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Progress & Challenges in Polio Eradication in Bihar
Mr. Sanjay KumarSecretary, Health
23rd IEAG MeetingNew Delhi
Political commitment at highest level
26th March’11: Meeting of Mininsters, MLAs, MLCs on Polio addressed by Hon. CM
“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 from 7 months but the risk of importation is still there.
We all should come together and give best effort now”
WPV Type-1 & Type-3 : 2007 - 10
2007 2008 2009
0
100
200
300
400
500
600
2007 2008 2009 2010 2011
P3 P1
2010
9 cases3 Districts
503 cases34 Districts
233 cases30 Districts
117 cases16 Districts
503
233
117
9 0
Oct 09 Nov 09 Dec 09 Jan 10 Feb 10
Mar 10 Apr 10 May 10 Jun 10 Jul 10
Aug 10 Sep 10 Oct 10 Nov 10 Dec 10
Jan 11 Feb 11 Mar 11 Apr 11 May 11
Jun 11 Jul 11
Month wise spot Map of WPV cases : Bihar
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
Recommendations of IEAG’10• 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 Started in April’11
Planned for Aug’11
Implemented
ImplementedIn process
Implemented
Implemented
Implemented
In process
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
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.
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.
• Prepared for mounting Rapid Mop Up in response to any transmission detected.
High quality of SIAs
• High quality SIAs: >99% evaluated coverage consistently.• High focus in High Risk areas.
Missed Children (%)
0
0.5
1
1.5
2
2.5
3
Jun_10
Jul_
10
Sep_10
Oct_
10
Nov_10
Dec_10
Jan_11
Feb_11
Mar_
11
Apr_
11
May_11
Jun-1
1
BIHAR HR_41
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
Responsible for persistence of virus over the years
NO CASE IN THIS AREA FOR MORE THAN 20 MONTHS
0.09 0.08 0.080.2 0.1 0.08
0
0.5
1
1.5
2
Satellite Office
Stay Point
21
39
Stay Facilities inside KOSI
0
10
20
30
40
50
60
70
2008 2010
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.
0
2
4
6
8
10
12
14
April'09 June'11
% Children missed in Basas % Missed Children at the end of round
• 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.
High Risk block plan
• Addressing contributing factors
High Risk block plan
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)
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
3. Routine Immunization0
5
10
15
20
25
Sep'10 Mar'11
Use of Zinc-ORS in children with diarrhea
High Sensitivity of Surveillance Col No.
KAIMURKATIHARKHAGARIAKISHANGANJLAKHISARAIMADHEPURAMADHUBANIMUNGERMUZAFFARPURNALANDANAWADAPATNAPURNIAROHTASSAHARSASAMASTIPURSARANSHEIKHPURA
Gaya
Patna
Jamui
Rohtas
Purnia
KaimurBanka
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
11.23 12.64 8.51
32.7 37.428.3
80.9
103.3
73.5
0
20
40
60
80
100
2009 2010 2011
India Bihar Kosi
< 22 to 1010 to 20
> 20
Legend
NPAFP Rate: 28.3(Min. Expected: 2)
Col No.
KAIMURKATIHARKHAGARIAKISHANGANJLAKHISARAIMADHEPURAMADHUBANIMUNGERMUZAFFARPURNALANDANAWADAPATNAPURNIAROHTASSAHARSASAMASTIPURSARANSHEIKHPURA
Gaya
Patna
Jamui
Rohtas
Purnia
KaimurBanka
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
< 70%70 to 80%
> 80%
Legend
83 85.782.283
86.6 87.684
88.191.3
50
60
70
80
90
100
India Bihar Kosi
2009 2010 2011
Adequate stool rate: 88.1(Min. Expected: 80)
NPAFP Rate
Adequate stool Rate
• Enhanced Surveillance in traditional reservoir areas of Kosi:– Community level informing units – Monthly active case searches– Strengthened sensitization of SIA manpower
Environmental Surveillance• Started on 21st April’11 at 3 sewage sites
in Patna
• Capacity building of Patna Medical College for primary processing
PatnaWeek
Choti pahari
Dujara
Transport nagar
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Negative for wild poliovirus
Result pending
Population in movement
• Un-defined migratory population:– People of Bihar migrating to other states/ country and returning
back seasonally (like Id, Deepawali, Chhath and Holi)
• Defined migratory population:– Nomads, Brick kiln/ construction workers etc.
Dilute the population immunity along with risk of carrying transmission
• Major congregations:– People from outside and inside state congregate on specific
occasions like Shrawani and Sonepur Mela.
‘Defined’ Migratory Population…
Mapping of Migratory sites•7635 Brick Kilns•4805 Nomadic sites
1.26
1.02
0.79
1.07
0.51
1.17
0.410.61
0
0.5
1
1.5
2
2.5
3
No
v_
10
De
c_
10
Ja
n_
11
Fe
b_
11
Ma
r_1
1
Ap
r_1
1
Ma
y_
11
Ju
n-1
1
% Missed children in migrant communities
>90,000 Children during high season
‘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
• 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 dayGaya
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
305,884 children 169,201 children
‘In-coming migrants’ …2
Congregations…
• Sonepur Mela (20th Nov to 3rd Dec’10):– Saran & Vaishali– 14 days– 137 Teams– 34,014 children vaccinated
• Shrawani Mela (25th July- 24th Aug’10):– Bhagalpur, Banka, Munger &
Indo-Nepal border
– 31 days
– 193 teams
– 308,691 Children vaccinated
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
Special communication efforts focusing on migrants
• Intensified IEC targeting migrants– Multilingual IEC Materials– IEC Vans– Miking– Booths– Mobilizers
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
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
Routine Immunization: Progress over the years
11 11.6
18.6
32.838
41.4
5449
66.8 68
0
10
20
30
40
50
60
70
80
90
100
NFHS 21998-99
CES 2002 CES 2005 NFHS 32005-06
CES 2006-07
DLHS 07-08 FRDS2008/09
CES 2009-10 Unicef
FRDS 2010-11
HtHMonitoring
2011
RI Augmentation
Muskan
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
% Full Immunization coverage
0 - 20 %21 - 40 %41 - 60 %61 - 80 %81 - 100 %Data Not Available
Col No.
KAIMURKATIHARKHAGARIAKISHANGANJLAKHISARAIMADHEPURAMADHUBANIMUNGERMUZAFFARPURNALANDANAWADAPATNAPURNIAROHTASSAHARSASAMASTIPURSARANSHEIKHPURA
Gaya
Patna
Jamui
Rohtas
Purnia
KaimurBanka
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
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.
% Full Immunization coverage
Routine Immunization: Gaps…
Col No.
KAIMURKATIHARKHAGARIAKISHANGANJLAKHISARAIMADHEPURAMADHUBANIMUNGERMUZAFFARPURNALANDANAWADAPATNAPURNIAROHTASSAHARSASAMASTIPURSARANSHEIKHPURA
Gaya
Patna
Jamui
Rohtas
Purnia
KaimurBanka
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
2
Col No.
KHA_GOGARIKHA_KHAGARIA URBANMDP_ALAMNAGARMDP_CHAUSAMDP_UDAKISHUNGANJMDB_JAINNAGARMZF_MARWANMZF_MUSAHRINLD_BIHAR SHARIFNLD_SARMERANWD_PAKRIBARAWANPTN_DANAPURPTN_MANERPTN_PHULWARISHARIFPTN_SADARPRN_BAISISAH_MAHISHISAH_SALKHUASAH_SIMRI BAKHTIARPURSAM_BIBHUTIPURSAM_BITHANSAM_HASANPURSAM_SINGHIASAM_WARISNAGAR
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
FRDS 2010/11HtH Monitoring Jun’10-May’11
Visited1
Up.shp
BCG_0M0 - 4040.1 - 6060.1 - 8080.1 - 100
Visited1
Up.shp
BCG_0M0 - 4040.1 - 6060.1 - 8080.1 - 100
Data not available<= 40%41% to 60%61% to 80%> 80%Not monitored
State Avg. : 66% HR Blocks Avg.: 66%
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
Me
as
les FI
• The problem in Bihar is of ‘Drop Outs’
• From 94% BCG or 89% DPT1, we are able to retain only 67%
Antigen wise coverage (FRDS-10/11)
Routine Immunization: Gaps…
Reason for children not being fully immunized
23.3 23.6 23.7
6.814.7
3.7 3.1 2.26.7
1.6 2.9 1.1 1.9 3.310.4
0
10
20
30
40
50
60
70
80
90
100
Did
not
feel
nee
d
Not
kno
win
g ab
out v
acci
nes
Not
kno
win
g w
here
to g
o fo
rim
mun
izat
ion
Tim
e no
t con
veni
ent
Fear
of S
ide
effe
cts
Do
not h
ave
time
Wro
ng a
dvic
e by
som
eone
Can
not a
fford
cos
t
Vac
cine
not
ava
ilabl
e
Pla
ce n
ot c
onve
nien
t
AN
M a
bsen
t
Long
wai
ting
time
Pla
ce to
o fa
r
Ser
vice
not
ava
ilabl
e
Oth
ers
40.5 36.8
21.115.9 15.4
9.9 6.1 5.3 3 1.8 0.6 0.40
10
20
30
40
50
60
70
80
90
100
Do
not k
now
wha
t vac
cine
sar
e ne
eded
and
whe
n
Chi
ld is
too
youn
g fo
rva
ccin
atio
n
Fear
of s
ide
effe
cts
Ser
vice
s ar
e no
t ava
ilabl
ew
hen
requ
ired
Do
not f
eel n
eed
for
vacc
inat
ion
Do
not k
now
whe
re to
take
the
child
for v
acci
natio
n
Opp
ositi
on fr
om fa
mily
mem
bers
Do
not h
ave
time
to ta
ke th
ech
ild fo
r im
mun
isat
ion
Adv
ised
aga
inst
imm
unis
atio
nby
som
e pe
ople
Ser
vice
cen
tre is
too
far
Can
not a
fford
the
cost
Oth
ers
CES 2009
FRDS 10/11
Key remaining challenge:Communication &
Mobilization
Service delivery…
86 86 8781
77 80 80 8175
7076
72
94 94 9692
87 89 92 9184 81 84 81
0
10
20
30
40
50
60
70
80
90
100
Jun
-10
Jul-
10
Au
g-1
0
Sep
-10
Oct
-10
No
v-10
Dec
-10
Jan
-11
Feb
-11
Mar
-11
Ap
r-11
May
-11
All Vaccines and diluents T-OPV
87 8884
66 69
85 8892 89 90 90 89
0
10
20
30
40
50
60
70
80
90
100
Jun
-10
Jul-
10
Au
g-1
0
Sep
-10
Oct
-10
No
v-10
Dec
-10
Jan
-11
Feb
-11
Mar
-11
Ap
r-11
May
-11
% Sessions held out of monitored
% Sessions with Antigens available
• 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.
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
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
Proposed SIA calendar, 2011
Aug Sep Oct Nov
NIDs
Dec
bOPV
Mar Apr May Jun JulJan Feb
SNIDZone 1 UP/Bihar,
Delhi
SNIDEndemic & risk states
tOPV
SNIDEndemic & risk states
SNIDZone 1 UP/Bihar
& Delhi
tOPV / bOPV
SNIDEndemic & risk states
SNIDZone 1 UP/Bihar,
Delhi
0
2
4
6
8
10
12
14
16
18
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
2005 2006 2007 2008 2009 2010
High transmission period &
SIA opportunity…
Concerns from Bihar…1
Mass refusals:• Due to development related
issues:– Demands of Road/ Tubewell– ICDS Services– School etc
• Some remain unsolved and occur repeatedly!4 7 17 1 2 5 62 15 10 17 2624
159325
1384
54 31
244
2393
554
239354
457
1024
0
10
20
30
40
50
60
70
80
90
100
Jun
_1
0
July_
10
Se
p_
10
Oct_
10
NO
V_
10
De
c_1
0
Jan
_1
1
Fe
b_
11
Ma
r_1
1
Ap
r_1
1
Ma
y_1
1
Jun
_1
1
0
500
1000
1500
2000
2500
3000Incidence of Refusal Number of houses
Incidences of Mass refusals
• 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.
Concerns from Bihar…2
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.
Thank you!
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