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Making progress towards leprosy elimination
Editorial
Science Photo Library
Making progress towards leprosy elimination Rights were not granted to include this image in electronic media. Please refer to the printed journal
For WHO’s 2005 to 2010 strategy see http://www.who.int/ lep/Reports/GlobalStrategyPDF-version.pdf For the Global Leprosy Situation, 2005 see http://www.who.int/wer/ 2005/wer8034.pdf
People have feared the effects of leprosy for thousands of years and, as a result, the stigma associated with the disease is deeply etched into our collective psyche. Europe was so badly affected during the 13th century that by 1225 there were around 19 000 leprosaria— hospitals to house lepers. By 1350, the disease started to wane in Europe, possibly because the black death killed so many of Mycobacterium leprae’s hosts. But today M leprae’s effects are still seen worldwide, especially in India where 260 000 of the 408 000 people diagnosed in 2004 reside. In 1991, the World Health Assembly adopted a resolution to eliminate leprosy by 2000, defining elimination as reducing the prevalence to below one case per 10 000 population. By 2005, the goal had not been met, despite the provision of free multidrug therapy by Novartis from 2000 onwards. Despite these failures, there will be a great deal to cheer about on World Leprosy Day on Jan 29. In 1985, 122 countries
had prevalence rates above one case per 10 000. Now, only nine do: Angola, Brazil, Central African Republic, Democratic Republic of Congo, India, Madagascar, Mozambique, Nepal, and Tanzania. Theoretically, leprosy should have been one of the easy targets for eradication: human beings are the main reservoir; it is easy to treat; and the supply of drugs is plentiful and free. So why has progress been so slow? Social stigma means that many people do not come forward for treatment. In addition, although the drugs are free, centralised leprosy centres can make access to treatment prohibitively expensive for patients—in terms of lost wages and travel costs. In its 2006–10 global strategy, WHO has identified the need to help educate local health workers about leprosy so that they can take responsibility for control of the disease in their area. If they succeed, and if resistance to rifampicin does not develop, then leprosy could well soon be consigned to the annals of history. ■ The Lancet
Science Photo Library
Cough guidelines choke on evidence
Rights were not granted to include this image in electronic media. Please refer to the printed journal
For ACCP cough guidelines see http://www.chestjournal.org/ content/vol129/1_suppl/
276
Cough is the commonest reason for medical consultations in many countries, and is estimated to cost Americans US$3 billion every year in over-the-counter medicines. The number of differential diagnoses for cough is almost as extensive as the list of putative remedies. Therefore, revised guidelines due to be published this week by the American College of Chest Physicians (ACCP) on the rational investigation and management of cough in adults and children have generated wide interest. Funded by the pharmaceutical industry, the international, multidisciplinary panel has obviously worked hard on this massive task, but it may have been an impossible mission. These days the term evidence-based seems to accompany most guidelines, but in an area of limited trial quality, such an aspiration could be difficult to achieve and can over-complicate simple messages, as it does here. Starting with 275 publications identified from an English-language search of Medline, the report comprises almost the same number of recommendations published in as many pages. Despite its title, over half of the recommendations are based more on opinion than on evidence. For any level of population evidence, the com-
mittee considered possible benefits before making an endorsement. The result is a confusing mismatch, with one third of the recommendations based on “low” evidence (non-randomised, case-control, or observational studies), yet backed with the second highest grade (B) of support. Another quarter is based on expert opinion only, giving some recommendations the musty air of aphorisms. While the expertise of this specialist committee may well provide valuable guidance concerning cough, it would be a mistake to interpret the recommendations as firmly evidence-based. This is a shame, because many of the goals are worthy, such as advocating smoke-free workplaces (evidence based on expert opinion, strength of recommendation A). If guidelines claim to be evidence-based, they must expect to be judged as such. Authors must not lose sight of the fact that guidelines are not an end in themselves, but a means to improving clinical care. With publication of these guidelines, the ACCP’s work will begin in earnest to ensure that they are implemented actively and that practice is audited appropriately. But without evidence at their heart, it may be a hollow exercise. ■ The Lancet www.thelancet.com Vol 367 January 28, 2006
Science Photo Library
Making progress towards leprosy elimination Rights were not granted to include this image in electronic media. Please refer to the printed journal
For WHO’s 2005 to 2010 strategy see http://www.who.int/ lep/Reports/GlobalStrategyPDF-version.pdf For the Global Leprosy Situation, 2005 see http://www.who.int/wer/ 2005/wer8034.pdf
People have feared the effects of leprosy for thousands of years and, as a result, the stigma associated with the disease is deeply etched into our collective psyche. Europe was so badly affected during the 13th century that by 1225 there were around 19 000 leprosaria— hospitals to house lepers. By 1350, the disease started to wane in Europe, possibly because the black death killed so many of Mycobacterium leprae’s hosts. But today M leprae’s effects are still seen worldwide, especially in India where 260 000 of the 408 000 people diagnosed in 2004 reside. In 1991, the World Health Assembly adopted a resolution to eliminate leprosy by 2000, defining elimination as reducing the prevalence to below one case per 10 000 population. By 2005, the goal had not been met, despite the provision of free multidrug therapy by Novartis from 2000 onwards. Despite these failures, there will be a great deal to cheer about on World Leprosy Day on Jan 29. In 1985, 122 countries
had prevalence rates above one case per 10 000. Now, only nine do: Angola, Brazil, Central African Republic, Democratic Republic of Congo, India, Madagascar, Mozambique, Nepal, and Tanzania. Theoretically, leprosy should have been one of the easy targets for eradication: human beings are the main reservoir; it is easy to treat; and the supply of drugs is plentiful and free. So why has progress been so slow? Social stigma means that many people do not come forward for treatment. In addition, although the drugs are free, centralised leprosy centres can make access to treatment prohibitively expensive for patients—in terms of lost wages and travel costs. In its 2006–10 global strategy, WHO has identified the need to help educate local health workers about leprosy so that they can take responsibility for control of the disease in their area. If they succeed, and if resistance to rifampicin does not develop, then leprosy could well soon be consigned to the annals of history. ■ The Lancet
Science Photo Library
Cough guidelines choke on evidence
Rights were not granted to include this image in electronic media. Please refer to the printed journal
For ACCP cough guidelines see http://www.chestjournal.org/ content/vol129/1_suppl/
276
Cough is the commonest reason for medical consultations in many countries, and is estimated to cost Americans US$3 billion every year in over-the-counter medicines. The number of differential diagnoses for cough is almost as extensive as the list of putative remedies. Therefore, revised guidelines due to be published this week by the American College of Chest Physicians (ACCP) on the rational investigation and management of cough in adults and children have generated wide interest. Funded by the pharmaceutical industry, the international, multidisciplinary panel has obviously worked hard on this massive task, but it may have been an impossible mission. These days the term evidence-based seems to accompany most guidelines, but in an area of limited trial quality, such an aspiration could be difficult to achieve and can over-complicate simple messages, as it does here. Starting with 275 publications identified from an English-language search of Medline, the report comprises almost the same number of recommendations published in as many pages. Despite its title, over half of the recommendations are based more on opinion than on evidence. For any level of population evidence, the com-
mittee considered possible benefits before making an endorsement. The result is a confusing mismatch, with one third of the recommendations based on “low” evidence (non-randomised, case-control, or observational studies), yet backed with the second highest grade (B) of support. Another quarter is based on expert opinion only, giving some recommendations the musty air of aphorisms. While the expertise of this specialist committee may well provide valuable guidance concerning cough, it would be a mistake to interpret the recommendations as firmly evidence-based. This is a shame, because many of the goals are worthy, such as advocating smoke-free workplaces (evidence based on expert opinion, strength of recommendation A). If guidelines claim to be evidence-based, they must expect to be judged as such. Authors must not lose sight of the fact that guidelines are not an end in themselves, but a means to improving clinical care. With publication of these guidelines, the ACCP’s work will begin in earnest to ensure that they are implemented actively and that practice is audited appropriately. But without evidence at their heart, it may be a hollow exercise. ■ The Lancet www.thelancet.com Vol 367 January 28, 2006