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)
WPV3
22/10/2010
Pakur (JH)
WPV1
13/01/2011
Howrah (WB)
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
Assessed
tOPV3 coverage
by CES 2009
A
• bOPV
– Introduced in Jan 2010
– Used extensively during
SNIDs in high risk states/
areas
70.4%
<60
60 - 70
70 - 80
>= 80
cVDPV cases, India 2009-2011
•cVDPV cases detected in 2009-10
•100% due to type 2
Type 2
District
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 2
Results from different serosurveys
Moradabad
Nov 2007
(N=121)
AFP cases
UP
Nov 08 –
mid 09
(169)
Moradabad
May 2009
(N=534)
UP & Bihar
Aug 2010
(N=1280)
UP & Bihar
Aug 2011
(N=1246)
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%
Age
Evaluated OPV3 coverage by district – DLHS 3 (2007-08)
and cVDPVs
State.shp
District.shp
0<-25%
24.9
25
49.9
25-to
50%
50
74.9
50 to 75%
75
100
>=-75%
Uttar Pradesh
N
cVDPV type 2
W
0
200
400 Miles
S
10
tOPV tOPV
sNID NID
9
tOPV
NID
tOPV
sNID
8
7
tOPV
c VDPV type 2
Number of cases
200
E
6
5
4
3
2
1
0
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
2009
2010
2011
iVDPV & aVDPV cases, India 2009 to 2012*
iVDPV
State
Chhattisgarh
Punjab
Tamil Nadu
Uttar Pradesh
Odisha
Total
*: data as on 10 March 2012
Type 1
Type 2
aVDPV
Type 3
1
1
1
1
1
1
3
1
State
Type 1
Assam
Bihar
Karnataka
Madhya Pradesh
Rajasthan
Uttar Pradesh
West Bengal
1
Total
1
Type 2
3
1
1
1
4
1
11
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 postswitch Sabin type 2 (not just VDPV type 2!)
• Stockpile/ Capacity to produce mOPV2 at
short notice
Certification standard surveillance to continue
beyond certification
Polio Endgame Strategy-India,
Possible Way Forward
tOPVbOPV
switch
Polio
certification
Last WPV
case
NID
NID NID
NID
NID
NID
NID
IPV
NID
Modelling, Research, Development
PQ/ licensing, stockpile
Postswitch
Sabin
type 2
risk mgt.
Certification standard surveillance, improved RI coverage
0
Jan
Mar
May
2011
Jul
Sep
Nov
Jan
Mar
May
Jul
2012
Sep
Nov
Jan
Mar
May
Jul
2013
Sep
Nov
Jan
Mar
May
2014
tOPV NID
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