Poliovirus Surveillance status of quality, actions to improve sensitivity WHO-India 15 March 2012

Outline of the presentation National overview of AFP surveillance in India Areas/Populations at a relatively higher risk of wild poliovirus circulation/importation Surveillance quality during last 6 months in areas/ populations at higher risk Recent efforts to improve surveillance sensitivity

AFP Surveillance Reporting *Data as on 10 March 2012 Number of AFP cases reported Number of AFP case reporting sites

Polio laboratory performance Number of stool specimens processed Number of days from stool received in laboratory to final result Days *2007 *Data as on 10 March 2012

% Non-polio AFP rateStool collection rate Surveillance performance indicators, last 6 months # AFP cases, Jan – Feb

Outline of the presentation National overview of AFP surveillance in India Areas/Populations at a relatively higher risk of wild poliovirus circulation/importation Surveillance quality during last 6 months in areas/ populations at higher risk Recent efforts to improve surveillance sensitivity

Where could the virus be? Leads from past incidence Wild poliovirus type 1 cases, Historic reservoir areas

107 High Risk blocks HR blocks Where could the virus be? Leads from past incidence Historic reservoir areas

WPV 1 cases, Areas with recent transmission HR blocks Where could the virus be? Leads from past incidence Historic reservoir areas

Wild poliovirus cases by migratory status Outside Bihar & Uttar Pradesh, Migrant sites (1 dot=50 sites) HR blocks Where could the virus be? Leads from past incidence Areas with recent transmission Historic reservoir areas

Where could the virus be? Leads from genetics Tajikistan 2010 Areas involved with international importations

Bangladesh 2006 Areas involved with international importations Where could the virus be? Leads from genetics Tajikistan 2010

Where could the virus be? Leads from genetics Bangladesh 2006 Angola 2005, 2007 Areas involved with international importations Tajikistan 2010

Bangladesh 2006 Angola 2005, 2007 Nepal 2004, 2005, 2006, 2010 Areas involved with international importations Where could the virus be? Leads from genetics Tajikistan 2010

Areas at risk of importation from neighbouring countries Where could the virus be? Threat from neighbouring countries with active circulation WPV 1 past 6 months, neighbouring countries

Outline of the presentation National overview of AFP surveillance in India Areas/Populations at a relatively higher risk of wild poliovirus circulation/importation Surveillance quality during last 6 months in areas/ populations at higher risk Recent efforts to improve surveillance sensitivity

Historic reservoir areas Non-polio AFP rate Non HR blocks U.P. 85% U.P. 86% U.P U.P Bihar 42.1 Bihar 31 Bihar 89% Bihar 89% Non HR blocks *Data – September 2011 to February HR blocks % adequate stool specimen collection rate

Areas with recent transmission Non-polio AFP rate Non HR blocks West Bengal Jharkhand West Bengal Jharkhand *Data – September 2011 to February 2012 Average 13.5 Average 89% % adequate stool specimen collection rate

Areas with recent transmission Non-polio AFP rate Non HR blocks *Data – September 2011 to February 2012 Average 12.9 Average 87% % adequate stool specimen collection rate

Migrant populations Migrant AFP cases, 2011* N=2,040 Estimated non-polio AFP rate** amongst migrants ** Estimate based on the number of migrant children vaccinated in SIAs *data as on 10 March 2011

Areas linked with international spread of poliovirus Non-polio AFP rate *Data – September 2011 to February 2012 % adequate stool specimen collection rate Average 33.5 Average 86%

Areas at risk of importation from neighbouring countries Non-polio AFP rate *Data – September 2011 to February 2012 % adequate stool specimen collection rate Average 6.8 Average 83%

Outline of the presentation National overview of AFP surveillance in India Areas/Populations at a relatively higher risk of wild poliovirus circulation/importation Surveillance quality during last 6 months in areas/ populations at higher risk Recent efforts to improve surveillance sensitivity

Field surveillance reviews, 2011 Number of states reviewed States reviewed Districts reviewed

West Bengal Significant efforts to improve AFP surveillance noticed post surveillance review in March’11 to ensure early detection of virus circulation Number of reporting sites AFP cases reported till week 10 Year to date comparison *Data as on 10 March 2012

Delhi AFP surveillance system sensitivity enhanced, particularly in high risk populations, following the surveillance review. # AFP cases Expansion of reporting network

Bihar & West UP “AFP surveillance system in Western UP & Bihar is sensitive enough to pick up virus transmission at the earliest” “Need for greater involvement of the district and block government staff in surveillance activities” Number of reporting sites in review districts Bihar West UP Data at the time of review

Maharashtra, Nov’11 Nasik (Malegaon) –Weak reporting network leading to delayed reporting of cases Rest of Maharashtra –Extensive reporting network with adequate government & private involvement –Timely & adequate response to all AFP cases reported # AFP cases reported, Nasik “AFP surveillance system is likely to pick up virus circulation; however, efforts need to be strengthened in Nasik.” *Data as on 10 March 2012 % adequate stool specimen, Nasik 2011

Andhra Pradesh, Dec 2011 Blocks without any AFP case in 2011* * data as on 3 December 2011 at the time of review % AFP cases with adequate stool specimen, 2011* Existing public health cadre under- utilized for surveillance Inadequate involvement of private sector health facilities in reporting AFP cases “AFP surveillance needs improvements to ensure early detection of any virus circulation”

Conclusions of recent surveillance reviews Surveillance sensitive to pick-up virus circulation Gaps identified, improvements made after review Gaps identified, improvements required

Surveillance reviews, 2011 Plans for 2012 Follow up on recommendations of 2011 reviews Field reviews in 6 additional states States reviewed 2011 Districts reviewed 2011 Proposed reviews, 2012 Surveillance reviews, 2012

Environmental surveillance expansion plans Mumbai 2001 Delhi May 2010 Patna April 2011 Kolkata December 2011 Punjab Gujarat WPV 1 past 6 months, neighbouring countries Existing environmental surveillance sites Proposed additional sites for environmental surveillance

Summary Overall surveillance quality maintained at high levels Areas at risk of WPV importation/circulation identified and being closely monitored for surveillance quality Actions being taken to enhance surveillance sensitivity in high risk areas following reviews e.g. West Bengal, Delhi, Nasik (Malegaon) Sewage sampling sites being expanded strategically to minimize risk of missing poliovirus in the environment

Thank You

Surveillance review, Gujarat, June’11 Extensive reporting network with government & private health facilities Well functional system of case investigation and specimen collection maintained by government Adequate focus on migrants Need of expansion of network in blocks without informers Need of greater involvement of government system in sensitization of network Blocks without informers Reporting network “AFP surveillance system is likely to pick up virus circulation if it happens” RU INFORMER

Districts with ‘Orphan’ viruses, WPV1 from 8 districts 1 isolate each in Mumbai & Delhi sewage WPV1 cases with >1.5% Genetic distance ~ 18 months undetected circulation Virus resurfaced after 18 months circulating undetected

Polio laboratories performance All 8 laboratories achieved WHO accreditation Polio network laboratories exceeded globally recommended target for timeliness of results 7 out of 8 polio laboratories in India performing intra-typic differentiation 2 additional laboratories (Patna and Kolkata) equipped for sewage sample collection/ testing