KATHMANDU, JANUARY 4 When unusual illnesses strike a village, it's often teachers who notice students falling sick in clusters. When livestock die unexpectedly, community health volunteers hear about it first. Now, the government wants to turn these everyday observers into Nepal's frontline defense against disease outbreaks. Health Minister Dr. Sudha Sharma Gautam launched the Community-Based Disease Surveillance System last week, along with a new directive that formally enlists community members, from Female Community Health Volunteers (FCHVs) to elected representatives, as key informants in detecting and reporting public health threats before they spiral out of control. The initiative comes as climate change and emerging infectious diseases pose growing risks to public health, particularly in remote areas where formal health infrastructure remains limited. 'This directive will play a crucial role in early identification and control of diseases at the community level, considering the increasing challenges of climate change and new infectious diseases,' the Ministry of Health and Population said in announcing the Community-Based Disease Surveillance Guidelines, 2082. From the community up, not the hospital down The new system flips traditional disease surveillance on its head. Rather than waiting for patients to arrive at health facilities, often after diseases have already spread, the government is betting on early detection by people living in communities themselves. Under the directive, issued under the Public Health Service Act, 2075, anyone who notices unusual health patterns can report them directly to nearby health facilities or through the government's toll-free Hello Health 1115 hotline. The system specifically targets unexpected public health events, unusual disease clusters and priority infectious diseases that could signal emerging outbreaks. What counts as reportable? If several people fall ill at once, if a new disease appears, if there's an unusual pattern of animal deaths, or if common symptoms like fever, diarrhea or respiratory problems suddenly spike across a community, those are red flags that warrant immediate reporting. The ministry emphasized that timely information from communities will enable rapid response to prevent potential epidemics and save lives and property. Why now? Nepal has learned hard lessons about delayed outbreak detection. COVID-19 exposed gaps in the country's ability to identify and respond to emerging threats quickly, particularly in areas far from major hospitals. But recent outbreaks have made the need for community-level surveillance impossible to ignore. Last August, a cholera outbreak in Birgunj caught authorities off guard. Health facilities reported a sudden surge in acute watery diarrhea, over 600 cases within days, eventually hospitalizing 851 patients across the Parsa district. The source remained unclear even after water testing. By the time hospitals recognized the pattern, the disease had already spread widely through the community. The cholera outbreak wasn't isolated. By late September, dengue had reached 4,814 cases across nearly all districts, while Japanese Encephalitis claimed 23 lives from 118 confirmed infections. In Chitwan, 246 scrub typhus cases were reported in October, part of a resurgence linked to climate change and environmental shifts following the 2015 earthquake. Similarly, dengue and scrub typhus were circulating simultaneously, with many fever patients diagnosed with both infections, complicating treatment and increasing risks. These overlapping outbreaks revealed a pattern: communities often knew something was wrong-people falling sick in clusters, unusual symptoms appearing-but lacked clear channels to report concerns before outbreaks escalated. The new directive is designed to close that gap. Operating under the International Health Regulations (IHR) 2005, which require Nepal to promptly detect, report and respond to health threats with potential national and international implications, the system acknowledges a reality health officials have long recognized: in a country as geographically diverse as Nepal, formal health systems can't be everywhere at once. 'The effective implementation of this system will minimize the potential outbreak of infectious diseases,' the Epidemiology and Disease Control Division (EDCD) noted. The launch event brought together high-level officials from the ministry and department, health secretaries and directors from all seven provinces, representatives from the National Federation of Rural Municipalities, and partner organizations, a show of coordination that past outbreak responses often lacked. How it works: 24 hours to report, digital systems to track Speed matters when dealing with infectious diseases. The directive requires health workers to report priority disease syndromes and cases within 24 hours of detection. Even unusual spikes in patient numbers must be logged as outbreak 'events.' All reports feed into two digital platforms. The Surveillance Outbreak Response Management and Analysis System (SORMAS) captures unexpected events and outbreak data, while the Early Warning and Reporting System (EWARS) handles routine disease reporting. Together, they create a real-time monitoring network that spans federal, provincial, and local levels. Importantly, health facilities must submit 'zero reports' even when no cases are detected, ensuring the system stays active and complete surveillance data flows continuously. Three-tier alert system Not every cough or fever requires a national response. The directive establishes a risk classification system that determines who responds and how quickly. Low-risk events stay at the local level, where community health workers and local government can manage them. Medium-risk events trigger joint responses from local authorities working with district or provincial rapid response teams. High-risk events-those with epidemic potential-activate coordinated response across all three tiers of government. Real-time alerts through SORMAS ensure rapid mobilization when needed, with response teams deployed based on the severity of the threat. Who does what The directive clearly defines responsibilities across government levels, ending previous confusion about who leads outbreak response. At the federal level, the Department of Health Services and EDCD coordinate overall policy, provide technical guidance, handle international reporting, and oversee the entire system. Provincial health directorates manage data analysis, offer technical support, and coordinate between districts. Local governments handle the critical first-response work-mobilizing communities, entering data, analyzing local trends, and taking immediate action. Health facilities themselves are held accountable for timely reporting, verification, and coordination with rapid response teams. To institutionalize the system, steering and technical committees at federal, provincial, district and local levels will oversee implementation, resource mobilization and monitoring. Building capacity from the ground up Technology alone won't make the system work. The government plans extensive training and orientation programs for health workers on disease case definitions, reporting protocols and digital systems. Community-level awareness campaigns will educate the public about symptoms, reporting channels and why early notification matters. The directive places strong emphasis on risk communication, using mass media, social media and local networks to keep communities informed and engaged. The goal is to ensure that when something unusual happens, people know what to look for and where to report it. The ministry stressed that citizens should immediately call the free Hello Health 1115 hotline or inform nearby health facilities if they observe any unexpected public health events in their communities. Flexibility built in Disease threats evolve. New pathogens emerge, climate patterns shift, and yesterday's priority diseases may not be tomorrow's biggest risks. The directive allows for future amendments based on scientific evidence and emerging threats, ensuring Nepal's surveillance framework can adapt. While the directive lists high-risk infectious diseases published in the Nepal Gazette as surveillance priorities, it also mandates monitoring any unusual or unexplained public health events-catching threats even before they're officially classified. A major shift in outbreak preparedness Health officials say the new system represents a fundamental change in how Nepal approaches disease surveillance and outbreak prevention. By shifting focus from facility-based detection to community-driven early warning, the government aims to reduce response time, limit disease spread and protect public health more effectively. The directive acknowledges that in remote and underserved areas-where health infrastructure is thin and geographic barriers are real-community members are often the first to know when something's wrong. Making them official partners in disease surveillance isn't just good policy; it's practical necessity. Whether the system lives up to its promise will depend on consistent implementation, adequate resources for training and technology, and, most critically, whether communities actually report what they see. But for now, Nepal has taken a concrete step toward ensuring that the next outbreak doesn't catch the country off guard.