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Current Strategies for
eradication of polio

SPEAKER :- PREETI RAI
TEACHER I/C:- Dr. Dheeraj
Mahajan
DATE :- 31 / 12 / 201...
What is polio?
The words polio (grey) and myelon (marrow,
indicating the spinal cord) are derived from
the Greek. It is th...
History of polio…
The disease of poliomyelitis
has a long history. The first
example may even have been
more than 3000 yea...
In the 1940s and 1950s “iron lungs” were used to
regulate breathing and keep polio patients alive.
PROBLEM STATEMENT
• When the World Health Assembly launched the Global
Polio Eradication Initiative (GPEI) in 1988, it was...
• In the mid-1990s, an estimated 150,000 polio cases
were reported annually in India.
• The last case of polio was reporte...
Number of polio cases worldwide from 2000 to 2010
Number of polio cases from 1998 to 2013.
Despite very high coverage during immunization activities & intensive use
of mOPV1, transmission of type-1 WPV has persist...


Last wild poliovirus type 1 (WPV1) case: 13 January
2011, Howrah, West Bengal

Last wild poliovirus type 2 (WPV2) case...
EPIDEMIOLOGY
•
•
•
•

AGENT: POLIOVIRUS
TYPE : THREE SERO TYPES(TYPE-1,TYPE-2,TYPE-3)
RESERVOIR: HUMAN ONLY
INFECTIOUS MAT...
• ENVIRONMENT : RAINY SEASON (JUNE TO
SEPTEMBER)
• MODE OF TRANSMISSION: FAECO – ORAL ROUTE,
DROPLET INFECTION.
• FAVOURAB...
POLIO VIRUS
THREE TYPES
• TYPE-1—EPEDEMICS causes outbreaks—is the most
likely virus to cause paralysis.
• TYPE-2---THIS I...
Clinical Spectrum of Polio
• Asymptomatic =inapparent=subclinical91-96%
• Minor non CNS=Abortive polio illness4-8%Aseptic ...
IPV (Salk)


killed formolised virus

OPV (Sabin)


live attenuated virus

Given SC or IM

 given orally

Induces cir...
VDPV
Vaccine-derived polioviruses (VDPVs) are rare but welldocumented strains of poliovirus ,which emerge after
prolonged...
The management of VDPVs is a necessary part of the
global polio eradication effort, and is similar to
management of wild ...
The Global Polio
Eradication Initiative
Four Pillars of the Global Polio Eradication
Initiative Strategy
1. Routine Immunization 1985
2. Supplemental Immunization...
WHY POLIO IS A CANDIDATE FOR ERADICATION ?
Four Pillars of the Global Polio Eradication Initiative Strategy
1. Routine Immunization 1985
• A major cornerstone of the...
According to WHO/UNICEF immunization coverage
estimates, 86% of infants received three doses of oral
polio vaccine in 2010...
2. Supplemental Immunization Activities 1995-96
• Mass polio immunization campaigns that
complement routine immunization p...
WHAT IS PULSE POLIO ?

TO IMMUNIZE ALL THE KIDS< 5YRS NATION WIDE
ON A SINGLE DAY IN THE SHORTEST POSSIBLE TIME
WITH OPV &...


National Immunization Days (NIDs) - which are conducted
countrywide 2 or 3 times per year, 1 month apart.

 National I...
Synchronized NIDs
Neighbouring countries are coordinating, or "synchronizing" their
National Immunization Days. This ensur...
Polio cases and SIAs
• 3. Acute Flaccid Paralysis (AFP) Surveillance -1997
• As many as 90% of people infected with the poliovirus
experience v...
AFP case definition broadened
Consequences of missing the case of polio are
more serious then occasionally including and
“...
AIM OF AFP SURVEILLANCE
TO DETECT POLIO TRANSMISSION & INTERRUPTION OF
TRANSMISSION
AFP CASE
POLIO CASE
RESERVOIR OF INFEC...
COMPONENTS OF AFP SURVEILANCE
1.The AFP surveillance network and case notification
2.Case and laboratory investigation
3.O...
The most important aspect of this classification is the collection of
2 adequate stool samples from all cases. Samples are...
AFP Reporting Network
Paediatrician

Neurologist

Physician

Gen. Pract.

Dist. Hospital
PHC
RH
MPW/ ANM
Traditional Heale...
Flow Diagram of AFP Case Investigation
WHY AFP SURVEILLANCE INSTEAD OF
POLIO SURVEILLANCE ?
• SURVEILLANCE OF A POLIO CASE ALONE IS NOT
SUFFICIENT BECAUSE IT IS ...
When too much polio is around…..

AFP cases
Polio cases
Borderline AFP cases
Non-AFP cases

Surveillance
sensitivity is
ad...
Data Flow
Mondays

Reporting Units
Tuesdays
Districts
Wednesdays
States
Thursday
Delhi

Districts
State
NPSU Delhi
WHO
Outbreak Response Immunization (ORI)


Measures to stop transmission of polio virus
Children <5 yrs in the locality are g...
AFP Surveillance is in the end
the only indicator for success
4. Targeted Mop-Up Campaigns
 Last stage in polio eradication
Low routine immunization coverage, very dense
or mobile po...
Before a WHO region can be certified polio-free, three
conditions must be satisfied:
(A) AT LEAST THREE YEARS OF ZERO POLI...
Social Mobilization Network (SMNet)
 In Uttar Pradesh, India, in response to low routine
immunization coverage and ongoin...
Current priorities for assessment
 Expanded Target Age Groups: expanding the
target age group for OPV beyond 5 years of a...
Achievements of Polio Eradication Strategy
A. Reduction in Cases
B. Prevention of Disabilities and Deaths- More then 4 lac...
Risks/Challenges to Polio Eradication Strategy:
a) International Importation of wild polio virus. Neighboring
countries li...
e) Areas with low population immunity.
f) Gaps in Routine Immunization & SIA especially in High Risk
Areas
g) Various resi...
The goal of the 2013-2018 Polio Eradication
and Endgame Strategic Plan is to complete
the eradication and containment of a...
Conclusion
• At present, polio is endemic in three countries—Until
poliovirus transmission is interrupted in these
strongh...
• But the outbreak also serves as a reminder that high
vaccination coverage is essential in countries where
the disease is...
Reference:
1.
2.
3.
4.

www.npspindia.org
www.mohfw.nic.in www.polioeradication.org
www.unicef.org/immunization
Super cour...
Current Strategies for eradication of polio
Current Strategies for eradication of polio
Current Strategies for eradication of polio
Current Strategies for eradication of polio
Current Strategies for eradication of polio
Current Strategies for eradication of polio
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Current Strategies for eradication of polio

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Current Strategies for eradication of polio

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Current Strategies for eradication of polio

  1. 1. Current Strategies for eradication of polio SPEAKER :- PREETI RAI TEACHER I/C:- Dr. Dheeraj Mahajan DATE :- 31 / 12 / 2013 1
  2. 2. What is polio? The words polio (grey) and myelon (marrow, indicating the spinal cord) are derived from the Greek. It is the effect of poliomyelitis virus on the spinal cord that leads to the classic manifestation of paralysis.
  3. 3. History of polio… The disease of poliomyelitis has a long history. The first example may even have been more than 3000 years ago. An Egyptian stele dating from the 18th Egyptian dynasty (1580 1350 BCE) shows a priest with a deformity of his leg characteristic of the flaccid paralysis typical of poliomyelitis. .
  4. 4. In the 1940s and 1950s “iron lungs” were used to regulate breathing and keep polio patients alive.
  5. 5. PROBLEM STATEMENT • When the World Health Assembly launched the Global Polio Eradication Initiative (GPEI) in 1988, it was widely acknowledged that India would be one of the most challenging countries for polio eradication. • By 2006, Afghanistan, India, Nigeria, and Pakistan were the only remaining polio endemic countries .Since the GPEI was launched, the number of cases has fallen by over 99%. • In 2013, only three countries in the world remain polioendemic: Nigeria, Pakistan and Afghanistan
  6. 6. • In the mid-1990s, an estimated 150,000 polio cases were reported annually in India. • The last case of polio was reported on 13th January 2011 from West Bengal and further no case of polio has been reported in the country since then. • . India has been polio free for more then a year and was removed from the Endemic. • P2 Wild Polio Virus eradicate from the world in 1999
  7. 7. Number of polio cases worldwide from 2000 to 2010
  8. 8. Number of polio cases from 1998 to 2013.
  9. 9. Despite very high coverage during immunization activities & intensive use of mOPV1, transmission of type-1 WPV has persisted in U.P. & Bihar
  10. 10.  Last wild poliovirus type 1 (WPV1) case: 13 January 2011, Howrah, West Bengal Last wild poliovirus type 2 (WPV2) case: October 1999, Aligarh, Uttar Pradesh Last wild poliovirus type 3 (WPV3) case: 22 October 2010, Pakur, Jharkhand Last positive case from monthly environmental sewage sampling (conducted in Delhi, Mumbai and Patna): November 2010, Mumbai .
  11. 11. EPIDEMIOLOGY • • • • AGENT: POLIOVIRUS TYPE : THREE SERO TYPES(TYPE-1,TYPE-2,TYPE-3) RESERVOIR: HUMAN ONLY INFECTIOUS MATERIAL: FAECES, OROPHARYNGEAL SECRETIONS • PERIOD OF COMMUNICABILITY: 7 TO 10 DAYS BEFORE AND AFTER ONSET OF SYMPTOMS • AGE : 6 MONTHS TO 3 YEARS ARE MOST VOLUNERABLE
  12. 12. • ENVIRONMENT : RAINY SEASON (JUNE TO SEPTEMBER) • MODE OF TRANSMISSION: FAECO – ORAL ROUTE, DROPLET INFECTION. • FAVOURABLE CONDITIONS: OVER CROWDING,POOR SANITATION,SLUMS • INCUBATION PERIOD: 7 TO 14 DAYS( 3- 35 DAYS)
  13. 13. POLIO VIRUS THREE TYPES • TYPE-1—EPEDEMICS causes outbreaks—is the most likely virus to cause paralysis. • TYPE-2---THIS IS THE FIRST SERO TYPE TO DISAPPEAR. • TYPE-3--- PARALYSIS LESS FREQUENT.
  14. 14. Clinical Spectrum of Polio • Asymptomatic =inapparent=subclinical91-96% • Minor non CNS=Abortive polio illness4-8%Aseptic meningitis =NON paralytic polio-1% stiffness and pain in neck n back • Paralytic Polio<1% ,Asymmetrical flaccid paralysis and fever at the time of onset of paralysis • Among children who are paralyzed by polio: 30% make a full recovery 30% are left with mild paralysis 30% have medium to severe paralysis 10% die
  15. 15. IPV (Salk)  killed formolised virus OPV (Sabin)  live attenuated virus Given SC or IM  given orally Induces circulating antibodies, but  immunity is both humoral and not local (intestinal immunity) Prevents paralysis but does not prevent reinfection Not useful in controlling epidemics More difficult to manufacture and is relatively costly intestinal. induces antibody quickly Prevents paralysis and prevents reinfection Can be effectively used in controlling epidemics. Easy to manufacture and is cheaper >90% immune after 2 doses >99% immune after 3 doses Duration of immunity not known with certainty  50% immune after 1 dose >95% immune after 3 doses Immunity probably lifelong
  16. 16. VDPV Vaccine-derived polioviruses (VDPVs) are rare but welldocumented strains of poliovirus ,which emerge after prolonged multiplication of attenuated strains of the virus contained in the oral polio vaccine (OPV) in the guts of children with immunodeficiency or in populations with very low immunity. In1999-2000 it was proven that vaccine-derived polioviruses (VDPVs) could regain the capacity to cause polio outbreaks (i.e. become circulating VDPVs or cVDPVs).
  17. 17. The management of VDPVs is a necessary part of the global polio eradication effort, and is similar to management of wild poliovirus outbreaks; i.e. by rapid implementation of high-quality SIAs. Global experience with VDPVs shows that they can be rapidly stopped, with 2-3 rounds of high-quality, large scale immunization rounds.
  18. 18. The Global Polio Eradication Initiative
  19. 19. Four Pillars of the Global Polio Eradication Initiative Strategy 1. Routine Immunization 1985 2. Supplemental Immunization Activities 1995-96 3. Acute Flaccid Paralysis (AFP) Surveillance 1997 4. Targeted Mop-Up Campaigns
  20. 20. WHY POLIO IS A CANDIDATE FOR ERADICATION ?
  21. 21. Four Pillars of the Global Polio Eradication Initiative Strategy 1. Routine Immunization 1985 • A major cornerstone of the polio eradication strategy is ensuring that at least 80% of children receive all the recommended routine childhood immunizations. • Good routine OPV coverage increases population immunity, reduces the incidence of polio and makes eradication feasible plan of routine immunization for out reach areas. .
  22. 22. According to WHO/UNICEF immunization coverage estimates, 86% of infants received three doses of oral polio vaccine in 2010, compared with 75% in 1990.
  23. 23. 2. Supplemental Immunization Activities 1995-96 • Mass polio immunization campaigns that complement routine immunization programs are intended to interrupt transmission by immunizing every child under the age of 5 with oral polio vaccine annually, regardless of the number of times they have been immunized previously. • These campaigns help protect children who are not immunized or only partially protected and boost the immunity of those who are immunized, thereby reducing or eliminating the pool of potential hosts.
  24. 24. WHAT IS PULSE POLIO ? TO IMMUNIZE ALL THE KIDS< 5YRS NATION WIDE ON A SINGLE DAY IN THE SHORTEST POSSIBLE TIME WITH OPV & THAT THE ENVIRONMENT WILL GET SATURATED WITH THE VACCINE VIRUS SO THAT IT WILL REPLACE THE WILD VIRUS AND THUS INTERUPT THE TRANSMISSION OF WILD VIRUS .
  25. 25.  National Immunization Days (NIDs) - which are conducted countrywide 2 or 3 times per year, 1 month apart.  National Immunization Days are conducted in two rounds, one month apart. Because oral polio vaccine does not require a needle and syringe, volunteers with minimal training can serve as vaccinators.  Three to five years of NIDs are usually required to eradicate polio, but some countries require more time, especially those where routine immunization coverage is low.  NIDs are normally conducted during the cool, dry season because logistics are simplified, immunological response to oral polio vaccine is improved and the potential damage to heatsensitive vaccine is reduced.
  26. 26. Synchronized NIDs Neighbouring countries are coordinating, or "synchronizing" their National Immunization Days. This ensures that children crossing borders for any reason are identified and immunized. It also allows health teams to cross borders and immunize children in pockets of territory otherwise isolated by rivers or mountains, or on islands that may be less accessible from the other side. This approach was first used between countries of eastern Europe and central Asia, in a successful campaign called "Operation MECACAR." Similar synchronized efforts have been undertaken along the borders of Afghanistan and Pakistan.
  27. 27. Polio cases and SIAs
  28. 28. • 3. Acute Flaccid Paralysis (AFP) Surveillance -1997 • As many as 90% of people infected with the poliovirus experience very mild or no symptoms. • A single symptomatic case can therefore represent a significant community-wide outbreak. Robust surveillance to detect and investigate every case of polio-like AFP is essential to polio eradication.
  29. 29. AFP case definition broadened Consequences of missing the case of polio are more serious then occasionally including and “ambiguous’’ case, specially during the final stage of polio eradication. Includes every case with  current flaccid paralysis  History of flaccid paralysis in the current illness  Boarder line and ambiguous case  Transient weakness / paralysis
  30. 30. AIM OF AFP SURVEILLANCE TO DETECT POLIO TRANSMISSION & INTERRUPTION OF TRANSMISSION AFP CASE POLIO CASE RESERVOIR OF INFECTION [ 100 TO 1000 SUB CLINICAL CASES ] CONTAINMENT MEASURES [ O.R.I. / MOP UP ]
  31. 31. COMPONENTS OF AFP SURVEILANCE 1.The AFP surveillance network and case notification 2.Case and laboratory investigation 3.Outbreak response and active case search in the community 4.60-day follow-up, cross-notification and tracking of cases 5.Data management and case classification 6.Virologic case classification scheme 7. Surveillance performance indicators
  32. 32. The most important aspect of this classification is the collection of 2 adequate stool samples from all cases. Samples are considered adequate if both the specimens. (1) are collected within 14 days of paralysis onset and at least 24 hours apart. (2) are of adequate volume (8-10g) and (3) arrives at a WHO-accredited laboratory in good condition (ie, no desiccation, no leakage), with adequate documentation and evidence of cold-chain maintenance.
  33. 33. AFP Reporting Network Paediatrician Neurologist Physician Gen. Pract. Dist. Hospital PHC RH MPW/ ANM Traditional Healer Quack DHO/ MOH/ SMO State Delhi WHO
  34. 34. Flow Diagram of AFP Case Investigation
  35. 35. WHY AFP SURVEILLANCE INSTEAD OF POLIO SURVEILLANCE ? • SURVEILLANCE OF A POLIO CASE ALONE IS NOT SUFFICIENT BECAUSE IT IS IMPOSSIBLEE TO PRECISELY IDENTIFY ALL CASES OF POLIO CLINICALLY DUE TO CONFUSING AND AMBIGUOUS CLINICAL SIGNS AND VARIABLE CLINICAL KNOWLEDGE & SKILLS OF DOCTOR. • CLINICALLY POLIO IN ACUTE STAGE, IS DIFFICULT TO DISTINGUISH FROM OTHER CAUSES OF ACUTE ONSET OF FLACCID PARALYSIS.
  36. 36. When too much polio is around….. AFP cases Polio cases Borderline AFP cases Non-AFP cases Surveillance sensitivity is adequate enough to detect 90% polio cases
  37. 37. Data Flow Mondays Reporting Units Tuesdays Districts Wednesdays States Thursday Delhi Districts State NPSU Delhi WHO
  38. 38. Outbreak Response Immunization (ORI)  Measures to stop transmission of polio virus Children <5 yrs in the locality are given one dose of OPV regardless of the number of doses received previously.  A house-to-house active case search is conducted to find additional AFP cases that may have occurred
  39. 39. AFP Surveillance is in the end the only indicator for success
  40. 40. 4. Targeted Mop-Up Campaigns  Last stage in polio eradication Low routine immunization coverage, very dense or mobile populations, inadequate sanitation, and poor access to health services exacerbate communities’ vulnerability to polio.  In focal areas where polio cases have been confirmed within the previous 3 years and circulating virus is confirmed or suspected. In mop-up campaigns vaccinators go house-tohouse to immunize every child under 5 and help to stop transmission.
  41. 41. Before a WHO region can be certified polio-free, three conditions must be satisfied: (A) AT LEAST THREE YEARS OF ZERO POLIO CASES DUE TO WILD POLIOVIRUS (B) EXCELLENT CERTIFICATION STANDARD SURVEILLANCE (C) EACH COUNTRY MUST ILLUSTRATE THE CAPACITY TO DETECT, REPORT AND RESPOND TO “IMPORTED” POLIO CASES. LABORATORY STOCKS MUST BE CONTAINED AND SAFE MANAGEMENT OF THE WILD VIRUS IN INACTIVATED POLIO VACCINE (IPV) MANUFACTURING SITES MUST BE ASSURED BEFORE THE WORLD CAN BE CERTIFIED POLIO-FREE.
  42. 42. Social Mobilization Network (SMNet)  In Uttar Pradesh, India, in response to low routine immunization coverage and ongoing poliovirus circulation, Social Mobilization Network (SMNet) was launched.  The SMNet’s goal was to improve access and reduce family and community resistance to vaccination in highrisk communities, encourage vaccination of children missing scheduled vaccinations, and mobilize local opinion leaders for promotion of vaccination awareness about sanitation hygiene.  Data suggest that the immunization coverage in SMNet communities was often higher than overall coverage in the district.
  43. 43. Current priorities for assessment  Expanded Target Age Groups: expanding the target age group for OPV beyond 5 years of age in SIAs may accelerate the interruption of polio transmission  Inactivated Poliovirus Vaccine: there is increasingly strong evidence that a supplementary dose of IPV can substantially boost mucosal immunity in OPV-vaccinated populations, potentially accelerating eradication.
  44. 44. Achievements of Polio Eradication Strategy A. Reduction in Cases B. Prevention of Disabilities and Deaths- More then 4 lac polio cases prevented so far in India (Over 20 years) C. Medical Care Cost Savings D. Enhanced Global Surveillance Capacity which could support other public health Programmes. E. Entero Virus Laboratory Network at par with Global Standards
  45. 45. Risks/Challenges to Polio Eradication Strategy: a) International Importation of wild polio virus. Neighboring countries like Afghanistan, Pakistan and China has had a major outbreak of Wild Polio Virus in 2011 who pose a major threat to Polio. b) The major barrier to eradication in Nigeria and Pakistan is access—security fears have prevented health workers from reaching the at-risk populations, and misplaced beliefs about vaccine safety has led to vaccine refusal. c) Gaps in AFP Surveillance or delays in detection of wild polio virus d) Delayed and or inadequate response to importation. .
  46. 46. e) Areas with low population immunity. f) Gaps in Routine Immunization & SIA especially in High Risk Areas g) Various resident societies in Delhi are not allowing vaccinators to enter their premises and immunize children in these societies. They have myth that OPV is an anti-fertility vaccine and would lead to impotence in male children or infect them with AIDS. h) Children in western UP from Muslim community have consistently been missed both during SIAs and for routine immunization. Significantly almost 66% of polio cases have occurred among Muslim children.
  47. 47. The goal of the 2013-2018 Polio Eradication and Endgame Strategic Plan is to complete the eradication and containment of all wild, vaccine-related and Sabin polioviruses, such that no child ever again suffers paralytic poliomyelitis
  48. 48. Conclusion • At present, polio is endemic in three countries—Until poliovirus transmission is interrupted in these strongholds, all countries remain at risk, as shown not only by the outbreak in Syria, but also in recurrent outbreaks across sub-Saharan Africa, including an ongoing outbreak in Somalia. • The outbreak in Syria could have major health consequences for other countries, and the government there must assist in providing health-care workers and aid organizations with access to at-risk populations.
  49. 49. • But the outbreak also serves as a reminder that high vaccination coverage is essential in countries where the disease is not currently circulating. • Although it seems like a major setback to eradication efforts, the polio outbreak in Syria might be used as an opportunity to reinvigorate eradication campaigns in Afghanistan, Nigeria, Pakistan, and surrounding countries.
  50. 50. Reference: 1. 2. 3. 4. www.npspindia.org www.mohfw.nic.in www.polioeradication.org www.unicef.org/immunization Super course/ Pittsburgh university(www.pitt.edu/~super1) 5. JIMA DECEMBER 2005 6. http://www.polionet.org/vaccine.htm 7. www.who.int

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