Sentinel Surveillance Model for Vaccine Preventable Childhood Infectious Diseases 15 July 2011 National Centre for Disease Control, Delhi

Background Vaccine Preventable Childhood illnesses are an important cause of under-five mortality There is a need for  Generating actionable data on disease occurrence and trends  Evaluating the effectiveness of VPD control programs/policies  Guiding program decisions Currently there is no reliable system present for the surveillance of VPDs in the country Good quality laboratory confirmed surveillance data can be collected from strategically located sentinel sites to deliver good quality actionable data

Objective To study the magnitude and epidemiology of selected childhood vaccine preventable diseases

Specific Objectives  Disease trends  Seasonality of disease  Age & Gender distribution of cases  Geographic distribution of the cases  Vaccination status for suspected disease  Laboratory data Proportion of lab confirmed cases Confirmation of aetiology To find out prevalent serotypes (e.g. Pneumococcus, H. Influenzae, Meningococcus, etc.) To find out the anti-biogram To stock isolates for future use

Sl. no. Selected DiseasesType of model proposed for surveillance 1.  Measles  Meningitis  Enteric fever Sentinel surveillance model at 30 Medical Colleges or tertiary care hospitals chosen as sentinel sites with the respective 30 District Hospitals linked to them 2.  Japanese EncephalitisThe surveillance for JE should be done through the existing NVBDCP Sentinel sites 3.  DiphtheriaSurveillance data to be collected from identified Infectious Disease Hospitals 4.  Pertussis  Rota virus  Strepto. pneumoniae  Hemophilus influenzae -B (HiB) Data for surveillance to be collected in a research mode from a few designated centers Types of models for surveillance of selected diseases

Models for sentinel surveillance of selected diseases 1. Sentinel surveillance model for Measles, Meningitis and Enteric fever at 30 Sentinel Sites 2. Surveillance for JE through the existing NVBDCP Sentinel sites 3. Diphtheria Surveillance from identified Infectious Disease Hospitals 4. Surveillance of Pertussis, Rota virus, Strepto. Pneumoniae, H. influenzae -B in a research mode from a few designated centers

Suggested model for Sentinel Surveillance for Measles, Meningitis & Enteric fever at 30 selected sites

Selection of sentinel site  30 Medical institutions (Medical Colleges or other reputed Tertiary care Hospitals) along with attached 30 District Hospitals (thus total 60 data collection sites) have been chosen as sentinel sites  Inclusion criteria for final selection:  Willingness to participate as a sentinel site  Catering to a large number of VPD cases  Functional departments of Paediatrics and Microbiology  Geographic representation  The District Hospital linked with the Sentinel site  Samples to be collected from District Hospital  Chosen district is based on the location of the Sentinel site or where the Sentinel site has its field practice area

Data Flow Sentinel Site (Medical College Hospital / Tertiary Hospital) PSM Dept. District Hospital Pediatrics and Micro Departments SSU, IDSP State Surveillance Unit CSU, IDSP Central Surveillance Unit DSU, IDSP (District Surveillance Unit)

Role of Sentinel Site Paediatric Dept:  Senior paediatric specialist - the nodal officer for the Sentinel site  All doctors to be sensitized regarding Standard Case definition  Treating pediatrician to put IDSP stamp on OPD card Microbiology laboratory facilities:  At the identified Medical Institute level only  Laboratory staff of Sentinel Site to visit District Hospital for sample collection Clinical samples:  Collection at the Centralized Sample Collection Centre/ Paediatric OPD and also from the District Hospital  Sample transportation to Microbiology dept. for laboratory investigation Data collection:  Flexibility given to each Sentinel Site for data collection procedures  Unique ID number linking field data and lab data to be developed before surveillance activities begin

Functioning of the Sentinel Sites Role of the Nodal officer of Sentinel site:  Supervise work of Data Entry Operator (DEO) and also ensure that data are collected when DEO is absent  Plan training of Pediatricians, Microbiologists, DEO and Lab technicians concerned with sentinel surveillance Flexi-funds to Sentinel sites  Honorarium to any person may be considered for coordination for ensuring collection and transfer of data as well as collection and testing of clinical samples  Rs pm would be provided to each department (Paediatrics, Microbiology and PSM) of the Medical Institution, as well as to the attached District Hospital The laboratories of sentinel sites would be provided funds for reagents/ diagnostic kits/ consumables

Role of Data Entry Operator at Sentinel Sites DEO recruitment Post of DEO has been sanctioned at 26 Govt. Medical Institutions under IDSP A new DEO may be appointed/trained for Sentinel surveillance activities at sites where none exists Patients with IDSP stamped card to be referred by the treating clinician to the DEO DEO to fill the Data-register with the data collected from the OPD IPD Lab DEO would transfer data from register to a computer and send it by to DSU, SSU, CSU on weekly basis (Week = Monday to Sunday)

Role of State/District Surveillance Units, IDSP Role of State Surveillance Officer (SSO) at the State level:  Sanctioned funds (for logistics, manpower and procurement) would be released through the concerned SSO  SSO to monitor the expenditure of the sites  Coordinate activities of the sentinel sites in the state Role of concerned District Surveillance Officer (DSO)  Assist Sentinel Site Nodal Officer in data collection and transfer Respective DSU/SSU would utilize the surveillance data for response in conjunction with IDSP data

Role of Central Surveillance Unit (CSU), IDSP in Sentinel Surveillance Overall data compilation and analysis would be done at CSU, IDSP at NCDC Additional manpower to be recruited at CSU:  4 Epidemiologists  1 Lab coordinator  1 Data Manager  2 Data Entry Operators Epidemiologists would coordinate overall functioning of the sentinel sites and would be assisted by the Data Manager and the DEO in the analysis of the data of the entire country Lab coordinator (Microbiologist) at the national level to ensure smooth functioning of the laboratories at all the Sentinel Surveillance sites

Monitoring of Sentinel Site activities Zonal coordinators  One coordinator identified for each zone  Each Zonal coordinator to supervise and monitor five sentinel sites under his/her respective Zone Performance indicators for Sentinel surveillance:  Consistency of reporting of sites per week: >80%  Timeliness of reporting of sites per week: >80% Implementation issues would be reviewed at CSU, IDSP/NCDC involving the nodal persons of sentinel sites after 3 months of initiation of data reporting Review of the pilot project to be done after one year Expansion of sentinel sites and/or disease syndromes may be considered later

List of Sentinel Sites for conducting Sentinel Surveillance for Meningitis, Measles and Enteric fever 1.GB Pant Hosptial, Port Blair 2.Niloufer Hospital, Hyderabad 3.Guwahati Medical College, Guwahati 4.Patna Medical College 5.Government Medical College & Hospital 6.Pt. JN Memorial Medical College, Raipur 7.Kalawati Saran Childrens’ Hospital, Delhi 8.Goa Medical College, Bambolim, Panaji 9.BJ Medical College, Ahmedabad 10.PGIMS, Rohtak 11.Indira Gandhi Medical College, Shimla 12.SKIMS, Srinagar 13.MGM Medical College, Jamshedpur 14.Bangalore Medical College, Bangalore 15.Govt. Med. College, Thiruvananthapuram 16.MGM Medical College, Indore 17.GS Medical college & KEM Hospital, Mumbai 18.JN Hospital, JNIMS, Porompat, Imphal East 19.NEIGRIHMS, Shillong 20.SCB Medical College & Hospital, Cuttack 21.JIPMER, Puducherry 22.Government Medical College, Patiala 23.SMS Hospital, Jaipur 24.ICH & Hospital for Children, Chennai 25.Christian Medical College, Vellore 26.BRD Medical College, Gorakhpur 27.BHU, Varanasi, Uttar Pradesh 28.KGMC (CSMMU UP), Lucknow 29.Govt. Doon Hospital, Dehradun 30.Medical College and Hospital, Kolkata

Types of models for surveillance of selected diseases 1. Sentinel surveillance model for Measles, Meningitis and Enteric fever at 30 Sentinel Sites 2. Surveillance for JE through the existing NVBDCP Sentinel sites 3. Diphtheria Surveillance from identified Infectious Disease Hospitals 4. Surveillance of Pertussis, Rota virus, Strepto. Pneumoniae and H. influenzae -B in a research mode from a few designated centers

Suggested model for Sentinel Surveillance for Acute Encephalitis Syndrome (AES)/ Japanese Encephalitis (JE)

Link with NVBDCP for Sentinel Surveillance of AES/JE The surveillance of AES with special reference to JE cases should be done at the Sentinel Sites identified by NVBDCP in the country National Vector borne Disease Control Programme (NVBDCP) has identified and strengthened the diagnostic facilities at 51 sites for surveillance of AES/JE Existing resources provided by NVBDCP would be adequate for surveillance of JE Data would be collected from the existing system of NVBDCP

Types of models for surveillance of selected diseases 1. Sentinel surveillance model for Measles, Meningitis and Enteric fever at 30 Sentinel Sites 2. Surveillance for JE through the existing NVBDCP Sentinel sites 3. Diphtheria Surveillance from identified Infectious Disease Hospitals 4. Surveillance of Pertussis, Rota virus, Strepto. Pneumoniae and H. influenzae -B in a research mode from a few designated centers

Suggested model for Sentinel Surveillance of Diphtheria at Infectious Disease Hospitals under IDSP

IDH network for Diphtheria Surveillance Surveillance data for Diphtheria cases would be collected from a the identified Infectious Disease Hospitals (IDH) under IDSP  ID Hospital (Ahmedabad)  ID Hospital (Bangalore)  Communicable Disease Hospital (Chennai)  Maharishi Valmiki ID Hospital (Delhi)  Sir Ronald Ross Fever Hospital (Hyderabad)  Beleghata ID Hospital (Kolkata)  Kasturba Hospital (Mumbai) Under IDSP, the ID Hospitals have been strengthened with provision of  ICT network  Recruitment of DEO to enable reporting of data ID Hospitals report simultaneously to District, State and Central Surveillance Units A meeting involving these ID Hospitals would be called for implementing the sentinel surveillance mechanism

Types of models for surveillance of selected diseases 1. Sentinel surveillance model for Measles, Meningitis and Enteric fever at 30 Sentinel Sites 2. Surveillance for JE through the existing NVBDCP Sentinel sites 3. Diphtheria Surveillance from identified Infectious Disease Hospitals 4. Sentinel Surveillance of infection/diseases due to Pertussis, Rota virus, Strepto. pneumoniae and H. influenzae - B in a research mode from a few designated centers

Suggested model for Sentinel Surveillance of Pertussis, Rota virus, Hemophilus influenzae- B and Strepto. Pneumoniae

Sentinel Surveillance in Research mode Surveillance data on infection/diseases due to Pertussis, Rota virus, Streptococcus pneumoniae and Hemophilus influenzae - B would be collected on a research mode from the identified centers:  AIIMS (Delhi)  PGI (Chandigarh)  CMC (Vellore)  NICED (Kolkata)  INCLEN ? Some centers have already generated some data on diseases due to Rota virus and H. influenzae- B infection and these data may be reviewed to arrive at indicative estimates. These centers may be given the responsibility to generate further required data A meeting involving these centers would be called for discussing the implementation strategy

Categories to be filled up in the Register for Sentinel Surveillance ID No. Date of Registration/ Admission Name Age Sex Address Date of onset of illness Major presenting features Clinical Diagnosis Treatment history Vaccination status of related disease  Name of Vaccine  No. of doses given Lab tests  Name of lab test done  Lab diagnosis H/O similar illness in neighborhood Outcome  Recovered/ Died/ LAMA

ID N o. Date of Registr ation/ Admiss ion Nam e AgeSex Addre ss Date of onset of illness Major presenti ng features Clinical Diagnos is Treatme nt history Vaccination status of related disease Lab tests H/O similar illness in neighborhood Outc ome (Rec over ed/Di ed/ LAM A) Name of Vaccine No. of doses given Name of lab test done Lab dia gno sis Format for filling up Register for Sentinel Surveillance

Diagnostic laboratory tests for Diseases under Sentinel Surveillance Sl. No. DiseaseCausative agentsSpecific lab tests 1 Diphtheria, Pertussis Corynebacterium diphtheriaeCulture, toxigenicity testing Bordetella pertussis Culture of naso-pharyngeal aspirate / swab 2 Meningitis / AES Neisseria meningitidisBacterial culture of CSF, blood Japanese Encephalitis virusELISA 3Enteric fever Salmonella enterica Serotype Typhi/ Paratyphi A Culture of blood/stool/urine + serotyping 4 Measles / Rubella Measles virusELISA Rubella virusELISA

Total Budget for Sentinel Surveillance of selected Vaccine Preventable Childhood Infectious Diseases Sl. No. Level of Activity for Sentinel Surveillance Total Average Cost at startup including annual cost for 1st yr. (Rs. in lakhs) Recurring cost per yr. (Rs. in lakhs) 1Central Surveillance Unit (CSU) Zonal coordinators (6 zones)6.0 3 Subtotal annual cost for 30 Sentinel sites for Sentinel Surveillance of Meningitis, Measles and Enteric Fever Subtotal annual cost for 7 ID Hospitals for Surveillance of Diphtheria Subtotal annual cost for 5 Research Institutes for Surveillance of Pertussis, Rota virus, H. influenzae and Strepto. Pneumoniae TOTAL

Budget for Sentinel Surveillance at Zonal levels and Central level Sl. No. Level of Activity for Sentinel Surveillance Total Average Cost at startup including annual cost for 1st yr. (Rs. in lakhs) Recurring cost per yr. (Rs. in lakhs) 1Central Surveillance Unit (CSU), IDSP Zonal coordinators (6) (one at each zone responsible for 5 sentinel sites) 6.0 Subtotal annual cost

Sl. No. Sub-activity Total Avg. Cost at startup including annual cost for 1st yr. (Rs. in lakhs) Recurring cost per yr. (Rs. in lakhs) Per siteFor 30 sites 1Laboratory tests Flexi-fund to each dept (PSM, Pediatrics and Microbiology) and to each linked District Hospital DEO salary (in those sites where DEO is not provided through IDSP consolidated salary of Rs 8500 pm; 5% pa) Miscellaneous: Operational cost including stationeries, printing and communication, Training and Travel to Delhi to attend review meetings, etc Subtotal annual cost Budget for Sentinel Surveillance of Meningitis, Measles and Enteric Fever at 30 identified Sentinel sites

Budget for Diphtheria Surveillance at the seven Infectious Disease Hospitals under IDSP Sl. No. Sub-activity Total Average Cost at startup including annual cost for 1st yr. (Rs. in lakhs) Recurring cost per yr. (Rs. in lakhs) Per ID Hospital For 7 ID Hospitals 1Laboratory tests Flexi-fund to each PSM, Paeds and Micro dept and to each linked District Rs.5000 each DEO salary 8500 pm) Miscellaneous: Operational cost including stationeries and communication, Training and travel Subtotal annual cost

Budget for Surveillance of Pertussis, Rota virus, H. influenzae and Strepto. pneumoniae at five Research Institutes Sl. No. Sub-activity Total Average Cost at startup including annual cost for 1st yr. (Rs. in lakhs) Recurring cost per yr. (Rs. in lakhs) Per Research Institute For 5 Research Institutes 1 Laboratory tests Flexi-fund to each PSM, Paeds and Micro dept and to each linked District Rs.5000 each DEO salary 8500 pm) Miscellaneous: Operational cost including stationeries and communication, Training and travel Subtotal annual cost

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