Progress & Challenges in Polio Eradication in BiharMr. Sanjay KumarSecretary, Health23rd IEAG MeetingNew Delhi

Political commitment at highest level26th March11: Meeting of Mininsters, MLAs, MLCs on Polio addressed by Hon. CMI hereby request all MLAs to stop by households in their constituencies to check finger markings of children for Polio vaccination; RI Cards and toiletsWe 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 - 1020072008200920109 cases3 Districts503 cases34 Districts233 cases30 Districts117 cases16 Districts50323311790

Month wise WPV cases : Kosi Districts2007200820092010201120072008200920102011No WPV1 in Kosi since Nov09 the longest P1 free period ever

bOPV Introduced

Oct 09Nov 09Dec 09Jan 10Feb 10Mar 10Apr 10May 10Jun 10Jul 10Aug 10Sep 10Oct 10Nov 10Dec 10Jan 11Feb 11Mar 11Apr 11May 11Jun 11Jul 11Month wise spot Map of WPV cases : BiharNo WPV1 in Kosi area since Nov09

No indigenous WPV1 since Nov09

Importation in mid 2010 curbed with quick mop ups

No WPV3 since Jan10

Recommendations of IEAG10Scale 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 populationsFull implementation of 107 Block plan/ Migrant strategy

Strengthen Immunization:DTF to review RI along with PolioWHO and UNICEF to support immunization spl planning & monitoringFilling of ANM Vacancies

Communication & Social Mobilization:Focus on renewed energy, safety of OPV during sickness, proactive for RI/ Polio spl among migrantsSpecific for 107 block spl RI

Sero-prevalence study

Environmental surveillance Started in April11Planned for Aug11ImplementedImplementedIn processImplementedImplementedImplementedIn 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 BiharRe-introduction of transmission through importation:High migration from/ to the stateFrequent intermixing of population with Nepal Foci of transmission outside UP/ Bihar in 2010 genetically linked to 2009 transmission of BiharWho took it there.can bring it back!!

Re-establishment:Decreased population immunityComplacencyLow RILess 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 SIAsHigh quality SIAs: >99% evaluated coverage consistently.High focus in High Risk areas.

Missed Children (%)

Persistence of Type 1 polio in Bihar 2007-09 Kosi River flood plain, Bihar, IndiaType 1 Polio 2008 Type 1 Polio 2007 Type 1 Polio 2009 KOSI: Persistence & Spread of P1Responsible 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 challengeCovers roughly 2000 Sq Km.KOSI riverine areasCompromised access around the kosi river poses unique challenges for programme planning, implementation & monitoring

Kosi IntensificationKosi Operational Plan:Reach to Kosi area increased.Satellite Offices and Stay pointsIntensified human resources from all partners100% teams monitoredFrequent field validation for Basas.% Children missed in Basas% Missed Children at the end of round

High Quality SIA Operations:Intensified monitoringDirect oversightState monitorsSMO for every blockTracking & review at highest level.

Key indicators on SIA Quality:Microplan:98.5% teams have rational workload96.5% 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 factorsHigh Risk block plan1. Diarrhea management with Zinc-ORSTraining of field staff including vaccinatorsMade available in ASHA KitsAvailability: >95%Use: 20% (Vs 5% in Sep10)2. Water and Sanitation issuesTotal Sanitation Campaign prioritized in these areasVaccinators trained for counseling590 CMCs from UNICEF for counseling in Hot spots3. 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 searchesStrengthened sensitization of SIA manpower

Environmental SurveillanceStarted on 21st April11 at 3 sewage sites in Patna

Capacity building of Patna Medical College for primary processingNegative for wild poliovirusResult pending

Sheet1

Patna

Week122334455667788991010111112121313141415151616171718181919202021212222232324242525262627272828292930303131323233333434353536363737383839394040414142424343444445454646474748484949505051515252

Choti pahari

Dujara

Transport nagar

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Sheet3

Population in movementUn-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 transmissionMajor congregations:People from outside and inside state congregate on specific occasions like Shrawani and Sonepur Mela.

Defined Migratory PopulationMapping of Migratory sites7635 Brick Kilns4805 Nomadic sites% Missed children in migrant communities>90,000 Children during high season

In-coming migrants 1Chhath (1st to 13 Nov10):Major railway/ Road transit points & Ghats13 Days2899 Teams1.3 million children vaccinatedHoli (14th-19th Mar11):Major railway & Road transit points6 Days715 Teams170,498 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 stationsFrom 27th May till end of high transmission season475,085 children covered till 37th dayMajor Railway Station305,884 children169,201 childrenIn-coming migrants 2

CongregationsSonepur Mela (20th Nov to 3rd Dec10):Saran & Vaishali14 days137 Teams34,014 children vaccinatedShrawani Mela (25th July- 24th Aug10):Bhagalpur, Banka, Munger & Indo-Nepal border31 days193 teams308,691 Children vaccinated

Indo-Nepal borderPorous border with frequent intermixing of populationMissed 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 May11

Special communication efforts focusing on migrantsIntensified IEC targeting migrantsMultilingual IEC MaterialsIEC VansMikingBoothsMobilizers

Response to WPV1 in 20102 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 SeptPreparedness for responding to importationEmergency preparedness & response group at the state level.Reporting to highest level

Team of experienced state level officers as State MonitorsResponded within 10 days when we had last importation

Routine Immunization: Progress over the yearsRI AugmentationMuskanFull 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

Chart1

11

11.6

18.6

32.8

38

41.4

54

49

66.8

68

Indicator

Sheet1

YearNFHS 2 1998-99CES 2002CES 2005NFHS 3 2005-06CES 2006-07DLHS 07-08FRDS 2008/09CES 2009-10 UnicefFRDS 2010-11HtH Monitoring 2011

Indicator1111.618.632.83841.4544966.868

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 coverageRoutine Immunization: GapsFRDS 2010/11HtH Monitoring Jun10-May11State 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 immunizedCES 2009FRDS 10/11Key remaining challenge:Communication & Mobilization

Service delivery% Sessions held out of monitored% Sessions with Antigens availableAround 90% of planned session are being held.The dip in Sep/ Oct10 due to strike

But, Non Availability of vaccines an issue since late 2010.

Further strengthening of ImmunizationImproving 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 RICommunication:IEC through Newspapers & Radio jingles

Posters

IPC through Polio Vaccinators

IPC through AWW/ ASHAs

Concerns from BiharOnly 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 mobilizationSame since 2002.

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

High transmission period & SIA opportunityConcerns from Bihar1

Mass refusals:Due to development related issues:Demands of Road/ TubewellICDS ServicesSchool etc

Some remain unsolved and occur repeatedly!Incidences of Mass refusalsCommunity 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 Bihar2

SummaryThere 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!

**I will be talking on progress made and remaining challenges in Polio Eradication in Bihar.*There is very strong political commitment in Bihar. Recently Hon CM briefed all MLAs and ministers in Bihar assembly on Polio. I will like to show you a small clip from the same.*Bihar has made significant progress. As you can see the number of Polio cases have gone down from 503 in 2007 to just 9 in 2010 and no cases till now in 2011. As you will note, historically most of the cases have been coming from North Central part of Bihar. *When we look at core endemic areas of Bihar, this area has been Polio free since last 17 months which is longest ever polio free period for this area. The bOPV was introduced in Jan2010 and might have acted as tipping factor.*Bihar has no indigenous WPV1 since Nov09 and no WPV3 since Jan10. There was importation of WPV1 in mid 2010 from Nepal which was curbed with two quick mop up rounds. The traditional reservoir are of Kosi has been P1 free for more than 20 months which longest ever polio free period.

*These are the recommendations from the last IEAG Meeting in Nov10 for action at our level. As you can see, we have implemented most of recommendations and some are still in process.*Bihar has inherent challenges to Polio eradication such as High Risk Blocks with unique features, Annual flooding in kosi riverine area, high migration in/ out of Bihar and gaps in routine immunization coverage.**Although we look to be in good position but some major risks are still there. Of which the risk of importation is very high as the state has high migration and most of the cases of 2010 outside UP/Bihar had genetic linkage with the 2009 transmission of Bihar.

Secondly there is risk of decreasing population immunity which will help the transmission to get established if it comes back. This low population immunity can be caused by lesser opportunity with SIAs, Complacency and low existing RI coverage.

These risks are very high in coming few months as this is high transmission season and is further compounded by possibility of floods.

Lastly, although very remote, but there is possibility of very low level undetected transmission. **To mitigate the risks as described, we have taken steps to sustain high population immunity by conducting frequent high quality SIAs, improving RI, Implementing Kosi Operation Plan and 107 Block Plan.

To detect even low level of transmission, we have intensified surveillance in core endemic areas of Kosi and have also started environmental surveillance. **To prevent the importation, we are covering migrant families, incoming migrants during festival seasons and also major congregations. Seeing the risk of importation, we have put the continuous vaccination booths at major entry points and Indo-Nepal border.

Despite these, if importation occurs, we are fully prepared to mount high quality Mop Up response within 10 days of detection of transmission. **Bihar has maintained very high quality of SIAs with more than 99% coverage in every campaign. The end of round coverage surveys show that we miss less than 1% children.

The quality is much higher in high risk blocks and Kosi riverine areas.*Kosi Riverine area has acted as reservoir of transmission over the years and is highly crucial area for achieving the goal of eradication. This area is free from P1 for around 20 months now.

*The area in question is highly challenging in terms of access and gets flooded every year for 3-5 months.**This has been achieved through implementation of Kosi Operational plan. With this plan the reach to Kosi area was increased by establishing Satellite offices and stay points, human resources were intensified. In this area, frequent basa validation is being done and all teams are being monitored in every round.

This has resulted in improved coverage as seen in less than 0.5% children being missed in SIAs and even the children missed in Basas reduced to 2% from 14% in 2009.******This year we had importation of transmission from Nepal. Although there was internal circulation giving rise to 3 cases, but transmission was limited to a small geographical area bordering to Nepal.

2 Quick mop up rounds were done in the area covering 1.8 million children in each round. Through our sensitive surveillance system, we picked the transmission early and mounted the response within 10 days of getting stool results.

With the last case having onset on 1st September, it looks like that the transmission has stopped.

This shows that we are vulnerable in areas where there is large intermixing of population like at the Nepal border or during festival seasons when migrant families return to Bihar. And also that, if we have high background population immunity, we can stop the transmission by doing quick mop rounds in sufficiently large areas.****We have revised incentive scheme for improving the fund flow. All DIOs have been trained on Routine Immunization and the training of all Medical Officers is going on.

Monitoring has been intensified with around 5000 session and 30,000 houses being monitored every month. We have developed process indicators to review the performance of RI in the districts on monthly basis. Weekly District Control Room on RI has been formed at each district to address the gaps found during monitoring.

We have rolled out RI in urban areas focusing on slums. Migratory Populations are being included in RI microplan for coverage. **