Over-the-counter stocking of anti-TB fueling spread of drug-resistant tuberculosis in Nigeria — Study

In a new study, experts say that the high stocking of over-the-counter anti-tuberculosis medications and dispensing practices of patent medicine vendors (PMVs) and community pharmacists (CPs) could be fueling the spread of drug-resistant tuberculosis, making Nigeria’s goal of eradicating TB by 2030 look unattainable.

They stated that in many situations, apprentices of PMVs are young and inexperienced, and that leaving the entire patient management, including stocking, dispensing and sales of medications, to them without the supervision is counterproductive to the goal of identification and referral of presumptive TB patients for confirmatory diagnosis and treatment at the hospital.

The study had assessed anti-TB medication stocking and dispensing practices among 405 retail outlets (322 PMVs and 83 CPs) across 16 Lagos and Kebbi local government areas (LGAs) between June 2020 and December 2020. These LGAs also have a high TB burden.

The retail outlets were already affiliated with the National TB, Buruli Ulcer and Leprosy Control Program (NTBLCP).

The study said overall, 91%, 71%, 49%, 43% and 35% of the respondents reported stocking loose rifampicin, streptomycin, pyrazinamide, isoniazid and ethambutol tablets, respectively.

In addition, being aware of directly observed therapy short course (DOTS) facilities and having previous training on TB reduced the odds of stocking anti-TB medication, while operating more than one shop, having three or more apprentices and seeing over 20 clients/day increased the odds of stocking loose anti-TB medications.

First-line drugs are usually administered in fixed-dose combinations (FDCs), which are combination tablets that contain two or more drugs in a single tablet. Some examples of first-line FDCs are rifampicin, isoniazid, pyrazinamide and ethambutol.

However, rifampicin, isoniazid, pyrazinamide and ethambutol can also be administered as individual, loose tablets, which would make them non-FDCs. In this case, the patient would take each drug separately rather than in a single, combined tablet.

According to the researchers, exposure to single, loose anti-TB drugs (monotherapy) could fuel drug-resistant-TB and reverse the gains of national tuberculosis control efforts because a risk factor for the development of drug resistant-TB includes the inappropriate use of non-FDC anti-TB regimens.

“The findings of this study have far-reaching implications on how regulatory institutions, programme managers and the ministry of health are engaging PMVs and CPs in Nigeria in the context of apprenticeship programmes.

“PMVs are usually managed by apprentices when the shop owners are away, as many owners have concurrent employment serving as multiple sources of income.

“Most donor-funded vertical programmes and public health interventions in Nigeria often engage PMVs and CPs through training workshops and other capacity-building activities, hence the need to re-imagine the engagement process beyond the licensed/registered shop owners and expand quality assurance efforts to include the apprenticeship programmes in light of current study findings.

“In many situations, apprentices are young and inexperienced and leaving the entire patient management, including stocking, dispensing and sales of medications, to these individuals without the supervision of a licensed operator would be counterproductive to the public health goal of saving lives and improving access to health services in hard to reach communities.”