global polio eradication and endgame strategy

Eradication Of poliomyelitis and End
Game Strategic Plan 2013-2018
Dr. Arun Kumar Pandey
Assist. Professor
Department of community medicine
Katihar Medical College, katihar

Success in India established strategic &
scientific feasibility of poliovirus
eradication.
Continued use of tOPV after eradication of
type 2 wild poliovirus a concern due to
vaccine-derived polio cases.
Beginning of the Endgame

• Poliovirus detection &
interruption
• OPV withdrawal, IPV
introduction, RI strengthening
• Containment & Global
Certification
• Legacy Planning
Polio Eradication &
Endgame Strategic Plan, 2013-2018

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Poliocases(thousands)
125 Polio Endemic
countries
Wild Poliovirus Eradication:1988-2014
19882014
Last wild type 2
polio in the world
Last wild polio
case in India
2016
3 Polio Endemic
countries
2 Polio Endemic
countries

• January 2011- Last WPV( Type-1) from India ( WB).
• November 2012: Most recent case of WPV3.
• March 2014- India certified Polio Free.
• 20 September 2015: WPV2 eradication certified
• 25 September 2015: Nigeria removed from list of
endemic countries by WHO ( Included again after
fresh WPV cases in 2016)
• April 2016- t-OPV replaced by b-OPV globally.
5
WPV milestones and achievements

Wild Poliovirus Eradication:2015-2016
54
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4
PAKISTAN AFGANISTAN NIGERIA
2015 2016

Afghanistan – Key Actions
• Better governance and coordination through the
National and Provincial Emergency Operations Centres
• Focusing resources on low-performing districts,
identifying and targeting persistently missed children
• Systematic vaccinator selection, training & supervision
• Closer cross-border coordination in border areas
with Pakistan

Pakistan: Insecurity & Inaccessibility
Military operation &
Active insurgency
Ban by local leaders
• N & S Waziristan
Threats & fatal attacks on
health workers
• Peshawar Valley & Karachi
WPV1 Cases in
Pakistan, 2014
N=306

Progress in Pakistan
• Intensified government commitment
• Emergency Operations Centres established
• Improved access in insecure areas
• Improved coordination with Army & security
agencies
• Innovations to reach missed children
– Female community volunteers, health camps, transit posts
• Focus on 12 high risk districts

520 532
343 180
35 937
-
100 000
200 000
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400 000
500 000
600 000
Jan
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Decline in Inaccessibility, Pakistan.
2013 2014 2015

Withdrawal of type 2 OPV
First serotype in the phased removal of all OPV

13
cVDPV outbreaks
cVDPV2
cVDPV1
VDPV2: S Sudan
cVDPV2: Nigeria
cVDPV2: Guinea
cVDPV1: Ukraine
cVDPV1: Madagascar
Type 2 MUST
BE
STOPPED!
Sufficiently in
advance of OPV2
withdrawal
cVDPV1: Lao DPR
cVDPV2: Myanmar

Vaccine-derived polio outbreaks
(cVDPVs) 2000-2015
Type 2 (478 cases)
Type 1 (79 cases)
Type 3 (9 cases)
Type 2
Type 1
Type 3
>90% VDPV cases are type 2
(40% of Vaccine-associated polio is also type
2)

1. cVDPV: >1 paralytic case with isolation of related
but non-identical viruses. Implies circulation of
VDPV due to low population immunity.
2. iVDPV: VDPV isolated from immuno-deficient
person. Implies long-term replication of the virus
within the same individual.
3. aVDPV: origin uncertain e.g. single isolate from
single AFP case, healthy or non-immuno-deficient
person.
Types of Vaccine derived Polio Viruses

Withdrawal of Oral Polio Vaccines
• Globally synchronized, phased withdrawal of OPV
strains, starting with OPV type 2.
• OPV type 2 withdrawal means that tOPV
(P1+P2+P3) must be replaced with bOPV (P1+P3)
• Withdrawal of OPV type 2 will reduce risk of
emergence of cVDPV type 2 and also reduce the
burden of VAPP cases due to OPV type 2

Rationale for OPV2 withdrawal
Last naturally occurring WPV case detected in Aligarh,
India in 1999
Type 2 polio vaccine causes >95% of Vaccine Derived
Polio Virus (VDPV) cases
Type 2 causes approximately 40% of Vaccine-associated
paralytic poliomyelitis (VAPP) cases
Type 2 component of OPV interferes with immune
response to types 1 and types 3
Risks of OPV2 now outweigh the benefits

Risks associated with OPV type 2
withdrawal
• Withdrawal of OPV type 2 will leave a gap in
population immunity against type 2 poliovirus
• Increased risk of outbreaks due to type 2 poliovirus
following reintroduction
• Re-introduction could occur if:
– cVDPV type 2 emerged during or shortly after OPV type 2
withdrawal
– Importation of cVDPVs occurs
– Break in bio-containment process in laboratories storing
viruses
Risks associated with OPV type 2 withdrawal can be mitigated

Mitigate the risk of low population
immunity against type 2 polio
Introduce at least one dose of IPV prior to
OPV type 2 withdrawal

OPV type 2 withdrawal
156 tOPV using countries and territories (tOPV
only and sequential IPV-OPV schedules)
20
Complete replacement of tOPV by bOPV

1. at least 1 dose of inactivated polio vaccine (IPV) in all OPV-
using countries
2. bivalent OPV (bOPV) licensed and available for routine
immunization
3. surveillance + response protocols for possible type 2
poliovirus outbreaks
4. completion of phase 1 (pre-containment lab survey/
inventory) + poliovirus type 2 containment
5. verification of global eradication of wild poliovirus type 2
(WPV2)
'Readiness' criteria for OPV2 withdrawal
(tOPV to bOPV switch)
 Trigger for OPV2 withdrawal: all persistent cVDPV2 circulation interrupted

• Reduce the risk of paralytic poliomyelitis if
exposure to type 2 virus occurred after OPV2
withdrawal
• Improve response to any future use of IPV or
mOPV2 in the case of an outbreak
• Reduce transmission of reintroduced type 2 virus
• Boost immunity to type 1 and 3
Role of IPV

Countries using IPV vaccine to date
and formal decision to introduce
Date of slide: 3 December 2015
The boundaries and names shown and the designations used on this map do not imply the
expression of any opinion whatsoever on the part of the World Health Organization concerning
the legal status of any country, territory, city or area or of its authorities, or concerning the
delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border
lines for which there may not yet be full agreement. ©WHO 2015. All rights reserved.
Introduced to date (132 countries or 68%)
Formal commitment to introduce in
2015
(24 countries or 12%)
Introduction delayed to 2016 due to global IPV
vaccine shortage
(38 countries or 20%)
Not available
Not applicable

bOPV registration status for routine
immunization
Approval for use (109 countries or 74%)
Review in progress (21 countries or 14%)
Pending submission (14 countries or 9%)
Focus country - Belarus
Not available/ non switch countries
Not applicable (switch area territories)
Data source: WHO/IVB Database, as of 03 December 2015
based on 148 OPV user countries and 7 Territories
Map production Immunization Vaccines and Biologicals (IVB),
World Health Organization
The boundaries and names shown and the designations used on this map do not imply the
expression of any opinion whatsoever on the part of the World Health Organization concerning
the legal status of any country, territory, city or area or of its authorities, or concerning the
delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border
lines for which there may not yet be full agreement. ©WHO 2015. All rights reserved.
(1 country or 1%)
(46 countries) + 3 countries switching from tOPV to IPV
Date of slide: 6 November 2015

Managing type 2 polio Risks, Post-switch
Enhanced detection & notification
• AFP & targeted environmental surveillance
Stopping type 2 outbreak
• Detection & Response protocol
• mOPV2 + IPV
Reducing outbreak consequences
• IPV in RI
– Reduce paralytic cases
– Facilitate outbreak response

Poliovirus containment
A system for confining polioviruses within a defined space
31
WHA resolution 68.3:
– The May 2015 resolution urges countries to
implement GAPIII

After type-specific eradication and containment of wild poliovirus
and cessation of oral polio vaccination, minimizing the risk of poliovirus
reintroduction is critical. In order to prevent reintroduction, the number
of international poliovirus facilities will need to be reduced to the
minimum necessary to perform critical functions of vaccine production,
diagnosis and research.
32
GAP III
WHO global action plan to minimize
poliovirus facility-associated risk after type-
specific eradication of wild polioviruses and
sequential cessation of OPV use

Containment of type 2 poliovirus (PV2)
•Goal: prevent inadvertent or malicious release from facilities
and transmission of PV2 to people
•Phase I: Reduce the number of facilities containing PV2:
• Countries: identify and destroy unneeded PV2
– WPV2 by end-2015
– OPV2/Sabin2 by July 2016
• Countries: designate poliovirus-essential facilities
for needed PV2
•Phase II: Reduce risk in remaining facilities:
• Countries and facilities: ensure appropriate
containment of PV2 in designated poliovirus-
essential facilities
33

Certification of WPV2
Eradication

World Health Assembly
Resolution 2015
• Calls on members states to be ready for the
withdrawal of OPV type 2 in April 2016 –
including introduction of IPV & each of the
additional criteria for preparedness
• Efforts required to:
– stop endemic transmission
– implement the temporary recommendations
under the IHR
– improve surveillance for poliovirus
– strengthen outbreak preparedness
– implement more rigorous outbreak response SOPs

• Poliovirus detection &
interruption
• OPV withdrawal, IPV
introduction, RI strengthening
• Containment & Global
Certification
• Legacy /Transition Planning
Polio Eradication &
Endgame Strategic Plan, 2013-2018

What is meant by “transition planning”?
• During more than 25 years of operations, the
GPEI has mobilized and trained millions of
volunteers, social mobilizers, and health workers.
• Accessed households untouched by other health
initiatives
• Mapped and brought health interventions to
chronically neglected communities
• Established a standardized, real-time global
surveillance and response capacity.

Legacy/Transition Planning
• As the initiative nears completion, the primary
goals are both to protect a polio-free world
• And to ensure that these investments, made
to eradicate polio, contribute to future health
goals after the completion of polio
eradication.

What are the key components?
1. Ensure that functions needed to maintain a polio free
world after eradication are mainstreamed into
ongoing public health programs.
2. Ensure that the knowledge generated and lessons
learned from polio eradication activities are
documented and shared with other health initiatives.
3. Where feasible, desirable, and appropriate, transition
capabilities and processes to support other health
priorities and ensure sustainability of the experience
of the GPEI program.

Summary
• WPV transmission lowest ever - restricted to parts of
Pakistan and Afghanistan
• Globally synchronized OPV2 withdrawal in April 2016 and
all type of OPV till 2020.
• Increasing focus on cVDPV – urgency to stop type 2
• Acceleration of GAP III – mitigate poliovirus facility
associated risks.
• Legacy/ Transition Planning to strengthen other health
programmes.

global polio eradication and endgame strategy

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