Availability of Antimalarial Medicines in Community Pharmacies of Lusaka District, Zambia: Implications on Compliance to Malaria Treatment Guidelines ()
1. Introduction
Malaria has been and continues to be one of the most public health concerns, as well as a global challenge, contributing to morbidity and mortality, with children under the age of five and pregnant women being the most vulnerable [1] [2] [3] . In 2015, there were 212 million new cases of malaria and a mortality of 429,000, whereas, in 2020, 241 million malaria cases and 627,000 malaria deaths were reported worldwide [4] [5] . Underestimation of the disease burden has contributed to malaria deaths, especially in young children, for the past two decades, with Africa having an even greater crisis than previously known [3] . One of the World Health Organization’s (WHO) goals is to reduce global malaria incidence and mortality rates by 90% by 2030, with malaria elimination in at least 35 endemic countries [6] .
In Zambia, malaria is endemic throughout the country and is still a significant public health problem in many areas of the country [7] [8] . Scaling up of interventions has been done for malaria control, such as the use of long-lasting insecticide-treated nets (LLIN), indoor residual spraying, and prompt, effective case management, including early diagnosis and treatment with an effective antimalarial drug, and intermittent preventive treatment during pregnancy (IPTp) [7] [8] .
In Africa, accessibility to interventions for the prevention and treatment of the disease is still low due to shortfalls in funding and, in some cases, fragile health systems, which have an impact on the attainment of global targets [5] . Availability and affordability of medicines are key determinants of universal health coverage, though this remains a challenge in most low-income countries [9] . The effective management of malaria depends on access to healthcare services, and for the large proportion of patients in sub-Saharan Africa, the private sector supplies antimalarial medicines and provides many service delivery points for malaria treatment [9] [10] .
Medicine retailers have played an important role that has been recognized in the distribution of antimalarial medicines [11] . In Uganda, the majority of anti-malarial medicines were distributed through the private sector (54.3%) [10] . The availability of artemether/lumefantrine and sulfadoxine/pyrimethamine in Malawi was high in public and Christian Health Association of Malawi (CHAM) facilities (93% and 100%), with CHAM charging their patients for medicines [12] . Further, the availability and usage of antimalarials were very high in sub-Saharan African countries with over 92.9% of clients who purchased antimalarial medicines [13] . In Zambia, the government facilities have been a major source of antimalarial drugs for among febrile children under five years of age, accounting for 77% in 2021.
The WHO has provided recommendations on the antimalarial to use depending on the type (uncomplicated or complicated) as well as other patient factors such as pregnancy [14] . However, the WHO recommends that each country develops its own policy/treatment guidelines [14] [15] . The WHO further guides that in deciding which artemisinin-based combination therapies (ACTs) to adopt in national treatment policies, national policy-makers should take into account the pattern of resistance to antimalarials in their country, the relative efficacy and safety of the combinations, their cost, the availability of paediatric formulations, and the availability of co-formulated products [14] [15] .
In Zambia, artemether/lumefantrine is the first-line treatment for uncomplicated Plasmodium falciparum (P. falciparum) malaria in children and adults (except pregnant women in their first trimester). The antimalarials listed in the guidelines for the diagnosis and treatment of malaria in Zambia are shown in Table 1 [16] .
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Table 1. Malaria treatment guidelines in Zambia
Therefore, this study assessed the availability of antimalarials in community pharmacies in the Lusaka district of Zambia and compared the stocking with the antimalarials listed in the guidelines for the diagnosis and treatment of malaria in Zambia.
2. Materials and Methods
The study was conducted from September to November 2022 in Lusaka district, targeting community pharmacies in high-density areas, including Mtendere/Kalingalinga, Chilenje/Libala, Chawama, Kabwata/Kamwala, Chelstone, Kaunda Square, Ng’ombe, Kanyama/Garden, Chipata, Mandevu, Matero, and the central business area. Lusaka district has the largest number of community pharmacies compared to any other district in Zambia, and it hosts the largest portion of the country’s population. In Zambia, community pharmacies are privately owned by individuals or companies.
2.1. Sample Size Estimation and Sampling Technique
The determination of sample size was done using Yamane’s sample size formula [17] . The sample size calculation was done at a 95% confidence level with a 5% margin of error. A total of 210 pharmacies were sampled using simple random sampling from the 444 registered pharmacies with Zambia Medicines Regulatory Authority (ZAMRA) in Lusaka district at the time of the study.
2.2. Data Collection and Analysis
A well-structured checklist was developed and used to collect information on the availability of a particular medicine for malaria. The Reported availability of a particular medicine was verified through a physical stock check. The checklist contained the medicines listed both in the 2017 Guidelines for Diagnosis and Treatment of Malaria in Zambia (GDTMZ) [16] as well as in the 2021 WHO guidelines for malaria [15] . The data collected was entered into the excel spreadsheet, analysed and presented in table form.
2.3. Ethical Approval
The study was approved by the University of Zambia Health Sciences Research Ethics Committee (UNZAHSREC), protocol ID: 202211231145. A permission letter from the University of Zambia to conduct the research was submitted to the community pharmacies, and the participants consented to be part of the study.
3. Results
A total number of 210 respondents participated in this survey and included 126 (60%) pharmacy technologists, 71 (33.8%) pharmacists, and 13 (6.2%) pharmacy dispensers (Table 2).
The distribution of community pharmacies that were included in the study are shown in Table 3. Most (21.9%) of the community pharmacies were sampled
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Table 2. Background characteristics.
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Table 3. Distribution of community pharmacies.
from Libala and Chilenje townships.
Of the 210 community pharmacies that were involved in the study, they all stocked thirteen (13) antimalarials listed under the 2017 Guidelines for Diagnosis and Treatment of Malaria in Zambia (GDTMZ), with artemether/lumefantrine being highly available in 209 (99.5%) premises. However, 3/16 (18.8%) of the antimalarials were not listed in the GDTMZ but were listed in the 2021 WHO guidelines for malaria (Table 4).
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Table 4. Availability of antimalarials in community pharmacies.
GDTMZ: Guidelines for diagnosis and treatment of malaria in Zambia.
4. Discussion
To our knowledge, this is the first study to report on the availability of antimalarial medicines in community pharmacies of Lusaka district, Zambia. The availability of antimalarial medicines is key to the effective management of malaria. The Zambia National Malaria Strategic Plan emphasizes on prompt diagnosis and treatment with an effective antimalarial drug whenever a case of malaria is confirmed [18] . Community Pharmacies in Zambia contribute immensely to the availability of malaria medicines in the country and stand as an alternative solution whenever a particular malaria drug is not available in public health facilities where the services are free [19] .
Our study revealed that 100% of the drugs listed in the 2017 guidelines for
diagnosis and treatment of malaria in Zambia that were under consideration were available in community pharmacies in Lusaka district though with the varying distribution. Artemether/lumefantrine, which is used for the treatment of uncomplicated malaria, was available in 99.95% of the community pharmacies. This high availability finding is similar to the finding by Kioko et al., 2013 in Kenya in which the availability of artemether/lumefantrine was 91% [20] .
In Zambia, dihydroartemisinin/piperaquine is also one of the first-line treatments for uncomplicated malaria; however, it was only available in 14.8% of community pharmacies, similar to the study findings by Kioko and colleagues in Kenya where it was available in 21% of the outlets [20] . In Zambia this drug has been used for mass drug administration as one of the intervention in parasite burden reduction and the guidelines recommends that it should not be used as first line treatment in areas where there is active mass drug administration of dihydroartemisinin/piperaquine [16] . This drug was used as the second-line treatment in Kenya [20] .
Doxycycline was available in 99% of the community pharmacies. Though its use in malaria spheres is for prophylaxis for travellers (non-immune) to Zambia, its high availability can also be attributed to its use as an antibacterial for a wide range of bacterial infections [21] .
The first-line drug for severe malaria, artesunate injection was available in 52% of the community pharmacies whereas, quinine and artemether injections were only available in 11.1% and 17.4% respectively. This low availability can be attributed to the fact that severe malaria cases are admissions mostly managed from public health facilities which are well stocked with antimalarials for treating severe malaria. This usually creates a low demand in private pharmacies hence the low availability, especially quinine injection. However, some pharmacies in Zambia are under National Health Insurance Management Authority (NHIMA) accreditation and readily stock essential medicines for those insured in case of no required drug in the public health facilities. As artesunate injection is the first line for severe malaria, it can be the reason why it was found in over 50 % of the community pharmacies compared to quinine injection and artemether injection.
Although not all the community pharmacies had the prophylactic drug, dapsone/pyrimethamine (deltaprim) was available in 55% of the private pharmacies in Lusaka. In Zambia, This combination of drugs is used for malaria prophylaxis, especially in individuals with sickle cell disease and this drug needs to be available as the sickle cell trait is carried by 20-25% of the population and 1-2% of babies are born with the disease [22] . Mefloquine and atovaquone/proguanil were found in a few pharmacies (14.1% and 7.1% respectively). Sulfadoxine/pyrimethamine was socked in 94.3% of the community pharmacies. In many countries, sulfadoxine/pyrimethamine is used for Intermittent Presumptive Treatment in pregnancy as recommended by the WHO [14] [15] [23] [24] [25] [26] [27] . This is similar to the practices and guidelines in Zambia and may be the reason for its high availability in community pharmacies.
Even though all the antimalarials stocked in community pharmacies were listed in the WHO malaria treatment guidelines, 19% were not listed in the guidelines for diagnosis and treatment of malaria in Zambia, with artesunate/sulfamethoxypyrazine/pyrimethamine (co-arinate) being the mostly (75.2%) distributed in community pharmacies in Lusaka. Artesunate/amodiaquine was available in 10.5% of the community pharmacies where as artesunate/mefloquine was available in 6.2% of the premises. These three drug combinations are among the recommended first-line treatments for uncomplicated malaria besides artemether/lumefantrine and dihydroartemisinin/piperaquine by the WHO [14] . The high availability of artesunate/sulfamethoxypyrazine/pyrimethamine implies its high demand by the population. Unfortunately, it is not listed in the Zambia local treatment guidelines for malaria because artemether/lumefantrine is still effective and recent therapeutic efficacy studies have shown that the artemether/lumefantrine is still 98% effective against P. falciparum [28] [29] [30] . The stocking and dispensing of antimalarials not listed in the malaria local treatment guidelines may limit treatment options in case of drug resistance challenges.
Irrational use of ACTs poses a risk for drug resistance, emerging cases which have been reported in some countries like Cambodia [31] [32] [33] . It is very important to protect the effectiveness of the current ACTs and WHO recommends monitoring the effectiveness of these ACTs through therapeutic efficacy studies [14] [34] . It is also important to have reserve drugs as options when there is reported drug resistance to the medicines in use [35] . For example, in Nigeria, artemether/lumefantrine is the medicine of choice with artesunate/amodiaquine as an alternative, and in Tanzania, artemether/lumefantrine is the first-line treatment for uncomplicated malaria in both adults and children, with dihydroartemisinin/piperaquine as a second-line treatment in cases of treatment failure [36] [37] .
This study provides an insight on the stocking of antimalarials in community pharmacies based on the Zambian guidelines for malaria diagnosis and treatment. However, the study was conducted in one district of Lusaka province, affecting the generalisation of the findings.
5. Conclusion
This study concluded that antimalarials were available for all categories of malaria management in community pharmacies of Lusaka district, though with a varying distribution from pharmacy to pharmacy. The presence of antimalarials not listed in the Zambian guidelines for the treatment of malaria is of public health concern with consequences on treatment options in the future. Therefore, there is a need to regulate the stocking and dispensing of antimalarials based on local treatment guidelines and this may be beneficial in preventing future occurrence of antimalarial drug resistance.
Appendix
Identification #……….
Availability of Antimalarial Drugs in Community Pharmacies of Lusaka District, Zambia: Implications on Compliance to Malaria Treatment Guidelines
Dear Respondents,
You have been randomly sampled to help in this research, referring to the above topic. You are kindly requested to answer as honestly as possible.
INSTRUCTIONS
1) Please do not indicate your name on the questionnaire.
2) Tick the answer that expresses your view as shown.
3) Only one response is required for each question. On questions where you have to write your response, you may be as brief as possible by filling in the spaces provided.
Please Note: this research is purely for academic purposes. Therefore, you are assured that the information obtained will be treated with the utmost confidentiality. Your cooperation will highly be appreciated.
Date…………………………………..
Location of facility…………………..