Eliminación de la Lepra

Objectives

The Specific Action Programme for the Elimination of Leprosy 2013-2018 forms part of Mexico’s Sectoral Health Programme and is aligned with the National Development Plan objective of an inclusive Mexico that prioritises health protection, promotion and disease prevention.[1][2]Its overarching purpose is to eliminate leprosy as a public-health problem, interrupt transmission, prevent disability and reduce the social harms of stigma and discrimination.[3][4]Elimination is defined as prevalence below one case per 10,000 inhabitants, with this threshold pursued at municipal level.[5][6]

• Strengthen prevention, epidemiological surveillance, health promotion, timely diagnosis, treatment, laboratory capacity and coordination across institutions, while promoting equitable, rights-based, gender-sensitive and intercultural care.[3][7]
• Identify cases promptly, particularly among household contacts and people with compatible dermatological symptoms, and provide multidrug therapy to cure patients and reduce transmission.[7][8][9]
• Reduce disability through comprehensive care, early detection, rehabilitation, post-treatment surveillance and systematic review of contacts, who are considered the highest-risk group.[10][11][12]
• Address stigma and discrimination through awareness among health professionals, communities and the wider public, supported by health promotion, education and community participation.[4][13][14]
• Consolidate governance of leprosy processes, validate areas free of leprosy as a public-health problem, support operational, clinical and epidemiological research, and disseminate successful community-control experiences.[6][15][16]

The programme builds on national elimination status achieved in 1994, but retains a focus on priority municipalities where prevalence remained above one case per 10,000 inhabitants.[11][12]At the end of 2012, 21 municipalities in 10 states remained priority areas.[17]Strategic targets include reducing annual incidence by 10% from the 2012 baseline of 0.173 new cases per 100,000 inhabitants by 2018, improving cure among multibacillary cases from 62% in 2012 to 80% in 2018, reducing prevalence by 10% from 0.043 existing cases per 10,000 inhabitants, reducing grade 2 disability among new cases to 4.29%, and reaching 80% annual contact-review coverage.[18][19][20][21][22]

Implementation

Implementation uses a standardised, sector-wide model across the National Health System and federal entities, combining primary-care-oriented services, epidemiological surveillance, laboratory support, case management, health promotion and inter-institutional coordination.[3][10][23]The Ministry of Health and state governments oversee compliance with Official Mexican Standard NOM-027-SSA2-2007, which is mandatory for personnel in National Health System medical-care units.[10][24]

• Deliver diagnosis through integrated clinical, bacteriological and epidemiological assessment, using medical judgement where not all diagnostic criteria are present.[25][9]
• Provide first-line multidrug therapy with rifampicin, clofazimine and dapsone through trained personnel, with second-line ofloxacin or minocycline reserved for specified persistent lesions after retreatment and prescribed by specialist staff.[9]
• Investigate household contacts and conduct dermatological review every six months to support early diagnosis before disability develops.[11]
• Maintain post-treatment surveillance for five years for multibacillary cases and two years for paucibacillary cases, including clinical assessment, bacilloscopy, histopathology and contact review.[26]
• Assess disability at the first interview and at least every six months until post-treatment surveillance ends.[5]
• Strengthen bacilloscopy and histopathology through coordination with the Institute of Epidemiological Diagnosis and Reference, establish laboratory networks, and improve information exchange between laboratories and operational health units.[27][28]

Operational delivery involves the Ministry of Health, the National Centre for Preventive Health Programmes and Disease Control, state health services, the Mexican Social Security Institute, the Institute for Social Security and Services for State Workers, Petróleos Mexicanos, the Ministries of Defence and Navy, the National System for Integral Family Development, private providers and other actors through a shared-responsibility matrix.[1][28]Academic institutions, civil-society organisations, communities, local authorities and health personnel are also expected to contribute to education, advocacy, stigma reduction, contact review and community projects.[29][13]

The programme calls for annual inter-institutional training in each federal entity, gender-sensitive comprehensive-care training, supervisory and advisory visits to priority states, active case-finding during consultations and dermatological campaigns, and public information activities including World Leprosy Day.[26][6][30]It also seeks to modernise and consolidate the Automated Leprosy Information System, maintain updated case registers and use routine epidemiological reporting, laboratory data and treatment records for annual measurement of incidence, prevalence, cure, contact-review coverage, supervision, training completion and grade 2 disability.[6][11][19][20][22]

Supervision is planned as 10 advisory and supervisory visits per year, with a six-year target of 60 cumulative visits and 100% coverage.[22]Monitoring and evaluation are intended to strengthen transparency, accountability, policy improvement and budgetary decision-making, with target-achievement information made available through Ministry of Health and related public websites.[16]The material identifies inadequate operating budgets and insufficient dedicated resources for training and supervision as implementation constraints, calls for guaranteed financial resources for technical and operational activities, but does not provide a quantified programme budget or financing allocation.[12]

Monitoring & Evaluation

Monitoring combines epidemiological surveillance, routine case registration, laboratory and clinical follow-up, supervisory review and annual performance indicators. The overarching elimination benchmark is a prevalence of fewer than one registered case per 10,000 inhabitants, assessed nationally, by federal entity and particularly in priority municipalities.[7][12][5]

• Maintain surveillance under Official Mexican Standard NOM-017-SSA2-2012 and the National Epidemiological Surveillance System, supported by surveillance, operational and laboratory manuals.[24]
• Use updated case registers, epidemiological study forms, quarterly reports from federal entities and Directorate-General of Epidemiology data to track incidence, prevalence, new cases, detection setting and priority municipalities.[11][31][17]
• Measure incidence annually against the 2012 baseline of 0.173 new cases per 100,000 inhabitants, with a six-year target of a 10% reduction to 0.1557 by 2018.[18]
• Track prevalence against a 2012 baseline of 0.043 existing cases per 10,000 inhabitants, with a 2018 target of 0.038, also representing a 10% reduction.[20]
• Measure the cure rate among multibacillary cases beginning treatment two years before assessment, increasing from a 62% baseline in 2012 to an 80% target in 2018.[19]
• Monitor annual contact-review coverage, calculated as contacts examined divided by contacts scheduled for review, with targets increasing from 61.3% in 2012 to 80% in 2018.[22]
• Monitor supervision coverage through visits completed relative to programmed visits; the programme specifies 10 advisory and supervisory visits annually, a 2012 baseline of nine visits, and a cumulative target of 60 visits by 2018.[22]
• Reduce grade 2 disability among newly diagnosed cases from a 6.1% baseline in 2012 to 4.29% by 2018.[21][28]
• Monitor completion of planned training events, with a target of 100% annually, based on one national event per year and six cumulative events by 2018.[14][30]

Clinical monitoring includes disability assessment at the first interview and every six months, or earlier where necessary, through to the end of post-treatment surveillance.[5]Post-treatment follow-up lasts five years for multibacillary cases and two years for paucibacillary cases, and includes dermatoneurological examination, bacilloscopy, histopathology and review of contacts.[26]Treatment completion requires clinical and laboratory assessment to classify outcomes, including cure, treatment failure, abandonment or refractory disease.[25]

Household contacts are a principal surveillance priority because they are at greatest risk.[11][12]The programme calls for dermatological examination of contacts every six months, while annual contact review is also used as a programme performance measure.[11][22]Areas reporting no cases are to be assessed to distinguish operational or epidemiological silence from genuinely leprosy-free areas and to verify that essential elimination activities are being delivered.[12][32]

Historical evidence indicates continuing but declining burden. National elimination status, defined by the threshold of fewer than one case per 10,000 inhabitants, had been achieved nationally and in all 32 federal entities, although more than 20 municipalities remained above the threshold.[7]At the end of 2012, 21 municipalities remained above that prevalence level.[12]Incidence declined from 0.417 in 2000 to 0.173 in 2012, while new cases fell from 414 to 196.[33]

Accountability is supported by a shared-responsibility matrix involving federal and state health services, social-security institutions, PEMEX, defence and navy services, the National System for Integral Family Development and other actors.[28]Supervisory and advisory visits are used to assess performance and identify improvements according to state priorities.[6]Monitoring and evaluation are also framed as tools for transparency, performance management, policy improvement and budgetary decision-making, with target-achievement information intended for publication through Ministry of Health, prevention and health-promotion, and disease-control websites.[16]The supplied material does not specify a consolidated reporting timetable, data-quality protocol, independent evaluation method or sanctions for non-performance.[24][31][16]

Costing & Financing

No quantified programme budget, expenditure plan, unit costs, financing allocation, funding-gap estimate or economic assumption is provided in the supplied material.[1][34][28]

• Identify insufficient operating budgets and inadequate dedicated resources for training and supervision in federal entities as implementation constraints.[12]
• Seek guaranteed financial resources for technical and operational programme activities, without stating an amount, source or allocation mechanism.[12]
• Seek funding for operational, clinical and epidemiological leprosy research projects, without quantifying available or required resources.[15]
• Manage ongoing procurement and distribution of comprehensive treatment through the World Health Organization and Pan American Health Organization, without specifying the financial terms or contributing funds.[13]
• Plan training activities with reference to available resources, although no resource level or budget ceiling is specified.[14]