Allarme per il superbatterio invincibile L’India contro Lancet: “Non è nato qui” – Repubblica.it

Allarme per il superbatterio invincibile
L’India contro Lancet: “Non è nato qui”

Un gruppo di ricercatori inglesi ha individuato un ceppo di microrganismi che resiste a ogni classe di farmaci e che si sta diffondendo in tutto il globo. E afferma: “La culla del superbatterio è l’India”. Sotto accusa l’uso scorretto degli antibiotici e il “turismo medico”. I parlamentari di Nuova Delhi: “E’ una cospirazione delle case farmaceutiche”

Qualche decennio fa sembrava quasi conclusa la lotta alle malattie infettive: dopo lo sviluppo di diverse famiglie di farmaci, era opinione diffusa che per i batteri non ci fosse più scampo. Adesso invece è chiaro che non è così. Come in una guerra, i microrganismi si sono armati di scudi potenti e sono tornati a far paura come un tempo. Il motivo principale di questa loro evoluzione è la pressione selettiva a resistere agli antibiotici, vale a dire l’estremo tentativo di non farsi uccidere da nuove classi di farmaci. I cosiddetti “superbatteri” appartengono soprattutto alla categoria dei Gram-negativi, i cui ceppi più resistenti sono da varie parti considerati una minaccia per la salute pubblica globale.

L’ultimo allarme arriva da uno studio pubblicato sulla rivista Lancet Infectious Diseases, una delle voci più autorevoli nel campo delle malattie infettive. La ricerca, dal titolo “Emergenza di un nuovo meccanismo di resistenza agli antibiotici in India, Pakistan e Regno Unito”, riporta dell’isolamento di ceppi di enterobatteri (microrganismi che popolano l’apparato digerente) resi resistenti a gran parte dei farmaci “grazie” – si fa per dire – all’opera di un gene di origine indiana.

Ma la pubblicazione non è passata inosservata e subito ha innescato le polemiche. Dall’India sono intervenuti diversi deputati e lo stesso ministro della Salute. Lo studio, che inivudua nel paese asiatico la ‘culla’ di un nuovo superbatterio resistente agli antibiotici, secondo i parlamentari sarebbe frutto di ‘una cospirazione’ delle multinazionali farmaceutiche.  “E’ scorretto legare questo virus all’India – ha affermato il ministro della Salute indiano in un comunicato – questa variante può essere contratta in qualunque paese del mondo”. Lo studio aveva esaminato 50 casi di infezione dovuta al batterio in Gran Bretagna, diversi dei quali erano stati trovati in persone che erano andate in India per sottoporsi a interventi di chirurgia estetica a basso costo.

“Noi rifiutiamo l’idea che gli ospedali indiani non siano sicuri per i turisti sanitari”, si legge ancora nel comunicato, mentre un membro del parlamento indiano citato dalla Bbc è ancora più esplicito: “L’India sta emergendo come una destinazione per il turismo medico – afferma – e questo tipo di notizia potrebbe far parte di un sinistro disegno delle multinazionali farmaceutiche”. Con il termine “medical tourism” o “medical travel” ci si riferisce a un fenomeno in crescita nel Regno Unito e non solo, ovvero la tendenza a viaggiare in paesi asiatici per sottoporsi a operazioni chirurgiche o trattamenti estetici senza liste d’attesa e a prezzi contenuti.

Il gene su cui si concentra la ricerca di Timothy R. Walsh, professore alla Cardiff University, e colleghi è chiamato New-Delhi-Metallo-1 (Ndm-1) ed è stato caratterizzato per la prima volta proprio in India. Già l’anno scorso il gruppo di Walsh aveva analizzato il caso di un paziente rimpatriato in Svezia dopo essere stato ricoverato in un ospedale di Nuova Deli. “Il paziente – spiegano gli autori – era colonizzato dai batteri Klebsiella pneumoniae ed Escherichia coli mutati con il gene Ndm-1”. E’ proprio la proteina codificata da questo gene (una metallo-beta-lattamasi) ad aver reso i batteri straordinariamente resistenti anche ai carbapenemici, ossia gli antibiotici di ultima generazione. Tale proteina, infatti, si discosta molto dalla “famiglia d’origine” che costituisce il bersaglio dei carbapenemici, ed è quindi completamente immune a questi farmaci.

Ad allarmare i medici di tutto il mondo è soprattutto la rapidità con cui questi ceppi si stanno diffondendo in diverse parti del globo. Il gruppo di Walsh, infatti, ha individuato oltre cento casi tra India, Pakistan e Bangladesh e 37 pazienti infetti nel Regno Unito. In particolare, fra i casi d’oltremanica 17 avevano viaggiato nel subcontinente nel corso dell’ultimo anno e in 14 erano stati ricoverati in un ospedale locale; per alcuni si trattava di situazioni d’emergenza, per altri di una precisa scelta di “turismo medico”. E’ proprio questa abvitudine, unita alla sempre maggiore frequenza dei viaggi intercontinentali, a far sì che questi ceppi non solo si diffondano su scala mondiale, ma siano più propensi a “incontrare” altri superbatteri. In tal senso, il timore dei ricercatori è la comparsa di microrganismi omni-resistenti pressoché invincibili.

L’aumento della farmacoresistenza nei batteri Gram-negativi è dovuto principalmente a geni “mobili” che si trovano sui plasmidi. Questi ultimi sono piccole molecole di Dna batterico che di norma contengono geni la cui attività è essenziale solo in determinate condizioni. Proprio per questo, i batteri hanno sviluppato diversi meccanismi per “passarsi” i plasmidi tra loro, così da sopravvivere anche in condizioni altrimenti proibitive. Facendo l’esempio del corpo umano, i microrganismi che riescono a “inventarsi qualcosa” sono gli unici a superare l’attacco – combinato, e dunque solitamente vincente – di sistema immunitario e antibatterici.

Una nuova era? In molti si stanno chiedendo se la scoperta dei superbatteri segni l’inizio di un’era “post-antibiotica”. La risposta a questa domanda oscilla tra punte di ottimismo e pessimismo, com’è tipico di ogni fase di incertezza nella ricerca scientifica. Un fatto certo, spiega Walsh, è che “gli enterobatteri mutati con l’enzima Ndm-1 sono altamente resistenti a molte classi di antibiotici e potenzialmente annunciano la fine dei trattamenti con β-lactami, fluoroquinoloni e amino glicosidi: le principali classi di antibiotici utilizzate per combattere le infezioni Gram-negative”. Da qui però non bisogna trarre conclusioni affrettate. Come hanno mostrato i ricercatori, infatti, questi ceppi sono ancora sensibili ad alcuni farmaci (colistina e tigeciclina).
In ogni caso, tutti concordano su un aspetto: l’importanza di diffondere una cultura ragionata dell’antibiotico. Da questo punto di vista, un corretto uso dei farmaci (sempre supervisionato dai medici) e l’osservazione di procedure di sterilizzazione più accurate negli ambienti clinici-ospedalieri potrebbero essere sufficienti a contenere lo sviluppo dei superbatteri, soprattutto in quelle parti del mondo in cui l’educazione medica dei pazienti non è ben radicata.

La ragione per cui paesi come l’India, il Pakistan e il Bangladesh sembrano essere terreni particolarmente fertili per il gene Ndm-1 può essere trovata, suggerisce Lancet, nell’utilizzo poco oculato degli antibiotici tra la popolazione locale. Nel suo studio Walsh cita un editoriale apparso sul Journal of Association of Phisicians of India a firma dell’esperto in malattie infettive Abdul Ghafur, emblematicamente intitolato: “Annuncio mortuario – sulla morte degli antibiotici!”. Ghafur spiega come in India sia sempre più diffusa la somministrazione di antibiotici senza prescrizione medica, il che ha portato a una pressione selettiva molto forte e destinata, a meno di interventi appositi, a crescere ulteriormente. In un mondo sempre più piccolo e connesso, insomma, non ci resta che sperare – e agire – affinché il corretto uso di farmaci e antibiotici diventi anch’esso globale.

Il sesso migliora con l’età per le donne il picco a 40 anni

Uno studio americano ha analizzato il rapporto – problematico – tra genere femminile e attività sessuale. Più dei due terzi delle intervistate soffre di qualche disfunzione. Fra i 18 e i 31 anni meno della metà raggiunge l’orgasmo di GIULIA BELARDELLI

PER le donne, il picco della soddisfazione sessuale arriva dopo i quarant’anni. E il sesso sembra essere un problema per quasi due terzi della popolazione femminile. A dirlo è uno studio americano pubblicato sulla rivista British Journal of Urology (BJUI) che ha analizzato il rapporto con il sesso in quasi 600 donne di tutte le età. I risultati mostrano che per lei la felicità tra le lenzuola rappresenta spesso un traguardo difficile da raggiungere, al quale ci si avvicina solo verso i quarant’anni. E’ dunque nella fascia della mezza età, sostengono i ricercatori, che una maggiore autostima e relazioni più mature consentono alle donne di trarre il massimo beneficio dalle esperienze sessuali.

La ricerca, condotta dallo Hackensack University Medical Center del New Jersey, si è svolta su 587 donne di età compresa tra i 18 e i 95 anni. Lo scopo, spiega la ricercatrice capo, Debra Fromer, era “testare l’evoluzione delle Disfunzioni Sessuali Femminili (FSD, Sexual Function and Dysfunction) con il passare dell’età”. Negli anni, infatti, è aumentata la consapevolezza dell’importanza di una vita sessuale soddisfacente per il benessere psicofisico. Se molto è stato fatto per analizzare disfunzioni erettili e vari altri problemi degli uomini, l’universo del piacere femminile è a lungo rimasto indietro nella lista delle priorità della ricerca.

Oggi la comunità scientifica internazionale concorda nel suddividere le Disfunzioni Sessuali Femminili in quattro gruppi: disordini del desiderio sessuale, problemi nell’eccitazione, difficoltà a raggiungere l’orgasmo e dolori durante il rapporto (è in questa categoria che rientra, ad esempio, la sindrome del vaginismo). I dati raccolti dall’Università del New Jersey parlano chiaro: ben il 63% delle donne (quasi i due terzi della popolazione) soffre di una qualche forma di disfunzione sessuale. A lamentare i problemi maggiori in fatto di orgasmo è, a sorpresa, la fascia d’età compresa tra i diciotto e i trentun anni, mentre le cose migliorano significativamente con l’avanzare dell’età, sebbene possano comparire altri problemi come lubrificazione e calo del desiderio.

“Il 54% delle donne più giovani ha difficoltà a raggiungere l’orgasmo”, spiega Former. Il problema rimane anche quando si è più grandi, ma in proporzioni minori: tra i trentuno e i quarantacinque anni, infatti, “solo” il 45% delle donne lamenta questa difficoltà, e anche dai quarantasei in su la percentuale è comunque inferiore rispetto a quella delle giovanissime (48%). Questo spiegherebbe anche la maggiore propensione all’attività sessuale durante la così detta mezza età: è attorno ai quarant’anni, infatti, che si colloca il “picco” della vita sessuale femminile.

Un fisiologico calo del desiderio si verifica verso i sessant’anni, ma non bisogna scoraggiarsi perché è un problema di cui soffre nel complesso il 47% della popolazione. “Si tratta – argomenta la ricercatrice – di un aspetto che compromette il senso di benessere generale delle donne, e influisce così sulla loro qualità della vita”. Numerosi studi hanno evidenziato come un rapporto tormentato con il sesso abbia implicazioni pesanti su fattori chiavi dell’esistenza, tra cui relazioni sociali, autostima e benessere psicofisico. “E’ per questo – aggiunge Former – che è così importante identificare i problemi e trovare delle soluzioni ogni volta che sia possibile. Finora diversi trattamenti a base di ormoni e altri medicinali si sono dimostrati efficaci nella cura di donne affette da FSD”. Prima di tutto, però, c’è l’aspetto psicologico e il rapporto con se stesse: è qui che si trova la chiave della maggiore soddisfazione in età più mature.

I risultati dello studio sono coerenti con una ricerca simile condotta sulla popolazione femminile turca. “Questa osservazione suggerisce – spiega la ricercatrice – che ci siano anche delle basi biologiche per le disfunzioni sessuali delle donne”. L’influenza culturale e sociale, insomma, ha sì un ruolo importante per quanto riguarda la dimensione psicologica, ma non è la sola responsabile dell’infelicità sessuale femminile. Il consiglio, per le donne di tutte le età, è guardare in faccia i problemi e non sentirsi “anormali”. E se le giovanissime possono stare tranquille perché la felicità a letto, prima o poi, arriva, le più mature non devono fare altro che godersi il loro “picco” e trasmettere un po’ di serenità alle nuove generazioni.

WHO: Observations on Vaccine Production Technologies and Factors Potentially Influencing Pandemic Influenza Vaccine Choices in Developing Countries, 2009 – WikiLeaks

  Observations on Vaccine Production
  Technologies and Factors Potentially
Influencing Pandemic Influenza Vaccine
    Choices in Developing Countries
                A discussion paper




                             World Health
                             Organization
            SoulMiitAtiaR*      WestwnhcMc~
�                                                        SEA-TRH-006
                                                 Distribution: Limited




  Observations on Vaccine Production
  Technologies and Factors Potentially
Influencing Pandemic Influenza vaccine
    Choices in Developing Countries
              A discussion paper




                       World Health
                       Organization
           Regional Office for South-East Asia
�@ World Health Organization 2009

This document is not issued to the general public, and all rights are reserved by the
World Health Organization (WHO). The document may not be reviewed,
abstracted, quoted, reproduced or translated, in part or in whole, without the prior
written permission of WHO. No part of this document may be stored in a retrieval
system or transmitted in any form or by any means - electronic, mechanical or
other - without the prior written permission of WHO.

The views expressed in documents by named authors are solely the responsibility
of those authors.

                                  Printed in India
�                                                          Contents

                                                                                                                                        Page


Acknowledgments .................................................................................................. v

Acronyms ..............................................................................................................vii

Introduction...........................................................................................................
                                                                                                                    1

        Background ...................................................................................................
                                                                                                                  2

        Overview of influenza vaccine production technologies ................................4
        Classic influenza vaccine produced in eggs .....................................................................                     4
        Live attenuated influenza vaccine ................................................................................... 5
        Influenza vaccines from cell culture ................................................................................                7
        Second generation biotech vaccines ............................................................................... 9
        Candidate seed strains and antigens..............................................................................                  10

        Issues and challenges...................................................................................11
        The question of adjuvants............................................................................................. 11
        Conditions imposed on commercial use of reverse genetics ........................................... 14
        Biotechnology and public perception ........................................................................... 15
        Export controls .............................................................................................................      17

        Options .......................................................................................................
                                                                                                                    19
        Timing and technology choices.....................................................................................                  19
        Fill/finish projects and importation of bulk antigen ........................................................
                                                                                                                    21
        The option of animal vaccine plant conversion.............................................................. 22

      Concluding discussion ...................................................................................24



                                                              Annexes

1.      Overview table of influenza vaccine technologies ........................................
                                                                                               27

2.      Relevant reports available online .................................................................
                                                                                                         31



                                                                                                                                        Page iii
�                        Acknowledgments
This paper has been written by Edward Hammond for the WHO Regional
Office for South-East Asia. It is intended as a contribution to the debate on
the sharing of influenza viruses and access to vaccines and other benefits
arising from their commercial exploitation, and to efforts to move forward
the issues raised by resolution WHA 60.28.




                                                                        Page v
�                        Acronyms

CBW     chemical and biological weapons

DNA     deoxyribonucleic acid

GAP     global action plan

GISN    global influenza surveillance network

IGM     intergovernmental meeting

IIV     inactivated influenza vaccine

LAIV    live attenuated influenza vaccine

MTA     material transfer agreement

PIP     pandemic influenza preparedness

RNA     ribonucleic acid

TRIPS   (Agreement on) Trade-Related Aspects of Intellectual
        Property Rights

VLP     virus-like particle

WHO     World Health Organization




                                                               Page vIi
�         Introduction
         As a result of concerns raised over the sharing of influenza viruses and the
         lack of affordable vaccines and medicines, the Pandemic Influenza
         Preparedness (PIP) Intergovernmental Meeting (IGM) is discussing the
         possible establishment of a new system for sharing of potentially pandemic
         influenza viruses, a well as sharing of the benefits resulting from research
                             s
         utilizing them.

              Among the possible benefits being discussed is expanded transfer of
         vaccine-related technology to developing countries, and a sustainable
         financing mechanism for developing country pandemic preparedness.
         WHO Member States hope that this financing and technology transfer
         would help close the gap between pandemic vaccine supply and demand.

              But what specific technological approaches are best suited for
         developing countries? Influenza vaccine technologies need to be
         categorized and assessed for their costlbenefit implications and respective
         tradeoffs and risks. Not all technologies are freely available or equally easy
         to use, so this codbenefit assessment needs to be made in the light of the
         constraints imposed by intellectual property claims as well as "hard"
         technology and know-how requirements.

               Other important considerations, including export controls and
         regulation of biotechnology, remain underexplored, but may influence
         decisions by developing countries with respect to a possible PIP IGM
         benefit sharing system.

               This paper discusses these issues in five sections. Section I provides a
         short background. Section II describes briefly the main technologies that are
         currently available or that are under development, as well as their
         comparative advantages and potential challenges1. Section Ill discusses a
         number of cross-cutting issues of practical significance (adjuvants,
         conditions related to seed strains, public perception of some of the
         technologies, and export controls) that lie outside the production-related
         questions, but that nevertheless need to be addressed. Section IV considers
         various options. Finally, Section V contains some concluding remarks.

' A table summarizing key features of the various technologies is attached as Annex 1.
�A discussion paper



          Background
          Ensuring adequate availability of pandemic influenza vaccines is not an easy
          task in any country of the world, and no single solution will be universally
          appropriate. Limited global production capacity for human influenza
          vaccines is the result of limited demand for seasonal influenza vaccines and
          technical challenges to influenza vaccine production. Adding to the
          difficulty is a recent sharp increase in patents and patent applications
          related to influenza vaccines, which may impede access to vaccine
          production technologies.

                Pandemic preparedness efforts cannot be considered in isolation from
          other public health concerns and must be weighed in the context of
          programmes to address other priorities, complementing them when
          possible. For example, the infrastructure to produce some types of
          influenza vaccine is useful for making other kinds of vaccines, yet
          paradoxically, the flu vaccine technologies that are most adaptable may be
          the most expensive and technologically-challengingto utilize, as well as the
          most impacted by intellectual property claims.

                Some have proposed to expand seasonal influenza vaccination in
          order to expand pandemic production capacity. This strategy is a key part
          of the WHO Global Action Plan (GAP), whose overarching goal is to
          increase pandemic influenza vaccine supply by stimulating demand for
          seasonal influenza vaccines. Greater seasonal demand, it is reasoned, will
          stimulate the private sector and others to construct additional influenza
          vaccine production capacity that can then be used in a pandemic.

                But in many countries, and especially developing countries, there is
          low demand for seasonal flu vaccines and limited prospects of expanding it,
          particularly among citizens in lower economic strata with competing health-
          care priorities. The cost of implementing the GAP, even with optimistic
          economic and antigen assumptions, is estimated to rise to US$ 3.5 billion
          to US$ 5 billion annually by 2012, with an emphasis on spending in
          developed countries to stimulate demand there, and the questionable
          assumption that excess pandemic vaccine will quickly be used to vaccinate
          those in other countries.'


* WHO IVR. The Global Action Plan (CAP) to Increase Supply of Pandemic Influenza Vaccines, First
  Meeting of the Advisory Croup, WHO/IVB/08.10, 19 October 2007, Geneva.


Page 2
�                         Observat ions on Vaccine Production technologies and Factors Potentially Influencing
                                                Pandemic Influenza Vaccine Choices in Develooine Countries



             It is unwise not to squarely recognize the limitations on seasonal
       influenza vaccine demand and the great challenges facing the GAP. Even in
       developed countries where demand and income are higher, and despite
       hefty economic stimuli, manufacturers currently are hesitant to expand
       production capacity. This is in large part due to limited seasonal vaccine
       demand. For instance, a large European manufacturer recently backed out
       of an agreement to build an influenza vaccine facility in the United States
       because it said that a US$ 298 million government subsidy was in~ufficient.~

             Others have proposed emergency conversion of animal vaccine plants
       if a pandemic strikes, particularly of poultry vaccine facilities with egg-based
       production systems that probably can be adapted to produce human
       influenza vaccine. With global human influenza vaccine production
       capacity at least 70% short of providing vaccination for the global
       population within six months of a pandemicI4 this suggestion makes
       obvious sense. Where such capacity exists, this could expand pandemic
       vaccine supply, but there are significant technical and safety hurdles.

              Another strategy that has been proposed is to concentrate vaccine
        antigen production in a small number of developed countries, on the theory
        that making vaccine antigen is best done in a few expert facilities and that, if
        these facilities are collectively made large enough, their surplus production
        can be exported to developing countries in the event of a pandemic. Yet this
        strategy, encouraged by the WHO GAP, leaves developing countries in a
        state of dependency and at the end of the queue to receive vaccine.

             All of the above factors, together with mounting pressure on health
        budgets as a result of the global economic downturn, make ensuring
        availability of influenza vaccines particularly difficult for most developing
        countries.

              Several studies have recently discussed options for expanding
        prepandemic and pandemic influenza vaccine production capacity. A
        number of these reports are listed in the annex to this report. While these
        are valuable and discuss some technical aspects of influenza vaccines in
        greater detail, there are key issues related to pandemic vaccination
        strategies that remain under-contextualized for policy-makers. This paper
        seeks to fill that gap.

McKenna M. Plant cancellation shows problems in flu vaccine business in CIDRAP News, 3 Ocl. 2008
WHO. Business Plan for the Global Pandemic Influenza Action Plan to Increase Vaccine Supply,
February 2008.


                                                                                                      Page 3
�A discussion oaoer



                 This paper assumes that developing countries will largely not be
          satisfied with reliance on pandemic vaccines and/or bulk antigen exported
          from Europe, North America, or Japan, particularly because such supplies
          currently cannot be made available in a timely fashion. Therefore is difficult
          to argue that such reliance is an adequate pandemic vaccine supply plan.
          Rather, here it is presumed that developing countries will continue to seek
          the development of national or regional 'vaccine production capacity
          through technology transfer and sharing of benefits of influenza research.


2.        Overview of influenza vaccine production
          technologies
          There are a variety of technologies that are used or have been proposed for
          production of human influenza vaccines. Often, significant parts of the
          production process are similar. This is especially true in the later stages of
          manufacture, such as packaging. The technologies may be categorized in
          several ways. Below, they have been divided into four basic technological
          approaches.


          Classic influenza vaccine produced in eggs

          With few exceptions, currently available seasonal and prepandemic
          influenza vaccines are manufactured through egg-based production
          methods. The system is cumbersome and inefficient in comparison to the
          theoretical possibilities of newer cell-based production (see below), leading
          some to characterize egg-based production as antiquated. Such
          comparisons, however, are invariably made against technologies that have
          yet to be fully commercially deployed and proven. Moreover, although it
          may not be new, this decades-old technology is relatively cheap, very well
          proven, and largely unencumbered by intellectual property claims.

                Egg-based production is employed throughout the world for animal
          and human vaccines. Apart from influenza, however, the only human
          vaccines for which the egg-based system is utilized are yellow fever and
          Japanese encephalitis vaccine. This means that apart from making flu
          vaccine, egg-based production lines have limited broader utility for human
          public health.'


  Egg-based lines arc important for animal heakh, however, as discussed below.


Page 4
�              Observations on Vaccine Production Technologies and Factors Potentially Influencing
                                    Pandemic Influenza Vaccine Choices in Developing Countries



      Egg-based production requires a supply of fertile chicken eggs
produced under relatively stringent conditions (in comparison to eggs
produced for food consumption). This is to ensure that they do not carry
pathogens that might taint the vaccine. The eggs are infected with a vaccine
strain and the fluid harvested from them yields vaccine after separation and
further production steps.

      The reluctance of H5 viruses to grow to high titer in eggs (because the
virus strains are too efficient at killing chicken embryos) is a problem that
has bedeviled H5 vaccine development. While this remains a significant
technical challenge, the problems with growing H5 viruses in eggs are being
overcome, mainly by attenuating the hemagglutinin (HA) gene of the
vaccine strain, typically through reverse genetics (see below). It may be
noted that some of these techniques are proprietary however.

      Major requirements of the egg-based production system include the
process of "candling" the eggs (inspection under bright light); equipment to
inoculate the eggs with virus; incubators in which to keep the eggs while
the virus is reproducing; and equipment to harvest, separate, and purify the
vaccine virus after incubation.

     Some of the technology required to produce the vaccine strain is
specialized; however, none of it is reported to be particularly expensive,
complicated or difficult to operate. In the newest facilities the entire
process is automated, while in others some steps in production (for
example, candling and harvesting) are conducted by human technicians.

     Later steps of egg-based vaccine production, including formulation
and packaging, may be similar or identical to the process used with other
technologies.


Live attenuated influenza vaccine

Live attenuated influenza vaccine, abbreviated "LAIV", is an influenza
vaccine production technology in limited commercial use in the Russian
Federation and in the United States. LAIV offers the possibility of producing
significantly more vaccine than classic egg-based production using same
production line; however there are significant additional scientific and
intellectual property hurdles that may reduce LAIVis attraction for
developing countries.

                                                                                          Page 5
�A discussion oaner


                  The production process for LAIV vaccines is similar to that of classic
            egg-based vaccines, with some notable exceptions. LAIVs are administered
            live. This means that when the vaccine strain-containing fluid is harvested
            from eggs, it is not exposed to a detergent. Thus, if adventitious pathogens
            are present in the eggs, these may survive the formulation process and
            eventually infect human vaccine recipients. Therefore, eggs used in LAIV
            production may require even higher production standards than those used
            to produce classic killed vaccine. This increased danger of contamination
            means biosafety practices in production need to be more stringent than
            those used for classic killed vaccine.

                  While there are a number of well-characterized backbone strains6
            available for classic vaccines, the "cold-adapted"' backbones used in LAIVs
            are proprietary, such as the "Ann Arbor" strain used in the United States
            and the "Leningrad" strain used in the Russian Federation. LAIVs thus
            require a proprietary backbone strain6 and cannot be produced using the
            vaccine seeds strains currently distributed by WHO global influenza
            surveillance network (which do not have "cold-adapted" backbones).

                  Harvesting is simpler for LAIVs (no detergent wash is needed), but the
            final product is more delicate because the live vaccine must be kept viable
            "alive") until it is used. This means LAIVs require cold storage.

                  The fact that LAIVs are not killed potentially offers a major advantage
            over classic vaccine, but at a cost. LAIVs reproduce in the body of
            immunized persons; thus, they effectively act as their own adjuvants, which
            means they should require a lower dose of antigen than killed vaccine. This
            means the same production line may yield considerably more LAIV than
            classic killed vaccine, although estimates of the increased yield vary widely.'


    Influenza vaccines typically are comprised of a(n) HA gene(s) taken from a viral isolate that is inserted
     into another, laboratory-adaptedstrain by reassortment or recombinant (reverse genetics) means.
     While the immunogenic HA gene is the most important part of the vaccine, the labadapted strain into
     which it is placed has typically been selected for useful characteristics for lab and industrial use (high
     growth rate, tolerance for lab conditions and temperature ranges, etc). This labadapted strain is called
     the "backbone" strain.
'   "Cold adapted" influenza strains are laboratory-adapted types that are suitable for use in live vaccines,
     which must be kept cold until use in order to maintain the vaccine's viability.
' Discussions to license the Russian "Leningrad" LAIV strains for H5 vaccine production .ire taking place,
   however, no detailed information concerning the terms and restrictions of any possible license is
   available, and no final agreement has been reported to have been reached.
' The WHO CAP estimate is 4.5 times, whereas others have estimated a yield as high as 10 limes that of
 '
   the c:lassic trivalent killed vaccine process.


Page 6
�               Observations on Vaccine Production Technologies and Factors Potentially Influencing
                                     Pandemic Influenza Vaccine Choices in iheloping Countries



      One price of this antigen efficiency is that LAIVs are administered as
an intranasal aerosol (i.e. sprayed into the nose), rather than being injected.
They thus require a special closer instead of standard syringes. Sufficient
supplies of this doser are required in order to use LAlVs.

      Another limitation of LAIVs is that they are unsuitable for
prepandemic vaccines because of the possibility that the live prepandemic
vaccine strain could mutate or recombine with circulating strains,
potentially causing or contributing to a new epidemic or even pandemic flu
strain. While this concern is not applicable to seasonal vaccines (because of
the antigens used), it does seriously limit the ability to test LAIV procedures
and formulations prior to an actual pandemic.

      Of note, in the future it may become practical for LAIVs to be
produced in cell culture (see below), although at present they are produced
in eggs.


Influenza vaccines from cell culture

Influenza vaccines produced by cell culture are currently under
development in several places but so far are not produced commercially on
a large scale. In the cell culture process, animal or other cells are infected
with a vaccine virus, which is then harvested and formulated into vaccine.
The process takes place in vessels called bioreactors (or fermenters), in basic
design not dissimilar from those used in brewing.

      Cell culture typically starts by growing cells in a nutrient-rich fluid in
small containers, scaling up to larger ones as the cells reproduce. When the
desired cell density and scale is reached (hundreds or thousands of litres for
commercial production), the cells are infected with vaccine strain virus.
After the virus reproduces, the cells are harvested and virus processed into
vaccine.

      In some cell culture systems, gently agitated cells grow freely in a sort
of "soup" mixed with nutrients and (eventually) with vaccine virus. In other
cell culture systems, the cells grow affixed to a substrate such as tiny gold-
coated beads. They are then released by agitation.



                                                                                              --

                                                                                           Page 7
�A discussion oamr


                For large-scale commercial production, the process requires large
          bioreactors, from hundreds to thousands of litres in size. Production of cell
          culture vaccines also requires equipment t o build and maintain a "cell
          bank" to provide a new supply of fresh identical cells after batches of virus-
          infected cells are harvested.

                 Cell culture systems are likely to be more flexible than egg-based
          systems for production of other human vaccines, potentially increasing a
          facility's utility. For H5 influenza viruses in particular, there are claims of cell
          culture systems that grow the virus to a higher titer than is possible in eggs.

                 Although cell culture vaccines are a major focus of research and
          development (R&D), as yet they remain in limited commercial use.
          Scientific limitations for their use in flu vaccines include the inability to be
          certain ahead of time that a particular cell line will be appropriate to grow
          the pandemic strain, and the need for substantial bioreactor capacity, of
          which there is little to no global surplus. Although investment may be
          recouped through a multi-use facility, cell culture has considerably higher
          facility construction costs at an industrial scale.

                In addition to potential patent claims over the influenza genes (which
          also impact egg-based vaccines) and backbones used in vaccine strains,
          there are additional intellectual property issues related to cell culture
          influenza vaccines. The cell lines that are used are themselves often
          patented, and the information necessary for their use and for regulatory
          approval is proprietary.

  Table 1 Examples of proprietary cells lines used in cell culture vaccine production
         :


 Avian embryonic stem cells         Vivalis (France)         Licensed to Novartis,
                                                             GlaxoSmithKline, and others


                                                             Vero cells per se are not
 cells (Vero)                                                proprietary, but Baxter's
                                                             process of using them is.

                To date, few cell culture-produced vaccines have been approved for
          human use, and they are likely to prompt more intense regulatory scrutiny
          than egg-produced vaccines. Cell culture vaccines require approval for the
          vaccine as well as characterization and safety demonstration of the cells used.

Page 8
�                              Olwervations on Vaccine Production technologies and factors Potentially Influencing
                                                    Pandemic Influenza Vaccine Choices in Uwelooinc Count rics



            Second generation biotech vaccines

            If cell culture vaccines, because of their sophisticated biological
            manufacturing process, may be considered the first generation of
            biotechnological flu vaccines, then a basket of different technologies currently
            under development could constitute the second. While supporters of these
            technologies believe they may be useful for pandemic influenza vaccines,
            several of them are at early stages of development and none are proven and
            ready for commercial use. Therefore, although it is difficult to generalize
            about these new technologies, they are unlikely to be selected in the short
            term for pandemic vaccine production in developed or developing countries.
            These technologies depend on the WHO global influenza surveillance
            network (GISN) for antigens and WHO selections of the best antigens for use
            in vaccines, but do not utilize WHO candidate seed strain.

                  Taking a longer a view, however, it is possible that some of these
            technologies, for example virus-like particles (VLPs), may become viable for
            large-scale use. The fact that they are new and mainly privately developed,
            however, means that in general they are heavily covered by intellectual
            property claims and may require very new kinds of know-how. For most
            countries it is too early to tell, however, if national patents will be issued, so
            the extent of intellectual property impediments for any particular
            developing country remains unclear.

                 Briefly, second-generation biotech vaccines include, among other
            approaches:

                   >     production of recombinant HA protein in other, easily grown,
                         organisms (e.g. transgenic bacteria);

                   >     "naked" and plasmid DNA vaccines in which "codon
                         ~ p t i m i z e d ' " flu genes are used directly as vaccine, and
                                               ~
                   >-    genetically engineered systems to co-express HA, NA,           M2
                         genes from flu, manufacturing a "virus like particle" (VLP) that is
                         purified from culture and used as vaccine.


lo   "Codon opiiniized" genes have nucleic acids that have been altered-typically changed from RNA to
     DNA-so 1h.11ihe gcnr can be he~terexpressed in a biotechnological application (e.g. . v,iccinc').
                                                                                          I



                                                                                                          Page 9
�A discussion paper



             Summary of the basic technological approaches to influenza vaccine
             production
             1. Egg-based "classic" influenza vaccine: Vaccine virus is injected into fertilized
             eggs. The eggs are placed in incubators and the virus reproduces in the eggs. Fluid
             is then harvested from the eggs and washed with detergent The resulting killed
             virus material is separated and used for vaccine formulation. This type of vaccine is
             one kind of inactivated (i.e. killed) influenza vaccine, or "11V".
             2. Live attenuated influenza vaccine ("LAIV"): Vaccine virus is grown in eggs (or
             in the future, potentially in cell culture) in a process similar to classic flu vaccine.
             The live virus uses a special type of genetic backbone (currently of limited
             availability since they are proprietary). Harvesting and formulation is simpler than
             with killed vaccines. The final product is more delicate and requires a cold chain,
             but the process potentially is considerably more efficient, producing more flu shots
             with the same number of eggs.
             3. Cell culture influenza vaccines: Mammalian, avian, or other cells are cultured in
             growth media. This culture is scaled up to the desired density of cells in large
             bioreactors (fermented up to thousands of litres in capacity. The culture is infected
             with vaccine strain, which multiplies in the cells, producing large quantities of vaccine
             virus. Harvesting, purification and packagingare essentially the same as with egg-
             based vaccines. This is another type of IIV, produced by a different method.
             4. "Second generation" biotechnologicalvaccines: Many techniques are under
             study, including: producing recombinant HA protein in other, easily grown,
             organisms (e.g. transgenic bacteria); "naked* and plasmid DNAvaccines in which
             "codon optimized" genes are used as vaccine; and genetically engineered systems
             to co-expressflu genes, making a virus-like particle (VLP) that is used a vaccine.
                                                                                        s


            Candidate seed strains and antigens

            The W H O system develops and distributes candidate H5 vaccine seed
            strains. he& seed strain; are suitable for producing vaccine in eggs and
            incorporate antigens that have been selected by WHO. In the event of a
            pandemic, the W H O system may develop and make available LAIV-
            suitable seed strains; however, W H O does not presently have rights to the
            proprietary LAIV backbones.

                Although at a technical level, current W H O candidate seed strains can
            be used to produce H5 vaccine, there are legal restrictions imposed on
            them in a required Material Transfer Agreement (MTA).ll This is because


l1    For example, the Material Transfer Agreement for the WHO candidate seed strain NIBRG-23, made
     from an HSN1 strain isolated in Turkey, can be viewed here:
     h~p://www.11ibsc.ac.uk~flu_site/Docs/spotlighl/H5N1MTA-NIBRG-23.doc


Page 10
�                     Observations on Vaccine Production Technologies and Factors Potentially Influencing
                                           Pandemic Influeni'a Vaccine Choices in Developing Countries



     they are created using proprietary reverse genetics technology. (See also the
     discussion on conditions imposed on commercial use of reverse genetics in
     section Ill below.)

           The advantage that the WHO seed strains theoretically offer is that the
     strain is a known quantity that may be quickly used, reducing the amount
     of work and time needed for new strains to go into production.

           Vaccine makers and other companies, however, may choose not to
     use WHO candidate seed strains for any of several reasons. These may
     include a desire to avoid the intellectual property restrictions imposed by
     the WHO MTA, or they may wish to use a technology type for which the
     WHO strain is not suitable (e.g. LAIVs), or they may wish to make other
     alterations particular to their production system (for example, to introduce a
     mutation intended to make the virus grow to higher titer).

            If a vaccine maker does not use the WHO candidate vaccine seed strain
     in actual production, however, it is still highly likely to use the antigens selected
     by the WHO system        C
                              SImost immunogenic. In this case, the maker would
     obtain the HA (andlor NA) gene(s) from the WHO system or synthesize them
     from sequence data. The maker then incorporates the WHO-selected
     antigenk) into its own vaccine strain. Thus, particularly in the future, of
     arguably even greater importance than the WHO candidate vaccine seed
     strain are the genes that the WHO system determines to be most suitable for
     use in vaccines, because these will be used by manufacturers whether or not
     the manufacturer utilizes the WHO candidate seed strain.


3.   Issues and challenges
     The question of adjuvants
     Adjuvants are substances that are added to a vaccine in order to enhance
     its immunological effect. Most adjuvants act on the human immune system
     and are not linked to a particular vaccine strain or even a particular disease.
     Thus a particular adjuvant may be used not only for influenza vaccine; but
     also in vaccines against other diseases.

          Adjuvants can both reduce the amount of antigen needed per vaccine
     dose (potentially of great importance in a pandemic) and increase the
     "take" of vaccines-lhat is, the rate of successful vaccination.


                                                                                                Page 1 7
�A discussion paper



                 Many adjuvants that may be used in influenza vaccines today are
            inorganic chemicals. These are sometimes aluminum-related compounds,
            such as aluminum hydroxide (or gibbsite, (Al(OH)J), which is more familiar
            in medicine for its use as an oral antacid. One adjuvant that has long been
            used, alum, is patent-free and easily obtained, but it is not generally
            considered promising for H5 vaccines.                 ,




                  Major influenza vaccine manufacturers are increasingly using newer
            adjuvants of a type called oil-in-water emulsions. Companies claim these
            offer substantial improvements over other adjuvants. The proprietary oil-in-
            water adjuvants used by Novartis and Gla~oSmithKline'~ based on
                                                                         are
            squalene, an organic compound produced in small quantities by many
            animals and some plants, and are subject to patents and trade secrets.

                 A large number of biotechnological adjuvants, such as short pieces of
            DNA that are active in the body and are designed to make vaccines more
            immunogenic through specific gene or protein-level effects on the immune
            system, are undergoing research. These, however, remain experimental.13

                   Not all vaccines contain an adjuvant. LAIVs do not need to be
            adjuvanted because they are alive and reproduce in the upper respiratory
            tract. One H5 vaccine, produced in cell culture by Baxter International, is
            a killed virus vaccine that is unadjuvanted.14

                  One problem with assessing the potential use of adjuvants for
            pandemic vaccine production in developing countries is that they are often
            highly proprietary. For instance, detailed information on production of
            vaccines with oil-in-water emulsion adjuvants is limited, as the adjuvants
            are often patented and their use is covered by trade secrets.

                   Table 2 provides an overview of a number of adjuvants.


  Sanofi's
'¥          proprietary formulation is reportedly similar, but its exact composition does not appear to
     have been made public.
" Because these     adjuvants are varied in nature and generally in earlier development stages, this paper
     focuses on adjuvants in current use or advanced development
l4    The Baxter vaccine has an unusual composition and production method. It uses unaltered H5N1 virus
     isolates that have not been placed on a labadapted backbone or had genetic alterations to reduce
     pathogenicity. Because the live vaccine virus is virulent for birds and, potentially, humans and other
     animals, it must be grown under very careful biosafety procedures in P-3 (BSL-3) containment. This
     method of production requires a cell culture system, with the added challenge of stringent BSL-3
     practices and facilities.


Page 12
�                                 Observations on Vaccine Production Technologies and Factors Potentially Influencing
                                                       Pandemic Influenza Vaccine Choices in DevelopingCountries



          Table 2: Adjuvants that may be used in pandemic influenza vaccines



What is it?           An inorganic     Chemicals         An oil-in-      An oil-in-       An oil-in-       Biological
                      chemical,        related to        water           water            water            materials
                      potassium        alum,             emulsion,       emulsion,        emulsion,        designed to
                      aluminum         including         consisting of   consisting of    whose            boost
                      sulfa~e.         aluminum          squalene,       squalene,        formulation      immune
                                       hydroxide         polysor'Jate    plysorbate       does not         syst-
                                       and               80 (Tween       80, and DL-      appear to        response.
                                       aluminum          801, and        a-               have been
                                       phosphate.        sorbitane       tocopherol.      published.
                                                         trioleate
                                                         (Span 85).
                                                                         Yes             1 yes            1 Yes. Includes
                                                                                                           JVRS-100
                                                                                          Avenlis)         fluventus),

                                                                                                           (Intercell) etc.
Use                   Has long         Clinical trials   Used in         Used in          Does not         Experimental:
                      been used in     are underway      vaccines        vaccines         currently        some have
                      various          of pandemic       licensed in     licensed in      appear to be     advanced to
                      vaccines.        flu vaccines      some            some             licensed.        human trials.
                                       utilizing         countries.      countries.                        Regulatory
                                       these. Also                                                         hurdles likely
                                       used in other                                                       to be quite
                                       vaccines.                                                           substantial.
Efficacy issues       Used in trials   Potentially       Deemed          Deemed           AF03 is           Unproven.
                      and in one       more              effective and   effective and    thought to
                      US-licensed      effective than    licensed for    licensed for     be similar to
                      prepandemic      alum, but less    use in non-     use in non-      MF59 and
                      vaccine; but     so than           influenza       influenza        ,4503.
                      often            proprietary       vaccines.
                      regarded as      adjuvants.
                      inadequate       Mixed results
                      for use with     in research to
                  '   H5 vaccines.     date.

                 Based on their reported composition, adjuvants such a MF59 do not
                                                                      s
           appear to utilize unusual or expensive ingredients; however, it cannot be
           assumed that effectively incorporating them into vaccines is as
           straightforward as their reported chemical composition because details of
           their use are proprietary.

                 In some countries, vaccination has been associated with social
           controversies due to perceived risks. Some vaccine critics have claimed that
           certain adjuvants are unsafe, including aluminum hydroxide (alleged to be


                                                                                                                  Page 13
�A discussion caper


          linked to Alzheimer disease) and MF59 (which has received scrutiny for its
          use in a controversial US anthrax vaccine). While the scientific merit of
          these criticisms is debated-the compounds have passed regulatory review
          in many countries-where concern exists it would be inappropriate to ignore
          the potential disruption to vaccination campaigns due to widespread worry
          over adjuvant safety.

                It is clear that in the event of a pandemic, the presently limited global
          vaccine virus production capacity means that the supply of pandemic
          vaccine antigen (in any form) will be far outstripped by demand, especially
          in the early stages. With the exception of unadjuvanted LAIVs, in the
          dominant planning scenario, widespread use of the most effective adjuvants
          is highly desirable because it will enable more people to be vaccinated with
          the limited amount of antigen available, especially at earlier stages of the
          pandemic. Failure to use the most effective adjuvants would "waste"
          antigen because each suboptimally adjuvanted dose would "rob" antigen
          from the global supply.


          Conditions imposed on commercial use of reverse genetics
          Reverse genetics is a relatively new proprietary technology that is being
          applied to the development of influenza vaccines as well as other products. At
          present the technology is used in the creation of WHO GISN H5 vaccine seed
          strains, although it is not strictly technically obligatory to use it when making
          pandemic vaccine strains. Because of the advantages it offers, however, the
          technology will likely be increasingly used in future vaccine strains.

                Primarily developed by American and British universities, and covered
          by a large number of patents, reverse genetics intellectual property has
          been accumulated by Medimmune, a US-based subsidiary of the United
          Kingdom's Astra Zeneca, a large flu vaccine maker. Meclimmune has thus
          far allowed use of its reverse genetics intellectual property in pandemic
          vaccine R&D, however, it has indicated that it will not permit commercial
          use of the technology without a license.

                Material transfer agreements for WHO candidate seed strains of H5
          vaccines thus include protections for Medimmune's intellectual property and
          thereby impose restrictions on those that receive seed strains (through contract
          law), even in countries where Medimmune's patents have not been issued.

               Reverse genetics technology involves creation of loops of DNA called
          plasmids whose key parts encode for influenza genes. When the plasmids


Page 14
�               Observations on Vaccine Production Technologies and Factors Potentially Influencing
                                     Pandemic Influenza Vaccine Choices in Developing Countries



are introduced into cells, the DNA is transcribed into RNA and influenza
virus is produced. The technology enables scientists to "edit" the influenza
viral genes by making alterations to the DNA plasmid, for example, deleting
bases from the HA gene to make the virus avirulent.

      In addition to allowing manipulation of individual genes, reverse
genetics allows scientists to relatively easily mix and match genes from
different influenza strains, particularly when inserting new genes onto
'backbone" strains for which plasmid systems are already constructed. This
is useful for research purposes and for creation of vaccine strains, because it
can be more straightforward and reliable than the traditional reassortment
method, whereby cells are coinfected with different strains and the resulting
hybrid viruses identified and selected by scientists.

      Reverse genetics is potentially a very useful technology for egg-based,
cell culture, and other types of flu vaccines. It is, however, controlled by
Medimmune and because it is used in current WHO candidate seed
strains, recipients of those strains are already obligated to negotiate with
Medimmune should they choose to commercially produce vaccine from
those strains. This point has perhaps not received the attention it warrants.


Biotechnology and public perception

An important policy and health consideration underappreciated to date is
the potential for problems with social and regulatory acceptance of
recombinant pandemic influenza vaccines-that is, those that are the
product of biotechnology. Some countries may have additional regulatory
requirements for such vaccines. This may influence the decisions that
governments take in vaccine supplies. Decisions may be complicated by
the fact that influenza vaccines make use of biotechnologies that might or
might not be popularly and legally understood as "genetic engineering".

      It is logical that in the event of a severe pandemic the vast majority of
people would opt for vaccination even if concerned about the safety of a
recombinant vaccine, for the simple reason that fear of severe illness or
death from the disease is greater than concern about the vaccine. It is also
true, however, that genetically engineered products used in humans remain
controversial in many parts of the world and some citizens may be reluctant
to be vaccinated, particularly in scenarios such as a slow-spreading
pandemic or widespread use of a recombinant (pre)pandemic vaccine.


                                                                                          Page 7 5
�A discussion paper



                 Although not strictly tied to biotechnology, recent cases of problems
           in polio vaccination campaigns and the rejection of childhood vaccination
           among some religious communities are evidence of the importance of
           safety perceptions and belief. In the case of pandemic influenza vaccines,
           the degree to which the vaccine could be termed "genetically engineered"
           varies by the technology used. Perceptions may be further influenced by
           other factors, such as use of animal products in cell culture, and whether
           the vaccine is live or killed, with killed vaccines presumably engendering
           less resistance.

                A brief breakdown of some pertinent influenza vaccine technologies
           and how they might be consideredis given in Table 3.

                 Table 3: Brief overview of key influenza vaccine technologies
      lechmtogy        -                    What is it?-                          Islt-geneticc~ng?
Reverse genetics              Assenlbly of influenza viruses through      Viruses produced by reverse genetics are
                              the creation of DNA plasmids bearing        recombinant products and are, as it is
                              influenza genes that are transcribed into   generally understood (and regulated),
                              virus in infected cells. Although not       genetically engineered. If the virus genes
                              strictly necessary for most influenza       have not been significantly changed,
                              vaccines, it may offer time savings and     however, then the resulting vaccine virus
                              other R&D advantages.                       may not substantially differ from
                                                                          reassortant viruses or natural virus isolates.
HA gene deletions             To facilitate safe handling of H5N1         The manipulation of the HA gene creates
                              research viruses and vaccine production.    a recombinant product. The modified HA
                              part of the HA gene is deleted to make      gene is not transgenic, however, because
                              it nonpathogenic. This altered gene is      it does not incorporate foreign genetic
                              then used in the vacane strain.             material.
Virus-like particles (VLPs)   Insertion of nucleic acids coding for       The VLP vaccine itself is non-living;
                              influenza virus genes into other cells,     however, i t is the product of an organism
                              triggering the production of non-living     that is genetically engineered to express
                              particles that mimic key parts of           non-native genes.
                              influenza viruses, and can trigger an
                              immune reaction.
Recombinant LAIV              While it is possible to create LAIVs        A live genetically engineered vaccine is
                              without use of recombinant DNA, lor         the type most likely to encounter stricter
                              technical reasons i t is likely that a      regulatory requirements and safety
                              pandemic LAIV would be produced             questions.
                              with reverse genetics and possibly
                              incorporate additional genetic
                              modifications.
                              For many of the same reasons as LAIVs,      These vaccines will contain a genetically
                              (pre)pandemickilled flu vaccines,           engineered product Regulatory and social
                              produced in eggs or cell culture, may be    concerns may be fewer, however,
                              recombinant products.                       because the vaccine virus is killed before
                                                                          administration.



Page 16
�                           Observations on Vaccine Production Technologies and factors Pofentially Influencing
                                                 Pandemic Influenza Vaccine Choices in Revelopinc Countries




         Export controls

        Export controls are imposed by national laws. They are designed to regulate
        and sometimes prevent the transfer of technologies (hat may be used to
        create nuclear, chemical, or biological weapons as well as certain other
        items, such as missile-related technology. They are discussed in particular
        here because they have generally not been discussed with respect to
        pandemic vaccine production to date.

              Export controls are necessary to consider because research on highly
         pathogenic influenza viruses and production of vaccines require facilities,
         know-how and equipment that could be abused in biological weapons
         programmes. As a result, some of the same technologies that can be used to
         protect public health by producing vaccines can be difficult to acquire
         because they may fall under export control laws.

               Biological export control laws are controversial and have been a
         matter of intense debate at the Biological and Toxin Weapons Convention.
         The countries that impose the most rigorous export controls (mainly
         developed countries) argue that they are necessary for national security and
         anti-proliferation reasons. On the other hand, the countries that are most
         often denied technology (mainly developing countries) counter that export
         controls are arbitrary and unfair, and that they are often motivated by
         political or economic considerations not related to weapons proliferation.

              Export controls are not governed by any international agreement.
         Some countries that have biological (and chemical) export control systems
         attempt to coordinate them through the Australia Croup, a collection of
         countries whose stated aim is "to minimise the risk of assisting chemical and
         biological weapon (CBW) proliferation".

               The majority of the members of the Australia Croup are OECD
         Member States. The Croup calls itself an "informal arrangement" that
         "meets annually to discuss ways of increasing the effectiveness of
         participating countries' national export licensing measures to prevent
         would-be proliferators from obtaining materials for CBW programme^".^^



'" See hltp://www.ai~straliagroup.net.

                                                                                                      Page 7 7
�A discussion paper



                 For influenza vaccines, export control laws may limit the transfer of a
            wide variety of research and vaccine production-related technology, and
            even shipments of vaccines themselves.16

                  Export controls are applied to equipment, organisms, and ideas. The
            different types of items that can fall under export controls,include:

                     >   Physical items used in research and vaccine production such as
                         bioreactors (fermenters), lyophilizers (freeze dryers), separation
                         and packaging (filling) equipment.
                     >   Know-how such a blueprints, design and engineering services
                                             s
                         for high-containment laboratories and biological production
                         facilities, as well as certain kinds of scientific procedures and
                         knowledge.
                     >   Biological materials-for example, highly virulent disease strains
                         or, in some cases, vaccines.

                  Export controls apply in different degrees to different countries and
            technologies. Items considered by export-controlling countries to be of
            highest risk1' may be more difficult to export than items that are considered
            lower risk (for example, vaccines). Generally, when an export license for a
            controlled item (or technology) is sought, the item is classified for its
            intrinsic risk and then cross-referenced against a list of countries that
            themselves have been categorized according to the degree of weapons
            proliferation threat they are alleged to impose.

                 An additional pertinent consideration may be the entity in the
            importing country that seeks access to the technology. For example, a well-
            known international pharmaceutical company may be less likely to be
            denied an export controlled item than a government research institute in
            the same country, if the exporting county is suspicious of the aims of the
            importing country's government research programme.

                Finally, when export licenses are issued, typically they are contingent
            upon the recipient of the controlled items agreeing to no further transfers of

"' A particularly severe export conlrol has recently been highlighted in news articles pointing out that
     export controls in the United States would apply to H5N1 vaccine exports to several countries. See,
     for example, URL: http://www.exportlawblog.com/archives/406(accessed 25 November 2008).
l7   For example, a large, high-quality fermentcr, which might be used to produce biological weapons
     agents instead of vaccine.


Page 7 8
�                               Observations on Vaccine Production Technologies and Factors Potentially Influencing
                                                     Pandemic Influenza Vaccine Choices in Developing Countries



            the technology. While as practical matter this type of re-export restriction is
            difficult to enforce, entities that transfer export-controlled technologies
            place at great risk their future ability to obtain export-controlled
            techn~logies.'~

                  While the Non-Aligned Movement and others have been critical of
            the Australia Group's biological export control system,'' there are no signs
            that export controls are being relaxed even with the prospect of an
            influenza pandemic. Countries must therefore take into consideration the
            issue of export controls when making pandemic preparedness decisions.
            Many developing countries are subject to Australia Group's export control
            restrictions, which could impede their access to influenza vaccine
            production technology.

                  The impact of export control regimes will vary by country and
            technology. While export controls will not be a major issue for all countries,
            particular technologies, such as cell culture systems, may be more prone to
            export control problems than others. Countries that wish to develop a
            domestic production capacity that utilizes imported technologies will need
            to address these issues.


4.           Options
             Timing and technology choices
             It is difficult to reconcile the severity of fears of an imminent pandemic with
             the slow pace of expansion of global influenza vaccination and vaccine
             production capacity. Years of meetings and rhetoric have passed since the
             H5 pandemic scare began, yet most countries in the world-including many
             wealthy countries-have thus far not ensured pandemic vaccine supplies for
             their own populations.


18   Countries that impose export controls maintain lists of commercial, governmental and other entities
     that have received (or sought to receive) export-controlled items for transfer to others without the
     approval of the original exporting country.
l9   See, for example, the statement of Cuba (on behalf of NAM) and other statements at the 2007
     Meeting of States Parties of the Biological and Toxin Weapons Convention, URL:
     http://www.opbw.org/newprocess/msp2007/msp2007_s>a~emcn~.htm
�A discussion oamr



                If the pandemic threat is so dire, why is the practical response so
          muted? Limited resources are certainly a factor; but clearly, not everyone
          shares the same views with respect to the imminence and likely severity of an
          outbreak.

                Those who warn that a pandemic may envelop the world within
          months from its onset, and there are many experts that do, suggest a health
          emergency that arguably would require strong government action such as
          nationalization of pertinent production facilities and invoking of TRIPS
          flexibilities to allow for greater availability of affordable treatments. A
          pandemic could circle the globe so quickly that initiating such steps after the
          appearance of a pandemic strain might be pointless.

                Despite the dire predictions, steps like compulsory licensing of antivirals
          have yet to be taken, suggesting that governments may be dubious of the
          claims made by some scientists of the imminence of a severe H5 human
          pandemic. Is this foolish, or an efficient use of overstretched resources?It will
          only become clearer in retrospect

                Nobody argues against improved pandemic preparedness now and in
          the future, for everyone seems to accept that a new pandemic will occur,
          sooner or later. Yet, at the same time, it is clearly not possible today to
          abandon other public health efforts because the argument that a highly lethal
          pandemic strain is nearly upon us may turn out to be correct

                For those seeking to get ready for a pandemic now, proven technology-
          mainly egg-based production of classic flu vaccine-offers degrees of certainty
          that emerging biotechnologies cannot. Methods to grow H5 viruses in eggs
          are improving, and egg-based production is already available and does not
          require any potentially expensive and unreliable "bleeding edge" technology.
          And in theory, the same production facility can also be used for production
          of pandemic LAIVs.

                  Although egg-based production is sometimes maligned as "antique", it
          is telling that major vaccine makers investing in biotechnology remain heavily
          reliant on egg-based systems for their own flu vaccine production. The major
          problem, of course, is what-if anything-to do with the production capacity
          when it is not required for (pre)pandemic vaccines, in view of the fact that
          there is limited other use for egg-based facilities and, for many developing
          countries, seasonal flu vaccination is a losing economic proposition.
          Maintaining an unused production base is expensive. WHO estimates that
          maintaining an idle capacity to produce 200 million seasonal vaccine doses
          would cost US $100 million per year.


Page 20
�               Observations on Vaccine Production Technologies and factors Potentially Influencing
                                     Pandemic Influenza Vaccine Choices in Developing Countries



     Viewed in a longer timeframe, technology selection may become
more complicated. The flexibilities and potential efficiencies of cell culture
are attractive because they may offer a faster pandemic response and,
especially, a facility with potentially broader public health uses-if the
technology is available and markets exist for the other types of human
vaccines that may be produced in cell culture.

     However, the relatively unproven status and considerably greater cost
of hardware for cell culture technologies (estimated at ten or more times
the cost of egg-based facilities), both in terms of equipment and intellectual
property, at present make them a daunting proposition for most developing
countries.


Fill/finish projects and importation of bulk antigen

Indonesian and Mexican vaccine manufacturers, with W H O support, are
developing filllfinish capacity for local vaccine sales. In the filllfinish
approach, developing country manufacturers import bulk vaccine antigen
produced by an overseas company and use it in a locally branded, finished
product. In the current WHO-supported projects, the antigen
manufacturers are Biken (to Indonesia) and Sanofi-Aventis (to Mexico).

      The imported bulk antigen, suitable for a classic killed vaccine, is
processed in-country into a finished product. The national manufacturer
creates filling and packaging facilities, and some associated technology
transfer takes place.

     Importation of bulk antigen and fillinglfinishing in developing
countries favours the argument, advanced by some, that it is rational for
global influenza antigen production to be concentrated in a few locations
with well-developed capacity and expertise.

      Local manufacturers importing bulk antigen remain dependent,
however, on product supplied from abroad, which is unlikely to be
available in the event of a pandemic (particularly in its early stages), so long
as global production capacity remains well below that which is necessary.




                                                                                          Page 21
�A discussion oaoer



            The option of animal vaccine plant conversion

            Current global capacity for human influenza vaccine production falls well
            short of that needed for pandemic response, even with optimistic
            assumptions about demandlyield of pandemic antigen. Often unmentioned
            is the substantial additional manufacturing base that uses egg-based
            production systems to make animal vaccines. These facilities could lessen
            the gap between pandemic vaccine supply and demand. They use a very
            similar production process as that used for human influenza vaccines.
            Estimates of the global size of the egg-based animal vaccine industry,
            however, vary wildly.

                  On the high end, according to one source20the annual global egg-
            based animal influenza vaccine capacity, as of 2006, was approximately 41
            billion avian doses (at 100 doses per egg), or about 410 million eggs. In
            terms of human vaccines, this implies a capacity of approximately 410
            million doses of human trivalent seasonal vaccine. Using this capacity
            estimate, output of a monovalent pandemic LAIV could be between 1.8
            billion (WHO conversion factor) and up to 4 billion or more vaccinations
            per year (other conversion fa~tor),~'
                                                depending on antigen assumptions. In
            either case, this would allow vaccination of a substantial proportion of the
            world's population.

                     But WHO CAP consultants, also citing industry sources, come up with
             very different numbers for the potential contribution of animal vaccine
             facilities. They report that the animal vaccine industry can handle only
             about 78 million eggs annually. This implies an annual pandemic LAIV
             output of approximately 340 to 750 million human vaccine courses per
             year, a much lower but still substantial figure.

                 It is thus difficult to be precise about (pre)pandemic capacity of
             animal vaccine facilities because of conflicting and limited data and the

2fl   Hcldens, J G M. Production capacity for human and veterinary influenza, June 2006,at URL: http://
     www.dut&bio.org/'meetings/list/dutch_vaccines_group/files/influenza_dag/
     DVC%2Ojacco%20Heldens,%2026.06.06.pdf           (Heldens represented Akzo Nobel, which owned
     Inletvet, a major animal vaccine maker, until it was sold to Schering Plough in 2007.)
21    See: Fedson DS, Dunnill P. New approaches to confronting an imminent influenza pandemic. Perm J
      2007;11:639,   URL: http://xnet.kp.orp/permancnteiournal/SUM07/influeriza-oandemic.h~rnl and
      Fedson DS, Dunnill P.From Scarcity to Abundance: Pandemic Vaccines and Other Agents for "Have
      Not"Countries in journal of Public Health Policy (2007) 28,322-340.
      doi: 10.1057/palgrave.jphp.3200147


Page 22
�              Observations on Vaccine Production Jechnohgies and Factors Potentially Influencing
                                    Pandemic Influenza Vaccine Choices in Developing Countries



variety of assumptions that could be made about antigen production and
vaccine type. But even a low-end estimate would represent a large addition
to human production capacity. Notably, a large proportion of global animal
vaccine production capacity is located in Asia, and additional capacity
exists in Latin America.

     Converting an animal influenza vaccine facility to human vaccine
production is not, however, as simple as switching vaccine seed strains.
There can be significant hurdles, the severity of which will vary with the
specific equipment and process used at each manufacturing plant.

       Major issues to be addressed in such a conversion are regulatory
certification of the manufacturing process to human vaccine standards,
ensuring appropriate biosafety practices, adequate egg supply, improved
virus purification processes, and adoption of adjuvants approved for human
use.

      Regulatory hurdles will be country-specific. In some places, animal
vaccine plants are already held to manufacturing standards near or equal to
those for human vaccines; however, this is not always the case. A related
issue is biosafety practices which, in some animal vaccine plants, would
need improvement-both in operating procedures and, potentially, to
equipment.

      Conversion of animal facilities to human vaccine production may also
strain egg supplies, especially in countries or regions where H5 vaccination
of poultry currently occurs, because eggs laid by hens vaccinated against H5
cannot be used to produce vaccine.

        Human flu vaccines produced in eggs go through an extensive
filtration process to remove egg proteins and other contaminants that can
cause an adverse reaction. Animal vaccines are generally not subjected to
the same level of filtration, and improvement of filtration in converted
animal vaccine plants would be necessary.

     The adjuvants used in animal vaccines are not typically approved for
use in humans, and animal vaccine plants would have to switch to
appropriate adjuvants, unless they are producing a human pandemic LAIV
(which is unadjuvanted).



                                                                                        Page 23
�A discussion oaoer


                 Human vaccine producers and pharmaceutical companies own a
          significant proportion of global animal vaccine production capacity. For
          example, Merial, the world's largest animal vaccine maker, is a joint venture
          of Sanofi Aventis and Merck. Ft. Dodge, another large animal vaccine
          company, is a division of Wyeth. Intervet, a third large animal vaccine maker,
          is owned by Schering Plough. Other drug companies, such as Pfizer and
          Novartis, also have animcil vaccine businesses. Thus, human and animal
          vaccine makers should not be thought of as wholly separate industries.


5.        Concluding discussion
          Which technologies should developing countries seek multilaterally to
          improve pandemic preparedness? The answer, of course, depends on many
          factors.

                 Reliance on a s m d number of developed country sources for
          pandemic vaccine and/or antigen is unlikely to remain an acceptable
          solution for most developing countries, particularly in view of the fact that
          the developed country industry is not currently in a position to offer
          sufficient quantities of antigen in a timely manner after the appearance of a
          pandemic strain.

                Practically, the present situation of dependency, which is effectively
          unaltered by the WHO Pandemic Action Plan, means that the vast majority
          of developing countries will only receive significant quantities of vaccine
          after the needs of developed countries are met, which will likely be many
          months after the onset of a pandemic-months during which pandemic
          mortality may be severe.

               As a result of the inequity, in the event of a pandemic, developing
          countries will suffer a disproportionate burden of serious disease and death,
          a problem that could be ameliorated by increased and equitably distributed
          global vaccine supplies, particularly in the developing world. These vaccine
          supply problems may be further exacerbated by non-health factors, in the
          form of export controls that may inhibit the ability of some countries to
          prepare for a pandemic because some kinds of technology transfer are
          unavailable to them.

                Developing country leaders are likely to face question from their
          citizens if they remain vulnerable while the citizens of wealthy countries are
          vaccinated; this situation could become especially tense if a pandemic is
          severe enough to cause serious socioeconomic disruption.

Page 24
�              Observations on Vaccine Production Technologies and factors Potentially Influencing
                                    Pandemic Influenza Vaccine Choices in Developing Countries



     Vaccination for the population at the earliest point possible following
the onset of a pandemic isn't the entirety of pandemic preparedness; but it
is a high priority. But at present, there is little consensus among experts
about how best to achieve that.

      It is also clear that no single technological approach will be
appropriate for all countries or regions and that greater funding and
improved access to proprietary technologies will be necessary for
developing countries to improve protection of their citizens from pandemic
flu. Regional cooperation in production and technology to take advantage
of economies of scale will likely be far more fruitful than trying to go it
alone for most countries.

      Several options for financing and technology transfer have been
mentioned in the context of the Pandemic Influenza Preparedness
Intergovernmental Meeting (IGM). These include increasing vaccine
production in developing countries, possibly supported by royalty-free
licensing of vaccine production technology. Contributions to a global fund,
and contributions of vaccines to a WHO stockpile by entities that use
pandemic preparedness biological materials in research and development
of vaccines and other biomedical items have also been proposed.

      While a WHO stockpile may be useful to help stamp out or slow down
the emergence of a pandemic influenza strain, it is not designed-nor will it
serve-to ensure any country's vaccine supply. A WHO vaccine stockpile is
also mandated by WHO Member States outside the WHO PIP IGM
discussions, and is thus not a central objective of the benefit-sharing
discussion.

      Because increasing national or regional vaccine production capacity in
developing countries requires flexibility in technological approaches, no
single technology transfer and cooperative arrangement is likely to be
effective. There is strong evidence that proprietary and emerging
technologies, such as reverse genetics, adjuvants, and in the future cell
culture, could serve to greatly increase the efficiency of preparedness
efforts. Specific technology selections, however, must be made in the
regional and national contexts.

     In principle, developing countries may seek to formalize a system of
equitable reciprocity wherein those developed country companies and
other entities that utilize Global Influenza Surveillance Network (GISN)


                                                                                         Page 25
�A discussion oaoer


          materials to develop vaccines commit to transfer their vaccine technologies
          so that they may be used by developing countries.

               Therefore, in the PIP ICM negotiations, developing countries have
          explored the possibility of creating a mechanism for transfer of influenza
          vaccine technology, through mandatory royalty-free licensing and other low
          or no-cost means, including for both formal patents and related know-how
          and trade secrets. The technologies prioritized by any such pandemic
          preparedness technology transfer program should be those that are used by
          industry to manufacture products that include WHO GISN materials (e.g.
          H5 vaccines) or are developed utilizing WHO GISN materials.
                Reducing proprietary barriers to the technology needed to produce
          pandemic vaccines would represent a significant step forward; however,
          making technology available does not guarantee that it will be effectively
          used. Ways to optimize the use of technologies include, for example, the
          creation of a financing mechanism by which the real-world transfer of these
          technologies can be effected (for instance, to pay for the necessary
          equipment and training to utilize them). A pandemic preparedness
          cooperation fund could also be established, with contributions from
          manufacturers that utilize WHO GISN materials in commercial products (to
          be defined in a WHO material transfer agreement), and possibly
          contributions from governments. A cooperation fund could also help enable
          the use of nonproprietary technologies, such as egg-based production lines
          and fill/finish capacity, which will be important elements of any national or
          regional effort to increase vaccine production capacity.
                Pandemic preparedness is a problem of daunting complexity, and
          solutions will only come with time and contributions from many quarters.
          The PIP IGM is an important process but not one that by itself can solve all
          problems. Developing countries may wish to focus on important specific
          benefits that will enhance their preparedness.

               With the timing of a pandemic uncertain, but the time needed to
          construct and validate vaccine facilities typically measured in years, it is
          urgent that progress be made now to expand developing country vaccine
          production capacity. Developing countries will have to work together to
          identify the best technologies for their circumstances. The PIP ICM's
          decisions may help to make key technologies affordably available to
          developing countries, and through a cooperation fund, provide means
          through which to effect their transfer and use.




Page 26
�                          Observations on Vaccine Produaion Technologies and Factors PotentiallyInfluencing
                                                Pandemic Influenza vaccine Choices in evel lop& ~ountries




                                              Annex 1

        Overview table of influenza vaccine technologies
                                      .- -            -

                                       Cell culture
                                     produced vacdnes
                                                      -
-
    -
    .                                                                                 -
                                                                                        vaccines, =-.
                                                                                       --     - -
                                                                                                  etc)   F
                                                                                                         -
                                                                                                          Z  --

Description    Inject vaccine        Animal, insect, or     A vaccine seed          Many techniques are
               virus into            other cells are        strain using a          under study, including:
               fertilized eggs,      cultured in growth     special type of
               allow virus to        media, scaling up      backbone (from a        - Producing
               grow. Harvest         the quantity to the    lab-adapted flu           recombinant HA in
               fluid from eggs,      desired density of     strain) is grown in       other, more easily
               wash with             cells in industrial    eggs (or potentially      grown organisms
               detergent to kill     bioreactors            cell culture). The        (e.g. transgenic
               cells, separate out   [fermenters) of        live virus is             bacteria).
               virus material for    hundreds to            harvested, purified     - "Naked"   and
               vaccine               thousands of litres    and formulated for        plasmid DNA
               formulation.          capacity. The          use. Harvesting and       vaccines in which
               Generally, the        culture is infected    formulation is            "codon optimized"
               vaccine strain        with vaccine strain,   simpler than with         flu genes are used
               consists of the H A   producing large        killed vaccines, but      directly as vaccine.
               and NA genes of a     quantities of          the live final
               "wild type" of        vaccine virus.         product is more         - Genetically
               influenza fused       Harvesting,            delicate.                 engineered systems
               onto a lab-           purification and                                 to co-express HA,
               adapted               packaging is                                     NA, and other flu
               "backbone" strain     essentially the                                  genes, making a
               with the other        same as with egg-                                "virus-like particle"
               viral genes.          based methods.                                   (VLP)which is used
                                                                                      as vaccine.
                                                                  -


"Hard"         Large BSL-2           Large BSL-2                        +
                                                            Large BSL-2 . May       Will vary with specific
technology     space, incubators,    bioreactors for cell   be grown in eggs or     technology; however,
requirements   inoculation and       culture, equipment     bioreactors (see        all are likely to require
               harvesting            to maintain cell       respective              BSL-2 CMP space and
               equipment.            bank and scale-up.     requirements at         microbial fermentation
               Centrifuges           In some cases          left), but currently    /coil culture capacity.
               (separationand        growth substrates.     the process is done
               purification) and     After harvestingof     in eggs. Purification
               packaging             virus, purification    and formulation
               equipment.            and formulation        differs from that for
                                     requirementsare        killed egg and cell
                                     the same as for        culture vaccines.
                                     eggs.
�A discussion paper




-                    Egg-based W&sicn'
                         flu vaccine           I
                                                                 -
                                                     0 1 1 culture
                                                   producedvaccines       -
                                                                              Liveatenuated
                                                                                 ("lAIVw)
                                                                                                -'




-
- - --
Major                The technology is         Theoretically higher       Live vaccine is likely     Dependent upon
advantages           well known and has        antigen output than        to be effective in         specific'


                     been successfully         eggs, theoretically        much lower doses           technology. Nearly
                     utilized for decades.     more scalable. May         than killed vaccines.      all purport to be
                     Essentially the same      grow some U    S           Assuming                   able to provide
                     technology is used        vaccines viruses to        production capacity        more vaa5ne
                     for some poultry          higher liter. Cell         can be harnessed,          faster, but these
                     vaccines, making          culture vaccine            more LAIV vaccine          claims are as yet
                     conversion of animal      plants likely to prove     may be made                unproven.
                     vaccine plants and        more flexible for          available in a             May offer more
                     personnel a               producing other            shorter time period
                                                                                                     dependable
                     possibility in an         kinds of human             than with other
                                                                                                     vaccine yield per
                     emergency.                vaccines than egg          '"T'es.                    production run.
                                               based plants.
Major                Not as efficient as       Cell culture vaccines      Not suitable for           Dependent upon
limitations          cell culture              are a major focus of       prepandemic                specific
                     theoretically is.         R&D; but as yet they       vaccines due to            technology.
                     Requires many eggs,       are in limited             recombination risks.
                     the availability of       commercial use.            Difficult to test with
                     which may be              Inability to be certain    prepandemic
                     limited in a              that a particular cell     strains. Requires
                     pandemic (eggs may        line will be               more stringent
                     be available from the     appropriate to grow        conditions on egg
                     broiler industry). Egg-   11iepandemic strain.       supplies than killed
                     based plants are          Requires substantial       vaccine production.
                     unlikely to be used       bioreactor capacity        Higher biosafety
                     for other human           of which there is little   requirements for
                     vaccines (except for      to no global surplus.      production. More
                     Japaneseencephalitis      Much higher cost           difficult to store
                     vaccine).                 facility at industrial     vaccine. Intranasal
                                               scale.                     administration
                                                                          requires special
                                                                          delivery device.
Regulatory1          Fewer impediments         Few cell-culture           Seasonal LAIVs             These products, if
safety               as these vaccines will    produced vaccines          have limited use in        successful, will be
approvals            he produced in the        hwe been approved          the U ("FluMist")
                                                                                S                    new to regulatory
                     same manner and           for human use and          and in Russia;             systems and are
                     with the same             they are likely to         however, most              highly likely to
                     facilities as seasonal    prompt more intense        regulatory                 require substantial
                     vaccines, although        regulatory scrutiny.       authorities would          safety review.
                     converted animal          Require approval for       be encounteringa
                     vaccine plants likely     the vaccine as well as     live (and likely
                     will not already          characteriition and        genetically
                     possess approvals to      safety demonstration       engineered)
                     produce human             of the cells used.         influenza vaccine
                     vaccine.                                             for the first time.



Page 28
�                           Observations on Vaccine Production Technologies and factors Potentially Influencing
                                                 Pandemic Influenza Vaccine Choices in Developing Countries




Administration   Syringe                 Syringe                  Intranasal (requires    Method of
                                                                  appropriate delivery    administration
                                                                  device)                 (injected, oral,
                                                                                          intranasal, etc.)
                                                                                          will depend on the
                                                                                          specific product
Recombinant      Probably. Seed strain   Same as egg-based        Probably, with the      Vaccine will be
(genetically-    may be produced         production. Other        notable difference      genetically
engineered?)     with reverse genetics   genetic modifications    that the vaccine is     engineered or be
                 and, for example,       of the vaccine strain    administered live.      the product of a
                 may contain a           may occur to                                     genetically-
                 modified HA gene        optimize growth in                               engineered
                 (deletions) to make     cell cullure.                                    organism.
                 the virus less
                 pathogenic. Virus is
                 killed before use.
Adjuvanled       Almost certainly, to    Same as egg-based.       Probably not. The       Depends on
(pandemic        make more efficient     One exception is         vaccine virus           specific
vaccine?)        use of bulk antigen     unadjuvanted killed      replicates in the       technology.
                 and potentially to      ''wild-type" virus       upper respiratory
                 reduce the number       (being tested by         tract, stimulating
                 and size of required    Baxter); however,        immune response.
                 doses.                  producingsuch a          Nevertheless, some
                                         vaccine is a biosafety   research has
                                         challenge, requiring     focused on
                                         cell culture in large    increasing immune
                                         scale BSL-3              response to LAIVs
                                         containment.             with adjuvants.
Intellectual     Few IPR problems        Many IP  R               Only a small            Impedimentswill
property         for egg-based           impediments. These       number of               depend on
                 process, except for     include patents on       backbone strains        specific
                 adjuvants where IPR     cell lines and           are suitable for use.   technology;
                 and supply problems     production systems,      Intellectual property   however, it may
                 may exist.              as well as trade         impediments exist       be anticipated that
                 Potential additional    secrets on safety        on the use of           these technologies
                 problem if seed         profile of cells. Cell   strains; patents and    will have robust
                 strain is produced      characterizationis       trade secrets cover     IPR coverage as
                 using reverse           only reportedly          the formulations.       they are mainly
                 genetics.               publicly available for   Seed may need           being developed
                                         Vero (monkey) cells.     reverse genetics.       by biotech
                                                                                          companies and/or
                                                                                          universities
                                                                                          seeking to sell this
                                                                                          technology.

                                                                  -
                                                                                                      Page 29
�A discussionpaper




Other issues        Some (generally       Requires supply of      Safe production       The vast majority
                    minor) side effects   growth media and        will require more     of R&D in these .
                    from egg proteins     other relatively        stringent biosafety   lines of research
                    and other possible    exotic supplies. In     procedures than       appears to be
                    impurities.           addition to technical   killed vaccines to    conducted by
                                          challenges, cell        prevent               companies in a
                                          culture production      contamination of      handful of
                                          may be especially       live final product.   developed
                                          prone to export         Societal resistance   countries.
                                          control issues for a    may be significant,
                                          number of countries.    particularly for
                                                                  seasonal use.




 Page 30
�                              Observations on Vaccine Production Technologies and factors Potentially Influencing
                                                    Pandemic Influenza Vaccine Choices in Developing Countries




                                                 Annex 2

                        Relevant reports available online

    Friede M, Serdobova I, Palkonyay L, Kieny MP. Technology transfer hub for pandemic influenza
    vaccine. Vaccine. 2008 Nov 18. (ht@://dx.doi.ore/lO. 1016/i.vaccine.2008.10.080 - accessed 9
    January2009).

    Lozano B. The veterinary hiological industry and the production of human pandemic influenza vaccines
    in Mexico. Geneva: WHO FA0 OIE Consultation Seminar. 2006.
    (http://www.who.int/entitv/csr/disease/influenza/Bernardo Lozano A v i m e x d f
    - accessed 9 January2009).
    National Academy of Engineering. V-36-3 engineering and vaccine production for an influenza
    pandemic. The Bridge. Fall 2006; 36(3). h~~://w.nae.edu/nae/brideecom.nsf/wel~links/MKEZ-
                                                                       -

    6SZRM2?OpenDocument- accessed 9 January 2009).

    Oliver Wyman Consultants. Influenza vaccine strategies for broad global access: key Findings and
    project methodology. Scatlle: Path, 2007. (htl~://www.~ath.or~/files/VAC publ rpt 1 0 - 0 7 . d -
                                                                              infl
    accessed 9 January 2009)

    World Health Organization. Business plan for the global pandemic influenza action plan to increase
    vaccine supply. Geneva, WHO, 2008.
    htt~://www.who.int/entitv/vaccine research/documents~Re~ort%2520McKinsev%2520Business%2520
    Plan%2520Flu3.pdf - accessed 9 January2009).

    World Health Organization. Mapping of intellectual property related to the production ofpandemic
    Influenza Vaccines. Geneva: WHO, 2007.
    (httD://www.who.int/vaccine research/diseases/influenza/Ma~~inp   Intellectual Propem Pandemic I
    nfluenza Vaccinemdf - accessed 9 January 2009).

    World Health Organization. Meeting with internationalpartners on influenza vaccine technology
    transfer to developing country vaccine manufacturers. Geneva: WHO, 2007. Document
    WHO/IVB/08.09. (ht~://w.who.int/immunization/documents/WHO IVB 08.09/en/index.html -
s
    accessed 9 January 2009).

    World Health Organization. Tables on the clinical trials of pandemic influenza prototype vaccines.
    Geneva: WHO.
1   httD://www.who.int/vacrine rcsearch/diseases/influenza/flu trials tables/en/index3.html - accessed 9
    January 2009).

    World Health Organization. The global action plan (CAP) to increase supply of pandemic influenza
    vaccines, first meeting of the advisory group. Geneva: WHO, 2007. Document WHO/IVB/08.10.
    (htt~://www.who.int/imm~~nization/documents/WHO 08.10/en/index.html - accessed 9 January
                                                           IVB
    2009).




                                                                                                         Page 3 1
�      This paper presents an overview of technologies currently available for the
      production of influenza vaccine, as well as others that are under
      development. It draws attention to pertinent issues and challenges that
      policy-makers in developing countries may need to consider when
      reviewing their options for accessing influenza vaccine production
      technologies. It is intended as a contribution to the debate on the sharing
      of influenza viruses and access to vaccines and other benefits arising from
      their commercial exploitation.




            World Health
            Organization
~ e ~ k nOffice for SouthEast Asia
         al
World Health House
Indraprastha Estate,
Mahatma Gandhi Marg,
New Delhi-110002, India

Baci e abbracci in culla contro il futuro stress le coccole di mamma fanno adulti più forti

L’affetto materno è un’arma fondamentale per divenire adulti capaci di resistere alle tensioni quotidiane, più sicuri di sè, meno ansiosi e ostili. Lo psichiatra: “Il legame inizia già dal ventre materno”. Ma attenzione a non adottare stili di vita malsani, potrebbero rovinare tutto

di ADELE SARNO

ROMA – Tensione, ansia, irritabilità, sbalzi di umore. In una parola stress. Un problema dei nostri tempi, tanto che solo in Italia colpisce sette persone su dieci, almeno secondo un recente studio dell’università La Sapienza di Roma e dell’Associazione italiana contro lo stress. Da tempo la scienza si chiede quale sia il modo migliore per combatterlo. Il Finnish forest research institute di Metla, in Finlandia, sostiene che lo stress si sconfigge con una gita in campagna o in montagna: merito degli ambienti verdi, gli unici in grado di ridurre le tensioni, migliorare l’umore, ridurre la rabbia e l’aggressività, rendendo le persone più felici. Gli effetti positivi si ripercuotono persino sul sistema immunitario: aumenta la quantità e l’attività delle cellule cosiddette natural killer, cioè quelle capaci di uccidere le cellule cancerose. Senza contare i benefici per cuore e muscoli.

Oggi un nuovo studio, pubblicato sul Journal of Epidemiology and Community Health, torna sul tema e tira in ballo la mamma. Secondo i ricercatori, la capacità di resistere allo stress da adulti è legata alla quantità di carezze e di affetto ricevute nei primi mesi di vita. Insomma, le coccole sono un’arma fondamentale per divenire adulti capaci di resistere alle tensioni quotidiane, per essere più sicuri di sè e meno ansiosi e ostili.

Per arrivare a questi risultati Joanna Maselko, della Duke University in North Carolina, ha selezionato 482 bebè e li ha seguiti nella crescita fino all’età di 34 anni. Gli psicologi hanno valutato il grado di affettività e di attaccamento materno quando il piccolo aveva solo otto mesi. Poi, a distanza di anni, con questionari ad hoc, hanno misurato il livello di salute psicologica di questi figli ormai divenuti adulti. Così è emerso che i bambini che hanno ricevuto più affetto da mamma sono adulti sicuri e forti, capaci di vincere gli stress della vita. Tali soggetti mostrano livelli di ansia e ostilità fino a sette punti inferiori a quelli mostrati dai loro coetanei le cui mamme non hanno instaurato coi figli ancora in fasce un legame altrettanto affettuoso. L’affetto materno, dunque, è un’ottima risorsa per crescere pronti ad affrontare la vita.

“Un buon rapporto con la mamma è fondamentale per la crescita di un bambino sano – conferma Claudio Mencacci, psichiatra all’ospedale Fatebenefratelli di Milano – basti pensare che il legame inzia già dal ventre materno. Un atteggiamento dolce e accogliente rende il bambino meno vulnerabile, lo fortifica e lo libera dall’ansia che troppo spesso causa stress”. Insomma, ha ragione l’epigenetica: non tutti i caratteri ereditati dai genitori dipendono dal Dna, per questo è importante controllare che la gravidanza avvenga in maniera più serena possibile. “E gli effetti benefici sul bambino non riguardano soltanto la salute psicologica, ma anche quella fisica. Studi molto recenti – dice Mencacci – suggeriscono che un rapporto affettuoso con i genitori nei primi mesi di vita difende il bambino da diabete e dalle allergie”.

Va detto però che le coccole di mamma non arrivano dove l’ex bambino, ormai diventato adulto, soccombe a stili di vita malsani. “Oggi riceviamo mille stimoli – dice Mencacci – tutti i giorni siamo destinati ad avere molte più richieste di quelle che possiamo soddisfare. E così, più deboli, abusiamo di fumo e alcool, mangiamo male, soffriamo di disturbi del sonno. Tutti fattori che contribuiscono a stressare il fisico. E così anche se la mamma ce l’ha messa tutta, può vincere la frenesia della quotidianità. E i genitori non sono colpevoli, anzi, hanno il diritto alla fuga”.

Le promesse mancate del Dna

GENETICA

Le promesse mancate del Dna
“Inattendibili i test in vendita”

In cambio di mille dollari promettono di rivelarci di cosa ci ammaleremo, ma sbagliano in due casi su tre. Il governo Usa smaschera il business online delle analisi fai-da-te: più che oracoli sono inganni di ELENA DUSI

Oscuri, ansiogeni, contraddittori: i test predittivi del Dna venduti da una ventina di aziende sono finiti nel mirino del “Government accountability office” (Gao), l’organismo governativo statunitense che ha deciso di mettere il naso in un mercato che per pubblicizzare se stesso spende 3 miliardi di dollari l’anno.

L’anonimo “paziente 3” per esempio, arruolato dalla Gao per il suo esperimento, ha spedito un campione di Dna alle quattro aziende chiedendo una valutazione sul suo rischio futuro di ammalarsi di cancro alla prostata. In due casi il responso è stato “rischio medio”, in uno “rischio superiore alla media” e nell’ultimo “rischio inferiore alla media”. Il “paziente 4” invece ha un pacemaker impiantato da 13 anni per combattere una pericolosa fibrillazione atriale. Ma il risultato del test del Dna cui si è sottoposto è in due casi “rischio inferiore alla media” per quanto riguarda questo disturbo, mentre gli altri due responsi parlano di “rischio medio”.

Oltre che nel prevedere il futuro, le aziende si sono fatte trovare impreparate anche nell’analizzare il presente.
Pagare fino a mille dollari in cambio di tanto spavento e nessuna certezza medica è ormai routine per chi decide di affidarsi ai test del Dna online. Le società scientifiche di genetica di tutto il mondo raccomandano da anni di affidarsi solo a istituti seri, evitando la giungla di internet. Una legge che ponga dei paletti a un mercato che prospera soprattutto online è invocata da anni negli Stati Uniti, ma nessuno si è mai preso la briga di pestare i piedi a un business ormai ben maturo. Solo ora per la prima volta la Goa è andata a toccare con mano quale livello di imprecisione e raggiro abbia raggiunto un settore uscito dai confini della scienza per tuffarsi nella ricerca del profitto.

Ogni test genetico  –  in Italia come in molti paesi europei dove le regole sono certe  –  deve essere accompagnato da una consulenza medica. Un esperto deve spiegare al paziente quali sono i limiti dell’analisi e precisargli che il concetto di “rischio” è ben diverso da quello di una diagnosi certa. Ma la distinzione è saltata del tutto in una delle conversazioni fra la “cavia” usata dal Gao e il rappresentante dell’azienda contattato per un chiarimento sui risultati. “Quindi se sono ad alto rischio, vuol dire che mi ammalerò di cancro al seno?” chiede la paziente. “Sa, in effetti, è molto reale questa ipotesi” risponde il consulente al telefono senza troppi giri di parole.

In un’altra conversazione, il rappresentante dell’azienda suggerisce (in maniera completamente errata) che un Dna danneggiato possa essere riparato. “Davvero potete?” chiede il paziente. “Ma sì, certo, si chiama epigenetica. I geni non sono più visti come la fonte della nostra biologia, sono un sintomo”. Il panorama non migliora quando si va a considerare la privacy. “Pensavo che sarebbe un’idea fantastica regalare alla mia fidanzata il test del suo Dna, insieme con il mio” propone uno dei finti pazienti arruolati dal Gao. “Grande idea” risponde il rappresentante dell’azienda. “Mi basterebbe  –  suggerisce il cliente  –  procurarmi un campione della sua saliva e spedirvelo”.

Segnalare la presenza di una malattia, vera o presunta che sia, resta poi il modo migliore per vendere un farmaco. Così si svolge un’altra conversazione telefonica: “I miei genitori hanno entrambi problemi di colesterolo e ipertensione” racconta il rappresentante dell’azienda. “Così anch’io ce l’ho scritto nei miei geni. Ma io prendo il prodotto. Se non lo prendessi avrei gli stessi problemi”. Semplici vitamine e antiossidanti sono gli integratori più venduti dalle aziende che effettuano test genetici predittivi, necessaria conseguenza di un’analisi minacciosa al punto giusto.

I risultati contraddittori riscontrati dal Gao non stupiscono Giuseppe Novelli, genetista e preside di medicina all’università romana di Tor Vergata. Che invita però a non confondere le distorsioni operate dal business con una scienza, quella della genetica, che ai pazienti ha invece molta serietà da offrire. “Non si tratta di problemi tecnici nel sequenziamento dei geni” spiega. “Le contraddizioni nascono da come i dati vengono interpretati. Ciascuna variante genetica può avere un peso più o meno grande nell’influenzare il rischio futuro di malattia. Ogni azienda decide in maniera autonoma quanti frammenti del Dna studiare e quanta importanza dare a ciascuna mutazione”.

L’associazione tra una variante genetica e il rischio di ammalarsi è poi legata alla geografia. “Le malattie non sono equamente distribuite nel mondo, e ogni etnia ha vulnerabilità diverse” spiega Novelli. “Né in un’analisi genetica si può prescindere dai problemi di genitori e altri antenati o dallo stato di salute attuale del paziente. Il test del Dna da solo, senza queste altre informazioni, serve effettivamente a poco”. I 5 o 6 laboratori privati che nel nostro paese effettuano test predittivi, fa notare Novelli, “non hanno mai visto fiorire i loro affari, anche se i costi sono paragonabili a quelli americani”.

Paolo Vezzoni, ricercatore del Consiglio Nazionale delle Ricerche, ricorda che la nostra conoscenza delle varianti genetiche associate alle malattie è ancora limitata. “Ogni mese nella letteratura scientifica si legge di nuove scoperte. È un settore che sta maturando giorno dopo giorno e ancora dobbiamo capire quanto la singola variazione di un gene contribuisca ad aumentare il rischio di ammalarsi”. Uno dei dilemmi irrisolti, spiega il ricercatore, è se una malattia genetica nasca da poche variazioni comuni a tutti i casi di malattia, o da un numero alto di variazioni assai diversificate tra loro.

“A dieci anni dal sequenziamento del Dna umano  –  sintetizza Vezzoni  –  la genetica è in quella fase grigia in cui deve soprattutto avere fiducia in se stessa e convincere gli altri della propria solidità. In Italia siamo poco abituati a pagare per ottenere prestazioni mediche, e il business dei test del Dna non ci tenta molto. Ma negli Stati Uniti il dibattito sulla regolamentazione o meno di questo mercato è molto vivo”.

Ma anche negli Stati Uniti della genetica selvaggia le autorità nelle scorse settimane si sono viste costrette a porre un freno al business. È accaduto quando l’azienda Pathway Genomics ha deciso di distribuire i kit per l’esame del Dna direttamente nei supermercati della catena Walgreen. La Food and Drug Administration, autorità incaricata di regolamentare il mercato di farmaci e presidi medici negli Usa, è subito intervenuta con una lettera durissima, costringendo la Pathway a rimandare la distribuzione dei suoi kit a tempo indeterminato. Il rapporto del Gao potrebbe essere un altro segnale forte mandato alle aziende: il governo americano non tollererà che la giungla dei test si estenda oltre ogni limite. Prevedere un cambiamento del vento, per i manager che stanno cavalcando l’onda della genetica, questa volta, dovrebbe essere facile anche in assenza di un test accurato.

Basta con gli incubi il sogno si può guidare

RICERCA

Basta con gli incubi
il sogno si può guidare

Negli Usa gli scienziati hanno messo a punto una terapia per eliminare le visioni choccanti durante il sonno. Si tratta di immaginare da svegli la stessa trama, ma in positivo, cancellando gli aspetti negativi e violenti di SARAH KERSHAW

STA guidando a folle velocità per le strade di una grande città e un essere raccapricciante, con dei bulbi oculari giganti, la insegue ed è sempre più vicino. È un sogno, ovviamente. Emily Gurule, 50 anni, insegnante, lo ha raccontato al dottor Barry Krakow. Barry Krakow è il  fondatore della P. T. S. D. Sleep Clinic presso il Maimonides Sleep Arts and Sciences ad Albuquerque, esperto nello studio degli incubi. Ma lui non le ha chiesto di provare a interpretarlo. Semplicemente, l’ha invitata a sognare ancora. “Si concentri qualche minuto, chiuda gli occhi e modifichi il sogno come vuole”. E l’automobile nera diventa una Cadillac bianca, che viaggia a velocità moderata, senza essere inseguita. I bulbi oculari diventano bolle di sapone che si librano placide in cielo. “Ecco, è un nuovo sogno”, prosegue Krakow. “Quello brutto è laggiù”, dice indicando l’altro lato della stanza. “Non ci interessa più ormai, ora ci occupiamo del sogno nuovo”.

Questa tecnica, utilizzata a paziente sveglio, si chiama scripting o dream mastery, sceneggiatura o gestione del sogno, e fa parte della imagery rehearsal therapy (IRT), ripetizione immaginativa, che Krakow ha ideato, assieme ad altri, per curare le persone soggette ad incubi. Da qualche anno gli incubi sono considerati una patologia precisa, e i ricercatori hanno prodotto una mole crescente di dati empirici che testimoniano come questo tipo di terapia cognitiva possa contribuire a ridurre la frequenza e l’intensità degli incubi, o addirittura eliminarli. Alcuni terapeuti, però, soprattutto di scuola junghiana, sono contrari alla strategia di mutare i contenuti onirici, sostenendo che i sogni inviano messaggi importantissimi alla mente sveglia. Gli incubi “evidenziano in grassetto temi particolari”, spiegano gli psicologi. Eliminarli significa “perdere l’opportunità di trarne un significato”. Nel caso di Emily Gurule, trasformando in bolle di sapone i bulbi oculari minacciosi, la paziente non saprà mai cosa quegli occhi cercavano di dirle.

Da secoli gli incubi affascinano e lasciano perplessi, terapeuti e analisti di ogni scuola si sono confrontati su come interpretarli. Un incubo terrificante può perseguitare un individuo per tutta la vita. È un’esperienza onirica inquietante, osservano gli scienziati, “che stuzzica e avvelena lo spirito e ha un substrato di potenza, lussuria, oralità aggressiva e morte”. Tra il 4 e l’8 per cento degli adulti riferisce incubi episodici, una volta la settimana o più. Ma l’incidenza passa al 90 per gli ex combattenti e le vittime di stupro. Krakow sostiene che nelle terapia dello stress post-traumatico bisognerebbe agire più attivamente nei confronti degli incubi. Kracow e altri clinici ricorrono con sempre maggior frequenza alla IRT per la cura dei veterani e dei militari in servizio attivo in Iraq e in Afghanistan.

Il mese scorso il ricercatore ha tenuto un seminario sulla IRT ed altre terapie del sonno per 65 terapeuti, medici e psichiatri, molti dei quali attivi in ambito militare. Anne Germain, professore associato di psichiatria presso la facoltà di medicina dell’Università di Pittsburgh, ha posto a confronto la terapia comportamentale, che include la ripetizione immaginativa, e la terapia farmacologica con il prazosin, un anti-ipertensivo che si è rilevato valido nel ridurre l’evenienza di incubi. I risultati preliminari dello studio, condotto su 50 veterani, hanno dimostrato l’efficacia di entrambe le terapie. Deirdre Barrett, psicologa della Harvard Medical School, esperta del rapporto tra trauma e sogni, si dice colpita dal sempre maggiore interesse riposto negli incubi che sono esito di traumi bellici e torture. “Oggi i terapeuti sanno che si possono influenzare i sogni, interrogarli su particolari tematiche e anche modificare gli incubi”.

Hollywood ha subito colto lo spunto del controllo dei sogni con “Inception”, un thriller che si muove sui terreni più oscuri del mondo onirico. La trama si basa sul concetto del sogno lucido, una tecnica utilizzata per aiutare i pazienti che hanno paura dei propri sogni a capire che di sogni si tratta. La Barrett è favorevole all’uso della tecnica di Krakow, sostiene però che andrebbe integrata da terapie psichiatriche e comportamentali. Il metodo Krakow prevede in genere quattro sedute di terapia di gruppo, intervallate da 10 colloqui individuali, anche se, a detta del ricercatore, in media sono sufficienti dai tre ai quattro incontri. Afferma che su centinaia di pazienti trattati, circa il 70 per cento ha riferito notevoli miglioramenti nella frequenza degli incubi, dopo una terapia da due a quattro settimane.

Una puntura «virtuale» contro il mal di testa

Una puntura «virtuale»
contro il mal di testa

Un flusso compresso d’azoto che in un attimo diffonde il farmaco attraverso la pelle

senza nessun dolore

Una puntura «virtuale»
contro il mal di testa

Un flusso compresso d’azoto che in un attimo diffonde il farmaco attraverso la pelle

MILANO – Per il mal di testa arriva la puntura virtuale: l’ago è un flusso compresso d’azoto, un gas che in un decimo di secondo diffonde il farmaco attraverso la pelle, senza che il paziente nemmeno se ne accorga. L’ultimo ritrovato è stato presentato da Alan Rapoport, della UCLA University di Los Angeles, al «IV Congresso ANIRCEF Cefalee, conoscenze attuali e prospettive future», concluso ieri a Genova. Simile a un grosso pennarello bianco, il nuovo dispenser si afferra fra le dita e la clip del cappuccio funge da grilletto: fatto scattare col pollice, libera il gas del serbatoio interno avviando l’inoculazione sottocutanea del farmaco che viene espulso dalla parte anteriore fatta appoggiare sulla pelle della coscia o dell’addome. In un attimo l’attraversa dissolvendosi in circolo: confrontato con un farmaco simile iniettato con una normale siringa ha dimostrato una pari diffusibilità, liberando almeno metà dei pazienti dal dolore entro mezz’ora. E seguendo le istruzioni ricevute dal medico durante la visita, impara ad usarlo il 98% dei pazienti. «Occorrono soluzioni sempre nuove per i pazienti che spesso lamentano un controllo imperfetto del dolore e cercano nuove terapie con effetto più rapido e duraturo — dice Rapoport —. L’anno scorso avevo annunciato il cerotto iontoforetico: in America è in fase di avanzata sperimentazione negli attacchi caratterizzati da forte nausea e vomito (soprattutto emicrania con aura) che rendono problematico l’uso di farmaci per bocca».
INDICAZIONI – Il principio attivo del cerotto e della puntura senz’ago è sempre lo stesso, il sumatriptan, ma ora oltre ad aggirare il malassorbimento gastrico che fa fallire farmaci assunti per bocca, il farmaco agisce anche entro 10 minuti. La Food & Drug Administration ha approvato l’impiego del nuovo dispositivo nell’emicrania con e senz’aura e, per la rapidità, nella cefalea a grappolo. Chi soffre di quest’ultima cefalea è disposto a ogni trattamento pur di liberarsi dal dolore, ma fra gli emicranici non erano pochi quelli che rinunciavano al sumatriptan iniettabile, già disponibile con normali punture. «Questo farmaco è il primo dei triptani, farmaci di riferimento in questa patologia, a essere diventato generico — dice Rapoport —. Ciò ha consentito lo sviluppo di nuove modalità di utilizzo per soddisfare esigenze ancora irrisolte, come i problemi di malassorbimento gastrico».