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 medicineKatihar 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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Polio

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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



• 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

PAKISTAN AFGANISTAN NIGERIA

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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

JanMar

May JulSe

pNov Jan

MarMay Jul

Sep

Nov JanMar

May JulSe

p -

100 000

200 000

300 000

400 000

500 000

600 000 520 532

343 180

35 937

Decline in Inaccessibility, Pakistan.

2013 2014 2015




• Legacy Planning


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 2Type 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)

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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 dateand 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 TerritoriesMap 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 surveillanceStopping type 2 outbreak • Detection & Response protocol • mOPV2 + IPVReducing outbreak consequences• IPV in RI

– Reduce paralytic cases – Facilitate outbreak response




• Legacy Planning


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Poliovirus containmentA system for confining polioviruses within a defined space

WHA resolution 68.3:– The May 2015 resolution urges countries to

implement GAPIII

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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.

GAP IIIWHO global action plan to minimize

poliovirus facility-associated risk after type-specific eradication of wild polioviruses and

sequential cessation of OPV use

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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

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




• Legacy /Transition Planning


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.

Thank You

global polio eradication and endgame strategy

Health & Medicine