Impact of COVID-19 in Turkey

May 14, 2020

Photo courtesy of Abdi İbrahim

Overview of the outbreak

First described as a “pneumonia of unknown cause” and compared to the SARS virus of 2003, the flu-like virus born in the Chinese city of Wuhan eventually became recognized as COVID-19 or coronavirus. On the 31st of December, the World Health Organization (WHO) was notified of the existence of the virus and, a month later, the organization declared the outbreak a public health emergency. At the moment of writing, over 1.3 million people across 212 countries have tested positive and more than 81,000 have died.  

Turkey was the last major economy with a population of over 50 million people free of the virus until 11th of March, when the first case was confirmed, at a time when most of Europe, the United States, Iran and China itself were either reaching towards or overcoming the peak of the epidemic. As of 15 of April, Turkey has registered over 38,000 cases of COVID 19, among which 812 fatalities and 1,846 recovered. (to be modified on the day of publication with WHO live stats)

The epicenter of the outbreak is Istanbul, the largest city, where 60% of all cases are found. On account of the country’s youthful demographic, incidences of virus-related deaths among Turkey’s under-60 patients are higher than in other countries: 25% of the first 356 deaths occurred in this age group.

Timeline:

  • 11th of March, the first COVID-19 case confirmed
  • 16th of March, schools close
  • 17th of March, first COVID-19 related death
  • 21st of March, partial curfew announced for over 65s and chronically ill
  • 30th of March, Erdoğan launches “We are self-sufficient” fund
  • 3rd of April, inter-city travel banned in 31 provinces
  • 5th of April, face masks made compulsory in public spaces
  • 10th of April, two-day curfew imposed in 31 provinces
  • 21st of April, 38, 226 confirmed cases

 

Turkey’s public response to the virus

Taking note of what Turkey criticized as lax measures taken in some European countries, Turkish authorities immediately imposed restrictions on travel and public gatherings. By the end of March, all international passenger flights had been suspended; coming to April, the President announced a 15-days ban on vehicles leaving or entering 31 provinces. People aged under 20 and over 65 continue to be prohibited from leaving their homes unless proven necessary, which means 30% of the population is under curfew.

However, the restrictions for people outside of these age brackets are much more lenient. Working age people are recommended to go into voluntary isolation, but they are not enforced to do so. There is also little financial aid for those choosing to stay at home, which forces many to continue working. Unionists and opposition leaders claim that firmer measures should be enforced to protect workers from contagion. Turkey has so far also resisted calls for a lockdown and only ordered national isolation on the 10th of April, when the authorities ordered a two-day curfew over the weekend. The order backfired because it was announced just hours before it was due to become active, and unprepared people crowded to the shops to make provisions for the weekend. The chaos that ensued caused Turkey’s popular minister of the Interior to resign, though the President predictably refused to accept his resignation.

Public figures indicate that the rate of new infections has dropped to 15.9% in April, down by 10 percentage points from the previous month, but international media suggest that the rate of spread of over 4,000 a day is one of the fastest in the world. Prof. Dr. Berrin Erdag, a representative of the GEBI research center within state-agency TÜBİTAK, is optimistic about the actions taken to date: “We believe that the coronavirus is not stronger than the precautions that will be taken.”

Having experienced a difficult economic crisis in 2018, Turkey is trying to overcome the epidemic without endangering its perilous economic recovery, which is why it hesitates to order a close-down, and cannot subsidize the salaries of those in isolation. Turkey’s economy posted growth of 0.9% in 2019, according to TurkStat, but was poised for robust growth of 6% in 2020. With dashed hopes for a propitious 2020, Turkey’s economy will experience a sharp contraction this year. Besides the energy sector, which will save Turkey US$12 billion in energy imports due to the collapsed oil prices, all other economic sectors are expected to be negatively affected.

The government allocated a rescue package of 100 billion lira (US$15 billion) to mitigate the slowdown, as well as allowing for the postponement of debt payments and a reduction in corporate taxes. Businesses are also helped with a three-year loan at fixed interest rates and six months repayment window. Turkey’s moderate debt of around 30% of its GDP allows it to sustain further borrowing. However, the caveat of Turkey’s economic recovery is that it remains strongly tied to the recovery of other countries. Economists have compared the unprecedented speed with which economies have shut down with the effects triggered by the fall of an asteroid. According to the Economist Intelligence Unit (EIU), the global economy will retract by 2.5% in 2020, which is a deeper recession than that experienced during the financial crisis of 2008.

 

Consequences of COVID-19 for the pharma industry

In times like these, the pharmaceutical sector is complexly affected, not only as an industry suffering from the general economic downturn and disruption of the supply chain, but also in its capacity as a key supplier of medicines to hospitals. Uniquely, the pharma industry is looked upon for its research ability in the direct fight against the novel virus. Pharma companies also bear a responsibility towards their workers. In view of these considerations, it is not surprising to see that 95% of global pharma executives surveyed are concerned about the impact of COVID-19, based on the European Pharmaceutical Review.

Turkey’s pharmaceuticals sector is not exempted from any of these pressures. “The COVID-19 outbreak brought to focus the need for a strong healthcare system and pharmaceutical industry. The Turkish pharmaceutical industry has a long-standing culture of production, which is vital in the current outbreak,” said Turgut Togsöz, Secretary General of IEIS. 

Many will consider the pharmaceuticals sector to enjoy a place of near impunity during a global health crisis, with some product demand even spiking at such times, but this is a simplistic take. Since the beginning of the outbreak, product demand has reeled out of its usual patterns. Antibiotics, antivirals, sedatives, IV fluids, as well as masks and medical devices like ventilators and testing kits, have been particularly sought after. In Turkey, the products which made the “Critical Product List” include muscle relaxants, blood pressure suppressors, antibiotics, analgesics, antibacterials, sedatives and others. Depending on each manufacturer’s focus, some companies were more prepared to respond to the growing demand in these categories. Sterile injectable producer Tüm Ekip has 32 products within this guide, of which 12 are considered of top priority. “At Tüm Ekip we are in the most crucial sector, since injectables have become even more important due to the higher rates of hospitalization. We are supporting all the hospitals in Turkey and many in the world for the treatment of infected patients,” said Ahmet Altuğ Oğuz, CEO of Tüm Ekip.

More commonly, though, local producers have adapted their production lines to fit the demand. Local manufacturer Atabay has increased the production of paracetamol and antiviral oseltamivir, both used to alleviate symptoms and complications in cases of influenza. Turkish manufacturer Birgi Mefar has also boosted its line of primary products to meet the needs of the country’s hospitals: “Birgi Mefar group continues its production by giving priority to products that are important in the pandemic treatment and we are planning in line with community needs,” said Faik Somer, CEO of Birgi Mefar group.

Outside the range of these products, however, demand for medicines not related to the COVID-19 virus has dropped due to the fact that patients neglect or delay their usual treatments to avoid contact with hospitals, which are considered hotbeds for the spread. “Focusing on the combat with COVID-19, the pharmaceutical activity has slowed down relatively, which has led to a contraction of the pharmaceutical market,” explained Philipp Haas, CEO and chairman of Deva Holding, a provider of a broad range of generics.

A more universal worry is caused by supply disruption in APIs due to production and shipping restrictions, explained Haas: “Supply of raw materials from Asia has become more difficult as production has slowed down in these hubs and even transportation is difficult to find. Deva has so far been able to provide the market with all its products and has taken every possible precaution to be able to do so in the future.”

Like the United States and other pharma hubs, Turkey imports most of its raw materials from India and China. While India entered nationwide lockdown on the 25th of March, China has recently lifted the 11-week lockdown, hoping to gradually resume production across its different industrial sectors. At present, most manufacturers of formulations rely on stockpiles to last for about six months, which is industry practice. They are also required to report potential shortages in drug supply, should this become the case. Even so, it is too early to comment on when global supply networks will be restored to normality, and harder to speculate whether the threat of a cut-back on APIs from the East could lead to more investment in Western API production. At the very least, the issue of API-dependency is likely to receive renewed attention.

Lastly, the pharmaceutical sector is not immune to the inevitable economic slowdown that COVID-19 will cause. Recordati, an Italian-based company that entered the Turkish market in 2008, has already seen losses in its share prices. Listed on the Italian Stock Exchange, Recordati enjoyed steady growth until 19th February, when share prices started to drop, hitting the lowest on the 12th March after Italy’s announcement of continued lockdown. For most private companies it is possible they will experience setbacks in their R&D programs. The biopharma space is likely to take a harsher hit than classic pharma since it is more dependent on both governmental and foreign investment.

 

The role of the pharmaceutical industry in fighting the pandemic

That the pharmaceutical industry falls under the category of “essential business” is an understatement in the current climate. The global pharmaceutical industry has a key role in helping nations and individuals to fight the pandemic through developing tests, treatments and vaccines. If until now the consequences on the pharma industry were principally discussed under a business imperative, the rest of this article deals with the special status of pharma companies. How the pharma industry is regarded and regulated after the pandemic will not be indifferent to the ways the industry players today engage with governments, with universities and with each other, nor to the ways they engage their own resources, especially when it comes to the science deployed in this period.

Ever since the local outbreak mutated into a pandemic, making it clear that the crisis was not one country’s problem, the spirit of the scientific community has been one of cooperation. This sentiment was confirmed by the CEOs of top leading biopharma companies during the digital conference held by the International Federation of Pharmaceutical Manufacturers and Associations. Seeking to outrun the speed of the spread, scientific inquiry traveled rapidly between countries.

Private companies and research institutions from all corners of the world are working on developing a vaccine to immunize the population. Names such as Janssen, Sanofi, Zydus Cadila, Novavox, together with the University of Hong Kong, the University of Oxford or the University of Pittsburgh have each put candidate vaccines in pre-clinical studies. Beijing Institute of Biotechnology and Moderna/NIAID, as well as Sanofi have advanced their candidates to Phase 1 clinical studies. Despite the global effort dedicated to developing a vaccine, it will take at least another 12 months before a vaccine formula is approved; this will be followed by the challenge of running a campaign of production and immunization on a global scale - an endeavor likely to bring more opportunities for collaboration.

Besides vaccines, R&D departments around the world are also studying medicines to ameliorate symptoms and treat complications. The common route taken by most research laboratories has been to repurpose existing, already accepted therapies and trialing out their efficiency in COVID-19 cases. WHO’s 10 countries mega-trial called “Solidarity” is testing out remdesivir, the antiviral originally designed to treat ebola. Ritonavir and lopinavir used normally in HIV patients is also tested to see if it can inhibit enzymes that the virus uses to replicate. Malaria treatments chloroquine and hydroxychloroquine have received the most attention, as the U.S. FDA approved their use, backed up by President Trump confident public endorsements, while the European EMA limited the medicines’ use to clinical trials only. Until now, however, there is insufficient data to evidence the arbitrary efficiency of any of these drugs in COVID-19 cases.

Filtering through the feedback received in other countries, Turkey is itself trialing these medicines to treat its patients. Koçak Pharma donated 10,000 packs of azithromycin, an antibiotic hypothesized to work in combination with hydroxychloroquine in the combat of COVID-19: “We are contributing to the battle against COVID-19 with products already in use such as azithromycin tablet as well as registering hydroxychloroquine tablet and oseltamivir capsules which are used in first-line treatment of COVID 19,” said Hakan Koçak, CEO of Koçak Pharma.

Biomedicines, including plasma therapy and the use of monoclonal antibodies, are also hoped to create an auto-immune defense against the virus. The Turkish Red Crescent, for instance, is assessing the use of plasma therapy, or the transfusion of antibodies from recovered patients to new patients, for the treatment of COVID-19. Koçak Pharma is working on an active vaccine and hyperimmune serum in the same scope.

Going a step further into the chain, Atabay is bringing to speed API production for COVID-19 treatments: “Atabay’s vigorous R&D work focuses on developing the API and the FDF to produce anti-viral drugs against the pandemic. In extraordinary times, having the expertise to produce both the API and the FDF makes the difference,” said Doğan Taşkent, board member at Atabay İlaç.

These efforts are already yielding results across the board. Top pharma producer Abdi Ibrahim has presented the Ministry of Health with the first batch for a drug which has shown positive results in COVID-19 cases; the company vouched to donate this year’s production to the government, starting with 1.6 million tablets in April. “We are utilizing all our resources to put an end to the threat facing our nation. As a company measuring its value by the contributions it makes to Turkey and the Turkish people, it is Abdi İbrahim’s greatest wish that both the world and our country will emerge victorious from this crisis with as few losses as possible,“ stated Nezih Barut, chairman of Abdi Ibrahim, in a press release.

Overall, Turkish pharma companies have stepped up to demonstrate the resourcefulness of the national sector and their commitment to helping Turkey traverse this testing time. Recordati alone donated 1.1 million Turkish lira to the COVID-19 fund opened by President Erdoğan. Recordati Group vice president İsmail Yormaz said: “We have been looking into how we can best support our healthcare professionals and our people since the beginning of the pandemic. Recordati continues the production of all our products, maintaining high quality and hygiene while looking after our workers who have shown heroic determination during these times”.

Balancing out the need for continued production with the health and safety of their employees, pharma companies need to keep up exemplary safety controls to further minimize contamination risks. “At Atabay, our first and utmost responsibility is towards our employees while working at full capacity,” said Zeynep Atabay, owner of Atabay İlaç.

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