Implementation of chemoporphylaxis in Pohnpei State, federated states of Micronesia

International Journal of Leprosy and Other Mycobacterial Diseases, Dec 1999 by Iehsi-Keller, Elizabeth

The leprosy team, consisting of six members, was selected from among the health workers of the Department of Public Health. The team leader was a physician who had earlier been trained in clinical leprosy. All of the team members worked full time on the project. Before beginning operations, a week's training was given to the team, focusing on the methods of screening, diagnosis and treatment; the rationale of chemoprophylaxis and its administration; possible side effects and their management; public information and community participation; and recording and reporting.

Each of the team members had been assigned specific responsibilities, such as registration, physical examination for signs and symptoms of leprosy, administration of chemoprophylaxis and health education. Their activities were directed by the team leader and a consultant assigned by the World Health Organization (WHO). Physical examination and diagnosis were performed by the team leader or the WHO consultant. Diagnosis and classification were based on clinical findings, according to the criteria published in the WHO "Guide to Eliminating Leprosy as a Public Health Problem." Skin-smear examination for leprosy bacilli was available when necessary.

The schedule of field visits was prepared by the leprosy team, the WHO consultant and the leaders of the municipalities before beginning operations, and was updated monthly. The time required for screening the populace of each municipality was decided on the basis of the 1994 census and the geographical setting of the villages. The first round was begun in March 1996 and completed in February 1997. The second round was begun in March 1997 and completed in March 1998.

Before each visit of the leprosy team to a village, usually a few days before, meetings were held with the village leaders, and the populace was informed by means of radio messages and community meetings. On these occasions, information on the transmission of Mycobacterium leprae and the signs and symptoms of leprosy and its treatment, as well as information on chemoprophylaxis and its contraindications, were given to the populace. A WHO poster on diagnosis and treatment was displayed. Community centers, schools and health centers were used as sites to which the residents of the locality were invited by the village leaders for physical examination and administration of chemoprophylaxis.

Upon entry into the site, each resident was queried with regard to name, age, sex, the possibility of pregnancy and other contraindications such as renal and liver disease. The information was recorded on prepared forms, as was the outcome of the physical examination. The residents were examined individually by the team leader or the WHO consultant. When leprosy was detected, this information was recorded and, for new cases, a patient clinical card was opened and the treatment begun immediately. Information on the intake of the multidrug therapy (MDT), its duration and possible side effects was given to the patient.

After the screening, those among the populace who were eligible were administered chemoprophylaxis, the intake supervised by the responsible team member. Pregnant women were told to present to the Department of Public Health to take the medication after delivery. Those with present or past history of renal or liver disease were also excluded from chemoprophylaxis. Ointments for treatment of the most common skin diseases were also dispensed.

Home visits were conducted in each village, for those unable to attend, and when attendance at the screening site was small. During home visits, the team would split into three groups; one group stayed at the screening place and the other two conducted home visits in different parts of the village. Home visits were conducted more systematically and more frequently during the second round than during the first.

In the first round, according to the 1994 population census, 66 percent of the total population were screened, and 62 percent were administered chemoprophylaxis. In the second round, 71 percent of the population was screened, and 69 percent received chemoprophylaxis. Altogether, 89 percent of the population received one dose and 42 percent received two doses of chemoprophylaxis.

During the first round, 153 new patients were detected, of whom 26 (17 percent) were multibacillary (MB) and 50 (33 percent) were children under 15 years of age. During the second round, 26 new patients were detected, of whom 11 (42 percent) were MB, 11 (42 percent) demonstrated a single lesion, and 5 (19 percent) were children under 15 years. The new-case detection rate in the first round was 45 per 10,000 and, in the second round, 8 per 10,000. Thus, the new-case detection rate decreased by 83 percent from the first to the second round.

The disease is unevenly distributed in Pohnpei State. During the first round, the prevalence was 45 per 10,000 population in Sokhes municipality, 275 per 10,000 on the outer island of Kapingamirangi and 193 per 10,000 on the outer island of Pingelap. Within Sokhes municipality, the villages of Kepira (15 new cases, 326 new cases per 10,000) and Kepin (4 new cases, 301 per 10,000) were the most affected. Within the municipality of Madolenihmw, the village of Metipw (9 new cases, 347 per 10,000) was the most affected.