The uncertain role of substandard and falsified medicines in the emergence and spread of antimicrobial resistance

Hide and seek with falsified medicines: Current challenges and physico-chemical and biological approaches for tracing the origin of trafficked products

The criminal trafficking of falsified medical products is a worldwide, yet still largely overlooked, public health problem. A falsified medicine fraudulently misrepresents its identity, composition and/or source, often being ineffective or toxic for patients. Although techniques have been developed to detect falsified medicines, it remains a challenge to trace where- and by whom- the products are manufactured. We aim to discuss plausible biological and physico-chemical analytical techniques that could reveal information about the origin of medical falsifications. We first provide a brief overview on the prevalence, criminal activities, health impacts and (bio)chemical features of falsified medical products. We then explore diverse laboratory approaches, that are used in food fraud, illicit drug and wildlife trafficking investigations, and discuss how they could be combined and redirected towards tracing falsified medicine origin and hence empowering enforcement to counter this pernicious but neglected global health problem.

Current access, availability and use of antibiotics in primary care among key low- and middle-income countries and the policy implications

INTRODUCTION

Antimicrobial resistance (AMR) poses a significant threat, particularly in low- and middle-income countries (LMICs), exacerbated by inappropriate antibiotic use, access to quality antibiotics and weak antimicrobial stewardship (AMS). There is a need to review current evidence on antibiotic use, access, and AMR, in primary care across key countries.

AREAS COVERED

This narrative review analyzes publications from 2018 to 2024 regarding access, availability, and use of appropriate antibiotics.

EXPERT OPINION

There were very few studies focussing on a lack of access to antibiotics in primary care. However, there was considerable evidence of high rates of inappropriate antibiotic use, including Watch antibiotics, typically for minor infections, across studied countries exacerbated by patient demand. The high costs of antibiotics in a number of LMICs impact on their use, resulting in short courses and sharing of antibiotics. This can contribute to AMR alongside the use of substandard and falsified antibiotics. Overall, limited implementation of national action plans, insufficient resources, and knowledge gaps affects sustainable development goals to provide routine access to safe, effective, and appropriate antibiotics.

CONCLUSIONS

There is a clear need to focus health policy on the optimal use of essential AWaRe antibiotics in primary care settings to reduce AMR in LMICs.

Investigation of CIP quality in over-the-counter drug stores of resource-limited countries: a comparative study in Vietnam and Nigeria

Introduction

CIP, a broad-spectrum antibiotic, is crucial for managing bacterial infections. Its efficacy relies on maintaining high-quality standards, which can be affected by manufacturing, regulatory oversight and storage practices. This study compares the quality of CIP preparations in Vietnam and Nigeria, two nations with contrasting regulatory frameworks, to assess compliance with pharmaceutical standards and identify risks from substandard or falsified medicines.

Methods

A total of 46 CIP preparations were analysed, 20 purchased from 13 vendors in Vietnam and 26 from 13 vendors in Nigeria. Data on vendor qualifications and storage conditions were collected. Antibacterial activity was tested using a modified disk diffusion assay, and content and purity were evaluated via reversed-phase HPLC.

Results

Vietnam's drug outlets showed stricter regulation, with 100% registration and 61.5% staffed by Bachelor of Pharmacy holders, compared with only 23.1% in Nigeria. Temperature and humidity monitoring was universal in Vietnam but minimal in Nigeria (23.1% and 15.4%, respectively). Antimicrobial testing confirmed effectiveness for all but one sample (Vietnam), while Nigerian samples had greater variability. Reversed-phase HPLC revealed seven Nigerian samples (26.9%) with <80% declared CIP content, all from one manufacturer. Median content was 91% in Vietnam and 88% in Nigeria, with most samples meeting purity standards.

Conclusions

The study highlights significant disparities in the regulation, storage practices and quality of CIP between Vietnam and Nigeria. These findings underscore the critical need for improved regulation, monitoring and enforcement in countries with weaker pharmaceutical oversight to ensure drug efficacy and safety.

A comparative study between Near-Infrared (NIR) spectrometer and High-Performance Liquid Chromatography (HPLC) on the sensitivity and specificity

It is estimated that 10.5% of medicines in low- and middle-income countries are substandard or falsified (SF), causing approximately 1 million deaths annually. Over the past two decades, there have been significant technological advancements in low-cost, portable screening devices to detect poor-quality medicines, which could be especially beneficial in these countries. The pharmaceutical market in Nigeria is valued at USD 4.5 billion and is growing at over 9% annually. However, SF medicines remain a major public health concern. We compared a novel Near-Infrared (NIR) Spectrometer with high-performance liquid chromatography (HPLC) by analyzing 246 drug samples purchased from retail pharmacies across the six geopolitical regions of Nigeria. We measured the sensitivity and specificity of a patented and Artificial Intelligence (AI) - powered handheld NIR spectrometer, which uses a proprietary machine-learning algorithm as well as hardware and software, across four categories of medicines: analgesics, antimalarials, antibiotics, and antihypertensives. Our findings reveal that the prevalence of SF medicines remains high, with 25% of samples failing the HPLC test. When tested with the NIR spectrometer, only a smaller subset of medicines-specifically analgesics-failed the test. Sensitivity and specificity for all medicines were 11% and 74%, respectively. For analgesics, the sensitivity was 37%, and the specificity was 47%. While these devices hold great potential, regulators should require more independent evaluations of various drug formulations before implementing them in real-world settings. Improving the sensitivity of these devices should be prioritized to ensure that no SF medicines reach patients.

Assessing informal healthcare providers' knowledge of diagnosis and treatment of malaria and diarrhea: evidence from urban informal settlements in Southeast Nigeria

Background

Despite the availability of effective interventions, malaria and diarrhea continue to be leading causes of disease burden in Nigeria. Informal healthcare providers (IHPs) account for a significant proportion of health service providers in urban slums and may pose a challenge to service quality if they are untrained and unregulated. This study assessed IHPs' knowledge of the diagnosis and treatment of malaria and diarrhea.

Methodology

A cross-sectional quantitative study was conducted in eight urban informal settlements (slums) in southeast Nigeria. Data were collected from 235 informal health providers using an interviewer-administered questionnaire.

Results

The mean overall knowledge scores for malaria and diarrhea were 5.2 (95% CI: 4.3-6.1) and 5.4 (95% CI: 4.1-6.7), respectively, among the different IHPs. However, private medicine vendors (PMVs) and traditional birth attendants (TBAs) showed higher knowledge of treating malaria and diarrhea. Having more than 8 years of formal education and receiving on-the-job training had a statistically significant effect on adequate knowledge of malaria and diarrhea treatment.

Conclusion

Institutionalizing and strengthening service delivery through appropriate training and support for IHPs can improve the quality of health service delivery in urban slums.

Community pharmacy professionals' knowledge, attitudes, and practices toward substandard and falsified medicines and associated factors in Bahir Dar City, Northwest Ethiopia

Background

The availability of substandard and/or falsified medicines (SFMs) in the market poses a severe threat to health and the national economy. Therefore, pharmacy professionals are highly responsible for controlling SFMs distribution in the market to improve the health of the population.

Objective

The aim of this study was to assess community pharmacy professionals' knowledge, attitudes, and practices (KAP) toward SFMs and to identify associated factors in Bahir Dar City, Northwest Ethiopia.

Methods

A community-based descriptive cross-sectional study was conducted from 1 August 2024, to 30 September 2024. Participants were recruited using a simple random sampling method. A structured and self-administered questionnaire was used to collect data on sociodemographic characteristics and KAP toward SFMs. The collected data were entered and analysed using SPSS version 26. Multivariate logistic regression analysis was used to identify factors associated with participants' KAP toward SFMs. Variables with a P value < 0.05 were considered statistically significant.

Results

Of the 162 participants, 80.5% had a good knowledge and 54.9% had a positive attitude toward SFMs. However, 46.3% had a good level of practice toward SFMs. Educational levels with a master's degree (AOR = 2.6, 95% CI: 1.06-4.35) and work experience of 21-25 years (AOR = 2.19, 95% CI: 1.79-2.80) were associated with participants' knowledge. Educational levels with a master's degree (AOR = 1.65, 95% CI: 0.85-2.95), work experience of 21-25 years (AOR = 1.3, 95% CI: 0.85-1.86), good knowledge (AOR: 1.21, 95% CI: 0.94-1.51), and good practice (AOR = 1.33, 95% CI: 0.85-2.01) were associated with the participants' attitude. The practice of participants is affected by educational levels with a master's degree (AOR = 1.2, 95% CI: 1.14-1.26), 21-25 years of work experience (AOR = 2.74, 95% CI: 1.33-5.63), good knowledge (AOR: 2.71, 95% CI: 1.50-4.92), and positive attitude (AOR = 1.06, 95% CI: 0.89-2.23).

Conclusion

The study revealed that the majority of the participants had a good knowledge, and more than half had a positive attitude; however, less than half of the participants had a good level of practice toward SFMs. Education/training is required to enhance the role of community pharmacy professionals to combat their distribution and threats in the future.

A randomised survey of the quality of antibiotics and other essential medicines in Indonesia, with volume-adjusted estimates of the prevalence of substandard medicines

The World Health Organization warns that substandard and falsified medicines threaten public health in low- and middle-income countries. However, medicine quality surveys are often small and unrepresentative of the market, and the true scale of the problem remains unknown. We conducted a large field survey of essential medicines in Indonesia, and investigated how weighting survey results by market volume altered estimates of medicine quality. We collected 1274 samples of allopurinol, amlodipine, cefixime, amoxicillin and dexamethasone from the internet and a randomised sample of all outlet-types where medicines are sold or dispensed in seven districts across the world's fourth most populous nation. We conducted compendial testing for identity, assay, dissolution and uniformity. Samples that failed any chemical test were considered substandard. We compared raw prevalence of substandard medicines with prevalence adjusted by the national sales volume of each brand, relative to its weight among survey samples. The weighted prevalence of substandard products was 4.4%, 47% lower than the raw estimate (8.2%). Only 0.5% of samples (unweighted 1.2%) deviated from permitted limits by more than 10%. More antibiotics failed testing than other medicines (weighted prevalence 8.5 vs 3.1; raw prevalence 13.6 vs 4.9, both p<0.000). We found no relationship between quality and price; branded status; public procurement status; or outlet type. In Indonesia, unweighted survey data appeared to substantially over-estimate the health threat posed by substandard or falsified medicines. The types of sampling bias that led to over-representation of poor quality products in our survey are also indicated in other published surveys, possibly exaggerating the scale of the threat to public health posed by substandard and falsified medicines globally. Weighting survey results by sales volume likely improves robustness of estimates of medicine quality measured in field surveys.

Recent developments in antibiotic resistance: an increasing threat to public health

Antibiotic resistance (ABR) is a major global health threat that puts decades of medical progress at risk. Bacteria develop resistance through various means, including modifying their targets, deactivating drugs, and utilizing efflux pump systems. The main driving forces behind ABR are excessive antibiotic use in healthcare and agriculture, environmental contamination, and gaps in the drug development process. The use of advanced detection technologies, such as next-generation sequencing (NGS), clustered regularly interspaced short palindromic repeats (CRISPR)-based diagnostics, and metagenomics, has greatly improved the identification of resistant pathogens. The consequences of ABR on public health are significant, increased mortality rates, the endangerment of modern medical procedures, and resulting in higher healthcare expenses. It has been expected that ABR could potentially drive up to 24 million individuals into extreme poverty by 2030. Mitigation strategies focus on antibiotic stewardship, regulatory measures, research incentives, and raising public awareness. Furthermore, future research directions involve exploring the potential of CRISPR-Cas9 (CRISPR-associated protein 9), nanotechnology, and big data analytics as new antibiotic solutions. This review explores antibiotic resistance, including mechanisms, recent trends, drivers, and technological advancements in detection. It also evaluates the implications for public health and presents strategies for mitigating resistance. The review emphasizes the significance of future directions and research needs, stressing the necessity for sustained and collaborative efforts to tackle this issue.

Diarrhoeagenic Escherichia coli associated with childhood diarrhoea in Osun state, Nigeria

INTRODUCTION

Diarrhoea is a major public health concern in developing countries, usually exacerbated by poor water, sanitation and hygiene but its aetiology is under-studied, particularly away from capital cities. We identified diarrhoeagenic Escherichia coli (DEC) from stools collected in Ile-Ife and Ilesa, Osun state, Nigeria and determined their antibiotic resistance profiles.

METHODS

Stool samples from 167 children with diarrhoea and 334 controls under the age of 5 years were cultured for Escherichia coli and Salmonella. Bacterial isolates were identified biochemically and DEC were identified by PCR. Antimicrobial susceptibility testing was by modified Kirby-Bauer disc diffusion method in accordance with the CLSI guidelines. Data were analyzed using Chi-square and Fisher's exact tests.

RESULT

Diarrhoea infection is significantly high among children under 12 months (p = 0.002), caregivers without at least primary school education (p = 0.006), breastfeeding for under 6 months (p˂0.001), and caregivers who were siblings (p = 0.004). DEC was detected in 69(41.3%) cases but only 86(25.7%) controls (p < 0.001) and more commonly recovered during the wet season (p < 0.001). Enterotoxigenic E. coli (p = 0.031), enteropathogenic E. coli (p = 0.031) and Shiga-toxin-producing E. coli (p = 0.044) were recovered more commonly from cases than controls. DEC from patients with diarrhoea were commonly resistant to sulphonamides (91.3%), trimethoprim (82.6%), and ampicillin (78.3%) but were largely susceptible to quinolones and carbapenems (97.1%).

CONCLUSION

Enteropathogenic, enterotoxigenic and Shiga toxin-producing E. coli are associated with diarrhoea in our setting, and show considerable resistance to first-line antimicrobials. Risk factors for DEC diarrhoea include infancy, inadequate breastfeeding and caregivers with education below primary school.

Access to and utilisation of antimicrobials among forcibly displaced persons in Uganda, Yemen and Colombia: a pilot cross-sectional survey

OBJECTIVES

Identifying key barriers to accessing quality-assured and affordable antimicrobials among forcibly displaced persons in Uganda, Yemen and Colombia and investigating their (1) utilisation patterns of antibiotics, (2) knowledge about antimicrobial resistance (AMR) and (3) perception of the quality of antimicrobials received.

DESIGN

Pilot cross-sectional survey.

SETTING

Data were collected from five health facilities in the Kiryandongo refugee settlement (Bweyale, Uganda), three camps for internally displaced persons (IDPs) in the Dar Sad district (Aden, Yemen) and a district with a high population of Venezuelan migrants (Kennedy district, Bogotá, Colombia). Data collection took place between February and May 2021. The three countries were selected due to their high number of displaced people in their respective continents.

PARTICIPANTS

South Sudanese refugees in Uganda, IDPs in Yemen and Venezuelan migrants in Colombia.

OUTCOME MEASURE

The most common barriers to access to quality-assured and affordable antimicrobials.

RESULTS

A total of 136 participants were enrolled in this study. Obtaining antimicrobials through informal pathways, either without a doctor's prescription or through family and friends, was common in Yemen (27/50, 54.0%) and Colombia (34/50, 68.0%). In Yemen and Uganda, respondents used antibiotics to treat (58/86, 67.4%) and prevent (39/86, 45.3%) a cold. Knowledge of AMR was generally low (24/136, 17.6%). Barriers to access included financial constraints in Colombia and Uganda, prescription requirements in Yemen and Colombia, and non-availability of drugs in Uganda and Yemen.

CONCLUSION

Our multicentred research identified common barriers to accessing quality antimicrobials among refugees/IDPs/migrants and common use of informal pathways. The results suggest that knowledge gaps about AMR may lead to potential misuse of antimicrobials. Due to the study's small sample size and use of non-probability sampling, the results should be interpreted with caution, and larger-scale assessments on this topic are needed. Future interventions designed for similar humanitarian settings should consider the interlinked barriers identified.

Quality of Essential Medicines from Different Sources in Enugu and Anambra, Nigeria

This study investigated the quality of 13 essential medicines in the states of Enugu and Anambra, Nigeria. A total of 260 samples were purchased from licensed pharmaceutical manufacturers and wholesalers and from vendors in pharmaceutical markets with unclear licensing status. Samples were analyzed for identity, content, and dissolution according to the United States Pharmacopeia (USP) 42 monographs. Forty-five samples of this study could be examined for authenticity with the Mobile Authentication Service scheme of the Nigerian National Agency for Food and Drug Administration and Control. Out of all samples, 25.4% did not comply with the USP 42 specifications. Strikingly, 21 out of 22 dexamethasone tablet samples (95%) were out of specification (OOS). Nine out of 19 glibenclamide samples (47%) failed dissolution testing, and 7 out of 17 cotrimoxazole samples (41%) failed assay testing. Medicines against noncommunicable diseases showed a slightly higher percentage of OOS samples than anti-infectives (21.2% versus 17.6%). The rates of OOS samples were similar in medicines stated to be produced in Nigeria, India, and China but were very different between individual manufacturers from each of these countries of origin. Therefore, prequalification of products, manufacturers, and suppliers are very important for quality assurance in medicine procurement. Unexpectedly, the total proportions of OOS samples were similar from licensed vendors (25.2%) and from markets (25.5%). Four samples (1.5%), all collected in markets, were clearly falsified and did not contain the declared active pharmaceutical ingredients. The proportion of falsified medicines was found to be lower than frequently reported in the media for Nigeria.

The comparison of the quality of selected brands of antibiotics in Tanzania sourced from different geographical regions

OBJECTIVES

The quality of amoxicillin capsules, ceftriaxone for injection, and ciprofloxacin tablets was evaluated to determine whether there is any difference in quality when comparing the country of origin. This was undertaken because it has been claimed that antibiotics manufactured in Europe are of superior quality to those originating from Africa or Asia.

METHODS

Samples of amoxicillin capsules, ceftriaxone for injection, and ciprofloxacin tablets were collected from three randomly selected wholesale pharmacies in each city, namely Arusha, Dar es Salaam and Mwanza, Tanzania. The collected samples of collected brands were subjected to quality control testing as per their respective pharmacopoeial monographs. Amoxil 250 mg capsules (Glaxo Wellcome, Mayenne, France), Rocephin (Roche, Switzerland) and Cipro-Denk 500 (Allphamed Pharbil Arzneimittel GmbH, Gottingen, Germany) were used as reference brands for the other generic brands of amoxicillin, ceftriaxone and ciprofloxacin, respectively.

RESULTS

A total of 31 brands (10 different brands of amoxicillin capsules, 9 of ceftriaxone sodium injections, and 12 of ciprofloxacin tablets) were collected from the targeted regions and subjected to quality control testing. All samples of collected brands complied with the requirements of their respective pharmacopoeial monographs.

CONCLUSIONS

There was no significant difference in quality between brands of amoxicillin capsules, ceftriaxone for injection, and ciprofloxacin tablets manufactured in Africa and Asia against those manufactured in Europe in terms of compliance with the respective pharmacopoeial monographs.

The scope of the antimicrobial resistance challenge

Each year, an estimated 7·7 million deaths are attributed to bacterial infections, of which 4.95 million are associated with drug-resistant pathogens, and 1·27 million are caused by bacterial pathogens resistant to the antibiotics available. Access to effective antibiotics when indicated prolongs life, reduces disability, reduces health-care expenses, and enables access to other life-saving medical innovations. Antimicrobial resistance undoes these benefits and is a major barrier to attainment of the Sustainable Development Goals, including targets for newborn survival, progress on healthy ageing, and alleviation of poverty. Adverse consequences from antimicrobial resistance are seen across the human life course in both health-care-associated and community-associated infections, as well as in animals and the food chain. The small set of effective antibiotics has narrowed, especially in resource-poor settings, and people who are very young, very old, and severely ill are particularly susceptible to resistant infections. This paper, the first in a Series on the challenge of antimicrobial resistance, considers the global scope of the problem and how it should be measured. Robust and actionable data are needed to drive changes and inform effective interventions to contain resistance. Surveillance must cover all geographical regions, minimise biases towards hospital-derived data, and include non-human niches.

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

Background

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

Objective

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

Design

We conducted a scoping review based on standard protocol.

Methods

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

Results

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

Conclusion

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

Quality assessment of medicines in selected resource-limited primary healthcare facilities using low- to medium-cost field testing digital technologies

Background

Digital technologies can assess the quality of medicines in resource-challenged health facilities in a timely manner and ensure effective healthcare.

Objectives

This study assessed the quality of some non-communicable disease medicines, antimalarials, antibiotics, non-steroidal anti-inflammatory drugs and hematinics in selected healthcare facilities as part of their (potential) participation in a digital pharmaceutical supply chain management system (Med4All).

Methods

All the sampled medicines were screened using TruScan analyzer and GPHF-minilab, that is, low-medium field technologies. The quality of a representative subset of the medicines (∼11%) was determined using pharmacopoeia gold standard methods.

Results

About 75% of the medicines were manufactured in Ghana, and 16% were imported from India, with the Ghana Food and Drugs Authority registering 72% of the medicines. There was over 90% availability of medicines in health facilities from the middle and southern sectors, while the northern sector had around 64%. Approximately 87% and 88% of the medicines passed TruScan™ Raman and GPHF-minilab analysis, respectively. There was no significant difference between the two screening methods for assessing the quality of the medicines (p > 0.05). Of the 21 medicine samples, 5 (∼24%) failed, and 16 (76%) passed the pharmacopoeia test. The failed medicines were diclofenac, azithromycin and glibenclamide. Compared to the pharmacopoeia method, the performance of the TruScan™ Raman analyzer and the GPHF-minilab technologies were 71% and 63%, respectively.

Conclusion

The study provides insights into the quality of medicines in resource-limited primary healthcare facilities.