Global eradication of poliomyelitis

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Global eradication of poliomyelitis
130 days

• Key elements for
• improving SIA

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Strategies for Polio Eradication

• Strong routine OPV immunization
• programme
• National Immunization Days (NIDs)
• Acute flaccid paralysis surveillance
• "Mopping-up" immunization (H-H)

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Objectives of NIDs

• To immunize ALL children under 5 with a
  supplementary dose of OPV during 2 nation wide
  rounds with 4-6 weeks interval.

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Strategies of SIA
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Polio Eradication Progress, 1988-99
350,000 cases

6,000 cases
Polio Eradication
as of 31 Jan 2000
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Acceleration of the PEI

• More NIDs / rounds
• India in 1999 and 2000 4 rounds nation-wide plus
  2 rounds SNID (50)
• DR Congo 3 rounds in 1999 and 2000
• Angola 3 rounds in 1999 and 2000
• Mop up in addition to NIDs
• Nigeria
• Ethiopia
• Bangladesh
• Pakistan 3 rounds in 1999 and 2000
• House to House strategy in several countries

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The Problem

• Persistent circulation of wild polio virus even
  after several consecutive years of NIDs.
• the quality of supplementary immunization (NIDs
  and SNIDs) is not consistently high.
• some areas or groups may have low coverage or be
  entirely missed.
• wild poliovirus still circulates in these pockets
  of unimmunized children.

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Experience in NIDs is NOT in itself a guarantee
for quality !!!
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Key elements for improvement

• General planning (including funding)
• Strategic choices
• Micro planning
• Logistics (fast chain)
• Monitoring
• Supervision
• Social mobilization

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Key elements for improvementGeneral planning (1)

• Plan timely (including for funds)
• From the beginning make a work plan and time
  table with
• Tasks
• Person(s) in charge
• Deadlines
• Critical progress indicators
• Share work plan with other levels and request
  theirs for harmonization

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Plan timely !!!
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Key elements for improvementGeneral planning (2)

• Adequate balance between national leadership and
  delegated responsibility to the district
• Specific national responsibilities
• Initial plan, dates, budget, etc.
• Monitoring al all levels
• Feed back and information to all levels
• Final evaluation
• Specific sub national responsibilities
• Micro planning
• Sub national monitoring
• Feedback and information to national and lower
  levels

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Ensure commitment consensus and involve other
sectors

• National authorities
• Major partner agencies
• Other government departments
• Private Sector
• Religious Sector
• Schools
• Communities

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Key elements for improvementStrategic choices

• Targeting NID
• increased emphasis on the planning, preparation,
  and conduct of immunization for areas or groups
  at high risk of ongoing wild poliovirus.

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Choose appropriate strategies

• Increase number of fixed posts
• Moving posts
• Mobile teams
• Railway/bus station teams
• Extra days to immunize children
• House-to-house immunization

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Key elements for improvement House to House
Immunization

• Objective
• To administer within the households a
  supplemental dose of OPV to all children under 5
  years of age in identified areas where the wild
  polio virus is still circulating, or where this
  is suspected

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What are the differences?
Children go to the post
The team goes to the children in the household
In both strategies, the objective is to immunize
all children under 5
150-300 children immunized/team/day
40-150 children immunized/team/day
Usually 2-3 days
May be up to a week
Teams of 2-4 persons
Teams of 2 persons
Community involvement and MP indispensable
Community involvement and MP important
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Key elements for improvementMicro planning (1)

• Special attention to risk areas
• Proven polio transmission
• Silent areas
• Low routine/NID coverage
• Low access to health services
• Populations with difficult access
• Areas bordering endemic zones
• Displaced populations
• Immunize each and every child available data on
  target populations are mere guides, and not
  maximum objectives

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Key elements for improvementMicro planning (2)

• For each team
• Maps and itinerary for catchment area per team
• Clear instructions how to deal with children not
  found at home
• Use knowledge of local conditions, geography,
  working hours (when are people home), culture...

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Itinerary team 1
Cattle camp
Compound
River
Chief
Police
Team 2
School
Store
Market
Bus stop
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Vaccination Teams H-H

• Each team is composed of 2 members
• Vaccinator
• Record-keeper/guide

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Market
Day 1
Day 2
Church
Supervisor
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Elements needed for each vaccination team

• Sufficient OPV with VVMs
• Vaccine carrier with frozen ice-packs
• Tally sheet to record
• - houses visited
• - doses OPV administered
• - cases AFP found
• - zero dose children
• Means to mark houses visited
• Hand written map of the area to cover/day

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Key figures
How many vaccines?? Population x Percentage
target population x Wastage x Number of rounds 1
000 000 x 0.17 x 1.25 x 2 425 000 doses
Operational unit is the household 5-6 persons/hh
How many teams?? Fixed, Urban 200 - 300 children
per team per day Fixed, Rural 100 - 150
children per team per day House to house, Urban
80 - 150 children per team per
day House to house, Rural 40 - 60 children per
team per day
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Do you really Reach the Unreached?
Example NIDs Tally Sheet
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Do the teams cover

• Markets?
• Stations?
• Slum areas?
• Housing areas with mobile/itinerant pops.?
• Remoter areas?
• The top floor of apartment buildings?
• Areas with poor road access?
• Islands?
• Areas where population often unreached?

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Should the cold chain be an obstacle?
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Key elements for improvementCold chain (2)

• Reaching hard to reach populations
• Distance
• Accessibility
• Seasons
• Weight and volume of equipment
• Cold chain
• Freezing and storage capacity
• NID cold chain over-sized for routine
• Costs
• Health workers
• 20 years EPI modules
• No ice, no move

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OPV unstable, but it can be monitored

• Vaccine Vial Monitor (VVM)

WHO STANDARD OPV 48 HOURS AT 37 C
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VVM specification

• The VVM should reach the discard point after
• 2 days at 37C
• 7 days at 25C
• 180 days at 5C
• The expiry date has priority over the VVM!!

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VVM Experience from the field (vaccine carrier
E4/83-M)
VVM good
VVM bad
days
Icepacks melted
VVM at discard point
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VVM specification
The absence of ice is not a reason to interrupt
immunization

• The VVM should reach the discard point after
• 2 days at 37C
• 7 days at 25C
• 180 days at 5C
• The expiry has priority over the VVM!!

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The fast cold chain
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Key elements for improvement Supervision

• At all levels
• Number of supervisors
• Urban 1 for 10 teams
• Peri urban 1 for 8 teams
• Rural 1 for 5 teams
• Identify and pay extra attention to risk areas
• See criteria on micro planning slide, plus
• areas where teams do not like to go
• Ensure mobility
• Supervisory forms

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Key elements for improvement Monitoring

• At all levels
• Independent and impartial
• monitoring staff not from the same home area
  but from different regions and levels (higher
  level monitors lower)
• Define, identify and pay extra attention to risk
  areas
• Rapid assessments
• quick and dirty
• targeted at suspected areas

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Key elements for improvement Social mobilization

• Involve all relevant partners at all relevant
  levels
• national (president), regional and district
  authorities
• religious leaders
• community associations
• Use regionally appropriate materials
• Continue mobilization during the NIDs
• loudspeakers
• Mosques, churches
• Artists
• Radio and television

Do not respect long established rules start in
time!
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• In the end surveillance is the only true
  indicator for success.

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Evaluation and monitoring

• Tally sheets simple and action oriented
• Number of children immunized rather than coverage
  
• Coverage surveys, a hot issue
• Unreached populations

Information for action, rather than .. !!
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H-H in Nigeria
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Good luck
127.7 days !!
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(No Transcript)
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Consider using the fast chain for your routine.
It allows immunizing remote people without fixed
CC.
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Establish planning structure responsibilities
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Polio Last Cases
Americas Region Luis Fermin Tenorio Peru 1991
Who's next??
Polio Eradication
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10 global priorities for eradication
Polio Eradication
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Steps for Planning Targeted NIDs

• Select high risk areas
• Make maps
• Estimate population under 5 yrs
• Select additional strategies to reach the
  unreached
• Make logistics resource calculations
• Obtain extra funds people
• Provide extra training for health
  workers/volunteers
• Ensure quality social mobilization supervision

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Key elements for improvementCold chain (1)

• Cold chain
• storage, freezing and transport quantity and
  quality
• Supplies
• vaccine
• equipment
• distribution plans
• Organization of the site
• access and visibility
• layout
• user friendly

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Simple map to show main features and plan
activities
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It takes courage to review ALL elements of your
strategy in the light of unsatisfactory results
Experience in NIDs is NOT in itself a guarantee
for quality !!!