Coronavirus: For chronically ill, uncertainty about drugs

Health personnel disinfect the hands of a visitor at the entrance of the Mbagathi Hospital in Nairobi on March 18. PHOTO | AFP

For John Gikonyo, the coronavirus pandemic only adds to his troubles. He has a kidney condition and his biggest worry is that as the deadly disease wreaks havoc worldwide, he might miss critical drugs he needs daily to survive.

In times of pandemic, he and other patients who suffer from chronic illnesses are required to have three months’ worth of drug supply.

While he has already shopped from this quarter, he is concerned about the next quarter’s supply especially now that the world is running short of critical drugs. “We need these drugs to live and while we might have them at the moment, we are not sure about the next few months,” he says.

Like most people with chronic illness, the thought of a possible lockdown gives him sleepless nights. He hopes it does not get to that. Worse still, he is considered among patients with a high risk for severe disease from Covid-19 together with those who have cardiovascular disease, diabetes, hepatitis B, chronic obstructive pulmonary disease, chronic kidney diseases and cancer. He has, therefore, chosen to stay indoors because of his condition to limit interaction with the public.

Gikonyo says amid the Covid-19 pandemic, people like him are living in an extraordinary time. Everyone’s life is affected, but for those with chronic conditions, tough times lie ahead. There is already a shortage of Heparin, a crucial drug used in dialysis. The medicine has been in short supply since last year. With the curfew, he wonders how people who need specialised clinics will make it to the hospital. “The national insurer also limits the hospitals we go for care, so our worry is where we will go for dialysis. We should not be limited to certain hospitals at this time. Rather, we should be able to visit the nearest facility,” he says.

His concerns are legitimate and even the World Health Organization (WHO) is fearful of the shortage of medical products and critical drugs. WHO executive director Michael Ryan said all elements of the supply chain have been disrupted in recent weeks and the health sector has been affected by this. “Supply chains have been affected by secondary effects of the virus such as cancellation of flights because many passenger flights also carry cargo. Difficulties in shipping have also made it hard to move products,” he said. The world, he said, was not ready for a pandemic and did not have security stockpiles in place.

PUBLIC CURFEW

The drug supply chain relies on what is known as active pharmaceutical ingredients (APIs) – the basic molecules used to make drugs - and the supply of these has also been hit. The coronavirus outbreak in China caused supply hitches for Chinese drug-ingredient manufacturers resulting in curtailed production and shipment.

India is the global leader in generic drug production while China is the world’s largest supplier of active pharmaceutical ingredients. These raw materials are manufactured in China and then exported to India and other countries where they are formulated into tablets or injections, for sale worldwide. Indian companies procure 70 per cent of their raw materials with ingredients from China, where manufacturing is cheap.

In early March, India restricted exports of 13 APIs and the drug formulations made from them to protect itself against domestic shortages.

That’s a problem for countries like Kenya, which rely on India’s drug makers for much of its supply of generic drugs. According to the India Brand Equity Foundation, India exported about $19 billion (Sh2 trillion) worth of drugs last year and accounted for about one-fifth of the world’s exports of generics by volume.

Now the Indian government is stepping up measures to control the outbreak on its soil. A 14-hour “public curfew” was implemented last week, transport was substantially restricted and authorities announced a lockdown in dozens of cities and districts.

The country recently banned exports of key medicines such as antibiotics, statins and paracetamol. In the long-term, this could wreak havoc on the world’s supply line, which will greatly affect Kenya.

Kenya, gets 35 per cent of its drugs from India. Dr Andrew Suleh, a consultant physician, renal and tropical medicine specialist, says drugs for hypertension, diabetes, heart conditions and antibiotics are among those likely to run out of stock given the demand for them.

Antibiotics are used to treat or prevent some types of bacterial infection. They work by killing bacteria or preventing them from reproducing and spreading.

Even though some Chinese factories have reopened, it is unclear when production will be fully restored or when India will lift its restrictions on drug exports.

DRUG HOARDING

Pharmaceutical Society of Kenya (PSK) has cautioned that drug shortages happen faster in today’s environment given customer hoarding and stockpiling. There is a concern that supply shortages could lead to price increases for consumers.

Chief executive officer of PSK Daniella Munene says there is a concern especially in the hoarding of — chloroquine, hydroxychloroquine and azithromycin — which are sold only on prescription. Kenyans have, however, managed to get hold of and hoard them, putting the country in great danger.

She says the hoarding of these drugs that have been touted as treatment for coronavirus will have adverse effects on patients who depend on them to daily improve their quality of life. The drugs are needed by patients who suffer Rheumatoid Arthritis, Systemic Lupus Erythematosus and other conditions.

Dr Munene says hydroxychloroquine, especially, is already not available in parts of the country, yet it is listed as part of the treatment guidelines for Covid-19 by the Ministry of Health. “It is produced by Norvatis, but the world cannot rely on just this one company for supply especially now that India has banned the export of it,” she says.

Even as the world battles one of the deadliest pandemics, scientists are worried about these populations of people who might be more affected should they get the virus.

The high fatality rate of Covid-19 in the population might result not from the virus but an exacerbation of the existing diseases. Experts have warned that while the government rushes to prevent the spread of the virus, it is also interfering with importation and the flow of life-saving drugs into the country. This, they say, is going to cause shortage as the cost of available drug shoots.

Pharmacy and Poisons Board (PPB) CEO, Dr Fred Siyoi, says should the Covid-19 crisis continue, the population is likely to be affected, considering they have to be on the drugs for life. “My heart goes out to people with chronic conditions. They are likely to be affected and, if possible, they should store their drugs to avoid interruption and inconveniences,” says Dr Siyoi.

ALTERNATIVE MARKETS

Early last month, however, Dr Jackson Kioko, the PPB chairman, said the board was working with the ministry’s Coronavirus Task Force to adopt a harmonised tactic to address the Covid-19 threat, adding that they are willing to explore other sources of health commodities, including Europe and the US.

Interestingly, however, Europe and the US are also adversely affected by the coronavirus outbreak and are in dire need of the very drugs and PPB has not communicated on other alternatives since.

Kenya Pharmaceutical Distribution Association Chairman Kamamia Murichu says there is not much going on in the world especially in Europe and America. “We have drugs to last us three months and we are trying to explore other nations such as Turkey because there is nothing much coming from most of Europe, China, US and India,” he says.

Even though he could not reveal to the HealthyNation what drugs are likely to be in shortage, Dr Jonah Mwangi, the Kenya Medical Supplies Authority (Kemsa) CEO says there are enough drugs for chronic illnesses to sustain the country for the next five months. “For diabetes and hypertension, we have enough drugs and patients should not be worried about that. For oncology drugs, we have the most critical drugs since each county has a different type of cancer,” says Dr Mwangi, adding that for breast cancer, all the drugs are available and cheaper than the market prices. “It is at this time that we want to reach our clients more. We have purchased enough and we are ready in case of any eventuality,” he says.

Public health experts, however, have warned that countries should put more emphasis on ensuring the chronically ill are not exposed since they are more likely to experience severe symptoms of Covid-19 and in most cases death.

In the first large study of the effect of an underlying illness, researchers in China analysed 1,590 patients from throughout the country with laboratory-confirmed disease. They calculated how co-morbidities, existing illnesses affected the risk of being admitted to intensive care, being put on a ventilator or dying.

After taking into account the patients’ ages and smoking status, the researchers found that the 399 patients with at least one additional disease (including cardiovascular diseases, diabetes, hepatitis B, chronic obstructive pulmonary disease, chronic kidney diseases, and cancer) had a 79 per cent greater chance of requiring intensive care or a respirator or both, or of dying. The 130 with two or more additional diseases had 2.5 times the risk of any of those outcomes.

Because it is not unusual for someone to have an underlying disease (especially diabetes and hypertension) co-morbidities also raise the risk of dying from Covid-19.

China Center for Disease Control (CDC) analysis of 44,672 patients found that the fatality rate in those who reported no other health conditions was 0.9 per cent.

It was 10.5 per cent for those with cardiovascular disease, 7.3 per cent for those with diabetes, six per cent for people with chronic respiratory diseases, six per cent for people with hypertension and 5.6 per cent for those with cancer.

That patients who suffer from underlying conditions are at a higher risk of suffering greatly from the coronavirus disease is especially true for Kenya where the first recorded death was of a 66-year-old man who had diabetes.

About 40 per cent of Kenyans die of non-communicable diseases each year, according to the Ministry of Health first-ever report on the state of non-communicable diseases in the country commissioned in 2016. Besides, close to 10 per cent of Kenyans aged between 40 and 69 years were said to have a cardiovascular disease risk. Nearly a quarter of Kenyan adults were hypertensive. Of even greater concern was that 92 per cent of this group were not on medication.

NCD PREVALENCE

Kenya, like other developing countries, is experiencing this emerging diabetes epidemic with a national prevalence rate of between 3.1 and 4.6 per cent (between 1.4 million and 2.1 million Kenyans). If left untreated, it increases the risk of heart attack, stroke, blindness, kidney failure and limb amputation.

Today, one in every 17 Kenyans has diabetes, and 12,890 people in the country died from both diabetes and high blood glucose in 2018, according to a report published by the WHO and Lancet in 2018. However, the country has in the past experienced shortage of insulin, which is very crucial for the survival of diabetic patients.

Hypertension is the leading Non-Communicable Disease (NCD) diagnosed during outpatient visits, contributing to 50 per cent of total hospital admissions, according to the 2018 Health Sector Performance Review Report for 2016/2017.

While counties of Turkana, West Pokot, Mandera, Samburu and Wajir recorded a lower rate Murang’a, Embu, Tharaka-Nithi, Lamu and Makueni recorded a higher rate of new cases of hypertension.

Kenya has a growing cancer problem. The country have about 47,000 new cases and 33,000 deaths annually. These are huge numbers for a country with a population of almost 50 million people, according to the International Agency for Research on Cancer.

The burden of cardiovascular diseases is significant in Kenya, where heart diseases cause 25 per cent of hospital admissions and 13 per cent of deaths.

Cardiovascular issues such as heart attacks are the number one cause of death in adults over 30. However, the trend of the disease is fast shifting to the youth as more young people are diagnosed with heart conditions. “Trends of diseases are changing,” said Dr Jeilan Mohamed, a Nairobi-based cardiologist. “Many people think that heart attacks only affect the elderly, but the age bracket we are seeing in the hospital is much younger.”

And it is not only patients of NCDs that need to be on drugs daily. As Covid-19 spreads across the globe, a section of people with HIV are worried that it might interfere with the supply of their drugs.

BUY IN BULK

They have since called on the government to make urgent interventions to safeguard them from the adverse effects of the new coronavirus.

Mr Erick Okioma, a member of the National Empowerment Network of People Living with HIV and Aids in Kenya, cautions against sidelining the group with underlying health conditions.

However, the association says it is doing all it can to make arrangements, so that its members can collect their drugs in advance where possible to avoid interruption. “This is the worst pandemic so far, but at the same time we must ensure that our members have their drugs on time,” says Nelson Otwoma, the chairperson.

In Kisumu, about 33,000 HIV/Aids patients in 61 facilities got their antiretroviral drugs in bulk to avoid any possibility of shortage in case of a lockdown.

However, not all patients can collect their drugs in earlier. Collecting the drugs in bulk might only apply to those who have attained the right viral load suppression while those still in the early stages of their treatment might be forced to go to the hospital every month for their viral load to be monitored. Those with poor adherence might also be forced to pick their drugs either after every fortnight or monthly.