Emergency Preparedness and Response Planning for Polio

Dr N K SinhaState Immunization Officer State Health Society, Bihar

WPV cases in Bihar

2009 2010

2011

Cross-border transmission with Nepal

20092012

0

100

200

300

400

500

600

2007 2008 2009 2010 2011

P3 P1

WPV 1 Cases in Bihar

2010

The risks to Polio situation in Bihar

• Re-introduction of transmission through importation:– High migration from/ to the state & – Frequent intermixing of population with Nepal

• Re-establishment:– Decreased population immunity

• Resulting from complacency

– Pockets of low RI

Risk analysis: Identification of high risk district and blocks

Gaya

Patna

Jamui

Rohtas

Purnia

Kaimur

Banka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Nawada

Champaran West

BhojpurBuxar

Nalanda

Muzaffarpur

Bhagalpur

Aurangaabad

Sitamarhi

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Madhepura

Kishanganj

ArwalLakhisaraiJehanabad Sheikhpura

Sheohar

Zone - 1

Zone - 2

Zone - 3

Gaya

Patna

Jamui

Rohtas

Purnia

Kaimur

Banka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Nawada

Champaran West

BhojpurBuxar

Nalanda

Muzaffarpur

Bhagalpur

Aurangaabad

Sitamarhi

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Madhepura

Kishanganj

ArwalLakhisaraiJehanabad Sheikhpura

Sheohar

HR Blocks

Non – HR Blocks

High Risk Districts High Risk Blocks

• Mobile population and population in movement:– Migratory population (Nomads/ Brick kiln workers)– Movement across long and porous Indo-Nepal Border– Returnee migrants to Bihar – Other population movement (like Sharawni Mela and Sonepur

Mela)

• Sub block high risk areas (Hot spots)

• Presence of access compromised Kosi riverine areas

• Pockets of low RI coverage

• Pockets of areas with refusal to OPV and instances of mass refusals

Risk analysis: Identification of migratory and other risk factors

Status of EPRP

• EPR Plan for the state made and communicated to GOI– Plan for risk mitigation and – Quick high quality mop up in case

of importation

• Risk mitigation strategies implemented– State level officers given

responsibility of high risk areas for oversight on risk mitigation strategies

• Rapid Response Team formed and trained

Risk mitigation strategies

Sustaining high population immunity in High Risk areasAnd

Preventing risk of re-importation

Sustained high quality SIA campaigns % Cildren found unimmunized in 'End of Round' Survey

0

1

2

3

4

5Dec_09

Jan_10

Feb_10

Mar_10

Apr_10

May_10

Jun_10

Jul_10

Sep_10

Oct_10

Nov_10

Dec_10

Jan_11

Feb_11

Mar_11

Apr_11

May_11

Jun_11

Aug_11

SEP_11

Nov_11

Jan_12

Feb_12

BIHAR HR_41

• High quality SIAs: less than 0.5% missed children.• High focus in High Risk areas.

• High Quality SIA Operations:– Intensified monitoring– Direct oversight

• State monitors• SMO for every block• Tracking & review at highest

level.

High Risk block plan% Teams monitored

0

20

40

60

80

100

120

Feb

_10

Mar

_10

Ap

r_10

May

_10

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_10

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_10

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_10

No

v_10

Dec

_10

Jan

_11

Feb

_11

Mar

_11

Ap

r_11

May

_11

Jun

_11

Au

g_1

1

Sep

_11

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v_11

Jan

_12

Feb

_12

BIHAR HR_41

Convergent interventions of WASH and Zinc ORS are going on in these blocks with focus on ‘hot spots’

Kosi Intensification• Kosi Operational Plan:

– Reach to Kosi area increased.

– Satellite Offices and Stay points

– Intensified human resources from all partners

– 100% teams monitored

– Frequent field validation for Basas.Persistence of Type 1 polio in Bihar – 2007-09

Kosi River flood plain, Bihar, India

Type 1 Polio – 2008

Type 1 Polio – 2007

Type 1 Polio – 2009

KOSI: Persistence & Spread of P1

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120

24M

ay_09

Jun_09

Aug_09

Sep_09

Oct_

09

Nov_09

Dec_09

Jan_10

Feb_10

Mar_

10

Apr_

10

May_10

Jun_10

Sep_10

Nov_10

Dec_10

JA

N_11

FE

B_11

Mar_

11

Apr_

11

May_11

Jun_11

Aug_11

Sep_11

Nov_11

Jan_12

Feb_12 0

2

4

6

8

10

Team days monitored Teams monitored

Missed children in Basa

Improved coverage with intensified monitoring

% Children missed among migrants

0

1

2

3

4

5

Nov

_10

Dec_1

0

Jan_

11

Feb_

11

Mar_1

1

Apr_1

1

May_1

1

Jun_

11

Aug

_11

SEP_1

1

Nov

_11

Jan_

12

Feb_

12

•Brick Kiln – 8079•Nomadic Site - 5022

MigrantsNumber of sites with migratory / mobile

populations identified in Bihar

• Field validation and mapping of migrant sites• Focused for coverage in SIA and RI• Dynamic list: regular updation• Surveillance:

– Health seeking behavior survey

– Related health facilities sensitized/ included in network

• Continuous vaccination activity at Indo-Nepal Border and Major railway stations:– 93 teams at 51 Indo-Nepal Border

sites & 198 at 11 Major railway stations

– Ongoing from 27th May’11.– 2,761,397 children vaccinated till

now

Gaya

Patna

Jamui

Rohtas

Kaimur

Purnia

Banka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Bhojpur

Nawada

Champaran West

Buxar

Nalanda

Muzaffarpur

Bhagalpur

Sitamarhi

Aurangaabad

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Kishanganj

Madhepura

ArwalLakhisaraiJehanabad

Sheikhpura

Sheohar

Major Railway Station

Continuous vaccination activity

Vaccinating returnee migrants

• Chhath:– Major railway/ Road transit

points & Ghats– 13 Days– 2899 Teams– 1.3 million children vaccinated

• Holi:– Major railway & Road transit

points– 6 Days– 738 Teams– 152,491 children vaccinated

Congregations• Shrawani Mela (16th July- 14th

Aug’11):– Bhagalpur, Banka, Munger &

Indo-Nepal border

– 31 days

– 103 teams

– 152,868 Children vaccinated

• Sonepur Mela (9th Nov—22nd Nov’11):– Hajipur Urban, Sonepur

– 14 days

– 192 teams

– 82144 Children vaccinated

Routine Immunization: Progress over the years

We strive to achieve beyond 85% by 2013 in ALL districts & Blocks

11 11.618.6

32.838 41.4

4954

66.8

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70

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100

NFHS 21998-99

CES 2002 CES 2005 NFHS 32005-06

CES 2006-07

DLHS2007-08

CES 2009Unicef

FRDS2009

FRDS 10-11

MuskanRI Augmentation drive

Newborn booklet & distribution of RI cards in Pulse Polio (Jan06)

Microplan updation with Polio microplan AndIntensified RI monitoring

% Full Immunization coverage

9489.3 89.6

84.8 84.579.8 79.5

68.1 66.8

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100

BC

G

DP

T 1

OP

V 1

DP

T 2

OP

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DP

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OP

V 3

Mea

sles F

I

Reasons for Non/ partial Immunization:

FRDS 2010-11 (multiple response)

16 Do not know what vaccines are needed and when

40.5

Child is too young for vaccination 36.8Fear of side effects 21.1Services are not available when required

15.9

Do not feel need for vaccination 15.4Do not know where to take the child for vaccination

9.9

Opposition from family members 6.1Do not have time to take the child for immunization

5.3

Others 5.8

Antigen wise coverage (FRDS-10/11)

• The problem in Bihar is of ‘Drop Outs’– From 94% BCG or 89% DPT1, we are able to retain only 67%

• Key gap in communication and mobilization

Service delivery

98 98 98 98 98 98 98 99 98 98 98 99 99 98 98 98 99 999890 87

6772

8791 93 92 92 92 91 92 89 89 90 90 92 9294

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100

Jul'1

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Sep

'10

No

v'10

Jan

'11

Mar

'11

May

'11

Jul'1

1

Sep

'11

No

v'11

Jan

'12

86 8781

77 80 80 8175

7076

72 75

62

52

3947

60

6966

94 9692

87 89 92 9184 81 84 81

85

69

57

4452

66

7776

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20

30

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60

70

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90

100

Jul'1

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Sep

'10

No

v'10

Jan

'11

Mar

'11

May

'11

Jul'1

1

Sep

'11

No

v'11

Jan

'12

All Vaccines and diluents T-OPV

% Sessions held and functional AVD % Sessions with Antigens available

• More than 90% of planned sessions being held.

• Alternate vaccine delivery functioning well

• Shortage of vaccine recently

62.569.7

0

10

20

30

40

50

60

70

80

90

100

Jul'1

0

Sep

'10

No

v'10

Jan

'11

Mar

'11

May

'11

Jul'1

1

Sep

'11

No

v'11

Jan

'12

% Full immunization

Strengthening of Immunization• Microplan:

– Revised in 2009 to include all villages from Polio microplan (>20,000 extra session sites added)

– But, number of sessions reduced after synchronization with VHND– Revision going on to incorporate all urban slums, migrants and

hamlets without AWC (Implementation by 1st April’12)

• Vaccine and logistic management:– EVM Passbooks implemented.– Training on cold chain and vaccine handling to DIO and staff. – Information flow of vaccine strengthened through software package

and mobile (Plan to implement OVLMS)

• Supervision, Monitoring & review:– More than 3000 sessions & 30,000 houses monitored/ month– Weekly district control room meeting and Weekly RI cell meeting– Bi-Monthly review meeting of DIOs with process indicators– Supervisory cadre?

Strengthening of Immunization• IRI Plan (12-13):

– Prioritization done on the bases of:• Low RI coverage and• Measles/ polio surveillance data

– Planed for improving coverage

• Immunization weeks:– April, May, June and July/ Dec

• AVD and Teeka Express:– AVD is successful in Bihar and reaches every where.– Teeka express planned for migrant/ urban slums

• Capacity building:– 1/3rd MOs trained in RI. Fast tracking planned– All DIOs trained, training of ANMs to be fast tracked

Strengthening of Immunization• Mobilization:

– Support from polio vaccination teams by convergence through newborn booklet.

– Close coordination with ICDS department for involvement of AWW– Revised incentive mechanism for ASHA (higher for Measles/

booster)– IEC through flexi-banners at AWC/ health facilities and mass media

• ANM Vacancies:– ~30% vacancy of ANMs– Rational distribution of existing ANM in process

• AEFI/ VPD Surveillance:– AEFI committees functional at all districts– AEFI workshop in pipeline

Sensitivity of surveillance

Key surveillance indicators

11.2 12.6 13.0

33.0 38.0 40.0

5668

7483.0

103.0 100.0

0

20

40

60

80

100

2009 2010 2011

India Bihar HR Blocks PT- Kosi

NPAFP Rate

83 83 8486 87 8885 87 89

8288 90

50

60

70

80

90

100

2009 2010 2011

India Bihar HR Blocks PT-Kosi

Adequate stool Rate

• Sustained sensitivity of surveillance.• Higher sensitivity in high risk areas (High risk blocks and

Kosi riverine areas)• Environmental Surveillance: Negative for polio• Surveillance Review (Nov’11): No major gaps

Expansion of reporting network

3473

4302 4321

5095

0

1000

2000

3000

4000

5000

6000

2008 2010 Jun-11 2012

314

570 578

712

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600

800

2008 2010 Jun-11 2012

88

312 306

359

0

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400

2008 2010 Jun-11 2012

BIHAR 41 High Risk Blocks

12 Kosi-PT Blocks• Intense network in vulnerable

areas

• HR Blocks are 7% of state but have 14% of reporting sites

• Kosi-PT are 2% of state and have 7% of reporting sites

Preparedness for Mop Upin case of detection of any

transmission

Preparedness for responding to importation• Bihar is prepared to hold first mop up with in 7 days of detection of

transmission.

• Following plans are in place:– Logistics:

• Marker pen: rolling stock with vendor at Patna which can be supplied with 3 days anywhere in state.

• Formats: printing decentralized and takes 3-4 days– Communication: State Health Society can take out advert within 2 days of

information– Cold chain: Although sufficient to do mop up, we have requested 50,000

vaccine carriers from GOI– Microplanning: Available at all PHCs and are updated regularly.– Manpower & training: Vaccinators are well identified and usually are

AWW/ ASHA. They can be mobilized within 3 days of information.

• EPRG & RRT can be activated within 24 hours

• District and Block task force will meet as soon as campaign is decided.

Response to WPV1 in 2010• 2 quick High Quality Mop Up response

with mOPV1 covering 1.8 million children

• 1st Cases:– Onset: 8th Aug.

– Investigated:13th Aug.

– Result: 25th Aug.

– Mop Up: 4th Sept. & 4th Oct.

• Onset of last case: 1st Sept

Experience in past

Responded within 10 days when we had last

importation

2009 2010

2011

Cross-border transmission with Nepal

20092012

WPV 1 Cases in Bihar

2010

Enhanced Political commitment at highest level

“I hereby request all MLAs to stop by households in their constituencies to check finger markings of children for Polio

vaccination; RI Cards and toilets”

“We are very close to the eradication and there is no case in Bihar but the risk of importation is still there. We all should

come together and give best effort now”

Thank you

What is being done• Sustaining high population immunity specially in High Risk

Areas and groups by:– High quality SIAs– Implementation of Kosi Operational Plan – Implementation of 107 Block Plan.– Steps to strengthen Routine Immunization.– Migrants in Bihar (Nomads, Brick Kiln labours etc.)– Coverage of incoming migrants during period of major movement

and Major congregations.– Continuous Vaccination at major entry points & Indo-Nepal border.

• Prepared for mounting Rapid Mop Up in response to any transmission detected.

• Intensified surveillance in core endemic areas of Kosi and environmental surveillance.

Surveillance: Migrants

Type of migrant site

Health facilities identified to be catering to migrants

Health facilities already part of network

Health facilities included in network after survey

Nomadic site 2132 1315 113

Brick Kilns 3242 1306 150

Urban slums 402 183 14

Construction sites

41 33 1

Rest of the health facilities were seeing very few cases and were sensitized for reporting AFP cases

Health seeking behavior survey of migrants: One time in late 2011 and from then on ‘on going’ basis