Population screening and chemoprophylaxis for household contacts of leprosy patients in the Republic of the Marshall Islands

International Journal of Leprosy and Other Mycobacterial Diseases, Dec 1999 by Tin, Kyaw

The Republic of the Marshall Islands (RMI) is a country of atolls and small islands spread over three-quarters of a million square miles in the central Pacific Ocean. Twenty-seven of the atolls and islands are inhabited, with a total population of 62,569 projected for 1998. About 68 per cent of the population live on Majuro and Kwajalein atolls; the remaining population is distributed among the outer islands, with populations ranging from around 100 to 2000. Majuro is the capital city of the country.

Leprosy is a serious public health problem in the RMI. The new-case detection rate for 1996 was 210 per 100,000 population, and the prevalence rate at the end of the year was 41 per 10,000; the corresponding rates for 1997, the year before this program was implemented, were, respectively, 115 per 100,000 and 27 per 10,000. Multidrug therapy (MDT) was available only on Majuro and Kwajalein atolls.

The government of the RMI aims to achieve elimination of leprosy, defined as reduction of the prevalence to less than I per 10,000 population, by the year 2000. The government planned to achieve this goal by detecting all cases in the country, and by making MDT available to the entire population. However, because of the high prevalence of the disease and the limited time remaining to achieve the goal, it was believed to be necessary to accelerate progress toward elimination. Therefore, it was planned to screen the entire population of the country to detect all current cases and to place them under treatment with MDT. At the same time it was planned to administer chemoprophylaxis to the household contacts of both past and current leprosy patients.

The program of population screening and chemoprophylaxis was implemented by the primary health care staff-, program activities were incorporated into the routine activities of the staff and no additional staff was involved, except for a World Health Organization (WHO) Short-Term Consultant (STC) who visited the RMI periodically. The program was to be implemented simultaneously on Majuro and Kwajalein atolls. After completing the program on these two atolls, teams of staff members who had already gained experience were to be sent to the outer islands for implementation of the program there. The staff members who were to be involved in the program were given training in the tasks they were expected to perform. For diagnosis and classification of cases, the criteria presented in the "Guide to Eliminating Leprosy as a Public Health Problem," published by the WHO, were followed.

For chemoprophylaxis of household contacts, a combination of 600 mg rifampin, 400 mg ofloxacin, and 100 mg minocycline (ROM) was administered to those at least 15 years of age, and rifampin alone to children under 15 years of age. Children 10 to 14 years of age were administered 450 mg, those 5 to 9 years 300 mg, and those I to 5 years 150 mg. Pregnant women, children under one year of age, people with liver or kidney disease and those known to be allergic to any of these drugs were not given the drugs, nor were patients with past or current leprosy. Household contacts were defined as those living under the same roof and sharing household facilities with an index case (a patient with past or current leprosy).

Screening of the population of Majuro atoll was begun during the third week of May 1998. Zonal nurses made house-tohouse visits, listed the members of each household using a standard screening form, and examined available members for signs of leprosy. After all of the households had been visited, absentees were sought at their places of work or schools. Suspects were referred to the Public Health Division of the Ministry of Health, where the diagnosis of leprosy was confirmed or rejected by the Director of Public Health, Director of the TB/Lep Program, or by the WHO STC. The suspects who did not present themselves to the Public Health Division were sought again at their residences. The screening and follow up of suspects were completed in February 1999. Chemoprophylaxis for household contacts was delivered at their residences by the zonal nurses, beginning in January 1999 and finishing at the end of March 1999.

In Kwajalein atoll, screening was begun in June 1998. Zonal nurses, primary health care staff and voluntary health workers screened the population in the course of house-to-house visits. The Director of Public Health at Ebeye Hospital confirmed the diagnosis, and the coordinator of the TB/Lep Program delivered the chemoprophylaxis to the household contacts in their homes. The program was completed in Kwajalein atoll in September 1998.

Of the 25 inhabited outer islands, nineAlinglaplap, Jaluit, Arno, Wotje, Ebon, Mololep, Mili, Namdrik and Namu, each with populations of 800 to 2000 and with a high prevalence-were targeted for the program. Teams consisting of the Director of Public Health, the Director of the TB/LEP Program or the WHO STC and two zonal nurses from Majuro are to visit these islands to implement the program in collaboration with the local health staff. During the visits, which will require about two weeks, the team is to screen the population by house-to-house visits, confirm the diagnosis, provide MDT to cases, and administer chemoprophylaxis to the household contacts. By mid-April 1999, only Alinglaplap and Jaluit atolls had been visited. The four nuclear-affected islands-Kili (Bikini), Ennewatak, Ronglap (Meijeto) and Utrik-are the responsibility of the staff of the Health Plan 177, who will conduct the screening, and of the Director of Public Health and Director of the TB/Lep Program, who will confirm the diagnosis. Thus far, a portion of the population of these four islands has been screened. When all of the targeted outer islands have been covered, the program will have included 92 per cent of the population of the country.