Accessibility of medicines used in the management of substance use disorders in selected hospitals in Nairobi

Background: Substance use disorder is a complex chronic disease that requires a multidisciplinary approach in treatment. Pharmacotherapy is one of the components in the treatment of this condition. This study sought to assess the accessibility of medicines used in the treatment of substance use disorders in both a public and a private health facility in Nairobi. Methodology: This descriptive cross-sectional study with both qualitative and quantitative components was carried out in April and May 2015 at two hospitals in Nairobi, Mathare Mental Hospital (public) and Chiromo Lane Medical Centre (private).  Data on availability and affordability was collected from the two sites and the WHO performance indicators for health facilities used to assess availability. Affordability was determined using the daily wage of the lowest paid government worker. Interviews with the key informants were conducted to determine factors that influence the accessibility of the medicines. Results: About 50% of medicines on the Kenya Essential Medicines List for management of substance use disorders were available in Mathare while Chiromo Lane had all of them. The mean stock out duration was 8 months and 0.5 months in Mathare and Chiromo Lane, respectively.  More than 67 % of the medicines required less than a single day’s wage to buy a month’s supply in Mathare while in Chiromo Lane all the medicines required more than a single day’s wage to purchase.  The cheapest medicine required 0.3 days wage to purchase while the most expensive drug required 50 days wage to purchase. Conclusion: Medicines for the treatment of substance use disorders had limited availability but were relatively affordable in Mathare while their availability was better in Chiromo Lane but with limited affordability.  The Kenya Essential Medicines List for substance use disorders requires updating to include newer and more efficacious medicines. National guidelines for the treatment of substance use disorders should be developed and disseminated. Key words: Substance use disorders, pharmacotherapy, accessibility and affordabilit

One-day out-patient prescribing patterns at a national referral hospital in Kenya

Background: Poor prescribing habits lead to ineffective and unsafe treatment for patients, exacerbating or prolonging of illness as well as causing distress and harm to them. Drug utilization studies can help identifying gaps in prescribing and feed the results back to prescribers to enhance future rational use of medicines. Objective: Evaluate outpatient prescribing practices and patterns in a leading national Hospital in Kenya. Methods: A sample of 60 prescriptions was selected by quasi-random sampling. Data was abstracted using a pre-designed data collection form, entered into and analyzed using Excel software. Results: The average number of drugs prescribed per prescription was three with a polypharmacy rate (>4 drugs) of 20%. Only two-thirds (65%) of the prescribed drugs were actually dispensed at the hospital pharmacy due to shortages, principally shortages of originators. Slightly more than half (52%) of the drugs were prescribed by generic name. Prescribing by brand names was highest among medical interns (61%). Almost all drugs prescribed (95%) were consistent with the hospital tender list. Conclusions: There is a need to increase the rate of prescribing of generics to save costs as well as reduce stock-out levels. This can be helped by instigating a comprehensive generics policy. There is also a need to strengthen and empower drugs and therapeutic committees (DTCs) to improve selection and availability of quality generics to win the confidence of prescribers. Keywords: Drug utilisation studies, generics, prescribing patterns, prescribing indicators, polypharmacy, WHO indicators, Keny

Herbal remedies and other risk factors for preterm birth in rural Kenya

Background: Premature infants contribute substantially to infant morbidity and mortality especially in low resource settings.  Information on herbal remedy use, previous preterm birth and low social-economic status and their association with incidence of preterm birth in Kenya is scanty. Objectives: To determine the use of herbal remedy use in pregnancy, previous preterm birth and low socio-economic status as risk factors for Preterm Birth in Kitui County among the immediate post-partum mothers. Methods: Unmatched case control study with a 1:4 ratio of cases to controls. The study was done in Kitui and Mwingi District Hospitals.  A total of 107 mothers with preterm birth (cases) and 453 mothers with term births (controls) were eligible and administered structured interviews. Results: Of the sample, 98% of cases resided in rural areas compared to 90% of controls.  The cases had a higher parity and were more likely to belong to the lowest three and four levels of socio-economic status. On multivariate logistic regression analysis, predictors of preterm birth were: preeclampsia (OR=9.06 [2.60-31.63], p=0.001), previous preterm, (OR=9.31 [2.82-30.68], p<0.001), low socioeconomic status (OR=1.51 [1.05-2.16], p=0.03), herbal use in first trimester for 2-5 days (OR=11.10 [4.34-28.41], p<0.001), herbal use in first trimester for 6-10 days (OR=44.87,[4.99-403.87] p=0.001), and herbal use in second trimester for 6-10 days (OR=16.43 [4.53-59.57], p<0.001). Use of prescribed folic acid in second trimester for more than 31 days was associated with lower risk of preterm birth (OR=0.20 [0.12-0.34], p<0.001). Conclusion: Herbal use in pregnancy regardless of gestation, previous preterm birth and low socio-economic status and are risk factors for preterm birth in Kitui County Kenya.  Interventions targeted to reduction of these risk factors will be an important additional prong in the reduction of preterm birth. Key words: Preterm birth, herbal remedy, risk factor

Challenges and issues in drug utilization research identified from the Latin American and African regions

Background: Despite advancements in drug utilization research (DUR), these have not been universal. Some regions such as the Latin America (LatAm) and African regions are facing challenges that are impeding the development of DUR. Objectives: To identify the main challenges and issues for DUR in the LatAm and African regions Methods: A collaborative initiative by the International Society of Pharmacoepidemiology Global Development Committee in partnership with the Latin America Drug Utilization Group and the Medicines Utilization Research in Africa Group was undertaken. A comprehensive literature review was conducted to identify local and international DUR publications. A core group of investigators and experts in DUR reviewed the publications and identified the main methodological challenges and issues. Subsequently, the group exchanged materials, participated in WebEx discussions, and reviewed the draft document. Results: Main issues: 1) Socioeconomic: high unemployment rate with poor standard of living, socioeconomic inequalities, low literacy levels, urban segregation, high migration rates, high rates of violent crime including drug trafficking and possession. 2) Healthcare-related: Disparities of social determinants of health, differences in the quality of public and private health sectors; and epidemiologic transition from communicable diseases to non-communicable diseases. Most health care systems are fragmented with variable access to medical care and medicines, and substandard record keeping. 3) Drug utilization-related: Inappropriate use of medicines including the elderly; limited infrastructure to reliably collect DU data; over-prescription of antimicrobials; polypharmacy; high rates of self-medication; and poor patient adherence (e.g. HIV/AIDS, diabetes mellitus and hypertension). Planning for DUR is affected by the multiplicity of drug distribution channels; trading in sub-standard, counterfeit medicines and insufficient quality control centers. Some publications are generated by local investigators, often suffering of methodological issues such as lack of representativeness of the population, limited data validity, and small sample sizes. Conclusions: There are common challenges for DUR when working within the LatAm and African regions. Based on our findings, the group is developing Guidance on Good Practices of Drug Utilization Research in those regions to assist researchers with issues pertaining to the planning, conduct, and evaluation of DUR

Response to the Novel Corona Virus (COVID-19) Pandemic Across Africa: Successes, Challenges, and Implications for the Future

Background: The COVID-19 pandemic has already claimed considerable lives. There are major concerns in Africa due to existing high prevalence rates for both infectious and non-infectious diseases and limited resources in terms of personnel, beds and equipment. Alongside this, concerns that lockdown and other measures will have on prevention and management of other infectious diseases and non-communicable diseases (NCDs). NCDs are an increasing issue with rising morbidity and mortality rates. The World Health Organization (WHO) warns that a lack of nets and treatment could result in up to 18 million additional cases of malaria and up to 30,000 additional deaths in sub-Saharan Africa. Objective: Document current prevalence and mortality rates from COVID-19 alongside economic and other measures to reduce its spread and impact across Africa. In addition, suggested ways forward among all key stakeholder groups. Our Approach: Contextualise the findings from a wide range of publications including internet-based publications coupled with input from senior-level personnel. Ongoing Activities: Prevalence and mortality rates are currently lower in Africa than among several Western countries and the USA. This could be due to a number of factors including early instigation of lockdown and border closures, the younger age of the population, lack of robust reporting systems and as yet unidentified genetic and other factors. Innovation is accelerating to address concerns with available equipment. There are ongoing steps to address the level of misinformation and its consequences including fines. There are also ongoing initiatives across Africa to start addressing the unintended consequences of COVID-19 activities including lockdown measures and their impact on NCDs including the likely rise in mental health disorders, exacerbated by increasing stigma associated with COVID-19. Strategies include extending prescription lengths, telemedicine and encouraging vaccination. However, these need to be accelerated to prevent increased morbidity and mortality. Conclusion: There are multiple activities across Africa to reduce the spread of COVID-19 and address misinformation, which can have catastrophic consequences, assisted by the WHO and others, which appear to be working in a number of countries. Research is ongoing to clarify the unintended consequences given ongoing concerns to guide future activities. Countries are learning from each other

Coronavirus disease 2019 (COVID-19) pandemic across Africa : current status of vaccinations and implications for the future

The introduction of effective vaccines in December 2020 marked a significant step forward in the global response to COVID-19. Given concerns with access, acceptability, and hesitancy across Africa, there is a need to describe the current status of vaccine uptake in the continent. An exploratory study was undertaken to investigate these aspects, current challenges, and lessons learnt across Africa to provide future direction. Senior personnel across 14 African countries completed a self-administered questionnaire, with a descriptive analysis of the data. Vaccine roll-out commenced in March 2021 in most countries. COVID-19 vaccination coverage varied from low in Cameroon and Tanzania and up to 39.85% full coverage in Botswana at the end of 2021; that is, all doses advocated by initial protocols versus the total population, with rates increasing to 58.4% in Botswana by the end of June 2022. The greatest increase in people being fully vaccinated was observed in Uganda (20.4% increase), Botswana (18.5% increase), and Zambia (17.9% increase). Most vaccines were obtained through WHO-COVAX agreements. Initially, vaccination was prioritised for healthcare workers (HCWs), the elderly, adults with co-morbidities, and other at-risk groups, with countries now commencing vaccination among children and administering booster doses. Challenges included irregular supply and considerable hesitancy arising from misinformation fuelled by social media activities. Overall, there was fair to reasonable access to vaccination across countries, enhanced by government initiatives. Vaccine hesitancy must be addressed with context-specific interventions, including proactive programmes among HCWs, medical journalists, and the public

One-day out-patient prescribing patterns at a national referral hospital in Kenya

Background: Poor prescribing habits lead to ineffective and unsafe treatment for patients, exacerbating or prolonging of illness as well as causing distress and harm to them. Drug utilization studies can help identifying gaps in prescribing and feed the results back to prescribers to enhance future rational use of medicines. Objective: Evaluate outpatient prescribing practices and patterns in a leading national Hospital in Kenya. Methods: A sample of 60 prescriptions was selected by quasi-random sampling. Data was abstracted using a pre-designed data collection form, entered into and analyzed using Excel software. Results: The average number of drugs prescribed per prescription was three with a polypharmacy rate (>4 drugs) of 20%. Only two-thirds (65%) of the prescribed drugs were actually dispensed at the hospital pharmacy due to shortages, principally shortages of originators. Slightly more than half (52%) of the drugs were prescribed by generic name. Prescribing by brand names was highest among medical interns (61%). Almost all drugs prescribed (95%) were consistent with the hospital tender list. Conclusions: There is a need to increase the rate of prescribing of generics to save costs as well as reduce stock-out levels. This can be helped by instigating a comprehensive generics policy. There is also a need to strengthen and empower drugs and therapeutic committees (DTCs) to improve selection and availability of quality generics to win the confidence of prescribers

Determinants of Adherence to Anti-Tuberculosis Treatment among Paediatric Patients in A Kenyan Tertiary Referral Hospital

Background: Non-adherence to anti-tuberculosis treatment increases the risk for development of drug resistance, TB recurrence and mortality. Objectives: This study was designed to determine the rate and predictors of adherence to anti-tuberculosis treatment in paediatric TB patients. Methodology: This was a cross sectional study carried out at the Kenyatta National Hospital TB clinic. Caregivers of children were interviewed and the patients requested to provide a urine sample which was tested for the presence of isoniazid to verify adherence to medication. Results: Adherence to anti-TB medications measured by urine testing and self-report, was 91.8% and 44.9% respectively. Patients who administered medication at 24 hour intervals were more likely to adhere to medication (OR = 7.70 [1.85 - 33.33], 95% CI). There was no significant association between adherence and regimen complexity factors, relationship between health care provider and caregiver or the pattern of healthcare delivery. The results suggested a slight agreement between self-reported adherence and the isoniazid urine test (κ= 0.20). Conclusion: Adherence to anti-TB medication in this population of children was relatively high, and could be attributed to the structures that have been put in place to ensure that TB patients have access to treatment services at the community level. Keywords: Adherence, tuberculosis in children, anti-tuberculosis treatment, isoniazi

Predictors of Breast Cancer Treatment Outcomes in Kenyan Women

Background: Breast cancer is the most prevalent cancer among Kenyan women.  Worldwide data show that diverse factors including socio-economic status, co-morbidities, and expression of hormonal receptors, have effect on disease recurrence or metastasis following treatment. Most studies on breast cancer treatment outcomes have been undertaken in developed countries, and there is scarcity of data on predictive indicators of breast cancer treatment outcomes in Africa. Objective: This study was designed to determine the factors that predict the treatment outcomes in breast cancer patients in a Kenyan teaching and referral hospital. Methods: This hospital based retrospective descriptive study was designed to evaluate the effect of the occurrence of estrogen receptor, progesterone receptor, human epidermal growth factor and cancer stage among other factors on the outcome of breast cancer treatment. Patients diagnosed with breast cancer and who had their first visit at the KNH in the period 2007-2008 were identified. Quantitative variables were described with medians or means. Association effects were determined by use of Chi-square test. Categorical variables were summarized using proportions. The time to event analysis was estimated using the Kaplan–Meier product limit method. Results: The mean age of the 219 participants was 46.5 years (range 23 to 92 years), majority (36.1%) of whom were aged between 41 to 50 years. Most study participants had stage 2B (21.9%) cancer type, and the histological grade 3 breast cancer was predominant type (50.2%). Nearly half of the patients (46.1%) developed metastases. In bivariate analyses, cancer stage 2A (OR 0.29, 95% CI 0.12 to 0.77) and stage 2B (OR 0.41, 95% CI 0.21- 0.77), presence of estrogen receptors (OR 0.24, 95% CI 0.12 to 0.77), presence of progesterone receptor (OR 0.26, 95% CI 0.09 to 0.72), human epidermal growth factors (OR 0.05, 95% CI 0.003 to 0.84), and those on hormonal treatment (OR 0.34, 95% CI 0.19 to 0.62) were factors less likely to be associated with development of metastasis after treatment. In multivariate analysis, HIV positive status (OR 0.004, 95% CI 0.002 to 0.75), presence of estrogen (OR 0.23, 95% CI 0.08 to 0.64) and human epidermal growth factors (OR 2.53, 95% CI 1.64 to 3.91) receptors and obesity (OR 2.53, 95% CI 1.64 to 3.91) were independent factors influencing development of metastasis after treatment. Conclusion: This study showed that development of metastasis after breast cancer therapy has associations with the expression of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor -2 (HER-2) as well as the stage of diagnosis.  This study demonstrates the need for enhanced screening for breast cancer to improve early diagnosis and the testing of ER, PR and HER-2 are crucial as they predict outcomes of therapy. Key words: Breast cancer, breast cancer treatment, cancer treatment outcomes, cancer treatment predictors