DEATHS CAUSE HONG KONG GOVERNMENT TO REVIEW DRUG

C O N F I D E N T I A L SECTION 01 OF 04 HONG KONG 001687 SIPDIS STATE FOR EAP/CM, PASS USTR FOR ALTBACH E.O. 12958: DECL: 09/04/2019 TAGS: ECON EFIN EINV ETRD KIPR HK CH SUBJECT: DEATHS CAUSE HONG KONG GOVERNMENT TO REVIEW DRUG SAFETY OVERSIGHT Classified By: A/DPO Martin Murphy for reasons 1.4 (b) and (d) ¶1. (SBU) Summary: A tainted locally manufactured generic drug caused five deaths in March 2009 in Hong Kong and prompted the government to initiate a sweeping review of its drug safety oversight mechanisms. A review committee with a special focus on generic pharmaceuticals will provide specific recommendations for public comment by the end of 2009 to improve drug safety, efficacy and manufacturing quality. Industry observers believe the committee will recommend tighter manufacturing standards, more rigorous testing procedures, and changes to pharmacy registration/oversight to bring Hong Kong's drug safety regulatory framework more in line with developed countries. Private hospitals have banned the use of generic prescription drugs for in-patients, due to safety concerns. This stands in sharp contrast to the public hospitals, where generic pharmaceuticals constitute approximately half of all drugs consumed. End summary. ¶2. (C) Comment: The Hong Kong government (HKG) was embarrassed by the recent generic drug-related deaths that called into question the government's drug safety framework. U.S. branded drug manufacturers such as Pfizer and Merck have complained for years about Hong Kong's relatively loose regulation (compared with the United States, European Union, Australia and Japan) of its local generic drug manufacturers, importers and distributors. The U.S. firms fully support the government's review committee and look forward to playing an active role in formulating the committee's recommendations. They note that generic drugs will likely face increased regulatory hurdles in testing, certification and manufacturing oversight, thereby narrowing the generics' price advantage versus branded pharmaceuticals. The HKG clearly wants to move forward quickly with legislative amendments designed to improve drug safety, while maintaining the substantial cost savings that high-quality generic drugs can provide. Health officials and members of the review committee expect the committee's report to directly address most areas of concern and lead to modernization of Hong Kong's pharmaceutical-related laws and regulations. In the meantime, safety concerns remain centered on unscrupulous drug procurement practices by community-based pharmacies and importers, drug dispensing by non-qualified individuals, and the use of outmoded manufacturing and product testing requirements for generic drugs. End comment. Background -------------- ¶3. (U) The manufacture and sale of pharmaceutical products in Hong Kong are regulated through the Pharmacy and Poisons Ordinance (PPO) of 1964. Pursuant to the PPO, pharmaceuticals sold in Hong Kong must be approved by the Pharmacy and Poisons Board (PPB),a statutory body within the Department of Health (DOH). The PPB determines whether a pharmaceutical product may be registered and sold based primarily on three criteria: safety, efficacy and manufacturing quality. The PPB has approved 19,500 drugs for sale in Hong Kong, of which almost 13,000 are imported. Generic products account for approximately 30 percent of total pharmaceutical sales here. Deaths Prompt Generic Drug Regulation Review -------------- ¶4. (U) The effectiveness of the PPO and Hong Kong's drug safety oversight mechanisms were called into question in March 2009, when five Hong Kong residents died after ingesting a locally produced generic drug that was contaminated by a lethal fungus during its manufacture. Hong Kong's Director of Health Lam Ping-yan confirmed that mold had formed during a delay between the mixing of the drug's granule powder and its compression into tablets by Europharm Laboratories, one of Hong Kong's largest manufacturers of generic pharmaceuticals. The DOH's subsequent testing of 41 other Europharm drugs found no similar contamination or other health risks. ¶5. (SBU) The deaths prompted the HKG's Food and Health Bureau (FHB) to establish a Review Committee on Regulation of Pharmaceutical Products (Review Committee),chaired by FHB Permanent Secretary Sandra Lee. The 20-member Review Committee is comprised of individuals representing local and international drug manufacturers, pharmacies, doctors, hospitals and consumers. It will assess Hong Kong's generic drug regulation system, quality control mechanisms, legislation and the drug procurement procedures of the HKG's HONG KONG 00001687 002 OF 004 public Hospital Authority (HA). In a related development, the DOH established a working group to draft proposals designed to strengthen the Good Manufacturing Practices (GMP) certification requirement that plays a large role in Hong Kong's generic drug approval process. The HKG expects the Review Committee and working group to complete their assessments by 2009 year-end, with the final report to be published for public comment. FHB Principal Assistant Secretary Shirley Lam told Econoff on August 27 that the Review Committee's report will form the basis for legislative amendments and new regulations governing drug safety. She confirmed that the report will address "all areas of the drug supply chain." Views of Private Hospitals and Pharmacists -------------- ¶6. (C) The Hong Kong Private Hospitals Association (PHA) represents 13 member hospitals that contained eleven percent of Hong Kong's total hospital beds at 2008 year-end. PHA Chairman Alan Lau is a member of the Review Committee. He told Econoff on August 18 that his association is "concerned" about generic drug safety in Hong Kong. He said the PHA established a Code of Practice in July 2009 that bans the use of generic drugs for in-patients at PHA hospitals; only branded pharmaceuticals from the original manufacturer are allowed. For out-patients, the PHA allows doctors to only prescribe a narrow range of generic drugs to treat non-life-threatening, temporary ailments such as headaches or allergies. The PHA's policy stands in stark contrast to the HA's continued efforts to save money by purchasing generics instead of branded drugs. HA Chief Pharmacist Anna Lee told Econoff on August 28 that "about 50 percent of HA's pharmaceutical product purchases are generics." She explained that, like other government-run providers of health care around the world, the HA remains under "intense budget pressure" and views the purchase of high-quality generic drugs as an effective cost-saving measure. She was unaware of the PHA's policy against generic drug use in its hospitals. ¶7. (C) Practicing Pharmacists Association of Hong Kong (PPAHK) members comprise a majority of Hong Kong's 1,785 government-registered pharmacists. PPAHK President Iris Chang holds a pharmacy degree from St. John's University in New York and is a member of the Review Committee. She questioned whether the Review Committee's recommendations will lead to substantive reforms and criticized the DOH's drug safety efforts. Chang told Econoff on August 12 that the HKG "wants to protect the interests of local generic drug manufacturers, importers and distributors." She asked, "Why are Hong Kong's drug safety efforts so far behind other developed parts of the world? The DOH is under-staffed and viewed by industry as a bird without wings." DOH Chief Pharmacist Anthony Chan (Review Committee member and an ex-officio member of the PPB) confirmed to Econoff on September 2 that "the pharmaceutical-related operations of DOH are under-funded." He said, "We hope the Review Committee's work will lead to increased staffing and a bigger budget for us." Public Hospitals Overloading Local Drug Manufacturers? -------------- -------------- ¶8. (C) Pfizer Hong Kong Country Manager Stephen Leung told Econoff on August 20 that the HA shifted its drug procurement practices toward generics in 2007 to save money. He said, "They're giving too many generic drug orders to local manufacturers that cannot be safely filled; the manufacturers are exceeding their production capacity." Leung added that local drug producers source many of their pharmaceutical ingredients from mainland China, thereby creating an additional safety risk. "The quality assurance programs for ingredients used by local generic drug producers are insufficient and lack proper government oversight," he said. "GMP Plus" and Bioavailability/Bioequivalence Testing -------------- -------------- ¶9. (C) The Hong Kong Association of the Pharmaceutical Industry (HKAPI) represents the interests of 42 international drug companies engaged in pharmaceutical research and development. Companies without R&D programs, such as Hong Kong-based generic drug manufacturers, are not allowed to join the HKAPI. The organization's members together account for approximately 70 percent of prescription medicines sold in Hong Kong, and HKAPI Executive Director Sabrina Chan sits HONG KONG 00001687 003 OF 004 on the Review Committee. Steven Hardacre, HKAPI President and Managing Director of U.S. drug manufacturer Merck & Co., told Econoff on July 31 that Hong Kong's regulatory framework governing generic drug manufacturing and certification must be "overhauled." He described two "high priority" steps needed to improve the safety of generic drugs here: stricter manufacturing requirements compared with the current GMP guidelines; and bioavailability/bioequivalence (BA/BE) certification to ensure the efficacy of generic drugs compared with their branded counterparts. ¶10. (C) The GMP standards enforced by the FHB are primarily used in developing countries, according to Hardacre, and should be "upgraded" to the stricter drug manufacturing safety standards adopted by the United States, European Union, Australia, Canada, Japan and Singapore. He said several of Hong Kong's 39 licensed drug manufacturers produce generic drugs under "less than advanced" conditions that may compromise consumer safety. "Moving beyond GMP standards would eliminate some smaller local generic drug manufacturers, if they are unable to upgrade their manufacturing processes and facilities to meet the new government requirements," he said. FHB's Lam confirmed to us that the HKG intends to use the Review Committee's report to "significantly upgrade" Hong Kong's GMP standards. She said FHB conducted "lots of surprise checks" of local generic drug manufacturers in the wake of the Europharm-related deaths. "Most of the companies" were in compliance with Hong Kong's existing GMP standards, according to Lam. ¶11. (C) The GMP issue extends beyond drugs manufactured in Hong Kong to those imported from China and other developing countries. In his June 10 response to an inquiry from Legislative Council (LegCo) member Andrew Cheng, FHB Secretary York Chow confirmed that Hong Kong allows the sale of drugs made in China, if they have a GMP certificate issued by China's State Food and Drug Administration. Industry observers generally consider the PRC's drug manufacturing inspection and enforcement efforts to be less effective than those of Hong Kong. Pfizer Legal Director Alex Cheung told Econoff on August 10 that Hong Kong has approved for sale several GMP-certified generic drugs manufactured in China, Indonesia, India and the Philippines that have "questionable" manufacturing quality and efficacy. ¶12. (SBU) BA/BE testing of generic drugs ensures that the generic product possesses essentially the same efficacy, active ingredient dosage delivery over time, and safety of the branded drug it emulates. The United States, EU, Australia and Singapore mandate BA/BE testing of generic drugs as part of their respective pharmaceutical registration processes. While the HA requires BA/BE certification of generic drugs approved for use in public hospitals, the FHB does not require BA/BE certification for generic drugs sold in local pharmacies. Lam said FHB intends to phase in a BA/BE certification mandate beginning next year for certain critical drugs sold in pharmacies, such as those used to treat cardiovascular or neurological disorders. She said testing labs at several Hong Kong universities "need to be upgraded to perform accurate and timely BA/BE testing" of locally manufactured generic drugs. DOH's Chan confirmed Lam's statements and added that BA/BE certification will be mandated as of April 1, 2010 for drugs that treat epilepsy, with other "highly sensitive" drug to follow. Pharmacists "Tools" of Unscrupulous Pharmacy Owners -------------- -------------- ¶13. (C) Chang said the ownership structure of Hong Kong's numerous non-chain pharmacies also diminishes drug safety; most local pharmacies are owned by non-pharmacists. She cited several examples of pharmacy owners stocking counterfeit, expired or illegally procured pharmaceuticals, often unbeknownst to the pharmacist employed in the shop. The pharmacist faces prosecution when Hong Kong Customs raids the pharmacy. Chang said, "I advise internationally trained pharmacists to avoid working in Hong Kong. They are often used as tools by pharmacy owners and then held criminally liable for the owners' shenanigans." Chang wants the HKG to emulate the UK, Canada and Australia in requiring community-based pharmacies to be majority-owned by registered pharmacists. To help address the problem of inventory manipulation by unscrupulous pharmacy owners, Lau said the Review Committee may recommend rules requiring pharmacists to: sign off on each drug procurement; use only licensed importers and distributors; and certify the legal compliance of their respective pharmacy's drug inventory. HA's Lee said, "We advise our patients who visit community-based HONG KONG 00001687 004 OF 004 pharmacies to ask to see the pharmacist and get their drugs directly from him or her." DOH's Chan told Econoff that the pharmacy ownership issue will not be addressed by the Review Committee. He said, "The government attaches great importance to free trade and tries not to get in the way of who owns what." No Separation of Prescribing and Dispensing -------------- ¶14. (C) While many developed economies require out-patient prescription drugs to be sold through regulated pharmacies, doctors in Hong Kong are allowed to prescribe, sell and dispense pharmaceuticals from their offices and clinics. This leads to patient injuries and occasional deaths, according to HA's Lee, when untrained employees in doctors offices or clinics misunderstand a doctor's verbal or written instructions and provide a patient with an incorrect medicine or dosage. Lee said many of Hong Kong's medical doctors significantly boost their earnings through drug sales to patients, and the doctors' "political clout" has stymied the HKG's repeated efforts to abolish the practice. She said the Review Committee "is not going to touch" the issue. In addition to the safety concerns generated when non-pharmacists dispense prescription drugs, U.S. manufacturers complain that the practice hurts sales of branded pharmaceutical products. Lee acknowledged that "doctors in Hong Kong prefer to sell generic drugs whenever possible, because their sales margin is bigger." MARUT