Will they deliver treatment access?: WTO rules and Canada's law on generic medicine exports

More than two years since Canada enacted the Jean Chrétien Pledge to Africa, no generic medication produced under compulsory license has yet been exported from Canada. In this feature article, Richard Elliott describes attempts by two Canadian generic pharmaceutical companies to navigate the complicated and unwieldy processes established under the Act, and, noting the government's pledge to review the law and fix it to make it work, prescribes a number of ways in which the process should be streamlined.

Preventing avian influenza in humans: the role of simple public health interventions

An influenza pandemic due to influenza virus A H5N1 subtype is considered highly likely. Strategies for prevention and control of a pandemic include actions that need to be taken by the national authorities and communities. The availability of a vaccine and antiviral drugs in sufficient quantities for billions of people in the developing world is doubtful. Simple cost effective public health interventions can significantly reduce the risk of contracting infection. These interventions include precautions that will prevent people from contracting infection from sick or dying poultry and their products, human cases and a contaminated environment. Specific measures are based on principles of cutting short the transmission of infection in humans and inactivating the virus at its source. The paper describes context specific actions that can be implemented in both rural and urban settings by the communities themselves.

Non-voluntary licensing of antivirals under patent: options the Australian Government should consider in light of a potential bird flu pandemic

In the face of a potential bird flu pandemic, Australian Federal Health Minister, Tony Abbott, has recently dismissed expert advice that the government should begin, or even publicly consider, authorising generic manufacturers to produce antivirals, such as Tamiflu and Relenza, under patent via non-voluntary licensing methods. This is despite the fact that the demand for antivirals in Australia, and throughout the world, cannot be met by manufacturers under the control of limited patent owners alone. This article proposes that Australian patent law, which allows for non-voluntary licensing when it comes to important public health issues that affect Australian citizens, is relevant in meeting the demand for increased antiviral treatments during a possible bird flu pandemic, domestically and abroad. It argues that the Australian Government must go beyond what is currently being done and investigate and pursue such options.

Strategies for mitigating an influenza pandemic

Development of strategies for mitigating the severity of a new influenza pandemic is now a top global public health priority. Influenza prevention and containment strategies can be considered under the broad categories of antiviral, vaccine and non-pharmaceutical (case isolation, household quarantine, school or workplace closure, restrictions on travel) measures. Mathematical models are powerful tools for exploring this complex landscape of intervention strategies and quantifying the potential costs and benefits of different options. Here we use a large-scale epidemic simulation to examine intervention options should initial containment of a novel influenza outbreak fail, using Great Britain and the United States as examples. We find that border restrictions and/or internal travel restrictions are unlikely to delay spread by more than 2-3 weeks unless more than 99% effective. School closure during the peak of a pandemic can reduce peak attack rates by up to 40%, but has little impact on overall attack rates, whereas case isolation or household quarantine could have a significant impact, if feasible. Treatment of clinical cases can reduce transmission, but only if antivirals are given within a day of symptoms starting. Given enough drugs for 50% of the population, household-based prophylaxis coupled with reactive school closure could reduce clinical attack rates by 40-50%. More widespread prophylaxis would be even more logistically challenging but might reduce attack rates by over 75%. Vaccine stockpiled in advance of a pandemic could significantly reduce attack rates even if of low efficacy. Estimates of policy effectiveness will change if the characteristics of a future pandemic strain differ substantially from those seen in past pandemics.

Vaccines and antiviral drugs in pandemic preparedness

Controlling a pandemic with vaccine and antiviral drugs will require a coordinated international approach to determine how the least amount of virus can immunize the largest segment of a population.

While measures such as closing schools and social distancing may slow the effects of pandemic influenza, only vaccines and antiviral drugs are clearly efficacious in preventing infection or treating illness. Unless the pandemic strain closely resembles one already recognized, vaccine will not be available early. However, studies can be conducted beforehand to address questions concerning vaccine dose, frequency of inoculation, and need for adjuvants. In contrast, antiviral drugs, particularly the neuraminidase inhibitors, will be effective for treatment and available if stockpiling takes place. Special questions need to be answered if a highly lethal virus, such as influenza A (H5N1), produces the pandemic. Both vaccines and antiviral drugs will be required for a coordinated strategy.

Economics of neuraminidase inhibitor stock piling for pandemic influenza, Singapore

We compared strategies for stock piling neuraminidase inhibitors to treat and prevent influenza in Singapore. Cost-benefit and cost-effectiveness analyses, with Monte Carlo simulations, were used to determine economic outcomes. A pandemic in a population of 4.2 million would result in an estimated 525-1,775 deaths, 10,700-38,600 hospitalization days, and economic costs of 0.7 dollars to 2.2 billion Singapore dollars. The treatment-only strategy had optimal economic benefits: stock piles of antiviral agents for 40% of the population would save an estimated 418 lives and 414 million dollars, at a cost of 52.6 million dollars per shelf-life cycle of the stock pile. Prophylaxis was economically beneficial in high-risk subpopulations, which account for 78% of deaths, and in pandemics in which the death rate was >0.6%. Prophylaxis for pandemics with a 5% case-fatality rate would save 50,000 lives and 81 billion dollars. These models can help policymakers weigh the options for pandemic planning.

Pandemics, antiviral stockpiles and biosecurity in Australia: what about the generic option?

In view of the possibility of a human pandemic of avian influenza, a first-line strategy for many countries is stockpiling of antiviral neuraminidase inhibitors (oseltamivir [Tamiflu] and zanamivir [Relenza]), which can reduce mortality, morbidity and influenza transmission. However, global supply of the antivirals is controlled by the European-based patent owners, Roche and GlaxoSmithKline. This prevents competition in the manufacturing and distribution of antivirals and has reduced global supply capacity and affordability. The Australian Government has acknowledged that, in the event of a pandemic, its own stockpile of antivirals will be limited and reserved for those on a confidential rationing list. Pharmacies are running out of stocks, limiting opportunities for individuals to secure supplies privately. Compulsory licensing provisions, permitted under domestic patent law, would allow Australian generic manufacturers to start producing antivirals locally or import them from generic producers at affordable prices. Australia also has an opportunity and a responsibility to promote compulsory licensing and generic antiviral production in the Asian region, to ensure our neighbours can establish pandemic stockpiles in a timely and affordable manner.

Increased antiviral medication sales before the 2005-06 influenza season--New York City

Oseltamivir, zanamivir, rimantadine, and amantadine are antiviral medications approved for the treatment and/or prophylaxis of influenza A and/or B, although high levels of resistance among circulating strains of influenza A led CDC to issue interim recommendations in January 2005, advising that amantadine and rimantadine not be used for the treatment or prevention of influenza A during the 2005-06 influenza season. As part of syndromic surveillance, the New York State Department of Health (NYSDOH) monitors sales of antiviral influenza medications paid for by the Medicaid system, and the New York City Department of Health and Mental Hygiene (NYCDOHMH) monitors sales of antiviral influenza medications by a retail pharmacy chain. Syndromic data are used in combination with data provided by laboratories, health-care facilities, and health-care providers to monitor influenza activity. In October 2005, a spike in antiviral medication sales was noted. The spike did not coincide with other markers of influenza activity but did coincide with the beginning of media coverage of avian influenza A (H5N1) and the potential for an influenza pandemic. Tracking prescription medication sales can detect spikes for which no immediate indication exists. Such syndromic data might be used to guide issuance of public health recommendations regarding the limited availability of certain medications and the inadvisability of personal stockpiling.

Intravenous cidofovir treatment for recalcitrant warts in the setting of a patient with myelodysplastic syndrome

Cidofovir is an acyclic nucleoside phosphonate with broad-spectrum activity against DNA viruses, including human papilloma virus (HPV). However, data on the efficacy of cidofovir in an immunosuppressive setting remain contradictory. We report for the first time on the promotion of the healing of recalcitrant warts in a patient with myelodysplastic syndrome with intravenous cidofovir treatment.