The integrity of the antimicrobial supply chain in Bangladesh: assessing the regulatory environment and contextual challenges.

Most low- and middle-income countries lack the regulatory capacity to contain substandard and falsified (SF) medicines. Innovations for strengthening regulatory systems are needed to protect public health. We assessed the integrity of the antimicrobial supply chain in Bangladesh. We employed qualitative methods comprising policy content analysis, and literature and database reviews. Using a framework modified from the World Health Organization's and the United States Pharmacopoeia's, the Bangladesh National Drug Policy (BNDP), was evaluated for provisions on medicines quality assurance mechanisms. We used newspaper, peer-reviewed, and post-marketing surveillance reports to assess prevalence of SF antimicrobials. The BNDP contains provisions for quality assurance. Newspaper reports identified circulation of substandard antimicrobials. We identified only six peer-review studies testing antimicrobial product quality with three studies reporting out-of-specifications products. We suggest three strategies for strengthening the regulatory system: community-based surveillance, task shifting, and technology-enabled consumer participation.

WHO essential medicines for children 2011-2019: age-appropriateness of enteral formulations.

INTRODUCTION: The WHO Essential Medicine List for children (EMLc) is used for promoting access to medicines. The age-appropriateness of enteral (oral and rectal) formulations for children depend on their adaptability/flexibility to allow age-related or weight-related doses to be administered/prescribed and the child's ability to swallow, as appropriate. There is scant information on the age-appropriateness of essential enteral medicines for children. OBJECTIVE: To evaluate the age-appropriateness of enteral essential medicines. MATERIALS AND METHODS: Age-appropriateness of all enteral formulations indicated and recommended in the EMLc 3rd to 7th (2011-2019) editions were determined by assessing swallowability and/or dose adaptability for children under 12 years, stratified into five age groups. RESULTS: Enteral formulations in the EMLc were more age-appropriate for older children aged 6-11 years than for younger children. In the 3rd edition, for older children, 77%, n=342, of formulations were age-appropriate. For younger children, age-appropriateness decreased with age group: 34% in those aged 3-5 years, 30% in those aged 1-2 years, 22% among those aged 28 days to 11 months and 15% in those aged 0-27 days. Overall, similar proportions were found for the 7th edition. In contrast, the majority of medicines in the 7th list were age-appropriate in targeted diseases like HIV and tuberculosis. CONCLUSION: Most recommended enteral essential medicines in EMLc 2011 and 2019 were not age-appropriate for children <6 years. Medicines which are not age-appropriate must be manipulated before administration, leading to potential issues of safety and efficacy. Evaluation of the age-appropriateness of formulations for medicines to be included in EMLc could improve access to better medicines for children in the future.

Higher seasonal temperature enhances the occurrence of methicillin resistance of Staphylococcus aureus in house flies (Musca domestica) under hospital and environmental settings.

Antimicrobial resistance (AMR) emergence in commensal and pathogenic bacteria is a global health issue. House flies (Musca domestica) are considered as biological and mechanical vectors for pathogens causing nosocomial infections, including methicillin-resistant Staphylococcus aureus (MRSA). However, the prevalence of antimicrobial resistance and the role of temperature on the occurrence of Staphylococcus aureus and MRSA in house flies in a hospital environment have not been studied. A total of 400 house flies were collected in winter and summer from four hospital-associated areas in Mymensingh, Bangladesh. Detection of S. aureus and MRSA in flies was done by culturing, staining, and PCR methods targeting nuc and mec genes (mecA and mecC), respectively. Disc diffusion test was used to detect resistance phenotype against six antimicrobials. Logistic regression models were constructed to assess the effect of temperature on the frequency of antimicrobial resistance, and on the presence of the nuc and mecA genes, and location of samples in and around a hospital environment. By PCR, S. aureus was detected in 208 (52%) samples. High frequencies of resistance (≥ 80% of isolates) to amoxicillin, azithromycin, and oxacillin were observed by disk diffusion test. Increase in temperature had a positive effect on the occurrence of S. aureus and MRSA isolates as well as on their resistance to individual and multiple antimicrobials. Among the study areas, hospital premises had increased odds of having S. aureus. Increased temperature of summer significantly increased the occurrence of MRSA in house flies in and around the hospital environment, which might pose a human and animal health risk.

Waves of attention: patterns and themes of international antimicrobial resistance reports, 1945-2020.

This article uses quantitative and qualitative approaches to review 75 years of international policy reports on antimicrobial resistance (AMR). Our review of 248 policy reports and expert consultation revealed waves of political attention and repeated reframings of AMR as a policy object. AMR emerged as an object of international policy-making during the 1990s. Until then, AMR was primarily defined as a challenge of human and agricultural domains within the Global North that could be overcome via 'rational' drug use and selective restrictions. While a growing number of reports jointly addressed human and agricultural AMR selection, international organisations (IOs) initially focused on whistleblowing and reviewing data. Since 2000, there has been a marked shift in the ecological and geographic focus of AMR risk scenarios. The Global South and One Health (OH) emerged as foci of AMR reports. Using the deterritorialised language of OH to frame AMR as a Southern risk made global stewardship meaningful to donors and legitimised pressure on low-income and middle-income countries to adopt Northern stewardship and surveillance frameworks. It also enabled IOs to move from whistleblowing to managing governance frameworks for antibiotic stewardship. Although the environmental OH domain remains neglected, realisation of the complexity of necessary interventions has increased the range of topics targeted by international action plans. Investment nonetheless continues to focus on biomedical innovation and tends to leave aside broader socioeconomic issues. Better knowledge of how AMR framings have evolved is key to broadening participation in international stewardship going forward.

Hospital Compounding in Nigeria: A Review of Needs, Practice, and Suggestions for Pharmaceutical Dispensing Ciurriculum Development.

Dispensing remains a key component of the pharmacy undergraduate curriculum, teaching skills in the individualized preparation of medicines. In hospitals, pharmacists compound medicines to improve access for patients who would otherwise not have the medicine in the suitable formulation. Current trends suggest that the dispensing curriculum needs to be improved to include topics that will equip students with skills and competences in hospital compounding. The objective of this review was to describe compounding needs and practices in hospitals in Nigeria with a view to curriculum development. Four studies were retrieved that show that compounding was for magistral preparations or products prepared from other existing products. Most of the compounded medicines were oral liquids for use in pediatric patients. The majority of compounded medicines were in three therapeutic groups: 1) cardiovascular, 2) antimicrobials, and 3) vitamins. These were commonly prepared by crushing tablets or emptying capsules into compounding vehicles such as distilled water, vitamin C, or vitamin B-complex syrups. Being magistral, these are not included in the curriculum by default, as the curriculum focuses on officinal preparations. Expanded training to include a module incorporating protocols for the preparation and quality and stability testing for these compounded medicines advances the practice of dispensing and is urgently needed.

Veterinary antimicrobial resistance containment in Bangladesh: Evaluating the national action plan and scoping the evidence on implementation.

OBJECTIVES: In 2015, the World Health Organization (WHO) released its global action plan (GAP) on antimicrobial resistance (AMR) as a blueprint for the design of national action plans for AMR containment. Bangladesh, with 80% rural household ownership of at least one livestock, introduced its national action plan in May 2017. The objective of this study was two-fold: (i) to perform a policy content evaluation of the Bangladesh National Action Plan (BNAP) against the GAP with a focus on veterinary AMR containment strategies; and (ii) to assess the evidence on the implementation of veterinary AMR containment strategies of the BNAP. METHODS: The BNAP was evaluated against the GAP to identify commonalities and policy gaps. A scoping review of peer-reviewed and grey literature was performed to identity evidence of policy implementation and practice gaps. RESULTS: The BNAP is strongly aligned with the GAP. However, the study identified policy gaps, including an explicit financing modality, specifications for antimicrobial stewardship (AMS) in the veterinary sector, and rigorous operational and monitoring & evaluation frameworks. More evidence on implementation is needed in terms of incorporation of AMR in the curriculum of veterinarians, AMS plans throughout the veterinary sector, and infection prevention and control protocols and implementation. CONCLUSION: Closing the identified gaps is essential for successful veterinary AMR containment in Bangladesh but will require sustained and significant investment in institutional and human resource development in the coming years.

Access to age-appropriate essential medicines: a retrospective survey of compounding of medicines for children in hospitals in Nigeria and implications for policy development.

Policies to improve access to medicines for children in Nigeria do not include compounding as a source of medicines. Compounding is often applied as a last resort in health institutions to provide age-appropriate formulations usually for oral use in young children; but it bears some risk. Some countries have adopted policies aimed at reducing the risk based on available data. There is not much data for Nigeria. This retrospective study examined compounding records from January to December 2011 in a sample of seven hospitals to describe what medicines for oral use were commonly compounded in Nigeria. It then determined if these medicines were commercially available in forms suitable for use in children in selected countries­the United Kingdom, United States and India. The study found that out of 2845 items compounded, over 65% were medicines for cardiovascular conditions, diarrhoea or tuberculosis. The main reason (96%, n = 2399) for compounding was the unavailability of age-appropriate formulations. Medicines were almost all compounded using simple syrup, vitamin C or vitamin B syrups as suspending vehicles. Final products were all oral liquids. Comprehensive stability testing was not reported for the products. Almost all of the commonly compounded medicines were found to be commercially available in dosage forms suitable for use in children in the selected countries. These medicines were all listed in the World Health Organization Essential Medicines List for children as well as in the current edition of the Essential Medicines List of Nigeria. The fact that they were compounded highlights the need for improved access to age-appropriate dosage forms for children in Nigeria. The study recommends policy expansion through a three-pronged approach to improving access: increased supply through facilitated importation/accelerated product registration, or in-country manufacturing; rational drug use including therapeutic substitution, and establishment of a national formulary for compounding.