workshop on “polio updates & end game strategies” organized by community medicine...
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Workshop on “Polio updates & End game strategies” Organized by Community Medicine Department, GMERS Medical College, Sola, in collaboration with NPSP (WHO), Gandhinagar 16 th April, 2013. Polio update, AFP Surveillance End game strategy. Dr. Anish Sinha - PowerPoint PPT PresentationTRANSCRIPT
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National Polio Surveillance Project: GoI & WHO
Workshop on
“Polio updates & End game strategies”
Organized by
Community Medicine Department,
GMERS Medical College, Sola,
in collaboration with
NPSP (WHO), Gandhinagar 16th April, 2013
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National Polio Surveillance Project: GoI & WHO
Polio update, AFP SurveillancePolio update, AFP Surveillance End game strategy
Dr. Anish Sinha State Surveillance Medical Officer
World Health OrganizationNational Polio Surveillance Project, India,
Gandhinagar.
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National Polio Surveillance Project: GoI & WHO
Contents….
• Global/ National / State update.
• Epidemiology of polio.
• AFP Surveillance.
• SIAs (NIDs / SNIDs).
• Certification of Polio eradication.
• End game strategy.
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National Polio Surveillance Project: GoI & WHO
1988
350 000 cases
125 countries
Areas with Active Polio Transmission
2012
223 cases
5 countries
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National Polio Surveillance Project: GoI & WHO
Rukhsar Khatoon last case of WPV detected in India (Jan 2011), her mother Shabida Bibi in Shahapar village, WB
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National Polio Surveillance Project: GoI & WHO
India• India last polio case on 13th Jan.2011
• Removed from list of ENDEMIC Countries list in Feb.2012
Looking forward for Certification (SEAR) in Feb.2014
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National Polio Surveillance Project: GoI & WHO
Nigeria(122) Pakistan
(58)
Afghanistan(37)
ONLY THREE ENDEMIC COUNTRIES
CHAD 5 WPV1 (IMPORTATION)Niger 1WPV1
Global Polio updates 2012
Till 9 Apr 13 – 18 cases (Nig-11, Pak-6, Afg-1)
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National Polio Surveillance Project: GoI & WHO
WPV transmission from Northern Sindh, Pakistan to Greater Cairo (environmental sample +ve), Egypt
Importation of WPV 2013 -, Egypt - polio free since 2004.
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National Polio Surveillance Project: GoI & WHO
WPV cases, India
P1 wild P3 wild
No case since Jan 2011
* data as on 12 April 2013
P2 wild
1600
1934
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National Polio Surveillance Project: GoI & WHO
State P2West Bengal 1Total 1
VDPVState P1 P3 Total
West Bengal 1 0 1
Total 1 0 1
WPVs
Location of wild poliovirus and VDPV cases by type, India
2011 2012 2013*
State P2
Bihar 1Total 1
VDPV
* data as on 12 April 2013
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National Polio Surveillance Project: GoI & WHO
Last wild poliovirus cases by type, India
WPV2 24/10/1999
Aligarh (UP)
WPV1 13/01/2011
Howrah (WB)
WPV3 22/10/2010Pakur (JH)
* data as on 12 April 2013
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National Polio Surveillance Project: GoI & WHOWild poliovirus type 1
Wild poliovirus type 3
Negative for wild poliovirus
Scheduled but sample not collectedX
Sampling not scheduled
Wild poliovirus detected in sewage samples, 2010 – 2011
2010Mumbai
Delhi
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
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National Polio Surveillance Project: GoI & WHO
Wild poliovirus type 1
Wild 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
* data as on 12 April 2013
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National Polio Surveillance Project: GoI & WHO
Wild poliovirus type 1
Wild 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 12 April 2013
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
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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National Polio Surveillance Project: GoI & WHO
Progress in India–A snapshot
P1 wild P3 wild
* data as on 12 April 2013
P2 wild
1600
1934•1995: Polio SIAs (campaigns) launched
•1997: Acute Flaccid Paralysis (AFP) Surveillance initiated
•1999: Last case of Wild Polio Virus (WPV) type 2 – (U.P)
•2010: Last case of WPV type 3 - (Jharkhand)
•2011: Last case of WPV type 1 - ( West Bengal)
•2012: India removed from list of endemic countries
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National Polio Surveillance Project: GoI & WHO
2005 - 1
Gujarat Wild Cases 2000-13
BAN
KTC
JMC
RJC
AML
BVC
KDA
PML
DHD
VDD
SRC
NAVDNG
AMD
AND VDC
SRN
GNR
VLD
AMC
NMDBRH
SBK
BVN
JUN
PATMSN
JMD
POR
SRT
RJT
2002 - 24
2003 - 3
2001 - 1
2004 - 0
Year - Cases 2000 - 2
2006 - 4
2007 - 1
2008 - 0
2009 - 0
2010 - 0
2011 - 02012 - 02013 - 0
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National Polio Surveillance Project: GoI & WHO
Epidemiology of Polio
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National Polio Surveillance Project: GoI & WHO
Polio: Epidemiology• Reservoir of infection: Man (for every clinical case,1000
sub clinical case (children) & 75 (adults)• Infective material: feces • Period of communicability: most infective 10 days before
& after onset. Host factors• Age:6 months to 3 years most common• Sex: 3:1 ---male: female• Precipitating factors: fatigue, trauma, I/M injections• Immunity : OPV (life long) Environmental factors• Rainy season (Jun – Sep), overcrowding & poor
sanitation
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National Polio Surveillance Project: GoI & WHO
Paralytic Poliomyelitis• Acute onset• Fever just prior to onset of paralysis• Associated symptoms: malaise, sore throat, constipation abdominal
pain. Muscle pain• Signs of meningeal irritation, stiffness in back & neck may be present.• Progression: maximum in <4 days. starts proximally and moves distally• Involvement: asymmetrical patchy paralysis ,proximal muscle groups>
distal muscle groups• DTR: diminished• Cranial nerve involvement : uncommon• Respiratory insufficiency: life threatening, uncommon• Sensory: no lossonly way to confirm is isolation of wild virus from stool.
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National Polio Surveillance Project: GoI & WHO
Strategies of Polio Eradication
1985 – Routine immunization Individual immunity
1995 – NID’s ( PPI / IPPI ) To replace wild with vaccine virus
1997 - AFP surveillance
To identify reservoir of transmission 2000 – Mopping up immunization
To eliminate last foci of transmission
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National Polio Surveillance Project: GoI & WHO
AFP Surveillance
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National Polio Surveillance Project: GoI & WHO
Objective of AFP surveillance
Reliably detect areas where polio transmission is occurring or likely to occur
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National Polio Surveillance Project: GoI & WHO
Principle of AFP Surveillance in identifying polio cases
Identify children with the SYNDROME of Acute Flaccid Paralysis
• Acute- Sudden onset, Rapid progression
• Flaccid- Floppy/ soft & yielding to passive stretching at anytime during the illness.
• Paralysis is loss of strength of muscles,
Severe loss of motor strength is called paralysis or plegia
Paresis- less severe loss of motor strength
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National Polio Surveillance Project: GoI & WHO
Definition of AFP for surveillance purposes
Sudden onset weakness & floppiness in
any part of the body in a child < 15
years of age or paralysis in a person of
any age in which polio is suspected.
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National Polio Surveillance Project: GoI & WHO
Logic of AFP investigation & stool sample collection
• Sensitivity increases when all AFP cases investigated
• Testing of stools of all AFP - most valid test for identification of Polio
• ALL cases with ‘AFP’ should be reported & their stools must be tested!!
• Even if other ‘tests’ (CT scan, MRI, etc.) or additional clinical information point to other diagnoses; stools must be tested to rule out Polio
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National Polio Surveillance Project: GoI & WHO
Reporting
• All AFP cases should be reported immediately
• ALL AFP cases reported within 6 months of
onset of paralysis should be investigated
• All reporting units, informers and other contacts
should continue to report AFP cases as per
existing case definition
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National Polio Surveillance Project: GoI & WHO
Action when AFP is reported• FIRST – Start stool collection process• Investigate - SMO/ DIO - Confirm if AFP, if not reject
case & record the same. There is only one category of cases - AFP • Allot EPID number & Report the case as AFP• CIF & LRF should be filled. • Use the revised CIF/ Linelist form.
• Ensure that stools are transported to lab in cold chain• NPSU will Classify after lab result received• Give feedback to the source that the AFP reported was/
was not polio.• Maintain documentation at ALL levels.
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National Polio Surveillance Project: GoI & WHO
Therefore…
The basic system of AFP surveillance remains
unchanged
• To enhance sensitivity, all cases of acute flaccid
paralysis should be reported & investigated
• Borderline cases should be included & stool
specimens tested
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National Polio Surveillance Project: GoI & WHO
The AFP Surveillance System
Hospitals ClinicsCommunity
Investigation
Non-Polio AFP Polio AFP
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National Polio Surveillance Project: GoI & WHO
When too much polio is around…..
Non-AFP cases
Polio cases
AFP cases
Borderline AFP cases
Surveillance sensitivity is
adequate enough to
detect 90% polio cases
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National Polio Surveillance Project: GoI & WHO
When transmission is very low…..
Non-AFP cases
Polio cases
AFP cases
Borderline cases
Surveillance sensitivity is
not good enough &
detects only 50% polio
cases
…Sensitivity increases and leads to 100%
detection of polio cases
If borderline cases are taken &
stool specimens collected …
Remember Non AFP cases still not taken
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National Polio Surveillance Project: GoI & WHO
Likely Likely to beto be AFP cases…. AFP cases….
• GBS of any variety
• Transverse myelitis
• Monoparesis
• Traumatic neuritis
• Flaccid Paraplegias
• Flaccid Quadriplegia
• Isolated bulbar paralysis
• Post-diphtheric polyneuritis
• Viral neuritis,
• Flaccid hemiplegia
• Isolated neck paralysis
• Wrist/foot drop, etc.
• Transient paresis
• Facial Palsy.
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National Polio Surveillance Project: GoI & WHO
Clinical Presentation 2006 2007 2008 2009 2010
Clinical Poliomyelitis 586 (86.7) 757 (86.71) 494 (88.37) 648 (87.45) 32 (76.19)
Only H/O Paralysis 24 (2.7) 14 (1.60) 14 (2.5) 10 (1.35) 1 (2.38)
Hemiplegia 35 (5.2) 54 (6.19) 25 (4.47) 48 (6.48) 3 (7.14)
G.B.Syndrome 6 (0.9) 3 (0.34) 3 (0.54) 3 (0.40)
Traumatic Neuritis 4 (0.6) 8 (0.92) 1 (0.18) 2 (0.27)
Only Limp 4 (0.6) 1 (0.11) 0 (0) 4 (0.54)
Acute Encephalitis 3 (0.4) 3 (0.34) 4 (0.72) 1 (0.13)
Isolated Facial Palsy 3 (0.4) 19 (2.18) 10 (1.79) 14 (1.89) 4 (9.52)
Isolated Neck Flop 4 (0.6) 5 (0.57) 4 (0.72) 4 (0.54)
Post Diptheric Polyneuritis
0 (0) 2 (0.23) 0 (0) 1 (0.13)
Others 7 (1.0) 7 (0.80) 4 (0.72) 6 (0.81) 2 (4.76)
Total 676 873 559 741 42
Analysis of initial clinical presentation of WPV 2006 - 10
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National Polio Surveillance Project: GoI & WHO
STOOL COLLECTION, STORAGE ,
TRANSPORT.• Adequate Stool.
– 2 Specimens, 24 Hours Apart.
– 8 gms.
– Within 14 Days of Paralysis Onset & with proper Cold Chain
• Procedure.
– Errors.
– Storage(Delayed Second Sample)
• Cold Chain.
• Rectal Tube.
• Transport.(PHN & HA)
• Death of AFP Case.( Spinal Cord , Intestinal Content)
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National Polio Surveillance Project: GoI & WHO
GOLD STANDARD FOR AFP SURVEILLANCE
• Non – Polio AFP Rate > 2.0
• Adequate Stool Samples > 80%
• Timeliness of Reporting > 80%
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National Polio Surveillance Project: GoI & WHO
VIROLOGIC CLASSIFICATION SCHEME
NO WILD POLIOVIRUS
AFP
WILD POLIOVIRUS
INADEQUATE
STOOL SPECIMENS
TWO ADEQUATE*
STOOL SPECIMENS
NO RESIDUAL WEAKNESS
CONFIRM
COMPATIBLE
DISCARD
DISCARD
RESIDUAL WEAKNESS, DIED OR LOST TO F/U
DISCARD
EXPERT REVIEW
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National Polio Surveillance Project: GoI & WHO
#
#
S
S
#S
#S
#S
###SSS
#S
#S
#S
##
SS
#S
2002 – 14 cases
2003 – 4 cases
2004 – 1 case
2005 – 7 cases
2006 – 3 cases2007 – 5 cases2008 – 1 case2009 – 1 case2010 – 1 case
2011 – 0 Case2012 – 0 Case2013 – 0 Case
Compatible Cases 2002-2013
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National Polio Surveillance Project: GoI & WHO
HOT CASE• A case of AFP with any of the following set of
conditions -Age < 5 year plus H/O fever at onset plus
asymmetrical proximal paralysis.Age < 5 year with rapidly progressive paralysis
leading to bulbar involvement (cranial nerves affected) & death.
Any case which in the opinion of SMO/DIO looks like polio.
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National Polio Surveillance Project: GoI & WHO
CONTACT SAMPLES
To be considered for cases fulfilling criteria like Hot cases, but adequate samples from case could not be taken
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National Polio Surveillance Project: GoI & WHO
Supplementary Immunization Activities:
NIDs/ SNIDs
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National Polio Surveillance Project: GoI & WHO
SIAs• NID: National Immunization Day.
- Booth Activity.- House-to house Activity.- Transit Teams.- Mobile Teams.
• SNID: Sub National Immunization Day.- Migratory SNID in Gujarat (11 districts & 5 corporations).
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National Polio Surveillance Project: GoI & WHO
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 & 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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National Polio Surveillance Project: GoI & WHO
Certification of polio eradication
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National Polio Surveillance Project: GoI & WHO
Background• Certification is done for WHO Regions; not for individual
countries
• WHO Regions certified polio free:
– Americas 1994
– Western Pacific 2000
– Europe 2002
• Certification of a region is considered only when
– All countries in the area demonstrate Absence of WPV transmission for at least 3 consecutive
yearsPresence of certification standard surveillanceGlobal action plan for laboratory containment of WPV
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National Polio Surveillance Project: GoI & WHO
Certification of SEAR*
* South East Asia Region of WHO
1995 2012 20131997 2011 2014
GCC formed
Feb: India will present final document
Certification of SEAR likely
2 RCCPE meetings planned
28 Aug: India presents
Preliminary Document
Dec: Special RCC Meeting for
India
Last WPV case in SEAR
SEARCCPE formed
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National Polio Surveillance Project: GoI & WHO
Certification standard surveillance• Non-polio AFP rate: ≥ 2 per 100,000 population
(< 15 years) annually
• Adequate stool specimens : ≥80%
• All stool specimens tested for poliovirus at
WHO-accredited laboratory • Additional Criteria
• Investigation of AFP cases within 48 hours of initial notification: ≥80%
• Timeliness of weekly AFP surveillance reports: ≥80%
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National Polio Surveillance Project: GoI & WHO
National Certification Committee for Poliomyelitis Eradication (NCCPE)
• Established in 1998 to
• Examine, assess & verify data collected by govt.
• Field visits to review evidence of interruption of
poliovirus transmission in the country
• Independent judgment of polio status
• Present country report to RCCPE**Regional Certification Commission for Poliomyelitis Eradication
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National Polio Surveillance Project: GoI & WHO
• Sep12 - Jun13
• Five categories of states have been formed
NCCPE Field Visits
Category 5 states
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National Polio Surveillance Project: GoI & WHO
Laboratory Containment
• Union Health Ministry already issued letter in this regard to all the States (dated 14th Feb 2013).
• National Task Force for Lab Containment of WPV formed, Health Secretary (GOI) - Chairman.
• To identify Labs, likely to store WPV – by Dec 2013.
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National Polio Surveillance Project: GoI & WHO
Polio Endgame Strategy
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National Polio Surveillance Project: GoI & WHO
Context• No WPV2 in India since 1999
• tOPV used in RI and during NIDs
• bOPV used in most SNIDs since Jan 2010
• Areas/ populations with low routine immunization coverage
• All cVDPVs in India due to type 2 in setting of low immunity to type 2
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National Polio Surveillance Project: GoI & WHO
cVDPV cases, India 2009-2011
•cVDPV cases detected in 2009-10
•100% due to type 2
DistrictType 2
2009 2010 2011
Badaun 3 0 0
Bulandshahar
2 0 0
Ghaziabad 0 1 0
Meerut 2 0 0
Moradabad 2 0 0
Pilibhit 4 0 0
Shahjahanpur
2 1 0
Total 15 2 0
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National Polio Surveillance Project: GoI & WHO
Trends in Seroprevalence Against PoliovirusResults from Different Serosurveys
Moradabad Nov 2007(N=121)
AFP cases UPNov 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%
High immunity levels sustained for P1 since 2009Increasing trend in immunity level for P3 in 2010-11
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National Polio Surveillance Project: GoI & WHO
Managing the risk of VDPVs
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National Polio Surveillance Project: GoI & WHO
Preparing for the polio endgame
• A tOPV- bOPV switch globally (~2014/2015)
• Use of IPV in conjunction with OPV (?)
• Eventual cessation of all OPV use globally at
some point in the future (e.g. 2017-18 period).
• Support research activities to generate evidence to
guide decision making
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National Polio Surveillance Project: GoI & WHO
Pre-switch boosting of type 2 immunity
• Switch soon after tOPV NIDs
• Improve RI, particularly DTP3 and OPV3 coverage
• Adding a dose of IPV in RI for infants prior to switch
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National Polio Surveillance Project: GoI & WHO
Conclusions• India can be in a position to move ahead with polio
endgame strategy• Careful planning and consideration of risks required
before implementation• Earliest possible timing for tOPV-bOPV switch: Qtr.1
2014• Lessons from tOPV-bOPV switch significant for
subsequent withdrawal of all OPV from programme
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National Polio Surveillance Project: GoI & WHO
Thank you