POLIO ERADICATION STRATEGIES

ROUTINE IMMUNIZATION
NIDs (PPIs)
Acute Flaccid Paralysis (AFP) SURVEILLANCE
MOPPING-UP

What is AFP surveillance?
•Detect any case of AFP <>

Standard Case Definition Acute Flaccid Paralysis
Any patient under 15 years of age with acute, flaccid paralysis; or any person in whom a clinician suspects polio.
Onset of paralysis during last six months to be included as a case of AFP.
Plan for covering special population
•Same populations are often missed by the routine as well as SIAs
–Religious minority groups
–Multi-storied building (flats)
– Fishermen colonies
–Pavement dwellers
–Slum dwellers
–People with working hours that do not coincide with team visits
–People living in peri-urban areas
•Identify all such populations and ensure they are included in micro plans for coverage during each round.
Migrant Population

•Construction sites

»Factories
»IT Parks
»Railway gauge conversion
»Road construction
»Bridge construction
»Housing
•Brick kiln, quarry, etc
•Nomads – Narikuravas,

Migratory populations - Actions

•Identification of clusters with migratory populations from Bihar/ UP
•Mapping such areas
•Focus during PPI campaigns
•Plan for special polio campaign during March, 2008
•Plan for routine immunization.

Measles
• Highly infectious

• Transmitted through respiratory droplets or airborne

• Fever, rash, cough, conjunctivitis and coryza

• CFR 0.1% - 10%

• Vitamin A deficiency increases mortality

Clinical features
• Incubation period from exposure to onset of fever is usually 10 days.
• Initial symptoms and signs are high fever, runny nose, coryza, cough, red eyes and Koplik spots (small white spots on the buccal mucosa).
• Characteristic erythematous (red) maculopapular (blotchy) rash appears on the 3rd to 7th day, starting behind the ears and on the hairline and then spreading to the rest of the body.

Case Definition of Suspected Measles
Any person in whom clinician suspects measles infection during last one month(OR)
Any person with fever and rash and cough, coryza (running nose) or conjunctivitis (red eyes) during last one month.

For epidemiological investigation, clinical measles would be a case within last 3 months

Measles death definition
“A death which occurs within one month [30 days] of onset of measles”
– The Global Epidemiology of Infectious Diseases, WHO-2004

Objectives of Measles Surveillance
• Detect and investigate suspected measles outbreaks
• Improve case management of measles cases
• Identify high-risk populations/areas for measles
• Strengthening measles immunization coverage in these areas
• Monitor progress in reduction in measles mortality and morbidity

Operational criteria for conducting extensive outbreak investigation
• > 5 suspect cases of measles in a block in a week(OR)

• > 1 death due to measles in a block in a week(OR)

• > 5 suspect cases in an area bordering several blocks


• Outbreak Flag:
– 5 or more suspected measles cases are reported from one block or contiguous blocks in a week, OR
– 1 or more suspected measles deaths are reported from one block in a week
• Collate information at District level from
– weekly reports,
– AFP Informer network
– Other sources like IDSP/ICMR Measles network etc.

Sample Collection and Transport Kit
• 5ml syringe and needle or Vacutainer tube with 22 gauge needle and adapter
• 5ml externally threaded screw cap vials
• Tourniquet, sterile swabs & band aid
• Gloves
• Uricol disposable bottles
• Specimen labels
• Zip lock plastic bags
• Autoclavable disposal bags
• Cold box with ice packs
• Measles lab request form

Blood sample collection
• Apply tourniquet 2 - 3’’ above elbow, swab the cubital fossa.
• Draw 3-5 ml of blood by venipuncture using syringe
• Discard Needle into disposable bags / needle destroyer. Be careful of needle stick injury
• Push the blood gently into sterile labeled tube. (do not push blood through the needle). Discard the barrel of syringe into auto clavable disposal bags
• Leave the tube at RT for 30mins for clot formation.
• Clotted Blood can be stored at 4-8deg C for up to 24 hours. Do not freeze whole blood
• Fill up lab request: Three dates are important: Dates of last measles vaccination, of rash onset, & collection of sample

Factors responsible for increased rate/severity of complications & deaths in measles
• Young age
• Malnutrition
• Vitamin A deficiency
• Overcrowding
• Immune deficiency (~HIV)

MEASLES REPORTING
• Gross under reporting
v Perception of disease
v Workers perception vs. immunization
v Outbreak response immunization

REPORTING GUIDELINES
Ø All Block PHC will be a reporting unit

Ø All the additional PHCs will send weekly report to the Block PHC every Monday (Form VPD-H002) (2 copies)
Ø All the Block PHCs will send consolidated weekly report VPD-H002 (2 copies) based on additional PHC reports including block PHC area to DDHS office by Tuesday noon
Ø Weekly Hospital report VPD-H002

Global Strategy for sustainable measles mortality reduction
Strong routine immunization of > 90%
Reaching Every District strategy.

2. Provide second opportunity for measles immunization
• One time only “catch-up” campaign (< 15)
• “Follow-up” campaigns every 3-4 years (< 5)
• Integration of campaigns with other priority health interventions
(Vit A, polio, TT, bed nets)
3. Surveillance

4. Improved case management Vitamin A - antibiotics

Cold Chain Maintanance

Cold chain and vaccine logistics
DEFINITION
Cold Chain is a system of transporting vaccine at recommended temperature from
the point of manufacturing to the point of use

ESSENTIALS OF COLD CHAIN
• Equipment
• Power
• Maintenance of Equipment
• Monitoring
EQUIPMENT - ELECTRICAL
• Walk-in-Freezer ( WIF ):. Stores bulk quantity of OPV/Measles & freezes Ice Packs at -20°C.
• Walk-in-Cooler ( WIC ): storage of bulk vaccine at State & Regional stores. Storage Temp. is + 2°C to + 8°C
• Deep Freezers ( DF )
• Ice Lined Refrigerators ( ILR )
In general,
• All Vaccines tend to lose potency on exposure to heat above +80 C
• Some Vaccines lose potency when exposed to freezing temperatures
• The damage is irreversible

Vaccines vulnerable to heat
BCG
OPV
Measles
HepB
DPT
DT
TT
Vaccines vulnerable to Freezing
Hep- B
DPT
DT
TT
Ice cream principle
Colder the better does not hold good for all vaccines
Ice lined refrigerators (ILRs)
• Capacity: 300 & 140 ltrs
• Ideal Temperature: +2°C to 8°C
• Vaccine Storage capacity:
– 300 ltrs stores 60000 doses of mixed antigen
– 140 ltrs stores 25000 doses of mixed antigen
• Safe Storage: Always in the basket section
Deep freezers (DF)
• Capacity: 300 & 140 ltrs
• Ideal Temperature: -18°C to -20°C
• Ice Pack Freezing Capacity:
300 ltrs freezes 40 packs every 24 hours.
140 ltrs freezes 25 packs every 24 hours.

Equipment – non electrical
• Cold Boxes: Placed at State/Region/ DHQ/PHC
• Vaccine Carrier: Placed at DHQ/PHC & sub centres.
• Ice Packs: Placed at State WIF /DHQ/PHC & sub centres.

Cold Boxes
• Type: Insulated boxes of 20 ltrs & 5 ltr capacity

• Usage: Stores & Transports vaccine. Also stores frozen Ice Packs

• Vaccine Layout: Direct contact of frozen Ice packs spoil the vaccine. Give carton spacers/surround vaccine by OPV vials.

• Label Protection: Place vaccine in cartons or polythene bags.

Vaccine Carrier
• Type: Insulated boxes used for carrying small quantities of vaccine.
• Capacity: 16-20 vials
• Ice packs: A maximum of 4 frozen packs
• Vaccine Layout: Keep vaccine clear off direct touch with the Ice Packs

Ice Packs
Water Fill: Do not fill 100%. Leave 10mm room for expansion as water freezes. Condition before use. Do fill the Ice packs up to the marked line.
• Usage: Lowers Temp range for safe vaccine storage. Placed in side lining of ILR to improve & maintain holdover time during electrical failure.
• Best Frozen: In WIF, DF & Ice factories.
Supplies
• Base supplies as per demand & utilization.
• Supply to Districts/PHC after assessing monthly usage & balance stock in hand.
• Districts need to maintain some buffer stock for any unforeseen demand.
• Transport the vaccine in strict cold chain.
• Rotate stocks – “vaccine in first out first”
• Check early expiry date vials & use first.

Vaccine Distribution
• Follow first-in-first - out rule (FIFO)
• Also: first to expire - first out. (FEFO)
• Vaccines are not stored at the sub-centre level and must be supplied on the day of use
• Note manufacturer, batch no., VVM status
• Use VVM stage-II vaccine near the cold chain point (do not distribute to remote areas)
Potency
• T series, Hep B and Hib and diluents should never be frozen.
• BCG, OPV & Measles (light) are sensitive to heat & lose potency fast.
• Potency lost due to heat exposure does not change the appearance of the vaccine.
• VVM is an effective tool in monitoring OPV (and measles) potency.
• Damage to vaccine cannot be reversed by re-freezing.
• Discard frozen vaccine.

Conditioning
• On the session day, take the frozen ice-packs you need from the freezer and place on a table
• Allow ice-packs to sweat at room temperature for some time
• Shake the ice pack to listen to melted for water.

Shake test
• Hold the Control and the Test sample together in hand and vigorously shake the samples
• Place both vials to rest on a flat surface, side-by-side observe them for 30 minutes.
• Compare for rate of sedimentation

Ensure Protection - Protocol
•Searching for undernourished, underweight children among poorer socio economic groups and families.
•Monitoring their growth.
•Underweight, undernourished children to receive measles vaccine at 6-8 months.
•Provide another dose after completion of 9 months of age.
•Asses nutritional status of children infected with Measles.
•Counsel the parents about nutritional inputs, Measles complications, growth monitoring and growth faltering.
•Take follow up visits and ensure protection and proper growth of these children.
Average Height and Weight at different Ages (ICMR (Boys) ).

Biology of under nutrition
•Under nutrition is widely prevalent among socially and economically deprived population groups around the world. Cluster of factors responsible:
-Inadequate income level
-Diets quantitatively and qualitatively deficient
-Poor environment, poor access to safe water
and poor sanitation
-Poor access to health care
-High levels of female illiteracy.

•Nutritional status depends on nutrition's availability at cellular level. Diets providing essential nutrients, Absorptions, utilisation and activity level and environmental factors like infections and stress situations.
•Under 5 constitutes the most sensitive segment of the population from the point of view of nutritional vulnerability.
Growth Retardation
•The minimal role of genetic factor.
•The differences in growth patterns are mostly attributable to differences in their socioeconomic status and not to genetic differences.
•The genetic potential for growth and development is nearly similar among most peoples of the world.
•There is often a linear relationship between the degree of growth retardation and the degree of physical and mental functional impairment.
•In Japan between 1957 and 1977 average mature height increased by 4.3 cm in males and 2.7cm in females. Practically all the height increase was due to increase in leg length, not in sitting height, with the result that within 20 years of economic advancement the entire body proportions of the Japanese had changed.
Child survival
• Regular nutritional assessment of mothers and under 5 is a must on the part of MCH workers.
• If under nourished status of a child is not corrected within 5 years, the child will get stunted.
• It can never be intervened and corrected beyond that age.
• MCH supervisors must become skilled in nutritional assessment and counseling so that they train their workers in the field.
• Child survival will be ensured only when you care to provide all the inputs:
Immunisation
Nutritional inputs
Health care
Female literacy
But where do we stand now?

Strengthening Immunisation (Devices and Desires)

Strengthening Immunisation (Devices and Desires)

Universal Immunisation Programme
•Need for sustaining UIP.
•Require a stronger programme.
•UIP as the most important input for child survival.
•Extensive – 100% fully immunised children
•The above demands fully aware, well informed mothers.
•Commitment on the part of the workers and supervisors.

FACTORS Behind The SUCCESS
• Our Alliance with women nutrition workers
• Energetic, enthusiastic, Free India’s women work force. Workers and supervisors.
• Well designed monitoring and review system.
• Must rededicate ourselves to strengthen the above facets of reality.

STATUS
• Polio free for the past 3 years.
• Indigenous polio transmission free for the past 7 years.
• Neonatal Tetanus Elimination status certification based on:
Ø Immunisation level assessment
Ø District with poor performance identified.
Ø Designed survey
Ø Trained personnel involved.
Ø Certification by WHO

Measles
•Classical childhood communicable disease- High transmission potential.
•Complications – Otitis media, pneumonia,
Diarrhea, post infectious encephalitis, corneal ulceration, ketatitis.
•85% alone among immunised offered protection.
•Undernourished do not develop optimum antibodies and hence may be infected with Measle

Measles and the undernourished
•Measles tends to be very severe in the under nourished child. Complications and mortality chances. Many times more than in well nourished child.
•Measles infection is the single most important factor in faltering in growth of children.
•Undernourished – poor cell – mediated immunity – Measles infection inspite of immunisation – complications of Measles – faltering in growth – cycle.

Medical Audit

1. Medical Audit
   AUDIT
   Official Examination and Verification of Accounts or Dealings
   
   Medical Audit
   Evaluation of Medical Care through retrospective analysis of Medical Records or prospective follow up of patients suffering from a particular disease by treating doctors and his team.
   
   Pre Requisites of Medical Audit
   To be carried out by fair and impartial clinicians who are thoroughly conversant with the current practice of medicine. The impetus must come from the Medical staff themselves, realising the benefits to the patients and themselves. A good system of Medical Record keeping preferably with a trained medical record Librarian. Well defined disease related criteria.
   
   Process of Medical Audit
   Retrospective
   Analysis of the records of the discharged patients
   Finding out the deficiencies, errors, omissions and commissions on these.
   
   Prospective
   To Ensure that the management of individual case on a particular diagnosis conforms to the prescribed standards.
   A group of patients suffering from a disease is followed up by treating doctors and his team.
   Criteria Development
   Step 1.
   Selection of the Diagnosis to be studied by audit or utilisation committee.
   Step 2.
   Develop the criteria
   i) Indicators for admission
   ii) Hospital services recommended for optimal care
   iii) Range of length of stay and indicators for discharge
   iv) Complications as a result of treatment procedures.
   
   Medical Audit of Infant Death
   Line listing of all cases
   Case investigation from against medical advice (AMA) discharge cases should also be investigated.
   u Verbal Autopsy at field level
   u Verbal determination of the non-clinical causes of death.
   u Verbal reporting of background characteristics
   u Medical Audit at institutional Level
   Analyse the information collected
   Find out the Medico Social cause
   Discuss with staff and community members to prevent such deaths in future.