STRENGTHENING SURVEILLANCE PREPARING NEPAL FOR THE VL POST-ELIMINATION PHASE

Visceral leishmaniasis in on the verge of being eliminated as a public health problem in Nepal. If the elimination initiative is to be successful in the long run, it will be crucial to have a well-functioning surveillance system in place that can identify resurgence early on, to allow for timely actions. The current surveillance system is not well adapted to address the changing needs associated to the declining VL burden, in particular with regard to infectious subgroups that are not captured in the current surveillance system, such as post-kala azar dermal leishmaniasis (PKDL) patients, HIV-VL co-infected patients, and cutaneous leishmaniasis (CL) patients.

Therefore, we will pilot and validate new approaches to strengthen visceral leishmaniasis surveillance at primary healthcare centers in Nepal. All proposed activities will be piloted in Province 1, historically the most VL affected province in Nepal, and carried out by the health staff available within the existing health infrastructure. All Primary Health care Centers (PHCs) will be provided with diagnostic tests for VL (the rK39 Rapid Diagnostic Test – RDT), regardless of their official endemicity status. Tests used as well as the positivity rate will be monitored; high positivity rates will help to identify PHCs with either too low testing rates or possible outbreaks. All new VL diagnoses will be confirmed using molecular methods, in order to monitor the accuracy of the diagnostic algorithm in the current low-prevalence setting in Nepal. In line with the National Guidelines, HIV testing of all VL cases will be strengthened, to bridge the gap of missing HIV information currently present for 80% of VL cases in Nepal. In addition, all VL cases will be followed up for five consecutive years post-treatment to screen both the former VL cases as well as their household members for (relapse) VL, PKDL, CL and leprosy. Household coordinates will be collected to allow for identification of high-incidence clusters warranting intensified disease control measures. Additionally, we will pilot a reporting tool for PKDL and CL to be implemented at the dermatologists’ level, in order to improve surveillance of all leishmania infections in Nepal.

At the end of this study, we expect to have new validated tools for improved VL surveillance in Nepal from a pilot setting in Province 1. All activities will be carried out in close collaboration with national as well as provincial level health authorities, aiming for scaling up of validated activities to other the provinces.