The Impact of EG and DEG Cases on Sales of Over-The-Counter Syrup

: The Indonesian Food and Drug Authority (BPOM) investigated and listed safe and unsafe syrup products in response to the contamination of Ethylene Glycol (EG) and Diethylene Glycol (DEG), causing Acute Kidney Injury in pediatric patients. Unsafe products were recalled and removed from distribution, leading to uncertainty and panic among the public and significantly impacting over-the-counter syrup sales in several pharmacies. This retrospective observational study assessed the impact of EG and DEG contamination on the sales of over-the-counter syrup in Pharmacy X in South Denpasar. Data from three months before (August to October 18 th , 2022) and three months following the official instruction was published (October 19 th, 2022 to December 2022) were analyzed using Wilcoxon test. The findings reveal a staggering decline in the sales of over-the-counter syrup by 35,03% (p-value of 0.03). Moreover, there was a notable increase of prescriptions in powder forms. The contamination cases caused panic, resulting in changes in behavior and consumption patterns. Despite the availability of safety information on an official website, public hesitance toward syrup products persists, indicating the need to implement a more effective strategy to address misinformation and restore public trust. Each individual must be responsible for educating the public during crises to prevent the spread of misinformation, ultimately restoring trust and normal consumer behavior. Furthermore, efficient stock management should be implemented to anticipate potential health crises in the future proactively


INTRODUCTION
After three consecutive years of dealing with the COVID-19 pandemic, at the end of August 2022, Indonesia was surprised by an unexpected surge in cases of Atypical Progressive Acute Kidney Injury (APAKI), primarily affecting children under five years old.Data from November 2022 shows 323 cumulative cases and 190 recorded deaths (Kemenkes RI, 2022a).Symptoms include fever, cough, flu, anuria, reduced urine volume (oliguria), and digestive infections such as vomiting and diarrhea.These cases were suspected to result from post-Covid-19 hyperinflammatory reactions in children, also known as multisystem inflammation in children (MIS-C) (Kemenkes RI, 2022).
Around the same time, 66 pediatric deaths were reported in Gambia due to Acute Kidney Injury (AKI)   Next, on October 24 th 2022, MoH re-issued official statement allowing primary health care and pharmacy to resume sales of proven safe over-the-counter syrup as published before (Kemenkes RI, 2022b).
BPOM continues monitoring and testing samples and has published a list of safe and unsafe syrup products.
However, despite the safety measures, there is still panic among the public regarding syrup consumption, leading to a significant decline in sales of over-the-counter syrups in primary health care and pharmacy.Furthermore, this phenomenon has led to a significant increase in the dispensing of alternative forms of medication such as powders and capsules, as substitutes for syrup products for children.As a result, there is an escalation in waiting time for medications and long queues at pharmacy, also experienced a decline in turnover.
This study aims to assess the impact of EG and DEG cases on the sales of over-the-counter syrup products and the number of dispensed-drug prescriptions in one of the Denpasar region's pharmacies.The findings of this study could be crucial for government authorities in formulating strategies to mitigate and respond to future outbreaks related to medication safety.

METHODS
The study utilized retrospective, analytical observational methods, using sales data from Pharmacy X in South

RESULT AND DISCUSSION
Although EG and DEG contamination cannot be confirmed as the main cause AKI in pediatric patients, these cases have resulted in uncertainty and panic among parents who typically purchase syrup to treat mild symptoms in their children.This uncertainty arises from recent purchases of possibly contaminated syrup for their children before the authorities release definitive findings.
Syrup is the preferred form of medication for children due to its palatable taste and smell.As a result of this ongoing phenomenon, pharmacy have experienced a significant reduction in syrup product sales and incurred turnover losses.Based on sales data from Pharmacy X, sales of over-the-counter syrup products decreased by 35.06% during the study period (Table 1).
The most drastic decline occurred after the temporary suspension of syrup prescriptions was announced by the authorities on October 18th, 2022.The lowest sales were observed between October 19th-31st, 2022, when social and mass media reported an escalation of death cases related to AKI in pediatric patients.Pharmacies and other primary healthcare providers were instructed to remove syrup products from their storefronts and advise patients to seek alternative medicine (IAI, 2022).Furthermore, the decline in sales was also linked to parental reluctance in administering recently purchased medication due to concerns about potential contamination with EG dan DEG, and the potential consequences of administering such drugs to their children.In contrast to the phenomenon of panic buying during pandemic of Covid-19 (Chua et al., 2021;Khusna et al., 2021;Nurazizah, Emelia and Listiani, 2021;Sari and Susanti, 2022), these cases caused public uncertainty about consuming syrup, resulting in a decline in sales.The potential impact of social conditions on personal health and well-being has been shown to change consumer behavior (Di Crosta et al., 2021).The condition triggered negative emotions that affected the mental states of individuals, leading to withdrawal behavior and distrust, which in turn affected purchasing interest (Landau et al., 2011).
BPOM has published an official site to check the safety of syrup products in Indonesia.Despite the availability of information, the confidence level in consuming syrup remains low.The digitalization of information has brought a positive impact in terms of access and availability, but it has also led to misinterpretation and the spread of rumors (Frank and Schvaneveldt, 2016).There has been a proliferation of misleading information, hoaxes, and click bait on social media, which tend to sway public opinion (Baker et al., 2020).The public tends to disregard information from authorities and become ignorant and distrustful of the government.In social media, many people mock and doubt the government for alleged negligence in allowing contaminated syrup products to be sold in the market.The level of public confidence in the government is influenced by various factors, such as sociodemographic characteristics (Galende et al., 2022), levels of knowledge, attitudes, and perceptions of the risks associated with the current phenomenon (Beca-Martínez et al., 2022).How authorities communicate information can significantly influence public acceptance.Fear-induced information is only effective if individuals feel capable of dealing with the threat and it does not become overwhelming.However, such messages can have a double-edged effect when targeting individuals experiencing panic and lacking knowledge about the ongoing phenomena (Id et al., 2020).In times of uncertainty, people often imitate others and believe that others better understand the situation (Sheu and Kuo, 2020;Zheng, Shou and Yang, 2020).This has led to a preference among parents to take their children to physician for mild symptoms that could be self-medicated.
The prescription trends in Pharmacy X show a significant increase in dispensed-drug in powder form compared to syrup product, there a significant escalation of dispenseddrug (Table 3), that reach 114,61% and the number of packages of each powder increased by 86,01%.Factors such as patient confidence and safety, influencing the prescription preference by the physician (Yağar and Dokme, 2017;Viswanath and Rao, 2019).
Denpasar.Sales data from three months before the statement of suspension on prescribing syrup (August -October 18 th 2022) and three months after the statement published by the MoH (October 19 th -December 2022) were compared.The data included sales of over-thecounter syrup products and dispensed drug prescriptions (powders) from August to December 2022.To conduct analysis, a comparison can be made between total sales three months prior and three months following the release of statement by MoH regarding the suspension of prescribing syrup.Data was analyzed using the Wilcoxon test to compare the total sales before and after the issue.

Table 1 .
Sales Data of Over-the-Counter Syrup During August to December 2022

Table 2 .
Sales Data of Over-The-Counter Syrup Based on Class Therapy

Table 3 .
Service data on drug-dispensed (powders) from August to December 2022