Workshop on “Polio updates & End game strategies” Organized by Community Medicine Department,

1. Workshop on “Polio updates & End game strategies” Organized by Community Medicine Department, GMERS Medical College, Sola, in collaboration with NPSP (WHO), Gandhinagar 16th April, 2013

2. Polio update, AFP SurveillanceEnd game strategy Dr. Anish Sinha State Surveillance Medical Officer World Health Organization National Polio Surveillance Project, India, Gandhinagar.

3. Contents…. • Global/ National / State update. • Epidemiology of polio. • AFP Surveillance. • SIAs (NIDs / SNIDs). • Certification of Polio eradication. • End game strategy.

4. Areas with Active Polio Transmission 1988 350 000 cases 125 countries 2012 223 cases 5 countries

5. Rukhsar Khatoon last case of WPV detected in India (Jan 2011), her mother Shabida Bibi in Shahapar village, WB

6. India • India last polio case on 13th Jan.2011 • Removed from list of ENDEMIC Countries list in Feb.2012 Looking forward for Certification (SEAR) in Feb.2014

7. Global Polio updates 2012 Nigeria (122) Pakistan (58) ONLY THREE ENDEMIC COUNTRIES Afghanistan (37) CHAD 5 WPV1 (IMPORTATION) Niger 1WPV1 Till 9 Apr 13 – 18 cases(Nig-11, Pak-6, Afg-1)

8. WPV transmission from Northern Sindh, Pakistan to Greater Cairo (environmental sample +ve), Egypt Importation of WPV 2013 -, Egypt - polio free since 2004.

9. WPV cases, India 1934 No case since Jan 2011 1600 P2 wild P1 wild P3 wild * data as on 12 April 2013

10. Location of wild poliovirus and VDPV cases by type, India 2013* 2011 2012 * data as on 12 April 2013

11. WPV2 24/10/1999 Aligarh (UP) WPV3 22/10/2010 Pakur (JH) WPV1 13/01/2011 Howrah (WB) Last wild poliovirus cases by type, India * data as on 12 April 2013

12. Mumbai 2010 Delhi Wild poliovirus detected in sewage samples, 2010 – 2011 Mumbai 2011 Delhi Patna Kolkata Wild poliovirus type 1 Sampling not scheduled Negative for wild poliovirus Wild poliovirus type 3 Scheduled but sample not collected X

13. Mumbai Delhi Patna Kolkata Wild poliovirus detected in sewage samples, 2012* Negative for wild poliovirus Wild poliovirus type 1 Scheduled but sample not collected X Wild poliovirus type 3 Result pending Sampling not scheduled * data as on 12 April 2013

14. Mumbai Delhi Patna Kolkata Wild poliovirus detected in sewage samples, 2013* Negative for wild poliovirus Wild poliovirus type 1 Scheduled but sample not collected X Wild poliovirus type 3 Result pending Sampling not scheduled * data as on 12 April 2013

15. Progress in India–A snapshot 1934 • 1995: 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 1600 P2 wild P1 wild P3 wild * data as on 12 April 2013

16. BAN Year - Cases 2000 - 2 KTC PAT PML SBK MSN GNR AMD 2001 - 1 KDA DHD AMC AND VDC SRN 2002 - 24 JMC BVC 2003 - 3 VDD RJT JMD RJC 2004 - 0 AML 2005 - 1 NMD POR BRH BVN SRC JUN SRT 2006 - 4 DNG NAV 2007 - 1 2012 - 0 2008 - 0 2009 - 0 2010 - 0 2011 - 0 2013 - 0 VLD Gujarat Wild Cases 2000-13

17. Epidemiology of Polio

18. 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

19. 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.

20. Strategies of Polio Eradication • 1985 – Routine immunization Individual immunity • 1995 – NID’s ( PPI / IPPI ) To replace wild with vaccine virus • 1997 - AFP surveillance To identify reservoir of transmission • 2000 – Mopping up immunization To eliminate last foci of transmission

21. AFP Surveillance

22. Objective of AFP surveillance Reliably detect areas where polio transmission is occurring or likely to occur

23. Principle of AFP Surveillance in identifying polio cases • Identify children with the SYNDROMEof 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

24. 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.

25. 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

26. 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

27. 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. • 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.

28. 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

29. The AFP Surveillance System Hospitals Clinics Community Investigation Polio AFP Non-Polio AFP

30. When too much polio is around….. Surveillance sensitivity is adequate enough to detect 90% polio cases AFP cases Polio cases Borderline AFP cases Non-AFP cases

31. When transmission is very low….. Surveillance sensitivity is not good enough & detects only 50% polio cases If borderline cases are taken & stool specimens collected … …Sensitivity increases and leads to 100% detection of polio cases AFP cases Polio cases Borderline cases Non-AFP cases Remember Non AFP cases still not taken

32. 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.

33. Analysis of initial clinical presentation of WPV 2006 - 10

34. 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)

35. GOLD STANDARD FOR AFP SURVEILLANCE • Non – Polio AFP Rate > 2.0 • Adequate Stool Samples > 80% • Timeliness of Reporting > 80%

36. WILD POLIOVIRUS CONFIRM COMPATIBLE RESIDUAL WEAKNESS, DIED OR LOST TO F/U EXPERT REVIEW AFP DISCARD INADEQUATE STOOL SPECIMENS NO RESIDUAL WEAKNESS DISCARD NO WILD POLIOVIRUS TWO ADEQUATE* STOOL SPECIMENS DISCARD VIROLOGIC CLASSIFICATION SCHEME

37. 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 2002-2013

38. 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.

39. CONTACT SAMPLES To be considered for cases fulfilling criteria like Hot cases, but adequate samples from case could not be taken

40. Supplementary Immunization Activities: NIDs/ SNIDs

41. 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).

42. Continued focus on high risk areas and populations Kosi river operational intensification • Immunization of newborns 107 blocks of UP and Bihar West UP: HR blocks – 66 Bihar: HR blocks – 41 • Intense focus on migrants & mobile populations • Religious congregations 2 million children vaccinated in congregations each year 8 million children in transit immunized in India each round 100,000 of these in running trains

43. Certification of polio eradication

44. 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

45. Certification of SEAR* Last WPV case in SEAR 2 RCCPE meetings planned 28 Aug: India presents Preliminary Document Dec: Special RCC Meeting for India GCC formed Feb: India will present final document Certification of SEAR likely SEARCCPE formed 1995 2011 2014 2013 2012 1997 * South East Asia Region of WHO

46. Certification standard surveillance Non-polio AFP rate: ≥ 2 per 100,000population (< 15 years) annually Adequate stool specimens : ≥80% All stool specimens tested for poliovirus at WHO-accreditedlaboratory Additional Criteria Investigation of AFP cases within 48 hours of initial notification: ≥80% Timeliness of weekly AFP surveillance reports: ≥80%

47. 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

48. Sep12 - Jun13 Five categories of states have been formed NCCPE Field Visits Category 5 states

49. Laboratory Containment Union Health Ministry already issued letter in this regard to all the States (dated 14th 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.

50. Polio Endgame Strategy