Supplementary Immunization Activities Quality, Risks and Risk Management IEAG Meeting 13 July 2011

Supplementary Immunization Activities (SIAs) India, Jan to June 2011 NIDSNID Endemic & risk states Zone 1 UP/Bihar, Delhi & HR areas MarAprMayJunJanFeb mop up in West Bengal / Jharkhand

SIAs – India, January to February Jan 2 nd week Feb 27 Feb mOPV1 mOPV3 bOPV tOPV

SIAs – India, March to June 2011 March bOPV tOPV April MayJune

Emergency Outbreak Response Howrah, West Bengal, 2011

Day 6 Mop up conducted Day 4 National level partners meeting Media plan operationalized Vaccine arrived in district Day 3 State & District Task Force Meetings 14 additional SMOs arrive in districts IEC plan developed Marker pens & other logistics procured Day 2 Field Investigation (NCDC/NPSP/UNICEF) National Technical Group Meeting Decision on mop up Day 1 Chief Minister & Chief Secretary WB informed by GoI Day 0 Wild Polio virus notified Day5 Vaccine & other logistics reach blocks Key Immediate Actions that followed detection of case 7 Feb Feb 2011

Major Issues Identified Microplanning –Missed Areas –High work load of vaccinators & supervisors –Composition of vaccination teams not appropriate –No revisits planned to ‘X’ houses Training –Weak interpersonal communication skills of vaccinators –Untrained vaccinators working as team members Non-acceptance of vaccine –High refusals (~ refusals in Howrah and 3 neighbouring districts) –Myths against vaccine safety

Outbreak Response Actions (GoI/ GoWB, WHO-NPSP, UNICEF, Rotary, CORE) Identification of 36 high risk blocks/municipalities & 222 high risk Gram Panchayats/wards to focus activities Enhanced oversight & coordination by central and state officials, DMs, CMOs, Municipality/ Ward Officers, BDOs, BMOs

Outbreak Response Actions (2) (GoI/ GoWB, WHO-NPSP, UNICEF, Rotary, CORE) 25 experienced additional SMOs deployed to the outbreak area for 4 months to support –Improvements in microplans: ensure no missed areas, appropriate team composition and workload –Trainings: to improve skills & performance of vaccinators and supervisors –Intensive monitoring of preparedness & implementation in high risk areas

Outbreak Response Actions (3) (GoI/ GoWB, WHO-NPSP, UNICEF, Rotary, CORE) Scale up of IEC/ mobilization efforts –1900 NGO mobilizers deployed –Additional IEC materials produced –Enhanced media support –Sensitization of Influencers/ religious leaders and local practitioners –Advocacy/ vaccination during community events –Health Camps –Vaccination at clinics of important practitioners Mandatory revisits to ‘X’ marked houses accompanied by doctors/ local influencers

Outbreak response, West Bengal Howrah, 2011 Murshidabad, 2010 bOPVmOPV1 JanFebMarAprMayJunJulAugSepOctNovDec WPV1 notified 07 Feb 2011 WPV1 notified 12 Feb Number of WPV 5 weeks 17 weeks 1 week 7 weeks WPV1 WPV3

Summary – SIAs in 2011 At least one SIA with tOPV conducted in all areas in the country – most areas got 2 tOPV rounds 3 to 5 campaigns conducted with bOPV in high risk areas Aggressive Emergency Outbreak Response conducted in West Bengal following detection of WPV type 1 in Howrah district in 2011

SIA quality in high risk areas/populations

Areas/ Populations at highest risk of polio Areas with recent polio transmission

Areas/ Populations at highest risk of polio Areas with recent polio transmission Endemic areas

Areas/ Populations at highest risk of polio Areas with recent polio transmission Endemic areas Areas with high migrant populations

West Bengal Jharkhand Malegaon (Maharashtra) Areas with recent transmission

Percent unvaccinated children End-of-round survey Southern districts, West Bengal Percent N= 7,5256,6658,19311,933 N=6,5567,5747,686 11,027 7,065 Northern districts, West Bengal 1,3714,4902,9964,0203,515 11,787 10,320

Howrah Percent 24-Parganas South N=2, ,0341,487 N=2,4052,3471,9982,341 Percent 24-Parganas North N=1, ,0672,535 2,858 2,018 1,423 Percent Kolkata N=1,4512,2202,6743,995 3,629 Percent unvaccinated children, End-of-round survey, 2011 Quality of SIAs in southern districts - West Bengal 2,092 3,393 2,846 2,847

Percent unvaccinated children, End-of-round survey Jharkhand West Bengal High coverage achieved in high risk areas of Jharkhand Percent Pakur & Sahibganj N= 2,9453,2135,9049,7798,3986,0884,1635,5685,5096,1976,151

Jharkhand West Bengal Lot Quality Assurance Sampling (LQAS) West Bengal & Jharkhand – Feb to June 2011 DistrictFeb 11Mar 11Apr 11May 11Jun 11 Murshidabad (West Bengal) # lots accepted # lots cautioned # lots rejected Birbhum (West Bengal) # lots accepted # lots cautioned # lots rejected Pakur (Jharkhand) # lots accepted # lots cautioned # lots rejected Hypothesis: “The SIA coverage in this LOT is > 90%.” Only 1 of 46 lots rejected in North Bengal/Jharkhand during last 5 SIAs LQAS findings validate monitoring findings from end-of-round surveys

Percent Percent unvaccinated children, End-of-round survey N= 1,9894,4244,1933,1513,8443,9463,1153,155 Malegaon Municipal Corporation # houses with reluctance to accept OPV, End-of-round Number 3,798

Summary – Areas with recent transmission West Bengal (Northern districts): Improvement in SIA quality since September sustained over last 9 months – a few pockets of low coverage persist West Bengal (Southern districts): Rapid improvement in SIA quality during past 4 months, however quality variable in districts; pockets with gaps in quality remain – require immediate addressal Jharkhand: Sustained good quality campaigns over last 9 months Malegaon (Maharashtra): Large proportion of unvaccinated children during multiple rounds – recent worsening of quality

Western UP Central Bihar Endemic Areas

Continued intensive focus on vaccination in field huts - Kosi area, Bihar > 280,000 clusters of field huts (basas) visited by vaccination teams each round Intensive supervision and monitoring Percent unvaccinated children detected in field huts (basas) ~ 3,000 children checked per round

Percent unvaccinated children – end of round survey West UP Bihar ~40,000 children checked for vaccination status each round in 107 high risk blocks High polio vaccination coverage sustained in 107 highest risk blocks of UP and Bihar 66 HR blocks 41 HR blocks

Lot Quality Assurance Sampling (LQAS), 66 highest risk blocks, West UP, June 2011 – A Pilot SIA round66 HR blocks June 2011 # lots accepted 58 # lots cautioned 11 # lots rejected 1 Hypothesis: “The SIA coverage in this LOT is > 95%.” HR blocks in which LQAS done

Percent households having a child with diarrhea that had received Zinc tablets, June 2011 Source: NPSP SIA monitoring data 1%22% Household checked =1,444 Households checked =2,115 Zinc distribution to children with diarrhea 107 highest risk blocks of UP and Bihar

Summary – Endemic Areas Intensive series of SIAs conducted with bOPV in endemic areas in first half of 2011 High coverage during polio SIAs being sustained in the high risk areas of UP and Bihar Implementation of certain components of 107 high risk block plan remain a challenge

# children: 0.8 mn in each round # children: 0.5 mn in each round # children: 1.1 mn in each round # children: 0.7 mn in each round Migrant populations vaccinated 5-6 times (Jan to June 2011) Areas with high migrants / mobile populations Delhi, Mumbai, Punjab, Haryana, Gujarat, Uttarakhand, West Bengal

Punjab Percent N= 3,0543,7256,1638,421 N= 8045,943 Gujarat ,4546, ,988 Delhi Percent N= 2,6081,2012,6812,802 N= 6,0284,432 Gr. Mumbai 2,2182,6402,6312,6113,2146,1898,4909,3669,7155,2975,320 Percent unvaccinated children, End-of-round survey 11,4305, ,084

Uttar Pradesh Bihar INDIA NEPAL ~314,000 children vaccinated (April to June 2011) Vaccination post Blocks with vaccination post Continuous vaccination along Indo-Nepal border 81 vaccination posts

Coverage during major religious congregations/ population movement 1.Ajmer Urs (Rajasthan) 22 May to 14 June 2011 ~ 300,000 children vaccinated 2. Piran Kaliyar (Uttarkhand): Feb 2011: ~60,000 children vaccinated 3. Holi - returnee migrants (West Bengal, UP, Bihar): March 2011: ~245,000 children vaccinated 4. Planned activity: Shrawani Mela (Bihar & Jharkhand): July – August 2011: ~300,000 children expected to be vaccinated

Migrants sites identification, India – June 2011 Number of sites with migrants identified : 150,000 Number of children < 5 yrs in these sites : ~ 4.2 million Number of sites identified by type = 10 migrant sites

Intensive SIAs to vaccinate migrants in high risk states during first half of 2011 Quality of coverage of migrants variable in different states Additional opportunities to vaccinate migrants at congregations, borders being utilized National data base of migrant families being prepared Summary – Coverage of migrants

Conclusions Number and scope of SIAs during first half of 2011 conducted as recommended by last IEAG Aggressive outbreak response conducted in West Bengal in early 2011 Endemic areas sustaining high SIA coverage Strategy to cover migrants in high risk states and other areas being optimized Overall SIA quality in areas with recent transmission improved in 2011, however certain pockets remain a matter of concern

Questions for consideration of IEAG What is the optimum number, timing and scope of SIAs between July and December 2011? What should be the scope and number of SIAs during early 2012? What types of polio vaccines should be used in the SIAs?

Proposed SIAs – India, July to December 2011 (As recommended by Nov 2010 IEAG) SNID SepOctNovDecJulAug SepNov bOPV SNID

Monthly incidence of WPV1 cases, JanFebMarAprMayJunJulAugSepOctNovDec Planned SNID Most recent SNID conducted

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