Effectiveness of population-wide screening and mass drug administration for leprosy control in Kiribati: the COMBINE protocol

Abstract

IntroductionProgress towards leprosy elimination is threatened by increasing incidence in ‘hot-spot’ areas where more effective control strategies are urgently required. In these areas, active case finding and leprosy prevention limited to known contacts is insufficient for control. Population-wide active case-finding together with universal prevention through mass drug administration (MDA) has been shown to be effective in ‘hot-spot’ areas, but is logistically challenging and expensive. Combining leprosy screening and MDA with other population-wide screening activities such as for tuberculosis may increase programme efficiency. There has been limited evaluation of the feasibility and effectiveness of combined screening and MDA interventions. The COMBINE study aims to bridge this knowledge gap.Methods and analysisThis implementation study will assess the feasibility and effectiveness of active leprosy case-finding and treatment, combined with MDA using either single-dose rifampicin or rifamycin-containing tuberculosis preventive or curative treatment, for reducing leprosy incidence in Kiribati. The leprosy programme will run over 2022–2025 in concert with population-wide tuberculosis screening-and-treatment in South Tarawa. The primary research question is to what extent the intervention reduces the annual leprosy new case detection rate (NCDR) in adults and children compared with routine screening and postexposure prophylaxis (PEP) among close contacts (baseline leprosy control activities). Comparisons will be made with (1) the preintervention NCDR separably among adults and children in South Tarawa (before–after study) and (2) the corresponding NCDRs in the rest of the country. Additionally, the postintervention prevalence of leprosy obtained from a survey of a ‘hot-spot’ sub-population will be compared with prevalence documented during the intervention. The intervention will be implemented in collaboration with the Kiribati National Leprosy Programme.Ethics and disseminationApproval has been obtained from the Kiribati Ministry of Health and Medical Services (MHMS), the University of Otago (H22/111) and the University of Sydney (2021/127) Human Research Ethics Committees. Findings will be shared with the MHMS, local communities and internationally through publication.

Single-Dose Rifampicin Leprosy Chemoprophylaxis for Household Contacts in Kiribati: An Audit of a Combined Retrospective and Prospective Approach

“…Defining the limits of significant contact exposure in such environments is very difficult. For this reason, a mass SDR-PEP programme was seen as necessary in addition to the contact tracing, and such a programme has now been commenced as part of a large implementation study combining leprosy treatment and mass chemoprophylaxis with enhanced tuberculosis detection, treatment and chemoprophylaxis [ 15 ]. The need for such an approach is also supported by the persisting high number of child cases and MB disease in children, which are suggestive of ongoing community transmission.…”

Finding and treating both tuberculosis disease and latent infection during population-wide active case finding for tuberculosis elimination

“…Another example aiming to assess the impact of combining ACF and TPT at population level is the PEARL [Pathway to the Elimination of Antibiotic Resistant and Latent Tuberculosis (and also Leprosy) in the Pacific] study conducted in South Tarawa, Kiribati ( 39 , 41 ). In this program, ACF is delivered using the best available combination of technologies (symptoms screening, mobile digital chest radiograph with computer-aided detection and sputum Xpert MTB/RIF Ultra ® on all who can expectorate) along with TPT (using short course regimens) for those who are TST positive.…”