1. Emergency Preparedness and Response Planning for Polio Dr N K Sinha State Immunization Officer State Health Society, Bihar

2. WPV cases in Bihar 2009 2010 2011 Cross-border transmission with Nepal 2009 2012 WPV 1 Cases in Bihar 2010

3. 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 Re-establishment: –Decreased population immunity Resulting from complacency –Pockets of low RI

4. Risk analysis: Identification of high risk district and blocks High Risk Districts High Risk Blocks

5. Mobile population and population in movement: –Migratory population (Nomads/ Brick kiln workers) –Movement across long and porous Indo-Nepal Border –Returnee migrants to Bihar –Other population movement (like Sharawni Mela and Sonepur Mela) Sub block high risk areas (Hot spots) Presence of access compromised Kosi riverine areas Pockets of low RI coverage Pockets of areas with refusal to OPV and instances of mass refusals Risk analysis: Identification of migratory and other risk factors

6. Status of EPRP EPR Plan for the state made and communicated to GOI –Plan for risk mitigation and –Quick high quality mop up in case of importation Risk mitigation strategies implemented –State level officers given responsibility of high risk areas for oversight on risk mitigation strategies Rapid Response Team formed and trained

7. Risk mitigation strategies Sustaining high population immunity in High Risk areas And Preventing risk of re-importation

8. Sustained high quality SIA campaigns High quality SIAs: less than 0.5% missed children. High focus in High Risk areas.

9. High Quality SIA Operations: –Intensified monitoring –Direct oversight State monitors SMO for every block Tracking & review at highest level. High Risk block plan Convergent interventions of WASH and Zinc ORS are going on in these blocks with focus on ‘hot spots’

10. 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. Improved coverage with intensified monitoring

11. Brick Kiln – 8079 Nomadic Site - 5022 Migrants Number of sites with migratory / mobile populations identified in Bihar Field validation and mapping of migrant sites Focused for coverage in SIA and RI Dynamic list: regular updation Surveillance: –Health seeking behavior survey –Related health facilities sensitized/ included in network

12. Continuous vaccination activity at Indo-Nepal Border and Major railway stations: –93 teams at 51 Indo-Nepal Border sites & 198 at 11 Major railway stations –Ongoing from 27 th May’11. –2,761,397 children vaccinated till now Major Railway Station Continuous vaccination activity

13. Vaccinating returnee migrants Chhath: –Major railway/ Road transit points & Ghats –13 Days –2899 Teams –1.3 million children vaccinated Holi: –Major railway & Road transit points –6 Days –738 Teams –152,491 children vaccinated

14. Congregations Shrawani Mela (16 th July- 14 th Aug’11): –Bhagalpur, Banka, Munger & Indo-Nepal border –31 days –103 teams –152,868 Children vaccinated Sonepur Mela (9 th Nov—22 nd Nov’11): –Hajipur Urban, Sonepur –14 days –192 teams –82144 Children vaccinated

15. Routine Immunization: Progress over the years We strive to achieve beyond 85% by 2013 in ALL districts & Blocks

16. Reasons for Non/ partial Immunization: FRDS 2010-11 (multiple response) 16 Do not know what vaccines are needed and when 40.5 Child is too young for vaccination 36.8 Fear of side effects 21.1 Services are not available when required 15.9 Do not feel need for vaccination 15.4 Do not know where to take the child for vaccination 9.9 Opposition from family members 6.1 Do not have time to take the child for immunization 5.3 Others 5.8 Antigen wise coverage (FRDS-10/11) The problem in Bihar is of ‘Drop Outs’ –From 94% BCG or 89% DPT1, we are able to retain only 67% Key gap in communication and mobilization

17. Service delivery % Sessions held and functional AVD % Sessions with Antigens available More than 90% of planned sessions being held. Alternate vaccine delivery functioning well Shortage of vaccine recently % Full immunization

18. Strengthening of Immunization Microplan: –Revised in 2009 to include all villages from Polio microplan (>20,000 extra session sites added) –But, number of sessions reduced after synchronization with VHND –Revision going on to incorporate all urban slums, migrants and hamlets without AWC (Implementation by 1 st April’12) Vaccine and logistic management: –EVM Passbooks implemented. –Training on cold chain and vaccine handling to DIO and staff. –Information flow of vaccine strengthened through software package and mobile (Plan to implement OVLMS) Supervision, Monitoring & review: –More than 3000 sessions & 30,000 houses monitored/ month –Weekly district control room meeting and Weekly RI cell meeting –Bi-Monthly review meeting of DIOs with process indicators –Supervisory cadre?

19. Strengthening of Immunization IRI Plan (12-13): –Prioritization done on the bases of: Low RI coverage and Measles/ polio surveillance data –Planed for improving coverage Immunization weeks: –April, May, June and July/ Dec AVD and Teeka Express: –AVD is successful in Bihar and reaches every where. –Teeka express planned for migrant/ urban slums Capacity building: –1/3 rd MOs trained in RI. Fast tracking planned –All DIOs trained, training of ANMs to be fast tracked

20. Strengthening of Immunization Mobilization: –Support from polio vaccination teams by convergence through newborn booklet. –Close coordination with ICDS department for involvement of AWW –Revised incentive mechanism for ASHA (higher for Measles/ booster) –IEC through flexi-banners at AWC/ health facilities and mass media ANM Vacancies: –~30% vacancy of ANMs –Rational distribution of existing ANM in process AEFI/ VPD Surveillance: –AEFI committees functional at all districts –AEFI workshop in pipeline

21. Sensitivity of surveillance

22. Key surveillance indicators NPAFP RateAdequate stool Rate Sustained sensitivity of surveillance. Higher sensitivity in high risk areas (High risk blocks and Kosi riverine areas) Environmental Surveillance: Negative for polio Surveillance Review (Nov’11): No major gaps

23. Expansion of reporting network BIHAR41 High Risk Blocks 12 Kosi-PT Blocks Intense network in vulnerable areas HR Blocks are 7% of state but have 14% of reporting sites Kosi-PT are 2% of state and have 7% of reporting sites

24. Preparedness for Mop Up in case of detection of any transmission

25. Preparedness for responding to importation Bihar is prepared to hold first mop up with in 7 days of detection of transmission. Following plans are in place: –Logistics: Marker pen: rolling stock with vendor at Patna which can be supplied with 3 days anywhere in state. Formats: printing decentralized and takes 3-4 days –Communication: State Health Society can take out advert within 2 days of information –Cold chain: Although sufficient to do mop up, we have requested 50,000 vaccine carriers from GOI –Microplanning: Available at all PHCs and are updated regularly. –Manpower & training: Vaccinators are well identified and usually are AWW/ ASHA. They can be mobilized within 3 days of information. EPRG & RRT can be activated within 24 hours District and Block task force will meet as soon as campaign is decided.

26. Response to WPV1 in 2010 2 quick High Quality Mop Up response with mOPV1 covering 1.8 million children 1 st Cases: –Onset: 8 th Aug. –Investigated:13 th Aug. –Result: 25 th Aug. –Mop Up: 4 th Sept. & 4 th Oct. Onset of last case: 1 st Sept Experience in past Responded within 10 days when we had last importation 2009 2010 2011 Cross-border transmission with Nepal 2009 2012 WPV 1 Cases in Bihar 2010

27. Enhanced Political commitment at highest level “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 but the risk of importation is still there. We all should come together and give best effort now”

28. Thank you

29. What is being done Sustaining high population immunity specially in High Risk Areas and groups by: –High quality SIAs –Implementation of Kosi Operational Plan –Implementation of 107 Block Plan. –Steps to strengthen Routine Immunization. –Migrants in Bihar (Nomads, Brick Kiln labours etc.) –Coverage of incoming migrants during period of major movement and Major congregations. –Continuous Vaccination at major entry points & Indo-Nepal border. Prepared for mounting Rapid Mop Up in response to any transmission detected. Intensified surveillance in core endemic areas of Kosi and environmental surveillance.

30. Surveillance: Migrants Type of migrant site Health facilities identified to be catering to migrants Health facilities already part of network Health facilities included in network after survey Nomadic site 21321315113 Brick Kilns 32421306150 Urban slums 40218314 Construction sites 41331 Rest of the health facilities were seeing very few cases and were sensitized for reporting AFP cases Health seeking behavior survey of migrants: One time in late 2011 and from then on ‘on going’ basis