P liPolioEndgame Strategydga e St ategy

Dr. N K GoelProfessor & Head,Department of Community MedicineGovt Medical College & HospitalGovt. Medical College & Hospital,Chandigarh.

S ifi L i Obj tiSpecific Learning Objectives

• Progress toward polio eradication.

• Polio Endgame Plan.

• Withdrawal of Oral Polio Vaccine type 2.

I t d ti f IPV• Introduction of IPV.

IntroductionIntroduction• Global polio cases an all time low• Global polio cases ‐ an all‐time low.• The Global Polio Eradication Initiative (GPEI)( )has developed a new planU d d i di li• Unprecedented opportunity to eradicate polio.

• In 2012 the world saw fewer polio cases inIn 2012, the world saw fewer polio cases infewer countries than ever before.

Wild Poliovirus Eradication, 1988‐2012

125 Polio Endemic

125 Polio Endemic countries

countries to 3 endemic countries400

300

usan

ds)

200

ases

(tho

u

19882012

100

Polio

ca Last type 2 polio in the world

Last Polio Case in India

0

1… 1… 1… 1… 1… 1… 1… 1… 1… 1… 1… 1… 1… 1… 1… 2… 2… 2… 2… 2… 2… 2… 2… 2… 2… 2… 2… 2…

Beginning of the EndgameBeginning of the Endgame

• Success in India established strategic & scientificfeasibility of poliovirus eradication

• Poliovirus Type 2 eradication raised concernsb t ti d f tOPVabout continued use of tOPV

• India, long regarded as the most difficult place, g g pto end polio, has not recorded a case in morethan 05 yearsthan 05 years.– On 13th January 2011: last case reportedy p– On 28th March 2014: declared polio‐free

• Outbreaks in re‐infected countries‐stopped• Outbreaks in re‐infected countries‐stopped– Angola and the Democratic Republic of the Congoregaining polio‐free status in the last 03 years.

• 03 remaining endemic countries(Afghanistan Pakistan and Nigeria)(Afghanistan, Pakistan and Nigeria)

• launched Emergency Action Plans in 2012to boost vaccination coverage to levelsnecessarynecessaryto stop polio transmission.

N l 2 t i (Af h i t dNow, only 2 countries (Afghanistan andPakistan) remain endemic for the diseasethe smallest geographic area in history.

• The Eradication and Endgame Strategic Plang g– a comprehensive, long‐term strategy– addresses what is needed to eradicate polio by2018.

• The plan was developed by the Global PolioEradication Initiative (GPEI)Eradication Initiative (GPEI)– a partnership launched in 1988 to guide the

ld’ li ffworld’s polio efforts.

Hi hli ht f GPEI lHighlights of GPEI plans

Routine Places an urgent emphasis on strengtheningImmunization

g p g groutine immunization to boost immunity and aidin the introduction of new vaccines, including poliovaccines.

Vaccine Addresses both wild and vaccine‐derivedSwitch poliovirus (VDPV), using a global vaccine switch to

manage long‐term poliovirus risks and potentiallyg g p p yaccelerate wild poliovirus eradication.

Risk Anticipates and prepares for potential challenges,RiskMitigation

Anticipates and prepares for potential challenges,particularly insecurity, to enable rapid responsesto obstacles and avoid delays.y

Concrete Employs rigorous data analysis of recent progressTimeline to project a concrete, realistic timeline and

budget to reach eradication.

LessonsL d

Builds upon recent successes in India andd i t i d id t t i fLearned endemic countries and provides strategies for

overcoming potential obstacles.

LegacyPlanning

Prepares to transfer the polio program’sknowledge assets and infrastructure to benefitPlanning knowledge, assets and infrastructure to benefitother health initiatives.

• The Strategic Plan involves fourOBJECTIVES, which the GPEI will pursuesimultaneously:simultaneously:

1. Detect and Interrupt Poliovirus.2 Strengthen Routine Immunization and Withdraw2. Strengthen Routine Immunization and Withdraw

OPV.i d if3. Contain and Certify.

4. Plan Polio’s Legacy.g y

1 D t t d I t t P li i1. Detect and Interrupt Poliovirus.

• The plan provides a strategy to interrupt all wildpoliovirus transmission by the end of 2014 by:poliovirus transmission by the end of 2014 by:

Improving immunization campaigns to boostimmunity

Heightening surveillance to detect circulating virusHeightening surveillance to detect circulating virus Responding rapidly to outbreaks to prevent spread

• The three remaining endemic countries are alreadyseeing results from implementing Emergency ActionPlans that incorporate these and other strategies.Plans that incorporate these and other strategies.

• In 2012, Nigeria increased the percentage of high‐risk communities reaching target vaccination levelsg gfrom 10% to 70%.

2. Strengthen Routine Immunization gand Withdraw OPV.

• Strengthening routine immunization (RI):iti l l t f di ti ff t– a critical element of eradication efforts.

– boosts immunity to minimize the risk and extentyof outbreaks andprovides a platform for introducing new vaccines– provides a platform for introducing new vaccines.

• The plan lays out a clear strategy for leveraging GPEIbest practices and infrastructure to strengthen RIbest practices and infrastructure to strengthen RI.– e.g. the polio program’s micro plans can be used

lto improve RI planning.

• To eliminate the risk of vaccine‐derived poliovirusTo eliminate the risk of vaccine derived poliovirus(VDPV), the plan introduces a strategy to replaceoral polio vaccines (OPV) with inactivated poliooral polio vaccines (OPV) with inactivated poliovaccines (IPV).

• Strong RI programs will be critical for the rapid and• Strong RI programs will be critical for the rapid andsuccessful introduction of these new vaccines.

3 C t i d C tif3. Contain and Certify.

• Before certifying eradication,y g , Labs and vaccine‐production facilities worldwidemust properly contain all virus samplesmust properly contain all virus samples.

Both recently infected and polio‐free countries mustaddress gaps in surveillance.

All regions must surpass three years without a caseAll regions must surpass three years without a caseto attain polio free status.

4 Pl P li ’ L4. Plan Polio’s Legacy.

• The polio program provides a blueprint for accessingthe most marginalized and hard to reachthe most marginalized and hard‐to‐reachcommunities in the world.

• Sharing this expertise can benefit other health andSharing this expertise can benefit other health anddevelopment initiatives.

d li i it i A d i li i– e.g. delivering vitamin A during polio campaigns.– to combat other vaccine‐preventable diseases.

A t ti li f di tiA concrete timeline for eradication

• The GPEI used rigorous data analysis to establish aThe GPEI used rigorous data analysis to establish arealistic eradication timeline.

• Learning from past experience, the GPEI anticipatesLearning from past experience, the GPEI anticipatespotential obstacles that could interfere with thistimeline and develops strategies to avoid andtimeline and develops strategies to avoid andrespond to them.

Th l id tifi i i i kThe plan identifies six main risks.k• Input Risks

Insufficient fundingInsufficient fundingInability to recruit and/or retain the necessary

ffstaffInsufficient supply of appropriate vaccinespp y pp p

• Implementation RisksInability to operate in areas of insecurityInability to operate in areas of insecurityDecline in political and/or social willLack of accountability for quality activities

• Upfront commitment to fully fund the plan iscritical for eradicating polio by 2018critical for eradicating polio by 2018.

• Funding the Eradication and EndgameStrategic Plan will cost the global communityUS$5.5 billion (Figure 5),US$5.5 billion (Figure 5),– will be raised from multiple sources–including

i ti d d d th h i tiexisting and new donors–and through innovativefinancing mechanisms.

Assurance of full fundingssu a ce o u u d g

• Enables advance planning for late stage• Enables advance planning for late‐stageactivities, ensuring they can be carried out promptly

ffand efficiently.• Increases operational certainty, protecting programsp y, p g p gfrom being delayed or cancelled.M i i h lth i t b bli• Maximizes health impact by enabling programextensions that benefit other health initiatives.

• Sharpens focus, allowing the GPEI to concentrate oneradication activities instead of fundraising oreradication activities instead of fundraising orpreparing for funding shortages.

Endgame Plan, 2013‐18Endgame Plan, 2013 18

• Poliovirus detection & interruption

• OPV withdrawal IPVOPV withdrawal, IPV introduction, RI strengtheningC i & Gl b l• Containment & Global Certification

• Legacy Planning

Not detected since Nov 2012

Global Wild Poliovirus 2014 ‐ 2015*Comparative Corresponding period

Year-to-date 2014 Total in Year-to-date 2015 Date of Countries Total in

2014* most recent caseWPV1 WPV3 W1W

3 Total WPV1 WPV3 W1W3 Total

Pakistan 90 90 306 26 26 06-Jun-15Pakistan 90 90 306 26 26 06-Jun-15Afghanistan 7 7 28 4 4 05-May-15Nigeria 5 5 6 0 0 24-Jul-14gSomalia 1 1 5 0 0 11-Aug-14Equatorial Guinea 4 4 5 0 0 03-May-14Iraq 2 2 2 0 0 07-Apr-14Cameroon 3 3 5 0 0 09-Jul-14Syria 1 1 1 0 0 21-Jan-14Ethiopia 1 1 1 0 0 05-Jan-14Total 114 114 359 30 30

26

Total 114 114 359 30 30Total in endemic countries 102 102 340 30 30

Total in Non-endemic countries 12 12 19 0 0

*Data in WHO HQ as of 8 July 2015

Wild Poliovirus type 1 Cases, 2014yp

306     

Endemic countriesInfected countries 359     

Israel = Env. positive isolates (2013 , N=136 ; 2014, N=14 , last 30 Mar 2014)Gaza =  Env. positve isolates (2013, N= 7 ; 2014, N=1, Jan ) 

350WPV1 Cases, 2012WPV1 Cases, 2012‐‐15*15*

306300

350

2012 2013 2014 2015

200

250

s

Global progress 2015Global progress 2015No case in Nigeria andNo case in Nigeria and

122150

200

Cas

es

No case in Nigeria and No case in Nigeria and All time low in Afghanistan & PakistanAll time low in Afghanistan & Pakistan..

375853

93

28 2650

100

3714 28

64 026

0

50

Afghanistan Nigeria Pakistan*Data as of 2 June 2015 *Data in WHO HQ as of 8 July 2015

Wild poliovirus type 1 and Circulating vaccine‐p yp gderived poliovirus cases

Total  Year‐to‐date 2016 Year‐to‐date 2015 Total in 2015

casesWPV cVDPV WPV cVDPV WPV cVDPV

Globally 9 3 21 1 74 32

Endemic  9 0 21 1 74 3countries 9 0 21 1 74 3

Non‐endemic  0 3 0 0 0 29countries

Year‐to‐date  Year‐to‐date  Total in 2015Countries 2016 2015 Total in 2015

WPV cVDPV WPV cVDPV WPV cVDPVWPV cVDPV WPV cVDPV WPV cVDPV

Afghanistan 2 0 1 0 20 0

Pakistan 7 0 20 1 54 2

Guinea 0 0 0 0 0 7

Lao PDR 0 3 0 0 0 8

Madagascar 0 0 0 0 0 10Madagascar 0 0 0 0 0 10

Myanmar 0 0 0 0 0 2

Nigeria 0 0 0 0 0 1

Ukraine 0 0 0 0 0 2

OPV withdrawal, IPV introductionOPV withdrawal, IPV introductionWhy…...???

Types of poliovirusesTypes of poliovirusesyp pyp p•99% reduction in cases of wild poliovirus since 1988•Type 1 (359 cases in 2014)T 2

Type 1ld

Type 3

yp ( )•Type 2 (eliminated worldwide in 1999)•Type 3 (none detected since November 2012)

Type 2

Wi

•Vaccine‐associated paralytic poliomyelitis (VAPP)**•Estimated ~250‐500 globally per yearVAPPed •Estimated one case in 2.7 million OPV dosage•Type 2 accounts for about 26‐31%% of VAPP

VAPP

relate

•Vaccine derived polioviruses (VDPV)•~54‐185 per year from 2008 to 2014T 2 VDPV f 97% f VDPV

VDPVsOPV

 

11/3/2018 32

•Type 2 cVDPVs account for 97% of cVDPVs

Paralysis associated with use of OPV

VAPP (V i A i d P l i P li li i )

y

• VAPP (Vaccine Associated Paralytic Poliomyelitis):• Vaccine virus acquires neurovirulence and causes paralysis invaccine recipient or close contactvaccine recipient or close contact.

• VDPVs (Vaccine Derived Polio Viruses):( )• Vaccine virus acquires the virulence and transmissibilitycharacteristics of wild virus following prolonged multiplication inth t itthe gut or community.

Vaccine derived Polio Viruses (VDPVs) h h ?What are they?

• Strains of poliovirus which emerge after prolongedmultiplication of attenuated strains of the virus contained inpthe oral polio vaccine (OPV).

• Prolonged multiplication happens in the guts of childrenwith immunodeficiency or in populations with very lowimmunityimmunity.

• After prolonged multiplication, these vaccine virus derivedAfter prolonged multiplication, these vaccine virus derivedstrains change and revert to a form that can cause paralysisin humans.

Types of Vaccine derived Polio Viruses 

• cVDPV:– >1 isolation of genetically related viruses from any source(AFP case/ healthy child/ environmental sample) impliescirculation of VDPV due to low population immunity.

• iVDPV:– VDPV isolated from immuno‐deficient person.– Implies long‐term replication of the virus within the sameindividual.

• aVDPV:i i i ( bi ) i l i l f i l– origin uncertain (ambiguous) e.g. single isolate from single

AFP case, healthy or non‐immuno‐deficient person.

Vaccine‐derived polio outbreaks ( VDPV ) 2000 2013(cVDPVs) 2000‐2013

>90% VDPV cases are type 2(40% of Vaccine‐associated polio is also type 2)

Type 2 (478 cases)

Type 1 (79 cases)

Type 3 (9 cases)

Type 2Type 1Type 2Type 3

R ti l f OPV2 ithd lRationale for OPV2 withdrawalLast naturally occurring case of WPV case detected in Aligarh, India in 1999Type 2 polio vaccine causes >95% of Vaccine Derived Polio Virus (VDPV) casesPolio Virus (VDPV) cases Type 2 causes approximately 40% of Vaccine‐associated 

l ti li liti (VAPP)paralytic poliomyelitis (VAPP) cases

Type 2 component of OPV interferes with immuneType 2 component of OPV interferes with immuneresponse to types 1 and types 3

Risks of OPV2 now outweigh the benefits 

37

Withdrawal of Oral Polio Vaccines 

Gl b ll h i d h d i hd l f OPV• Globally synchronized, phased withdrawal of OPVstrains, starting with OPV type 2

• OPV type 2 withdrawal means that tOPV (P1+P2+P3) must be• OPV type 2 withdrawal means that tOPV (P1+P2+P3) must bereplaced with bOPV (P1+P3)

• Withdrawal of OPV type 2 will reduce risk of emergence ofyp gcVDPV type 2 and also reduce the burden of VAPP cases due toOPV type 2yp

National Switch DayNational Switch Day

• Country will select one day during two weeks of April2016 as their National Switch Day2016 as their National Switch Day.

• On this day, countries will:– Recall tOPV from cold chain and initiate its disposal– Recall tOPV from cold chain and initiate its disposal– Begin administration of bOPV

• tOPV and bOPV should not be administeredtOPV and bOPV should not be administeredsimultaneously

Switch example (April 2016)Switch example (April 2016)

Global Validation 

National Switch Day:stop tOPV use  

National Validation Day:all tOPV disposed

k k

Daydisposal and validation 2-week window

week  1                week  2                   week 3 week 4

Global switch  Global validation    2‐week window2‐week window 

The country selects a ‘National Switch Day’ from this window

window

Only bOPV used globallyafter this date

40

Risks associated with OPV type 2 ypwithdrawal

• Withdrawal of OPV type 2 will leave a gap in populationimmunity against type 2 poliovirusimmunity against type 2 poliovirus

• Increased risk of outbreaks due to type 2 poliovirus followingreintroductionreintroduction

• Re‐introduction could occur if:VDPV t 2 d d i h tl ft OPV t 2– cVDPV type 2 emerged during or shortly after OPV type 2withdrawal

– Importation of cVDPVs occurs– Break in bio‐containment process in laboratories storingviruses.

• Risks associated with OPV type 2 withdrawal can bemitigated

Mitigate the risk of low population g p pimmunity against type 2 polio

• Emphasis on routine immunizationt th istrengthening– raising coverage critical for achieving the endgameg g g g

• Introduce IPV prior to OPV type 2 withdrawal.

126 OPV‐only using countries*126 OPV‐only using countriesshould introduce IPV by the end ofshould introduce IPV by the end of 

2015   

OPV ONLY (126 countries)IPV ONLY   (47 countries)IPV/OPV (24 countries and 6 Territories)

43

IPV/OPV  (24 countries  and 6 Territories)

* Status as on January 2013

Gl b l IPV i t d tiGlobal progress on IPV introduction

• 126 OPV using countries to introduce IPV in their RIschedule before tOPV to bOPV switchschedule before tOPV to bOPV switch.

• 20 countries already introduced IPVy

• India have introduced IPV in Oct 2015.

SummarySummary• Globally no polio virus type 2 detected since 1999.

• Withdrawal of type 2 OPV implies switching from tOPVyp p gto bOPV in the programme– Globally coordinated withdrawal of OPV type 2 essential toGlobally coordinated withdrawal of OPV type 2 essential toeliminate VDPV and VAPP risks associated with continueduse of OPV type 2use of OPV type 2

Si l d f IPV i i i k f l l i• Single dose of IPV to mitigate risk of low populationimmunity against type 2 polio virus.

h kThank You