Many a time the challenge health care providers face all over the world in is the patients lack of compliance with medication therapy regimens as agreed with prescriber. Various research have been done on medication compliance which is a major topic within the pharmaceutical care space. Several reasons are documented for patients non compliance.

Compliance issues are commonly faced by patients who are on medications for short term treatment of curable diseases such as infectious diseases - hypercholesteremia, Malaria, Typhoid, or for life long illnesses that are managed such as Diabetes, Phaechromocytoma, Hypertension, Congestive heart Failure, etc. During the process of dispensing and counseling patients on their medication the Pharmacist usually requests for information on previous medication being taken and compliance to the medication especially if it is a refill prescription. When the Pharmacist identifies a lack of compliance an inquiry is made as to reasons for non compliance. Excuses normally given by patients for not being able to follow medication regimen include:

• 1) Cost -drug is not affordable or there was an upward market review of the price.
• 2) Side Effects - the drug causes more discomfort than the patient can tolerate.
• 3) Forgetfulness - normally the patient forgets to take or apply a particular dose resulting in some missed doses.
• 4) Communication - patient was inadequately counseled and so did not fully understand how to use medication as well as the importance of the medication.
• 5) Concerns about Privacy - HIV positive patients on ARVs usually make this complaint related ti stigma and so have to travel long distances avoiding their nearest pickup location for bimonthly refills of prescriptions. When transportation affordability becomes a problem compliance becomes an issue.

Interestingly while looking at the available literature from the United states and Europe the reason of "availability with the medicine" (i.e patient could not find the drug in a Pharmacy) is not indicated as one of the common reasons for poor medication compliance. Rather such reason seems to be more common in the African setting.

One of the commonest excuses given by patients for non compliance is that the medicine was not accessible. Further drill down into this excuse will break the lack of accessibility to :

• a) The medication is not affordable to the patient
• b) Patient could not find the medication in any Pharmacy outlet.
• c) Patient can not find the recommended brand or generic form.
• d) The patient doubted the genuineness/authenticity or the brand seen.

This is a Health supply chain challenge. Research shows that health supply chain interruptions have a direct Compliance, Pharmacoepidemiological and Pharmacoeconomic impact on the patience medication therapy and National treatment planning. The specifics are :

1)It affects the patients ability to afford the drug. Scarcity increases value (Basic economics).
3) It impacts health supply chain data negatively by causing inaccuracy in drug consumption patterns across populations.
4) It impacts health planning at the facility, state and national level by its effect on (3) above.
5) It affects patients trust and confidence in the health system.
6) It compels Physicians to prescribe less desirable alternatives
7) It exposes patients to less efficacious or more expensive alternatives.
8) It increases the overall cost of the patients access to treatment.
9) It increases the overall cost of healthcare to the system.

Health Supply Chain expertise is important to patient medication compliance because it operates on the principle of bridging the gap between the drug and the patient. It is the movement of the drug product from the point of origin to the last mile where it is consumed. It involves several robust components such as manufacturing, inventory Management, Information management, distribution (logistics transportation), warehousing and service points or point of care.

A Supply chain that is well planned and working optimally will bring the right drug at the right quality from the manufacturer to the patient at the right location, the right time, in the right condition, at the right price. This is the concept of the 6 rights that serves as the fulcrum of Health Logistics and Supply chain management. They must be guaranteed and are non negotiable just like the fundamental human rights of an individual.

An example is HIV treatment drugs known as ARVs (Anti retroVirals) which are used extensively and in different Fixed Dose Combinations (FDC) in HAART (Highly Active Anti Retroviral Treatment). A cardinal principle being that treatment with ARVs can not be interrupted as the consequences are huge and ranges from drug resistance and cross resistance, treatment failure to death. Same goes for Tuberculosis (TB). I personally experienced the impact of supply chain interruptions on HIV positive patients who were meant to refill bimonthly supplies of ARV FDCs at the Special Treatment Clinic. Patients on regimens that had Lopinavir as part of the combination had issues because the drug was out of stock for almost 3 months. This was because Lopinavir had been touted as one of the Antiviral drugs effective against the nCovid-19 Virus. Consequently this caused an instant shortage of the drug as the main source China stopped exporting it and National governments started redirecting remaining supplies in stock towards managing Covid-19 treatment in Isolation centers. There was a national shortage in Nigeria. We were helpless in the treatment clinic. One patient even told me she had gone without the drug for the second month running and it was part of a second line regimen recommended for her since the first line FDC had failed due to resistance. All I had to give at that point was empathy. It was almost a month later that I saw on a friends status who is a warehouse manager at GHSC-PSM that Chemonics had been able to secure fresh supplies of Lopinavir for the country.

The above are ample reasons public health experts and health policy makes in the executive arms of government and legislature should prioritize optimizing and integrating Pharmaceutical supply chains in both private and public sectors nationwide towards maximizing utilization of funds and reducing the overal cost of healthcare.

References

Cennimo D.J, 2020, What is the role of the antivirals lopinavir/ritonavir in the treatment of coronavirus disease 2019 (COVID-19)?, Medsacpe, accessed at url https://www.medscape.com/answers/2500114-197452/what-is-the-role-of-the-antivirals-lopinavirritonavir-in-the-treatment-of-coronavirus-disease-2019-covid-19 on 4th February 2021.

McGrail S, 2020, Fundamentals of Pharmaceutical Supply Chain, Supply Chain News, Pharmanews intelligence, Xtellingent Healthcare Media, accessed at https://pharmanewsintel.com/news/fundamentals-of-the-pharmaceutical-supply-chain on 4th February 2021.

Ross M, What is Medication Compliance: 5 Things Providers Should Know, Medication Compliance, Cureatr (Comprehensive Medication Management), Accessed at url https://blog.cureatr.com/what-is-medication-compliance-5-things-providers-should-know on 4th February 2021.

Resnick R, 2018, How Medication Compliance Affects Patient Outcomes, Cureatr (Comprehensive Medication Management), accessed at https://blog.cureatr.com/how-medication-compliance-affects-patient-outcomes on 4th February 2021

The post HEALTH SUPPLY CHAINS IMPACT ON MEDICATION COMPLIANCE first appeared on CPAN WORLD.

The Minister of State for health Dr. Olorunimbe Mamora and the Chairman Presidential Task Force on Covid 19 Mr Boss Mustapha have both advised that Nigerians do not become complacent once they receive their first dose of the Covid-19 vaccine. They have insisted that safety protocols involving frequent handwashing, use of sanitizers and face masks in public remain in force and will be enforced to the letter.

The government officials have made this assertions in the light of ongoing efforts by the Federal government to acquire the Covid-19 vaccines and initiate distribution nationwide based on a planned strategy. Public health experts have also advised that Vaccines will only facilitate 95% immunity against the prevailing strain of Corona virus and there is still a very small window of opportunity or risk of infection. The government officials have also advised that even though individuals may have been vaccinated and acquired immunity, they could still be carriers and transmit the virus to individuals who are at risk of contracting the disease. Consequently individuals are strongly advised to sustain all safety protocols.

While briefing the Presidential Task Force on Covid-19 earlier this month the Minister for Health Dr Osagie Ehanire reported that there was a reduction in case fatalities. He warned Nigerians not to let down their guard even as case fatality rates were reducing.

The current Corona virus pandemic has claimed millions of lives worldwide in the past 2 years and has necessitated what could eventually become the costliest vaccine development effort and biggest vaccination campaign on history.

Many Clinical trials are ongoing world wide both for drug treatment regimens and Vaccines. Drugs are meant for  treatment of already infected individuals exhibiting symptoms of illness while vaccines are meant to prevent the disease by stimulating immunity in individuals whom have been administered the vaccines.

According to the World Health Organization (WHO) vaccines work by training the body's immune system (natural defense mechanism) to recognize and fight off antigens like Viruses and Bacteria. The vaccines themselves contain microbial part or whole viruses which have been inactivated. The body is able to keep records of these microbes when exposed to them via vaccines thereby developing a natural defense against them. If infected by the virus, the body would have enough antibodies to combat the Virus and prevent full blown disease. WHO currently recognizes more than 50 Covid-19 vaccine candidates undergoing clinical trials. COVAX is the consortium comprising WHO, GAVI and CEPI that is responsible for ensuring adequate vaccine distribution to nations and prioritizing at risk individuals. Currently the vaccines which have been released require administration of a first dose and then a booster dose 3 weeks later to activate the recipient’s immune system and minimize the risk of infection from the virus.

A vaccinated person may not fall sick if infected but can still transmit the virus to friends, family and close contacts.

Lets know what you think in the comments section

The post DO NOT LOWER YOUR GUARD : MINISTER FOR HEALTH first appeared on CPAN WORLD.

By Pharm Nathan Ohiomokhare

A child first learns to avoid a candle light or hot lantern because it burnt him/her. Subsequently the child will literaly run away from any bright object, especially one that emits heat. The brain has a very strong Adrenergic system which registers sources of danger and will activate fear and apprehension as soon as such a signal is identified. The same effect is imparted by an Adverse drug reaction. The same goes for the Covid-19 vaccine.

As people all over the world start receiving shots of the vaccine they are beginning to realize that there are adverse reactions related to administering the vaccine. It is not the reactions that may be the problem, it's that they were not fore-warned, they did not know, they were not informed. Consequently they go and tell their family and friends. There have been reports of fainting, itching, redness at the area if inoculation, and even death. I once fainted when I was about 14 years old after my nurse administered a shot of the highly potent antipyretic Nolvagin (metamizol) to bring down my malaria fever. This was because the drug is a chemoreceptor trigger and caused me to vomit and suddenly lose energy.

Adverse drug reactions (ADR) are described as untoward, undesirable or unwanted effects observed by a patient during or after a medication has been administered or taken. They cause discomfort of various degrees and may cause injuries that are reversible or permanent. Many ADRs are life threatening and require emergency care in the ICU of a Hospital facility. ADRs are particularly popular amongst healthcare experts because they represent a major source of discomfort to the patients and the major reason the patient will stop taking the medication or be reluctant to take the medication in the first place. Thus ADRs affect patient compliance, adherence and persistence tremendously. 

 

Compliance is the ability of the patient to follow instructions on how to take the medication and other lifestyle modifications to support the medication therapy. Adherence is the patients willingness co-operate and collaborate with the healthcare provider on the guideline and play an integral role in his/her medication therapy. Though compliance and adherence are used interchangeably compliance is more instruction based which adherence is more of a collaboration. Persistence is the patient's ability to continue with medication therapy for the entire duration of treatment. For the purpose of discussing Covid-19 related ADRs I have simplified these definitions and narrowed their use. 

 

The interesting thing about ADRs is that they are not entirely the fault of the drug alone. The fault actually goes around or extends as follows;

 

·         It's the Drugs fault - if the drug was not compatible with the patients physiology or genetics.

·         It's the patients fault - If he or she failed to communicate any underlying condition, any other medication being taken, any other fruit or supplement being taken, any unusual food being taken. (Underlying conditions refer to illness/disease or disability - hypertension, Diabetes, kidney disease, Imunocompromised, genetic disease, etc )

·         It's the patients fault- if he or she fails to take the medication as advised (non compliance) is argumentative and uncooperative on how to take the medication (non adherence) or is  lazy about taking the medication for the length of time desired (lacks persistence).

·         It's the Healthcare providers fault - if he or she fails to advise properly on the proper mode of administration resulting in over dosage or under dosage (prescription error).

·         It's the Healthcare providers fault - if he or she fails to advise properly on what to avoid while using the medication.

·         It's the Healthcare providers fault - if he or she fails to put into consideration any underlying medical condition(s) (co-morbidities) the patient might have.

·          

Just last month a video was shared in one of my professional groups on Wattsap where a nurse who was the first to receive the Pfizer/Biontech Covid-19 Vaccine fainted on live TV shortly after receiving the vaccine. Later, news circulated that she claimed to suffer from a fainting condition, which was not listed in her medical history. Another recent story which is currently circulating is of a lady who lost the love of her life due to an ADR after taking the Covid-19 Vaccine. 

 

According to her very touching story "her husband Gregory Michael MD an Obstetrician with Mount Sinai Medical Centre (MSMC) in Miami Beach died due to a strong reaction to the COVID vaccine. He was a very healthy 56 year old, loved by everyone in the community delivered hundreds of healthy babies and worked tirelessly through the pandemic." Gregory was said to have been vaccinated at MSMC on December 18, 3 days later he observed a strong set of petechiae on his feet and hands which made him seek attention at the emergency room at MSMC. The Full Blood Count (FBC) done on arrival showed his platelet count to be 0 (A normal platelet count ranges from 150,000 to 450,000 platelets per microliter of blood.) he was admitted in the ICU with a diagnosis of acute Immune Thrombocytopenia caused by a reaction to the COVID vaccine. A team of expert doctors tried for 2 weeks to raise his platelet count to no avail. 2 days before a last resort surgery,  he had a hemorrhagic stroke caused by the lack of platelets that took his life in a matter of minutes. Gregory was said to be a pro vaccine advocate that is why he took the vaccine himself.''

 

Clinical Pharmacists role in advising and informing about potential Adverse Drug Reactions seem to have been underplayed here. Are the Pharmacists not being involved in Vaccine administration?

 

As the Federal government of Nigeria begins to roll out Vaccine supplies nationwide patient medication education on potential adverse drug reactions should be put at the forefront. And Pharmacists should be actively engaged to provide that information. There is not better placed professional on the planet trained to provide services in this role than a Pharmacist. While other professionals wait to hear of the adverse reactions experienced by other patients in other climes before understanding cause and effect relationships, Clinical Pharmacists are already trained in a unique position to foresee, predict, inform the patient and educate other professionals on what to expect and what actions to take should an Adverse Reaction Occur. 

 

The Covid-19 Vaccine program stands a risk of losing momentum due to negative publicity caused by ADRs. The Covid-19 Vaccine program in Nigeria cannot afford to wait for rumours or stories from the west about ADRs. A more proactive approach is needed otherwise vaccine uptake by the populace will be truncated as people begin to lose confidence in the vaccine due to bad press and negative publicity.  Pharmacists Drug Information Services are a structure already in place to carry out this sensitive role. Facilities lacking proper drug information units manned by a Pharmacist should be adequately equipped and staffed to share such information with the necessary authorities and carry out intervention where necessary. The NAFDAC yellow form for reporting ADRs are in the custody of the Pharmacists who are uniquely qualified to investigate and fill such forms to make reports to NAFDAC. 

 

Pharmacists counseling prior to vaccine administration is a way of giving the client a "heads up" on potential reactions that may be observed while receiving the Vaccine or after receiving the vaccine. Medication counseling is a form of full disclosure of the risks (major and minor) if any, inherent in taking the Vaccine and is a legal obligation of every healthcare expert.  

 

These points are meant to generate discussions and thought amongst the Healthcare provider community. Your comments will be treated with love.

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