Components of AFP Surveillance The AFP surveillance network and case notification Case & laboratory investigation Outbreak response & active case search in the community 60 day follow up, cross notification & tracking of cases
Data management & case classification Virologic classification scheme Surveillance performance indications
Case and laboratory investigation Immediate investigation into the case within 48 hrs of notification Stool specimen collection & transportation 2 stool specimen collected as soon as possible after the onset of paralysis (ideally within 14 days of onset of paralysis & at least 24 hrs apart) Each specimen should be 8 gms- each about the size of the adult thumb
Collected in a clean, dry, screwed capped container No preservative or transport media should be used The specimens collected, labeled ,transported in the cold chain-on frozen ice packs/ ice, in a stool specimen carrier or a vaccine carrier In Pakistan, the specimen is sent to NIHL( National Institute 0f Health Laboratories ) at Islamabad
Poliomyelitis Two Greek words: polios (gray) & myelios (spinal cord..anterior horn cells ) In 1908, the polio virus was discovered by Karl Landsteiner
An enterovirus 3 serotypes-P1,P2,P3 P1 - causes outbreaks—is the most likely virus to cause paralysis. P2 - the easiest to eradicate followed by P3 Human are the only hosts without which the virus cannot survive
The Virus is excreted in the stools for three to six weeks. It is more stable than most viruses ,can stay alive for several weeks in contaminated food or water. It is one of the most contagious viruses. If one family member is infected, nearly all the rest of the family becomes infected.
Portal of entry multiplies in the cells of the mucousis the mouth membranes in the pharynx and intestines Hematological Invades local lymphoid spread tissue • virus becomes neurotropic • produces destruction of the motor neurons in the anterior horn and brainstem
Cold chain- Maintenance of temperature from vaccines synthesis to delivery to child. Reverse cold chain- Maintenance of cold chain from stool collection to delivery to the laboratories
Yearly report …of Pakistan In Pakistan, one new WPV3 case was reported on the 17th February 2010, from Quetta, Baluchistan. Bivalent OPV was used for the first time in Pakistan in NIDs held from 15-17 Feb 2010 The next round will be held from 15-17 March 2010 in targeted high and medium risk districts, using bOPV
Number of confirmed cases ofpoliomyelitis in Pakistan, 1997–2008
Number of districts with confirmedpoliomyelitis cases in Pakistan,1997–2008
Pakistan has recorded 76 cases in 2009 to date: 52 type 1 23 type 3 one type 1/3 mixture.
SNIDs in Afghanistan the Provincial Government of Nangarhar, UN agencies jointly launched sub-national immunization days (SNID) in Jalalabad on Sunday, 14 February 2010.
Disease Surveillance The ongoing systematic collection & analysis of data & the provision of information which leads to action being taken to prevent & control a disease, usually one of an infectious nature
Herd immunity Immunity of a sufficient number of individuals in a population such that infection of one individual will not result in an epidemic.
Wild polioviruses Isolates known or believed to have circulated persistently in the community & reference strains derived from these isolates. May be present in a variety of clinical materials faeces & throat specimens less commonly in blood rarely in CSF in non-paralytic & paralytic infections..
In fatal infections, wild poliovirus may be present in faeces intestinal contents lymph nodes brain tissue spinal cord tissue
Vaccination 1955 - Mr. Salk discovered IPV 1957 - Mr. Sabin discovered OPV EPI- globally launched in 1974 In Pakistan in 1978 training was started and became apparent in 1979
Polio Eradication In 1988 , World Health Assembly, in its resolution 41.28 – set goals of A global polio eradication program OPV was recommended. In Pakistan started in 1993-94 Led by the World Health Organization, UNICEF, and The Rotary Foundation
Global Eradication of polio program was established in 1989. Today only 4 countries are endemic to polio Pakistan, Nigeria, India, Afghanistan
What is Eradication ??? The World Health Organization (WHO) defines polio eradication essentially as ‘zero incidence of wild poliovirus transmission anywhere in the world’.
Polio eradication requires + Finding and Finding and controlling wild controlling wildpoliovirus in human poliovirus in populations laboratories
Why was it launched ??? Humans are thought to be polioviruss only host Virus survival in the environment is limited. Immunization with vaccines interrupts virus transmission
Objectives of the Global polio Eradicationinitiative To interrupt transmission of the wild poliovirus as soon as possible To achieve certification of global polio eradication To contribute to health system ,development & strengthening routine immunization & surveillance for communicable disease in a synergistic way
Strategies of achieving the goal High routine infant immunization Supplementary doses of OPV to all children under 5 yrs of age during SIAS( Supplementary immunization activities) Active AFP Surveillance for wild poliovirus through reporting & lab testing of all AFP cases among children under 15 yrs of age Targeted “Mop-up" campaigns once wild poliovirus transmission is limited to a specific focal area.
High routine infant immunization All countries aim to immunize at least 90% of infants with four OPV doses These doses are part of the basic (EPI) High routine immunization coverage decreases the incidence of polio & sets the stage for eradication
National Immunization Days(NIDs) It is the 2nd part of the four-pronged strategy and is also known as mass immunization campaign. Important activity for interrupting wild poliovirus circulation in endemic countries A supplementary immunization Intended to complement - not replace - routine immunization.
The aim of mass campaigns is to interrupt circulation of poliovirus by immunizing every child under 5 years of age with two doses of OPV, regardless of previous immunization status. Three to five years of NIDs are usually required to eradicate polio NIDs are needed for at least 3 consecutive years to interrupt transmission
NIDs are normally conducted during the cool, dry season ( immunological response to OPV is improved and the potential damage to heat-sensitive OPV is reduced.) SNIDs) target children for polio vaccination in specific high-risk regions of countries rather than the entire country.
Surveillance of new cases of polio Countries to ensure that all cases of poliomyelitis are detected The goal of AFP surveillance is to report and investigate “any case of acute flaccid (floppy) paralysis
surveillance systems should be capable of detecting at least one case of AFP per 100 000 population < 15 years; collecting adequate stool specimens from at least 80% of AFP cases testing all specimens at a WHO-accredited laboratory.
Mop-up Activities AFP surveillance data are used to identify the final chains of wild poliovirus transmission in each geographical area In these areas, two doses of OPV are administered to all children < 5 years, regardless of their prior immunization status, by immunization teams that go house-to-house.
Improve coverage & ensure that the most difficult-to- reach children are immunized, thereby interrupting the last chains of wild poliovirus transmission In addition to delivering supplemental OPV doses, mop-up activities often include an active search for AFP cases
Summary of Proposed Milestones Milestones for future Target year 1. Establish comprehensive policy for future 2003 management. 2. Eliminate wild poliovirus transmission. 2003 3. Certification of ‘eradication’ of wild viruses. 2006 4. Introduction of IPV in routine immunization. 2006 5. Complete withdrawal of OPV. 2009 6. Certification of ‘true eradication’ of 2012 polioviruses. 7. Discontinue polio immunization. 2015
Polio Eradication in Pakistan In Jan 2010, meeting covered the tribal leaders and religious scholars In South Waziristan, Mufti Maulana Abdul Qayuum issued a fatwa supporting polio efforts, 15 mosques were made after the ceremony Women also played an important role in increasing the coverage
Special teams of women were mobilized & trained to go house-to-house and address the recent rise in refusal rates The delivery teams equipped with appropriate messages, were able to cover 61% of all the refusal families in Larana.
Recent advances of polio virus Researches use crippled Polio Virus to attack Brain Cancer Polio virus has a natural affinity to invade the brain, by binding to the CD155 receptor on the surface of the motor neurons Brain tumors overproduce the CD155 receptors which makes the cell in the tumors more susceptible to poliovirus infection
The genetically engineered altered poliovirus when introduced in the body Enters the normal motor neurons (it shares the same CD155 receptors as brain tumour cells )but cannot grow in normal neurons Kills the brain tumor cells