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Kassahun H, Van Schepdael A, Ketema G, Adams E. Development and validation of a simple and affordable LC-UV method for identification and assay of selected antimicrobial medicines. J Pharm Biomed Anal 2024; 244:116127. [PMID: 38554556 DOI: 10.1016/j.jpba.2024.116127] [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: 02/01/2024] [Revised: 03/14/2024] [Accepted: 03/25/2024] [Indexed: 04/01/2024]
Abstract
Antimicrobials, particularly antibiotics, are among the most common classes of drugs reported as substandard and falsified (SF) in developing countries. Therefore, it is important to develop simple and affordable analytical methods for the quality control of antimicrobial medicines. In this study, a liquid chromatographic method with ultraviolet detection (LC-UV) was developed and validated for the screening and quantification of 13 antimicrobial medicines and one beta-lactamase inhibitor in pharmaceutical formulations. LC separation was carried out on a Kinetex C18 column (150 mm × 4.6 mm, 2.6 µm) with gradient elution. The mobile phase consisted of mixtures of acetonitrile-water-10 mM phosphate buffer pH 3.5 at ratios of 3:92:5, v/v/v for mobile phase A and 50:45:5, v/v/v for mobile phase B with a flow rate of 0.5 mL/min. The screening method was intended for confirmation of the identity of the actives and validated for specificity and robustness, whereas the quantification method (using only a different detection wavelength) was further validated in terms of linearity, accuracy, sensitivity and precision (repeatability, intermediate precision). For all compounds, the method was found to be linear (r2 > 0.999), precise (%RSD < 1%), accurate (% recovery of 98-102%), sensitive, specific and robust. The developed LC method was successfully applied for the identification and assay of 12 antimicrobial samples from Ethiopia. Among the 12 samples analyzed, one (8.3%) product was confirmed to be falsified.
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Affiliation(s)
- Haile Kassahun
- KU Leuven, Department of Pharmaceutical and Pharmacological Sciences, Pharmaceutical Analysis, Herestraat 49, O&N2, PB, 923, Leuven 3000, Belgium; Wollo University, College of Medicine and Health Sciences, Department of Pharmacy P.O. Box 1145, Dessie, , Ethiopia
| | - Ann Van Schepdael
- KU Leuven, Department of Pharmaceutical and Pharmacological Sciences, Pharmaceutical Analysis, Herestraat 49, O&N2, PB, 923, Leuven 3000, Belgium
| | - Gebremariam Ketema
- Wollo University, College of Medicine and Health Sciences, Department of Pharmacy P.O. Box 1145, Dessie, , Ethiopia
| | - Erwin Adams
- KU Leuven, Department of Pharmaceutical and Pharmacological Sciences, Pharmaceutical Analysis, Herestraat 49, O&N2, PB, 923, Leuven 3000, Belgium.
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Adhikari B, Ranabhat K, Khanal P, Poudel M, Marahatta SB, Khanal S, Paudyal V, Shrestha S. Procurement process and shortages of essential medicines in public health facilities: A qualitative study from Nepal. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003128. [PMID: 38696399 PMCID: PMC11065305 DOI: 10.1371/journal.pgph.0003128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 03/25/2024] [Indexed: 05/04/2024]
Abstract
Ensuring access to essential medicines remains a formidable challenge in Nepal. The specific reasons for the shortage of essential medicines within Nepal have not been extensively investigated. This study addresses challenges associated with access to essential medicines, procurement process difficulties, and functionality of inventory management systems at different levels of public health facilities. Fifty-nine semi-structured in-depth interviews were conducted with health managers and service providers at provincial and local levels in six randomly selected districts of Bagmati province, Nepal. Interviews were audiotaped and transcribed verbatim, and the results were analyzed using the inductive approach and were later mapped within the four domains of "Procurement of essential medicines". The major barriers for the effective management of essential medicines included delays in the procurement process, primarily locally, leading to frequent stock-out of essential drugs, particularly at the health post level. Additionally, challenges arise from storage problems, mainly due to insufficient storage space and the need to manage additional comorbidities related to COVID-19. Other identified challenges encompass the absence of training on logistics management information systems, a lack of information technology resources in primary health facilities, inadequate qualified human resources to operate the IT system, and insufficient power backup. Moreover, unrealistic demand estimation from the service points, inadequate transportation costs, and manual inventory management systems further contributed to the complex landscape of challenges. This study identified procurement delays as the primary cause of essential medicine shortages in Bagmati Province, Nepal. We recommend implementing comprehensive procurement guidelines, collaborative training, and dedicated budgets to address this issue. Improving the procurement and inventory management process in low-resource settings requires a well-trained workforce, suitable storage spaces, and enhanced coordinated administrative tiers within health facilities at different levels to ensure the year-round availability of essential medicines in these settings.
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Affiliation(s)
- Basant Adhikari
- Ministry of Health, Bagmati Province, Hetauda, Nepal
- Nepal Public Health Association, Lalitpur, Nepal
- ASEAN Institute for Health Development, Mahidol University, Salaya, Thailand
| | - Kamal Ranabhat
- Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
- Central Department of Public Health, Institute of Medicine, Tribhuwan University, Kathmandu, Nepal
| | - Pratik Khanal
- Nepal Public Health Association, Lalitpur, Nepal
- Department of Global Public Health and Primary Care, Bergen Centre for Ethics and Priority Setting in Health, University of Bergen, Bergen, Norway
| | - Manju Poudel
- Oxford University Clinical Research Unit, Patan Academy of Health Science, Lalitpur, Nepal
| | - Sujan Babu Marahatta
- Nepal Open University, Lalitpur, Nepal
- Manmoohan Memorial Institute of Health Science, Kathmandu, Nepal
- Department of Public Health Sciences, University of California Davis, Davis, California, United States of America
- Bournemouth University, Poole, United Kingdom
| | - Saval Khanal
- Health Economics Consulting, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Vibhu Paudyal
- School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College, London, United Kingdom
| | - Sunil Shrestha
- School of Pharmacy, Monash University Malaysia, Selangor, Malaysia
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Ravinetto R, Henriquez R, Srinivas PN, Bradley H, Coetzee R, Ochoa TJ, Semuto Ngabonziza JC, Mazarati JB, Van Damme W, van de Pas R, Vandaele N, Torreele E. Shaping the future of global access to safe, effective, appropriate and quality health products. BMJ Glob Health 2024; 9:e014425. [PMID: 38195155 PMCID: PMC10807033 DOI: 10.1136/bmjgh-2023-014425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 12/10/2023] [Indexed: 01/11/2024] Open
Affiliation(s)
- Raffaella Ravinetto
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
- School of Public Health, University of the Western Cape, Cape Town, Western Cape, South Africa
| | - Rodrigo Henriquez
- Maestría de Epidemiología y Salud Colectiva, Universidad Andina Simón Bolívar, Quito, Ecuador
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Hazel Bradley
- School of Public Health, University of the Western Cape, Cape Town, Western Cape, South Africa
| | - Renier Coetzee
- School of Public Health, University of the Western Cape, Cape Town, Western Cape, South Africa
| | - Theresa J Ochoa
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Jean Claude Semuto Ngabonziza
- Research, Innovation and Data Science Division, Rwanda Biomedical Center, Kigali, Rwanda
- Department of Clinical Biology, University of Rwanda, Kigali, Rwanda
| | | | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | | | - Nico Vandaele
- Access-To-Medicines Research Centre, KU Leuven, Leuven, Belgium
| | - Els Torreele
- , Institute for Innovation and Public Purpose, University College London, London, UK
- Independent Researcher and Advisor, Geneva, Switzerland
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4
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Tack B, Vita D, Ntangu E, Ngina J, Mukoko P, Lutumba A, Vangeluwe D, Toelen J, Allegaert K, Lunguya O, Ravinetto R, Jacobs J. Challenges of Antibiotic Formulations and Administration in the Treatment of Bloodstream Infections in Children Under Five Admitted to Kisantu Hospital, Democratic Republic of Congo. Am J Trop Med Hyg 2023; 109:1245-1259. [PMID: 37903440 DOI: 10.4269/ajtmh.23-0322] [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: 05/18/2023] [Accepted: 09/08/2023] [Indexed: 11/01/2023] Open
Abstract
Severe bacterial infections in children need prompt, appropriate antibiotic treatment. We report challenges observed within a prospective, cohort study on antibiotic efficacy in non-typhi Salmonella bloodstream infection (NCT04850677) in Kisantu district hospital (Democratic Republic of Congo). Children (aged > 28 days to < 5 years) admitted with suspected bloodstream infection (August 1, 2021 through July 31, 2022) were enrolled and followed until day 3 or discharge for non-typhi Salmonella patients. Antibiotics were administered to 98.4% (1,838/1,867) of children, accounting for 2,296 antibiotic regimens (95.7% intravenous, 4.3% oral). Only 78.3% and 61.8% of children were, respectively, prescribed and administered antibiotics on the admission day. At least one dose was not administered in 3.6% of children, mostly because of mismatch of the four times daily cefotaxime schedule with the twice-daily administration rounds. Inappropriate intravenous administration practices included multidose use, air-venting, and direct injection instead of perfusion. There was inaccurate aliquoting in 18.0% (32/178) of intravenous ciprofloxacin regimens, and thus administered doses were > 16% below the intended dose. Dosing accuracy of oral suspensions was impaired by lack of instructions for reconstitution, volume indicators, and/or dosing devices. Adult-dose tablets were split without/beyond scoring lines in 84.4% (27/32) of tablets. Poor availability and affordability of age-appropriate oral formulations contributed to low proportions of intravenous-to-oral switch (33.3% (79/237) of non-typhi Salmonella patients). Other quality issues included poor packaging, nonhomogeneous suspensions, and unsafe water for reconstitution. In conclusion, poor antibiotic products (no age-appropriate formulations, poor quality and access), processes (delayed prescription/administration, missed doses), and practices (inaccurate doses, [bio]safety risks) must be urgently addressed to improve pediatric antibiotic treatment.
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Affiliation(s)
- Bieke Tack
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Belgium
- Department of Pediatrics, KU Leuven University Hospitals Leuven, Belgium
| | - Daniel Vita
- Saint Luc Hôpital Général de Référence Kisantu, Democratic Republic of Congo
| | - Emmanuel Ntangu
- Saint Luc Hôpital Général de Référence Kisantu, Democratic Republic of Congo
| | - Japhet Ngina
- Saint Luc Hôpital Général de Référence Kisantu, Democratic Republic of Congo
| | - Pathy Mukoko
- Saint Luc Hôpital Général de Référence Kisantu, Democratic Republic of Congo
| | - Adèle Lutumba
- Saint Luc Hôpital Général de Référence Kisantu, Democratic Republic of Congo
| | | | - Jaan Toelen
- Department of Pediatrics, KU Leuven University Hospitals Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, the Netherlands
| | - Octavie Lunguya
- Department of Microbiology, Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo
- Department of Medical Biology, University Teaching Hospital of Kinshasa, Democratic Republic of Congo
| | - Raffaella Ravinetto
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Belgium
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Khuluza F, Chiumia FK, Nyirongo HM, Kateka C, Hosea RA, Mkwate W. Temperature variations in pharmaceutical storage facilities and knowledge, attitudes, and practices of personnel on proper storage conditions for medicines in southern Malawi. Front Public Health 2023; 11:1209903. [PMID: 37808988 PMCID: PMC10556513 DOI: 10.3389/fpubh.2023.1209903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Objective We assessed the temperature variations in pharmacies and medicine storage areas in southern Malawi and conducted a knowledge, attitude and practices survey for personnel who manage medicine stores in various health facilities. Methods This was a longitudinal study design that used installed Tempmate® thermometers in 27 selected health facilities to record temperatures every 15 min for a period of 9 months. In addition, a questionnaire was used to assess the knowledge, attitude, and practices regarding good pharmaceutical storage. Observations were also made on the storage structures of the facilities and compared with the mean kinetic temperature. Results Storage temperature ranged from 13.8°C to 42°C with mean kinetic temperature (MKT) being 25.3°C (95% CI 24.4-26.2°C). Mean temperature for public facilities was lower (23.8°C) than the faith-based facilities (25.2°C) and private facilities (26.6°C). In terms of level of health care, lower temperatures were recorded in facilities offering tertiary level of care as compared to secondary and primary care facilities, p < 0.001. For the type of storage facilities, storage-in-a-box unit (SIAB) presented lower temperatures than ordinary storage areas (non-SIAB), p < 0.001. Majority of health workers (69%) had good knowledge on proper storage conditions. Air conditioners and thermometers were available in 88.4 and 76.9% of the facilities, respectively. However, few facilities utilized the air conditioners due to electricity problems. About 46.15% of the participants were able to correctly record temperatures (at least twice a day) for the storage facilities, 23.07% did not properly record while 30.77% of the personnel did not keep temperature records at all. Limited storage space was among the challenges that facilities encounter to maintain proper storage conditions. Conclusion Despite having the necessary knowledge on proper storage conditions, the pharmacy personnel failed to adhere to good pharmaceutical storage practices due to resource limitations. There is a need for stakeholder interventions such as increasing budget allocation to address the challenges faced by the health facilities.
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Kingori P, Peeters Grietens K, Abimbola S, Ravinetto R. Uncertainties about the quality of medical products globally: lessons from multidisciplinary research. BMJ Glob Health 2023; 6:e012902. [PMID: 37344004 PMCID: PMC10367018 DOI: 10.1136/bmjgh-2023-012902] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 05/30/2023] [Indexed: 06/23/2023] Open
Affiliation(s)
- Patricia Kingori
- Wellcome Centre for Ethics and Humanities. Ethox Centre, University of Oxford, Nuffield Department of Population Health, University of Oxford, UK
| | | | - Seye Abimbola
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Raffaella Ravinetto
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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7
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Chiumia FK, Nyirongo HM, Kampira E, Muula AS, Khuluza F. Burden of and factors associated with poor quality antibiotic, antimalarial, antihypertensive and antidiabetic medicines in Malawi. PLoS One 2022; 17:e0279637. [PMID: 36574444 PMCID: PMC9794066 DOI: 10.1371/journal.pone.0279637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To assess the prevalence and factors associated with substandard and falsified (SF) medicines among antibiotic, antimalarial, antihypertensive and antidiabetic medicines in Malawi. METHODS We conducted a cross-sectional study in 23 public, faith-based and private health facilities in Zomba, Machinga and Nsanje districts. We analyzed oral medicine samples of commonly used medicines among antibiotics, antimalarial, antihypertensive and antidiabetics in accordance with Malawi Essential Medicines List and local treatment guidelines. These medicines were subjected to visual inspection for any defects and screening for the content of active pharmaceutical ingredient and disintegration of dosage units. Samples that failed during screening and at least 10% of those that passed were subjected to pharmacopeia assay and dissolution test for confirmation. We used thin layer chromatography and disintegration test methods provided in the Global Pharma Health Fund minilab® for the screening purposes. We conducted confirmatory test using High-Performance Liquid Chromatography (HPLC) or ultra-violet/visible spectrophotometer and dissolution. RESULTS Of the 293 medicine samples collected, 14.3% were SF medicines. Among the SF medicines were 12.5% of Amlodipine (1/8), 19.2% of Amoxicillin (5/26), 72.2% of Atenolol (8/11), 21.2% of Ciprofloxacin (7/33), 14.3% of Enalapril (1/7), 44.4% of Flucloxacillin (4/9), and 35.7% of sulfadoxine/ pyrimethamine (10/28). Medicine quality was associated with therapeutic medicine class, stated origin of manufacturer, primary packaging material and geographical location. Antimalarial and antidiabetic medicines were of better quality as compared to antibiotics, odds ratio OR 4.2 (95% CI 1.7-9.49), p < 0.002 and OR 5.6 (95% CI 1.21-26.09), p < 0.028 respectively. In terms of stated country of origin, the prevalence of SF medicines was 30% (15/50), 33% (9/27), 26.7% (4/15) and 6.6% (8/122) for medicines stated to be manufactured in Malawi, China, Kenya and India respectively. CONCLUSION This study presents the first findings on the assessment of quality of medicines since the establishment of the national pharmacovigilance center in 2019 in Malawi. It is revealed that the problem of SF medicines is not improving and hence the need for further strengthening of quality assurance systems in Malawi.
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Affiliation(s)
| | | | - Elizabeth Kampira
- Department of Medical Laboratory Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Felix Khuluza
- Department of Pharmacy, Kamuzu University of Health Sciences, Blantyre, Malawi
- * E-mail:
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Chabalenge B, Jere E, Nanyangwe N, Hikaambo C, Mudenda S, Banda M, Kalungia A, Matafwali S. Substandard and falsified medical product recalls in Zambia from 2018 to 2021 and implications on the quality surveillance systems. THE JOURNAL OF MEDICINE ACCESS 2022; 6:27550834221141767. [PMID: 36601496 PMCID: PMC9806395 DOI: 10.1177/27550834221141767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/08/2022] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Billy Chabalenge
- Department of Medicines Control, Zambia
Medicines Regulatory Authority, Lusaka, Zambia,Billy Chabalenge, Department of Medicines
Control, Zambia Medicines Regulatory Authority, P. O Box 31890, Lusaka 10101,
Zambia.
| | - Elimas Jere
- Department of Medicines Control, Zambia
Medicines Regulatory Authority, Lusaka, Zambia
| | - Namuchindo Nanyangwe
- Department of Medicines Control, Zambia
Medicines Regulatory Authority, Lusaka, Zambia
| | - Christabel Hikaambo
- Department of Chemistry, Faculty of
Science, University of Cape Town, Cape Town, South Africa
| | - Steward Mudenda
- Department of Pharmacy, University of
Zambia, Lusaka, Zambia
| | - Michelo Banda
- Department of Pharmacy, University of
Zambia, Lusaka, Zambia
| | - Aubrey Kalungia
- Department of Pharmacy, University of
Zambia, Lusaka, Zambia
| | - Scott Matafwali
- Department of Clinical Research,
Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical
Medicine, London, UK
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Shedul G, Sanuade OA, Ugwuneji EN, Ojo TM, Vijay A, Ponzing P, Okpe I, Shedul GL, Huffman MD, Ojji D, Hirschhorn LR. Stakeholder perspectives on the demand and supply factors driving substandard and falsified blood pressure lowering medications in Nigeria: a qualitative study. BMJ Open 2022; 12:e063433. [PMID: 36549744 PMCID: PMC9791447 DOI: 10.1136/bmjopen-2022-063433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Although substandard and falsified (SF) blood pressure (BP) lowering medications are a global problem, qualitative research exploring factors driving this in Nigeria has not been reported. This study provides information on factors driving demand for and supply of low-quality BP lowering medications in Nigeria and potential strategies to address these factors. METHODS This was a cross-sectional qualitative study. Between August 2020 and September 2020, we conducted 11 in-depth interviews and 7 focus group discussions with administrators of health facilities, major manufacturers and distributors of BP lowering medications, pharmacists, drug regulators, patients and primary care physicians purposively sampled from the Federal Capital Territory, Nigeria. Data were analysed using directed content analysis, with the aid of Dedoose. RESULTS We found that demand for SF BP lowering medications in Nigeria was driven by high out-of-pocket expenditure and stockouts of quality-assured BP lowering medications. Supply of low-quality BP lowering medications was driven by limited in-country manufacturing capacity, non-adherence to good manufacturing and distribution practices, under-resourced drug regulatory systems, ineffective healthcare facility operations, poor distribution practices, limited number of trained pharmacists and the COVID-19 pandemic which led to stockouts. Central medicine store procurement procedures, active pharmaceutical ingredient quality check and availability of trained pharmacists were existing strategies perceived to lower the risk of supply and demand of SF BP lowering medications. CONCLUSION Our findings suggest that demand for and supply of SF BP lowering medications in Nigeria are driven by multi-level, interrelated factors. Multi-pronged strategies need to target stakeholders and systems involved in drug production, distribution, prescription, consumption, regulation and pricing.
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Affiliation(s)
- Grace Shedul
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Olutobi Adekunle Sanuade
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah, USA
- Robert J Havey Institute for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Eugenia N Ugwuneji
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Tunde M Ojo
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Aishwarya Vijay
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Patrick Ponzing
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Inuwa Okpe
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Gabriel Lamkur Shedul
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Mark D Huffman
- Robert J Havey Institute for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Cardiovascular Division and Global Health Center, Washington University in St Louis, St Louis, Missouri, USA
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Dike Ojji
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
- Department of Internal Medicine, Faculty of Clinical Sciences, University of Abuja, Abuja, Nigeria
| | - Lisa R Hirschhorn
- Robert J Havey Institute for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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10
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Shabani JBB, Kayitare E, Nyirimigabo E, Habyalimana V, Murindahabi MM, Ntirenganya L, Irasabwa C, Rutungwa E, Munyangaju JE, Hahirwa I. The capacity of young national medicine regulatory authorities to ensure the quality of medicines: case of Rwanda. J Pharm Policy Pract 2022; 15:90. [PMID: 36434730 PMCID: PMC9700871 DOI: 10.1186/s40545-022-00492-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/13/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Access to quality medicines is a global initiative to ensure universal health coverage. However, the limited capacity of National Medicines Regulatory Authorities (NMRAs) to prevent and detect the supply of poor-quality medicines led to the predominance of sub-standard and falsified (SF) medicines in the supply chains of many countries. Therefore, this study was designed to assess the capacity of a young NMRA to ensure the quality of medicines with Rwanda as a case study. OBJECTIVE This study aimed to assess the capacity of the Rwanda FDA, a young NMRA, to identify gaps and existing opportunities for improving regulatory capacity and ensuring the quality of medicines. METHODS This study used a descriptive cross-sectional design with both quantitative and qualitative approaches. The quantitative approach used a self-administered questionnaire to collect data from employees of Rwanda FDA who are involved in medicine regulatory practices based on their positions while the qualitative research approach covered a desk review of key regulatory documents. The data collection tool was developed from the World Health Organization (WHO) Global Benchmarking Tool (GBT) for "Evaluation of National Regulatory System of Medical Products Revision VI". RESULTS Of the 251 WHO sub-indicators assessed, 179 sub-indicators (71%) were fully implemented, 17 sub-indicators (7%) were partially implemented, 9 sub-indicators (4%) were ongoing and 46 sub-indicators (18%) were not implemented by the time of the study. The results of the study showed that the estimated maturity level at which Rwanda FDA operates is maturity level 2. The study reported the challenges hindering the implementation of key regulatory functions that need to be addressed. Challenges reported include but are not limited to understaffing, lack of automation system, poor implementation of the quality management system, lack of screening technologies for SF medicines, low capacity of the quality control laboratory to test all sampled medicines and lack of regulatory inspection tools/equipment. CONCLUSION Findings indicated that all key regulatory functions were operating and supported by the legal framework. However, the implementation of key regulatory functions faced challenges that need to be addressed for better organizational effectiveness and compliance with the requirements of a higher maturity level.
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Affiliation(s)
- Jean Baptiste B. Shabani
- grid.10818.300000 0004 0620 2260EAC Regional Centre of Excellence for Vaccines, Immunization, and Health Supply Chain Management, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda ,Rwanda Food and Drugs Authority, Kigali, Rwanda
| | - Egide Kayitare
- grid.10818.300000 0004 0620 2260School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | | | | | | | | | - Eugene Rutungwa
- grid.10818.300000 0004 0620 2260EAC Regional Centre of Excellence for Vaccines, Immunization, and Health Supply Chain Management, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda ,grid.10818.300000 0004 0620 2260School of Business, College of Business and Economics, University of Rwanda, Kigali, Rwanda
| | | | - Innocent Hahirwa
- grid.10818.300000 0004 0620 2260School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
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11
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Jenkins D, Diallo C, Payne M. Detecting falsified oral contraceptives by visual assessment and diffuse reflectance spectroscopy (350–2500 nm): the need for supplementing traditional pharmacopeia techniques and the public health implications. Heliyon 2022; 8:e10837. [PMID: 36217469 PMCID: PMC9547234 DOI: 10.1016/j.heliyon.2022.e10837] [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: 06/09/2022] [Revised: 09/14/2022] [Accepted: 09/26/2022] [Indexed: 11/08/2022] Open
Abstract
Objectives Substandard and falsified pharmaceuticals can present a major health risk, particularly for low- and middle-income countries. In a Sub-Saharan African market, United States Agency for International Development (USAID) staff found an oral contraceptive product (0.15 mg levonorgestrel/0.03 mg ethinyl estradiol) labeled with a logo (and brand name) visually matching one historically used by USAID but purportedly manufactured by an unauthorized source. Additional assessment was conducted to determine if more evidence of falsification was present to better understand the public health impact. Study design Relative to a control, the suspect sample was assessed visually for tablet features and with United States and International Pharmacopeia methods for levonorgestrel/ethinyl estradiol tablets. Diffuse reflectance spectra (350–2500 nm) were collected to further characterize the sample. Results Although the suspect sample aligned with pharmacopeia tests, visual examination of tablet characteristics and diffuse reflectance spectroscopy (350–2500 nm) assessments supported the tablets were not the same as control samples, confirming the suspect sample was falsified. These results raised concerns for the overall regulatory oversight available for the market with uncertainty regarding the true clinical bioequivalence levels (although adequate dissolution levels were observed). Conclusions Comprehensive characterization of suspect pharmaceuticals from the field can often be required depending on the nature of the sample and can have dramatic implications for understanding the public health risks to the end user within the local market. Simple visual assessment and spectroscopic techniques to screen a sample can help to supplement traditional pharmacopeia approaches. Implications Proper characterization of suspect pharmaceuticals is necessary to best understand their potential public health impact. Situations can occur where traditional pharmacopeial techniques may not adequately characterize a sample. Visual assessments and diffuse reflectance spectroscopy can be supplemented to provide a more holistic analysis.
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12
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Vidhamaly V, Bellingham K, Newton PN, Caillet C. The quality of veterinary medicines and their implications for One Health. BMJ Glob Health 2022; 7:bmjgh-2022-008564. [PMID: 35918072 PMCID: PMC9351321 DOI: 10.1136/bmjgh-2022-008564] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 07/03/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Substandard and falsified (SF) veterinary medicines affect animal health, agricultural production and food security and will influence antimicrobial resistance (AMR) in both animals and humans. Yet, our understanding of their extent and impact is poor. We assess the available public domain evidence on the epidemiology of SF veterinary medicines, to better understand their prevalence and distribution and their public health impact on animals and humans. METHODS Searches were conducted in Embase, PubMed, MEDLINE, Global Health, Web of Science, CAB Abstracts, Scopus, Google Scholar, Google and websites with interest in veterinary medicines quality up to 28 February 2021. Identified articles in English and French were screened for eligibility. The Medicine Quality Assessment Reporting Guidelines were used to assess the quality of prevalence surveys. RESULTS Three hundred and fourteen publications were included with a failure frequency (the percentage of samples that failed at least one quality test) of 6.5% (2335/35 733). The majority of samples were from post-marketing surveillance by medicines regulatory authorities of the Republic of Korea and China. A small proportion (3.5%) of samples, all anti-infectives, were from 20 prevalence surveys, with more than half (53.1%, 662/1246) collected in low-income and lower middle-income countries in Africa and Asia. The prevalence survey sample size ranged from 4 to 310 samples (median (Q1-Q3): 50 (27-80)); 55.0% of surveys used convenience outlet sampling methods. In 20 prevalence surveys more than half of the samples (52.0%, 648/1246) failed at least one quality test. The most common defects reported were out-of-specification active pharmaceutical ingredient(s) (API) content, failure of uniformity of units and disintegration tests. Almost half of samples (49.7%, 239/481) that failed API content tests contained at least one of the stated APIs below pharmacopoeial limits. Fifty-two samples (4.2% of all samples) contained one or more incorrect API. One hundred and twenty-three publications described incidents (recalls/seizures/case reports) of SF veterinary medicines in 29 countries. CONCLUSION The data suggest that SF veterinary products are likely to be a serious animal and public health problem that has received limited attention. However, few studies of SF veterinary medicines are available and are geographically restricted. Lower API content and disintegration/dissolution than recommended by pharmacopoeial standards risks treatment failure, animal suffering and contribute to AMR. Our findings highlight the need of more research, with robust methodology, to better inform policy and implement measures to assure the quality of veterinary medicines within supply chains. The mechanism and impact of SF veterinary products on animal and human health, agricultural production, their economy and AMR need more transdisciplinary research.
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Affiliation(s)
- Vayouly Vidhamaly
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Medicine Quality Research Group, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Nuffield Department of Medicine, Medicine Quality Research Group, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, UK.,Nuffield Department of Medicine, Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Medicine Quality Research Group, University of Oxford, Oxford, UK
| | - Konnie Bellingham
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Medicine Quality Research Group, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Nuffield Department of Medicine, Medicine Quality Research Group, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, UK.,Nuffield Department of Medicine, Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Medicine Quality Research Group, University of Oxford, Oxford, UK
| | - Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Medicine Quality Research Group, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Nuffield Department of Medicine, Medicine Quality Research Group, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, UK.,Nuffield Department of Medicine, Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Medicine Quality Research Group, University of Oxford, Oxford, UK
| | - Céline Caillet
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Medicine Quality Research Group, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic .,Nuffield Department of Medicine, Medicine Quality Research Group, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, UK.,Nuffield Department of Medicine, Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Medicine Quality Research Group, University of Oxford, Oxford, UK
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13
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Masini T, Macé C, Heide L, Hamill H, Hampshire K, Newton PN, Ravinetto R. Out of the boxes, out of the silos: The need of interdisciplinary collaboration to reduce poor-quality medical products in the supply chain. Res Social Adm Pharm 2022; 18:3694-3698. [DOI: 10.1016/j.sapharm.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/06/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
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14
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Macé C, Rägo L, Ravinetto R. How the concept of WHO-listed authorities will change international procurement policies for medicines. BMJ Glob Health 2022; 6:e008109. [PMID: 35144982 PMCID: PMC8883025 DOI: 10.1136/bmjgh-2021-008109] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/26/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Lembit Rägo
- Secretary-General, Council for International Organisations of Medical Sciences, Geneva, Switzerland
| | - Raffaella Ravinetto
- Department of Public Health, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
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Maci J, Marešová P. Critical Factors and Economic Methods for Regulatory Impact Assessment in the Medical Device Industry. Healthc Policy 2022; 15:71-91. [PMID: 35082542 PMCID: PMC8784272 DOI: 10.2147/rmhp.s346928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/30/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Methods Results Discussion
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Affiliation(s)
- Jan Maci
- Department of Economics, Faculty of Informatics and Management, University of Hradec Králové, Hradec Králové, Czech Republic
| | - Petra Marešová
- Department of Economics, Faculty of Informatics and Management, University of Hradec Králové, Hradec Králové, Czech Republic
- Correspondence: Petra Marešová Department of Economics, Faculty of Informatics and Management, University of Hradec Králové, Rokitanskeho 62, Hradec Králové, 50003, Czech RepublicTel +420 737928745 Email
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Hasnida A, Kok MO, Pisani E. Challenges in maintaining medicine quality while aiming for universal health coverage: a qualitative analysis from Indonesia. BMJ Glob Health 2021; 6:bmjgh-2020-003663. [PMID: 34049935 PMCID: PMC8166595 DOI: 10.1136/bmjgh-2020-003663] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/11/2020] [Accepted: 10/21/2020] [Indexed: 01/15/2023] Open
Abstract
Introduction Indonesia, the world’s fourth most populous nation, is close to achieving universal health coverage (UHC). A widely-publicised falsified vaccine case in 2016, coupled with a significant financial deficit in the national insurance system, has contributed to concern that the rapid scale-up of UHC might undermine medicine quality. We investigated the political and economic factors that drive production and trade of poor-quality medicines in Indonesia. Methods We reviewed academic publications, government regulations, technical agency documents and news reports to develop a semi-structured questionnaire. We interviewed healthcare providers, policy-makers, medicine regulators, pharmaceutical manufacturers, patients and academics (n=31). We included those with in-depth knowledge about the falsified vaccine case or the pharmaceutical business, medicine regulation, prescribing practice and the implementation of UHC. We coded data using NVivo software and analysed by constant comparative method. Results The scale-up of UHC has cut revenues for physicians and pharmaceutical manufacturers. In the vaccine case, free, quality-assured vaccines were available but some physicians, seeking extra revenue, promoted expensive alternatives. Taking advantage of poor governance in private hospitals, they purchased cut-price ‘vaccines’ from freelance salespeople. A single-winner public procurement system which does not explicitly consider quality has slashed the price paid for covered medicines. Trade, industrial and religious policies simultaneously increased production costs, pressuring profit margins for manufacturers and distributors. They reacted by cutting costs (potentially threatening quality) or by market withdrawal (leading to shortages which provide a market for falsifiers). Shortages and physician-promoted irrational demand push patients to buy medicines in unregulated channels, increasing exposure to falsified medicines. Conclusion Market factors, including political pressure to reduce medicine prices and healthcare provider incentives, can drive markets for substandard and falsified medicines. To protect progress towards UHC, policy-makers must consider the potential impact on medicine quality when formulating rules governing health financing, procurement, taxation and industry.
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Affiliation(s)
- Amalia Hasnida
- Health Care Governance, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, Netherlands .,Migunani Research Institute, Yogyakarta, Indonesia
| | - Maarten Olivier Kok
- Health Care Governance, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, Netherlands.,Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Elizabeth Pisani
- Health Care Governance, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, Netherlands.,Policy Institute, King's College London, London, London, UK
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Narwal S, Jain S. Building Resilient Health Systems: Patient Safety during COVID-19 and Lessons for the Future. JOURNAL OF HEALTH MANAGEMENT 2021. [DOI: 10.1177/0972063421994935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: The COVID-19 pandemic has profoundly impacted the country’s health systems and diminished its capability to provide safe and effective healthcare. This article attempts to review patient safety issues during COVID-19 pandemic in India, and derive lessons from national and international experiences to inform policy actions for building a ‘resilient health system’. Methods: Systematic review of existing published articles, government and media reports was undertaken. Online databases were searched using key terms related to patient safety during COVID-19 and health systems resilience. Seventy-three papers were included dependent on their relevance to research objectives. Findings: Patient safety was impacted during COVID-19, owing to sub-optimal infection prevention and control measures coupled with reduced access to essential health services. This was largely due to inadequate infrastructure, human and material resources resulting from chronic underinvestment in public health systems, paucity of reliable data for evidence-based actions and limited leadership and regulatory capacity. Conclusions: India’s health systems were found ill prepared to tackle large-scale pandemic, which has major implications for patient safety. The shortcomings observed in the COVID-19 response must be rectified and comprehensive health sector reforms should be initiated for building agile and resilient health systems that can withstand future pandemics.
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Affiliation(s)
| | - Susmit Jain
- Associate Professor, IIHMR University, Jaipur, India
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18
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Ali GKM, Ravinetto R, Alfadl AA. The importance of visual inspection in national quality assurance systems for medicines. J Pharm Policy Pract 2020; 13:52. [PMID: 32939287 PMCID: PMC7487550 DOI: 10.1186/s40545-020-00264-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
| | - Raffaella Ravinetto
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
| | - Abubakr Abdelraouf Alfadl
- Pharmacy Practice Department, Unaizah College of Pharmacy, Qassim University, Buraydah, Saudi Arabia
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