization of first-line ART regimens needs to take account of the toxicities in HIV-infected children, in particular as they will take ART much longer than adults and during the period of growth and development. The benefits of ART in pregnancy are clear, but long-term follow-up of ART-exposed infants in LMICs through integrated surveillance systems would be invaluable.

Healthcare providers' experiences with adverse drug reactions and adherence challenges in antiretroviral therapy of HIV patients in the Eastern Cape Province, South Africa

PURPOSE

To gain insight into the experiences and handling of adverse drug reactions (ADRs) by the staffs of public primary healthcare (PHC) clinics in Eastern Cape Province, South Africa, as well as their perceptions of related adherence challenges in the treatment and follow-up of human immunodeficiency virus (HIV)-positive patients.

METHODS

Healthcare providers working at the PHC level in the public sector in the study area were approached and asked to participate in focus group discussions (FGDs). Seven FGDs were conducted with 32 healthcare providers (9 nurses, 23 auxiliary staff). Questions introduced by the moderator of each FGD were freely discussed by the participants. Discussions were audio-recorded and subjected to thematic content analysis.

RESULTS

Several challenges in the treatment and follow-up of patients on ART were identified. These include: (1) lack of training of healthcare providers in PHC clinics to confidently identify, manage and treat the ADRs HIV-positive patients receiving ART; (2) patients' difficulty in communicating information on ADRS; (3) insufficient pharmacovigilance; (4) role of poverty.

CONCLUSION

Both nurses and auxiliary staff expressed lack of knowledge and confidence regarding ADRs in HIV patients and management of this. More emphasis is warranted on training the healthcare providers to identify ADRs and provide adequate advice for continued treatment of patients experiencing potential drug related problems.