Health Risk Assessment of Antibiotic Pollutants in Large Yellow Croakers from Zhejiang Aquaculture Sites.

Intensive aquaculture combatting the decline of large yellow croaker populations can trigger bacterial outbreaks, resulting in extensive antibiotic use. In this study, we screened 5 aquaculture sites in the coastal areas of Zhejiang and identified 17 antibiotics in large yellow croakers using UPLC-MS/MS. The distribution and occurrence of antibiotic pollutants were different in the different tissues of large yellow croakers, being primarily dominated by quinolones. Relatively higher average residue levels of enrofloxacin and ciprofloxacin were detected in the inedible parts, specifically the gills (37.29 µg/kg). Meanwhile, relatively high average residue levels of enrofloxacin and ciprofloxacin were also found in the edible parts, particularly in the muscle (23.18 µg/kg). We observed that the residue levels detected in the swim bladder exceeded the prescribed limit for fish muscle, but there is currently no specific regulatory limit established for this particular tissue. Despite the HI values of enrofloxacin and ciprofloxacin being below 0.01, the health risks should not be disregarded. The findings of this research provide significant practical implications for assessing antibiotic contamination and enhancing the risk management of coastal regions.

Evaluating access to oral anti-diabetic medicines: A cross-sectional survey of prices, availability and affordability in Shaanxi Province, Western China.

OBJECTIVES: To assess the availability and affordability of oral anti-diabetic medicines in Shaanxi Province, Western China. METHODS: In 2015, the prices and availability of 8 anti-diabetic medicines covering 31 different dosage forms and strengths were collected in six cities of Shaanxi Province. A total of 72 public hospitals and 72 private pharmacies were sampled, using a modified methodology developed by the World Health Organization (WHO) and Health Action International (HAI). Medicine prices were compared with international reference prices to obtain a median price ratio. For urban residents, affordability was assessed as the lowest-paid unskilled government workers to purchase cost of standard treatment in days' wages; for rural residents, days' net income was used. RESULTS: The mean availabilities of originator brands (OBs) and generics were 34.3% and 28.7% in public hospitals, and 44.1% and 64.4% in the private pharmacies. OBs and the lowest priced generics (LPGs) were procured at 12.38 and 4.52 times the international reference price in public hospitals, and 10.26 and 2.81 times the international reference prices in private pharmacies. Treatments with OBs were unaffordable even for urban residents. The affordability of the LPGs was good, except for acarbose, repaglinide and pioglitazone. CONCLUSIONS: Most anti-diabetic medicines cannot met the WHO's availability target (80% availability) in Shaanxi Province. The high prices of OBs had severely influenced the affordability of medicines, especially for the rural residents. Effective policies should be initiated to ensure the Chinese people a better access to more affordable anti-diabetic medicines.

Assessment of non-prescription antibiotic dispensing at community pharmacies in China with simulated clients: a mixed cross-sectional and longitudinal study.

BACKGROUND: Non-prescription dispensing of antibiotics at community pharmacies is a major driver of antimicrobial resistance. China has regarded curbing non-prescription sales of antibiotics at community pharmacies as an important task for tackling antibiotics resistance and planned to eliminate this practice nationwide before 2020. We aimed to quantify non-prescription dispensing of antibiotics cross-sectionally at community pharmacies in China in 2017, and longitudinally (2011-17) in a single province. METHODS: A simulated client method was used to measure non-prescription antibiotic dispensing based on scenarios about paediatric diarrhoea and adult acute upper respiratory tract infection (URTI), which were presented at each pharmacy. We collected cross-sectional data for 2423 community pharmacies from 221 counties or districts in six provinces in different regions of China, in 2017. We also assessed 213 community pharmacies in Shaanxi province with a baseline survey in 2011 and subsequent follow-up surveys every 2 years until 2017. In the cross-sectional analysis, multivariate binary logistic regression with random-intercepts was used to evaluate the factors associated with non-prescription dispensing of antibiotics. We also estimated unadjusted period effects of non-prescription antibiotic dispensing using generalised estimated equations. FINDINGS: After excluding invalid interactions within 12 community pharmacies, the study included 4822 simulated interactions within 2411 community pharmacies. Non-prescription antibiotic dispensing was observed during 1169 (48·5% [95% CI 46·5-50·5]) of 2411 diarrhoea interactions and 1690 (70·1% [68·2-71·9]) of 2411 adult URTI interactions. Non-prescription antibiotic dispensing was more prevalent in rural areas and the central and western provinces, and was negatively associated with the presence of a pharmacist on-site (odds ratio 0·66 [0·56-0·78], p<0·0001) and being part of a chain pharmacy (0·75 [0·62-0·89], p=0·0012). In Shaanxi province, significant decreases of non-prescription antibiotic dispensing occurred in paediatric cases (from 154 [72·3%] of 213 community pharmacies to 107 [50·2%], p<0·0001) and adult cases (from 204 [95·8%] to 148 [69·5%], p<0·0001) between 2011 and 2017. INTERPRETATION: Non-prescription dispensing of antibiotics at community pharmacies was still prevalent nationwide in China in 2017, although a decrease was observed in Shaanxi Province since 2011. Multifaceted measures, including regulatory interventions, professional training, and public health education are needed. FUNDING: Young Talent Support Plan and High Achiever Plan of Health Science Center, Xi'an Jiaotong University, Central University Basic Research Fund, Early Career Research Start-up Plan of Xi'an Jiaotong University.

Prices, availability and affordability of insulin products: a cross-sectional survey in Shaanxi Province, western China.

OBJECTIVE: To evaluate price, availability and affordability of insulin products in Shaanxi Province, western China. METHODS: We used a simplified and adapted WHO/Health Action International method to obtain the availability and prices of insulin products and five oral anti-diabetic medicines as comparators in public general hospitals and private retail outlets. In addition, we investigated the price components of eight selected insulin products by tracing the supply chain. RESULTS: All three kinds of insulin products, prandial, basal and premixed insulin, are 100% available in public hospitals, and have fairly high availability in the private sector (62.5-68.8%). The prices of most insulin products were higher than international reference prices in both sectors (ranging from 0.95 times to 2.33 times). All insulin products were unaffordable as they would cost 3.5-17.1 days' wage of the lowest-paid government workers in Shaanxi. The manufacturer's markup (selling price), which comprised more than 60% of the final price of all insulin products surveyed, was the largest price component. CONCLUSIONS: Although availability of insulin products was high in public general hospitals and private retail pharmacies, their high price made them unaffordable to diabetes patients, especially low-income patients. The government should increase insurance compensation for those who need these life-saving medicines or decrease the cost of insulin products through negotiation with suppliers.

The current status and effects of emergency drug shortages in China: Perceptions of emergency department physicians.

OBJECTIVES: The shortage of emergency drugs in China is severe. This study aimed to characterize emergency drug shortages in China and to measure their effects. METHODS: An online questionnaire based on a literature review was sent to emergency department physicians in Chinese secondary and tertiary hospitals from November 2016 to February 2017. The survey asked physicians questions about their experiences with emergency drug shortages. RESULTS: In total, 236 physicians from 29 provinces participated in the survey. According to their responses, 90.7% of the respondents experienced drug shortages during the last year. More than half of the physicians (65.7%) reported that drug shortages occurred at least once a month. Hospitals in the eastern and western regions of China had more emergency drugs in shortage than hospitals in central China, especially those with many inpatient beds (≥800). In addition, the shortage situation was more serious in secondary hospitals than in tertiary hospitals. More respondents agreed that original medicines, injections, essential medicines, medicines without alternative agents and cheap medicines were more susceptible to shortages than generics, oral medicines, nonessential medicines, medicines with alternative agents and expensive medicines, respectively. Most respondents thought that drug shortages always, often or sometimes affected patients [delayed therapy (62.6%), longer rescue and recovery times (58.9%) and higher costs (58.7%)] and physicians [inconvenience (81.0%), higher pressure (76.5%) and harm to patient-doctor relationships (72%)] and compromised hospital reputations (55.1%). CONCLUSIONS: The shortage of emergency drugs in China is serious, especially in secondary hospitals located in eastern and western China. Emergency drug shortages have significant effects on patients and physicians.

Disparities in out-of-pocket inpatient expenditures in rural Shaanxi Province, western China from 2011 to 2014: a time series analysis.

OBJECTIVE: To investigate the long-term trend of disparity of monthly average out-of-pocket inpatient expenditures (OOP) between areas with different developing levels since the new healthcare reform. METHODS: Time series regression was used to assess the trend of disparities of OOP and monthly average inpatient expenditures (AIE) between areas with different developing levels in rural Shaanxi Province, western China. The data of OOP and AIE in primary health institutions, secondary hospitals, tertiary hospitals and also all levels of the hospital were analysed separately covering the period 2011 through to 2014. RESULTS: The disparity of AIE at all levels of hospitals was increasing (coefficient = 0.003, P = 0.029), and only the disparity of AIE in secondary hospitals was statistical significant (coefficient = 0.003, P = 0.012) when separately considering different levels of the hospital. The disparity of OOP in all levels of the hospital was increasing (coefficient = 0.007, P = 0.001), and the OOP in primary hospitals contributed most of the disparity (coefficient = 0.019, P = 0.000), followed by OOP in secondary (coefficient = 0.008, P = 0.003) and tertiary hospitals (coefficient = 0.004, P = 0.091). CONCLUSIONS: A statistically significant absolute increase in the trend of disparities of OOP and AIE at all levels of hospital was detected after the new healthcare reform in Shaanxi Province, western China. The increase rate of disparity of OOP was bigger than that of AIE. A modified health insurance plan should be proposed to guarantee equity in the future.

Impact of the zero-markup drug policy on hospitalisation expenditure in western rural China: an interrupted time series analysis.

OBJECTIVES: To assess the long-term effects of the introduction of China's zero-markup drug policy on hospitalisation expenditure and hospitalisation expenditures after reimbursement. METHODS: An interrupted time series was used to evaluate the impact of the zero-markup drug policy on hospitalisation expenditure and hospitalisation expenditure after reimbursement at primary health institutions in Fufeng County of Shaanxi Province, western China. Two regression models were developed. Monthly average hospitalisation expenditure and monthly average hospitalisation expenditure after reimbursement in primary health institutions were analysed covering the period 2009 through to 2013. RESULTS: For the monthly average hospitalisation expenditure, the increasing trend was slowed down after the introduction of the zero-markup drug policy (coefficient = -16.49, P = 0.009). For the monthly average hospitalisation expenditure after reimbursement, the increasing trend was slowed down after the introduction of the zero-markup drug policy (coefficient = -10.84, P = 0.064), and a significant decrease in the intercept was noted after the second intervention of changes in reimbursement schemes of the new rural cooperative medical insurance (coefficient = -220.64, P < 0.001). CONCLUSIONS: A statistically significant absolute decrease in the level or trend of monthly average hospitalisation expenditure and monthly average hospitalisation expenditure after reimbursement was detected after the introduction of the zero-markup drug policy in western China. However, hospitalisation expenditure and hospitalisation expenditure after reimbursement were still increasing. More effective policies are needed to prevent these costs from continuing to rise.

Current Situation, Determinants, and Solutions to Drug Shortages in Shaanxi Province, China: A Qualitative Study.

OBJECTIVE: Drug shortages were a complex global problem. The aim of this study was to analyze, characterize, and assess the drug shortages, and identify possible solutions in Shaanxi Province, western China. METHODS: A qualitative methodological approach was conducted during May-June 2015 and December 2015-January 2016. Semi-structured interviews were performed to gather information from representatives of hospital pharmacists, wholesalers, pharmaceutical producers, and local health authorities. RESULTS: Thirty participants took part in the study. Eight traditional Chinese medicines and 87 types of biologicals and chemicals were reported to be in short supply. Most were essential medicines. Five main determinants of drug shortages were detected: too low prices, too low market demands, Good Manufacturing Practice (GMP) issues, materials issues, and approval issues for imported drugs. Five different solutions were proposed by the participants: 1) let the market decide the drug price; 2) establish an information platform; 3) establish a reserve system; 4) enhance the communication among the three parties in the supply chain; and 5) improve hospital inventory management. CONCLUSIONS: Western China was currently experiencing a serious drug shortage. Numerous reasons for the shortage were identified. Most drug shortages in China were currently because of "too low prices." To solve this problem, all of the stakeholders, especially the government, needed to participate in managing the drug shortages.