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					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
Types of models for surveillance of selected diseases
Sl. Selected Diseases            Type of model proposed for surveillance
no.

1.   Measles                    Sentinel surveillance model at 30
     Meningitis                 Medical Colleges or tertiary care
     Enteric fever              hospitals chosen as sentinel sites with the
                                 respective 30 District Hospitals linked to
                                 them

2.   Japanese Encephalitis      The surveillance for JE should be done
                                 through the existing NVBDCP Sentinel
                                 sites
3.   Diphtheria                 Surveillance data to be collected from
                                 identified Infectious Disease Hospitals
4.   Pertussis                  Data for surveillance to be collected in a
     Rota virus                 research mode from a few designated
     Strepto. pneumoniae        centers
     Hemophilus influenzae -B
     (HiB)
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
                                                                SSU, IDSP
       CSU, IDSP                                          State Surveillance Unit
Central Surveillance Unit



                                                                 DSU, IDSP
                                                        (District Surveillance Unit)




                                  Sentinel Site
                        (Medical College Hospital / Tertiary
                                     Hospital)




                                         PSM                   District Hospital
      Pediatrics and Micro               Dept.
         Departments
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. 5000 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
    e-mail 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                16.MGM Medical College, Indore
2.Niloufer Hospital, Hyderabad                17.GS Medical college & KEM Hospital,
3.Guwahati Medical College, Guwahati            Mumbai
4.Patna Medical College                       18.JN Hospital, JNIMS, Porompat, Imphal East
5.Government Medical College & Hospital       19.NEIGRIHMS, Shillong
6.Pt. JN Memorial Medical College, Raipur     20.SCB Medical College & Hospital, Cuttack
7.Kalawati Saran Childrens’ Hospital, Delhi   21.JIPMER, Puducherry
8.Goa Medical College, Bambolim, Panaji       22.Government Medical College, Patiala
9.BJ Medical College, Ahmedabad               23.SMS Hospital, Jaipur
10.PGIMS, Rohtak                              24.ICH & Hospital for Children, Chennai
11.Indira Gandhi Medical College, Shimla      25.Christian Medical College, Vellore
12.SKIMS, Srinagar                            26.BRD Medical College, Gorakhpur
13.MGM Medical College, Jamshedpur            27.BHU, Varanasi, Uttar Pradesh
14.Bangalore Medical College, Bangalore       28.KGMC (CSMMU UP), Lucknow
15.Govt. Med. College,                        29.Govt. Doon Hospital, Dehradun
Thiruvananthapuram                            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.                         Vaccination status of
   Date of Registration/           related disease
    Admission                          Name of Vaccine
   Name                               No. of doses given
   Age                            Lab tests
   Sex                                Name of lab test done
                                       Lab diagnosis
   Address
   Date of onset of illness       H/O similar illness in
                                    neighborhood
   Major presenting features
                                   Outcome
   Clinical Diagnosis
                                       Recovered/ Died/ LAMA
   Treatment history
               Format for filling up Register for Sentinel
                               Surveillance


     Date of                     Addre   Date of    Major      Clinical   Treatme                                          H/O similar illness   Outc
     Registr                     ss      onset of   presenti   Diagnos       nt                                            in neighborhood       ome
     ation/                              illness    ng            is      history                                                                (Rec
     Admiss                                         features                        Vaccination status                                           over
                                                                                                         Lab tests
     ion                                                                            of related disease                                           ed/Di
ID                                                                                                                                               ed/
               Nam
N                    Age   Sex                                                                                                                   LAM
               e
o.                                                                                                                                               A)
                                                                                                         Name        Lab
                                                                                                No. of
                                                                                    Name of              of lab      dia
                                                                                                doses
                                                                                    Vaccine              test        gno
                                                                                                given
                                                                                                         done        sis
 Diagnostic laboratory tests for Diseases
      under Sentinel Surveillance
Sl.
No.   Disease         Causative agents              Specific lab tests


                      Corynebacterium diphtheriae   Culture, toxigenicity testing
      Diphtheria,
 1
      Pertussis                                     Culture of naso-pharyngeal
                      Bordetella pertussis
                                                        aspirate / swab

                      Neisseria meningitidis        Bacterial culture of CSF, blood
      Meningitis /
 2
         AES
                      Japanese Encephalitis virus   ELISA

                      Salmonella enterica           Culture of blood/stool/urine
 3    Enteric fever
                      Serotype Typhi/ Paratyphi A       + serotyping

                      Measles virus                 ELISA
      Measles /
 4
      Rubella
                      Rubella virus                 ELISA
       Total Budget for Sentinel Surveillance of selected
      Vaccine Preventable Childhood Infectious Diseases

                                                    Total Average
                                                   Cost at startup
Sl.         Level of Activity for Sentinel                            Recurring cost per yr.
                                                  including annual
No.                 Surveillance                                         (Rs. in lakhs)
                                                   cost for 1st yr.
                                                    (Rs. in lakhs)

1     Central Surveillance Unit (CSU)                   58.6                  54.3

2     Zonal coordinators (6 zones)                       6.0                   6.0

      Subtotal annual cost for 30 Sentinel
3     sites for Sentinel Surveillance of               690.2                  541.8
      Meningitis, Measles and Enteric Fever

      Subtotal annual cost for 7 ID Hospitals
4                                                       96.7                  62.1
      for Surveillance of Diphtheria

      Subtotal annual cost for 5 Research
      Institutes for Surveillance of Pertussis,
5                                                      205.1                  180.4
      Rota virus, H. influenzae and Strepto.
      Pneumoniae

                   TOTAL                               1056.6                 844.5
            Budget for Sentinel Surveillance at
              Zonal levels and Central level


Sl.   Level of Activity       for Total Average Cost at     Recurring
No.   Sentinel Surveillance       startup including         cost per yr.
                                  annual cost for 1st yr.   (Rs. in lakhs)
                                  (Rs. in lakhs)

1     Central Surveillance Unit
      (CSU), IDSP                           58.6                 54.3

2     Zonal coordinators (6)
      (one   at    each    zone
                                             6.0                  6.0
      responsible for 5 sentinel
      sites)

           Subtotal annual cost             64.6                 60.3
    Budget for Sentinel Surveillance of Meningitis, Measles and
            Enteric Fever at 30 identified Sentinel sites

                                                    Total Avg. Cost at      Recurring
                                                    startup including        cost per
Sl.                                               annual cost for 1st yr.   yr. (Rs. in
                    Sub-activity
No.                                                   (Rs. in lakhs)          lakhs)
                                                  Per site   For 30 sites
1     Laboratory tests                              9.6          288           288
2     Flexi-fund to each dept (PSM, Pediatrics
      and Microbiology) and to each linked          2.4          71.6          71.6
      District Hospital
3     DEO salary (in those sites where DEO is
      not provided through IDSP consolidated
                                                    1.0          30.6          32.1
      salary of Rs 8500 pm; enhancable @ 5%
      pa)
4     Miscellaneous: Operational cost including
      stationeries, printing and communication,
                                                    10.0        300.0         150.0
      Training and Travel to Delhi to attend
      review meetings, etc.
                          Subtotal annual cost      23.0        690.2         541.8
      Budget for Diphtheria Surveillance at the seven
        Infectious Disease Hospitals under IDSP
                                         Total Average Cost at startup    Recurring
                                         including annual cost for 1st   cost per yr.
Sl.                                             yr. (Rs. in lakhs)         (Rs. in
                Sub-activity
No.                                                                        lakhs)
                                             Per ID        For 7 ID
                                            Hospital      Hospitals

1      Laboratory tests                       1.0             7.0            7.0
       Flexi-fund to each PSM, Paeds
       and Micro dept and to each
2                                             1.8            12.6           12.6
       linked District Hospital @
       Rs.5000 each

3      DEO salary (@Rs 8500 pm)               1.0             7.1            7.5

       Miscellaneous: Operational
       cost including stationeries and
4                                             10.0           70.0           35.0
       communication, Training and
       travel

                Subtotal annual cost          13.8           96.7           62.1
Budget for Surveillance of Pertussis, Rota virus, H. influenzae and
         Strepto. pneumoniae at five Research Institutes


                                          Total Average Cost at startup    Recurring
                                          including annual cost for 1st   cost per yr.
 Sl.                                             yr. (Rs. in lakhs)         (Rs. in
                Sub-activity                                                lakhs)
 No.                                                          For 5
                                          Per Research
                                                            Research
                                            Institute
                                                            Institutes
  1    Laboratory tests                        27.6           138.0          138.0
       Flexi-fund to each PSM, Paeds
       and Micro dept and to each
  2                                            2.4            12.0           12.0
       linked District Hospital @
       Rs.5000 each
  3    DEO salary (@Rs 8500 pm)                1.0             5.1            5.4
       Miscellaneous:       Operational
       cost including stationeries and
  4                                            10.0           50.0           25.0
       communication, Training and
       travel
                Subtotal annual cost           41.0           205.1          180.4
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