Download - Polio Endgame Strategy in India Considerations and Way Forward WHO-India, NPSP 15 March 2012
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