Impact of substandard and falsified antimalarials in Zambia: application of the SAFARI model

Improving access to medicines to reduce marketing and use of substandard and falsified medicines in Africa: Scoping review

Background

Both constrained access to essential medicines and combatting marketing of substandard and falsified (SF) medicines are unmet health sector goals in Africa.

Objective

To answer the question of how improved access can reduce the continuous surge of SF medicines in Africa.

Design

We conducted a scoping review based on standard protocol.

Methods

We searched articles published in the English language from PubMed/Medline, Cochrane Library, Embase, Scopus, Web of Science, and Google Scholar by using a systematic search query.

Results

Seventy-one articles were included in this review. Access to quality essential medicines is still a major problem in developing countries in Africa and will continue as a threat for the next decade of health care. Ensuring access to quality medicines and preventing SF medicines in Africa need a systematic approach to address their underlying causes. Failure to ensure access to medicines is the major reason for the availability of SF medicines. Improving access to quality medicines can reduce SF medicine marketing and use. Manipulating the entire supply chain for efficiency, avoiding trade agreements that could reduce access, using compulsory licensing provisions, and pharmaceutical price control, providing incentives for drug development, and promoting rational use of medicines can improve access.

Conclusion

Ensuring access to medicines and preventing SF medicine marketing cannot be achieved in the planned period in developing countries in Africa unless a comprehensive strategy is used. Improving access to quality medicines can reduce SF medicine marketing and use, that is, ensuring access through uninterrupted supply, improved efficiency, enhanced local production, preventing SF medicine entry, improved medication use system, and improved affordability. Therefore, it is essential to improve supply chain capability, address challenges of the supply chain, improve leadership and governance, establish country-specific anti-counterfeiting and anti-substandardization committees, and collaborate with all relevant stakeholders.

Quality of antiretroviral, antimalarial and antituberculosis medicines in Zambia: Findings of routine post-marketing surveillance

Background

There is growing concern in sub-Saharan Africa that poor-quality antimicrobial medicines may negate management of infectious diseases of public health importance should they fail to meet the set criteria of quality, safety and efficacy.

Objectives

The objective was to ascertain the quality of antiretroviral, antimalarial and antituberculosis medicines supplied and available in the public health sector in Zambia.

Design

A descriptive cross-sectional study was conducted involving the analysis of data from the continuous routine in-country post-marketing surveillance programme in Zambia that assessed the quality of antiretroviral, antimalarial and antituberculosis medicines supplied to public healthcare facilities between January 2018 and June 2023.

Methods

Data were extracted from laboratory quality analysis results from samples collected as part of routine post-marketing surveillance by the Zambia Medicines Regulatory Authority between January 2018 and June 2023. The samples were collected from various levels of the pharmaceutical supply chain across Zambia. Samples were analysed according to their respective pharmacopoeia standards at the Medicines Control Authority of Zimbabwe Quality Control Laboratory, a World Health Organization prequalified laboratory. Data were extracted using a structured Excel database and analysed using Microsoft Excel, and GraphPad Prism Software was used for visualizations.

Results

Of the 198 samples, 86 (43.43%) were antiretrovirals, 54 (27.27%) antimalarials and 58 (29.29%) antituberculosis medicines. Of these 198 samples, 171 (86.36%) originated from Asia, 19 (9.60%) Africa and 8 (4.04%) Europe. All sampled medicines met their respective quality specifications with respect to tests, which included appearance, identification, assay, uniformity of mass, weight variation, disintegration, dissolution, pH and specific gravity, giving a compliance rate of 100%.

Conclusion

Antiretrovirals, antimalarials and antituberculosis medicines obtained from public healthcare facilities in Zambia through routine post-marketing surveillance met their quality standards. This might positively impact treatment outcomes for HIV/AIDS, malaria and tuberculosis. There is a need for large-scale continuous monitoring of the quality of medicines in order to ensure quality is maintained and substandard products removed from the pharmaceutical supply chain.

Health, Economic, and Social Impacts of Substandard and Falsified Medicines in Low- and Middle-Income Countries: A Systematic Review of Methodological Approaches

Little is known about the adverse health, economic, and social impacts of substandard and falsified medicines (SFMs). This systematic review aimed to identify the methods used in studies to measure the impact of SFMs in low- and middle-income countries (LMICs), summarize their findings, and identify gaps in the reviewed literature. A search of eight databases for published papers, and a manual search of references in the relevant literature were conducted using synonyms of SFMs and LMICs. Studies in the English language that estimated the health, social, or economic impacts of SFMs in LMICs published before June 17, 2022 were considered eligible. Search results generated 1,078 articles, and 11 studies were included after screening and quality assessment. All included studies focused on countries in sub-Saharan Africa. Six studies used the Substandard and Falsified Antimalarials Research Impact model to estimate the impact of SFMs. This model is an important contribution. However, it is technically challenging and data demanding, which poses challenges to its adoption by national academics and policymakers alike. The included studies estimate that substandard and falsified antimalarial medicines can account from 10% to ∼40% of total annual malaria costs, and SFMs affect rural and poor populations disproportionately. Evidence on the impact of SFMs is limited in general and nonexistent regarding social outcomes. Further research needs to focus on practical methods that can serve local authorities without major investments in terms of technical capacity and data collection.

Impact of the COVID-19 pandemic on the quality of medical products in Zimbabwe: a qualitative study based on key informant interviews with health system stakeholders

OBJECTIVE

To explore the impact of the Coronavirus disease 2019 (COVID-19) pandemic on the quality of medical products in Zimbabwe, including market risks for substandard and falsified products and impacts on quality assurance activities.

DESIGN

Qualitative study based on in-depth key informant interviews.

SETTING

Health system stakeholders across the medical product supply chain in Zimbabwe.

PARTICIPANTS

36 key informants were interviewed between April and June 2021.

RESULTS

We found that the COVID-19 pandemic disrupted quality assurance and regulatory activities of medical products in Zimbabwe, resulted in observations of poor-quality personal protective equipment (PPE) and other COVID-19-related products and led to increased risks to quality. Risks to quality due to COVID-19-related disruptions included increased layers of agents in the supply chain and an influx of non-traditional suppliers. COVID-19-related movement restrictions reduced access to health facilities and thus may have increased the usage of the informal market where smuggled and unregistered medical products are sold with less oversight by the regulator. Most reports of poor-quality medical products were for PPE, such as masks and infrared thermometers, used for the COVID-19 response. Besides these reports, many participants stated that the quality of essential medicines in the formal sector, not related to COVID-19, had largely been maintained during the pandemic due to the regulator's stringent quality assurance process. Incentives for suppliers to maintain quality to retain large donor-funded contracts, and the need for local wholesalers and distributors to comply with quality-related aspects of distribution agreements with global manufacturers of brand-name medical products, mitigated threats to quality.

CONCLUSIONS

The COVID-19 pandemic presented opportunities and market risks for circulation of substandard and falsified medical products in Zimbabwe. There is a need for policymakers to invest in measures to safeguard the quality of medical products during emergencies and to build resiliency against future supply chain shocks.

Modeling the Health and Economic Impact of Substandard and Falsified Medicines: A Review of Existing Models and Approaches

Substandard and falsified medicines are harmful to patients, causing prolonged illness, side effects, and preventable deaths. Moreover, they have an impact on the health system and society more broadly by leading to additional care, higher disease burden, productivity losses and loss of trust in health care. Models that estimate the health and economic impacts of substandard and falsified medicines can be useful for regulators to contextualize the problem and to make an economic case for solutions. Yet these models have not been systematically catalogued to date. We reviewed existing models that estimate the health and economic impact of substandard and falsified medicines to describe the varying modeling approaches and gaps in knowledge. We compared model characteristics, data sources, assumptions, and limitations. Seven models were identified. The models assessed the impact of antimalarial (n = 5) or antibiotic (n = 2) quality at a national (n = 4), regional (n = 2), or global (n = 1) level. Most models conducted uncertainty analysis and provided ranges around potential outcomes. We found that models are lacking for other medicines, few countries' data have been analyzed, and capturing population heterogeneity remains a challenge. Providing the best estimates of the impact of substandard and falsified medicines on a level that is actionable for decision-makers is important. To enable this, research on the impact of substandard and falsified medicines should be expanded to more medicine types and classes and tailored to more countries that are affected, with greater specificity.

Substandard and falsified medical product recalls in Zambia from 2018 to 2021 and implications on the quality surveillance systems

Background

Substandard and falsified (SF) medical products are removed from circulation through a process called 'product recall' by medicines regulatory agencies. In Zambia, the Zambia Medicines Regulatory Authority (ZAMRA) is responsible for recalling SF medical products from the Zambian market through passive and active surveillance methods. This study aimed to describe the prevalence of recalls of SF medical products and to analyse the frequently recalled therapeutic categories, dosage forms, categories of defects that led to the recalls and their sources with respect to the country of the marketing authorisation holder (MAH) or manufacturer.

Methods

We conducted a descriptive cross-sectional review of the product recalls issued by ZAMRA between January 2018 and December 2021. A search for all medical product alerts and recalls issued by ZAMRA was carried out by reviewing the internal post-marketing surveillance database kept at ZAMRA headquarters. Data were extracted using a structured Excel database and analysed using Microsoft Excel.

Results

A total of 119 alerts were received during the review period, of which 83 (69.7%) were product recalls. Oral solid dosage forms were the most recalled dosage form (53%). Furthermore, the number of recalls increased in 2020 (44.6%) and 2021 (22.9%), with the majority (20.5%) of the recalled products being substandard products classified as antiseptics and disinfectants and were attributed to the high demand during the COVID-19 pandemic. Manufacturing laboratory control issues were the reason for product recall in almost half (47.4%) of the cases. Most of the products recalled originated from India (38.6%), followed by Zambia (25.3%). Only one suspected falsified product was recalled between 2018 and 2021. A total of 66 recalls of the 83 products were initiated by ZAMRA, with only 17 voluntarily by foreign MAHs. No product recall was initiated by the local representatives of foreign manufacturers or MAH.

Conclusion

The majority of the pharmaceutical product recalls in Zambia were substandard products. Manufacturing laboratory control issues lead to most recalls and require investigation of the root causes, preventive action, and strict compliance with the good manufacturing practices guidelines by manufacturers.

Assessing the Impact of Substandard and Falsified Antimalarials in Benin

Substandard and falsified antimalarials contribute to the global malaria burden by increasing the risk of treatment failures, adverse events, unnecessary health expenditures, and avertable deaths, yet no study has examined this impact in western francophone Africa to date. In Benin, where malaria remains endemic and is the leading cause of mortality among children younger than 5 years, there is a lack of robust data to combat the issue effectively and inform policy decisions. We adapted the Substandard and Falsified Antimalarial Research Impact model to assess the health and economic impact of poor-quality antimalarials in this population. The model simulates population characteristics, malaria infection, care-seeking behavior, disease progression, treatment outcomes, and associated costs of malaria. We estimated approximately 1.8 million cases of malaria in Benin among children younger than 5 years, which cost $193 million (95% CI, $192-$193 million) in treatment costs and productivity losses annually. Substandard and falsified antimalarials were responsible for 11% (n = 693) of deaths and nearly $20.8 million in annual costs. Moreover, we found that replacing all antimalarials with quality-ensured artemisinin combination therapies (ACTs) could result in $29.6 million in cost savings and prevent 1,038 deaths per year. These results highlight the value of improving access to quality-ensured artemisinin combination therapies for malaria treatment and increasing care-seeking in Benin. Policymakers and key stakeholders should use these findings to advocate for increased access to quality-ensured antimalarials, inform policies and interventions to improve health-care access and quality, and reduce the burden of malaria.

Substandard and Falsified Medicines: Proposed Methods for Case Finding and Sentinel Surveillance

The World Health Organization and others warn that substandard and falsified medicines harm health and waste money, especially in low- and middle-income countries. However, no country has measured the market-wide extent of the problem, and no standardized methods exist to estimate the prevalence of either substandard or falsified medicines. This is, in part, because the task seems overwhelming; medicine markets are huge and diverse, and testing medicines is expensive. Many countries do operate some form of postmarket surveillance of medicine, but their methods and goals differ. There is currently no clear guidance on which surveillance method is most appropriate to meet specific public health goals. In this viewpoint, we aimed to discuss the utility of both case finding and risk-based sentinel surveillance for substandard and falsified medicines, linking each to specific public health goals. We posit that choosing the system most appropriate to the goal, as well as implementing it with a clear understanding of the factors driving the production and sale of substandard and falsified medicines, will allow for surveillance resources to be concentrated most efficiently. We adapted principles used for disease outbreak responses to suggest a case-finding system that uses secondary data to flag poor-quality medicines, proposing risk-based indicators that differ for substandard and falsified medicines. This system potentially offers a cost-effective way of identifying “cases” for market withdrawal, enhanced oversight, or another immediate response. We further proposed a risk-based sentinel surveillance system that concentrates resources on measuring the prevalence of substandard and falsified medicines in the risk clusters where they are most likely to be found. The sentinel surveillance system provides base data for a transparent, spreadsheet-based model for estimating the national prevalence of substandard and falsified medicines. The methods we proposed are based on ongoing work in Indonesia, a large and diverse middle-income country currently aiming to achieve universal health coverage. Both the case finding and the sentinel surveillance system are designed to be adaptable to other resource-constrained settings.

Supply-Side Barriers to the Use of Public Healthcare Facilities for Childhood Illness Care in Rural Zambia: A Cross-Sectional Study Linking Data from a Healthcare Facility Census to a Household Survey

Child mortality due to malaria and diarrhea can be reduced if proper treatment is received timely at healthcare facilities, but various factors hinder this. The present study assessed the associations between the use of public healthcare facilities among febrile/diarrheal children in rural Zambia and supply-side factors (i.e., the distance from the village to the nearest facility and the availability of essential human resources and medical equipment at the facility). Data from the Demographic and Health Survey 2018 and the Health Facility Census 2017 were linked. Generalized linear mixed models were used to assess the associations, controlling for clustering and other variables. The median distances to the nearest facility were 4.5 km among 854 febrile children and 4.6 km among 813 diarrheal children. Children who were over 10 km away from the facility were significantly less likely to use it, compared to those within 5 km (fever group: odds ratio (OR) = 0.36, 95% confidence interval (CI) = 0.20-0.66; diarrhea group: OR = 0.30, 95% CI = 0.18-0.51). The availability of human resources and equipment was, however, not significantly associated with facility use. Poor geographic access could be a critical barrier to facility use among children in rural Zambia.