IEAG Findings 5-6 December 005
Surveillance Quality
Surveillance Indicators India 005* 5.47 8% Less than 60% 60% to 69% 70% to 79% 80% and above No AFP case * data as on 6th November 005
AFP cases India 1998-005 4000 000 0000 18000 16000 14000 1000 10000 8000 6000 4000 000 0 3979 3513 1384 9466 9587 9705 8103 8508 7470 1998 1999 000 001 00 003 004 005 AFP Non AFP
Epidemiology of Polio in India
Number of cases 800 Monthly incidence of polio in India January 1998 September 005* NID NID NID SNID SNID NID SNID NID SNID NID SNID NID Mop-up NID SNID NID SNID 700 600 500 400 300 00 100 0 Jan- 9 8 Mar- 98 M ay- 9 8 Jul- 98 Sep-98 N ov- 98 Jan- 9 9 Mar- 99 M ay- 9 9 Jul- 99 Sep-99 N ov- 99 Jan- 0 0 Mar- 00 M ay- 0 0 Jul- 00 Sep-00 N ov- 00 Jan- 0 1 Mar- 01 M ay- 0 1 Jul- 01 Sep-01 N ov- 01 Jan- 0 Mar- 0 M ay- 0 Jul- 0 Sep-0 N ov- 0 Jan- 0 3 Mar- 03 M ay- 0 3 Jul- 03 Sep-03 N ov- 03 Jan- 0 4 Mar- 04 M ay- 0 4 Jul- 04 Sep-04 N ov- 04 Jan- 0 5 Mar- 05 M ay- 0 5 Jul- 05 Sep-05 1998 1999 000 001 00 003 004 005 NID National Immunization Day SNID Sub-National Immunization Day Large scale mop-up * data as on 9 th November, 005
800 700 600 500 400 300 00 100 P3 Virus: Number of cases by year 0 1998 1999 000 001 00 003 004 005
Characteristics of Polio Cases India, 005* >=10 doses 33% 0 dose 0% 1-3 doses 9% 4-6 doses 8% 4-59 mths 36% 60+ mths % <1 mths 31% 7-9 doses 30% 1-3 mths 31% OPV Status AGE * data as on 1 st December 005
Wild polio cases by Community, 005 Bihar 005* Uttar Pradesh 005* Hindu 54% Muslim 46% Hindu 4% Muslim 58% (N=4) (N=4)
Most recent virus 13 th October 005, Sitamarhi Location of poliovirus, 005* (53 cases) Polio in AFP Uttar Pradesh Bihar Jharkhand Delhi Uttaranchal Punjab 4 4 1 1 1 * data as on 9 th November, 005
* data as on 1 st December, 005 Spread of polio from Bihar, 005 # # # # # # # # # # # # # # # # # # # # # # # Nepal # # # # # # # ### # # # # # # # # # # # # # %
SIA Quality in High Risk Areas
100% 80% 60% 40% 0% Immunization Status (children < 5 years) Uttar Pradesh 0-3 doses 4-6 doses 0% Bihar 100% 1 3 4 1 3 4 1 3 4 1 1999 000 001 00 003 004 3 4 1 3 4 1 3 4 1 3 005* 80% 60% 40% 0% 0% 1 3 * data as on 6th November 005 4 1 3 4 1 3 4 1 1999 000 001 00 003 004 005* 3 4 1 3 4 1 3 4 1 3
Supervisors Cross-checking Work September 005 93% 8% West UP < 80 % 80% to 90% > 90% Bihar
Comparison of PPI Coverage Number of children in million 0 18 16 14 1 10 8 0 19.6 19.5 19.7 0. 0.3 0.4 0.4 0.3 0.4 6 ~ 43.5% increase in April 05 coverage over Oct 04 40 38 36 34 3 30 0 Oct-04 Nov-04 Jan-05 Feb-05 Apr-05 May-05 Jun-05 Aug-05 Sep-05 35. 36.4 37.4 Bihar still has 1-14% of houses with missed children vs. just 6-8% in UP. 38.5 39.0 39.3 39.0 38.9 38.7 8 6 ~ 411% increase in April 05 coverage over Oct 04 Oct-04 Nov-04 Jan-05 Feb-05 Apr-05 May-05 Jun-05 Aug-05 Sep-05 Bihar Uttar Pradesh
Teams not working by SIA microplan May 05 Sep 05 7.3% 9.1%
Impact of mopv1
Summary of mopv1 Use, 005 4-6 mopv1 rds, Apr-Nov in the 3 reservoir areas. 1 round rounds 4 rounds 5 rounds 6 rounds 300 m doses used in Apr-Nov 005
Number of Polio cases, India 10 100 116 104 80 60 40 3 36 0 0 5 8 003 004 005 February April May October Data as of nd December 005
WPV1 Positive Mumbai Sewage Samples Jan 04 Oct 05 topv mopv1 topv % positive for Wild P 1 100% 90% 80% 70% 60% 50% 40% 30% 0% 10% 0% J- 04 F M A M J J A S O N D J- 05 58% +ve in May-Oct '04 vs. 7% in same period in 005. F M A M J J A S O Month of sample collection August, September, October isolates are importations
P1 wild, 004-005 16 13 high risk districts-up 16 Bihar 14 14 1 1 10 10 8 8 6 6 4 4 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 004 005 004 005 Data as of nd December 005
Proportion of AFP with Wild Poliovirus by season & state, 003-005 Positive AFP Cases (%) 6 5 4 3 1 mopv1 Uttar Pradesh Bihar 0 Low 03 High 03 Low 04 High 04 Low 05 High 05
Summary Introduction of mopv1 & innovative SIA approaches has reduced polio to lowest incidence and geographic extent ever. Progress is fragile, and Bihar now poses highest risk, as evidenced by recent exports to Jharkhand, Punjab and Nepal. The enhanced impact of mopv1 during the low season could stop all polio in early-006.
topv Immune Response & Season * Mumbai, India, 1977 100 90 Seroconversion (%) 80 70 60 50 40 30 0 10 0 I II III Poliovirus Type High (Feb-Apr) Low (Nov-Jan) * Pangi NS, Master JM, Dave KH. Ind Ped XIV(7); 1977.
Recommendations
Programme Priorities Bihar: districts in north east, north west & Patna are the highest priority due to: high case numbers, geographic extent, exportations to polio-free areas, suboptimal SIA quality. Uttar Pradesh: western districts remain very high priority due to ongoing WPV1 transmission & last type 3 isolations.
State Government Oversight Bihar: Build on engagement of new Chief Minister with full polio briefing, as soon as possible. Propose biweekly CM briefing during the critical 3 month period through end-feb. CS to consider (a) weekly oversight of Jan/Feb preps (esp. high priority districts) and (b) establish Polio Task Force & Polio Cell. UP: sustain high level State Government & District Administration oversight of eradication activities.
Recommended SIA Schedule NIDs NIDs SNIDs SNIDs SNIDs Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 006 007
SNIDs Jan-Feb 006 Extent: all of UP, Bihar, Delhi, Greater Mumbai/Thane & selected districts of Jharkhand and Uttaranchal. Vaccine: mopv1 in WUP, Bihar & Greater Mumbai; elsewhere topv. International Coordination: with infected areas of Nepal.
Vaccine mopv1: use in all SIAs in all areas of known type 1 transmission & at highest risk. topv: use for all routine immunization activities and SIAs in polio-free states. mopv3: use in all SIAs responding to WPV3; in absence of WPV3, and if feasible, mopv3 could be used in at least 1 rd in WUP districts at highest risk of WPV3.
Enhancing SIA Impact 1 Continue Recent Innovations: High Risk Area (HRA) approach. Underserved strategies. Transit sites (incl. railway plan). Deploy as many SMOs as possible to HRAs (esp. in Bihar), to facilitate SIA planning, monitoring, etc in Jan/Feb. Expand SM Net as proposed in Bihar & ensure adequate resources for same.
Enhancing SIA Impact - Bihar State government: consider assigning a senior IAS Officer on Special Duty to oversee day-to-day operations with CS & Secretary for FW. District & Block Administrations: Ensure existing/acting DMOs & MOICs fully involved in block level planning/preps; DM to monitor engagement. if positions vacant, immediately assign DMO & MCIO polio responsibilities to other, existing staff. December Planning Meeting: review & enhance mechanisms for reaching missed children (i.e. X houses, revisiting, children outside households)
Surveillance NPSP should continue current approach to monitor & address state & sub-state surveillance issues. During the detailed investigations of 'hot cases' and virus-confirmed cases, the IEAG reaffirms the importance of also reviewing the history of compatible cases in the area.
Routine Immunization IEAG notes the work to implement national & state routine EPI plans and recommends: Enhanced work, under the NTAG, to link the monitoring of outreach sessions to coverage data. High priority districts in WUP & Bihar should be targeted for intensive efforts to improve routine immunization. Consideration should be given to expanding external monitoring activities to other states.
Summary
Summary Introduction of mopv1 & innovative SIA approaches has reduced polio to lowest incidence and geographic extent ever. Progress is fragile, and Bihar now poses highest risk, as evidenced by recent exports to Jharkhand, Punjab and Nepal. Enhanced impact of mopv1 during low season could stop all polio in early-006. Strong partner support to GoI is essential.