Vaccines and medicines for the world's poorest

BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7264.834 (Published 30 September 2000) Cite this as: BMJ 2000;321:834

Quality of vaccines and medicines must be monitored

  1. Subhash C Arya, research physician (subhashji{at}hotmail.com)
  1. Centre for Logistical Research and Innovation, M-122 (of part 2), Greater Kailash-II, New Delhi-110048, India
  2. Cumbernauld, Glasgow G67 2BZ

    EDITOR—Smith points to increasing international awareness about inadequate supplies of vaccines and drugs in tropical countries.1 Future private-public partnerships for better supply of vaccines and medicines for the world's poorest countries with “push” and “pull” mechanisms and financial allocation of billions of dollars by the American Congress would indeed imply adequate funds for researchers and others. Nevertheless, even that exorbitant fiscal input would provide little relief to many people living in tropical countries. Funds should be spared to monitor the quality of vaccines, drugs, and diagnostics in such countries.

    There have been frequent reports of the poor quality of vaccines, drugs, and diagnostics in Asia, Africa, and Latin America. In Kelantan, a state in northwestern Malaysia, the contents of 14 of 33 phials of live poliovirus vaccine did not meet the criteria of a potent vaccine.2 Assay of active ingredients of tetracycline, co-trimoxazole, ampicillin-clavulanate, and chloroquine being offered to patients in Nigeria and Thailand showed 37% of samples to be substandard; in six samples of chloroquine no active ingredient was left.3 Reagents for HIV antibody assay that had been improperly stored or were past the expiry period in a Zambian hospital had their sensitivity and specificity reduced by 11-18%. The use of blood pretested with such reagents was associated with at least a six times higher than expected risk of HIV transmission.4

    The prospective international collaborators to address current issues with vaccines, drugs, and diagnostics in tropical countries should allocate money to assess the quality of these items available for local use. Representative aliquots should be retrieved for measurement of the active ingredients. Research towards standardisation of simple tests to assay active ingredients in the field is essential. A paracetamol specific test that does not require costly equipment and trained staff has been useful as an initial screening test to monitor the quality of individual tablets in the field.5

    Only pilot programmes for surveillance of vaccines, drugs, and diagnostics in the world's poorest countries would determine if there was any need to stabilise them. The addition of stabilisers to labile vaccines might well ensure the full stability and utility of vaccines, drugs, and diagnostics among people in the world's poorest countries. An inbuilt programme for surveillance of these items in any global push and pull strategy would ensure that billions of dollars would assist in alleviating the misery of masses.


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    Attempts of Global Forum for Health Research should be viewed with optimistic scepticism

    1. Rhona MacDonald, specialist registrar in public health, Lanarkshire Health Board (rhonamac{at}public-health.demon.co.uk)
    1. Centre for Logistical Research and Innovation, M-122 (of part 2), Greater Kailash-II, New Delhi-110048, India
    2. Cumbernauld, Glasgow G67 2BZ

      EDITOR—The Global Forum for Health Research mentioned in Smith's editorial is attempting to tackle the complex issues involved in supplying vaccines and medicines for the world's poorest people,1 but many areas of major concern remain.

      The focus on the development, supply, availability, and use of vaccines and medicines is similar to that in the vertical disease programmes used in the past few decades. Such a targeted approach may have some benefits but does nothing to address the root cause of morbidity and mortality in poor countries—namely, poverty. Such programmes have always been favoured by donor countries as they achieve rapid results and seemingly pleasing statistics.

      The supply of vaccines and medicines to the poorest in the world might attract publicity and media attention, but vaccines and medicines achieve little in the long term if the root causes of ill health are not addressed with similar resources and enthusiasm. Children may survive their first few years because of the high uptake of vaccines only to succumb later to diarrhoeal illness and malnutrition.

      Some drug companies are selling products in developing countries that are of no health benefit, simply because they know they can be sold. Many products available in poor countries are not on the World Health Organization's essential drugs list and are not formulated for use in richer countries. Sugar coated vitamin pills are a prime example of this. The way that such items are marketed makes them seem desirable to poor families, who may give up a day's wages to buy them. As long as these activities continue the sincerity of certain pharmaceutical companies in their involvement in the battle to improve the health of people in poor countries remains questionable.

      Before more medicines are to be made available, urgent action needs to be taken on the monitoring and control of the sale of medicines in developing countries. Inappropriate use of many medicines has led to ineffective treatment and drug resistance. For example, street vendors in some of these countries can sell various drugs used in the treatment and prophylaxis of malaria with no knowledge of their effectiveness. This has contributed to the rising morbidity and mortality from malaria and to resistance to chloroquine.

      Until these concerns have been addressed this well intentioned initiative should be viewed with optimistic scepticism.


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