Ideally these days in Nigeria one should be able to get supplies of the recommended artemisinin-based combination therapy (ACT) drugs in public outlets throughout the country. Major malaria partners/donors in Nigeria include the Global Fund to fightÂ AIDs, TB and Malaria (GFATM), the US President’s Malaria Initiative (PMI), the SuNMaP project of the UK’s Department for International Develoment (DfID) and the World Bank’s Malaria Booster Program.
In reality one finds shortages of medicines that drive consumers and patients to medicine shops in search of whatever is available, and importantly, affordable.Â The pictures herein detail what we bought in two patent medicine shops, one urban and one rural, in Sokoto State.
First, even though testing of chloroquine (CQ) for the past 10 years has shown it lacks efficacy, and in fact only ACTs are recommended first-line treatment, we found CQ in both tablet form as well as syrup for children.Â Of equal concern is the sale of syrups, which in and of themselves are unstable in the environment.
That said, each of the CQ medicines was duly registered by the National Agency for Food and Drug Administration and Control (NAFDAC). This demonstrates a lack of communication between NAFDAC, one arm of the Federal Ministry of Health, and the National Malaria Control Program, another arm of the same ministry.
The ‘questionable’ products also include Artesunate, a monotherapy drug. It has only artesunate, not a combination, a situation deplored by the World Health Organizations, who explains that use of monotherapy leads down the road to resistance, and we have little in the pipeline to replace the artemisinin derivatives.Â This product is registered by NAFDAC, who had promised to not renew licenses for such drugs, and in addition this packet is set to expire in a few months.
We found numerous brands of sulfadoxine-pyrimethamine (SP).Â According to national malaria drug and treatment policies, SP should also not be used for first-line treatment due to increasing parasite resistance. SP should therefore be reserved only for use as Intermittent Preventive Treatment in pregnant women (IPTp).Â This use is clearly stated on the Melofan packet, though we are not sure that the NMCP has given permission for such labeling. The key reason for this is that SP for IPTp should not be taken as self-treatment, but integrated into a comprehensive antenatal care program.
Finally we did find ACTs.Â The card showing Coartem (artemether-lumefantrine – AL) was the only one of the four different age-specific Coartem packagings seen in the shops.Â Supposedly this Coartem was being made available in shops at subsidized rates through the Affordable Medicines Facility malaria (AMFm) administered through GFATM.Â Normally drugs for this program have different packaging than seen here, which is the normal format for medicines supplied for the public sector from donor programs.
We bought this Coartem pack for $1.33, which was more than the going price for AMFm drugs. The shopkeeper said she also previously had some artesunate-amodiaquine (AA), another ACT in stock, but this had sold out.
Also seen in the ACT picture is an empty carton of AL provided through private wholesalers as part of the AMFm program as evidenced by the small green leaf logo.Â The medicine seller with this empty box informed us that he bought many of these cartons and shared with fellow medicine dealers. Unfortunately they did not pay him back and he has been unable to order more. He was excited that these were purchased from the wholesaler for only 50 Naira (about 33 US Cents) compared to proces of several dollars under normal commercial arrangements. Not shown was a bottle of AL suspension that could be reconstituted with water for child use.
We have been rolling back malaria since at least 1998. Nigeria changed its malaria drug policy to ACTs in 2005. Based on the Abuja Declaration of 2000, we should be seeing near universal coverage of malaria illness episodes with ACT drugs by now. There are not gaps in the system – there are wide crevasses.