Progress of Polio Eradication in India, Current Risks & Actions taken

on last IEAG report

24th IEAG, New Delhi 15 March 2012

Dr. Ajay KheraDeputy Commissioner & Pubic Health Expert

Child Health & ImmunizationMinistry of Health & Family Welfare

Government of India

Progress of Polio Eradication in India

P1 wild P3 wild

•1995: Polio SIAs launched

•1997: AFP Surveillance initiated

•1999: Last case of WPV 2 – (U.P)

•2001: 14 States and UTs free of polio

•2010: Last case of WPV 3 - (Jharkhand)

•2011: Last case of WPV 1 - (Howrah, West Bengal)

•2012: India removed from list of endemic countries

741

42 1

mOPV 1bOPV

Year-wise result of AFP Surveillance system

Year AFP WPV Compatible VDPV

2009 50,405 741 473 21

2010 55,785 42 190 5

2011 60,751 1 50 7

2012 7,122 0 1

•17 circulating Type 2 VDPVs in areas of low routine coverage in West UP in 2009-10 •No genetic linkage amongst 2011 VDPVs

Spot map of VDPVs 2011-12

Data as on 7 March 2012

YearType 1 Type 2 Type 3

Totala i c a i c a i c

2009 1 1 0 4 0 15 0 0 0 21

2010 0 0 0 2 1 2 0 0 0 5

2011 0 0 0 4 2 0 0 1 0 7

2012  1                 1

Total 2 1 0 10 3 17 0 1 0 34

Wild Polio Virus in environmental (sewage) samples

2007 2008 2009 2010 2011

Mumbai

WPV1 WPV3Delhi

Collection of sewage samples started from April 2010

2012*

Sewage samples collection sites

* data as on 7 March 2012

• Patna & Kolkata sewage sample collection from 2011

• No WPVs isolated

Trends in Seroprevalence Against PoliovirusResults from Different Sero-surveys

Moradabad Nov 2007(N=121)

AFP cases UP

Nov 08 – mid 09(169)

Moradabad May 2009(N=534)

UP & BiharAug 2010(N=1280)

UP & BiharAug 2011(N=1246)

Age 6-7 mo 6-11 mo 6-7 mo 6-7 mo 6-11 mo

Type 1 78% 96.5% 99% 98% 98.5%

Type 2 56% 33.7% 75% 65% 85%

Type 3 69% 42.6% 49% 77% 88.2%

Confirms high immunity levels for all three sero-types in 2011 specially in high risk areas of Uttar Pradesh and Bihar

1. Intensive polio SIAs in the reservoir, amplification and migrant areas

2. Enhance routine immunization especially in high risk areas

3. Ensure outbreak preparedness plans

4. Roll out the new communication approach

5. Accelerate research for programmatic decisions

6. Enhance AFP and Laboratory surveillance

7. Initiate post eradication planning

Update on action points based on last IEAG recommendations

Action No. 1: Intensive Polio SIAs in 2011-12

SNIDNID

2011 2012

• 902 million doses of OPV administered in 2011

• Missed children varied from 0.3% to 7.8%

Average percent children found unimmunized by monitors during Polio SIAs in 2011

% u

nim

mu

niz

ed

Source : Independent monitoring

Action No. 2: Intensifying Routine Immunization

• Nationwide intensified RI campaigns planned – 2012-2013 declared as the Year of RI intensification

– Immunization weeks initiated in Northeast states

• RI monitoring intensified with special focus on high risk areas of UP, Bihar, West Bengal and Karnataka through WHO-NPSP

• Proposal to modernize alternate vaccine delivery system

• Supply chain management being revamped

• Involvement of ASHA and Mother and child tracking system is proposed to be used for follow-up of children for vaccination.

Action No. 3: Focus on Migrants Populations

Migrant populations of states with high migration Delhi, Mumbai, Punjab, Haryana, Gujarat & West

Bengal vaccinated during each SIA

• 162,000 migrant sites identified in India

• All migrant sites included in SIA microplans

• ~ 4.2 million migrant children vaccinated in NID

• Average 4.8% children (range: 3.9% to 6.2%) < 2 yrs missed in migrant sites,

• Religious congregations also covered

• Any polio case detected will be declared “a public health emergency”

• State Emergency Preparedness & Response Groups (EPRGs) constituted in all states

• Rapid response teams (RRTs) identified and trained

• Risk analysis in states ongoing, 207 poor performing districts

• States need to focus on improving surveillance & immunization in identified HR populations

Action No 4: Emergency Preparedness and Response Plan (EPRP)

Action No 5: Communication challenges & actions

1. Risk of decreased threat perception without WPV

2. Continued pocket of resistance in some areas in UP, Maharashtra and West Bengal - requires continued focus at local level

3. Reporting of AFP cases as Polio - need to train Media

4. Integrated IEC campaigns on RI and Polio

5. New communications approach rolled out

6. Sustained the SM network in UP & Bihar and consolidated in West Bengal

RI and convergence materials produced.

UNICEF Polio Ambassador Amitabh Bachchan launches Communications campaign in December 2011

• Surveillance reviews conducted in Western UP, Bihar, Andhra Pradesh, Maharashtra, Gujarat, West Bengal, Pakur in Jharkhand & Delhi

• Overall surveillance quality exceeds Global standards– Non Polio AFP rate below 2 per 100,000 popn. < 15 yrs in parts of

Chhattisgarh, Andhra Pradesh & Arunachal Pradesh

– Stool collection below 80% in some districts of Chhattisgarh, Andhra Pradesh & Orissa

Action No. 6 : AFP and Environmental Surveillance

INDIA

NEPAL

• Alerted states bordering Pakistan & China • Enhanced sensitivity of AFP surveillance in border

districts, migrants and high risk areas• Continuous vaccination along Pakistan-India-Nepal

border86 vaccination posts>1.5 million children

vaccinated from Apr 2011 to Feb 2012

Vaccination post

Blocks with vaccination post

PAKISTAN

Action No. 7: Response to threat of importation from neighboring countries

5 vaccination posts~1,400 children

vaccinated from Sep 2011 to Feb 2012

• Seroprevalence surveys completed in UP and Bihar indicating high level of immunity in 2011

• Mucosal immunity study field operations completed in December 2011, results expected by July 2012 – 990 study subjects

– assess levels of mucosal immunity

– evaluate which Polio vaccine (IPV or bOPV) is more efficient in boosting mucosal immunity

Action No. 8 : Research to guide programme activities and measure progress

International importation

Gaps in AFP surveillance or

delays in detection of WPV

Delayed and / or inadequate response to importation

Areas with low population immunity

Current Risks to Polio Eradication in India

Risks due to VDPV

Complacency

Risks

Sustaining the quality of

coverage in SIA including

migrant and slum population

Routine immunization

intensification with focus on pockets of

low coverage

Continued Multipronged

strategy in 107 blocks of UP and

Bihar

Maintaining high level of

acceptance of OPV by

communities

Program priorities for Polio Eradication in India

Rapid and effective

response to any Wild Polio virus

detection

Intensified surveillance for early detection

Program Priorities

Summary• Country achieved longest ever polio free period

• Routine Immunization strengthening is a key program priority at this juncture

• Maintain the quality of coverage in NIDs and SNIDs

• Threat of importation needs to be tackled by early detection and rapid mop-up response

Questions for the IEAG• What are the challenges that India is likely to face to

maintain zero polio status until certification and beyond?

• What lessons from other countries can be applied in India to protect the gains made so far?

• What strategies should India follow from 2012 to 2014?

• Is the isolation of VDPVs a concern for India?

• How should India plan for the polio endgame strategy?

Thanks