FW: (LML) Single-dose rifampicin PEP increased the risk of MB disease

 

 

Leprosy Mailing List – October 9,  2019

Ref.:    (LML) Single-dose rifampicin PEP increased the risk of MB disease

From:  Geoff Warne, Geneva, Switzerland

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Dear colleagues,

I read with interest Dr Joel Almeida's contribution on 6 October entitled Single-dose rifampicin PEP increased the risk of MB disease. Dr Almeida has also sent me (and perhaps others) a copy of his fuller paper on the topic. I'd like to mention three things on this.

First, Dr Almeida has raised a number of important issues over recent months. Some of these were discussed by the ILEP Technical Commission (ITC) at its meeting in Manila last month. There is particular interest in the questions of whether there are groups of people that PEP will miss but who are still transmitting leprosy, and whether there are transmission pathways which we are not thinking about. The ITC plans to examine these concerns in detail over the coming months. The prevention of MB leprosy is certainly a key concern, though reviews are somewhat hampered by two issues. Firstly, the definition of MB and PB cases has changed very significantly over the years, making comparisons and trend evaluation difficult. And secondly, the actual number of MB cases in many studies and trials is small, often making sub-group analysis difficult.

Second, the leprosy world should not, as Dr Almeida implies, stop further studies involving PEP implementation, nor its careful use in routine leprosy control programs as recommended by WHO. The WHO Guidelines recommending the introduction of SDR-PEP for the prevention of leprosy in contacts of new leprosy patients were based on the most rigorous scientific review of the available literature. Instead, we should support more work, with good recording and reporting of data (both in research studies and in any routine programs using PEP), so that these issues, and especially trends in MB cases, can be studied more rigorously. In this way, more advanced strategies for prevention that are fully effective against MB leprosy can be developed. It's worth emphasising that one definite, widely observed advantage of further work on PEP, whether research or routine, is the emphasis on contact examination and improved follow-up of anyone receiving PEP, which means early case detection for an increasing proportion of those unfortunate enough to develop leprosy. In addition, at the recent International Leprosy Congress, most countries that had introduced SDR-PEP in recent years reported a strongly positive effect of the introduction of PEP on the whole leprosy programme in the concerned areas.

Finally, I come to the question of what is the best venue or mechanism to either support or dispute Dr Almeida's opinions expressed in this and similar articles. I find LML a good venue for the sharing of opinions on leprosy related topics, but what Dr Almeida has written is more than an opinion, it's a fully-fledged article with citations, similar to what I might expect to see in Leprosy Review or other journals. And here exactly is the problem. I expect Dr Almeida's claim that SDR causes MB leprosy based on the results of the Maltalep trial to be strongly disputed. I encourage him to consider submitting this article to Leprosy Review or to another recognized, peer-reviewed scientific journal so that – if validated – his views move beyond one person's professional opinion to becoming part of the scientific body of literature on this important topic. To me as ILEP CEO, this is serious. ILEP member associations want their programs to reflect evidence-based best practice, and we rely on the scientific publications for that. I would not expect an ILEP member to change its programs on the basis of an opinion in LML, but I would expect it to take very seriously what is published and discussed in the recognized journals. Of course, scientists and researchers also have differences of opinion, and I find that, because they are peer reviewed, the journals are excellent venues for exploring those differences of opinion and prompting action on the findings.

With kind regards

Geoff Warne

CEO, International Federation of Anti-Leprosy Associations (ILEP)

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LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

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