14 Dec 2023

Drug trafficking / Best practices address counterfeit malaria medication in West Africa

The region has a number of successful interventions that can serve as models for combating the trade in counterfeit malaria medication.

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Malaria infected 234 million people in Africa in 2021 and killed 593 000 of those, according to the World Health Organization (WHO). Equally shocking is that counterfeit and substandard antimalarial medicines result in the deaths of as many as 267 000 people in sub-Saharan Africa every year.

Over the years, the antimalarial drugs that were widely recommended and supplied in West Africa, chloroquine and sulfadoxine-pyrimethamine, have lost their efficacy. ‘Something needed to be done,’ said Dr Sunday Olise at Abuja’s Orozo Medical Centre. ‘Many governments in the sub-region went with the recommendation of the WHO to shift to artemisinin-based combination therapies (ACT).’

However, because of their efficacy and widespread use, antimalarial medications, especially ACT, were among the most common counterfeit drugs in the world, he said. Globally China and India are reportedly the main producers of ACTs and numerous other drugs. The United Arab Emirates, Singapore, and Hong Kong serve as transit hubs in the global supply chain.

This market is constantly evolving. Dr Modu Sonkoh of the Edward Francis Small Teaching Hospital in The Gambia explained that counterfeit malaria drugs were typically produced in illicit laboratories, often in African and Asian countries with weak regulatory systems.

A 2023 United Nations Office on Drugs and Crime report identifies West Africa, especially Guinea and Burkina Faso, as hotspots for the sale of fake medicines. The report explains how unauthorised importers in these two countries directly request legal and illegal laboratories in India to produce specific quantities of drugs with reduced active ingredients to cut costs. The illicit supply chain includes employees in authorised distribution centres, pharmacists, private depot sellers, government officials, and people engaged in healthcare sector corruption.

Malaria killed 593 000 people in Africa in 2021 – and counterfeit antimalarials kill half that number every year

However, African governments are fighting back. Technological advancements and track-and-trace systems are valuable in addressing counterfeit ACT. James Ogoegbulem, Managing Director of Aid Emergency Consolidated Services in Abuja, told ENACT that the track-and-trace system required ‘a scan at each interaction with a medical product, spanning from its entry point to its [being dispensed].’ In the case of ACTs, he said, ‘All reputable pharmacies in Nigeria have signed up to the system.’

‘Nigeria is now adopting forensic techniques and systems that can embed unique authentication markers throughout the pharmaceutical distribution chain, ensuring the integrity of products up to the point of patient administration.’

Ifeoma Nnamuchi, a micro-biologist at Vintage Pharmacy in Abuja, Nigeria, told ENACT that Nigeria’s government had intervened by introducing medicine authentication technologies.

She said one successful example was the use of the Mobile Authentication Service (MAS). This text message-based initiative was introduced by the National Agency for Food and Drug Administration and Control (NAFDAC). Using a code concealed under a scratch panel on drug packages, the authenticity of purchased ACTs can be confirmed through a free text message service.

Collaboration, information sharing, and partnerships among African countries are vital in combatting counterfeit ACT. Lansana Saccoh, a politician who campaigned in Sierra Leone’s 2023 elections on an anti-crime platform, said, ‘The effort to eliminate counterfeit ACTs in West Africa necessitates a comprehensive approach involving collaboration.’

Nigeria and Cameroon have signed a cooperation agreement to fight fake medicines

He said although the Economic Community of West African States and the West Africa Health Organisation supported the region’s pharmaceutical industry, ‘more is needed to combat counterfeit ACTs through collaboration to ensure the operationalisation of Africa’s Pharmaceutical Manufacturing Plan.’

A collaborative law enforcement operation spanning Africa, coordinated by INTERPOL and AFRIPOL, has identified hundreds of suspects. It led to the confiscation of over 12 million illicit health products and the imprisonment of seven executives from a multinational pharmaceutical distribution firm in Benin for their involvement in selling counterfeit medications.

On 22 February 2023, Nigeria and Cameroon signed a cooperation agreement to disrupt the manufacture and distribution of fake medicines. This agreement aims to facilitate the exchange of experiences and technical expertise between the two nations.

Such collaboration needs to be supported by robust regulatory frameworks and effective enforcement mechanisms. The African Union’s (AU) African Medicines Regulatory Harmonization programme could be another useful model. It works through regional economic communities to facilitate access to good-quality, safe, and efficacious medical products. In support of the AU’s programme, the Medicines Control Agency, The Gambia, is implementing stringent regulations for ACT, including licensing requirements for importers and quality testing of drugs.

The Lomé Initiative, a binding agreement to criminalise the trafficking of counterfeit and substandard drugs in Africa, is also proving useful. For the first time, leaders from the Republic of the Congo, Ghana, Niger, Senegal, Togo, and Uganda have elevated counterfeit and substandard medicines to a top-tier political priority.

Addressing counterfeit antimalarial drugs poses a significant challenge

The initiative has led to the development of a ‘comprehensive strategy to prevent, detect and respond to substandard and falsified medical products, including … actions from education to border control, from supply chain integrity to transparent legal processes,’ said WHO Director-General Dr Tedros Adhanom Ghebreyesus.

In April 2021, The Gambia announced its intention to join the initiative. ‘More West African countries should join,’ said Sonkoh. He said education was key to preventing counterfeit ACT use. He cited the Fight the Fakes Alliance as an example of where information dissemination was working. Led by a coalition of international organisations, the campaign engages communities and healthcare providers to raise awareness about the risks of counterfeit drugs. This campaign has been active in Ghana since 2020.

In Nigeria, NAFDAC spearheads public awareness initiatives, and since August 2021, has initiated public education campaigns in eight states. Dr Adebola Ajeye of Karshi General Hospital said they ‘educate the public through media campaigns, community dialogues, and grassroots engagement to combat counterfeit ACT.’

Addressing counterfeit antimalarial drugs poses a significant challenge, primarily because of the limited resources and inadequate techniques available for detecting and identifying fake drugs. By employing appropriate technologies, together with collaboration and information sharing, stakeholders are enhancing their efforts to ensure the availability of authentic ACT. This protects public health services and contributes to the global action against counterfeit pharmaceuticals.

Dr Feyi Ogunade, Regional Organised Crime Observatory Coordinator, West Africa

Image: Riccardo Mayer/Shutterstock/The Conversation


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