Progress & Challenges in Polio Eradication in Bihar Mr. Sanjay Kumar Secretary, Health 23 rd IEAG Meeting New Delhi

Political commitment at highest level 26 th March’11: Meeting of Mininsters, MLAs, MLCs on Polio addressed by Hon. CM “I hereby request all MLAs to stop by households in their constituencies to check finger markings of children for Polio vaccination; RI Cards and toilets” “We are very close to the eradication and there is no case in Bihar from 7 months but the risk of importation is still there. We all should come together and give best effort now”

WPV Type-1 & Type-3 : cases 3 Districts 503 cases 34 Districts 233 cases 30 Districts 117 cases 16 Districts

Month wise WPV cases : Kosi Districts No WPV1 in Kosi since Nov’09– the longest P1 free period ever bOPV Introduced

Oct 09 Nov 09 Dec 09 Jan 10Feb 10 Mar 10 Apr 10 May 10 Jun 10Jul 10 Aug 10 Sep 10 Oct 10 Nov 10Dec 10 Jan 11 Feb 11 Mar 11 Apr 11May 11 Jun 11 Jul 11 Month wise spot Map of WPV cases : Bihar No WPV1 in Kosi area since Nov’09 No indigenous WPV1 since Nov’09 Importation in mid 2010 curbed with quick mop ups No WPV3 since Jan’10

Recommendations of IEAG’10 Scale of NID/ SNIDs in 2011 to be same as 2010 Preparedness for rapid mop up (1 st round within 2 weeks of confirmation) Maintaining the focus on highest risk areas and highest risk populations –Full implementation of 107 Block plan/ Migrant strategy Strengthen Immunization: –DTF to review RI along with Polio –WHO and UNICEF to support immunization spl planning & monitoring –Filling of ANM Vacancies Communication & Social Mobilization: –Focus on renewed energy, safety of OPV during sickness, proactive for RI/ Polio spl among migrants –Specific for 107 block spl RI Sero-prevalence study Environmental surveillance Started in April’11 Planned for Aug’11 Implemented In process Implemented In process

Inherent Challenges in Bihar High Risk Blocks with unique social, demographic and geographic features Population density/ Birth rate, Water/ sanitation issues, Access Compromised Areas and Socio-economic disparities. Annual flooding in Kosi riverine areas High migration from the state Gaps in Routine Immunization coverage

The risks to Polio situation in Bihar Re-introduction of transmission through importation: –High migration from/ to the state –Frequent intermixing of population with Nepal –Foci of transmission outside UP/ Bihar in 2010 genetically linked to 2009 transmission of Bihar Who took it there….can bring it back!! Re-establishment: –Decreased population immunity Complacency Low RI Less opportunity with SIAs High transmission season compounded by possibility of floods in high risk areas Probability of very low level undetected transmission

What is being done? Sustaining high population immunity specially in High Risk Areas by: –High quality SIAs in frequency & scope as per the GOI guidelines. –Steps to strengthen Routine Immunization. –Implementation of Kosi Operational Plan. –Implementation of 107 Block Plan. –Strong oversight from state level. Intensified surveillance in core endemic areas of Kosi and environmental surveillance.

What is being done? Preventing risk of re-importation through Coverage of : –Migrants in Bihar (Nomads, Brick Kiln labours etc.) –Incoming migrants during period of major movement. –Major congregations. –Continuous Vaccination at major entry points & Indo- Nepal border. Prepared for mounting Rapid Mop Up in response to any transmission detected.

High quality of SIAs High quality SIAs: >99% evaluated coverage consistently. High focus in High Risk areas. Missed Children (%)

Persistence of Type 1 polio in Bihar – Kosi River flood plain, Bihar, India Type 1 Polio – 2008 Type 1 Polio – 2007 Type 1 Polio – 2009 KOSI: Persistence & Spread of P1 Responsible for persistence of virus over the years NO CASE IN THIS AREA FOR MORE THAN 20 MONTHS

Most difficult access compromised areas. Flooded for 4-6 months/ year. Poor Infrastructure. Change in topography. Very high concentration of under served population. Health service delivery a challenge Covers roughly 2000 Sq Km. KOSI riverine areas Compromised access around the kosi river poses unique challenges for programme planning, implementation & monitoring

Kosi Intensification Kosi Operational Plan: –Reach to Kosi area increased. –Satellite Offices and Stay points –Intensified human resources from all partners –100% teams monitored –Frequent field validation for Basas. % Children missed in Basas % Missed Children at the end of round

High Quality SIA Operations: –Intensified monitoring –Direct oversight State monitors SMO for every block Tracking & review at highest level. Key indicators on SIA Quality: –Microplan: 98.5% teams have rational workload 96.5% teams have community appropriate female vaccinators –Newborn strategy: 99.7% teams are tracking every newborns for RI and SIA doses. –Coverage of migrant population: 100% migrant sites monitored and NO missed site found. 0.25% Missed children at migrant sites. High Risk block plan

Addressing contributing factors High Risk block plan 1. Diarrhea management with Zinc-ORS –Training of field staff including vaccinators –Made available in ASHA Kits –Availability: >95% –Use: 20% (Vs 5% in Sep’10) 2. Water and Sanitation issues –Total Sanitation Campaign prioritized in these areas –Vaccinators trained for counseling –590 CMCs from UNICEF for counseling in Hot spots 3. Routine Immunization

High Sensitivity of Surveillance NPAFP Rate: 28.3 (Min. Expected: 2) Adequate stool rate: 88.1 (Min. Expected: 80) NPAFP Rate Adequate stool Rate Enhanced Surveillance in traditional reservoir areas of Kosi: –Community level informing units –Monthly active case searches –Strengthened sensitization of SIA manpower

Environmental Surveillance Started on 21 st April’11 at 3 sewage sites in Patna Capacity building of Patna Medical College for primary processing Negative for wild poliovirus Result pending

Population in movement Un-defined migratory population: –People of Bihar migrating to other states/ country and returning back seasonally (like Id, Deepawali, Chhath and Holi) Defined migratory population: –Nomads, Brick kiln/ construction workers etc. Dilute the population immunity along with risk of carrying transmission Major congregations: –People from outside and inside state congregate on specific occasions like Shrawani and Sonepur Mela.

‘Defined’ Migratory Population… Mapping of Migratory sites 7635 Brick Kilns 4805 Nomadic sites % Missed children in migrant communities >90,000 Children during high season

‘In-coming migrants’ …1 Chhath (1 st to 13 Nov’10): –Major railway/ Road transit points & Ghats –13 Days –2899 Teams –1.3 million children vaccinated Holi (14 th -19 th Mar’11): –Major railway & Road transit points –6 Days –715 Teams –170,498 children vaccinated

Continuous vaccination activity at Indo-Nepal Border and Major railway stations: –93 teams at 50 Indo-Nepal Border sites & 198 at 11 Major railway stations –From 27 th May till end of high transmission season –475,085 children covered till 37 th day Major Railway Station 305,884 children 169,201 children ‘In-coming migrants’ …2

Congregations… Sonepur Mela (20 th Nov to 3 rd Dec’10): –Saran & Vaishali –14 days –137 Teams –34,014 children vaccinated Shrawani Mela (25 th July- 24 th Aug’10): –Bhagalpur, Banka, Munger & Indo-Nepal border –31 days –193 teams –308,691 Children vaccinated

Indo-Nepal border Porous border with frequent intermixing of population –Missed opportunity to vaccinate children in movement Synchronization of border activity: –Nepal starts SIA from Saturday and Bihar from Sunday Hence, to synchronize –The SIA in border areas of Bihar is started on Saturday instead of Sunday since May’11

Special communication efforts focusing on migrants Intensified IEC targeting migrants –Multilingual IEC Materials –IEC Vans –Miking –Booths –Mobilizers

Response to WPV1 in quick High Quality Mop Up response with mOPV1 covering 1.8 million children 1 st Cases: –Onset: 8 th Aug. –Investigated:13 th Aug. –Result: 25 th Aug. –Mop Up: 4 th Sept. & 4 th Oct. Onset of last case: 1 st Sept Preparedness for responding to importation Emergency preparedness & response group at the state level. –Reporting to highest level Team of experienced state level officers as State Monitors Responded within 10 days when we had last importation

Routine Immunization: Progress over the years RI Augmentation Muskan Full Immunization coverage increased from 18.6 to 66.8% in 6 Years! We strive to achieve beyond 80% by 2013 in ALL districts of Bihar % Full Immunization coverage

State Avg. : 66.8% There is wide inter/ intra district variation in RI coverage Some HR Block with very low RI coverage. These areas are specially being focused. % Full Immunization coverage Routine Immunization: Gaps … FRDS 2010/11 HtH Monitoring Jun’10-May’11 Data not available <= 40% 41% to 60% 61% to 80% > 80% Not monitored State Avg. : 66%HR Blocks Avg.: 66%

The problem in Bihar is of ‘Drop Outs’ From 94% BCG or 89% DPT1, we are able to retain only 67% Antigen wise coverage (FRDS-10/11) Routine Immunization: Gaps …

Reason for children not being fully immunized CES 2009 FRDS 10/11 Key remaining challenge: Communication & Mobilization

Service delivery… % Sessions held out of monitored % Sessions with Antigens available Around 90% of planned session are being held. –The dip in Sep/ Oct’10 due to strike But, Non Availability of vaccines an issue since late 2010.

Further strengthening of Immunization Improving implementation: –Intensive ‘House to house’ & Session site monitoring ~5000 session & 30,000 houses monitored/Month –‘Weekly District Control Room for RI’ to address the gaps found during monitoring. –Monthly review meetings of DIO at state with ‘Process Indicators’ –District Task Force for Polio also reviews RI Communication: –IEC through Newspapers & Radio jingles –Posters –IPC through Polio Vaccinators –IPC through AWW/ ASHAs

Concerns from Bihar Only 2 SIAs in 2 nd half of 2011 which is high transmission period in Bihar. Incidences of Mass refusals/ Cluster of refusal at Patna Urban. Erratic SIA and RI vaccine supply Operational feasibility: –Rs 650 per vehicle/ day (incl POL) for vaccine mobilization –Same since Sustaining motivation of vaccinators: –Only Rs 75 per day for vaccinators

High transmission period & SIA opportunity… Concerns from Bihar…1

Mass refusals : Due to development related issues: –Demands of Road/ Tubewell –ICDS Services –School etc Some remain unsolved and occur repeatedly! Incidences of Mass refusals Community related refusals: –Responsible for only 0.1% of remaining X houses of state –1631 refusal houses remaining at the end of June round in whole state –But, 56% of this (910) in just 3 planning units of Patna Urban (having 0.8% houses of state) –Persisting over the time. Concerns from Bihar…2

Summary There has been immense progress with no P1 for more than 10 months & no P3 for more than 17 months. But, risk of importation is high considering high migration from state Bihar is taking all the measure to prevent importation by covering in coming population in state. We are maintaining sensitive surveillance to detect the transmission at the earliest. Bihar is prepared to respond rapidly for any importation which occurs.

Thank you!