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Many challenges of containing COVID-19 pandemic

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Kingsley

Dr. Kingsley Chiedu Amibor is the National Chairman, Association of Hospital and Administrative Pharmacists of Nigeria (AHAPN), who are at the frontlines of the novel coronavirus (COVID-19) containment efforts in Nigeria. Amibor in this exclusive interview with The Guardian, enumerated the many challenges faced by hospital pharmacists in containing the virus. CHUKWUMA MUANYA writes.

Hospital pharmacists are at the front lines of the COVID-19 containment efforts. What are the challenges?
For one, our members are directly involved in making medications used in managing COVID-19 patients available to them. They also provide pharmaceutical care and medication therapy management services. As such, they are at risk of contracting the virus just like other healthcare workers,
Besides, hospital pharmacists that attend to patients outside isolation centres are equally at risk of contracting the virus from asymptomatic carriers, who they may come across in their day-to-day interactions with patients who visit the hospital for treatment of other conditions not related to COVID-19.

The coronavirus pandemic took many hospitals unawares. Most hospitals did not have adequate personal protective equipment (PPE), which are necessary ingredients in prevention efforts. When COVID 19 started spreading, some hospital pharmacists did not have access to basic PPE such as hand gloves and facemasks.

In fact, my attention was drawn to a particular teaching hospital, where junior pharmacists were being forced to attend to patients without face masks and hand gloves and I told them to march to the office of their Chief Medical Director (CMD) and demand for PPE and when he refuses, they should stop work and stay in their offices until the hospital provided them with PPE. Luckily, the CMD obliged them and the ugly situation was averted. In some other institutions, pharmacists are being made to wear cloth facemasks while attending to patients. These cloth masks as evidenced from several studies, cannot protect health workers who are managing confirmed COVID-19 patients from contracting the virus.

Also, some pharmacists working in isolation centres have complained of being short-changed in the payment of hazard allowance. This report is coming from Lagos State and we are looking into that allegation. A situation whereby seven pharmacists work in an isolation unit and the hospital management using unknown criteria decide to pay only two and leave out the remaining five, and even the two that manage to get paid, the discrepancy between their hazard allowance and those of other healthcare professionals is so mind bogging that you begin to wonder. This scenario is not acceptable to us and needs to be redressed as quickly as possible.

And of course, as drug experts, we are not happy that there is no cure for COVID-19 but our consolation is that our pharmacist colleagues in academia and industry are currently engaged in serious research efforts and we are optimistic that a drug to treat COVID-19 will soon emerge. Hospital pharmacists are also part of these efforts.

Several studies have shown that healthcare workers (HCWs) are at greater risk of getting infected with this virus. Does that bother you?
Of course it is an established fact from studies that HCWs are at great risk of infection from the virus. The statistics is there, In Italy, over 100 medical doctors, six pharmacists, countless nurses all died from COVID-19. In Nigeria, we were told that as at April 30, about 113 HCWS were infected already. The reason for this is nor farfetched. Inadequate PPE means HCWs are virtually unprotected while at work and we are dealing with a very virulent pathogen in COVID-19. Again, some patients do not disclose their full history when they visit hospitals, they conceal some of their symptoms and give HCWS the impression they are suffering mild illness and some of these HCWs relax and lower their guard, and that is why many HCWs get infected. Provision of PPE is sine qua non in curtailing the spread of COVID-19.

What are your recommendations on how best to contain the pandemic?
Multi concerted efforts must be put in place if we really want to contain the pandemic. Both short and long term measures will need to be put in place, not just by government, but citizens as well, including non-governmental organisations (NGOs). I must commend government for the role they have played so far; creating awareness of the pandemic, making palliatives available even though some people complained it did not get to them, introducing the lockdown and interventions to healthcare workers.

Despite all these however, the number of new cases keeps increasing on daily basis, so also the number of deaths. It means the infection is still on the rise within the communities, especially with the lifting of lockdown by government.

They say a chronic problem requires a drastic solution. I will like to propose the following:
•The selective lockdown of the three states of Lagos, Federal Capital Territory (FCT) and Ogun helped in curtailing the spread, but the lifting of the lockdown has brought back to the beginning again. States and the Federal Government must come together, agree with one voice and put palliatives in place in every community and then lock down Nigeria for one or two months. No movement, no flight, nothing. Everybody stay where you are for the period. It worked in Wuhan China, and it will work in Nigeria if palliatives are put in place to sustain the populace for the lockdown period. Of course this calls for huge sacrifices on the part of all- government and citizens alike. Pharmacists in hospitals should be adequately empowered to produce in house detergents and hand sanitizers. Government should import the necessary active ingredients and distribute to all hospitals for production of the products. This will ensure high quality products at affordable prices.

•While the lockdown is in place, community testing of the populace should be intensified to detect, isolate and treat carriers. Community pharmacists should be trained to assist in carrying out tests so as to facilitate testing of majority of the population within the lock down period.

•Government should partner pharmaceutical companies that can produce facemasks and hand sanitizers locally by allowing them to import the active pharmaceutical ingredients necessary for production of these products. Hospital pharmacists have produced millions of liters of hand sanitizers since COVID-19 started spreading. Hospital pharmacist should be motivated by government and their CMDs to produce more of these hand sanitizers for use within the hospital and also make available to those hospitals without capacity to produce theirs.

•Government is to be applauded for granting waivers for importation of medical equipment but we are saying that government can go a step further and grant waivers for importation of pharmaceuticals into the country including drugs currently in use to manage COVID-19 patients. This will lead to crashing of prices of medicines, which have skyrocketed since advent of COVID-19

•PPEs are sine qua non to the control process. Government should flood all hospitals with PPEs to protect HCWs. These PPEs should be extended to pharmacists and medical doctors in private practice to protect their lives as well or at worst offered to them at highly subsidized prices.

•On the long term, our government hospitals will need to be upgraded post-COVID-19, to encourage citizens to patronize them and curb brain drain among healthcare professionals.

There has been ongoing debate on the use of hydroxyl chloroquine and chloroquine in the treatment of COVID-19. What is your take on this?
The arguments are there for and against the use of chloroquine and hydroxyl chloroquine. In some countries that used both drugs, it worked for them while in other countries, there was no noticeable improvement. The National Agency for Food and Drug Administration and Control (NAFDAC) recently issued a Health Alert on both medicines, warning that use of both medicines for clinical trials of COVID-19 resulted in risk of heart rhythm problems. So caution is required with their use.

A new study just recommended triple drug therapy including the antiviral drugs interferon, lopinavir and ribavirin after showing promise in phase clinical trials. Please shed more on this and the implications in the COVID-19 fight?
Specific highly active antiviral drugs are always needed for any novel emerging infectious disease like COVID-19 because the development of a new anti-viral drug takes years before it’s approval for clinical use. In place of new drugs, drugs repurposing can be used to mitigate the burden of such disease by testing existing broad-spectrum antiviral drugs that have been used to treat other viral infections. This is the most feasible approach to adopt in a pandemic as the current Corona pandemic. Early treatment with a triple combination of active antivirals is appropriate for the treatment of COVID-19 because the viral load reaches a peak around the time of symptom onset. This is the basis of the use of the triple combination above, which was found to be quite safe when used in Phase 2 clinical trials of COVID -19 patients and was useful in alleviating symptoms and shortening duration of hospital stay. Further clinical trials are however recommended.

Several reports show that the management of other diseases suffers because of the pandemic. How are hospital pharmacists coping and managing the situation?
This is not quite true. Yes, there is a lot of attention on COVID-19 as it should be, but it is not true that non COVID-19 patients are being turned back in hospitals. I am personally aware that specialist clinics are operating full time, general practice clinics are equally on. So patients should feel free to visit hospitals to access care for their health conditions.

Have you received any memo as regards the FG promise of increase in hazard allowance and life insurance for your members?
Well, reports reaching us indicate that at least one institution may have received the hazard allowance. We don’t have reason to doubt the government. We know our hazard allowance will be paid very shortly and also our insurance policy covers should be in place very soon as well.

Some experts advocate that we look inwards for solutions to the pandemic just like Madagascar with its herbal tonic cure. What is your take on this?

Do you recommend herbal medicine for COVID-19? If yes or no, why?
Herbal products are good in themselves; most of them have challenge of not being standardized. And this tends to create safety concerns since you are not too sure of the dose being taken at any point in time, even though herbal products are thought to be less toxic than orthodox medicines. So I can say that I support use of herbal products to treat COVID-19 as long as their efficacy and safety concerns have been addressed and they have been certified fit for use by NAFDAC.

It is in the news that Madagascar is exporting her herbal remedy for COVID-19 known as COVID Organics (COV) to several African countries including Nigeria. As for whether I support the move or not, the fact is that there is no known cure for COVID-19, at the same time it would be counterproductive for us to fold our hands and bemoaning our fate. We are dealing with a novel disease without cure; any remedy that can ameliorate the suffering associated with the disease should be given a trial. Yes, the World Health Organization is skeptical about its use because the product has not undergone clinical trial which is fundamental, but any interventions to save lives of COVID-19 patients should be given a trial, whether of herbal origin or not. But I support that such products should first pass through NAFDAC tests for efficacy and safety so we do not compound a bad situation.

Regarding Prof. Maurice Iwu’s claim of having found a cure for the disease, the same principle applies. His product should be subjected to tests for efficacy and safety before introduction to the population. I am not opposed to clinical trials of these herbal products, but you know clinical trials take time, but now we need quick interventions to mitigate the disease process and I support use of herbal products after ascertaining their efficacy and safety from NAFDAC.

Beyond COVID-19, what are the major problems of the country’s health sector? What are your recommendations on how to address them?
Thank you so much for this all-important question. There are myriads of challenge confronting Nigerian’s healthcare sector, some of them created inadvertently by government herself.

For one thing, there is a lot of distrust in the sector, leading to lack of harmony. Government has increased the salaries of medical doctors twice since 2014, while other healthcare workers have been stagnated including pharmacists. This has formed the basis of JOHESU’s struggles over the years. The government created the problem inadvertently and should redress it by increasing basic salary of pharmacists and others like it did for medical doctors in 2014. Until this is done, I am afraid the much sought after harmony may take a long time to actualize. I am happy though with the recent Memorandum of Understanding signed between the Pharmaceutical Society of Nigeria, the Nigeria Medical Association and the National Association of Nigeria Nurses and Midwives (NANNM). I see that as the beginning of harmony and possible reintegration of all professionals in the healthcare sector.

Another challenge is that globally, healthcare delivery is a team work and collaborative, with the patient at the center and each professional playing its role to better the lot of the patient. Unfortunately, this hasn’t been the case in Nigeria. For instance, in many hospitals, pharmacists are denied access to patients’ bedside and this is very ridiculous in this time and age of pharmaceutical care. The end result is that patients are denied the benefits of pharmaceutical care, which the pharmacist’s expertise would have provided. Elsewhere in the world, studies have shown improved patient outcomes when pharmacists participate in patient ward rounds than places where they do not participate. Why Nigeria’s case is like this still baffles me.

Another challenge we are having is the fall out of absence of drug distribution guidelines, which has meant that anybody can access any medicine from any medicine shop in Nigeria without prescription. Patent medicine shops stock medicines beyond their scope, while some are even said to administer injections behind their curtains. The open drug markets in Nigeria have compounded the challenge of chaotic drug system in Nigeria and completely disrupted the entire supply chain. Part of the consequence is that some patients prescribed drugs that are not available inside hospital pharmacies may end up buying fake and substandard medicines from open drug markets or patent medicine shops.

My recommendation to circumvent this is that government should summon the political will to put an end to these open drug markets that have done more harm than good in Nigeria. The Pharmaceutical Society of Nigeria has been spearheading efforts to implement the National Drug Distribution Guidelines designed to replace the chaotic drug distribution network in Nigeria. It’s time for the federal government to give her full backing to the implementation of those guidelines.

Closely tied to this issue of chaotic drug distribution is the Pharmacy Council of Nigeria (government agency in charge of regulation of Pharmacy Education and Practice in Nigeria) Bill of 2018, seeking powers to sanitize the chaotic drug distribution system in Nigeria. Unfortunately, that Bill is yet to be signed into law. It is meant to check faking and falsification of medicines and quackery among others. Until that is done, drug faking may continue unchecked and anyone can be a victim of fake drugs.

Most patent medicines vendors in addition to stocking outside their mandate, also stock fake and substandard medicines. With enough well trained pharmacists being churned out of Pharmacy Schools annually, these patent medicines shops in major cities and towns should no longer be granted licenses to operate, but they should be screened and those found to be above board should relocate to rural areas where there are no pharmacists and where their services would be needed.


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