Transcript National Polio Surveillance Project: GoI & WHO
Workshop on “Polio updates & End game strategies” Organized by Community Medicine Department, GMERS Medical College, Sola, in collaboration with NPSP (WHO), Gandhinagar 16 th April, 2013 National Polio Surveillance Project: GoI & WHO
Polio update, AFP Surveillance End game strategy
Dr. Anish Sinha
State Surveillance Medical Officer World Health Organization National Polio Surveillance Project, India, Gandhinagar.
National Polio Surveillance Project: GoI & WHO
Contents….
• Global/ National / State update.
• Epidemiology of polio.
• AFP Surveillance.
• SIAs (NIDs / SNIDs).
• Certification of Polio eradication.
• End game strategy.
National Polio Surveillance Project: GoI & WHO
Areas with Active Polio Transmission
1988 350 000 cases 2012 223 cases 125 countries 5 countries National Polio Surveillance Project: GoI & WHO
Rukhsar Khatoon last case of WPV detected in India (Jan 2011), her mother Shabida Bibi in Shahapar village, WB
National Polio Surveillance Project: GoI & WHO
India
• India last polio case on 13
th
Jan.2011
• Removed from list of
ENDEMIC
Countries list in Feb.2012
Looking forward for Certification (SEAR) in Feb.2014 National Polio Surveillance Project: GoI & WHO
Global Polio updates 2012 Nigeria (122) Pakistan (58) Afghanistan (37) ONLY THREE ENDEMIC COUNTRIES
CHAD 5 WPV1 (IMPORTATION) Niger 1WPV1 Till 9 Apr 13 – 18 cases
(Nig-11, Pak-6, Afg-1) National Polio Surveillance Project: GoI & WHO
WPV transmission from Northern Sindh, Pakistan to Greater Cairo (environmental sample +ve), Egypt Importation of WPV 2013 -, Egypt - polio free since 2004.
National Polio Surveillance Project: GoI & WHO
WPV cases, India 2100 1934 1800 No case since Jan 2011 1600 1500 1200 1126 874 900 741 676 600 559 300 0 265 268 225 134 66 42 1 0 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013* P1 wild P2 wild P3 wild National Polio Surveillance Project: GoI & WHO
* data as on 12 April 2013
Location of wild poliovirus and VDPV cases by type, India 2011 2012 2013* State
West Bengal
Total State
Chhattisgarh Madhya Pradesh Orissa Punjab Rajasthan Uttar Pradesh
Total
* data as on 12 April 2013
WPVs P1
1
1 VDPVs P2
1 1 0 1 1 2
6 P3
0
0 P3
0 0 1 0 0 0
1 Total
1
1 Total
1 1 1 1 1 2
7
VDPV State West Bengal Total P2 1 1
State
Bihar
Total VDPV P2
1
1 National Polio Surveillance Project: GoI & WHO
* data as on 12 April 2013
Last wild poliovirus cases by type, India WPV2 24/10/1999 Aligarh (UP) WPV3 22/10/2010 Pakur (JH) WPV1 13/01/2011 Howrah (WB) National Polio Surveillance Project: GoI & WHO
Wild poliovirus detected in sewage samples, 2010 – 2011
2010
Mumbai Week F ward 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
X X X X X
G ward M ward
2011
Week Red cross hospital Bhalaswa lake Wazirpur JJ colony Swarn cinema Batala house (Okhla) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
X X X X X X X X X X X X X X X X
Mumbai Week F ward G ward M ward Delhi Week Red cross hospital Bhalaswa lake Wazirpur JJ colony Swarn cinema Batala house (Okhla) Sonia vihar Nangloi Patna Week Choti pahari Dujara Transport nagar Kolkata Week Ward 8, MM Ward 135, KMC 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
X X X
1
X
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Wild poliovirus type 1 Wild poliovirus type 3
X
Negative for wild poliovirus Sampling not scheduled
Wild poliovirus detected in sewage samples, 2012* Mumbai F ward G ward M ward Delhi Week Week Red cross hospital Bhalaswa lake Wazirpur JJ colony Swarn cinema Batala house (Okhla) Sonia vihar Nangloi Patna Week Choti pahari Dujara Transport nagar Kolkata Week Ward 8, MM Ward 135, KMC Ward 29, KMC Ward 66, KMC 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 X X X X 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 X X X X X X X X X X 52 X X X X X X X X X X X X X X X X X X X X X X X 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
`
Wild poliovirus type 1 Wild poliovirus type 3 Negative for wild poliovirus
X
Scheduled but sample not collected Result pending Sampling not scheduled National Polio Surveillance Project: GoI & WHO
* data as on 12 April 2013
Wild poliovirus detected in sewage samples, 2013* Mumbai F ward G ward M ward Delhi Week Week Red cross hospital Bhalaswa lake Wazirpur JJ colony Swarn cinema Batala house (Okhla) Sonia vihar Nangloi Patna Week Choti pahari Dujara Transport nagar Kolkata Week Ward 8, MM Ward 135, KMC Ward 29, KMC Ward 66, KMC 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 X 3 4 X 5 6 X 7 8 X 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 X X X X 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 X X X X X X X X X X X X X X X X 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Wild poliovirus type 1 Wild poliovirus type 3 Negative for wild poliovirus
X
Scheduled but sample not collected Result pending Sampling not scheduled National Polio Surveillance Project: GoI & WHO
* data as on 12 April 2013
2100 1934 1800 1500 Progress in India–A snapshot 1600
• • • • • •
1995: Polio SIAs (campaigns) launched 1997: Acute Flaccid Paralysis (AFP) Surveillance initiated 1999: Last case of Wild Polio Virus (WPV) type 2 – (U.P) 2010: Last case of WPV type 3 - (Jharkhand) 2011: Last case of WPV type 1 - ( West Bengal) 2012: India removed from list of endemic countries 1200 1126 874 900 741 676 600 559 300 0 265 268 225 134 66 42 1 0 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013* P1 wild P2 wild P3 wild National Polio Surveillance Project: GoI & WHO
* data as on 12 April 2013
Year - Cases 2000 - 2 2001 - 1 2002 - 24 2003 - 3 2004 - 0 2005 - 1 2006 - 4 2007 - 1 2008 - 0 2009 - 0 2010 - 0 2011 - 0 2012 - 0 2013 - 0
Gujarat Wild Cases 2000-13 BAN KTC RJT JMD JMC RJC POR AML JUN SRN PAT MSN SBK GNR AMC KDA AMD BVC AND VDC VDD BVN BRH SRC SRT PML NMD DHD DNG NAV VLD National Polio Surveillance Project: GoI & WHO
Epidemiology of Polio
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Polio: Epidemiology
• Reservoir of infection: Man (for every clinical case,1000 sub clinical case (children) & 75 (adults) • Infective material: Host factors feces • Period of communicability: before & after onset.
most infective 10 days • Age:6 months to 3 years most common • Sex: 3:1 ---male: female • Precipitating factors: fatigue, trauma, I/M injections • Immunity : OPV (life long) Environmental factors • Rainy season ( Jun – Sep ), overcrowding & poor sanitation
National Polio Surveillance Project: GoI & WHO
Paralytic Poliomyelitis
• Acute onset • Fever just prior to onset of paralysis • Associated symptoms: malaise, sore throat, constipation abdominal pain. Muscle pain • Signs of meningeal irritation, stiffness in back & neck may be present.
• Progression: maximum in <4 days. starts proximally and moves distally • Involvement: asymmetrical patchy paralysis ,proximal muscle groups> distal muscle groups • DTR: diminished • Cranial nerve involvement : uncommon • Respiratory insufficiency: life threatening, uncommon • Sensory: no loss
only way to confirm is isolation of wild virus from stool.
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Strategies of Polio Eradication
1985 – Routine immunization Individual immunity 1995 – NID’s ( PPI / IPPI ) To replace wild with vaccine virus 1997 - AFP surveillance To identify reservoir of transmission 2000 – Mopping up immunization To eliminate last foci of transmission
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AFP Surveillance
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Objective of AFP surveillance Reliably detect areas where polio transmission is occurring or likely to occur
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Principle of AFP Surveillance in identifying polio cases
Identify children with the
SYNDROME
Paralysis of Acute Flaccid • Acute- Sudden onset, Rapid progression • Flaccid- Floppy/ soft & yielding to passive stretching at
anytime during the illness
. • Paralysis is loss of strength of muscles,
Severe loss of motor strength is called paralysis or plegia Paresis- less severe loss of motor strength
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Definition of AFP for surveillance purposes
Sudden onset weakness & floppiness in any part of the body in a child < 15 years of age or paralysis in a person of any age in which polio is suspected.
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Logic of AFP investigation & stool sample collection
• Sensitivity increases when all AFP cases investigated • Testing of stools of all AFP identification of Polio
most valid test
for • ALL cases with ‘AFP’ should be reported &
their stools must be tested!!
• Even if other ‘tests’ (CT scan, MRI, etc.)
or
additional clinical information point to other diagnoses;
stools must be tested to rule out Polio
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Reporting
• All AFP cases should be reported immediately • ALL AFP cases reported within 6 months of onset of paralysis should be investigated • All reporting units, informers and other contacts should continue to report AFP cases as per
existing case definition
National Polio Surveillance Project: GoI & WHO
Action when AFP is reported
• FIRST – Start stool collection process • Investigate - SMO/ DIO - Confirm if AFP, if not reject case & record the same.
There is only one category of cases - AFP
• Allot EPID number & Report the case as AFP • • CIF & LRF should be filled.
Use the revised CIF/ Linelist form .
• Ensure that stools are transported to lab in cold chain • NPSU will Classify after lab result received • Give feedback to the source that the AFP reported was/ was not polio.
• Maintain documentation at ALL levels.
National Polio Surveillance Project: GoI & WHO
Therefore…
The basic system of AFP surveillance remains unchanged • To enhance sensitivity, all cases of acute flaccid paralysis should be reported & investigated • Borderline cases should be included & stool specimens tested
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The AFP Surveillance System
Hospitals Clinics Community Non-Polio AFP Investigation Polio AFP National Polio Surveillance Project: GoI & WHO
When too much polio is around
…..
AFP cases Polio cases Borderline AFP cases Non-AFP cases
Surveillance sensitivity is adequate enough to detect 90% polio cases National Polio Surveillance Project: GoI & WHO
When transmission is very low…..
If borderline cases are taken & stool specimens collected … Surveillance sensitivity is not good enough & detects only 50% polio cases
AFP cases Polio cases Borderline cases Non-AFP cases
…Sensitivity increases and leads to 100% detection of polio cases Remember Non AFP cases still not taken National Polio Surveillance Project: GoI & WHO
• • • • • • • Likely
to be
AFP cases….
GBS of any variety Transverse myelitis Monoparesis Traumatic neuritis Flaccid Paraplegias Flaccid Quadriplegia Isolated bulbar paralysis
• • • • • • •
Post-diphtheric polyneuritis Viral neuritis, Flaccid hemiplegia Isolated neck paralysis Wrist/foot drop, etc.
Transient paresis Facial Palsy.
National Polio Surveillance Project: GoI & WHO
Analysis of initial clinical presentation of WPV 2006 - 10 Clinical Presentation 2006 2007 2008 2009 2010 Clinical Poliomyelitis Only H/O Paralysis Hemiplegia G.B.Syndrome
Traumatic Neuritis Only Limp Acute Encephalitis Isolated Facial Palsy Isolated Neck Flop Post Diptheric Polyneuritis Others Total
24 (2.7) 35 (5.2) 6 (0.9) 4 (0.6) 4 (0.6) 3 (0.4) 3 (0.4) 4 (0.6) 0 (0) 7 (1.0)
676
586 (86.7) 757 (86.71) 494 (88.37) 648 (87.45) 32 (76.19) 14 (1.60) 54 (6.19) 3 (0.34) 8 (0.92) 1 (0.11) 3 (0.34) 19 (2.18) 5 (0.57) 14 (2.5) 25 (4.47) 3 (0.54) 1 (0.18) 0 (0) 4 (0.72) 10 (1.79) 4 (0.72) 10 (1.35) 48 (6.48) 3 (0.40) 2 (0.27) 4 (0.54) 1 (0.13) 14 (1.89) 4 (0.54) 1 (2.38) 3 (7.14) 4 (9.52) 2 (0.23) 0 (0) 1 (0.13) 7 (0.80)
873
4 (0.72)
559
6 (0.81)
741
2 (4.76)
42 National Polio Surveillance Project: GoI & WHO
• • • • • •
STOOL COLLECTION, STORAGE , TRANSPORT .
Adequate Stool.
– 2 Specimens, 24 Hours Apart.
– 8 gms.
– Within 14 Days of Paralysis Onset & with proper Cold Chain
Procedure.
– Errors.
– Storage(Delayed Second Sample)
Cold Chain.
Rectal Tube.
Transport.(PHN & HA) Death of AFP Case.( Spinal Cord , Intestinal Content) National Polio Surveillance Project: GoI & WHO
GOLD STANDARD FOR AFP SURVEILLANCE • Non – Polio AFP Rate > 2.0
• Adequate Stool Samples > 80% • Timeliness of Reporting > 80%
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VIROLOGIC CLASSIFICATION SCHEME AFP WILD POLIOVIRUS RESIDUAL WEAKNESS, DIED OR LOST TO F/U INADEQUATE STOOL SPECIMENS NO WILD POLIOVIRUS EXPERT REVIEW NO RESIDUAL WEAKNESS TWO ADEQUATE* STOOL SPECIMENS CONFIRM COMPATIBLE DISCARD DISCARD DISCARD
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KTC JM D PO R
Compatible Cases 2002-2013 2002 – 14 cases 2003 – 4 cases
JM C RJ T RJ C PA T SR N BA N
# #
AM D BV C BV N MSN SB K GN R AM C KD A PM L AN D V D C V D D BR H NM D DH D
2004 – 1 case 2005 – 7 cases 2006 – 3 cases 2007 – 5 cases 2008 – 1 case 2009 – 1 case 2010 – 1 case 2011 – 0 Case 2012 – 0 Case 2013 – 0 Case
AM L JU N SR C SR T NA V V LD DN G National Polio Surveillance Project: GoI & WHO
HOT CASE
• A case of AFP with any of the following set of conditions Age < 5 year plus H/O fever at onset plus asymmetrical proximal paralysis.
Age < 5 year with rapidly progressive paralysis leading to bulbar involvement (cranial nerves affected) & death.
Any case which in the opinion of SMO/DIO looks like polio.
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CONTACT SAMPLES
To be considered for cases fulfilling criteria like Hot cases, but adequate samples from case could not be taken
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Supplementary Immunization Activities:
NIDs/ SNIDs
National Polio Surveillance Project: GoI & WHO
• NID: SIAs National Immunization Day.
-
Booth Activity.
- House-to house Activity.
- Transit Teams.
- Mobile Teams.
• SNID: Sub National Immunization Day.
- Migratory SNID in Gujarat (11 districts & 5 corporations).
National Polio Surveillance Project: GoI & WHO
Continued focus on high risk areas and populations 107 blocks of UP and Bihar Kosi river operational intensification Immunization of newborns West UP: HR blocks – 66 Bihar: HR blocks – 41 Intense focus on migrants & mobile populations Religious congregations 2 million children vaccinated in 8 million children in transit immunized in India each round 100,000 of these in running trains congregations each year National Polio Surveillance Project: GoI & WHO
Certification of polio eradication
National Polio Surveillance Project: GoI & WHO
Background
• Certification is done for WHO Regions; not for individual countries • WHO Regions certified polio free: – Americas 1994 – Western Pacific – Europe 2000 2002 • Certification of a region is considered only when –
All countries
in the area demonstrate Absence of WPV transmission for at least 3 consecutive years Presence of certification standard surveillance Global action plan for laboratory containment of WPV
National Polio Surveillance Project: GoI & WHO
Certification of SEAR*
GCC formed SEARCCPE formed Last WPV case in SEAR 28 Aug: India presents Preliminary Document Dec: Special RCC Meeting for India 2 RCCPE meetings planned Feb: India will present final document Certification of SEAR likely 1995 1997 2011 * South East Asia Region of WHO 2012 2013 2014
National Polio Surveillance Project: GoI & WHO
Certification standard surveillance
• Non-polio AFP rate: ≥ 2 per 100,000 population (< 15 years) annually • Adequate stool specimens : ≥80% • All stool specimens tested for poliovirus at WHO-accredited laboratory • Additional Criteria • Investigation of AFP cases within 48 hours of initial notification: ≥80% • Timeliness of weekly AFP surveillance reports: ≥80%
National Polio Surveillance Project: GoI & WHO
National Certification Committee for Poliomyelitis Eradication (NCCPE) • Established in 1998 to • Examine, assess & verify data collected by govt. • Field visits to review evidence of interruption of poliovirus transmission in the country • Independent judgment of polio status • Present country report to RCCPE* * Regional Certification Commission for Poliomyelitis Eradication
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NCCPE Field Visits
• Sep12 - Jun13 • Five categories of states have been formed
Category 5 states National Polio Surveillance Project: GoI & WHO
Laboratory Containment • Union Health Ministry already issued letter in this regard to all the States (dated 14
th
Feb 2013).
• National Task Force for Lab Containment of WPV formed, Health Secretary (GOI) Chairman.
• To identify Labs, likely to store WPV – by Dec 2013.
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Polio Endgame Strategy
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Context
• No WPV2 in India since 1999 • tOPV used in RI and during NIDs • bOPV used in most SNIDs since Jan 2010 • Areas/ populations with low routine immunization coverage • All cVDPVs in India due to type 2 in setting of low immunity to type 2
National Polio Surveillance Project: GoI & WHO
cVDPV cases, India 2009-2011
•cVDPV cases detected in 2009-10 •100% due to type 2
District
Badaun Bulandshah ar Ghaziabad Meerut Moradabad Pilibhit Shahjahanp ur
Total 2009
3
Type 2 2010
0
2011
0 2 0 2 2 4 2
15
0 1 0 0 0 1
2
0 0 0 0 0 0
0 National Polio Surveillance Project: GoI & WHO
Age Type 1 Type 2 Type 3 Trends in Seroprevalence Against Poliovirus
Results from Different Serosurveys
Moradabad Nov 2007 (N=121) 6-7 mo 78% AFP cases UP Nov 08 – mid 09 (169) 6-11 mo 96.5% Moradabad May 2009 (N=534) UP & Bihar Aug 2010 (N=1280) 6-7 mo 99% 6-7 mo 98% UP & Bihar Aug 2011 (N=1246) 6-11 mo 98.5% 56% 69% 33.7% 42.6% 75% 49% 65% 77% 85% 88.2%
High immunity levels sustained for P1 since 2009 Increasing trend in immunity level for P3 in 2010-11
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Managing the risk of VDPVs
National Polio Surveillance Project: GoI & WHO
Preparing for the polio endgame • A tOPV- bOPV switch globally (~2014/2015) • Use of IPV in conjunction with OPV (?) • Eventual cessation of all OPV use globally at some point in the future (e.g. 2017-18 period).
• Support research activities to generate evidence to guide decision making
National Polio Surveillance Project: GoI & WHO
Pre-switch boosting of type 2 immunity
• Switch soon after tOPV NIDs • Improve RI, particularly DTP3 and OPV3 coverage • Adding a dose of IPV in RI for infants prior to switch
National Polio Surveillance Project: GoI & WHO
Conclusions
• India can be in a position to move ahead with polio endgame strategy • Careful planning and consideration of risks required before implementation • Earliest possible timing for tOPV-bOPV switch: Qtr.1 2014 • Lessons from tOPV-bOPV switch significant for subsequent withdrawal of all OPV from programme
National Polio Surveillance Project: GoI & WHO
Thank you
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