polio endgame strategy in india considerations and way forward who-india, npsp 15 march 2012
TRANSCRIPT
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Polio Endgame Strategy in India
Considerations and Way Forward
WHO-India, NPSP
15 March 2012
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Outline of the presentation
• Background/Context
• Considerations
• Possible Way forward
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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
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Last wild poliovirus cases by type, India
WPV2 24/10/1999
Aligarh (UP)
WPV1 13/01/2011
Howrah (WB)
WPV3 22/10/2010Pakur (JH)
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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
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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
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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%
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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
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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
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Managing the risk of VDPVs
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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
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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
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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
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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
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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
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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
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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