• WORLD HEALTH ORGAN I ZATION ORGANISATION MONDIALE DE LA SANT~
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R~GIONAL DU PACIFIQUE OCCIDENTAL
RIDIONAL CCH4I'ITEE
TECHNICAL DISCUSSIONS
Fourteenth Session Port Moresby 5-10 September 1963
WP/RC14/Trr( 10.July 1963 ORIGINAL: ENGLISH
THE CONTROL OF LEPROSY IN FIJI WITHIN THE PUBLIC HEALTH PROGRAMME
by D.W. Beckett M.A., M.D., D.T.M. & H (Consultant in leprosy) and A.J. Hibell M.B., D.P.H., D.I.H. (Assistant Director of Medical Services, Health)
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WP/RC14/TT17 page 1
1.
HISTORICAL BACKGROUND
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It is impossible to be definite with regard to the duration of leprosy in Fiji but the facts that there are definite words in the Fijian language for the disease and many of its manifestations and that there are several traditional remedies for it would lead one to believe that it must have been endemic long before the cOming of the Europeans in the early years of the nineteenth century. The earliest mention of the disease in Fiji was made by ~h of the Methodist Mission who, in 1837, briefly recorded that cases were being treated by him and his colleagues in the Mission. Corney in 1891 calculated that about 0.8 per cent of deaths among Fijians were due to leprosy. It was not until the end of the century, however, that the first direct administrative step was taken by the Government of Fiji concern· ing leprosy and this was the passage of tiThe Lepers Ordinance 1899". This ordinance forbade certain callings to "lepers" and gave the Governor power to establish "leper asylums" and to consign thereto any leper found guilty on a second occasion of an offence against the ordinance. This ordinance was amended in 1907 so as to give magistrates the power to commit lepers to hospital on medical evidence alone. The amendment also made it an offence to harbour or trade with lepers.
As a result of the Lepers Ordinance 1899, a leprosy station was established in 1900 on the island of Beqa to the south of Suva. It is remarkable that the Chief Medical Officer was able to report in 1910 that 90 per cent of the patients had came there voluntarily. However, it was impossible to acquire the whole island which is a rather large one, and it gradually became obvious that this was essential if isolation was to be absolute. In 1909, the island of Makogai was bought for the purpose of establishing a leprosarium by the Government and, after some delays due to financial stringency and staffing problems, forty patients were transferred from Beqa in 1911. 2. MAKDGAI
The island of Makogai is about three miles in length from north to south and about two miles across from east to west. Volcanic in origin, it rises steeply to a maximum height of 876 feet. It lies in the Koro Sea between the two main islands of the group and is about seventeen miles from Levuka, the former capital of Fiji. When the leprosy hospital was founded on Makogai in 1911 the Government had extreme difficulty in recruiting nurSing staff. Eventually the Roman Catholic Bishop was approached and, as a result, the Missionary Sisters of the Society of Mary voluntee:-.-ed to staff the hospital. They have been there ever since and, ~n addition to the general nursing in the hospital wards, they assist the Medical Superintendent in a host of ways. For example, the Sisters train a number of patients as nurses and dressers; they
WP/RC14/TD7 page 2
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carry out dispensing and laboratory work, give anaesthetics and assist at operations; they run the X-ray and Physiotherapy Departments and supervise occupational therap~; they control the medical records and deal with the more medical aspects of the clerical work; they control the issue of rations, the hospital kitchen and the hospital laundry; they run the patients' co-operative store and operate the hospital cinema.
up to 31st December 1962, 3939 patients had passed through the Fiji Leprosy Hospital and on that date there were 243 patients still on Makogai. This number has fluctuated since the first 40 patients were carried ashore from Beqa in 1911. Thus at the end of 1912 the number was 154, rising to 219 in 1914 and to 352 by the end of 1919. For the next few years, however, a number of Indians who had improved under treatment were repatriated at their own request and it was not until 1926 that the 300 mark was again reached. Neighbouring Administrations began to realise that the Fiji Government was seriously and, on the whole, success:fUlJ..y tackling the problem of leprosy and, fram 1920 onwards, discussions took place regarding the possibility of Fiji's undertaking the treatment of patients from other island groups. The first few Samoans were admitted in 1922 and in 1925 twenty patients were transferred fram isolation in New Zealand. Cook Islanders were first adm1 tted in 1926 and Tongans the following year, by which time the number of patients had increased to 438. Gilbert Islanders arrived in 1935 and the total number of patients rose to 575. Thereafter, in spite of occasional fluctuations due to discharges and deaths, the number of patients rose steadily until 1951 when it reached a maximum of 744. Sulphone treatment had been introduced in 1948 and its success was becoming so apparent by that time that the Government felt justified late in 1951 in reducing the period of surveillance of inactive cases at Makogai fram two years to on~with a consequent sudden decrease in numbers to 668. Since then, the continual decrease in numbers has been maintained as a result of the greatly increased rate of arrest of the disease until the present figure has been reached. Indications in 1963 are that the number of patients is continuing to decline. So successfUl, indeed, has modern therapy proved that the Government of Fiji is now turning to domiciliary treatment of leprosy and it is likely, therefore, that the Fiji Leprosy Ho~ital will be removed fram Makogai in the next few years and established in a smaller form near to Suva, where it will be used only for those patients too ill to be treated as out-patients and for the assessment of newly discovered cases.
WP/RC14/rwr page
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3. 3.1 Incidence
PATTERN OF LEPROSY IN FIJI
B,y 1916, five years after the foundation of the Fiji Leprosy Hospital, sufficient admissions had been made for the Medical Superintendent to estimate that the leprosy rate among Fijians was 0.32 per thousand of the population and among Indians 0.84. The latter figure is of interest when one realizes that the Indian immigrants had been carefully screened both before leaving India and after arrival in Fiji. One can only assume that this comparatively high rate must have been due to the herding together of the indentured workers in labour lines combined with their coming into contact for the first time with the Fiji strain of M. leprae. was
This incidence rate fell slowly over the years until by 1950 it 0.13 among Fijians and 0.24 per thousand among Indians. This marked reduction before the widespread introduction of specific treatment is potent argument for the efficacy of segregation in the prevention of the spread of leprosy. The rate in 1960 was the same for both races, being 0.13 per thousand.
The more rapid decrease of incidence among the Indians as compared to the Fijians may be due to their more rapid improvement in social and educational conditions since 1911, but is perhaps more likely to be due to the fact that Indians tend to 11ve in small groups on isolated farms whereas Fijians live a close cOIlDIIWlB.l life in villages.
3.2
Distribution
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The distribution of leprosy in Fiji appears to depend exclusively on the distribution of population. Maps of distribution for the fiveyear periods 1929-1933, 1934-1938 (Austin) and 1955-1960 (Beckett) differ in no marked degree from one another, or from one prepared to show all cases admitted since the inauguration of the hospital in 1911, and offer no support to the suggestion that leprosy is more prevalent in areas of higher rainfall and humidity. Viti Levu has a dry side and a wet side - western and eastern, respectively - but there is no discrepancy between the distribution on the two sides that cannot be explained in ter.ms of relative population. The fact that the distribution among the two main ra.ces is now the same is also of interest in so far as the socia.l structure, diet, housing conditions, physique and demographic history of the Indian and Fijian peoples are entirely different. In fact, about the only factor which is common to both is overcrowding in the home.
3.3
Sex
Throughout the history of Makogai the ratio of males to females has been about three to one. This is about the usual proportion.
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Judging from the school roll taken at random over many years, the average number of children under the age of fourteen at Makogai at any time is about ten per cent of the total number of patients. However, the statistics of admissions show that about twenty per cent of the total annual intake falls into this group. This would seem to indicate that children are diagnosed earlier than adults and get better more qui ckly •
3.5
Type of disease
Over the last five years, the number of cases of tuberculoid leprosy admitted to hospital has been 48.2 per cent of the total. In 1947 it was 30 per cent so the ratio of tuberculoid cases appears to be rising and this probably indicates an increasing degree of inherent resistance among the people of Fiji. In 1961, however, there were actually 3.28 cases of lepromatous leprosy in hospital for every one of tuberculoid. This would seem to indicate very strongly how InUch better the outlook is for tuberculoid cases and howInUch more rapidly they can expect to be cured and discharged fram hospital.
3.6
Conclusion
Thanks largely to efficient segregation of patients and, in the last decade, to specific therapy, the problem of leprosy in Fiji has never been allowed to get out of hand. A steady decline in the incidence has now made it both unnecessary and uneconomical to continue with the policy of rigid isolation and more and more patients are being per.mitted to receive treatment at home. With the exception of the actual hospital, there has never been a separate leprosy control service in Fiji and the degree of control achieved has been obtained within the general public health service. Now that domiciliary care is to become the main method of dealing with the disease this too will be integrated with the general health programme of the country.
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4.
THE PUBLIC HEALTH SERVICE
The Public Health Service in Fiji is under the overall direction of the Director of Medical Services with a Deputy Director of Medical Services in charge of the day-to-day running of the Medical Department. The actual public health aspect of the Department's activities is under the care of the Assistant Director of Medical Services (Health). Fiji is divided into four administrative divisions each under the care of a Divisional Medical Officer. These came under the Assistant Director of Medical Services (Health). Each division is divided
WP/RC14/TD7 page 5
into smaller districts many of which have a smaller district hospital and each district has a varying number of rural dispensaries. The Fiji School of Medicine in Suva trains assistant medical officers who are nowadays of a standard approximating that of University graduated doctors. Each district hospital is under the care of a fairly senior assistant medical officer and the more junior ones staff the rural dispensaries. Each ~sistant medical officer is expected to tour his district frequently and get to know the people. He institutes and supervises public health and sanitary measures and carries out a good deal of health education. The system of assistant medical officer has enabled Government to scatter medical stations with a highly trained and highly skilled staff widely throughout the Colony, so that all but the most isolated and small islands have adequate clinical skill within fairly easy reach. So diagnosis of new cases and the treatment of known cases presents no problem. Central control by means of a Central Leprosy Registr,y and a Consultant Leprologist ensures that known cases are not lost, and variations in treatment from a standard routine can be dealt with. New cases are likely to be diagnosed reasonably early because of' two things: 1. In many places the population looked after by an assistant medical officer is small. This is mainly because of the fact that a number of assistant medical officers are posted on small islands, and in these circumstances he comes to know allnost the whole of his population. This does not, of course, apply to anything like the same extent on the two larger islands. 2. When a new patient is diagnosed, all his contacts (the definition of a contact being someone who regularly sleeps in the same house as the patient) are examined ever,y six months for a period of five years - and the results of these examinations are sent to the Central Regist~. Thus control can be exerted to ensure that the examination of contacts is not overlooked. A BCG campaign has been undertaken in Fij i-all the children under 21 were Heaf tested and BCG vaccinated where necessary. This is being continued by vaccinating the newly born in many areas, and it is hoped to extend this to cover the whole Colony shortly. Admittedly this has been done mainly with tuberculosis in view, but it may have an effect in increasing resistance of susceptibles to leprosy.
5.
THE ROLE OF THE PUBLIC HEALTH SERVICE IN THE CONTROL OF LEPROSY IN FIJI
The main aspects of the control of leprosy are the finding of cases in an early stage of the disease, the following up of discharged patients to ensure that they do not relapse and the supervision of
WP/RC14/TD7 page 6 patients who are on treatment. or at home. The last may be done in the hospital
Isolation as a means of controlling leprosy is obviously ideal provided that (a) the case is diagnosed early enough and (b) there are not so many cases that it is impossible to isolate them all. However, when treatment becomes effective enough and the number of cases becomes small enough to give each of them something approaching individual attention, then isolation, though still effective, becomes no longer vital. Fiji is reaching that stage now. In order, therefore, to permit patients to be treated at home when considered desirable by the Director of Medical Services, legislation was enacted in 1960. This was the "Lepers (Conditional Discharge) Regulations 1960", which empowered the Director of Medical Services to permit leprosy patients to be discharged fram hospital and treated at home, subj ect to their agreeing to comply with various elementary rules of hygiene and to remain in the place of domicile appointed by the Director of Medical Services. This, of course, would normally be their hame, but the regulation was necessary to prevent patients wandering all over the country and contact being lost with them by the public nealth authorities. These patients had also to agree to abstain from certain trades which brought them into frequent and close contact with other people. As previously explained, over the course of years, a simple and effective system has been evolved by the Public Health Service for the examination of contacts and for the follow-up of discharged patients. The domiciliary care of active cases is now being fitted into the same pattern.
With regard to the follow-up of discharged patients, we have evolved what is known as the "Makogai Sandwich". This consists of a thick piece of cardboard with eight holes in it sandwiched between two sheets of paper. A 100 mg. tablet of DDS nestles in each hole. The sandwich measures about three inches by an inch and a half (10 x 4 ems.) and is attached to a numbered form. When patients are discharged from hospital details of their proposed place of dom.lcile are taken and they are instructed to visit their local rural dispensary every month. The detailed address is then forwarded to the Medical Registry whiCh passes the information on to the appropriate doctor together with a supply of Makogai sandwiches. Each time the patient visits the doctor, he is given a sandwich and instructed to poke a stick through one of the holes in it every Monday and Thursday and to swallow the tablet that pops out. The form is then torn off and returned to the Medical Registry with the patient's name, address and condition and the date of issue of the sandwich entered on it. In this way we ensure that all ex-patients receive a maintenance dose of sulphone and we have a foolproof system of checking on how often they are seen. After a year they are seen o~ every three months and, of course, given three sandwiches on each occasion. After three years, they are seen every six months and, after five years, annually.
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WP/RC14/TD7 page 7 Maintenance dosage of DDS is only enforced for three years but patients are informed that after this time they may continue with it if they so desire and a great many of them elect to do so indefinitely. Under this regimen, there have been 86 cases of relapse of the disease among discharged patients since 1950 which can be taken as the beginning of sulphone therapy as routine treatment. During the same period, there were 958 discharges which gives a relapse rate of 8.9 per cent. When one considers that many of these cases were first dis'charged in the pre-sulphone ds\ys and had never had sulphone therapy prior to their relapse, the rate is g,ui t e creditably low. So far as domiciliary treatment of active cases of leprosy is concerned, we in Fiji are feeling our way with some care. At the time of writing (June 1963), there are only nine such cases being treated at home and-two of them are non-infectious tuberculoid cases who live in Suva and are under the direct supervision of the leprologist. The other seven constitute a preliminary trial of the new procedure and it is proposed to discharge a fUrther ~ive patients in the near future. To start with, at any rate, the criteria ~or such conditional discharge from hospital are ~airly stringent. They are as follO'W"s: (a) the patient's leprosy should be inactive or nearly so (this is not to be confused with being bacteriologically negative); he must not be in need o~ continuous care and attention for any concomitant condition (e.g., trophic plantar ulcer); his leprosy should not be patently infectious (we interpret patent infectiousness as having a bacteriological index of over 3+ on the Ridley scale) .; he should be able to visit his nearest govermnent station at monthly intervals (i.e., he must live in an accessible region) •
(b)
(c) '>
(d)
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It may be possible to lessen the stringency o~ these criteria at a later date but it was thought better not to have too many active cases of leprosy around until the public became accustomed to the idea and the Medical Department was able to assess how the Public Health Service was absorbing them.
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As already stated, these patients are obliged by law to obey certain conditions upon their discharge. A copy of these regulations is given to them upon their leaving hasp! tal and, iii. order to bring home to them the 1m;portance of obeying them, the patients are asked to sign a statement to the effect that they have read them and appreciate that if they do not obey them they may be ~orcibly returned to Makogai. They are also given a cyclostyled copy o~ simple health regulations.
WP/RC14/TD7 page 8 will be seen, it is not envisaged that any doctor in Fiji will have to look after a severely ill case of leprosy at home. All patients will be admitted to hospital in the first instance for assessment, stabilization on treatment and indoctrination with the importance of taking their drugs and preventing the spread of disease. Only when they can satisfy the medical authorities that they can comply with the various conditions outlined above will they be discharged to domiciliary care. The duties of the district medical officer will then consist of seeing that they take their drugs, that they have regular clinical examinations, including skin scrapings, that they obey the simple rules of public health that they have been taught and dealing with any relapse or lepra reaction that may occur. As
Only one standard treatment is being used for administrative case and that is DDS 100 mg. (one tab) daily although this may be reduced
occasionally in the case of children. The patient is directed to his nearest rural dispensary to collect his tablets each month and the doctor issues him with the exact number of tablets necessary to last him until his next appointment as this serves to remind him when the visit is due. This date is entered in his diary by the doctor and, should the patient not attend, a visit is made to his home. Should the excuse be inadequate, a report is submitted through the Divisional Medical Officer to the Medical Registry. Every third month the patient is directed to his divisional or district hospital where a clinical examination is performed, a skin scraping taken and a brief report on his condition is thereafter submitted to the Medical Registry with a copy to the leprologist. Family and household contacts are followed up in the usual manner. Mild relapses and lepra reactions may be treated at home by reduction of the dose of DDS (for example, to every second day) and administration of antihistamines or chloroquine. Should the lepra reaction be so severe that it does not respond to this line of therapy or if the reactions are frequent or if the patient seems to be steadily deteriorating, he is re-admitted temporarily to hospital. Treatment ct severe l~rosy or acute exacerbations thereof is a time-consuming and difficult business and it is fair on neither the doctor nor the patient to attempt to undertake it at home. Thus the key to leprosy control in Fiji is the assistant medical officer on the district who treats the known cases, diagnoses the new cases, examines contacts and supervises the cases on domiciliary treatment as part of his normal clinical and public health job. More and more it is proposed to make assistant medical officers in rural areas leaders of a medical team that will fulfill most of the criteria laid down by WHO for rural health services, and the control of leprosy will simply form part of his job. It may be of interest to record that one of us (DWB) was instrumental in having a scheme on much the same lines introduced in Western Samoa in 1962 and another very similar programme has recently been commenced in the British Solamon Islands Protectorate
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WP/RC14/TIf( page 9 .
by the Director of Medical Services, Dr. J.. Il. MacGregor. It is appreciated that such schemes are on~ feasible in countries where leprosy is not an overwhelming problem and where there is a reasonably satisfactory public health service. However, in Fiji at any rate, we feel that it should work and, in fact, our small pilot scheme is already working well although it is, of course, still too early to assess its influence on the overall incidence of leprosy in the Colony. We are grateful to Dr. C. H. Gurd, Director of Medical Services, Fiji, for permission to publish this paper.