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Emergency Preparedness and Response Planning for Polio
Dr N K SinhaState Immunization Officer State Health Society, Bihar
WPV cases in Bihar
2009 2010
2011
Cross-border transmission with Nepal
20092012
0
100
200
300
400
500
600
2007 2008 2009 2010 2011
P3 P1
WPV 1 Cases in Bihar
2010
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
Risk analysis: Identification of high risk district and blocks
Gaya
Patna
Jamui
Rohtas
Purnia
Kaimur
Banka
Araria
Saran
Katihar
Siwan
Supaul
Madhubani
Nawada
Champaran West
BhojpurBuxar
Nalanda
Muzaffarpur
Bhagalpur
Aurangaabad
Sitamarhi
Vaishali
Darbhanga
Champaran East
Samastipur
Gopalganj
Saharsa
Begusarai
Munger
Khagaria
Madhepura
Kishanganj
ArwalLakhisaraiJehanabad Sheikhpura
Sheohar
Zone - 1
Zone - 2
Zone - 3
Gaya
Patna
Jamui
Rohtas
Purnia
Kaimur
Banka
Araria
Saran
Katihar
Siwan
Supaul
Madhubani
Nawada
Champaran West
BhojpurBuxar
Nalanda
Muzaffarpur
Bhagalpur
Aurangaabad
Sitamarhi
Vaishali
Darbhanga
Champaran East
Samastipur
Gopalganj
Saharsa
Begusarai
Munger
Khagaria
Madhepura
Kishanganj
ArwalLakhisaraiJehanabad Sheikhpura
Sheohar
HR Blocks
Non – HR Blocks
High Risk Districts High Risk Blocks
• 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
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
Risk mitigation strategies
Sustaining high population immunity in High Risk areasAnd
Preventing risk of re-importation
Sustained high quality SIA campaigns % Cildren found unimmunized in 'End of Round' Survey
0
1
2
3
4
5Dec_09
Jan_10
Feb_10
Mar_10
Apr_10
May_10
Jun_10
Jul_10
Sep_10
Oct_10
Nov_10
Dec_10
Jan_11
Feb_11
Mar_11
Apr_11
May_11
Jun_11
Aug_11
SEP_11
Nov_11
Jan_12
Feb_12
BIHAR HR_41
• High quality SIAs: less than 0.5% missed children.• High focus in High Risk areas.
• High Quality SIA Operations:– Intensified monitoring– Direct oversight
• State monitors• SMO for every block• Tracking & review at highest
level.
High Risk block plan% Teams monitored
0
20
40
60
80
100
120
Feb
_10
Mar
_10
Ap
r_10
May
_10
Jun
_10
Sep
_10
Oct
_10
No
v_10
Dec
_10
Jan
_11
Feb
_11
Mar
_11
Ap
r_11
May
_11
Jun
_11
Au
g_1
1
Sep
_11
No
v_11
Jan
_12
Feb
_12
BIHAR HR_41
Convergent interventions of WASH and Zinc ORS are going on in these blocks with focus on ‘hot spots’
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.Persistence of Type 1 polio in Bihar – 2007-09
Kosi River flood plain, Bihar, India
Type 1 Polio – 2008
Type 1 Polio – 2007
Type 1 Polio – 2009
KOSI: Persistence & Spread of P1
0
20
40
60
80
100
120
24M
ay_09
Jun_09
Aug_09
Sep_09
Oct_
09
Nov_09
Dec_09
Jan_10
Feb_10
Mar_
10
Apr_
10
May_10
Jun_10
Sep_10
Nov_10
Dec_10
JA
N_11
FE
B_11
Mar_
11
Apr_
11
May_11
Jun_11
Aug_11
Sep_11
Nov_11
Jan_12
Feb_12 0
2
4
6
8
10
Team days monitored Teams monitored
Missed children in Basa
Improved coverage with intensified monitoring
% Children missed among migrants
0
1
2
3
4
5
Nov
_10
Dec_1
0
Jan_
11
Feb_
11
Mar_1
1
Apr_1
1
May_1
1
Jun_
11
Aug
_11
SEP_1
1
Nov
_11
Jan_
12
Feb_
12
•Brick Kiln – 8079•Nomadic Site - 5022
MigrantsNumber 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
• 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 27th May’11.– 2,761,397 children vaccinated till
now
Gaya
Patna
Jamui
Rohtas
Kaimur
Purnia
Banka
Araria
Saran
Katihar
Siwan
Supaul
Madhubani
Bhojpur
Nawada
Champaran West
Buxar
Nalanda
Muzaffarpur
Bhagalpur
Sitamarhi
Aurangaabad
Vaishali
Darbhanga
Champaran East
Samastipur
Gopalganj
Saharsa
Begusarai
Munger
Khagaria
Kishanganj
Madhepura
ArwalLakhisaraiJehanabad
Sheikhpura
Sheohar
Major Railway Station
Continuous vaccination activity
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
Congregations• Shrawani Mela (16th July- 14th
Aug’11):– Bhagalpur, Banka, Munger &
Indo-Nepal border
– 31 days
– 103 teams
– 152,868 Children vaccinated
• Sonepur Mela (9th Nov—22nd Nov’11):– Hajipur Urban, Sonepur
– 14 days
– 192 teams
– 82144 Children vaccinated
Routine Immunization: Progress over the years
We strive to achieve beyond 85% by 2013 in ALL districts & Blocks
11 11.618.6
32.838 41.4
4954
66.8
0
10
20
30
40
50
60
70
80
90
100
NFHS 21998-99
CES 2002 CES 2005 NFHS 32005-06
CES 2006-07
DLHS2007-08
CES 2009Unicef
FRDS2009
FRDS 10-11
MuskanRI Augmentation drive
Newborn booklet & distribution of RI cards in Pulse Polio (Jan06)
Microplan updation with Polio microplan AndIntensified RI monitoring
% Full Immunization coverage
9489.3 89.6
84.8 84.579.8 79.5
68.1 66.8
0
10
20
30
40
50
60
70
80
90
100
BC
G
DP
T 1
OP
V 1
DP
T 2
OP
V 2
DP
T 3
OP
V 3
Mea
sles F
I
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 36.8Fear of side effects 21.1Services are not available when required
15.9
Do not feel need for vaccination 15.4Do not know where to take the child for vaccination
9.9
Opposition from family members 6.1Do 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
Service delivery
98 98 98 98 98 98 98 99 98 98 98 99 99 98 98 98 99 999890 87
6772
8791 93 92 92 92 91 92 89 89 90 90 92 9294
0
10
20
30
40
50
60
70
80
90
100
Jul'1
0
Sep
'10
No
v'10
Jan
'11
Mar
'11
May
'11
Jul'1
1
Sep
'11
No
v'11
Jan
'12
86 8781
77 80 80 8175
7076
72 75
62
52
3947
60
6966
94 9692
87 89 92 9184 81 84 81
85
69
57
4452
66
7776
0
10
20
30
40
50
60
70
80
90
100
Jul'1
0
Sep
'10
No
v'10
Jan
'11
Mar
'11
May
'11
Jul'1
1
Sep
'11
No
v'11
Jan
'12
All Vaccines and diluents T-OPV
% 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
62.569.7
0
10
20
30
40
50
60
70
80
90
100
Jul'1
0
Sep
'10
No
v'10
Jan
'11
Mar
'11
May
'11
Jul'1
1
Sep
'11
No
v'11
Jan
'12
% Full immunization
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 1st 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?
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:– 1/3rd MOs trained in RI. Fast tracking planned– All DIOs trained, training of ANMs to be fast tracked
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
Sensitivity of surveillance
Key surveillance indicators
11.2 12.6 13.0
33.0 38.0 40.0
5668
7483.0
103.0 100.0
0
20
40
60
80
100
2009 2010 2011
India Bihar HR Blocks PT- Kosi
NPAFP Rate
83 83 8486 87 8885 87 89
8288 90
50
60
70
80
90
100
2009 2010 2011
India Bihar HR Blocks PT-Kosi
Adequate 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
Expansion of reporting network
3473
4302 4321
5095
0
1000
2000
3000
4000
5000
6000
2008 2010 Jun-11 2012
314
570 578
712
0
200
400
600
800
2008 2010 Jun-11 2012
88
312 306
359
0
100
200
300
400
2008 2010 Jun-11 2012
BIHAR 41 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
Preparedness for Mop Upin case of detection of any
transmission
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.
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
Experience in past
Responded within 10 days when we had last
importation
2009 2010
2011
Cross-border transmission with Nepal
20092012
WPV 1 Cases in Bihar
2010
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”
Thank you
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.
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 2132 1315 113
Brick Kilns 3242 1306 150
Urban slums 402 183 14
Construction sites
41 33 1
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