INVESTIGATION: Eleven years after ban, Chloroquine still used for malaria treatment in Nigeria

Eleven years after Nigeria banned the use of oral artemisinin-based monotherapies (oAMTs) for malaria treatment, chloroquine, a notable oAMT, is still readily available at patent medicine stores across the country and is being used for treatment of malaria.

A PREMIUM TIMES’ investigation shows Nigerians have continued to use chloroquine against malaria, and some have done so unaware of the ban and the attendant danger.

Chloroquine was banned as a first line treatment drug for malaria in Nigeria in 2005. The decision, based on the recommendation of the World Health Organisation, was taken by the Federal Ministry of Health due to high treatment failures resulting from drug resistance.

NAFDAC said it has continued to grant licenses for the production of the drug because of its use for the treatment of other ailments.

But since most drugs are dispensed over the counter in Nigeria without prescription notes, many Nigerians, unaware of the limitations of the drug, have continued to use chloroquine for malaria treatment.

In 2014, the Nigeria National Malaria Elimination Programme reported that malaria accounted for approximately 60 percent of outpatient visits and 30 percent of hospital admissions.

Due to recurring drug resistance, monitoring of the efficacy of antimalarial drugs is a critical component of global efforts to eliminate malaria.

In 2002, the WHO recommended the ban of chloroquine for treatment of malaria when the Therapeutic Efficacy Testing conducted across the six geopolitical zones in Nigeria showed that the drug had an efficacy of 35% as against the standard 95% efficacy.

This led to the removal of chloroquine as a first line treatment for malaria in the National Antimalarial Treatment Policy 2005.

Awareness of chloroquine ban in Nigeria

According to WHO recommendation, the withdrawal of manufacturing licenses of oral artemisinin-based monotherapies should be conducted six months after the deployment of Artemisinin Combination Therapies (ACTs).

Though this target had been met in Nigeria as reported in the 2010 Nigeria Malaria Indicator Survey, in which only ACTs are sold in the public hospitals and prescribed by health care providers, the drugs remain available elsewhere without regulation of its use.

Although a WHO document updated in 2015 lists Nigeria as one of the countries that have taken regulatory measures to withdraw the marketing authorisation of oral artemisinin-based monotherapies (Chloroquine inclusive), chloroquine tablets are still widely sold in Nigeria, with many manufactured as recently as 2016, and bearing authentic NAFDAC registration numbers.

In 2014, NAFDAC said chloroquine was being gradually phased out. However, it is taking longer than anticipated.

An examination of medicine stores in Abuja, revealed that chloroquine under brand names such as “Albequine” and “Quimal” could be readily purchased for as low as N200.

An official at Dana Pharmaceuticals, one of the producers of the drug, told PREMIUM TIMES the company was producing chloroquine for non-malarial treatment.

“Chloroquine is not banned but no longer recognised for malaria treatment because it is believed not to be effective,” the official who refused to be named said. “We produce Chloroquine for other ailments but we know some people still buy our Chloroquine for malaria treatment.”

While the drug remains in the market for other illnesses, many Nigerians buy them for malaria treatment — many, unaware of the ban.

Celine Egbuchulem, a patent medicine vendor, says she not only sells chloroquine for malaria treatment, but uses same for her treatment.

“Chloroquine is very effective against malaria…. I use Chloroquine and it doesn’t itch me. Some of my customers prefer buying drugs that end with quine for malaria treatment,” she said. “One of my customers, a 45 years old man always come once in 2-3 months to buy Chloroquine for malaria treatment.”

Esther Peters, another vendor at Gwarimpa, Abuja, told PREMIUM TIMES that she was unaware the drug had been banned for the treatment of Malaria.

She said she routinely buys the drug from a supplier at Jabi in Abuja, and emphasised the authenticity of the drug by showing the reporter the NAFDAC registration number.

“I only sell the Chloroquine tablets to people who ask for them to treat malaria because some people complain of side reactions to the drug. Six tablets are sold for N50,” Mrs. Peters said.

In Delta State, a pack of Chloroquine (10 tablets) goes for N200.

Poor monitoring and regulation

At the 30th World Health Assembly in 2007, after Nigeria and other WHO member states agreed to stop the sale and use of oral artemisinin-based monotherapies (including Chloroquine) against malaria, a monitoring system was launched by WHO to track compliance at the country level and pharmaceutical companies. The pharmaceutical companies manufacturing the banned drugs were identified from the drugs advertised online.

However, a limitation to this system is that most of the domestic pharmaceutical companies in Nigeria operate offline.

In fact, only six companies were involved in the list: Bond Chemical Ind Ltd, Jubilee & Associate Ind Ltd, Justeen Pharm Ltd, NPL, Neros Pharm Ltd, Geneith Pharmaceutical Ltd, and Vixa Pharmaceuticals Co. Ltd.  In Nigeria, 43 percent of the listed companies declined to disclose their intention to comply with WHO’s resolution.

A search of the NAFDAC’s website revealed that a total of 374 Chloroquine products had been registered by the agency.

Although NAFDAC acknowledged that chloroquine was being registered, manufactured and sold in Nigeria, Abubakar Jimoh, Director, Special Duties/ Public Relations and Protocol Unit of the agency, said the drugs were for the treatment of rheumatoid arthritis and intestinal infections.

“NAFDAC is constrained in putting a blanket ban on chloroquine in Nigeria because of other indicators. We are constrained in banning chloroquine outrightly because it is used for other purposes like treatment of arthritis and also intestinal infections and disease. So, if we want to ban it, then what of the other ailments it is meant for?”

“What we decided to do was to do a kind of selective banning and tell all stakeholders or manufacturers that they should not produce chloroquine for the treatment of malaria. We are still registering chloroquine but for other indications, not for malaria and that is why we are promoting the use of combined therapy, artemisinin combined therapy for treatment of malaria.”

He said NAFDAC had launched a campaign to dissuade the public from using the drug for malaria treatment.

“We have embarked on massive public health campaigns, nobody goes around now to start buying Chloroquine for treatment of malaria,” Mr. Jimoh insisted.

PREMIUM TIMES asked the WHO Nigeria office if it was monitoring pharmaceutical companies involved in the manufacturing of Chloroquine and other oral artemisinin-based monotherapies in Nigeria.

A WHO spokesperson, Rex Mpazanje, said “In Nigeria, NAFDAC is such a regulatory body. NAFDAC is responsible for monitoring local manufacturing of Chloroquine and local marketing/importation of oral artemisinin monotherapies in Nigeria.”

He said NAFDAC, does report to WHO annually on status on the status of the pharmaceutical market.

“However this report does not normally go into details of specific drugs. In addition to NAFDAC reports, the national malaria elimination programme (NMEP) does also report to WHO on malaria control and these reports do include specifics on therapeutic efficacy testing assessments/studies conducted,” he said.

The National Malaria Elimination Programme said while chloroquine is also used for other ailments aside malaria, the agency is involved in awareness creation amongst Nigerian citizens of the use of ACTs in malaria treatment and training of health workers.

“The availability of chloroquine is due to market dynamism, law of demand and supply driven by clients that use it for malaria treatment,” Godwin Ntadom, Head of Case Management of the agency, told PREMIUM TIMES.

He said the success story is that chloroquine is “no longer openly advertised and also the government doesn’t stock chloroquine in her health facilities”.