Progress & Challenges in Polio Eradication in Bihar

1. Progress & Challenges in Polio Eradication in Bihar Mr. Sanjay Kumar Secretary, Health 23rd IEAG Meeting New Delhi

2. Political commitment at highest level 26th March’11: Meeting of Mininsters, MLAs, MLCs on Polio addressed by Hon. CM “We are very close to the eradication and there is no case in Bihar from 7 months but the risk of importation is still there. We all should come together and give best effort now” “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”

4. WPV Type-1 & Type-3 : 2007 - 10 2007 2008 2009 233 cases 30 Districts 117 cases 16 Districts 503 cases 34 Districts 2010 503 233 117 9 cases 3 Districts 9 0

5. Month wise spot Map of WPV cases : Bihar Jan 10 Feb 10 Nov 09 Oct 09 Dec 09 Jun 10 Jul 10 Apr 10 Mar 10 May 10 Nov 10 Dec 10 Sep 10 Aug 10 Oct 10 No WPV1 in Kosi area since Nov’09 No indigenous WPV1 since Nov’09 Importation in mid 2010 curbed with quick mop ups No WPV3 since Jan’10 Apr 11 May 11 Feb 11 Jan 11 Mar 11 Jul 11 Jun 11

6. Recommendations of IEAG’10 Implemented • Scale of NID/ SNIDs in 2011 to be same as 2010 • Preparedness for rapid mop up (1st round within 2 weeks of confirmation) • Maintaining the focus on highest risk areas and highest risk populations • Full implementation of 107 Block plan/ Migrant strategy • Strengthen Immunization: • DTF to review RI along with Polio • WHO and UNICEF to support immunization spl planning & monitoring • Filling of ANM Vacancies • Communication & Social Mobilization: • Focus on renewed energy, safety of OPV during sickness, proactive for RI/ Polio spl among migrants • Specific for 107 block spl RI • Sero-prevalence study • Environmental surveillance Implemented Implemented Implemented In process Implemented In process Planned for Aug’11 Started in April’11

7. 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 Foci of transmission outside UP/ Bihar in 2010 genetically linked to 2009 transmission of Bihar Who took it there….can bring it back!! Re-establishment: Decreased population immunity Complacency Low RI Less opportunity with SIAs High transmission season compounded by possibility of floods in high risk areas Probability of very low level undetected transmission

8. What is being done? Sustaining high population immunity specially in High Risk Areas by: High quality SIAs in frequency & scope as per the GOI guidelines. Steps to strengthen Routine Immunization. Implementation of Kosi Operational Plan. Implementation of 107 Block Plan. Strong oversight from state level. Intensified surveillance in core endemic areas of Kosi and environmental surveillance.

9. What is being done? Preventing risk of re-importation through Coverage of : Migrants in Bihar (Nomads, Brick Kiln labours etc.) Incoming migrants during period of major movement. Major congregations. Continuous Vaccination at major entry points & Indo-Nepal border. Preparedfor mounting Rapid Mop Up in response to any transmission detected.

10. High quality of SIAs High quality SIAs: >99% evaluated coverage consistently. High focus in High Risk areas. Missed Children (%)

11. KOSI: Persistence & Spread of P1 Kosi River flood plain, Bihar, India Type 1 Polio – 2007 Type 1 Polio – 2008 Type 1 Polio – 2009 Responsible for persistence of virus over the years NO CASE IN THIS AREA FOR MORE THAN 20 MONTHS Persistence of Type 1 polio in Bihar – 2007-09

12. 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. % Children missed in Basas % Missed Children at the end of round

13. High Risk block plan • High Quality SIA Operations: • Intensified monitoring • Direct oversight • State monitors • SMO for every block • Tracking & review at highest level. • Key indicators on SIA Quality: • Microplan: • 98.5% teams have rational workload • 96.5% teams have community appropriate female vaccinators • Newborn strategy: • 99.7% teams are tracking every newborns for RI and SIA doses. • Coverage of migrant population: • 100% migrant sites monitored and NO missed site found. • 0.25% Missed children at migrant sites.

14. High Risk block plan • 2. Water and Sanitation issues • Total Sanitation Campaign prioritized in these areas • Vaccinators trained for counseling • 590 CMCs from UNICEF for counseling in Hot spots • Addressing contributing factors • 1. Diarrhea management with Zinc-ORS • Training of field staff including vaccinators • Made available in ASHA Kits • Availability: >95% • Use: 20% (Vs 5% in Sep’10) 3. Routine Immunization

15. High Sensitivity of Surveillance NPAFP Rate NPAFP Rate: 28.3 (Min. Expected: 2) • Enhanced Surveillance in traditional reservoir areas of Kosi: • Community level informing units • Monthly active case searches • Strengthened sensitization of SIA manpower Adequate stool Rate Adequate stool rate: 88.1 (Min. Expected: 80)

16. Environmental Surveillance • Started on 21st April’11 at 3 sewage sites in Patna • Capacity building of Patna Medical College for primary processing Negative for wild poliovirus Result pending

17. Population in movement • Defined migratory population: • Nomads, Brick kiln/ construction workers etc. • Un-defined migratory population: • People of Bihar migrating to other states/ country and returning back seasonally (like Id, Deepawali, Chhath and Holi) • Major congregations: • People from outside and inside state congregate on specific occasions like Shrawani and Sonepur Mela. Dilute the population immunity along with risk of carrying transmission

18. ‘Defined’ Migratory Population… • Mapping of Migratory sites • 7635 Brick Kilns • 4805 Nomadic sites % Missed children in migrant communities >90,000 Children during high season

19. ‘In-coming migrants’ …1 • Chhath (1st to 13 Nov’10): • Major railway/ Road transit points & Ghats • 13 Days • 2899 Teams • 1.3 million children vaccinated • Holi (14th-19th Mar’11): • Major railway & Road transit points • 6 Days • 715 Teams • 170,498 children vaccinated

20. ‘In-coming migrants’ …2 • Continuous vaccination activity at Indo-Nepal Border and Major railway stations: • 93 teams at 50 Indo-Nepal Border sites & 198 at 11 Major railway stations • From 27th May till end of high transmission season • 475,085 children covered till 37th day Major Railway Station 169,201 children 305,884 children

21. Congregations… • Shrawani Mela (25th July- 24th Aug’10): • Bhagalpur, Banka, Munger & Indo-Nepal border • 31 days • 193 teams • 308,691 Children vaccinated • Sonepur Mela (20th Nov to 3rd Dec’10): • Saran & Vaishali • 14 days • 137 Teams • 34,014 children vaccinated

22. Indo-Nepal border • Porous border with frequent intermixing of population • Missed opportunity to vaccinate children in movement • Synchronization of border activity: • Nepal starts SIA from Saturday and Bihar from Sunday • Hence, to synchronize • The SIA in border areas of Bihar is started on Saturday instead of Sunday since May’11

23. Special communication efforts focusing on migrants • Intensified IEC targeting migrants • Multilingual IEC Materials • IEC Vans • Miking • Booths • Mobilizers

24. Preparedness for responding to importation Emergency preparedness & response group at the state level. Reporting to highest level Team of experienced state level officers as State Monitors Responded within 10 days when we had last importation Response to WPV1 in 2010 • 2 quick High Quality Mop Up response with mOPV1 covering 1.8 million children • 1st Cases: • Onset: 8th Aug. • Investigated:13th Aug. • Result: 25th Aug. • Mop Up: 4th Sept. & 4th Oct. • Onset of last case: 1st Sept

25. Routine Immunization: Progress over the years % Full Immunization coverage Muskan RI Augmentation Full Immunization coverage increased from 18.6 to 66.8% in 6 Years! We strive to achieve beyond 80% by 2013 in ALL districts of Bihar

26. Routine Immunization: Gaps… Data not available <= 40% 41% to 60% 61% to 80% > 80% Not monitored % Full Immunization coverage HtH Monitoring Jun’10-May’11 FRDS 2010/11 State Avg. : 66% HR Blocks Avg.: 66% State Avg. : 66.8% • There is wide inter/ intra district variation in RI coverage • Some HR Block with very low RI coverage. • These areas are specially being focused.

27. Routine Immunization: Gaps… 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%

28. Reason for children not being fully immunized FRDS 10/11 Key remaining challenge: Communication & Mobilization CES 2009

29. Service delivery… % Sessions held out of monitored • Around 90% of planned session are being held. • The dip in Sep/ Oct’10 due to strike • But, Non Availability of vaccines an issue since late 2010. % Sessions with Antigens available

30. Further strengthening of Immunization Improving implementation: Intensive ‘House to house’ & Session site monitoring ~5000 session & 30,000 houses monitored/Month ‘Weekly District Control Room for RI’ to address the gaps found during monitoring. Monthly review meetings of DIO at state with ‘Process Indicators’ District Task Force for Polio also reviews RI • Communication: • IEC through Newspapers & Radio jingles • Posters • IPC through Polio Vaccinators • IPC through AWW/ ASHAs

31. Concerns from Bihar • Only 2 SIAs in 2nd half of 2011 which is high transmission period in Bihar. • Incidences of Mass refusals/ Cluster of refusal at Patna Urban. • Erratic SIA and RI vaccine supply • Operational feasibility: • Rs 650 per vehicle/ day (incl POL) for vaccine mobilization • Same since 2002. • Sustaining motivation of vaccinators: • Only Rs 75 per day for vaccinators

32. Concerns from Bihar…1 High transmission period & SIA opportunity…

33. Concerns from Bihar…2 Incidences of Mass refusals Mass refusals: • Due to development related issues: • Demands of Road/ Tubewell • ICDS Services • School etc • Some remain unsolved and occur repeatedly! • Community related refusals: • Responsible for only 0.1% of remaining X houses of state • 1631 refusal houses remaining at the end of June round in whole state • But, 56% of this (910) in just 3 planning units of Patna Urban (having 0.8% houses of state) • Persisting over the time.

34. Summary • There has been immense progress with no P1 for more than 10 months & no P3 for more than 17 months. • But, risk of importation is high considering high migration from state • Bihar is taking all the measure to prevent importation by covering in coming population in state. • We are maintaining sensitive surveillance to detect the transmission at the earliest. • Bihar is prepared to respond rapidly for any importation which occurs.

35. Thank you!