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Feeney AJ, Goad JA, Flaherty GT. Global perspective of the risks of falsified and counterfeit medicines: A critical review of the literature. Travel Med Infect Dis 2024; 61:102758. [PMID: 39218049 DOI: 10.1016/j.tmaid.2024.102758] [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: 08/13/2024] [Revised: 08/29/2024] [Accepted: 08/29/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The increasing prevalence of falsified and counterfeit medicines globally poses risks to international travellers. This narrative literature review examines the global challenge of falsified and counterfeit medicines, with a specific focus on risks for travellers. The aim is to provide a comprehensive understanding of this multidimensional issue, exploring potential solutions for effective intervention. METHODS A comprehensive search of databases, including PubMed, MEDLINE, and Scopus, as well as relevant reports from international organisations, was undertaken. There was a focus on extracting information pertaining to the prevalence, types, and geographical patterns of falsified and counterfeit medicines encountered by international travellers. Synthesising this information helped to identify overarching trends and patterns. This narrative review utilised a thematic analysis approach to synthesise the findings. RESULTS The findings revealed a diverse range of counterfeit drug categories, spanning from antibiotics to lifestyle medications, posing unique risks to travellers navigating the global pharmaceutical landscape. The review emphasises the geographical distribution of these drugs, with varying consequences for both high- and low-income nations. The inadequate formulations and inconsistent drug release arising from these practices pose severe threats to public health, especially for individuals travelling abroad. The review also highlights the significance of international collaboration in addressing this global challenge, as pharmaceutical supply chains seamlessly cross borders, necessitating a collaborative approach for effective regulation and enforcement. CONCLUSIONS This review underscores the need for targeted research, collaborative interventions, and technological innovations to address the complexities associated with falsified and counterfeit medicines, ensuring the safety and well-being of international travellers.
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Affiliation(s)
- Aonghus J Feeney
- School of Medicine, College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland
| | | | - Gerard T Flaherty
- School of Medicine, College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland.
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Osman A, Amoako Johnson F, Mariwah S, Amoako-Sakyi D, Asiedu Owusu S, Ekor M, Hamill H, Hampshire K. Antimalarial stocking decisions among medicine retailers in Ghana: implications for quality management and control of malaria. BMJ Glob Health 2023; 6:e013426. [PMID: 37734858 PMCID: PMC10846845 DOI: 10.1136/bmjgh-2023-013426] [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: 07/14/2023] [Accepted: 08/12/2023] [Indexed: 09/23/2023] Open
Abstract
Global health efforts such as malarial control require efficient pharmaceutical supply chains to ensure effective delivery of quality-assured medicines to those who need them. However, very little is currently known about decision-making processes within antimalarial supply chains and potential vulnerabilities to substandard and falsified medicines. Addressing this gap, we report on a study that investigated decision-making around the stocking of antimalarial products among private-sector medicine retailers in Ghana. Licensed retail pharmacies and over-the-counter (OTC) medicine retail outlets were sampled across six regions of Ghana using a two-stage stratified sampling procedure, with antimalarial medicines categorised as 'expensive,' 'mid-range,' and 'cheaper,' relative to other products in the shop. Retailers were asked about their motivations for choosing to stock particular products over others. The reasons were grouped into three categories: financial, reputation/experience and professional recommendation. Reputation/experience (76%, 95% CI 72.0% to 80.7%) were the drivers of antimalarial stocking decisions, followed by financial reasons (53.2%, 95% CI 48.1% to 58.3%) and recommendation by certified health professionals (24.7%, 95% CI 20.3% to 29.1%). Financial considerations were particularly influential in stocking decisions of cheaper medicines. Moreover, pharmacies and OTCs without a qualified pharmacist were significantly more likely to indicate financial reasons as a motivation for stocking decisions. No significant differences in stocking decisions were found by geographical location (zone and urban/rural) or outlet (pharmacy/OTC). These findings have implications for the management of antimalarial quality across supply chains in Ghana, with potentially important consequences for malaria control, particularly in lower-income areas where people rely on low-cost medication.
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Affiliation(s)
- Adams Osman
- Department of Geography Education, University of Education, Winneba, Ghana
| | - Fiifi Amoako Johnson
- Department of Population and Health, University of Cape Coast Faculty of Social Sciences, Cape Coast, Ghana
| | - Simon Mariwah
- Department of Geography and Regional Planning, University of Cape Coast Faculty of Social Sciences, Cape Coast, Ghana
| | | | - Samuel Asiedu Owusu
- Directorate of Research, Innovation and Consultancy, University of Cape Coast, Cape Coast, Ghana
| | - Martins Ekor
- School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | | | - Kate Hampshire
- Department of Anthropology, Durham University, Durham, UK
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Ocan M, Nakalembe L, Otike C, Omali D, Buzibye A, Nsobya S. Pharmacopeial quality of artemether-lumefantrine anti-malarial agents in Uganda. Malar J 2023; 22:165. [PMID: 37237283 DOI: 10.1186/s12936-023-04600-8] [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: 08/24/2022] [Accepted: 05/20/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Substandard anti-malarial agents pose a significant challenge to effective malaria control and elimination efforts especially in sub-Saharan Africa. The quality of anti-malarials in most low-and-middle income countries (LMICs) is affected by several factors including inadequate regulation and limited resources. In this study, the pharmacopeial quality of artemether-lumefantrine (AL) in low and high malaria transmission settings in Uganda was assessed. METHODS This was a cross-sectional study conducted among randomly selected private drug outlets. The AL anti-malarials available in drug outlets were purchased using overt method. The samples were screened for quality using visual inspection, weight uniformity, content assay and dissolution tests. The assay test was done using liquid chromatography-mass spectrometry (LC-MS). The samples were considered substandard if the active pharmaceutical ingredient (API) content was outside 90-110% range of the label claim. Dissolution test was conducted following United States Pharmacopoeia (USP) method. Data was analysed using descriptive statistics and presented as means with standard deviations, frequencies, and proportions. Correlation between medicine quality and independent variables was determined using Fisher's exact test of independence at 95% level of significance. RESULTS A total of 74 AL anti-malarial samples were purchased from high (49/74; 66.2%) and low (25/74; 33.8%) malaria transmission settings. The most common batch of AL was LONART, 32.4% (24/74), with 33.8% (25/74) being 'Green leaf'. Overall prevalence of substandard quality artemether-lumefantrine was 18.9% (14/74; 95% CI: 11.4-29.7). Substandard quality AL was significantly associated with setting (p = 0.002). A total of 10 samples (13.5%) failed artemether content assay test while, 4 samples (5.4%, 4/74) failed the lumefantrine assay test. One sample from a high malaria transmission setting failed both artemether and lumefantrine assay content test. Of the samples that failed artemether assay test, 90% had low (< 90%) artemether content. All the samples passed visual inspection and dissolution tests. CONCLUSION Artemether-lumefantrine agents, the recommended first-line treatment for uncomplicated malaria with APIs outside the recommended pharmacopeial content assay limit is common especially in high malaria transmission settings. There is need for continuous surveillance and monitoring of the quality of artemisinin-based anti-malarials across the country by the drug regulatory agency.
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Affiliation(s)
- Moses Ocan
- Department of Pharmacology and Therapeutics, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda.
| | - Loyce Nakalembe
- Department of Pharmacology, Soroti University, P.O. Box 211, Soroti, Uganda
| | - Caroline Otike
- Data Department, Joint Clinical Research Centre, Lubowa, P. O Box 10005, Kampala, Uganda
| | - Denis Omali
- Pharmacokinetics Laboratory Unit, Infectious Disease Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Allan Buzibye
- Pharmacokinetics Laboratory Unit, Infectious Disease Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Sam Nsobya
- Department of Pathology, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
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Girma M, Umeta B, Hasen G, Suleman S. Quality of Antimalarial Drugs in East Africa: A Systematic Review. Infect Drug Resist 2022; 15:6085-6092. [PMID: 36277242 PMCID: PMC9585264 DOI: 10.2147/idr.s373059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
Background The use of poor quality drugs will have multiple consequences with an extended hazard of growing drug-resistant strains. Purpose The review aimed to provide the quality status of antimalarial drugs in East Africa. Data Source PubMed, Scopus, Web of Science, and Google Scholar were searched from September 5 to September 12, 2021. Study Selection The review included articles available as original research targeted at evaluating the quality of antimalarial drugs. For inclusion, data on at least one of the following quality control parameters were required: packaging and labeling, hardness, friability, weight variation/uniformity of weight, disintegration, dissolution, and assay/percentage purity. Mendeley citation manager version 1.19.4 was used to avoid duplication and organize references, and titles and abstracts were primarily used for screening. Data Extraction The sample collection site, drug name, and the quality control parameters tested were retrieved from the selected studies. Data synthesis Totally, 300 antimalarial drug samples from Ethiopia, Kenya and Tanzania were included in this review. No antimalarial drug tested failed the identification and disintegration test. However, 15.93% (36/226), 5.00% (15/300), and 1.90% (3/158) of antimalarial samples failed the dissolution, assay and mass uniformity test, respectively. Moreover, amodiaquine and sulfadoxine/pyrimethamine samples failed dissolution and assay tests. In addition, amodiaquine samples failed the mass uniformity test. However, artemether/lumefantrine and quinine passed all quality control parameters tested. Overall, 19.67% (59/300) of antimalarial drug samples did not meet at least one quality control parameter. And the higher faller rate was reported for sulfadoxine/pyrimethamine accounting for 52.86% (37/70). Conclusions An unneglected amount of antimalarial drug failed to meet at least one quality control parameter. Strengthening pharmaceutical management systems, including post-marketing surveillance, and providing the resources required for medication quality assurance, are recommended.
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Affiliation(s)
- Million Girma
- School of Pharmacy, College of Medicine and Health Sciences, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Belachew Umeta
- School of Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia,Correspondence: Belachew Umeta, School of Pharmacy, Institute of Health, Jimma University, Po. Box: 378, Jimma, Oromia, Ethiopia, Email
| | - Gemmechu Hasen
- School of Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Sultan Suleman
- School of Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia,Jimma University Laboratory of Drug Quality (JuLaDQ), Jimma University, Jimma, Ethiopia
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5
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Lusiyana N, Ahdika A. Evaluating recurrent episodes of malaria incidence in Timika, Indonesia, through a Markovian multiple-state model. Infect Dis Model 2022; 7:261-276. [PMID: 35754556 PMCID: PMC9201011 DOI: 10.1016/j.idm.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/30/2022] [Accepted: 05/31/2022] [Indexed: 10/27/2022] Open
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Hoellein L, Kaale E, Mwalwisi YH, Schulze MH, Vetye-Maler C, Holzgrabe U. Emerging Antimicrobial Drug Resistance in Africa and Latin America: Search for Reasons. Risk Manag Healthc Policy 2022; 15:827-843. [PMID: 35519501 PMCID: PMC9064051 DOI: 10.2147/rmhp.s205077] [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: 11/16/2021] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
Medicine quality and methods for its assessment play a major role in the effectiveness of therapies and the treatment of many infectious diseases. However, poor-quality and/or falsified products are circulating in huge amounts in many low- and middle-income countries and are one of the major reasons why more and more resistant bacteria emerge. The development of resistance is additionally triggered by a plethora of antibiotic medicines which is easily available through pharmacies and unofficial sources. The uncontrolled overuse of these products is a huge problem not only in single countries but worldwide. In this review, we aim to demonstrate the factors which are involved in an emerging resistance development and how strong regulatory authorities, routine quality control by means of proficiency testing, and post-marketing surveillance as well as training personnel and patients can be combined to curb the problem.
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Affiliation(s)
- Ludwig Hoellein
- Institute for Pharmacy and Food Chemistry, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
| | - Eliangiringa Kaale
- Muhimbili University of Health and Allied Sciences, School of Pharmacy, Dar es Salaam, Tanzania
| | | | - Marco H Schulze
- Georg-August-Universität Göttingen, Institut für Krankenhaushygiene und Infektiologie, Göttingen, Germany
| | | | - Ulrike Holzgrabe
- Institute for Pharmacy and Food Chemistry, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
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Kamba PF, Nambatya W, Aguma HB, Charani E, Rajab K. Gaps and opportunities in sustainable medicines use in resource limited settings: a situational analysis of Uganda. Br J Clin Pharmacol 2022; 88:3936-3942. [PMID: 35342977 DOI: 10.1111/bcp.15324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/27/2022] [Accepted: 03/15/2022] [Indexed: 11/30/2022] Open
Abstract
Resource constraints and widespread poverty among populations undermine disease prevention in low- and middle-income countries (LMICs) and ensure that these countries carry a disproportionate share of the global disease burden. Lack of access to efficacious medicines in LMICs further exacerbates this inequity. Addressing inequitable access to medicines and assuring their sustainable use is critical to the well-being of these populations. Whilst inadequate access to medicines in LMICs has drawn much attention, less is known about the sustainable use of available medicines, particularly to ensure their efficacy and mitigate harm to the population and the environment. Uganda has adopted various measures to ensure sustainable medicines use, including a national medicines policy, essential medicines list, medicines regulation framework, and promotion of domestic medicines production. Despite progress, challenges remain to achieving sustainable medicines use in the country, including fragmented access, inappropriate use, poor-quality, and inappropriate disposal. There is need to consolidate the globally embraced One Health approach (fostering collaboration between human, animal and environmental health sectors) to addressing these challenges as espoused in the country's One Health strategic plan. Medicines supply chain management in public sector health facilities needs to be strengthened to minimize inventory shortages (stock-outs). A strategy for universal health insurance can minimize economic barriers to medicines access. Enhanced professional and medicines regulation in the private health market needs to be implemented. There are opportunities to build further capacity in Uganda, particularly infrastructure for regulation of its healthcare systems, policy and governance, workforce capacity building, and population action and engagement.
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Affiliation(s)
- Pakoyo F Kamba
- Department of Pharmacy, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Winnie Nambatya
- Department of Pharmacy, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Herbert B Aguma
- Department of Pharmacy, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Esmita Charani
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, W12 0NN.,Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, South Africa
| | - Kalidi Rajab
- Department of Pharmacy, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
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Rahman MS, Yoshida N, Tsuboi H, Maeda E, Ibarra AVV, Zin T, Akimoto Y, Tanimoto T, Kimura K. Patient safety and public health concerns: poor dissolution rate of pioglitazone tablets obtained from China, Myanmar and internet sites. BMC Pharmacol Toxicol 2021; 22:12. [PMID: 33653417 PMCID: PMC7923830 DOI: 10.1186/s40360-021-00478-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/17/2021] [Indexed: 11/23/2022] Open
Abstract
Background Poor quality medicines have serious implications for public health. The aim of this study was to explore the quality of the antidiabetic pioglitazone, using samples collected in China and Myanmar, and samples purchased online. Methods In this cross-sectional study, we examined samples (n = 163) collected from hospitals in Shanghai, China in 2012 (n = 44), products purchased via the internet and imported into Japan in 2013 (n = 59), and samples purchased in shops in Yangon, Myanmar in 2015 (n = 60). Collected samples were subjected to visual inspection, authenticity investigation and quality testing (potency, content uniformity and dissolution test) by high-performance liquid chromatography. Samples were rated as compliant or non-compliant based on the relevant pharmacopoeial acceptance criteria. Results Visual inspection of all samples revealed compliant products. However, responses from manufacturers during authenticity investigation were poor. Among the n = 44 samples from China, one was non-compliant in the potency test. Among the n = 59 samples personally imported into Japan, 38% of generic samples were found to be non-compliant. In Myanmar, 13.3% of samples were non-compliant. Non-compliant samples predominantly failed in the dissolution test. All non-compliant samples were generic. Conclusions Despite the apparent satisfactory outcome on the samples from China, pioglitazone samples collected in Myanmar and purchased online for personal import into Japan included many substandard products, which failed quality assessment predominantly because of poor dissolution. Internet providers did not comply with Japanese regulations in various respects. Supplementary Information The online version contains supplementary material available at 10.1186/s40360-021-00478-x.
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Affiliation(s)
- Mohammad Sofiqur Rahman
- Medi-Quality Security Institute, Graduate School of Medical Sciences, Kanazawa University, 920-1192, Kanazawa, Japan.
| | - Naoko Yoshida
- Department of Clinical Pharmacy and Healthcare Sciences, Kanazawa University, 920-1192, Kanazawa, Japan
| | - Hirohito Tsuboi
- Department of Clinical Pharmacy and Healthcare Sciences, Kanazawa University, 920-1192, Kanazawa, Japan
| | - Erina Maeda
- Department of Clinical Pharmacy and Healthcare Sciences, Kanazawa University, 920-1192, Kanazawa, Japan
| | | | - Theingi Zin
- Department of Food and Drug Administration (FDA), Ministry of Health and Sports, Naypyidaw, Myanmar
| | - Yoshio Akimoto
- Medi-Quality Security Institute, Graduate School of Medical Sciences, Kanazawa University, 920-1192, Kanazawa, Japan
| | - Tsuyoshi Tanimoto
- Pharmaceutical and Medical Device Regulatory Science Society of Japan, 150-0002, Osaka, Japan
| | - Kazuko Kimura
- Medi-Quality Security Institute, Graduate School of Medical Sciences, Kanazawa University, 920-1192, Kanazawa, Japan
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Rojas-Cortés R. Substandard, falsified and unregistered medicines in Latin America, 2017-2018. Rev Panam Salud Publica 2020; 44:e125. [PMID: 33033498 PMCID: PMC7537817 DOI: 10.26633/rpsp.2020.125] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/10/2020] [Indexed: 11/24/2022] Open
Abstract
Objective To assess all the incidents of substandard, falsified and unregistered medicines in 2017 and 2018 in Latin America, determining the types of products affected, stages of the supply chain in which incidents were detected, quality deviations identified in tested samples, and regulatory measures taken by authorities. Methods A comprehensive search of the websites of the Latin American national regulatory authorities was conducted, identifying all eligible incidents during 2017-2018. Standardized values were collected from each incident for pre-determined variables: country, year, type of incident, therapeutic group, supply chain, regulatory measures and laboratory data. Results A total of 596 incidents in 13 countries were included (236 substandard, 239 falsified, 116 unregistered and 5 stolen). The therapeutic categories with the highest incidents were: anti-infectives, medicines for pain/palliative care, hormones/contraceptives, medicines for the respiratory tract, and medicines for mental/behavioural disorders. The most common places where incidents were detected were commercial establishments, pharmacies, health services and manufacturers. The most recurrent quality deviations were failure in parameters (appearance or physicochemical), incorrect labelling, different quantity of active pharmaceutical ingredient, presence of unknown particles, and microbiological contamination. The most frequent regulatory measures identified were alerts, withdrawals, seizures, and prohibition of marketing/distribution/use. Conclusions In Latin America, substandard, falsified and unregistered medicines persist as a highly prevalent problem. An advanced degree of regulatory development in countries is associated with higher incident detection/reporting rates and a more comprehensive set of measures. The pharmaceutical supply chain is more vulnerable in its final node. Quality deviations identified in tested samples pose serious risks to public health.
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Affiliation(s)
- Robin Rojas-Cortés
- Regional Network for the Prevention, Detection and Response to Substandard and Falsified Medical Products in the Americas Washington DC United States of America Regional Network for the Prevention, Detection and Response to Substandard and Falsified Medical Products in the Americas, Washington, DC, United States of America
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10
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Saka C. Analytical Methods on Determination in Pharmaceuticals and Biological Materials of Chloroquine as Available for the Treatment of COVID-19. Crit Rev Anal Chem 2020; 52:19-34. [PMID: 32628049 DOI: 10.1080/10408347.2020.1781592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
With the outbreak caused by the severe acute respiratory syndrome coronavirus (COVID-19), people's health and existing economies on a global scale are seriously threatened. Currently, most of the countries all over the world are studying extensively to better understand the antimalarial chloroquine (CQ) and hydroxychloroquine (HCQ) for therapeutic purposes due to the COVID-19 outbreak. However, CQ and HCQ can have serious side effects, from psychiatric effects to sudden death. Therefore, a faster and more effective detection method is needed to monitor drug concentrations. In this review, a large study was conducted on the detection techniques and quantitative determination methods of CQ and its related metabolites. In this review, chromatography, electrophoresis, electroanalytical, spectroscopic, and immunological methods for CQ and related metabolites are discussed extensively. It is hoped that a better understanding of the CQ used for therapeutic purposes in the COVID-19 outbreak will be provided.
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Affiliation(s)
- Cafer Saka
- Faculty of Health Sciences, Siirt University, Siirt, Turkey
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11
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Evans DR, Higgins CR, Laing SK, Awor P, Ozawa S. Poor-quality antimalarials further health inequities in Uganda. Health Policy Plan 2020; 34:iii36-iii47. [PMID: 31816072 PMCID: PMC6901073 DOI: 10.1093/heapol/czz012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/13/2018] [Accepted: 02/13/2019] [Indexed: 12/16/2022] Open
Abstract
Substandard and falsified medications are a major threat to public health, directly increasing the risk of treatment failure, antimicrobial resistance, morbidity, mortality and health expenditures. While antimalarial medicines are one of the most common to be of poor quality in low- and middle-income countries, their distributional impact has not been examined. This study assessed the health equity impact of substandard and falsified antimalarials among children under five in Uganda. Using a probabilistic agent-based model of paediatric malaria infection (Substandard and Falsified Antimalarial Research Impact, SAFARI model), we examine the present day distribution of the burden of poor-quality antimalarials by socio-economic status and urban/rural settings, and simulate supply chain, policy and patient education interventions. Patients incur US$26.1 million (7.8%) of the estimated total annual economic burden of substandard and falsified antimalarials, including $2.3 million (9.1%) in direct costs and $23.8 million (7.7%) in productivity losses due to early death. Poor-quality antimalarials annually cost $2.9 million to the government. The burden of the health and economic impact of malaria and poor-quality antimalarials predominantly rests on the poor (concentration index −0.28) and rural populations (98%). The number of deaths among the poorest wealth quintile due to substandard and falsified antimalarials was 12.7 times that of the wealthiest quintile, and the poor paid 12.1 times as much per person in out-of-pocket payments. Rural populations experienced 97.9% of the deaths due to poor-quality antimalarials, and paid 10.7 times as much annually in out-of-pocket expenses compared with urban populations. Our simulations demonstrated that interventions to improve medicine quality could have the greatest impact at reducing inequities, and improving adherence to antimalarials could have the largest economic impact. Substandard and falsified antimalarials have a significant health and economic impact, with greater burden of deaths, disability and costs on poor and rural populations, contributing to health inequities in Uganda.
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Affiliation(s)
- Daniel R Evans
- Duke University School of Medicine, DUMC 3710 Durham, NC 27710, USA
| | - Colleen R Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA
| | - Sarah K Laing
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA
| | - Phyllis Awor
- Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Mulago Hospital Complex, Mulago Hill, P.O. Box 7072, Kampala, Uganda
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, NC 27599, USA
- Corresponding author. Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA. E-mail:
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12
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Abuye H, Abraham W, Kebede S, Tatiparthi R, Suleman S. Physicochemical Quality Assessment of Antimalarial Medicines: Chloroquine Phosphate and Quinine Sulfate Tablets from Drug Retail Outlets of South-West Ethiopia. Infect Drug Resist 2020; 13:691-701. [PMID: 32161477 PMCID: PMC7051250 DOI: 10.2147/idr.s234684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/03/2020] [Indexed: 11/23/2022] Open
Abstract
Background Malaria is a complex disease and main community health problem in Africa and the top leading cause of outpatient visits, admissions, and deaths in Ethiopia. Its effective management is possible through early diagnosis and immediate treatment employing antimalarials. The quality of these drugs has to be good enough to attain their intended purpose. However, there are treatment failures resulted from the consumption of falsified and substandard antimalarials. Therefore, the current study was undertaken to evaluate the quality of two commonly used antimalarial drugs [chloroquine phosphate and quinine sulfate tablets] and to determine whether the quality of these drugs was affected by the origin, brand and sample collection sites in South-West Ethiopia. Methods Random sampling based on Ethiopian malaria eco-epidemiological strata map, with different levels of medicines outlets, was applied to select sampling sites. Results Sixty samples were bought from 43 drug retails (pharmacy, drug store, and drug vendor) in twelve different geographical locations of South-West Ethiopia between June and July 2016. Visual inspection was done for all samples before the lab experiment. A 28.3%, 31.7%, and 6.8% of samples failed to comply with the Pharmacopoeial quality standards for visual inspection, hardness and weight variation tests, respectively. Statistical analysis revealed that origin and geography from which samples were collected significantly affects the active pharmaceutical content of both drugs at P < 0.05 level. Significant variation was observed for chloroquine samples within batches of the same manufacturing and between origins. Conclusion This study indicated that all the chloroquine and quinine tablets met the quality specification concerning friability, dissolution and assay. Out-of-specification results for weight variation, hardness and visual inspection tests for the chloroquine tablets are signs of substandard/spurious/falsely labeled/falsified/counterfeit actions that may compromise the quality of these drugs. Besides, within the acceptance limit, the origin of drugs and collection sites have found to determine the quality which raises good manufacturing practice and storage (drug supply chain system) issues to be evaluated.
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Affiliation(s)
- Habtamu Abuye
- Department of Pharmacy, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia
| | - Woldemichael Abraham
- Department of Pharmacy, College of Medicine and Health Sciences, Wolayita Sodo University, Wolayita Sodo, Ethiopia
| | - Selass Kebede
- Department of Pharmacy, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia
| | - Ramanjireddy Tatiparthi
- Department of Pharmaceutics, School of Pharmacy, College of Health Sciences, Jimma University, Jimma, Ethiopia.,Jimma University Laboratory of Drug Quality (JuLaDQ), College of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Sultan Suleman
- Jimma University Laboratory of Drug Quality (JuLaDQ), College of Health Sciences, Jimma University, Jimma, Ethiopia.,School of Pharmacy, College of Health Sciences, Jimma University, Jimma, Ethiopia
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Kilonzi M, Minzi O, Mutagonda R, Baraka V, Sasi P, Aklillu E, Kamuhabwa A. Usefulness of day 7 lumefantrine plasma concentration as a predictor of malaria treatment outcome in under-fives children treated with artemether-lumefantrine in Tanzania. Malar J 2020; 19:66. [PMID: 32046718 PMCID: PMC7014606 DOI: 10.1186/s12936-020-3150-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/04/2020] [Indexed: 12/18/2022] Open
Abstract
Background Day 7 plasma lumefantrine concentration is suggested as a predictor for malaria treatment outcomes and a cut-off of ≥ 200 ng/ml is associated with day 28 cure rate in the general population. However, day 7 lumefantrine plasma concentration can be affected by age, the extent of fever, baseline parasitaemia, and bodyweight. Therefore, this study assessed the usefulness of day 7 lumefantrine plasma concentration as a predictor of malaria treatment outcome in under-fives children treated with generic or innovator drug-containing artemether-lumefantrine (ALu) in Tanzania. Methods This study was nested in an equivalence prospective study that aimed at determining the effectiveness of a generic ALu (Artefan®) in comparison with the innovator’s product (Coartem®). Children with uncomplicated malaria aged 6–59 months were recruited and randomized to receive either generic or innovator’s product. Children were treated with ALu as per World Health Organization recommendations. The clinical and parasitological outcomes were assessed after 28 days of follow up. PCR was performed to distinguish recrudescence and re-infections among children with recurrent malaria. Analysis of day 7 lumefantrine plasma concentration was carried out using a high-performance liquid chromatographic method with UV detection. Results The PCR corrected cure rates were 98.7% for children treated with generic and 98.6% for those treated with the innovator product (p = 1.00). The geometric mean (± SD) of day 7 plasma lumefantrine concentration was 159.3 (± 2.4) ng/ml for the generic and 164 (± 2.5) ng/ml for the innovator groups, p = 0.87. Geometric mean (± SD) day 7 lumefantrine plasma concentration between cured and recurrent malaria was not statistically different in both treatment arms [158.5 (± 2.4) vs 100.0 (± 1.5) ng/ml, (p = 0.28) for generic arm and 158.5 (± 2.3) vs 251.2 (± 4.2) ng/ml, (p = 0.24) for innovator arm]. Nutritional status was found to be a determinant of recurrent malaria (adjusted hazardous ratio (95% confidence interval) = 3(1.1–8.2), p = 0.029. Conclusion Using the recommended cut-off point of ≥ 200 ng/ml, day 7 plasma lumefantrine concentration failed to predict malaria treatment outcome in children treated with ALu in Tanzania. Further studies are recommended to establish the day 7 plasma lumefantrine concentration cut-off point to predict malaria treatment outcome in children.
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Affiliation(s)
- Manase Kilonzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P. O. BOX 65013, Dar es Salaam, Tanzania.
| | - Omary Minzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P. O. BOX 65013, Dar es Salaam, Tanzania
| | - Ritah Mutagonda
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P. O. BOX 65013, Dar es Salaam, Tanzania
| | - Vito Baraka
- Department of Research, National Institute of Medical Research, Tanga Centre, P O Box 5004, Tanga, Tanzania
| | - Philip Sasi
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, P. O. BOX 6515, Dar es Salaam, Tanzania
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital-Huddinge, C1:68, SE-141 86, Stockholm, Sweden
| | - Appolinary Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P. O. BOX 65013, Dar es Salaam, Tanzania
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Chatterjee C, Mohapatra DP, Estay M. From courts to markets: New evidence on enforcement of pharmaceutical bans in India. Soc Sci Med 2019; 237:112480. [DOI: 10.1016/j.socscimed.2019.112480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 06/12/2019] [Accepted: 08/02/2019] [Indexed: 10/26/2022]
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Sherma J, Rabel F. Advances in the thin layer chromatographic analysis of counterfeit pharmaceutical products: 2008–2019. J LIQ CHROMATOGR R T 2019. [DOI: 10.1080/10826076.2019.1610772] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Joseph Sherma
- Department of Chemistry, Lafayette College, Easton, PA, USA
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Doua YJ, Dominicus H, Mugwagwa J, Gombe SM, Nwokike J. Scarce quality assurance documentation in major clinical trial registries for approved medicines used in post-marketing clinical trials. Trials 2019; 20:212. [PMID: 30975193 PMCID: PMC6460528 DOI: 10.1186/s13063-019-3277-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 03/01/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND This research reviewed major Clinical Trial Registries (CTRs) and assessed the availability of fields on quality assurance for approved medicines used as Investigational Medicinal Products (IMPs) in phase IV clinical trials. METHODS Two reviewers independently assessed CTRs of the International Committee of Medical Journal Editors (ICJME) and of World Health Organization (WHO) platforms. Each CTR was checked by two reviewers on availability of fields on brand name, manufacturer's name, approval status, approving authority, compliance with Good Manufacturing Practices, and quality testing. In case of discrepancy, consensus was sought between the two reviewers. RESULTS Of 19 identified CTRs, 8 and 6 belonged to WHO and ICMJE, respectively, while 5 were equally part of both platforms. All CTRs had an 'intervention' field where data on IMPs and IMP comparators are captured. The Canadian CTR used 'drug name' rather than 'intervention'. The EU, Peruvian, and UK CTRs had fields for 'brand name'. However, only the EU CTR had fields for 'manufacturer's name', 'approval status', and 'approving authority'. None of the CTRs had fields on 'compliance with Good Manufacturing Practices' or 'quality testing'. CONCLUSION This study demonstrates that none of the CTRs of ICMJE and WHO platforms has adequate fields to establish that the source of post-marketing IMPs is of assured quality. This is astonishing given the lengthy requirements in WHO and ICMJE guidelines. Considering the relation between IMP quality and safety of clinical trial participants, the gap of quality assurance fields should be bridged at CTRs concurrently to adjustments of WHO and ICMJE guidelines on CTRs. Specifically, IMP quality testing addressing issues on IMP appearance, impurities, microbial contamination, and dosing should be conducted and reported before, during, and after clinical trial conduct. Until adoption of these measures, the EU CTR should be preferred for registration of phase IV clinical trials conducted in countries lacking stringent regulatory capacities.
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Affiliation(s)
- Yorokpa Joachim Doua
- Consortium for African Regulatory Expertise Development (CARED), Voorburg, The Netherlands
- Clinical and Medical Department, Janssen Infectious Diseases and Vaccines, Crucell Holland BV, Leiden, The Netherlands
| | - Hanneke Dominicus
- Consortium for African Regulatory Expertise Development (CARED), Voorburg, The Netherlands
- Dominicus Medicus Consultancy, Voorburg, The Netherlands
| | - Julius Mugwagwa
- Consortium for African Regulatory Expertise Development (CARED), Voorburg, The Netherlands
- Department of Science, Technology, Engineering and Public Policy, University College London, London, UK
| | | | - Jude Nwokike
- United States Pharmacopeial Convention (USP), Promoting the Quality of Medicines (PQM) Program, Washington, DC USA
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Ozawa S, Evans DR, Higgins CR, Laing SK, Awor P. Development of an agent-based model to assess the impact of substandard and falsified anti-malarials: Uganda case study. Malar J 2019; 18:5. [PMID: 30626380 PMCID: PMC6327614 DOI: 10.1186/s12936-018-2628-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 12/13/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Global efforts to address the burden of malaria have stagnated in recent years with malaria cases beginning to rise. Substandard and falsified anti-malarial treatments contribute to this stagnation. Poor quality anti-malarials directly affect health outcomes by increasing malaria morbidity and mortality, as well as threaten the effectiveness of treatment by contributing to artemisinin resistance. Research to assess the scope and impact of poor quality anti-malarials is essential to raise awareness and allocate resources to improve the quality of treatment. A probabilistic agent-based model was developed to provide country-specific estimates of the health and economic impact of poor quality anti-malarials on paediatric malaria. This paper presents the methodology and case study of the Substandard and Falsified Antimalarial Research Impact (SAFARI) model developed and applied to Uganda. RESULTS The total annual economic impact of malaria in Ugandan children under age five was estimated at US$614 million. Among children who sought medical care, the total economic impact was estimated at $403 million, including $57.7 million in direct costs. Substandard and falsified anti-malarials were a significant contributor to this annual burden, accounting for $31 million (8% of care-seeking children) in total economic impact involving $5.2 million in direct costs. Further, 9% of malaria deaths relating to cases seeking treatment were attributable to poor quality anti-malarials. In the event of widespread artemisinin resistance in Uganda, we simulated a 12% yearly increase in costs associated with paediatric malaria cases that sought care, inflicting $48.5 million in additional economic impact annually. CONCLUSIONS Improving the quality of treatment is essential to combat the burden of malaria and prevent the development of drug resistance. The SAFARI model provides country-specific estimates of the health and economic impact of substandard and falsified anti-malarials to inform governments, policy makers, donors and the malaria community about the threat posed by poor quality medicines. The model findings are useful to illustrate the significance of the issue and inform policy and interventions to improve medicinal quality.
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Affiliation(s)
- Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599 USA
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC USA
| | | | - Colleen R. Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599 USA
| | - Sarah K. Laing
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599 USA
| | - Phyllis Awor
- Department of Community Health and Behavioural Sciences, Makarere University School of Public Health, Kampala, Uganda
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Paul P, Sänger-van de Griend C, Adams E, Van Schepdael A. Recent advances in the capillary electrophoresis analysis of antibiotics with capacitively coupled contactless conductivity detection. J Pharm Biomed Anal 2018; 158:405-415. [PMID: 29940496 DOI: 10.1016/j.jpba.2018.06.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 01/04/2023]
Abstract
This review describes briefly the high rate of counterfeiting of antimicrobial drugs with focus upon its immediate health consequences. The major part of this review encompasses accounts of the improvements achieved in the domain of miniaturization of capillary electrophoresis with capacitively coupled contactless conductivity detection (CE-C4D). The application of this principle into the development of portable devices as well as its application to counter the health-system-crippling phenomenon of counterfeit antibiotic formulations, are discussed in the context of developing countries.
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Affiliation(s)
- Prasanta Paul
- KU Leuven - University of Leuven, Pharmaceutical Analysis, Department of Pharmaceutical and Pharmacological Sciences, O&N2, PB 923, Herestraat 49, Leuven, 3000, Belgium
| | - Cari Sänger-van de Griend
- Department of Medicinal chemistry, Uppsala University, Husargatan 3, Uppsala, 751 23, Sweden; Kantisto BV, Callenburglaan 22, Baarn, 3742 MV, The Netherlands
| | - Erwin Adams
- KU Leuven - University of Leuven, Pharmaceutical Analysis, Department of Pharmaceutical and Pharmacological Sciences, O&N2, PB 923, Herestraat 49, Leuven, 3000, Belgium
| | - Ann Van Schepdael
- KU Leuven - University of Leuven, Pharmaceutical Analysis, Department of Pharmaceutical and Pharmacological Sciences, O&N2, PB 923, Herestraat 49, Leuven, 3000, Belgium.
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Caillet C, Sichanh C, Assemat G, Malet-Martino M, Sommet A, Bagheri H, Sengxeu N, Mongkhonmath N, Mayxay M, Syhakhang L, Lapeyre-Mestre M, Newton PN, Roussin A. Role of Medicines of Unknown Identity in Adverse Drug Reaction-Related Hospitalizations in Developing Countries: Evidence from a Cross-Sectional Study in a Teaching Hospital in the Lao People's Democratic Republic. Drug Saf 2017; 40:809-821. [PMID: 28528487 PMCID: PMC5569138 DOI: 10.1007/s40264-017-0544-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
INTRODUCTION The health dangers of medicines of unknown identity (MUIs) [loose pharmaceutical units repackaged in individual bags without labelling of their identity] have been suspected in L/MICs. Using visual and analytical tools to identify MUIs, we investigated the frequency of, and factors associated with, adverse drug reaction (ADR)-related hospitalizations in a central hospital in Vientiane Capital, Lao People's Democratic Republic (PDR). METHODS All unplanned admissions, except for acute trauma and intentional overdose, were prospectively recorded during a 7-week period in 2013, leading to include 453 adults hospitalized for ≥24 h. The patients or their relatives were interviewed to complete the study questionnaire. MUIs suspected of being involved in ADR(s) were identified through comparison of visual characteristics of tablets/capsules with that of reference medicines (photograph tool), and by proton nuclear magnetic resonance and mass spectrometry analyses. Factors associated with ADRs were identified by multivariate logistic regression. RESULTS The frequency of hospitalizations related to an ADR was 5.1% (23/453, 95% confidence interval [CI] 3.1-7.1). Forty-eight (12.8%) patients used MUI(s) in the last 2 weeks preceding hospitalization. They were more likely to be hospitalized because of an ADR (adjusted odds ratio 4.5, 95% CI 1.7-11.5) than patients using medicines of known identity. MUIs were mainly involved in bleeding gastroduodenal ulcers. The photograph tool led to the misidentifications because of look-alike pharmaceutical units in the medicines photograph collection. CONCLUSION According to the results of this study, there is a need to ensure appropriate labelling of medicines at dispensing and to provide well-suited tools to identify MUIs in clinical settings to improve drug safety and patients' care in developing countries with limited capacities for drug analysis.
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Affiliation(s)
- Céline Caillet
- Pharmacoépidémiologie, Faculté de Médecine, UMR 1027 INSERM-Université Toulouse III, 37, Allées Jules Guesde, 31000, Toulouse, France.
- Infectious Diseases Data Observatory-WorldWide Antimalarial Resistance Network, Centre for Tropical Medicine and Global Health, Churchill Hospital, CCVTM, University of Oxford, Oxford, UK.
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.
| | - Chanvilay Sichanh
- Infectious Diseases Data Observatory-WorldWide Antimalarial Resistance Network, Centre for Tropical Medicine and Global Health, Churchill Hospital, CCVTM, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Gaëtan Assemat
- Groupe de RMN Biomédicale, Laboratoire SPCMIB, UMR CNRS 5068-Université Toulouse III, Toulouse, France
| | - Myriam Malet-Martino
- Groupe de RMN Biomédicale, Laboratoire SPCMIB, UMR CNRS 5068-Université Toulouse III, Toulouse, France
| | - Agnès Sommet
- Pharmacoépidémiologie, Faculté de Médecine, UMR 1027 INSERM-Université Toulouse III, 37, Allées Jules Guesde, 31000, Toulouse, France
- Service de Pharmacologie Médicale et Clinique, Faculté de Médecine, Centre d'Investigation Clinique, CIC1436, Toulouse University Hospital, Toulouse, France
| | - Haleh Bagheri
- Pharmacoépidémiologie, Faculté de Médecine, UMR 1027 INSERM-Université Toulouse III, 37, Allées Jules Guesde, 31000, Toulouse, France
- Service de Pharmacologie Médicale et Clinique, Faculté de Médecine, Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Toulouse University Hospital, Toulouse, France
| | - Noudy Sengxeu
- Faculty of Pharmacy, University of Health Sciences, Vientiane, Lao People's Democratic Republic
| | - Niphonh Mongkhonmath
- Faculty of Pharmacy, University of Health Sciences, Vientiane, Lao People's Democratic Republic
| | - Mayfong Mayxay
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Lao People's Democratic Republic
| | - Lamphone Syhakhang
- Food and Drug Department, Ministry of Health, Vientiane, Lao People's Democratic Republic
| | - Maryse Lapeyre-Mestre
- Pharmacoépidémiologie, Faculté de Médecine, UMR 1027 INSERM-Université Toulouse III, 37, Allées Jules Guesde, 31000, Toulouse, France
- Service de Pharmacologie Médicale et Clinique, Faculté de Médecine, Centre d'Investigation Clinique, CIC1436, Toulouse University Hospital, Toulouse, France
| | - Paul N Newton
- Infectious Diseases Data Observatory-WorldWide Antimalarial Resistance Network, Centre for Tropical Medicine and Global Health, Churchill Hospital, CCVTM, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Anne Roussin
- Pharmacoépidémiologie, Faculté de Médecine, UMR 1027 INSERM-Université Toulouse III, 37, Allées Jules Guesde, 31000, Toulouse, France
- Service de Pharmacologie Médicale et Clinique, Faculté de Médecine, Centre d'Investigation Clinique, CIC1436, Toulouse University Hospital, Toulouse, France
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Abstract
BACKGROUND The growing menace of poor quality and falsified drugs constitutes a major hazard, compromising healthcare and patient outcomes. Efforts to assess drug standards worldwide have almost exclusively focused on anti-microbial drugs; with no study to date on cardiovascular drugs. Our study aims to assess quality of seven routinely used cardiovascular medications (anticoagulants, antihypertensives and statins) in ten Sub-Saharan African countries. METHODS Drugs were prospectively collected using standardized methods between 2012 and 2014 from licensed (random pharmacies) and unlicensed (street-markets) places of sale in Africa. We developed a validated reversed-phase liquid chromatography with tandem mass spectrometry method to accurately quantify the active ingredient in a certified public laboratory. Three quality categories were defined based on the ratio of the measured to the expected dosage of the active ingredient: A (good quality): 95% to 105%, B (low quality): 85 to 94.99% or 105.01 to 115%, C (very low quality): <85% or >115%. RESULTS All expected medicines (n=3468 samples) were collected in Benin, Burkina-Faso, Congo-Brazzaville, the Democratic Republic of Congo, Guinea, Côte d'Ivoire, Mauritania, Niger, Togo and Senegal. Out of the 1530 samples randomly tested, poor quality (types B and C) was identified in 249 (16.3%) samples. The prevalence of poor quality was significantly increased in certain specific drugs (amlodipine 29% and captopril 26%), in generic versions (23%) and in drugs produced in Asia (35%). The proportion of poor quality reached 50% when drugs produced in Asia were sold in street-markets. CONCLUSION In this first study assessing the quality of cardiovascular drugs in Africa, we found a significant proportion of poor quality drugs. This requires continued monitoring strategies.
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Anyanwu PE, Fulton J, Evans E, Paget T. Exploring the role of socioeconomic factors in the development and spread of anti-malarial drug resistance: a qualitative study. Malar J 2017; 16:203. [PMID: 28521791 PMCID: PMC5437569 DOI: 10.1186/s12936-017-1849-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 05/09/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria remains a global health issue with the burden unevenly distributed to the disadvantage of the developing countries of the world. Poverty contributes to the malaria burden as it has the ability to affect integral aspects of malaria control. There have been renewed efforts in the global malaria control, resulting in reductions in the global malaria burden over the last decade. However, the development of resistance to artemisinin-based combination therapy threatens the sustainability of the present success in malaria control. Anti-malarial drug use practices/behaviours remain very important drivers of drug resistance. This study adopted a social epidemiological stance in exploring the underlying socioeconomic factors that determine drug use behaviours promoting anti-malarial drug resistance. METHODS A qualitative approach, involving the use of interviews, was used in this inquiry to explore the existing anti-malarial drug use practices in the Nigerian population; and the different socioeconomic factors influencing the behaviours. RESULTS The significant malaria treatment behaviours influenced by socioeconomic factors in this study were the practice of 'mixing' drugs for malaria treatment, presumptive treatment, sharing of malaria treatment course, and the use of anti-malaria monotherapies. All the rural dwellers in this study reported they have mixed drugs for malaria treatment. When symptoms were experienced, socio-economic factors, like type of settlement, income level and occupation, tended to determine the treatment behaviour and, therefore, informed and determined the experience of the illness. DISCUSSION Social and economic contexts can influence behaviours as they contribute in shaping norms and in creating opportunities that promote certain behaviours. As shown in this study, income level and type of settlement, as structural factors, affect the decision on where to seek malaria treatment and whether or not a malaria diagnostic test will be used prior to treatment. One of the dangers of using the mixed anti-malarial drugs is that it offers a safe route for the sale of expired and fake anti-malarial drugs as the mixed drugs are not sold or dispensed in their original packets. CONCLUSIONS AND RECOMMENDATIONS Population-wide improvements in income, education, environmental and structural conditions of rural dwellers in malaria-endemic settings will encourage behavioural change on how anti-malarial drugs are used.
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Affiliation(s)
- Philip Emeka Anyanwu
- University of Sunderland, Pasteur Building, Sciences Complex, City Campus, Sunderland, SR1 3SD UK
| | - John Fulton
- University of Sunderland, Pasteur Building, Sciences Complex, City Campus, Sunderland, SR1 3SD UK
| | - Etta Evans
- University of Sunderland, Pasteur Building, Sciences Complex, City Campus, Sunderland, SR1 3SD UK
| | - Timothy Paget
- University of Sunderland, Pasteur Building, Sciences Complex, City Campus, Sunderland, SR1 3SD UK
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Wafula F, Dolinger A, Daniels B, Mwaura N, Bedoya G, Rogo K, Goicoechea A, Das J, Olayo B. Examining the Quality of Medicines at Kenyan Healthcare Facilities: A Validation of an Alternative Post-Market Surveillance Model That Uses Standardized Patients. Drugs Real World Outcomes 2017; 4:53-63. [PMID: 27888478 PMCID: PMC5332304 DOI: 10.1007/s40801-016-0100-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Promoting access to medicines requires concurrent efforts to strengthen quality assurance for sustained impact. Although problems of substandard and falsified medicines have been documented in low- and middle-income countries, reliable information on quality is rarely available. OBJECTIVE The aim of this study was to validate an alternative post-market surveillance model to complement existing models. METHODS The study used standardized patients or mystery clients (people recruited from the local community and trained to pose as real patients) to collect medicine samples after presenting a pre-specified condition. The patients presented four standardized conditions to 42 blinded facilities in Nairobi, Kenya, resulting in 166 patient-clinician interactions and dispensing of 300 medicines at facilities or nearby retail pharmacies. The medicine samples obtained thus resemble those that would be given to real patients. RESULTS Sixty samples were selected from the 300, and sent for analysis at the Kenya National Quality Control Laboratory. Of these, ten (17%) did not comply with monograph specifications (three ibuprofen, two cetirizine, two amoxicillin/clavulanic acid combinations, and one each for prednisone, salbutamol and zinc). Five of the ten samples that failed had been inappropriately prescribed to patients who had presented symptoms of unstable angina. There was no association between medicine quality and ownership, size or location of the facilities. CONCLUSION The study shows that the standardized patient model can provide insights into multiple dimensions of care, thus helping to link primary care encounters with medicine quality. Furthermore, it makes it possible to obtain medicines from blinded sellers, thus minimizing the risk of obtaining biased samples.
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Affiliation(s)
- Francis Wafula
- Health, Nutrition and Population Global Practice, The World Bank, Menengai Road, Upper Hill, P.O. Box 30577-00100, Nairobi, Kenya.
- Institute of Healthcare Management, Strathmore University, Nairobi, Kenya.
| | - Amy Dolinger
- Development Economics Research Group, The World Bank, Washington DC, USA
| | - Benjamin Daniels
- Development Economics Research Group, The World Bank, Washington DC, USA
| | - Njeri Mwaura
- Health, Nutrition and Population Global Practice, The World Bank, Menengai Road, Upper Hill, P.O. Box 30577-00100, Nairobi, Kenya
| | - Guadalupe Bedoya
- Development Economics Research Group, The World Bank, Washington DC, USA
| | - Khama Rogo
- Health, Nutrition and Population Global Practice, The World Bank, Menengai Road, Upper Hill, P.O. Box 30577-00100, Nairobi, Kenya
| | - Ana Goicoechea
- Trade and Competitiveness Global Practice, The World Bank, Washington DC, USA
| | - Jishnu Das
- Development Economics Research Group, The World Bank, Washington DC, USA
| | - Bernard Olayo
- Health, Nutrition and Population Global Practice, The World Bank, Menengai Road, Upper Hill, P.O. Box 30577-00100, Nairobi, Kenya
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Debrah P, Nettey H, Miltersen KK, Ayeh-Kumi P, Brock B, Sarkodie JA, Akwo-Kretchy I, Owusu-Danso P, Adjei S, Petersen E, Hardlei TF. Artemether-Lumefantrine Concentrations in Tablets and Powders from Ghana Measured by a New High-Performance Liquid Chromatography Method. Am J Trop Med Hyg 2016; 95:158-63. [PMID: 27139437 PMCID: PMC4944682 DOI: 10.4269/ajtmh.15-0868] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/15/2016] [Indexed: 11/07/2022] Open
Abstract
We developed and validated a new analytical method for the simultaneous quantification of artemether and lumefantrine in fixed-dose tablets and powders for reconstitution into pediatric suspensions (PSs). The method showed linearity (r(2) > 0.9947), precision (coefficient of variation < 2%), accuracy (deviation of mean from actual concentrations < 4%), and specificity (peak purities > 99%). The validated method was used to analyze 24 batches of fixed-dose tablets and PSs of artemether and lumefantrine. Of the samples, 23 were obtained using convenience sampling of commonly available brands within Accra in Ghana and one was obtained from Aarhus University Hospital. In all, 83.3% (confidence interval: 80-120%) passed for both artemether and lumefantrine contents, 16.7% failed by the U.S. Pharmacopoeia standards, 8.3% failed for one content, and 8.3% failed for both contents. All four products (16.7%) that failed were PSs, and two (8.3%) showed higher levels of artemether than prescribed (222% and 756%).
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Affiliation(s)
- Philip Debrah
- Department of Pharmaceutics and Microbiology, School of Pharmacy, University of Ghana, Legon, Ghana.
| | - Henry Nettey
- Department of Pharmaceutics and Microbiology, School of Pharmacy, University of Ghana, Legon, Ghana
| | | | - Patrick Ayeh-Kumi
- School of Allied Health Sciences, University of Ghana, Korle-Bu, Ghana
| | - Birgitte Brock
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus University, Skejby, Denmark
| | - Joseph Adusei Sarkodie
- Department of Pharmacognosy and Herbal Medicine, School of Pharmacy, University of Ghana, Legon, Ghana
| | - Irene Akwo-Kretchy
- Department of Pharmacy Practice and Clinical Pharmacy, School of Pharmacy, University of Ghana, Legon, Ghana
| | - Patrick Owusu-Danso
- Laboratory Services Department, Food and Drugs Authority, Cantonments, Ghana
| | - Samuel Adjei
- Department of Animal Experimentation, Noguchi Memorial Institute for Medical Research, Legon, Ghana
| | - Eskild Petersen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus University, Skejby, Denmark
| | - Tore Forsingdal Hardlei
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus University, Skejby, Denmark
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Hamilton WL, Doyle C, Halliwell-Ewen M, Lambert G. Public health interventions to protect against falsified medicines: a systematic review of international, national and local policies. Health Policy Plan 2016; 31:1448-1466. [PMID: 27311827 DOI: 10.1093/heapol/czw062] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Falsified medicines are deliberately fraudulent drugs that pose a direct risk to patient health and undermine healthcare systems, causing global morbidity and mortality. OBJECTIVE To produce an overview of anti-falsifying public health interventions deployed at international, national and local scales in low and middle income countries (LMIC). DATA SOURCES We conducted a systematic search of the PubMed, Web of Science, Embase and Cochrane Central Register of Controlled Trials databases for healthcare or pharmaceutical policies relevant to reducing the burden of falsified medicines in LMIC. RESULTS Our initial search identified 660 unique studies, of which 203 met title/abstract inclusion criteria and were categorised according to their primary focus: international; national; local pharmacy; internet pharmacy; drug analysis tools. Eighty-four were included in the qualitative synthesis, along with 108 articles and website links retrieved through secondary searches. DISCUSSION On the international stage, we discuss the need for accessible pharmacovigilance (PV) global reporting systems, international leadership and funding incorporating multiple stakeholders (healthcare, pharmaceutical, law enforcement) and multilateral trade agreements that emphasise public health. On the national level, we explore the importance of establishing adequate medicine regulatory authorities and PV capacity, with drug screening along the supply chain. This requires interdepartmental coordination, drug certification and criminal justice legislation and enforcement that recognise the severity of medicine falsification. Local healthcare professionals can receive training on medicine quality assessments, drug registration and pharmacological testing equipment. Finally, we discuss novel technologies for drug analysis which allow rapid identification of fake medicines in low-resource settings. Innovative point-of-purchase systems like mobile phone verification allow consumers to check the authenticity of their medicines. CONCLUSIONS Combining anti-falsifying strategies targeting different levels of the pharmaceutical supply chain provides multiple barriers of protection from falsified medicines. This requires the political will to drive policy implementation; otherwise, people around the world remain at risk.
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Affiliation(s)
- William L Hamilton
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0SP, UK .,Wellcome Trust Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge, CB10 1SA, UK
| | - Cormac Doyle
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0SP, UK
| | - Mycroft Halliwell-Ewen
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0SP, UK
| | - Gabriel Lambert
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0SP, UK
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Iroh Tam PY, Obaro SK, Storch G. Challenges in the Etiology and Diagnosis of Acute Febrile Illness in Children in Low- and Middle-Income Countries. J Pediatric Infect Dis Soc 2016; 5:190-205. [PMID: 27059657 PMCID: PMC7107506 DOI: 10.1093/jpids/piw016] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 03/04/2016] [Indexed: 01/01/2023]
Abstract
Acute febrile illness is a common cause of hospital admission, and its associated infectious causes contribute to substantial morbidity and death among children worldwide, especially in low- and middle-income countries. Declining transmission of malaria in many regions, combined with the increasing use of rapid diagnostic tests for malaria, has led to the increasing recognition of leptospirosis, rickettsioses, respiratory viruses, and arboviruses as etiologic agents of fevers. However, clinical discrimination between these etiologies can be difficult. Overtreatment with antimalarial drugs is common, even in the setting of a negative test result, as is overtreatment with empiric antibacterial drugs. Viral etiologies remain underrecognized and poorly investigated. More-sensitive diagnostics have led to additional dilemmas in discriminating whether a positive test result reflects a causative pathogen. Here, we review and summarize the current epidemiology and focus particularly on children and the challenges for future research.
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Affiliation(s)
- Pui-Ying Iroh Tam
- Department of Pediatrics
,
University of Minnesota Medical School
,
Minneapolis,Corresponding Author:
Pui-Ying Iroh Tam, MD, 3-210 MTRF, 2001 6th St. SE, Minneapolis, MN 55455. E-mail:
| | - Stephen K. Obaro
- Department of Pediatrics, University of Nebraska Medical Center, Omaha
| | - Gregory Storch
- Department of Pediatrics
,
Washington University School of Medicine
,
St Louis, Missouri
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Pharmaceutical evaluation of atorvastatin calcium tablets available on the Internet: A preliminary investigation of substandard medicines in Japan. J Drug Deliv Sci Technol 2016. [DOI: 10.1016/j.jddst.2015.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Routine quality control of medicines in developing countries: Analytical challenges, regulatory infrastructures and the prevalence of counterfeit medicines in Tanzania. Trends Analyt Chem 2016. [DOI: 10.1016/j.trac.2015.11.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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30
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Public Awareness and Identification of Counterfeit Drugs in Tanzania: A View on Antimalarial Drugs. ADVANCES IN PUBLIC HEALTH 2016. [DOI: 10.1155/2016/6254157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background. The illicit trade in counterfeit antimalarial drugs is a major setback to the fight against malaria. Information on public awareness and ability to identify counterfeit drugs is scanty.Aim. Therefore, the present study aimed at assessing public awareness and the ability to identify counterfeit antimalarial drugs based on simple observations such as appearance of the drugs, packaging, labelling, and leaflets.Methodology. A cross-sectional study was conducted using interviewer administered structured questionnaire and a checklist. Respondents were required to spot the difference between genuine and counterfeit antimalarial drugs given to them. Data was analysed using SPSS version 20.Results. The majority of respondents, 163 (55.6%), were able to distinguish between genuine and counterfeit antimalarial drugs. Respondents with knowledge on health effects of counterfeit drugs were more likely to identify genuine and counterfeit drugs than their counterparts (P=0.003; OR = 2.95; 95% CI: 1.47–5.65). The majority of respondents, 190 (64.8%), perceived the presence of counterfeit drugs to be a big problem to the community.Conclusions. A substantial proportion of respondents were able to distinguish between genuine and counterfeit antimalarial drugs. Public empowerment in identifying counterfeit drugs by simple observations is a major step towards discouraging the market of counterfeit drugs.
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Tshilumba PM, Kagoha ER, Chiribagula VB, Kalubandika GM, Ntabaza Ndage V, Nzuzi TS, Wa Ilunga EN, Duez P, Kalonji Ndoumba JB. Preliminary Study on Counterfeiting of Artemether and Artesunate Marketed in Lubumbashi. ACTA ACUST UNITED AC 2016. [DOI: 10.4236/pp.2016.75024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kobayashi T, Gamboa D, Ndiaye D, Cui L, Sutton PL, Vinetz JM. Malaria Diagnosis Across the International Centers of Excellence for Malaria Research: Platforms, Performance, and Standardization. Am J Trop Med Hyg 2015; 93:99-109. [PMID: 26259937 PMCID: PMC4574279 DOI: 10.4269/ajtmh.15-0004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 06/23/2015] [Indexed: 12/14/2022] Open
Abstract
Diagnosis is “the act of identifying a disease, illness, or problem by examining someone or something.” When an individual with acute fever presents for clinical attention, accurate diagnosis leading to specific, prompt treatment often saves lives. As applied to malaria, not only individual patient diagnosis is important but also assessing population-level malaria prevalence using appropriate diagnostic methods is essential for public health purposes. Similarly, identifying (diagnosing) fake antimalarial medications prevents the use of counterfeit drugs that can have disastrous effects. Therefore, accurate diagnosis in broad areas related to malaria is fundamental to improving health-care delivery, informing funding agencies of current malaria situations, and aiding in the prioritization of regional and national control efforts. The International Centers of Excellence for Malaria Research (ICEMR), supported by the U.S. National Institute of Allergy and Infectious Diseases, has collaborated on global efforts to improve malaria diagnostics by working to harmonize and systematize procedures across different regions where endemicity and financial resources vary. In this article, the different diagnostic methods used across each ICEMR are reviewed and challenges are discussed.
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Affiliation(s)
- Tamaki Kobayashi
- *Address correspondence to Tamaki Kobayashi, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, W4612, Baltimore, MD 21205, E-mail: or Joseph M. Vinetz, Division of Infectious Diseases, Department of Medicine, University of California San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093-0760, E-mail:
| | | | | | | | | | - Joseph M. Vinetz
- *Address correspondence to Tamaki Kobayashi, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, W4612, Baltimore, MD 21205, E-mail: or Joseph M. Vinetz, Division of Infectious Diseases, Department of Medicine, University of California San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093-0760, E-mail:
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Act Consortium Drug Quality Project Team And The Impact Study Team. Quality of Artemisinin-Containing Antimalarials in Tanzania's Private Sector--Results from a Nationally Representative Outlet Survey. Am J Trop Med Hyg 2015; 92:75-86. [PMID: 25897065 PMCID: PMC4455080 DOI: 10.4269/ajtmh.14-0544] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 01/05/2015] [Indexed: 11/07/2022] Open
Abstract
Ensuring that artemisinin-containing antimalarials (ACAs) are of good quality is a key component of effective malaria treatment. There are concerns that a high proportion of ACAs are falsified or substandard, though estimates are rarely based on representative data. During a nationally representative survey in Tanzania, ACAs were purchased from private retail drug outlets, and the active pharmaceutical ingredient (API) was measured. All 1,737 ACAs contained the labeled artemisinin derivative, with 4.1% being outside the 85-115% artemisinin API range defined as acceptable quality. World Health Organization (WHO) prequalified drugs had 0.1 times the odds of being poor quality compared with non-prequalified ACAs for the artemisinin component. When partner components of combination therapies were also considered, 12.1% were outside the acceptable API range, and WHO prequalified ACAs had 0.04 times the odds of being poor quality. Although the prevalence of poor quality ACAs was lower than reported elsewhere, the minority of samples found to be substandard is a cause for concern. Improvements in quality could be achieved by increasing the predominance of WHO prequalified products in the market. Continued monitoring of quality standards is essential.
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Yong YL, Plançon A, Lau YH, Hostetler DM, Fernández FM, Green MD, Sounvoravong S, Nara S, Boravann M, Dumrong T, Bangsawan N, Low MY, Lim CC, Ai RLC, Newton PN. Collaborative health and enforcement operations on the quality of antimalarials and antibiotics in southeast Asia. Am J Trop Med Hyg 2015; 92:105-112. [PMID: 25897069 PMCID: PMC4455084 DOI: 10.4269/ajtmh.14-0574] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 01/05/2015] [Indexed: 11/23/2022] Open
Abstract
Counterfeit (or falsified) and substandard medicines pose a major public health risk. We describe the findings of Operation Storm I and II conducted in 2008–2009 to combat counterfeit medicines through partnership between national customs, Drug Regulatory Agencies (DRAs), and police in Cambodia, Indonesia, Laos, Myanmar, Singapore, Thailand, and Vietnam. Samples were obtained from seizures and market surveillance by national DRAs. Laboratory analysis using spectroscopic and chromatographic techniques and examination of packaging were performed. Ninety-three suspect antibiotics and 95 antimalarial samples were collected. Of the 93 antibiotics, 29 (31%) had % active pharmaceutical ingredient content (%API) < 85% or > 115% (including one counterfeit). Of the 95 antimalarials, 30 (32%) had %API < 85 > 115% API (including one counterfeit). A significant minority of samples, antimalarials (13%) and antibiotics (15%), were collected in plastic bags with minimal or no labeling. Of 20 ampicillin samples, 13 (65%) contained < 85% API (with one counterfeit containing additional amoxicillin). Of 34 oral artesunate samples, 7 (21%) contained %API out of the 85–115% range. Coordinated and synergistic partnership adopted by the participating countries, International Criminal Police Organization (INTERPOL), World Health Organization (WHO), and laboratories facilitated a platform for discussions and intelligence sharing, helping to improve each participating country's capacity to combat poor-quality medicines.
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Affiliation(s)
| | - Aline Plançon
- *Address correspondence to Paul N. Newton, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR, E-mail: or Aline Plançon, Medical Product Counterfeiting and Pharmaceutical Crime Sub-Directorate, INTERPOL, Lyon, France, E-mail:
| | | | | | | | | | | | | | | | | | | | | | | | | | - Paul N. Newton
- *Address correspondence to Paul N. Newton, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR, E-mail: or Aline Plançon, Medical Product Counterfeiting and Pharmaceutical Crime Sub-Directorate, INTERPOL, Lyon, France, E-mail:
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Ho NT, Desai D, Zaman MH. Rapid and specific drug quality testing assay for artemisinin and its derivatives using a luminescent reaction and novel microfluidic technology. Am J Trop Med Hyg 2015; 92:24-30. [PMID: 25897061 PMCID: PMC4455072 DOI: 10.4269/ajtmh.14-0392] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 03/14/2015] [Indexed: 11/14/2022] Open
Abstract
Globally, it is estimated that about 10–30% of pharmaceuticals are of poor quality. Poor-quality drugs lead to long-term drug resistance, create morbidity, and strain the financial structure of the health system. The current technologies for substandard drug detection either are too expensive for low-resource regions or only provide qualitative results. To address the current limitations with point-of-care technologies, we have developed an affordable and robust assay to quantify the amount of active pharmaceutical ingredients (APIs) to test product quality. Our novel assay consists of two parts: detection reagent (probe) and a microfluidic testing platform. As antimalarials are of high importance in the global fight against malaria and are often substandard, they are chosen as the model to validate our assay. As a proof-of-concept, we have tested the assay with artesunate pure and substandard samples (Arsuamoon tablets) from Africa and compared with the conventional 96-well plate with spectrophotometer to demonstrate the quantitative efficacy and performance of our system.
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Affiliation(s)
| | | | - Muhammad H. Zaman
- *Address correspondence to Muhammad H. Zaman, Department of Biomedical Engineering, Boston University, 44 Cummington Mall, Boston, MA 02215. E-mail:
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Muhindo Mavoko H, Ilombe G, Inocêncio da Luz R, Kutekemeni A, Van geertruyden JP, Lutumba P. Malaria policies versus practices, a reality check from Kinshasa, the capital of the Democratic Republic of Congo. BMC Public Health 2015; 15:352. [PMID: 25885211 PMCID: PMC4396810 DOI: 10.1186/s12889-015-1670-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 03/20/2015] [Indexed: 11/22/2022] Open
Abstract
Background Artemisinin-based combination therapy (ACT) following a confirmed parasitological diagnosis is recommended by the World Health Organization (WHO) and the Congolese National Malaria Control Program (NMCP). However, commitment and competence of all stakeholders (patients, medical professionals, governments and funders) is required to achieve effective case management and secure the “useful therapeutic life” of the recommended drugs. The health seeking behaviour of patients and health care professionals’ practices for malaria management were assessed. Methods This was an observational study embedded in a two-stage cluster randomized survey conducted in one health centre (HC) in each of the 12 selected health zones in Kinshasa city. All patients with clinical malaria diagnosis were eligible. Their health seeking behaviour was recorded on a specific questionnaire, as well as the health care practitioners’ practices. The last were not aware that their practices would be assessed. Results Six hundred and twenty four patients were assessed, of whom 136 (21.8%) were under five years. Three hundred and thirty five (55%) had taken medication prior to the current consultation (self -medication with any product or visiting another HC) of whom 47(14%) took an antimalarial drug, and 56 (9%) were treated presumptively. Among those, 53.6% received monotherapy either with quinine, artesunate, phytomedicines, sulfadoxine-pyrimethamine or amodiaquine. On the other side, when clinicians were informed about laboratory results, monotherapy was prescribed in 39.9% of the confirmed malaria cases. Only 285 patients (45.7%) were managed in line with WHO and NMCP guidelines, of whom 120 (19.2%) were prescribed an ACT after positive blood smear and 165 (26.4%) received no antimalarial after a negative result. Conclusion This study shows the discrepancy between malaria policies and the reality on the field in Kinshasa, regarding patients’ health seeking behaviour and health professionals’ practices. Consequently, the poor compliance to the policies may contribute to the genesis and spread of antimalarial drug resistance and also have a negative impact on the burden of the disease.
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Affiliation(s)
- Hypolite Muhindo Mavoko
- Département de Médecine Tropicale, Université de Kinshasa, B.P. 747, Kin XI, Kinshasa, République Démocratique du Congo. .,International Health Unit, Department of Epidemiology, University of Antwerp, Campus Drie Eiken, Universiteitsplein 1, 2610, Kinshasa, République Démocratique du Congo.
| | - Gillon Ilombe
- Département de Médecine Tropicale, Université de Kinshasa, B.P. 747, Kin XI, Kinshasa, République Démocratique du Congo.
| | - Raquel Inocêncio da Luz
- International Health Unit, Department of Epidemiology, University of Antwerp, Campus Drie Eiken, Universiteitsplein 1, 2610, Kinshasa, République Démocratique du Congo.
| | - Albert Kutekemeni
- Programme National de Lutte contre le Paludisme, Ministère de la Santé Publique, Kinshasa, République Démocratique du Congo.
| | - Jean-Pierre Van geertruyden
- International Health Unit, Department of Epidemiology, University of Antwerp, Campus Drie Eiken, Universiteitsplein 1, 2610, Kinshasa, République Démocratique du Congo.
| | - Pascal Lutumba
- Département de Médecine Tropicale, Université de Kinshasa, B.P. 747, Kin XI, Kinshasa, République Démocratique du Congo.
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Abstract
Substandard/counterfeit antimicrobial drugs are a growing global problem. The most common substandard/counterfeit antimicrobials include beta-lactams (among antibiotics) and chloroquine and artemisin derivatives (among antimalarials). The most common type of substandard/counterfeit antimicrobial drugs have a reduced amount of the active drug, and the majority of them are manufactured in Southeast Asia and Africa. Counterfeit antimicrobial drugs may cause increased mortality and morbidity and pose a danger to patients. Here we review the literature with regard to the issue of substandard/counterfeit antimicrobials and describe the prevalence of this problem, the different types of substandard/counterfeit antimicrobial drugs, and the consequences for the individuals and global public health. Local, national, and international initiatives are required to combat this very important public health issue.
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Affiliation(s)
- Theodoros Kelesidis
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Matthew E Falagas
- Alfa Institute of Biomedical Sciences, Athens, Greece Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
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Chikowe I, Osei-Safo D, Harrison JJEK, Konadu DY, Addae-Mensah I. Post-marketing surveillance of anti-malarial medicines used in Malawi. Malar J 2015; 14:127. [PMID: 25890029 PMCID: PMC4377194 DOI: 10.1186/s12936-015-0637-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 03/03/2015] [Indexed: 11/25/2022] Open
Abstract
Background The growing concern over the extent of anti-malarial medicine resistance in sub-Saharan Africa, driven largely by administration of sub-therapeutic doses derived from falsified and substandard medicines necessitates regular monitoring of the quality of these medicines to avert any potential public health disaster. This study aimed at determining the active pharmaceutical ingredient (API) content of anti-malarial medicines available in Malawi with respect to the manufacturers’ label claim and pharmacopoeia specifications. Methods Samples of anti-malarial medicines (112) collected from both licensed and unlicensed markets throughout Malawi were subjected to visual inspection of dosage form and packaging, and registration verification with the regulatory body. Basic (colourimetric) tests were employed to establish the presence and identity of the requisite APIs. Semi-quantitative thin layer chromatography (SQ-TLC) was employed as a quick assay for the verification of identity and estimation of the API content while HPLC assays were used to quantify the APIs. The results were compared with pharmacopoeia specifications and manufacturers’ label claims. For combination therapies, a sample was considered to have failed if one or more of its component APIs did not meet pharmacopoeia specifications. Results There was 86.6% registration status and 100% compliance with visual inspection and basic tests confirming the presence of requisite APIs. The identification test was confirmed by the SQ-TLC assay. API quantification by HPLC assay however, showed that 88.4% (99/112) of the samples failed the quality tests due to the presence of either insufficient or excessive API. Conclusions The results suggest the existence of substandard anti-malarial medicines in Malawi. The presence of both excessive and insufficient artemisinin-based and non-artemisinin-based API, clearly points to poor adherence to GMP and improper handling during storage or distribution. The country relies heavily on imported anti-malarial medicines so there is an urgent need to carry out regular and thorough post-market surveillance of medicines to ensure better quality health care delivery. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0637-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ibrahim Chikowe
- Department of Chemistry, University of Ghana, Legon, Accra, Ghana. .,Ministry of Education, Science and Technology, Lilongwe, Malawi.
| | - Dorcas Osei-Safo
- Department of Chemistry, University of Ghana, Legon, Accra, Ghana.
| | | | - Daniel Y Konadu
- Department of Chemistry, University of Ghana, Legon, Accra, Ghana.
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Bernard M, Akrout W, Van Buu CT, Metz C, Antignac M, Yagoubi N, Do B. Liquid chromatography with tandem mass spectrometry for the simultaneous identification and quantification of cardiovascular drugs applied to the detection of substandard and falsified drugs. J Sep Sci 2015; 38:562-70. [DOI: 10.1002/jssc.201401301] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 11/19/2014] [Accepted: 12/08/2014] [Indexed: 12/23/2022]
Affiliation(s)
- Mélisande Bernard
- Laboratories Departement; Agence Générale des Equipements et Produits de Santé; Assistance Publique-Hôpitaux de Paris; Paris France
- Faculty of pharmacy; Paris Sud University, UA 401 Matériaux et Santé; Châtenay-Malabry France
| | - Wiem Akrout
- Laboratories Departement; Agence Générale des Equipements et Produits de Santé; Assistance Publique-Hôpitaux de Paris; Paris France
| | - Christelle Tran Van Buu
- Laboratories Departement; Agence Générale des Equipements et Produits de Santé; Assistance Publique-Hôpitaux de Paris; Paris France
| | - Carole Metz
- Laboratories Departement; Agence Générale des Equipements et Produits de Santé; Assistance Publique-Hôpitaux de Paris; Paris France
| | - Marie Antignac
- Pharmacy, Saint-Antoine Hospital-Hôpitaux Universitaires Est Parisien HUEP; Assistance Publique-Hôpitaux de Paris; Paris France
| | - Najet Yagoubi
- Faculty of pharmacy; Paris Sud University, UA 401 Matériaux et Santé; Châtenay-Malabry France
| | - Bernard Do
- Laboratories Departement; Agence Générale des Equipements et Produits de Santé; Assistance Publique-Hôpitaux de Paris; Paris France
- Faculty of pharmacy; Paris Sud University, UA 401 Matériaux et Santé; Châtenay-Malabry France
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Read AF, Huijben S. Evolutionary biology and the avoidance of antimicrobial resistance. Evol Appl 2015; 2:40-51. [PMID: 25567846 PMCID: PMC3352414 DOI: 10.1111/j.1752-4571.2008.00066.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 12/11/2008] [Indexed: 11/29/2022] Open
Abstract
Evolutionary biologists have largely left the search for solutions to the drug resistance crisis to biomedical scientists, physicians, veterinarians and public health specialists. We believe this is because the vast majority of professional evolutionary biologists consider the evolutionary science of drug resistance to be conceptually uninteresting. Using malaria as case study, we argue that it is not. We review examples of evolutionary thinking that challenge various fallacies dominating antimalarial therapy, and discuss open problems that need evolutionary insight. These problems are unlikely to be resolved by biomedical scientists ungrounded in evolutionary biology. Involvement by evolutionary biologists in the science of drug resistance requires no intellectual compromises: the problems are as conceptually challenging as they are important.
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Affiliation(s)
- Andrew F Read
- Center for Infectious Disease Dynamics, Departments of Biology and Entomology, Pennsylvania State University, University Park PA, USA
| | - Silvie Huijben
- Center for Infectious Disease Dynamics, Departments of Biology and Entomology, Pennsylvania State University, University Park PA, USA ; School of Biological Sciences, University of Edinburgh West Mains Road, Edinburgh, UK
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Almuzaini T, Sammons H, Choonara I. Quality of medicines in Canada: a retrospective review of risk communication documents (2005-2013). BMJ Open 2014; 4:e006088. [PMID: 25361839 PMCID: PMC4216865 DOI: 10.1136/bmjopen-2014-006088] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 10/06/2014] [Accepted: 10/07/2014] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To explore the quality and safety of medicines in Canada. DESIGN A retrospective review of drug recalls and risk communication documents conveying issues relating to defective (ie, substandard and falsified) medicines. SETTING The Health Canada website search for drug recalls and risk communication documents issued between 2005 and 2013. ELIGIBILITY CRITERIA Drug recalls and risk communication documents related to quality defect in medicinal products. MAIN OUTCOME MEASURE Relevant data about defective medicines reported in drug recalls and risk communication documents, including description of the defect, type of formulation, year of the recall and category of the recall or the document. RESULTS There were 653 defective medicines of which 649 were substandard. The number of defective medicines reported by Health Canada increased from 42 in 2005 to 143 in 2013. The two most frequently reported types of defects were stability (205 incidents) and contamination issues (139 incidents). Some of these defects were found to be more prominent and repetitive over other types within some manufacturers. Tablet formulation (251 incidents) was the formulation most frequently compromised. No significant differences were observed between the manufacturers and distributors in the number of substandard medicines reported under each defect type. There were only four falsified medicines reported over the 9-year period. CONCLUSIONS Substandard medicines are a problem in Canada and have resulted in an increasing number of recalled medicines. Most of the failures were related to stability issues, raising the need to investigate the root causes and for stringent preventative measures to be implemented by manufacturers.
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Affiliation(s)
- Tariq Almuzaini
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Helen Sammons
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Imti Choonara
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
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Evaluation of the quality of artemisinin-based antimalarial medicines distributed in ghana and togo. Malar Res Treat 2014; 2014:806416. [PMID: 25400975 PMCID: PMC4225840 DOI: 10.1155/2014/806416] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 09/26/2014] [Accepted: 09/29/2014] [Indexed: 12/18/2022] Open
Abstract
This study, conducted as part of our overall goal of regular pharmacovigilance of antimalarial medicines, reports on the quality of 132 artemisinin-based antimalarial medicines distributed in Ghana and Togo. Three methods were employed in the quality evaluation—basic (colorimetric) tests for establishing the identity of the requisite active pharmaceutical ingredients (APIs), semi-quantitative TLC assay for the identification and estimation of API content, and HPLC assay for a more accurate quantification of API content. From the basic tests, only one sample totally lacked API. The HPLC assay, however, showed that 83.7% of the ACTs and 57.9% of the artemisinin-based monotherapies failed to comply with international pharmacopoeia requirements due to insufficient API content. In most of the ACTs, the artemisinin component was usually the insufficient API. Generally, there was a good correlation between the HPLC and SQ-TLC assays. The overall failure rates for both locally manufactured (77.3%) and imported medicines (77.5%) were comparable. Similarly the unregistered medicines recorded a slightly higher overall failure rate (84.7%) than registered medicines (70.8%). Only two instances of possible cross-border exchange of medicines were observed and there was little difference between the medicine quality of collections from border towns and those from inland parts of both countries.
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Johnston A, Holt DW. Substandard drugs: a potential crisis for public health. Br J Clin Pharmacol 2014; 78:218-43. [PMID: 24286459 PMCID: PMC4137817 DOI: 10.1111/bcp.12298] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 11/01/2013] [Indexed: 01/26/2023] Open
Abstract
Poor-quality medicines present a serious public health problem, particularly in emerging economies and developing countries, and may have a significant impact on the national clinical and economic burden. Attention has largely focused on the increasing availability of deliberately falsified drugs, but substandard medicines are also reaching patients because of poor manufacturing and quality-control practices in the production of genuine drugs (either branded or generic). Substandard medicines are widespread and represent a threat to health because they can inadvertently lead to healthcare failures, such as antibiotic resistance and the spread of disease within a community, as well as death or additional illness in individuals. This article reviews the different aspects of substandard drug formulation that can occur (for example, pharmacological variability between drug batches or between generic and originator drugs, incorrect drug quantity and presence of impurities). The possible means of addressing substandard manufacturing practices are also discussed. A concerted effort is required on the part of governments, drug manufacturers, charities and healthcare providers to ensure that only drugs of acceptable quality reach the patient.
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Affiliation(s)
- Atholl Johnston
- Clinical Pharmacology, Barts and The London School of Medicine and Dentistry, Queen Mary, University of LondonLondon, UK
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He L, Nan T, Cui Y, Guo S, Zhang W, Zhang R, Tan G, Wang B, Cui L. Development of a colloidal gold-based lateral flow dipstick immunoassay for rapid qualitative and semi-quantitative analysis of artesunate and dihydroartemisinin. Malar J 2014; 13:127. [PMID: 24678609 PMCID: PMC4113134 DOI: 10.1186/1475-2875-13-127] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 03/12/2014] [Indexed: 11/10/2022] Open
Abstract
Background Artemisinin-based combination therapy (ACT) plays an indispensable role in malaria control and elimination. However, the circulation of counterfeit, substandard drugs has greatly threatened malaria elimination campaigns. Most methods for the analysis of artemisinin and its derivatives require expensive equipment and sophisticated instrumentation. A convenient, easy-to-use diagnostic device for rapid evaluation of the quality of artemisinin drugs at the point-of-care is still lacking. In this study a lateral flow dipstick immunoassay was developed for qualitative and semi-quantitative analysis of artesunate (ATS) and dihydroartemisinin (DHA) in anti-malarial drugs. Methods This assay was based on a monoclonal antibody (mAb) raised against ATS. ATS-bovine serum albumin and goat anti-mouse IgG, used as the test capture reagent and the control capture reagent, were coated on the nitrocellulose membrane to form the test line and control line, respectively. The conjugate pad was saturated with the gold-labelled anti-ATS mAb. Results The indicator range of the dipsticks, defined as lowest concentration of the target analytes between which the test line was not visible, were 100-200 and 200-500 ng mL-1 for ATS and DHA, respectively. No competitive inhibition was observed up to 5,000 ng mL-1 of quinine, chloroquine diphosphate salt, primaquine phosphate, pyrimethamine, lumefantrine, amodiaquine, piperaquine tetraphosphate tetrahydrate or pyronaridine tetraphosphate. Semi-quantitative analysis of ATS and DHA in commercial drugs and raw drug materials with the dipsticks produced result agreeable with those determined by high performance liquid chromatography (HPLC). Storage test showed that the indicator range for artemisinins remained unchanged after a week at 37°C and increased four-folds after six months of storage at 4°C or ambient temperature. Conclusions The new selected mAb 3D82G7 with high avidity and broad cross reactivity for artemisinins was used to develop and optimize a dipstick immunoassay for qualitative and semi-quantitative analysis of ATS and DHA in anti-malarial drugs. The semi-quantitative analysis of ATS and DHA in commercial drugs and raw drug materials, and the specificity test of the artemisinin-related drugs both proved the accurate performance of the developed dipsticks for semi-quantitation of ACT samples. The dipstick may be used as a point-of-care device for identifying substandard and counterfeit ATS- and DHA-containing anti-malarial drugs.
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Affiliation(s)
| | | | | | | | | | | | | | - Baomin Wang
- College of Agronomy and Biotechnology, China Agricultural University, Beijing, People's Republic of China.
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Mujinja PGM, Mackintosh M, Justin-Temu M, Wuyts M. Local production of pharmaceuticals in Africa and access to essential medicines: 'urban bias' in access to imported medicines in Tanzania and its policy implications. Global Health 2014; 10:12. [PMID: 24612518 PMCID: PMC4021829 DOI: 10.1186/1744-8603-10-12] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 02/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND International policy towards access to essential medicines in Africa has focused until recently on international procurement of large volumes of medicines, mainly from Indian manufacturers, and their import and distribution. This emphasis is now being challenged by renewed policy interest in the potential benefits of local pharmaceutical production and supply. However, there is a shortage of evidence on the role of locally produced medicines in African markets, and on potential benefits of local production for access to medicines. This article contributes to filling that gap. METHODS This article uses WHO/HAI data from Tanzania for 2006 and 2009 on prices and sources of a set of tracer essential medicines. It employs innovative graphical methods of analysis alongside conventional statistical testing. RESULTS Medicines produced in Tanzania were equally likely to be found in rural and in urban areas. Imported medicines, especially those imported from countries other than Kenya (mainly from India) displayed 'urban bias': that is, they were significantly more likely to be available in urban than in rural areas. This finding holds across the range of sample medicines studied, and cannot be explained by price differences alone. While different private distribution networks for essential medicines may provide part of the explanation, this cannot explain why the urban bias in availability of imported medicines is also found in the public sector. CONCLUSIONS The findings suggest that enhanced local production may improve rural access to medicines. The potential benefits of local production and scope for their improvement are an important field for further research, and indicate a key policy area in which economic development and health care objectives may reinforce each other.
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Affiliation(s)
- Phares GM Mujinja
- Muhimbili University of Health and Allied Sciences, PO Box 65105, Dar es Salaam, Tanzania
| | - Maureen Mackintosh
- Department of Economics, Faculty of Social Sciences, The Open University, Walton Hall, Milton Keynes MK7 6AA, UK
| | - Mary Justin-Temu
- Muhimbili University of Health and Allied Sciences, PO Box 65105, Dar es Salaam, Tanzania
| | - Marc Wuyts
- International Institute of Social Studies, Erasmus University Rotterdam, P.O. Box 29776, 2502 LT The Hague, The Netherlands
- REPOA, 157 Mgombani Street, Regent Estate, P.O. Box 33223, Dar es Salaam, Tanzania
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Mboera LE, Mazigo HD, Rumisha SF, Kramer RA. Towards malaria elimination and its implication for vector control, disease management and livelihoods in Tanzania. MALARIAWORLD JOURNAL 2013; 4:19. [PMID: 38828111 PMCID: PMC11138750 DOI: 10.5281/zenodo.10928325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Over the years, malaria has remained the number one cause of morbidity and mortality in Tanzania. Population based studies have indicated a decline in overall malaria prevalence among under-fives from 18.1% in 2008 to 9.7% in 2012. The decline of malaria infection has occurred in all geographical zones of the country. Malaria mortality and cumulative probability of deaths have also shown a marked decline from 2000 to 2010. During the same period, area specific studies in Muheza, Korogwe, Muleba and Mvomero have also reported a similar declining trend in malaria prevalence and incidence. The decline in malaria prevalence has been observed to coincide with a decline in transmission indices including anopheline mosquito densities. The decline in malaria prevalence has been attributed to a combination of factors including improved access to effective malaria treatment with artemisinin combination therapy and protection from mosquito bites by increased availability of insecticide treated bednets and indoor residual spraying. The objective of this paper was to review the changing landscape of malaria and its implication for disease management, vector control, and livelihoods in Tanzania. It seeks to examine the links within a broad framework that considers the different pathways given the multiplicity of interactions that can produce unexpected outcomes and trade-offs. Despite the remarkable decline in malaria burden, Tanzania is faced with a number of challenges. These include the development of resistance of malaria vectors to pyrethroids, changing mosquito behaviour and livelihood activities that increase mosquito productivity and exposure to mosquito bites. In addition, there are challenges related to health systems, community perceptions, community involvement and sustainability of funding to the national malaria control programme. This review indicates that malaria remains an important and challenging disease that illustrates the interactions among ecosystems, livelihoods, and health systems. Livelihoods and several sectoral development activities including construction, water resource development and agricultural practices contribute significantly to malaria mosquito productivity and transmission. Consequently, these situations require innovative and integrative re-thinking of the strategies to prevent and control malaria. In conclusion, to accelerate and sustain malaria control in Tanzania, the prevention strategies must go hand in hand with an intersectoral participation approach that takes into account ecosystems and livelihoods that have the potential to increase or decrease malaria transmission.
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Affiliation(s)
- Leonard E.G. Mboera
- National Institute for Medical Research, P.O. Box 9653, Dares Salaam, Tanzania
| | - Humphrey D. Mazigo
- Catholic University of Health and Allied Sciences-Bugando, P.O. Box 1464, Mwanza, Tanzania
| | - Susan F. Rumisha
- National Institute for Medical Research, P.O. Box 9653, Dares Salaam, Tanzania
| | - Randall A. Kramer
- Duke Global Health Institute, Duke University, Durham NC, United States of America
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Wang M, Cui Y, Zhou G, Yan G, Cui L, Wang B. Validation of ELISA for quantitation of artemisinin-based antimalarial drugs. Am J Trop Med Hyg 2013; 89:1122-8. [PMID: 24080636 DOI: 10.4269/ajtmh.12-0592] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The circulation of counterfeit or substandard artemisinins (ARTs) in malaria-endemic areas poses a serious threat to the long-term use of these drugs. Here, we validated an indirect competitive enzyme-linked immunosorbent assay (icELISA) for quantification of ARTs and found that 50% of inhibitory concentrations of dihydroartemisinin, artemether, and artesunate were 8.1, 207.0, and 4.7 ng/mL, respectively. We compared the icELISA with high-performance liquid chromatography (HPLC) for quantifying ART and its derivatives in 22 convenience samples of commercial antimalarial drugs. Paired t tests showed a borderline significant difference between the two methods (mean = 0.03, 95% confidence interval [CI] 0.00-0.07, P = 0.074) and the icELISA results were more variable than those of the HPLC analysis (P < 0.001), suggesting that further improvement is needed to enhance the performance of the icELISA. Our results showed that the icELISA has the potential to be improved for quality assurance of ARTs at the point of care in endemic settings.
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Affiliation(s)
- Min Wang
- Beijing Key Laboratory of Plant Resources Research and Development, College of Science, Beijing Technology and Business University, Beijing, China; College of Agronomy and Biotechnology, China Agricultural University, Beijing, China; Program in Public Health, University of California, Irvine, California; Department of Entomology, Pennsylvania State University, University Park, Pennsylvania
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Oduro A, Anyorigiya T, Anto F, Amenga-Etego L, Ansah N, Atobrah P, Ansah P, Koram K, Hodgson A. A randomized, comparative study of supervised and unsupervised artesunate–amodiaquine, for the treatment of uncomplicated malaria in Ghana. ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 2013; 102:565-76. [DOI: 10.1179/136485908x337508] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Njau JD, Kabanywanyi AM, Goodman CA, Macarthur JR, Kapella BK, Gimnig JE, Kahigwa E, Bloland PB, Abdulla SM, Kachur SP. Adverse drug events resulting from use of drugs with sulphonamide-containing anti-malarials and artemisinin-based ingredients: findings on incidence and household costs from three districts with routine demographic surveillance systems in rural Tanzania. Malar J 2013; 12:236. [PMID: 23844934 PMCID: PMC3710484 DOI: 10.1186/1475-2875-12-236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 06/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anti-malarial regimens containing sulphonamide or artemisinin ingredients are widely used in malaria-endemic countries. However, evidence of the incidence of adverse drug reactions (ADR) to these drugs is limited, especially in Africa, and there is a complete absence of information on the economic burden such ADR place on patients. This study aimed to document ADR incidence and associated household costs in three high malaria transmission districts in rural Tanzania covered by demographic surveillance systems. METHODS Active and passive surveillance methods were used to identify ADR from sulphadoxine-pyrimethamine (SP) and artemisinin (AS) use. ADR were identified by trained clinicians at health facilities (passive surveillance) and through cross-sectional household surveys (active surveillance). Potential cases were followed up at home, where a complete history and physical examination was undertaken, and household cost data collected. Patients were classified as having 'possible' or 'probable' ADR by a physician. RESULTS A total of 95 suspected ADR were identified during a two-year period, of which 79 were traced, and 67 reported use of SP and/or AS prior to ADR onset. Thirty-four cases were classified as 'probable' and 33 as 'possible' ADRs. Most (53) cases were associated with SP monotherapy, 13 with the AS/SP combination (available in one of the two areas only), and one with AS monotherapy. Annual ADR incidence per 100,000 exposures was estimated based on 'probable' ADR only at 5.6 for AS/SP in combination, and 25.0 and 11.6 for SP monotherapy. Median ADR treatment costs per episode ranged from US$2.23 for those making a single provider visit to US$146.93 for patients with four visits. Seventy-three per cent of patients used out-of-pocket funds or sold part of their farm harvests to pay for treatment, and 19% borrowed money. CONCLUSION Both passive and active surveillance methods proved feasible methods for anti-malarial ADR surveillance, with active surveillance being an important complement to facility-based surveillance, given the widespread practice of self-medication. Household costs associated with ADR treatment were high and potentially catastrophic. Efforts should be made to both improve pharmacovigilance across Africa and to identify strategies to reduce the economic burden endured by households suffering from ADR.
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Affiliation(s)
- Joseph D Njau
- Department of Health Policy and Management, Rollins School of Public Health (Emory University), Atlanta, GA 30322, USA.
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Binagwaho A, Bate R, Gasana M, Karema C, Mucyo Y, Mwesigye JP, Biziyaremye F, Nutt CT, Wagner CM, Jensen P, Attaran A. Combatting substandard and falsified medicines: a view from Rwanda. PLoS Med 2013; 10:e1001476. [PMID: 23843747 PMCID: PMC3699445 DOI: 10.1371/journal.pmed.1001476] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Agnes Binagwaho and colleagues describe Rwanda's experience of pharmacovigilance for malaria and tuberculosis, and call for a global treaty and leadership by the World Health Organization to address the global manufacture and trade in substandard and falsified medicines. Please see later in the article for the Editors' Summary
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