Major Strategies of Nepal's Ministry of Health to Eliminate Kala-Azar (Visceral Leishmaniasis)

Background and Elimination Goal

The 5 Core Elimination Strategies

1. Early Diagnosis and Complete Case Management

• Rapid Diagnostic Tests (RDT): The rK39 rapid diagnostic test was scaled up to peripheral health facilities, enabling diagnosis without referral to higher centres.
• First-line treatment shift to Liposomal Amphotericin B (L-AmB): The Revised National Guidelines (2019) replaced miltefosine with L-AmB as the first-line treatment for primary kala-azar. L-AmB is donated through WHO and requires only a single-dose or short-course regimen, improving completion rates.
• Management of PKDL (Post-Kala-Azar Dermal Leishmaniasis): PKDL patients act as a parasite reservoir. Guidelines now mandate active detection and treatment of PKDL using miltefosine (12-16 weeks) to break the transmission cycle.
• HIV-VL co-infection management: The 2019 revised guidelines specifically address HIV-VL co-infection, a growing complication that complicates treatment response.
• Inclusion of Cutaneous Leishmaniasis (CL) and Mucocutaneous Leishmaniasis (MCL): Both forms are now notifiable and included in the national programme, as their increasing prevalence threatens overall elimination.
• Passive Case Detection (PCD): All suspected cases presenting to health facilities are tested and notified under a standardized reporting system.

2. Integrated Vector Management (IVM) and Vector Surveillance

• Indoor Residual Spraying (IRS): IRS with DDT (historically) and synthetic pyrethroids has been the mainstay of vector control in endemic districts. IRS activities are ongoing in selected endemic districts.
• Insecticide-Treated Nets (ITNs) and Long-Lasting Insecticidal Nets (LLINs): Distributed to households in high-risk areas.
• Insecticidal Wall Painting (IWP) and Durable Wall Lining (DWL): Research-informed alternatives to IRS - DWL combined with environmental vector management was shown by TDR-funded studies (Banjara et al., Huda et al.) to offer long-lasting vector control, and has been integrated into the national strategy.
• Vector surveillance: Entomological monitoring to track insecticide resistance and sandfly density.
• Environmental management: Addressing housing conditions (mud walls, dark humid interiors) identified as risk factors for VL transmission.

3. Effective Disease Surveillance (Passive and Active Case Detection)

• Passive Case Detection (PCD): All health facilities in endemic districts are equipped to diagnose and report cases using standardized formats.
• Active Case Detection (ACD): Systematic house-to-house searches in high-burden areas and contact tracing around index cases. Research informed cost-effective ACD strategies for Nepal's specific settings.
• DHIS2-based Online Surveillance: The surveillance system was strengthened with online DHIS2-based real-time reporting, replacing paper-based systems and improving data quality and timeliness.
• Expanded geographic surveillance: Originally focused on 12 endemic districts, the programme has been expanded to 18 districts following verified local transmission in previously non-endemic areas, including the mountainous district of Dolpa (which exceeded elimination threshold in 2017).
• Updated surveillance indicators aligned with recent WHO global recommendations.

4. Social Mobilization and Building Partnerships

• IEC/BCC (Information, Education, Communication / Behaviour Change Communication): Community-level awareness campaigns to promote early care-seeking, particularly in rural Terai populations.
• Training and orientation: Capacity-building of frontline health workers (Female Community Health Volunteers - FCHVs) who play a key role in case referral and IRS support.
• Regional collaboration: Active participation in the WHO SEARO Regional Kala-Azar Elimination Initiative involving Bangladesh, India, Nepal, Bhutan, and Sri Lanka - enabling shared protocols, technical guidance, and supply chain coordination.
• International partnerships: Collaboration with WHO, the Bill & Melinda Gates Foundation, DNDi (Drugs for Neglected Diseases initiative), TDR (WHO/UNDP/World Bank Special Programme), and USAID has been central to capacity building and drug procurement (notably L-AmB through WHO donation).
• Symposia and stakeholder engagement to maintain national political commitment.

5. Implementation and Operational Research

• Establishing the burden of VL and characterizing health-seeking behaviour.
• Investigating feasibility of new diagnostics (DAT, rK39, PCR).
• Identifying barriers to early diagnosis and treatment completion.
• Evaluating IRS versus alternative vector control methods.
• Exploring environmental determinants (housing as a VL risk factor).
• Research on miltefosine resistance and noncompliance led to the shift away from miltefosine as first-line treatment.
• Ongoing evaluation of newer drugs like LXE408 (oral agent in trials) to sustain decentralized care as cases become sporadic.

Current Challenges Threatening Elimination

Key Outcomes (as of 2025)

• Over 95% reduction in cases across India-Nepal-Bangladesh since 2007.
• 98% of endemic areas now meeting the elimination target.
• WHO formally recognized the elimination of VL as a public health problem in the South-East Asia region in 2025, marking a historic milestone after 20 years of the regional initiative (DNDi, October 2025).

• EDCD Nepal - Kala-Azar Elimination Program (official government page)
• Joshi et al., 2023 - Impact of Implementation Research on VL Elimination in Nepal (PMID: 37943733)
• National Kala-azar Elimination Program Nepal - EDCD Programme Document
• WHO TDR - Impact of IR on VL in Nepal
• Harrison's Principles of Internal Medicine 22E (2025) - Visceral Leishmaniasis chapter