Breathless in the city

By M H Ahssan

The market for respiratory products is on an upswing, with younger age groups showing an alarming rise in the incidence of such ailments.

The news of a school girl in Delhi succumbing to an asthma attack not only threw up questions about schools being ill equipped to handle medical emergencies but also the growing incidence of respiratory ailments. Besides hereditary reasons, growing industrialisation is one of the main reason for this situation. In the quest to become a developed nation, unchecked industrialisation, with a scant regard for pollution control norms might have paved the way for more such dreaded diseases in India.

Growing figures
Respiratory diseases can be divided into two subtypes, communicable and non communicable of which the former has been proved to be more fatal. According to statistics provided by Murlidharan Nair, Partner, Advisory Services, Ernst & Young, communicable respiratory diseases accounted for maximum deaths amongst communicable diseases. Statistics reveal that nearly 67 percent of the reported deaths in top 13 communicable diseases were attributable to respiratory infections in 2007.

Nair says, "Communicable respiratory diseases (acute respiratory infections, pulmonary tuberculosis and pneumonia) have the maximum incidence across all communicable diseases in the country. In 2007, approximately 23.3 million cases of acute respiratory infections were reported followed by other communicable diseases like acute diarrhoeal cases (9 million), malaria cases (1.3 million) 0.72 million cases of pulmonary tuberculosis and 0.66 million cases of pneumonia were also reported in the said period."

Acute respiratory diseases, non communicable/ chronic diseases are not far behind communicable diseases in terms of nuisance value. Not only the growth rate but also the market share is a 'point to be noted' thing for medical fraternities. Negative predictions about the growth rate of asthma will only add to their woes. "Acute respiratory diseases also have reported one of the fastest growths with morbidity having grown by 33 percent during 2000-2006 which is a significantly higher growth compared to other communicable diseases. Non-communicable/ chronic respiratory ailments like Chronic Obstructive Pulmonary Disease (COPD) and asthma also account for nearly 1.5 percent of total disease burden in the country. There are currently 15 million cases of COPD and 25 million cases of asthma which are expected to grow by 50 percent by 2015. Six states (Kerala, Andhra Pradesh, Himachal Pradesh, Uttar Pradesh, Karnataka and West Bengal) account for more than 68 percent of the acute respiratory burden with Kerala topping the list," informs Nair.

Many reasons
Not surprisingly, respiratory ailments are dominant in urban areas, thanks to man made environmental changes. One of the leading respiratory product manufacturers in India, Lupin has a wide range of oral and inhalation medications for the treatment of all types of airway disorders (asthma and COPD). The inhalation product range consists of Dry Powder Inhalers as well as Metered Dose Inhalers. They also have a dry powder device which is used with their dry powder capsules. The oral anti-asthma medications help complete the treatment options across the respiratory treatment value chain in order to treat the different kinds of respiratory ailments prevalent today.

Shakti Chakraborty, President - India Region Formulations, Lupin, opines, "Respiratory diseases are one of the most common forms of ill-health plaguing the Indian population today. They are also a leading cause of hospitalisation and death. Allergic respiratory disorders, in particular asthma, have recorded abnormally high levels, and this is not an India-specific, but in fact, a global phenomenon. Even though genetic predisposition is one of the factors in children for the increased prevalence, urbanisation, air pollution and environmental tobacco smoke contribute more significantly."

He adds, "Over the years, the most prominent trend that has emerged in India in the area of respiratory ailments is its increased incidence in children. While asthma and bronchitis were ailments largely restricted to the elderly, over the years, research has shown that more and more children are being affected. A lot of this is correlated to demographic changes in Indian cities, like the increase in the number of industries, density of population in migration from rural areas in search of jobs, and increased number of carbon-emitting automobiles on Indian roads."

According to Chakraborty, recent reports say that, there has been a 30 percent increase in asthma and congestion cases last year due to smog. Also, infections, genetic factors, and anything else that affects lung development, either directly or indirectly, can cause respiratory symptoms. The increase in population and widespread use of vaccines has also given rise to different varieties of the TB virus, most notably - Multi Drug Resistant (MDR) TB and the extensively drug resistant (XDR) TB. The next challenge for the pharma industry is to combat these newly developed strains of the bacterium. The industry is sure to see development on this front in a short time.

Nair puts his point of view. He says, "Acute respiratory ailments rank the highest with 23.3 million cases of reported ailments. These are followed by chronic conditions like asthma which account for approximately 25 million cases and COPD with 15 million cases. The key reasons for high incidence of respiratory diseases include seasonal/weather variations, growing air pollution, family history (for eg. incidence of asthma is 19 percent if one parent has asthma), allergens, malnutrition and poor living conditions, occupational hazards, limited primary and preventive healthcare facilities. And most importantly a rising number of active and passive smokers with India estimated to have 120 million smokers (nearly 40 percent of Indian males smoke)."

Pradeep Rane, President (formulation business), Alembic Pharmaceuticals mentions that disorders like bacterial and viral infections of the respiratory systems, respiratory allergic disorders and tuberculosis have shown a steady increase over the last few years. Environmental pollution, rapid urbanisation, changing lifestyles, increasing prevalence of smoking in the younger generation, unhealthy food habits and stress of urban life decreases the body immunity. Also, AIDS patients are highly susceptible to develop TB.

Medical practitioners, with their regular direct contact with patients are best positioned to forecast and track incidence levels of ailments they commonly see in patient populations and their observations too support this trend. Dr. Zarir Udwadia, Consultant, Pulmonary Department, Hinduja Hospital, Mumbai opines, "Asthma prevalence has increased globally and in India. People are exposed to more allergens indoors and outdoor pollution also contributes. Inhaled steroids remain the cornerstone of treatment of asthma. A new molecule useful in resistant asthma is OMALIZUMAB (an IgE monoclonal antibody)."

Flourishing market
A densely populated country like India is the natural breeding ground for respiratory infections. This huge patient pool has already lured many pharma companies to establish product lines in this particular category. No wonder, a large chunk of total pharma products market in India is dedicated to respiratory products. "The total drug spend on respiratory disease in India is approximately $600-625 million accounting for nearly 9-10 percent of the total drug market. If we split this into chronic and acute segments, the chronic respiratory segment accounts for three percent of the total drug market and acute respiratory segment accounts for nearly six-seven percent of the total drug market. The market is dominated by domestic players who hold nearly 80 percent of the market share. Cipla, Piramal Healthcare, Pfizer, GSK, Zydus Cadila and Alembic are the leading players in this segment. With rising incidence of chronic respiratory ailments - for example, COPD and asthma are expected to grow by 50 percent by 2015 and ever increasing incidence of acute ailments, the respiratory drugs market is expected to show robust growth of 12-14 percent over the next four-five years,"opines Nair

According to Chakraborty, the market for respiratory products is huge. That, combined with India being the TB capital of the world makes the potential of market enormous. As of February 2009, the asthma inhalation market stood at Rs 510 crores, showing a growth of 13 percent. (Data IMS MAT Feb 2009). On the other hand, the anti-TB market is at Rs 300 crores. Currently, this market is showing a negative growth of 5.6 percent, (Data IMS MAT Feb 2009) mainly due to the government's programme on tuberculosis, which gives free medicines to all patients. Lupin has dominant 48.2 percent market share , in the anti TB segment in the South Asia region.

Trends
Every new product comes into the market with some new features embedded into it.

Pharma companies, researchers/inventors look into the minute details in order to make medicine more patient friendly and 'more than just a tablet'. Chakraborty opines, "The industry is seeing new trends in the drug delivery system of the TB drug. The industry is now moving focus to developing new ways in which a drug can be delivered. While the oral method is the preferred method, companies are now focusing on delivering dry powder capsule and oral metered dose inhalers. We may later witness this trend moving to skin patches and use of magnets to deliver drugs, but that is very nascent and predicting at this stage would be very difficult."

He adds, "Lupin leads this development and with our strong focus on innovation, we already have drugs and dosage delivery systems consisting of dry powder capsules along with a dry powder device that administers this dose to patients. Apart from these, we also provide metered dose inhalers that help administer the requisite quantity of dosage for maximum impact."

According to Rane new trends in the treatment of respiratory ailments will include increasing usage of anti-bacterials, anti-allergics, cough suppressants, bronchodilators etc, development of newer medications such as antibiotics, antihistamines etc, which are even safer and more effective against drug-resistant bacteria, development of newer vaccines for prevention of bacterial and viral respiratory infections and development of newer methods such as immunotherapy for the treatment of respiratory allergies.

Nair states that according to World Health Organisation (WHO) estimates, there are 300 million asthma patients and 210 million COPD patients world over. Estimates indicate that India accounts for 25 million asthma and 15 million COPD patients which means that India accounts for eight-nine percent of total global asthma and COPD burden. The respiratory drugs segment accounts for four-five percent of the $750 billion pharma market which implies a market size of approximately $ 35 billion. India's respiratory drug market size is approximately $ 600 million implying a miniscule 1.7 percent share of the global respiratory drug market. These figures may not look that alarming but predictions about increasing incidence of diseases like COPD and asthma could well change this scenario. Though the slowly growing incidence of respiratory ailments is not a healthy sign, it is also an opportunity for pharma companies to add more effective remedies to their kitty.