Polio End Game Strategy _ India

Polio EradicationFrom Emergency to “Endgame”

Dr. Anil KumarDistrict Immunization & Child Health

OfficerDoPHFW, KURNOOL

In 2012, the world saw the fewest polio cases in the fewest countries ever. India, long regarded as the most difficult place to end polio, has not recorded a case in more than two years.

The 'polio emergency' 2012-13

The ”Year of Intensification of RI”2013-14

The 'polio endgame' 2014-18

EPRP

Emergency Preparedness andResponse Plan

EPRP Goals

Ensure preparedness &Rapidly respond to any WPV outbreak

To support the transformational change

Serve as a critical precursor for the End game

Focus on Chronically missed children

Intensification of RI 2013 - 14

Special Immunization Weeks – 4 Rounds

Special Immunization Weeks – 2 Roundsin HRAs

Focus on High priority Districts

1• Augmented Supervision

2• Accelerated Monitoring

3• Enhanced Financial Support

4• Focus on Quality

What is the polio 'endgame'?

The endgame: addressing risks due to the oral polio vaccine (OPV) after eradication

● Vaccine-Associated Paralytic Poliomyelitis (VAPP): very rare adverse event.

● Outbreaks of circulating vaccine-derived poliovirus (cVDPV): very rare event;

occurs when vaccine virus regains ability to paralyze

and circulate.

'After interruption of wild poliovirus, continued use of OPV would compromise the goal of a polio-free world.

Expert Consultation on Vaccine-derivedPolioviruses (VDPVs), Sept 2003, Geneva

Detect and Interrupt Polio Virus

Strengthen systemWithdraw OPV

Contain & Certify

Plan Polios’ legacy

The plan provides a strategy to interrupt all wild poliovirus transmission by the end of 2014To eliminate the risk of vaccine-derived poliovirus (VDPV), oral polio vaccines (OPV) will be phased out & inactivated polio vaccines (IPV) will be gradually introduced. Strong immunization systems will help rapidly and successfully introduce new polio vaccines.

All regions must pass three years without a case to attain polio-free status, to be followed by global certification.

The polio program provides a blueprint for accessing the most marginalized and hard-to-reach communities in the world. Sharing this expertise can benefit other health and development initiatives

The Strategic Plan has four objectives.

2013 2014 2015 2016 2017 2018

OPV2Withdrawal

Certify Eradication

Interrupt Wild Polio transmission

Respond to continuing vaccine derived polio outbreaks

Strengthen Immunization

system, Prepare vaccine switch

Introduce IPV

Withdraw OPV2

Continue immunization with IPV and

OPV

Finalize containment plans

Carry out eradication certification

Identify legacy opportunitiesMainstream knowledge,

infrastructure to benefit other programs

1. Detect and Interrupt Polio Virus

2. Strengthen Immunization systems & Withdraw OPV

3. Contain and Certify

4. Plan Polio Legacy

Eradication and Endgame Timeline

2019 –bOPV cessation

Advantages of the New Approach

• accelerate type 1 & 3 eradication (with bOPV)

• address >90% of VDPV risk while surveillance &

response capacity is optimized

• substantially shorten the post-eradication phase

• boost routine immunization coverage (i.e. IPV at DPT3)

Strategic Advisory Group of Experts on immunization

Polio Endgame Strategy in IndiaConsiderations and Way Forward

● 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 24/10/1999Aligarh (UP)

WPV1 13/01/2011

Howrah (WB)

WPV3 22/10/2010Pakur (JH)

Current pattern of vaccine use-India

A

• 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%

<60

60 - 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

iVDPV & aVDPV cases, India 2009 to 2012*

State Type 1 Type 2

Assam 1

Bihar 3

Karnataka 1

Madhya Pradesh 1

Rajasthan 1

Uttar Pradesh 4

West Bengal 1

Total 1 11

*: data as on 10 March 2012

State Type 1 Type 2 Type 3

Chhattisgarh 1

Punjab 1

Tamil Nadu 1

Uttar Pradesh 1

Odisha 1

Total 1 3 1

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

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

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

The 'Polio Endgame‘_ Conclusions

While the past cannot be re-enacted, the future can certainly be redesignedSequential IPV/OPV schedules considered 1st phase transition towards all IPV schedule in

Routine Immunization.The program should attend

TO COUNTRY SPECIFIC NEEDSAnd Not get overawed by Global needs

Ultimately success of the whole initiative will depend on steps being taken now to improve the economics of IPV.

V Vashishtha RTC Series 2010(24) RSF India

HOPE THIS IS

THE HISTORICAL

LAST POLIO CASE

OF INDIA

LET US THANK ALL THE DEDICATED VOLUNTEERS, WITHOUT THEM POLIO ERADICATION IN INDIA IS NOT POSSIBLE

• Each national immunization day involved:

• 225,000,000 doses of polio vaccine• 172,000,000 children vaccinated

• 2,500,000 vaccinators• 2,000,000 vaccine carriers

• 155,000 supervisors

Polio Eradication and Endgame Strategic Plan

2013–2018 will pay dividends for generations to come.