Ethnobotanical Survey of Medicinal Plants Used in Breast Cancer Treatment by Traditional Health Practitioners in Central Uganda.

Purpose: The study aimed to document the existing knowledge and practices related to breast cancer recognition and treatment using medicinal plants by traditional health practitioners in Central Uganda. Methods: This cross-sectional exploratory survey, conducted between February and August 2020, applied a mixed methods research approach. A semi-structured questionnaire was administered to 119 traditional health practitioners (THPs) in Kampala, Wakiso and Mukono. Content analysis of qualitative data was done. Quantitative ethnobotanical survey indices, namely user reports (Nur), percentage of respondents with knowledge (PRK), informant consensus factor (Fic), fidelity level (FL), preference ranks (PR) and direct matrix ranking (DMR) were determined. Results: Most THPs recognized breast cancer by breast swelling (n=74, 62.2%) and breast pain (n=29, 24.4%). They cited 30 plants from 30 genera in 23 families (Fic 0.75 on breast cancer). Asteraceae, Apocynaceae, Euphorbiaceae, Fabaceae, Lamiaceae and Rutaceae were the predominant families. The ten most cited plants were Annona muricata L. (Nur=24), Rhoicissus tridentata (L.f.) Wild & R.B.Drumm (Nur =19), Erythrococca bongensis Pax (Nur=11), Ficus sp. (Nur=10), Cannabis sativa L. (Nur=8), Ipomoea wightii (Wall.) Choisy (Nur=7), Erythrina abyssinica DC. (Nur=5), Leucas martinicensis (Jacq.) R.Br. (Nur=4), Abelmoschus esculentus (L.) Moench (Nur=4) and Zanthoxylum chalybeum Engl. (Nur=3). Annona muricata L. was highly preferred by THPs (PR 1), Ficus sp. had highest fidelity level (FL=77%) and Zanthoxylum chalybeum Engl. ranked as the highest multipurpose plant (DMR 1). Herbs (n=14, 47%) were the most commonly used life forms besides trees (n=11, 37%) and shrubs (n=5, 16%). THPs mostly used leaves (46%), prepared decoctions (82%) and applied residues on the breast. Conclusion: THPs in Central Uganda recognized breast cancer by symptoms. Medicinal plants applied in its folk treatment have been documented and the claims of cure by THPs merit further investigation.

Safety and Efficacy of Medicinal Plants Used to Manufacture Herbal Products with Regulatory Approval in Uganda: A Cross-Sectional Study.

Introduction: The Uganda National Drug Authority requires phytochemical screening, freedom from microbial contamination, and evidence of safety and efficacy of the constituent plants to register herbal products. Since Uganda has no pharmacopeia, safety, efficacy, and plant processing information are not readily available. We documented the plant materials used to manufacture products in Uganda and established evidence of their safety and efficacy and availability of monographs. Methods: The NDA register of herbal products was reviewed, and a product list was extracted. The herbal products were purchased from local pharmacies, and their labels were studied to identify plant ingredients and drug use. Literature was reviewed to document evidence of the safety and efficacy of the plant materials concerning manufacturer's claims. Also, the WHO and available African Pharmacopeia were searched to establish the availability of the plant monographs. Results: Of the 84 NDA-registered local products, only 18 were obtained from the market; 82% were indicated for respiratory tract disorders. Thirty-three plant materials were listed with Eucalyptus globulus Labill, being the commonest. Several in vitro and in vivo studies demonstrate efficacy, thus supporting the use of the selected plant species for empirical treatment as stated on the product label. While most plants were safe, some species such as Albizia coriaria Oliv. had dose-dependent toxicities that cannot be predicted in combinations. The WHO, African Pharmacopoeia, and West African Herbal Pharmacopoeia had only 16 plant monographs of the 33 plants of interest. Nevertheless, Aloe vera (L.) Burm.f., Azadirachta indica A.Juss., Zingiber officinale Roscoe, and Allium sativum L. monographs were published by all three pharmacopoeias. Conclusions: Preclinical evidence of safety and efficacy exists in the literature for most of the plants used to manufacture registered herbal products in Uganda. More specific bioassays and clinical trials are required for the products to provide conclusive evidence of safety and toxicity. Monographs are urgently needed for the Ugandan plants.

Evaluation of the Clinical Use of Ceftriaxone among In-Patients in Selected Health Facilities in Uganda.

Ceftriaxone has a high propensity for misuse because of its high rate of utilization. In this study, we aimed at assessing the appropriateness of the clinical utilization of ceftriaxone in nine health facilities in Uganda. Using the World Health Organization (WHO) Drug Use Evaluation indicators, we reviewed a systematic sample of 885 patients' treatment records selected over a three (3)-month period. Our results showed that prescriptions were written mostly by medical officers at 53.3% (470/882). Ceftriaxone was prescribed mainly for surgical prophylaxis at 25.3% (154/609), respiratory tract infections at 17% (104/609), and sepsis at 11% (67/609), as well as for non-recommended indications such as malaria at 7% (43/609) and anemia at 8% (49/609). Ceftriaxone was mostly prescribed once daily (92.3%; 817/885), as a 2 g dose (50.1%; 443/885), and for 5 days (41%; 363/885). The average score of inappropriate use of ceftriaxone in the eight indicators was 32.1%. Only 58.3% (516/885) of the ceftriaxone doses prescribed were administered to completion. Complete blood count and culture and sensitivity testing rates were 38.8% (343/885) and 1.13% (10/885), respectively. Over 85.4% (756/885) of the patients improved and were discharged. Factors associated with appropriate ceftriaxone use were gender, pregnancy status, days of hospitalization, health facility level of care, health facility type, and type of prescriber.

Predictors of controlled prescription drug non-medical and lifetime use among patients accessing public mental health services in Uganda: a cross-sectional study.

OBJECTIVES: We determined the prevalence of controlled prescription drug (CPD) non-medical and lifetime use and their predictors among patients at three public psychiatric clinics in Uganda to identify missed care opportunities, enhanced screening priorities, and drug control needs. METHODS: A cross-sectional survey of 1275 patients was performed from November to December 2018. Interviewer-administered semi-structured questionnaires, desk review guide and urine drug assays were employed. Questionnaire recorded CPD non-medical and illicit drug use history from patients' files, CPD lifetime use and risk factors. Desk review guide recorded recently prescribed drugs in patients' files to corroborate with urine assays. Predictors were analysed by multivariate logistic regression. RESULTS: From desk review, 145 (11.4%) patients had history of CPD non-medical use and 36 (2.8%) had used illicit drugs. Of 988 patients who provided urine, 166 (16.8%) self-medicated CPDs, particularly benzodiazepines while 12 (1.2%) used illicit drugs. Of those with drug-positive urine, 123 (69.1%) had no documented history of CPD non-medical and illicit drug use. Being an inpatient (OR=10.90, p<0.001) was independently associated with CPD non-medical use. Additionally, being an inpatient (OR=8.29, p<0.001) and tobacco consumption (OR=1.85, p=0.041) were associated with CPD non-medical and illicit drug use combined. Among participants, 119 (9.3%) reported CPD lifetime use, and this was independently associated with education level (OR=2.71, p<0.001) and history of treatment for substance abuse (OR=2.08, p=0.018). CONCLUSIONS: CPD non-medical use is common among Uganda's psychiatric patients, and more prevalent than illicit drug use. Rapid diagnostic assays may be needed in psychiatric care in resource limited settings. It is necessary to assess how CPD non-medical use impacts mental care outcomes and patient safety. High risk groups like inpatients and tobacco consumers should be prioritised in psychiatric screening.

Compliance of private pharmacies in Uganda with controlled prescription drugs regulations: a mixed-methods study.

BACKGROUND: Controlled prescription drug use disorders are a growing global health challenge in Sub-Saharan Africa. Effective supply chain regulations on dispensing and stock control are important for controlling this epidemic. Since compliance with these regulations in resource-limited countries is poor, there is need to understand its predictors in order to reduce the risk of prescription drug use disorders. METHODS: A mixed-methods study utilizing a structured questionnaire and a simulated client guide was undertaken in Kampala and Mbale towns in Uganda. The questionnaire recorded self-reported dispensing and verified stock control practices and their covariates from 101 private pharmacies. The guide recorded actual dispensing practices from 27 pharmacies. Snowball sampling was done to enrich the sample with pharmacies that stock opioids. The mean compliance with good dispensing and stock control practices was calculated. Multivariate logistic regression analyses were applied to identify predictors of compliance. RESULTS: The mean compliance with dispensing and stock control requirements was 82.9% and 23%, respectively. Twenty percent and 40% of the pharmacies dispensed pethidine without a prescription and with invalid prescriptions, respectively. Having a pharmacist on duty (OR = 5.17; p = 0.02), prior in-service training on narcotics regulations (OR = 3.51; p = 0.04), and previous narcotics audits by the regulator (OR = 5.11; p = 0.01) were independent predictors of compliance with stock control requirements. Pharmacies with a previous history of poor compliance with dispensing requirements were less likely to demonstrate good compliance (OR = 0.21; p = 0.01). CONCLUSIONS: There is suboptimal compliance to controlled prescription drug regulations among Uganda's pharmacies. A previous history of poor compliance to dispensing requirements predicted low compliance in subsequent assessments. Training and regulatory audits increased compliance in stock control but not dispensing. Expansion of training and audits to more pharmacies and/or incentives for compliance are necessary.

Threats posed by stockpiles of expired pharmaceuticals in low- and middle-income countries: a Ugandan perspective.

In some low- and middle-income countries, the national stores and public-sector health facilities contain large stocks of pharmaceuticals that are past their expiry dates. In low-income countries like Uganda, many such stockpiles are the result of donations. If not adequately monitored or regulated, expired pharmaceuticals may be repackaged and sold as counterfeits or be dumped without any thought of the potential environmental damage. The rates of pharmaceutical expiry in the supply chain need to be reduced and the disposal of expired pharmaceuticals needs to be made both timely and safe. Many low- and middle-income countries need to: (i) strengthen public systems for medicines' management, to improve inventory control and the reliability of procurement forecasts; (ii) reduce stress on central medical stores, through liberalization and reimbursement schemes; (iii) strengthen the regulation of drug donations; (iv) explore the salvage of officially expired pharmaceuticals, through re-analysis and possible shelf-life extension; (v) strengthen the enforcement of regulations on safe drug disposal; (vi) invest in an infrastructure for such disposal, perhaps based on ultra-high-temperature incinerators; and (vii) include user accountability for expired pharmaceuticals within the routine accountability regimes followed by the public health sector.

Dans certains pays à revenu faible et intermédiaire, les pharmacies nationales et les centres publics de santé détiennent d'énormes stocks de produits pharmaceutiques périmés. Dans les pays à revenu faible comme l'Ouganda, nombre de ces stocks proviennent de dons. Or, s'ils ne sont pas correctement contrôlés et réglementés, les produits pharmaceutiques périmés peuvent être reconditionnés et revendus en tant que contrefaçons ou bien jetés sans considération du danger pour l'environnement. Dans la chaîne d'approvisionnement, le pourcentage des produits pharmaceutiques périmés doit diminuer, et les produits périmés doivent être éliminés au bon moment et de façon sûre. De nombreux pays à revenu faible et intermédiaire doivent: (i) renforcer les systèmes publics pour la gestion des médicaments, afin d'améliorer le contrôle des stocks et la fiabilité des prévisions d'approvisionnement; (ii) réduire la pression à laquelle les pharmacies centrales sont soumises, grâce à des programmes de libéralisation et de remboursement; (iii) renforcer la régulation des dons de médicaments; (iv) étudier les options envisageables pour réemployer les produits pharmaceutiques officiellement périmés mais dont la durée de conservation pourrait éventuellement être prolongée après la réalisation de nouveaux tests; (v) renforcer l'application des réglementations pour une élimination sans risques des médicaments; (vi) investir dans des infrastructures d'élimination sans risques des médicaments, éventuellement au moyen d'incinérateurs à ultra-haute température; et (vii) responsabiliser les utilisateurs, en intégrant dans les programmes d'encadrement du secteur de la santé publique une obligation de rendre compte pour les produits périmés.

En algunos países con ingresos bajos y medios, los almacenes nacionales y las instalaciones del sector sanitario público contienen grandes cantidades de existencias de medicamentos que han superado su fecha de caducidad. En países con ingresos bajos como Uganda, muchas de estas existencias son el resultado de donaciones. Si no se controlan o regulan adecuadamente, puede ser que los medicamentos caducados sean empaquetados de nuevo y vendidos como falsificaciones o que se depositen sin tener conciencia del potencial daño medioambiental. Deben reducirse las tasas de caducidad de los medicamentos en la cadena de suministro y los medicamentos caducados deben depositarse a tiempo y de forma segura. Muchos países con ingresos bajos y medios necesitan: (i) fortalecer los sistemas públicos para la gestión de medicamentos para mejorar el control del inventario y la fiabilidad de la adquisición de provisiones; (ii) reducir el estrés en los almacenes médicos centrales a través de sistemas de reembolso y liberación; (iii) aumentar la regulación de las donaciones de medicamentos; (iv) investigar la recuperación de medicamentos oficialmente caducados a través de análisis y una posible extensión de la vida útil; (v) fortalecer la aplicación de regulaciones sobre la eliminación segura de medicamentos; (vi) invertir en una infraestructura para dicha eliminación, tal vez basada en incineradores de alta temperatura; e (vii) incluir la responsabilidad por parte de los usuarios en relación con los medicamentos caducados en los regímenes de responsabilidad rutinaria seguidos por el sector sanitario público.

Why regulatory indifference towards pharmaceutical pollution of the environment could be a missed opportunity in public health protection. a holistic view.

The last generation has witnessed bludgeoning of the world's population, a spike in disease burden, and unprecedented levels of pharmaceutical consumption and production. Unfortunately, pharmaceuticals have left their industrial and household confines and leaked into the environment. Pharmaceuticals are now major environmental pollutants, and are ubiquitous in waters and soils. Unlike other environmental contaminants, pharmaceutical pollutants are not yet regulated globally, simply because acute risk assessments show insignificant human health hazard. But the pitfalls of pharmaceutical pollutants extend beyond acute effects to delayed effects from bioaccumulation, amplified effects from drug-drug interactions, exacerbation of drug resistance, and reduction in aquatic and terrestrial food production. Therefore, ignoring pharmaceutical pollutants deprives society of holistic public health protection.

Factors associated with occupancy of pharmacist positions in public sector hospitals in Uganda: a cross-sectional study.

BACKGROUND: Pharmacists are invaluable resources in health care. Their expertise in pharmacotherapy and medicine management both ensures that medicines of appropriate quality are available in health facilities at the right cost and are used appropriately. Unfortunately, some countries like Uganda have shortage of pharmacists in public health facilities, the dominant providers of care. This study investigated the factors that affect the occupancy of pharmacist positions in Uganda's public hospitals, including hiring patterns and job attraction and retention. METHODS: A cross-sectional survey of 91 registered pharmacists practicing in Uganda and desk review of records from the country's health care worker (HCW) recruiting agency was done in the months of May, June, and July, 2016. Pharmacist interviews were done using self-administered structured questionnaire and analyzed by descriptive statistics and chi-square test. RESULTS: Slight majority (53%) of the interviewed pharmacists work in two sectors. About 60% of the pharmacists had ever applied for public hospital jobs. Of those who received offers (N = 46), 30% had declined them. Among those who accepted the offers (N = 41), 41% had already quit. Meanwhile, the pace of hiring pharmacists into Uganda's public sector is too slow. Low socio-economic status of family in childhood (χ 2 = 2.77, p = 0.10), admission through matriculation and diploma scheme (χ 2 = 2.37, p = 0.12), internship in countryside hospitals (χ 2 = 2.24, p = 0.13), working experience before pharmacy school (χ 2 = 2.21, p = 0.14), salary expectation (χ 2 = 1.76, p = 0.18), and rural secondary education (χ 2 = 1.75, p = 0.19) favored attraction but in a statistically insignificant manner. Retention was most favored by zero postgraduate qualification (χ 2 = 4.39, p = 0.04), matriculation and diploma admission scheme (χ 2 = 2.57, p = 0.11), and working experience in private sector (χ 2 = 2.21, p = 0.14). CONCLUSIONS: The pace of hiring of pharmacists into Uganda's public health sector is too slow and should be stepped up. Besides work incentives, affirmative action to increase admissions into pharmacy degree training programs through matriculation and diploma schemes and for children with rural childhoods should be considered.

Threats posed by stockpiles of expired pharmaceuticals in low- and middle-income countries: a Ugandan perspective

In some low- and middle-income countries, the national stores and public-sector health facilities contain large stocks of pharmaceuticals that are past their expiry dates. In low-income countries like Uganda, many such stockpiles are the result of donations. If not adequately monitored or regulated, expired pharmaceuticals may be repackaged and sold as counterfeits or be dumped without any thought of the potential environmental damage. The rates of pharmaceutical expiry in the supply chain need to be reduced and the disposal of expired pharmaceuticals needs to be made both timely and safe. Many low- and middle-income countries need to: (i)strengthen public systems for medicines' management, to improve inventory control and the reliability of procurement forecasts; (ii) reduce stress on central medical stores, through liberalization and reimbursement schemes; (iii) strengthen the regulation of drug donations; (iv) explore the salvage of officially expired pharmaceuticals, through re-analysis and possible shelf-life extension; (v) strengthen the enforcement of regulations on safe drug disposal; (vi) invest in an infrastructure for such disposal, perhaps based on ultra-high-temperature incinerators; and (vii) include user accountability for expired pharmaceuticals within the routine accountability regimes followed by the public health sector

Expiry of medicines in supply outlets in Uganda.

PROBLEM: The expiry of medicines in the supply chain is a serious threat to the already constrained access to medicines in developing countries. APPROACH: We investigated the extent of, and the main contributing factors to, expiry of medicines in medicine supply outlets in Kampala and Entebbe, Uganda. A cross-sectional survey of six public and 32 private medicine outlets was done using semi-structured questionnaires. LOCAL SETTING: The study area has 19 public medicine outlets (three non-profit wholesalers, 16 hospital stores/pharmacies), 123 private wholesale pharmacies and 173 retail pharmacies, equivalent to about 70% of the country's pharmaceutical businesses. Our findings indicate that medicines prone to expiry include those used for vertical programmes, donated medicines and those with a slow turnover. RELEVANT CHANGES: Awareness about the threat of expiry of medicines to the delivery of health services has increased. We have adapted training modules to emphasize management of medicine expiry for pharmacy students, pharmacists and other persons handling medicines. Our work has also generated more research interest on medicine expiry in Uganda. LESSONS LEARNED: Even essential medicines expire in the supply chain in Uganda. Sound coordination is needed between public medicine wholesalers and their clients to harmonize procurement and consumption as well as with vertical programmes to prevent duplicate procurement. Additionally, national medicine regulatory authorities should enforce existing international guidelines to prevent dumping of donated medicine. Medicine selection and quantification should be matched with consumer tastes and prescribing habits. Lean supply and stock rotation should be considered.