Polio Endgame Strategy in India

Considerations and Way Forward

WHO-India, NPSP

15 March 2012

Outline of the presentation

• Background/Context

• Considerations

• Possible Way forward

Context

• No WPV2 in India since 1999

• tOPV used in RI and during NIDs

• bOPV used in most SNIDs since Jan 2010

• Areas and populations with low routine immunization coverage

• All cVDPVs in India due to type 2 in setting of low immunity to type 2

Last wild poliovirus cases by type, India

WPV2 24/10/1999

Aligarh (UP)

WPV1 13/01/2011

Howrah (WB)

WPV3 22/10/2010Pakur (JH)

Current pattern of vaccine use-India

• tOPV– EPI schedule: 6,10,14 wks

Birth dose for institutional births

– SIAs: 2 NIDs with tOPV each year

• bOPV– Introduced in Jan 2010– Used extensively during

SNIDs in high risk states/ areas

70.4%

<6060 - 7070 - 80>= 80

AssessedtOPV3 coverageby CES 2009

cVDPV cases, India 2009-2011

•cVDPV cases detected in 2009-10

•100% due to type 2

DistrictType 2

2009 2010 2011

Badaun 3 0 0

Bulandshahar 2 0 0

Ghaziabad 0 1 0

Meerut 2 0 0

Moradabad 2 0 0

Pilibhit 4 0 0

Shahjahanpur 2 1 0

Total 15 2 0

Low seroprevalence against poliovirus type 2Results from different serosurveys

Moradabad Nov 2007(N=121)

AFP cases UP

Nov 08 – mid 09(169)

Moradabad May 2009(N=534)

UP & BiharAug 2010(N=1280)

UP & BiharAug 2011(N=1246)

Age 6-7 mo 6-11 mo 6-7 mo 6-7 mo 6-11 mo

Type 1 78% 96.5% 99% 98% 98.5%

Type 2 56% 33.7% 75% 65% 85%

Type 3 69% 42.6% 49% 77% 88.2%

0

1

2

3

4

5

6

7

8

9

10

J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D

cVDPV type 2

Uttar Pradesh

2009 2010 2011

Nu

mb

er

of

ca

se

s

c VDPV type 2

tOPV

< 25%25 to 50%50 to 75%>= 75%

District.shp0 - 24.925 - 49.950 - 74.975 - 100

State.shp

200 0 200 400 Miles

N

EW

S

View1

tOPVsNID

tOPVNID

tOPVsNID

tOPVNID

Evaluated OPV3 coverage by district – DLHS 3 (2007-08) and cVDPVs

iVDPV & aVDPV cases, India 2009 to 2012*

*: data as on 10 March 2012

iVDPV aVDPV

State Type 1 Type 2 Type 3

Chhattisgarh 1Punjab 1Tamil Nadu 1Uttar Pradesh 1Odisha 1

Total 1 3 1

ambiguous VDPV (aVDPV): origin uncertain e.g. single isolate from single AFP case, non-immunodeficient person

Managing the risk of VDPVs

tOPV-bOPV switch in India? Considerations

• Pre-switch increase in type 2 immunity• Rapidly improve routine immunization coverage• Use of IPV in conjunction with bOPV/tOPV to reduce

risk of emergence and consequences of cVDPV• Availability of vaccines

– IPV availability for use in routine immunization– bOPV availability for routine immunization and SIAs

• Management of post-switch risks of type 2 VDPVs• cVDPV type 2 circulation stopped everywhere &

switch synchronised globally

Pre-switch boosting of type 2 immunity

• Switch soon after tOPV NIDs

• Improve RI, particularly DTP3 and OPV3 coverage

• Adding a dose of IPV in RI for infants prior to switch

IPV introduction

• Benefit – impact on RI ?

• Timing/Age/Doses/Route – follow global SAGE recs ?

• Frequency: 2 doses in known cVDPV risk areas?

Modelling and Research in the India context may help optimise strategy for India

bOPV availability

• Licensure and pre-qualification of additional manufacturers to meet requirements of India pre and post-switch

bOPV assessment study to support licensure

of additional manufacturers

Post-switch VDPV type 2 risk management

• Heightened surveillance to detect post-switch Sabin type 2 (not just VDPV type 2!)

• Stockpile/ Capacity to produce mOPV2 at short notice

Certification standard surveillance to continue beyond certification

NID NID

0Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May

Polio Endgame Strategy-India, Possible Way Forward

2011 2012 2013 2014

Last WPV case

Polio certification

IPV NID NID

tOPV NID

Post-switch Sabin type 2 risk mgt.

tOPV-bOPV switch

NID NID NID NID

Certification standard surveillance, improved RI coverage

PQ/ licensing, stockpile

Modelling, Research, Development

Conclusions

• India can be in a position to move ahead with polio endgame strategy

• Careful planning and consideration of risks required before implementation

• Earliest possible timing for tOPV-bOPV switch: Qtr.1 2014

• Lessons from tOPV-bOPV switch significant for subsequent withdrawal of all OPV from programme