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Quality Problems with Antimalarials

The quality of antimalarial medicines is crucial for public health, especially in Africa, where 30-50% of samples can be of poor quality. A study involving 429 samples from Cameroon, Madagascar, and Chad found an alarming 18% failure rate, with counterfeit drugs prevalent. Similar trends emerged from Tanzania, Nigeria, and Zimbabwe. Major quality issues stem from unregulated markets, poor manufacturing practices, and inadequate storage conditions. WHO and partners are prioritizing the prequalification of essential drugs to address these challenges, aiming to ensure the effectiveness and safety of antimalarial therapies.

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Quality Problems with Antimalarials

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  1. Quality Problems with Antimalarials Dr Mary R. Couper Quality Assurance and Safety: Medicines World Health Organization

  2. Quality of Medicines • Good quality medicines are essential to promote public health - in some African countries 30-50% of samples tested are of poor quality • 429 samples from Cameroon, Madagascar, Chad tested - 18% failed, 16 were counterfeit • 175 samples from Tanzania tested - 17% failed • 581 samples from Nigeria tested - 48% failed • 788 samples tested in Zimbabwe - 17% failed

  3. Identifying quality problem Seven-country study: antimalarial quality differs among countries - content and dissolution problems Samples were judged to have “failed” if content was <93% or >107%, and dissolution <80% in 45 minutes. Samples were judged to have “failed” if content was <90% or >110%, and dissolution <65% in 30 minutes.

  4. Quality problems • Many African countries medicines are sold in open market places and by street vendors • Many medicines are smuggled or imported illegally • Most domestic manufacturers do not meet Good Manufacturing Practices • Storage and distribution conditions are inappropriate • Corruption is a serious problem

  5. About 50% of the countries in sub-Saharan Africa have very limited/no capacity to control the market-where regulatory authorities exist enforcement is weak

  6. Antimalarial Drugs on WHO’s Essential Drug List • artemether + lumefantrine (core) • chloroquine (core) • primaquine (core) • quinine (core) • doxycycline (comp.) • sulfamethoxazole+pyrimethamine (comp.) • artemether (restrict) • artesunate (restrict)

  7. Artemisinin derivatives available • artesunate (oral) • arteminol (dihydroartemisinin) (oral and rectal) • artemether (oral and i.m.) • artemether+lumefantrine (oral) • artesunate (i.v. and i.m.) • artemotil (i.v and i.m.) • artesunate + mefloquine (oral) • artesunate + amodiaquine (oral) • artesunate + sulfadoxine/pyrimethamine (oral)

  8. Quality concerns • Partners in Roll Back Malaria, such as WHO, UNICEF, and UNDP, and many other UN organizations are involved in the procurement of antimalarial drugs. • The supply of antimalarial products that are effective and of acceptable quality has become a major concern at both international and country level.

  9. Prequalification scheme • Why was the launch considered? • Countries and other interested parties asking WHO to initiate pre-qualification of essential drugs referring to positive experience of vaccines pre-qualification • Increasing pressures to increase access to artemisinin derivatives owing to resistance • … but artemisinin combinations are not typical “generic” drugs

  10. Not Typical “generic” drugs • Usually generic drugs “well established” … • Artemisinin combinations are relatively new, or very new drugs • Limited information available in public domain • For most artemisinin products reference standards not readily available and for combinations no “originator” product exists • Difficulties of proving “interchangeability” • Regulators have limited experience with this group of drugs ...

  11. Activities of Prequalification Scheme • Assessment of dossiers: teams of professionals from national drug regulatory authorities::Including Canada, Denmark, Estonia, Finland, France, Hungary, Indonesia, Malaysia, Philippines, Spain, South-Africa, Sweden and Zimbabwe • Manufacturing site inspections:teamwork of inspectors:WHO representative (qualified GMP inspector), inspector from well-established inspectorate (Pharmaceutical Inspection Cooperation Scheme countries) and inspector(s) from national drug Regulatory authorities

  12. Current Status • 20 Product dossiers assessed • 2 Manufacturers have been inspected • No dossier meets WHO standards yet • Incomplete data include lack of safety and efficacy data, lack of specifications for starting materials, information on method of manufacture of the product, lack of process validation, incomplete stability data. • Assessment is ongoing

  13. How WHO can help • Issue guidelines and information • Provide training seminars - 3 planned for 2003 • New monographs for all artemisinin based products recently published in International Pharmacopoeia • http://www.who.int/medicines/library/pharmacopoeia/pharmacop-content.shtml • Provide Basic Tests for confirmation of identity of active ingredient

  14. Counterfeit • 40% of artemisinin-based antimalarials on the market are counterfeit • Nigeria reported 50% of the medicines on the market are counterfeit • Some other African countries show that about 19% of products are counterfeit

  15. Counterfeit database 2002 • Reports from 46 countries of which 3 are African countries: • Zambia - chloroquine phosphate • Gabon - chloroquine and quinine • Tanzania - quinine

  16. Examples of Counterfeit

  17. Challenge • Quality of products can only be achieved by building reliable and effective national regulatory authority

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