RESEARCH Figure 4. Hansen disease prevalence as cases per 10,000 population, Federated States of Micronesia (FSM) and Republic of the Marshall Islands (RMI) 1991–2005 (1,2,13). 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. This study has several limitations. Hawaii did not report to the NHDP system until the late 1990s. 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. The increase in case reports since 2004 could reﬂect this requirement. 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 Figure 5. Hansen disease cases per 100,000 population, Federated States of Micronesia (FSM) and Republic of the Marshall Islands (RMI) (1,2,13), 1990–2008. 1206 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 7, July 2011