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Quality of anthelminthic medicines available in Jimma Ethiopia

Article  in  Acta Tropica · October 2017

DOI: 10.1016/j.actatropica.2017.10.006

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 Acta Tropica 177 (2018) 157–163

Contents lists available at ScienceDirect

Acta Tropica
journal homepage: www.elsevier.com/locate/actatropica

Quality of anthelminthic medicines available in Jimma Ethiopia MARK

a,b b a a a
Sileshi Belew , Sultan Suleman , Evelien Wynendaele , Matthias D’Hondt , Anne Kosgei ,
⁎
Luc Duchateauc, Bart De Spiegeleera,
a
Drug Quality and Registration (DruQuaR) Group, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, B-9000 Ghent, Belgium
b
School of Pharmacy, Jimma University, PO Box 378, Jimma, Ethiopia
c
Department of Biometrics, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, B-9820 Merelbeke, Belgium

A R T I C L E I N F O A B S T R A C T

Keywords: Soil-transmitted helminthiasis and schistosomiasis are major public health problems in Ethiopia. Mass de-
Anthelminthics worming of at-risk population using a single dose administration of 400 mg albendazole (ABZ) or 500 mg me-
Ethiopia bendazole (MBZ) for treatment of common intestinal worms and 40 mg of praziquantel (PZQ) per kg body
Pharmaceutical quality weight for treatment of schistosomiasis is one of the strategies recommended by World Health Organization
Survey
(WHO) in order to control the morbidity of soil-transmitted helminthiasis and schistosomiasis. Since storage
condition, climate, way of transportation and distribution route could all affect the quality of medicines, regular
assessment by surveys is very critical to ensure the therapeutic outcome, to minimize risk of toxicity to the
patient and resistance of parasites. Therefore, this study was conducted to assess the pharmaceutical quality of
ABZ, MBZ and PZQ tablet brands commonly available in Jimma town (south west Ethiopia). Retail pharmacies
(n = 10) operating in Jimma town were selected using simple random sampling method. Samples of anthel-
minthic medicines available in the selected pharmacies were collected. Sample information was recorded and
encompassed trade name, active ingredient name, manufacturer’s name and full address, labeled medicine
strength, dosage form, number of units per container, dosage statement, batch/lot number, manufacturing and
expiry dates, storage information and presence of leaflets/package insert. Moreover, a first visual inspection was
performed encompassing uniformity of color, uniformity of size, breaks, cracks, splits, embedded surface spots or
visual contaminations. Finally, physico-chemical quality attributes investigated encompassed mass uniformity,
quantity of active pharmaceutical ingredient (API), disintegration and dissolution, all following Pharmacopoeial
test methods The physical characteristics of dosage form, packaging and labeling information of all samples
complied with criteria given in the WHO checklists. The mass uniformity of tablets of each brand of ABZ, MBZ
and PZQ complied with the pharmacopoeial specification limits, i.e no more than 2 individual masses > 5% of
average tablet weight, and none deviate by more than 10%. The quantity of APIs in all investigated tablet brands
were within the 90–110% label claim (l.c.) limits, ranging between 95.05 and 110.09% l.c. Disintegration times
were in line with the pharmacopoeial specification limit for immediate release (IR) tablets, ranging between 0.5
and 13 min. However, the dissolution results (mean ± SD, n = 6) of one ABZ brand (i.e. Wormin®,
Q = 59.21 ± 0.99% at 30 min) and two PZQ brands (i.e. Bermoxel®, Q = 63.43% ± 0.7 and Distocide®,
Q = 62.43% ± 1.67, at 75 min) showed poor dissolution, failing the United States Pharmacopoeia (USP) dis-
solution specification limit.

1. Introduction and soil-transmitted helminthiasis are affecting millions of people

Neglected tropical diseases (NTDs) are affecting 500 million people
living in Sub-Saharan Africa countries. In this region, NTDs are an-
nually causing an estimated 534, 000 deaths and 57 million disability-
adjusted life years loss (Conteh et al., 2010). Ethiopia is one of the Sub-
Saharan Africa countries, where different NTDs mainly schistosomiasis
living in endemic areas (Bajiro et al., 2016; Bitew et al., 2016; Dana
et al., 2014; Mengistu et al., 2011). The prevalence of soil-transmitted
helminths and schistosomiasis in Ethiopia is 48–52% (Tefera et al.,
2017; Mekonnen et al., 2016) and 31–81% (Tadege and Shimelis, 2017;
Bereket and Zewdneh, 2015), respectively. To reduce morbidity and
eliminate NTDs by 2020, the World Health Organization (WHO)

⁎
Corresponding author.
E-mail addresses: sbphar2009@gmail.com (S. Belew), sultan.suleman@ju.edu.et (S. Suleman), Ejwynend.Wynendaele@UGent.be (E. Wynendaele),
Matthias.DHondt@UGent.be (M. D’Hondt), Anne.Kosgei@UGent.be (A. Kosgei), Luc.Duchateau@UGent.be (L. Duchateau), Bart.Despiegeleer@UGent.be (B. De Spiegeleer).

http://dx.doi.org/10.1016/j.actatropica.2017.10.006
Received 30 June 2017; Received in revised form 15 September 2017; Accepted 7 October 2017
Available online 13 October 2017
0001-706X/ © 2017 Elsevier B.V. All rights reserved.
S. Belew et al.
recommends mass drug administration for at-risk populations as one of
the best strategies (WHO, 2010). However, in low-income and middle-
income countries, high prevalence of poor quality medicines (Caudron
et al., 2008; Cohn et al., 2012; Fadeyi et al., 2015; Suleman et al., 2014)
and failure of pharmaceutical distributors to apply stringent criteria for
selecting products and suppliers (Giralt et al., 2017), are prevailing
challenges in patient’s access to quality medicines.
In Ethiopia, the existing weak regulatory enforcement, lack of in-
formal market control, weak port control, poor cooperation between
executive bodies and resource constraint (Suleman et al., 2016) and
long border that Ethiopia shares with neighbouring countries, could
contribute to infiltration of poor quality medicines into the pharma-
ceutical supply chain. Since poor quality of medicine is linked with
reduced efficacy (Belew et al., 2015; Lacey, 1990; Leslie et al., 2009)
and toxicity to patients (Peyraud et al., 2017), evaluating the quality of
essential medicines is crucial for delivering quality health services. In
Ethiopia, owing to the prevalence of schistosomiasis and soil-trans-
mitted helminthiasis as well as other parasitic worms, different brands
of anthelminthic medicines are indiscriminately used in the treatment
of parasitic infections. However, there is little information about the
quality of these medicines circulating in the market (Belew et al., 2015;
Suleman et al., 2014). Therefore, this study was conducted to assess the
quality of anthelminthic medicines encompassing ABZ, MBZ and PZQ
tablets brands commonly available in legally operating retail pharma-
cies in Jimma town.
2. Materials and methods
2.1. Survey area
The survey was conducted in Jimma town. Jimma town is located at
352 km from the capital Addis Ababa. According to Central Statistical
Agency (CSA) report the projected population of Jimma zone from 2014
to 2017 is estimated to be 2,986,957 (CSA, 2013). Jimma is a relatively
large town with nine legally operating wholesalers of pharmaceutical
products which are currently supplying pharmaceutical products to
retail pharmacies (n = 22), health centers (n = 4), clinics (n = 15) and
hospitals (n = 2).
2.2. Sample collection
From a total of 22 pharmacies officially operating in Jimma town,
10 pharmacies were selected using simple random sampling method.
One box of anthelminthic was bought in each of retailing pharmacy
resulting in samples for quality verification. One pharmacy did not have
one of the requested anthelminthics. All samples were transported to
Jimma University Laboratory of Drug Quality (JuLaDQ) on the same
day of sample collection. In addition, survey on the sales volume and
price of ABZ, MBZ and PZQ products available in legally operating
wholesalers (n = 9) and retail pharmacies (n = 22) was conducted.
2.3. Chemicals/reagents/solvents
ABZ (USP reference standard), MBZ (Janssen Pharmaceutica) and
PZQ (Sigma-Aldrich) reference standards were used as received.
Hydrochloric acid (37% w/v, Sigma-Aldrich), methanol (HPLC grade,
Fishers Scientific), acetonitrile (HPLC grade, Fishers Scientific), ortho-
phosphoric acid (Fluka Chemicals Ltd.), potassium phosphate mono-
basic (KH2PO4) (Sigma-Aldrich), ammonium phosphate monobasic
(Sigma-Aldrich), sodium hydroxide (Sigma-Aldrich), sodium lauryl
sulphate (Sigma-Aldrich) and ultra pure water (18.2 Ωcm) were used.
2.4. Physical characteristics, packaging and labelling information
Visual inspection of the physical characteristics of dosage form,
packaging and labelling information was performed following the WHO
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Acta Tropica 177 (2018) 157–163
checklist (WHO, 2015) designed to health professionals to carry out
visual inspection of medicines for signs of counterfeiting and report to
appropriate national authority or directly to WHO. All samples under-
went visual inspection for trade name, active ingredient name, the
manufacturer’s name and full address, labeled medicine strength, do-
sage form, number of units per container, dosage statement, batch/lot
number, manufacturing and expiry dates, storage information, presence
of leaflets/package insert. Moreover, a first visual inspection was per-
formed encompassing uniformity of color, uniformity of size, breaks,
cracks, splits, embedded surface spots or visual contaminations. Finally,
samples were stored between 21.6 °C ± 1.09 as minimum and
22.09 °C ± 0.89 as maximum daily average temperature (mean ±
SD, n = 119 days,), with a relative humidity (%RH) of 36.63% ± 7.04
until analysis.
2.5. Mass uniformity
The mass uniformity test was performed according to the method
given in European Pharmacopoeia (Ph. Eur., 2014a). Randomly se-
lected tablets (n = 20) from each brand of ABZ (Albenzole®, Ovis® and
Wormin®), MBZ (Mebepharm®, Wormin® and Thelmox®) and PZQ
(Bermoxel®, Distocide® and Praziquantel) were weighed using a cali-
brated analytical balance (Mettler Toledo, AB204-5, Switzerland). The
average weight was calculated and the mass uniformity of tablets was
evaluated against Pharmacopoeia specification limit (i.e. no more than
2 individual masses > 5% of the average tablet weight, and none de-
viating by more than 2 × 5% of the average tablet weight).
2.6. Amount of API
2.6.1. System suitability
System suitability test was evaluated according to European
Pharmacopoeia method (Ph. Eur., 2014b). The symmetry factor of
principal peak of reference standard and percent relative standard de-
viation of replicate injections (6 times) of reference standard were
calculated and compared against Pharmacopoeia specification limit i.e
symmetry factor of the principal peak (0.8-1.5) and maximal permitted
percent relative standard deviation (%RSD) of replicate injections
(0.85).
2.6.2. Albendazole
The amount of API of samples of ABZ tablets was investigated ac-
cording to the United States Pharmacopoeia method (USP, 2015a).
2.6.2.1. Preparation of standard solution. Approximately 100.0 mg of
ABZ reference standard (RS) was accurately weighed into a 50.0 mL
volumetric flask and dissolved in 5.0 mL of acidified methanol (sulfuric
acid/methanol, 1/99% v/v). The prepared stock solution was diluted
with methanol to volume and mixed. A volume of 5.0 mL of the solution
was transferred into a second 50.0 mL volumetric flask and diluted with
methanol to volume and mixed again.
2.6.2.2. Preparation of sample solution. Randomly selected tablets
(n = 20) were finely powdered. A portion of powder equivalent to
approximately 100.0 mg ABZ was transferred into a 50.0 mL volumetric
flask, dissolved in 5.0 mL of acidified methanol (sulfuric acid/
methanol, 1/99% v/v), shaken for 15 min, diluted with methanol to
volume, mixed and filtered with Whatman No. 1 filter paper by
discarding the first 15.0 mL of the filtrate. A 5.0 mL of clear filtrate
was transferred into a second 50.0 mL volumetric flask, diluted with
methanol to volume and mixed.
2.6.2.3. HPLC method. The samples were analyzed using HPLC
equipped with a 254 nm UV–vis detector and a C18 column (4.6 mm
x 25 cm, 5 μm) (Zorbax, Agilent). The mobile phase was a mixture of
0.50 g monobasic ammonium phosphate (NH4H2PO4) in 400.0 mL
S. Belew et al.
water/methanol (40/60% v/v). The column temperature, injection
volume and flow rate were 25 °C, 20.0 μL and 2.0 mL/min.,
respectively.
2.6.3. Mebendazole
The amount of API was investigated according to the United States
Pharmacopoeia method (USP, 2015b).
2.6.3.1. Preparation of standard solution. Approximately 25.0 mg of
MBZ RS was transferred into a 100.0 mL volumetric flask and
dissolved in 10.0 mL of formic acid and heated in a water bath at
50 °C for 15 min. The sample was mechanically shaken for 5.0 min,
dissolved in 90.0 mL methanol and cooled. The solution was diluted to
volume with methanol and mixed. A 5.0 mL of the solution was
transferred to 25.0 mL volumetric flask, diluted with mobile phase to
volume, mixed and filtered through a filter paper having a porosity of
0.5 μL. A 0.05 mg/mL of MBZ RS was prepared in mobile phase and
used.
2.6.3.2. Preparation of sample solution. Randomly selected tablets
(n = 20) were finely powdered. A portion of powder approximately
equivalent to 500.0 mg MBZ was transferred into a 100.0 mL
volumetric flask and dissolved in 50.0 mL of formic acid and heated
in a water bath at 50 °C for 15 min. The flask was mechanically shaken
for 1 h, diluted with water to volume, mixed and filtered with Whatman
No. 1 filter paper. A 5.0 mL of the filtrate was transferred into a
100.0 mL volumetric flask and diluted with a solution of formic acid in
methanol (formic acid/methanol, 1/9% v/v) to volume. Finally,
0.05 mg/mL of MBZ solution was prepared in mobile phase and used.
2.6.3.3. HPLC method. The samples were analyzed using HPLC
equipped with 247 nm UV–vis detector and a C18 column
(4.6 mm × 25 cm, 5 μm) (Zorbax, Agilent). The mobile phase used
was a mixture of 0.05 M monobasic potassium phosphate (KH2PO4) and
methanol (0.05 M monobasic potassium phosphate/methanol, 40/60%
v/v, pH = 5.5). The column temperature, injection volume and flow
rate were 30 °C, 15.0 μL and 1.5 mL/min., respectively.
2.6.4. Praziquantel
2.6.4.1. Preparation of standard solution. The amount of API was
investigated according to the United States Pharmacopoeia method
(USP, 2015c). An accurately weighed amount of PZQ RS was dissolved
in mobile phase (acetonitrile/water, 60/20% v/v) to obtain a solution
having a concentration of about 0.18 mg/mL.
2.6.4.2. Preparation of sample solution. Randomly selected tablets
(n = 20) were finely powdered. A portion of powder approximately
equivalent to 150.0 mg PZQ was transferred into a 100.0 mL volumetric
flask, dissolved in 70.0 mL mobile phase (acetonitrile/water, 60/40%
v/v), sonicated for 5 min, diluted with mobile phase to volume, mixed
and filtered with Whatman No. 1 filter paper. A volume of 3.0 mL of the
filtrate was transferred into a 25.0 mL volumetric flask and diluted with
mobile phase to volume and used.
2.6.4.3. HPLC method. The samples were analyzed using HPLC
equipped with 210 nm UV–vis detector and a C18 column (4.6 mm x
25 cm, 5 μm) (Hypersil ODS, Thermo Scientific). The mobile phase used
was a mixture of acetonitrile/water (60/40% v/v). The column
temperature, injection volume and flow rate were 30 °C, 10.0 μL and
1.5 mL/min., respectively.
2.7. Disintegration
The disintegration test was performed according to the European
Pharmacopoeia (Ph. Eur., 2014c). Six tablets from each brand of ABZ,
MBZ and PZQ were randomly selected and placed into tubes of the
159
Acta Tropica 177 (2018) 157–163
disintegration apparatus with disk (ERWEKA, GmbH, Germany). The
test was performed for 15 min using a medium of 1000.0 mL de-ionized
water at a temperature of 37 ± 0.5 °C and device’s basket raising and
lowering frequency rate of 32 cycles/min.
2.8. Dissolution
2.8.1. Albendazole
The dissolution of tablet samples of each brand of ABZ was eval-
uated using a dissolution apparatus II (paddle) (Varian VK-7010
Dissolution apparatus, Agilent Technologies) following United States
Pharmacopoeia test method for ABZ tablets (USP, 2015a). The test was
performed for 45 min at a medium temperature and the spindle rotation
speed of 37 ± 0.5 °C and 50 rpm, respectively. Six tablets, two from
each brand of anthelminthics medicines were randomly assigned into
the dissolution vessels containing a dissolution medium (900.0 mL
0.1 N HCl). A 10.0 mL samples was withdrawn at predetermined time
points (15, 30, 45 min), immediately filtered using Whatman No. 1
filter paper and diluted in 250.0 mL volumetric flask with 0.1 N sodium
hydroxide. The absorbance of each sample was determined at 308 and
350 nm using a UV/Visible spectrophotometer (Ultrospec-4000, Phar-
macia Biotech) and the difference taken as absorbance value. A 0.1 N
sodium hydroxide solution was used as the background. The quantity in
milligram (mg) of dissolved ABZ was calculated by the formula
22.5 × C(Au/As), where C is the concentration of the ABZ reference
standard (RS) in the standard solution (μg per mL) and Au and As are the
absorbance differences, obtained at 308 and 350 nm, of the solution
under test (Au) and the standard solution (As).
2.8.2. Mebendazole
The dissolution of tablet samples of each brand of MBZ was eval-
uated using a dissolution apparatus II (paddle) (Varian VK-7010
Dissolution apparatus, Agilent Technologies) following United States
Pharmacopoeia test method for MBZ tablets (USP, 2015b). The test was
performed for 120 min at a medium temperature and the spindle ro-
tation speed of 37 ± 0.5 °C and 75 rpm, respectively. Six tablets, two
from each brand of anthelminthics medicines were randomly assigned
into the dissolution vessels containing a dissolution medium (900.0 mL
0.1 N HCl containing 10 mg sodium lauryl sulphate per mL). A 10.0 mL
samples was withdrawn at predetermined time points (30, 60, 90,
120 min) and immediately filtered using Whatman No. 1 filter paper.
The samples were analyzed using HPLC equipped with 254 nm UV–vis
detector and C-18 column (4.6 mm × 25 cm, 5 μ) (Microsorb Varian).
The mobile phase used was mixture of acetonitrile (HPLC grade) and
buffer solution (8.0 g of sodium hydroxide and 3.0 g of sodium lauryl
sulphate in 2.0 L of water, pH of 2.5 adjust with phosphoric acid)
(acetonitrile/buffer, 3/7% v/v). The column temperature, injection
volume and flow rate were 25 °C, 10.0 μL and 1.0 mL/min, respectively.
2.9. Praziquantel
The dissolution of tablet samples of each brand of PZQ was eval-
uated using a dissolution apparatus II (paddle) (Varian VK-7010
Dissolution apparatus, Agilent Technologies) following United States
Pharmacopoeia test method for PZQ tablets (USP, 2015c). The test was
performed for 75 min at a medium temperature and the spindle rotation
speed of 37 ± 0.5 °C and 50 rpm, respectively. Six tablets, two from
each brand of anthelminthics medicines were randomly assigned into
the dissolution vessels containing a dissolution medium (900.0 mL
0.1 N HCl containing 2.0 mg of sodium lauryl sulphate per mL). A
10.0 mL samples was withdrawn at predetermined time points (15, 30,
60, 75 min) and immediately filtered using Whatman No. 1 filter paper.
The amount of PZQ dissolved was determined at an absorbance wave
length of 263 nm using a UV/Visible spectrophotometer (Ultrospec-
4000, Pharmacia Biotech).
S. Belew et al. Acta Tropica 177 (2018) 157–163

3. Results Table 2
Results of quantity of API of tablet samples (n = 20) of ABZ, MBZ and PZQ brands.
The survey results on weekly sales volume of anthelminthic medi-
Product % lable claim (%RSD, n = 2)a
cines in legally operating wholesalers (n = 9) and retail pharmacies
(n = 22) (S3 Table) revealed that the products of ABZ, MBZ and PZQ Albendazole
sampled for this study account for respectively 27, 60 and 100% of the Albezole® 400 mg 97.74 (0.19)
Ovis® 400 mg 96.88 (1.51)
products of each API of anthelminthic medicines available in Jimma. In
Wormin® 400 mg 95.05 (0.98)
addition, the weekly sales data of anthelminthic medicines in retail endazole
pharmacies in Jimma indicate that relatively large numbers of dosage Mebepharm® 100 mg 102.53 (0.00)
units (n = 12,144) of the investigated products are dispensed per week. Wormin® 100 mg 108.24 (0.41)
The price of the investigated products is presented in S4 Table. Thelmox® 100 mg 110.09 (0.01)
Praziquantel
Considering the doses recommended by WHO, the average (n = 3)
Bermoxel® 600 mg 99.46 (0.02)
price per treatment of ABZ, MBZ and PZQ is 0.20, 0.45 and 0.40 USD, Distocide® 600 mg 96.83 (0.02)
respectively. This shows that an average estimated minimum and Praziquantel 600 mg 102.12 (0.04)
maximum cost of the investigated anthelminthic medicines per treat-
a
ment is 4.72 and 10.63 Ethiopian Birr (ETB), respectively. number of injections.

3.1. Physical characteristics of tablets, packaging and labelling Table 3

Disintegration time ranges of tablet samples (n = 6) of different brands of ABZ, MBZ and
PZQ tablets.
The results of visual inspection on physical characteristics, packa-
ging and labelling information of samples of each brand of ABZ, MBZ Product name API Time range (min)
and PZQ are presented in supplementary information table (S1 Table).
Albendazole
The price of the investigated anthelminthic medicines is presented in Albezole® 400 mg 5.0–8.0
supplementary information table (S4 Table). The results of visual in- Ovis® 400 mg 10.0–13.0
spection on physical characteristics of dosage form, packaging and la- Wormin® 400 mg 8.0–12.0
beling revealed that all samples did not show signs of counterfeit Mebendazole
Mebepharm® 100 mg 1.0–1.5
medicines defined by WHO.
Wormin® 100 mg 1.0–1.1
Thelmox® 100 mg 3.0–4.0
3.2. Mass uniformity Praziquantel
Bermoxel® 600 mg 1.0–2.0
Distocide® 600 mg 9.0–11.0
The mass uniformity results (Table 1) of tablet samples of each
Praziquantel 600 mg 0.5–1.0
brand of ABZ, MBZ and PZQ were within the European Pharmacopoeia
specification limit (i.e. no more than 2 individual masses > 5% of the
average tablet weight and none deviating by more than 10% of the 3.5. Dissolution
average tablet weight).
The dissolution profile (mean ± SD, n = 6) of tablet brands of
3.3. Amount of active pharmaceutical ingredient ABZ, MBZ and PZQ (Fig. 1A–C) revealed that two PZQ brands (i.e
Bermoxel®, Q = 63.43 ± 0.70, Distocide®, Q = 62.43 ± 1.67) and
The assay results (Table 2) of API (mean ± SD% l.c.) showed that one ABZ brand (i.e Wormin®, Q = 59.21 ± 0.99) failed to comply with
samples of all anthelminthic brands comply with the USP specification the USP specification limits (i.e. ABZ: Q ≤ 80% at 30 min, MBZ:
limit (90–110% l.c.). The percent relative standard deviation (%RSD) Q ≤ 75% at 120 min, PZQ: Q ≤ 75% at 60 min).
values (< 2%) of all samples indicated adequate analytical precision.

3.4. Disintegration 4. Discussion

The results of disintegration time (Table 3) of all product samples Evaluating the quality of medicines circulating in the market is
complied with the specification limits given in the European Pharma- important to reduce risk of having poor quality medicines in the supply
copoeia (i.e complete disintegration of immediate release (IR) table- chain. In this study, we assessed the pharmaceutical quality of com-
ts ≤ 15 min). monly available brands of ABZ, MBZ and PZQ tablets in Jimma town.

Table 1
Mass uniformity results of samples of different brands of ABZ, MBZ and PZQ tablets.

Product Average tablet weight (mg) (n = 20) Range of tablet weight (mg) %RSD (n = 20) LV – UV (mg)

Albendazole
Albezole® 400 mg 1039.4 996.2–1078.1 0.12 987.4–1091.4
Wormin® 400 mg 685.1 670.4–696.2 0.07 650.8–719.3
Ovis® 400 mg 698.5 679.7–729.3 0.11 663. 6–733.4
Mebendazole
Mebepharm® 100 mg 262 248.7–270.6 0.11 248.9–275.1
Wormin® 100 mg 302.6 289.5–308.6 0.1 287.4–317.7
Thelmox® 100 mg 315 313.9–318.1 0.01 299.3–330.8
Praziquantel
Bermoxel® 600 mg 734.7 721.4–742.2 0.03 697.9–771.4
Distocide® 600 mg 910.1 884.1–929.8 0.07 864.6–955.6
Praziquantel 600 mg 747.9 737.7–767.9 0.05 710.5–785.5

%RSD: percent relative standard deviation; LV: lower limit; UV: upper limit.

160
S. Belew et al.
The results of visual inspection of packaging and labelling information
on the tested brands of ABZ, MBZ and PZQ tablets did not show signs of
spurious, falsely labelled, falsified or counterfeit products as defined by
WHO (WHO, 2009). This suggests that packaging and labeling in-
formation of each brand of anthelminthic medicines is in line with
WHO guideline on packaging for pharmaceutical products (WHO,
2002). The results of mass uniformity of tablet samples of all anthel-
minthic medicines comply with pharmacopoeia specification limit (Ph.
Eur., 2014a) (i.e. no more than 2 individual masses > 5% of the
average tablet weight and none deviating by more than 2 × 5% of the
average tablet weight). Though the mass uniformity results comply
with pharmacopoeia specification limit, the presence of outlier tablets
indicates inconsistency of tablet manufacturing process (Adeley et al.,
2014). For a single dose preparation, variations in mass of tablets could
influence uniformity of API and/or entire composition of a dosage unit.
According to USP tablets of ABZ, MBZ and PZQ should contain the
required amount of API (%l.c. = 90–110%) (USP, 2015a,b,c). The
assay results of API (mean ± SD% l.c.) of all tablet samples of an-
thelminthic brands complied with the Pharmacopoeial specification
limit. Thus, with respect to amount of API, interchangeable use of tablet
brands containing the same API will most probably result in a similar
clinical efficacy. Also, the assay results suggest that there is not a sig-
nificant quality difference in the different tablet samples.
The disintegration times complied with the pharmacopoeial speci-
fication limit (complete disintegration of IR tablets ≤ 15 min).
However, 3–4 min disintegration time difference was observed in a set
of samples of all ABZ tablet brands and one PZQ tablet brand
(Distocide®). Moreover, Distocide® showed longer disintegration time
(9–11 min) compared with the other praziquantel tablet brands
(0.5–2 min). This might be attributed to variations in the manu-
facturing process and/or differences in the type and amount of ex-
cipient used (King Chiu et al., 1957).
Considering the single point dissolution specification (mean ± SD,
n = 6), one third of the tablet samples (one ABZ brand (Wormin®,
Q = 59.21 ± 0.99) and two PZQ brands (Bermoxel®,
Q = 63.43 ± 70 and Distocide®, Q = 62.43 ± 1.67)) failed to
comply with the USP acceptance criteria (USP, 2015a,c) (i.e. ABZ:
Q ≥ 80% at 30 min and PZQ: Q ≥ 75% at 60 min). For Biopharma-
ceutical Classification System (BCS) class II drugs like ABZ, MBZ and
PZQ, dissolution is a rate limiting factor for absorption into the blood
but assumed also into the parasite system (Takano et al., 2008). Thus,
poor dissolution could be a risk of reduced efficacy. Indeed, it has been
shown that ABZ tablet brands (Azol®, RDZ® and Bendex®) which failed
to comply with the USP acceptance criteria for dissolution (Q ≥ 80 at
30 min) showed low percent egg reduction rate (i.e. RDZ®: 80.8%,
Azol®: 73.1% and Bendex®: 88.7%) against hookworm (Ancylostoma
duodenale or Necator americanus), while other brands (Zentel® and
Ovis®) which did comply with the dissolution specification demon-
strated relatively high percent egg reduction rate (i.e. Zentel®: 87.1%
and Ovis®: 98.1%). On the other hand, having poor dissolution, Azol®,
161
Acta Tropica 177 (2018) 157–163
Fig. 1. Dissolution profile (Mean ± SD, n = 6) of
(A) ABZ tablet brands in 900 mL 0.1N HCl
(37 ± 0.5 °C, rpm = 50), (B) MBZ tablet brands in
900 mL 0.1N HCl containing 1% sodium lauryl sul-
phate (37 ± 0.5 °C, rpm = 75) and (C) PZQ tablet
brands in 900 mL 0.1N HCl containing 2.0 mg/mL
sodium lauryl sulphate (37 ± 0.5 °C, rpm = 50)
using a USP II apparatus.
RDZ® and Bendex® showed an egg reduction rate ranging between 91.9
and 98.7% against round worm (Ascaris lumbricoides), which is almost
similar to the percent egg reduction rate observed for Zentel® (92.6%)
and Ovis® (97.8%) (Albonico et al., 2007; Belew et al., 2015). This
suggests that dissolution might not have an equally significant effect for
roundworms as for hookworms. The differences in efficacy results ob-
served against hookworm and roundworm might be attributed to the
differences in feeding behaviour and/or routes of nutrient uptake be-
tween the two parasites (Gilbert, 1996; John et al., 2004; Skelly et al.,
2014). This suggests that the in-vivo relevance of the in-vitro dissolu-
tion will depend on parasite type, with its life cycle, the medicine up-
take mechanism and the internal parasite medicine pharmacology. Poor
dissolution may thus not necessarily and automatically be linked to a
reduced efficacy in all helminth parasitic species. Different mechanisms
such as active efflux, reduced drug uptake, drug modification, drug
sequestration, by-pass shunt of helminth parasites (Ouellette, 2001)
should be taken into consideration for the in vitro-in vivo relationship
(IVIVC).
However, the concept of ‘substandard’ drugs, defined as ‘genuine
medicines produced by the manufacturers authorized by the national
medicines regulatory authority which do not meet quality specifications
set for them by national standards’ (WHO, 2009) is not directly and
automatically linked to IVIVC. Both aspects, i.e the regulatory stan-
dards based on quality consistency as well as the clinical relevance, are
to be considered in the overall evaluation. Ideally, both aspects should
be consistent; however, currently, due to the absence of well developed
PK-PD models, there is not yet proof of this consistency, remaining a
challenge for future research. Generally, since dissolution is a critical
quality attribute, the poor dissolution of investigated medicines, could
minimize the clinical efficacy and pose a challenge in chemotherapeutic
approach which is one of the strategies that Ethiopia has been im-
plementing to prevent, control and eliminate NTD by 2020 (FMoH,
2016). In addition, the poor quality of medicines could have a negative
impact on some of the progress in Ethiopia that has been made in
prevention, control and elimination of soil-transmitted helminths and
schistosomiasis so far (Nebiyu et al., 2017). Moreover, poor quality of
investigated anthelminthic medicines could increase the risk of drug
resistance (Newton et al., 2010). Furthermore, since legally operating
retail pharmacies in Jimma are dispensing relatively large numbers of
dosage units (n = 12,144) of the investigated anthelminthic medicines
per week, the poor dissolution of these medicines could have a negative
impact on the recovery of a significant number of patients infected with
STHs, schistosomiasis and other gastrointestinal worms.
5. Conclusion
The results of the present study showed that all the samples of each
brand of ABZ, MBZ and PZQ tablets complied with the pharmacopeial
specification acceptance criteria for packaging and labeling informa-
tion, mass uniformity, amount of API and disintegration. However, one
S. Belew et al.
third of samples failed to comply with the pharmacopoeial specification
limit set for dissolution test. In general, the results of this study suggest
that anthelminthic medicines circulating in the market could have risk
of reduced efficacy. Therefore, poor quality of medicines could influ-
ence the chemotherapeutic intervention approach in reducing mor-
bidity caused by soil-transmitted helminths and schistosomiasis. Thus,
continuous monitoring, in a systematic way, the quality of anthel-
minthic medicines circulating in the market is recommended.
Conflict of interest
Authors declare no conflict of interest.
Authors’ contribution
Conceived and designed the experiments: BDS MD EW LD SS SB.
Performed the experiments: SB, SS, MD, EW. Analyzed the data: BDS,
LD, SB, EW, AK. Contributed reagents/materials/analysis tools: BDS,
MD, LD, SS. Wrote the paper: BDS, MD, EW, LD, SS, SB, AK.
Funding
BOF (Special Research Fund) is funding a PhD scholarship of Sileshi
Belew in Gent University (Scholarship code 01W03714, Reference
number DOZA/ILDDC/AM/0866b-2014). The funders had no role in
study design, data collection and analysis, decision to publish, or pre-
paration of the manuscript.
Acknowledgement
The authors would like to thank Laboratory of Drug Quality and
Registration (DruQaR), Gent University, Belgium for the provision of
the reference substances. Additionally, we would like to thank the staff
of the Laboratory of Drug Quality of Jimma University (JuLaDQ)
(Markos Duguma, Henok Teshome, Tesfaye Mohammed and Yimer
Mekonnen) for their kind support and collaboration.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at http://dx.doi.org/10.1016/j.actatropica.2017.10.
006.
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