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Poor-quality medicines: a global threat to health

Chanvilay Sichanh ; Mayfong Mayxay ; Lamphone Syhakhang ; Bounxou Keohavong ; Paul Newton ; Celine Caillet

Lao Medical Journal.2019;10(10):3-11.

Poor quality medicines have been described as a global pandemic that threatens the lives of millions of people. The problem is much more severe in poor-resource countries where pharmaceutical legislation and regulation are limited. Poor quality medicines are divided into three categories: substandard, degraded and falsified and the countermeasures vary according to each category. The use of poor quality medicine leads from minimal to severe complications (including death) for the individuals but also harms the community. Furthermore, they lead to a loss of confidence of the patients in essential medicines, in manufacturers and in health system and they increase the work burden for health workers, customs and police. To detect them, different techniques have been developed, each with advantages and limits. This article describes these aspects of poor quality medicines and also presents the factors that contribute to the existence and spread of poor quality medicines. A section of the article is devoted to the issue of poor quality medicine in Laos.

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Bacterial Contamination in Intensive Care Units of a Hospital in Vientiane, Lao People’s Democratic Republic

Panomphanh Mahaphonh ; Ganjana Nathapindhu

Lao Medical Journal.2013;4(4):2-8.

Background and rationale: Intensive Care Units (ICU) are wards where very sick patients are admitted and they are usually connected to invasive devices such as respirator, urine catheter etc. Patients in ICU are more likely (5 – 10 times) to have hospital-acquired infections than those admitted to other wards of the same hospitals. Very little is known about hospital-acquired infections in Laos, including the species of bacterial contaminating ICU. Information on this issue is essential for a hospital to plan on how to manage the environment and set stricter measures to avoid nosocomial infections in the ICU. Methodology: This was a research survey conducted to determine the types and quantity of bacterial contamination in ICUs of a hospital in Vientiane. Open plate technique was applied by placing 256 media plates in 8 rooms of paediatric (n=3) and adult (n=5) ICUs. Controls were closed plates. Plates were sent to and bacteria were identified at National Centre of Laboratory and Epidemiology, Vientiane, Laos. Results: Eight pathogens were identified and the most predominant bacteria found was Coagulase negative Staphylococcus spp. (56.0%), followed by Bacillus spp. (19.7%), Acinetobacter spp. (12.5%), Micrococcus spp. (8.4%), Escherichia coli (1.9%), Klebsiella pneumoniae (0.8%), Providencia rettgeria (0.4%) and Proteus mirabilis (0.3%). Escherichia coli, Klebsiella pneumoniae and Providencia rettgeri were not found in adult ICUs and Proteus mirabilis was not found in paediatric ICUs. The overall mean (95%CI) colonies of pathogens found in paediatric and adults ICUs was 83.04 CFU/dm2 (43.21 - 149.42 CFU/dm2) and 48.54 CFU/dm2 (21.96 - 135.00 CFU/dm2), respectively. Conclusion This study suggested that there were many bacteria contaminated in the ICUs of this hospital with a considerable quantity. Therefore, the hospital should have a better strategic plan to manage its environment and improve sterilization in the ICUs in order to reduce hospital-acquired infections among patients.

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Factors Associated with Oral Diseases Among Pregnant Women in Attapeu Province, Lao PDR

Sysavanh Phommachanh ; Borisouth Phommakhoth ; Mayfong Mayxay

Lao Medical Journal.2013;4(4):9-15.

Rational and Background: Oral disease is an important problem affecting people’s health in Lao PDR, but can be prevented. Pregnant women are more at risk of having oral disease than other groups of people. Oral disease during pregnancy not only affects mothers’ health but also that of babies. Many factors are associated with oral disease during pregnancy, but very few studies were conducted especially in rural areas. Methodology: An analytical, cross-sectional study was carried out from July to September 2012 using close and open questionnaire forms and oral health check up in order to describe oral health status, risk behavior, oral hygiene practice, and factors associated with oral health for pregnant women in three districts of Attapeu Province. Data were analyzed using STATA 10.0 and logistic regression was applied to determine factors associated with oral disease. Results: Five hundred fifty-six pregnant women were studied with a median (range) age of 24 (16-42) years. Most of participants were housewives or famers (78.8%), 62.4% of them with low education level, and 52.0% were Lao-loum (out of 13 ethnic groups). The percentage of the pregnant women who had at least one oral disease was 66.4 %, and the most common oral problems found were dental plaques and carries (53.2% and 10.8%, respectively). Occupation (AOR=2.1 95%CI= 1.4-3.2, P<0.001), ethnic (AOR =2.2, 95%CI=1.5-3.2, P<0.001) and religion (AOR=2.1, 95%CI= 1.4-3.1, P<0.001) were significantly associated with oral diseases during pregnancy. Pregnant women with past and current smoking were 2 times more likely to have oral diseases compared to those who never smoked (AOR=2.1, 95%CI =1.4-3.1, P<0.001). Higher family income (AOR= 0.6, 95%CI= 0.2-0.4, P<0.001) and ANC visits at least once during pregnancy (AOR=0.7, 95%CI=0.5-0.9, P= 0.005) were significant apparent protective factors against oral disease. Conclusion More than half of the pregnant women in rural Laos (Attapeu Province) had at least one oral health problem (mostly dental plaques and carries). Oral diseases were more common in the second than in the first and the third trimester of the pregnancy. Many pregnant women had risk factors associated with oral disease, particularly smoking. ANC visit at least one during pregnancy was associated with less oral disease during pregnancy.

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Knowledge, Attitude and Practice of Eating and Drinking among Patients with Diabetes Mellitus II at Mahosot Hospital, Vientiane, Laos

Vatsana Thammavongsa ; Benja Muktabhant

Lao Medical Journal.2013;4(4):16-22.

Background and rationale: Diabetes mellitus (DM) remains an important health problem worldwide, including in Laos. Most deaths among DM type-2 patients result from complications due to poor control of glycemia. Eating and drinking behaviors are vital factors for glycemia control in DM patients and study of their knowledge, attitude and practice for eating-drinking behavior may help us to understand the problem and plan engagement and how to promote appropriate changes in patients’ behavior. Methodology: A descriptive, cross-sectional study was conducted to explore knowledge, attitude and practice on eating-drinking of DM type-2 patients who visited the Outpatient Department of Mahosot Hospital from February to March 2012. A questionnaire was designed and pre-tested before interviewing patients following their consent. Patients were selected into the study using systematic random sampling. Results: Two hundred DM type-2 patients (60% females) were interviewed. The overall mean (SD) age of the patients was 58 (9.2) years; 35.5% of them had at least a family member with DM. The mean (SD) duration the patients knew that they had DM was 6.1 years (SD = ±5.8). On the day of interview, 42% and 32.5% of the patients had blood glucose levels that were high (130-180 mg/dL) and very high (>180 mg/dL), respectively. Twenty-two percent of the respondents had a good level of DM diet knowledge while 59% of them had a moderate level and the remainder (19%) had a low level. Most of interviewees (98.5%) had correct knowledge on food restriction (rice, flour, sugar, and lipid) and 93.5% knew that food control, exercise, and taking antidiabetics regularly are the best ways to control blood sugar. Less than 50% of the respondents knew that DM patients have to restrict the quantity of rice to eat and that patients with complications must control their diets strictly. Although 68.5% and 31.5% of the patients had a good and moderate level, respectively, of attitude on DM nutrition, some of them still had beliefs that are not medically recommended. For example, 15.5% of patients thought that they could stop their medication by themselves, 28% said that DM patients can live normally regardless of blood sugar control, and 49.5% believed that DM was a bad karma. Approximately 1/4 of the interviewees reported that they mostly did not eat on time, 30.5% did not restrict their food, 41% just ate what they needed and 41.5% said that they ate any fruits that they liked. Conclusion Although most of DM patients had correct knowledge on DM diets, some of them had attitudes and practice on food consumption, including poor blood sugar control, that are at odds with current medical advice. Engagement methods are needed to inform patients of optimal dietary practice in order to prevent DM complications.

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Motivations Associated with the Performance of Health Staff Who Implemented Strategic Plan on HIV/AIDS/STIs in Two Districts of Vientiane Capital, Lao PDR

Chanthasouk Bansalith ; Chanaphol Sriruech

Lao Medical Journal.2013;4(4):23-29.

Background and rationale: HIV/AIDS is an important and challenging public health problem although Laos has a relatively low infection rate. In order to maintain a low infection rate, the government developed the national strategic plan on HIV/AIDS/STIs prevention. Study on the motivations associated with the performance of health staff who implemented this strategic plan is essential and required so that the results can be used to improve their jobs aimed at maintaining the low infection rate. Methodology: A descriptive, cross-sectional study was conducted with all health staff who were implementing the work related to the national strategic plan on HIV/AIDS/STIs prevention in two districts (Hatxayfong and Xaythany) of Vientiane Capital. A pre-designed and tested questionnaire was used to interview the target sample of 63 people, of these 8 were also interviewed in depth. Pearson Product Moment Correlation Coefficient was applied to detect correlation between different study variables and content analysis was used for data from indepth interview. Results: Of 63 respondents interviewed (females 71.4%), the mean age was 38.4 years, 83% were married, 63% were medical assistants, and 47.6% had working experience between 21-30 years. The overall mean (SD) motivation score of staff was 4.13 (0.40) over 5 while the overall mean (SD) score for job performance was 3.26 (0.59) over 5. Demographic characteristics were not associated with job performance. Motivation factors that were significantly correlated with job performance were respectfulness (r = 0.36, P = 0.01) and job promotion (r = 0.33, P = 0.007). Supportive factors statistically correlated with job performance were salary/incentives (r = 0.32, P = 0.01), professional status (r = 0.31, P = 0.01), and job security (r = 0.43, P<0.001). Obstacles and problems for the strategy implementation found from indepth interviews were discontinuous activity implementation due to insufficient budget, unavailability of campaign materials and medical supplies, some target HIV/AIDS patients not accepting their infection status (difficult to provide them with information) and limited knowledge of some staff. Conclusion Although some factors were significantly correlated with job performance for the national HIV/AIDS/STIs prevention strategic plan, others were also linked to each other and cannot be missed. Therefore, all factors should be integrated during development and improved in order to motivate staff performance aimed at achieving the objectives.

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Effect of Congruence in the Estimation of the Intensity of Pain Between Lao Patients and Their Doctor on Its Control

Phonethépha Phasavath ; Nengyang Wangkou ; Marc Corbière ; Daniel Reinharz

Lao Medical Journal.2013;4(4):30-39.

Background and rationale: No study in Laos has focused on the affects of an accurate estimation by a doctor of his/her patient's level of pain. Methodology: The McGill pain questionnaire was validated into Lao language. The validated version was then administrated to a cohort of 180 new patients as well as to their 88 doctors. The questionnaire was re- administrated to the patients 2 weeks later. Results: A good estimation by a doctor of the intensity of pain felt by his patient is associated with the disappearance of a level of pain that hinders the possibility to carry out daily chores. Three factors were retained in a regression model on the congruence between doctors and patients in the estimation of the pain level: ethnicity and level of education of the patient, and physicians' number of years of practice. Conclusion Teaching future health care providers on how to estimate pain should be considered as a crucial component of medical training.

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Factors Associated with Voluntary Blood Donation among People in Chanthabouly District, Vientiane Capital, Lao PDR

Thongphanh Chanthalak ; Pornnapa Suggaravetsiri

Lao Medical Journal.2013;4(4):40-45.

Background and rationale: In the Lao PDR, shortage of blood for transfusion for use in hospitals is an important and challenging problem, which has not been adequately resolved. This is due to the very low number of voluntary blood donation by the general population. Many factors may contribute to the low number of voluntary blood donation of Lao people, which we do not all know and understand. Results: Eight hundred and ninety-eight subjects were enrolled in the study and interviewed (449 cases and 449 controls). The median (range) age of the respondents was 26 years (17 – 40). Factors significantly associated with voluntary blood donation were males (OR = 1.71; 95% CI = 1.31-1.23, P= 0.001), being single (OR = 2.01; 95% CI = 1.52-2.65, P<0.001), having a positive attitude toward voluntary blood donation (OR = 3.17; 95% CI = 2.37-4.22, P<0.001), convenience in traveling to and short distance from home to blood donation centre (OR = 2.35; 95% CI = 1.73-3.20, P=0.01), (OR = 1.67; 95% CI = 1.25-2.22, P=0.001), respectively, and having received information on blood donation from any channels (OR = 1.88; 95%CI = 1.38-2.55, P<0.001). Another important but not statistically significant reinforcing factor for voluntary blood donation was blood donation during important occasion (birthday, marriage anniversary and valentine’s day). Conclusion This study suggested that (1) voluntary blood donation campaign should be carried out continuously and focus on young people at educational institutions and (2) it is very vital that mobile blood donation teams continue their activities regularly in order to ensure that blood demand in hospital can be achieved.

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Uncommon Presentation of Infective Endocarditis

Pany Kesone ; Sayaphet Rattanavong ; Khamthavy Thepsouvanh ; Vang Chu ; Rattanaphone Phetsouvanh ; Mayfong Mayxay ; David Dance ; Paul Newton

Lao Medical Journal.2013;4(4):46-54.

Diagnosis of infective endocarditis is challenging as the clinical diversity of the disease sometimes misleads clinicians in the recognition, correct diagnosis and rapid treatment, which are important to reduce the morbidity and mortality associated with this disease. We report the case of a 14-year-old girl who presented with left axillary pain and fever. She was eventually diagnosed with infective endocarditis caused by Abiotropia defectiva, complicated by a large saccular aneurysm of the left axillary artery.

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Parenteral Artesunate Will Save ~ 200,000 Children with Severe Malaria Annually

Mayfong Mayxay

Lao Medical Journal.2011;8(2):3-8.

Severe P. falciparum malaria kills people, particularly African children ~ 200,000 per year. Quinine and quinidine infusions were the only antimalarial drugs available to treat severe malaria until recently. The rediscovery of artemisinins in 1972 and subsequent synthesis of artemether and artesunate have provided highly effective alternatives to quinine. Results from meta¬analysis demonstrated that artemether significantly reduced mortality in adult patients with severe malaria from Southeast Asia. Pharmacokinetic studies suggest that the oil¬soluble artemether, which can be given intramuscularly but not intravenously, is poorly and slowly absorbed from the injection site while the water¬soluble artesunate is absorbed rapidly and reliably. The SEAQUAMAT study comparing intravenous artesunate vs quinine among adults and children in 4 Asian countries and demonstrated a significant absolute reduction of mortality of 34.7% (95%CI = 18.5 – 47.6%). A subsequent study (AQUAMAT study) conducted in African children with severe malaria in 9 countries confirmed the excellent efficacy of artesunate with a significant relative reduction of death of 22.5% (95%CI = 8.1 – 36.9%). A large meta¬analysis with more than 7,000 patients also confirmed that artesunate significantly reduced mortality in Africa of 22.5% and that in Asia of 38.6%. Patients treated with quinine had significantly higher incidence of hypoglycemia when compared to those who received artesunate. If these studies had been conducted 20 years earlier, perhaps 4 million patients with severe malaria would not have died particularly African children. Parenteral artesunate should replace quinine everywhere in the world as the first line treatment of severe falciparum malaria. Such a change in policy would save an estimated 200,000 live of children with severe malaria each year. With support from the Global Fund for the fight against AIDS, Tuberculosis and Malaria (GFATM), Laos changed the national policy of severe malaria treatment to artesunate as first line in 2006.

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The Diagnosis of Infantile Beriberi and Lao infants with Vitamin B1 Deficiency without Apparent Signs

Mayfong Mayxay

Lao Medical Journal.2011;8(2):9-14.

Beriberi (vitamin B1 or thiamin deficiency) is neglected health problem that probably remains as a significant cause of mortality among infants in Asia. There has been very little research in the last 4 decades. Although there are few data from Laos, the clinical experience of Lao pediatricians, along with some data from Mahosot Hospital in Vientiane, suggests that beriberi is probably an important cause of infant mortality, which is currently very high in Laos. Diagnosis of infantile beriberi can be clinically if signs are evident. However, a significant number of infants may have clinical unapparent vitamin B1 deficiency, complicating their illness, which is impossible to diagnose unless biochemical assays are performed. Unapparent vitamin B1 deficiency may complicate the illness of infants presenting with other diseases and supplementary treatment with vitamin B1 could potentially improve their outcome and reduce infant mortality. Two recently published papers by the Wellcome Trust – Mahosot Hospital – Oxford Tropical Medicine Research Collaboration suggested that approximately 13% of Lao sick infants admitted with diarrhea, pneumonia and sepsis (without clinical evidence of beriberi) at the Pediatric Wards, Mahosot Hospital, Vientiane had evidence of biochemical vitamin B1 deficiency particularly among those aged > 2 months. Infants with biochemical vitamin B1 deficiency had higher mortality than those who were not B1 deficient. The study also demonstrated that the activation coefficient (α), which has been used to diagnose vitamin B1 among adults living in non¬rice eating societies, cannot be reliably used for the diagnosis of vitamin B1 deficiency in infants, that basal ETK < 0.59 micromoles/min/gHb is a better biochemical marker of infantile beriberi, and that detection of the cardiac dysfunction marker troponin T may be useful indicator of infantile beriberi. The implication of the findings in these two papers were that (i) since clinical unapparent vitamin B1 deficiency is common among Lao sick infants, co¬treatment with vitamin B1 may reduce disease severity and mortality, (ii) since basal ETK is more accurate than activation coefficient (α) in the diagnosis of infantile beriberi, basal ETK should be used for the diagnosis of vitamin B1 deficiency among infants, and (iii) since troponin T may be useful in the diagnosis of infantile beriberi and as this assay is now available as a bedside test these should be evaluated as accessible markers.

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