Completing Polio Eradication in Bihar

1. Completing Polio Eradication in Bihar 24th January

2. Risk factors for transmission of WPV (population density, diarrhea, low routine OPV3 coverage) Due to various factors, western UP and north central Bihar are at highest risk for Polio transmission. Therefore, Are most challenging for Polio Eradication • High force of infection • Sub-optimal vaccine efficacy due to these factors Source : N Grasley et al , Imperial College , London

3. Virologic evidence: elimination of all but 1 genetic lineage of type 1 poliovirus 2006 2007 2008 2009* In past 3 years, 8 of 9 P1 sub types have been eradicated. Only one sub type is in circulation now. Grey 1 Grey 2 Grey 3 Black 1 Black 2 Pink 1 Yellow 2 Yellow 3 Yellow 4 Grey 1 Grey 2 Grey 3 Black 1 Pink 1 Yellow 2 Yellow 3 29 14 1 1 32 3 2 2 2 71 Grey 1 Grey 2 89 38 2 11 12 459 11 14 4 Pink 1 18 Pink 1 *as of 22nd Jun, 2009

4. Polio Update

5. Location of poliovirus by type, 2009* Most recent virus 31 December 09 Bareilly, UP ** One case reported mixture of P1 wild & P3 wild

6. WPV Type-1 & Type-3 : 2007 - 10 2007 2008 2009 2010

7. Persistent Transmission Blocks High Risk Blocks Additional High Risk Blocks Focus Districts High Priority Prioritization in Bihar(Done in 2007)

8. Persistent Transmission Blocks High Risk Blocks Additional High Risk Blocks Prioritization in Bihar 13 of 38 P1 cases in PT Blocks 7 of 13 in inside embankment 30 of 38 P1 cases in pre identified HR Blocks P1 mostly limited to pre-identified HR Blocks of 6 Districts. Sharp decline in number of P1 in last quarter with NO P1 from more than 2 months WPV P1 - 2009

9. 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 And is Focus of intervention along with other HR Blocks Persistence of Type 1 polio in Bihar – 2007-09

12. KOSI riverine areas • Most difficult access compromised areas. • Often flooded. • Poor Infrastructure. • Change in topography. • Very high concentration of under served population. • R.I. – Very low in this region. Compromised access around the kosi river poses unique challenges for programme planning, implementation & monitoring

13. Access Compromised Areas • ACA : 16 % of Bihar • Major continuous area -In and around Kosi river and its tributaries • Inaccessible area: 25 - 50 km wide by 125 km long= 3000 sq. km • covers parts of 10 districts • Flooded for more than 6 months in a year • movement is only by motorbike/boat / horse

14. WPV P3: Status 88 Blk Partial 433 Blk 433 Blk 433 Blk 561 Blk • P3 cases have declined sharply from 233 in 2008 to 79 in 2009. • Remaining focus is limited to area with lesser P3 antigen. • bOPV in NIDs in same areas to tackle the problem mOPV1 -88 mOPV3- 345 mOPV1 – 58 mOPV3- 503 Total : 459 Total : 3 Total : 79 Total : 230 (District : 33) (District : 11) (District : 1) (District : 30) 2009 2008 2007 Partial Round Mix Round Mix Round Mix Round Complete Round (mOPV3) (mOPV3 & mOPV1) (tOPV & mOPV1) (bOPV, tOPV & mOPV1)

15. Summary • Number of families of P1 reduced to 1 in 2009 from 9 in 2006. • Total WPV cases in Bihar in 2009 is down to 117 from 233 in 2008 and 503 in 2007. • Although there was resurgence in P1 cases in 2009, but it was: • Limited geographically to small area. • Most of cases in pre-identified HR Blocks specially around KOSI. • There is sharp decline in P1 cases and no P1 since October’09. • P3 cases have reduced to 77 in 2009 from 230 in 2008. • Most of cases limited to the areas with lesser P3 antigen opportunity. • bOPV in NIDs in Bihar in these areas: • Will hit hard on P3 transmission. • Without taking off pressure from P1.

16. Intensified efforts

17. Operations… • KOSI: • Satellite offices in inside KOSI embankment • Increased presence of Medical Officers, UNICEF and WHO. • State monitors being sent to KOSI area in every round • Rotary support • Intensified monitoring: Each team • CMCs in KOSI • HR Blocks: • Intensified operations. • MOs deployed from Non HR blocks to HR blocks • District Health Officials deployed for direct oversight. • Strong oversight by highest levels of government.

18. Stay Facilities inside KOSI Satellite Office 20 37 Stay Point

19. OPV type wise SIA Round in Bihar : 2009 Mar-09 Feb-09 5Apr-09 3May-09 24May-09 • bOPV in High risk zones of Bihar in NIDs • To break the transmission of P3 without releasing pressure from P1 Jun-09 Sep-09 Aug-09 Oct-09 Nov-09 Dec-09 Jan-10 P1 P3 VDPV mOPV1 mOPV3 bOPV tOPV

20. More and more BASAs being covered • Coverage of BASA increased with BASA Strategy. • >1,70,000 BASAs being covered in KOSI riverine areas

21. Newborns being registered & tracked for 8 doses!!

22. Nomadic Population coverage

23. Coverage during floods/ Monsoon

24. 1.2 Communication efforts: Underserved strategy Madarsa Involvement: Supaul Imam Meeting: Madhubani Mothers being convinced regarding Polio in Madhepura

25. Operations… • All newborns being identified and tracked. • BASAs: Survey before every round to cover all BASAs. • Transit teams: children in movement • Migratory families of Nomads, Brick Kilns and construction workers being covered. • Repeated efforts to convert X houses.

26. Efforts… • Routine Immunization: • From 11% in 2002 to 56%. • Statewide microplan revision to include all areas. • Focused monitoring of RI including HtH monitoring. • Convergence: • Intensification of MC Health, nutrition, water and sanitation efforts in KOSI area.

27. Summary… • P1 circulation in 2009 was in limited geographical area mostly HR blocks and has declined sharply. The intensified efforts in KOSI and HR Blocks along with bOPV/ mOPV1 rounds planned in 2010 present unique opportunity to finish the transmission. • P3 in Bihar has declined sharply and use of bOPV in NIDs in concerned area has presented the opportunity to stop transmission without releasing the pressure from P1

28. Thank You