Science and surveillance in the visceral leishmaniasis elimination programme in India.

Early case detection is a pillar of India’s strategy to eliminate visceral leishmaniasis (VL) as a public health problem by 2030. To identify and treat the several thousand VL cases remaining within a population of 150 million people, surveillance must be continuously refined and reinforced. In Bihar, India’s most endemic state, strategising efficient and long-term surveillance requires understanding current and projected costs of active- and passive-case detection (ACD and PCD) alongside the degree to which policy-relevant research is able to inform and adjust elimination activities. This thesis is separated into two research themes. First, the impact of economic analyses on surveillance is reviewed and findings are presented on the costs and outcomes of ACD and PCD activities in Bihar. Bottom-up micro-costing and top-down expenditure analyses compare programme costs, cost per case detected, and the cost to scale-up activities across a heterogeneous landscape of incidence. Districts with medium- or high-incidence might be sufficiently addressed through passive case detection accompanied by less costly index case-based active detection, whereas low-incidence districts might require higher cost house-to-house active surveillance to reduce the risk of resurgence. The second theme explores the extent to which VL modelling research is practically applied within India’s elimination programme. In-depth interviews with decision makers, programme managers, and researchers examine the use and perceived value of incidence predictions, the likelihood of reaching elimination targets, and projected effects of different interventions for informing programme strategy. Decision makers and researchers reported that knowledge utilisation may be impeded by assumptions that 1) models accurately reflect transmission dynamics, 2) modellers apply their analyses to specific programme operations, and 3) there is accountability in the process of translating knowledge to policy. Engaging decision makers in the later stages of the modelling process, especially interpretation, may be crucial to garnering the political support needed to translate knowledge into programme activities. Modelling and economics are critical research disciplines for projecting incidence and programme costs throughout the process of neglected tropical disease elimination. This DrPH thesis examines and contributes to actionable research and its use in policy through the lens of strategising case detection to eliminate VL as a public health problem in India.