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DR.SHWETHASHREE M

GUIDE: DR.JAYARAM S

Current Status …

Achievements….

Challenges for

eradication ….!!! 31/01/2014

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Introduction Epidemiology Clinical scenario History Status- past & current Achievements Eradication – Steps, challenges &strategy Summery

Out line

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an acute infection caused by an RNA virus

Inflammation of grey matter of the spinal cord

INTRODUCTION

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Agent: poliovirus sero types-

Type 1 (Brunhilde/Mahoney): mostly causes outbreaks

Type 2 (Lansing): easiest to eradicate

Type 3 (Leon): often last to be eradicated

Host : age : 6 months to 3 years

Environment : rainy season

Infectious material : faeces, oro-pharyngeal secretions

Incubation period: 7 to 14 days( 3- 35 days)

EPIDEMIOLOGYGroup:

Group IV ((+)ssRNA)Family:

PicornaviridaeGenus:

EnterovirusSpecies:

Poliovirus

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Period of communicability: 7 to 10 days

Reservoir: man

Mode of transmission: faeco – oral route, droplet infection

Highly contagious (usually infects 100% of all susceptible)

Occurs worldwide and is seasonal

Inapparent to apparent infection ratio = 200-1000:1

cont…

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CLINICAL SPECTRUM

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Among children who are paralyzed by polio:o 30% make a full recovery o 30% are left with mild paralysis o 30% have medium to severe paralysis o 10% die

prognosis

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Polioviruses: Are human enteroviruses ,which infect cells via a specific receptor [PVR: CD 155]

Wild polioviruses: field isolates and reference strains of polioviruses known to have circulated persistently in the community.

Oral poliovirus vaccine strains: attenuated polioviruses approved for use in oral vaccines by national control authorities.

Vaccine derived polioviruses : mutated progeny of approved poliovirus vaccine strain.

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HISTORY

1580-1350 BC an Egyptian tablet portrays a priest with a withered leg , indicating that the disease dates backs to ancient times

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GLOBAL

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INDIA

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1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011*

0

250

500

750

1000

1250

1500

1750

2000Indian epidemiological approach

P1 wild P3 wild

P2 cases eradicated in 1999 14 States and UTs free of polio Since 2001 NIDs conducted since 1995 covering 170 million children per round Sharp decline in polio cases in 2010 Single WPV 1 case reported in 2011 and longest polio free period

741

42 1

mOPV 1

bOPV

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STATUS …..

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Country or territory3 2008 2009 2010 2011 2012 2012 2008 2009 2010 2011 2012 2013Israel 0 0 0 0 0 0 0 NA NA 159 01-Dec-13Pakistan 117 89 144 198 58 56 75 18-Apr-12 26-Nov-13 18 79 142 89 49 11-Nov-13Afghanistan 31 38 25 80 37 34 11 11-Apr-10 12-Nov-13 2 27-Jul-09Cameroon 0 3 0 0 0 0 4 15-Oct-09 30-Oct-13Somalia 0 0 0 0 0 0 183 NA 09-Oct-13Nigeria 798 388 21 62 122 119 50 10-Nov-12 08-Oct-13 1 15 3 29-Apr-13Syria 0 0 0 0 0 0 17 NA 08-Oct-13Ethiopia 3 0 0 0 0 0 6 NA 19-Sep-13West Bank and Gaza 0 0 0 0 0 0 0 NA NA 3 20-Aug-13Kenya 0 19 0 1 0 0 14 NA 14-Jul-13Egypt 0 0 0 0 0 0 0 NA 03-May-04 2 1 2 06-Dec-12Niger 12 15 2 5 1 0 0 NA 15-Nov-12Chad 37 64 26 132 5 5 0 10-Mar-11 14-Jun-12DRC 5 3 100 93 0 0 0 24-Jun-09 20-Dec-11CAR 3 14 0 4 0 0 0 09-Aug-09 08-Dec-11China 0 0 0 21 0 0 0 NA 09-Oct-11Guinea 0 42 0 3 0 0 0 03-Aug-11 03-Nov-09Côte d'Ivoire 1 26 0 36 0 0 0 24-Jul-11 06-Aug-09Angola 29 29 33 5 0 0 0 17-Nov-08 07-Jul-11Mali 1 2 4 7 0 0 0 23-Jun-11 01-May-10Congo4 0 0 441 1 0 0 0 NA 22-Jan-11Gabon 0 0 0 1 0 0 0 NA 15-Jan-11India5 559 741 42 1 0 0 0 22-Oct-10 13-Jan-11 33 2 19 10-Nov-10Uganda 0 8 4 0 0 0 0 NA 15-Nov-10Russian Federation 0 0 14 0 0 0 0 NA 25-Sep-10Liberia 0 11 2 0 0 0 0 NA 08-Sep-10Nepal 6 0 6 0 0 0 0 15-Oct-08 30-Aug-10 1 12-Jul-10Kazakhstan 0 0 1 0 0 0 0 NA 12-Aug-10Tajikistan 0 0 460 0 0 0 0 NA 04-Jul-10Turkmenistan 0 0 3 0 0 0 0 NA 28-Jun-10Senegal 0 0 18 0 0 0 0 NA 30-Apr-10Mauritania 0 13 5 0 0 0 0 NA 28-Apr-10Sierra Leone 0 11 1 0 0 0 0 NA 28-Feb-10Burkina Faso 6 15 0 0 0 0 0 NA 25-Oct-09Burundi 0 2 0 0 0 0 0 NA 12-Sep-09Sudan 26 45 0 0 0 0 0 16-Dec-08 27-Jun-09 1 09-Jan-09Benin 6 20 0 0 0 0 0 01-Dec-08 19-Apr-09Togo 3 6 0 0 0 0 0 NA 28-Mar-09Ghana 8 0 0 0 0 0 0 NA 08-Nov-08Total 1651 1604 1352 650 223 214 360 35 23 100 143 106 214Total wild virus type 16 976 482 1265 583 202 192 360Total wild virus type 3 675 1122 87 67 21 22 0Tot. in endemic countries 1505 1256 232 341 217 209 136Tot. in non-end countries 146 348 1120 309 6 5 224No. of countries 18 23 20 16 5 4 8No. of endemic countries 4 4 4 4 3Countries in yellow are endemic. Countries in pale yellow are considered to have active transmission (i.e. within the previous 6 months) of an imported poliovirus

Wild virus confirmed cases Wild virus reported from other sources2

01 Jan - 17 Dec1 Date of most recent type 3

Date of most recent type 1

Date of most recent virus2013

1Data in WHO HQ on 18 Dec 2012 for 2012 data and 17 Dec 2013 for 2013 data. 2Wild viruses from environmental samples, contacts and other non-AFP sources. 3All cases, except

those occurring in endemic countries, are importation related. 4The 2010 total includes cases with inadequate specimens that were exceptionally classified as confirmed polio

based on their association with the WPV1 outbreak.5As of 28 February 2012, India is no longer considered to be a polio-endemic country. 6Includes 1 case in 2012, 3 in 2009 and 2 in 2008 with a mixture of W1W3 virus. NA - Most recent case had onset prior to 1999.

Total Total

Wild Poliovirus 2008 - 2013

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Global polio cases, last 6 months

Horn of AfricaOutbreak

Middle EastOutbreak

Central AfricaOutbreak

Wild Poliovirus type 1

Virus concentrated in poor access areasSubstantial new

international spread

2013360 cases8 countries

India: 2yr 11 mnts without a Polio case

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International spread of polioRisk of WPV importation into India

• Afghanistan re-infected• Egypt, Israel, Palestine sewage• Horn of Africa re-infected• Syria re-infected• Cameroon re-infected31/01/2014 23

China polio outbreak 2011

Xinjiang

Hotan

Immunization of migrants–cotton harvesting

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India’s immunization coverage 61% as of

2012

Estimated and Reported Cases, India

Before 1978*

1994 1998 2002 2008 2009 2010 2011 2012 20130

50,000

100,000

150,000

200,000200000

50000

1934 1600 559 741 42 1 0 0

*Based on IAP/WHO estimates

• OPV introduced in RI in 1978

• Pulse Polio started in 1995

• AFP Surveillance started in 1998

•No WPV case since 13th January 2011

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Last wild poliovirus cases by type, India

WPV2 24/10/1999Aligarh (UP)

WPV1 13/01/2011Howrah (WB)

WPV3 22/10/2010Pakur (JH)

* data as on 10 January 2014 31/01/2014

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Location of wild poliovirus and VDPV cases by type, India

2011

State P2 P3 TotalChhattisgarh 1 0 1Madhya Pradesh 1 0 1Orissa 0 1 1Punjab 1 0 1Rajasthan 1 0 1Uttar Pradesh 2 0 2Total 6 1 7

VDPVs

State P1 P3 TotalWest Bengal 1 0 1Total 1 0 1

WPVs

State P2West Bengal 1Total 1

VDPV

2012 2013*

State P2Bihar 1Maharashtra 2Odisha 1Uttar Pradesh 1Total 5

VDPV

* data as on 10 January 2014 31/01/2014

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Environmental surveillance, India

*: data as on 10 January 2014

YearNumber of

sewage sample collection sites

Number of sewage samples collected

Number of sewage samples

with WPV

2005 3 151 16

2006 3 24 2

2007 3 102 12

2008 3 156 32

2009 3 156 2

2010 8 297 20

2011 15 501 0

2012 17 742 0

2013* 21 885 0

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Wild poliovirus type 1Wild poliovirus type 3

Negative for wild poliovirusScheduled but sample not collectedX

Sampling not scheduled

Wild poliovirus detected in sewage samples, 2010 – 20112010

2011Mumbai

Delhi

Patna

Kolkata

Week

F ward

G ward

M ward

Week

Red cross hospital

Bhalaswa lake

Wazirpur JJ colony

Swarn cinema

Batala house (Okhla)

Sonia vihar

Nangloi

Week

Choti pahari

Dujara

Transport nagar

Week

Ward 8, MM

Ward 135, KMC

49 50 51 5245 46 47 4841 42 43 4437 38 39 4033 34 35 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

XX XXX

XXX

XXXXXXX

X XXXX

X XXXX

XX

X

XXX

X XXXXXX

X

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 39 4033 34 35 36 5245 46 47 48

X

49 50 5141 42 43 4437 38

Mumbai

Delhi

Week

F ward

G ward

M ward

Week

Red cross hospital

Bhalaswa lake

Wazirpur JJ colony

Swarn cinema

Batala house (Okhla)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

X X X X X

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

X X X

X X X

X X X

X X

X X X X X

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Wild poliovirus type 1Wild poliovirus type 3 Result pending

Negative for wild poliovirus Scheduled but sample not collectedX

Sampling not scheduled

Wild poliovirus detected in sewage samples, 2012

Mumbai

Delhi

Patna

Kolkata

Week

F ward

G ward

M ward

Week

Red cross hospital

Bhalaswa lake

Wazirpur JJ colony

Swarn cinema

Batala house (Okhla)

Sonia vihar

Nangloi

Week

Choti pahari

Dujara

Transport nagar

Week

Ward 8, MM

Ward 135, KMC

Ward 29, KMC

Ward 66, KMC `

49 5037 38 39 4033 34 41 42 43 44 5245 46 47 48 5135 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

49 50 51 5245 46 47 4841 42 43 4437 38 39 4033 34 35 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

49 50 51 5245 46 47 4841 42 43 4437 38 39 4033 34 35 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

X X X X

X X X X X X X X X X X

X X X X X X X X X X X

X X X X X X X X X X X

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

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Wild poliovirus type 1Wild poliovirus type 3 Result pending

Negative for wild poliovirus Scheduled but sample not collectedX

Sampling not scheduled

Wild poliovirus detected in sewage samples, 2013*

* data as on 10 January 2014

Mumbai

Delhi

Patna

Kolkata

Punjab

Week

F ward

G ward

M ward

Week

Red cross hospital

Bhalaswa lake

Wazirpur JJ colony

Swarn cinema

Batala house (Okhla)

Sonia vihar

Nangloi

Week

Choti pahari

Dujara

Transport nagar

Week

Ward 8, MM

Ward 135, KMC

Ward 29, KMC

Ward 66, KMC

Week

MHL - Zirakpur (ZKP)

SAN_Adawal Near Losara Drain(ADW)

ASR-Fatahpur Pumping Station(FPS)

PTL-Near Railway Crossing(RWC)

49 5037 38 39 4033 34 41 42 43 44 5245 46 47 48 5135 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

49 50 51 5245 46 47 4841 42 43 4437 38 39 4033 34 35 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

49 50 51 5245 46 47 4841 42 43 4437 38 39 4033 34 35 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

1 2 3 4 5 6 7 8 9 10 12 1311 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

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Wild Polio virus case detection from AFP Cases

AFP Surveillance Sensitivity

* data as on 21st December 2013

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

10000

20000

30000

40000

50000

60000

70000

74699705 8508

13274

27049

32194

4152445585

50405

5588060540 60922

50688

271 1603 225 134 66 676 877 559 742 42 1 0 0

AFP Cases Wild Polio cases

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Circulating Vaccine-derived Poliovirus Cases1, 2000 - 2013

1Circulating vaccine-derived poliovirus (cVDPV) is associated with 2 or more AFP cases. Niger 2006, Niger 2009, Niger 2010, Chad 2010 cVDPVs are linked to the Nigeria outbreak. Kenya 2012 cVDPVs are linked to the Somalia outbreak. VDPV type 2 cases with greater than or equal to 6nt difference from sabin in VP1; VDPV types 1 and 3 cases with greater than or equal to 10nt difference from sabin in VP1 are reported here. Figures exclude VDPV from non-AFP sources. Nigeria figures include the following cases with WPV1/cVDPV2 mixture: 2005 - 2, 2006 - 1, 2007 - 1, 2008 - 3, 2009 - 1, 2011 - 1; WPV3/cVPDV2 mixture 2007 - 2. *Figures include multiple emergences and transmission chains. Data in WHO HQ as of 17 Dec 2013

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013cVD

First case Most recent case

Duration in weeks

Mozambique 2 10-Feb-11 02-Jun-11 16Myanmar 1 4 30-Apr-07 06-Dec-07 31Indonesia 46 09-Jul-05 26-Oct-05 15China 2 13-Jun-04 11-Nov-04 21Philippines 3 15-Mar-01 26-Jul-01 19DOR/Haiti 12 9 12-Jul-00 12-Jul-01 52Total type 1 12 12 0 0 2 46 1 4 0 0 0 2 0 0

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013cVD

First case Most recent case

Duration in weeks

Pakistan 16 44 30-Aug-12 10-Nov-13 62Cameroon 4 09-May-13 12-Aug-13 13Niger 2 2 1 1 1 11-Jul-13 11-Jul-13 <1Nigeria 3 22 71 66 154 27 34 8 1 02-Jul-05 06-Jun-13 413Chad 1 12 4 15-Aug-12 12-May-13 38Afghanistan 5 1 9 3 10-Jun-10 13-Mar-13 143Somalia 1 6 1 9 1 1 18-Aug-09 09-Jan-13 177Kenya 3 18-Apr-12 29-Aug-12 19DRCongo 13 5 18 11 17 04-Nov-11 04-Apr-12 21China 2 10-Jan-12 06-Feb-12 3Yemen 9 09-Apr-11 05-Oct-11 25India 15 2 19-Oct-09 18-Jan-10 13Ethiopia 3 1 04-Oct-08 16-Feb-09 19Madagascar 1 4 3 26-Jun-05 13-Jul-05 2Total type 2 0 1 4 0 0 6 24 71 83 183 55 65 68 58

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013cVD

First case Most recent case

Duration in weeks

Yemen 2 27-Apr-12 24-Aug-12 17Ethiopia 1 6 27-Apr-09 17-May-10 55Cambodia 1 1 26-Nov-05 15-Jan-06 7Total type 3 0 0 0 0 0 1 1 0 0 1 6 0 2 0

Most recent transmission chain

cVDPV type 2* Most recent transmission chain

cVDPV type 3* Most recent transmission chain

cVDPV type 1*Country

Country

Country

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Achievements ……

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19883, 50,000 Cases in 125

Countries

20101,291 Cases

in 20 Countries4 Endemic Countries

2011650 Cases

in 16 Countries4 Endemic Countries

2012213 cases

3 countries

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ERADICATION…STEP TAKEN, CHALLENGES & STRATEGY

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Rapid Response Team (RRT) - polio outbreak

Emergency Preparedness & Response Plan (EPRP)-polio case detection

Special booths @ areas bordering neighbouring countries*

high level of vigilance - surveillance - importation or circulation

Continuation existing environmental surveillance

rolling emergency stock of OPV is being maintained .

STEPS TAKEN

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expert sub-group tOPV to Bopv switch in routine immunization IPV introduction

multi pronged strategy @ 107 High risk blocks( ensure sanitation, hygiene & clean drinking water)

Social Mobilization

every new born child in UP and Bihar-tracked for 8 subsequent rounds.

transit site strategy

cont…

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Continued focus on high risk areas and populations

West UP: HR blocks – 66 Bihar:

HR blocks – 41

107 blocks of UP and Bihar Kosi river operational intensification

Immunization of newborns

Intense focus on migrants and mobile populations

Religious congregations

• 8 million children in transit immunized in India each round • 100,000 of these in running trains • 2 million children vaccinated in

congregations each year

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International

importation

Gaps in AFP surveillance or delays in detection of

WPV

Delayed and / or inadequate response to importation

Areas with low

population immunity

(HRAs)

CHALLENGES - eradication in India

Complacency/ Lack of

focus

Risks

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STRATEGY

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SUMMERY

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World Health Assembly

"DECLARES polio

eradication….emerg

ency for global

public health"

25 May 2012

Global Emergency

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Thank yu

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