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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 6, November/December 2019
AFRICA
371
Discussion
This pragmatic survey included 14 countries with responses from
North, South, East, West and Central Africa. Most respondents
work in governmental hospitals that typically treat patients with
RHD. This survey unmasked major barriers to the use of BPG
in African countries where RHD constitutes a major public
health problem and was documented to be the most common
indication for BPG use.
Shortages of BPG at the point of care were reported in
nearly a third of countries surveyed. This is similar to the 2013
global survey of clinicians in 24 countries when 42% (16/39) of
respondents indicated problems with BPG supply.
6
Similarly,
a more recent survey conducted by the WHO and the Clinton
Health Access Initiative (CHAI) of 81 countries in America
and Africa revealed that at least 41% of countries experienced
BPG shortages, which were attributed to shortfalls in supply,
demand and procurement.
6
The market analysis by CHAI
highlights the perceived issues with quality and safety, leading
to underutilisation of BPG by health staff.
4,6,7
Substitution
behaviour may increase the use of alternative, less effective
and more expensive antibiotics. In turn, orders for BPG have
decreased, leading to delays in production and distribution.
The beliefs and preferences of people who provide, administer
and receive BPG injections drive supply. Therefore supporting
safe and appropriate use of BPG is important for stabilising
demand and the market. Clinical guidelines and administration
guides are important parts of supporting health workers. This
survey revealed that although some countries reported that they
do have BPG administration guidelines, they are not universally
used. A clear need for training courses and resources was also
identified. The PASCAR Penicillin Working Group is developing
a task aid for BPG administration to respond to this need but
ongoing support and education is needed to ensure this effective
medication is safely used.
One of the areas of greatest confusion in use of BPG centres
on skin testing. In some countries there is a belief that skin testing
is needed to assess for risk of penicillin allergy prior to BPG
administration. This study indicates that 40% of respondents use
some kind of skin testing with dilute BPG. In addition to Africa,
we are aware of other countries that use dilute BPG skin testing,
including Iran,
8
Nepal
9
and India (pers commun). Despite this
widespread practice, there is no evidence that skin testing is
useful in reducing adverse reactions to BPG. It is possible that
the practice stems from the 2001 WHO guidelines on ARF and
RHD, which suggest that health workers need to be trained
on skin testing before giving BPG injections for secondary
prophylaxis.
10
In this reference there was no specification of the
type of skin test. This recommendation might explain the widely
practiced use of dilute BPG for skin testing.
The standard test for BPG allergy is conducted using
benzylpenicilloyl polylysine (major determinant), penicillin
G diluted with normal saline to 10 000 units/ml (minor
determinant), positive and negative controls.
11
It is indicated in
patients with a prior history of hypersensitivity to penicillin and
it is not recommended for routine use prior to BPG injection.
This test is not expected to be readily available in African
primary healthcare settings therefore there is no need to include
it as a guideline.
In contrast to the widespread use of skin testing, emergency
kits containing adrenaline were reported to be available to only
30% of respondents. Prompt administration of adrenaline is
the mainstay of treating anaphylaxis. Ensuring that adrenaline
and other resuscitation equipment are available when BPG
is administered is important for safe use of the medication.
Similarly, training of health workers on management of
anaphylaxis will increase their confidence, as has been reported
from the Zambian experience.
12
The survey showed variations in BPG interval for secondary
prophylaxis. Most countries follow the WHO recommendation
of three- to four-weekly injections however some respondents
administer BPG two weekly. This emphasises the need for
standardised administration guidelines and may require
conducting research to study the best interval for BPG to be
effective for secondary prophylaxis.
Adverse reactions to BPG are not rare and have been one
of the barriers to the use of the drug. The commonest minor
adverse reaction to BPG is pain at the site of injection. There is
some evidence that this can be managed by using an anaesthetic
solution such as lidocaine 2% as diluent for the BPG powder.
13
However, this practice is not endorsed by manufacturers and
clinical guidelines are not yet in place to support the use of local
anaesthetic.
Major adverse reactions have also been reported, including
deaths associatedwith BPGadministration. A third of respondents
in this survey identified major adverse reactions associated with
BPG. This result is similar to the World Heart Federation survey
in 2013 that included 39 physicians, where 26% reported serious
adverse reactions related to BPG, including deaths.
6
The mechanism of these deaths is not entirely understood.
Anaphylaxis can cause death following injection, however other
mechanisms such as inadvertent intravenous injection and
arrhythmias need to be considered. Sudden deaths without
signs of anaphylaxis have been reported and may be related to
arrhythmias in patients who have a severe valve dysfunction.
14
Improving health workers’ knowledge and practices can
largely decrease these adverse events and improve workers’
confidence in dealing with them. As is seen in this report, health
workers’ reluctance to give BPG and the lack of confidence were
common and directly related to their fear of adverse reactions.
Further improvement is sorely needed in order to overcome such
serious reactions.
This survey has a number of limitations. The number of
participants is small. Clinicians with concerns and adverse
experiences with BPG may have been more inclined to respond,
leading to bias over-representing concerns. Although respondents
may not have been representative, it is clear that shortages of
BPG and concerns about use persist in a number of places across
the African continent.
Conclusion
This survey demonstrates that shortages of BPG supply occur
in Africa and this can limit use of the drug for prevention and
management of RHD. Skin testing is quite widespread despite
the lack of evidence that it can reduce the risk of major adverse
events. In contrast, lifesaving access to emergency kits and
adrenaline to manage anaphylaxis are limited. Adverse reactions
do occur and health workers reported that they are not confident
in managing these. Safe and reliable supplies of BPG are critical
for managing the ongoing burden of RHD in Africa. Penicillin is