WHO

This presentation contains

• Current Epidemiology
• Impact & future strategy in regard to current
epidemiology
• What is AFP Surveillance
• Why AFP Surveillance
• Role of Medical Officer & DIO in AFP Surveillance
•

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 WHO

Current Scenario

2|
 WHO

Polio type 1

3|
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Polio type 3

4|
Impact of polio eradication initiative
 Impact of Polio Eradication WHO

Strategies
Time from 1st NID to last indigenous virus*
The average time to
interrupt indigenous wild
poliovirus has been 2.5
years

Remaining endemic
countries as of 2002

* excluding Americas & countries 'endemic' in

6 | 2007: Afghanistan, India, Nigeria, Pakistan. 6
 Impact of Outbreak Response Tactics

2006

10 of 13 re-infected
countries are again polio-
free.
2007
circulating imported virus,
2006

Continuing
7
Newoutbreak
importation,
 WHO

Program Follow-up

• Maintained focus on stopping WPV1

• Control of WPV3 outbreaks
• Greater emphasis on improvement of SIA quality
in high-risk blocks of Bihar
• Mopping up
• Continued focus on young children - identification
and tracking of newborns
• Attention to surveillance and laboratory timelines
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 WHO

Mean Number of days from Paralysis Onset to ITD

Result for Samples with WPV
New algorithm
implemented

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 WHO

Polio type 1
Uttar Pradesh (UP)

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 WHO
In 2007, immunity in UP rose above the levels that
stopped type 1 in the Rest of India

Direct protection by vaccination

against type 1 polio among children
aged 0-4 yrs 2001-7
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 WHO

Summary: WPV1 in UP
2007-2008
• West UP: Until the Badaun case in May, 20 of 24
districts were free since Nov 2006, all districts free
since August 2007 – longest period ever
• All UP:
– Highest levels of immunity to WPV1
– Transmission likely stopped in late 2007
– Recent 7 cases in and adjacent to Badaun district
following importation from Bihar

12 – Risk of spread to other districts in West UP

 Genetic linkages – 2008 WPV1 WHO

WPV1 – 2007
WPV1 – 2008
WPV1 – Sewage 2008
12 of the 13 WPV1 isolates in 2008 are linked to WPV1
circulating in Bihar

13
 WHO

Summary : WPV1 in Bihar

• 57% of cases in high-risk blocks, 96% including

adjacent blocks in 2007
• Continued low level WPV1 transmission in high-
risk blocks
• High-risk blocks in central Bihar main source of
WPV1 in 2008
• Intensified SIAs being implemented with the goal
to stop WPV1 transmission before the end of
2008 which is the top program priority
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 WHO

Polio type 3

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 P3 polio cases, India
2005
2004 2006
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346
 WHO

Summary WPV3
• WPV3 outbreaks have declined

• mOPV3 appears to have been effective in

curtailing WPV3 transmission

• Most WPV3 cases are in areas of UP and Bihar

with less than 3 mOPV3 rounds

• Data indicate that WPV3 transmission can be

interrupted with more aggressive use of mOPV3
17
AFP surveillance
 WHO

Poliovirus
• Belongs to genus:
Enterovirus, family
Picornaviridae.
• Made up of single
strand of RNA
• Three well defined
serotypes: 1,2 and 3
– all types cause
paralysis
– Type 1 most
frequent

19
 WHO

AFP (Acute flaccid Paralysis)

ANY CHILD AGED <15 YEARS

WITH SUDDEN ONSET OF
WEAKNESS AND FLOPPINESS
IN ANY PART OF BODY
DURING LAST 6 MONTHS

Or paralytic illness in person of any age in

whom polio is suspected

20
 Assumptions About Polio WHO

Prior to Eradication Program

• Highly contagious
• Vaccine-induced immunity short-lived
• High vaccination coverage needed to meet herd-
immunity threshold

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 WHO

Pillars of Polio Eradication

• Strong Routine Immunization Program – High uniform

coverage with OPV
• Supplementary Immunisation Activities-SIAs
• AFP Surveillance – to detect polio virus/ transmission/
polio cases
• Mop Up – intensive immunization campaigns in the last
remaining foci of transmission

22
 WHO

Enhanced Surveillance

• Individual case investigations

• Vaccination status
• Laboratory confirmation
• Highly specific case definitions

23
 WHO

Factors Influencing Polio Spread

• Temperature/Humidity – Lower temperature/humidity,

higher viability
• Intensity and duration of contact
• Length of contagious period
• Personal hygiene practices

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 WHO

Spread of Polio in Community

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 WHO

26
 WHO

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 WHO

Clinical Outcome of Poliovirus Infections

Paralytic poliomyelitis 0.5-1%

Clinical illness, no paralysis 8-10%

Asymptomatic infection 90%

Paralysis is unusual manifestation of infection

Spinal Bulbospinal Bulbar Encephalitic

85-90% 10-15% <1% Rare

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 WHO

Chain of Transmission

Source Index
Case

29
Sub clinical
 WHO

Herd Immunity
Sustained
transmission

Transmitting Susceptible Transmitting Susceptible

case case

Transmission
terminated

Transmitting Immune Susceptible

Case (A) (B) (C)
(Indirectly
Protected)

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 WHO

Principle of AFP Surveillance

Identify children with the SYNDROME of Acute Flaccid Paralysis
AFP is not a diagnosis
– Different diagnosis can present as acute, flaccid, paralysis.
– We report AFP cases irrespective of diagnosis
– Purpose of reporting is not diagnosis for treatment but to know whether
there is transmission of the Polio virus in the area where the child
resides.
– Confirmation is by stool collection for Polio virus isolation at WHO
accredited laboratories

31
 WHO

Why AFP must be reported

polio reporting alone is not sufficient

 Clinical diagnosis may not be immediately apparent or

may be inaccurate.
 Atypical presentations of polio
 Detection of the poliovirus in AFP cases that do not look
like polio clinically.

32
 Why AFP cases must be WHO

reported immediately
 collection of stool specimens should be
within 14 days of disease onset
 case investigation should begin before
the patient leaves hospital/village
 response activities require planning and
must begin soon

33
 WHO

AFP Surveillance System

Reporting unit SMO/DIO
AFP case
Informer unit
Polio/ Compatible or Non polio
Case Investigation
Final Classification
At NPSU
Stool result Stool Collection<14 days

or
Stool Shipment to Lab
Special tests for expert Group Stool collection>14 days

34
 WHO

Role of Clinicians
in
AFP Surveillance

35
 WHO

Acute Weakness/paresis/paralysis

• Upper Motor Neuron.

• Lower Motor Neuron

• Myopathic

36
 WHO

Pattern of weakness
Sign UMN LMN Myopathic
• Atrophy - +++ +

• Fasciculation's - +++ -

• Tone +++ - +/-

• Distribution Regional Segmental Proximal

• Tendon reflexes +++ -/-- +/-

• Babinski’s sign + - -

37
 WHO

How to differentiate Electro

physiologically

• Spinal Cord ( Transverse Myelitis/ Ascending Myelitis)

• Nerve Roots ( Predominant Motor Radiculapathies/ GBS
& mixed sensory motor{post Infectious}
• Anterior Horn Cells( Acute polio, toxins & Neural
degenerations MMND)
• Peripheral Nerves( traumatic Neuritis, post infectious &
Toxin Induced)
• Muscles it self(Acute Myopathies & AC AMG)

38
 WHO

Clinical dilemma…..
• Polio Vs other causes of paralysis
– Issue resolved by having surveillance of all cases of
flaccid paralysis
• AFP Vs Borderline AFP
– How to resolve it?
Solution: Investigate borderline cases too!!
• Include every case, if currently the child has flaccid
paralysis or if there is history of flaccid paralysis
• If in doubt, include the case…
This will help in increasing the Surveillance sensitivity

39
 WHO

Transverse Radiculapathies
Myelitis
Traumatic neuritis Other enteroviruses

Acute flaccid paralysis

Coxsackie virus Echovirus

Guillain-Barre Syndrome Poliovirus

40
 WHO

When too much polio is around…..

Surveillance
sensitivity is
True AFP cases
adequate
Polio cases enough to
Non-AFP cases detect 90% polio
cases
Borderline/ambiguous AFP cases
41
 WHO
When transmission is very low…..

If stool is Surveillance
collected sensitivity is
from not good
borderline enough &
or detects only
ambiguous 50% polio
cases… cases

Sensitivity
increases
and leads
True AFP cases to nearly
Polio cases 100%
detection
Non-AFP cases of polio
Borderline/ambiguous AFP cases cases
42
 Virological AFP Case Classification Scheme WHO

Wild Polio Virus Confirm

Compatible
Expert
Review

AFP CASE Residual Discard

Inadequate Weakness, Died
Specimen or lost to FUP

No Residual
Discard
No Wild Polio Weakness
Virus

2 Adequate Specimen Discard

43
 What is Expected from you… WHO

 Report all cases immediately –

 Whom to report ? - Nodal person & SMO / DIO
 By what means ? - Phone ( 240155/ 9416076066 – Dr.
Mahipal DIO Sirsa // 276593/9416038593,Dr. Kailash, SMO WHO
Unit Hisar)
 What information ? - Name A/S, Bed no./Ward
 If for any reason child cannot be admitted or treated in OPD,
take complete address of child including
 Name of grandfather, Caste
 Landmarks
 Village/mohalla
 Block/ District
 Telephone no
 Admit the case to facilitate Investigation & stool Collection.
 Arrange for stool collection ASAP.

44
 AFP Reporting network WHO

Reporting units Informers

• Reporting network consists of govt. and private

hospitals, health centers, medical practitioners,
traditional healers, temples etc.

• Total of 29,932 reporting sites

• 107,000 visits made to reporting units by SMOs during

2007

• 10,675 units reporting every week, including zero

reports
10,675 reporting units 19,257 informers

45
 WHO

Surveillance Indicators

• Developed to assess the quality of national surveillance

• The ability of our surveillance system to identify all
cases*
• Assess investigative effort and the completeness of
epidemiologically important surveillance data

46
 Surveillance Indicators for WHO

Polio
• Indicator

• % of cases reported within 10

days of onset of paralysis

• % of cases investigated within 48

hrs of notification

• % of reported cases with 60-day

FU, wherever required

• % of reported AFP cases with

completed case investigation
47 form
 WHO
Overall indicators and targets
“Gold standard” of AFP surveillance

• Number of non-polio ≥ 2 case per 1,00,000

AFP cases reported children under 15
yearly years of age

• % of AFP cases with ≥ 80%

2 adequate stools

48
 WHO

Issues

• Reporting of cases
• Interest in national health program
• Completeness of CIF
• Active case search in community , Reporting site
• Clinical examination of case
• Feed back to patients relatives

49
Role and responsibility
 WHO

Case Investigation & Stool

Tracking
• Personally investigate all AFP cases d to ASAP &
l ea
within 48 hrs of notificationain can
ch s , ion
• HtH search must be carried ol d
s e
out by t
ic ANM /
a
rse
c
C a Er
a d
MPHW for additional f rev AFP
e
l i o cases,
pol i o
following
report of an tAFP e o
case,P o for
phfrom an area.
nc i c
ena d
e atas r o
ain
• Stool collection
m s
is should
t
be initiated without
oor M bec
P
waiting for case ould investigation.
i c hc
wh
• Person designated for stool collection changes
ice packs every 24 hrs, till shipment to Lab.
• All stool samples must reach Lab within 72 hrs
of 2nd stool collection.
51
 WHO

Records in DIO’s office & RUs

• List of reporting units/informers
• Copy of all Hospital weekly reports (H002)
Surveillance
• Timelinessis of a function
hospital of (D002)
reports state govt.
• Copy of all district &weekly reports (D001)
• Active Case Searches done (D003)
Documentation
• All CIFs (updated) and LRF is must
• for Certification
Updated line-list of Eradication
• Copy of lab receipts
• All AFP/wild virus/compatible cases plotted
on a district map
• Poster, Weekly Surveillance Calendar and
Feedback forms
52
 WHO

Summary
• AFP is a Public Health Emergency.
• AFP is a notifiable disease as per GoI guidelines
• AFP reporting helps Patient, Clinician & Nation
• PE programme is based on quality AFP Surveillance &
Your role is critical.

53
 WHO

3 regions are now polio-free

Americas
Last case
Peru 1991
Lets Give it a Final
Push , ‘IndiaWestern
willPacific
DO it’
Last case
Cambodia 1997

Europe
Last case
Turkey 1998 4
54
 NPSP - WHO

Thank you…