General Medicine Department, University of Freiburg, Freiburg, Germany.
Central Department of Microbiology, Tribhuvan University, Kathmandu, Nepal.
Trop Med Int Health. 2019 Feb;24(2):192-204. doi: 10.1111/tmi.13189. Epub 2018 Dec 18.
At the time when Nepal is on the verge of reaching the maintenance phase of the Visceral Leishmaniasis (VL) elimination program, the country is facing new challenges. The disease has expanded to 61 of the country's 75 districts including previously non-endemic areas where there is no control or patient management program in place. This study aimed to assess which elements of the surveillance and reporting systems need strengthening to identify cases at an early stage, prevent further transmission and ensure sustained VL elimination.
In a cross-sectional mixed-method study, we collected data from two study populations in VL program and non-program districts. From February to May 2016, structured interviews were conducted with 40 VL patients, and 14 in-depth and semi-structured interviews were conducted with health managers.
The median total delay from onset of symptoms to successful reporting to the Ministry of Health was 68.5 days in the VL-program and 83 days in non-program districts. The difference in patient's delay from the onset of symptoms to seeking health care was 3 days in VL-program and 20 days in non-program districts. The diagnostic delay (38.5 days and 36 days, respectively), treatment delay (1 vs. 1 days) and reporting delay (45 vs. 36 days) were similar in program and non-program districts. The diagnostic delay increased three-fold from 2012, while treatment and reporting delay remained unchanged. The main barriers to surveillance were: (i) lack of access and awareness in non-program districts; (ii) growing private sector not included in and not participating to referral, treatment and reporting; (iii) lack of cooperation and coordination among stakeholders for training and deployment of interventions; (iv) insufficient validation, outreach and process optimisation of the reporting system.
Corrective measures are needed to maintain the achievements of the VL elimination campaign and prevent resurgence of the disease in Nepal. A clear patient referral structure, reinforcement of report notification and validation and direct relay of data by local hospitals and the private sector to the district health offices are needed to ensure prompt treatment and timely and reliable information to facilitate a responsive system of interventions.
在尼泊尔即将进入内脏利什曼病（VL）消除计划维持阶段之际，该国正面临新的挑战。该疾病已蔓延至该国 75 个区中的 61 个区，包括以前没有控制或患者管理计划的非流行区。本研究旨在评估监测和报告系统的哪些要素需要加强，以便及早发现病例，防止进一步传播，并确保持续消除 VL。
在一项横断面混合方法研究中，我们从 VL 计划和非计划地区的两个研究人群中收集数据。2016 年 2 月至 5 月，对 40 名 VL 患者进行了结构化访谈，并对 14 名卫生管理人员进行了深入和半结构化访谈。
从症状发作到成功向卫生部报告的总延迟中位数在 VL 计划区为 68.5 天，在非计划区为 83 天。患者从症状发作到寻求医疗保健的延迟差异在 VL 计划区为 3 天，在非计划区为 20 天。诊断延迟（分别为 38.5 天和 36 天）、治疗延迟（分别为 1 天和 1 天）和报告延迟（分别为 45 天和 36 天）在计划区和非计划区相似。诊断延迟增加了两倍，而治疗和报告延迟保持不变。监测的主要障碍是：（i）非计划区缺乏准入和意识；（ii）不断增长的私营部门未被纳入并参与转诊、治疗和报告；（iii）利益攸关方之间缺乏合作与协调，以进行培训和部署干预措施；（iv）报告系统的验证、推广和流程优化不足。
需要采取纠正措施，以维持 VL 消除运动的成果，并防止该病在尼泊尔死灰复燃。需要建立明确的患者转诊结构，加强报告通知和验证，并由当地医院和私营部门直接向区卫生办公室转达数据，以确保及时治疗和及时可靠的信息，从而促进干预措施的响应系统。
