Immunization is not an Expenditure. Its an Investment.: 2013

The last case of wild polio virus reported in India was exactly one year ago, on January 13, when stool samples showed that 18-month-old Rukhsar Khatoon in West Bengal had polio. She has since recovered, but it is the progress of whittling down from the largest number of cases in the world to zero that is fascinating to public health experts globally.

Clearly, the nation had to overcome tremendous challenges to get here – not least of them, a huge population, the logistics of covering a vast geographical area, poor sanitation and infrastructure, resistance among some groups of people to taking the vaccine, and children of migrant communities who were difficult to cover.

It was with the Expanded Immunisation Programme in the late 1970s that India started its battle against polio. In 1985, it became a part of the Universal Immunisation Programme launched throughout the country. A significant milestone in the journey was the launch of the National Pulse Polio Initiative (PPI) in 1995-96, targeting coverage of every child under five in the country with the Oral Polio Vaccine (OPV) to be given on two National Immunisation Days, one each in December and January, followed by more focused state-level immunisation campaigns throughout the year. The PPI set for the nation a new target — eradication of polio by 2005.

This involved better social mobilisation through involvement of millions of frontline workers from the private health sector, members of Rotary International, volunteers, anganwadi workers, besides the massive public health workforce. In addition, the PPI created systems – cold chains for storage and transportation of the vaccines, ensuring vaccine vial monitors on each vial, follow up and mop up campaigns to track children left out during immunisation days.

India has spent more than Rs. 12,000 crore on PPI, a Union Ministry of Health release said. One of its major partners, Rotary International says it has spent over $149 million in India over the years, as part of its contributions. In each PPI, 24 lakh vaccinators visit over 20 crore households to ensure that nearly 17.2 crore children, less than five years, are immunised with the OPV. Mobile and transit vaccination teams immunise children at railway stations, bus stands, market areas, and construction sites. Special rounds were held to give the OPV to children of migrants and refugees.

And yet, concerns remained. Pockets of Uttar Pradesh and Bihar were still endemic, responsible for the cases being reported in the country, directly, and through migration. In recent years, the government targeted 107 ‘high risk' blocks in Uttar Pradesh and Bihar, and identified the challenges, which included remote locations, refusal of vaccine in some areas, and migrating populations. ‘Influencers', including religious leaders, were enlisted and tracked for each high risk area, and this helped polio teams reach more families. Positive results were seen as a consequence: UP and Bihar have not reported any case of polio since April 2010, and September 2010, respectively.

While India has clearly stepped into the endgame stage, it is by no means closure, public health specialists warn. Mr. Azad tempered his joy over the achievement with concerns about the future. “We are excited and hopeful, and at the same time, vigilant and alert”. He cautioned that there was no room for complacency, with the nation having to maintain its zero-cases record for the next three years to be able to totally ‘eradicate' poliomyelitis. “It is a great stride forward,” Deepak Kapur, Rotary International's India Polio chair, said. “However, it is just one stride ahead. Only one third of the journey has been completed, we need three clean years for the certification.”

The greatest concern is the possibility of infections carried across borders by migrating populations. GPEI points out that in 2011, Pakistan and Afghanistan both saw alarming increases in polio cases, and poliovirus from Pakistan re-infected China (which had been polio-free since 1999). In Africa, active polio transmission continues in Nigeria, Chad and the Democratic Republic of the Congo, with outbreaks in West and Central Africa in the past 12 months reminding the world that as long as polio exists anywhere, it remains a threat everywhere. Lieven Desomer, Polio Chief, UNICEF India, said, “The key challenge now is to ensure any residual or imported poliovirus in the country is rapidly detected and eliminated. This requires very high levels of vigilance and emergency preparedness to respond to any importation of wild poliovirus.”

In an e-mail response to The Hindu, Nata Menabde, WHO Representative to India, explained, “India must now capitalise on this progress and secure polio eradication. It must continue to protect children in polio campaigns and through improved routine immunisation coverage. Complacency is not a luxury the program can afford; continued high level vigilance for polio, emergency preparedness, and intense immunisation activities will be essential for rapid detection and elimination of any circulating poliovirus.”

(With inputs from Aarti Dhar in New Delhi

Polio free does not mean paralysis free_An article form THE HINDU

OPINION » LEAD

January 3, 2013

Polio free does not mean paralysis free

N. GOPAL RAJ

There is no room for complacency that India has eliminated this crippling disease as Uttar Pradesh and Bihar have recorded a high incidence of a condition symptomatic of it

Identifying children who suddenly display muscle weakness, often not moving one or more of their limbs as a result, forms the cornerstone of polio surveillance. Such children could have “acute flaccid paralysis” (AFP) that is symptomatic of polio, a disease caused by a virus. But AFP can also arise for other reasons, including infection by non-polio pathogens.

No child in India has been diagnosed with polio for nearly two years now and all the indications are that the virus responsible for it is no longer circulating here. However, the country’s polio surveillance system has indicated a sharp increase during recent years in the number of non-polio AFP cases.

Alarming data

Data published by the World Health Organisation show that close to 8,000 non-polio AFP cases were identified in India during 2003. They went up to over 12,000 the following year, more than 26,000 in 2005 and crossed 40,000 by 2007. In 2011, there were more than 60,000 non-polio AFP cases.

A good polio surveillance system ought to pick up all AFP cases among children so that they can be screened for poliovirus infection. On average, only about one child out of every 200 children carrying the poliovirus develops AFP. Such cases must be identified so that appropriate immunisation measures can be undertaken.

India’s polio surveillance shows that the country is polio-free. But it also indicates that the country now has the world’s highest rate of non-polio AFP cases. According to data published in WHO’s Weekly Epidemiological Record, India’s annualised non-polio AFP rate for 2011 stood at 15.06 per one lakh children below 15 years of age, compared to a global rate that year of 5.48.

Moreover, most of the country’s non-polio AFP cases occur in just two States — Bihar and Uttar Pradesh. They accounted for about 61 per cent of the 53,000-odd non-polio AFP cases identified in the country in 2012, according to data from WHO’s National Polio Surveillance Project. As a result, the two States have far higher annualised non-polio AFP rates than other States — around 34 for Bihar and about 23 for Uttar Pradesh. The rate for the country as a whole is slightly over 12.

“The increased non-polio AFP rate is due to increased reporting of AFP cases due to deliberate efforts of the programme to increase the sensitivity of the surveillance system since 2004,” according to the WHO Country Office for India. In a written response provided to this correspondent, the health body said these efforts were more intense and closely monitored in the traditionally polio-endemic states of Bihar and U.P., resulting in even higher rates of reporting of AFP cases in those States.

In 2004, a number of steps were initiated to strengthen surveillance in order to accurately and more rapidly detect all polio cases in the country, it said. Those measures included expanding the definition of AFP; increasing the number of AFP reporting sites; increasing the number of active surveillance visits; and more training for health professionals on what constituted an AFP case.

Since then, the number of AFP cases that were reported and investigated continued to increase, it noted. This was not due to an increase in the incidence of a specific disease that might cause these symptoms. Rather, it was the direct result of surveillance activities for AFP cases being strengthened.

The programme in India had taken a much broader interpretation of what would qualify as an AFP case than other countries have. Although facial paralysis would not be part of a standard definition of AFP, it was included in that definition for India. Other similar examples were diseases like meningo-encephalitis, Bells palsy, post-diphtheria polyneuritis and spinal muscular atrophy. Data had shown that broadening the case definition led to the detection of some polio cases that would have otherwise been missed, the WHO Country Office noted.

Moreover, in the remaining polio-endemic countries of Nigeria, Pakistan and Afghanistan too, efforts to strengthen polio surveillance were resulting in increased non-polio AFP cases being reported, it added.

The high non-polio AFP rates in the country ought to be a “red flag”, remarked T. Jacob John, a leading virologist who was with Christian Medical College, Vellore, and is known for his work on polio eradication.

With heightened polio surveillance, sick children with suspected paralysis or possible neurological maladies were being identified and tested by the polio surveillance system, he remarked. However, the neurological disorders given by the WHO Country Office as examples of the expanded definition of AFP were likely to account for only a small part of the increase in non-polio AFP cases being seen in India.

No clear picture

Unfortunately, the cases of children with non-polio AFP were not being monitored by either the polio eradication programme or the larger state health care system. As a result, there was no clear picture of what was causing the AFP, the kind of diseases these children displayed, or how many of them were seriously affected, he pointed out.

A range of non-polio pathogens could produce AFP, said Dr. John. With many such pathogens, the paralysis they caused would often disappear in a short period of time. However, others were capable of causing quite serious diseases, disability and even death.

Two teams of Indian scientists recently studied the sorts of enteroviruses found in children with non-polio AFP. Enteroviruses are a diverse group, most of which replicate in the alimentary tract. The poliovirus is part of this group. Several non-polio enteroviruses have been associated with a range of acute and chronic human diseases, including polio-like paralysis.

In a study published in 2009, a team at the Sanjay Gandhi Postgraduate Institute of Medical Sciences in Lucknow tested over 46,000 stool samples from children with AFP in U.P., Bihar and other northern States between 2004 and 2007. In the other study, C. Durga Rao of the Indian Institute of Science, Bangalore, and his colleagues looked for enteroviruses in stool samples collected from more than 2,700 children with non-polio AFP in Kerala, Karnataka and Uttar Pradesh between 2007 and 2009.

Enteroviruses

Both groups found that only about 30 per cent of the non-polio AFP cases were associated with enteroviruses. These viruses could therefore only partially explain the non-polio AFP cases being detected.

In a paper published early last year in the Indian Journal of Medical Ethics, Neetu Vashisht and Jacob Puliyel of the St. Stephens Hospital, Delhi, gave another perspective on the issue. Children in Bihar and U.P. have received more doses of oral polio vaccine than elsewhere in the country. The oral vaccine, it was found, became less efficacious in the face of gut infections and diarrhoea that were widely prevalent in those States.

In their paper, Dr. Vashisht and Dr. Puliyel analysed the non-polio AFP rates across all States over 10 years up to 2010, and found that the rate “increased in proportion to the number of polio vaccine doses received in each area.” In 2012, the number of doses of oral vaccine given to children in Bihar and U.P. had come down and, for the first time, there was a decrease in the non-polio AFP cases in those States, Dr. Puliyel told this correspondent.

There was need for “a critical appraisal to find the factors contributing to the increase in non-polio AFP with increase in OPV [oral polio vaccine] doses — perhaps looking at the influence of strain shifts of entero-pathogens induced by the vaccine,” said Dr. Vashisht and Dr. Puliyel in the paper.

The non-polio AFP rate was not correlated with the number of oral vaccine doses that were administered, countered the WHO Country Office in its response. The largest number of oral vaccine doses given in India was in 2004, which had the lowest non-polio AFP rate in the last eight years. Moreover, although the number of oral vaccine doses given in the country had shown a continuous decline since 2007, the non-polio AFP rate had increased during the same period. In Bihar and U.P. too, there were similar trends of reduced oral vaccine doses and rising AFP rates during 2007-2011.

“The ICMR [Indian Council of Medical Research] is leading the investigations into non-polio causes of AFP,” the WHO Country Office stated.

Keywords: Polio, acute flaccid paralysis, WHO, ICMR, public health, health ministry

COMMENTS(2)RECOMMENDED POST A COMMENT

I wish very happy new year to all of readers. We have won a crusade like polio. But there is another enemy have appeared like AFP. We should also aware of this challenging disease. And government should take a serious step to eradicate it. As we surmount polio, we also surmount AFP.

from: AMIT KUMAR SHUKLA

Posted on: Jan 3, 2013 at 15:43 IST

This is an eye-opener. Though India has been declare polio-free, we do
want any other epidemic out there to hurt out children. Non-Polio AFP
seems to be the next epidemic, if left unchecked. There is an urgent
need to find the root causes behind AFP and eliminate them. We should
not let AFP become the next Polio type disease.

from: Manas

Posted on: Jan 3, 2013 at 14:38 IST

Frequently Asked Questions on Pulse Polio Activity

FREQUENTLY ASKED QUESTIONS AND ANSWERS

Q1. Why so many repeated rounds of OPV campaigns?

Ans. For individual protection, every child during the first year of life should receive at least three doses of OPV (routine doses). Like any other vaccine, OPV is not 100%effective. Even children who have received all routine doses and pulse polio doses can get the disease. The only way to completely eliminate the risk of getting children paralysed by polio is to completely interrupt the circulation of wild poliovirus by administration of OPV to all under-five children over a few days and repeated a few times each year as happens during NID/SNID. It is essential that all children receive OPV during such NID/SNID rounds otherwise children in the area will continue to be affected by polio paralysis. Once polio is eradicated all children will be freed of the risk of getting polio throughout their life. Even areas that are currently

polio free, have to continue with NIDs/SNIDs to prevent the risk of importation of wild poliovirus into such areas.

Q.2 How long will Pulse Polio rounds continue? Will immunization activities stop soon?

Ans. National Immunization Days, Sub-National Immunization Days and Mop-Up campaigns need to continue to get rid of the virus from the country. SIAs will continue in India, for at least the next few years even after the last case is seen to ensure that polio is really gone from India and till it is certified that polio has been eradicated from the whole world.

Q3. How soon can we achieve polio eradication in India?

Ans. After the programme suffered a setback in 2002 when 1600 cases were confirmed in the country, satisfactory progress has been made due to concerted efforts to improve the quality of SIAs coupled with increasing the number of rounds to 6-8 each year. This resulted in only 225 cases being confirmed in 2003, with further decline to 134 cases in 2004 and an all time low of only 66 cases in 2005. With the use of mOPV1 since April 2005 in high risk areas, which is continuing in the low season (when the effect of OPV is maximum) of 2006, India is poised to attain eradication in 2006. With the last case being recorded in Jan 13 2011, we are hopeful to eradicate by 2014.

Q4. Why we need to give OPV to children who have received routine OPV doses?

Ans. Routine OPV drops are given for individual protection of the children against polio.

However, like most vaccines OPV is not 100% effective. Some children do not develop complete immunity in spite of receiving all OPV doses. The only way to protect all children from polio is by stopping the circulation of wild polio virus from the environment. This is possible only if all children less than 5 years of age receive additional OPV doses simultaneously as is done during the NIDs/SNIDs. This helps to interrupt circulation of wild poliovirus and thus attain eradication. This is the only way to ensure that all children are safe and will not get polio.

Q5. Does administration of OPV lead to impotence or sterility?

Ans. No, OPV does not lead to any impotence or sterility. It is just a rumour which has been spread by some unscrupulous persons. OPV, in fact is one of the safest vaccines which has been in use for more than 30 years. Repeated doses of OPV minimize the risk of getting polio and are safe. Same OPV is being used for all communities in India and in several other countries including our neighbours Bangladesh and Pakistan. Even in Americas OPV was used successfully during the eradication phase. As with many successful programs, pulse polio programme also attracts the attention of a few people who try to spread rumours about the vaccine. None of these rumours have any basis and the people spreading such rumours are actually working against the interest of the children of this country.

Q6. Does administration of OPV have any side effects? Does it lead to illness in any child?

Ans. No, OPV does not have any side effects and it does not lead to any illness. Many children get sick every day due to different diseases and if these diseases occur during mass OPV campaigns, it is a mere coincidence.

Q7. Should OPV drops be given to newborn children?

Yes, OPV drops must be given to newborn children also, even if they were born

only a few hours ago.

Q8. Why do children get polio even after getting OPV?

Ans. As is true of any other vaccine or medicine, OPV also is not 100% effective. While adequate immunity will develop in most children receiving the vaccine, a few will still remain unprotected after receiving repeated doses. This small group of children who have received vaccine but have not developed adequate immunity can get polio if the wild poliovirus is circulating in the area. The fact that some children may get polio even after receiving polio drops, emphasizes the need to eradicate the poliovirus quickly. It is essential that for complete protection of all children wild poliovirus should be eradicated and this is only possible through repeated mass campaigns with OPV as during NIDs/SNIDs. If a few children do not receive OPV during NIDs/SNIDs, they maintain the circulation of wild poliovirus and this virus can then attack any child and produce paralysis in children that are not fully protected.

Unless we reach high coverage uniformly without pockets of children being left

out, there will always be a risk that some children who have been vaccinated could be affected by polio since they can still come into contact with virus.

Thus the only way to assure 100% protection from polio is to eliminate the poliovirus and thus stop it from circulating from child to child. It is therefore important that every child under 5 years of age receives polio drops during every pulse polio immunization round, in addition to their routine immunizations.

Q9. Should a child having diarrhoea or other sickness be given OPV drops?

Ans. OPV drops must be given to all children even those who have diarrhoea or other sickness.

Q10. Does administration of OPV interfere with administration of drugs or antibiotics being given to a sick child?

No, administration of OPV does not interfere with administration of other drugs or antibiotics.

Q11. Is there any difference in the vaccine if the colour of the liquid is different?

Ans. Usually the colour of the OPV is pink. However, the colour could be yellow or white also and there is no difference in the quality or type of vaccine.

Q12. Can an overdose be given accidentally and what would be the consequences?

Ans. There is no danger of overdose. Multiple doses do not cause adverse reactions.

Q13. Could it be that the Polio drops are not working properly? Are there problems with the vaccine in India?

Ans. Oral Polio vaccine, given multiple times has eliminated polio in the vast majority of countries in the world. It is the recommended vaccine to eradicate polio, and goes through rigorous testing arranged by WHO and the Government of India. The polio drops are working and there is no problem with the vaccine. A drop in the efficacy, or effectiveness, of vaccine can occur if it has not been maintained at the recommended temperatures as per the national protocol. However such a drop is unlikely because of the strict discipline and rigorous monitoring system built for cold chain maintenance. For example if the vaccine has lost efficacy due to faulty storage or long power cuts, the colour of the Vaccine Vial Monitor will change and clearly indicate that vaccine is no longer potent. The vaccine will then be discarded.

Q14. What is the cold chain?

Ans. The cold chain is a network of electrical and non-electrical equipment and human handlers who facilitate safe keeping and transportation of the vaccine from manufacturers’ level to the point of administration to children. During all this time the vaccine needs to be kept within a safe temperature range. Normally, below freezing while being stored at state and district stores and between 2-8 degrees celsius in the period immediately prior to distribution and use.

Extract from IPPI guide published by MoHFW in 2006

Wednesday, 2 January 2013

2013 Pulse Polio dates

Pulse Polio dates for the Year 2013 are

January 20 2013 _ Sunday
February 24 2013 _ Sunday

Pulse Polio is conducted on Sundays to ensure

Wider Inter Sectoral Convergence
Larger Community involvement

Wednesday, 11 December 2013

Saturday, 7 December 2013

Tuesday, 5 November 2013

Tuesday, 15 October 2013

Wednesday, 31 July 2013

Monday, 22 July 2013

Thursday, 13 June 2013

Tuesday, 23 April 2013

Saturday, 20 April 2013

Saturday, 13 April 2013

Thursday, 21 March 2013

Monday, 4 March 2013

Wednesday, 13 February 2013

Saturday, 26 January 2013

Friday, 25 January 2013

Saturday, 19 January 2013

Wednesday, 16 January 2013

Monday, 14 January 2013

Saturday, 12 January 2013

Friday, 11 January 2013

Saturday, 5 January 2013

Thursday, 3 January 2013

Wednesday, 2 January 2013