Supplementary Immunization Activities

Quality, Risks and Risk Management

IEAG Meeting

13 July 2011

Supplementary Immunization Activities (SIAs) India, Jan to June 2011

NID SNID

Endemic & risk states

Endemic & risk states

Zone 1 UP/Bihar, Delhi & HR areas

Mar Apr May JunJan Feb

mop up in West Bengal / Jharkhand

SIAs – India, January to February 2011

23 Jan

2nd week Feb

27 Feb

mOPV1mOPV3

bOPV

tOPV

SIAs – India, March to June 2011

March

bOPV

tOPV

April

May June

Emergency Outbreak Response Howrah, West Bengal, 2011

Day 6

Mop up conducted

Day 4

•National level partners meeting•Media plan operationalized•Vaccine arrived in district

Day 3

•State & District Task Force Meetings•14 additional SMOs arrive in districts•IEC plan developed•Marker pens & other logistics procured

Day 2

•Field Investigation (NCDC/NPSP/UNICEF)•National Technical Group Meeting •Decision on mop up

Day 1

Chief Minister & Chief Secretary WB

informed by GoI

Day 0

Wild Polio virus

notified

Day5

Vaccine & other logistics reach blocks

Key Immediate Actions that followed detection of case

7 Feb 2011 13 Feb 2011

Major Issues Identified• Microplanning

– Missed Areas– High work load of vaccinators & supervisors– Composition of vaccination teams not appropriate – No revisits planned to ‘X’ houses

• Training– Weak interpersonal communication skills of vaccinators– Untrained vaccinators working as team members

• Non-acceptance of vaccine– High refusals (~ 47000 refusals in Howrah and 3 neighbouring districts)– Myths against vaccine safety

Outbreak Response Actions(GoI/ GoWB, WHO-NPSP, UNICEF, Rotary, CORE)

• Identification of 36 high risk blocks/municipalities & 222 high risk Gram Panchayats/wards to focus activities

• Enhanced oversight & coordination by central and state officials, DMs, CMOs, Municipality/ Ward Officers, BDOs, BMOs

Outbreak Response Actions (2)(GoI/ GoWB, WHO-NPSP, UNICEF, Rotary, CORE)

• 25 experienced additional SMOs deployed to the outbreak area for 4 months to support

– Improvements in microplans: ensure no missed areas, appropriate team composition and workload

– Trainings: to improve skills & performance of vaccinators and supervisors

– Intensive monitoring of preparedness & implementation in high risk areas

Outbreak Response Actions (3)(GoI/ GoWB, WHO-NPSP, UNICEF, Rotary, CORE)

• Scale up of IEC/ mobilization efforts– 1900 NGO mobilizers deployed– Additional IEC materials produced– Enhanced media support– Sensitization of Influencers/ religious

leaders and local practitioners– Advocacy/ vaccination during community

events– Health Camps– Vaccination at clinics of important

practitioners

• Mandatory revisits to ‘X’ marked houses accompanied by doctors/ local influencers

Outbreak response, West Bengal

Howrah, 2011

Murshidabad, 2010

bOPV mOPV1

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

WPV1 notified

07 Feb 2011

WPV1 notified

12 Feb 2010

1

123

45

6

7

2

3

456

7

Num

ber

of W

PV

5 weeks 17 weeks

1 week7 weeksWPV1

WPV3

Summary – SIAs in 2011

• At least one SIA with tOPV conducted in all areas in the country – most areas got 2 tOPV rounds

• 3 to 5 campaigns conducted with bOPV in high risk areas

• Aggressive Emergency Outbreak Response conducted in West Bengal following detection of WPV type 1 in Howrah district in 2011

SIA quality in high risk areas/populations

Areas/ Populations at highest risk of polio

Areas with recent polio transmission

Areas/ Populations at highest risk of polio

Areas with recent polio transmission

Endemic areas

Areas/ Populations at highest risk of polio

Areas with recent polio transmission

Endemic areas

Areas with high migrant populations

West Bengal Jharkhand

Malegaon (Maharashtra)

Areas with recent transmission

Percent unvaccinated children End-of-round survey

Southern districts, West Bengal

Per

cent

Per

cent

N= 7,525 6,665 8,193 11,933

N= 6,556 7,574 7,686

11,027

7,065

Northern districts, West Bengal

1,371 4,490 2,996 4,020 3,515

11,787

10,320

Howrah

Per

cent

Per

cent

24-Parganas South

N= 2,158 762 1,034 1,487

N= 2,405 2,347 1,998 2,341

Per

cent

24-Parganas North

N= 1,153 866 2,067 2,535 2,858 2,018

1,423

Per

cent

Kolkata

N= 1,451 2,220 2,674 3,995 3,629

Percent unvaccinated children, End-of-round survey, 2011

Quality of SIAs in southern districts - West Bengal

2,092 3,393

2,846 2,847

Percent unvaccinated children, End-of-round survey

Jharkhand

West Bengal

High coverage achieved in high risk areas of Jharkhand

Per

cent

Pakur & Sahibganj

N= 2,945 3,213 5,904 9,779 8,398 6,088 4,163 5,568 5,509 6,197 6,151

Jharkhand

West Bengal

Lot Quality Assurance Sampling (LQAS) West Bengal & Jharkhand – Feb to June 2011

District Feb 11 Mar 11 Apr 11 May 11 Jun 11

Murshidabad (West Bengal)

# lots accepted 6 2 1 3 4

# lots cautioned 1 2 3 2 1

# lots rejected 1 0 0 0 0

Birbhum (West Bengal)

# lots accepted 1 - - - -

# lots cautioned 0 - - - -

# lots rejected 0 - - - -

Pakur

(Jharkhand)

# lots accepted 8 - - - 10

# lots cautioned 1 - - - 0

# lots rejected 0 - - - 0

Hypothesis: “The SIA coverage in this LOT is > 90%.”

Only 1 of 46 lots rejected in North Bengal/Jharkhand during last 5 SIAs

LQAS findings validate monitoring findings from end-of-round surveys

Per

cent

Percent unvaccinated children, End-of-round survey

N= 1,989 4,424 4,193 3,151 3,844 3,946 3,115 3,155

Malegaon Municipal Corporation

# houses with reluctance to accept OPV, End-of-round

Num

ber

3,798

Summary – Areas with recent transmission

• West Bengal (Northern districts): Improvement in SIA quality since September 2010 - sustained over last 9 months – a few pockets of low coverage persist

• West Bengal (Southern districts): Rapid improvement in SIA quality during past 4 months, however quality variable in districts; pockets with gaps in quality remain – require immediate addressal

• Jharkhand: Sustained good quality campaigns over last 9 months

• Malegaon (Maharashtra): Large proportion of unvaccinated children during multiple rounds – recent worsening of quality

Western UPCentral Bihar

Endemic Areas

Continued intensive focus on vaccination in field huts - Kosi area, Bihar

• > 280,000 clusters of field huts (basas) visited by vaccination teams each round

• Intensive supervision and monitoring

Percent unvaccinated children detected in field huts (basas)

~ 3,000 children checked per round

Percent unvaccinated children – end of round survey

West UP

2009 2010 2011

Bihar

2009 2010 2011

~40,000 children checked for vaccination status each round in 107 high risk blocks

High polio vaccination coverage sustained in 107 highest risk blocks of UP and Bihar

66 HR blocks

41 HR blocks

Lot Quality Assurance Sampling (LQAS), 66 highest risk blocks, West UP, June 2011 – A Pilot

SIA round 66 HR blocks

June 2011

# lots accepted 58

# lots cautioned 11

# lots rejected 1

Hypothesis: “The SIA coverage in this LOT is > 95%.”

HR blocks in which LQAS done

Percent households having a child with diarrhea that had received Zinc tablets, June 2011

Source: NPSP SIA monitoring data

1% 22%

Household checked =1,444 Households checked =2,115

Zinc distribution to children with diarrhea 107 highest risk blocks of UP and Bihar

Summary – Endemic Areas

• Intensive series of SIAs conducted with bOPV in endemic areas in first half of 2011

• High coverage during polio SIAs being sustained in the high risk areas of UP and Bihar

• Implementation of certain components of 107 high risk block plan remain a challenge

# children: 0.8 mn in each round

# children: 0.5 mn in each round # children: 1.1 mn

in each round

# children: 0.7 mn in each round

Migrant populations vaccinated 5-6 times (Jan to June 2011)

Areas with high migrants / mobile populations

Delhi, Mumbai, Punjab, Haryana, Gujarat, Uttarakhand, West Bengal

Punjab

Per

cent

Per

cent

N= 3,054 3,725 6,163 8,421 N= 8045,943

Gujarat

537 650 5,454 6,306 5345,988

Delhi

Per

cent

Per

cent

N= 2,608 1,201 2,681 2,802 N= 6,0284,432

Gr. Mumbai

2,218 2,640 2,631 2,611 3,2146,189 8,490 9,366 9,715 5,297 5,320

Percent unvaccinated children, End-of-round survey

11,430 5,503

8046,084

Uttar Pradesh

Bihar

INDIA

NEPAL

~314,000 children vaccinated (April to June 2011)

Vaccination post

Blocks with vaccination post

Continuous vaccination along Indo-Nepal border

81 vaccination posts

Coverage during major religious congregations/ population movement

1. Ajmer Urs (Rajasthan)

22 May to 14 June 2011

~ 300,000 children vaccinated

2. Piran Kaliyar (Uttarkhand): Feb 2011: ~60,000 children vaccinated

3. Holi - returnee migrants (West Bengal, UP, Bihar): March 2011: ~245,000 children vaccinated

4. Planned activity: Shrawani Mela (Bihar & Jharkhand): July – August 2011: ~300,000 children expected to be vaccinated

Migrants sites identification, India – June 2011

Number of sites with migrants identified : 150,000Number of children < 5 yrs in these sites : ~ 4.2 million

Number of sites identified by type

= 10 migrant sites

• Intensive SIAs to vaccinate migrants in high risk states during first half of 2011

• Quality of coverage of migrants variable in different states

• Additional opportunities to vaccinate migrants at congregations, borders being utilized

• National data base of migrant families being prepared

Summary – Coverage of migrants

Conclusions

• Number and scope of SIAs during first half of 2011 conducted as recommended by last IEAG

• Aggressive outbreak response conducted in West Bengal in early 2011

• Endemic areas sustaining high SIA coverage

• Strategy to cover migrants in high risk states and other areas being optimized

• Overall SIA quality in areas with recent transmission improved in 2011, however certain pockets remain a matter of concern

Questions for consideration of IEAG

• What is the optimum number, timing and scope of SIAs between July and December 2011?

• What should be the scope and number of SIAs during early 2012?

• What types of polio vaccines should be used in the SIAs?

Proposed SIAs – India, July to December 2011(As recommended by Nov 2010 IEAG)

SNID

Sep Oct Nov DecJul Aug

Sep Nov

bOPV

SNID

Monthly incidence of WPV1 cases, 2005-2011

0

5

10

15

20

25

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Planned SNID

Planned SNID

Most recent SNID conducted

Thank You