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