# Implementation of India’s largest sentinel surveillance for meningitis: an exploratory qualitative analysis of the facilitators and challenges in this sentinel site network

## TL;DR

India implemented a large meningitis surveillance network, facing challenges like consent and data management, but succeeded through training and coordination.

## Contribution

The paper provides insights into implementing a nationwide meningitis surveillance system in India, highlighting lessons for global health initiatives.

## Key findings

- Challenges included case identification, consent, and data management issues.
- Successful implementation was achieved through training, supervision, and digital communication.
- A decentralized network with strong coordination is recommended for tracking pneumococcal serotypes.

## Abstract

Meningitis remains a leading cause of childhood morbidity and mortality in India, with Streptococcus pneumoniae as the most common bacterial pathogen. The Pneumococcal Conjugate Vaccine (PCV) was introduced into India’s Universal Immunization Program in 2017 with PCV-13 across five states and was later replaced by the indigenously manufactured PCV-10 in 2019. However, the absence of a nationwide surveillance platform for pneumococcal and other meningitis-causing pathogens limited data on disease burden and vaccine impact. To address this, the ICMR launched a project in 2018 to strengthen laboratory surveillance for pneumococcal meningitis, establishing India’s largest meningitis surveillance network. This paper documents the challenges encountered during its implementation and the actions taken to overcome them, offering insights for countries planning similar surveillance systems.

An exploratory qualitative evaluation was conducted to identify facilitators and challenges faced during implementation of the surveillance network. Using multistage purposive sampling, 15 study sites across six zones of India were selected, representing National Apex Laboratories, Regional Reference Laboratories, and Clinical Recruitment Sites. Twenty-five key informant interviews were conducted with project implementers from both high- and low-performing sites. Audio-recorded data were transcribed, translated, and analyzed using a framework approach.

The project team encountered challenges throughout the implementation of the surveillance network, including case identification, obtaining informed consent—particularly from illiterate populations—and incomplete clinical or vaccination histories. Difficulties were also noted in CSF collection, storage, transport, and delayed laboratory reporting. Data management issues arose from manual CRF entry, along with interdepartmental coordination problems due to frequent staff transfers and the need for repeated training. Dependence on external supplies for reagents and primers posed additional limitations. These challenges were addressed through root cause analysis, timely corrective and preventive actions, regular trainings, improved supervision, and enhanced communication via SOPs and digital platforms. Key facilitators for successful implementation included stakeholder motivation, capacity building, and strengthened coordination mechanisms.

The successful implementation of this nationwide laboratory surveillance despite multiple challenges offers valuable lessons for future initiatives. A decentralized sentinel laboratory network with integrated data management and strong central coordination is crucial for effective monitoring. Based on this experience, establishing similar surveillance systems is recommended for countries to track circulating pneumococcal serotypes and support evidence-based vaccine decisions.