AFP ALERT

NATIONAL POLIO SURVEILLANCE PROJECT

Country Office for India

june 2012

Twenty-fourth Meeting of the India Expert Advisory Group (IEAG) for Polio Eradication-Key Findings & Recommendations
The twentyfourth meeting of the advisory body on polio eradication-the India Expert Advisory Group (IEAG) was held at New Delhi on 15-16 March 2012. This was for the first time that the IEAG met in the context of India being polio-free for more than 12 months. The Group reviewed the progress on polio eradication and made recommendations on strategies to ensure that India remains polio-free until global eradication is achieved. The IEAG meeting commenced with a very encouraging note from Ms Anuradha Gupta, Additional Secretary, Ministry of Health & Family Welfare, Government of India. She stated India has passed a polio-free year and is no longer considered a polio-endemic country by World Health Organization. However, she cautioned that India is at high risk of importation from countries with active circulation.

Dr Nata Menabde, Country Representative for World Health Organization-India, appreciated Indias success in polio eradication and highlighted the committed role of the government and polio partners in the programme. She emphasized the significant impact of IEAG recommendations on polio eradication since 1999. She commented It takes a lot of effort to achieve success and a lot more to sustain it.

cONTExT
A POlIO FREE INdIA
Punjab Rajisthan Gujarat Maharashtra Haryana Delhi Uttar Pradesh Madhya Pradesh Bihar Orrisa Sikkim Meghalaya Tripura Arunachal Pradesh Assam Jammu & Kashmir

Major findings and conclusions of the IEAG

India has not reported wild poliovirus from any source since January 2011 and has been removed from the list of endemic countries by the World Health Organization. India has been able to maintain high quality polio immunization campaigns and AFP surveillance activities. There are significant risks to the programme that need to be identified and mitigated to sustain the gains made so far.

calcutta

Mizoram

Manipur

Nagaland

No WPV from any source since January 2011. India is no longer an endemic country
Arabian Sea Lakshadeep Kerala Pondicherry Tamil Nadu Madras Bay of Bengal

Andhra Pradesh

Last confirmed case of polio detected in January 2011

Risks to maintaining poliofree status in India

1. International importation of wild poliovirus from endemic countries such as Afghanistan, Pakistan and Nigeria and other countries with active circulation. 2. The rare situation of emergence of cVDPVs (particularly cVDPV type 2) can develop in areas with low routine immunization coverage.
*23rd May 2011 - 22nd May 2012 Wild virus type 1 Wild virus type 3 Wild virus type 1/3 Endemic country Country with WPV case in previous 6 months Country with WPV case 6-12 months ago
1Excludes viruses detected from environmental surveillance and vaccine derived polioviruses. Data in WHO HQ as of 22nd May 2012

IEAG Recommendations
1. Maintaining immunity High quality supplementary immunization activities (SIAs) and routine immunization (RI) will help maintain optimum population immunity to minimize the risk and consequences of any WPV importation and reduce the occurrence of cVDPVs. OPV Supplementary Immunization Schedule (SIAs) Polio SIAs in 2012: 2 Nationwide campaigns (NIDs) with tOPV + 5 SubNational Immunization Days (SNIDs) with bOPV Polio SIAs in 2013: 2 NIDs with tOPV + 4 SNIDs with bOPV Polio SIAs in 2014: 2 NIDs with tOPV + 3 SNIDs with bOPV

Recommended SIAs, 2012 - 2014

NId with tOPV

SNId with bOPV

2012
jan feb mar apr jan feb mar apr

may

jun

jul

aug

sep

oct

nov

dec

2013
may jun jul aug may jun jul aug

sep

oct

nov

dec

jan

feb

mar

apr

2. Maintaining surveillance and laboratory performance The IEAG was satisfied with the overall performance of the AFP surveillance system. The IEAG recommended the following actions: A high level of vigilance in the coming months to rapidly detect any importation or circulation of wild poliovirus and VDPVs, particularly in high risk areas and populations.

Expansion of environmental surveillance to Punjab and Gujarat during 2012. Regular field reviews of surveillance system to identify gaps and follow up reviews to assess progress. Greater involvement of district and block level government officials in all components of AFP surveillance. Ensure sufficient human and financial resources for the polio laboratory network to maintain the current level of performance.

2014
sep oct nov dec

Surveillance performance indicators, last 6 months

Non-polio AFP rate Stool collection rate

Polio laboratory performance

Number of stool specimens processed
83,528 65,011 91,148 100,102 109,090 118,866

2006

2007

2008

2009

2010

2011*

Number of days from stool received in laboratory to final result

35 30 25 20 15 10 5 0

Less than 0.70 0.70 to 0.99 1 to 1.99 2 and above No AFP case

Less than 60% India 60% to 69% Less than 60% 70% to 79% 60% to 69% 70% to 79% 80% and above 80% and above No AFP case No AFP case

Days

14.3

86%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2006
*Data as on 10 March 2012

2007

2008

2009

2010

2011*

3. Readiness to respond Emergency preparedness and response plans (EPRPs) from all the states and union territories (UTs) should be reviewed and evaluated by Government of India and polio partners. All state plans must adequately address plans for overcoming staff vacancies in high risk areas; systematic field validation and inclusion of high risk areas & populations for strengthening immunization activities; strengthening of RI micro-plans with help from SIA plans in high risk areas; assignment of high risk districts to Rapid Response Team (RRT) members for review of AFP surveillance, SIAs and RI and plans for procurement of logistics and IEC materials for undertaking urgent mopups, if required. All EPRPs should be updated at least annually with a full new risk analysis. Government of India should undertake simulations of the emergency response plans at national and state levels on an urgent basis.

Any evidence of a circulating VDPV (cVDPV) should be immediately addressed with an urgent mop-up response to prevent circulation and risk of further VDPV emergence. Continued community engagement and other ground level initiatives through the social mobilization network (SMNet) in Uttar Pradesh, Bihar, West Bengal and Malegaon (Maharashtra) must be maintained through 20122013. Engage journalists to ensure accuracy of reporting. Conduct media training for all identified EPRP and health spokespersons in key states
Bollywood Superstar Mr Amitabh Bachchan actively campaigning for a polio-free India

Communications and social mobilization

4. Reducing risk

Importation of wild poliovirus from areas with current circulation Focus on immunization of border populations during each SIA and RI campaign and continue vaccination of children crossing the border points with Pakistan and Nepal.

A child being vaccinated at a border crossing point at Munabao Railway Station, Rajasthan

A childderived polioviruses (VDPVs) a border being vaccinated at Vaccine crossing point at are to be thoroughly All detected VDPVs Munabao Railway investigated to determine Station, Rajasthan risk of circulation. Any
identified deficiencies in RI coverage in these areas should be shared with State Secretary of Health for corrective actions.

Bollywood Superstar Mr Amitabh Identify migrant areas, urban and peri-urban Bachchan populations and incorporate them into high risk actively campaigning for SIA, surveillance and a polio-free India RI plans on priority.

Continued focus on high risk areas and groups

Government and partners to focus on 107 high risk blocks of UP and Bihar.

OPV supply The Union Government should: Undertake appropriate steps to ensure timely and sufficient supplies of OPV for polio vaccination campaigns. Ensure a rolling emergency stock of 50 million doses of OPV (40 million bOPV+10 million tOPV) to enable rapid response to both WPV and cVDPV detection.

5. Building on polio eradication The intensification of routine immunization and activities related to EPRP are synergistic and need coordination on following issues: Converge polio eradication and routine immunization activities by applying the lessons learnt from polio eradication in strengthening RI. Consolidate and operationalize state EPRPs and universal immunization programme (UIP) plans with a greater focus on high risk (HR) areas and populations. Improve routine immunization in 239 low performing priority districts identified by the national programme and ensuring presence of Auxiliary Nurse Midwives (ANMs) and Medical Officers (MOs) in these areas. Conduct immunization weeks in the low performing HR states. Scale-up the monitoring of RI sessions and the use of monitoring data for programme decision making at all levels Expand the AFP surveillance system to other vaccine preventable diseases.

Districts with Low RI coverage, India

DLHS 3 coverage < 50%

6. Preparing for the endgame The national immunization programme should plan to switch from tOPV to bOPV in RI in 2014 and eventual global cessation of all OPV possibly by 20172018. Consider introduction of at least one dose of IPV (e.g. at DPT 3 contact) before tOPV-bOPV

switch to boost population immunity and reduce risk of type 2 cVDPV emergence. Examine the programmatic need and cost implications of adding an IPV dose to the routine EPI schedule in advance of a global tOPV-bOPV switch.
Polio Certification tOPVbOPV switch

Polio Endgame Strategy-India, Potential Timeline

tOPV NID NID NID NID NID

Last WPV case NID NID

jan

mar

2011

may

jul

sep

nov

Certification standard surveillance, improved RI coverage

jan mar may

Modeling, Research, Development

jul sep nov jan mar

NID IPV intro?

NID

Post switch VDPV type 2 risk mgt.

2012

2013

may

jul

sep

nov

jan

mar

2014

may

7. Research activities The Indian programme should implement the planned research agenda, giving priority to: Complete mucosal immunity study which started in November 2011. Conduct seroprevalence surveys in 5 high risk and 5 non high risk blocks in both UP and Bihar during 2012.

Assess the immunogenicity of bOPV from different manufacturers. Assess immunogenicity and programme feasibility of administering bOPV plus IPV as a part of EPI schedule. Assess the socio-demographic characters of households which influence OPV compliance during vaccination campaigns in Malegaon, Maharashtra.

Pulse Polio Immunization Programme receives the National Innovation Star Award

important criteriathe impact of the innovation on the lives of people; newness of the idea and rigorous implementation with involvement of all stakeholders. The Ministry of Health & Family WelfareGovernment of India was selected for this award this year for a successful implementation and management of the pulse polio programme, which led to India achieving polio free status. Mr P.K Pradhan, Secretary, (Health & Family Welfare), Ministry of Health & Family Welfare received the award on behalf of Government of India. During the panel discussion titled innovation insights, Mr Pradhan mentioned that Indias victory against polio can be attributed to the strong political commitment, government ownership and contribution by polio partners such as WHO India-NPSP, UNICEF and Rotary. He also highlighted the role of fixing accountability at all levels and zero tolerance for missed children for this achievement. Dr Montek Singh Ahluwalia, Deputy Chairman, Planning Commission was the Chief Guest for the National Innovation Awards programme on 4 May 2012. In his address he mentioned India has made an amazing achievement in the polio eradication programme. It has been 16 months that India has not reported any case of polio. We could not have eliminated this disease if the vaccination coverage was not close to 100 per cent.

Mr P.K Pradhan, Secretary, (Health & Family Welfare), Ministry of Health & Family Welfare, Govt of India receiving the National Innovation Star Award from Dr Montek Singh Ahluwalia, Deputy Chairman, Planning Commission

Mr P.K Pradhan, Secretary, (Health & Family The Indian Innovation Awards programme of the Welfare), Ministry andHealth & Family Welfare, Entrepreneurship of Management Processes Govt International (EMPI) Group ofNational in of India receiving the Institutions Innovation collaboration with the Indian Express has been Star Award from Dr Montek Singh Ahluwalia, recognizing innovative organizations to promote a Deputy Chairman, Planning Commission culture of innovation in India since 2005. The awardees

are selected by an independent jury based on three

WHO India supports Polio eradication in Nigeria

India has been in the spot light this year for having been removed from the list of polio endemic countries, however wild virus transmission continues in the other three remaining endemic countries, namely Afghanistan, Nigeria and Pakistan. The World Health Assembly has escalated the Polio Eradication Initiative to a Global Public Health Emergency. This declaration essentially commits the organization, and appeals to the global partners, to place additional resources in support of the intensive polio eradication efforts in the remaining endemic and re-infected countries. WHO-India has been called on to help support this global public health emergency by sending Medical Officers to Nigeria to assist the WHONigeria staff in strengthening SIA microplans, supporting trainings to improve quality of polio campaigns and improving the quality of monitoring. This team of sixteen Medical Officers from WHO India NPSP has left for the Nigeria mission.