The document outlines the goals and strategic plan of the Global Polio Eradication Initiative from 2009-2013. The goal is to ensure no child is paralyzed by wild or vaccine-derived poliovirus. The plan focuses on interrupting wild poliovirus transmission in the remaining endemic countries, ensuring global surveillance, achieving certification of eradication, preparing for a post-OPV world, and restructuring the initiative for the post-eradication phase. Key strategies include aggressive supplemental immunization activities, optimizing OPV delivery and outbreak response, and establishing high quality surveillance globally.

1. Highlights of the Global Polio Eradication Initiative Strategic Plan 2009-2013 Virology Discipline Meeting - 24 February 2009 Dr Preneshni R Naicker

2. Goal of the Global Polio Eradication Initiative: To ensure that no child will ever again be paralysed by either a wild or vaccine-derived poliovirus

3. Objective 1: Interrupt wild poliovirus transmission

4. Areas with Active Polio Transmission 1988 > 125 endemic countries 2006* 4 endemic countries 8 reinfected countries

5. Situation analysis Indigenous poliovirus eradicated from all but 4 countries worldwide India, Nigeria, Pakistan, Afghanistan, indigenous type 1 and 3 wild poliovirus transmission is continuing Type 2 wild poliovirus has been eradicated globally since 1999

6. Key challenges 1) Sub-optimal OPV delivery 2) Sub-optimal OPV efficacy 3) Prolonged outbreaks (persistent transmission for >12 months) due to suboptimal outbreak response 4) Continued international spread of poliovirus from areas of indigenous (eg Nigeria, India) and imported poliovirus transmission (eg Angola, Chad, parts of the Horn of Africa)

7. Strategic approach In all polio-infected areas: Implement an aggressive SIA strategy prioritize eradication of type 1 poliovirus (higher paralytic attack rate and propensity for geographic spread) Optimize the OPV campaign In areas of prolonged outbreaks International outbreak response guidelines To address international spread Maintain/increase routine immunization Ensure immediate notification of newly-infected areas

9. Objective 2: Ensure sustainable surveillance for polioviruses

10. Situation analysis Surveillance for acute flaccid paralysis (AFP) cases: In endemic regions 59 of 66 countries are achieving certification standard surveillance In polio-free regions 16 of 80 countries are achieving certification standard surveillance Global Polio Laboratory Network (GPLN): 141 of 145 laboratories are fully accredited by WHO In 2008, new Real-time PCR assays to improve screening for vaccine-derived polioviruses (VDPVs) were evaluated Environmental surveillance : Systematic environmental sampling (in Egypt and Mumbai, India) Environmental surveillance elsewhere (especially in polio-free regions as part of broader enterovirus surveillance systems)

11. Key challenges Persistence of surveillance gaps Revitalizing AFP surveillance to achieve certification-standard in polio free areas Enhancing the speed of detection of wild polioviruses and VDPVs globally Coordinating a system for environmental surveillance efforts globally

12. Achieve certification-standard surveillance, down to subnational level Achieve certification-standard surveillance globally, at national level Initiate global environmental surveillance strategy Introduce new laboratory procedures globally Achieve enhanced surveillance standards (AFP rate >2) at the subnational level in all high risk, re-infected and endemic areas Through end-2013, achieve certification-standard surveillance, down to subnational level End-2013 End-2012 End-2011 End-2010 End-2009 5-year target

13. Objective 3: Achieve certification & containment of wild polioviruses

14. Certification-standard surveillance A minimum AFP detection rate of 1 case per 100,000 children <15 yrs At least 80% of AFP cases have adequate stool collection Stool adequacy  2 x 5-10g stool specimens taken 24-48 hrs apart within 14 days of onset of paralysis

15. Certification of Global Polio eradication Before a WHO region can be certified polio-free:  at least 3 years of no wild polio virus cases  under conditions of certification-standard surveillance  demonstrate capacity to detect, report & respond to ‘imported’ polio cases

16. Situation analysis Three Regions are certified polio-free (AMR, EUR, WPR). Regional Certification Commissions (RCCs) are functioning in all three remaining endemic Regions, with National Certification Committees A framework for long-term containment of all polioviruses has been established

17. Containment of wild polio virus stocks Purpose: To minimize the risk of an accidental or intentional reintroduction of wild poliovirus into the community from a laboratory or vaccine production site post-eradication Aim: to locate laboratories worldwide that store wild poliovirus and potentially infectious materials, and ensure that those materials are handled under appropriate biosafety conditions.

18. Key challenges Establishing international consensus on long-term containment requirements for all polioviruses Strategic approach Establish an area-specific process for certifying eradication in each conflict-affected area Finalize and implement the long-term containment activities

19. Objective 4: Prepare for VAPP & VDPV elimination & the post-OPV era

20. Situation analysis The VAPP burden is 250-500 cases/yr Since 2000, at least 10 cVDPV outbreaks in 10 countries Of 33 recorded individuals with iVDPVs, 5 have excreted for >5 years (chronic excretors) ?date for the eventual cessation of the use of OPV in routine immunization programmes

21. Key challenges Fully characterising VDPV risks in low- and middle-income settings Coordinating OPV cessation internationally as soon as possible after certification of wild poliovirus eradication. Developing affordable options for IPV use in low- and middle-income countries Establishing a process for verification of VAPP/VDPV elimination.

22. Strategic approach Expand new laboratory diagnostic procedures to enhance sensitivity to detect VDPVs Implement studies to better quantify and characterize iVDPV risks/implications Develop antiviral drugs to treat chronic iVDPVs Establish affordable IPV options Establish WHA Resolutions on the eventual coordination of OPV cessation, long-term containment of all polioviruses and use of mOPV in response to cVDPVs following OPV cessation (including use of international stockpile of mOPV) Update risk assessment on potential for intentional use of polioviruses in the post-eradication era.

23. Objective 5: Plan for Re-structuring of the Global Polio Eradication Initiative for the VAPP/VDPV Elimination Phase

24. Polio status in South Africa Last lab confirmed case was in 1989 AFP is notifiable since 1994 Case-based surveillance since 1995 4 strategies High routine coverage with OPV Mass immunisation campaigns ‘ Mopping-up’ campaigns AFP surveillance

25. National immunisation campaigns 1995, 1996, 1997, 2000 (2002 = WC), 2004, 2007 SA: national certificate in Oct 2006 Target for 2008: AFP detection rate of at least 2/100,000 SA 2008: AFP 2/100,000, stool adeq 82% WC 2008: AFP 2,3/100, 000 Stool adequacy 96% **************************************************