Progress of Polio Eradication in India, Current Risks & Actions taken on last IEAG report 24 th IEAG, New Delhi 15 March 2012 Dr. Ajay Khera Deputy Commissioner & Pubic Health Expert Child Health & Immunization Ministry of Health & Family Welfare Government of India

Progress of Polio Eradication in India P1 wildP3 wild 1995: Polio SIAs launched 1997: AFP Surveillance initiated 1999: Last case of WPV 2 – (U.P) 2001: 14 States and UTs free of polio 2010: Last case of WPV 3 - (Jharkhand) 2011: Last case of WPV 1 - (Howrah, West Bengal) 2012: India removed from list of endemic countries mOPV 1 bOPV

Year-wise result of AFP Surveillance system YearAFPWPVCompatibleVDPV , , , , circulating Type 2 VDPVs in areas of low routine coverage in West UP in No genetic linkage amongst 2011 VDPVs Spot map of VDPVs Data as on 7 March 2012 Year Type 1Type 2Type 3 Total aicaicaic Total

Wild Polio Virus in environmental (sewage) samples Mumbai WPV1 WPV3 Delhi Collection of sewage samples started from April * Sewage samples collection sites * data as on 7 March 2012 Patna & Kolkata sewage sample collection from 2011 No WPVs isolated

Trends in Seroprevalence Against Poliovirus Results from Different Sero-surveys Moradabad Nov 2007 (N=121) AFP cases UP Nov 08 – mid 09 (169) Moradabad May 2009 (N=534) UP & Bihar Aug 2010 (N=1280) UP & Bihar Aug 2011 (N=1246) Age 6-7 mo6-11 mo6-7 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% Confirms high immunity levels for all three sero-types in 2011 specially in high risk areas of Uttar Pradesh and Bihar

1.Intensive polio SIAs in the reservoir, amplification and migrant areas 2.Enhance routine immunization especially in high risk areas 3.Ensure outbreak preparedness plans 4.Roll out the new communication approach 5.Accelerate research for programmatic decisions 6.Enhance AFP and Laboratory surveillance 7.Initiate post eradication planning Update on action points based on last IEAG recommendations

Action No. 1: Intensive Polio SIAs in SNIDNID million doses of OPV administered in 2011 Missed children varied from 0.3% to 7.8%

Average percent children found unimmunized by monitors during Polio SIAs in 2011 % unimmunized Source : Independent monitoring

Action No. 2: Intensifying Routine Immunization Nationwide intensified RI campaigns planned – declared as the Year of RI intensification –Immunization weeks initiated in Northeast states RI monitoring intensified with special focus on high risk areas of UP, Bihar, West Bengal and Karnataka through WHO-NPSP Proposal to modernize alternate vaccine delivery system Supply chain management being revamped Involvement of ASHA and Mother and child tracking system is proposed to be used for follow-up of children for vaccination.

Action No. 3: Focus on Migrants Populations Migrant populations of states with high migration Delhi, Mumbai, Punjab, Haryana, Gujarat & West Bengal vaccinated during each SIA 162,000 migrant sites identified in India All migrant sites included in SIA microplans ~ 4.2 million migrant children vaccinated in NID Average 4.8% children (range: 3.9% to 6.2%) < 2 yrs missed in migrant sites, Religious congregations also covered

Any polio case detected will be declared “a public health emergency” State Emergency Preparedness & Response Groups (EPRGs) constituted in all states Rapid response teams (RRTs) identified and trained Risk analysis in states ongoing, 207 poor performing districts States need to focus on improving surveillance & immunization in identified HR populations Action No 4: Emergency Preparedness and Response Plan (EPRP)

Action No 5: Communication challenges & actions 1.Risk of decreased threat perception without WPV 2.Continued pocket of resistance in some areas in UP, Maharashtra and West Bengal - requires continued focus at local level 3. Reporting of AFP cases as Polio - need to train Media 4. Integrated IEC campaigns on RI and Polio 5. New communications approach rolled out 6. Sustained the SM network in UP & Bihar and consolidated in West Bengal RI and convergence materials produced. UNICEF Polio Ambassador Amitabh Bachchan launches Communications campaign in December 2011

Surveillance reviews conducted in Western UP, Bihar, Andhra Pradesh, Maharashtra, Gujarat, West Bengal, Pakur in Jharkhand & Delhi Overall surveillance quality exceeds Global standards –Non Polio AFP rate below 2 per 100,000 popn. < 15 yrs in parts of Chhattisgarh, Andhra Pradesh & Arunachal Pradesh –Stool collection below 80% in some districts of Chhattisgarh, Andhra Pradesh & Orissa Action No. 6 : AFP and Environmental Surveillance

INDIA NEPAL Alerted states bordering Pakistan & China Enhanced sensitivity of AFP surveillance in border districts, migrants and high risk areas Continuous vaccination along Pakistan-India-Nepal border 86 vaccination posts >1.5 million children vaccinated from Apr 2011 to Feb 2012 Vaccination post Blocks with vaccination post PAKISTAN Action No. 7: Response to threat of importation from neighboring countries 5 vaccination posts ~1,400 children vaccinated from Sep 2011 to Feb 2012

Seroprevalence surveys completed in UP and Bihar indicating high level of immunity in 2011 Mucosal immunity study field operations completed in December 2011, results expected by July 2012 –990 study subjects –assess levels of mucosal immunity –evaluate which Polio vaccine (IPV or bOPV) is more efficient in boosting mucosal immunity Action No. 8 : Research to guide programme activities and measure progress

International importation Gaps in AFP surveillance or delays in detection of WPV Delayed and / or inadequate response to importation Areas with low population immunity Current Risks to Polio Eradication in India Risks due to VDPV Complacency Risks

Sustaining the quality of coverage in SIA including migrant and slum population Routine immunization intensification with focus on pockets of low coverage Continued Multipronged strategy in 107 blocks of UP and Bihar Maintaining high level of acceptance of OPV by communities Program priorities for Polio Eradication in India Rapid and effective response to any Wild Polio virus detection Intensified surveillance for early detection Program Priorities

Summary Country achieved longest ever polio free period Routine Immunization strengthening is a key program priority at this juncture Maintain the quality of coverage in NIDs and SNIDs Threat of importation needs to be tackled by early detection and rapid mop-up response

Questions for the IEAG What are the challenges that India is likely to face to maintain zero polio status until certification and beyond? What lessons from other countries can be applied in India to protect the gains made so far? What strategies should India follow from 2012 to 2014? Is the isolation of VDPVs a concern for India? How should India plan for the polio endgame strategy?

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