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Integrated Disease Surveillance Project (IDSP)
- 1. Integrated Disease Surveillance Project(IDSP): Current Status 1 12/25/2016 Mentor Prof.(Dr.) E. Venkata Rao Community Medicine Presenter Dr. Vivek Varat Pattanaik PG Community Medicine
- 2. Outline Introduction Managementstructure of the Integrated Disease Surveillance Project Reporting units, participants and their roles Private sector participation in disease surveillance Case definitions of diseases and syndromes under surveillance Working with the laboratory Outbreak investigation, response and control Analysis and interpretation of data Feedback Monitoring, supervision and quality control Inter-sectoral coordination and social mobilization Human resources development in the integrated disease surveillance project 2 12/25/2016
- 3. History 1997-98: NationalSurveillance Program for Communicable Diseases (NSPCD) initiated March, 2003: Central Surveillance Unit (CSU) Nov, 2004: Integrated Disease Surveillance Project (IDSP) 2007-08: Making of IDSP as part of National Rural Health Mission (NRHM) 12/25/2016 3
- 4. Public health Surveillance Surveillance is defined as the ongoing systematic collection, collation, analysis and interpretation of data and dissemination of information to those who need to know in order that action be taken. 4 12/25/2016
- 5. Public health Surveillance Surveillance is defined as the ongoing systematic collection, collation, analysis and interpretation of data (disease / health event) and dissemination of information to those who need to know in order that action be taken. 5 12/25/2016
- 6. Why do weneed to do surveillance? Recognize cases or cluster of cases to trigger intervention to prevent transmission or reduce morbidity and mortality. Identify high risk groups or geographical areas to target interventions and guide analytic studies. Develop hypotheses that lead to analytic studies about risk factors for disease causation, propagation or progression. Assess the public health impact of health events and measure trends. Demonstrate the need for public health intervention programme and resources during public health planning. Monitor effectiveness of prevention and control measures and prevent outbreaks. 6 12/25/2016
- 7. Objectives of theIntegrated Disease Surveillance Project. To establish a decentralized district based system of surveillance for communicable and non-communicable diseases so that timely and effective public health actions can be initiated in response to health changes in the urban and rural areas. To integrate existing surveillance activities to avoid duplication and facilitate sharing of information across all disease control programmes and other stake holders so that valid data is available for health decision making in the district, state and national levels 7 12/25/2016
- 8. Classification of surveillancein IDSP Syndromic Diagnosis made on the basis clinical pattern by paramedical personnel and members of community Presumptive Diagnosis is made on typical history and clinical examination by medical officers Confirmed Clinical diagnosis by medical officer and or positive laboratory identification 8 12/25/2016
- 9. Conditions under regularsurveillance Type of disease Disease Vector borne diseases •Malaria Water borne diseases •Diarrhea (Cholera) •Typhoid Respiratory diseases •Tuberculosis Vaccine preventable diseases •Measles Disease under eradication •Polio Other conditions •Road traffic accidents International commitment •Plague Unusual syndromes •Meningo-encephalitis •Respiratory distress •Hemorrhagic fever 12/25/2016 9
- 10. Other conditions undersurveillance Type of surveillance Categories Conditions Sentinel surveillance •STDs •HIV/HBV/HCV •Other conditions •Water quality •Outdoor air quality Regular surveys •Non communicable disease risk factors •Anthropometry •Physical activity •Blood pressure •Tobacco, blood pressure •Nutrition •Blindness Additional state priorities •Up to five diseases 12/25/2016 10
- 11. Reporting units fordisease surveillance Public sector (Exhaustive) Private (Sentinel) Rural •Community health centres •District hospitals •Practitioners •Hospitals Urban •Urban hospitals •ESI •Railways •Medical colleges •Nursing homes •Hospitals •Medical colleges •Laboratories 12/25/2016 11
- 12. Phases of implementationfor the Integrated Disease Surveillance Project Phase I (2004-05) Madhya Pradesh, Andhra, Himachal, Karnataka, Kerala, Maharashtra, Mizoram, Tamil Nadu & Uttaranchal Phase II (2005-06) Chattisgarh, Goa, Gujarat, Haryana, Orissa, Rajasthan, West Bengal, Manipur, Meghalaya, Tripura, Chandigarh, Pondicherry, Nagaland, Delhi Ph III (2006-07) UP, Bihar, J&K, Punjab, Jharkhand, Arunachal, Assam, Sikkim, A&N Island, D&N Haveli, Daman & Diu, Lakshadweep 12/25/2016 12
- 13. Management structure ofthe Integrated Disease Surveillance Project13 12/25/2016
- 14. National surveillance committee Centralsurveillance unit State surveillance committee State surveillance unit District surveillance committee District surveillance unit Organizational structure 12/25/2016 14
- 15. District surveillance committee 15 Chairperson CMO Representative WaterBoard Superintendent Of Police IMA Representative NGO Representative Medical College Representative District Surveillance Officer (Member Secretary) District Panchayat Chairperson District Training Officer(IDSP) Representative Pollution Board District Data Manager (IDSP) Chief District PH Laboratory District Program Manager Polio, Malaria, TB, HIV - AIDS 12/25/2016
- 16. Functions of thedistrict surveillance unit Centralize and analyze data from all reporting units Constitute rapid response teams and their deputation Implement and monitor all project activities Coordinate with laboratories, medical colleges, non governmental organizations and private sector Send regular feedback to the reporting units Organize training and communication activities Organize district surveillance committee meetings 12/25/2016 16
- 17. Functions of statesurveillance unit Collate and analyze data received from districts Coordinate activities of rapid response teams Monitor and review the activities of district surveillance units Coordinate with state public health laboratories, medical colleges and other state level institutions Feedback trend analysis to district surveillance units Organize and coordinate training activities Organize meetings of the state surveillance committee 12/25/2016 17
- 18. Functions of centralsurveillance unit Execute the approved annual plan of action Monitor progress of implementation Obtain reports and statements of expenditure Seek reimbursement from the World Bank Report to the national surveillance committee Procure goods and services at central level Analyze data and send feedback to states Coordinate with NICD, ICMR and others Organize non communicable diseases surveys Conduct periodic review meetings with state surveillance officers Organize independent evaluation studies Produce guidelines, manuals and modules 12/25/2016 18
- 19. Information flow ofthe weekly surveillance system Sub-centres P.H.C.s C.H.C.s Dist. hosp. Programme officers Pvt. practitioners D.S.U. P.H. lab. Med. col. Other Hospitals: ESI, Municipal Rly., Army etc. S.S.U. C.S.U. Nursing homes Private hospitals Private labs. Corporate hospitals 12/25/2016 19
- 20. Reporting units, participants andtheir roles20 12/25/2016
- 21. Surveillance: A systematic, ongoingprocess Data collection Transmission Analysis Feedback Action 12/25/2016 21
- 22. Reporting unit Nature Health facility / individual in private/ public sector Located in rural or urban area Function Collects information of health conditions identified in specified formats Transmits these in pre-specified timely manner to the next higher level 12/25/2016 22
- 23. Reporting units fordisease surveillance Public sector (Exhaustive) Private (Sentinel) Rural •Community health centres •District hospitals •Practitioners •Hospitals Urban •Urban hospitals •ESI •Railways •Medical colleges •Nursing homes •Hospitals •Medical colleges •Laboratories 12/25/2016 23
- 24. Active and passivereporting Active reporting Health workers House visits Passive reporting All other reporting units 12/25/2016 24
- 25. Three levels ofcase definitions for three levels of actors Level Actor of the surveillance system •Syndromic (Form “S”) •Health workers •Presumptive (Form “P”, probable) •Medical officers •Confirmed •Laboratories * Except for malaria and tuberculosis 12/25/2016 25
- 26. Reportable diseases formulti-purpose health workers and health assistants Diarrhea Jaundice Fever Cough Acute flaccid paralysis Unusual events (Death, hospitalization) 12/25/2016 26
- 27. Reportable diseases formedical officers Diarrhea Jaundice Fever Malaria Typhoid Japanese encephalitis Dengue Measles Cough Tuberculosis Acute flaccid paralysis Unusual events (Death, hospitalization) 12/25/2016 27
- 28. Zero reporting Zeroreporting is important to confirm that the condition was looked for and not found 12/25/2016 28
- 29. Person responsible fordata compilation and transmission Levels Person responsible •Primary health centres •Pharmacists •Community health centres •Computer / pharmacists •Sentinel private providers •Medical officers •District hospitals •Computer / pharmacists •Medical colleges •Statistical officer •Laboratories •Medical officer / technician 12/25/2016 29
- 30. Time sequence •Community healthcentre reports to district Tuesday •Primary health centre reports to community health centre Monday EventDay of the week 12/25/2016 30
- 31. Private sector participationin disease surveillance31 12/25/2016
- 32. Need for privatesector participation in disease surveillance Most patients (>70%) go to private sector Private physicians are the preferred first contact Private sector is more likely to detect early warning signs of outbreak Lack of public sector service provider especially in urban areas 12/25/2016 32
- 33. Initiating partnership MOU(memorandum of understanding) with IMA/IAP/other professional bodies National/State/District level Training 12/25/2016 33
- 34. Criteria for inclusion Reporting units Hospitals Nursing homes Clinics Various systems of medicine Geographical distribution Involve professional associations Indian Medical Association Indian Academy of Pediatrics 12/25/2016 34
- 35. Expected numbers ofpractitioners to include Rural areas 15-45/100,000 population Urban areas 15-30/100,000 population Increase the number in phases More private practitioners in rural areas 12/25/2016 35
- 36.
- 37. Case definitions ofdiseases and syndromes under surveillance37 12/25/2016
- 38. Types of casedefinitions in use Case definition Criteria Who uses it Syndromic Clinical pattern Paramedical personnel and members of community Presumptive Typical history and clinical examination Medical officers of primary and community health centres Confirmed Clinical diagnosis by a medical officer and positive laboratory identification Medical officer and Laboratory staff 12/25/2016 38
- 39. Rationale for theuse of case definitions Uniformity in case reporting at district, state and national level Use of the same criteria by reporting units to report cases Compatibility with the case definitions used in WHO recommended surveillance standards • Allow international information exchanges 12/25/2016 39
- 40. Levels of casedefinitions Suspect case A case that meets the clinical case definition Probable case A suspect case that is diagnosed by a medical officer Confirmed case A suspect case that is laboratory confirmed 12/25/2016 40
- 41. Levels of responseto different triggers Trigger Significance Levels of response 1 Suspected /limited outbreak • Local response by health worker and medical officer 2 Outbreak • Local and district response by district surveillance officer and rapid response team 3 Confirmed outbreak • Local, district and state 4 Wide spread epidemic • State level response 5 Disaster response • Local, district, state and centre 12/25/2016 41
- 42. Conditions under regularsurveillance Type of disease Disease Vector borne diseases •Malaria Water borne diseases •Diarrhea (Cholera) •Typhoid Respiratory diseases •Tuberculosis Vaccine preventable diseases •Measles Disease under eradication •Polio Other conditions •Road traffic accidents International commitment •Plague Unusual syndromes •Meningo-encephalitis •Respiratory distress •Hemorrhagic fever 12/25/2016 42
- 43. Other conditions undersurveillance Type of surveillance Categories Conditions Sentinel surveillance •STDs •HIV/HBV/HCV •Other conditions •Water quality •Outdoor air quality Regular surveys •Non communicable disease risk factors •Anthropometry •Physical activity •Blood pressure •Tobacco, blood pressure •Nutrition •Blindness Additional state priorities •Up to five diseases12/25/2016 43
- 44. Working with thelaboratory44 12/25/2016
- 45. Role of laboratoriesin disease surveillance Early diagnosis of diseases under surveillance Epidemiological investigation Rapid laboratory confirmation of diagnosis Implementation of effective control measures 12/25/2016 45
- 46. Laboratory network forthe Integrated Disease Surveillance Project Laboratories Description L1 • Peripheral laboratories and microscopic centres L2 • District public health laboratory L3 • Disease based state laboratories L4 • Regional laboratories and quality control laboratories L5 • Disease based reference laboratories 12/25/2016 46
- 47. Conditions under regularsurveillance Type of disease Disease Vector borne diseases •Malaria Water borne diseases •Diarrhea (Cholera) •Typhoid Respiratory diseases •Tuberculosis Vaccine preventable diseases •Measles Disease under eradication •Polio Other conditions •Road traffic injuries International commitment •Plague Unusual syndromes •Meningo-encephalitis •Respiratory distress •Hemorrhagic fever 12/25/2016 47
- 48. Other conditions undersurveillance Type of surveillance Categories Conditions Sentinel surveillance •STDs •HIV/HBV/HCV •Other conditions •Water quality •Outdoor air quality Regular surveys •Non communicable disease risk factors •Anthropometry •Physical activity •Blood pressure •Tobacco, blood pressure •Nutrition •Blindness Additional state priorities •Up to five diseases12/25/2016 48
- 49. Syndrome Action •Fever •Bloodsmear for all patients •Acute flaccid paralysis •2 stool samples at interval of 24 hours transported to the medical officer of the primary health centre in reverse cold chain •Fever with rash, altered sensorium or bleeding •Refer to the medical officer of the primary health centre for specific laboratory action•Fever more than 14 days •Cough < or > 3 weeks •Loose watery stools •Acute jaundice •Unusual syndromes Action to be taken by the multi-purpose worker in the field 12/25/2016 49
- 50. Information to berecorded on each specimen/ accompanied with each specimen Name, age, sex Address in detail Reporting unit referring the sample Syndromic diagnosis Date of onset of illness Nature of sample, date of collection, date of receipt and condition of sample Investigation requested Whether convalescent specimen or not 12/25/2016 50
- 51. ID no Nameand address of patient Age Sex Prov. Diag. Lab tests ordered Lab results Date sent to L2 Result from L2 Date of result Sample laboratory register 12/25/2016 51
- 52. The L form Weekly reports from laboratories to the district surveillance officer Prepared on the basis of the laboratory register Filled by nodal person in the laboratory Sent every Saturday of each week Zero/NIL reporting Electronic link between District public health laboratory District surveillance unit 12/25/2016 52
- 53. Outbreak investigation, response andcontrol53 12/25/2016
- 54. Definition of anoutbreak Occurrence in a community of cases of an illness clearly in excess of expected numbers The occurrence of two or more epidemiologically linked cases of a disease of outbreak potential constitutes an outbreak (e.g., Measles, Cholera, Dengue, Japanese encephalitis, or plague) 12/25/2016 54
- 55. Sources of information todetect outbreaks Rumour register To be kept in standardized format in each institution Rumours need to be investigated Community informants Private and public sector Media Important source of information, not to neglect Review of routine data Triggers 12/25/2016 55
- 56. Early warning signalsfor an outbreak Clustering of cases or deaths Increases in cases or deaths Single case of disease of epidemic potential Acute febrile illness of an unknown etiology Two or more linked cases of meningitis, measles Unusual isolate Shifting in age distribution of cases High vector density Natural disasters 12/25/2016 56
- 57. Objectives of anoutbreak investigation 1. Verify 2. Recognize the magnitude 3. Diagnose the agent 4. Identify the source and mode of transmission 5. Formulate prevention and control measures 12/25/2016 57
- 58. Outbreak preparedness: A summaryof preparatory action Formation of rapid response team Training of the rapid response team Regular review of the data Identification of ‘outbreak seasons’ Identification of‘outbreak regions’ Provision of necessary drugs and materials Identification and strengthening appropriate laboratories Designation of vehicles for outbreak investigation Establishment of communication channels in working conditions (e.g., Telephone) 12/25/2016 58
- 59. Basic responses totriggers There are triggers for each condition under surveillance Various trigger levels may lead to local or broader response Tables in the operation manual propose standardized actions to take following various triggers Investigations are needed in addition to standardized actions 12/25/2016 59
- 60. Levels of responseto different triggers Trigger Significance Levels of response 1 Suspected /limited outbreak • Local response by health worker and medical officer 2 Outbreak • Local and district response by district surveillance officer and rapid response team 3 Confirmed outbreak • Local, district and state 4 Wide spread epidemic • State level response 5 Disaster response • Local, district, state and centre 12/25/2016 60
- 61. Importance of timelyaction: The first information report (Form C) Filled by the reporting unit Submitted to the District Surveillance Officer as soon as the suspected outbreak is verified Sent by the fastest route of information available Telephone Fax E-mail 12/25/2016 61
- 62. The rapid responseteam Composition Epidemiologist, clinician and microbiologist Gathered on ad hoc basis when needed Role Confirm and investigate outbreaks Responsibility Assist in the investigation and response Primary responsibility rests with local health staff 12/25/2016 62
- 63. Incidence of acutehepatitis by source of water supply, Bhimtal block, Uttaranchal, India, July 2005 Mehragaon main village Dov Water supply Spring Reservoir Pipeline Attack rate < 5% 5-9% 10% + Mehragaon Hydle colony Chauriagaon Mehragaon Suspected spring Place 12/25/2016 63
- 64. Specific outbreak controlmeasures Waterborne outbreaks Access to safe drinking water Sanitary disposal of human waste Frequent hand washing with soap Adopting safe practices in food handling Vector borne outbreaks Vector control Personal protective measures Vaccine preventable outbreaks Supplies vaccines, syringes and injection equipment Human resources to administer vaccine Ring immunization when applicable 12/25/2016 64
- 65. Analysis and interpretationof data65 12/25/2016
- 66. Selected outcomes ofdata analysis Identification of outbreaks / potential outbreaks Identification of appropriate and timely control measures Prediction of changes in disease trends over time Identification of problems in health systems Improvement of the surveillance system through: Identification of regional differences Identification of differences between the private and the public sectors Identification of high-risk population groups 12/25/2016 66
- 67. Types of data Syndromic case data Presumptive case data Confirmed case data Sentinel case data Regular surveillance data Urban data Rural data 12/25/2016 67
- 68. Basic surveillance dataanalysis 1. Count, divide and compare Direct comparisons between number of cases are not possible in the absence of the calculation of the incidence rate 2. Descriptive epidemiology A. Time B. Place C. Person 12/25/2016 68
- 69. Reported varicella andtyphoid cases, Darjeeling district, West Bengal, India, 2000-4 Figure 3: Reported varicella and typhoid cases, Darjeeling district, WB, India, 2000-2004 1 10 100 1000 10000 100000 2000 2001 2002 2003 2004 Years Numberofcases(Log) Typhoid Varicella Incidence by year 12/25/2016 69
- 70. Mangalore Nallur Vridha- chalam Kattumannar Kail Kumaratchi Parangipattai Kamma- puram Panruti Cuddalore Annagraman Kurinjipadi Bhuvanagiri Keerapalayam Reportedcases of measles, Cuddalore district, Tamil Nadu, Dec 2004 – Jan 2005 Spot map of absolute number of cases 12/25/2016 70
- 71. 81% 19% Immunized Unimmunized Immunization statusof probable measles cases, Nai, Uttaranchal, India, 2004 Distribution of cases according to a characteristic 12/25/2016 71
- 72. Malaria in Kurseongblock, Darjeeling District, West Bengal, India, 2000-2004 0 5 10 15 20 25 30 35 40 45 January February March April May June July August September October November December January February March April May June July August September October November December January February March April May June July August September October November December January February March April May June July August September October November December January February March April May June July August September October November December 2000 2001 2002 2003 2004 Months Incidenceofmalariaper10,000 Incidence of malaria Incidence of Pf malaria Example of monthly and yearly analysis 12/25/2016 72
- 73. Review of analysisresults by the technical committee Meeting on a fixed day of every week Review of a minimum of: 4 reports weekly 7 reports monthly Review by disease wise Search for missing values Check the validity Interpret Prepare summary reports and share Take action 12/25/2016 73
- 74.
- 75. Difficulties with surveillancesystem with no feedback Lack of motivation Unreliability Sluggishness Data falsification 12/25/2016 75
- 76. Data collection Analysis and action Feedback Thesurveillance cycle 12/25/2016 76
- 77. Data flow andfeedback Centre State District Primary / Community health centre Data Feedback Community 12/25/2016 77
- 78. Feedback methods Newsletters Monthly review meetings Reports Informal feedback Electronic communication 12/25/2016 78
- 79. Monitoring, supervision and qualitycontrol79 12/25/2016
- 80. Supervision and monitoring Good supervision helps health staff to perform their best Monitoring is also a vital component of any surveillance programme Monitor all surveillance activities using standard performance indicators District surveillance office monitor indicators of reporting on a regular basis 12/25/2016 80
- 81. Creative monitoring solutions, Haryana,2007 District register keeping track of reports Reporting units that are not timely are flagged with a highlighter 12/25/2016 81
- 82. WEEKS 1 23 4 5 6 7 8 9 10 Baripada(DHH) B.Pahad CHC B.posi BahaldaCHC BarasahiCHC Betnati CHC Bijatala PHC Dukura CHC G.mahisani PHC JamdaPHC Jashipur CHC K.tandiUHPHC KaptipadaCHC Karanjia,SDH KC PurPHC Khunta PHC KosthaCHC KulianaPHC ManadaCHC RangamatiaPHC Raruan PHC RG PHC RR Pur, SDH SC Pur PHC ShirsaCHC Sukruli PHC T.mundaCHC TatoPHC Tiring PHC Udala, SDH Colour-coded monitoring of reporting, Mayurbhanj district, Orissa, India, 2004 Legend Timely, complete Timely, incomplete Complete, not timely Incomplete and late No reports The colour coding stimulates reporting units that are not performing Monitoring 12/25/2016 82
- 83. Central agencies responsible forquality control Central surveillance office National Institute of Communicable Diseases (NICD) Indian Council of Medical Research (ICMR) Quality 12/25/2016 83
- 84. Other agencies identifiedby the Ministry of Health and Family Welfare for external evaluation World Bank World Health Organization United States Centers for Diseases Control and prevention (CDC) INDIACLEN 12/25/2016 84
- 85. Inter-sectoral coordination andsocial mobilization 85 12/25/2016
- 86. Coordination The processof linking the activities of various departments of an organization The process by which managers achieve integrated patterns of group and individual effort i.e., Develop unity of action in common purposes The integration, synchronization or orderly patterning of group efforts by an organization towards the accomplishment of common goals or objectives 12/25/2016 86
- 87. Stakeholders Medical officerof primary health centres Sentinel private practitioners Community representatives District All members of the district surveillance unit State All members of the state surveillance unit 12/25/2016 87
- 88. Aim of thesocial mobilization campaign Create awareness among: Partners Private practitioners Non governmental organizations Community Establish an institutional mechanism to involve community and their leaders Rotating membership in: District surveillance committee Block surveillance committee 12/25/2016 88
- 89. Strategizing communication Adaptmessage and format to the audiences Consider all media Electronic media Press Hoardings Handbills Posters Inter-personal communication through health providers 12/25/2016 89
- 90. Being close fromthe community People volunteer in areas where health workers enjoy a good relationship with their communities Individual initiatives taken by enthusiastic health staff make a difference Key contacts Village elders’ Ladies Pradhan (Village head) Panchayat members Chowkidar (Village guard) 12/25/2016 90
- 91. Engaging medical colleges Responsibility of the state surveillance unit Memoranda of understanding Selection of a coordinating medical college by the Director of Medical Education Facilitation by the health secretary Possibility for medical colleges to work in urban surveillance Contacts at the central level will facilitate these synergies 12/25/2016 91
- 92. Institutional Integrated DiseaseSurveillance Project sub-committee within medical colleges Principal / superintendent Report to Integrated Disease Surveillance Project Community medicine Medicine Pediatrics Chest and tuberculosis Microbiology Cardiology 12/25/2016 92
- 93. Additional potential rolesof medical colleges Reference laboratories Quality assurance and evaluation Training Outbreak investigations In collaboration with the district surveillance officer / medical officer Non communicable disease risk factor surveillance 12/25/2016 93
- 94. Human resources developmentin the integrated disease surveillance project94 12/25/2016
- 95. Principles for humanresources development in the Integrated Disease Surveillance Project No additional staff to be employed Existing personnel will be provided training Training will be provided locally Public private partnership Quality assurance process in the training of the trainers process 12/25/2016 95
- 96. Categories of trainees I.State and district surveillance teams II. Medical officers III. Clinical medical officers IV. Sub-block staff V. State and district level laboratory staff VI. Laboratory staff at sub district level VII. Data entry operators VIII. Statisticians at district and state level 12/25/2016 96
- 97. Induction training courses 1.State and district teams (The trainers) 2. Medical officers PHC / CHC / Urban Health services / Medical colleges 1. Medical officers • Private sector 2. Peripheral workers 3. Microbiologists and technicians - State and district 4. Laboratory technicians at sub district level 5. Data entry operators - State/ district/ sub district 6. Data managers - District and State 12/25/2016 97
- 98. Location and durationof the training 12/25/2016 98 Target audience Site Duration 1. Trainers Region / state 6 days 2. Medical officers District headquarters 3 days 3. Other officers District headquarters 1 day 4. Health workers Community health centre 2 days 5. Microbiologists Region / state 6 days 6. Lab assistants District headquarters 3 days 7. Data operators District headquarters 2 days 8. Data managers Region / state 3 days
- 99.