title: Visceral leishmaniasis diagnosis and reporting delays as an obstacle to timely response actions in Nepal and India.
abstract: BACKGROUND
  To eliminate visceral leishmaniasis (VL) in India and Nepal, challenges of VL diagnosis, treatment and reporting need to be identified. Recent data indicate that VL is underreported and patients face delays when seeking treatment. Moreover, VL surveillance data might not reach health authorities on time. This study quantifies delays for VL diagnosis and treatment, and analyses the duration of VL reporting from district to central health authorities in India and Nepal.
  
  
  METHODS
  A cross-sectional study conducted in 12 districts of Terai region, Nepal, and 9 districts of Bihar State, India, in 2012. Patients were interviewed in hospitals or at home using a structured questionnaire, health managers were interviewed at their work place using a semi-structured questionnaire and in-depth interviews were conducted with central level health managers. Reporting formats were evaluated. Data was analyzed using two-tailed Mann-Whitney U or Fisher's exact test.
  
  
  RESULTS
  92 VL patients having experienced 103 VL episodes and 49 district health managers were interviewed. Patients waited in Nepal 30 days (CI 18-42) before seeking health care, 3.75 times longer than in Bihar (8d; CI 4-12). Conversely, the lag time from seeking health care to receiving a VL diagnosis was 3.6x longer in Bihar (90d; CI 68-113) compared to Nepal (25d; CI 13-38). The time span between diagnosis and treatment was short in both countries. VL reporting time was in Nepal 19 days for sentinel sites and 76 days for "District Public Health Offices (DPHOs)". In Bihar it was 28 days for "District Malaria Offices". In Nepal, 73% of health managers entered data into computers compared to 16% in Bihar. In both countries reporting was mainly paper based and standardized formats were rarely used.
  
  
  CONCLUSIONS
  To decrease the delay between onset of symptoms and getting a proper diagnosis and treatment the approaches in the two countries vary: In Nepal health education for seeking early treatment are needed while in Bihar the use of private and non-formal practitioners has to be discouraged. Reinforcement of VL sentinel reporting in Bihar, reorganization of DPHOs in Nepal, introduction of standardized reporting formats and electronic reporting should be conducted in both countries.
authors: Centre for Biological Threats and Special Pathogens, Robert Koch-Institute, Nordufer 20, Berlin, 13353, Germany. boettcherJ@rki.de.
authors: Jan P
authors: JP
authors: Boettcher
authors: Valley College of Technical Sciences, Purbanchal University, Maharajgunj, Kathmandu, 44600, Nepal. mryubaraj2007@yahoo.com.
authors: Yubaraj
authors: Y
authors: Siwakoti
authors: Clinical and Molecular Oncology, Max Delbrück Centrum für Molekulare Medizin, Berlin-Buch, Germany. ana.milojkovic@charite.de.
authors: Ana
authors: A
authors: Milojkovic
authors: Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, India. niyamatalisiddiqui@yahoo.com.
authors: Niyamat A
authors: NA
authors: Siddiqui
authors: Public Health and Infectious Disease Research Center, New Baneshwor, Kathmandu, Nepal. ckgurung@yahoo.com.
authors: Chitra K
authors: CK
authors: Gurung
authors: BP Koirala Institute of Health Sciences, Dharan, Nepal. sumanrijal2@yahoo.com.
authors: Suman
authors: S
authors: Rijal
authors: Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, India. drpradeep.das@gmail.com.
authors: Pradeep
authors: P
authors: Das
authors: Special Programme for Research and Training in Tropical Diseases WHO-TDR, Geneva, Switzerland. kroegera@who.int.|Freiburg University Medical Centre, Zentrum für Medizin und Gesundheit, Freiburg, Germany. kroegera@who.int.
authors: Axel
authors: A
authors: Kroeger
authors: Central Department of Microbiology, Tribhuvan University, Kirtipur, Kathmandu, Nepal. banjaramr@gmail.com.
authors: Megha R
authors: MR
authors: Banjara
mesh_terms: D000328:Adult; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D018563:Disease Notification / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D006301:Health Services Needs and Demand; D006801:Humans; D007194:India / Q000453:epidemiology; D007898:Leishmaniasis, Visceral / Q000175:diagnosis* / Q000453:epidemiology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009390:Nepal / Q000453:epidemiology; D061665:Time-to-Treatment / Q000458:organization & administration / Q000706:statistics & numerical data*; D014850:Waiting Lists
references: PLoS Negl Trop Dis. 2008;2(10):e313
references: 18958165
references: PLoS Negl Trop Dis. 2010;4(2):e599
references: 20161727
references: PLoS Negl Trop Dis. 2011;5(2):e960
references: 21347452
references: Nat Rev Microbiol. 2007 Nov;5(11):873-82
references: 17938629
references: Trop Med Int Health. 2012 May;17(5):666-73
references: 22385129
references: PLoS Negl Trop Dis. 2009;3(1):e355
references: 19159009
references: Trop Med Int Health. 2013 Jun;18(6):725-33
references: 23464638
references: Trop Med Int Health. 2010 Jul;15 Suppl 2:36-41
references: 20591080
references: J Trop Med. 2012;2012:126093
references: 22649459
references: PLoS Negl Trop Dis. 2010;4(10). pii: e832. doi: 10.1371/journal.pntd.0000832
references: 20957193
references: Lancet Infect Dis. 2011 Apr;11(4):322-5
references: 21453873
references: Natl Med J India. 2012 Mar-Apr;25(2):85-9
references: 22686715
references: BMJ. 2006 Oct 7;333(7571):723
references: 16882683
references: Southeast Asian J Trop Med Public Health. 2010 Jan;41(1):1-12
references: 20578475
references: Am J Trop Med Hyg. 2010 Sep;83(3):507-11
references: 20810811
references: Mem Inst Oswaldo Cruz. 2012 Aug;107(5):609-20
references: 22850951
references: Trop Med Int Health. 2006 Jun;11(6):899-905
references: 16772012
references: J Vector Borne Dis. 2008 Jun;45(2):105-11
references: 18592839
references: Womens Health Issues. 2011 Jan-Feb;21(1):12-8
references: 21185987
references: Geospat Health. 2012 May;6(2):177-93
references: 22639120