PEP stands for post-exposure prophylaxis. It is the term for a medicine that is provided after a person has been exposed to a disease but does not yet have symptoms. The intention is that this medicine will prevent the person from developing the disease.
To prevent leprosy through PEP, healthcare workers prescribe rifampicin, one of the three antibiotics that make up Multi-Drug Therapy. PEP has become crucial to the global fight to defeat leprosy and is now a central part of the WHO’s Global Leprosy Strategy 2021-2030. Alongside contact tracing and active case finding, PEP is the key to ending the transmission of leprosy.
However, in leprosy’s 4,000-year history, the discovery of PEP and the evidence base for its efficacy is very recent. Research teams are still working to establish the perfect dose for PEP and many country programmes are not yet ready for PEP.
In order to ensure a full, effective, and long-term roll out of PEP, nations must first trial PEP within their own contexts. That is exactly what is happening through Nigeria’s Ready4PEP programme, which is happening in collaboration with NLR and the Leprosy and Tuberculosis Relief Initiative (LTR). Here’s how it works.
©Ala Kheir
Dr Saminu Msheliza is managing TLM Nigeria’s Ready4PEP programme. He tells us that the initial pilot of PEP in Nigeria is taking place in six Nigerian states where they will be tracing contacts of newly diagnosed leprosy cases and providing them with a single dose of rifampicin. PEP has already been established as part of Nigeria’s National Leprosy Control Programme Guidelines, so the government has been working closely with TLM Nigeria to enable the READY4PEP project.
Their aim is to answer one simple question: does providing a single dose of rifampicin to the contacts of newly diagnosed leprosy cases reduce the number of people who develop leprosy. Even simpler, does PEP work in Nigeria?
The team knows the number of leprosy cases that have been diagnosed in the six participating states over the last three years. If that number drops significantly during the pilot period (2021-2023), then this is a strong indication that PEP does work in Nigeria.
In each of the six states that are running the READY4PEP project, TLM Nigeria is working in four local government areas - two local governments each in two states of the six. The local governments’ healthcare workers have received training in conducting contact tracing, screening contacts, and providing PEP to close contacts who do not have symptoms of leprosy. The local healthcare workers will trace the contacts of 100 percent of new leprosy cases within their districts throughout the pilot.
© Ricardo Franco
They have also been instructed to keep close records of what they are finding, which are shared with TLM Nigeria, as Dr Saminu tells us,
“We will collect data on the number of people who receive PEP and the number of new cases we identify through the screening of contacts. We will continue to follow up with PEP recipients until 2023, having started the programme in July 2021. We will determine how many of the PEP recipients have gone on to develop leprosy. So far, we are pleased to say that none of the PEP recipients has gone on to develop leprosy.”
The TLM Nigeria team will share the data they collect with NLR via LTR, who have substantial experience with PEP. NLR, working with academics in the Netherlands, will analyse the data provided to determine the efficacy of PEP in Nigeria.
They will compare the data to the previous three years of cases in the six participating states and will compare the trends they are seeing in these pilot states with the trends across Nigeria more broadly and with the data from past PEP projects.
“On average, PEP reduces the chance of developing leprosy by almost 60 percent among close contacts, so we are hopeful that we will see similar trends. This prospect has proved very exciting in Nigeria, with the government and persons affected by leprosy expressing a real interest in what we are doing.”
PEP roll out is different in every country, so there will be a lot to learn from this pilot about how PEP works in the Nigerian context, as Dr Saminu explains,
“We have already seen how PEP is different from what we were expecting. We had thought that we would be providing around 15 people with PEP for each newly diagnosed person. However, in communities in Niger State and Kebbi State, we have been providing closer to 50 people with PEP for each newly diagnosed case. Already we have learnt that we need to adjust our stockpile of rifampicin accordingly.
“Our project is also different from other PEP projects because we have trained local healers, pharmacists, and traditional healers to recognise leprosy. We have set up referral pathways so that they can direct people with suspected leprosy symptoms to a healthcare professional who can provide them with treatment and begin the contact tracing process. At the end of the project, we will be keen to establish whether these referral pathways worked.”
“When we have established the efficacy of PEP in Nigeria and have conducted a review of how the experience of the pilot was different in Nigeria when compared to other pilots, we will be ready to roll this out across the whole country. The government is waiting on the outcome of READY4PEP before they take PEP national.
“There is real excitement within Nigeria about the potential of PEP. We are hopeful that it can be the pathway through which we can achieve leprosy elimination. Of course, we will continue to track the progress of PEP within Nigeria to be sure that it is remaining effective.”
Dr. Saminu Msheliza
Right now, Anandaban's research lab is at risk of closing. It is too small and was severely damaged in the disastrous earthquakes of 2015. The lab simply won’t pass the upcoming Nepali Government inspection.
The Leprosy Mission is currently raising funds for a rebuild project, so our researchers can stay on track towards a world without leprosy.
