Leprosy Mailing List Blog: Fw: Ref.: (LML) Comments on GPZL “MDT Last-Mile Supply Chain Survey” – scope, transparency, and SDR-PEP question

Tuesday, January 27, 2026

Fw: Ref.: (LML) Comments on GPZL “MDT Last-Mile Supply Chain Survey” – scope, transparency, and SDR-PEP question

Leprosy Mailing List – January 27, 2026

Ref.: (LML) Comments on GPZL "MDT Last-Mile Supply Chain Survey" – scope, transparency, and SDR-PEP question

From: Claudio Salgado, Pará, Brazil

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Dear colleagues,

I am writing to share some concerns regarding the Global Partnership for Zero Leprosy (GPZL), Global Survey "Leprosy MDT Last-Mile Supply Chain Survey", recently circulated by e-mail and available at https://www.surveymonkey.com/r/X7FN2JQ.

First, I would like to acknowledge that mapping "last-mile" bottlenecks in MDT availability is a relevant initiative. However, after reading the questionnaire, I believe there are important methodological and practical limitations that should be addressed, so that the survey can better reflect the real-world needs of leprosy programs and clinicians.

1) The survey does not clearly define its ultimate purpose and use of results

The introduction mentions that the survey will help identify bottlenecks and "develop practical, evidence-based solutions and recommendations." However, it is not clear: i) who will lead the analysis and governance of the results; ii) what decisions or investments the results will directly inform; iii) whether findings will be publicly available and in what format; and iv) how participating programs will receive feedback and support.

For an initiative intended to guide supply-chain decisions, transparency about outputs, intended actions, and accountability is essential.

2) The survey focuses exclusively on MDT blister packs and ignores substitute/alternative regimens

While MDT blister pack availability is obviously central, the survey's scope is limited to blister packs and logistics for standard MDT.

In clinical practice, especially from the perspective of a hansenologist (leprologist), substitute regimens and alternative drugs are increasingly necessary (for example, resistance, intolerance, adverse events, drug–drug interactions, and complex clinical scenarios).

A supply-chain discussion that excludes the availability (or lack) of substitute drugs risks producing recommendations that are disconnected from real clinical care and program resilience.

3) The last question introduces SDR-PEP, which is not MDT and is scientifically controversial

The final question asks whether, "as your program scales up leprosy prevention," the supply chain for single-dose rifampicin post-exposure prophylaxis (SDR-PEP) faces similar bottlenecks as MDT.

This is problematic for two reasons:
Conceptual scope drift: SDR-PEP is not MDT, and introducing it in an MDT supply survey (as the final question) may bias the narrative toward "scale-up prevention" as an assumed program direction, instead of a debated policy choice.

Safety and effectiveness are not settled: SDR-PEP remains controversial in outcomes, and there is evidence raising concern about possible adverse consequences. In particular, an article recently contributed to a quantitative analysis showing a substantial increase in visible deformity at diagnosis following chemoprophylaxis implementation in an endemic setting, with a strong statistical association between the number of contacts who received chemoprophylaxis and visible deformity detected in the subsequent year (p=0.0002; R²=0.9132).
This paper, available at: https://www.ijl.org.in/article-detail/97/544, argues that potential harms should be better elucidated before expanding brief chemoprophylaxis strategies.

In summary, if GPZL wishes to obtain a robust map of "last-mile" MDT barriers, the survey should be strengthened by:
1) clarifying the purpose, governance, and expected outputs.
2) incorporating the reality of substitute regimens and non-standard MDT needs, and
3) avoiding conflation between MDT supply and SDR-PEP scale-up, particularly given ongoing scientific debate.

I am sharing these comments in the spirit of strengthening the initiative and aligning it with the realities of both field programs and clinical practice.

Kind regards,

Claudio Salgado