DARU Journal of Pharmaceutical Sciences

https://doi.org/10.1007/s40199-020-00358-5

SHORT COMMUNICATION

Short and long term impacts of COVID-19

on the pharmaceutical sector
Nayyereh Ayati 1 & Parisa Saiyarsarai 1,2 & Shekoufeh Nikfar 1,2,3

Received: 12 May 2020 / Accepted: 23 June 2020

# Springer Nature Switzerland AG 2020

Abstract
Background The novel coronavirus disease 2019 (COVID-19) was characterized as a global pandemic by the WHO on
March 11th, 2020. This pandemic had major effects on the health market, the pharmaceutical sector, and was associated with
considerable impacts; which may appear in short and long-term time-horizon and need identification and appropriate planning to
reduce their socio-economic burden.
Objectives Current short communication study assessed pharmaceutical market crisis during the COVID-19 era; discussing
short- and long-term impacts of the pandemic on the pharmaceutical sector.
Results Short-term impacts of COVID-19 pandemic includes demand changes, regulation revisions, research and development
process changes and the shift towards tele-communication and tele-medicine. In addition, industry growth slow-down, approval
delays, moving towards self-sufficiency in pharm-production supply chain and trend changes in consumption of health-market
products along with ethical dilemma could be anticipated as long-term impacts of COVID-19 pandemic on pharmaceutical sector
in both global and local levels.
Conclusion The pandemic of COVID-19 poses considerable crisis on the health markets, including the pharmaceutical sector;
and identification of these effects, may guide policy-makers towards more evidence-informed planning to overcome accompa-
nying challenges.

Keywords COVID-19 . Corona virus . Pharmaceutical industry . Pharmaceutical market . Health market . Tele-health .
SARS-CoV-2

Introduction the COVID-19 outbreak was characterized as a global pandemic

by the world health organization (WHO) [1]. In the following
In December 2019, the novel coronavirus disease (COVID-19) months, COVID-19 rapidly spread around the globe and infected
was discovered and identified in Wuhan, China. On March 11th, about 2.5 million people by April 23, 2020 [1]. The COVID-19
pandemic affected world economics, including the pharmaceuti-
cal sector. While currently there is no definitive treatment for this
* Shekoufeh Nikfar novel infectious disease, pharmaceutical industry is assisting
nikfar_sh@tums.ac.ir
governments to address the COVID-19 unmet needs, from re-
1 search and development actions on potential treatment strategies
Department of Pharmacoeconomics and Pharmaceutical
Administration, School of Pharmacy, Tehran University of Medical to balancing medicines supply chain in the time of crisis. Along
Sciences, Tehran, Iran this, pharmaceutical sectors are struggling to maintain natural
2
Evidence-Based Evaluation of Cost-Effectiveness and Clinical market flow; as the recent pandemic affects access to essential
Outcomes Group, Pharmaceutical Sciences Research Center (PSRC), medicines at an affordable price, which is the main goal of every
and the Pharmaceutical Management and Economics Research pharmaceutical system [2].
Center (PMERC), The Institute of Pharmaceutical Sciences (TIPS),
Alongside of evaluation the pharmaceutical system chal-
Tehran University of Medical Sciences, Tehran, Iran
3
lenges in global level, the situation analysis of this industry in
Personalized Medicine Research Center, Endocrinology and
developing country with pharmaerging market, because of diver-
Metabolism Clinical Sciences Institute, Tehran University of
Medical Sciences, Tehran, Iran sities, could highlight more impacts. Assessment of Iran as a
 DARU J Pharm Sci

developing country that was extremely affected by COVID-19 Short-term impacts Demand change, supply shortages, panic
disease could be a good example for demonstration. buying and stocking, regulation changes and shift of commu-
To the best of our knowledge, this is the first to identify these nication and promotions to remote interactions through tech-
challenges in the context of a developing country with a nology and research and development (R&D) process changes
pharmerging market. Iran, as a developing middle-income can be seen as short-term impacts of COVID-19 on the health
country, has a generic-based pharmerging market [3]; which market.
is regulated under local national drug policy (NDP), last up-
dated on 2014. The main components of Iran’s NDP are 1. Demand change, which leads to shortage, in the case of
generic-based medicine policy, promotion of local production, induced demand and panic-buying of oral home-
price control and formulation-based national industry [4]. Iran medications especially for chronic disease may be due to
ministry of health (MOH) supported local production aiming to the pandemic (COVID-19-related), and also shortages
improve availability and affordability of medicines; which are due to supply-chain inconsistencies.
resulted in improved access to the quality medicines in Iran [5].
Although more than 95% (in terms of sale volume) of marketed & COVID-19-related: Increased hospitalization, inci-
pharmaceuticals in Iran are produced locally [6], but the depen- dence of COVID-19-related pneumonia and in-
dence of the production of these medicines on the import of raw creased demand for assigning patients to ventilators,
materials is a challenging issue. Currently, more than half of the contributes to related prescription medicine shortages.
active pharmaceutical ingredient (API) are produced in the A medicine shortage is defined as a “supply issue that
country, and the remaining are supplied by reputable compa- affects how the pharmacy prepares or dispenses a
nies in India and China, and in some cases by some European drug product or influences patient care when pre-
and eastern European companies [4]. The dependence of med- scribers must use an alternative agent” [9]. On the
icine production on the importation of raw materials from coun- global levels, many regulatory authorities announced
tries such as China, which are affected by COVID-19, is one of confirmed shortage list, mostly including potential
the serious concerns of pharmaceutical sector. COVID-19 treatments and also associated pneumo-
As of April 28, 2020, the number of people infected with nia. For example, United States food and drug admin-
the SARS-CoV-2 in Iran was 0.9 million [7] with death ratio istration (FDA) shortage list included anti-COVID-19
of 1.38%; which was consistent with the adjusted statistics of potential pharmacotherapies, hydroxychloroquine
the world [8]. The overall cumulative COVID-19-associated (HQC) and chloroquine (QC), and also frequently
hospitalization rate was from <0.1% in 10–19 year-olds to prescribed medications for COVID-19 hospitalized
4.3% in 40–49 year-olds and doubled in 50–59 year-olds to patients with respiratory signs in critical care units,
8.2% based on worldwide data [8]. azithromycin, dopamine, dobutamine, fentanyl, hep-
Current short-communication study assessed pharmaceuti- arin, midazolam, propofol and dexmedetomidine
cal market crisis during the COVID-19 era; discussing short- [10]. In addition, the American Society of Health-
and long-term impacts of the pandemic on pharmaceutical System Pharmacists (ASHP) announced an 11-
market natural flow and regulations, first at the global and medicine list of shortage; which mainly included hos-
then at Iran’s national level as a case in point for developing pital level antibiotics and anesthetic medications; in-
countries. Identification of these effects is essential for policy- cluding meropenem, ceftazidim, ampicillin and doxy-
maker guidance towards more evidence-informed planning to cycline, as antibiotics and vecuronium, rocuronium,
overcome accompanying challenges. as anesthetics. Also, this list included albuterol and
fluticasone which are used to open airways in the
lungs [11].
Results In global levels, the impact on medicine shortage
was differed by medicine access level, retail and hos-
COVID-19 short and long-term impacts on pharma- pital-only, and type. Use of medicines currently being
ceutical sector investigated in trials but not yet fully approved by
FDA or so-called investigational treatments—
COVID-19 may be seen as a century’s opportunity for including hydroxychloroquine, lopinavir+ritonavir,
pharmaceutical industry; as it increases the demand for tocilizumab and sarilumab—had seen a two-fold in-
prescription medicines, vaccines and medical devices. crease in use over the past month, with 8 times higher
This can be seen as one of the main short-term effect use in hospitals [12]. Medicines used in hospitals for
of COVID-19 epidemic; however, there are more short COVID-19—including respiratory treatments, seda-
and long-term implications to it; which will be discussed tives and pain treatments—had experienced an in-
below: crease of 100% to 700%, since the beginning of
DARU J Pharm Sci

January [12]. March 2020, asthma medications spiked by 65%, and type
In local levels, Iran food and drug administration 2 diabetes medications increased by 25% [17]. Similarly,
(IFDA) sale’s data indicates that HQ, QC and medicines treating high cholesterol, migraine, and hypo-
lopinavir+ritonavir experiences 2, 6 and 23 times in- thyroidism also saw a noteworthy increase in claims [17].
crease in their monthly sale volume, respectively; Also, in USA, Excess buying for hypertension, Diabetes,
however, IFDA’s list of medicine shortage for respiratory, and mental health and anxiety was 0.6%,
emergency-supply did not report any shortage of 0.3%, 0.4%, 0.4% and 0.1% respectively [12]. In
aforementioned medicines and/or the drugs required Australia, a one-month-stock regulation for dispensing
by pneumonia-related hospitalized COVID-19 pa- of prescription medicines, is somehow handling the situa-
tients. One of the explanations for this may be the tion of panic-buying [18]. In Germany, German Federal
high stock of raw materials; which is justified by the Institute for Drugs and Medical Devices (BfArM) pub-
market uncertainties due to Iran’s economic and po- lished an allocation order on the storage and demand-
litical factors, which leads companies to over-stock. driven supply of human medicines, on March 2020. The
The other reason was currency allocation to importa- allocation order requested the pharmaceutical companies
tion of COVID-19 required medications, by the gov- and wholesalers not to supply medicines beyond the usual
ernment. For example, lopinavir+ritonavir accounted demand [19]. In contrast, the “stay at home” order in some
for 0.18% (2 of 1101 billion US Dollars) of six-month countries may have caused a decrease in demand; howev-
approved currency order by IFDA to Iran central er, in Iran, due to lack of such regulation only induced
bank, for raw materials, finished pharmaceuticals demand was reported informally by retail pharmacies.
and dietary formula. & Supply shortage of both active pharmaceutical ingredi-
This COVID-19 related shortage also affected the ents (APIs) and finished products: China and India are
health market for medical devices and personal pro- the world’s main supplies of APIs, key starting materials
tective equipment (PPE), which includes protective (KSMs) and also finished pharmaceuticals. As they are
goggles and visors, mouth-nose protection equip- struggling with the disease and also a slow-down in pro-
ment, and protective clothing and gloves, that made duction, this may have contributed to shortage and also
countries to legislate regulations in this regards. The price increase in essential prescription medicines, includ-
market entry facilitation and export restrictions of ing antibiotics. This is more critical when non-
PPE and selected medical devices European substitutional essential APIs, such as amoxicillin, potassi-
Commission (2020/403 of 13 March 2020) is one um clavulanate, ceftriaxone potassium sterile,
example, in global levels [13]. In Iran on March 1st meropenam, vancomycin, gentamycin and ciprofloxacin
2020, national medical device directorate of Iran an- are being concerned. In India, the Indian Pharmaceutical
nounced that restrictions on PPE export is legislated Alliance (IPA) asked government to restrict of all pharma-
by Iran custom office [14]. Also, in order to expedite ceutical products, APIs and formulation to domestic con-
the supply of required goods and also to reduce the sumption only. This shortage has already begun to affect
number of face-to-face visits, the process of issuing API and bulk prices in Indian party trades. The average
emergency licenses for medical equipment supplies increase was reported to be about 10–15%; however, may
has been accelerated by sending them to the online reach to 50% in some cases [20].
communication system and receiving initial approval In global levels, to avoid shortages, FDA and European
within one business day. Customs measures to com- Commission proposed and published regulations focusing
bat this pandemic included banning the export of on both demand optimization and rational supply [21].
masks, medical gown, gloves, disinfectants, soap, de- These regulation revisions include:
tergents and alcohol, and also expediting the issuance
of clearance permits for imported items related to co- & Fast-track approvals for COVID-19-related treatments; In
ronavirus and exemptions from costume tariffs [15]. Iran, this is in terms of Iran medicine list (IML) inclusion
and registration process.
& Induced demand and panic buying: Induced demand for & Compulsory licensing for potential COVID-19 treatments;
stocking medication by public, which is called “panic buy- however, this is in the context of countries who are World
ing”, may cause periodic shortage in the market; especial- Trade Organization (WTO) members and are following
ly for chronic disease medications. Studies reported that intellectual property laws; and it is not subjected to Iran.
induced demand in global pharmaceutical market, mainly & More regulations to enhance importation, in order to
due to “panic buying” of pharmaceuticals for chronic dis- maintain integration of supply chain; however, regarding
orders, was estimated to be +8.9%, by March 2020 [16]. the economic crisis and currency shortage in Iran and also
An study in USA indicated that from 13th to the 21st of Iran’s NDP component on enhancing local production and
 DARU J Pharm Sci

importation minimization, this regulation is not subjected investigation through Iran MOH-registered clinical trials
to current context. [23, 24]. This medication was obtained emergency autho-
In Iran, again due to over-stocking based on economic rization approval by the FDA on May 1st, 2020 for hos-
and political uncertainties, this impact has not yet to be pitalized patients with severe disease condition [25].
sensed completely; however, as about 5% of sale volume Above being noted, there is a dilemma regarding
and 30% of sale-value of finished pharmaceuticals [6] and pseudo-researches and industrial investments on medi-
about 50% of the API are being imported into the country cines which will be identified as non-effective in the near
[4], this shortage type will impact the local pharmaceutical future; which may eventually pose a considerable burden
industry. on the health system. Ethical considerations must be taken
into account within the excited decision making about the
2. Shift of communication and promotions to remote inter- use of the treatment strategies based on the results of these
actions through tele-communication and tele-health: In pseudo-researches [26].
both global and local levels, due to the social distancing
precautions, marketing and promotions of health-care
products to providers are being shifted from face-to-face Long-term impacts Approval delays, moving towards self-
towards remote interactions and tele-communications; for sufficiency in pharm-production supply chain, industry
both promotional and patient-support acts. In USA, the growth slow-down and possible trend changes in consump-
number of patients who have visited physician offices or tion could be seen as long-term impacts of COVID-19 on the
clinics reduced by 70 to 80% [12]. health and pharmaceutical market.
In Iran insurance coverage for tele-medicine is legislat-
ed for the first time by high council of insurance on 1. Delayed approvals for non-COVID-related pharmaceuti-
May 2020. This may lead to long-term behavioral chang- cal products; as all countries, including Iran, are being
es in the health market. under pressure of the crisis and their priority is COVID-
3. Research and development changes 19 management, approval delays may be seen due to sev-
In global levels, at least 113 medicines or regimens and eral month of application review postponements. In Iran,
53 vaccines are in research and development pipelines or due to economic crisis, IML inclusion, registrations and
active clinical trials, as therapeutics for patients diagnosed reimbursement decisions was being made with a consid-
with COVID-19 [12]. As of April 23, 2020, there are erable delay; and this situation may maximize it. It also is
about 924 ongoing trials in the world for the treatment affected by about one-month semi-closure of regulatory
of COVID-19. Only 15% of these studies are based on agencies.
conventional RCT methods, double-blind and multi- 2. Moving towards self-sufficiency in pharma industry; po-
center randomized with comparator arm, but about 40% tential shortages due to export bans in India and China,
are not even randomized [12]. who are main suppliers of API and generics, made gov-
In Iran, HCQ is available through local production with ernments of many countries to consider self-sufficiency in
five active suppliers and a price of 0.1 US$ and is being supply chain and they have announced regulations to
investigated in 64 MOH-registered clinical trials on avoid shortages in such crisis [27]. In this regards, on
COVID-19 patients. CQ, which is also available by one March 2020 the European commission has published a
local manufacturer with the price of 0.03 US$, is the in- new guideline concerning foreign direct investment and
tervention arm in 29 Iran MOH trials and lopinavir/rito- free movement of capital from third countries; stating that
navir, which is included in Iran local COVID-19 manage- foreign investments, especially those which affect the
ment guideline for high risk patients as an additive to CQ health market, in European Union (EU), must be subject-
or HCQ regimen [22] and is available through generics ed to risk-assessments to avoid any harmful impact on the
importation from Indian suppliers with a registered price EU’s capacity to cover the health needs of its citizens [28].
of 0.82 US$ per unit, is being investigated in 20 Iran In Iran, due to sanctions and difficulties in importation,
MOH trials on patients with confirmed COVID-19. In Iran’s pharmaceutical industry was going towards self-
addition, multiple clinical trials are being conducted to sufficiency prior to this crisis; however, COVID-19 pan-
test non-IML-included medications; naming favipiravir demic may lead to more importation restrictions and fur-
and remdesevir. Favipiravir is currently being tested ther regulation incentives for local manufacturing.
through three MOH-supervised clinical trials in Iran and 3. Ph armaceutical indu stry growth slo w-do wn ;
three local manufacturers are conducting pharmacokinetic Coronavirus pandemic resulted in economical slow-
and stability analysis on aforementioned pharmaceutical downs for many countries and this will possibly lead
strategy. Also, Remdesivir which is an antiviral in first to pharma industry growth slow-down, which are
steps of drug development, is being under clinical sensitive to country economic growth; especially, in
DARU J Pharm Sci

Table 1 The world-wide reported short- and long impact of COVID-19 on pharmaceutical sector

Impact Middle-East [31] EU5 countries [30] United States [12]

Short-term Medication shortage COVID-19 related +10.8%: OTC category +10.8%: OTC Investigational treatments have
due to induced (cold, cough) category seen a 2-fold increase
demand (vitamin--
minerals,…)
+403%: Personal hygiene +62%: Personal Medicines used in hospitals for
hygiene the treatment of COVID-19
have increased between
100% and 700% since the
beginning of January
+67%: ICU medications
General (panic buying) +23%: Lipid lowering +7.0%: Highest 7, 6, 5, 4 and 2 million excess
volume growth in prescription in hypertension,
ATC N class of mental health, respiratory,
RX-category in diabetes and anxiety
Spain
+40%: Anti-diabetes
+29.1%:
Anti-hypertensives
Supply shortage Medicines for chronic Supply shortage of both active
diseases are at high risk APIs and finished products
of shortage or supply (About 40% of APIs for the
chain U.S. generic drug market
come from India)
Supply shortage of the
COVID-19 related complica-
tions treatment
R & D shifts 156 clinical trials are 140 clinical trials are
running for COVID-19 running for
COVID-19
Shifts towards WhatsApp calls is the most 320% increase (v. PY) in 70–80% reduction in
tele-medicine preferred digital channel remote interactions in the number of
for both patient Spain. The patient visits to
consultation and corresponding increase doctor offices
communication with in Italy (v. PY) was
peers 471%
Digital channel has wide 51% decline in specialist Tele-medicine
adoption with over 75% consultations and 25% growth accounts
of physicians but decline in GPs visits for 23% of
physicians prefer interactions
traditional F2F
communication
Long-term Approval delays Clinical trial 8% delay Pharma companies report
(non-COVID-rela- existing enrolment delay in new trial starts
ted products)
16% delay new trials only Product launches delayed,
32% delay new trials and disrupted or impacted
existing patient enrolment
Shifts towards Direct investment and free
self-sufficiency in movement of capital
pharma industry from other countries

OTC Over the Counter, ICU Intensive Care Unit, ATC N Anatomical Therapeutic Chemical Classification Nervous system, U.S. United States, v. PY:
versus Previous Year, F2F Face-to-Face, GPs General Practitioners, APIs Active Pharmaceutical Ingredients, R&D Research and Development

countries with pharmerging markets, like Iran. This However, it should be noted that in previous reces-
slowdown in market growth is more due to the entry sions, there were cases in which the health industry
of newer medications. Because the priorities of phar- was less sensitive to slowing economic growth and
maceutical companies change in their portfolio. did not always follow this trend [29].
 DARU J Pharm Sci

4. Ethical considerations: One of the long-term effects of Compliance with ethical standards
growing clinical research related to the current pandemic
is the use of poorly evidence centered therapies. Ethical Conflicts of interest/competing interests All the authors declare no con-
flict of interests which may affect our objectivity.
issues should be considered in the use of these medicines
as off-label [26]. In confirming the proposed therapies, the
Code availability Not applicable.
long-term clinical effects of the use of these strategies in
the coming years should be examined and healthcare pro-
viders should make informed decisions on using off-label
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