[Epilepsy in Lao Popular Democratic Republic: difficult procurement of a first-line antiepileptic contributes to widening the treatment gap].
Résumé
In Laos, over 95% of people with epilepsy (PWE) do not receive a proper treatment. Traditional beliefs and practices have long explained this wide treatment gap. From 2008 to 2010 we evaluated the procurement process for phenobarbital, the leading first-line antiepileptic drug (AED) in Laos, and its availability at a national scale as a potential additional major cause of this treatment gap in Laos. Data were drawn from several surveys conducted from 2008 to 2010: (i) semi structured interviews of key persons from the Ministry of Health and from pharmaceutical factories, wholesalers, pharmacists, neurologists, psychiatrists, and non-governmental organisations; (ii) retrospective survey of AED prescriptions in three main hospitals of Vientiane the capital city during two randomised weeks from June to August 2009; (iii) self-administered questionnaires of pediatricians regarding their knowledge about phenobarbital; (iv) a national survey of the AED availability in pharmacies and drug shops in 16/17 provinces, 16 districts and 96 villages (multistage randomised survey) in 2010 and a survey among the population in 2009. Phenobarbital is imported in Laos via a carefully controlled importation process either as raw material to be processed by factory N(o) 2 or in the form of tablets. The International Narcotics Control Board (Vienne) delivers a yearly quota of 25kg of raw phenobarbital to the Food and Drug department (FDA). This allows the production of 245000 tablets per year (around 671 annual adult treatments). The overall importation process for phenobarbital lasts 6months. Grade 1 pharmacists (mostly located in urban areas) and regional and district hospitals are authorized to deliver phenobarbital. The cost of phenobarbital ranged from 0.11 to 0.2US dollars/tablet per day (39 to 67US dollars per year). High cost of transportation and increased cost of phenobarbital (5- to 10-fold greater than the international market) contribute to reduce access to treatment. Needs for phenobarbital at delivery sites should be re-assessed by the health authorities based on the expected number of PWE. Improved training of health and pharmacist personnel and increased awareness of the population concerning effective long-term treatment for epilepsy are crucial to improve access of PWE to AED in Laos.