Filariasis control: ethics, economics, and good science

Filariasis control: ethics, economics, and good science

CORRESPONDENCE Medical litigation in Ireland Sir—In her March 3 news item,1 Karen Birchard refers to the Medical Defence Union’s (MDU) policy towards...

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CORRESPONDENCE

Medical litigation in Ireland Sir—In her March 3 news item,1 Karen Birchard refers to the Medical Defence Union’s (MDU) policy towards our obstetrician members, but the information she gives is inaccurate. Last year, when we launched an insurance policy, underwritten by Zurich Insurance Company, for medical negligence claims for our UK members, we told all our Irish members that it would not be possible to offer a policy in Ireland, because there was a crisis in litigation in obstetrics and gynaecology. We had been engaged in discussions with the Irish Department of Health about the introduction of enterprise indemnity (similar to National Health Service indemnity in the UK), and hoped that we would be able to work with the department on a solution to the crisis. Members in Ireland remained entitled to request discretionary assistance from the MDU in the usual way (as does the other discretionary mutual, the Medical Protection Society), but they did not have the additional security of an insurance contract. Since that time, it has become clear that enterprise indemnity will be delayed, and we have decided to offer an insurance policy to members in Ireland, in addition to our traditional discretionary benefits of membership, pending a solution to the crisis. The policy will be for IR£10 million and will be underwritten by Eagle Star Ireland. Because there is as yet no solution to the crisis in litigation in obstetrics and gynaecology, we can offer no policy to our obstetrician and gynaecologist members since they will not be able to afford the subscriptions necessary to cover their risk. We have written to all such members to tell them that they remain entitled to seek our assistance on a discretionary basis as they have always done. Although this action has caused them some concern, it is certainly not true, as Birchard has written, that we “no longer include obstetricians in our cover package”. This distinction might be merely semantic, but it is very important to the MDU that our position is reported correctly. It is in our members’ interests, as well as their patients’, that they can continue to practise without fear of litigation. We shall continue to do all we can to achieve a satisfactory solution. Michael Saunders MDU Services Limited, London SE1 8PJ, UK

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Birchard K. Ireland discusses how to handle projected increase in medical litigation. Lancet 2001; 357: 698.

Filariasis control: ethics, economics, and good science Sir—Administration of a single annual dose of diethylcarbamazine citrate to the population is already being done by many less-developed countries for control of lymphatic filariasis. The adoption of this control strategy is based on the observed reduction in microfilariae prevalence or density after single annual administration of diethylcarbamazine citrate for 2–5 years.1 Scrutiny of these data reveals an important omission: a control group of untreated microfilariae carriers has not been monitored to find out whether the observed effect on decrease in density in the treated group was not due to loss of circulating microfilariae during the natural course of infection. Limited reports suggest that microfilariae rate decreases quite substantially in carriers without chemotherapy—26% in 1 year in Egypt,2 38% in 5 years in Pondicherry,3 and 63% in 13 years in Orissa.4 The observed decrease in microfilariae rate must be unequivocally a consequence of administration of one annual dose of diethylcarbamazine citrate in a given geographical area and be significantly more than the loss of circulating microfilariae due to natural attrition over 4–5 years. More interestingly, widespread and indiscriminate use of broad spectrum antibiotics such as tetracycline and doxycycline in some less-developed nations could also contribute to the observed decrease in microfilariae density. These drugs compromise the survival of filarial worms in mammalian hosts by eliminating endosymbionts such as Wolbachia residing inside the worms, since filarial parasites seem to be dependent on them for development as well as embryogenesis. The need to include a control group is further emphasised by this mechanism. Although inclusion of an untreated group of microfilariae carriers is clearly unethical, use of several million dollars on a control strategy not based on good science could be perceived as equally unethical. In view of the enormous cost involved in implementing nationwide control programmes, the ethics, economics, and good science involved in filariasis

control programmes currently being pursued should be debated. Analysis of even a small group of symptom-free microfilariae carriers would assist in assessment of the cost-benefit ratio of the current control programme. Persistence of filarial infection after more than three decades of biannual distribution of diethylcarbamazine citrate in a remote island in French Polynesia5 clearly indicates that midcourse correction of the filariasis control strategy would be inevitable. Balachandran Ravindran Division of Immunology, Regional Medical Research Center, Indian Council of Medical Research, Bhubaneswar 751 023, India (e-mail: [email protected]) 1

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Mataika JU, Kimura E, Koroivueta J, Shimada M. Eficacy of five annual single doses of diethylcarbamazine for treatment of lymphatic filariasis in Fiji. Bull World Health Organ 1998; 76: 575–79. Weil GJ, Reda MRR, Setouhy MEL, Kandil AM, Ahmed ES, Faris R. A longitudinal study of bancroftian filariasis in the Nile delta of Egypt: baseline data and one-year follow-up. Am J Trop Med Hyg 1999; 61: 53–58. Vanamail P, Subramanian S, Das PK, Pani SP, Rajagopalan PK. Estimation of fecundic life span of Wuchereria bancrofti from longitudinal study of human infection in an endemic area of Pondicherry (South India). Ind J Med Res 1990; 91: 293–97. Satapathy AK, Sahoo PK, Babu Geddam JJ, Mohanty MC, Ravindran B. Human Bancroftian filariasis: loss of patent microfilaraemia is not associated with production of antibodies to microfilarial sheath. Parasitol Immunol 2001; 23: 163–67. Esterre P, Plichart C, Sechan Y, Nguyen NL. The impact of 34 years of massive DEC chemotherapy on Wuchereria bancrofti infection and transmission: the Maupiti cohort. Trop Med Int Health 2001; 6: 190–95.

DEPARTMENT OF ERROR Fake artesunate in southeast Asia—In this Research letter by Paul Newton and colleagues (June 16, p 1949), there was a mistake in the table. The specificity, NPV, and PPV for “No hologram on artesunate manufactured after 1998” under “Myanmar (Burma)” should have been 100, 1·00, and 1·00, respectively. Oral amiodarone for prevention of atrial fibrillation after open heart surgery, the Atrial Fibrillation Suppression Trial (AFIST): a randomised placebo-controlled trial—In this Article by Satyendra Giri and colleagues (March 17, p 830), the key to the Kaplan-Meier curves (figure 2, p 833) is wrong: the dashed upper curve should represent amiodarone and the solid curve placebo. Prenatal detection of fetal Down’s syndrome—In this Correspondence letter by Y M Dennis Lo and Leo L Poon (March 24, p 599), in the third paragraph, the third sentence should have read “Sekizawa and colleagues have shown that 42·7% of fetal nucleated red blood cells in maternal blood are apoptotic”.

THE LANCET • Vol 358 • July 21, 2001

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