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Ozawa S, Chen HH, Lee YF(A, Higgins CR, Yemeke TT. Characterizing Medicine Quality by Active Pharmaceutical Ingredient Levels: A Systematic Review and Meta-Analysis across Low- and Middle-Income Countries. Am J Trop Med Hyg 2022; 106:1778-1790. [PMID: 35895431 PMCID: PMC9209904 DOI: 10.4269/ajtmh.21-1123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/03/2022] [Indexed: 11/07/2022] Open
Abstract
Substandard and falsified medicines are often reported jointly, making it difficult to recognize variations in medicine quality. This study characterized medicine quality based on active pharmaceutical ingredient (API) amounts reported among substandard and falsified essential medicines in low- and middle-income countries (LMICs). A systematic review and meta-analysis was conducted using PubMed, supplemented by results from a previous systematic review, and the Medicine Quality Scientific Literature Surveyor. Study quality was assessed using the Medicine Quality Assessment Reporting Guidelines (MEDQUARG). Random-effects models were used to estimate the prevalence of medicines with < 50% API. Among 95,520 medicine samples from 130 studies, 12.4% (95% confidence interval [CI]: 10.2-14.6%) of essential medicines tested in LMICs were considered substandard or falsified, having failed at least one type of quality analysis. We identified 99 studies that reported API content, where 1.8% (95% CI: 0.8-2.8%) of samples reported containing < 50% of stated API. Among all failed samples (N = 9,724), 25.9% (95% CI: 19.3-32.6%) reported having < 80% API. Nearly one in seven (13.8%, 95% CI: 9.0-18.6%) failed samples were likely to be falsified based on reported API amounts of < 50%, whereas the remaining six of seven samples were likely to be substandard. Furthermore, 12.5% (95% CI: 7.7-17.3%) of failed samples reported finding 0% API. Many studies did not present a breakdown of actual API amount of each tested sample. We offer suggested improved guidelines for reporting poor-quality medicines. Consistent data on substandard and falsified medicines and medicine-specific tailored interventions are needed to ensure medicine quality throughout the supply chain.
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Affiliation(s)
- Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Hui-Han Chen
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Yi-Fang (Ashley) Lee
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Colleen R. Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Tatenda T. Yemeke
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
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Sengxeu N, Aon C, Dufat H, Boumediene F, Chan S, Ros S, Preux PM, Ratsimbazafy V, Jost J. Availability, affordability, and quality of essential anti-seizure medication in Cambodia. Epilepsia Open 2021; 6:548-558. [PMID: 34101380 PMCID: PMC8408618 DOI: 10.1002/epi4.12514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/16/2021] [Accepted: 05/30/2021] [Indexed: 01/22/2023] Open
Abstract
Objective Epilepsy is a major neurological disorder that requires long‐term medical treatment. Once epilepsy is diagnosed, people with epilepsy face many difficulties in accessing treatment (treatment gap). Our objective was to assess the situation regarding the availability, price, affordability, and quality of anti‐seizure medication (ASM), which are major determinants of access to treatment. Method A cross‐sectional study was performed in provincial/district hospitals and private pharmacies in urban and rural areas in Cambodia. Data on ASM availability and price were obtained through drug suppliers. Affordability was estimated as the number of day wages the lowest‐paid government employee must work to purchase a monthly treatment. Samples of ASM were collected, and the quality of ASM was assessed through Medicine Quality Assessment Reporting Guidelines. Results Out of 138 outlets visited, only 72 outlets (52.2% [95% CI 43.5‐60.7]) had at least one ASM available. Phenobarbital 100 mg was the most available (35.5%), followed by carbamazepine 200 mg (21.7%), phenobarbital 50 mg (11.6%), sodium valproate 500 mg (9.4%), and phenytoin 100 mg (9.4%). In provincial/district hospitals, ASM was provided free of charge. In private pharmacies, affordability for phenobarbital 50 mg and 100 mg was the best, with 0.6 and 0.5 days, respectively, compared to phenytoin 100 mg (1.8 days), and other ASM. No counterfeit ASM was found in this study. Phenytoin sample presented the worst quality (33.0%) compared to carbamazepine (27.8%), and other ASM. Significance A lack of access to affordable and effective ASM due to low availability and poor quality of ASM was identified. Our research highlights the need for future policy efforts to ensure the quality of ASM and improve their availability. This can be achieved by involving the calculation of their annual needs for these drugs and increasing the national production of ASM.
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Affiliation(s)
- Noudy Sengxeu
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France.,Faculty of Pharmacy, University of Health Sciences, Vientiane, Lao PDR
| | - Chanraksmey Aon
- Cambodian Society of Neurology, Calmette Hospital, Phnom Penh, Cambodia
| | - Hanh Dufat
- Natural Products, Analysis and Synthesis, CiTCoM (Cibles Thérapeutiques et Conception de Médicaments)-UMR 8038 CNRS/Université de Paris, Faculty of Health-Pharmacie, Université de Paris, Paris, France
| | - Farid Boumediene
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Samleng Chan
- Cambodian Society of Neurology, Calmette Hospital, Phnom Penh, Cambodia
| | - Sina Ros
- Cambodian Society of Neurology, Calmette Hospital, Phnom Penh, Cambodia
| | - Pierre-Marie Preux
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Voa Ratsimbazafy
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France.,Department of Pharmacy, CHU Limoges, Limoges, France
| | - Jeremy Jost
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France.,Department of Pharmacy, CHU Limoges, Limoges, France
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Sengxeu N, Dufat H, Boumediene F, Vorachit S, Chivorakoun P, Souvong V, Manithip C, Preux P, Ratsimbazafy V, Jost J. Availability, affordability, and quality of essential antiepileptic drugs in Lao PDR. Epilepsia Open 2020; 5:550-561. [PMID: 33336126 PMCID: PMC7733656 DOI: 10.1002/epi4.12432] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/19/2020] [Accepted: 08/27/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Epilepsy is a chronic condition treatable by cost-effective antiepileptic drugs (AEDs), but limited access to treatment was documented. The availability and affordability of good quality of AEDs play a significant role in access to good health care. This study aimed to assess the availability, affordability, and quality of long-term AEDs in Lao PDR. METHOD A cross-sectional study was performed in both public and private drug supply chains in urban and rural areas in Lao PDR. Data on AEDs availability and price were obtained through drug suppliers. Affordability was estimated as the number of day wages the lowest-paid government employee must work to purchase a monthly treatment. Samples of AEDs were collected, and the quality of AEDs was assessed through Medicine Quality Assessment Reporting Guidelines. RESULTS Out of 237 outlets visited, only 50 outlets (21.1% [95% CI 16.1-26.8]) had at least one AED available. The availability was significantly different between urban (24.9%) and rural areas (10.0%), P = .017. Phenobarbital 100 mg was the most available (14.3%); followed by sodium valproate 200 mg (9.7%), phenytoin 100 mg (9.7%), and carbamazepine 200 mg (8.9%). In provincial/district hospitals and health centers, AEDs were provided free of charge. In other healthcare facilities, phenytoin 100 mg and phenobarbital 100 mg showed the best affordability (1.0 and 1.2 day wages, respectively) compared to carbamazepine 200 mg (2.3 days) and other AEDs. No sample was identified as counterfeit, but 15.0% [95% CI 7.1-26.6] of samples were classified as of poor quality. SIGNIFICANCE We quantified and qualified the various factors contributing to the high treatment gap in Lao PDR, adding to diagnostic issues (not assessed here). Availability remains very low and phenobarbital which is the most available and affordable AED was the worst in terms of quality. A drug policy addressing epilepsy treatment gap would reduce these barriers.
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Affiliation(s)
- Noudy Sengxeu
- INSERMUniv. Limoges, CHU LimogesIRDU1094 Tropical NeuroepidemiologyInstitute of Epidemiology and Tropical NeurologyGEISTLimogesFrance
- Faculty of pharmacyUniversity of Health sciencesVientianeLao PDR
| | - Hanh Dufat
- Natural Products, Analysis and SynthesisCiTCoM‐UMR 8038 CNRS/Université de Paris, Faculty of Health‐Pharmacy, Université de ParisParisFrance
| | - Farid Boumediene
- INSERMUniv. Limoges, CHU LimogesIRDU1094 Tropical NeuroepidemiologyInstitute of Epidemiology and Tropical NeurologyGEISTLimogesFrance
| | | | | | | | | | - Pierre‐Marie Preux
- INSERMUniv. Limoges, CHU LimogesIRDU1094 Tropical NeuroepidemiologyInstitute of Epidemiology and Tropical NeurologyGEISTLimogesFrance
| | - Voa Ratsimbazafy
- INSERMUniv. Limoges, CHU LimogesIRDU1094 Tropical NeuroepidemiologyInstitute of Epidemiology and Tropical NeurologyGEISTLimogesFrance
| | - Jeremy Jost
- INSERMUniv. Limoges, CHU LimogesIRDU1094 Tropical NeuroepidemiologyInstitute of Epidemiology and Tropical NeurologyGEISTLimogesFrance
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Ozawa S, Evans DR, Bessias S, Haynie DG, Yemeke TT, Laing SK, Herrington JE. Prevalence and Estimated Economic Burden of Substandard and Falsified Medicines in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis. JAMA Netw Open 2018; 1:e181662. [PMID: 30646106 PMCID: PMC6324280 DOI: 10.1001/jamanetworkopen.2018.1662] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Substandard and falsified medicines burden health systems by diverting resources to ineffective or harmful therapies, causing medical complications and prolonging illnesses. However, the prevalence and economic impact of poor-quality medicines is unclear. OBJECTIVE To conduct a systematic review and meta-analysis to assess the prevalence and estimated economic burden of substandard and falsified essential medicines in low- and middle-income countries. DATA SOURCES Five databases (PubMed, EconLit, Global Health, Embase, and Scopus) were searched from inception until November 3, 2017. STUDY SELECTION Publications were assessed to determine whether they examined medicine quality and the prevalence and/or economic burden of substandard and falsified medicines in low- and middle-income countries. Studies with a sample size of 50 or more were included in the meta-analysis. DATA EXTRACTION AND SYNTHESIS The study is registered in PROSPERO and reported via the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Study quality was assessed using an adapted Medicine Quality Assessment Reporting Guidelines scoring metric. Multiple reviewers conducted the data extraction and quality assessment independently. MAIN OUTCOMES AND MEASURES Prevalence and/or estimated economic impact of substandard and falsified medicines. RESULTS Two hundred sixty-five studies that estimated the prevalence of poor-quality essential medicines in low- and middle-income countries were identified. Among 96 studies that tested 50 samples or more (67 839 total drug samples), overall prevalence of poor-quality medicines was 13.6% (95% CI, 11.0%-16.3%), with regional prevalence of 18.7% in Africa (95% CI, 12.9%-24.5%) and 13.7% in Asia (95% CI, 8.2%-19.1%). Of studies included in the meta-analysis, 19.1% (95% CI, 15.0%-23.3%) of antimalarials and 12.4% (95% CI, 7.1%-17.7%) of antibiotics were substandard or falsified. Eight approximations of the economic impact, focused primarily on market size, with poor or undisclosed methods in estimation were identified, ranging from $10 billion to $200 billion. CONCLUSIONS AND RELEVANCE Poor-quality essential medicines are a substantial and understudied problem. Methodological standards for prevalence and rigorous economic studies estimating the burden beyond market size are needed to accurately assess the scope of the issue and inform efforts to address it. Global collaborative efforts are needed to improve supply-chain management, surveillance, and regulatory capacity in low- and middle-income countries to reduce the threat of poor-quality medicines. TRIAL REGISTRATION PROSPERO Identifier: CRD42017080266.
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Affiliation(s)
- Sachiko Ozawa
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Daniel R. Evans
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Sophia Bessias
- Enterprise Analytics and Data Sciences, University of North Carolina Health Care, Chapel Hill
| | | | - Tatenda T. Yemeke
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Sarah K. Laing
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - James E. Herrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
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Holtkamp M, Theodore WH. Generic antiepileptic drugs-Safe or harmful in patients with epilepsy? Epilepsia 2018; 59:1273-1281. [PMID: 29894004 DOI: 10.1111/epi.14439] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 11/28/2022]
Abstract
Generic antiepileptic drugs (AED) are significantly cheaper than brand name drugs, and may reduce overall health care expenditures. Regulatory bodies in Europe and North America require bioequivalence between generic and innovator drugs with regard to area under the plasma concentration-time curve (AUC) and peak plasma concentration (Cmax ); strict cutoff values have been defined. The main issue is if bioequivalence ensures therapeutic equivalence. Are switches from brand to generic, or between generic AEDs entirely safe or potentially harmful in patients with epilepsy? We summarized and evaluated the available evidence from bioequivalence, health care utilization, and clinical studies on safety of generic AEDs. In most cases, variations in AUC and Cmax were negligible when comparing innovator and generic AEDs. Due to interindividual pharmacokinetic and pharmacodynamic variability, measured differences between innovator and generic drugs may be the same as differences between different lots of the same brand. Studies from several countries based on insurance data have reported an increase in health care usage after switch from brand to generic AEDs; switchback rates are significantly higher for AEDs compared to other compounds. Patients may be confused, and nonadherence may increase, when AEDs are switched between manufacturers, perhaps due to changes in medication shape and color. But clinical studies do not report changes in seizure frequency and tolerability attributable to generics. Sufficient evidence indicates that most generics are bioequivalent to innovator AEDs; they do not pose a relevant risk for patients with epilepsy. However, some patients are reluctant towards variations in color and shape of their AEDs which may result in nonadherence. We recommend administering generics when a new AED is initiated. Switches from brand to generic AEDs for cost reduction and between generics, which is rarely required, generally seem to be safe, but should be accompanied by thorough counseling of patients on low risks.
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Affiliation(s)
- Martin Holtkamp
- Epilepsy-Center Berlin-Brandenburg, Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - William H Theodore
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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Jost J, Ratsimbazafy V, Nguyen TT, Nguyen TL, Dufat H, Dugay A, Ba A, Sivadier G, Mafilaza Y, Jousse C, Traïkia M, Leremboure M, Auditeau E, Raharivelo A, Ngoungou E, Kariuki SM, Newton CR, Preux PM. Quality of antiepileptic drugs in sub-Saharan Africa: A study in Gabon, Kenya, and Madagascar. Epilepsia 2018; 59:1351-1361. [PMID: 29893991 DOI: 10.1111/epi.14445] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Epilepsy is a major public health issue in low- and middle-income countries, where the availability and accessibility of quality treatment remain important issues, the severity of which may be aggravated by poor quality antiepileptic drugs (AEDs). The primary objective of this study was to measure the quality of AEDs in rural and urban areas in 3 African countries. METHODS This cross-sectional study was carried out in Gabon, Kenya, and Madagascar. Both official and unofficial supply chains in urban and rural areas were investigated. Samples of oral AEDs were collected in areas where a patient could buy or obtain them. Pharmacological analytical procedures and Medicine Quality Assessment Reporting Guidelines were used to assess quality. RESULTS In total, 102 batches, representing 3782 units of AEDs, were sampled. Overall, 32.3% of the tablets were of poor quality, but no significant difference was observed across sites: 26.5% in Gabon, 37.0% in Kenya, and 34.1% in Madagascar (P = .7). The highest proportions of substandard medications were found in the carbamazepine (38.7%; 95% confidence interval [CI] 21.8-57.8) and phenytoin (83.3%; 95% CI 35.8-99.5) batches, which were mainly flawed by their failure to dissolve. Sodium valproate was the AED with the poorest quality (32.1%; 95% CI 15.8-42.3). The phenobarbital (94.1%; 95% CI 80.3-99.2) and diazepam (100.0%) batches were of better quality. The prevalence of substandard quality medications increased in samples supplied by public facilities (odds ratio [OR] 9.9; 95% CI 1.2-84.1; P < .04) and manufacturers located in China (OR 119.8; 95% CI 8.7-1651.9; P < .001). The prevalence of AEDs of bad quality increased when they were stored improperly (OR 5.4; 95% CI 1.2-24.1; P < .03). SIGNIFICANCE No counterfeiting was observed. However, inadequate AED storage conditions are likely to lead to ineffective and possibly dangerous AEDs, even when good-quality AEDs are initially imported.
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Affiliation(s)
- Jeremy Jost
- INSERM, CHU Limoges, UMR_S 1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, University of Limoges, Limoges, France
| | - Voa Ratsimbazafy
- INSERM, CHU Limoges, UMR_S 1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, University of Limoges, Limoges, France
| | - Thu Trang Nguyen
- Laboratory of Pharmacology-UMR COMETE 8638, School of Pharmacy of Paris, University of Paris Descartes USPC, Paris, France
| | - Thuy Linh Nguyen
- Laboratory of Pharmacology-UMR COMETE 8638, School of Pharmacy of Paris, University of Paris Descartes USPC, Paris, France
| | - Hanh Dufat
- Laboratory of Pharmacology-UMR COMETE 8638, School of Pharmacy of Paris, University of Paris Descartes USPC, Paris, France
| | - Annabelle Dugay
- Laboratory of Pharmacology-UMR COMETE 8638, School of Pharmacy of Paris, University of Paris Descartes USPC, Paris, France
| | - Alassane Ba
- CHMP, Humanitarian Center for Pharmaceutical Careers, Clermont-Ferrand, France
| | - Guilhem Sivadier
- CHMP, Humanitarian Center for Pharmaceutical Careers, Clermont-Ferrand, France
| | - Yattussia Mafilaza
- CHMP, Humanitarian Center for Pharmaceutical Careers, Clermont-Ferrand, France
| | - Cyril Jousse
- Institute of Chemistry of Clermont-Ferrand (ICCF), UMR CNRS 6296, University of Clermont Auvergne, Aubière, France
| | - Mounir Traïkia
- Institute of Chemistry of Clermont-Ferrand (ICCF), UMR CNRS 6296, University of Clermont Auvergne, Aubière, France
| | - Martin Leremboure
- Institute of Chemistry of Clermont-Ferrand (ICCF), UMR CNRS 6296, University of Clermont Auvergne, Aubière, France
| | - Emilie Auditeau
- INSERM, CHU Limoges, UMR_S 1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, University of Limoges, Limoges, France
| | - Adeline Raharivelo
- INSERM, CHU Limoges, UMR_S 1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, University of Limoges, Limoges, France.,Joseph Raseta Befelatanana Hospital, Antananarivo, Madagascar
| | - Edgard Ngoungou
- INSERM, CHU Limoges, UMR_S 1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, University of Limoges, Limoges, France.,Unit of Neuroepidemiology and Tropical Infectious Diseases, Department of Epidemiology, Biostatistics, University of Health Sciences, Libreville, Gabon
| | - Symon M Kariuki
- KEMRI-Welcome Trust Programme - Centre for Geographical Medicine (Coast) Kenya Medical Research Institute, Kilifi, Kenya
| | - Charles R Newton
- KEMRI-Welcome Trust Programme - Centre for Geographical Medicine (Coast) Kenya Medical Research Institute, Kilifi, Kenya.,Department of Psychiatry, University of Oxford, Oxford, UK
| | - Pierre-Marie Preux
- INSERM, CHU Limoges, UMR_S 1094, Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, University of Limoges, Limoges, France
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Wilmshurst JM, Guekht A, Secco M, Helen Cross J, Perucca E. Advocacy for children with epilepsy: Leveraging the WHA resolution. Advocacy Task Force, Commission of Pediatrics, International League Against Epilepsy. Epilepsia Open 2018; 3:167-174. [PMID: 29881796 PMCID: PMC5983105 DOI: 10.1002/epi4.12220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 12/24/2022] Open
Abstract
In May 2015 the World Health Assembly (WHA) approved the Resolution on the Global Burden of Epilepsy. This report addresses how the Resolution can be leveraged to improve the care of children with epilepsy worldwide. Children with epilepsy have unique needs and face unique challenges from stigma at all levels of society. Children lack a voice to lobby for their own needs, including their right to have access to education. Effective leadership and governance should be enhanced through the support of stakeholders empowered to counsel, advise, and lobby for appropriate care. National health care plans should integrate primary and specialist care, and they need to be adapted to local specificities. Antiepileptic medicines should be widely accessible in appropriate, sustained, and affordable ways. Public awareness initiatives are needed to improve the inclusion of affected children in society and to reduce stigma. Cost-effective interventions are also needed to address preventable causes of epilepsy. Without greater investment in research, evidence-based interventions cannot be implemented. Through all of this, civil society must be engaged to ensure that the multivariate dimensions from the clinic to the community are addressed to fulfil the needs of children with epilepsy.
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Affiliation(s)
- Jo M Wilmshurst
- Department of Paediatric Neurology Red Cross War Memorial Children's Hospital Neuroscience Institute, University of Cape Town Cape Town South Africa
| | - Alla Guekht
- Department of Neurology, Neurosurgery and Genetics Russian National Research Medical University and Moscow Research and Clinical Center for Neuropsychiatry Moscow Russia
| | - Mary Secco
- Epilepsy Southwestern Ontario Western University International Bureau for Epilepsy London Ontario Canada
| | - J Helen Cross
- Developmental Neurosciences Programme UCl Great Ormond Street Institute of Child health London U.K.,Young Epilepsy Lingfield U.K
| | - Emilio Perucca
- Department of Internal Medicine and Therapeutics University of Pavia Pavia Italy.,Clinical Trial Center C. Mondino National Neurological Institute Pavia Italy
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Nizard M, Jost J, Tanamasoandro R, Andriambololona R, Megherbi M, Solofomalala GD, Marquet P, Preux PM, Ratsimbazafy V. Overview of accessibility and quality of antiepileptic drugs in Madagascar. Seizure 2016; 41:134-40. [DOI: 10.1016/j.seizure.2016.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 07/21/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022] Open
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Medication prescribing and patient-reported outcome measures in people with epilepsy in Bhutan. Epilepsy Behav 2016; 59:122-7. [PMID: 27131914 DOI: 10.1016/j.yebeh.2016.03.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 03/22/2016] [Accepted: 03/25/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this study was to assess medication prescribing and patient-reported outcomes among people with epilepsy (PWE) in Bhutan and introduce criteria for evaluating unmet epilepsy care needs, particularly in resource-limited settings. METHODS People with epilepsy in Bhutan (National Referral Hospital, 2014-2015) completed a questionnaire, the Quality of Life in Epilepsy Inventory (QOLIE-31), and an electroencephalogram (EEG). Management gap was the proportion of participants meeting any of six prespecified criteria based on best practices and the National Institute for Health and Care Excellence (NICE) guidelines. RESULTS Among 253 participants (53% female, median: 24years), 93% (n=235) were treated with antiepileptic drugs (AEDs). Seventy-two percent (n=183) had active epilepsy (≥1 seizure in the prior year). At least one criterion was met by 55% (n=138) of participants, whereas the treatment gap encompassed only 5% (n=13). The criteria were the following: 1. Among 18 participants taking no AED, 72% (n=13) had active epilepsy. 2. Among 26 adults on subtherapeutic monotherapy, 46% (n=12) had active epilepsy. 3. Among 48 participants reporting staring spells, 56% (n=27) were treated with carbamazepine or phenytoin. 4. Among 101 female participants aged 14-40years, 23% (n=23) were treated with sodium valproate. 5. Among 67 participants reporting seizure-related injuries, 87% (n=58) had active epilepsy. 6. Among 111 participants with a QOLIE-31 score below 50/100, 77% (n=86) had active epilepsy. Years since first AED treatment (odds ratio: 1.07, 95% CI: 1.03, 1.12) and epileptiform discharges on EEG (odds ratio: 1.95, 95% CI: 1.15, 3.29) were significantly associated with more criteria met. CONCLUSIONS By defining the management gap, subpopulations at greatest need for targeted interventions may be prioritized, including those already taking AEDs.
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10
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Perucca E. The safety of generic substitution in epilepsy. Lancet Neurol 2016; 15:344-5. [DOI: 10.1016/s1474-4422(16)00042-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 01/27/2016] [Indexed: 11/16/2022]
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Jost J, Preux PM, Druet-Cabanac M, Ratsimbazafy V. How to reduce the treatment gap for people with epilepsy in resource-limited settings by innovative galenic formulations: A review of the current situation, overview of potential techniques, interests and limits. Epilepsy Res 2016; 119:49-61. [DOI: 10.1016/j.eplepsyres.2015.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 08/24/2015] [Accepted: 10/25/2015] [Indexed: 10/22/2022]
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Laroche ML, Merle L. GENERIC AND BRAND-NAME DRUGS. ARE DIFFERENT CRITERIA SUFFICIENTLY TAKEN INTO ACCOUNT BEFORE GRANTING MARKET AUTHORISATION? Acta Clin Belg 2014. [DOI: 10.1179/acb.2006.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Conway J, Bero L, Ondari C, Wasan KM. Review of the quality of pediatric medications in developing countries. J Pharm Sci 2013; 102:1419-33. [PMID: 23450511 DOI: 10.1002/jps.23474] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 01/15/2013] [Accepted: 01/18/2013] [Indexed: 12/27/2022]
Abstract
The quality of essential medicines for pediatric populations in developing countries is largely unknown. This review examines quality studies (2000-2011) of medicines on the WHO Essential Medicine List for Children, the quality of a subset of pediatric formulations, and the association of these poor quality medicines with adverse clinical outcomes. We searched Embase, Medline, BIOSIS, and IPA using MeSH subject terms for quality measures, medicine formulations, and substandard medicines and combined these with 267 medicines, and 91 low-income and lower-middle-income countries. Seventy articles met our inclusion criteria examining the quality of 75 medicines from 28 countries. Content and dissolution tests were utilized most often. Results indicate that antibacterials, antifungals, and antiretrovirals were consistently of good quality. Quality tests on pediatric formulations were performed on 55 of 75 of the medicines studied and followed the general trend of quality results. Three studies were included that examined clinical consequences of substandard medicines-two cases of diethylene glycol poisoning and one case of substandard malaria drugs. We conclude that there is a need for more quality studies of pediatric formulations of essential medicines in developing countries and their clinical consequences.
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Affiliation(s)
- Jocelyn Conway
- Neglected Global Diseases Initiative, University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada
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Dunne S, Shannon B, Dunne C, Cullen W. A review of the differences and similarities between generic drugs and their originator counterparts, including economic benefits associated with usage of generic medicines, using Ireland as a case study. BMC Pharmacol Toxicol 2013; 14:1. [PMID: 23289757 PMCID: PMC3579676 DOI: 10.1186/2050-6511-14-1] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 12/24/2012] [Indexed: 12/31/2022] Open
Abstract
Generic medicines are those where patent protection has expired, and which may be produced by manufacturers other than the innovator company. Use of generic medicines has been increasing in recent years, primarily as a cost saving measure in healthcare provision. Generic medicines are typically 20 to 90% cheaper than originator equivalents. Our objective is to provide a high-level description of what generic medicines are and how they differ, at a regulatory and legislative level, from originator medicines. We describe the current and historical regulation of medicines in the world's two main pharmaceutical markets, in addition to the similarities, as well as the differences, between generics and their originator equivalents including the reasons for the cost differences seen between originator and generic medicines. Ireland is currently poised to introduce generic substitution and reference pricing. This article refers to this situation as an exemplar of a national system on the cusp of significant health policy change, and specifically details Ireland's history with usage of generic medicines and how the proposed changes could affect healthcare provision.
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Affiliation(s)
- Suzanne Dunne
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
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Abstract
Epilepsy is a common disorder, particularly in poor areas of the world, and can have a devastating effect on people with the disorder and their families. The burden of epilepsy in low-income countries is more than twice that found in high-income countries, probably because the incidence of risk factors is higher. Many of these risk factors can be prevented with inexpensive interventions, but there are only a few studies that have assessed the effect of reducing risk factors on the burden of epilepsy. The mortality associated with epilepsy in low-income countries is substantially higher than in less impoverished countries and most deaths seem to be related to untreated epilepsy (eg, as a result of falls or status epilepticus), but the risk factors for death have not been adequately examined. Epilepsy is associated with substantial stigma in low-income countries, which acts as a barrier to patients accessing biomedical treatment and becoming integrated within society. Seizures can be controlled by inexpensive antiepileptic drugs, but the supply and quality of these drugs can be erratic in poor areas. The treatment gap for epilepsy is high (>60%) in deprived areas, but this could be reduced with low-cost interventions. The substantial burden of epilepsy in poor regions of the world can be reduced by preventing the risk factors, reducing stigma, improving access to biomedical diagnosis and treatment, and ensuring that there is a continuous supply of good quality antiepileptic drugs.
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Ravinetto RM, Boelaert M, Jacobs J, Pouget C, Luyckx C. Poor-quality medical products: time to address substandards, not only counterfeits. Trop Med Int Health 2012; 17:1412-6. [PMID: 22909082 DOI: 10.1111/j.1365-3156.2012.03076.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Raffaella M Ravinetto
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium Department of Medical Microbiology, Faculty of Health and Life Sciences, Mastricht, The Netherlands Consultant, Institute of Tropical Medicine, Antwerp, Belgium
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Abstract
According to World Health Organization (WHO), the prevalence of epilepsy is highest in low- and lower middle-income countries, which include over eighty percent of the countries of sub-Saharan Africa, where the majority of people with epilepsy are not receiving appropriate care. In sub-Saharan Africa, shortages of trained health workers, limited diagnostic equipment, inadequate anti-epileptic drug supplies, cultural beliefs, and social stigma contribute to the large treatment gap for epilepsy. The number of people with epilepsy, particularly children, will continue to rise as a result of projected epidemiologic and demographic changes. This paper examines the state of epilepsy care and treatment in sub-Saharan Africa and discusses priorities and approaches to scale up access to medications and services for people with epilepsy.
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Cameron A, Bansal A, Dua T, Hill SR, Moshe SL, Mantel-Teeuwisse AK, Saxena S. Mapping the availability, price, and affordability of antiepileptic drugs in 46 countries. Epilepsia 2012; 53:962-9. [DOI: 10.1111/j.1528-1167.2012.03446.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mac TL, Gaulier JM, Le VT, Vu AN, Preux PM, Ratsimbazafy V. Quality of antiepileptic drugs in Vietnam. Epilepsy Res 2008; 80:77-82. [DOI: 10.1016/j.eplepsyres.2008.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Revised: 03/08/2008] [Accepted: 03/10/2008] [Indexed: 10/22/2022]
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Krämer G, Steinhoff BJ, Feucht M, Pfäfflin M, May TW. Experience with generic drugs in epilepsy patients: an electronic survey of members of the German, Austrian and Swiss branches of the ILAE. Epilepsia 2007; 48:609-11. [PMID: 17346253 DOI: 10.1111/j.1528-1167.2007.01084_1.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Odermatt P, Ly S, Simmala C, Angerth T, Phongsamouth V, Mac TL, Ratsimbazafy V, Gaulier JM, Strobel M, Preux PM. Availability and Costs of Antiepileptic Drugs and Quality of Phenobarbital in Vientiane Municipality, Lao PDR. Neuroepidemiology 2007; 28:169-74. [PMID: 17536229 DOI: 10.1159/000103270] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE In developing countries, availability and quality of drugs are critical factors for effective management and control of epilepsy. This study investigated the availability and costs of antiepileptic drugs (AEDs), and the quality of phenobarbital in Vientiane Municipality, Lao PDR. METHODS In March 2004, we enrolled all pharmacies (categories I and II) of four central districts of Vientiane eligible to sell AEDs. Two hundred and eight pharmacies of category III (75.1% of all registered pharmacies) were excluded as the sale of AEDs was not authorized. All pharmacists were interviewed with a standard questionnaire. Whenever phenobarbital was available, a sample was purchased and assayed by liquid chromatography. Phenobarbital was defined as being of correct quality if the active substance average content corresponded to +/-15% of the indicated amount. RESULTS 66 pharmacies were enrolled (13 and 45 of categories I and II, respectively, and 8 hospital pharmacies). Six generics of AEDs were found (phenobarbital, phenytoin, valproic acid, clonazepam, carbamazepine, diazepam) and all pharmacies sold at least 1 AED. The 2 most widely available drugs were diazepam (5 mg) and phenobarbital (100 mg), present in 87.9 and 53.0% of the pharmacies, respectively. All 34 phenobarbital samples examined showed a correct concentration of the active compound. However, the concentration of phenobarbital 100 mg tablets produced in Lao PDR (mean concentration 94.7 mg) was significantly lower (p = 0.005) than the imported equivalent (mean concentration 99.7 mg). The direct drug costs of a yearly treatment with phenobarbital were estimated to be at least 25.2 USD. CONCLUSIONS A variety of AEDs are present. Their availability, particularly of phenobarbital, is restricted to higher-category pharmacies and within those it is rather limited. To meet the costs of AEDs in this setting is a major challenge for people with epilepsy. However, the quality of the available phenobarbital was rather satisfactory.
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Affiliation(s)
- Peter Odermatt
- Institut de la francophonie pour la médecine tropicale, Vientiane, Lao PDR.
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