Pneumococcal vaccine complexity

Hey there bathhousers,

Wow, haven’t done one of these for a while but I just learnt something and feel the urge to share. I’ve been reading about how vaccines work and also about the geographical variation of disease.

This brings me to today’s post which as sciency as it gets round here so hold on to your autoclaves and let’s get stuck in.

Invasive pneumococcal disease kills over 1.5 million children each year according to the World Health Organization (WHO), Ninety percent of these deaths occur in the developing world. [1][2]

You might think that if a vaccine is available in Europe and the US then it should be made available in the developing world too. One of the main vaccines for Pneumococcal disease is called Prenvar. Prevnar is among Wyeth’s top revenue producers, with sales in 2005 of $1.5 billion. [3]

So on the face of it there is an effective vaccine used in Europe and the US that should be rolled out across Africa, seems like a straight forward case where the drugs exist, Pharma has recouped their investment from Western consumers, so there is a moral imperative to bring this drug to the people that need it. Perhaps, within our current system of IP as long as the rich world needs the same drugs then they can pay for the R&D costs and everyone can get the benefit, assuming the minefield of international IP law can be negotiated.

Unfortunately it’s not as simple as that. There are around 90 different bacteria (serotypes) which cause pneumococcal disease. Prenvar is formulated to prevent 7 of those strains. Unfortunately the prevalence of different strains varies geographically. The table below shows the results of a study to determine the relative prevalence in descending order for the developed and developing world [4]. Bear in mind that ‘developed’ and ‘developing’ represent huge areas so there is likely to be a large amount of additional variation between regions. (the number represents serotype number)

Developed 14 6 19 18 9 23 7 4 1 15
Developing 6 14 8 5 1 19 9 23 18 15 7

The table below shows the 7 serotypes present in Prenvar and a new GSK drug Synflorix.

Prenvar 14 6 19 18 9 23
Synflorix (GSK) 14 6 19 18 9 23 1 5 7

You’ll notice that the Prenvar vaccine is designed to prevent the most common strains in the developed world, as you might expect. Unfortunately the 3rd, 4th and 5th most common forms of the disease in the developing world are not covered by this vaccine.

This example illustrates why even if access to drugs developed for the developed world could be assured, in some cases, the efficacy wouldn’t be the same. Furthermore, If you’re going to go to the trouble to run a mass vaccination for a disease that kills millions, you’d at least want a drug that treated most of the common strains in your country, otherwise it could be expensive and ineffective.

Also in the table you can see another drug developed by GSK.  Synflorix, which as you can see covers two of the missing serotypes and is therefore  likely to add to the overall effectiveness significantly in the developing world. But if the missing serotypes aren’t prevalent in the developed world why did GSK develop this drug?

It was possible because of an advanced market commitment from Gavi [5] (the Global Alliance for Vaccines and Immunisation). This means that Gavi have committed to buying up to 300 million doses over 10 years and in return for this GSK have developed the drug.

In conclusion, in some cases the developing world will need drugs developed specifically for their own needs. Where there aren’t rich consumers with insurance companies and government funded healthcare, innovative financing mechanisms like advanced market commitments or perhaps publicly developed and owned IP will be needed to ensure that drugs get developed.

[1] http://en.wikipedia.org/wiki/Pneumococcal_conjugate_vaccine

[2] (http://www.who.int/vaccines/en/pneumococcus.shtml

[3] http://en.wikipedia.org/wiki/Pneumococcal_conjugate_vaccine#cite_note-pmid17324490-11

[ 4] (Pediatric Infectious Disease Journal
Volume 14, Issue 6 http://www.scopus.com/record/display.url?eid=2-s2.0-0029057617&origin=inward&txGid=z2jb5-sWfwbAl6CATF7Gvif%3a2)

[5] http://www.gsk.com/media/pressreleases/2009/2009_pressrelease_10012.htm

Water politics

Take a look at this really neat animation crafted by Isobel Foulsham on water access and privatisation.

It’s really interesting to think about the extent to which safe water is understood as a commodity, rather than as an equally accessible resource or as a human right. There’s a lot to be said for the ways in which corporations are increasingly commodifying and branding ‘health’, such as Unilever’s Lifebuoy campaign, which seeks massive profits through social missions which target the handwashing practices of millions of people living in poverty, encouraging them to buy Unilever’s branded antibacterial soap. I’ve been meaning to post on this for ages, there’s plenty to be said… Alongside the many issues the water rights animation raises, it’s awful to assume that this kind of health-and-hygiene-right commodification could happen with branded water too. Er, is it?

Prostitution in Bangladesh

The Guardian posted a really fantastic piece of journalism today, though I should perhaps use that word warningly. It’s, I think, looking at the political economy of prostitution – how the role of pharmacies, prostitutes, contraceptives, relationships, poverty, trade, love, drivers, gender, sadness and security are all tangled up together and implicate each other, told through the stories of women and men working and using a legal brothel. Brilliant, sensitive, and avoids sentimentalism. Definitely take a look at the accompanying video.

Elizabeth Pisani sounds off about why HIV treatment is a bad thing

Hi bathousers,

Sorry for not posting for a while but to make up for it here here’s a quick post about an article written by Pisani, in which she provides anyone wanting an excuse for not funding ARVs in Africa. Brilliant.

http://www.guardian.co.uk/commentisfree/2010/feb/22/the-drugs-wont-work

In this article, as ever, Pisani seeks media attention by making a point in an inflammatory and simplistic way.

This is in response to another story, in which some researchers have suggested that screening and in some cases blanket prescription of ARVs could prove effective.
href=”http://www.guardian.co.uk/world/2010/feb/21/blanket-testing-hiv-aids”>

In this case her argument runs like this:
1.) The AIDS mafia want treatment to replace prevention in Africa because they think that people on ARVs are less infectious, therefore reducing the spread of HIV.
2.) What the fools don’t realise is that people are most infectious soon after having contracted HIV so the screening is unlikely to help identify people in time
3.) Availability of treatment makes people less worried about HIV and so indulge in more risky behaviours
4.) Treatment is bad and people who think it is a good idea are optimistic simpletons

This ignores several important factors. Firstly the scientific argument, obviously there will be a decrease in inflections if everyone who needs drugs gets them as viral load is reduced, but this effect will not help those infections that take place before people have received treatment. Clearly then, the balance between effectiveness and screening interval needs to be considered. Annual screening could reduce all infections which aren’t caused by newly HIV+ people. No doubt this is still a significant chunk, though this is not the most risky time. It will also catch a good amount, though by no means all, people while they are at their most infectious. Assuming people are at their most infectious for several months you will find 8.3% (100/12months) of people in their first month and 25% of people within their first three months. This is still a big reduction. To increase this rate further you could increase screening intervals, perhaps of ‘at risk’ groups to achieve greater success.

As the true effectiveness of the idea will depend on loads of diverse factors, the only way to really know how well this will work is to do a trial. This is actually what is being proposed, so the whole thing sounds very sensible to me.

Secondly, the moral argument. You really can’t just go letting people die preventable deaths. If it costs money to bring the new infections and deaths under control in a way that rich counties have, then that is money well spent.

Once we acknowledge that it is morally right to reduce the spread of HIV the interesting question, and the one the researchers will set out to answer is “is screening and increased access to ARVs more effective, cost effective and practical than other forms of prevention?” That question won’t be answered by misrepresenting the augment as if the researchers have made a basic error in understanding the virus.

From Creating Drugs to Creating Markets (A response to “Hating Big Pharma and Flibanserin”)

Brilliant article, if you haven’t yet read it, you should. Who’d want to live in a world where we were medicated into having the same feelings or desires as everyone else? It would be a bit like allowing Simon Cowell to be in charge of UK arts funding.

Our conception of the power and respectability of medicine stem from an out of date idea about what medicine is. Interventions focussing on curing or treating disease or physical injury no longer represents the main focus of medicine. Most new public health interventions (in the developed world at least) are no longer about saving millions of lives but small improvements to existing practises. As a result the creative and entrepreneurial pharmaceutical industry looks for other ways to sell patented compounds.

It is worth dwelling for a moment on the achievements of medicine in the last 100 years. In the UK the life expectancy of new born children in 1999 was 75 years for boys and 80 years for girls. In 1901 baby boys were expected to live for 45 years and girls 49 years. [http://www.parliament.uk/commons/lib/research/rp99/rp99-111.pdf]. A good chunk of this improvement is down to the continued in advances in preventative and curative medicine, and the investment by made by private firms in order to reap rewards when they demonstrated positive health outcomes.

The problem is that once the industry was established it needed to continue to introduce drugs and get paid for them. To the companies it makes no difference if the drug ends widespread childhood measles or if it has no positive impact at all. All that matters is that someone will pay for it.

As with all markets there are constant calculations going on in the background to work out what is the best way to make money. For much of the last 100 years the most cost effective thing to do was to pick a medical problem that didn’t seem to have effective or side effect free treatment and to pay for R&D to develop a better one. More recently, straightforward research had been taken and the cost of a health breakthrough began to rise. The balance began to tip so that the best use of investment became to create a market for products rather than create products for the market. This is borne out in the deployment of resource of the companies:

“Lauzon and Hasbani showed that between 1996 and 2005, these firms [pharmaceuticals] globally spent a total of US$739 billion on “marketing and administration.” In comparison, these same firms spent US$699 billion in manufacturing costs, US$288 billion in R&D, and had a net investment in property and equipment of US$43 billion, while receiving US$558 billion in profits”- http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050001

Once pharma’s engine of innovation became focussed on creating a market for their products rather than creating products the market wants, the whole market idea starts to look rather sorry.

This leads pharma to define a Platonic human experience and sell this ideal in pill form. The more people can be made to feel inadequate, the more effective this approach will be. It seems to me that the model that gave humanity so many improved health outcomes has run its course and should now be disbanded and replaced with something better.

Hating Big Pharma and Flibanserin

Christine Ottery, in the Guardian’s pinnacle of participatory media, Comment is Free, published a short piece today reviewing the recent arrival of Flibanserin, a new drug on the sexual-cure-all market. You’ve probably read the hype, but try this if you haven’t.

Anyway, this is what I said on CIF and as I’ve been soaking quietly in the corner of the Bathhouse recently, I thought I’d post it here too. Probably read Ottery’s original piece of writing first for some background.

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I’m really pleased to see this article has been written. There is huge need for discussion and debate on this.

We are, as is suggested, in a newer era of the medicalisation of sexuality/womens’ bodies, another chapter in the relationship between medicine and personhood. We see medicine, with its lab coated authority and magic pill-stocked pharmacy, as deciding what is appropriate and normal for a person to experience, and as the largest and strongest stakeholder in defining just how people should live. In this particular episode, we learn about the statistical parameters which define a woman’s ‘normal’ sexuality. We learn that 43% of women ‘suffer’ from Hypoactive Sexual Desire Disorder. We learn that a branded drug can return us to our ‘natural’, ‘normal’ state where nothing can come between us and our ability to orgasm.

I find it disgusting that profit is to be made by exploiting sexual insecurity and sexual identity, and kid yourselves not, this is exactly what is going on here.

Why is it abnormal for a woman (or man) to experience a lack of libido? The interference of stress in one’s desire to have sex? A loss of confidence in sexual identity? Why is it normal to refrain from confronting the aggressive marketisation of sexuality, the exhaustion of the daily commute, the sexist bullying at work, the lads mags and women-focused lifestyle magazines, the thousand small mundane ways in which women are consistently sold the idea of a healthy sexual lifestyle, when it is made in such narrow and profitable parameters, and instead accept that there must be something fundamentally wrong if you find you’re feeling just a little turned off. That there must be some biological/psychological/genetic reason why you’re sexually ‘underperforming’ and can’t be moved to experiment with that triumph of heterosexual bed-standards, More!’s latest Position Of The Month. Dig out your wallet and pop a pill. Embrace the sole responsibility for your own body, mind and heart wanting to say ‘no, I don’t feel like it’ sometimes. Because according to Boehringer Ingelheim, that just doesn’t constitute a normal way of feeling about sex.

What a devastating diagnosis.

How dare it be a community of pharmacological experts and company managers and business associates and shareholders, earning thousands from a branded lifestyle drug, who get to define the parameters of what a woman understands to be a ‘normal’ sexuality and sexual identity?

We should not accept this aggressively belittling remedy. If a woman doesn’t feel like having sex, she should never have to feel the obligation to take a drug to ‘solve’ it. There is no fundamental problem in a woman not being turned on. There is no failure. There is no ‘thing’ wrong with her to be solved. All women and men have complex relationships with themselves and others, assume multiple identities amongst all the people in their lives, and will all experience a lack of libido at varing moments. Boehringer Ingelheim and all the godparents of Flibanserin should be held to account for contributing to the demeaning market in standards for sexual identity.