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 16 th April, 2013

National Polio Surveillance Project: GoI & WHO Polio update, AFP Surveillance Polio update, AFP Surveillance End game strategy Dr. Anish Sinha State Surveillance Medical Officer World Health Organization National Polio Surveillance Project, India, Gandhinagar.

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.

National Polio Surveillance Project: GoI & WHO cases 125 countries Areas with Active Polio Transmission cases 5 countries

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

National Polio Surveillance Project: GoI & WHO India India last polio case on 13 th Jan.2011 Removed from list of ENDEMIC Countries list in Feb.2012 Looking forward for Certification (SEAR) in Feb.2014

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)

National Polio Surveillance Project: GoI & WHO WPV transmission from Northern Sindh, Pakistan to Greater Cairo (environmental sample +ve), Egypt Importation of WPV , Egypt - polio free since 2004.

National Polio Surveillance Project: GoI & WHO WPV cases, India P1 wildP3 wild No case since Jan 2011 * data as on 12 April 2013 P2 wild

National Polio Surveillance Project: GoI & WHO Location of wild poliovirus and VDPV cases by type, India * * data as on 12 April 2013

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

National Polio Surveillance Project: GoI & WHO Wild poliovirus type 1 Wild poliovirus type 3 Negative for wild poliovirus Scheduled but sample not collected X Sampling not scheduled Wild poliovirus detected in sewage samples, 2010 – Mumbai Delhi 2011 Mumbai Delhi Patna Kolkata

National Polio Surveillance Project: GoI & WHO Wild poliovirus type 1 Wild poliovirus type 3Result pending Negative for wild poliovirus Scheduled but sample not collected X Sampling not scheduled Wild poliovirus detected in sewage samples, 2012* Mumbai Delhi Patna Kolkata * data as on 12 April 2013

National Polio Surveillance Project: GoI & WHO Wild poliovirus type 1 Wild poliovirus type 3Result pending Negative for wild poliovirus Scheduled but sample not collected X Sampling not scheduled Wild poliovirus detected in sewage samples, 2013* * data as on 12 April 2013 Mumbai Delhi Patna Kolkata

National Polio Surveillance Project: GoI & WHO Progress in India–A snapshot P1 wildP3 wild * data as on 12 April 2013 P2 wild : 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

National Polio Surveillance Project: GoI & WHO Gujarat Wild Cases BAN KTC JMC RJC AML BVC KDA PML DHD VDD SRC NAV DNG AMD AND VDC SRN GNR VLD AMC NMD BRH SBK BVN JUN PAT MSN JMD POR SRT RJT Year - Cases

National Polio Surveillance Project: GoI & WHO Epidemiology of Polio

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

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.

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  AFP surveillance To identify reservoir of transmission  2000 – Mopping up immunization To eliminate last foci of transmission

National Polio Surveillance Project: GoI & WHO AFP Surveillance

National Polio Surveillance Project: GoI & WHO Objective of AFP surveillance Reliably detect areas where polio transmission is occurring or likely to occur

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

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.

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

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

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.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.

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

National Polio Surveillance Project: GoI & WHO The AFP Surveillance System Hospitals Clinics Community Investigation Non-Polio AFP Polio AFP

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

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

National Polio Surveillance Project: GoI & WHO Likely to be 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.

National Polio Surveillance Project: GoI & WHO Clinical Presentation Clinical Poliomyelitis586 (86.7)757 (86.71)494 (88.37)648 (87.45)32 (76.19) Only H/O Paralysis24 (2.7)14 (1.60)14 (2.5)10 (1.35)1 (2.38) Hemiplegia35 (5.2)54 (6.19)25 (4.47)48 (6.48)3 (7.14) G.B.Syndrome6 (0.9)3 (0.34)3 (0.54)3 (0.40) Traumatic Neuritis4 (0.6)8 (0.92)1 (0.18)2 (0.27) Only Limp4 (0.6)1 (0.11)0 (0)4 (0.54) Acute Encephalitis3 (0.4)3 (0.34)4 (0.72)1 (0.13) Isolated Facial Palsy3 (0.4)19 (2.18)10 (1.79)14 (1.89)4 (9.52) Isolated Neck Flop4 (0.6)5 (0.57)4 (0.72)4 (0.54) Post Diptheric Polyneuritis 0 (0)2 (0.23)0 (0)1 (0.13) Others7 (1.0)7 (0.80)4 (0.72)6 (0.81)2 (4.76) Total Analysis of initial clinical presentation of WPV

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)

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%

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 RESIDUAL WEAKNESS, DIED OR LOST TO F/U DISCARD EXPERT REVIEW

National Polio Surveillance Project: GoI & WHO 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

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.

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

National Polio Surveillance Project: GoI & WHO Supplementary Immunization Activities: NIDs/ SNIDs

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).

National Polio Surveillance Project: GoI & WHO Continued focus on high risk areas and populations West UP: HR blocks – 66 Bihar: HR blocks – 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

National Polio Surveillance Project: GoI & WHO Certification of polio eradication

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

National Polio Surveillance Project: GoI & WHO Certification of SEAR* * South East Asia Region of WHO 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

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%

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

National Polio Surveillance Project: GoI & WHO Sep12 - Jun13 Five categories of states have been formed NCCPE Field Visits Category 5 states

National Polio Surveillance Project: GoI & WHO Laboratory Containment Union Health Ministry already issued letter in this regard to all the States (dated 14 th 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.

National Polio Surveillance Project: GoI & WHO Polio Endgame Strategy

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

National Polio Surveillance Project: GoI & WHO cVDPV cases, India cVDPV cases detected in % due to type 2 District Type Badaun300 Bulandshah ar 200 Ghaziabad010 Meerut200 Moradabad200 Pilibhit400 Shahjahanp ur 210 Total1520

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 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% High immunity levels sustained for P1 since 2009 Increasing trend in immunity level for P3 in

National Polio Surveillance Project: GoI & WHO Managing the risk of VDPVs

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 period). Support research activities to generate evidence to guide decision making

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

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 Lessons from tOPV-bOPV switch significant for subsequent withdrawal of all OPV from programme

National Polio Surveillance Project: GoI & WHO Thank you