Malaria Drug in Short Supply
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Date: 12/07/04
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Date: 7 Dec 2004 07:18:10 -0800
Global Network for Women's and Children's Health Research
http://gn.rti.org/news/index.cfm?id=90&fuseaction=detail
Plan Shortage Leaves Campaigns Against Malaria at Risk
16 Nov 2004 - Donald G. McNeil Jr.
A Chinese herbal drug that is strikingly effective against malaria is
in critically short supply because of rising demand, public health
officials and pharmaceutical executives say.
A Chinese herbal drug that is strikingly effective against malaria is
in critically short supply because of rising demand, public health
officials and pharmaceutical executives say.
As a result, prices for the drug, artemisinin, have quadrupled, and the
few companies that make compounds containing it have drastically cut
back production. Supply crises are looming in 40 tropical countries
that have recently made it the centerpiece of their antimalarial
efforts.
Malaria kills about one million people a year, most of them children.
Strains resistant to older drugs have spread rapidly, and artemisinin
(pronounced are-TEM-is-in-in), which is extracted from the sweet
wormwood plant, was embraced this year by Western health agencies and
donors as the most cost-effective solution.
The sudden shortage "has created a major wave of shock in our
organization," said Dr. Andrea Bosman of the World Health
Organization's malaria control team. Paul Lalvani, procurement manager
for the Global Fund to Fight AIDS, Tuberculosis and Malaria, said the
countries that had just adopted the drug were "really in a bind."
While other drugs are available, switching to a new one takes up to a
year and can create dangerous confusion, especially in a poor country,
he explained; the new drug must be registered, doctors and nurses must
be retrained in dosages and side effects, and rural pharmacies must be
alerted and restocked.
"Now they're sitting on the fence wondering if they should go ahead, or
wait until the price drops, or pick another drug," he said.
Wormwood is an ancient Asian fever treatment, and Chinese military
doctors trying to aid the Vietcong in the 1970's proved that its
extracts kill malaria parasites. It has been popular in Southeast Asia,
but was largely ignored in the West until this year.
Although sweet wormwood grows wild around the world, virtually all of
the cultivation is in the hills of China and Vietnam.
Each crop must be planted in January, harvested in the fall, and then
dried and processed. Some would-be growers outside China are
complaining that they cannot buy seeds.
The shortage began soon after a series of meetings in April at which
the Global Fund, the W.H.O., the World Bank, Unicef, the United States
Agency for International Development and other donors jointly announced
that they wanted malaria-prone countries to phase out older drugs like
chloroquine and sulfadoxine-pyrimethamine and adopt multidrug
combinations containing artemisinin or its derivatives artemether or
artesunate.
Even though the new drugs cost 10 to 20 times as much, the donors chose
them because resistance to older drugs was running as high as 60
percent in parts of Africa. (A typical adult course of 24 of the newer
pills costs the W.H.O. $2.40, as against 20 cents for chloroquine.)
Until early this year, the world consumed about 30 tons of raw
artemisinin a year, mostly in Asia, and the price had been steady for
several years at about $115 a pound.
But immediately after the W.H.O.'s April forecast that the world would
need 130 to 220 tons in 2005, the price rose to $180 a pound. It is now
$365 to $455 a pound.
Drug companies in Switzerland and India say they cannot get enough at
any price, and blame is being directed at all corners.
Mr. Lalvani, the Global Fund procurement specialist, said the refiners
stopped selling this summer, "waiting for the prices to stabilize or go
higher."
Pradeep Nambiar, an executive at Ipca Laboratories, an Indian company,
said that its Chinese suppliers had reneged on contracts and that he
believed they could be "holding back stock anticipating a price rise."
The most vivid evidence of the shortage emerged last Monday, when
Novartis, a major Swiss drug company, said it could produce only about
half of the 4.5 million courses of its Co-Artem drug that it had
promised to deliver to the W.H.O. by March. Its lone artemisinin
supplier in China had fallen short, it said.
Co-Artem is the only malaria drug prequalified by the W.H.O., an
endorsement of its safety. It also combines two drugs in one pill,
making it harder for a patient to give away or sell part of a dose.
As a result, many poor countries, encouraged by donors and Novartis,
specifically adopted Co-Artem. Now some, like Zambia and Ethiopia, will
have their supplies rationed.
Novartis has a 10-year contract to make its "reasonable best effort" to
supply, at cost, all the Co-Artem the W.H.O. asks for. It had made a
commitment to deliver 60 million doses by the end of 2005, but even its
relatively small first batch will fall short.
Daniel Berman, a campaigner for lower drug prices at the medical
charity Doctors Without Borders, criticized Novartis, saying it had
underestimated how much raw material it would need and had relied on
one supplier. Daniela Currie, a Novartis spokeswoman, said the W.H.O.
had made its forecast only after the 2004 crop was in the ground and
some planned extraction plants were still not built. "These are things
we can't really influence," she said, adding that Novartis has now
found two more suppliers.
She said she had "no evidence" that the company's Chinese suppliers,
who also make drugs that compete with Co-Artem, had cut it off in hopes
of taking some of its market share now that the W.H.O. is under
pressure to prequalify more drugs.
In conversations with visiting experts from two Western public health
agencies, summaries of which were obtained by The New York Times,
executives from several Chinese artemisinin refiners blamed their own
suppliers for the sudden rise in prices. After the April meetings, they
said, the word spread in China that the West wanted the drug.
Because of the artemisinin shortage, the W.H.O. now ranks several pills
made in India and China that combine artemisinin with other drugs like
amodiaquine and mefloquine as "approved for procurement in the absence
of prequalified product."
Plans are also afoot to grow wormwood in India, Tanzania and southern
Africa. Some farmers have had trouble getting potent seeds, but Mr.
Nambiar said Ipca had stockpiled them.
Mr. Lalvani said he was worried.
"For 2005, we're stuck," he said. "But let's not be stuck for the year
after that. We need to come up with a solution for this - and right
away."
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