Tamiflu stockpiles vary widely throughout world

Poor countries likely to suffer most in a swine flu outbreak have the smallest stockpiles of antiviral medicines to fight it.
Affluent countries like Japan, Britain and the United States have enough Tamiflu and similar medicines to reach about a quarter to half their populations, while developing countries like Guatemala, Indonesia and India have enough for only 2 percent of their people or less.
The disparities are not surprising given the high cost of stockpiling and maintaining expensive medicines for future epidemics that may never develop, especially when many are already coping with high rates of malaria and HIV. But experts fear the countries with low supplies may suffer higher death rates if swine flu becomes more lethal outside of Mexico, where it has already killed more than 150 people.
Elspeth Garman, an Oxford University professor of molecular biophysics who co-authored an influential 2001 report urging Britain to stockpile antivirals, said having low supplies creates severe political problems because the government has to determine who gets access to scarce tablets.
"With 50 percent there is a good chance all the people in the UK would get it if they need it, but with 1 percent it's very problematic," she said. "They won't be able to treat as many people, that's obvious, but the much harder issue is who decides who gets it and who pays and whether it can be released in an orderly way or is just for people with a lot of money."
The problem for poorer countries is compounded, she said, because Tamiflu is only effective if used within 48 hours of the time when symptoms develop, and there is no quick, easy way to diagnose and confirm the presence of swine flu. Countries without sophisticated labs, and without quick distribution methods, may not be able to use their small stocks properly, she said.
"It's completely ineffective if it's too late," she said. "And you can confuse the symptoms with malaria, so that's very problematic."
The flu medicines Tamiflu and Relenza are not cures for any type of flu, but lab tests suggest they might be effective against the new virus. Little is known about whether they lower the chances for serious flu complications, like pneumonia, and few studies have tested them in children. But they have been found to cut the duration of ordinary seasonal flu by about one day.
A spokesman for the Roche Group, which makes Tamiflu, said U.S. federal and state governments and a number of foreign governments have stockpiled treatments for roughly 220 million people. Drugmaker GlaxoSmithKline would not say how many courses of its antiviral Relenza have been stored.
In the United States, the government recommends that states stockpile enough flu-treatment doses to treat about 25 percent of the population. But an Associated Press survey found that more than 29 states have yet to reach that level.
Several were just under it, but 15 states had enough medicine on hand to treat fewer than 20 percent of residents. Seven states — Arizona, Colorado, Connecticut, Florida, Idaho, Massachusetts and Montana — could treat about 15 percent.
The global disparities are striking: Oil-rich Kuwait has enough Tamiflu for nearly one-third of its population, while India has medicine for less than one percent of its people, although more is expected within seven days. In Mexico, the epicenter, there are enough antivirals for about 1.3 percent of the population. Indonesia, the country hardest hit by bird flu in recent years, has tablets for roughly .2 percent of its 235 million people, officials said.
Indonesian Health Minister Siti Fadilah Supari, who has long argued that lifesaving antiviral drugs are too expensive for developing countries, said only wealthy countries can afford protection.
"They can buy all the drugs they can get their hands on," she said. "But if poor countries are hit, will the World Health Organization be ready with a global stockpile — say — of Tamiflu or with the other resources we'll need to cope with this?"
She said her aim was not to criticize the global body, but to point to the need to address such inequities as quickly as possible.
Adrian Sleigh, a professor of epidemiology at Australian National University in Canberra, said past influenza pandemics have infected 30 percent to 40 percent of the population so, in theory, countries' Tamiflu stockpiles should correspond to those figures.
But for poor nations such goals are unrealistic.
"It may be that, tragically, the poor parts of this world are going to miss out on the benefits of modern antivirals," he said. "We've been talking about that for years. The WHO was developing a global stockpile and had millions of tablets. But how does that compare to the billions required in the developing world?"
Some public health advocates believe rich countries should donate some of their antiviral stockpiles to those less fortunate, but Garman cautions this might not be effective unless recipients have a credible pandemic plan in place so the medicine could be properly used in a timely way. Otherwise the resources would be wasted.
There would also likely be strong political resistance among rich nations to the idea of giving away antiviral medicines to less fortunate countries.
Several years ago, planners at the World Health Organization tested the idea during a simulated pandemic exercise — but found none of the participants was willing to part with precious supplies while a disease was spinning out of control.
Sandra Mounier-Jack, a professor at the London School of Hygiene and Tropical Medicine who advises the House of Lords on health policy, said donations might be possible in a case where a pandemic flu carries a low mortality rate but would be politically impossible with high death rates.
"Some countries in Europe have invested little, some have invested a lot, so why should this country that has spent a lot of taxpayers' money donate to countries that made another choice?" she said. "Public health advocates say there should be donations, but it's a bit naive."
The only exception, she said, would be cases where a country could slow the spread of the disease near its borders by making medicine available to a neighboring country that needed it.
"That would make perfect sense," she said.