The Polio Emergency & Endgame

Strategy & Timelines

• context

• the polio emergency

• the polio endgame

Context

Oct 2011

Rukhsar Khatoon

West Bengal, India

January 2011

"WHO has removed

India from the list of

countries with wild

poliovirus"

Dr Margaret Chan

Director-General, WHO

25 February 2012

2010 & 2011

Recent Polio Outbreaks

World Health Assembly

"DECLARES polio

eradication…emergency

for global public health"

25 May 2012

The Polio Emergency

Nigeria, Pakistan, Afghanistan reach

eradication coverage thresholds by end-2012

Chad, DR Congo, Angola finish in 2012

Polio partners heighten accountability &

coordination & close the funding gap

Goals

Focus: chronically missed children

> 6500 more personnel at local levels

Multiple strategies for missed children

New national accountability structures

12

Activation of emergency centres/procedures

Strategic Health Operations Centre (WHO)

Emergency Operation Center (CDC)

Oct 2012

Pakistan & Afghanistan

Nigeria

0

250

500

750

1000

1250

2007 2008 2009 2010 2011 2012*

Ca

se

s

Polio, type 3 cases

Only Nigeria & Pakistan had type 3

in the last 15 months

* 25 Oct 2012: Nigeria = 17 cases; Pakistan = 2 cases

0

25

50

75

100

125

150

Pakistan Afghanistan Nigeria

Ca

se

s

2011 2012

Polio-paralyzed children at 25 Oct 2011 vs. 2012

Nigeria is the only country in the world

with increasing cases.

Management

Security

Current Gap: US$ 700 m

Firm Prospects: US$ 360 m

Best Case Gap: US$ 340 m

Financing gap, 2012-13

OPV campaigns were

cancelled in >25 high

risk countries due

to insufficient funds.

UN General Assembly Special Event on Polio, September 2012

Afghanistan

Pakistan

Bill Gates

Nigeria

Rotary

WHO

IDB

CDC

UNICEF

The Polio Endgame

World Health Assembly

"DECLARES polio eradication an

emergency for global public health…

…requests DG to rapidly finalize

a polio endgame plan, with a tOPV-

bOPV switch".

25 May 2012

Goal: to complete the eradication &

containment of all wild, vaccine-related

and Sabin polioviruses.

Vaccine-derived polioviruses

• circulating (cVDPVs)

• 1o immunodeficiency (iVDPVs)

• ambiguous (aVDPVs)

circulating Vaccine-Derived Poliovirus

Outbreaks (cVDPVs), 2000-2011

Type 2 (478 cases)

Type 1 (79 cases)

Type 3 (9 cases)

World Health Assembly:

2008 synchronize OPV cessation

2012 begin with OPV 2 cessation

SAGE Working Group, Sept 2012

OPV2 cessation has real risks with huge consequences.

'At least 1 IPV dose' – for at least 5 years after bOPV

cessation – will reduce consequences.

'Affordable' IPV is <$1.00/dose (ideally $0.50/dose).

2 viable options: ID IPV (1/5th dose) & adjuvanted IPV.

Wild virus eradication end-2014

OPV type 2 cessation 2015/2016

Global Certification end-2018

The Polio 'Endgame' Strategy

Post-OPV surveillance

2013 2014 2015 2016 2017 2018 2019

Years

Last wild polio case

Wild Virus Eradication

Sabin Virus Elimination

WPV Phase 2 containment

WPV certification

Sabin 2 elimination & validation

Containment & Certification Wild virus

eradication

1-dose IPV introduction

Sabin 2 cessation

Sabin 1 & 3 cessation

Independent Monitoring Board Oct 12

SAGE Nov 12

Polio Partners Group Nov 12

WHO Executive Board Jan 12

Next Steps

Summary

At 26 October 2012, polio

cases & infected countries are

the lowest in history.

Emergency

Last wild polio case

Endgame

Legacy

WPV certification

Stop bOPV; transition key staff,

infrastructure & systems

Stop transmission, build RI, introduce IPV,

switch tOPV:bOPV, develop legacy plan

Implement

Emergency

Action Plan

2012 2013 2014 2015 2016 2017 2018 2019 2020-25

The Polio Emergency & Endgame

Implications for Manufacturers

• increased OPV demand through 2019

• all countries need licensed bOPV

• IPV introduction in the near-term

• high priority for IPV <US$1.00/dose

Extra Slides

SAGE Polio Working Group: rationale for 'at

least 1 IPV dose prior to OPV2 cessation'

• prevent polio if exposed to a VDPV2 or WPV2

• improve response to mOPV2 in an outbreak

• reduce transmission of a reintroduced type 2

• boost immunity to wild poliovirus 1 & 3

• OPV cessation is essential to stop all polio disease

• OPV2 cessation may eliminate most risk while global surveillance & response capacity strongest

• IPV reduces risks associated with OPV cessation

• IPV price now in 'cost-benefit' range for 1 dose

• SAGE

• World Health Assembly

• VDPV expert consultation

• Global Certification Commission

Vaccine-associated paralytic polio (VAPP)

Vaccine-derived polioviruses (VDPVs)

250-500 VAPP cases/year

(40% due to Sabin type 2)

Polio outbreaks due to cVDPVs, 2000-12

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 First caseMost recent

case

Duration

in weeks

Mozambique 2 10-Feb-11 02-Jun-11 16

Myanmar 1 4 30-Apr-07 06-Dec-07 31

Indonesia 46 09-Jul-05 26-Oct-05 15

China 2 13-Jun-04 11-Nov-04 21

Philippines 3 15-Mar-01 26-Jul-01 19

DOR/Haiti 12 9 12-Jul-00 12-Jul-01 52

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 First caseMost recent

case

Duration

in weeks

Chad 1 5 25-Aug-12 28-Aug-12 <1

Nigeria 3 22 71 66 154 27 34 4 05-Jun-06 16-Aug-12 323

Somalia 1 6 1 9 1 19-Apr-11 23-Jul-12 65

Kenya** 3 18-Apr-12 25-Jun-12 9

DRCongo 13 5 18 11 17 04-Nov-11 04-Apr-12 21

Niger** 2 2 1 1 11-Nov-11 11-Nov-11 <1

Yemen 9 08-Aug-11 05-Oct-11 8

Afghanistan 5 1 10-Jun-10 20-Jan-11 32

India 15 2 18-Oct-09 18-Jan-10 13

Ethiopia 3 1 04-Oct-08 16-Feb-09 19

Madagascar 1 4 3 26-Jun-05 13-Jul-05 2

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 First caseMost recent

case

Duration

in weeks

Ethiopia 1 6 27-Apr-09 17-May-10 55

Cambodia 1 1 26-Nov-05 15-Jan-06 7

Most recent transmission chain

cVDPV type 2* Most recent transmission chain

cVDPV type 3* Most recent transmission chain

cVDPV type 1*

Country

Country

Country

Type 1

Type 2

Type 3

Immunodeficiency-associated VDPV

excretors (iVDPVs), 1962-2011

Duration No. Type 2

Prolonged > 6 mos 37 69%

Chronic >5 years 7 29%

SAGE Working Group, 4-5 Sept 2012 (1)

1. OPV2 cessation should be central goal of new endgame.

2. OPV2 cessation takes the world into uncharted territory

with real risks, which could have huge consequences.

3. 'At least 1 IPV dose' in all countries to reduce consequences

& help contain new viruses; add'l measures in HR areas.

4. 'Affordable' IPV is <$1.00/dose (ideally 0.50/dose); 2 viable

options: ID (1/5th dose) IPV and adjuvanted IM IPV.

SAGE Working Group (2)

5. Countries have preferences for ID and IM IPV; both

approaches should be pursued.

6. Countries should plan to continue at least 1 IPV dose

through at least 5 years after bOPV cessation.

7. OPV2 cessation to be targeted for 2015-16; by April 2013

SAGE will review prerequisites & potential timeline.