[A-List] China: successful antimalarial drug

["Michael Keaney" <michael.keaney@xxxxxx>]

This looks interesting, especially if the role of US/UK "aid" in the
prioritisation of certain lucrative drugs is considered. Also of note is how
long ago this treatment was discovered.

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Herbal Drug Widely Embraced in Treating Resistant Malaria
By DONALD G. McNEIL Jr.
New York Times: May 10 2004

fter years of hesitation, world health agencies are racing to acquire 100
million doses of a Chinese herbal drug that has proved strikingly effective
against malaria, one of the leading killers of the poor.

The drug, artemisinin (pronounced are-TEM-is-in-in), is a compound based on
qinghaosu, or sweet wormwood. First isolated in 1965 by Chinese military
researchers, it cut the death rate by 97 percent in a malaria epidemic in
Vietnam in the early 1990's.

It is rapidly replacing quinine derivatives and later drugs against which
the disease has evolved into resistant strains.

To protect artemisinin from the same fate, it will be given as part of
multidrug cocktails.

Until recently, big donors like the United States and Britain had opposed
its use on a wide scale, saying it was too expensive, had not been tested
enough on children and was not needed in areas where other malaria drugs
still worked.

Unicef, the United Nations Children's Fund, which procures drugs for the
world's poorest countries, opposed its use during an Ethiopian epidemic last
year, saying that there was too little supply and that switching drugs in
mid-outbreak would cause confusion.

But now almost all donors, Unicef and the World Bank have embraced the drug.
The new Global Fund for AIDS, Tuberculosis and Malaria has given 11
countries grants to buy artemisinin and has instructed 34 others to drop
requests for two older drugs - chloroquine and sulfadoxine-pyrimethamine -
and switch to the new one.

"We want countries to move very rapidly to use it as a first-line
treatment," said Dr. Vinand Nantulya, the fund's malaria adviser. The fund
expects to spend $450 million on the drug over the next five years, he said.

The World Health Organization, a United Nations agency based in Geneva,
estimates that 100 million doses will be needed by late 2005.

Malaria causes about 300 million illnesses a year, and at least 1 million
deaths, 90 percent of them in Africa and most of them children under 5.
Despite more than a century of eradication efforts, the disease is endemic
from the Mekong Delta in Vietnam to the Amazon Basin in Brazil, and is
particularly severe across central Africa, from the cane fields of
Mozambique to the oases of Somalia to the rubber plantations of Liberia.

Like many tropical disease drugs, artemisinin is a fruit of military
research. Chinese scientists first isolated it in 1965 while seeking a new
antimalarial treatment for Vietnamese troops fighting American forces, said
Dr. Nelson Tan, medical director of Holley Pharmaceuticals, which makes the
drug in Chongqing, China.

Another antimalarial drug still in use, mefloquine, was isolated at the
Walter Reed Army Institute of Research in 1963 for American troops in the
same jungles. Under the name Lariam, it is still issued to troops and sold
to travelers.

Artemisinin, which has no significant side effects, quickly reduces fevers
and rapidly lowers blood-parasite levels, which can keep small outbreaks in
mosquito-infested areas from becoming epidemics.

Two years ago, Dr. Dennis Carroll, a health adviser to the United States
Agency for International Development, said artemisinin was "not ready for
prime time." But on April 30 at a malaria conference at the Columbia
University School of Public Health, he led a session on ways to induce
farmers to plant more wormwood.

Dr. Carroll said that more evidence had emerged that the drug was safe and
that older drugs were not working. Also, the creation of the Global Fund
expedited grants for it.

Dr. Stewart Tyson, a health expert with the British Department for
International Development, said his agency changed its opinion about the
drug after its experience in Uganda, where resistance to older drugs had
climbed to 31 percent in some areas in 2003 from 6 percent in 2000.

The price of artemisinin cocktails has fallen from $2 per treatment to 90
cents or less as more companies in China, India and Vietnam have begun
making them. (Older drugs cost only 20 cents.) Novartis, the Swiss drug
giant, sells its artemisinin-lumefantrine mix, Coartem, to poor countries
for 10 cents less than it costs to make, a company official said. The same
drug, under the name Riamet, is sold to European travelers for about $20.

As a plant material, artemisinin cannot be patented, said Dr. Allan
Schapira, a policy specialist for the Roll Back Malaria campaign of the
World Health Organization. Nor can the simple extraction process. Some
synthetics, he said, are old and off patent, which public health officials
like but pharmaceutical companies do not, because they make a larger profit
from drugs on which they have patent monopolies.

No company has registered artemisinin in the United States, said Dr. Nick
White, a professor of tropical medicine at Mahidol University in Thailand,
because sales would be too small to justify the cost of seeking approval
from the Food and Drug Administration.

Now, with more purchases, fears of a shortage that would push prices up are
developing. The W.H.O. estimates that 100 million doses will be needed by
late 2005, and the world now has only about a third of that.

Though it grows wild even in the United States, wormwood is cultivated only
in China, Vietnam and pilot projects in Tanzania and India. It is planted in
December and needs eight months to mature. Drug companies want firm orders
from donors before they try to triple production.

Dr. Tan said he had seed banks ready to plant 62,000 acres, "but we need to
pay farmers to give up other crops and arrange for fertilizer."
"Time is against us," he said.

Even if enough artemisinin can be made, obstacles will arise, experts
warned. For example, Dr. Kopano Mukelabai, a malaria specialist at Unicef,
said shopkeepers would have to be trained not to sell one or two pills to
patients who lacked the money for a full course of 12.

And what Richard Allan, director of the Mentor Initiative, a public health
group that fights malaria epidemics, called "the love of chloroquine" will
have to be broken. That quinine derivative, in use since the 1950's, is now
almost useless against parasites, but poor people still buy it because it is
cheap and lowers fever as aspirin does.

Also, counterfeiting will become a problem. In Kenya in 1997, Mr. Allan
said, he found 120 versions of sulfadoxine-pyrimethamine for sale, "ranging
from very good drugs to talcum powder." A recent study of artemisinin drugs
in Asia "found that 38 percent were fakes," he said. "We can expect the same
thing to happen in Africa."

He favors giving artemisinin away to remove the counterfeiters' profit
motive.