1. Current Strategies for eradication of polioSPEAKER :- PREETI RAI TEACHER I/C:- Dr. Dheeraj Mahajan DATE :- 31 / 12 / 2013 1

2. What is polio? The words polio (grey) and myelon (marrow, indicating the spinal cord) are derived from the Greek. It is the effect of poliomyelitis virus on the spinal cord that leads to the classic manifestation of paralysis. 3. History of polio The disease of poliomyelitis has a long history. The first example may even have been more than 3000 years ago. An Egyptian stele dating from the 18th Egyptian dynasty (1580 1350 BCE) shows a priest with a deformity of his leg characteristic of the flaccid paralysis typical of poliomyelitis.. 4. In the 1940s and 1950s iron lungs were used to regulate breathing and keep polio patients alive. 5. PROBLEM STATEMENT When the World Health Assembly launched the Global Polio Eradication Initiative (GPEI) in 1988, it was widely acknowledged that India would be one of the most challenging countries for polio eradication. By 2006, Afghanistan, India, Nigeria, and Pakistan were the only remaining polio endemic countries .Since the GPEI was launched, the number of cases has fallen by over 99%. In 2013, only three countries in the world remain polioendemic: Nigeria, Pakistan and Afghanistan 6. In the mid-1990s, an estimated 150,000 polio cases were reported annually in India. The last case of polio was reported on 13th January 2011 from West Bengal and further no case of polio has been reported in the country since then. . India has been polio free for more then a year and was removed from the Endemic. P2 Wild Polio Virus eradicate from the world in 1999 7. Number of polio cases worldwide from 2000 to 2010 8. Number of polio cases from 1998 to 2013. 9. Despite very high coverage during immunization activities & intensive use of mOPV1, transmission of type-1 WPV has persisted in U.P. & Bihar 10. Last wild poliovirus type 1 (WPV1) case: 13 January 2011, Howrah, West BengalLast wild poliovirus type 2 (WPV2) case: October 1999, Aligarh, Uttar Pradesh Last wild poliovirus type 3 (WPV3) case: 22 October 2010, Pakur, Jharkhand Last positive case from monthly environmental sewage sampling (conducted in Delhi, Mumbai and Patna): November 2010, Mumbai . 11. EPIDEMIOLOGY AGENT: POLIOVIRUS TYPE : THREE SERO TYPES(TYPE-1,TYPE-2,TYPE-3) RESERVOIR: HUMAN ONLY INFECTIOUS MATERIAL: FAECES, OROPHARYNGEAL SECRETIONS PERIOD OF COMMUNICABILITY: 7 TO 10 DAYS BEFORE AND AFTER ONSET OF SYMPTOMS AGE : 6 MONTHS TO 3 YEARS ARE MOST VOLUNERABLE 12. ENVIRONMENT : RAINY SEASON (JUNE TO SEPTEMBER) MODE OF TRANSMISSION: FAECO ORAL ROUTE, DROPLET INFECTION. FAVOURABLE CONDITIONS: OVER CROWDING,POOR SANITATION,SLUMS INCUBATION PERIOD: 7 TO 14 DAYS( 3- 35 DAYS) 13. POLIO VIRUS THREE TYPES TYPE-1EPEDEMICS causes outbreaksis the most likely virus to cause paralysis. TYPE-2---THIS IS THE FIRST SERO TYPE TO DISAPPEAR. TYPE-3--- PARALYSIS LESS FREQUENT. 14. Clinical Spectrum of Polio Asymptomatic =inapparent=subclinical91-96% Minor non CNS=Abortive polio illness4-8%Aseptic meningitis =NON paralytic polio-1% stiffness and pain in neck n back Paralytic Polio90% immune after 2 doses >99% immune after 3 doses Duration of immunity not known with certainty 50% immune after 1 dose >95% immune after 3 doses Immunity probably lifelong 16. VDPV Vaccine-derived polioviruses (VDPVs) are rare but welldocumented strains of poliovirus ,which emerge after prolonged multiplication of attenuated strains of the virus contained in the oral polio vaccine (OPV) in the guts of children with immunodeficiency or in populations with very low immunity. In1999-2000 it was proven that vaccine-derived polioviruses (VDPVs) could regain the capacity to cause polio outbreaks (i.e. become circulating VDPVs or cVDPVs). 17. The management of VDPVs is a necessary part of the global polio eradication effort, and is similar to management of wild poliovirus outbreaks; i.e. by rapid implementation of high-quality SIAs. Global experience with VDPVs shows that they can be rapidly stopped, with 2-3 rounds of high-quality, large scale immunization rounds. 18. The Global Polio Eradication Initiative 19. Four Pillars of the Global Polio Eradication Initiative Strategy 1. Routine Immunization 1985 2. Supplemental Immunization Activities 1995-96 3. Acute Flaccid Paralysis (AFP) Surveillance 1997 4. Targeted Mop-Up Campaigns 20. WHY POLIO IS A CANDIDATE FOR ERADICATION ? 21. Four Pillars of the Global Polio Eradication Initiative Strategy 1. Routine Immunization 1985 A major cornerstone of the polio eradication strategy is ensuring that at least 80% of children receive all the recommended routine childhood immunizations. Good routine OPV coverage increases population immunity, reduces the incidence of polio and makes eradication feasible plan of routine immunization for out reach areas. . 22. According to WHO/UNICEF immunization coverage estimates, 86% of infants received three doses of oral polio vaccine in 2010, compared with 75% in 1990. 23. 2. Supplemental Immunization Activities 1995-96 Mass polio immunization campaigns that complement routine immunization programs are intended to interrupt transmission by immunizing every child under the age of 5 with oral polio vaccine annually, regardless of the number of times they have been immunized previously. These campaigns help protect children who are not immunized or only partially protected and boost the immunity of those who are immunized, thereby reducing or eliminating the pool of potential hosts. 24. WHAT IS PULSE POLIO ?TO IMMUNIZE ALL THE KIDS< 5YRS NATION WIDE ON A SINGLE DAY IN THE SHORTEST POSSIBLE TIME WITH OPV & THAT THE ENVIRONMENT WILL GET SATURATED WITH THE VACCINE VIRUS SO THAT IT WILL REPLACE THE WILD VIRUS AND THUS INTERUPT THE TRANSMISSION OF WILD VIRUS . 25. National Immunization Days (NIDs) - which are conducted countrywide 2 or 3 times per year, 1 month apart. National Immunization Days are conducted in two rounds, one month apart. Because oral polio vaccine does not require a needle and syringe, volunteers with minimal training can serve as vaccinators. Three to five years of NIDs are usually required to eradicate polio, but some countries require more time, especially those where routine immunization coverage is low. NIDs are normally conducted during the cool, dry season because logistics are simplified, immunological response to oral polio vaccine is improved and the potential damage to heatsensitive vaccine is reduced. 26. Synchronized NIDs Neighbouring countries are coordinating, or "synchronizing" their National Immunization Days. This ensures that children crossing borders for any reason are identified and immunized. It also allows health teams to cross borders and immunize children in pockets of territory otherwise isolated by rivers or mountains, or on islands that may be less accessible from the other side. This approach was first used between countries of eastern Europe and central Asia, in a successful campaign called "Operation MECACAR." Similar synchronized efforts have been undertaken along the borders of Afghanistan and Pakistan. 27. Polio cases and SIAs 28. 3. Acute Flaccid Paralysis (AFP) Surveillance -1997 As many as 90% of people infected with the poliovirus experience very mild or no symptoms. A single symptomatic case can therefore represent a significant community-wide outbreak. Robust surveillance to detect and investigate every case of polio-like AFP is essential to polio eradication. 29. AFP case definition broadened Consequences of missing the case of polio are more serious then occasionally including and ambiguous case, specially during the final stage of polio eradication. Includes every case with current flaccid paralysis History of flaccid paralysis in the current illness Boarder line and ambiguous case Transient weakness / paralysis 30. AIM OF AFP SURVEILLANCE TO DETECT POLIO TRANSMISSION & INTERRUPTION OF TRANSMISSION AFP CASE POLIO CASE RESERVOIR OF INFECTION [ 100 TO 1000 SUB CLINICAL CASES ]CONTAINMENT MEASURES [ O.R.I. / MOP UP ] 31. COMPONENTS OF AFP SURVEILANCE 1.The AFP surveillance network and case notification 2.Case and laboratory investigation 3.Outbreak response and active case search in the community 4.60-day follow-up, cross-notification and tracking of cases 5.Data management and case classification 6.Virologic case classification scheme 7. Surveillance performance indicators 32. The most important aspect of this classification is the collection of 2 adequate stool samples from all cases. Samples are considered adequate if both the specimens. (1) are collected within 14 days of paralysis onset and at least 24 hours apart. (2) are of adequate volume (8-10g) and (3) arrives at a WHO-accredited laboratory in good condition (ie, no desiccation, no leakage), with adequate documentation and evidence of cold-chain maintenance. 33. AFP Reporting Network PaediatricianNeurologistPhysicianGen. Pract.Dist. Hospital PHC RH MPW/ ANM Traditional Healer QuackDHO/ MOH/ SMOState DelhiWHO 34. Flow Diagram of AFP Case Investigation 35. WHY AFP SURVEILLANCE INSTEAD OF POLIO SURVEILLANCE ? SURVEILLANCE OF A POLIO CASE ALONE IS NOT SUFFICIENT BECAUSE IT IS IMPOSSIBLEE TO PRECISELY IDENTIFY ALL CASES OF POLIO CLINICALLY DUE TO CONFUSING AND AMBIGUOUS CLINICAL SIGNS AND VARIABLE CLINICAL KNOWLEDGE & SKILLS OF DOCTOR. CLINICALLY POLIO IN ACUTE STAGE, IS DIFFICULT TO DISTINGUISH FROM OTHER CAUSES OF ACUTE ONSET OF FLACCID PARALYSIS. 36. When too much polio is around..AFP cases Polio cases Borderline AFP cases Non-AFP casesSurveillance sensitivity is adequate enough to detect 90% polio cases 37. Data Flow MondaysReporting Units Tuesdays Districts Wednesdays States Thursday DelhiDistricts State NPSU Delhi WHO 38. Outbreak Response Immunization (ORI) Measures to stop transmission of polio virus Children