Annals of Community Health (ISSN 2347-5455, eISSN 2347-5714), Peer Reviewed, Indexed Journal focusing exclusively on Community Medicine and Public Health

Polio Eradication End Game- Dr.Pavana Murthy, WHO

3 areas of engagement

  • Strengthening Routine Immunization
  • Certification of South-East Asia Region as polio-free
  • Polio end-game strategy

Certification of polio eradication

  • Certification is done for WHO Regions and not for individual countries
  • WHO Regions that have been certified polio free:
    • Americas: 20 August 1994
    • Western Pacific: 29 October 2000
    • Europe: 21 June 2002
  • Certification of a region is considered only when
    • All countries in the area demonstrate
      • the absence of wild poliovirus transmission for at least three consecutive years
      • presence of certification standard surveillance
      • global action plan for laboratory containment of wild poliovirus

Regional Certification Commission for Poliomyelitis Eradication (RCCPE)

  • Appointed by Regional Directors
  • Authority to certify polio eradication in the region
  • Decision based on
    • Opinion of national committees
    • Supporting evidence provided by national committees
    • Visits to countries to verify the data
    • Completeness and accuracy of data
  • Certification of global polio eradication will be announced only after all regional commissions have certified their respective regions

National Certification Committee for Poliomyelitis Eradication (NCCPE)

  • Government established independent NCCPE in 1998
  • Examine, assess and verify data collected by government
  • Field visits to review evidence of interruption of poliovirus transmission in the country
  • Independent judgment of polio status
  • Present country report to RCCPE

Certification of SEAR

Certification standard surveillance

  • Non-polio AFP rate: ≥2 per 100,000 population aged less than 15 years annually
  • Adequate stool specimens : ≥80%
  • All stool specimens tested for poliovirus at a WHO-accredited laboratory
  • Additional Criteria
    • Investigation of AFP cases within 48 hours of initial notification: ≥80%
    • Timeliness of weekly AFP surveillance reports: ≥80%

Laboratory containment of WPV

To minimize the risk of reintroduction of WPV into the community from a laboratory

  • WHO action plan comprises three phases:
    • Phase 1: laboratory survey and inventory
    • Phase 2: global certification: implement appropriate biosafety measures
    • Phase 3: post global certification: more stringent, will be prepared when there is global strategy to stop OPV
    • For regional certification evidence that phase 1 has been implemented

Polio Endgame Strategy

  • 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

Trends in Seroprevalence Against Poliovirus

Managing the risk of VDPVs

  • Preparing for the polio endgame
  • A tOPV-bOPV switch globally (? 2015/2016)
  • Use of IPV in conjunction with OPV (?)
  • Eventual cessation of all OPV use globally at some point in the future (e.g. 2017-18 period).
  • Support research activities to generate evidence to guide decision making

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

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/Dose/Route

Planned Research

  • Compare immunogenicity against poliovirus types 1 and 3 by bOPV & tOPV given as part of routine EPI schedule
  • Assess gain in immunity (booster effect) of a full dose or fractional dose of IPV when added to tOPV or bOPV at 14 weeks (DPT3 contact) in EPI schedule
  • Assess operational feasibility of intra-dermal IPV fractional dose using BCG syringe

bOPV availability

Planned Research

  • Generate data on immunogenicity and safety of additional bOPV products for potential licensing by national regulatory authority (DCGI) in India
  • Demonstrate superiority of 2 doses of bOPV of different manufacturers over tOPV for seroconversion to types 1 and 3
  • Additional options for bOPV supply to meet high vaccine requirement in India & globally – important specially for the endgame strategy

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


Conclusions

  • India can be in a position to move ahead with polio endgame strategy.
  • Careful planning and consideration of risks required before implementation.
  • Lessons from tOPV-bOPV switch significant for subsequent withdrawal of all OPV from programme.


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