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Polio updatesss
1. 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
2. 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 Organization
National Polio Surveillance Project, India,
Gandhinagar.
3. 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.
4. National Polio Surveillance Project: GoI & WHO
1988
350 000 cases
125 countries
Areas with Active Polio Transmission
2012
223 cases
5 countries
5. 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
6. 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
7. 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)
8. 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.
9. 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
10. National Polio Surveillance Project: GoI & WHO
State P2
West Bengal 1
Total 1
VDPV
State 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 1
Total 1
VDPV
* data as on 12 April 2013
11. 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
22/10/2010
Pakur (JH)
* data as on 12 April 2013
13. 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
14. 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
15. 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
16. National Polio Surveillance Project: GoI & WHO
2005 - 1
Gujarat Wild Cases 2000-13
BAN
KTC
JMC
RJC
AML
BVC
KDA
PML
DHD
VDD
SRC
NAV
DNG
AMD
AND VDC
SRN
GNR
VLD
AMC
NMDBRH
SBK
BVN
JUN
PAT
MSN
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 - 0
2012 - 0
2013 - 0
18. 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
19. 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 loss
only way to confirm is isolation of wild virus from stool.
20. 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
22. National Polio Surveillance Project: GoI & WHO
Objective of AFP surveillance
Reliably detect areas where polio
transmission is occurring or likely to occur
23. 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
24. 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.
25. 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
26. 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
27. 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.
28. 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
29. National Polio Surveillance Project: GoI & WHO
The AFP Surveillance System
Hospitals
Clinics
Community
Investigation
Non-Polio AFP Polio AFP
30. 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
31. 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
32. National Polio Surveillance Project: GoI & WHO
LikelyLikely 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.
34. 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)
35. 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%
36. 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
37. National Polio Surveillance Project: GoI & WHO
#
#
S
S
#S
#S
#S
#
##S
SS
#S
#S
#S
#
#
S
S
#S
KTC
RJT
BAN
JMD
SRN
JUN
BVN
SBK
SRT
AML
AMD
VDD
PAT
PML
BRH
DHD
KDA
MSN
VLD
AND
NMD
POR
NAV
GNR
DNG
VDC
BVC
JMC
SRC
AMC
RJC
2002 – 14 cases
2003 – 4 cases
2004 – 1 case
2005 – 7 cases
2006 – 3 cases
2007 – 5 cases
2008 – 1 case
2009 – 1 case
2010 – 1 case
2011 – 0 Case
2012 – 0 Case
2013 – 0 Case
Compatible Cases 2002-2013
38. 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.
39. 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
41. 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).
42. 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
44. 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
years
Presence of certification standard surveillance
Global action plan for laboratory containment of WPV
45. 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
46. 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%
47. 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
48. National Polio Surveillance Project: GoI & WHO
• Sep12 - Jun13
• Five categories of states have been formed
NCCPE Field Visits
Category 5 states
49. 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.
51. 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
52. National Polio Surveillance Project: GoI & WHO
cVDPV cases, India 2009-2011
•cVDPV cases detected in 2009-10
•100% due to type 2
District
Type 2
2009 2010 2011
Badaun 3 0 0
Bulandshah
ar
2 0 0
Ghaziabad 0 1 0
Meerut 2 0 0
Moradabad 2 0 0
Pilibhit 4 0 0
Shahjahanp
ur
2 1 0
Total 15 2 0
53. National Polio Surveillance Project: GoI & WHO
Trends in Seroprevalence Against Poliovirus
Results from Different Serosurveys
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 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 2009
Increasing trend in immunity level for P3 in 2010-11
55. 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
56. 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
57. 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
