An analysis of antibiotic consumption in Nigeria and its...
Transcript of An analysis of antibiotic consumption in Nigeria and its...
Nigeria Centre for Disease ControlProtecting the health of Nigerians
An analysis of antibiotic consumption in Nigeria and its potential contribution to rising antimicrobial resistance
Abiodun Egwuenu1, J. Obasanya1, A. Ogunniyi1, I.N. Okeke2, A.O. Aboderin3, A. Olayinka4, M. Aworh5, K. Jinadu1, E. Mbadiwe6, L. Omoniyei6, D. Kwange5, F. Abba1, O.
Hamzat7, C. Ogar8, A. Aremu9, F. Kudla9, M. Niyang10, Patrick Nguku4, AMR-TWG11, C. Ihekweazu1
1Nigeria Centre for Disease Control, 2Global Antibiotic Resistance Partnership/University of Ibadan, 3Obafemi Awolowo University/Obafemi Awolowo
University Teaching Hospitals Complex, Ile-Ife, 4Nigeria Field Epidemiology and Laboratory Training Programme, 5Federal Ministry of Agriculture and
Rural Development, 6Global Antibiotic Resistance Partnership/Ducit Blue Solutions, 7World Health Organisation-Nigeria, 8National Agency for Food
and Drug Administration and Control, 9Federal Ministry of Environment, 10University of Maryland Baltimore, 11Antimicrobial Resistance Technical
Working Group
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Nothing to disclose
Nothing to disclose
Nothing to disclose
Nothing to disclose
Nothing to disclose
Conflict of interest
Introduction
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• “Time may come when penicillin (antibiotics) can be bought by anyone…exposing microbes to non-lethal quantities may make them resistant…I hope this evil can be averted”
- Alexander Fleming (1945)*
• Antibiotic exposure => risk of resistant infection
Response to AMR threat: Nigeria
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2015• An integrated global programme for surveillance of antimicrobial
resistance (AMR) adopted by the 68th World Health Assembly
2016• Nigeria committed to establishing a national AMR surveillance system,
in conformity with the global action plan
2016• AMR Coordinating Body established at Nigeria Centre Disease Control
by Honourable Minister for Health
2017• One Health AMR Technical Working Group inaugurated, to conduct an
analysis of the AMR and antibiotic consumption situation in Nigeria
Objectives
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• Describe legislations guiding antimicrobial use
• Describe existing workforce and framework for antimicrobial distribution
• Characterize antibiotic use in humans and animals
• Elucidate factors related to antimicrobial consumption and its potential contribution to antimicrobial resistance
Conceptual framework: Antibiotic access and use
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• Rational use of medicines‒ appropriate to clinical needs
‒ In doses that meet individual requirements
‒ An adequate period
‒ At lowest cost
Data collection process
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• January to April 2017
• Review of national reports, policy documents, programmatic data
• Stakeholder interviews:‒ Federal Ministries of Health and
Agriculture
‒ National Agency for Food and Drug Administration and Control
‒ Pharmacists Council of Nigeria (PCN),
‒ Pharmaceutical Manufacturers Group
‒ Academia
‒ Health professional regulatory agencies
Data collation and analysis
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• Systematic review on antibiotic use in humans• Type: observational studies, 2000-2017
• Databases: Medline, Pubmed, Google Scholar, Embase, AJOL
• Protocol: PRISMA
• Primary data on antimicrobial consumption in animals• National database on antibiotics used in animals, 2014-2015
• Data collation• Entered into purpose-built word and excel templates
• Data analysis• Numeric data: frequencies and proportions calculated
• Thematic synthesis: text responses
Laws and regulations guiding antimicrobial use, Nigeria - 2016
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Regulations Examples
Humans
5 Regulatory agencies1993: National Agency for food and Drugs Administration and Control (drug access)
8 Healthcare policies1990: National Drug Policy (drug use)2008: Standard Treatment Guidelines
Animals
2 Regulatory agencies1966: Federal Ministry of Agriculture (surveillance)2004: Veterinary Surgeons (practice)
3Medicine use policies
1968: Meat Law (abattoirs)2007: Veterinary Formulary (medicines)
5Medicine use policies (both)
1976: Food and Drugs Act (manufacture)?? NCDC
Antimicrobial production in Nigeria, 2016
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Characteristic Value
Local manufacturers
% Capacity used for local manufacturing 40%
% Market share local medicine production 25%
% Audited local manufacturers 58%
Amount antibiotics manufactured 16 billion grams
Number drug procurement companies 1,304
Procurement of veterinary antimicrobials Mainly imports
Workforce and medicine distribution framework, Nigeria - 2016
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HW/100,000 pop• Medical doctors: 38• Pharmacist: 12• Veterinarians: 3
Registered medicines(n=45,552)
• 6833 (15%) Antibiotics
Regulatory workforce2/100,000 pop
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1
Retail medicine stores
Registered OTC premises(n=66974)
*OTC: Over-the counter premises
Antimicrobials sold or used in animals and humans in Nigeria
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Antibiotic use in humans, Nigeria 2000 - 2017
Characteristic Median %
Persons using antibiotics without prescription
46.8
Patient drug encounters with antibiotic prescribed
49.1
0
80
160
Tonne
Antimicrobial class
20142015
Antimicrobials used/sold in animals, Nigeria 2014-2015
0
50
100
Cep
hal
exin
Am
oxi
cilli
n
Am
oxi
clav
Met
ron
idaz
ole
Am
oxi
cilli
n
Am
pic
lox
Am
oxy
cilli
n
Am
pic
illin
Co
trim
oxa
zole
Pen
icill
ins
Nwolisaet al -2004
Akandeet al -2007
Sadoh etal - 2009
Ekwochiet al -2012
Rasaq etal - 2013
Sanya etal - 2013
Sanya etal - 2013
Sanya etal - 2013
Ekwochiet al -2014
Fadare etal - 2015
Perc
en
t
Year-Author
Antibiotics used or prescribed to humans in Nigeria, 2000-2017
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Themes related to antimicrobial consumption in Nigeria
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WeakRegulation
Inadequate funding
Human-resource limited
Low staff retention
Fragmented Procurement
Counterfeit/Poor quality control
Access to medicated feeds
Over-reliance on importation
Multi-molecule antibiotics
Stock-outs
Chaotic Distribution
Over-counter sales
Unlicensed persons or premises
Poor public-private network
Urban-rural disparity
Non-adherence to guidelines
Consumer demand
Low awareness
Poor access to health insurance
Unrestricted access
Demand for antibiotics
Fragmented surveillance: resistant bugs, antibiotic use
Conclusion, actions taken and next steps
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• Large volumes of antibiotics used in agriculture
• Access to antibiotics is poorly regulated
• Actions taken‒ National Action Plan developed to address gaps
‒ Policies reviewed: National Standard Treatment Guidelines, National Drug Policy
‒ National AMR surveillance data collection (2017)
‒ National Antibiotic Awareness Campaign established: Nov - 2017, 2018
• Next steps‒ NCDC and National AMR TWG support antimicrobial
stewardship in hospitals: consumption, PPS
‒ “Hub and spoke” model: pharmacies and OTC premises
References
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• Penicillin's finder assays its future. Sir Alexander Fleming. 1945. New York Times
• Van Boeckel TP et. al, 2000-2010
• Cizman et. al 1998
• CNN vital signs 2016: Antimicrobial Resistance -https://edition.cnn.com/2016/09/21/health/what-is-antimicrobial-resistance-amr/index.html
Further information:
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• https://ncdc.gov.ng/themes/common/docs/protocols/56_1510840387.pdf
• https://ncdc.gov.ng/themes/common/docs/protocols/77_1511368219.pdf