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

Background: Meningitis remains a leading cause of childhood morbidity and mortality in India, with Methods: 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. Findings: 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. Interpretation: 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.