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Ulaanbaatar, Mongolia Rie Nakajima1, Takehito Takano2, Vaanchig Urnaa2, Nyambayar Khaliun1 Keiko Nakamura1
1International Health and Medicine, Graduate School of Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku Tokyo, Japan2Health Promotion, Graduate School of Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku Tokyo, Japan
Address for Correspondence:
Takehito Takano, Department of Health Promotion, Tokyo Medical and Dental University, 1-5-45 Yushima,
Bunkyo-ku Tokyo, Japan. E-mail: firstname.lastname@example.org
Nakajima R, Takano T, Urnaa V, Khaliun N, Nakamura K. Antimicrobial use in a country with insufficient enforcement of pharmaceutical
regulations: a survey of consumption and retail sales in Ulaanbaatar, Mongolia. Southern Med Review (2010) 3; 1:19-23
To examine the inappropriate use of antimicrobials by investigating (1) actual utilization pattern and retail sales and (2)
antimicrobial resistant information provided by health professionals in Ulaanbaatar, Mongolia.
We investigated antimicrobial use in Ulaanbaatar, Mongolia by surveying 619 consenting customers who attended 250
randomly chosen pharmacies in December 2006. Pharmacy staff were also interviewed about antimicrobials purchased. In January
2007, we surveyed 117 consenting Ulaanbaatar medical doctors from seven local hospitals about their perceptions of treatment failure
due to antimicrobial resistance.
Among 619 pharmacy customers, 48% of them had bought at least one type of antimicrobial medicine and, of these,
42% had a prescription to purchase antimicrobials. On average, 67% of the customers reported that a pharmacy worker had given
them information regarding the dose and timing at which the medicine should be used but only 9% reported that they had been
given information regarding possible adverse effects. The survey of medical doctors suggested that some antibiotics had become less
effective clinically between 2001 and 2006.
The study shows that less than half of all customers who purchased an antibiotic at a pharmacy had a prescription. This
shows that antimicrobials can be readily purchased without a prescription despite the existence of laws making such practices illegal.
There is a need to establish a vigilant drug regulatory authority to promote enforcement and regulation of medicines in Mongolia. To
create awareness regarding the dangers of antimicrobial resistance, educational campaigns for consumers are also necessary.
antimicrobial utilization, antimicrobial resistance, developing country, Mongolia.
Organization (WHO) warns that the purchase of antimicrobials
without a prescription leads to the misuse and overuse of
During the past few decades, the number of antimicrobial-
antimicrobials, resulting in the emergence of antimicrobial-
resistant pathogens has increased rapidly in many parts of
the world1. Of note, the rate of increase of antimicrobial-resistant pathogens in Asia is the highest in the world2-4. One
Many developing countries have a limited ability to
of the major reasons for the increase in antimicrobial-resistant
manufacture antimicrobial medicines; therefore, they must
pathogens in many developing countries is that antimicrobials
obtain antimicrobial medicines from other countries. Numerous
can be purchased without a prescription5. The World Health
commercial dealers of pharmaceutical products compete with
Southern Med Review
Vol 3 Issue 1 Feb 2010
one another to extend sales in developing countries, providing
conducted to train the interviewers, providing them with
imported medicines to meet the demand for antimicrobials in
knowledge and interviewing skills. Two interviewers visited
these countries6. However, the control and regulation measures
each of the pharmacies and interviewed the pharmacy staff.
for the sale of pharmaceuticals in developing countries are often
Following individual interviews with the pharmacy workers,
insufficient. Mongolia is one such country where antimicrobials
the study team spent one hour outside of the pharmacy and
can be widely purchased without a prescription, despite the
approached customers who had just left the pharmacy and
existence of laws prohibiting this act. Penalties imposed on
asked for their cooperation in completing a short interview. A
offenders guilty of such acts include closure of a store where
total of 619 pharmacy customers agreed to participate in the
such a trade has been conducted7. Despite this, the measures
to control and regulate the sale and purchase of antimicrobials
The survey for practicing medical doctors was a self-administered
in Mongolia are insufficient8, 9. This is a problem that not only affects Mongolia, but also impacts many developing countries
report based on a structured questionnaire form: the reports
were collected after a complete explanation of the purpose
10-12. In this context, the objectives of
the present study were to explore the antimicrobial utilization
of the survey and a step-by-step explanation of the questions
pattern and retail sales; another objective was to explore the
had been made by specially trained doctors. All queries were
perceptions of clinicians regarding antimicorbial resistance.
collected and answers and clarifications were given to the participating medical doctors before they submitted their
completed questionnaire forms. The self-administered survey of the medical doctors was completed by 117 medical doctors who
We conducted three surveys using structured questionnaires:
agreed to participate in the study. These doctors were selected
one for pharmacy workers, one for pharmacy customers, and
from amongst 7 leading hospitals in Ulaanbaatar .
one for practicing medical doctors. The study protocol was
Face to face in depth interview of ten medical doctors were
approved by the ethical review boards of the Tokyo Medical and Dental University and the Ministry of Health, Mongolia.
conducted. These doctors were randomly selected from participants of the medical doctor’s survey. These doctors
answered questions regarding antimicrobial therapy. The questions were also asked regarding doctors’ knowledge on
The study was carried out in Ulaanbaatar, the capital city
Centre for Disease Control guidelines15.
of Mongolia, where the general public’s accessibility to antimicrobials has been rapidly increasing in recent years as a
result of the rapid economic development.
The interview questionnaire for the pharmacy workers included
Mongolia is a landlocked central Asian country, with a total area
the following items: the names of all the antimicrobial medicines
of 1.6 million square kilometers. Among the total 2.7 million
sold at the pharmacy (regardless of strength), the average
populations, 32% are living in Ulaanbaatar, the capital of
number of customers who bought medicine per day, and
Mongolia8. On the financial side, the Mongolian economy has
the average number of customers who bought antimicrobial
experienced positive GDP growth averaging 8.7 percent from
medicine per day during the two week period prior to the study.
The interview questionnaire for the pharmacy customers
Mongolia’s current health system has been evolving for more
included the following items: customer’s age, sex, educational
than 70 years and is characterized by three levels of care: primary,
background, purchase of antimicrobial and non antimicrobial
secondary and tertiary care14. Although these health facilities still
medicines, types and whether it was the oral or injectable form.
do not meet the current needs of the country, 8 it is reported that
The other questions were age, symptoms of the expected user
for every 1000 Mongolians 2.7 physicians are available14. Health
of the medicine, presentation of the prescription (to purchase
insurance was introduced in 1994 and it is estimated that about
antimicrobial medicines), and instructions given by the pharmacy
78% of the population is covered. However, it is still common
staff regarding the use of the medicines.
that patients have to pay out of pocket in private pharmacies to obtain the necessary medications8.
The self-administered questionnaire for the medical doctors asked for their professional estimates as to the current
Subjects, sampling and questionnaire procedures
prevalence of antimicrobial resistance, their clinical experiences with antibiotics and the expected number of ineffective
The pharmacies surveyed in the present study (both pharmacy
treatments encountered during the application of each of the
workers and customers) were selected from a list provided by
the Mongolian Ministry of Health. A total of two hundred and fifty pharmacies were randomly selected from amongst the five
Period of the survey
hundred pharmacies registered in Ulaanbaatar. Interviewers of the pharmacy and customer survey were clinical pharmacology
The pharmacy staff and customer interviews were conducted
professionals with sufficient knowledge of antimicrobials and
in December 2006, while the survey of medical doctors was
pharmaceutical practice. A three day training workshop was
performed in January 2007. The study was performed during
Southern Med Review
Vol 3 Issue 1 Feb 2010
the winter season because the prevalence of acute respiratory
Table 2. Number of customers who bought
infection is typically high during this time and thus a large
antimicrobials per 50 customers who visited
number of antimicrobials are prescribed.
pharmacies to buy medicine.
Number of customers who bought antimicrobials per 50 customers
All data were entered and analyzed using SPSS software (version
14.0). The average numbers of pharmacy customers who bought
specific antimicrobial medicines per fifty customers (who bought both antimicrobial and non-antimicrobial medicines) from that
pharmacy were calculated for each type of antimicrobial. This
indicator was used to represent the retail sales of antimicrobials.
Results and knowledge from pharmacy workers reveal the
types of antimicrobials which has been sold to customers at
pharmacies during the two weeks prior to the study (Table 1).
Table 1. Types of antimicrobials sold to customers at
community pharmacies in Ulaanbaatar, Mongolia
* Average for 250 pharmacies located in Ulaanbaatar,
Table 2 shows the number of customers who bought each
type of antimicrobial medicine per 50 customers who visited pharmacies to buy medicine.
Among the 619 pharmacy customers who agreed to participate in this study, 48.0% of them (297 customers) had bought at
least one type of antimicrobial medicine. Among those who
bought antimicrobials, 42.1% of them (125 customers) had a
prescription for the antimicrobial medicine that was purchased.
Antimicrobials commonly used by injection were benzylpenicillin
(used by 90% of customers who bought antimicrobials), cefazolin (80%) and gentamicin (90%).
The most common reasons for purchasing antimicrobials
were acute respiratory disease (54.8%), genitourinary disease (15.5%), and gastrointestinal disease (10.7%). Among the
pharmacy customers who suffered from acute respiratory disease, 45.1% of them bought oral penicillin, either amoxicillin
(24.6%) or ampicillin (20.5%). The most common strength of these two antimicrobials was 500 mg (selected by 70% of
Antimicrobials reported to have been sold during the 2 weeks
customers who bought amoxicillin or ampicillin), and rest of
prior to the interview day at community pharmacies.
them (30%) bought 250 mg which mainly used for children.
Southern Med Review
Vol 3 Issue 1 Feb 2010
Table 3. Instructions given by pharmacy staff to
antimicrobials had a prescription, while the pharmacy customer
customers regarding various parameters
survey showed that 42.1% of the customers who purchased antimicrobials had a prescription. These results are based on
customers who visited community pharmacies in Ulaanbaatar.
The pharmacy worker survey indicated that, amoxicillin and
ampicillin, sulfamethoxazole-trimethoprim, and metronidazole were the most frequently sold antimicrobials in Ulaanbaatar
pharmacies. The frequent sale of amoxicillin and ampicillin, both of which are oral penicillins, as over-the-counter drugs has also
been reported in Vietnam and Mexico16, 17. The frequent use
of these medications is most likely explained by their cost and availability: amoxicillin and ampicillin are generally less expensive
than other antimicrobials, and over 70% of all pharmacies
throughout the world sell amoxicillin18. All pharmacies in the
present study sold both amoxicillin and ampicillin. Generally, variations in the types, frequency, and methods in which
antimicrobials are used by the general public vary in countries according to disease patterns, patient characteristics, and
the quantity and quality of care services at health facilities19.
Variations in the general characteristics of antimicrobial use in developing counties also arise from the ability to purchase
antimicrobials inexpensively and without a prescription.
Among the pharmacy customers who bought over-the-counter medicines, more than half of the customers were
seeking treatment for acute respiratory diseases; amoxicillin and ampicillin were sold to more than half of these customers.
Antimicrobials were also frequently sold to patients suffering
from genitourinary or gastrointestinal diseases.
Table 3 shows the summary of instructions given by pharmacy
Antimicrobials sold to these patients included not only
workers to pharmacy customers. On average, 67.3% of the
penicillins, but also a wide range of other antimicrobials
customers reported that a pharmacy worker had given them
including chloramphenicol and gentamicin. There is a concern
information regarding the dose and timing at which the
that the amount of antimicrobial use is related to the increase
medicine should be used; 8.9% of them reported that they had
in drug-resistant pathogens20. In fact, our survey of perception
also been given information regarding adverse effects.
of medical doctors showed that the antimicrobials which were frequently sold in community pharmacies were losing their
The study reveals that the doctors feel that the medicines such
effectiveness for the treatment of patients.
as benzyl penicillin, gentamicin, metronidazole, ampicillin, phenoxymethyl penicillin, and ciprofloxacin are no longer very
High consumption of antimicrobials among patients with
effective in treatment as they may have a problem of antibiotic
common diseases such as acute respiratory disease and
gastrointestinal disease were frequently reported in several countries16, 17 and the same has been observed in Mongolia.
Especially the patients who are suffering from genitourinary disease are on rise in Mongolia and these patients frequently
The results of the pharmacy worker and pharmacy customer
surveys were consistent, with about half of the pharmacy
There is a tendency in developing countries to take antimicrobials
customers purchasing antimicrobial medicines: the pharmacy
even when their symptoms are not serious or even when
worker survey indicated that an average of 4.6 (SD = 1.8) out
there are no signs of infection21. One such medicine is
of 10 customers purchased antimicrobial medicines, while the
chloramphenicol, which is widely used in developing countries,
pharmacy customer survey showed that 48.0% of the pharmacy
primarily because it is cheap and broad spectrum. However, this
customers purchased antimicrobial medicines. The results of
medicine is now rarely used in developed countries because of
the pharmacy worker and pharmacy customer surveys also
its serious adverse effects, such as the development of aplastic
consistently showed that 40% of the customers who purchased
anemia22. The present survey shows that chloramphenicol is
antimicrobials had a prescription: the pharmacy worker survey
commonly used in Mongolia, especially for the treatment of
reported that 4.0 (SD = 2.3) out of 10 customers who purchased
gastrointestinal disease. However, the present study shows that
Southern Med Review
Vol 3 Issue 1 Feb 2010
only 4% of the customers, who purchased chloramphenicol,
received information regarding side effects.
1. World Health Organization Global Strategy for Containment of
To date, there have been limited laboratory studies conducted
Antimicrobial Resistance. World Health Organization, 2001. WHO/
on antimicrobial sensitivity in Mongolia and it is difficult to
establish whether antimicrobial resistance has increased or not.
drugresist/en/EGlobal_Strat.pdf (Accssed 17/11/ 2009)
2. Lee NY et al. Carriage of antibiotic-resistant Pneumococci among
Hence, promoting the use of an antimicrobial sensitivity test
Asian children: A multinational surveil ance by the Asian Network
before prescribing antimicrobials is an important approach to
for Surveil ance of Resistant Pathogens. (ANSORP). Clin Infect Dis
monitor and to control the further emergence of antimicrobial
3. Song JH et al. High prevalence of antimicrobial resistance among
clinical Streptococcus pneumoniae isolates in Asia (an ANSORP
Although it is a crude measure of changes in resistance,
study). Antimicrob Agents Chemother 2004; 48:2101-2107.
4. Akita H. Penicil in resistant Streptococcus pneumoniae: Actual
this survey of experienced medical doctors in Ulaanbaatar
condition of overseas. Shonika Rinsho 2002; 55:2291-2296. [in
also suggested that based on their clinical experience some
antimicrobials are losing their effectiveness for the treatment of
5. Hoban D et al. Demographic analysis of antimicrobial resistance
among Streptococcus pneumoniae: worldwide results from PROTEKT 1999-2000. Int J Infect Dis 2005:9; 262-273.
There are no specific antibiotic guidelines in Mongolia and it
6. WHO. Priority medicines for Europe and the world. In: World
is necessary to promote and establish best practice clinical
Health Organization. 2001. http://archives.who.int/prioritymeds/report/index.htm ( Accssed 17/11/2009)
guidelines. These guidelines should not be limited to medical
7 Ministry of health Mongolia. Drugs act of 1998. Ulaanbaatar,
doctors, but should also target and include pharmacists and
Mongolia, 1998. http://moh.mn/moh%20db/Healthreports.nsf/
pharmacy workers. The knowledge of pharmacy workers about
antimicrobials play a key role in promoting the rational use
8. Bolormaa T et al. Mongolia: Health system review. Health Systems
of antimicrobials, considering the fact that many consumers
9. Ministry of health Mongolia. Mongolia Pharmaceutical sector
purchase directly in Ulaanbaatar. Hence, the education of
assessment report. Ulaanbaatar, Mongolia, 2004.
prescribers and dispensers (including drug sellers) is important
10. Borg MA, Scicluna EA. Over-the-counter acquisition of antibiotics
for appropriate antimicrobial use and for the containment of
in the Maltese general population. Int J Antimicrob Agents 2002; 20:253-257.
11. Al Bakri AG et al. Community consumption of antibacterial
drugs within the Jordanian population : sources, pattrns and
This study provides an understanding of the sale and use of
appropriateness. Int J Antimicrob Agents 2005; 26: 389-395.
antimicrobials by a sample of the general public in Ulaanbaatar,
12. Mitsi G et al. Patterns of antibiotic use among adults and parents
Mongolia. At present, the public can purchase antimicrobials for
in the community: A questionnaire-based survey in a Greek urban
the treatment of common diseases, such as acute respiratory
population. Int J Antimicrob Agents 2005; 25: 439-443.
13. UNDP. Employment and poverty in Mongolia. In: United Nations
infection, without requiring a prescription and without receiving
proper instructions regarding the use of such medicines. The
development of comprehensive and consistent control measures
at national level to regulate the medicine quality and distribution
14. WHO Regional Office for the Western Pacific. Country health
information profiles. In: World Health Organization Regional
is urgently needed in Mongolia. Also, antimicrobials should not
Office for the Western Pacific. 2007. http ://www.wpro.who.int/
be available as over-the-counter drugs.
countries/2007/mog/ (Accessed 17 Nov 2009).
15. CDC. Infectious Disease guidelines. In: Centers for Disease
Control and Prevention. http://www.cdc.gov/ncidod/guidelines/guidelines_topic.htm (Accessed 10 Aug 2009).
16. Duong DV et al. Availability of antibiotics as over-the-counter
The present study is first of its kind and it explores the use of
drugs in pharmacies: a threat to public health in Vietnam. Trop
antimicorbials in Mongolia. The study reveals that antibiotics
are commonly available in Mongolia and the consumers have
17. Calva J. Antibiotic use in periurban community in Mexico: a
easy access to these medicines. Establishing a drug regulatory
household and drug store survey. Soc Sci Med 1996; 8: 1121-1128.
authority could improve the enforcement and also can aid to
18. Cameron A et al. Medicines prices, availability, and affordability
improve the quality use of antimicrobials. Mass educational
in 36 developing and middle-income countries: a secondary
campaigns could also create awareness regarding the use of
19. Dong H et al. Association between health insurance and antibiotics
prescribing in four counties in rural China. Health Policy 1999; 48:29-45.
20. Albrich WC et al. Antibiotic selection pressure and resistance in
Streptococcus pneumoniae and Streptococcus pyogenes. Emerg
The authors report no conflicts of interest.
21. Okumura J et al. Drug utilization and self-medication in rural
communities in Vetnam. Soc Sci Med 2002; 54:1875-1886.
22. Duke T, et al. Chloramphenicol versus benzylpenicil in and
gentamicin for the treatment of severe pneumonia in children in
This study was supported by Grants-in-Aid of Scientific Studies
Papua New Guinea: a randomized trial. Lancet 2002; 359:474-
of the Japan Society for the Promotion of Science.
Southern Med Review
Vol 3 Issue 1 Feb 2010
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