Poliovirus Surveillance
status of quality, actions to improve sensitivity
WHO-India
15 March 2012
Outline of the presentation
• National overview of AFP surveillance in India
• Areas/Populations at a relatively higher risk of
wild poliovirus circulation/importation
• Surveillance quality during last 6 months in
areas/ populations at higher risk
• Recent efforts to improve surveillance
sensitivity
AFP Surveillance Reporting
Number of AFP case reporting sites
26,036
27,919
29,932
30,595
31,269
32,877
2007
2008
2009
2010
35,478
35,824
2011
2012*
21,403
2004
2005
2006
Number of AFP cases reported
55,785
41,524
27,049
45,585
60,782
50,405
32,194
13,274
2004
*Data as on 10 March 2012
2005
2006
2007
2008
2009
2010
2011*
Polio laboratory performance
Number of stool specimens processed
83,528
91,148
100,102
109,090
118,866
65,011
2006
2007
2008
2009
2010
2011*
Number of days from stool received in laboratory to final result
35
30
Days
25
20
15
10
5
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2006
*Data as on 10 March 2012
2007
2008
2009
2010
2011*
Surveillance performance indicators, last 6 months
Non-polio AFP rate
Stool collection rate
# AFP cases, Jan – Feb
14.3
86%
8156
7375
6515
In d ia
5460
L e s s th a n 6 0%
60 % to 6 9 %
70 % to 7 9 %
80 % a n d a b o v e
N o AF P case
2009
2010
2011
2012
Outline of the presentation
• National overview of AFP surveillance in India
• Areas/Populations at a relatively higher risk of
wild poliovirus circulation/importation
• Surveillance quality during last 6 months in
areas/ populations at higher risk
• Recent efforts to improve surveillance
sensitivity
Where could the virus be?
Leads from past incidence
Historic reservoir areas
Wild poliovirus type 1 cases, 2007-11
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Where could the virus be?
Leads from past incidence
Historic reservoir areas
HR blocks
107 High Risk blocks
Where could the virus be?
Leads from past incidence
Historic reservoir areas
HR blocks
Areas with recent transmission
WPV 1 cases, 2010-11
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Where could the virus be?
Leads from past incidence
Historic reservoir areas
HR blocks
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Areas with recent transmission
Migrant sites (1 dot=50 sites)
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Wild poliovirus cases by migratory status
Outside Bihar & Uttar Pradesh, 2007-11
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Migratory,
19 WPV1 cases,
40%
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Non-migratory,
29 WPV1 cases,
60%
Where could the virus be?
Leads from genetics
Tajikistan
2010
Areas involved with
international importations
Where could the virus be?
Leads from genetics
Tajikistan
2010
Areas involved with
international importations
Bangladesh
2006
Where could the virus be?
Leads from genetics
Tajikistan
2010
Angola
2005, 2007
Areas involved with
international importations
Bangladesh
2006
Where could the virus be?
Leads from genetics
Tajikistan
2010
Areas involved with
international importations
Nepal
2004, 2005, 2006, 2010
Angola
2005, 2007
Bangladesh
2006
Where could the virus be?
Threat from neighbouring countries with active circulation
Areas at risk of importation
from neighbouring countries
WPV 1 past 6 months,
neighbouring countries
Outline of the presentation
• National overview of AFP surveillance in India
• Areas/Populations at a relatively higher risk of
wild poliovirus circulation/importation
• Surveillance quality during last 6 months in
areas/ populations at higher risk
• Recent efforts to improve surveillance
sensitivity
Historic reservoir areas
107 HR blocks
% adequate stool specimen
collection rate
Non-polio AFP rate
U.P.
U.P.
28.4
55.2
85%
86%
Bihar
42.1
31
Bihar
89%
In d ia
L e s s th a n 6 0 %
Non HR blocks
*Data – September 2011 to February 2012
6 0 % to 6 9 %
7 0 % to 7 9 %
80 % a n d a b o v e
N o AHR
FP c
ase
Non
blocks
Areas with recent transmission
Non-polio AFP rate
% adequate stool specimen
collection rate
In d ia
L e s s th a n 6 0 %
6 0 % to 6 9 %
7 0 % to 7 9 %
80 % a n d a b o v e
N o AHR
FP c
ase
Non
blocks
Jharkhand
Average
Jharkhand
89%
13.5
West Bengal
*Data – September 2011 to February 2012
Average
West Bengal
Areas with recent transmission
Non-polio AFP rate
% adequate stool specimen
collection rate
Average
Average
12.9
87%
In d ia
L e s s th a n 6 0 %
6 0 % to 6 9 %
7 0 % to 7 9 %
80 % a n d a b o v e
N o A HR
FP c
ase
Non
blocks
*Data – September 2011 to February 2012
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Migrant AFP cases, 2011*
Estimated non-polio AFP rate**
amongst migrants
16
15.5
12
8
12.7
9.0
4
0
2009
N=2,040
*data as on 10 March 2011
2010
#
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2011*
** Estimate based on the number of migrant
children vaccinated in SIAs
##
#
#
#
Areas linked with international spread
of poliovirus
% adequate stool specimen
collection rate
Non-polio AFP rate
U TT AR P R AD E S H
B IH A R
Average
Average
33.5
JH AR K H AN D
86%
In d ia
L e s s th a n 6 0%
*Data – September 2011 to February 2012
60 % to 6 9 %
70 % to 7 9 %
80 % a n d a b o v e
N o AF P case
Areas at risk of importation from
neighbouring countries
% adequate stool specimen
collection rate
Non-polio AFP rate
Average
Average
6.8
83%
In d ia
L e s s th a n 6 0%
*Data – September 2011 to February 2012
60 % to 6 9 %
70 % to 7 9 %
80 % a n d a b o v e
N o AF P case
Outline of the presentation
• National overview of AFP surveillance in India
• Areas/Populations at a relatively higher risk of
wild poliovirus circulation/importation
• Surveillance quality during last 6 months in
areas/ populations at higher risk
• Recent efforts to improve surveillance
sensitivity
Field surveillance reviews, 2011
JA M M U & K A S H M I R
States reviewed
Districts reviewed
H IM A C H A L
PR A D E S H
PU N JAB
CH
UTTARA NCHAL
H AR YA N A
DL
S IK K IM
AR U N A C H A L PR .
U T T A R P R A D E SH
R AJA S T H A N
AS S AM
B IH A R
N AG A L AN D
M E G H A LA YA
M A N IP U R
JH A R K H A N D
M A D H Y A PR AD ES H
GU JAR AT
T R IP U R A
W E ST BE N G A L
M IZ O R A M
C H H A T T IS G A R H
Number of states reviewed
O R IS S A
D AM A N & D IU
D &N H A V EL I
M A H A R A SH T R A
7
AN D H R A P R A D E S H
GO A
4
3
KA R N A T A K A
A& N ISL AN D S
P O N D IC H E R R Y
LA KS H A D W EE P
T A M IL N A D U
KE R A LA
2009
2010
2011
West Bengal
Number of reporting sites
1495
973
2009
1611
982
2010
2011*
2012*
AFP cases reported till week 10
Year to date comparison
416
248
248
2010
2011*
215
2009
*Data as on 10 March 2012
2012*
Significant efforts to
improve AFP surveillance
noticed post surveillance
review in March’11 to
ensure early detection of
virus circulation
Delhi
Expansion of reporting network
340
182
2008
184
182
2009
2010
2011
# AFP cases
Non-migrant
Migrant
281
136
30
171
158
156
2009
2010
2011
AFP surveillance system
sensitivity enhanced,
particularly in high risk
populations, following the
surveillance review.
Bihar & West UP
Number of reporting sites in review districts
300
244
250
Bihar
254
245
239
224
218
208
200
206
192
190
174 176
164
170174
151156
149
150
127
107
96 94
100
82
74
50
“AFP surveillance system
in Western UP & Bihar is
sensitive enough to pick
up virus transmission at
the earliest”
0
CHAMPARAN EAST
DARBHANGA
KHAGARIA
PATNA
SAHARSA
SAMASTIPUR
“Need for greater
involvement of the district
and block government
staff in surveillance
activities”
300
West UP
250
200
150
100
50
0
AGRA
BADAUN
FARRUKHABAD
2008
Data at the time of review
GB Nagar
2009
GHAZIABAD
2010
2011
MORADABAD
SHAHJAHANPUR
Maharashtra, Nov’11
# AFP cases reported, Nasik
46
39
29
24
Q1
Q2
2011
Q3
Q4
% adequate stool specimen, Nasik
80
68
Before review, 2011
*Data as on 10 March 2012
“AFP surveillance system is
likely to pick up virus
circulation; however, efforts
need to be strengthened in
Nasik.”
• Nasik (Malegaon)
– Weak reporting network leading
to delayed reporting of cases
• Rest of Maharashtra
– Extensive reporting network with
adequate government & private
involvement
After review till date
– Timely & adequate response to
all AFP cases reported
Andhra Pradesh, Dec 2011
% AFP cases with adequate stool specimen, 2011*
A D ILA B A D
S R IK A K U L A M
K A R IM N A G A R
N IZ A M A B A D
V IZ IA N A G A R A M
W A RANGAL
ME D A K
V IS A K H A P A TN A M
KHAM M AM
HYDERAB AD
EAST G OD AVARI
RANG AR EDDY
N A LG O N D A
W E ST GODAV ARI
K R IS H N A
MA H B U B N A G A R
G U N TU R
In d ia
PRAKA SAM
KURNOOL
ANANT PUR
L e s s th a n 6 0%
N E LLO R E
CUDDAP AH
60 % to 6 9 %
70 % to 7 9 %
80 % a n d a b o v e
N o AF P case
C H ITTO O R
Blocks without any AFP case in 2011*
“AFP surveillance needs
improvements to ensure
early detection of any virus
circulation”
• Existing public health cadre underutilized for surveillance
• Inadequate involvement of private
sector health facilities in reporting
AFP cases
Conclusions of recent surveillance reviews
Surveillance sensitive to pick-up virus circulation
Gaps identified, improvements made after review
Gaps identified, improvements required
Surveillance reviews, 2012
2011
JAM
U & K
KA
JA
M MU
A S HM
M IR
IR
States reviewed 2011
Districts reviewed 2011
H
CH
HIM
I MAAC
HA
A LL
PPR
R AAD
D EES
SH
H
Proposed reviews, 2012
PU
N JJ A B
B
P
UN
C
CH
H
U
AR
NC
L
UTTTTA
R AAN
CH
HA
AL
HAARR Y
YAAN
A
H
NA
D
DLL
IM
SSIKK
IK K IM
NAAC
PRR .
AAR
R UUN
C HHAALL P
U
AR
UTTTTA
R P
PR
RA
A DE SH
H
R
S T HA N
RA
A JJA
AS
M
AAS
S SSA
AM
BBI
IHHAARR
NNAAGGAALLA
ND
AN
D
M
GH
YA
MEEG
HAA LLAAY
A
M
N IP
MAAN
IP U
UR
R
JJHHA
ARRK
KHH A
AN
ND
D
MAAD
HY
YA
A P
PR
D E SH
M
DH
R AD
SH
G
A R AT
AT
GU
U J AR
IPUUR
RAA
TTR
R IP
W
S TT B
NG
W EES
BEEN
GA
A LL
M
M
MIZ
IZOORRAAM
C
T IS
GA
RH
CHHHHAATTT
ISG
AR
H
O
A
ORRIS
ISSSA
D
N &
U
DA
AM
MA
AN
& D
D IIU
D
ELI
D&
&NN H
HA
AV
VE
M
HA
RA
S H TR
T RA
M AAH
AR
A SH
A
ND
SH
H
AN
DH
HR
RA
A P
PRADE
ES
G
GO
OAA
Plans for 2012
Follow up on recommendations of 2011 reviews
Field reviews in 6 additional states
K
AR
TA
KA
KA
RN
N AAT
A KA
AA&
&N
S LL A
ND
N IIS
AN
DS
S
PPO
O NND
D IC
ICHH E
ER
RR Y
Y
LLA
AK
HA
DW
EP
KSSH
AD
WE
EE
TTA
AM
M IL
IL N
NA DU
K
ER
KE
RA
ALA
A
Environmental surveillance expansion plans
WPV 1 past 6 months,
neighbouring countries
Punjab
Delhi
May 2010
Patna
April 2011
Gujarat
Mumbai
2001
Existing environmental
surveillance sites
Proposed additional sites
for environmental surveillance
Kolkata
December 2011
Summary
• Overall surveillance quality maintained at high levels
• Areas at risk of WPV importation/circulation identified
and being closely monitored for surveillance quality
• Actions being taken to enhance surveillance
sensitivity in high risk areas following reviews
e.g. West Bengal, Delhi, Nasik (Malegaon)
• Sewage sampling sites being expanded strategically
to minimize risk of missing poliovirus in the
environment
Thank You