AFP Surveillance Update 2010

Expanded Program on Immunization,

Ministry of Health, Islamabad

(Polio Eradication Initiative - National Surveillance Cell)

AFP Surveillance Update 2010

Today, four new type-1 polio cases have been confirmed by laboratory. They include one case each from Ghotki and Sukkur districts in Sindh province, Mianwali district in Punjab province and Mohmand agency in Federally Administered Tribal Areas. This brings the total number of polio cases country-wide in 2010 so far to 78 including 58 type-1 and 20 type-3 cases. Mianwali and Sukkur are newly infected districts bringing the total number of infected districts/towns/tribal agencies in 2010 to 27.

Following the massive floods initiated in July 2010 badly affecting the region of central Pakistan (including southern Punjab, northern Sindh and adjoining parts of Balochistan), a total of 4 districts have been infected with WPV in the region (Ghotki, Khairpur and Sukkur in Sindh and Muzaffargarh in Punjab) which is of concern. Uniform high quality vaccination activities covering all the populations are obligatory to arrest the spread of poliovirus transmission in the region and beyond.

Detailed epidemiological investigation of the cases and genetic analyses of the isolated polioviruses are under process. The available information is mentioned below.

1.     Mianwali: Polio case (type-1)

Zar Muhammad S/o Gul Muhammad is a 36-months old male child having onset of paralysis on 21^st September, 2010.  The child resides in Afghan Camp area UC Kot Chania of tehsil Essa Khel. As per recall of the parents, the child has received more than 7 OPV doses including 1 dose through Routine Immunization. Followings are important to highlight:

• This is the first polio case from the district after over 10 years; last case was reported in November 1999 which was also a type-1 case.
• Mianwali is one of the worst affected districts by the recent massive floods. The UC of the child’s residence was also severely affected.
• The child belongs to an Afghan family and lives in an Afghan Refugees camp. There is frequent population movement between the camp and parts of Khyber Pakhtunkhwa and Afghanistan.
• A total of 12 vaccination campaigns have been conducted in the district since January 2009 (5 in 2010), 11 of which were conducted using vaccine containing component against type-1 poliovirus (Table 1).

• The overall coverage based on finger marking at district level has been more than 90% during all the campaigns since January 2009. However the proportion of union councils with coverage below 90% by finger marking was above 10% during two vaccination campaigns each in 2009 and 2010.

Table 1: Vaccination coverage verified by finger marking in less than 5 years children in Mianwali district – 2009 and 2010

Year	SIAs  Month	Type of SIAs	Type of OPV	% Coverage in below 5 years children	% Union Councils with coverage below 90%
2009	January	NIDs	tOPV	97	8
	March	NIDs	tOPV	98	0
	May	NIDs	tOPV	98	0
	July	NIDs	tOPV	96	11
	August	SNIDs	mOPV3	98	3
	October	NIDs	tOPV	98	10
	November	NIDs	tOPV	99	5
2010	February	NIDs	tOPV	96	11
	April	NIDs	tOPV	95	14
	May	SNIDs	mOPV1	97	7
	July	NIDs	tOPV	97	4
	August	High Risk UCs campaign	bOPV	96	*

*Data not available

Recommendations:

• Ensuring high quality vaccination activities during the upcoming vaccination round scheduled from 11-13 October (i.e. within 3 days of the notification of the polio case) with special focus on returning IDPs, migratory and other high risk population groups.
• Intensifying surveillance activities in the district to ensure reporting of all paralyzed children below 15 years of age.
• Enhanced routine immunization outreach activities in between the campaigns.

2. Ghotki: Polio case(type-1)

Asma D/o Peeral Faqir is a 42-month old female child having onset of paralysis on 20^th September, 2010. The child resides in village Haji Rahab Mahar, UC Lohi of tehsil Khan Garh. As per recall of the parents, the child has received more than 7 OPV doses, all through SIAs. Followings are important to highlight:

• This is the 4^th type-1 case from the district this year. These cases have date of onset of paralysis within almost 4 weeks (18 August – 20 September).
• Ghotki district is situated in the central Pakistan which has been adversely affected by the floods.
• Ghotki district was included in phase-1 of the recent NIDs conducted from 27-29 September i.e. within one week of the date of onset of paralysis of the newly reported polio case.
• A total of 18 vaccination campaigns have been conducted in Ghotki district since January 2009 (7 in 2010), fifteen of which were conducted with OPV containing component against type-1 poliovirus (Table 2).
• Overall coverage by finger-marking in vaccination campaigns at district level is more than 90% except in 3 rounds in 2009 and one in 2010. However there is lack of uniformity in coverage at sub district level indicated by high proportion of union councils having finger-marking coverage below 90%.

Table 2:  Vaccination coverage verified by finger marking in less than 5 years children in Ghotki district 2009 and 2010

Year	SIAs  Month	Type of SIAs	Type of OPV	Coverage in children below 5 years (%)	Percentage of  Union Councils with below 90% coverage
2009	January	NIDs	tOPV	91	30
	March	NIDs	tOPV	95	19
	April	SNIDs	mOPV1	95	9
	May	NIDs	tOPV	94	19
	June	SNIDs	mOPV1	97	9
	July	NIDs	tOPV	96	13
	August	SNIDs	mOPV3	92	34
	September	Case Response	mOPV1	87	50
	October	NIDs	tOPV	81	33
	November	NIDs	tOPV	94	17
	December	SNIDs	mOPV1	91	23
2010	January	SNIDs	mOPV3	93	31
	February	NIDs	bOPV	92	15
	March	SNIDs	bOPV	88	40
	April	NIDs	tOPV	94	20
	May	SNIDs	mOPV3	93	25
	July	NIDs	bOPV	96	0
	September	NIDs	bOPV	Results awaited

Recommendations:

• High Quality vaccination activities i.e. routine immunization and during scheduled SIAs.
• Enhanced routine vaccination outreach activities in between the campaigns

3. Sukkur: Polio case (type-1)

Azizan d/o Nazir Ali is 36-month old female child having onset of paralysis on 26^th September, 2010. The child resides in Village Muhammad Hareef, UC Pahnwaro of Tehsil Rohri. Child received more than 7 OPV doses, all through SIAs.

• This is first polio case reported from the district since October 2006 which was a type-3 case while last type1 polio case from the district was reported in June 2002.
• The child along with his family lived in an IDPs’ camp in Rohri city for 10-15 days in mid August (due to flood warning in their village) with flood displaced population from other areas in the region.
• A total of 17 vaccination campaigns have been conducted in the district since January 2009 (6 in 2010), 14 of which were conducted with vaccine containing antigen against types-1 poliovirus (Table 3). Overall vaccination coverage in the district during SIAs has been above 90% except 3 campaigns in 2009. However, high proportion of the UCs with coverage below 90% verified by finger marking indicates performance gaps at the sub-district level.
• Sukkur was included in the recently held mass vaccination campaign during which mOPV1 was given to all under 5 years’ children in addition to measles vaccine. Next NIDs in Sukkur are scheduled from 11-13 October with trivalent OPV.

Table 3:  Vaccination coverage verified by finger marking in less than 5 years children in Sukkur district 2009 and 2010

Year	SIAs  Month	Type of SIAs	Type of OPV	Coverage in children below 5 years (%)	Percentage of  Union Councils with below 90% coverage
2009	January	NIDs	tOPV	88	46
	March	NIDs	tOPV	95	16
	April	SNIDs	mOPV1	96	3
	May	NIDs	tOPV	93	28
	June	SNIDs	mOPV1	93	28
	July	NIDs	tOPV	94	22
	August	SNIDs	mOPV3	98	3
	September	Case Response	mOPV1	94	0
	October	NIDs	tOPV	87	47
	November	NIDs	tOPV	89	43
	December	SNIDs	mOPV1	90	47
2010	January	SNIDs	mOPV3	93	27
	February	NIDs	bOPV	95	17
	March	SNIDs	bOPV	92	37
	April	NIDs	tOPV	96	8
	May	SNIDs	mOPV3	94	17
	July	NIDs	bOPV	92	25

Recommendation:

• Uniform High quality vaccination for routine immunization and scheduled SIAs
• Enhanced AFP surveillance activities to ensure that every paralyzed child below 15 years of age is detected by the surveillance system
• Enhanced routine vaccination outreach activities in between the SIAs

4.         Mohmand: polio case (type-1)

Nazia d/o Sher Bahadar is a 12-month old female child having onset of paralysis on 26^th September, 2010. The child resides in Village Gharrai, Machine Karona, area Sagai of Tehsil Safi.  Child has not received any dose OPV through SIAs or Routine immunization

• This is third type-1 polio case reported from the agency this year and 2nd from Tehsil Safi. The last type-1 case had onset of paralysis on 25^th August.
• A total of 19 vaccination campaigns have been conducted in the accessible areas of the agency since January 2009 (8 in 2010), 17 of which were conducted with vaccine containing antigen against the types-1 poliovirus.
• NIDs with bivalent OPV in the agency have already been conducted from 27-29 September 2010 i.e. within a day of the date of onset of paralysis of the case.
• The overall adjusted coverage verified by finger marking taking into account the factor of inaccessibility has been very low.  (Table 4).

Table 4:  Vaccination coverage verified by finger marking in less than 5 years children in Mohmand agency 2009 and 2010

Year	SIAs  Month	Type of SIAs	Type of OPV	Inaccessible children		Coverage in children below 5 years in accessible areas (%)	Adjusted finger marking coverage (%)	Percentage of  Union Councils with below 90% coverage (among accessible areas)
				No.	%
2009	January	NIDs	tOPV	55,138	49	96	49	10
	March	NIDs	tOPV	50,551	45	95	52	7
	April	SNIDs	mOPV1	49,443	44	95	53	4
	May	NIDs	tOPV	49,443	44	96	53	8
	June	SNIDs	mOPV1	49,443	44	93	52	19
	July	NIDs	tOPV	37,495	34	95	63	7
	August	SNIDs	mOPV3	35,300	32	95	65	0
	September	Case response	mOPV3	35,300	32	96	66	*
	October	NIDs	tOPV	35,050	31	96	66	0
	November	NIDs	tOPV	29,451	26	95	70	2
	December	SNIDs	mOPV1	23,700	21	96	76	0
2010	January	SNIDs	mOPV1	22,768	20	94	75	0
	February	NIDs	bOPV	20,310	18	91	74	0
	March	SNIDs	bOPV	18,257	16	94	78	19
	April	NIDs	tOPV	18,050	16	94	79	9
	May	SNIDs	bOPV	18,200	16	94	78	7
	July	NIDs	bOPV	16,802	15	94	80	14
	August	High Risk UCs campaign	bOPV	4,927	3	94	92	0
	September	NIDs	bOPV	17,530	16	Results awaited

* Data not available

Recommendations:

• Urgent implementation of the decisions made by the Crisis Task Force for FATA.
• Extra alertness in all accessible areas of the agency for ensuring high quality vaccination coverage and reporting of all paralyzed children.

Overall case count of 2010:

1      Total number of confirmed polio cases (as on 08^th of October, 2010) =78

2      58 type-1 cases; one case each from Dir Upper, Swabi, Kohat and Charsadda; 2 cases from Lakki Marwat; three cases from Peshawar and 4 from Hangu district in Khyber-Pakhtunkhwa province; two cases from Orakzai, three cases from Mohmand, four from Kurram, five cases each from North Waziristan and Bajour and fourteen cases from Khyber agency in FATA; 1 case from Killa Abdullah district in Balochistan; 1 each from Muzaffargarh, Mianwali and 2 cases from DG Khan in Punjab; and 1 case each from Sanghar, Sukkur and Khairpur and 4 from Ghotki district in Sindh province.

3      20 type-3 cases; one case from South Waziristan, two from Bajour and five from Khyber agency in FATA; one each from Swat and Swabi and two from Peshawar in Khyber-Pakhtoonkhwa province; one from Karachi (Gulshan-e-Iqbal town) in Sindh; three from Quetta, two from Chaghai and one case from Killa Abdullah district in Balochistan; and one case from Rawalpindi in Punjab.

Dr. Altaf Bosan

National Program Manager EPI

08^th October, 2010

Tables attached: -

1.    Table 1,2,3, 4:  Vaccination coverage of Mianwali, Ghotki, Sukkur districts and Mohmand agency respectively in 2009 and 2010.

2.    Table 5: Confirmed polio cases by month and year, 2001 – 2010

3.    Table 6: Confirmed polio cases by province, district and type of poliovirus in 2010

Table 5: Confirmed polio cases by month & by year, Pakistan (2001-2010^£)

Month/Year	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010
January	9	4	6	4	4	0	5	2	7	6
February	3	4	7	3	0	2	1	1	2	4
March	4	4	7	4	2	0	1	0	0	2
April	4	9	14	1	1	1	0	6	6	8
May	3	3	7	4	3	5	2	5	4	5
June	4	6	7	3	2	4	2	3	3	6
July	7	2	8	4	3	4	0	18	14	6
August	18	11	11	10	2	3	2	18	19	15
September	24	20	14	2	3	6	4	30	11	26
October	20	14	7	8	2	8	1	21	12
November	16	7	10	2	3	6	6	7	7
December	7	6	5	8	3	1	8	6	4
Total	119	90	103	53	28	40	32	117	89	78

^£ As of 08^th October, 2010
Table 6: Confirmed polio cases by province, district & by type in 2010^£

Province / Region	District Name	Type of Wild Poliovirus	No. Cases	No. infected  Districts	Total Cases
Punjab	DG Khan	NSL1	2	4	5
	Muzaffargarh	NSL1	1
	Mianwali*	NSL1	1
	Rawalpindi	NSL3	1
Sindh	Karachi-Gulshan-e-Iqbal	NSL3	1	5	8
	Sanghar	NSL1	1
	Sukkur*	NSL1	1
	Khairpur	NSL1	1
	Ghotki*	NSL1	4
Khyber-Pakhtoonkhwa	Peshawar	NSL1	3	8	17
		NSL3	2
	Swat	NSL3	1
	Charsada	NSL1	1
	Lakki Marwat	NSL1	2
	Kohat*	NSL1	1
	Dir Upper	NSL1	1
	Swabi	NSL3	1
		NSL1	1
	Hangu	NSL1	4
FATA	Bajour	NSL1	5	7	41
		NSL3	2
	Khyber	NSL1	14
		NSL3	5
	Kurram	NSL1	4
	Waziristan North	NSL1	5
	Waziristan South	NSL3	1
	Orakzai	NSL1	2
	Mohmand*	NSL1	3
Balochistan	Quetta	NSL3	3	3	7
	Chaghai	NSL3	2
	Kila Abdullah	NSL1	1
		NSL3	1
Pakistan				27	78

* New case; ^£ As of 08^th October, 2010.