26 May 2000, NPSP, JNU Stadium, New Delhi
The third meeting of experts was convened on Friday, 26 May 2000 at the NPSP to:
1) Review the status of polio eradication in India
2) Review the implementation of polio eradication strategies, with special attention to the quality of implementation
3) Review the status of the global OPV supply
4) Provide recommendations for the MOH & FW as needed for supplementing immunization strategies in India for the autumn and winter of 2000 and spring of 2001.
The participants were :
- Dr. R.N. Basu, Chairperson
- Dr. Bruce Aylward
- Dr. Stephen Cochhi, Rapporteur
- Dr. Stephen Atwood
- Dr. T. Jacob John
- Dr. N.K. Ganguly
- Dr. Swatu Bhave
- Dr. Harsh Vardhan
- Prof. Ranjit Roy Choudhary
- Prof. Lalit Kant - unable to attend
- Dr. Jon Andrus, Chairperson
- Dr. Kaushik Banerjee
- Dr. Brent Burkholder
- Dr. Arun Thapa
- Mr. Reza Hossaini
- Mr. John Gilmartin
- Ms. Shanelle Hall
- Ms. Vidhya Ganesh
- Mr. Carl Tinstman
- Mr. Graham Sale
- Mr. John Fitzsimmons
Dr. R.N. Basu, who served as Chairman opened the meeting; Dr. Stephen Cochi served as rapporteur.
Dr. Andrus welcomed the participants, and Dr. Basu recapitulated the proceeding of the two previous meetings and gave on overview of the objectives of the meeting. The absence of Government of India participation was noted and participants expressed the need for Government of India, as the major and leading partner, to be also present in deliberations such as these.
Following introductions, global and regional progress on polio eradication was reviewed. The impact of India's 4+2 strategy conducted during October 1999-March 2000 was discussed. This was followed by a review and discussion of the global situation of supply of oral polio vaccine (OPV), and a presentation by the IAP on its recommendations.
Globally, reported cases have declined from an estimated 350,000 cases in 1988 to 9,071 in 1999 (as of 11 May 2000). Wild poliovirus transmission is now limited to the South Asia sub-continent, sub-Saharan Africa, and parts of the Middle East, halland appear to have reached "0" polio virus and wild virus circulation is now confined to India, Nepal, Bangladesh, and along the Myanmar-Bangladesh border zone. Global TCG in 2000 confirmed there is overwhelming evidence that the existing strategies for polio eradication work but sub-optimal quality of implementation have compromised their impact.
Polio-endemic countries have implemented enhanced polio eradication strategies consisting of accelerated supplementary immunization activities including additional rounds, especially in the other global polio reservoir countries of DR Congo, Angola, Nigeria, Pakistan, and Ethiopia. The global target date for interruption of transmission by the end of 2000 has not changed, although it is likely that up to 15-20 countries will not meet this target on time. Nonetheless, extraordinary progress toward polio eradication is occurring in all of the three remaining WHO regions still endemic for polio.
In India, transmission of polio has been dramatically reduced from 1942 laboratory confirmed cases in 1998 to 1160 in 1999 and 70 cases (as of 11 May 2000) n the first quarter of 2000. Of the 70 cases in 2000, 34 are in UP (31P3, 3P1); 28 in Bihar (25P3,3P1); 1P1 each in Gujarat and Karnataka; 2P3 each in Maharashtra and Madhya Pradesh; and 1P3 each in West Bengal and Haryana. Wild poliovirus type 2 was isolated in Uttar Pradesh and West Bengal in 1999, making India the only known reservoir of type 2 wild virus that year. However, wild virus type 2 has not been isolated since October 1999. In 1999, a large P3 outbreak occurred in Uttar Pradesh. In late 1999 and early 2000, the neighboring states of Delhi and Bihar also reported an increase in wild P3 associated cases.
India continued to sustain its excellence in AFP surveillance in 199 by achieving a non-polio AFP rate of 1.84 per 100,000 children aged less than 15 years, improving on the 1998 non-polio AFP rate of 1.40 per 100,100 children aged less than 15 years. This achievement has occurred in the majority of districts nationwide. Thus AFP surveillance is now able to accurately define the extent of wild virus transmission in India. In the first quarter of 2000, the stool collection rate for the country has exceeded 80% for the first time ever.
India completed its 4+2 strategy with the second round of intensified SNIDs in the eight high-risk states in March 2000. The conclusions drawn include the following:
While the impact of implementation of India's 4+2 strategy cannot yet be fully assessed given that the country is only now heading into the high transmission season, nevertheless, three distinct epidemiologic zones are emerging in India. The southern half of the country is an emerging polio-free zone. The second zone consists of a band of States in the middle of the country with only 7 wild virus-confirmed cases reported from 5 States so far in 2000 (as of 13 May). The third zone is the northern belt of 4 densely populated States comprising Delhi, Uttar Pradesh, Bihar and West Bengal continued to have intense virus transmission.
The global OPV supply situation continues to be of concern.
Recommendations
Having noted the remarkable progress in India, the Religion, and the Globe, and considering the differential progress within India and the availability of vaccine and other intra-country factors, the participants reached a consensus on the following recommendations. They incorporate some of the recommendations that the Indian Academy of Pediatrics presented during the meeting.
1.
2.
(a) One round of SNIDS in the high burden zone states (Delhi, Uttar Pradesh, Bihar, and West Bengal) starting in September, followed by one round of SNIDS in the high and mid-burden zones (4+7), followed by NIDs in December and January, with a maximum 6 wk. Interval between each round.
(b) The option would be to shift the first SNIDs in the 4 HBZ states from September to October and complete the rounds as in (a).
(c) The contingency (in case of delays in vaccine supply) would be to conduct the first SNIDs in November in the 4 HBZ states followed by one round of NIDs each in December 2000 and January 2001, followed by one SNIDs in March in MBZ and HBZ states (4+7).
3. Additional SMOs should be recruited to assist in strengthening AFP surveillance in weak performing areas, rather than to continue the practice of shifting existing SMOs from high performing areas.
4. The NIDs should be conducted using the combined fixed post and house-to-house approach. Attention should be given to ensuring the quality of immunization by increasing the house-to-house from 3 days to 7 days, and ensuring the full participation of other government sectors, including the defence, security and education services. The low burden zone may not require house-to-house immunization.
5. The SNIDs in the four high burden states should be fixed post followed by extensive house-to-house with attention to quality as mentioned in recommendation no. 4 and will apply to all four rounds.
6. Aggressive mop-ups of high-quality should be conducted in the states that comprise the middle and low burden zones in 2000.
7. To ensure the estimated 620m doses of OPV required for the supplementary immunization activities between September and January 2001 is available on time, the Government of India and Unicef should:
(a) Request that Indian suppliers provide by June 2000 a guaranteed delivery schedule for their 2000 production projections,
(b) 60m doses of the OPV procured through Unicef and delivered to India during the summer of 2000, be earmarked and set aside for use only during the fall/winter SNIDs and NIDs.
(c) Prepare for the rapid release and distribution of up to 80m additional doses of internationally procured OPV that would need to be delivered in the 1st week of January for use in the last NIDs round at the end of that month.
8. Micro-planning is critical for successful implementation of polio vaccination campaigns. Successful implementation of micro-plans requires widespread use of mapping in high-risk areas and logistic and financial support for completion. Lack of funds should not impede successful development and implementation of micro-plans.
9. Special efforts and investment should be made in intensifying EPI activities in all HBZ states between June and the first SNIDs.
10. The government of India should begin now to coordinate with Nepal and Bangladesh synchronized immunization days in bordering districts for each of the rounds in UP and Bihar.
11. The government should develop a contingency plan of action in the event that transmission continues into 2001, which would include having sufficient vaccine for aggressive mopping-up campaigns.
In 28 states, these strategies should lead to interruption of wild virus transmission by end of the year 2000. In the remaining 4 high-burden states, the risk of continued transmission is wholely contingent on the quality of supplementary activities conducted in 2000. Data from India, the Americas, and the Western Pacific have shown this level of quality can be achieved through a house-to-house or child-to-child approach to supplementary immunization.