demographic and disease - related data were abstracted for january 1990october 
 2009 nhdp surveillance and clinical records of cases that identified 
 patients place of birth as the former trust territory ( marshall islands or 
 micronesia ) . to facilitate global comparison , us cases ( reported by using the 
 ridley - jopling classification system ) 
 were reclassified into the who multibacillary / paucibacillary system ( 12 ) . country - of - origin hd data 
 ( case numbers or rates and age / sex / disease - classification ) were abstracted from who 
 reports ( 1,2,13 ) . country - of - origin demographic data , us census 
 reports , and published reports relevant to migration patterns were abstracted to 
 obtain denominator estimates where possible ( 1417 ) . data were analyzed by using the spss 
 version 16.0 statistical analysis program ( spss inc . , the study 
 was approved by the tulane university institutional review board and exempted from 
 review by the university of arkansas for health sciences institutional review 
 board . the number of hd case - patients of micronesian or marshallese origin as a proportion 
 of all us cases has risen over the past decade , with micronesian and marshallese 
 patients constituting 90 ( 13% ) of all 686 cases in the united states during 
 20042008 ( figure 1 ) ; the total source 
 population of these 2 countries is only 170,000 . new patients of marshallese or micronesian origin with hansen disease , 
 compared with total new us patients with hansen disease , 20002008 . white bars , total us patients ; black bars , total patients of marshallese or 
 micronesian origin ; red line , patients of marshallese or micronesian origin 
 as percentage of total us patients . * data from national hansen s disease program surveillance and clinical 
 records , january 1990october 2009 . mb , multibacillary ; mdt , 
 multidrug therapy ; enl , erythema nodosum leprosum ; rr , reversal reaction ; 
 na , data not available . of 29 micronesian patients , 22 ( 76% ) 
 had multibacillary hd , 5 were female , and 3 were children . of 43 marshallese 
 patients , 31 ( 72% ) had multibacillary hd , 17 ( 17% ) were female , and 1 was a child . cases in hawaii were not consistently reported to nhdp until the late 1990s ; 
 however , bomgaars et al . reported that hd cases in 15 micronesian and 23 marshallese 
 patients were noted there from 1990 through mid-1998 , including the marshallese 
 cluster summarized in table 2 ( 6 ) . * since 1990 , 88 cases have been reported in 26 states of the us mainland ( figures 2 , 3 ) , 66 of these since 2000 . hansen disease in patients of marshallese or micronesian origin , us mainland , 
 by year reported , january 1990october 2009 . states reporting hansen disease in patients of marshallese or micronesian 
 origin , us mainland , january 1990october 2009 . the number of cases 
 reported from each state is indicated . among micronesians , 55 cases occurred in 22 states of the us mainland ( table 1 ) , 41 of these since 2000 . all but 2 
 patients were < 40 years of age , 42 ( 76% ) had multibacillary disease , 10 ( 18% ) 
 were female , and 6 ( 10% ) were children . six patients reported having a previous hd 
 diagnosis in the federated states of micronesia ; 4 of these patients reported having 
 completed the who - recommended 1 year of multidrug therapy ( mdt ) there . of these 
 patients , 14 ( 25% ) originated in chuuk state and 13 ( 24% ) in pohnpei state ; for 28 
 ( 51% ) , the specific federated state was not documented . during the 1990s , 11 of 14 
 us - mainland hd cases were reported in the western coastal states of california , 
 washington , and oregon . since 2000 , a total of 28 of 41 cases were reported in 
 midwestern and southern states ( e.g. , 6 in iowa , 5 each in texas and florida , 3 in 
 missouri ) . before moving to the reporting state , 21 patients had resided in other 
 mainland states ( often in multiple locations ) , 5 in hawaii , and 8 in guam . of the 33 
 patients for whom clinical data were available , 25 ( 76% ) had 
 > 1 complication , including 15 patients with erythema 
 nodosum leprosum ( enl ) and 3 with severe facial involvement ( lagophthalmos , 
 blindness , nasopalatal destruction ) . of the 24 patients for whom pharmacy data were available ( excluding 8 who 
 had recently begun treatment ) , the complete us - recommended mdt course had been 
 dispensed to 10 ( 42% ) ( table 1 ) . of the 33 us mainland marshallese patients since 1990 ( 25 of these since 2000 ) , 
 single cases were reported in 9 states , 2 in california , 5 in washington , and 17 in 
 arkansas . all but 1 patient were < 40 years of age , 25 ( 76% ) had multibacillary 
 disease , 11 ( 33% ) were female , and 3 ( 10% ) were children . three patients reported 
 that their hd had been diagnosed in the marshall islands ; none had completed mdt 
 there . nine patients had resided in other mainland states before moving to the 
 reporting state ; 5 had first lived in hawaii . of the 16 patients for whom clinical 
 data were available , 12 had > 1 complication , including 6 
 patients with enl . of the 22 
 patients for whom pharmacy data were available ( excluding 3 currently being 
 treated ) , the complete us - recommended mdt course had been dispensed to 7 ( 32% ) 
 ( table 1 ) . beginning in 1996 , 17 hd cases have been reported among the 
 8,00010,000 marshallese living in northwestern arkansas , 10 of these 
 since 2004 . all patients were < 40 years of age , 15 ( 88% ) had multibacillary 
 disease , 5 ( 30% ) were female , and none were children . ( two 25-year - old men with 
 multibacillary disease , reported in november 2009 after completion of data 
 collection for this study , are not included in this analysis . ) specific island origin within the 
 marshall islands was not reported ; however , the general arkansas marshallese 
 population is known to come from several different atolls . of the 10 patients for 
 whom clinical data were available , 7 had > 1 complication , 
 including 4 patients with enl . excluding the 2 patients currently being treated , the 
 us - recommended mdt course had been dispensed to 3 ( 20% ) ( table 1 ) . hd prevalence reported in the countries of origin is summarized in figures 4 and figure 5 . because of the epidemiologic characteristics of hd ( e.g. , lack 
 of biomarker , prolonged latency ) , surveillance is generally based on program records 
 rather than population surveys ; prevalence and case - detection rate ( an approximation 
 of incidence ) are highly dependent on operational factors ( figure 5 ) . active case - detection programs were done in the 
 federated states of micronesia in 1996 and 2005 and in the marshall islands in 1996 
 and 19981999 ( 1820 ) . patterns of age / sex / classification 
 distribution differed markedly during these years , with more children and 
 paucibacillary disease being identified than during the usual passive surveillance 
 years ( table 2 ) ; this pattern was also noted 
 in the 1998 marshallese cluster in hawaii . hansen disease prevalence as cases per 10,000 population , federated states of 
 micronesia ( fsm ) and republic of the marshall islands ( rmi ) 19912005 
 ( 1,2,13 ) . hansen disease cases per 100,000 population , federated states of micronesia 
 ( fsm ) and republic of the marshall islands ( rmi ) ( 1,2,13 ) , 19902008 . this study was descriptive ; thus , comparisons among the various population subgroups 
 are not statistically valid because of small numbers , varied data sources , and 
 unknown age / sex distribution and denominators for the overall migrant populations . however , because age and sex distributions for the arkansas , hawaii , and republic of 
 the marshall islands marshallese populations are similar ( 17 ) , some crude comparisons can be made for 
 these groups . unless an unidentified confounder is present , rates and distribution 
 of cases would be expected to be similar in the 3 groups . the arkansas and hawaii marshallese populations were approximately the same size 
 ( 3,000 each ) and age / sex distribution ( median age 20 years , m : f = 1 ) in 
 19982001 ; rough estimates place the current arkansas population at 
 8,00010,000 and hawaii at 6,0008,000 . however , hawaii has identified 
 2.6 more cases since 2000 , more female patients , and more paucibacillary 
 disease and has found disease in children . estimated case detection rates for 
 arkansas marshallese persons are approximately half those for the marshall islands 
 ( figure 6 ) and more skewed toward 
 multibacillary disease , male , and adult patients ( table 1 ) . this arkansas and general us mainland pattern of predominantly 
 multibacillary disease in men does not reflect disease distribution patterns in the 
 countries of origin or in hawaii , suggesting under - detection of child , female , and 
 paucibacillary disease patients rather than a biologic disease pattern ( tables 1 , 2 ) . estimated hansen disease cases per 100,000 population , arkansas marshallese 
 and republic of the marshall islands ( rmi ) , 20002009 . rmi rates from 
 world health organization reports ( 1,2,13 ) ; arkansas cases 
 from national hansen s disease program records . arkansas marshallese 
 population ( denominator ) derived from us census estimates ( 15,17 ) . of 49 mainland patients from both the federated states of micronesia and the marshall 
 islands for whom clinical data were available , 37 ( 75% ) had 
 > 1 complication , such as leprosy reaction , neuropathy , 
 or other tissue involvement ( e.g. , palatal , renal , testicular ) . although this 
 finding could certainly reflect reporting bias , with the most severely affected 
 being more likely to seek care and to be reported , it does indicate the magnitude of 
 the need for treatment resources for this population with limited health care 
 access . the most severe cases of blindness and disfigurement occurred in 
 micronesians living alone or in very small ethnic communities , limiting the 
 potential impact of ethnic - targeted services . the high number of enl cases is of 
 note because these patients may require corticosteroid treatment for many years . the 
 low rates of mdt completion may contribute to poor clinical outcomes and possibly to 
 drug resistance and ongoing transmission . cases in guam and northern marianas and among us military personnel 
 are not reported to the nhdp . reporting is not mandatory in all states but is likely 
 to be fairly complete because of us physicians need for consultation on 
 management of this unfamiliar condition . since the 2004 us food and drug 
 administration designation of clofazimine as an investigational drug , any patients 
 with multibacillary disease are likely to have been reported so they would be able 
 to receive the recommended mdt , although paucibacillary disease may be 
 underreported . measures of adherence and completion of treatment , complications , and other clinical 
 data were available only for mainland patients receiving direct or pharmacy care 
 from the baton rouge nhdp facility . mdt is dispensed directly to active patients or 
 provided to local physicians or health departments for supervision of treatment . although adherence to and completion of treatment are monitored at national program 
 level for hd patients attending clinics funded through contracts with the nhdp , for 
 whom compliance exceeds 90% ( d. scollard , unpub . data ) , this level of follow - up has 
 not been possible with private physicians , who are the providers for all of the 
 marshallese and micronesian patients . in this situation , dispensing of mdt by the 
 nhdp pharmacy was the only treatment measure available ; actual adherence to 
 treatment is unknown but is likely to be much lower and could be a subject for 
 future study . a variety of cultural factors are likely to contribute to the low rate 
 of treatment completion in this group , but evaluation of these cultural issues is 
 beyond the scope of this study since achievement of the global leprosy elimination target of < 1 case per 10,000 
 persons , attention has waned in some regions in which this neglected tropical 
 disease persists . although prevalence in the republic of the marshall islands and 
 the federated states of micronesia fell during the 1990s , rates have remained stable 
 at high levels for the past decade . in these nonindustrialized nations , leprosy 
 receives low priority in relation to more urgent public health concerns ( rising 
 rates of multidrug - resistant tuberculosis , 30% adult prevalence of type 2 diabetes , 
 high infant mortality , and many others ) . under the compacts of free association , 
 since the 1986 independence of the federated states of micronesia and the republic 
 of the marshall islands most health funding to these former territories flows from 
 the united states . assistance with leprosy control in the countries of origin would , 
 in addition to improving health conditions there , be the first step toward 
 preventing importation of cases to the united states . because of the unique status 
 of migrants from these nations to the united states , micronesian and marshallese 
 migrants receive neither the health screening required for immigrants ( which is not 
 effective at preventing importation of hd because of its decades - long incubation 
 period ) nor targeted health services often available to large immigrant or refugee 
 populations . although legally residing in the united states , they remain citizens of 
 their home nations and are thus ineligible for us health programs such as medicare 
 and medicaid , although nhdp services such as biopsy interpretation , mdt , and direct 
 outpatient care at the baton rouge facility are available . many remain uninsured 
 ( > 50% of the arkansas marshallese population ) ( 17 ) . mainland state and local health departments 
 are not typically resourced to serve either this population or this otherwise - rare 
 condition . hawaii receives more than $ 15 million annually in compact impact funds to 
 partially address the multiple health issues of the marshallese and micronesian 
 migrant populations , but these additional us funds have not been available to the 
 mainland states ( 21 ) . with the goal of decreasing health disparity and preventing disability , case - finding 
 and case - management interventions are needed in us - resident marshallese and 
 micronesian communities that are integrated into general health services and avoid 
 the stigma of leprosy - labeled activities . large populations , such as the 
 arkansas marshallese community , may be easier to reach with targeted but 
 nonstigmatizing efforts , as has occurred in hawaii . the small , widely distributed 
 micronesian communities , where the most severe , disabling cases have been 
 identified , may be more difficult to reach .
an increasing proportion of hansen disease cases in the united states occurs 
 among migrants from the micronesian region , where leprosy prevalence is high . we 
 abstracted surveillance and clinical records of the national hansen s 
 disease program to determine geographic , demographic , and clinical patterns . 
 since 2004 , 13% of us cases have occurred in this migrant population . although 
 hawaii reported the most cases , reports have increased in the central and 
 southern states . 
 multibacillary disease in men predominates on the us mainland . 
 of 49 patients for whom 
 clinical data were available , 37 ( 75% ) had leprosy 
 reaction , neuropathy , or other complications ; 17 ( 37% ) of 46 completed 
 treatment . 
 comparison of data from the us mainland with hawaii and 
 country - of - origin suggests under - detection of cases in pediatric and female 
 patients and with paucibacillary disease in the united states . 
 increased case 
 finding and management , and avoidance of leprosy - labeled stigma , is needed for 
 this population .