progress & challenges in polio eradication in bihar mr. sanjay kumar secretary, health 23 rd...

Progress & Challenges in Polio Eradication in Bihar

Mr. Sanjay KumarSecretary, Health

23rd IEAG MeetingNew Delhi

Political commitment at highest level

26th 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 : 2007 - 10

2007 2008 2009

0

100

200

300

400

500

600

2007 2008 2009 2010 2011

P3 P1

2010

9 cases3 Districts

503 cases34 Districts



503

233

117

9 0

Oct 09 Nov 09 Dec 09 Jan 10 Feb 10

Mar 10 Apr 10 May 10 Jun 10 Jul 10

Aug 10 Sep 10 Oct 10 Nov 10 Dec 10

Jan 11 Feb 11 Mar 11 Apr 11 May 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 (1st 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

ImplementedIn process

Implemented

Implemented

Implemented

In process

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 (%)

0

0.5

1

1.5

2

2.5

3

Jun_10

Jul_

10

Sep_10

Oct_

10

Nov_10

Dec_10

Jan_11

Feb_11

Mar_

11

Apr_

11

May_11

Jun-1

1

BIHAR HR_41

Persistence of Type 1 polio in Bihar – 2007-09

Kosi River flood plain, Bihar, India

Type 1 Polio – 2008



KOSI: Persistence & Spread of P1

Responsible for persistence of virus over the years

NO CASE IN THIS AREA FOR MORE THAN 20 MONTHS

0.09 0.08 0.080.2 0.1 0.08

0

0.5

1

1.5

2

Satellite Office

Stay Point

21

39

Stay Facilities inside KOSI

0

10

20

30

40

50

60

70

2008 2010

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.

0

2

4

6

8

10

12

14

April'09 June'11

% 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 Immunization0

5

10

15

20

25

Sep'10 Mar'11

Use of Zinc-ORS in children with diarrhea

High Sensitivity of Surveillance Col No.

KAIMURKATIHARKHAGARIAKISHANGANJLAKHISARAIMADHEPURAMADHUBANIMUNGERMUZAFFARPURNALANDANAWADAPATNAPURNIAROHTASSAHARSASAMASTIPURSARANSHEIKHPURA

Gaya

Patna

Jamui

Rohtas

Purnia

KaimurBanka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Nawada

Champaran West

BhojpurBuxar

Nalanda

Muzaffarpur

Bhagalpur

Aurangaabad

Sitamarhi

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Madhepura

Kishanganj

ArwalLakhisaraiJehanabad

Sheikhpura

Sheohar

11.23 12.64 8.51

32.7 37.428.3

80.9

103.3

73.5

0

20

40

60

80

100

2009 2010 2011

India Bihar Kosi

< 22 to 1010 to 20

> 20

Legend

NPAFP Rate: 28.3(Min. Expected: 2)

Col No.


Gaya

Patna

Jamui

Rohtas

Purnia

KaimurBanka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Nawada

Champaran West

BhojpurBuxar

Nalanda

Muzaffarpur

Bhagalpur

Aurangaabad

Sitamarhi

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Madhepura

Kishanganj


Sheikhpura

Sheohar

< 70%70 to 80%

> 80%

Legend

83 85.782.283

86.6 87.684

88.191.3

50

60

70

80

90

100

India Bihar Kosi

2009 2010 2011

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 21st April’11 at 3 sewage sites

in Patna

• Capacity building of Patna Medical College for primary processing

PatnaWeek

Choti pahari

Dujara

Transport nagar

12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

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

1.26

1.02

0.79

1.07

0.51

1.17

0.410.61

0

0.5

1

1.5

2

2.5

3

No

v_

10

De

c_

10

Ja

n_

11

Fe

b_

11

Ma

r_1

1

Ap

r_1

1

Ma

y_

11

Ju

n-1

1

% Missed children in migrant communities

>90,000 Children during high season

‘In-coming migrants’ …1

• Chhath (1st to 13 Nov’10):– Major railway/ Road transit

points & Ghats– 13 Days– 2899 Teams– 1.3 million children vaccinated

• Holi (14th-19th 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 27th May till end of high transmission season

– 475,085 children covered till 37th dayGaya

Patna

Jamui

Rohtas

Kaimur

Purnia

Banka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Bhojpur

Nawada

Champaran West

Buxar

Nalanda

Muzaffarpur

Bhagalpur

Sitamarhi

Aurangaabad

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Kishanganj

Madhepura


Sheikhpura

Sheohar

Major Railway Station

305,884 children 169,201 children

‘In-coming migrants’ …2

Congregations…

• Sonepur Mela (20th Nov to 3rd Dec’10):– Saran & Vaishali– 14 days– 137 Teams– 34,014 children vaccinated

• Shrawani Mela (25th July- 24th 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 2010• 2 quick High Quality Mop Up response

with mOPV1 covering 1.8 million children

• 1st Cases:– Onset: 8th Aug.

– Investigated:13th Aug.

– Result: 25th Aug.

– Mop Up: 4th Sept. & 4th Oct.

• Onset of last case: 1st 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

11 11.6

18.6

32.838

41.4

5449

66.8 68

0

10

20

30

40

50

60

70

80

90

100

NFHS 21998-99

CES 2002 CES 2005 NFHS 32005-06

CES 2006-07

DLHS 07-08 FRDS2008/09

CES 2009-10 Unicef

FRDS 2010-11

HtHMonitoring

2011

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

0 - 20 %21 - 40 %41 - 60 %61 - 80 %81 - 100 %Data Not Available

Col No.


Gaya

Patna

Jamui

Rohtas

Purnia

KaimurBanka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Nawada

Champaran West

BhojpurBuxar

Nalanda

Muzaffarpur

Bhagalpur

Aurangaabad

Sitamarhi

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Madhepura

Kishanganj


Sheikhpura

Sheohar

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…

Col No.


Gaya

Patna

Jamui

Rohtas

Purnia

KaimurBanka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Nawada

Champaran West

BhojpurBuxar

Nalanda

Muzaffarpur

Bhagalpur

Aurangaabad

Sitamarhi

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Madhepura

Kishanganj


Sheikhpura

Sheohar

2

Col No.

KHA_GOGARIKHA_KHAGARIA URBANMDP_ALAMNAGARMDP_CHAUSAMDP_UDAKISHUNGANJMDB_JAINNAGARMZF_MARWANMZF_MUSAHRINLD_BIHAR SHARIFNLD_SARMERANWD_PAKRIBARAWANPTN_DANAPURPTN_MANERPTN_PHULWARISHARIFPTN_SADARPRN_BAISISAH_MAHISHISAH_SALKHUASAH_SIMRI BAKHTIARPURSAM_BIBHUTIPURSAM_BITHANSAM_HASANPURSAM_SINGHIASAM_WARISNAGAR

Gaya

Patna

Jamui

Rohtas

Purnia

Kaimur

Banka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Nawada

Champaran West

BhojpurBuxar

Nalanda

Muzaffarpur

Bhagalpur

Aurangaabad

Sitamarhi

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Madhepura

Kishanganj

ArwalLakhisaraiJehanabad Sheikhpura

Sheohar

FRDS 2010/11HtH Monitoring Jun’10-May’11

Visited1

Up.shp

BCG_0M0 - 4040.1 - 6060.1 - 8080.1 - 100

Visited1

Up.shp

BCG_0M0 - 4040.1 - 6060.1 - 8080.1 - 100

Data not available<= 40%41% to 60%61% to 80%> 80%Not monitored

State Avg. : 66% HR Blocks Avg.: 66%

9489.3 89.6

84.8 84.579.8 79.5

68.1 66.8

0

10

20

30

40

50

60

70

80

90

100

BC

G

DP

T 1

OP

V 1

DP

T 2

OP

V 2

DP

T 3

OP

V 3

Me

as

les FI

• 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

23.3 23.6 23.7

6.814.7

3.7 3.1 2.26.7

1.6 2.9 1.1 1.9 3.310.4

0

10

20

30

40

50

60

70

80

90

100

Did

not

feel

nee

d

Not

kno

win

g ab

out v

acci

nes

Not

kno

win

g w

here

to g

o fo

rim

mun

izat

ion

Tim

e no

t con

veni

ent

Fear

of S

ide

effe

cts

Do

not h

ave

time

Wro

ng a

dvic

e by

som

eone

Can

not a

fford

cos

t

Vac

cine

not

ava

ilabl

e

Pla

ce n

ot c

onve

nien

t

AN

M a

bsen

t

Long

wai

ting

time

Pla

ce to

o fa

r

Ser

vice

not

ava

ilabl

e

Oth

ers

40.5 36.8

21.115.9 15.4

9.9 6.1 5.3 3 1.8 0.6 0.40

10

20

30

40

50

60

70

80

90

100

Do

not k

now

wha

t vac

cine

sar

e ne

eded

and

whe

n

Chi

ld is

too

youn

g fo

rva

ccin

atio

n

Fear

of s

ide

effe

cts

Ser

vice

s ar

e no

t ava

ilabl

ew

hen

requ

ired

Do

not f

eel n

eed

for

vacc

inat

ion

Do

not k

now

whe

re to

take

the

child

for v

acci

natio

n

Opp

ositi

on fr

om fa

mily

mem

bers

Do

not h

ave

time

to ta

ke th

ech

ild fo

r im

mun

isat

ion

Adv

ised

aga

inst

imm

unis

atio

nby

som

e pe

ople

Ser

vice

cen

tre is

too

far

Can

not a

fford

the

cost

Oth

ers

CES 2009

FRDS 10/11

Key remaining challenge:Communication &

Mobilization

Service delivery…

86 86 8781

77 80 80 8175

7076

72

94 94 9692

87 89 92 9184 81 84 81

0

10

20

30

40

50

60

70

80

90

100

Jun

-10

Jul-

10

Au

g-1

0

Sep

-10

Oct

-10

No

v-10

Dec

-10

Jan

-11

Feb

-11

Mar

-11

Ap

r-11

May

-11

All Vaccines and diluents T-OPV

87 8884

66 69

85 8892 89 90 90 89

0

10

20

30

40

50

60

70

80

90

100

Jun

-10

Jul-

10

Au

g-1

0

Sep

-10

Oct

-10

No

v-10

Dec

-10

Jan

-11

Feb

-11

Mar

-11

Ap

r-11

May

-11

% 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 2nd 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 2002.

• Sustaining motivation of vaccinators:– Only Rs 75 per day for vaccinators

Proposed SIA calendar, 2011

Aug Sep Oct Nov

NIDs

Dec

bOPV

Mar Apr May Jun JulJan Feb

SNIDZone 1 UP/Bihar,

Delhi

SNIDEndemic & risk states

tOPV


SNIDZone 1 UP/Bihar

& Delhi

tOPV / bOPV


SNIDZone 1 UP/Bihar,

Delhi

0

2

4

6

8

10

12

14

16

18

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

2005 2006 2007 2008 2009 2010

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!4 7 17 1 2 5 62 15 10 17 2624

159325

1384

54 31

244

2393

554

239354

457

1024

0

10

20

30

40

50

60

70

80

90

100

Jun

_1

0

July_

10

Se

p_

10

Oct_

10

NO

V_

10

De

c_1

0

Jan

_1

1

Fe

b_

11

Ma

r_1

1

Ap

r_1

1

Ma

y_1

1

Jun

_1

1

0

500

1000

1500

2000

2500

3000Incidence of Refusal Number of houses

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!

progress & challenges in polio eradication in bihar mr. sanjay kumar secretary, health 23 rd...

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