A simple and rapid external standard calibration HPLC method for determination of lumefantrine in dried blood spot samples from malaria patients in Botswana.

A simple external calibration liquid chromatography-diode array detector method was developed, validated, and applied for the determination of lumefantrine (Lum) in dried blood spot (DBS) samples collected from malaria patients in Botswana. The samples were validated in accordance with the United States Food and Drug Administration guidelines for bioanalytical methods after sample preparation using solid-liquid extraction. Separation was achieved using an XTerra C18 column (50 × 4.6 mm, 5 µm), and a binary solvent system of acetonitrile and water adjusted to pH 2.3 was used as the mobile phase. The validated method was applied for the determination of Lum in DBS samples collected from malaria patients infected with Plasmodium falciparum in Botswana. The calibration curve was linear between 0.5 and 12 µg/mL with a coefficient of determination (R2 ) of 0.9996. The limit of detection and the lower limit of quantification were 0.5 and 1.4 µg/mL, respectively. The efficiency of extraction measured as percentage recovery ranged between 84.2% and 107.8% at the three quality control (QC) levels, that is, low QC, mid QC, and high QC. In conclusion, data suggest that the method is suitable for the determination of trace Lum in biofluids and can also be used for therapeutic drug monitoring and pharmacokinetic profiling.

A Narrative Review of Recent Antibiotic Prescribing Practices in Ambulatory Care in Tanzania: Findings and Implications.

Background and objectives: There are concerns with the current prescribing practices of antibiotics in ambulatory care in Tanzania, including both the public and private sectors. These concerns need to be addressed as part of the national action plan (NAP) of Tanzania to reduce rising antimicrobial resistance (AMR) rates. Issues and concerns include high rates of prescribing of antibiotics for essentially self-limiting conditions. Consequently, there is a need to address this. As a result, the aims of this narrative review were to comprehensively summarize antibiotic utilization patterns particularly in ambulatory care and their rationale in Tanzania and to suggest ways forward to improve future prescribing practices. Materials and Methods: We undertook a narrative review of recently published studies and subsequently documented potential activities to improve future prescribing practices. Potential activities included instigating quality indicators and antimicrobial stewardship programs (ASPs). Results: Published studies have shown that antibiotics are being excessively prescribed in ambulatory care in Tanzania, in up to 95% to 96.3% of presenting cases depending on the sector. This is despite concerns with their appropriateness. High rates of antibiotic prescribing are not helped by variable adherence to current treatment guidelines. There have also been concerns with extensive prescribing of 'Watch' antibiotics in the private sector. Overall, the majority of antibiotics prescribed across the sectors, albeit inappropriately, were typically from the 'Access' group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than 'Watch' antibiotics to limit AMR. The inappropriate prescribing of antibiotics in ambulatory care is linked to current knowledge regarding antibiotics, AMR, and ASPs among both prescribers and patients. Recommended activities for the future include improved education for all groups, the instigation of updated quality indicators, and the regular monitoring of prescribing practices against agreed-upon guidelines and indicators. Education for healthcare professionals on ASPs should start at undergraduate level and continue post qualification. Community advocacy on the rational use of antibiotics should also include social media activities to dispel misinformation. Conclusion: The quality of current prescribing practices of antibiotics in ambulatory care is sub-optimal in Tanzania. This needs to be urgently addressed.

Current rates of purchasing of antibiotics without a prescription across sub-Saharan Africa; rationale and potential programmes to reduce inappropriate dispensing and resistance.

INTRODUCTION: Antimicrobial resistance (AMR) is a global concern. Currently, the greatest mortality due to AMR is in Africa. A key driver continues to be high levels of dispensing of antibiotics without a prescription. AREAS COVERED: A need to document current rates of dispensing, their rationale and potential ways forward including antimicrobial stewardship programmes (ASPs). A narrative review was undertaken. The highest rates of antibiotic purchasing were in Eritrea (up to 89.2% of antibiotics dispensed), Ethiopia (up to 87.9%), Nigeria (up to 86.5%), Tanzania (up to 92.3%) and Zambia (up to 100% of pharmacies dispensing antibiotics without a prescription). However, considerable variation was seen with no dispensing in a minority of countries and situations. Key drivers of self-purchasing included high co-payment levels for physician consultations and antibiotic costs, travel costs, convenience of pharmacies, patient requests, limited knowledge of antibiotics and AMR and weak enforcement. ASPs have been introduced in some African countries along with quality targets to reduce inappropriate dispensing, centering on educating pharmacists and patients. EXPERT OPINION: ASP activities need accelerating among community pharmacies alongside quality targets, with greater monitoring of pharmacists' activities to reduce inappropriate dispensing. Such activities, alongside educating patients and healthcare professionals, should enhance appropriate dispensing of antibiotics and reduce AMR.

Current Antibiotic Use Among Hospitals in the sub-Saharan Africa Region; Findings and Implications.

Background: The rapid rise in antimicrobial resistance (AMR) globally, impacting on morbidity, mortality and costs with sub-Saharan African countries reporting the greatest burden is a concern. Instigation of antimicrobial stewardship programs (ASPs) can improve antibiotic use in hospitals and reduce AMR. Implementing ASPs requires knowledge of antibiotic utilization against agreed quality indicators with the data obtained from point prevalence surveys (PPS), hence the need to document antibiotic utilization patterns in sub-Saharan Africa. Methods: A narrative review to document current utilization patterns, challenges, indicators and ASPs across sub-Saharan Africa based on previous reviews by the authors, supplemented by the considerable knowledge and experience of the co-authors. Results: Results from multiple PPS studies showed a high prevalence of antibiotic use among hospitals, mostly over 50%. Prevalence rates ranged from as low as 37.7% in South Africa to as high as 80.1% in Nigeria. There was also considerable prescribing of broad-spectrum antibiotics which could be due to lack of facilities within hospitals, alongside concerns with co-payments to perform microbiological tests, resulting in empiric prescribing. This is a concern alongside lack of guidelines or adherence to guidelines, which was as low as 4% in one study. Another concern was the high rates of extended prophylaxis to prevent surgical site infections (SSIs), with antibiotics often prescribed for longer than 24 hours, usually multiple doses. Several quality indicators have been used to evaluate antibiotic utilization providing exemplars for the future. Among the initiatives being instigated to improve antibiotic use, ASPs have proved effective. For ASPs to be successful objectives and indicators must be agreed, and regular audits undertaken. Conclusion: Antibiotic prescribing across Africa is characterised by high prevalence, usually empirical. Various prescribing and quality indicators are being employed to assess antibiotic use, and ASPs have shown to improve antibiotic prescribing providing direction to reduce AMR.

Ongoing Efforts to Improve Antimicrobial Utilization in Hospitals among African Countries and Implications for the Future.

There are serious concerns with rising antimicrobial resistance (AMR) across countries increasing morbidity, mortality and costs. These concerns have resulted in a plethora of initiatives globally and nationally including national action plans (NAPs) to reduce AMR. Africa is no exception, especially with the highest rates of AMR globally. Key activities in NAPs include gaining a greater understanding of current antimicrobial utilization patterns through point prevalence surveys (PPS) and subsequently instigating antimicrobial stewardship programs (ASPs). Consequently, there is a need to comprehensively document current utilization patterns among hospitals across Africa coupled with ASP studies. In total, 33 PPS studies ranging from single up to 18 hospitals were documented from a narrative review with typically over 50% of in-patients prescribed antimicrobials, up to 97.6% in Nigeria. The penicillins, ceftriaxone and metronidazole, were the most prescribed antibiotics. Appreciable extended prescribing of antibiotics up to 6 days or more post-operatively was seen across Africa to prevent surgical site infections. At least 19 ASPs have been instigated across Africa in recent years to improve future prescribing utilizing a range of prescribing indicators. The various findings resulted in a range of suggested activities that key stakeholders, including governments and healthcare professionals, should undertake in the short, medium and long term to improve future antimicrobial prescribing and reduce AMR across Africa.

Key Considerations From a Health Authority Perspective When Proton Pump Inhibitors Are Used to Treat Gastroesophageal Reflux Disease (GERD) and Their Implications.

The growing prevalence of gastroesophageal reflux disease (GERD) needs to be carefully managed to relieve the symptoms and prevent complications. Complications of GERD can include erosive esophagitis, Barrett's esophagus and gastrointestinal (GI) bleeding. Proton pump inhibitors (PPIs) are typically first-line treatment for GERD alongside lifestyle changes in view of their effectiveness and cost-effectiveness. However, there are concerns with adherence to dosing regimens and recommended lifestyle changes reducing their effectiveness. There are also concerns about potential complications from chronic high-dose PPIs. These include an increased risk of chronic kidney disease, cardiovascular events and infections. Recommendations to physicians include prescribing or dispensing the lowest dose of PPI for the shortest time, with ongoing patient monitoring. Activities among community pharmacists and others have resulted in increased dispensing of PPIs without a prescription, which can be a challenge. PPIs are among the most prescribed and dispensed medicines in view of their effectiveness in managing GERD. However, there are concerns with the doses prescribed and dispensed as well as adherence to lifestyle advice. These issues and challenges need to be addressed by health authorities to maximize the role and value of PPIs.

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.

Tackling antimicrobial resistance across sub-Saharan Africa: current challenges and implications for the future.

INTRODUCTION: Antimicrobial resistance (AMR) is a concern as this increases morbidity, mortality, and costs, with sub-Saharan Africa having the highest rates globally. Concerns with rising AMR have resulted in international, Pan-African, and country activities including the development of national action plans (NAPs). However, there is variable implementation across Africa with key challenges persisting. AREAS COVERED: Consequently, there is an urgent need to document current NAP activities and challenges across sub-Saharan Africa to provide future guidance. This builds on a narrative review of the literature. EXPERT OPINION: All surveyed sub-Saharan African countries have developed their NAPs; however, there is variable implementation. Countries including Botswana and Namibia are yet to officially launch their NAPs with Eswatini only recently launching its NAP. Cameroon is further ahead with its NAP than these countries; though there are concerns with implementation. South Africa appears to have made the greatest strides with implementing its NAP including regular monitoring of activities and instigation of antimicrobial stewardship programs. Key challenges remain across Africa. These include available personnel, expertise, capacity, and resources to undertake agreed NAP activities including active surveillance, lack of focal points to drive NAPs, and competing demands and priorities including among donors. These challenges are being addressed, with further co-ordinated efforts needed to reduce AMR.

Challenges and Innovations Brought about by the COVID-19 Pandemic Regarding Medical and Pharmacy Education Especially in Africa and Implications for the Future.

BACKGROUND: Multiple measures introduced early to restrict COVID-19 have dramatically impacted the teaching of medical and pharmacy students, exacerbated by the lack of infrastructure and experience with e-learning at the start of the pandemic. In addition, the costs and reliability of the Internet across Africa pose challenges alongside undertaking clinical teaching and practical programmes. Consequently, there is a need to understand the many challenges and how these were addressed, given increasingly complex patients, to provide future direction. METHOD: An exploratory study was conducted among senior-level medical and pharmacy educators across Africa, addressing four key questions, including the challenges resulting from the pandemic and how these were dealt with. RESULTS: Staff and student members faced multiple challenges initially, including adapting to online learning. In addition, concerns with the lack of equipment (especially among disadvantaged students), the costs of Internet bundles, and how to conduct practicals and clinical teaching. Multiple activities were undertaken to address these challenges. These included training sessions, developing innovative approaches to teaching, and seeking ways to reduce Internet costs. Robust approaches to practicals, clinical teaching, and assessments have been developed. CONCLUSIONS: Appreciable difficulties to teaching arising from the pandemic are being addressed across Africa. Research is ongoing to improve education and assessments.

Enhancing Choices Regarding the Administration of Insulin Among Patients With Diabetes Requiring Insulin Across Countries and Implications for Future Care.

There are a number of ongoing developments to improve the care of patients with diabetes across countries given its growing burden. Recent developments include new oral medicines to reduce cardiovascular events and death. They also include new modes to improve insulin administration to enhance adherence and subsequent patient management thereby reducing hypoglycaemia and improving long-term outcomes. In the case of insulins, this includes long-acting insulin analogues as well as continuous glucose monitoring (CGM) systems and continuous subcutaneous insulin infusion systems, combined with sensor-augmented pump therapy and potentially hybrid closed-loops. The benefits of such systems have been endorsed by endocrine societies and governments in patients with Type 1 diabetes whose HbA1c levels are not currently being optimised. However, there are concerns with the low use of such systems across higher-income countries, exacerbated by their higher costs, despite studies suggesting their cost-effectiveness ratios are within accepted limits. This is inconsistent in higher-income countries when compared with reimbursement and funding decisions for new high-priced medicines for cancer and orphan diseases, with often limited benefits, given the burden of multiple daily insulin injections coupled with the need for constant monitoring. This situation is different among patients and governments in low- and low-middle income countries struggling to fund standard insulins and the routine monitoring of HbA1c levels. The first priority in these countries is to address these priority issues before funding more expensive forms of insulin and associated devices. Greater patient involvement in treatment decisions, transparency in decision making, and evidence-based investment decisions should help to address such concerns in the future.

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.

Challenges facing drug utilization research in the Latin American region.

PURPOSE: The International Society of Pharmacoepidemiology (ISPE) in collaboration with the Latin America Drug Utilization Research Group (LatAm DURG), the Medicines Utilization Research in Africa (MURIA) group, and the Uppsala Monitoring Center, is leading an initiative to understand challenges to drug utilization research (DUR) in the Latin American (LatAm) and African regions with the goal of communicating results and proposing solutions to these challenges in four scientific publications. The purpose of this first manuscript is to identify the main challenges associated with DUR in the LatAm region. METHODS: Drug utilization (DU) researchers in the LatAm region voluntarily participated in multiple discussions, contributed with local data and reviewed successive drafts and the final manuscript. Additionally, we carried out a literature review to identify the most relevant publications related to DU studies from the LatAm region. RESULTS: Multiple challenges were identified in the LatAm region for DUR including socioeconomic inequality, access to medical care, complexity of the healthcare system, limited investment in research and development, limited institutional and organization resources, language barriers, limited health education and literacy. Further, there is limited use of local DUR data by decision makers particularly in the identification of emerging health needs coming from social and demographic transitions. CONCLUSIONS: The LatAm region faces challenges to DUR which are inherent in the healthcare and political systems, and potential solutions should target changes to the system.

Nature and sources of poisoning in patients admitted to a referral hospital in Gaborone, Botswana; findings and implications.

BACKGROUND: Intentional poisoning is becoming an important public health concern particularly among young women globally. Consequently, there is a need to analyze this further within countries to establish pertinent policies to reduce current incidence rates. This includes sub-Saharan African countries where there has been a scarcity of information. Consequently, we sought to establish the nature and sources of poisoning in patients admitted to a leading hospital in Botswana to help develop pertinent future policies for Botswana and surrounding countries. METHODS: Retrospectively reviewing the medical records of all patients admitted to Princess Marina Hospital (PMH), which is a leading tertiary hospital in the capital city of Botswana, due to acute poisoning over a six-year period. RESULTS: The records for 408 patients were reviewed. The majority of admissions (58%) were females, and the mean age of patients was 21(±14) years. Most poisoning cases (53%) were intentional. The 15-45 years age group was most likely to intentionally poison themselves compared to other age groups, with females four and half times more likely to intentionally poison themselves compared to males (AOR 4.53, 95% CI: 2.68-7.89, p < 0.001). Half of the patients were poisoned by medicines followed by household chemicals (22%), with females overall four times more likely to be poisoned by medicines compared to males. The medicine mostly ingested was paracetamol (30%). Failing relationships (57%) were the principal reason for intentional poisoning. Six patients died from poisoning representing a 1.5% mortality rate. CONCLUSIONS: The findings suggest in-depth and urgent investigations on intentional poisoning are needed among young women across countries including sub-Saharan African countries to inform future policies on prevention strategies. Further, strategies for poisoning prevention should target social and family relationship problems. We will be following this up in the future.

Pharmacotherapeutic interventions for bipolar disorder type II: addressing multiple symptoms and approaches with a particular emphasis on strategies in lower and middle-income countries.

Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middle-income countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed.Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments.Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients' rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.

Antimicrobial utilization research and activities in Botswana, the past, present and the future.

A number of activities are ongoing to reduce AMR in Botswana by improving antimicrobial utilization across all sectors. However, there is a need to share experiences. With the objective of sharing these, the second one day symposium was held in the University of Botswana in October 2018 involving both private and public hospitals. In Lenmed Bokamoso hospital, ESKAPE organisms were associated with 50-90% of clinical infections; however, there was no correlation between healthcare associated infections (HAIs) and admission swab positivity with ESKAPE or ESBL isolates. Hang times, the time between a prescription and IV administration, were also discussed. At Nyangabwe Hospital, the prevalence of HAIs was 13.54%, 48.9% were laboratory confirmed of which 8.5% were blood stream infections (BSIs). The prevalence of different bacteria causing neonatal BSIs was also investigated. At Princess Marina Hospital, positive cultures were seen in 22.4% of blood cultures with contaminants comprising the majority. Several activities are ongoing in Botswana across sectors as a result of the findings and will be periodically reported to further improve antibiotic utilization.

Point prevalence study of antimicrobial use among hospitals across Botswana; findings and implications.

Objective: There is an urgent need to undertake Point Prevalence Surveys (PPS) across Africa to document antimicrobial utilisation rates given high rates of infectious diseases and growing resistance rates. This is the case in Botswana along with high empiric use and extended prophylaxis to prevent surgical site infections (SSIs) Method: PPS was conducted among all hospital sectors in Botswana using forms based on Global and European PPS studies adapted for Botswana, including rates of HIV, TB, malaria, and malnutrition. Quantitative study to assess the capacity to promote appropriate antibiotic prescribing. Results: 711 patients were enrolled with high antimicrobial use (70.6%) reflecting an appreciable number transferred from other hospitals (42.9%), high HIV rates (40.04% among those with known HIV) and TB (25.4%), and high use of catheters. Most infections were community acquired (61.7%). Cefotaxime and metronidazole were the most prescribed in public hospitals with ceftriaxone the most prescribed antimicrobial in private hospitals. Concerns with missed antibiotic doses (1.96 per patient), high empiric use, extended use to prevent SSIs, high use of IV antibiotics, and variable infrastructures in hospitals to improve future antibiotic use. Conclusion: High antibiotic use reflects high rates of infectious diseases observed in Botswana. A number of concerns have been identified, which are being addressed.

Reported needs of information resources, research tools, connectivity and infrastructure among African Pharmacological Scientists to improve future patient care and health.

INTRODUCTION: The potentials of Africa for growth and economic transformation through science remains challenging because of existing gaps in knowledge and infrastructure. The Africa Pharmacological Science Gateway project and the Medicines Utilization Research in Africa Group seek to meet the research needs of African pharmacologists. This study aimed at identifying priority needs that might be met by access to information and tools through e-infrastructure. METHODS: A web-based cross-sectional study among 472 members of pharmacological societies in Africa to obtain information on their research interests and skills, available resources, needs, and knowledge gaps. Descriptive analyses were done. RESULTS: A total of 118 responses from 13 countries were received, mostly from Nigeria (48.3%) and South Africa (21.3%). Respondents had wide ranges of research interests predominantly in drug utilization research. The desired resources included drug utilization research training and tools, pharmacokinetics and pharmacometrics modeling training and tools, drug-drug interaction and medicine prices resources, statistical analysis resources, access to journals, training in specific laboratory techniques, equipment and funding for research-related activities. CONCLUSIONS: Key areas of needs not currently provided by the African Pharmacological Science Gateway e-infrastructure were identified to guide the further provision of resources on the e-infrastructure and potentially enhance research capacity within the continent.

Determinants of glycemic control among diabetes mellitus patients in a tertiary clinic in Gaborone, Botswana: findings and implications.

BACKGROUND AND AIMS: Glycemic control among patients with diabetes mellitus is associated with a marked reduction of both macrovascular and microvascular complications; however, glycemic control remains an elusive goal worldwide. The aim of this study was to determine factors associated with glycemic control among patients attending a tertiary clinic in Botswana as limited information to date. METHODS: Cross-sectional study in a tertiary clinic in Gaborone, Botswana. Patients were recruited between 21 July 2015 and 21 September 2015. The majority of the randomly recruited patients (368/380-96.8%) had documentation of glycemic control (HbA1c) within three months of study recruitment and were subsequently included in the analysis. Glycemic control was categorized as desirable, suboptimal and poor if HbA1c was <7%, 7-9% and >9%, respectively. Data were analyzed using SPSS for descriptive statistics including both bivariate and multinomial logistic regression. A value of p < 0.05 was considered statistically significant. RESULTS: The analyzed study population consisted of 258/368 (70.1%) females with a mean age (SD) of 56.7 ± 13.6 years. Means (SDs) for diabetes duration and glycated hemoglobin were 7.2 ± 7.1 years and 7.97 ± 2.02%, respectively. Of the 368 patients, 136 (36.95%) and 132/368 (35.86%) had desirable and suboptimal glycemic control, respectively. Older age, attending the clinic for more or equal to 3 years and not being on insulin were associated with both desirable and suboptimal glycemic control whereas duration of diabetes between 5 and 10 years was associated with poor glycemic control. CONCLUSIONS: The majority of patients had poor glycemic control. Older age and not being on insulin were associated with better glycemic control. The fact that patients on insulin had poor glycemic control calls for more research to determine the timing of insulin initiations and dosing schedule factors as these will help to improve overall glycemic control in Botswana and elsewhere.

Status of antimicrobial stewardship programmes in Nigerian tertiary healthcare facilities: Findings and implications.

OBJECTIVES: The problem of antimicrobial resistance (AMR) is increasing worldwide, with health-related and economic consequences. This is a concern in Africa, including Nigeria, the most populous country in Africa, with its high rates of infectious diseases. Approaches to reducing AMR include instigating antimicrobial stewardship programmes (ASPs) in hospitals. Currently, no information is available regarding the extent of ASPs in Nigerian hospitals. Consequently, the objective was to address this starting in tertiary hospitals. METHODS: This was a cross-sectional, questionnaire-based study among tertiary healthcare facilities. Tertiary hospitals were chosen initially since if there are concerns in these training hospitals, such concerns will likely to be exacerbated in other hospitals. RESULTS: Completed questionnaires were received from 17 of 25 tertiary healthcare facilities across five of the six geopolitical regions of Nigeria. Ten (59%), four (24%), two (12%) and one (6%) respondents were in internal medicine, infectious diseases, medical microbiology and clinical pharmacology, respectively. Only six healthcare facilities (35%) had a formal organisational structure and a team responsible for ASP. Facility-specific treatment recommendations, based on local AMR patterns, were available in only four facilities (24%). Policies on approval for prescribing specified antimicrobials and formal procedures for reviewing their appropriateness after 48h were present in only two facilities (12%). A cumulative antimicrobial susceptibility report for the previous year was available in only two facilities (12%), and only one facility routinely monitored antimicrobial use. CONCLUSION: Significant inadequacies in the availability of ASPs were observed. This needs to be urgently addressed to reduce AMR rates in Nigeria.

Barriers for Access to New Medicines: Searching for the Balance Between Rising Costs and Limited Budgets.

Introduction: There is continued unmet medical need for new medicines across countries especially for cancer, immunological diseases, and orphan diseases. However, there are growing challenges with funding new medicines at ever increasing prices along with funding increased medicine volumes with the growth in both infectious diseases and non-communicable diseases across countries. This has resulted in the development of new models to better manage the entry of new medicines, new financial models being postulated to finance new medicines as well as strategies to improve prescribing efficiency. However, more needs to be done. Consequently, the primary aim of this paper is to consider potential ways to optimize the use of new medicines balancing rising costs with increasing budgetary pressures to stimulate debate especially from a payer perspective. Methods: A narrative review of pharmaceutical policies and implications, as well as possible developments, based on key publications and initiatives known to the co-authors principally from a health authority perspective. Results: A number of initiatives and approaches have been identified including new models to better manage the entry of new medicines based on three pillars (pre-, peri-, and post-launch activities). Within this, we see the growing role of horizon scanning activities starting up to 36 months before launch, managed entry agreements and post launch follow-up. It is also likely there will be greater scrutiny over the effectiveness and value of new cancer medicines given ever increasing prices. This could include establishing minimum effectiveness targets for premium pricing along with re-evaluating prices as more medicines for cancer lose their patent. There will also be a greater involvement of patients especially with orphan diseases. New initiatives could include a greater role of multicriteria decision analysis, as well as looking at the potential for de-linking research and development from commercial activities to enhance affordability. Conclusion: There are a number of ongoing activities across countries to try and fund new valued medicines whilst attaining or maintaining universal healthcare. Such activities will grow with increasing resource pressures and continued unmet need.