Polio Eradication Post Eradication Vaccination Policy March 2007

Polio Eradication & Post Eradication Vaccination Policy March 2007 1

A bit of background…. 2

Egyptian stele with polioafflicted priest circa 3000 B. C. Polio Eradication 3

Two Excellent Vaccines Dr Jonas Salk IPV, 12 April 1955 Dr Albert Sabin OPV, 1961 & 1962 4

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Polio – the world in 1988 >350, 000 cases >125 polio-endemic countries 1988: World Health Assembly Voted to Eradicate Polio 6

Polio Eradication Strategies 1. Routine Immunization 2. National Immunization Days (NIDs/SNIDs) 3. Surveillance 4. Mop-ups 7

Successful Proof of Principle Americas Last Polio Case Peru 1991 Polio Eradication 8

A Brief History of Eradication Polio Eradication 9

A glimpse at recent history…. 10

Polio - the world in 2003 784 cases 6 polio-endemic countries >99% reduction in disease 11

Challenge 1: Persistent Polio Despite Very High Coverage 12

Challenge 2: International Spread of Poliovirus, 2003 -6 25 countries, 71 events Indian origin: 13 (18%) Wild virus type 1 Wild virus type 3 Endemic countries Case or outbreak following importation (last 6 months) Nigerian origin: 58 (82%) 13

Challenge 3: Campaigns in key areas were still missing too many children Very young children & minorities Insecure areas & mobile populations OPV rumours & very poor quality NIDs 14

A new, 2 -pronged approach… 15

1. New tools were developed to stop polio in infected areas & limit international spread. 16

New Polio Vaccines monovalent OPV types 1 & 3 (m. OPV 1 & m. OPV 3) New Trial Data, Egypt 'monovalent' OPV protects 2 x greater 17

New approaches to engage all societies Muslim Leader Conclave Northern India Community Dialogues Northern Nigeria 20

New Recommendations to Reduce International Spread World Health Assembly EB 22 January 2007 'Establish 'standing recommendation' under International Health Regulations, requiring full OPV immunization of all travellers from all infected areas' Saudi Arabia now requires proof of OPV for entry visas. 22

Polio – the world at end-2006 1, 968 cases 4 endemic countries district with type 1 polio district with type 3 polio endemic areas 23

2. New strategies were developed to address the unique challenges in the last 4 endemic areas. 25

Northern Nigeria 26

New 'Immunization Plus Days' (IPDs) Fixed Sites: • 5 days • m. OPV 1, measles, DPT • deworming medicine, bednets, etc Mobile Teams (house-to-house): • 5 days • m. OPV 1, social mobilization. 27

Impact of IPDs & m. OPV 1, Nigeria 2006 t. OPV m. OPV 29

Northern India 30

Polio is now a disease of very young children (P 1 cases by age, Uttar Pradesh, 2006) >85% of cases are aged <3 years 31 * data as on 9 th December 2006

New plan to close immunity gap in young children m. OPV 1 rounds every 4 IMMUNE weeks & m. OPV 1 at birth SUSCEPTIBLE Age range 32

Pakistan & Afghanistan Shared border areas & populations 33

New Strategies, AFG & PAK President Karzai Announces Polio Action Group to Coordinate all Ministries AFG & PAK Ministers Announce Synchronized, Cross-Border 'Final Push', Nov 2006 35

In 2007 -8 we have a 2 nd, and best, chance to eradicate polio using new tools & strategies that are 2 x times better than before. 36

The optimum vaccination strategy in a polio-free world… 37

…depends on the overall plan for managing longterm polio risks 38

Risks of Polio After 'Eradication' Risk Frequency to date Annual burden Evolution over time VAPP 2 -4/m birth cohort 250 -500 stable i. VDPV 28 identified (since 1963) <1 decreases c. VDPV 1* per year 10 increases IPV sites 1 accident (1990 s) <1 decreases Lab accident 1 investigation NK decreases Deliberate NK unknown 0 39 *based on current understanding

c. VDPV Outbreaks (Circulating Vaccine-derived Polioviruses, 2000 -5) China 2004 2 cases Hispaniola 2000 22 cases Indonesia 2005 46 cases Madagascar 2002 & 2005 7 cases Philippines 2001 3 cases 40

Advisory Committee on Polio Eradication (ACPE), 2004 Policy Directive: after interruption of wild type poliovirus, continued OPV use would be incompatible with eradication. Timing: cessation of routine OPV must occur while population immunity & surveillance sensitivity are high. 41

Options for Longterm Polio Immunization Policy Could inadvertantly increase longterm risks (due to lack of vaccines, bioterrorism, etc) • Stop all polio immunization. • Stop all OPV; limited IPV use. • Replace all OPV with IPV. • Introduce new polio vaccines. Not possible or realistic from regulatory, 43 manufacturer & other perspectives

Global Risk of c. VDPV Emergence after Synchronous OPV Cessation 44 * from Duintjer-Tebbens RJ et al. Risks of Paralytic Disease due to Wild or Vaccine-derived Poliovirus after Eradication. Risk Analysis 2006; 26(6): 1471 -1505.

Potential Options in the 'Post-OPV' Era Countries with 'biohazards' (handling/storing poliovirus) coverage routine IPV very high 4 -5 dose schedule Countries perceiving high risk routine IPV (e. g. bioterrorism, biohazards) 2 dose schedule (? ) fractional dosing (? ) 45

A 'Sabin-IPV'? 1. Reduce risk of virus release from IPV production sites 2. Maintain access to OPV after commercial production ends. Advisory Committee on Polio Eradication "…urges acceleration of studies to demonstrate 46 safety and efficacy of an IPV using Sabin strains. "

In battle, no plan survives contact with the enemy. von Moltke, the elder. 47

Conclusions 48

Immediate Priorities - Polio Eradication • Reaching the missed kids in 4 areas, • Managing outbreaks, • Closing the financing gap, • Opening & sustaining a dialogue with the heads of governments. 49

Closing the Funding Gap Risk Financing, 1988 -2008 (at 1 Jan 2007) G 8 51% Multilateral Sector 16% Other Private Sector 21% 2007 -8 Funding Gap US$ 575 million Non-G 8 OECD/ Other 12% ‘Other’ includes: the Governments of Austria, Australia, Belgium, Czech Republic, Finland, Hungary, Iceland, Ireland, Italy, Luxembourg, Malaysia, Monaco, New Zealand, Oman, Pakistan, Portugal, Qatar, Republic of Korea, Russian Federation, Saudi Arabia, Singapore, Spain, Switzerland, Turkey, the United Arab Emirates; African Development Bank; AG Fund; American Red Cross; De Beers, Inter-American Development Bank, Central Emergency Response Fund (CERF), International Federation of 50 Red Cross and Red Crescent Societies, Oil for Food Programme, OPEC Fund, Sanofi Pasteur; Saudi Arabian Red Crescent Society, Smith Kline Biologicals, UNICEF National Committees, UNICEF Regular and Other Resources, United Arab Emirates Red Crescent Society, WHO Regular Budget and Wyeth.

'We will finish polio eradication' Dr Margaret Chan WHO Director-General Elect WHA acceptance speech 9 Nov 2006 51