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.