NPSP – Structure and Function

National Polio Surveillance Project - India

Past to the Present

• 1997– NPSP created as a WHO-GoI collaboration– 57 Surveillance Medial Officers (SMOs) for

Acute Flaccid Paralysis (AFP) surveillance

• 2012– 339 SMOs– AFP surveillance, Supplementary

Immunization Activities (SIA) assistance, Research, Routine Immunization (RI) and measles

Structure of NPSP

• National Polio Surveillance Unit (Delhi)

• Field staff (regional team leaders, sub regional team leaders, SMOs, Administrative Assistants, drivers)

• Field Volunteers and External Monitors

The National Polio Surveillance Unit

• the country HQ of the project

• provides

– technical support to the MOHFW

– technical, administrative and logistic support to the field staff

– support to the lab network

WR – India

Nata Menabde

WHO INDIANATIONAL SURVEILLANCE PROJECT

Project Manager

Hamid Jafari

Deputy Project ManagerOperations

Virginia Swezy

Deputy Project ManagerUIP

Stephen Sosler

Routine Immunization&

Measles Team

Finance&

AccountsTeam

Senior Technical Advisor

Sunil Bahl

1. Surveillance2. SIA3. Data4. Research

Polio Team

Regional Team Leaders

( 7 )

Field Units

RAFFPs

( 10 )

Planning Officer

Kudzai Chisewe

HR&

PersonnelTeam

Admin.

Team

The Field Offices

• led by the Surveillance Medical Officer (SMO)

• one administrative assistant and one driver

• typically located in government premises

• holder of imprest accounts for managing expenses

NPSP Field Staff

• Currently over 384 medical officers (SMOs plus Regional, Sub-Regional Team Leaders and Officers on Special Assignment)

• Average no of districts covered by one SMO now:

• UP and Bihar: 1 per district

• West Bengal/Jharkhand: 1 to 3 districts

• Rest of India: ~ 5 districts

(7 Regions)

Average no of districts covered by one SMO now:UP and Bihar: 1 per districtWest Bengal/Jharkhand: 1 to 3 districtsRest of India: ~ 5 districts

MO Locations, India

8Labs

339SMO’s

38SRTLs/ OSA’s

7RTL’s

Positions

274 locations

WHO / NPSP Structure

National Polio Surveillance Unit

Regional Team leader

Sub-regional Team Leader

Surveillance Medical Officer

National

Regions (1-7 states)

Sub-regions

District (<1-11 districts)

Blocks, in HR areas“Field Volunteer”

Main Functions

• High quality Acute Flaccid Paralysis (AFP) surveillance

• Technical support to mass polio vaccinations campaigns - supplementary immunization activities (SIAs)

• Research activities for refinement of polio vaccination strategies

• Monitoring SIAs and Routine Immunization

• Measles Surveillance and SIAs

Acute Flaccid Paralysis Surveillance Reporting Network

Reporting site

N=35,824

*Data as on 10 February 2012

• Reporting network consists of govt. and private hospitals, health centers, medical practitioners, traditional healers, temples etc.

• More than 151,000 visits made to these reporting sites for active case searches by the SMOs during 2011

• Nearly 2000 training workshops on surveillance conducted by SMOs in 2011 – 70,000 people trained

Kasauli

Delhi

Lucknow

Ahmedabad Kolkata

Mumbai

Bangalore

Chennai

National labs

Upgraded national labs

Reference lab

India Poliovirus Laboratory NetworkAcute Flaccid Paralysis Surveillance

Laboratory Network

•Children vaccinated: 172 million

• Houses visited: 220 million

•Vaccinators deployed: 2.3 million

•Supervisors: 150,000

National Immunization Days (NIDs)

Polio SIAs in India – a massive effort

• Developing guidelines

• Refining strategies for reaching children during campaigns – newborns, resistant families, migrants, hard to reach areas etc.

• Building capacity of government staff and vaccinators through ongoing training

• Monitoring campaigns to support corrective actions

Support to polio immunization campaigns

Some recent initiatives based on epidemiological analysis provided to the programme

> 1 million children vaccinated(April to December 2011)

Multipronged strategy for 107 high risk blocks in UP & Bihar

Overcoming challenges of access in Kosi river area of Bihar to reach the unreached Mitigating the risk of importations

Identifying, vaccinating and tracking all new borns for polio vaccination

Monitoring SIAs

• Independent monitoring system

• 3500 monitors across India (2000 of these in UP and Bihar) – SMOs and field volunteers of WHO-NPSP– Monitors hired locally by SMOs for the duration of the campaign– WHO staff

• Scope of monitoring in UP and Bihar: – 420,000 houses checked (1% of total houses) each round– 11,000 vaccination teams checked (8% of total teams) each round– 680,000 children checked (1% of total children) each round

• Daily feedback to supervisors and block medical officers at block and to CMO/DM at district during evening meetings

• Rapid survey at the end of the round to assess the overall coverage in the area

• Data generated through WHO-NPSP monitoring is used by the state, district and sub-district governments to improve quality of polio campaigns

Monitoring SIAs

% unimmunized children in field huts in Kosi riverine area

Source of data : NPSP monitoring

Coverage in field huts of Kosi area, Bihar

2008 2009

~ 3,000 children checked each round

2010 2011

Supporting Research for Polio Eradication

• Vaccine immunogenicity studies- Best vaccines • Sero-prevalence studies- Population immunity levels• Mucosal immunity study- Immunity levels & vaccines to boost it• Product development (IPV studies, vaccine delivery techniques)• Operational researches planned

Informed program decisions:• Switch from tOPVs to the use of mOPVs and bOPVs• Monitor the seroprevalence against polio in the HRAs• Strategize for polio “end game” and post eradication approach (Type of vaccines, RI schedule)

W.H.O.• Surveillance

• Operations

• Monitoring

UNICEF• Vaccine

• Communication

• Monitoring

Rotary• Advocacy

• Communication

• Fundraising

GoI Polio Partners

Expanded NPSP support to GoI and States

National-level Policy and strategic formulation, standards and norms

– Development of national guidelines – measles outbreak surveillance, RI monitoring, Hepatitis B and Hib-pentavalent vaccine introduction, AEFI surveillance, measles catch-up campaigns

– Participation in National Technical Advisory Group on Immunization meetings

Immunization curriculum development for Medical Officers and Health Workers

Operations research in key programme areas

State and district level Harmonization of polio and RI microplans Expansion of measles outbreak surveillance and laboratory

network Support for VPD surveillance introduction in select states Program monitoring, data management, analysis and feedback New vaccine introduction support and training

Improving and expanding RI monitoring

Methodology revised in 2009

Initially rolled out to UP, Bihar and Jharkhand

Expanded to West Bengal, Karnataka, Rajasthan

Data outputs– Session site:

Availability of manpower and logistics Reasons for session not held Safe injection practices and waste

disposal– Household surveys

RI coverage and gaps in community Reasons for left-outs and drop-outs

RI monitoring: January – December 2011

In 2011, more than 13,000 session sites and 100,000 children monitored per month in priority states of Bihar, UP and Jharkhand

StateSessions

monitored

Children surveyed

0 to 11 months12 to 23 months

Bihar 40,990 226,127 107,407

Jharkhand 8,646 35,519 16,913

Karnataka 526 2,136 1,242

Uttar Pradesh 112,859 591,170 244,724

West Bengal 1,426 8,238 5,627

TOTAL 164,447 863,190 375,913

<Empty Picture>

KRI

SBD

STPHDO

LLP

JNS

JAL

AHB

BAD

BJN

BRC

PIL

SHA

FTP

MZP

UNN

JNP

BNA

BRL

AZG

MZN

AGR

SHP

ALG

HMP

GNDBBK

PTG

BLS

MRD

KSN

FAI

BRP

GZP

RBL

GRPBST

BAL

KPN

MTR

MAI

CKT

KPD

SULCSN

ETA

MHB

SDN

MRT

LNO

DOR

CND

JPN

FER

FKB

RMP

MHG

ABN

ETW

KNA

AUR

KAN

GZA

SRWHTR

KSM

MAU

SKN

VRN

BGT

GBN

BDH

% Fully immunized children, Uttar Pradesh:

January – December 2011

5955

42

53

30

40

50

60

70

Jan(15,736)

Feb(17,124)

Mar(12,155)

Apr(16,217)

May(18,834)

Jun(19,136)

Jul(28,187)

Aug(22,807)

Sep(18,957)

Oct(19,874)

Nov(24,865)

Dec(30,832)

Non HR Block HR Block

N=

State: UPTotal Children (12-23) 244,724

Percent (%) of FI 56%

Dist with Minimum Coverage Jaunpur (34)

Dist with Maximum Coverage Hamirpur (85)

HR Blocks: UPTotal HR Blocks 66

Total Children (12-23) 47,193

Percent (%) of FI 49%

  <=20

  21-40

  41-60

  61-80

  >80

 Not MonitoredSource : RI HtH Monitoring data;

children 12-23 months of age N = No. of children monitored

BAD

BJN

PIL

SHA

BRL

MZN

AGR

SHP

ALG

BLS

MRD

MTR

MAI

ETA

MRT

JPN

FER

FKB

RMP

ETW

KAN

GZA

HTR

BGT

GBN

Availability of all vaccines and diluents, Bihar:

January – December 2011

67

80

81 78

30

40

50

60

70

80

90

100

J an(2,524)

Feb(2,813)

Mar(2,503)

Apr(3,078)

May(3,065)

J un(3,689)

J ul(3,929)

Aug(3,446)

Sep(2,796)

Oct(2,447)

Nov(3,042)

Dec(4,036)

Non HR Block HR Block

  <=70

  71-80

  81-90

  >90

 Not Monitored

State: BiharSession held 37,368

All Vaccine available 23,840

Percent (%) 64

Dist with Minimum value Supaul (29)

Dist with Maximum value Kishangabj (89)

HR Block: BiharTotal HR blocks 41

Session held 4,232

All Vaccine available 2,927

Proportion 69

N=

tOPV Stock-out

Source: RI monitoring data

MCV2 introduction through catch-up campaigns

14 states, children 9m – 14 yrs– Approximately 130 million

Role of WHO NPSP:– Strategy formulation, guideline

and training module development

– Pre-campaign planning, training, establishment of AEFI management networks

– External monitors for RCA monitoring and feedback

RI: MCV1 > 80%

SIA: MCV1 <80%

NPSP assisted measles surveillance

Surveillance initiated

2006

2007

2010

2009

2011

Reporting of Clinical Measles cases, linked with AFP weekly reporting in these states; Weekly aggregate data shared with IDSP

One state level lab strengthened in each state for Lab testing for measles and rubella IgM.

200 outbreaks

# Outbreak confirmation for Measles: 2011 ≥ 2 cases IgM positive for measles, Similarly for Rubella@ Surveillance started from June, 2011 in Bihar and July 2011 in Assam and Jharkhand

* data as on 16th Jan, 2012

172 Measles outbreaks confirmed

15 Rubella outbreaks confirmed

13 Mixed outbreaks confirmed

Vaccinated Unvaccinated

Unknown

> 90% of measles cases are found among 1 - 10 years old

~ 70% of measles cases are unvaccinated

Serologically confirmed# measles, rubella and mixed outbreaks,

2011 India

Challenges

Ensuring that the message of polio eradication remains on the top of the agenda (we are not done yet!)

Trying to meet the increasing expectations to be involved in other areas;

Field MOs trying to balance all the priorities at the field level (increasing activities and overall work of already overloaded MOs);

Managing a level of uncertainty and anxiety from the field in the context of transition;

Maintaining donor funding over next 5 years (through certification and post eradication phase)