Concerns regarding the Japanese Ministry of Health’s Fact Sheet on ME

Japanese legislators rely on the Japanese Ministry of Health for accurate and current information on diseases. For this reason, our Association was deeply concerned when we discovered (on February 7, 2019) the fact sheet on ME/CFS that the Ministry of Health currently distributes to Japanese legislators who request information from the Ministry to learn about the disease. 

Presented in a one-page fact sheet, the information (translated below) contains careless inaccuracies which combine to depict ME/CFS as a mild condition with psychiatric components. It is careless and misleading in what it includes and what it excludes: ME/CFS is summarized as a list of symptoms that any healthy person might have: chronic malaise, fatigue, headaches, and cognitive dysfunction. The list notably includes depression, which is not a symptom of the disease, while it excludes the hallmark ME symptom of post-exertional malaise—the prolonged worsening of physical and cognitive function following physical or cognitive exertion. 

Further, the fact sheet prominently lists several psychiatric conditions as “co-morbid symptoms” in the second sentence of the short document. We are concerned that taken together with the mention of antidepressants and psychological therapy in the treatment section of the document, any individual relying on this fact sheet alone would conclude that ME/CFS is a mild condition with psychiatric components, misrepresenting both the medical literature about the nature and severity of the illness and reflecting a denial and disregard for the lived reality of ME patients. 

The fact sheet surprisingly makes no mention of the Health Ministry’s own 2014 ME/CFS Patient Survey, which found that approximately 30% of ME patients in Japan are severe patients who are bedridden or close and require assistance with activities of daily living and that moderate and severe ME/CFS patients are unable to work. 

The fact sheet also conveys the incorrect impression that the illness was first reported in 1988, omitting information about earlier reports which led to its classification in 1969 as a neurological disorder in the WHO International Classification of Diseases. 

The following is an English translation of the fact sheet in its entirety: 

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

(1) What is ME/CFS

(1)   Summary

A syndrome where patients are affected by severe generalized malaise of unknown cause followed by strong fatigue along with symptoms such as mild fever, headache, muscle pain, a feeling of exhaustion, cognitive dysfunction, and depression which continue over a long period. Comorbid symptoms include mood disorders, somatic symptom disorders, anxiety disorders, fibromyalgia, and irritable bowel syndrome.

Chronic fatigue syndrome is a syndrome that was reported by the United States Centers for Disease Control in 1988 (Chronic Fatigue Syndrome: CFS). In the United Kingdom it was also called myalgic encephalomyelitis (Myalgic Encephalomyelitis: ME) but in recent years it is being said that these might be the same syndrome.

(2)   Cause

The involvement of infectious disease, immune function abnormalities, autonomic nervous system abnormalities, and endocrine abnormalities have been suggested but the cause is unknown.

(3)   Diagnostic criteria / Treatment

At present no diagnostic criteria which uses objective markers has been created in any country. Vitamins, antidepressants, Chinese herbal medicine, and psychological therapy are being tried, but no effective treatment methods have been established.

 

Status of the 2017 Proposed ME/CFS Treatment Guidelines (Draft)

In late 2017, JMEA submitted its opposition to the publication of national ME/CFS treatment guidelines for Japan (Draft), which was scheduled to be published in spring 2018. The document was not published in spring 2018 but was set to be filed as a research report with the government health agency Japan Agency for Medical Research and Development (AMED). We are currently awaiting the release of this report and will provide a further update on the research report when it becomes publicly available.

The Association is deeply grateful to the international ME/CFS medical experts and advocacy organizations which kindly responded to our request to provide comments on the draft treatment guidelines document. We immediately shared your comments with the research committee which drafted the document and with the Ministry of Health.

In August 2018, we held a press conference at the Ministry of Health on the opinion letter we received from the International Association for CFS/ME (IACFS/ME) in response to our request for the association’s opinion on translated excerpts of the document. In the opinion letter, the IACFS/ME expressed concern that the document could be of potential harm to ME/CFS patients in Japan due to the recommendation of Graded Exercise Therapy (GET) as an effective treatment. The letter also shared our concern that the discussion in the document of behavioral interventions such as Cognitive Behavioral Therapy and yoga and of antidepressant drug therapy could give the mistaken impression that ME is a psychological illness which can be cured by such interventions. Questions from the press included why the opinions of the international and Japanese ME/CFS experts differed, among more specific questions about the document.

 

 

 

 

 

Japanese National Diet Adopts JMEA’s 2018 Petition for ME/CFS Research

We are pleased to announce that the Japanese National Diet has adopted Japan ME Association’s 2018 petition to the national government,  “Petition Seeking Research Advancement for the Neurological Disease ME/CFS,” as a result of voting on the petition by the House of Representatives and the House of Councillors, respectively. The adoption of our most recent petition follows the successful adoption of our formal petitions to the Japanese national legislature in 2014 and 2015, and again in 2016.

The petition was introduced to the 2018 Diet session by 99 Diet members across multiple political parties and submitted with more than 13,500 signatures. We are deeply grateful to all of the individuals (which included not only patients but those who first learned about ME/CFS through the petition effort) and Diet members who generously contributed to this significant result.

The petition will now be delivered to the Cabinet, and the Cabinet will produce approximately two reports annually to the House of Representatives on progress on the petition items.

ME/CFS has been classified in the World Health Organization’s International Classification of Diseases as a neurological disorder since 1969, and the disease has again been classified as a neurological disorder in the revised ICD-11 announced on June 18, 2018. This past April, AMED (the Japan Agency for Medical Research and Development) adopted the neurologist Dr. Takashi Yamamura’s research team for ME/CFS. ME/CFS was also featured in the scientific publication Nature this year, indicating that the disease is now recognized at a global level.

Japan ME Association greatly appreciates your continued support as we advocate for ME/CFS to be designated as Intractable/Rare Disease in Japan and for research advancements that will bring much-needed effective treatments to ME/CFS patients.

JMEA signs Letter to WHO Director-General Dr. Tedros Adhanom Ghebreyesus

As part of our collaborative actions with international ME advocacy organizations along with our participation in the global day for health equality for ME/CFS #MillionsMissing, Japan ME Association has co-signed an open letter to the WHO Director-General Dr. Tedros Adhanom Ghebreyesus from the International Alliance for ME requesting a meeting to highlight the serious and significant impact of ME and to “explain why we are seeking urgent national and international action to increase research on [ME] and ease the suffering of patients around the world.”

We support this letter along with ME advocacy organizations from the UK, the United States, Australia, South Africa, Spain, and other countries in our sincere hope that the Director-General will accept the International Alliance’s invitation to speak with him to address the urgent situation facing ME patients worldwide at the WHO level. The full text of the letter can be found here.

JMEA to participate in #MillionsMissing at Geneva Event

On Saturday, May 12, 2018, Japan ME Association will participate in the global #MillionsMissing protest as part of the International Alliance for ME’s Visibility Event at Place Des Nations in Geneva, Switzerland, the location of the World Health Organization (WHO).

#MillionsMissing is a global day of public action that calls for health equality for patients with ME. This year, Japan ME Association joins for the first time through its participation in the event in Geneva, where messages from Japanese ME patients will be displayed among those from many other countries. The International Alliance for ME is a joint international advocacy movement which aims to raise the profile and awareness of ME at the WHO level. The goal of the Alliance is to collaborate with organizations and individuals at the national and international levels to advocate for the adoption of a resolution by the WHO and its Member States recognizing ME as a “serious, chronic, complex and multisystem disease that frequently and dramatically limits the activities of affected patients (Institute of Medicine, 2015)” and to adopt measures to provide a global and coordinated public health response to ME.

JMEA believes that it is critically important to combine our efforts with ME advocacy organizations internationally to more effectively convey to the Japanese government the urgent need to improve the current public health response to ME. We firmly believe that advances at the WHO level and in other countries will positively influence the situation of ME patients in Japan and vice versa.  

Public Comments on the Proposed Treatment Guidelines

In December 2017, in addition to requesting an external review from Japan ME Association among other groups on its “ME/CFS Treatment Guidelines for Japan,” the Research Committee on the Development of Treatments and Treatment Guidelines for ME/CFS also solicited comments from the public.

Several organizations and individuals within Japan have shared with us the public comments they submitted to the guidelines research committee. We highlight three of them (translated from the original Japanese) here.

  • “According to a 2012 to a survey conducted with the ME/CFS association, 47% of patients visited more than six medical institutions before they obtained a diagnosis. Patients struggled from misunderstanding and prejudice even after receiving an ME/CFS diagnosis, with a lack of understanding from family and friends. They are often viewed as being malingerers. The proposed guidelines include many problems as the patient association has indicated, and will result in further deepening misunderstanding about the disease among medical professionals who do are not familiar with ME/CFS. I hope these guidelines can be reconsidered using reliable factors such as diagnostic criteria and clinical treatment information.” – Dr. Miwako Hosoda, Vice President, Seisa University 
  • “What patients seek regardless of where they live is discovery of the pathology of ME/CFS and the development of effective treatments. It is unacceptable to have situations that may result in harm to patients even outside the context of clinical treatment. This is because the suffering that accompanies illness onset, diagnosis, and visiting doctors in search of treatment is endured by patients and their families, and more precisely, by patients. Of course, risks accompanying research such as clinical treatment trials may be unavoidable. But such risks must be minimized as much as possible, not just limited to clinical trial research… At the very least, I am uncomfortable with the release of the current proposed guidelines, which have been created without convening a panel consisting of stakeholders such as patients, members of the public, and specialist researchers.” – Natsuko NojimaResearcher, Japan Society for the Promotion of Science
  • “In treating illnesses like ME/CFS where the pathology is not yet known, it is only with the passage of time when the actual situation becomes known that medical treatment and medical policies may be truly evaluated. For example, there could be a treatment that may be applied with the best of intentions, but which could constitute a human rights issue. There is a need to be cautious. If there is no treatment with an A-grade recommendation, I believe the guidelines should make clear that there are currently no effective treatments. Since there is no such statement, many clinicians may overlook this important fact and may select graded exercise therapy, which is recommended as a B-grade treatment but has the potential to make patients worse. It could spread the promotion of exercise for illnesses with fatigue even if they make patients worse, as these incidences often remain unreported and patients may end up paying for treatment only to find themselves suffering more.” – Keiji Nakazawa, President, Non-Profit Organization Healthcare Innovation in Japan

Our Opposition to Proposed National Treatment Guidelines for ME/CFS

Japan ME Association held a press conference at the Ministry of Health, Labour and Welfare’s press club on December 14, 2017 to announce our opposition to the public draft of proposed “Treatment Guidelines for ME/CFS for Japan,” issued by the Research Committee for the Development of Treatments and Treatment Guidelines for ME/CFS for public comment. The  proposed clinical treatment guidelines for ME/CFS are scheduled to be published in spring 2018 in Nihon Iji Shimpou, one of the most widely read medical journals in Japan.  JMEA received a request to submit an external review in November 2017, and we announced our opposition to the proposed guidelines at the press conference. NHK, The Asahi Shimbun, The Sankei Shimbun, Kyodo News, and several regional media outlets attended.

JMEA believes that the proposed treatment guidelines do not provide an adequate, reliable, or safe basis for clinicians in Japan to make treatment decisions for ME/CFS patients in real-life clinical settings. The research committee evaluated various treatments to create the proposed treatment guidelines solely on the basis of a literature review (using an “Evidence-Based Medicine” analysis), with each treatment given an effectiveness grade of an ‘A’ to ‘I’ grade-rating (with an A-grade being the most effective).

The result is a document that merely discusses the results of the committee’s literature review, with no A-grade treatments and with a single B-grade treatment recommendation for Graded Exercise Therapy (GET) (all other treatments mentioned in the guideline document — CBT, antidepressants and other drug treatments, Chinese herbal medicines, and yoga — were rated C-grade or lower), with no discussion or guidance on how to distinguish among the appropriateness of the various treatments for actual ME/CFS patients, each with varying symptoms and severity of illness.

Further, the proposed treatment guidelines pose a risk to worsening the symptoms and overall health of ME/CFS patients in recommending Graded Exercise Therapy (GET) as the single treatment with the highest B-grade rating. In particular, gradually increasing aerobic exercise until the patient can return to their normal lives is recommended. (The guidelines recommend GET under the guidance of an appropriate instructor. However, as the document acknowledges apart from its recommendation, primary care doctors, rehabilitation specialists, and physical therapists in Japan do not have knowledge or training about ME/CFS or its symptoms.)

We believe that there is a serious problem where GET is set be established in the national treatment guidelines for Japan as the most highly-rated treatment where GET has been under harsh scrutiny and is being re-evaluated or rejected in the rest of the world. The document acknowledges in footnotes, for example, that the United States Centers for Disease Control (CDC) recently removed GET from its ME/CFS website. Nevertheless, GET is still presented in the proposed guidelines as a highly effective ME/CFS treatment based on the result of the committee’s “evidence-based medicine” literature analysis of research studies mostly from the United States and Europe. The guidelines cite to old studies where the diagnostic criteria used to screen patients are opaque, as well as to studies published in psychology journals and to the highly criticized PACE trial in its list of references in support of its treatment recommendations.

Recent research studies have shown that increasing exercise after a certain (low) threshold leads to a worsening of symptoms, with more medical institutions finally acknowledging this reality in the West. Japan and Japanese ME/CFS patients should not remain in the dark ages on this critical development.

In addition to posing a risk of worsening symptoms – especially where there is a complete lack of knowledge among Japanese physicians, physical therapists, and exercise specialists about ME/CFS and its symptoms, including the post-exertion exacerbation of symptoms – the recommendation of GET in the treatment guidelines will inevitably (and unnecessarily) deepen prevalent and mistaken beliefs about ME/CFS that are currently held among the vast majority of Japanese medical professionals (for example, that ME/CFS is a psychological illness that can be improved by gradually increasing exercise).

JMEA opposes the proposed treatment guidelines for the simple reason that they pose a serious risk to ME/CFS patients. With only a very small handful of doctors in Japan who have experience diagnosing and treating ME/CFS, the individuals who stand to suffer most from this document are ME/CFS patients in Japan of all severities of illness, including and especially severely ill patients.

We outlined the following seven reasons for our opposition to the proposed ME/CFS treatment guidelines in our written external review submitted to the research committee:

1. With no A-grade treatment recommendation and one single B-grade recommendation, the proposed ME/CFS treatment guidelines do not provide an adequate and reliable basis for physicians to determine safe and appropriate treatments for ME/CFS patients of varying illness severity in real-life clinical settings.

2. We are seriously concerned that the mostly highly recommended treatment in the proposed treatment guidelines for Japan will be for Graded Exercise Therapy (GET), a treatment being rejected around the world, and which poses a risk of worsening, and not improving, patients’ symptoms.

3. We question whether the research committee took into account the diagnostic criteria employed in the research studies that were evaluated for the “evidence-based medicine” literature review analysis on which the development of the proposed guidelines was based.

4. We question the paper’s analysis regarding the effectiveness of antidepressants to treat ME/CFS. If the selected literature included studies where there were a mix of ME/CFS patients and patients with major depression (which can easily result from the use of old diagnostic criteria such as the Oxford criteria), there is a question about the effectiveness of antidepressants to treat ME/CFS, distinguished from its effectiveness for treating depression, including secondary depression symptoms that some ME/CFS patients experience as a result of the social, financial, and personal consequences of living with a serious disabling physical illness. Because this distinction is not explained in the document, the proposed treatment guidelines gives a misleading impression about the effectiveness of antidepressants to treat ME/CFS itself.

5. In its explanation of ME/CFS, the draft treatment guidelines omit the fact that the ME is classified as a neurological disorder in the World Health Organization’s International Classification of Diseases.

6. In its explanation of ME/CFS, the proposed treatment guidelines state that the estimated the number of ME/CFS patients in Japan is 300,000, while the most recent (2012) AMED research committee concluded that the number is 0.1% of the population (a number closer to 100,000).

7. The proposed treatment guidelines were created solely using a literature review, without considering clinical information or data.

Patients already suffer from being told that the illness is “all in their heads,” that they can be cured with a change in thinking, antidepressants, or exercise, with even close family members and friends not grasping the seriousness of the illness. Patients often do not look sick and are often viewed as being malingerers. As a patient association, we cannot permit a foreseeable situation to come about that harms patients by perpetuating and exacerbating the existing problems about how the illness is viewed, understood, and treated by medical professionals in Japan.

Questions from the press included: “Did the Ministry of Health commission the drafting of these guidelines?” “Why do you believe guidelines were drafted which would be opposed by patient groups?” “If the treatment guidelines are published, will they actually be implemented?” “What kind of treatments are patients currently receiving?” and “What position is the Japanese Neurology Society taking?”

We welcome your comments in English or Japanese on the serious issues raised by the proposed national treatment guidelines for ME/CFS. Please send them to the following email address for Japan ME Association: cfsnon@gmail.com