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Gabel J, Lächele M, Sander K, Gnegel G, Sunny-Abarikwu N, Ohazulike RE, Ngene J, Chioke JF, Häfele-Abah C, Heide L. Quality of Essential Medicines from Different Sources in Enugu and Anambra, Nigeria. Am J Trop Med Hyg 2024; 111:179-195. [PMID: 38740019 PMCID: PMC11229646 DOI: 10.4269/ajtmh.23-0837] [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: 11/29/2023] [Accepted: 01/18/2024] [Indexed: 05/16/2024] Open
Abstract
This study investigated the quality of 13 essential medicines in the states of Enugu and Anambra, Nigeria. A total of 260 samples were purchased from licensed pharmaceutical manufacturers and wholesalers and from vendors in pharmaceutical markets with unclear licensing status. Samples were analyzed for identity, content, and dissolution according to the United States Pharmacopeia (USP) 42 monographs. Forty-five samples of this study could be examined for authenticity with the Mobile Authentication Service scheme of the Nigerian National Agency for Food and Drug Administration and Control. Out of all samples, 25.4% did not comply with the USP 42 specifications. Strikingly, 21 out of 22 dexamethasone tablet samples (95%) were out of specification (OOS). Nine out of 19 glibenclamide samples (47%) failed dissolution testing, and 7 out of 17 cotrimoxazole samples (41%) failed assay testing. Medicines against noncommunicable diseases showed a slightly higher percentage of OOS samples than anti-infectives (21.2% versus 17.6%). The rates of OOS samples were similar in medicines stated to be produced in Nigeria, India, and China but were very different between individual manufacturers from each of these countries of origin. Therefore, prequalification of products, manufacturers, and suppliers are very important for quality assurance in medicine procurement. Unexpectedly, the total proportions of OOS samples were similar from licensed vendors (25.2%) and from markets (25.5%). Four samples (1.5%), all collected in markets, were clearly falsified and did not contain the declared active pharmaceutical ingredients. The proportion of falsified medicines was found to be lower than frequently reported in the media for Nigeria.
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Affiliation(s)
- Julia Gabel
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Micha Lächele
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Katharina Sander
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Gesa Gnegel
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
| | | | | | - Juliet Ngene
- Faith-Based Central Medical Foundation (FBCMF), Enugu, Nigeria
| | | | | | - Lutz Heide
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
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Sultan P. The 2023 Gerard W. Ostheimer Lecture. A Contemporary Narrative Review of Maternal Mortality and Morbidity: Opportunities to Improve Peripartum Outcomes. Anesth Analg 2024:00000539-990000000-00855. [PMID: 38917035 DOI: 10.1213/ane.0000000000006885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
The Gerard W. Ostheimer lecture is given annually to members of the Society for Obstetric Anesthesia and Perinatology. This lecture summarizes new and emerging literature that informs the clinical practice of obstetric anesthesiology. This is a narrative review of 2022 literature pertinent to maternal morbidity and mortality in all income settings globally. Themes associated with worse maternal mortality rate (MMR), challenges health care workers face, public health priority areas, and initiatives to help countries achieve the United Nations Sustainable Development Goal targets for MMR are discussed. MMRs are higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Cesarean delivery rates are rising most rapidly in LMICs, warranting urgent maternal health care workforce planning efforts in these settings. Globally racial, ethnic, and geographical disparities in maternal mortality continue to be evident in global health care settings. In the United States, the MMR is rising. The evolving changes in abortion legislation in the United States may further negatively impact maternal morbidity and mortality. The need to implement American Society of Anesthesiologists-recommended obstetric anesthesia quality metrics to facilitate benchmarking and to improve patient experience and outcomes is discussed as well as the need for professional society guidance on minimum staffing levels in American labor and delivery units.
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Affiliation(s)
- Pervez Sultan
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK
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Karna P, Sharma KA, Grossman A, Gupta M, Chatterjee T, Williams N, Prata N, Sorhaindo A, Läser L, Rehnström Loi U, Ganatra B, Chaudhary P. Landscape assessment of the availability of medical abortion medicines in India. Reprod Health 2024; 20:193. [PMID: 38840263 PMCID: PMC11151496 DOI: 10.1186/s12978-024-01774-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/11/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Medical abortion with mifepristone and misoprostol can be provided up to 63 days' gestation in India. This accounts for 67.5 percent of all abortions in the country. We conducted an assessment to determine the availability of medical abortion medicines, specifically the combi-pack, in India. METHODS We applied the World Health Organization landscape assessment protocol at the national level. The assessment protocol included a five-step adaptation of an existing availability framework, including online data collection, desk review, country-level key informant interviews, and an analysis to identify barriers and opportunities to improve medical abortion availability. The assessment was conducted between August and March 2021. RESULTS Medicines for medical abortion are included in the national essential drug list and available with prescription in India. The assessment identified 42 combi-pack products developed by 35 manufacturers. The quality of medical abortion medicines is regulated by national authorities; but as health is devolved to states, there are significant inter-state variations. This is seen across financing, procurement, manufacturing, and monitoring mechanisms for quality assurance of medical abortion medicines prior to distribution. There is a need to strengthen supply chain systems, ensure consistent availability of trained providers and build community awareness on use of medical abortion medicines for early abortions, at the time of the assessment. CONCLUSION Opportunities to improve availability and quality of medical abortion medicines exist. For example, uniform implementation of regulatory standards, greater emphasis on quality-assurance during manufacturing, and standardizing of procurement and supply chain systems across states. Regular in-service training of providers on medical abortion is required. Finally, innovations in evidence dissemination and community engagement about the recently amended abortion law are needed.
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Affiliation(s)
- Priya Karna
- World Health Organization, Country Office for India, New Delhi, India
| | - K Aparna Sharma
- Department of Obstetrics and Gynecology, All India Institute of Medical Science (AIIMS), New Delhi, India
| | - Amy Grossman
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
| | - Madhur Gupta
- World Health Organization, Country Office for India, New Delhi, India
| | - Tapas Chatterjee
- World Health Organization, Country Office for India, New Delhi, India
| | - Natalie Williams
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
| | - Ndola Prata
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
- Bixby Center for Population, Health & Sustainability, School of Public Health, University of California, Berkley, CA, USA
| | - Annik Sorhaindo
- UNDP‑UNFPA‑UNICEF‑WHO‑World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Laurence Läser
- UNDP‑UNFPA‑UNICEF‑WHO‑World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland.
| | - Ulrika Rehnström Loi
- UNDP‑UNFPA‑UNICEF‑WHO‑World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Bela Ganatra
- UNDP‑UNFPA‑UNICEF‑WHO‑World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Pushpa Chaudhary
- World Health Organization, Country Office for India, New Delhi, India
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Bower J, Chinery L, Fleurent A, Gülmezoglu AM, Im-Amornphong W, Kilfedder C, Procter P, Tomazzini A. Quality testing of mifepristone and misoprostol in 11 countries. Int J Gynaecol Obstet 2024; 165:405-415. [PMID: 37775986 DOI: 10.1002/ijgo.15148] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/24/2023] [Accepted: 09/07/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE Previous studies have demonstrated quality concerns with misoprostol. Mifepristone, however, has not been extensively assessed for quality. Between 2020 and 2021, Concept Foundation and the International Planned Parenthood Federation conducted a study to determine the quality of these medical abortion drugs in low- and middle-income countries (LMIC). METHODS The collection of batch samples of misoprostol and mifepristone was carried out by trained sampling agents in selected LMIC. Single drug packs and combipacks were sampled. A World Health Organization prequalified laboratory conducted testing method verifications and subsequent sample analysis. Tests included identification, assay, related substances, and content uniformity for misoprostol, and identification, assay, related substances, and dissolution for mifepristone. RESULTS Samples were collected from Burkina Faso, Cambodia, Democratic Republic of Congo, India, Kyrgyzstan, Moldova, Nepal, Nigeria, Pakistan, Uganda and Vietnam. Sixty-four pooled batch samples were tested, consisting of 31 combipacks, 26 misoprostol-only and seven mifepristone-only products. Overall, 54.7% of samples were non-compliant with one or more of the specifications, representing 51.6% of combipack products, 57.1% of misoprostol tablets analyzed and 23.7% of mifepristone tablets. One falsified misoprostol-only product was found. CONCLUSION The present study confirms that a significant problem still exists in relation to the quality of medical abortion drugs in LMIC. For misoprostol, our findings suggest that historical concerns around primary packaging may have been largely resolved but that manufacturing processes for both finished product and active pharmaceutical ingredient need to be improved. The present study also provides evidence of mifepristone quality issues.
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Rojas-Suarez J, Paruk F. Maternal high-care and intensive care units in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 93:102474. [PMID: 38395025 DOI: 10.1016/j.bpobgyn.2024.102474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
Despite notable advancements in minimizing maternal mortality during recent decades, a pronounced disparity persists between high-income nations and low-to middle-income countries (LMICs), particularly in intensive and high-care for pregnant and postpartum individuals. This divergence is multifactorial and influenced by factors such as the availability and accessibility of community-based maternity healthcare services, the quality of preventive care, timeliness in accessing hospital or critical care, resource availability, and facilities equipped for advanced interventions. Complications from various conditions, including human immunodeficiency virus (HIV), unsafe abortions, puerperal sepsis, and, notably, the COVID-19 pandemic, intensify the complexity of these challenges. In confronting these challenges and deliberating on potential solutions, we hope to contribute to the ongoing discourse around maternal healthcare in LMICs, ultimately striving toward an equitable health landscape where every mother, regardless of geographic location or socioeconomic status, has access to the care they require and deserve. The use of traditional and innovative methods to achieve adequate knowledge, appropriate skills, location of applicable resources, and strong leadership is essential. By implementing and enhancing these strategies, limited-resource settings can optimize the available resources to promptly recognize the severity of illness in obstetric individuals, ensuring timely and appropriate interventions for mothers and children. Additionally, strategies that could significantly improve the situation include increased investment in healthcare infrastructure, effective resource management, enhanced supply chain efficiency, and the development and use of low-cost, high-quality equipment. Through targeted investments, innovations, efficient resource management, and international cooperation, it is possible to ensure that every maternal high-care and ICU unit, regardless of geographical location or socioeconomic status, has access to high-quality critical care to provide life-saving care.
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Affiliation(s)
- José Rojas-Suarez
- Intensive Care and Obstetric Research Group (GRICIO), Universidad de Cartagena, Colombia; GINUMED Research Group, Corporación Universitaria Rafael Núñez, Cartagena, Colombia.
| | - Fathima Paruk
- Department of Critical Care, Steve Biko Academic Hospital and Faculty of Health Science University of Pretoria, South Africa.
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Maharjan P, Ponganam MP, Lambert P, Vogel JP, McIntosh M, McDougall A. The quality of medicines for the prevention and management of hypertensive disorders of pregnancy: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002962. [PMID: 38412179 PMCID: PMC10898726 DOI: 10.1371/journal.pgph.0002962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 02/01/2024] [Indexed: 02/29/2024]
Abstract
The quality of medicines for the prevention and management of hypertensive disorders of pregnancy globally is a critical challenge in the reduction of maternal mortality rate. We aimed to conduct a systematic review of available studies on the quality of the eight medicines recommended globally for the prevention and management of hypertensive disorders of pregnancy. We searched five electronic databases- Ovid MEDLINE, EMBASE, CINAHL, ProQuest and Cochrane Library, and also grey literature, without year or language limitations. Any study assessing the quality parameters (Active Pharmaceutical Ingredients, pH, sterility, solubility, impurities) of medicines by using any valid laboratory methods was eligible. Two reviewers independently screened the studies, extracted data and applied Medicine Quality Assessment Reporting Guidelines tool for quality assessment. Results were narratively reported and stratified by the drug types. Of 5669 citations screened, 33 studies from 27 countries were included. Five studies reported on the quality of magnesium sulphate-two (Nigeria and USA) found substandard medicine due to failing API specification and contaminants, respectively. Another study from Nigeria and a multi-country study (10 lower-middle- and low-income countries) found poor-quality due to failing the pH criteria. Seven of eight studies evaluating aspirin found quality issues, including degraded medicines in five studies (Brazil, USA, Yugoslavia and Pakistan). Five studies of calcium supplements found quality issues, particularly heavy metal contamination. Of 15 antihypertensives quality studies, 12 found substandard medicines and one study identified counterfeit medicines. This systematic review identified pervasive issues of poor-quality medicines across all recommended medicines used to prevent or treat hypertensive disorders of pregnancy, raising concerns regarding their safety and effectiveness.
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Affiliation(s)
- Pooja Maharjan
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | | | - Pete Lambert
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Joshua P Vogel
- Burnet Institute, Maternal, Child and Adolescent Health Program, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michelle McIntosh
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Annie McDougall
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
- Burnet Institute, Maternal, Child and Adolescent Health Program, Melbourne, Australia
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Yenuberi H, Mathews J, George A, Benjamin S, Rathore S, Tirkey R, Tharyan P. The efficacy and safety of 25 μg or 50 μg oral misoprostol versus 25 μg vaginal misoprostol given at 4- or 6-hourly intervals for induction of labour in women at or beyond term with live singleton pregnancies: A systematic review and meta-analysis. Int J Gynaecol Obstet 2024; 164:482-498. [PMID: 37401143 DOI: 10.1002/ijgo.14970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/08/2023] [Accepted: 06/13/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Misoprostol is widely used for cervical ripening and labour induction as it is heat-stable and inexpensive. Oral misoprostol 25 μg given 2-hourly is recommended over vaginal misoprostol 25 μg given 6-hourly, but the need for 2-hourly fetal monitoring makes oral misoprostol impractical for routine use in high-volume obstetric units in resource-constrained settings. OBJECTIVES To compare the efficacy and safety of oral misoprostol initiated at 25 or 50 μg versus 25 μg vaginal misoprostol given at 4- to 6-hourly intervals for labor induction in women at or beyond term (≥ 37 weeks) with a single viable fetus and an unscarred uterus. SEARCH STRATEGY We identified eligible randomized, parallel-group, labor-induction trials from recent systematic reviews. We additionally searched PubMed, Cochrane CENTRAL, Epistemonikos, and clinical trials registries from February 1, 2020 to December 31, 2022 without language restrictions. Database-specific keywords for cervical priming, labor induction, and misoprostol were used. SELECTION CRITERIA We excluded labor-induction trials exclusively in women with ruptured membranes, in the third trimester, and those that initiated misoprostol at doses not specified in the review's objectives. The primary outcomes were vaginal birth within 24 h, cesarean section, perinatal mortality, neonatal morbidity, and maternal morbidity. The secondary outcomes were uterine hyperstimulation with fetal heart rate changes, and oxytocin augmentation. DATA COLLECTION AND ANALYSIS Two or more authors selected studies independently, assessed risk of bias, and extracted data. We derived pooled weighted risk ratios with 95% confidence intervals (CIs) for each outcome, subgrouping trials by the dose and frequency of misoprostol regimens. We used the I2 statistic to quantify heterogeneity and the random-effects model for meta-analysis when appropriate. We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach to assess certainty (confidence) in the effect estimates. MAIN RESULTS Thirteen trials, from Canada, India, Iran, and the US, randomizing 2941 women at ≥37 weeks of gestation with an unfavorable cervix (Bishop score <6), met the eligibility criteria. Five misoprostol regimens were compared: 25 μg oral versus 25 μg vaginal, 4-hourly (three trials); 50 μg oral versus 25 μg vaginal, 4-hourly (five trials); 50 μg followed by 100 μg oral versus 25 μg vaginal, 4-hourly (two trials); 50 μg oral, 4-hourly versus 25 μg vaginal, 6-hourly (one trial); and 50 μg oral versus 25 μg vaginal, 6-hourly (two trials). The overall certainty in the evidence ranged from moderate to very low, due to high risk of bias in 11/13 trials (affecting all outcomes), unexplained heterogeneity (1/7 outcomes), indirectness (1/7 outcomes), and imprecision (4/7 outcomes). Vaginal misoprostol probably increased vaginal deliveries within 24 h compared with oral misoprostol (risk ratio [RR] 0.82, 95% CI 0.70-0.96; 11 trials, 2721 mothers; moderate-certainty evidence); this was more likely with 4-hourly than with 6-hourly vaginal regimens. The risk of cesarean sections did not appreciably differ (RR 1.00, 95% CI 0.80-1.26; 13 trials, 2941 mothers; very low-certainty evidence), although oral misoprostol 25 μg 4-hourly probably increased this risk compared with 25 μg vaginal misoprostol 4-hourly (RR 1.69, 95% CI 1.21-2.36; three trials, 515 mothers). The risk of perinatal mortality (RR 0.67, 95% CI 0.11-3.90; one trial, 196 participants; very low-certainty evidence), neonatal morbidity (RR 0.84, 95% CI 0.67-1.06; 13 trials, 2941 mothers; low-certainty evidence), and maternal morbidity (RR 0.83, 95% CI 0.48-1.44; 6 trials; 1945 mothers; moderate-certainty evidence) did not differ appreciably. The risk of uterine hyperstimulation with fetal heart rate changes may be lower with oral misoprostol (RR 0.70, 95% CI 0.52-0.95; 10 trials, 2565 mothers; low-certainty evidence). Oxytocin augmentation was probably more frequent with oral compared with vaginal misoprostol (RR 1.29, 95% CI 1.10-1.51; 13 trials, 2941 mothers; moderate-certainty evidence). CONCLUSIONS Low-dose, 4- to 6-hourly vaginal misoprostol regimens probably result in more vaginal births within 24 h and less frequent oxytocin use compared with low-dose, 4- to 6-hourly, oral misoprostol regimens. Vaginal misoprostol may increase the risk of uterine hyperstimulation with fetal heart changes compared with oral misoprostol, without increasing the risk of perinatal mortality, neonatal morbidity, or maternal morbidity. Indirect evidence indicates that 25 μg vaginal misoprostol 4-hourly may be more effective and as safe as the recommended 6-hourly vaginal regimen. This evidence could inform clinical decisions in high-volume obstetric units in resource-constrained settings.
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Affiliation(s)
- Hilda Yenuberi
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Jiji Mathews
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Anne George
- Department of Community Health, Christian Medical College, Vellore, India
| | - Santosh Benjamin
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Swati Rathore
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Richa Tirkey
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Prathap Tharyan
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
- Clinical Epidemiology Unit, Christian Medical College, Vellore, India
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Mehmood Y, Shahid H, Barkat K, Arshad N, Rasul A, Uddin MN, Kazi M. Novel Hydrolytic Degradable Crosslinked Interpenetrating Polymeric Networks (IPNs): An Efficient Hybrid System to Manage the Controlled Release and Degradation of Misoprostol. Gels 2023; 9:697. [PMID: 37754378 PMCID: PMC10529051 DOI: 10.3390/gels9090697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/28/2023] Open
Abstract
PURPOSE The goal of this study was to make pH-sensitive HPMC/Neocel C19-based interpenetrating polymeric networks (IPNs) that could be used to treat different diseases. An assembled novel carrier system was demonstrated in this study to achieve multiple functions such as drug protection and self-regulated release. METHODS Misoprostol (MPT) was incorporated as a model drug in hydroxyl-propyl-methylcellulose (HPMC)- and Neocel C19-based IPNs for controlled release. HPMC- and Neocel C19-based IPNs were fabricated through an aqueous polymerization method by utilizing the polymers HPMC and Neocel C19, the initiator ammonium peroxodisulfate (APS), the crosslinker methylenebisacrylamide (MBA), and the monomer methacrylic acid (MAA). An IPN based on these materials was created using an aqueous polymerization technique. Samples of IPN were analyzed using scanning electron microscopy (SEM), atomic force microscopy (AFM), differential scanning calorimetry (DSC), thermal analysis (TGA), and powder X-ray diffraction (PXRD). The effects of the pH levels 1.2 and 7.4 on these polymeric networks were also studied in vitro and through swelling experiments. We also performed in vivo studies on rabbits using commercial tablets and hydrogels. RESULTS The thermal stability measured using TGA and DSC for the revised formulation was higher than that of the individual components. Crystallinity was low and amorphousness was high in the polymeric networks, as revealed using powder X-ray diffraction (PXRD). The results from the SEM analysis demonstrated that the surface of the polymeric networks is uneven and porous. Better swelling and in vitro results were achieved at a high pH (7.4), which endorses the pH-responsive characteristics of IPN. Drug release was also increased in 7.4 pH (80% in hours). The pharmacokinetic properties of the drugs showed improvement in our work with hydrogel. The tablet MRT was 13.17 h, which was decreased in the hydrogels, and its AUC was increased from 314.41 ng h/mL to 400.50 ng h/mL in hydrogels. The blood compatibility of the IPN hydrogel was measured using different weights (100 mg, 200 mg, 400 mg, and 600 mg; 5.34%, 12.51%, 20.23%, and 29.37%, respectively). CONCLUSIONS As a result, IPN composed of HPMC and Neocel C19 was successfully synthesized, and it is now possible to use it for the controlled release of MPT.
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Affiliation(s)
- Yasir Mehmood
- Department of Pharmaceutics, Faculty of Pharmaceutical Sciences, Government College University Faisalabad, Faisalabad P.O. Box 38000, Pakistan;
- Riphah Institute of Pharmaceutical Sciences (RIPS), Riphah International University Faisalabad, Faisalabad P.O. Box 38000, Pakistan
| | - Hira Shahid
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Government College University Faisalabad, Faisalabad P.O. Box 38000, Pakistan;
| | - Kashif Barkat
- Faculty of Pharmacy, The University of Lahore, Lahore P.O. Box 54000, Pakistan;
| | - Numera Arshad
- Department of Pharmacy, COMSATS University Islamabad, Lahore Campus, Lahore P.O. Box 54000, Pakistan;
| | - Akhtar Rasul
- Department of Pharmaceutics, Faculty of Pharmaceutical Sciences, Government College University Faisalabad, Faisalabad P.O. Box 38000, Pakistan;
| | - Mohammad N. Uddin
- College of Pharmacy, Mercer University, 3001 Mercer University Drive, Atlanta, GA 30341, USA;
| | - Mohsin Kazi
- Department of Pharmaceutics, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia
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Ozawa S, Chen HH, Lee YF(A, Higgins CR, Yemeke TT. Characterizing Medicine Quality by Active Pharmaceutical Ingredient Levels: A Systematic Review and Meta-Analysis across Low- and Middle-Income Countries. Am J Trop Med Hyg 2022; 106:1778-1790. [PMID: 35895431 PMCID: PMC9209904 DOI: 10.4269/ajtmh.21-1123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/03/2022] [Indexed: 11/07/2022] Open
Abstract
Substandard and falsified medicines are often reported jointly, making it difficult to recognize variations in medicine quality. This study characterized medicine quality based on active pharmaceutical ingredient (API) amounts reported among substandard and falsified essential medicines in low- and middle-income countries (LMICs). A systematic review and meta-analysis was conducted using PubMed, supplemented by results from a previous systematic review, and the Medicine Quality Scientific Literature Surveyor. Study quality was assessed using the Medicine Quality Assessment Reporting Guidelines (MEDQUARG). Random-effects models were used to estimate the prevalence of medicines with < 50% API. Among 95,520 medicine samples from 130 studies, 12.4% (95% confidence interval [CI]: 10.2-14.6%) of essential medicines tested in LMICs were considered substandard or falsified, having failed at least one type of quality analysis. We identified 99 studies that reported API content, where 1.8% (95% CI: 0.8-2.8%) of samples reported containing < 50% of stated API. Among all failed samples (N = 9,724), 25.9% (95% CI: 19.3-32.6%) reported having < 80% API. Nearly one in seven (13.8%, 95% CI: 9.0-18.6%) failed samples were likely to be falsified based on reported API amounts of < 50%, whereas the remaining six of seven samples were likely to be substandard. Furthermore, 12.5% (95% CI: 7.7-17.3%) of failed samples reported finding 0% API. Many studies did not present a breakdown of actual API amount of each tested sample. We offer suggested improved guidelines for reporting poor-quality medicines. Consistent data on substandard and falsified medicines and medicine-specific tailored interventions are needed to ensure medicine quality throughout the supply chain.
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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, North Carolina
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Hui-Han Chen
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Yi-Fang (Ashley) Lee
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Colleen R. Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Tatenda T. Yemeke
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
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Ammerdorffer A, Rushwan S, Timms R, Wright P, Beeson L, Devall AJ, Mammoliti KM, Alwy Al-Beity FM, Galadanci H, Hofmeyr GJ, Singata-Madliki M, Qureshi Z, Lambert P, Gallos ID, Coomarasamy A, Gülmezoglu AM. Quality of oxytocin and tranexamic acid for the prevention and treatment of postpartum hemorrhage in Kenya, Nigeria, South Africa, and Tanzania. Int J Gynaecol Obstet 2022; 158 Suppl 1:46-55. [PMID: 35762808 PMCID: PMC9543376 DOI: 10.1002/ijgo.14197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To check the quality of oxytocin and tranexamic acid-two recommended products for prevention and treatment of postpartum hemorrhage (PPH)-used in facilities taking part in an implementation research project to improve PPH diagnosis and management. METHODS Between September 2020 and August 2021, oxytocin and tranexamic acid products used in the study facilities in Kenya, Nigeria, South Africa, and Tanzania were collected and transported in cold storage for analysis. Samples were analyzed according to the International (oxytocin) and British Pharmacopeia (tranexamic acid) standards. RESULTS Of the 17 unique oxytocin products, 33 individual measurements were made. Only six unique products had adequate content and no related substances exceeding the recommended limits. Of 14 tranexamic acid samples, 10 showed adequate content. One product in Kenya and two products in Nigeria from different manufacturers had a high content of related substances, which classified them as substandard. CONCLUSION While we were unable to investigate the origin regarding poor manufacturing or poor storage or both, the high number of substandard oxytocin samples is of great concern. Most of the tranexamic acid samples had adequate content but the presence of impurities in multiple products is worrying and requires further study.
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Affiliation(s)
| | | | - Rebecca Timms
- Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health, University of Birmingham, Birmingham, UK
| | - Philip Wright
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Leanne Beeson
- Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health, University of Birmingham, Birmingham, UK
| | - Kristie-Marie Mammoliti
- Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health, University of Birmingham, Birmingham, UK
| | - Fadhlun M Alwy Al-Beity
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Hadiza Galadanci
- Africa Center of Excellence for Population Health and Policy, Bayero University, Kano, Kano, Nigeria
| | - G Justus Hofmeyr
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana.,University of the Witwatersrand, Johannesburg, South Africa.,Walter Sisulu University, South Africa
| | - Mandisa Singata-Madliki
- Effective Care Research Unit, Department of Obstetrics and Gynaecology, Universities of the Witwatersrand, East London, South Africa
| | - Zahida Qureshi
- Department of Obstetrics and Gynecology, School of Medicine, University of Nairobi, Kenyatta National Hospital Campus, Nairobi, Kenya
| | - Pete Lambert
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Ioannis D Gallos
- Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health, University of Birmingham, Birmingham, UK
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A descriptive study of healthcare-providers' experiences with the use and quality of oxytocin for the prevention of post-partum hemorrhage in Nigeria: A nation-wide survey. PLoS One 2021; 16:e0258096. [PMID: 34614012 PMCID: PMC8494301 DOI: 10.1371/journal.pone.0258096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 09/17/2021] [Indexed: 11/19/2022] Open
Abstract
Background Oxytocin is recommended as an affordable and effective drug in the prevention of postpartum hemorrhage—one of the leading causes of maternal morbidity and mortality in low- and middle-income countries, however, there are concerns about its proper use and quality. This study builds on earlier work conducted in a South-Western state in Nigeria. Objective The study assessed the knowledge around oxytocin, usage, storage practices and perceived quality of oxytocin used by healthcare providers that directly administer oxytocin for the prevention of postpartum hemorrhage across Nigeria. Methods This was a descriptive cross-sectional study that surveyed a representative sample of 6,299 healthcare providers who offer obstetrics and gynecological services and recruited from 1,894 healthcare facilities in Public and Private sectors in 12 states across Nigeria. Data were collected using an electronic questionnaire, analyzed using SPSS, and presented in frequencies and percentages. Results Only forty-six percent of respondents (52.8% in private; 40.0% in public sector) had proper knowledge that oxytocin storage is in the refrigerator. Proper knowledge also varied by professional cadre, doctors (71.2%); nurses (46.6%); Community Health Workers (28.4%) and by years of experience, less than 10 years (51.4%); more than 10 years (40.8%). Only 34% of the respondents (41% in private and 27.5% in public sector) reported good practices that oxytocin is stored in the refrigerator in their facilities. Most healthcare providers used oxytocin for prevention of PPH (77.9%). Oxytocin was also used for augmentation (66.7%) and induction of labor (52.6%). Half of respondents used above the WHO-recommended oxytocin dose of 10IU for prevention of PPH. Twenty-three percent of respondents reported experiencing oxytocin failure in PPH prevention of whom, 54.3% changed to another uterotonic and 37.1% doubled the dose of oxytocin for their patients. Conclusion Our study findings should be used to establish clinical guidelines and trainings for healthcare providers to improve their knowledge and storage practices and use to safeguard the quality of these lifesaving medicines.
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Oli AN, Nwankwo EJ, Umeyor CE, Umeh US, Okoyeh JN, Ofomata CM, Okoro CC, Otakagu EC, Afunwa RA, Ibeanu GC. Emergency medicine: magnesium sulphate injections and their pharmaceutical quality concerns. Heliyon 2021; 7:e07099. [PMID: 34095588 PMCID: PMC8166754 DOI: 10.1016/j.heliyon.2021.e07099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/03/2021] [Accepted: 05/14/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives World Health Organization has recognized magnesium sulphate as the drug of choice for prevention and treatment of fits associated with preeclampsia and eclampsia which are amongst the leading causes of maternal morbidity and mortality. In this study, the pharmaceutical quality of magnesium sulphate injections marketed in Anambra state was assessed. Methods Ninety samples of magnesium sulphate obtained from the 3 senatorial zones in Anambra state were subjected to identification tests, microbiological analysis consisting of Growth promotion test, sterility and endotoxin test. Content analysis using titrimetric method and pH analysis were also carried out on the samples. Results Twenty percent (20%) of samples obtained from Onitsha failed identification test as they had no Registration number in Nigeria. All samples subjected to the microbiology tests (sterility and endotoxin test) passed. Twenty percent (20%) and thirty-three percent (33.3%) of samples sourced from Onitsha and Nnewi respectively failed the pH analysis test. All the samples passed microbiological tests and had their Active Pharmaceutical Ingredients (API) within the acceptable limit. Conclusions This study reveals that there are still some substandard magnesium sulphate injections in circulation in the locality. The supply chain of these drugs should be monitored to ensure a reduction in the incidences of substandard magnesium sulphate and positive therapeutic outcome which translates to reduced maternal mortality associated with pre-eclampsia and eclampsia in Nigeria.
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Affiliation(s)
- Angus Nnamdi Oli
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Awka, Agulu, Anambra state, Nigeria
| | - Ezinne Janefrances Nwankwo
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Awka, Agulu, Anambra state, Nigeria
| | - Chukwuebuka Emmanuel Umeyor
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Agulu, Awka, Anambra State, Nigeria
| | - Ugochukwu Stanley Umeh
- Department of Ear, Nose and Throat (ENT), Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Jude Nnaemeka Okoyeh
- Department of Biology and Clinical Laboratory Science, Division of Arts and Sciences, Neumann University, One Neumann Drive, Aston, PA, 19014-1298, USA
| | - Chijioke M Ofomata
- Department of Clinical Pharmacy and Pharmacy Management, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Agulu, Awka, P.M.B 5025, Anambra State, Nigeria
| | | | - Emmanuel Chinedum Otakagu
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Agulu, Awka, Anambra State, Nigeria
| | - Ruth Asikiya Afunwa
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, ChukwuemekaOdumegwuOjukwu University, Igbariam Campus, Anambra state, Nigeria
| | - Gordon C Ibeanu
- Department of Pharmaceutical Science, North Carolina Central University, Durham, NC, 27707, USA
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Amimo F, Lambert B, Magit A, Hashizume M. A review of prospective pathways and impacts of COVID-19 on the accessibility, safety, quality, and affordability of essential medicines and vaccines for universal health coverage in Africa. Global Health 2021; 17:42. [PMID: 33832487 PMCID: PMC8027968 DOI: 10.1186/s12992-021-00666-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 01/11/2021] [Indexed: 01/15/2023] Open
Abstract
Background The ongoing pandemic of coronavirus disease 2019 (COVID-19) has the potential to reverse progress towards global targets. This study examines the risks that the COVID-19 pandemic poses to equitable access to essential medicines and vaccines (EMV) for universal health coverage in Africa. Methods We searched medical databases and grey literature up to 2 October 2020 for studies reporting data on prospective pathways and innovative strategies relevant for the assessment and management of the emerging risks in accessibility, safety, quality, and affordability of EMV in the context of the COVID-19 pandemic. We used the resulting pool of evidence to support our analysis and to draw policy recommendations to mitigate the emerging risks and improve preparedness for future crises. Results Of the 310 records screened, 134 were included in the analysis. We found that the disruption of the international system affects more immediately the capability of low- and middle-income countries to acquire the basket of EMV. The COVID-19 pandemic may facilitate dishonesty and fraud, increasing the propensity of patients to take substandard and falsified drugs. Strategic regional cooperation in the form of joint tenders and contract awarding, joint price negotiation and supplier selection, as well as joint market research, monitoring, and evaluation could improve the supply, affordability, quality, and safety of EMV. Sustainable health financing along with international technology transfer and substantial investment in research and development are needed to minimize the vulnerability of African countries arising from their dependence on imported EMV. To ensure equitable access, community-based strategies such as mobile clinics as well as fees exemptions for vulnerable and under-served segments of society might need to be considered. Strategies such as task delegation and telephone triage could help reduce physician workload. This coupled with payments of risk allowance to frontline healthcare workers and health-literate healthcare organization might improve the appropriate use of EMV. Conclusions Innovative and sustainable strategies informed by comparative risk assessment are increasingly needed to ensure that local economic, social, demographic, and epidemiological risks and potentials are accounted for in the national COVID-19 responses. Supplementary Information The online version contains supplementary material available at 10.1186/s12992-021-00666-8.
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Affiliation(s)
- Floriano Amimo
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan. .,Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique.
| | - Ben Lambert
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, W2 1PG, UK
| | - Anthony Magit
- Human Research Protection Program, University of California San Diego School of Medicine, San Diego, California, USA
| | - Masahiro Hashizume
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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14
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Ruysen H, Shabani J, Hanson C, Day LT, Pembe AB, Peven K, Rahman QSU, Thakur N, Shirima K, Tahsina T, Gurung R, Tarimo MN, Moran AC, Lawn JE. Uterotonics for prevention of postpartum haemorrhage: EN-BIRTH multi-country validation study. BMC Pregnancy Childbirth 2021; 21:230. [PMID: 33765962 PMCID: PMC7995712 DOI: 10.1186/s12884-020-03420-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is a leading cause of preventable maternal mortality worldwide. The World Health Organization (WHO) recommends uterotonic administration for every woman after birth to prevent PPH. There are no standardised data collected in large-scale measurement platforms. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) is an observational study to assess the validity of measurement of maternal and newborn indicators, and this paper reports findings regarding measurement of coverage and quality for uterotonics. METHODS The EN-BIRTH study took place in five hospitals in Bangladesh, Nepal and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data. We compared observation data for uterotonics to routine hospital register-records and women's report at exit-interview survey. We analysed the coverage and quality gap for timing and dose of administration. The register design was evaluated against gap analyses and qualitative interview data assessing the barriers and enablers to data recording and use. RESULTS Observed uterotonic coverage was high in all five hospitals (> 99%, 95% CI 98.7-99.8%). Survey-report underestimated coverage (79.5 to 91.7%). "Don't know" replies varied (2.1 to 14.4%) and were higher after caesarean (3.7 to 59.3%). Overall, there was low accuracy in survey data for details of uterotonic administration (type and timing). Register-recorded coverage varied in four hospitals capturing uterotonics in a specific column (21.6, 64.5, 97.6, 99.4%). The average coverage measurement gap was 18.1% for register-recorded and 6.0% for survey-reported coverage. Uterotonics were given to 15.9% of women within the "right time" (1 min) and 69.8% within 3 min. Women's report of knowing the purpose of uterotonics after birth ranged from 0.4 to 64.9% between hospitals. Enabling register design and adequate staffing were reported to improve routine recording. CONCLUSIONS Routine registers have potential to track uterotonic coverage - register data were highly accurate in two EN-BIRTH hospitals, compared to consistently underestimated coverage by survey-report. Although uterotonic coverage was high, there were gaps in observed quality for timing and dose. Standardisation of register design and implementation could improve data quality and data flow from registers into health management information reporting systems, and requires further assessment.
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Affiliation(s)
- Harriet Ruysen
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine (LSHTM), London, UK.
| | - Josephine Shabani
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
| | - Claudia Hanson
- Public Health Sciences - Global Health - Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden
| | - Louise T Day
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences (MUHAS), Dar Es Salaam, Tanzania
| | - Kimberly Peven
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine (LSHTM), London, UK
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Qazi Sadeq-Ur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Kizito Shirima
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
| | - Tazeen Tahsina
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rejina Gurung
- Research division, Golden Community, Lalitpur, Nepal
| | - Menna Narcis Tarimo
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar Es Salaam, Tanzania
| | - Allisyn C Moran
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Joy E Lawn
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine (LSHTM), London, UK
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Bizimana T, Hagen N, Gnegel G, Kayumba PC, Heide L. Quality of oxytocin and misoprostol in health facilities of Rwanda. PLoS One 2021; 16:e0245054. [PMID: 33417602 PMCID: PMC7793248 DOI: 10.1371/journal.pone.0245054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/21/2020] [Indexed: 11/18/2022] Open
Abstract
Sustainable Development Goal 3.1 calls for a reduction of the maternal mortality ratio to less than 70 per 100,000 live births by 2030. The most important cause of maternal mortality is post-partum haemorrhage (PPH). Oxytocin injections and misoprostol tablets are medicines of first choice for the management of PPH in low- and middle-income countries (LMICs). Unfortunately, both substances are chemically unstable, and previous studies have revealed serious quality problems of these medicines in LMICs. The present study is the first report on their quality in Rwanda. From 40 randomly selected health facilities (hospitals, health centers, retail pharmacies and private clinics) in different parts of Rwanda, as well as from six wholesalers and government stores, oxytocin injections and misoprostol tablets were collected. Oxytocin storage temperatures in the health facilities were monitored for six months using temperature data loggers, and found to correctly follow the storage requirements stated by the manufacturers (2–8°C, or room temperature) with few minor deviations. Oxytocin injections (57 samples, representing seven batches of four brands) were tested for their oxytocin content and pH value according to the United States Pharmacopeia. Twenty-four samples from three European manufacturers passed all tests. However, all nine samples of one batch of a Chinese manufacturer showed an excessive content of oxytocin (range 117.2–121.5% of the declared amount). Another batch of the same manufacturer showed extreme variations of the concentration of the preservative benzyl alcohol. Misoprostol tablets (25 samples, representing ten batches of six brands) were tested for content and dissolution according to the International Pharmacopoeia. Fifteen samples passed, but all 10 samples of two brands from India failed with extreme deviations, containing only 42.5–48.7% of the stated amount of misoprostol. In conclusion, oxytocin quality in Rwanda was better than reported from other African countries. However, two extremely substandard brands of misoprostol tablets were found. The Rwandan authorities reacted quickly and efficiently, and recalled these substandard medicines from the market. For oxytocin and misoprostol, with their well-known problems of quality and stability, procurement should possibly be restricted to medicines which are WHO-prequalified or which have been manufactured in countries with stringent regulatory authorities.
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Affiliation(s)
- Thomas Bizimana
- Department of Pharmacy, School of Medicine and Pharmacy, College of Medicine and Health Sciences (CMHS), University of Rwanda, Kigali, Rwanda
| | - Nhomsai Hagen
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Gesa Gnegel
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Pierre Claver Kayumba
- East African Community Regional Centre of Excellence for Vaccines, Immunizations and Health Supply Chain Management (EAC RCE-VIHSCM), University of Rwanda, Kigali, Rwanda
| | - Lutz Heide
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
- * E-mail:
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16
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Kibira D, Ooms GI, van den Ham HA, Namugambe JS, Reed T, Leufkens HG, Mantel-Teeuwisse A. Access to oxytocin and misoprostol for management of postpartum haemorrhage in Kenya, Uganda and Zambia: a cross-sectional assessment of availability, prices and affordability. BMJ Open 2021; 11:e042948. [PMID: 33414148 PMCID: PMC7797249 DOI: 10.1136/bmjopen-2020-042948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess access (availability and affordability) to oxytocin and misoprostol at health facilities in Kenya, Uganda and Zambia to improve prevention and management of postpartum haemorrhage (PPH). DESIGN The assessment was undertaken using data from Health Action International (HAI) research on sexual and reproductive health commodities based on a cross-sectional design adapted from the standardised WHO/HAI methodology. SETTING Data were collected from 376 health facilities in in Kenya, Uganda and Zambia in July and August 2017. OUTCOME MEASURES Availability was calculated as mean percentage of sampled medicine outlets where medicine was found on the day of data collection. Medicine prices were compared with international reference prices (IRP) and expressed as median price ratios. Affordability was calculated using number of days required to pay for a standard treatment based on the daily income of the lowest paid government worker. RESULTS Availability of either oxytocin or misoprostol at health facilities was high; 81% in Kenya, 82% in Uganda and 76% in Zambia. Oxytocin was more available than misoprostol, and it was most available in the public sector in the three countries. Availability of misoprostol was highest in the public sector in Uganda (88%). Oxytocin and misoprostol were purchased by patients at prices above IRP, but both medicines cost less than a day's wages and were therefore affordable. Availability of misoprostol was poor in rural settings where it would be more preferred due to lack of trained personnel and cold storage facilities required for oxytocin. CONCLUSION Availability and affordability of either oxytocin or misoprostol at health facilities met the WHO benchmark of 80%. However, countries with limited resources should explore mechanisms to optimise management of PPH by improving access to misoprostol especially in rural areas.
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Affiliation(s)
- Denis Kibira
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Coalition for Health Promotion and Social Development (HEPS-Uganda), Kampala, Uganda
| | - Gaby Isabelle Ooms
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Health Action International, Amsterdam, The Netherlands
| | - Hendrika A van den Ham
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Juliet Sanyu Namugambe
- Department of Pharmacy, Mbarara University of Science and Technology Mbarara, Mbarara, Uganda
| | - Tim Reed
- Health Action International, Amsterdam, The Netherlands
| | - Hubert Gm Leufkens
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Aukje Mantel-Teeuwisse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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17
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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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18
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Hagen N, Bizimana T, Kayumba PC, Khuluza F, Heide L. Stability of Oxytocin Preparations in Malawi and Rwanda: Stabilizing Effect of Chlorobutanol. Am J Trop Med Hyg 2020; 103:2129-2141. [PMID: 32748770 PMCID: PMC7646793 DOI: 10.4269/ajtmh.20-0255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Oxytocin is used for the prevention and treatment of postpartum hemorrhage, the leading cause of maternal mortality in low- and middle-income countries. Because of the high instability of oxytocin, most products are labeled for storage at 2–8°C. Some other products are on the market which are labeled for non-refrigerated storage, but independent evaluations of their stability hardly exist. In the present study, seven brands (nine batches) of oxytocin were purchased from wholesalers and medical stores in Malawi and Rwanda and investigated by accelerated stability testing according to the ICH/WHO guidelines. Two oxytocin brands approved by a stringent regulatory authority (SRA) or by the WHO Prequalification of Medicines program and purchased in Europe were used as comparison. All investigated brands which were either produced in countries with SRAs, or were WHO-prequalified products, were labeled for storage at 2–8°C, and all of them passed stability testing with very good results. Even exposure to 25°C or 30°C for several months hardly affected their oxytocin content. However, two other investigated brands were labeled for non-refrigerated storage, and both of them had been produced in countries without SRAs. These two preparations showed not higher but lower stability than the brands labeled for storage at 2–8°C, and, for both of them, noncompliance with pharmacopoeial specifications was found after accelerated stability testing. At 40°C, and in forced degradation studies at 80°C, chlorobutanol showed a remarkable stabilizing effect on oxytocin, which may deserve further investigation. The results of the present study support the policy “Buy Quality Oxytocin, Keep It Cool.”
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Affiliation(s)
- Nhomsai Hagen
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Thomas Bizimana
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Pierre Claver Kayumba
- East African Community Regional Centre of Excellence for Vaccines, Immunizations and Health Supply Chain Management (EAC RCE-VIHSCM), University of Rwanda, Kigali, Rwanda
| | - Felix Khuluza
- Pharmacy Department, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Lutz Heide
- Pharmaceutical Institute, Eberhard Karls University Tübingen, Tübingen, Germany
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Stewart R, Perera GD. Keeping up with the medical abortion revolution: The Marie Stopes International abortifacient quality assurance system. Int J Gynaecol Obstet 2020; 152:288-290. [PMID: 32989727 DOI: 10.1002/ijgo.13401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/31/2020] [Accepted: 09/24/2020] [Indexed: 11/09/2022]
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Hagen N, Bizimana T, Kayumba PC, Khuluza F, Heide L. Stability of misoprostol tablets collected in Malawi and Rwanda: Importance of intact primary packaging. PLoS One 2020; 15:e0238628. [PMID: 32877459 PMCID: PMC7467217 DOI: 10.1371/journal.pone.0238628] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/14/2020] [Indexed: 11/26/2022] Open
Abstract
Misoprostol is listed in the WHO essential medicines list and can be used for induction of labour, for prevention and treatment of post-partum haemorrhage, and for abortions. The compound is unstable, and substandard misoprostol preparations have been detected in low- and middle-income countries. We now investigated the stability of misoprostol tablets according to the international guidelines for stability testing of pharmaceutical products. Three brands (four batches) of misoprostol tablets were collected in Malawi and Rwanda: the originator product, a WHO-prequalified product, and a generic product without WHO prequalification. A further batch of the originator product was collected in Germany. To investigate the effect of damage to the primary packaging, additional blister strips of one sample were intentionally damaged with a needle and investigated in parallel. Samples were placed in stability chambers for six months at 40°C/75% relative humidity (RH) and at 25°C/60% RH. After 0, 1, 2, 3 and 6 months, misoprostol content was determined according to the International Pharmacopeia. At 40°C/75% RH, all samples showed a decline of misoprostol content, but four of the batches still remained within the pharmacopeial specifications, while one of the two batches of the generic product without WHO-prequalification showed a final content of 86.2% which is out of specifications. Damage to the primary packaging greatly decreased stability, resulting in a final content of only 48.2% of the declared misoprostol amount. At 25°C/60% RH all samples remained in specifications for six months, even the sample with the damaged blister. Dissolution of misoprostol remained in specifications of the pharmacopoeia for six months for all batches, except for the sample with damaged blisters stored at 40°C/75% RH. This study confirms that the stability of misoprostol tablets must be ensured by intact, good-quality primary packaging. Careful supplier qualification is required in the procurement process.
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Affiliation(s)
- Nhomsai Hagen
- Pharmaceutical Institute, Eberhard Karls University Tubingen, Tubingen, Germany
| | - Thomas Bizimana
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - P. Claver Kayumba
- East African Community Regional Centre of Excellence for Vaccines, Immunizations and Health Supply Chain Management (EAC RCE-VIHSCM), University of Rwanda, Kigali, Rwanda
| | - Felix Khuluza
- Pharmacy Department, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Lutz Heide
- Pharmaceutical Institute, Eberhard Karls University Tubingen, Tubingen, Germany
- * E-mail:
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Carvalho N, Hoque ME, Oliver VL, Byrne A, Kermode M, Lambert P, McIntosh MP, Morgan A. Cost-effectiveness of inhaled oxytocin for prevention of postpartum haemorrhage: a modelling study applied to two high burden settings. BMC Med 2020; 18:201. [PMID: 32718336 PMCID: PMC7385867 DOI: 10.1186/s12916-020-01658-y] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/07/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Access to oxytocin for prevention of postpartum haemorrhage (PPH) in resource-poor settings is limited by the requirement for a consistent cold chain and for a skilled attendant to administer the injection. To overcome these barriers, heat-stable, non-injectable formulations of oxytocin are under development, including oxytocin for inhalation. This study modelled the cost-effectiveness of an inhaled oxytocin product (IHO) in Bangladesh and Ethiopia. METHODS A decision analytic model was developed to assess the cost-effectiveness of IHO for the prevention of PPH compared to the standard of care in Bangladesh and Ethiopia. In Bangladesh, introduction of IHO was modelled in all public facilities and home deliveries with or without a skilled attendant. In Ethiopia, IHO was modelled in all public facilities and home deliveries with health extension workers. Costs (costs of introduction, PPH prevention and PPH treatment) and effects (PPH cases averted, deaths averted) were modelled over a 12-month program. Life years gained were modelled over a lifetime horizon (discounted at 3%). Cost of maintaining the cold chain or effects of compromised oxytocin quality (in the absence of a cold chain) were not modelled. RESULTS In Bangladesh, IHO was estimated to avert 18,644 cases of PPH, 76 maternal deaths and 1954 maternal life years lost. This also yielded a cost-saving, with the majority of gains occurring among home deliveries where IHO would replace misoprostol. In Ethiopia, IHO averted 3111 PPH cases, 30 maternal deaths and 767 maternal life years lost. The full IHO introduction program bears an incremental cost-effectiveness ratio (ICER) of between 2 and 3 times the per-capita Gross Domestic Product (GDP) ($1880 USD per maternal life year lost) and thus is unlikely to be considered cost-effective in Ethiopia. However, the ICER of routine IHO administration considering recurring cost alone falls under 25% of per-capita GDP ($175 USD per maternal life-year saved). CONCLUSIONS IHO has the potential to expand access to uterotonics and reduce PPH-associated morbidity and mortality in high burden settings. This can facilitate reduced spending on PPH management, making the product highly cost-effective in settings where coverage of institutional delivery is lagging.
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Affiliation(s)
- Natalie Carvalho
- Centre for Health Policy & Global Burden of Disease Group, School of Population and Global Health, The University of Melbourne, Melbourne, VIC, 3010, Australia.
| | - Mohammad Enamul Hoque
- Agency for Clinical Innovation, NSW Ministry of Health, Sydney, NSW, 2067, Australia
| | - Victoria L Oliver
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
| | - Abbey Byrne
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
| | - Michelle Kermode
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Pete Lambert
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
| | - Michelle P McIntosh
- Drug Delivery Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
| | - Alison Morgan
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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Quality of medicines for life-threatening pregnancy complications in low- and middle-income countries: A systematic review. PLoS One 2020; 15:e0236060. [PMID: 32649710 PMCID: PMC7351160 DOI: 10.1371/journal.pone.0236060] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/26/2020] [Indexed: 02/02/2023] Open
Abstract
Background There are concerns about the quality of medicines available in low- and middle-income countries (LMIC) to manage hemorrhage, pre-eclampsia/eclampsia and sepsis. We aimed to identify, critically appraise, and synthesize the findings of studies on the quality of these three types of medicines available in LMIC. Methods This systematic review searched Medline, EMBASE and LILACS (from inception to 25 May 2020) for studies on the quality of selected medicines available in LMIC that provided at least the amount of active pharmaceutical ingredient. We contacted study authors for additional information. We excluded simulation studies. We used the MEDQUARG tool to assess study quality. The main outcome was the prevalence of failed samples. Findings We identified 9699 unique citations and included 34 studies (3159 samples from 40 countries) in the review. Most studies (65%) had low quality (scores <6/12). Overall, 48.9% of 1890 uterotonic samples (19 studies) failed quality tests; failures rates were 75% for ergometrine and nearly 40% each for oxytocin and misoprostol. The overall prevalence of failed injectable antibiotics (1090 samples, 18 studies) was 13.4%, ranging from 2.9% for injectable metronidazole (34 samples, 3 studies) to 16.0% for cefazolin (449 samples, 2 studies). The prevalence of low quality magnesium sulphate (179 samples, 2 studies) was 3.4%. We did not find any studies on the quality of carbetocin, tranexamic acid, or clindamycin. Conclusions There is a widespread problem with the quality of medicines used to manage life-threatening maternal conditions in LMIC. This can be a contributing factor to high maternal mortality rates in these regions.
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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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Hagen N, Khuluza F, Heide L. Quality, availability and storage conditions of oxytocin and misoprostol in Malawi. BMC Pregnancy Childbirth 2020; 20:184. [PMID: 32223759 PMCID: PMC7104524 DOI: 10.1186/s12884-020-2810-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 02/13/2020] [Indexed: 12/04/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) is the leading cause of maternal mortality in low- and middle-income countries (LMICs). Oxytocin and misoprostol are used for the prevention and treatment of PPH. However, both medicines are chemically unstable and sensitive to environmental conditions. Previous studies reported a high prevalence of substandard oxytocin and misoprostol preparations in LMICs. Methods In randomly selected health facilities of four districts of Malawi, the availability of oxytocin and misoprostol was determined, and the knowledge of health workers on storage requirements and use of oxytocics was assessed. Temperature loggers were used to record the storage temperature of oxytocics. Samples of oxytocin injections and misoprostol tablets were collected from the health facilities and from wholesalers. Oxytocin samples were analysed for identity, assay (= quantity of oxytocin) and for pH value according to United States Pharmacopeia 40. Misoprostol samples were analysed for identity, assay, dissolution and related substances according to the International Pharmacopeia 2017. Results All visited hospitals and health centers had oxytocin available. At non-refrigerated storage sites, the recorded mean kinetic temperature exceeded the oxytocic’s storage temperature stated on the labels in 42% of the sites. At refrigerated storage sites, the required temperature of 2–8 °C was exceeded in 33% of the sites. Out of 65 oxytocin samples, 7 (11%) showed moderate deviations from specification, containing 82.2–86.8% of the declared amount of oxytocin. Out of 30 misoprostol samples, 5 (17%) showed extreme deviations, containing only 12.7–30.2% of the declared amount. The extremely substandard misoprostol was reported to the national authorities and to WHO, leading to an immediate recall of the respective brand in Malawi. The UK-based distributor of this brand closed its business shortly thereafter. Conclusion Availability of oxytocin was excellent in Malawi, and its quality was better than reported in previous studies in other LMICs. However, storage conditions at the health facilities often did not meet the requirements. Extremely substandard misoprostol tablets were found, representing a serious risk to maternal health. This shows the need for continued efforts for quality assurance in medicine procurement and registration, as well as for post-marketing surveillance.
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Affiliation(s)
- Nhomsai Hagen
- Pharmaceutical Institute, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Felix Khuluza
- Pharmacy Department, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Lutz Heide
- Pharmaceutical Institute, Eberhard Karls University Tuebingen, Tuebingen, Germany.
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Jin XH, Li D, Li X. Carbetocin vs oxytocin for prevention of postpartum hemorrhage after vaginal delivery: A meta-analysis. Medicine (Baltimore) 2019; 98:e17911. [PMID: 31764790 PMCID: PMC6882650 DOI: 10.1097/md.0000000000017911] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of carbetocin for prevention of postpartum hemorrhage in women undergoing vaginal delivery compared with oxytocin. METHODS We conducted a systemic literature search in PubMed, the Cochrane Library, and Embase without language restrictions from inception of each of database to November 18th, 2018. Randomized controlled trials with outcome measure of blood loss ≥500 ml were eligible if they compared carbetocin with oxytocin to prevent postpartum hemorrhage during the third stage of labor in women undergoing vaginal delivery. RESULTS This meta-analysis of 5 randomized controlled trials (30,314 women) indicated that there was no significant difference between carbetocin and oxytocin in blood loss ≥500 ml in women undergoing vaginal delivery (relative risks (RRs), 0.52; 95% confidence intervals (CIs), 0.24 to 1.15; P = .11; I = 69%). Sensitivity analyses showed the same results. No significant differences were found in blood loss ≥1000 ml, use of additional uterotonic agents, blood transfusion, uterine massage, flushing, vomiting, abdominal pain, nausea, dizziness, headache, palpitation, itching, and shivering. CONCLUSIONS This meta-analysis showed that carbetocin was as effective and safe as oxytocin for prevention of postpartum hemorrhage in women undergoing vaginal delivery, and the choice of carbetocin for routine prophylaxis will depend on cost-effectiveness.
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Affiliation(s)
- Xin-Hang Jin
- Department of Obstetrics & Gynecology, Affiliated Hangzhou First People's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang
| | - Dan Li
- Department of Ultrasound, Hangzhou Red Cross Hospital, Hangzhou
| | - Xia Li
- Department of Chemotherapy and Radiotherapy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Ejekam CS, Okafor IP, Anyakora C, Ozomata EA, Okunade K, Oridota SE, Nwokike J. Clinical experiences with the use of oxytocin injection by healthcare providers in a southwestern state of Nigeria: A cross-sectional study. PLoS One 2019; 14:e0208367. [PMID: 31600195 PMCID: PMC6786624 DOI: 10.1371/journal.pone.0208367] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 09/15/2019] [Indexed: 12/05/2022] Open
Abstract
Background Postpartum hemorrhage (PPH) is a leading cause of maternal mortality in Nigeria and in most low- and middle-income countries. The World Health Organization (WHO) strongly recommends oxytocin as effective, affordable, and the safest drug of first choice in the prevention and treatment of PPH in the third stage of labor. However, there are concerns about its quality. Very high prevalence of poor-quality oxytocin, especially in Africa and Asia, has been reported in literature. Excessive and inappropriate use of oxytocin is also common in low-resource settings. Objective To assess clinical experiences with quality of oxytocin used by healthcare providers in Lagos State, Nigeria. Methods This was a descriptive cross-sectional study conducted in 2017, with 705 respondents (doctors and nurses) who use oxytocin for obstetrics and gynecological services recruited from 195 health facilities (public and registered private) across Lagos State. Data collection was quantitative, using a pretested self-administered questionnaire. Data analysis was performed with IBM SPSS version 21. Statistical significance was set at 5 percent (p<0.05). Ethical approval was obtained from Lagos University Teaching Hospital Health Research Ethics Committee. Results Only 52 percent of the respondents knew oxytocin should be stored at 2°C to 8°C. About 80 percent of respondents used oxytocin for augmentation of labor, 68 percent for induction of labor, 51 percent for stimulation of labor, and 78 percent for management of PPH. Forty-one percent used 20IU and as much as 10% used 30IU to 60IU for management of PPH. About 13 percent of respondents reported believing they had used an ineffective brand of oxytocin in their practice. Just over a third (36%) had an available means of documenting or reporting perceived ineffectiveness of drugs in their facility; of these, only about 12 percent had pharmacovigilance forms in their facilities to report the ineffectiveness. Conclusion The inappropriate and inconsistent use of oxytocin, especially overdosing, likely led to the high perception of medicine effectiveness among respondents. This is coupled with lack of suspicion of medicine ineffectiveness by clinicians as a possible root cause of poor treatment response or disease progression. Poor knowledge of oxytocin storage and consequent poor storage practices could have contributed to the ineffectiveness reported by some respondents. It is necessary to establish a unified protocol for oxytocin use that is strictly complied with. Continuous training of healthcare providers in medicine safety monitoring is advocated.
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Affiliation(s)
- Chioma Stella Ejekam
- Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Ifeoma Peace Okafor
- Department of Community Health and Primary care, College of Medicine, University of Lagos, Akoka Lagos, Nigeria
| | - Chimezie Anyakora
- Promoting the Quality of Medicines Program, U.S. Pharmacopeial Convention, Rockville, Maryland, United States of America
| | - Ebenezer A Ozomata
- Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Kehinde Okunade
- Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Sofela Ezekiel Oridota
- Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria.,Department of Community Health and Primary care, College of Medicine, University of Lagos, Akoka Lagos, Nigeria
| | - Jude Nwokike
- Promoting the Quality of Medicines Program, U.S. Pharmacopeial Convention, Rockville, Maryland, United States of America
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Droti B, O'Neill KP, Mathai M, Yao Tsidi Dovlo D, Robertson J. Poor availability of essential medicines for women and children threatens progress towards Sustainable Development Goal 3 in Africa. BMJ Glob Health 2019; 4:e001306. [PMID: 31673436 PMCID: PMC6797404 DOI: 10.1136/bmjgh-2018-001306] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/24/2019] [Accepted: 07/05/2019] [Indexed: 11/28/2022] Open
Abstract
Background Most maternal and child deaths are preventable or treatable with proven, cost-effective interventions for infectious diseases and maternal and neonatal complications. In 2015 sub-Saharan Africa accounted for up to 66% of global maternal deaths and half of the under-five deaths. Access to essential medicines and commodities and trained healthcare workers to provide life-saving maternal, newborn and post-natal care are central to further reductions in maternal and child mortality. Methods Available data for 24 priority medicines for women and children were extracted from WHO service availability and readiness assessments conducted between 2012 and 2015 for eight countries in sub-Saharan Africa. The mean availability of medicines in facilities stating they provide services for women or children and differences by facility type, ownership and location are reported. Results The mean availability of 12 priority essential medicines for women ranged from 22% to 40% (median 33%; IQR 12%) and 12 priority medicines for children ranged from 28% to 57% (median 50%; IQR 14%). Few facilities (<1%) had all nominated medicines available. There was higher availability of priority medicines for women in hospitals than in primary care facilities: range 32%–80% (median 61%) versus 20%–39% (median 23%) and for children’s medicines 31%–71% (median 58%) versus 27%–57% (median 48%). Availability was higher in public than private facilities: for women’s medicines, range 21%–41% (median 34%) versus 4%–36% (median 27%) and for children’s medicines 28%–58% (median 51%) versus 5%–58% (median 46%). Patterns were mixed for rural and urban location for the priority medicines for women, but similar for children’s medicines. Conclusions The survey results show unacceptably low availability of priority medicines for women and children in the eight countries. Governments should ensure the availability of medicines for mothers and children if they are to achieve the health sustainable development goals.
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Affiliation(s)
- Benson Droti
- Health Systems and Services, World Health Organization, the Regional Office for Africa, Brazzaville, Congo
| | | | - Matthews Mathai
- Department of maternal, newborn and adolescent health, Organisation mondiale de la Sante, Geneve, GE, Switzerland
| | - Delanyo Yao Tsidi Dovlo
- Health Systems and Services Cluster, World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | - Jane Robertson
- Health Technology and Pharmaceuticals, World Health Organization, Regional Office for Europe, Copenhagen, Denmark.,Clinical Pharmacology, University of Newcastle, Waratah, New South Wales, Australia
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Residual active pharmaceutical ingredient on the primary packaging of medicines: A valuable GMP-marker. Talanta 2019; 201:259-265. [DOI: 10.1016/j.talanta.2019.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/24/2019] [Accepted: 04/04/2019] [Indexed: 12/18/2022]
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Vogel JP, Williams M, Gallos I, Althabe F, Oladapo OT. WHO recommendations on uterotonics for postpartum haemorrhage prevention: what works, and which one? BMJ Glob Health 2019; 4:e001466. [PMID: 31139461 PMCID: PMC6509591 DOI: 10.1136/bmjgh-2019-001466] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/10/2019] [Accepted: 03/16/2019] [Indexed: 11/18/2022] Open
Affiliation(s)
- Joshua P Vogel
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- Maternal and Child Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Myfanwy Williams
- Cochrane Pregnancy and Childbirth, University of Liverpool, Liverpool, United Kingdom
| | - Ioannis Gallos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham Women's Hospital Foundation Trust, Birmingham, United Kingdom
| | - Fernando Althabe
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Theunissen FJ, Chinery L, Pujar YV. Current research on carbetocin and implications for prevention of postpartum haemorrhage. Reprod Health 2018; 15:94. [PMID: 29945640 PMCID: PMC6019985 DOI: 10.1186/s12978-018-0529-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is the leading cause of maternal mortality in low-income countries and is a significant contributor to severe maternal morbidity and long-term disability. Carbetocin may be an underused uterotonic for prevention of PPH. A number of studies are being conducted that may challenge the place of oxytocin as the first choice of uterotonics for prevention of PPH. This paper describes the current research into carbetocin and ranking of effectiveness of uterotonics that may provide important new information to assist healthcare decision makers to ensure that women receive an effective uterotonic for prevention of PPH. METHODS We searched the WHO International Clinical Trials Registry Platform for current studies on effectiveness of carbetocin for prevention of PPH following vaginal delivery with sample sizes large enough to provide quality evidence to support potential changes to international guidelines. We also searched the Cochrane Library for current systematic reviews including carbetocin used in prevention of PPH. RESULTS Susceptibility to degradation from exposure to heat is one of the key causes of reduced effectiveness of oxytocin in preventing PPH from uterine atony. Although heat stable and effective in preventing PPH, misoprostol is also subject to degradation due to exposure to moisture and produces some side-effects. Other uterotonics (including ergometrine and combinations of oxytocin, ergometrine and misoprostol) are also available and used with varying safety and effectiveness profiles and quality issues. Efforts to reduce maternal mortality from PPH include research studies seeking to identify safe, stable, effective uterotonics. Heat stable carbetocin is the subject of two major clinical studies into its effectiveness in preventing PPH following vaginal deliveries, information that could expand its application for prevention of PPH. CONCLUSION Heat stable carbetocin is being investigated as a potential alternative to oxytocin. This paper describes two current clinical trials on carbetocin and a network meta-analysis ranking of all uterotonic agents, including carbetocin, which combined may provide evidence supporting expansion of the use of the heat stable formulation of carbetocin in PPH prevention.
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Affiliation(s)
| | | | - Yeshita V. Pujar
- Department of Obstetrics & Gynaecology, KLE Academy of Higher Education and Research’s J. N. Medical College, Belagavi, Karnataka India
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