RF_DIS_6_SUDHA.pdf1.pdf
Media
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RF_DIS_6_SUDHA.
V) 5- 6
diseases, SARS seems to present a particularly serious threat to international
health. Although SARS has a low mortal
ity rate - 4 per cent - its clinical and
epidemiological features remain poorly
understood. Except for the Human Im
munodeficiency Virus-Acquired Im
mune
Deficiency
Syndrome
(HIV-AIDS), most diseases that
emerged during the past two and a half
decades, or became endemic in new ge
ographical areas, have features that limit
their capacity to pose a major threat to
international public health. Diseases
such as avian influenza, and those caused
by the Nipah virus, the Hendra virus and
the Hanta virus failed to establish effi
cient human-to-human transmission.
Others such as Escherichia coli
O157:H7 and variant Creutzfeldt-Jakob
d.'^ase depend on the food chain for
^^Ismission.
Although outbreaks of the Ebola
haemorrhagic fever have been associated
with high fatality rates - 53 per cent in
Uganda to 88 per cent in Congo - person-to-person transmission requires
close physical exposure to infected blood
and other bodily fluids. Moreover, pa
tients suffering from this disease cannot
undertake travel. In contrast, SARS,
whose mode of transmission has been
likened to that of Ebola, is emerging in
ways that suggest great potential for rapid international spread. Epidemiological
data indicate that the gestation period for
SARS is two to 10 days (an average of
two to seven days), which gives ample
time for the infectious agent to be transported from one city to another through
an asymptomatic air traveller.
The Indian case and that of a patient
t.r
'ling from Hong Kong to 'Vladivos'
tc
.lave highlighted the emergence of
another international path for the virus,
namely the sea-route. Since the foci of
the disease seem to lie in the West Pacific
rim, it is surprising that even rhe WHO
had not considered this as an important
epidemiological factor. Should SARS
continue to spread, the global economic
consequences - already estimated at
around $30 billion - could be enormous.
However, the outbreak of SARS has
demonstrated how well the WHO can
tackle a newly identified disease. The in
ternational collaborative research effort
in understanding the cause of SARS was
put together by the WHO in record
time. The WHO believes that the sys
tem, which is now in operation can ’be
applied to other pandemic outbreaks, in
cluding the release of a biological agent
in an act of warfare or terrorism. ■
FRONTLINE, MAY 9. 2003
| PUBLIC HEALTH
A reluctant battle
against polio
Uttar Pradesh accounts for 64 per cent of the polio cases reported
worldwide, but its Chief Minister, Mayawati, is honoured with the
Rotary International award for her "outstanding personal
contribution" towards eradicating the disease from the State.
PURNIMA S. TRIPATHI
r I ' HE World Health Organisation
J- (WHO) has described Uttar Pra
desh as the “epicentre of polio epidemic”
in the world. As per WHO estimates,
the State accounts for 64 per cent of all
polio cases reported worldwide. In com
parison with 2001, the State registered a
sixfold increase in the incidence of polio
in 2002. According to the WHO, the
sharp increase was because of a decrease
in the number of polio eradication campaigns that year. Besides, the campaigns
that were conducted failed to reach near
ly 15 per cent of the targeted population,
Launching the third phase of the national pulse polio campaign on April 7,
WHO Director-General Dr. Gro Harlem Brundtland said: “Eighty-three per
cent of all new polio cases are now found
in India. Uttar Pradesh, in particular,
should be the number one priority in
order to stop the transmission of the
polio virus around the world.”
According to WHO estimates, In
dia’s record in polio eradication is worse
than that of countries such as Bangla
desh. (Bangladesh has been declared ‘po
lio free’.) India tops the list of seven
countries, where polio is still widespread,
India and Nigeri.
geria are the only countries
that have registered increases in the
number of polio cases. The other countries where polio is prevalent are Egypt,
Pakistan, Afghanistan, Niger and
Somalia.
According to the WHO, in 2002,
the epidemic spread across northern In
dia and to hitherto polio-free States such
as Maharashtra, Gujarat and West Ben
gal. In January 2003, a child was paralysed by polio in Lebonan for the first
time in nearly 10 years. Genetic se
quencing of the virus confirmed that it
originated from Uttar Pradesh, WHO
sources said. According to Rotary In
ternational, even in Bulgaria, which was
declared polio free, cases were reported
in 2002, and genetic analysis of the virus
revealed it was from Moradabad in Uttar
Padesh.
Given the State’s poor record in
dealing with the polio epidemic, it was
rather surprising that Rotary Interna
tional conferred the Paul Harris Fellow
award on Chief Minister Mayawati for
her “outstanding contribution” towards
eradicating polio. The award, which in
cludes a certificate, a gold medal and a
Rotary pin, was presented to her by rep
resentatives of Rotary International and
the United Nations Children’s Fund
(UNICEF), at her official residence on
January 20. Mayawati, who became
Chief Minister only in May 2002, said
that eradicating polio would continue to
be her government’s priority. However,
government officials seem to be at a loss
for words when asked to elaborate on
Mayawati’s ‘personal contribution’ to
eradicating polio. Even Rotary function
aries are unable to explain why the State
had registered a sixfold increase in polio
cases in 2002, despite the Chief Minis
ter’s “outstanding contribution”.
A senior Rotary functionary, who
has been associated with the pulse polio
campaign, said the award had been con
ferred on the Chief Minister to “motiva
te” her to take more interest in the polio
eradication campaign. A Rotary member
said: “The increase has not been due to
mismanagement at the government lev
el. There are other factors responsible for
it. One is the people’s apathy to such
campaigns, which lack credibility. Be
sides, misinformation about the polio
vaccine being administered is also greatly
responsible for the increase.” According
to him, an alarming factor was the resist
ance of people belonging to the minority
125
§ economic justification for
| any child anywhere in the
g world toi be crippled by
| polio,” 1Dr. Brundtland
S said.
The Central govern
ment is allocating more
funds for the pulse polio
programme. Against last
year’s allocation of Rs.4
billion, Rs.4.5 billion has
he said.
been earmarked for this
Other factors respon
year. Dr. Daniel Tarantosible for the resurgence of
la, Director of Vaccines
the epidemic in Uttar Pra
and Biologicals at the
desh are the high density
WHO, said: “This is an
of population and the lack
extraordinary epidemic. It
of awareness about the
requires an extraordinary
pulse polio campaign. Ex
effort by a whole range of
tensive publicity cam
national and international
paigns, involving film and
partners. After 15 years of
cricket personalities, have
progress, we are very ^9'
mitigated the opposition
cussed on India, where
to a great extent, the Ro
stopping transmission will
tary official said. Although
be a monumental task.”
the exact numbers of those
Maria Calivis, Coun
vaccinated would
be
try Representativeof UNI
known only after a few
CEF in India, said: “We’re
days, the third phase of the
facing an enormous job.
campaign had been suc
We have to stop polio in
cessful when compared to
India. We all have to work
the previous two, he said.
together to reach every In
In association with the
dian child with polio vac
Rotary International, the
cine and make sure that
UNICEF, the State and
the vast numbers of chil
Central governments and
dren in Uttar Pradesh re
non-governmental organi
ceive vaccine throughout
sations, the WHO has
2003 and 2004. Beyond
planned six pulse polio
campaigns in Uttar Pra WHO Director-GeneralDr. Gro Harlem Bruntland administers a dose of this programme, a huge ef
fort is needed to ensure
desh for the entire year. polio vaccine to an infant at a function in Lucknow on April 6.
According to WHO estimates, in the grant helped meet the costs of hiring vol routine immunisation and quality pri
first two phases of the campaign, over 66 unteers, including women, who would mary health services. Today, most of In
million children were immunised. Cam do a house-to-house vaccination cam dia is polio-free and none of us war' ’ to
e
paigns have been scheduled for June, paign. In the current phase, over 80 mil see a reversal of the gains made i
September and November, and similar lion children across six States are past several years.”
Worldwide, the polio eradication
high-quality campaigns will be required expected to be vaccinated.
The resurgence of polio, especially its campaign is facing a shortfall of $275
in 2004 if the virus is to be eradicated.
According to the WHO, as of April spread outside India has alarmed the million in funds; India alone needs $100
1, 2003, 1,925 polio cases were reported world medical fraternity. “The support million. To counter this shortfall, Rotary
from across the world. Eighty-five per of the international community has nev International is intensifying its fund-rais
cent of the cases are in India, nearly 75 er been more crucial than it is today,” ing efforts. It plans to raise $80 million
per cent of them in Uttar Pradesh. As per said Dr. Brundtland. “We need donors by June 2003, in addition to the $500
WHO estimates, in India, 1,934 cases to fill the $275-million funding gap that million that Rotary has committed since
were detected in 1998; followed by we face globally, so that all activities can 1985. “We will do everything in our
1,186 in 1999; 265 in 2000; and 211 in go ahead as planned. The generosity of power to ensure that nothing derails the
2001. However, there was a stupendous the international community and the dream of a polio-free world,” said Bill
increase last year, when 1,556 cases were successful partnership that has been Sergeant of Rotary International. “The
reported in India, most of them in Uttar formed with polio-infected countries are international community must also step
crucial to ensure the success of this initia up efforts so that all children are protect
Pradesh.
ed from this tragic disease,” he said. Six
In October 2002, Rotary Interna tive,” she said.
“We have 15 years of experience in ty-five Rotary volunteers from around
tional reinforced its polio eradication ac
tivities in India and brought in a grant of polio eradication.... We have the tools the world will travel to Uttar Pradesh
almost $5 million, taking its total contri and we have the strategies to finish this and Delhi to administer the polio vac
bution to more than $46 million. The job. Today there is simply no moral or cine to children. ■
community,
especially
those from the lower in
come groups, to vaccinate
their children. “Apparent
ly, there is a belief that the
polio vaccine causes impotency,” he said. Religious
leaders and prominent
members of the communi
ty could help remove that,
126
FRONTLINE, MAY 9, 2003
Page 1 of2
yis - -6 •
Community Health Cell
From:
indira chakravarthi [indirachakravarthi@yahoo.com]
Sent:
Thursday, September 28, 2006 12:12 PM
To:
JSA jsa
Subject: [pha-ncc] JSA & polio eradication programme
Friends,
This is regarding the pulse polio programme and the increase in the number of polio cases in UP.
From the newspaper reports since September 1st, what we get to know is:
1.
2.
3.
4.
5.
6.
7.
8.
9.
According to our MoH&FW the programme has failed to deliver because of bad implementation; and the number of
drop-outs m every round has been on the rise in UP.
According to WHO-UNICEF the reasons for western UP reporting a high incidence of polio are several - the most
immediate ones are a slack government health machinery which simply missed covering many children, as well as
localized pressures from muslim clergy spreading the canard among the most poor that the polio drops aims to reduce
the community’s fertility; and also lack of sanitation, and contamination of piped water by sewers.
According to WHO-UNICEF evaluation in April 2006, the coverage had deteriorated between late 2005 and early
2006, resulting in large number of children not receiving polio vaccine, although records said that the children had
been vaccinated.
The UNICEF representative in UP denied that the muslims as a community resisted polio immunisation, and that it
was the chief reason for the failure of the programme. Resistance was localised to a few places.
The MoHFW has set up a special committee to check cases of polio, which is to work in collaboration with NGO
The Centre is to step up the fight against polio, with UP being the focus. There will be special awareness programme^
among the muslims in UP.
ASHAs will be deployed for the purpose, and incentives maybe given to the vaccinators to ensure that the chain is not
broken.
The government is thinking of introducing the injectable inactivated polio vaccine, as a pilot project in western UP.
Un like UP the rest of the country is considered to have an excellent record, having completely eradicated the virus.
UP is one of the few places where the wild polio virus still exists.
The health minister will go to Geneva to discuss the issue with WHO.
Several of us have, on the
1’ pha-ncc forum, expressed our concern and indicated that JSA should take it up - inform the
general
authorities, based
.. .public, dialogue
- with the health 7
-----J on specific demands force a correct policy decision, stop the polio
eradication programme and revert to polio control, compensation for the VAPP cases, etc.
I have also put up several papers written by public health professionals, within and outside of JSA, arguing out the
problems with the very definition and concept of polio eradication, and the grave problem of vaccine associated
paralytic polio. The IMA too, in May itself, has come out on the polio eradication programme.
The media (in the name of objectivity and impartiality) has given us the above 'information’. There is no mention of the fact
that there are reservations/criticisms among public health professionals with the programme and the OPV, that it can and has
caused paralytic polio, can revert to the neuro-virulent strain, etc.. The usual reasons of'bad implementation by government’
resistance by ignorant people’ 'poor sanitation’ are being cited as the reasons for the 'failure’. Can polio be eradicated at all’
by such means is a question that is not raised at all, or should not be raised in the media.
S°me of us would probably be aware that at least one interview, of Abhay Shukla by the Mumbai NDTV, where he talked of
the problems with the OPV and that it can cause paralytic polio, was not carried because the Head Office felt it was being
too critical of the government’. So much for our independent and democratic media!
Coming to the main point - I am once again re-iterating what some of us have already said last week on this group (and
probably in other fora). JSA should come out and not just take a position. We should, either independently as JSA, or with
some civil liberties group, or with the NHRC, take up a review of the entire programme in the context of this outbreak of
polio cases; have a mass dissemination campaign, disseminate the correct information on the so-called 'technical aspects’
etc., and ask for the eradication programme to be stopped altogether.
9/28/2006
Page 2 of 2
Tk° bM/,nuWIth ~ *et us.come out on this discussion group and say what we feel. Let us at least come out and say why we
should/should not do it. Then, can we form a small sub-group, and start working on it? We already have sufficient
information. We need to build on it.
Indira Chakravarthi
people's rural health watch - JSA
9/28/2006
Giobai Polio Eradication initiative in India
A Cause for Concern
Dr Onkar Mittal1
Dr C Sathyamala2
[Abstract: The paper suggests that the inability of the pulse-polio program to achieve
polio eradication in India should surprise no one. This should not be misconstrued as a
failure of a gigantic effort by lakhs of health workers and million of volunteers and
participants in the program in the last eight years. The limitations of the efficacy of the
oral polio vaccine and low routine immunization coverage in several parts of the state
were well known to the WHO and all the other important decision-makers in the country
Despite this the case for early eradication of polio was aggressively promoted and the
real possibility of failure was underplayed. The expensive gamble has however failed
just as it happened in the past with other eradication programmes like malaria. Neither
the giobai leaders of this initiative nor the Indian government are taking responsibility for
V
this failure. The complete lack of transparency and accountability has meant that
enormous amount of public resources, both in terms of money and manpower, has been
wasted in this misadventure. The Global Polio Eradication Initiative illustrates the
process of health policy making in the country and the role of international cooperation in
health in the time of Globalization and Liberalization.)
1 General Secretary. Society for Action in Community health (SACK). New Delhi.
E-maiI: o_m itta1@rediffmaiI. co m
2 Epidemiologist; •visiting professor. Centre of Social Medicine and Community Health, JNU, New Delhi.
E-mail: c_sathyamala@rediiimail. com.
Executive Summary
1. The paper is an initial oven/iew of the Global Polio Eradication Initiative (GPEI)
in India. It attempts to address three key issues arising from failure to meet the target of
polio eradication in the country:
•
How fair was it to impose the ambitious target of polio eradication on India, and
other developing countries; a target which implies that a single case of polio
anywhere would be tantamount to the failure of the entire global initiative? Could
we have not managed better with less ambitious and more feasible target of polio
reduction and control?
•
Did we have a sound technical basis and operational strategy to embark on this
super-ambitious polio eradication program? If yes, what went wrong with the
implementationof this strategy?
•
If the strategy of polio eradication initiative was faulty to begin with, what were
the interests and influences that have played key roles in aggressively promoting
this strategy in India and globally?
2 Failure to achieve polio eradication in India despite eight years of intensive
effort. It is argued here that while the magic bullet of pulse polio and Intensive Pulse
Polio Immunization (IPPI) might have contributed to the reduction of the transmission of
poliovirus in India and other developing countries, it has singularly failed to achieve the
eradication of polio. The first deadline of the year 2000 for achieving poiio eradication
has already passed. The new deadline of the year 2004 too is very close. In the high
echelon of decision making, it is now agreed that this goal is not going to be achieved in
the near future. Therefore the IPPI strategy has lost its meaning altogether and should
be abandoned immediately.
3. The paper makes a plea for an independent review of the strategy from 2004 onwards
to decide the future of the IPPI and other SIAs (Supplementary Immunization Activities)
in India. There is an urgent need to leam lessons from the failure of the programme if we
have to avoid repeating the same mistakes. This would also require a review of the lead
role played by the international agencies like the WHO, UNICEF, Rotary International
and Centre of Disease Control (CDC), Atlanta, in order to avoid being misled by them in
future.
4. Real Magnitude of the Problem: Is polio eradication an overarching priority? It is
also argued that when the WHO launched the global polio eradication program in 1988,
the estimates of polio cases in India (and globally) were perhaps gross overestimates.
Considering that, currently, in India the continued polio cases amongst the reported
(Acute Flaccid Paralysis) AFP cases are just 10-20 % of the total, the previous
estimation of the paralyses attributed to polio virus requires a review. This has to be
seen in the context of, how the proponents of the GPEI have admitted that polio
eradication is not a priority for the developing countries. Yet the program has been
justified on the grounds that it may result in small savings to the western countries which
would no longer need to spend on vaccination once polio eradication is achieved
globally This is an unacceptable reason for over loading the already weak health
systems of the developing countries to this exhausting marathon run. The billions of
dollars spent on this program could have been more efficiently utilized to solve more
pressing problems and in the rehabilitation of the decaying health systems of the
developing countries It calls for making a realistic exercise of estimation of the
opportunity cost of implementing this program and opportunities lost in not implementing
the more appropriate programs.
5. Is it possible to repeat the great marvel of eradication of small pox? The high
optimism of repeating the success of small pox eradication with poliovirus too has been
belied. There are several differences in the two situations. First, surveillance to
determine whether and where smallpox virus was present was comparatively simple
compared to polio surveillance and could be rapidly accomplished. The vast majority of
patients with smallpox had a distinctive rash. There were no asymptomatic patients and
no chronic carriers. Thus, it was possible to do this without recourse to a laboratory.
With Polio, there are 200 or more asymptomatic infections for every paralyzed patient.
The only way one can ascertain whether the virus continues to circulate in an area is by
an extended period of surveillance during which a great number of stool specimens are
examined. The second difference is with respect to the efficacy of vaccination. One
inoculation of smallpox vaccine protected nearly 100% of those vaccinated. In contrast,
OPV in now endemic areas requires at least 3 doses and often 5 or 6 doses to reach
protective levels of 90% for types I and ill poliovirus, the predominant paralytic strains.
Thus, in areas, where access and reach of vaccination programs was limited,
vaccination immunity against smallpox could be rapidly increased because of the single
dose inoculation but this is not possible with polio.
6. Why did the WHO aggressively promote the case for eradication? It is further
argued that WHO over-pushed the case for eradication of poliovirus in India by using the
example of Latin American countries that was not really applicable in the Indian
situation. It also underplayed the real possibility of failures to achieve the goal due to
well known limitations in India and other developing countries. These limitations
pertained to the (i) very low routine immunization coverage in certain states in India and
(ii) the low efficacy of the OPV in providing sufficient immunity in India and other
developing countries. The WHO also overemphasized the possible benefits from the
global eradication of poliovirus and underplayed the negative impacts on the general
health services as well as the risks and costs of the failure of the program. It did all this
against its own wisdom. It narrates how, after the failure of Malaria Eradication Programs
globally, eradication became a bad word' in the WHO, notwithstanding the success
achieved in small pox eradication earlier It asserts; therefore that the WHO; in its
organizational wisdom could not have, on its own, embarked on a global eradication
program for polio. Based on the information available, it is difficult to figure out what
influences have played a role in WHO for pushing polio eradication as an utmost urgent
priority for the developing countries. We admit our failure in solving this riddle and invite
others to help us in this endeavor.
7. The paper suggests that GPEI is yet another negative exercise in mismanaging the
health priorities and programmes in developing countries. The UN institutions, their
corporate philanthropic partners and the gullible health bureaucracies, technocracies
and political leaderships of the developing countries, all are equal partners in this futile
and absurd exercise. We also question the right of the G-8 nations and international
philanthropies like Gates Foundation to provide earmarked resources for particular
disease control programs and thereby distorting the health policies, priorities and
programs of the developing countries. This appears to us as the biggest blemish on the
international cooperation in health. Considering that global commitments are involved, it
is necessary for India to play a more proactive role with the governments of the other
I
(
the last several years. The paper also calls for learning lessons from the entire GPEI for
the functioning of WHO and the GPPP within the WHO.
8. The way forward for India. There is a great urgency to make critical decisions for
strengthening the heaith systems in india. Only this can enable us io strengthen our
routine immunization programme and achieve control of polio in due course. There is no
shortcut to this process. The positive lessons should be drawn from the gigantic efforts
made by lakhs of health workers and millions of volunteers and participants in the
programme throughout the country. The programme should be publicized as a success
in reducing the transmission of poliovirus in the country and not as a failure, just
because some cases are still occurring. The live contact made with millions of poor and
disadvantaged people for the first time by the country’s health systems should be
strengthened for health improvements in other areas and with involvement of the newly
activated civil society.
9. Right of compensation for those who have suffered from Vaccine Induced
Paralytic Poliomyelitis (VIPP). A considerable proportion of children who have
developed AFP due to polio virus are those who have received 3 or more doses of OPV.
There is need for comprehensive rehabilitation of those suffering from residual paralyses
(due to poliovirus and other causes). In the current strategy these aspects find no place.
The inferences made in this paper are based on available information on the issue. It is
perhaps not possible to avoid hasty conclusions and ideological biases while stimulating
discussion and debate, especially while all the data and information has not been placed
on the table We invite the readers and the experts in the field to place other facts
and information on the table, challenge the inferences made in this paper and
provide alternative interpretations and explanations.
120th Session
Agenda item 4.1
EB120.R1
24 January 2007
Poliomyelitis: mechanism for management of
potential risks to eradication
The Executive Board,
Having considered the report on eradication of poliomyelitis,1
RECOMMENDS to the Sixtieth World Health Assembly the adoption of the following
resolution:
The Sixtieth World Health Assembly,
Having considered the report on eradication of poliomyelitis;
Recalling resolution WHA59.1, urging Member States in which poliomyelitis is endemic
to act on their commitment to interrupting transmission of wild poliovirus;
Recognizing that the occurrence of endemic poliovirus is now restricted to geographically
limited areas in four countries;
Recognizing the need for international consensus on long-term policies to minimize and
manage the risks of re-emergence of poliomyelitis in the post-eradication era;
Recognizing that travellers from areas where poliovirus is still circulating may pose a risk
of international spread of the virus;
Noting that planning for such international consensus must commence in the near future,
URGES all Member States where poliomyelitis is still prevalent, especially the four
1.
countries in which poliomyelitis is endemic:
(1) to establish mechanisms to enhance political commitment to, and engagement in,
poliomyelitis eradication activities at all levels, and to engage local leadership and
members of the remaining poliomyelitis-affected populations in order to ensure full
acceptance of, and participation in, poliomyelitis immunization campaigns;
1 Document EB120/4 Rev. 1.
EB120.R1
(2) to intensify poliomyelitis eradication activities in order rapidly to interrupt all
remaining transmission of wild poliovirus;
2.
URGES all Member States:
(1) to protect against importations and international spread of wild polioviruses by
reviewing and, if appropriate, updating national policy to recommend full immunization
against poliomyelitis for travellers to areas in which poliovirus is circulating;
(2) to revise national policy and legislation on immunization of travellers from
countries in which poliovirus is circulating in accordance with temporary or standing
recommendations which may be established under the International Health Regulations
(2005) once they enter into force;
(3) to reduce the potential consequences of importation of wild poliovirus by achieving
and maintaining routine immunization coverage against poliomyelitis greater than 90%
and, where appropriate, conducting supplementary poliomyelitis immunization activities;
(4) to strengthen active surveillance for acute flaccid paralysis in order rapidly to
detect any circulating wild poliovirus and prepare for certification of poliomyelitis
eradication;
(5) to prepare for the long-term biocontainment of polioviruses by implementing the
measures set out under phases 1 and 2 in the current edition of the WHO global action
plan for laboratory containmentof wild polioviruses;1
3.
REQUESTS the Director-General:
(1) to continue to provide technical support to the remaining Member States where
poliomyelitis is still prevalent in their efforts to interrupt the final chains of transmission
of wild-type poliovirus, and to Member States at high risk of an importation of poliovirus;
(2) to assist in mobilizing financial resources to eradicate poliomyelitis from the
remaining areas where poliovirus is circulating, to provide support to countries currently
free of poliomyelitis that are at high risk of an importation of poliovirus, and to minimize
the risks of re-emergence of poliomyelitis in the post-eradication era;
(3) to continue to work with other organizations of the United Nations system on
security issues, through mechanisms such as “days of tranquillity”, in areas where better
access is required to reach all children;
(4) to initiate the process for a potential standing recommendation, under the
International Health Regulations (2005), on the immunization against poliomyelitis of
travellers from areas where poliovirus is circulating;
1 Document WHO/V&B/03.11 (second edition).
2
EB120.R1
(5) to submit proposals to the Sixty-first World Health Assembly with a view to
minimizing the long-term risks of reintroduction of poliovirus or re-emergence of
poliomyelitis in the post-eradication era, by establishing international consensus on the
long-term use of poliomyelitis vaccines and biocontainment of infectious and potentiallyinfectious poliovirus materials.
Fourth meeting, 23 January 2007
EB120/SR/4
3
WHO/POLIO/O7.02
REPORT 2006
GLOBAL POLIO ERADICATION INITIATIVE ■wnmmm
DRAFT VERSION FOR WHA
For your final print copy, please send an email to polionews@who.intor drop your business card in the box at the Global Polio Eradication Initiative stand."
World Health
Organization
WHO document reference: WH0/Polio/07.02
Copies may be requested from:
World Health Organization
20 Avenue Appia
CH-1211 Geneva 27, Switzerland
Fax:+41 22791 1571
email: polioepi@who.int
© World Health Organization,2007
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TABLE OF CONTENTS
1 ■ EXECUTIVE SUMMARY
4
2 ■ KEY EVENTS 2006
6
3 ■ STRATEGIC OBJECTIVES
8
3.1 Interruption of poliovirus transmission
8
3.2 Surveillance and certification of global polio eradicdation
16
3.3 Develpoment of products for potential Global OPV cessation
22
3.4 Mainstreaming of the Global Polio Eradication Initiative
27
4 ■ FINANCING
30
5 ■ GLOSSARY OF TERMS
34
ANNUAL REPORT 2006
EXECUTIVE SUMMARY
The year 2006 began with the confirmationthat indigenous wild poliovirus transmission had been stopped in Egypt and Niger,
reducing the number of endemic* countries to a historic low of four. In the remaining countries - Afghanistan, India, Nigeria
and Pakistan - intensification of immunization campaigns succeeded in geographically restricting virus transmission by the
end of 2006.
I he number of
countries which
had never stopped
indigenous polio was
reduced to a historic
low of four.
In response to rising number of cases in the early part of the year, by May Nigeria
rolled out “Immunization Plus Days”, adding other health interventions to polio
vaccination campaigns and leading to improved coverage. Aggressive immunization
response to a large outbreak in India made the outbreak far smaller than in previous
years: analysis of the vaccination status of cases showed that children over two years
of age were well-vaccinated, enabling a focus on the youngest children, to whom
the ‘immunity gap’ is now limited. New epidemiological studies showed that unique
demographic and sanitation conditions in northern India make trivalent oral polio
vaccine less effective there than elsewhere, informing a decision to use the more
efficacious monovalent vaccine on a larger scale.
The sustained poliovirus circulation between Pakistan and Afghanistan, aided by the frequent movement of people across a porous
border, sparked closer synchronization of vaccination campaigns and activities at crossing points. In Afghanistan, President Hamid
Karzai took close oversight of polio eradication activities, prompted in part by an outbreak in the Southern Region during the first
part of the year which was exacerbated by deteriorating security.
I he Advisory
Committee on Polio
E rad i cat i o n re - a ffi r m ed
the technical and
operational feasibility
of polio eradication.
Only 10 of the 26 countries re-infected since 2003 were still reporting polio
transmission in the second half of2006, following rapid and intense immunization
response. An important success was the end of the Indonesia and Yemen outbreaks,
the largest in numbers. By the end of the year, high-risk outbreaks from imported
virus were limited to central Africa, the Horn of Africa and Bangladesh.
Based on the progress in 2006, the Advisory Committee on Poliomyelitis
Eradication (ACPE), which provides independent technical counsel to the Global
Polio Eradication Initiative, re-affirmed in October the technical and operational
feasibility of polio eradication. The ACPE noted that success depended on the
remaining four countries, which now have the best tools available to complete
eradication: the more potent monovalent oral polio vaccine (mOPV) to boost
immunity faster than before and laboratory procedures which halve the time
needed to confirm poliovirus and allow for a rapid immunization response.
* Countries that have never interrupted indigenous wild poliovirus transmissionare referred to as endemic throughout this report.
GLOBAL POLIO ERADICATION INITIATIVE
The national technical advisory bodies of the four endemic countries convened in
December 2006, to recommend new and tailored approaches for 2007 to overcome
the specific operational challenges in each of these last four endemic areas. Success
now hinges on rapidly raising the levels of vaccination coverage and immunity in
the areas with endemic transmission to at least those levels attained in the poliofree areas of these countries.
With polio geographically more restricted than ever before, and equipped with
new-generation tools and tactics, the world now has the best-ever opportunity
to assign this ancient scourge to the history books definitively, providing there
is a collective global will and sustained political commitment from the highest
levels. Instrumental to success will be full implementation of the targeted new
approaches, high-quality operations and the continued support of donors, most
notably in urgently filling the global funding gap of US$ 540 million for 2007-2008
(as of May 2007).
Equipped with newgeneration tools and
tactics, the world
now has the best-ever
opportunity to assign
this ancient scourge to
the history books.
ANNUAL REPORT 2006
K E Y EVENTS
In 2006, partners in the Global Polio
Eradication Initiative vaccinated
375 million children during
187 immunization campaigns in
36 countries, with 2.1 billion doses
of vaccine.
Egypt and
Niger confirm
interruption of
indigenous polio.
Bangladesh suffers
importation of
Indonesia and
virus after five
Yemen outbreaks
are stopped.
polio-freeyears.
January
February
CLOIAl FOLIO ERADICATION INITIATIVE
6
Outbreak begins
in Uttar Pradesh
state in India,
peaking in
September.
Fire in Mumbai
polio laboratory
necessitates
reassignment of
staff and stool
samples.
March
April
Outbreak from
imported virus
in Namibia is
stopped in 50 days
by following new
Eradication loses outbreak response
a champion at the
guidelines
endorsed by
death of WHO
Director-General
World Health
LEE Jong-wook. Assembly in May.
June
2 0 06
■■
■.
Saudi Arabia
begins requiring
vaccination of
travellers from
polio-endemic
countries.
While most of the
territory of each
endemic country
Outbreak in
is polio-free,
Southern Region
tailored
strategies
of Afghanistan
are adopted
Research
is exacerbated
in remaining
published in
by deteriorating
Science magazine endemic countries
security situation.
indicates
to raise immunity
High-risk
In response to the
levels among
monovalent
outbreak, Afghan
outbreaks
Lab network
children in the
OPV can boost
President Hamid
continue in the
launches
ACPE re-affirms immunity enough endemic areas to
Horn of Africa,
Karzai launches
procedures to
central Africa and feasibility of polio to stop polio in those in the polioNational Polio
halve poliovirus
northern India.
free areas.
eradication.
Bangladesh.
Action Group
confirmationtime.
July
August
September
October
November December
ANNUAL REPORT 2006
STRATEGIC OBJECTIVES
3.1 INTERRUPTION OF POLIOVIRUS TRANSMISSION
Progress in polio eradication is measured against milestones set out in the Global Polio Eradication Initiative Strategic Planfor 2004-2008.
The strategic objectives outlined in that plan form the foundation for eradication:
1. interruption of wild poliovirus transmission
2. global certification of eradication
3. development of products for potential OPV cessation
4. mainstreaming of the Global Polio Eradication Initiative.
The milestones set for each strategy are periodically reviewed and amended as necessary as per recommendations by the Advisory
Committee on Poliomyelitis Eradication (ACPE), which provides independent technical counsel to the Global Polio Eradication
Initiative.
MILESTONES 2006
MILESTONE 1: NO COUNTRIES WILL BE P 0 L I 0 - E N D E M I C AT THE END OF 2006.
status:
achieved — Four areas of four countries remain polio-endemic. Transmission of endemic poliovirus is now concentrated in
northern Nigeria, two states of India (Bihar and Uttar Pradesh), and border areas of Pakistan and Afghanistan.
not
Egypt and Niger are no longer polio-endemic. The ACRE in October 2006 reaffirmed that the global eradication of wild poliovirus is both technically and operationally
feasible and concluded that the four remaining endemic countries now have the best tools ever to rapidly achieve polio eradication.
MILESTONE 2: ALL PLANNED SUPPLEMENTARY IMMUNIZATION ACTIVITIES (SIAs) WILL BE IMPLEMENTED IN
HIGHEST-RISK POLIO-FREE AREAS.
status:
achieved
— SIAs were implemented as planned in Bangladesh, Benin, Cameroon, Chad, Nepal and Niger.
Highest-risk polio-free areas are those bordering endemic reservoir areas (re-infected areas are considered under outbreak response below).
MILESTONE 3l 50% OF COUNTRIES WILL ACHIEVE GAVI ALLIANCE TARGETS FOR DTP3/OPV3.
status
:
(2005 data ) — 43/72 (60%) of GAVI Alliance-eligiblecountries had national DTP3/OPV3 coverage greater than 80%;
22/72 (30%) of countries had national DTP3/OPV3 coverage greater than 90%.
achieved
The GAVI Alliance target calls for all countries to have greater than 80% routine immunization coverage in every district and 90% routine immunization coverage
nationally by the year 2010. In 2005,7/72 (10%) of GAVI Alliance-eligiblecountries had reached this target.
MILESTONE 4: ALL EMERGENCY MOP-UPS WILL BEGIN WITHIN FOUR WEEKS OF CASE CONFIRMATION.
status
:
partially
achieved
— Emergency mop-ups were conducted within four weeks of case confirmation in 5/6 (83%) importation
events in 2006.
Cameroon, the Democratic Republic of the Congo (DR Congo), Kenya and Namibia conducted activities within four weeks of case confirmation. Bangladesh conducted
activities within 39 days of case confirmation.
Note: In Chad, a late-2006 case was reportedin January2007, and an emergencymop-up was conducted within four weeks ofconfirmation. Additionally, emergencyoutbreak
response activities continuedin a number ofcountries with ongoing transmission ofimportedpolioviruses from 2005, e.g. Angola, Ethiopia, Nepal, Niger and Somalia.
MILESTONE 5: ALL N 0 N - C E R T I F I E D COUNTRIES WILL HAVE C E R T I F I C A T I 0 N - S T A N D A R D SURVEILLANCE.
status
:
partially
achieved
— 61/76 (80%) of non-certified countries have met certification-standard surveillance targets1.
The following countries did not meet the required standards: Algeria, Bhutan, Cyprus, Djibouti, Gabon, Guinea-Bissau, Kuwait, Lebanon, Malawi, Maldives, Morocco,
Saint Helena, Sri Lanka, Timor Leste and United Arab Emirates.
<5
’Excludes island nations with populationsless than 300,000, e.g. Comoros,Mauritius,Reunion, SaoTome and Principe and Seychelles.
EGYPT AND NIGER REMOVED
■ FROM ENDEMIC COUNTRY LIST
COUNTRIES WITH INDIGENOUS POLIO: TAILORED STRATEGIES
MONITORED BY TOP POLITICAL LEADERSHIP
The world’s success in eradicating polio now depends on four countries - Nigeria,
India, Pakistan and Afghanistan - according to the Advisory Committee on Polio
Eradication (ACPE), meeting in October 2006. These countries have at their disposal
the best set of technical tools in the history of eradication.
In January 2006, Egypt and Niger were
removed from the list of polio-endemic
countries, reducing the number of remaining
countries with indigenous polio transmission
to an all-time low of four. Neither country has
experienced indigenous circulation of wild
poliovirus since January 2005.
Transmission of indigenous poliovirus is geographically restricted to limited areas
of these four countries, in specific populations. In December 2006, all four countries
convened national technical advisory body meetings to outline local tactics for
reaching all children under five years of age with vaccine enough times to protect
them from polio.
■ NIGERIA:
"IMMUNIZATION PLUS days " LEAD TO PROGRESS IN LATTER HALF OF 2006
In December 2005, President Olusegun Obasanjo of Nigeria set the tone for polio
eradication activities in the following year, mandating the Ministry of Health and
the National Programme on Immunization (NPI) to eradicate polio and strengthen
routine immunization.
The number of cases of polio in Nigeria in 2006 rose to 1,124 from 830 in 2005.
As the first quarter of the year signalled a three-fold rise in numbers over the
same period in 2005, the Expert Review Committee for Polio Eradication (ERC)
- Nigeria’s technical advisory body - endorsed a strategy of ‘Immunization Plus
Days’ (IPDs) in March 2006. Launched by the new management of NPI in May,
IPDs offer other antigens and health interventions to communities in addition to
OPV. Since the introduction of IPDs, the proportion of children in northern states
who had never been immunized was reduced to an average of 20% (from more than
50% at end-2005). The number of new cases dropped after June: fewer than a third
of Nigeria’s cases in 2006 occurred in the second half of the year.
Nigeria: Risk classification by state
1 he proportion of
never-immunized
children in northern
stales fell from over 50%
to an average of 20%.
NIGERIA
KEY POINTS 2006
• Presidential mandate for polio eradication
• New strategy of Immunization Plus Days
recommended by Nigeria's Expert Review
Committee on Polio Eradication
• Increase in number of children reached in
northern states
• Decrease in new cases in second half of year
FOCUS FOR 2007
• Build on progress achieved in 2006 through IPDs
• Use risk-classificationto target Kano, Katsina
and Jigawa states as'very high risk'for ongoing
polio transmission
• Further engage all communities
• Ensure all activities are state-driven
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIUIIIIIIIIIIIIIII
Key to success: reduce the number of'missed children'
to <10% in Kano, Katsina andJigawa
- V
aa Very
RiM
• Medium K-gh RHk
g|| Medkew <>•*
tel
.
ANNUAL REPORT 2006
9
AFRICAN UNION COMMISSION
HELPING TO
■ "KICK POLIO OUT OF AFRICA"
The IPDs have also proven popular with local communities and political leadership.
‘Community Dialogues’ organized in key areas before IPDs give community
At the end of 2006, indigenouspolio in
Africa was restricted to Nigeria, as most of
the countries re-infected in 2003-05 had
successfullystopped polio transmissionor
were close to doing so. Political leadership
from the Chairpersonof the African Union
Commission,ProfessorA.0. Konare and
the strong support of the Union's Social
Affairs Commissionerwas importantto this
development.
ChairpersonKonare reviewed the progress
of polio eradication in Africa on a quarterly
basis with the World Health Organization,
and actively advocated with the Heads
of State of polio-affectedcountries. He
also encouraged donor nations, especially
the G8 and the EU memberstates to
continue their financial support to ensure
the success of this historic effort on the
continent.
members the opportunity to ask questions about polio eradication efforts and have
given rise to a nascent sense of ownership by civil society.
The new approach does not come without drawbacks, not the least of which
is financing. Operational costs are 60% more than polio-only supplementary
immunization activities. This level of cost is difficult to sustain and demands new
sources of funding. The IPDs are also operationally complex to manage, straining the
health infrastructure in the north of the country. The availability of the additional
vaccines, vitamins and medications that are offered is erratic due to weaknesses in
operational planning or deficiencies in stock.
The ERC re-convenedin December 2006 to analyse local strategies to overcome local
challenges. Each geographical area was classified by the level of risk of poliovirus
transmission, to enable states to better prioritize their activities. Kano, Katsina
and Jigawa states - which accounted for 60% of the country’s cases in 2006 - were
classified as ‘very high risk’ due to ongoing coverage gaps of greater than 25% during
IPDs. Key to successfully eradicating polio in Nigeria will be to urgently reduce the
proportion of missed children in very high risk states to less than 10%.
■ SPIRITUAL LEADER REMINDS COMMUNITIES OF THE OBLIGATION TO PROTECT CHILDREN
Cheikh Hassan Cisse, a spiritual leader with
followers across western Africa, embarked
in November2006 on a two-week tour of
eight high-risk northern Nigerian states to
impress upon communitiesthere that polio
immunization is a religious obligation of
parents, in keepingwith the teachingsof Islam
Hadith to underscore"the need for protecting
children, as they are the future,"as he put it.
to protect children from disease. This tour took
place at the request of the Secretary-Generalof
the Organizationof the Islamic Conference.
speeches was broadcast on and printed in local
and international media.
During this extraordinarymobilization
campaign,the Cheikh, who is the Grand Imam
of Medina Kaolack in Senegal,travelled most
nights and met by day with Governors, Emirs
and religious leaders and scholars. He addressed
vast gatherings of his followers in all the major
cities of the area and visited Quranicschools and
mosquesto speak with parents and religious
leaders, quoting from the Holy Quran and the
GLOBAL POLIO ERADICATION INITIATIVE
IO
In press conferences,the Cheikh encouraged
membersof the media to communicate his
message that Islamic teachings advocate for
immunization.Coverage of his sermons and
At the end of the tour, PresidentOlusegun
Obasanjo invited Cheikh Cisse to the capital to
express his gratitude and appreciationfor the
Cheikh's efforts.
Cheikh Hassan Cisst, respectedspiritual
leader, immunizesa child againstpolio
duringhis visit to Nigeria.
■ INDIA:
OUTBREAK IN NORTHERN INDIA, BUT IMMUNITY GAP LIMITED TO UNDER-TWO YEAR-OLDS
INDIA
In India, an outbreak originating in the western end of Uttar Pradesh state resulted in
KEY POINTS 2006
the re-infection of polio-freeareas of the country and a ten-fold increase in new polio
• Bihar and Uttar Pradesh only remaining
endemic states
• Outbreak originating in western Uttar Pradesh
results in ten-fold increase in cases
• Immunity gap reduced to children under two
years old
cases in 2006 over the previous year (674 cases, compared to 66 cases in 2005).
The outbreak occurred primarily due to a drop in vaccination campaign quality and
children being missed in late 2005 and early 2006. The Government of India reacted
with swift improvements in vaccination campaign coverage in the highest-risk areas.
This response, coupled with wide-spreaduse of monovalent oral polio vaccine type 1
(mOPVl), resulted in 60% fewer cases than India’s most recent outbreak in 2002.
Epidemiological research published in November showed that trivalent OPV is less
effective at protecting children from polio in northern India than in the rest of the
country or other parts of the world, due to the unique demographic, health and
sanitation conditionsprevalent in Uttar Pradesh and Bihar. The research vindicated
the large-scale use of mOPV in these areas and indicated that immunity levels of
children there would have to be boosted with more intense vaccination activities
before they could reach the levels reached in other parts of India.
FOCUS FOR 2007
• Increase frequency of supplementary
immunization activities to rapidly close
immunity gap
• Focus on youngest children in high-risk districts
of western Uttar Pradesh and Bihar
• Maximize each contact through expanded use of
monovalent OPV type 1
iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii
Key to success: raising and maintainingimmunity
levels above the levels in polio-freeparts ofIndia
In addition, analysis of the epidemiological and programmatic data from the 2006
outbreak revealed that 73% of children affected were less than two years old, showing
that mOPV had effectively immunized older children. The programme could now
concentrateon reaching the youngest children more frequently, so that they would
have more doses of mOPV before the age of two than previous birth cohorts.
Armed with the vaccine efficacy research and
this immunological profile, the India Expert
Advisory Group on Polio Eradication (IEAG),
which provides independent technical counsel
to the programme, recommended in December
2006 a tactical refinement to close the immunity
gap in the youngest age group.
Despite the outbreak,
new monovalent OPV
significantly reduced
the last immunity gap,
in children less than
2 years old.
Launched in early 2007, the approach calls for
sharply increasing the number of large-scale
supplementary immunization activities (SIAs)
in the highest-risk districts of western Uttar
Wild poliovirus in 2006 in Uttar Pradesh and
Bihar states of India
Pradesh and Bihar and focusing on children
aged less than three years of age. Large-scale SIAs
with mOPVl will be held on average every four
weeks, supplemented by the administration of a
dose of mOPVl at birth.
Full implementation of this strategy is expected
to close the immunity gap in the youngest
children in Uttar Pradesh and Bihar states and
to raise immunity levels in these areas to levels
V
above those in the rest of India.
ANNUAL REPORT 2006
■ ROTARY RACES TO END POLIO
More than 200 Rotarians from Canada,
Europe and the United States joined
thousands of their counterparts in India
and in African countries to immunize
children against polio during numerous
supplementary immunizationactivities
in 2006.
A humanitarianservice organization
that has made polio eradication its top
philanthropicgoal, Rotary International is
a spearheadingpartner in the Global Polio
EradicationInitiativeand is committed to
the cause until global certification.
To that end, Rotary membersaround
the world, including those based in the
endemicand high-risk countries, donate
their time and personal resources to raise
funds and volunteer in the field. During
mass immunizationcampaigns,Rotarians
regularly administerthe drops of oral polio
vaccine, staff immunizationposts, deliver
the vaccine to remote villagesand educate
families on the importance of protecting
every child against polio.
"Until polio is eradicatedworldwide, every
child remainsat risk,"said Anil Garg, US
team leader of a group that travelled to his
homeland of India. "Preventing paralysis
from polio in just one child has major social
and economic consequences for the victim,
family and entire country."
fcrol
''t'NDSHp J
Through its PolioPlus program,
established in 1985, Rotary was the first
to have the vision of a polio-freeworld,
and continues to play a crucial role in
global efforts to eradicate polio. More
than one million Rotary members have
volunteered to protect more than two
billion children in 122 countriesfrom
polio. Rotary provides urgently needed
funds: to date, the organization has
contributedmore than US$ 616 million
to eradicate polio. In addition, Rotary has
played a major role in decisionsby donor
governmentsto contribute more than
©
o
US$3 billion to the effort.
a:
RotarianAnil Garg ofSimi Valleyin the USA. Born andraisedin Delhi, India,
Garg has led numerouspolio immunizationtrips to Indiaandhas also
providedTsunamirelief.
■ PAKISTAN:
PAKISTAN
CLOSE BILATERAL COORDINATION NEEDED TO STOP POLIO AS VIRUS LARGELY LIMITED TO
BORDER AREAS
KEY POINTS 2006
• Most ofthe country polio-free
• Polio transmissionsustained in mobile or
socially conservativecommunities and in
insecure areas
• Corridor of cross-border transmissionwith
Afghanistan
FOCUS FOR 2007
•
•
•
Increase cross-bordercoordination with
Afghanistan to close immunity gap
Strengthen federal and provincial political
ownership of polio eradication
Improve access to tribal agencies
iiiiiiiiiniiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiliiiiiiiiiiiiiiniiiiiii
Key to success:fully coordinatingactivities with
Afghanistan to increaseaccess to hard-to-reach
populations
GlbBAL POLIO ERADICATION INITIATIVE
12
Of the remaining areas which have yet to stop polio, the single epidemiological
block represented by Pakistan and Afghanistan stands to achieve eradication most
rapidly. In 2006, even though the number of polio cases rose to 40 (from 28 in
2005), transmission in Pakistan was limited to a handful of clearly-identified areas,
largely along the Afghan border. These include the corridors between southern
and eastern Afghanistan and Pakistan’s North West Frontier Province (NWFP)
and Balochistan.
The interruption of transmission in 80% of the districts in Pakistan testifies to the
solidity of the overall strategies of mass vaccination campaigns to reach every child
repeatedly to boost immunity. The vast majority of polio cases in 2006 came from
previously identified zones of transmission in NWFP, Balochistan and Sindh. In a
demonstration of the impact of mOPVl, no type 1 polio cases have been reported from
reservoir areas in northern Sindh since 2005 and southern Punjab since July 2006.
In some of the high-risk areas, most notably the Federally AdministeredTribal Areas
in NWFP and some areas of Balochistan, access to communities is compromised
by security risks. While efforts to overcome this constraint are ongoing, further
mechanisms are needed to improve access in these areas. In 2006, work focused
on the identification of and access to mobile populations and engagement with the
semi-autonomous tribal communities and their leaders.
In a joint technical meeting between Pakistan and Afghanistan, held in Oman
in December 2006, advisers recommended closer cooperation between the two
countries. The Ministers of Health of both countries met that same month at the
Torkham border post and agreed on specific steps, including an increase in the
numbers of immunization posts at formal crossings points - to vaccinate children
who are travelling - and the establishment of regular inter-ministerial meetings
to coordinate planning. After the meeting, each minister crossed the border and
administered OPV to children in the neighbouring country.
Successfully eradicating polio in Pakistan depends on implementing a multi
pronged strategy to reach children in mobile groups, to involve conservative and
semi-autonomous tribal communities and to synchronize vaccination campaigns
carefully with Afghanistan in order to clear the border of poliovirus. A significant
affirmation of national and provincial commitment will be vital to the effective
implementation of this strategy.
■ AFGHANISTAN!
OUTBREAK IN SOUTHERN REGION CONTAINED DESPITE SECURITY CHALLENGES
Most of Afghanistan is today polio-free, but the country suffered an outbreak in
the Southern Region due to sustained cross-infection with Pakistan, with which
it forms a single epidemiological block. Cases in Afghanistan increased from 9 in
2005 to 31 in 2006.
The outbreak in the Southern Region was exacerbated by deteriorating security
conditions - making it perilous for health workers to move around and vaccinate
children - but contained by intense vaccination activities which exploited every
opportunity within the constraints of the conflict. By year-end, the outbreak had
been contained within the region and Afghanistan was closer to polio eradication
than any of the other three endemic countries.
In tandem with the fluctuating security situation, polio teams worked with various
sectors of society at the district, state and national level to negotiate increased access
to children. More local community members were recruited as vaccinators and
supervisors. Teams took advantage of any opportunity when areas could be accessed
to conduct rapid and focused mop-up activities, in addition to the planned large
scale vaccination rounds. In August, the President of Afghanistan Hamid Karzai
established a National Polio Action Group to align and strengthen national and
provincial oversight of these activities.
Polio was largely
limited to a
shared corridor of
transmission alone the
common border.
AFGHANISTAN
KEY POINTS 2006
• Most ofthe country polio-free
• Polio transmission sustained in mobile or
socially conservative communities and in
insecure areas
• Corridor of cross-border transmission with
Pakistan
FOCUS FOR 2007
• Increase cross-border coordination with
Pakistan to close immunity gap
• Sustain political ownership of polio eradication
at national and provincial levels
• Exploit any improvement in security conditions
by coordinating with relevant actors
iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii
Key to success: fully coordinatingactivities with
Pakistan to increase access to hard-to-reach
populations
Indigenous transmission of endemic poliovirus is sustained in Afghanistan among
mobile groups - whether nomadic, displaced or seasonally migratory - and in
communities who live in insecure or socially conservative areas. The poliovirus
that straddles the Afghanistan-Pakistan border circulates among and with these
communities. The movements of the mobile communities were mapped more
systematically in 2006 and long-term immunization posts set up at key migrant
gathering areas and known border crossings between Afghanistan and Pakistan.
ANNUAL REPORT 2006
Wild poliovirus in 2006 in Afghanistan and Pakistan
To rapidly close the immunity gap among these
“hard-to-reach” populations, in December 2006
independent technical advisers for Pakistan and
Afghanistan, meeting in Oman, recommended that
both surveillance and SIAs be increasingly coordinated
between the two countries. In one of their first actions
after this, Ministers of Health of both countries jointly
addressed a historical health jirga of tribal leaders to
advocate for the latters’ support and the participation
of their communities in reaching each child with
vaccine.
/iilmar-J* •
Kandah;
Baiocruit&n .
Successfully eradicating polio in Afghanistan
now depends on exploiting any positive security
developments, on tighter coordination of activities
with Pakistan and on continued top-level oversight
at the federal and provincial levels to make sure no
child is missed.
■ AFGHANISTAN: PRESIDENT TAKES OVERSIGHT OF POLIO ERADICATION
The most significant chain of wild poliovirus
in this region straddles the Afghan-Pakistan
border and caused an outbreak in 2006 in
Afghanistan's Southern Region. Deteriorating
security in the region presented immediate
hazards for health workers attempting to
vaccinate children in the area, exacerbating
the outbreak. To align the response in the
provinces concerned, President Hamid Karzai
established a National Polio Action Group in
August, tasking governors in the Southern
Region to oversee the development and
implementation of plans to increase access to
all populations.
Polio eradication in the Southern Region
focused on three immediate objectives:
• To ensure the safety of staff working in the
field.
• To maintain the highest levels of
continuity of operations possible, given the
deteriorating situation.
GLOBAL POLIO ERADICATION INITIATIVE
14
• To ensure that polio transmission did not
re-infect other areas of Afghanistan.
Polio teams used any window of opportunity
to access districts in security-compromised
areas, while continuing large-scale campaigns
in other regions to maintain high-population
immunity levels.
With these efforts, polio eradication remained
one of the few public health initiatives to
maintain operations in the Southern Region in
2006, and the outbreak was contained. Other
areas of Afghanistan were protected from re
infection, and by the end of the year only three
cases had been reported outside the Southern
Region, one of which was on a frequentlytravelled area on the border with Pakistan's
North West Frontier Province.
I
E
President Hamid Karzai
vaccinates an Afghan child.
©
I
NEW RESPONSE GUIDELINES
■ SHORTEN POLIO OUTBREAKS
RE-INFECTED COUNTRIES: NEW RESPONSE GUIDELINES
SHORTEN OUTBREAKS
The World Health Assembly, where WHO
Member States set global health policies,
adopted in May 2006 a resolution with clear
guidelinesfor polio-free countries to respond
to importationsof virus.
2006 was a testing ground for the effectiveness of new outbreak response guidelines,
adopted by the World Health Assembly in May (Resolution WHA59.1). Of the 26
countries re-infected with importations of poliovirus since 2003, only 10 continued
to report polio cases in the second half of 2006. An outbreak in June in Namibia,
Given the ease with which poliovirus travels,
the risk of importationis very real as long as
the virus circulatesanywhere in the world,
following an importation of Indian virus via Angola, affected mostly adults and
caused a number of deaths. Using the outbreak response guidelines and vaccinating
the entire population several times, officials limited the outbreak to a record 50
days from first case to last. Indonesia and Yemen, which suffered the largest, single
and the guidelinesare designedto minimize
both this risk and the consequencesof an
importation.The main characteristicsof the
response are:
country epidemics in recent years, succeeded in stopping their respective outbreaks
in the first two months of2006. As a result, re-infected countries only accounted for
6% of all polio cases in 2006, down from more than 50% of cases in 2005.
•
It is rapid and creates an emergencyplan
- a rapid investigationwithin 72 hours
of confirmation of a case to establishan
emergencyplan of action;
•
It is swift and sustained- a minimum of
three large-scalerounds of immunization
The focus for 2007 will be on rapidly
stopping the high-risk outbreaks where
polio transmission continues: in central
Africa (Angola and the Democratic
Republic of the Congo), the Horn of
Africa (Ethiopia, Kenya and Somalia)
and Bangladesh. Areas contiguous
to endemic countries are also at
heightened risk until the interruption
of transmission in the latter.
Re-infected countries
with type-specific vaccine, the first of
which starts within four weeks, with at
least two campaignsafter the last case;
accounted for 6% of
all polio cases in 2006,
•
down from more than
50% in 2005.
It is large-scale- targeting at least two
million children aged less than five years
in the affected and adjacent geographical
areas;
•
It is high quality - house-to-house
campaigns where applicable and
independentmonitoringto determine
whetherimmunization coverage is at
least 95%; with higher-than-standard
surveillancefor acute flaccid paralysis for
the duration of the outbreak and at least
12 months thereafterand high routine
immunization coverage.
i
I
!
I
©
i
MM
I
©
o
Polio immunizationofa nomadicchildin Somali region, Ethiopia: 2006 witnessedrapidprogress in stoppingoutbreaks
in re-infectedcountries, but active polio transmissioncontinuesin Angola, Bangladesh, the DemocraticRepublic ofthe
Congo, Ethiopia, Kenya andSomalia.
X
Swiftand massive vaccinationcampaignssuch as this
one, targeting the entirepopulation, shutdown the
Namibiaoutbreak within 50 days.
ANNUAL REPORT 2006
3.2 SURVEILLANCE AND CERTIFICATION OF GLOBAL POLIO ERADICD ATIO N
Confirming that transmission of wild poliovirus is stopped depends on solid surveillance and is followed by certification for poliofree regions that have maintained the necessary levels of surveillance. Recognizing the delays in detecting transmission of poliovirus
in some areas in 2003-04, the surveillance target for acute flaccid paralysis (AFP) detection rates* has been doubled since 2005 in
high-risk areas. To this is added the strength of new laboratory procedures that halve the confirmation time for poliovirus.
MILESTONES 2006
MILESTONE 1: PERCENTAGE OF N 0 N - C E RTI FI E D COUNTRIES WITH C E R TI F IC AT 10 N-STA N D A R D SURVEILLANCE: 100%.
status
:
achieved — 97% of non-certified countries have certification-standard surveillance (the exceptions are Algeria, Guinea
Bissau, Bhutan, East Timor, Djibouti and Lebanon).
partially
MILESTONE 2: PERCENTAGE OF AFP SPECIMENS PROCESSED IN A WHO-ACCREDITED LABORATORY 100%.
status
:
achieved
— All AFP specimens were processed in a WHO-accredited laboratory.
MILESTONE 3: PERCENTAGE OF COUNTRIES COMPLETING PHASE I LABORATORY BI 0-CONTA INMENT PHASE! 100%.
status
:
partially
achieved
— 75% of polio-free countries have completed Phase I activities, including all countries of the
WHO European Region.
MILESTONE 4: PERCENTAGE OF COUNTRIES SUBMITTING "FINAL' CERTIFICATION DOCUMENTATION: 85%.
status
:
8 0 % of eligible countries submitted final documentation for certification.
AFP SURVEILLANCE SENSITIVITY CONTINUES TO CLIMB
The very high sensitivity and reliability of AFP surveillance was sustained and even
further improved in 2006. All WHO regions, including those already certified as
polio-free (the Americas, Western Pacific and European Regions), maintained AFP
surveillance at or substantially above certification quality’ (see Table 1).
Continued sensitive AFP surveillance in polio-free countries is critical in order
protect to countries from importations of poliovirus and to enable swift outbreak
response if necessary. The Regional and National Polio Certification Commissions
assist countries and regions striving to maintain or achieve polio-free status.
'Certification-standardsurveillanceis defined as the abilityto detect at least one case of non-polio AFP for every 100,000children
under 15 years of age, to collect two adequate stool specimensfrom at least 80% of cases of acute flaccid paralysis and to process all
specimens at a WHO accreditedlaboratory.
GLOBAL POLIO ERADICATION INITIATIVE
I6
Table 1: Quality of AFP reporting by WHO Region in 2005 and 20062
% AFP with
adequate
specimens
Reported AFP cases
Non-polio AFP rate
2005
2006
2005
2006
2005
2006
African Region
11683
12478
33
4.0
86
89
Americas
2 213
2154
1.3
1.1
80
79
Eastern MediterraneanRegion
8849
8740
3.7
3.9
88
89
European Region
1479
1550
1.1
1
82
82
South-EastAsian Region
31530
36631
5.4
5.9
82
83
Western Pacific Region
6680
6873
1.7
1.7
88
88
Global total
62434
68426
3.3
3.6
84
85
WHO Region
AFP surveillance quality in all three endemic regions, already well above
certification standards, further increased in 2006. The total number of non-polio
AFP cases reported from the African (AFRO), Eastern Mediterranean (EMRO) and
South-East Asian (SEARO) Regions increased from 52,062 in 2005 to 57,849 in 2006,
mainly due to heightened surveillance and resultant increases in AFP reporting in
the four large remaining endemic countries in those regions: Afghanistan, India,
Nigeria and Pakistan. The sheer increase in AFP cases reported in 2006 in these
regions led to overall non-polio AFP rates of 3 or more per 100,000 - as the vast
majority of AFP cases turn out to be caused by conditions other than polio after
stool analysis. All three regions also recorded increases in the second important
surveillance quality indicator, the percentage of AFP cases with collection of
adequate stool specimens.
AFP surveillance quality
in all three endemic
regions, already well
above certification
standards, further
increased in 2006.
A country-by-countryanalysis of AFP surveillance quality shows improvements
in the great majority. The proportion of countries which reached a level of AFP
reporting of 2 or more per 100,000 in the two endemic regions with the greatest
disease burden increased from 62% to 75% of countries in AFR and from 54% to
63% of countries in SEAR.
A limited number of countries in each endemic region did not reach certification
quality AFP surveillance. These include Algeria and Guinea Bissau in AFRO, Bhutan
and East Timor in SEARO, and Djibouti and Lebanon in EMRO. A few other
countries in EMRO achieved AFP indicatorsjust below the certification cut-off’ and
are considered to have maintained certification-quality AFP surveillance: Morocco,
United Arab Emirates, Lebanon, and the Occupied Palestinian Territories.
22006 data as of 17 April, 2007.
ANNUAL REPORT 2006
LAB NETWORK CONFIRMS VIRUS TWICE AS FAST
Laboratory results are used to confirm the presence of poliovirus, to plan
immunization responses and to monitor progress towards achievement of the
eradication goal. Rapid and accurate laboratory results are paramount to these
goals. A global network of 145 laboratories continues to support AFP surveillance.
The networks quality assurance programme incorporates a WHO-administered
accreditation program involving annual (usually on-site) evaluation of facilities and
procedures, results of proficiency tests, timeliness and accuracy of results. Ninety
seven per cent of laboratories were fully accredited in 2006, and all samples from
AFP cases were tested in accredited laboratories with arrangements for parallel
testing of samples from poorly performing laboratories where necessary.
The laboratory networks workload in 2006 was approximately 125,000 faecal samples
from 63,000 AFP cases and 8,600 non-AFP samples. The workload for investigated
AFP cases was 25% higher than that of 2005. Wild polioviruses were isolated from
AFP cases in 16 countries in 2006.
Genetic characterization of isolates showed that indigenous viruses were transmitted
in four countries (Afghanistan, India, Nigeria and Pakistan). Five countries had
continued transmission of imported viruses introduced in 2005 (Angola, Ethiopia,
Indonesia, Somalia and Yemen), while other countries had new importations
(Bangladesh, Cameroon, Chad, Namibia, Nepal, Niger, Kenya, DR Congo). Viruses
in five countries (Angola, Bangladesh, DR Congo, Namibia and Nepal) were
genetically linked to India viruses, while all other importations linked directly or
indirectly (via transmission in intermediate countries) to Nigeria.
CURRENT TIME TO CONFIRM POLO: 42 DAYS TOTAL LAB TIME
National laboratory
activites:
•Cell culture
• Polio sero-typing
<28 days
Shipment of isolates
< 7 days
Regional reference
laboratory activities:
• Intratypic differentiation
• Confirmation of wild polio
<14 days
■H
J
START
7 DAYS
14 DAYS
21 DAYS
28 DAYS
1
National laboratory
activites:
• Cell culture
<14 days
Shipment of isolates Regional reference
<7 days
laboratory activities:
• Simultanious
polio sero-typing
and intratypic
differentiation
• Confirmationof wild
polio
< 7 days
NEW, REDUCED TIME TO CONFIRM POLIOZ 21 DAYS TOTAL LAB TIME
GLOBAL POLIO ERADICATION INITIATIVE
Id
35 days
42 DAYS
49 DAYS
In 2006 the laboratory network evaluated, and subsequently adopted, a new testing
strategy that reduces poliovirus confirmation time within laboratories by 50%
(from 42 days using the traditional approach to 21 days) without compromising
poliovirus detection sensitivity. The new approach involves use of technologies that
are already available within the network but in a different algorithm (i.e. sequence of
testing). The strategy was evaluated in reference laboratories in Atlanta in the USA,
Islamabad in Pakistan and Mumbai in India. Approximately 5,200 faecal samples,
including 900 poliovirus positive samples, were tested during the field evaluation.
It is estimated that the new strategy will increase cell culture costs by 25% and
intratypic differentiation (ITD) costs by 100%.
In 2006 the laboratory
network evaluated,
and subsequently
adopted, a new
testing
strategy
that
O
O/
reduces poliovirus
confirmation time
within laboratories
bv 50%.
Key to achieving faster results will be testing of samples in laboratories with capacity
for both virus isolation in cell cultures and intratypic differentiation (of viruses as
wild or vaccine like) using polymerase chain reaction (PCR) and Enzyme Linked
Immunosorbent Assay (ELISA). The network has established a goal of testing at least
75% of faecal samples from polio endemic regions in laboratories with such capacities
by December 2007. This will require upgrading of 11 existing national laboratories
to perform ITD tests with implications for investing in capital equipment, reagents
and staff training. Staff training has already begun. An ITD training workshop was
held in Uganda in November 2006 for participants from eight network laboratories.
Additionally staff of four existing ITD laboratories of South East Asia were oriented
on the requirements of the new test strategy in April 2006.
The network suffered a serious setback in 2006 when fire destroyed the sequence
unit at the global specialized laboratory in Mumbai, India, and caused damage to
the cell culture unit and office areas within the facility. The impact included: loss of
equipment; closure of the laboratory for cleaning and renovation; re-directing of
L.
s
o
S
©
o
Participantsfrom eightpolio networklaboratoriesare trainedin Ugandain November2006, on use of the newprotocolwhich halves
the time requiredto confirm thepresence ofpoliovirus.
ANNUAL REPORT 2006
over 10,000 faecal samples and 6,000 polio isolates to 2 other network laboratories
(situated in Lucknow and Chennai, India) for testing; loss of 15 trained staff who
obtained jobs elsewhere; suspension of testing of sewage samples collected in
Mumbai; suspension of Mycoplasma testing of cell cultures used in 16 laboratories
in South East Asia; and long delays in obtaining sequence data on polioviruses from
India. At year-end, sequencing was being performed in Mumbai at a non-network
laboratory that generously offered part-time access to its equipment. The Mumbai
polio laboratory is expected to become fully functional by mid-2007 following
completion of renovation works.
NOTABLE PROGRESS ON CONTAINMENT PREPARATIONS FOR
POLIOVIRUS
Laboratory containment remains an integral part of polio eradication activities in
all six WHO Regions. In 2006, regional and sub-regional meetings on laboratory
containment were held to either monitor progress with Phase I implementation or
review documentation from countries reporting completion of the work.
Over 75% of all
polio-free countries
nave completed Phase I
containment activities.
Notable progress towards completion of Phase I was reported from China, central
America, and eastern and southern Africa. China has successfully completed a
thorough survey of all facilities falling under the jurisdiction of the Ministry of
Health, with plans to complete the survey of remaining facilities in 2007. Similarly,
Mexico reported expanding its initial survey of facilities to include an additional
50,000 laboratories throughout the country. In southern and eastern Africa, all
polio-free countries either submitted a report on the completion of the activities to
the Regional Certification Commission at their meeting in 2006 or report that the
process is ongoing.
Progress with Phase I of Global Containment
| Polio endemic
Q Polio outbreak from
importation
J Conducting survey
H Reporting completionof
survey and inventory
GLOBAL POLIO ERADICATION INITIATIVE
20
In WHO regions with a large number of countries which previously completed the
Phase I activities, work continues to ensure that complete documentation on the
process is reviewed by Regional Certification Commissions (RCCs). EMR conducted
such a review for the 16 countries which reported completion of Phase I. Countries
were requested to submit standardized information which was first reviewed by
WHO and subsequently by independent experts. The results will be made available
to the RCC at their meeting in 2007.
The Phase I laboratory containment activities work towards the objective of
identifying facilities with poliovirus materials and raising awareness of the need
for containment of polioviruses once eradication is achieved. To date, over 75% of
all polio-free countries have completed Phase I activities, including all countries of
the WHO European Region.
INCREASE IN NUMBER OF COUNTRIES SUBMITTING
FINAL CERTIFICATION DOCUMENTS
National Polio Certification Committees (NCCs) and Regional Certification
Commissions (RCCs) in endemic Regions continued to scrutinize in detail
national documentation to show polio-free status submitted by eligible* countries.
The number of eligible countries for which RCCs accepted final certification
documentation increased from 10 to 14 in APR (of 46 Member States), and from
6 to 8 in SEAR (of 11 Member States); it remained steady at 15 of 22 Member States
in EMR because several countries, including Sudan, were re-infected after they had
already had successfully submitted final certification documentation. The percentage
of total WHO Member States which successfully submitted final certification
documentation increased slightly from 78% in 2005 to 80% in 2006.
’Eligible countries are those where no wild poliovirushas been found for at least three years, in the presenceof certification quality
surveillance.Countries can file documentationbut cannot receive polio-free certification,which can only be conferred on a WHO Region
as a whole.
ANNUAL REPORT 2006
3.3 DEVELPOM ENT OF PRODUCTS FOR POTENTIAL GLOBAL OPV CESSATION
The current risk posed by wild polioviruses remains far greater than the risk of vaccine-associated paralytic polio (VAPP) or
circulating vaccine-derived polioviruses (cVDPVs). However, after interruption of wild poliovirus transmission, Sabin vaccine
viruses could continue to cause individual paralysis or outbreaks. Consequently, as recommended by the ACPE, the Global Polio
Eradication Initiative undertakes a programme of work for the identification, reduction and management of the potential risks
associated with the cessation of OPV, whether the re-emergence of polio due to a cVDPV or re-introduction of either a wild or
Sabin poliovirus. Progress on these strategies and related products are detailed in the section below.
MILESTONES 2006
MILESTONE 1: CESSATION OF OPV FOR ROUTINE IMMUNIZATION! CONSOLIDATE OPV CESSATION STRATEGY AND
NATIONAL IPV DECISIONS.
status:
achieved — Research is ongoing in a variety of settings to determine the scope and nature of the risks and risk
mitigation options associated with OPV cessation and use of inactivated polio vaccine (IPV).
partially
MILESTONE 2: DETECTION AND IMMEDIATE NOTIFICATION OF CIRCULATING POLIOVIRUSES: INCORPORATE POLIO
SURVEILLANCE INTO INTERNATIONAL HEALTH REGULATIONS (2005) AND THE GLOBAL OUTBREAK AND
ALERT RESPONSE NETWORK.
status:
ACHIEVED.
MILESTONE 3: POLIO VACCINE STOCKPILES AND EMERGENCY RESPONSE: LICENSURE OF AT LEAST TWO mOPV
SUPPLIERS.
status:
ACHIEVED.
MILESTONE 4: LONG-TERM CONTAINMENT OF POLIOVIRUS STOCKS! FULLY ALIGN WITH SECURITY PROCESSES
FOR SIMILAR PATHOGENS.
status:
ACHIEVED.
Bio-risk management standard developed in consultation with those responsible for bio-containmentof smallpox and experts in bio-safety and risk management.
IDENTIFICATION OF RISKS ASSOCIATED WITH OPV
CESSATION
As our knowledge of VDPVs continues to evolve, a better understanding of the risks
they pose to polio eradication has become a priority of the Global Polio Eradication
Initiative. In terms of identifying and defining these risks, the focus is currently on:
modelling of VDPV risk associated with OPV cessation; further defining VDPV
prevalence among immuno-deficient persons (iVDPVs) in middle- and low income
countries; and analysing poliovirus isolates emanating from the global acute flaccid
paralysis (AFP) surveillance system and other sources.
GLOBAL POLIO ERADICATION INITIATIVE
ll
■iVDPV STUDY SERIES
A known potential source of VDPVs are people suffering from primary immune
deficiencies (PIDs) who excrete vaccine-derived polioviruses (iVDPV). It has been
recognized that the risk of circulating VDPVs (cVDPVs) will eventually be reduced
over time once OPV is no longer in use; however the risk of iVDPVs is likely to
persist as long as there are persons excreting iVDPVs.
Thirty-two persons shedding iVDPVs have been reported to WHO since 1962. All
of the iVDPVs identified to date have been reported from upper- or middle-income
countries. Although most of the reported iVDPVs have spontaneously stopped
poliovirus excretion or died, at least four have reported excretion for more than five
years. Limited data are available on the prevalence and natural history of prolonged
or chronic poliovirus excretion among persons with PIDs in middle- and lowincome countries, and whether this population may serve as an important reservoir
of VDPVs in these countries is unknown. To address the knowledge gaps associated
with the incidence and behaviour of iVDPVs, as well as to increase local capacity for
the surveillance and monitoringof iVDPVs, the Global Polio Eradication Initiative
has begun planning a study series to generate information regarding the prevalence
of PIDs with long-term poliovirus excretion in low- and middle-income countries
currently using OPV.
After interruption
of wild poliovirus
transmission, Sabin
vaccine viruses could
continue to cause
individual paralysis or
outbreaks.
■ LABORATORY ANALYSIS OF VDPVs
During 2006, the laboratory network detected Vaccine Derived Polioviruses
(VDPVs) in a number of locations, including:
• Locations with evidence of person-to-person spread: Nigeria (type 2 VDPVs
from 16 AFP cases in 4 different provinces), China (type 1 VDPV from 1 AFP
case and 8 community contacts in Gaunxi), Myanmar (type 1 AFP case and 7
contacts); Cambodia (type 3 VDPV from 1 AFP case following isolation of a
genetically related VDPV from an AFP case with onset in late 2005).
• VDPVs from AFP cases with follow up investigations pending: Syria (a single
type 2 case)
• VDPVs detected in sewage waters without paralyzed persons found during
follow up investigations: Czech Republic (10 type 1 VDPVs); Israel (2 type 2
VDPVs).
• VDPVs (type 2) in an immuno-deficient person from Tunisia, the case having
been detected in France.
REDUCTION OF RISKS ASSOCIATED WITH OPV CESSATION
Reducing the potential risks of OPV cessation involves the preparation for
containment of all polioviruses in a post-eradication world and the demonstration
of the scientific and logistic feasibility of producing inactivated vaccine based on
Sabin rather than wild poliovirus. Additional projects include the development of
products such as rapid diagnostics and antiviral compounds against polioviruses.
ANNUAL REPORT 2006
■ CONTAINMENT OF POLIOVIRUSES
In 2006, the plan for long-term containment of poliovirus was completed with the
development of the draft WHO Global Action Plan to minimize poliovirus facility
associated risk in the post-eradication/post-OPV era (GAP III). The development of
GAP III provides the Global Polio Eradication Initiative with a long-term vision and
rational plan to ensure that polioviruses are not reintroduced to human populations
once circulation has been interrupted.
GAP III provides
the Global Polio
I Eradication Initiative
with a long-term
vision and rational
plan to ensure that
polioviruses are not
reintroduced to human
populations once
circulation has been
interrupted.
A key recommendation of GAP III is to reduce to fewer than 20 the number of
research or production facilities retaining polioviruses worldwide that serve essential
functions and meet defined primary and secondary safeguards against transmission.
GAP III outlines a two-pronged strategy of risk elimination and risk management
implementedin four phases, each linked to achievement of milestones in global polio
eradication. The first three phases of the plan focus on eliminating and managing
the risk of wild polioviruses in facilities after eradication is achieved.
In countries retaining wild poliovirus materials, primary and secondarysafeguards
are described based on findings from risk assessment and risk consequence models.
Primary safeguards were developed in consultation with the WHO department
responsible for bio-containment of smallpox along with experts in biosafety and risk
management. The resulting Biorisk managementstandard (BSL 3/polio)for essential
poliovirusfacilities in the post-eradication/post-OPVera establishes a new international
benchmark for managing the risk of an eradicated pathogen. This documentoutlines
goals to be achieved by each facility in 16 broad areas based on the principles of
a quality management system. It places the responsibility of risk management
squarely on the facility and its management and requires that appropriate controls
and systems for managing the risk be not only developed but demonstrated during
periodic national and international accreditation procedures.
Beyond these primary safeguards, secondary safeguards are necessary in order
to minimize the consequences in the unlikely event of a poliovirus release. These
include the location of essential poliovirus facilities in areas with high routine
national population coverage with IPV (more than 90%) and high quality closed
sewage systems with secondary or greater effluent treatment.
■ SABIN IPV
A critical element of risk-reduction in the post-eradication era is the effort to
replace wild poliovirus in vaccines with Sabin virus, which is less neuro-virulent and
therefore safer. A vaccine manufacturerhas been contracted to establish the feasibility
of inactivated vaccine production from Sabin strains. Once this “proof-of-principle”
is established through the production of what is known as a pharmaceutical batch,
the Global Polio Eradication Initiative will sponsor the clinical development of Sabin
IPV. In addition, work has begun to establish standards for Sabin IPV through the
United Kingdoms National Institute for Biological Standardization and Control.
The goal of both these lines of work is a potent vaccine based on the least neurovirulent strain of virus, reducing the potential risks of manufacturing, handling
and taking vaccine.
GLOBAL POLIO ERADICATION INITIATIVE
24
MANAGEMENT OF RESIDUAL RISKS ASSOCIATED WITH
OPV CESSATION
While research and policy activities are focused on identifying and reducing the risks
associated with OPV cessation, the residual risk must be managed. The scientific
guidance for national immunizationpolicies, the preparation for a vaccine stockpile
and the development of monovalent oral polio vaccine type 3 (mOPV3) are all
integral to both reduction and management of these risks. Ensuring long-term
surveillance of polioviruses must be planned for as well.
■ IPV INTRODUCTION AND FRACTIONAL DOSE STUDIES
Scientific research helps form national policy decisions on maintaining population
immunity in a post-eradication world: this is the goal of fractional IPV dose trials
in Cuba and Oman and an IPV project in a tropical country.
The various natural disasters in Indonesia and the importation and a large outbreak
of poliomyelitis led to substantial delays in the introduction of IPV in the province
of Yogyakarta. This project continues to be a high priority for the Global Polio
Eradication Initiative and will answer key scientific questions, including whether
IPV-induced immunity will prevent the emergence of VDPVs in a tropical setting,
which will potentially influence a future recommendationfor an IPV-only schedule
for tropical developing countries. While environmentalsurveillance in the context
of this project is ongoing, a policy switch from OPV to IPV is expected in 2007.
Above and beyond the various scientific, programmatic and operational issues
affecting IPV use in the developing world, the cost of IPV vaccination is a
major decision factor (especially when weighted against limited resources and
the opportunity costs). For the past year, AMRO, EMRO and WHO HQ have
collaborated in promoting research to evaluate fractional doses of IPV administered
intra-dermally by needle-free devices. Such an approach could lead to substantial
cost-saving for an IPV schedule.
The implementationof a study series to compare the immunogenicityof fractional
doses of IPV administered by needle-free device versus full doses of IPV administered
by intramuscular injection began in September 2006, with an initial study set in
Cuba, while another set in Oman is expected to begin enrolment in early 2007. The
data generated by this study series are intended to facilitate the regulatory approval
of fractional doses of IPV
■ VACCINE STOCKPILE SOPsAND TENDER PROCESS
Hie Standard Operating
Procedures for the
vaccine stockpile set
forth the concepts for
emergency response
in the post-eradication
world.
The Standard Operating Procedures for an mOPV stockpile were drafted and
presented to the ACPE in October 2006. This document sets forth the basis for
emergency response in the post-eradication world. Furthermore, it outlines the
triggering events for such an emergency response as well as a decision-making
mechanism in case mOPV has to be released in an emergency situation. This work
represents a major step forward for the Global Polio Eradication Initiative in terms
of tools and products to manage a post-eradicationresponse to the re-introduction
or re-emergence of poliovirus.
ANNUAL REPORT 2006
25
In 2006, mOPVl was licensed by four different producers: GSK (in Indonesia,
Belgium and Nigeria), Panacea and Bio Farma (in Indonesia) and Sanofi Pasteur (in
Pakistan). GSK also licensed its mOPV3 in Belgium. Several more applications for
licensure of mOPV products are pending with national regulatory authorities.
Another significant achievement in the preparedness for emergency response in a
post-eradication world was the UNICEF Request for Commercial Indication (RCI).
In December 2006, UNICEF issued its RCI to four manufacturers - all of which
are WHO pre-qualified for trivalent OPV products - to provide them with basic
information on stockpile requirements for suppliers, such as presentation of the
vaccine, the number of doses per serotype, storage and security, etc.
Plans to finance the necessary preparations for a post-eradication world were aided
by the launching of the innovative financial issuer, the International Finance Facility
for Immunization. The Executive Committee of the GAVI Fund in September 2006
approved the use of US$ 191 million from this issue to help build the stockpile of OPV
for the post-eradication era.
Circulating
wild polioviruses will
become one of the four
I diseases specifically
mentioned in - and
'[notifiable” under - the
International Health
Regulations 2005.
■ POLIO SURVEILLANCE UNDER THE INTERNATIONAL HEALTH REGULATIONS (2005)
With the global reduction and eventual interruption of wild poliovirus, and in
a post-eradication world, long-term surveillance for polioviruses takes on a new
role. Circulating wild polioviruses will become one of the four diseases specifically
mentioned in and “notifiable” under the International Health Regulations 2005
(IHR 2005), which come into effect in June 2007. The evolving relationship between
IHR and vaccine-preventable disease control and polio eradication activities,
especially at regional and country level, is expected to increase in importanceas the
Initiative approaches the global interruption of wild poliovirus circulation.
Event-based reporting for polio cases will need to be fully incorporated into existing
mechanisms for dealing with events of internationalpublic health importance, such
as the IHR. Integration of polio into the IHR will further help to prevent, protect,
and control the international spread of the disease in the event of an outbreak. As
the IHR comes into force, countries will be assessing their capacity to identify, verify,
and control potential polio outbreaks.
■ CURBING THE RISK OF INTERNATIONAL SPREAD OF POLIO
The poliovirus has repeatedly shown its
ability to travel great distances, causing
importations by land, sea or air travel.
To minimize the risk and consequences
of potentialfuture importations,
countries are protectingthemselveswith
immunization measures.
Full vaccination of all travellers from any
polio-affectedarea may be necessary in
the near future. The Executive Board of
the World Health Assembly,convening
GLOBAL POLIO ERADICATION INITIATIVE
26
in January2007 in Geneva, Switzerland,
called for an appropriatestanding
recommendationunder the International
Health Regulations(2005), after their
entry into force in June 2007.
Individual countries are already enforcing
similar policies at national level. Saudi
Arabia, for example, requires all Hajj
travellers from Nigeria, India, Pakista and
Afghanistan to be immunized against
polio.
©
1
Pilgrims from Peshawar, Pakistan, are immunizedprior to their departure.
Such polio immunizationrequirementsmay be institutedby other countries.
3.4 MAINSTREAMING OF THE GLOBAL POLIO E R A D I C A T I 0 N I N I T I A T I V E
Mainstreaming of the Global Polio Eradication Initiative is one of the key strategic objectives. It includes integration of the long
term functions of polio eradication into national and internationalmechanisms for managing other pathogens and the transition
of the polio infrastructure to other programmes such as immunization and outbreak response.
■■■■■■■■ MILESTONES 2006
MILESTONE 1: 75% OF JOINT GAVI/POLIO PRIORITY COUNTRIES IMPLEMENTING INTEGRATED PLANS.
status:
achieved
— 43/52 (83%) joint GAVI Al I iance/Polio priority countries have drafted or finalized comprehensive multi-year plans.
MILESTONE 2: 100% OF COUNTRIES WITH INTEGRATED OR EXPANDED AFP REPORTING, AS APPROPRIATE (ESPECIALLY
FOR MEASLES AND NEONATAL TETANUS):
status:
PARTIALLY ACHIEVED.
• 118/180 (66%) countries with AFP case-based reporting also have measles case-based reporting;
• 180/193 countries have AFP case-based reporting systems.
MILESTONE 3: 75% OF COUNTRIES WILL HAVE GAVI-SUPPORTED ICC AND IF APPROPRIATE, TAG.
status:
— 43/52 (83%) of joint GAVI Alliance/Pol io priority countries have GAVI Alliance-supported Interagency Coordinating
Committees (ICCs) which work on broader issues as demonstrated by their development, approval, dissemination and implementation of
comprehensive multi-year plans. Joint GAVI Alliance/Polio priority countries are defined as all GAVI Alliance-eligiblecountries in polio endemic
regions (i.e. AFRO, EMRO, SEARO).
achieved
MILESTONE 4: 75% OF POLIO-FUNDED 'HUMAN RESOURCES' FORMALLY CONTRIBUTING TO M U L T I - D I S E A S E
PROGRAMMES.
status:
ACHIEVED.
100% of polio-funded staff contributes formally to multi-disease programmes.
MILESTONE 5: 100% OF COUNTRIES WITH POLIO OPERATIONS ARE FULLY INTEGRATED WITH THOSE FOR
MEASLES.
status
:
ACHIEVED.
85% of the institutions performing polio laboratory surveillance are also involved in national measles laboratory surveillance.
ANNUAL REPORT 2006
INTEGRATION OF LONG-TERM FUNCTIONS
Once wild poliovirus transmission is interrupted, all other poliovirus must be
contained, surveillance for them sustained and a stockpile of vaccine maintained.
These long-term functions of polio eradication will be integrated with existing
mechanisms to help countries prepare for, monitor and respond to public health
emergencies and outbreaks.
The International Health Regulations 2005 (IHR - which come into force in June
2007) call on signatories to develop, strengthen and maintain surveillance and
response capacities for public health emergencies which may have an international
impact. Polio eradication functions which are being incorporated into existing
mechanisms to help countries comply with this instrument of international law
include: surveillance - in the form of the AFP surveillance and laboratory network;
vaccine stockpile and response functions to help deal with disease outbreaks; and
laboratory containment functions such as those necessary for smallpox.
INTEGRATION OF CAPACITY AND EXPERIENCE
The global polio infrastructure encompasses its human resources, standards and
operational guidelines governing polio eradication activities and the physical assets
of the programme such as cars, computers and laboratory equipment. These have
each over the years become an integral component of national and regional health
systems. An indicator in WHO’s Medium Term Strategic Plan 2008-2013 is the
number of countries in which the polio surveillance infrastructure contributes to
national core capacity building for IHR.
Countries with implementationof'RED' activities in 2002-2006
c
rY
’>
■\<rV
GLOBAL POLIO ERADICATION INITIATIVE
26
Some 3,300 AFP surveillance and response staff operate in 54 countries, along with
thousands more polio communication and social mobilization workers. A survey
of 1,500 Global Polio Eradication Initiative-funded staff indicated that 85% give
an average of half their time to work that is related to immunization, surveillance
and outbreak response for other diseases - constituting the single largest source
of such technical assistance to low-income countries. Polio staff helped to support
measles mortality reduction activities that have averted 2.3 million deaths between
1999 and 20051, bringing the world closer to Millennium Development Goal 4; the
human and physical infrastructure of polio eradication is fully involved in routine
immunization coverage, the introduction of new and under-used vaccines, the
distribution of insecticide-treated bed nets against malaria and the response to health
emergencies following earthquakes and other disasters. The “Reach Every District”
(RED) strategy that aims to improve access to routine immunization is built on the
polio model and is operational in 53 countries. The global polio laboratory network
serves to identify and track other diseases, including measles and yellow fever.
Over 85% of polio
staff spend an average
of half their time on
other diseases of public
health importance.
As AFP surveillance officers are highly trained and on the ground, they are often
the first to respond to haemorrhagic fever outbreaks like Marburg and Ebola, avian
influenza, cholera and other serious infectious disease outbreaks for which the
WHO’s Global Outbreak Alert and Response Network (GOARN) was set up. As the
Global Polio Eradication Initiative moves towards interruption of wild poliovirus,
GOARN is expected to assume a greater role in polio surveillance.
1 Wolfson LJ, Strebel P, Gacic-Dobo M, Hoekstra E, McFarlandJW, Hersh B, for the Measles Initiative.Has the 2005 measlesmortality
reductiongoal been achieved? A natural historymodellingstudy. Lancet2007; 369:191 -200.
ANNUAL REPORT 2006
FINANCING
Ihe international community has over the past 19 years invested US$ 5.3 billion in polio eradication, US$ 695 million of this in
2006, a year in which the international donor community continued to make strong promises of financial support. In a statement
to the 59th World Health Assembly in May 2006, EU member states re-affirmed their “full support” for polio eradication. G8
leaders, meeting in July 2006 at the G8 Summit in St Petersburg, pledged to continue support to polio eradication, following their
2005 commitmentat Gleneagles to “continue or increase” their contributions to consign polio to the history books.
A broad public-private partnership that includes 44 donors of more than US$ 1 million and 27 donors of more than US$ 5 million,
the Global Polio Eradication Initiative is, at the end of 2006, in its most precarious financial position ever. Unless additional funds
are contributed quickly, the global programme will start to run out of money by mid-2007 and activities will have to be curtailed,
putting at risk the 19-year eradication effort. The 2007-2008 global funding gap as of May 2007 stands at US$ 540 million.
In 2006, governments of polio-affected countries,
including Bangladesh, India, Indonesia, Namibia, Nigeria
and Pakistan provided domestic funding at unprecedented
levels.
Hie Global Polio
Eradication Initiative
is, at the end of 2006,
in its most precarious
financial position ever.
GLOBAL POLIO ERADICATION INITIATIVE
30
The international donor community is urged to translate
its public statements of support into funding for countries
to finish the job. The humanitarian and economic case
for finishing eradication is sound. A new study from
Harvard University demonstrates that over a 20 year
period, controlling polio at high levels would cost more, in
human suffering and dollars, than finishing eradication.
The world has an opportunity to come together to finish
polio eradication once and for all and give a perpetual
gift to children across the world. The alternative is
unacceptable: hundreds of thousands of children would
again be paralysed by this disease over the coming
years, and billions of dollars would be spent on outbreak
response activities, rehabilitation/treatment costs and
associated loss of economic productivity. The international
community has very few opportunities to do something
that is unquestionably good for every child and every
country in the world. We owe it to all future generations
to succeed.
Austria continued its support to polio
eradication by committing US$ 710,000
in 2006 for Ethiopia’s polio eradication
efforts, bringing its total contributions
to US$ 1.67 million.
continued to support the international
assignment of epidemiologists,
virologists and technical officers to assist
WHO, UNICEF and polio-endemic
countries in implementing polio
eradication activities.
■ AUSTRALIA
■ CENTRAL EMERGENCY
In 2006 Australia provided US$ 804,000
- vaccine funding for polio outbreak
response in Nepal, as well as
global funding - bringing its total
contributions to US$ 16.3 million.
The CERF provided US$ 830,000 to
help Somalia and the Democratic
Republic of the Congo respond to polio
outbreaks.
■ BILL AND MELINDA GATES
■ DENMARK
■AUSTRIA
FOUNDATION
The Bill and Melinda Gates Foundation
provided US$ 39.8 million for Nigeria
and surrounding countries, with the
objective of minimizing spread of
poliovirus along the Hajj pilgrimage
route. This latest funding brings the
Foundation’s total commitments to
US$ 149.80 million.
■CANADA
Taking steps towards fulfilling its G8
promise to “continue or increase” polio
funding for 2006-08, Canada in 2006
provided US$ 39 million in global
funding, and earmarked an additional
US$ 4 million for 2006-07 activities in
Afghanistan. These latest contributions
bring Canada’s total commitments to
US$ 181 million.
■ US CENTERS FOR DISEASE
CONTROL AND PREVENTION
(CDC)
In addition to its role as a core technical
spearheading partner, CDC provided
funding for OPV, operational costs and
programme support to UNICEF and
WHO. It also continued to support the
Investment Partnership for Polio, which
sees CDC providing funding to allow
countries to buy down to zero World
Bank loans for OPV, in effect turning the
loans into grants. US Congress in its fiscal
year 2006 allocated US$ 101.25 million
to CDC for polio eradication. CDC
investment case under the International
Finance Facility for Immunisation
(IFFIm). This investment will provide
the up-front financing needed to
establish a mOPV stockpile that GAVI
Alliance-eligible countries can access
(as needed) in the post-eradication
era.
RESPONSE FUND (CERF)
Denmark contributed US$ 500,000
in 2006 to support Niger’s polio
eradication programme.
■ EUROPEAN COMMISSION (EC)
The EC in 2006 continued its support
to the polio eradication efforts of
14 African countries and provided
US$ 7 million in new funding for
Niger. The European Community
Humanitarian Office (ECHO)
supported the Democratic Republic
of the Congo’s (DRC’s) polio outbreak
response with US$ 480,000.
■ FRANCE
France, which joined the Global Polio
Eradication Initiative in 2004, provided
US$ 12.6 million in global funding in
2006, as it paid its final instalment on
its three-year, US$ 36 million pledge.
It also provided technical staff to
assist Chad and Niger in their polio
eradication programmes.
■GERMANY
Germany committed an additional
US$ 37.2 million in multi-year
OPV funding for India’s polio
eradication effort and signed a new
US$ 1.3 million global agreement for
2007-08. These latest contributions
bring Germany’s total contributions to
US$ 142 million.
■ ICELAND
Iceland followed its first-ever
contribution to global polio eradication
activities in 2005 with a second
contribution of US$ 50,000 in 2006.
■ IRELAND
Ireland signed a 2006-08 global pledge
of US$ 10.4 million, double its 2003-05
contribution to polio eradication, and
bringing its total polio funding to
US$ 16.6 million.
■JAPAN
Japan provided US$ 13.4 million for
OPV for SIAs in priority countries.
Eighty per cent of this funding was
earmarked for Pakistan, India, Ethiopia
and Nigeria. Japan’s 2006 contributions
bring its total polio commitments to
US$ 312 million.
■ GLOBAL ALLIANCE FOR
VACCINES AND IMMUNIZATION
ALLIANCE (GAVI ALLIANCE) AND
THE INTERNATIONAL FINANCE
FACILITY FOR IMMUNIZATION
(IFFIm)
The Executive Committee of the GAVI
Fund at its September 2006 meeting
approved US$ 191.28 million for the
creation, procurement and evaluation
of a polio vaccine stockpile as an
■ LUXEMBOURG
Luxembourg pledged US$ 2.76 million
for 2006-08, bringing its total polio
contributions to US$ 9.08 million.
Luxembourg is the highest per capita
government donor to the Global Polio
Eradication Initiative, having provided
US$ 19.14 for every man, woman and
child in Luxembourg.
ANNUAL REPORT 2006
31
■ MONACO
■SULTANATE OF OMAN
■RUSSIAN FEDERATION
Monaco continued its support for polio
The Sultanate of Oman continued its
The Russian Federation, during its
eradication by providing US$ 78,000
support for global polio eradication
efforts by contributing US$ 100,000 in
2006, bringing its total contribution to
Presidency of the G8 in 2006, kept
polio eradication on the G8 agenda
during the Summit at St Petersburg
US$ 200,000.
and pledged US$ 10 million in global
funding for 2006-08, a 25% increase
■ ROTARY INTERNATIONAL
Rotary International, a spearheading
partner of the Global Polio
Eradication Initiative, is the largest
over its 2003-05 funding.
private sector donor to the Global
Espanola de Cooperacion International,
■NEW ZEALAND
Polio Eradication Initiative, and the
continued its strong support by
New Zealand contributed US$ 300,000
second-largest contributor, after the
for global polio eradication efforts
through their partnership with local
Government of the United States. In
2006, Rotary International contributed
US$ 22.6 million to support polio
providing US$ 1.25 million for global
polio eradication activities, including
funding to maintain and improve
certification standard surveillance in
for polio eradication activities in
Niger.
■ NETHERLANDS
The Netherlands Ministry of Health
committed US$ 210,000 to support
polio work at the Dutch National
Institute of Public Health.
Rotary clubs in the country.
DNORWAY
Norway signed a two-year pledge to
provide US$ 15.2 million in global
eradication efforts in priority countries,
bringing its total contributions to more
than US$ 616 million.
funding for 2006-07, bringing its total
polio contribution to US$ 50 million.
■ TRIBUTE TO KOFI ANNAN
The former United Nations Secretary-GeneralKofi Annan played a critical
leadership role in the strong progress made in global polio eradication efforts over
the past 10 years. When he assumed his office in 1997, polio was endemic in most
of Africa, South-East Asia and the Eastern Mediterranean; even Europe had not
been certified polio-free. By the end of his tenure in 2006, only four countries in
the world reported indigenous wild poliovirus transmission, and only one of these
-Nigeria-is in Africa.
The former Secretary-General personally raised the polio eradication in bilateral
meetings with Heads of State of key polio-affected and donor countries and
regularly included the subject in his speeches at major events. In 2006, Mr. Annan
took some extraordinary actions to advocate with leaders of polio-endemic
countries, writing to the Heads of State to express his concern and that of the
international community at the increase in the number of reported polio cases. His
message of alarm caught the attention of the Heads of State and helped mobilize
efforts to improve the quality of polio immunization activities.
Noting that the program faced a critical funding gap for implementing activities
in 2006, the Secretary-Generalalso took the initiative to write to the Kings and
Heads of Government of the Gulf Cooperation Council member states requesting
that they partner in this global effort and provide financial resources. Contributions
and pledges are now being received in response to his request. Mr. Annan also
contacted the leaders of a number of G8 countries, urging them to fulfil their
funding commitments for polio eradication.
GLOBAL POLIO ERADICATION INITIATIVE
32
■SPAIN
In 2006, Spain, through its Agencia
Cape Verde, Guinea Bissau, Angola
and Namibia.
■ UNITED NATIONS
CHILDREN'S FUND (UNICEF)
In 2006, spearheading partner UNICEF
provided funding for polio eradication
activities through several channels:
Regular Resources: UNICEF allocated
regular resources of US$ 12 million
for polio activities in Afghanistan,
Pakistan, India, Nigeria, Angola,
Namibia and Sudan.
National Committees: UNICEF
National Committees in Switzerland,
Iceland, Australia, Canada and the UK
together contributed US$ 954,000 for
polio eradication activities in priority
countries.
UNICEF Country Offices: UNICEF
offices in Angola, Bangladesh,
DRC, India and Namibia locally
reprogrammed USS 1.7 million
in funding for polio eradication
activities.
■ UNITED KINGDOM'S
DEPARTMENT FOR
INTERNATIONAL
DEVELOPMENT (DFID)
DFID’s US$ 53.65 million in global
and country-specific funding in 2006
brought its total polio contributions
to more than US$ 600 million. DFID
complemented its flexible global
funding with support for Pakistan,
India, Somalia, Indonesia and
Myanmar, as it continued to take action
on the pledge of G8 leaders at the 2005
G8 Summit at Gleneagles to “continue
or increase” funding for 2006-08.
■ UNITED NATIONS
FOUNDATION (UNF)
In 2006, the UNF provided
US$ 3.34 million for surveillance in
WHO’s AFRO and EMRO regions, for
OPV for Myanmar and operations costs
for Nigeria, while also continuing its
support to the Global Polio Eradication
Initiative’s resource mobilization
efforts.
■WORLD BANK
The World Bank provided a
US$ 6 million grant to Afghanistan
for the purchase of OPV in 2006-07.
Nigeria and Pakistan continued to
benefit from the World Bank Investment
Partnership for Polio, which sees the
Bill and Melinda Gates Foundation,
Rotary International, CDC and UNF
providing funding to allow countries
to buy down to zero World Bank loans
for OPV, in effect turning the loans
into grants. This innovative financing
mechanism has since 2003 facilitated
the purchase of US$ 165.5 million of
OPV in Nigeria and Pakistan.
■ USAID
US Congress in its fiscal year 2006
allocated US$ 32 million through
USAID to support global polio
eradication efforts. In addition, USAID’s
Office of US Foreign Disaster Assistance
(OFDA) provided US$ 200,000 for polio
eradication activities in south/central
Somalia. USAID’s total contributions
to polio eradication are more than
US$ 322 million.
r
ANNUAL REPORT 2006
GLOSSARY OF TERMS
ACRE
AFP
AFRO
AMRO
CDC
cVDPV
DFID
EC
EMRO
EURO
EPI
GAP III
GAVI Alliance
GCC
ICC
IFFim
IPV
ITN
mOPV
NCC
NID
OIC
OPV
RCC
RED
SEARO
SIA
SNID
tOPV
UN
UNF
UNICEF
USAID
VAPP
VDPV
WHA
WHO
WPRO
Advisory Committee on Poliomyelitis Eradication
Acute flaccid paralysis
WHO Regional Office for Africa
WHO Regional Office for the Americas
US Centers for Disease Control and Prevention
Circulating vaccine-derived poliovirus
Department for International Development
European Commission
WHO Regional Office for the Eastern Mediterranean
WHO Regional Office for Europe
Expanded Programme on Immunization
WHO Global Action Plan to minimize poliovirus facility associated risk in the post-eradication/post-OPVera
Global Alliance for Vaccines and Immunization
Global Commission for the Certification of the Eradication of Poliomyelitis
Interagency Coordinating Committee
International Financing Facility for Immunization
Inactivated polio vaccine
Insecticide treated net
Monovalent oral polio vaccine
National Certification Committee
National Immunization Days
Organization of the Islamic Conference
Oral polio vaccine
Regional Certification Commission
Reaching Every District
WHO Regional Office for South-East Asia
Supplementary immunization activity
Sub-national Immunization Days
Trivalent oral polio vaccine
United Nations
United Nations Foundation
United Nations Childrens Fund
United States Agency for International Development
Vaccine-associated paralytic polio
Vaccine-derived poliovirus
World Health Assembly
World Health Organization
WHO Regional Office for the Western Pacific
GLOBAL POLIO ERADICATION INITIATIVE
34
I
T
The World Health Organization
The Case for Completing Polio Eradication
'As an international community, we have few opportunities to do something that is
unquestionably goodfor every country and every child, in perpetuity.'
Dr Margaret Chan
Director-General
World Health Organization
The Issue
Without an urgent infusion of internationalfunds, the opportunity to complete polio
eradication could be lostforever...
By July 2007 the Global Polio Eradication Initiative (GPEI) will have a negative cash
flow, which if not addressed will require an immediate reduction in planned polio
eradication activities in the remaining infected countries1. Even a temporary cutback
would result in the reinfection of polio-free areas, delays in outbreak response, a surge
in polio-paralyzed children and an increase in overall costs. Insufficient funds at this
late stage imperil the entire 20-year eradication effort, as well as related gains in
routine childhood immunization, global communicable disease control, preparedness
and response, and other child survival and international health activities.
Thefollowing 'case statement' was developedfollowing an 'Urgent Stakeholder
Consultation on Polio Eradication' convened by the Director-General of the World
Health Organization (WHO) on 28 February 2007 at the WHO Headquarters in
Geneva, Switzerland. The list ofparticipants, agenda, presentations and other related
materialsfrom the Consultation are available at www.polioeradication.org.
1 At 10 May 2007, 4 countries had yet to stop indigenous poliovirus (i.e. 'endemic' countries:
Afghanistan, India, Nigeria, Pakistan); 6 of the 26 countries reinfected since 2003 by virus that
originated in an endemic country had not yet stopped transmission again (i.e. Angola, Bangladesh,
Democratic Republic of the Congo, Ethiopia, Myanmar, Somalia); 4 additional countries that border
'endemic' areas continue to suffer sporadic importations (i.e. Cameroun, Chad, Nepal, Niger).
The Context
In 1988, over 350 000 children were being paralyzed by polio every year...
Despite the availability of an effective, cheap, oral polio vaccine (OPV) for more than
25 years, over 350 000 children in at least 125 countries were still being permanently
paralyzed by wild polioviruses2 each year when the Global Polio Eradication Initiative
(GPEI) was launched in 1988.
By 1999, the GPEI had reduced annual polio cases by 99% and proven the feasibility
of eradication...
The technical feasibility of eradicating wild-type poliovirus was confirmed in October
1999 when the last case of paralytic polio due to wild poliovirus type 2 (1 of 3 types)
was detected anywhere in the world. By 2002, the feasibility of eradication was
reaffirmed by certification of eradication of all 3 wild poliovirus types in 3 of the 6
WHO Regions.
In 2003, limited cutbacks in eradication activities led to a huge resurgence ofpolio...
In mid-2003 two northern Nigeria states that were heavily infected with polio
unexpectedly suspended OPV use (stating it might be 'contaminated'), leading to a
national epidemic3. This occurred shortly after the GPEI shifted tactics, in part due to
limited financing, stopping campaigns in most polio-free areas of Africa, Asia and the
Middle East to focus resources on endemic countries. Since 2003, 20 polio-free
countries in these areas have suffered new outbreaks following importations of a
poliovirus from Nigeria while virus originating in India re-infected another 6
countries. In total, thousands of children in polio-free areas were paralyzed, requiring
the additional expenditure of over USS 450 million for emergency response activities.
In 2006, 4 countries still had indigenous poliovirus, prompting some to propose that
eradication be abandoned...
Citing the high costs of completing polio eradication relative to the low number of
remaining cases, and suggesting the last 4 endemic countries and some re-infected
countries could not fully implement the strategies, some public health officials
proposed the eradication goal be abandoned for one of'effective control'. This
proposal was made amid increasing international awareness and discussion of other
risks, such as the fatigue of health workers and volunteers after years of campaigns,
historical gaps in surveillance quality and competing development priorities.
2 'Wild' denotes naturally occurring polioviruses which circulate(d) among humans. 'Sabin-strain'
denotes the attenuated polioviruses that are used to make oral poliovirus vaccine (OPV).
3 Centers for Disease Control and Prevention. Resurgence of wild poliovirus type 1 transmission and
consequences of importation into 21 previously polio-free countries, 2002-2005. Morbidity and
Mortality Weekly Report 2006; 55: 145-50.
2
The Case for Completing Polio Eradication
A new study shows switching to polio 'control' would actually cost more than
completing eradication...
Advocates of'effective control' (which they define as maintaining <500 polio
cases/year indefinitely) predicted this could be achieved at lower costs than
completing eradication4. However, an independent analysis found that 'effective
control' would actually result in a much higher burden of disease and at costs that
would exceed, by billions of dollars over a 20-year period, those of completing
eradication5.
New analyses confirm that returning to routine immunization alone for polio control
would result in over 200 000 children again paralyzed by polio each year...
The international spread of polio from Nigeria in 2003 showed that the number of
cases could increase very rapidly if eradication were not completed3. New
mathematical models found that regardless of the control strategy, in low-income
countries alone a switch to 'control' would result in up to 4 million polio-paralyzed
children over the next 20 years5. This increase in polio would disproportionately
affect poor populations, with the vast majority of cases occurring in countries with a
GDP of < USS 1000/year.
New tools greatly enhance the impact of the eradication strategies6...
A recent study confirms that new polio vaccines ('monovalent OPVs' or 'mOPVs'),
developed by an extraordinary public-private partnership in 2005-6, substantially
enhance the impact of polio campaigns7. Dose for dose, these vaccines more than
double a child's protection against the specific type of polio present in a country, as
compared with the traditional trivalent OPV. GPEI is also assessing the potential role
of inactivated polio vaccine (IPV) in case polio is found to persist in an area with very
high mOPV coverage.
New measures are reducing the risk and consequences of new outbreaks in polio-free
areas...
Since the World Health Assembly in 2006 endorsed faster, larger and more sustained
polio outbreak responses, only 6% of new cases have been due to importations,
compared with 52% in 2005. The speed of outbreak response activities has been
4 Arita I. Public health. Is polio eradication realistic? Science 2006; 312(5775): 852-4.
5 Thompson KM, Tebbens RJ. Eradication versus control for poliomyelitis: an economic
analysis. Lancet. 2007; 369(9570): 1363-71.
6 GPEI's 4-pronged strategy (routine immunization, National Polio Immunization Days (NIDs), acute
flaccid paralysis (AFP) surveillance, and 'mop-ups') used trivalent oral poliovirus vaccine (tOPV).
7 Crassly NC. Protective efficacy of a monovalent oral type 1 poliovirus vaccine: a case-control study.
Lancet. 2007; 369(9570): 1356-62.
3
further enhanced by new laboratory methods introduced in late 2006 to reduce by
50% the time needed to confirm polio infections and, since 2005, a doubling of
surveillance sensitivity performance targets in all high-risk countries.
New tactics are tailored to address the specific challenges in the last 4 endemic
countries...
By late 2006, 'Immunization Plus Days' (IPDs) in Nigeria were combining mOPV
with other interventions, substantially increasing routine immunization coverage,
community acceptance and political support. In India, a new accelerated mOPV
campaign schedule is boosting young child immunity more rapidly than in 2006. In
Pakistan and Afghanistan, a new, multi-pronged approach includes cross-border
synchronization of campaigns, tracking of nomad populations and negotiating access
with local leaders and military forces. In all 4 countries, religious and traditional
leaders have substantially increased their role to better engage local communities.
In the last 4 endemic countries, the Head of Government is now directly engaged in
completing eradication ...
On 28 February 2007, the Heads of Government of Afghanistan, India, Nigeria and
Pakistan sent personal envoys to lead their delegations to the Director-General's
Urgent Stakeholder Consultation on Polio Eradication at WHO, Geneva. This level
of government can marshal cross-ministerial, cross-sectoral support for new tactics to
reach every child in each infected area. In 2 of the 4 countries the impact of this
support is already evident in new pledges totalling USS 311 million in domestic
financing for polio activities.
Completing eradication will benefit the Millennium Development Goals (MDGs)...
The investment in GPEI pays major dividends beyond preventing 5 million polio
cases to date. Over 85% of the fulltime GPEI staff (approximately 3 400 people at 1
May 2007) work on other disease control activities for an average of 50% of their
time. This GPEI investment has helped avert 1.25 million deaths through Vitamin A
supplementation and 2.3 million deaths through measles mortality reduction
activities8; boost routine immunization and introduce new vaccines in GAVI-eligible
countries; respond to international health emergencies such as SAKS and Avian
Influenza9; and facilitate a rapid response to humanitarian crises such as the South
Asia Tsunami in 2004 and the Pakistan earthquake in 2005. Further investing in
eradication will facilitate the continued integration of the GPEI's infrastructure and
operations with other activities, and prevent the harmful consequences of an
inadvertent collapse in GPEI support.
8 Wolfson LJ. Measles Initiative. Has the 2005 measles mortality reduction goal been achieved? A
natural history modelling study. Lancet 2007; 369(9557): 191-200.
9 Heymann DL, Aylward RB. Poliomyelitis eradication and pandemic influenza. Lancet 2006;
367(9521): 1462-4.
4
Immediate Actions to Intensify Polio Eradication Efforts (within 6 months)
Exploiting the new tools, tactics and commitments to accelerate polio eradication
during 2007-8 requires immediate action by all GPEI stakeholders. For endemic
countries, the priority is to increase the number of children vaccinated with the new
mOPVs in each polio-infected district during each campaign. At the international
level, the focus is on ensuring the GPEI has the financing and political support needed
to implement polio campaigns and surveillance of the highest possible quality.
National activities (polio-endemic countries)
1. Polio as a National Priority: a government mechanism will be established at
national and state/province levels to coordinate cross-ministerial and crosssectoral inputs regularly (at least every 2 months) and report to the head of
government. 'Polio officers' will implement the decisions of these bodies, with
overall responsibility for performance in their area.
2. Social Mobilization & Communications: a national-international review will
develop a comprehensive plan of action to engage communities in infected
districts, optimize mass media use, increase the role of local influencers and
proactively deal with rumours. Standard indicators will be analyzed during each
campaign, with a revision of the plan if appropriate.
3. Campaign Quality & Monitoring: to reach >95% of children in infected districts,
microplans will be redone to international standards with all areas mapped and
assigned to vaccinators acceptable to the community; local organizations and
NGOs will be engaged, especially religious and women's groups. Independent
teams will monitor campaigns in high-risk areas10 and report to the national polio
technical advisory body, hi infected districts, areas achieving <90% coverage will
be revisited and revaccinated.
4. Routine Immunization: coverage targets will be established for polio-infected
districts and, with key process indicators1 ’, included in data reviewed during each
meeting of national technical advisory body.
5. Research & Introduction ofNew Tools: research to guide activities (e.g.
serosurveys, IPV studies, pilots of new interventions) will be identified by
technical advisory bodies and addressed within 6 months. New tools will be
rapidly introduced (e.g. by licensing at least 2 of each mOPVl and mOPV3).
6. Domestic Financing: 3-year eradication budgets will be established or updated,
domestic financing will be finalized, and a high-level national Interagency
Coordinating Committee (ICC) meeting will be convened 2 times per year with
development partners and the Ministry of Finance to discuss or clarify domestic
financing.
10 Highest risk areas for missing children during polio campaigns, as identified by a high burden of
disease, a high proportion of'never vaccinated children', historicallypoor campaign performance, etc.
11 Key process indicators may include the proportion of routine immunization positions that are vacant,
routine immunization sessions conducted and vaccine stockouts.
5
International activities (donors and partner agencies)
1. International Financing: development partners will include the 'Case for
Completing Polio Eradication' in G8 meetings, meetings of the OECD-DAC, the
World Bank Development Committee, the Organization of Islamic Conference
(OIC) and Boards of the Global Alliance for Vaccines and Immunization (GAVI).
2. International Advocacy: the Director-General of WHO will travel to each of the 4
endemic countries to discuss the intensified eradication effort with the Head of
Government. The 'Case for Completing Polio Eradication' will also be brought to
the attention of the political leaders and organizations that support the GPEI,
through the summits of the G8, the Organization of Islamic Conference (OIC), the
African Union, the South Asian Association for Regional Cooperation (SAARC)
and the Commonwealth.
3. Enhancing the Safety of Polio Workers & Volunteers: WHO, UNICEF and
relevant international stakeholders will assist national efforts to advocate for Days
of Tranquillity and/or other mechanisms to ensure the safe passage of vaccinators
to reach all children in insecure areas and areas of active conflict.
4. International Coordination of Campaigns: WHO and UNICEF will assist
countries to synchronize campaigns where this is needed to optimize coverage of
moving populations (e.g. Afghanistan/Pakistan, India/Nepal, Nigeria/Niger).
5. Limiting International Spread of Polio: WHO and UNICEF will assist reinfected
countries to implement rapid responses to polio outbreaks. WHO will also assist
in updating national immunization policy to reduce the risk of polio importations.
6
Milestones for an Intensified Polio Eradication Effort
Progress towards the following milestones will demonstrate whether the ’immediate
actions for an intensified eradication effort' are being implemented and achieving the
expected impact on stopping polio transmission in endemic and reinfected countries.
1. Endemic Countries: Reduction in Polio-Infected Districts
•
by end-2007 there should be a 50% reduction in the number of polio-infected
districts relative to 2006.
•
by end-2008 polio transmission should be interrupted or there should be at
least a further 50% reduction in the number of infected districts relative to
2007.
2. Endemic Countries: Increase in Protection Against Polio in Infected Districts
12
•
by end-2007 the level of immunity against polio among children aged 6-35
months in infected districts should be at least at the level in polio-free districts.
•
by end-2008 the level of polio immunity among children aged 6-35 months in
infected districts should have been at least as high as in polio-free districts, for
at least 12 months.
3. Reinfected Countries: Rapid Cessation of New Polio Outbreaks
•
by end-2007, countries reinfected in 2006 will have implemented appropriate
response activities’ 3 and interrupted transmission of the imported poliovirus.
•
by end-2008, any country reinfected in 2007 will have implemented response
activities and interrupted transmission of the imported poliovirus.
4. International Stakeholders: Closure of the Financing Gap14
•
by mid-2007 sufficient funding will have been pledged to finance all
eradication activities planned through end-2007.
•
by end-2007 sufficient funding will have been pledged to finance all
eradication activities planned through end-2008.
12 Measured by the vaccination status of non-polio acute flaccid paralysis (AFP) cases aged 6-35
months and, if appropriate, adjusted for differences in vaccine efficacy compared with polio-free areas.
13 World Health Assembly Resolution WHA59.1.
14 As outlined in the relevant edition of the Financial Resource Requirements of the Global Polio
Eradication Initiative (FRRs) at www.polioeradication.org.
7
Monitoring the Intensified Polio Eradication Effort
Stakeholders can monitor progress towards the milestones and activities of the
intensified eradication effort on the GPEI website www.po1ioeradication.org, and in
GPEI publications (e.g. PolioNews and the GPEI Annual Report).
In each endemic country, activities will be monitored and guided every 4-6 months by
the polio technical advisory body (the Expert Review Committee (ERC) in Nigeria;
the Technical Advisory Group (TAG) in Afghanistan and Pakistan; and the India
Expert Advisory Group (IEAG)). At the international level, activities will be
monitored by the Advisory Committee on Polio Eradication (ACPE) every 6 months
(with a face-to-face meeting every 12 months) and by regional advisory committees
each year.
The findings of the technical advisory bodies will be posted on the GPEI website
within 10 days of each meeting and will be reflected in the annual reports of the
Secretariat to the World Health Assembly. Follow-up stakeholder consultations will
be convened every 12 months.
8
A Call to Action to Finance an Intensified Eradication Effort, 2007-8
Implementing the ’immediate actions' to intensify the GPEI requires a rapid injection
of multi-year flexible funding, without which the opportunity to eradicate polio will
be lost. As of 10 May 2007, the GPEI had a funding gap of USS 540 million for
2007-8. Activities and staff will have to be cut back as early as July 2007 if USS 100
million of the funding gap is not secured by that time. A further USS 100 million of
the funding gap requirement is needed by November 2007.
Summary of externalfinancing required by major category of expenditure, 2007-8
(USS millions)15
2007-2008
2008
2007
Major Expenditures
Oral polio vaccine
$
227.98
$
176.09
$
404.07
Campaign operations
$
230.69
$
163.81
$
394.50
Outbreak response/ mOPV evaluation
$
50.00
$
35.00
$
85.00
Surveillance
$
61.09
$
59.47
$
120.56
Laboratory
$
8.37
$
8.45
$
16.82
Technical assistance
$
87.90
$
83.35
$
171.25
Certification and containment
$
12.00
$
12.00
$
24.00
Products for the post-eradication era
$
5.00
$
5.00
$
10.00
Vaccine for post-eradication stockpile
$
12.70
$
31.60
$
44.30
Subtotal
$
695.72
$
574.77
$
1,270.50
Contributions
$
493.80
$
237.73
$
731.53
Funding gap
$
201.92
$
337.04
$
538.97
Budget notes:
.
conducting additional campaigns to raise immunity in polio-free countries at
moderate risk of importations would cost an additional USS 110 million per year.
a 12-month delay in completing eradication in the Pakistan/Afghanistan reservoirs,
Nigeria or India would increase costs by a minimum of USS 45 million, USS 80
million and USS 140 million, respectively.
•
after interrupting wild poliovirus transmission globally, USS 661 million will be
required over the next 3 years for certification and post-eradication preparedness.
15 Details can be found in the Financial Resource Requirements of the Global Polio Eradication
Initiative (FRRs) at www.polioeradication,org .
9
International Health Regulations (2005)
Designation of National IHR Focal Points in WHO African Region, as of
Algeria
Mauritania
Mali
Niger
Cape-Verde
Gambia
Guinea-Bissau
(
Guinea
J
Sierra Leone
Ethiopia
/Ghana)
Cameroon
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Kenya
Gabon
Democratic
Republic
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Bi
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concerning the legal status of any country, territory, city or area or of its authorities, or corcerring the deli m lalion of its frontiers or boundaries.
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International Health Regulati
The boundaries and names shown and the designations used on this map do not imply the expressionof any opinion whatsoeveron the part of the World Health Organization
concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitationof its frontiers or boundanes.
Dolled lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2007. All rights reserved
International Health Regulations (2005)
Designation of National IHR Focal Points in WHO Western Pacific Region, as
Mongolia
China
Lao People's Demo'cratic Reffublic
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The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization
concerning the legal status of any country, tern lory, city or area or of its authorities, or concerning the delimitation of its frontiers cr boundaries.
Dotted lines on maps represent approximate border lines fcr which there may not yet be lull agreement. ©WHO 2007. All rights reserved
International Health Regulations (2005)
Designation of National IHR Focal Points in WHO European Region, as o
1
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Hnland
Sweden
Norway
Russian Federatio
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Data source: International HealIh Coordination Programme
Administrative boundanes soiree: FAO Gobai AdmnislrativeUnit Layers (GAUL) 2007.
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization
concerning the legal status of anycountry, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundanes.
Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2007. All rights reserved
International Health Regulations (2005)
Designation of National IHR Focal Points in WHO Region of the Americas, as of
Canada
United States ofAmerica
Mexico f
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El Salvador
C<
Pa
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Tobago
Venezuela
Solombia
Guyana
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Map production: Public Health Mapping and GIS Unit, Intemalionsi Health Coordination Programme.
Data source: International Health Coordination Programme.
Administrativeboundanes source: FAO Gobal Administrative Unit Layers (GALL) 2007.
International Health Regula
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization
concerning the legal status of any country, territory, city or area or of its authorities, or concerning the deli citation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2007. All rights reserved
Wild Poliovirus*, 09 Nov 2006 to 08 Ma
Wild virus type 1
Wild virus type 3
Wild virus type 1 & 3
Endemic countries
Case or outbreak following importation (0-6 months)
* Excludes viruses detected from environmental
surveillance and vaccine derived polio viruses.
Data in WHO HQ as of 08 May 2007
The boundaries and names shown and t
the expression of any opinion whatsoeve
concerning the legal status of any countr
concerning the delimitation of its frontiers
represent approximate border lines for w
© WHO 2007. All rights reserved
Wild Poliovirus 2000 - 2007
Wild virus confirmed cases
01 Jan - 08 May’ Advance Date of most Date of most
notice
recent type3 recent typel
2002 2003 2004 2005 20063 2006 2007
Total
Country or territory
2000 2001
27
28
Pakistan
199
2
Myanmar**
India
265
46
Somalia**
28
DRC**
Niger***________________
2
4
Nepal**
0
Cameroon*
4
Chad**
Bangladesh**
1
55
Angola**
0
Kenya*
3
Ethiopia**
Afghanistan
Nigeria
Namibia*
Indonesia*
Yemen*________________
Sudan**
Mali*
Eritrea*_________________
Guinea*
CAR**
Saudi Arabia*
Cote d'Ivoire**
Burkina Faso*
Benin**
Egypt
Botswana*______________
Ghana**
Togo*
Lebanon*_______________
Zambia*________________
Algeria*
Georgia*
Bulgaria*
0
0
0
4
0
0
0
3
0
1
0
1
4
0
1
0
0
0
0
0
0
Mauritania^5____________
0
3
Iran*
12
Cape Verde*
22
Congo
4
Iraq____________________
0
Oman
0
West Bank & Gaza Strip
Total___________________ 719
Tot. in endemic countries 702
17
Tot. in non-end countries
23
No. of countries_________
20
No. of endemic countries
11
56
119
0
268
7
0
6
0
0
0
0
1
0
1
0
0
0
1
0
0
0
0
0
0
0
0
5
0
0
0
0
3
1
1
2
1
0
0
0
0
0
0
483
475
8
15
10
10
202
90
0
1600
3
0
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
7
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
1918
1915
3
2
7
8
355
103
0
225
0
0
40
0
2
25
0
0
0
0
0
0
0
0
0
0
0
1
0
1
11
2
1
0
8
1
1
0
0
0
0
0
0
0
0
0
0
0
784
732
52
15
6
9
31
830 1123
53
28
40
0
0
0
134 66 674
0
185 36
0
0
13
25
11
10
0
4
5
1
13
2
24
2
1
18
0
0
0
10
2
0
0
2
1
17
22
0
18
0
2
0
303
1
478
0
128 27
0
19
0
3
1__
0
0
7
0
0
30
0
0
1
0
0
17
0
0
9
0
0
6
0
0
1
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1255 1979 1996
999 943 1868
256 1036 128
18
17
16
4
6
6§
Wild virus
Date of most
recent
2002 2003 20
confirmed case
4
6
1
17-OC1-06
10-Apr-07
10-Apr-07
782
245
68
28-Mar-07
29- Mar-07
29-Mar-07
2
0
7
2
27-Mar-07
30- Jan-07
NA
A 26-Mar-07
27-Mar-07
26-Mar-07
26
20
44
8
09-Mar-07
06-0ct-02
25-Mar-07
25-Mar-07
0
12
07-Sep-00
16- Mar-07
16- Mar-07
3
3
0
0
11-Feb-07
28- NovOO
22- Aug-06
05-Mar-07
22-Dec-06
06-Dec-06
05-Mar-07
22-Dec-06
06-Dec-06
0
0
26-Nov-06
1 (16 Mar) 23- Oct-99
07-Dec-05
22-Nov-06
26- NOV-06
22- Nov-06
14-NOV-06
Countries highlighted in yellow are currentlyendemic.
Countries highlighted in pale yellow are currentlyconsidered to have
1
0
0
1
0
25-Mar-07
25-Mar-07
0
NA
„ 14-Nov-06
0
0
NA
13-NOV-06
13-NOV-06
2
0
2
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
309
279
30
11
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
NA
A 07-NOV-06
NA
4 26-Jun-06
NA
, 20-Feb-06
NA
t 02-Feb-06
07-Sep-04
17- Jun-05
NA
t 01-May-05
NA
, 23-Apr-05
NA
A 06-Dec-04
NA
„ 10-Nov-04
NA
4 09-Nov-04
03-0ct-04
16-Feb-99
NA
_ 29-Sep-04
NA
4 01-Jun-04
07-Dec-00 03-May-04
, 08-Feb-04
NA
NA
t 29-Sep-03
NA
4 22-Jul-03
NA
4 23-Jan-03
NA
, 27-Feb-02
NA
4 13-Oct-O1
NA
4 02-Sep-01
NA
4 24-Apr-O1
07-Nov-06
26-Jun-06
20-Feb-06
02-Feb-06
17- Jun-05
01-May-05
23- Apr-05
06-Dec-04
IO-Nov-04
09-Nov-04
03-0ct-04
29-Sep-04
01-Jun-04
03-May-04
08-Feb-04
29-Sep-03
22- Jul-03
23- Jan-03
27- Feb-02
13-Oct-O1
02-Sep-01
24-Apr-01
0
0
0
0
0
0
0
145
120
25
8
NA
,
NA
t
NA
4
29-Sep-00
NA
4
NA
t
NA
31-Mar-01
18-Dec-00
13-Dec-00
28-Nov-00
28-Jan-00
NA
4
NA
31-Mar-01
18-Dec-00
13-Dec-OO
28-Nov-00
28-Jan-00
NA
NA
1
2
5
73
49
10
1
5
26
14
1
1
2
103
64
13
3 Data for 2006 is not final.
5 In 2005, no wild viruses occurred in Egypt, but it’s status remained endemic.
active transmission of an imported poliovirus.
‘All cases are importation related. ’’All cases from 2003 onward are importation re
’Data in WHO HQ on 09 May06 for2006 data and 08 May07 for2007 data
•**All cases from 2005 onward are importation related. ^^Wiid virus of unknown orig
2 Wild viruses from environmental samples, contacts and other non-AFP sources.
NA. Most recent case had date of onset prior to 1999.
Data in WHO HQ as of 08 May 2007
Progress in eradication polio s
Polio in 1988:
•More than 125 polio-endemic
Countries
•More than 350,000 cases
•WHA Resolution to eradicate
polio
Polio in 2007:
•99% reduction since 1988
•145 cases (as at 8 May 2007)
•Lowest number of endemic
countries ever
| I Polio-endemic country
j
| Outbreak following re-infection
(since Nov 2006)
NOW, MORE THAN EVER: BgBW'OtJQ-FOREVER.
O
l-U
•<> '&v
unicefW
I'wi m I
Itu«
Monthly Situation Report
All data as of 8 May 2007
For detailed news and latest polio case data by country, updated every week: www.polioeradication.org
Headlines
■
■
■
■
■
■
WHO DG meets Afghanistan and Pakistan heads of state on polio : On 29 April and 1 May, WHO DirectorGeneral Dr Margaret Chan and EMRO Regional Director Dr Hussein A Gezairy met with President Hamid Karzai of
Afghanistan, and Prime Minister Shaukat Aziz of Pakistan. Discussionsfocused on both countries' combined efforts to
interrupt the final chains of polio transmission which straddle their common border. In particular, the leaders discussed
new approachesto increasing access to all populations, including the use of Days of Tranquility in Afghanistan,
engaging semi-autonomouspopulations in Pakistan and reaching mobile populations travelling across the common
border. In Afghanistan, Dr Chan also met with NATO and the International Security Assistance Force to explore ways
of negotiating pauses in conflict to allow polio vaccination teams safe passage during campaigns. For further
information, please click here.
Lancet studies show cost-effectiveness of polio eradication and efficacy of monovalent OPV type 1: The
Lancet published two studies with important implications for the Global Polio Eradication Initiative. The first study, by
Kim Thompson et al from Harvard University, demonstrates the cost-effectiveness of polio eradication, both from an
economic and public health point of view. The second study, by Nick Grassly et al from the Imperial College of London,
highlights the greater efficacy of the new monovalentoral polio vaccine type 1 (mOPV1) compared with trivalent OPV.
For detailed interpretationsof both studies, please click here.
Immediate injection of cash urgently needed: By July 2007, the Global Polio Eradication Initiative will have a
negative cash flow, which if not addressed will require an immediate reduction in planned polio eradication activities in
the remaining infected countries. Even a temporary cutback would result in the reinfection of polio-free areas, delays
in outbreak response, a surge in polio-paralyzed children and an increase in overall costs. Insufficientfunds at this
late stage imperil the entire 20-year eradication effort, as well as related gains in routine childhood immunization,
global communicabledisease control, preparedness and response, and other child survival and international health
activities. For further information, please visit www.polioeradicatiQn.Qrg/fundinqbackqround.asp.
WHA to urge intensified polio efforts: At the upcoming World Health Assembly (WHA) on 14-23 May in Geneva,
Member States are expected to adopt a resolution urging an intensification of eradication efforts to rapidly interrupt the
remaining chains of indigenous transmission and further limit potential international spread of the virus. In follow-up to
the WHO Director-General's (DG's) 28 February Urgent Stakeholder Consultation, a side meeting with key
stakeholders is planned in the margins of the WHA, to discuss the DG's final 'Case for Finishing Polio Eradication'.
The 'Case' document will summarize the financial and humanitarian benefits of completing polio eradication, and will
set the stage for intensive resource mobilization activities to fill the 2007-2008 global funding gap of US$540 million.
Polio confirmed in Myanmar: a polio case is confirmed in Myanmar, the first wild polio in the country since 2000 and
is most likely an importation. (See 'Re-infected countries' section below, for further details.)
Less type 1 than type 3 polio in 2007: In 2007, for the first time ever, there are fewer type 1 polio cases than type 3
cases in the endemic areas (see 'Nigeria', 'India' and 'Pakistan' sections below). This suggests that the strategy of
large-scale use of monovalent oral polio vaccine type 1 (mOPV1) to prioritize the eradication of this virus, given its
historically higher disease burden and potential to spread internationally, is working.
Country Focus
Nigeria
• In 2007, 68 cases have been reported, of which 52 are due to type 3 poliovirus.
• Plans are continuing to integrate the government's National Programme for Immunization (NPI) with the National
Primary Health Care Development Agency. All efforts must be undertaken to ensure that such a move does not
adversely affect the gains made in polio eradication and routine immunization over the past 12 months.
• The Expert Review Committee on Polio Eradication (ERC) convened in Abuja on 3-4 May. The ERC noted the steep
decline (78%) in type 1 polio in 2007 compared to previous year, as well as progress achieved towards strengthening
of routine immunization and polio eradication. At the same time, however, the ERC highlighted the need to close the
immunity gap in critical northern states (some of which still have 25% of children below five years of age who have
never received a dose of OPV), through higher quality immunization campaigns achieving consistently high coverage.
• The next Immunization Plus Days (IPDs) will be held on 23-26 June.
India
•
In 2007, 44 cases have been reported. In Uttar Pradesh state, one of only two remaining endemic states (along with
Bihar), 17 of the state's 26 cases are due to type 3 poliovirus. No type 1 polio has been reported in the five traditional
high-risk districts of western Uttar Pradesh (Moradabad, JP Nagar, Bareilly, Rampur, Badaun), since 2 October 2006.
• Four large-scale immunization campaigns have already been conducted in 2007 with mOPV1. To support campaigns
in key high risk districts, WHO surveillance medical officers (SMOs) from polio-free areas are routinely re-deployed.
• A recent campaign on 8 April was made possible in part thanks to a rapid, last-minute effort by polio partners Rotary
and the National Polio Surveillance Project (NPSP). During the planning stages of the campaign, it became apparent
that a vaccine-shortfallof more than four million doses was going to affect 17 districts in Bihar. To ensure this shortfall
was filled in time of the campaign, Rotary arranged for special permission from Union Railway Minister Laloo Prasad
Yadav, to transport 3.3 million doses of vaccine from Delhi, Haryana, Punjab and Uttar Pradesh, on the high-speed
Rajdhani Express train. At the same time, a Rotary-hired truck took 700,000 doses of vaccine from Lucknow, Uttar
Pradesh, to Patna, Bihar.
Afghanistan and Pakistan
• In 2007, in Pakistan, 7 cases have been reported; 1 case has been reported in Afghanistan. In Pakistan, 5 of the 7
cases are due to type 3 polio.
• A joint Afghanistan/Pakistan Technical Advisory Group (TAG) convened in Islamabad on 17-19 April, to review
epidemiological and programmatic data. The TAG highlighted that real progress was achieved in 2006, with the virus
now limited to known reservoirs that straddle the two countries and which must be tackled together. The TAG'S
recommendations focused on intensifying efforts in areas of known polio transmission, and increasing access to
populations living in insecure areas, semi-autonomouspopulations and mobile populations.
• In April, Pakistan and Afghanistan coordinated the fourth large-scale immunization campaign of 2007 (following
activities in January, February and March), collectively reaching nearly 50 million children under the age of five years.
Focus was again on increasing access to populations in border areas and mobile populations. Nomadic routes were
mapped, and vaccination points were set up at key gathering places and at major border-crossings.
• Officially launching polio immunization activities in Pakistan, Prime Minister Shaukat Aziz re-affirmed the government's
commitment, vowing: "Pakistan is committed to eradicate polio from the country very soon."
• An audio-slideshowof polio vaccination campaigns along the Afghanistan-Pakistan border is available for viewing (and
in downloadableformat) at www.polioeradication.org.
Re-infected countries
• Myanmar is currently planning a targeted polio immunization campaign as a rapid response to a probable importation
from neighbouring Bangladesh, and in advance of the onset of the rainy season in July. Three large-scale,
internationally-coordinatedcross-border campaigns with Bangladesh are being planned, the first of which is to be
launched on 14 May. An immediate immunization response has already been conducted, immunizing approximately
50,000 children in/around the immediate geographic vicinity of the index case. Active disease surveillance activities
are also ongoing in the area, to rapidly detect any further cases.
• In the Democratic Republic of the Congo (DR Congo), 2 of the 3 outbreaks due to imported poliovirus from Angola
appear to have been stopped, with expanded outbreak response activities continuing to address the ongoing
transmission in Bandundu/Equateur provinces. A total of 12 cases have been reported in DR Congo this year.
Although no new cases have been reported from Angola this year, undetected circulation cannot be ruled out due to
ongoing subnational surveillance gaps (as confirmed by genetic sequencing of the 2006 cases in Angola and some of
the 2007 cases from DR Congo). At an Angola TAG meeting held in April, rapidly filling these surveillance gaps was
discussed.
• In the Horn of Africa, outbreak response activities are continuing to stop the two known areas of ongoing transmission,
in the cross-border area in northern Somalia and the Somali region of Ethiopia, and central Somalia. At a Horn of
Africa TAG meeting in April, the need for intensified cross-borderactivities was highlighted.
• Niger and Nepal continue to be at particular risk of repeated, isolated polio importations, due to their geographic
proximity to endemic areas (northern Nigeria, and Bihar and Uttar Pradesh, India).
Polio eradication will only succeed if the necessary funds are made available, and with strong political commitment in polioaffected countries. More than 10 million children will be paralysed in the next 40 years if the world fails to capitalize on its
>US$5 billion global investment in eradication.
2
The state of polio eradication
The world now has a second and best chance to eradicate The remaining challengesto a polio-free world are:
1. Rapidly overcoming the remaining operational challenges
polio: almost all outbreaks in re-infected countries after the
to reaching every child in the four endemic areas of Nigeria,
international spread of 2003-2006 have been stopped. Only
India, Pakistan and Afghanistan.
four parts of four countries have never interrupted indigenous
2. Rapidly making available the necessary financial resources
wild poliovirus transmission: Nigeria, India, Pakistan and
to fully implement polio eradication strategies.
Afghanistan. Global polio eradication depends on the
3. Continue outbreak response activities in the remaining re
engagement of the leaders of these four countries.
infected countries, and minimise the risk and consequences of
The tools to eradicate polio are better than ever, The
further
international spread of polio.
programme now has vaccines which are twice as effective and
4.
polio vaccination coverage through routine
Increasing
diagnostic tools that detect and track poliovirus twice as fast.
immunization
services.
Policies to minimize the risks and consequences of
5. Maintaining high quality AFP surveillance in all countries.
international spread of poliovirus are now in place:
travellers to and from polio-endemiccountries are advised to be
fully vaccinated before travel.
Polio eradication will only succeed if the necessary funds are made available, and with strong political commitment in polioaffected countries. More than 10 million children will be paralysed in the next 40 years if the world fails to capitalize on its
>US$5 billion global investment in eradication.
3
4
Articles
I
Eradication versus control for poliomyelitis: an economic
analysis
Kimberly M Thompson, RadboudJ DuintjerTebbens
Summary
Background Worldwide eradication of wild polioviruses is likely to yield substantial health and financial benefits, Published Online
provided we finish the job. Challenges in the four endemic areas combined with continuing demands for financial APril 12,2007
- 001:10.1016/50140resources for eradication have led some to question the goal of eradication and to suggest switching to a policy of 6736(07)60532-7
control.
See Online/Comment
001:10.1016/50140-
Methods We developed a dynamic model, based on modelling of the currently endemic areas in India, to show the 6736(07)60533-9
importance of maintaining and increasing the immunisation intensity to complete eradication and to illustrate how Kids Risk Project, Harvard
policies based on perception about high short-term costs or cost-effectiveness ratios without consideration of long- School of Public Health,
MA, USA
term benefits could undermine any eradication effort. An extended model assesses the economic implications and Boston,
(Prof K M Thompson ScD,
disease burden of a change in policy from eradication to control.
RJ DuintjerTebbens PhD); and
Massachusetts Institute of
Findings Our results suggest that the intensity of immunisation must be increased to achieve eradication, and that Technology, sioan school of
Management, Cambridge, MA,
even small decreases in intensity could lead to large outbreaks. This finding implies the need to pay even higher USA (KMThompson)
short-run costs than are currently being spent, which will further exacerbate concerns about continued investment in
Correspondenceto:
interventions with high
cost-effectiveness ratios. We show that a wavering commitment leads to a failure to Prof Ki mberly M Thompson, Kids
_ perceived
_
era<idicate, greater cumulativecosts, and a much larger number ofcases. We further show that as long as it is technically Risk project, Harvard School of
achievable, eradication offers both lower cumulative costs and cases than control, even with the costs of achieving Public Health, Boston, MA
USA
eradication exceeding several billion dollars more. A low-cost control policy that relies only on routine immunisation 02115,
lcimt@hsph.harvard.edu
for 20 years with discounted costs of more than $3500 million could lead to roughly 200000 expected paralytic
poliomyelitis cases every year in low-income countries, whereas a low-case control policy that keeps the number of
cases at about 1500 per year could cost around $10 000 million discounted over the 20 years.
Interpretation Focusing on the large costs for poliomyelitis eradication, without assessing the even larger potential
benefits of eradication and the enormous long-term costs of effective control, might inappropriately affect
commitments to the goal of eradication, and thus debate should include careful consideration of the options.
"maintaining a very high level of control can never be
Introduction
Economic assessments have prospectively supported the optimal, given the technical feasibility of eradication.”
case for poliomyelitis eradication worldwide.’"3 While This insight is particularly important because it runs
preventing hundreds of thousands of cases of paralytic counter to the recent suggestion that control should be
poliomyelitis and premature deaths, the US domestic maintained such that the “annual global number of cases
poliomyelitis vaccination programme also yielded net is less than 500” (ie, a policy ofhigh control in perpetuity).14
economic benefits that exceeded US$180 000 million, Barrett and Hoel8 explicitly explore the dynamics of
even without considering the large, intangible benefits poliomyelitis eradication and provide estimates of
associated with avoided fear and suffering.4 These US net thresholds for the welfare cost of paralytic poliomyelitis
benefits greatly exceed the cumulative global investment that must be exceeded to justify eradication (shown
ofmore than $4000 million (with much more contributed separately for rich and poor countries). Geoffard and
at the national level) over nearly 20 years for the Global Philipson9 showed that private markets might have
Polio Eradication Initiative (GPEI) by external donors.5 difficulty achieving eradication when the demand for
We anticipate that retrospective economic analysis of the vaccines depends on the prevalence of disease (ie, the
GPEI will also show substantial net benefits, iferadication demand for vaccine vanishes when prevalence is low
enough), and they explore the incentives of various
is completed.
In addition to these specific analyses for poliomyelitis, stakeholders. They also show that, for public health
numerous other analyses address the questions and expenditures, if the prevalence inversely affects demand
issues related to eradication versus control.6-13 Notably, for vaccination (ie, perceived benefit of vaccination drops
Barrett6 emphasised that a disease could be controlled as prevalence decreases) then this leads to a failure to
and eliminated locally, but that eradication requires eradicate.
The GPEI succeeded in reducing yearly cases of
elimination everywhere at the same time, which requires
cooperation. Building on that work, Barrett7 specifically paralysis from wild polioviruses from an estimated
explores the investment in eradication and finds that 350000 cases in 1988 to about 2000 cases in 2006.15
www.thelancet.com Published online April 12, 2007 001:10.1016/50140-6736(07)60532-7
i
Articles
than 5 years) at roughly the same rate,30 motivated us to intensity (ie, setting u to a value below u) as soon as the
simplifyto a single-age-cohortmodel. Since Uttar Pradesh perceived cost-effectiveness ratio reaches the tolerable
and Bihar clearly represent a geographic area in which cost-effectiveness ratio compared with a decision rule that
polioviruses show high transmissibility,we assume an Ro ceases vaccination after the prevalence of infection drops
of 16 (a theoretical measure that represents the average below 1 (ie, eradication). We define the perceived
number of secondary infections introduced by one cost-effectiveness ratio as the yearly vaccination costs
infectious person in a fully susceptible population).35 corresponding to a particular immunisation intensity
Currently, the relatively low incidence of paralytic divided by the perceived yearly incidence of paralytic cases,
poliomyelitis in Uttar Pradesh and Bihar compared with The perceived incidence equals the true incidence with a
its current population size suggests that the average 1-year delay, which represents the time taken to recognise
aggregate oral poliovirus vaccine immunisation intensity changes in incidence and react by changing the
has been close to the threshold (u) necessary to eradicate immunisation intensity. This model starts atthe pre-vaccine
polioviruses from this population.44 We explore the effects equilibrium. For these and subsequent analyses, we report
costs in USS (2002) and discount costs and cases over time
of changes in u on the burden of paralytic cases.
Building on the insights of others,7"9 we extend the Uttar using a 3% rate following standard methods/5
To extend the insights obtained from these modelling
Pradesh and Bihar model to explore the implications of
adding a constraint of tolerable cost-effectiveness ratio (in efforts to a broader region and the larger debate about
$ per paralytic case). We implement this extension by use eradication versus control, we explored the meaning of
of a decision rule that substantially reduces immunisation control compared with eradication for the group of
Routine
vaccination
SIA rounds peryear
Surveillance
Response
1
Population immunity
At outset
Heterogeneity*
—
Theoretical control scenarios (shown in figure 5A)
No control
None
None
Passive
No response
NA
NA
Very low control
OPV
None
Passive
No response
NA
NA
Very high controlt
OPV
Two
AFPt
Very aggressivet
NA
NA
Extreme controls
IPV
None
AFP
NA
NA
NA
None
Modelled control scenarios (sh(town in figure 5B)4f
0
OPV
None
Passive
No response
Realistic
1
OPV
None
Passive
2 xtOPV, delay 180 days
Realistic
None
2
OPV
None
AFP
2 xtOPV, delay 180 days
Realistic
None
3
OPV
None
Passive
3 x mOPV, delay 120 days
Realistic
None
4
OPV
None
AFP
3 x mOPV, delay 120 days
Realistic
None
5
OPV
Two in three years ||
Passive
No response
Maximum
High
6
OPV
Two in three years ||
Passive
2 xtOPV, delay 180 days
Maximum
High
7
OPV
Two in three years ||
Passive
3 x mOPV, delay 120 days
Maximum
High
8
OPV
One
Passive
No response**
Maximum
Medium
9
OPV
Two ||
Passive
No responsett
Maximum
Low
Post-eradication options (shown in figure 5B)
No routine
None
None
Passive
3 x mOPV, delay 45 days
Realistic
None
IPV
IPV
None
Passive
3 x mOPV, delay 45 days
Realistic
None
OPV
OPV
None
Passive
3 x mOPV, delay 45 days
Realistic
None
OPV+SIAs
OPV
Itt
Passive
3 x mOPV, delay 45 days
Maximum
Medium
J
SIA=supplemental immunisation activity. OPV=oral poliovirusvaccine. AFP=acuteflaccidparalysis. IPV=inactivatedpoliovirusvaccine. tOPV=trivalent oral poliovirus vaccine.
mOPV=monovalentoral poliovirus vaccine.‘Column indicates different distributionsforthe probabilityof population immunity reduction from the income group average
population immunityfor a given importationoutbreak. Withthe distribution noted as probability (no reduction, 2-fold increasein proportion effectivesusceptible, 3-fbld
increase in proportion effective susceptible), the different reduction levels are: none=probability (1,0,0); low=probability(0-9.01,0); medium=probability(0-75,0-25,0 05);
and high-probability(0-6,0-3,01). tOption indudes costs oftwoyearly SIAs in all non-endemic low-incomecountries and sixyearly SIAs in endemic areas. tSurveillanceand
responsecosts included in S280 million annual costs of maintainingA in the endemic areas. SThis extreme scenario includes costs for a universal campaignwith two doses of
IPV attaining 100% coverage among all people(indudingadults) to ensure immunityfor all individuals at the outset in addition to 100% coveragewith three inactivated
poliovirusvaccine doses throughoutthe 20-year time horizon. ^Assumingeffective controlthat costs $280 millionperyeartomaintainA=1300 cases in endemic areas per
year (see webappendixfor effect of reductions in the goal for endemic cases A), plus the costs and cases associatedwiththe strategies in non-endemic areas listedhere.
| jAssuming the two rounds occur in a paired fashion at a 30-day interval. “Assumingthe next single tOPV SIA round starts 180 days after virus introduction. ttAssuming
next two tOPV SIA rounds start 165 days aftervirus introduction. ttFor post-eradication scenarios, we modelledthe numberof rounds probabilisticallyto account for
uncertaintyin the future frequency using a triangular distribution with a mean closeto 1.
Table: Scenarios and key assumptions
www.thelancet.com Published online April 12,2007 001:10.1016/50140-6736(07)60532-7
J
3
Articles
to an average of around 1300 per year during the past
5 years,15 which implies for this scenario that A=1300.’5
With respect to more realistic modelled control scenarios
(table), we characterise a range of possible control
scenarios for the non-endemic areas, and added to these
the costs and cases associated with very high control
that keeps endemic cases at A.
We assume that during the next few years the current
high intensity of supplemental immunisation activities,
aggressive outbreak control, and robust surveillance of
acute flaccid paralysis will continue, and thus the time
horizon begins at the point when cases drop to A, which
might imply additional costs and time to get from the
current incidence to any lower A (eg, fewer than 500 cases
as has been suggested by others14). The eradication
options begin with complete interruption of poliovirus
transmission and include four future vaccination
policies for the post-eradication world (ie, no routine
immunisation, routine oral poliovirus vaccination with
supplemental immunisation activities, routine oral
poliovirus vaccination without supplemental immun
isation activities, or routine inactivated poliovirus
vaccination). We do not include any additional costs of
eradication for these options so that we can explore the
amounts that we should be willing to pay to finish
eradication when comparing these options to the control
options. The total number of paralytic poliomyelitis
cases includes wild poliovirus cases in endemic areas as
well as importations into areas previously free of wild
pohovirus transmission for each control scenario, cases
of vaccine-associated paralytic poliomyelitis for any
scenarios that use routine oral poliovirus vaccine,
supplemental immunisation activities, or outbreak
response, and cases from outbreaks of circulating
vaccine-derivedpoliovirus for all scenarios.
120000
-A- 75% reduction
*• 50% reduction
25% reduction
-e- 10% reduction
0
5 iooooo 80000 -
60000 -
I
40000 -
AZ
20000 -
. ...............................................................
04*
0
HIHMlTtT
. [ ... .|
1
2
3
4
|. ■...
■ ■ H ■ ■■ .|. H ■ |.
9 10 11 12 13 14 15 16 17 18 19 20
8
7
6
5
Time (years)
Figure3;The incidence of paralytic cases per year in the Indian states of Uttar Pradesh and Bihar with u equal
to or less than the threshold (u) needed for eventual eradication
II
I
1
Results
Based on modelling the recent experience in northern
India, we show the effects of changing the intensity of
immunisation (u) with respect to paralytic incidence.
Figure 1 shows that u must be increased to achieve
eradication and that the relative amount of increase
determines the time until eradication. Even small
reductions of u from the immunisation intensity required
for eventual eradication u couldlead to rapid accumulation
of susceptible people and result in many paralytic cases
(figure 2). For example, a reduction of only 10% in u leads
to more than 110000 cumulative paralytic cases over
20 years (ie, more than 5000 cases per year on average),
and a reduction by 50% leads to around 500000 cases.
The greater the reduction away from u, the larger the
oscillationstoward a new equilibrium, with the possibility
of a large outbreak in the second or third year following
the change in u (figure 3). These results suggest that
greater intensity of effort will be needed, which in the
short-run will increase the perception of high costs and
cost-effectiveness ratios.
I
— Intense vaccination only if perceived cost effective
• — Intense vaccination until eradication
1-60-.
1-40-
1000700-600400-2000D-
250000-.
}
« 200000-
I
150000-
S 100000-
i
50000-
® r i
0 1
i i
i
i
i
i
i
i
i
i
■
i
i
i
i
i
i
i
i
2 3 4 5 6 7 8 9 io 11 12 13 14 15 16 17 18 19 20
Time (years)
Figure 4: Cumulative costs and cases in Uttar Pradesh and Biharfor a
strategyof pursuing eradication versus intense vaccinationonly while the
perceived cost-effectivenessratio (PCER, $ per case) remains below the
tolerable cost-effectivenessratio (TCER, $ per case)
(A) Cumulative costs. (B) Cumulative paralytic cases.
www.thelancet.com Published online April 12, 2007 D0l:10.1016/50140-6736(07)60532-7
5
Articles
number of cases achievable for a given investment of
costs in control), the actual kinetics are uncertain, and
will depend on the assumptions. Nonetheless, we find
that the realistic control scenarios all imply costs and
cases that far exceed the eradication options despite
assuming the challenging objective ©factually controlling
transmission to keep the number of endemic cases below
A. Low cost options (ie, implying low control) will lie in
the region to the right and slightly below the very low
control theoretical bound.
The control scenario with no supplemental immun
isation activities and no outbreak response (labelled with
a 0 in figure 5B) is the model equivalent of the theoretical
very low control scenario, except that it assumes higher
costs in the endemic areas to keep endemic cases below
A and thus falls below and to the right of the theoretical
bound. On the other end of the scale, the control scenario
with two rounds of supplemental immunisation activities
per year and no outbreak response (labelled with a 9 in
figure 5 B) lies above the corresponding theoretical bound
of very high control, because some possibility exists of
circulating vaccine-derived polioviruses or outbreaks of
wild poliovirus in the non-endemic areas even with
frequent supplemental immunisation activities, while
both assume A cases per year in the endemic areas at the
same cost. The difference in costs stems from a different
assumption about surveillance in the non-endemic areas
(table 1). Increasing A moves the control options left and
up, which translates into lower cost but more cases. The
very low control scenario yields a total of more than
3 million discounted cases over the 20-year time horizon,
or about 200 000 cases per year.
Finally, we can also assess the difference in the net
benefits of a selected eradication option (eg, no routine
immunisation after eradication) and the best possible
control option as a function of the societal willingness to
pay to prevent a case, and view the difference as the
amount that we should be willing to spend to achieve
eradication. This analysis implies that for a willingness
to pay of $5 300 per paralytic poliomyelitis case, we should
be willing to invest more than $8000 million to achieve
eradication based on analysis of low-income countries
alone and a 20-year time horizon.
Discussion
Our analysis of low-income countries suggests that
eradication is always a better option than control, and
that we should be willing to pay thousands of millions
of dollars more to achieve this goal. Although we
intentionally focused most of our analysis on the
low-income countries because they will incur most of
the burden of cases if eradication fails, all nations will
continue to incur financial costs, implying that the true
global willingness to pay is even higher. By contrast, for
any low-control scenario we will probably see a disease
burden approaching the implied equilibrium number
seen in 1988 of 350 000 cases for a worldwide population
of 5000 million people.49 Although the rate with which
the number of cases would increase would depend on
how quickly the percentage of the population immune
to disease declines, our results suggest that low control
would ultimately lead to a world with many hundreds
of thousands of children paralysed every year (ie,
approaching the theoretical bound of very low control),
while still needing a sustained financial investment in
poliovirus vaccination and treatment. We characterised
numerous options for high control, and we note that
they all lead to very high costs, which would be difficult
to sustain in view of the challenges that exist in closing
the financial gaps for eradication now. The GPEI faces
financial challenges in the face of large potential savings
of both costs and cases. The world is unlikely to
support high control in the absence of these potential
savings. Thus, our results suggest a very strong
economic and public health case for completing
poliovirus eradication now.
We believe that focusing on the large costs for
poliomyelitis eradication in the absence of estimates of
the even larger potential benefits of eradication and the
enormous long-term costs of effective control might
inappropriately affect commitments to the goal of
eradication. This concern is particularly important in
view of the reality of constraints on financial resources,
many competing opportunities for resources, and the
cognitive challenges that arise in considering stocks and
flows.50 Short-term thinking often prevails. As a result
we are overly affected by the state of the world now, we
fail to adequately account for the state of the world that
will follow, and we misunderstand how much the choices
we make now will determine our future options and
opportunites.51 In the context of poliomyelitis eradication,
we only face the choice of eradicating now because the
global investment thus far has produced enough
immune people to make worldwide simultaneous
elimination of wild polioviruses possible. Thus, the
investment in eradication led to high levels of population
immunity that might not be fully recognised by many
people.5051 Assuming that we could later simply pay the
same financial amount to finish the job represents a
cognitive fallacy.51
Our analysis suggests that we either complete
eradication now, or pay much more (and risk that we
might not have another chance) to try to do so later,
while continuing to cumulate both costs and cases,
Although economic models suggest that when
eradication is desirable it should happen instantly,8 we
acknowledge the real and important social, logistical,
and managerial challenges that exist and we emphasise
that they could unfortunately lead to a failure to achieve
the optimum outcome of eradication when combined
with concerns about current high costs or cost
effectiveness. Our results suggest that stakeholders in
the debate about whether to give up or pursue the
current option to eradicate the poliovirus should make
www.thelancet.com Published online April 12, 2007 001:10.1016/50140-6736(07)60532-7
7
Articles
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28
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36
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Duintjer Tebbens RJ, Pallansch MA, Kew OM, et al. Risks of
paralytic disease due to wild or vaccine-de rived poliovirus after
eradication. Risk Analysis 2006; 26:1471-1505.
Henderson DA. Countering the posteradication threat of smallpox
and polio. Clin Infect Dis 2002; 34: 79-83.
Kew OM, Wright PF, Ago! VI, et al. Circulating vaccine-derived
polioviruses: current state of knowledge. Bull World Health Organ
2004; 82:16-23.
Aylward RB, Sutter RW, Cochi SL, Thompson KM, Jafari H,
Heymann DL Risk management in a polio-free world. Risk Analysis
2006; 26:1441-48.
Aylward RB, Sutter RW, Heymann DL. OPV cessation—the final
step to a “polio-free" world. Science 2005; 310: 625-26.
Dowdle WR, Birmingham ME. The biologic principles of poliovirus
eradication. J Infect Dis 1997; 175 (suppl 1): S286-92.
Crassly NC, Fraser C, Wenger J, et al. New strategies for the
elimination of polio from India. Science 2006; 314:1150-53.
World Health Organization. Progress towards poliomyelitis
eradication in India, January 2005 to June 2006. Wkly Epidemiol Rec
2006; 81: 286-91.
World Health Organization. Conclusions and recommendations of
the Advisory Committee on Poliomyelitis Eradication, Geneva,
11-12 October 2006, Part I. Wkly Epidemiol Rec 2006; 81: 453-60.
Henderson DA. Eradication: lessons from the past.
MMWR Morb Mortal Wkly Rep 1999; 48:16-22.
Sangrujee N, Duintjer Tebbens RJ, Ciceres VM, Thompson KM.
Policy decision options during the first 5 years foDowing
certification of polio eradication. Medscape Gen Med 2003; 5: 35.
Duintjer Tebbens RJ, Pallansch MA, Kew OM, Caceres VM,
Sutter RW, Thompson KM. A dynamic model of poliomyelitis
outbreaks: learning from the past to help inform the future.
Am J Epidemiol 2005; 162: 358-72.
Duintjer Tebbens RJ, Sangrujee N, Thompson KM. The costs of
polio risk management policies after eradication. Risk Analysis 2006;
26:1507-31.
Thompson KM, Duintjer Tebbens RJ, Pallansch MA. Evaluation of
response scenarios to potential polio outbreaks using mathematical
models. Risk Analysis 2006; 26:1541-56.
World Bank. World Bank list of economies (July 2002). http://www.
worldbank.org/data/databytopic/CLASS.XLS (accessed December,
2002).
1
39 Census of India 2001. Population projections for India and states
2001-2026. New Dehli, 2006.
40 South East Asia Regional WHO Office. VPD Surveillance Bulletin.
http: //www.searo.who.int/EN/Sectionl226/showfiles.asp(accessed
Jan 30, 2007).
41 Eastern Mediterranean Regional WHO Office. Polio Fax.
http://www.emro.who.int/Poliofax/(accessed Jan 30, 2007).
42 Office ARW. Wild Poliovirus Information for 2005, WHO/African
Region, http://www.afro.who.int/polio/surveillance_maps/wp2005.
html (accessed Jan 30, 2007).
43 World Health Organization. Polio case count, http://www.who.int/
vaccines/immunization_monitoring/en/diseases/polio myelitis /
case_count.cfm (accessed Jan 30, 2007).
44 Anderson RM, May RM. Infectious diseases of humans: dynamics
and control. New York: Oxford University Press, 1991.
45 Gold MR, Siegel JE, Russel LB, Weinstein MC. Cost-effectiveness in
health and medicine. New York: Oxford University Press. 1996.
46 Centers for Disease Control and Prevention. Resurgence of wild
poliovirus type 1 transmission and consequences of importation—
21 previously polio-free countries, 2002-2005.
Morb Mortal Wkly Report 2006; 55:145-50.
47 Kimman TG, Boot H. The polio eradication effort has been a great
success—let’s finish it and replace it with something even better.
Lancet Infect Dis 2006; 6: 675-78.
48 World Health Organization. Unpublished projections: Department
of Immunization Vaccines and Biologicals, 2004.
49 UN Population Division. World population prospects population
database: the 2002 revision population database, http://esa.un.org/
unpp/index.asp?panel=2 (accessed July 31, 2003)
50 Sterman J. Misperceptions of feedback in dynamic decision
making. Organ Behav Human Decision Proc 1989; 43: 301-35.
51 Sterman J. Business dynamics: systems thinking and modeling for
a complex world. Boston: McGraw-Hill, 2000.
52 Fenner F, Henderson DA, Arita I, et al. Smallpox and its
eradication. Geneva: World Health Organization, 1988.
www.thelancet.com Published online April 12,2007 DOI:lO.lO16/SO14O-6736(O7)6O532-7
9
i
i
I
1
The World Health Organization
The Case for Completing Polio Eradication
'As an international community, we havefew opportunities to do something that is
unquestionably goodfor every country and every child, in perpetuity.'
Dr Margaret Chan
Director-General
World Health Organization
The Issue
Without an urgent infusion of internationalfunds, the opportunity to complete polio
eradication could be lostforever...
By July 2007 the Global Polio Eradication Initiative (GPEI) will have a negative cash
flow, which if not addressed will require an immediate reduction in planned polio
eradication activities in the remaining infected countries1. Even a temporary cutback
would result in the reinfection of polio-free areas, delays in outbreak response, a surge
in polio-paralyzed children and an increase in overall costs. Insufficient funds at this
late stage imperil the entire 20-year eradication effort, as well as related gains in
routine childhood immunization, global communicable disease control, preparedness
and response, and other child survival and international health activities.
The following 'case statement' was developedfollowing an ’Urgent Stakeholder
Consultation on Polio Eradication’ convened by the Director-General of the World
Health Organization (WHO) on 28 February 2007 at the WHO Headquarters in
Geneva, Switzerland. The list ofparticipants, agenda, presentations and other related
materialsfrom the Consultation are available at www.polioeradication.org.
1 At 10 May 2007, 4 countries had yet to stop indigenous poliovirus (i.e. 'endemic’ countries:
Afghanistan, India, Nigeria, Pakistan); 6 of the 26 countries reinfected since 2003 by virus that
originated in an endemic country had not yet stopped transmission again (i.e. Angola, Bangladesh,
Democratic Republic of the Congo, Ethiopia, Myanmar, Somalia); 4 additional countries that border
'endemic' areas continue to suffer sporadic importations (i.e. Cameroun, Chad, Nepal, Niger).
The Context
In 1988, over 350 000 children were being paralyzed by polio every year...
Despite the availability of an effective, cheap, oral polio vaccine (OPV) for more than
25 years, over 350 000 children in at least 125 countries were still being permanently
paralyzed by wild polioviruses2 each year when the Global Polio Eradication Initiative
(GPEI) was launched in 1988.
By 1999, the GPEI had reduced annual polio cases by 99% and proven the feasibility
of eradication...
The technical feasibility of eradicating wild-type poliovirus was confirmed in October
1999 when the last case of paralytic polio due to wild poliovirus type 2 (1 of 3 types)
was detected anywhere in the world. By 2002, the feasibility of eradication was
reaffirmed by certification of eradication of all 3 wild poliovirus types in 3 of the 6
WHO Regions.
In 2003, limited cutbacks in eradication activities led to a huge resurgence ofpolio...
In mid-2003 two northern Nigeria states that were heavily infected with polio
unexpectedly suspended OPV use (stating it might be 'contaminated'), leading to a
national epidemic3. This occurred shortly after the GPEI shifted tactics, in part due to
limited financing, stopping campaigns in most polio-free areas of Africa, Asia and the
Middle East to focus resources on endemic countries. Since 2003, 20 polio-free
countries in these areas have suffered new outbreaks following importations of a
poliovirus from Nigeria while virus originating in India re-infected another 6
countries. In total, thousands of children in polio-free areas were paralyzed, requiring
the additional expenditure of over USS 450 million for emergency response activities.
In 2006, 4 countries still had indigenous poliovirus, prompting some to propose that
eradication be abandoned...
Citing the high costs of completing polio eradication relative to the low number of
remaining cases, and suggesting the last 4 endemic countries and some re-infected
countries could not fully implement the strategies, some public health officials
proposed the eradication goal be abandoned for one of’effective control'. This
proposal was made amid increasing international awareness and discussion of other
risks, such as the fatigue of health workers and volunteers after years of campaigns,
historical gaps in surveillance quality and competing development priorities.
2 'Wild' denotes naturally occurring polioviruses which circulate(d) among humans. 'Sabin-strain'
denotes the attenuated polioviruses that are used to make oral poliovirus vaccine (OPV).
3 Centers for Disease Control and Prevention. Resurgence of wild poliovirus type 1 transmission and
consequences of importation into 21 previously polio-free countries, 2002-2005. Morbidity and
Mortality Weekly Report 2006; 55: 145-50.
2
The Case for Completing Polio Eradication
A new study shows switching to polio 'control' would actually cost more than
completing eradication...
Advocates of'effective control' (which they define as maintaining <500 polio
cases/year indefinitely) predicted this could be achieved at lower costs than
completing eradication4. However, an independent analysis found that 'effective
control' would actually result in a much higher burden of disease and at costs that
would exceed, by billions of dollars over a 20-year period, those of completing
eradication .
New analyses confirm that returning to routine immunization alonefor polio control
would result in over 200 000 children again paralyzed by polio each year...
The international spread of polio from Nigeria in 2003 showed that the number of
cases could increase very rapidly if eradication were not completed3. New
mathematical models found that regardless of the control strategy, in low-income
countries alone a switch to 'control' would result in up to 4 million polio-paralyzed
children over the next 20 years5. This increase in polio would disproportionately
affect poor populations, with the vast majority of cases occurring in countries with a
GDP of < USS 1000/year.
New tools greatly enhance the impact of the eradication strategies6...
A recent study confirms that new polio vaccines ('monovalent OPVs' or 'mOPVs'),
developed by an extraordinary public-private partnership in 2005-6, substantially
enhance the impact of polio campaigns7. Dose for dose, these vaccines more than
double a child's protection against the specific type of polio present in a country, as
compared with the traditional trivalent OPV. GPEI is also assessing the potential role
of inactivated polio vaccine (IPV) in case polio is found to persist in an area with very
high mOPV coverage.
New measures are reducing the risk and consequences of new outbreaks in polio-free
areas...
Since the World Health Assembly in 2006 endorsed faster, larger and more sustained
polio outbreak responses, only 6% of new cases have been due to importations,
compared with 52% in 2005. The speed of outbreak response activities has been
4 Arita I. Public health. Is polio eradication realistic? Science 2006; 312(5775): 852-4.
5 Thompson KM, Tebbens RJ. Eradication versus control for poliomyelitis: an economic
analysis. Lancet. 2007; 369(9570): 1363-71.
6 GPEI's 4-pronged strategy (routine immunization, National Polio Immunization Days (NIDs), acute
flaccid paralysis (AFP) surveillance, and 'mop-ups') used trivalent oral poliovirus vaccine (tOPV).
7 Grassly NC. Protective efficacy of a monovalent oral type 1 poliovirus vaccine: a case-control study.
Lancet. 2007; 369(9570): 1356-62.
3
further enhanced by new laboratory methods introduced in late 2006 to reduce by
50% the time needed to confirm polio infections and, since 2005, a doubling of
surveillance sensitivity perfonnance targets in all high-risk countries.
New tactics are tailored to address the specific challenges in the last 4 endemic
countries...
By late 2006, 'Immunization Plus Days' (IPDs) in Nigeria were combining mOPV
with other interventions, substantially increasing routine immunization coverage,
community acceptance and political support. In India, a new accelerated mOPV
campaign schedule is boosting young child immunity more rapidly than in 2006. hi
Pakistan and Afghanistan, a new, multi-pronged approach includes cross-border
synchronization of campaigns, tracking of nomad populations and negotiating access
with local leaders and military forces. In all 4 countries, religious and traditional
leaders have substantially increased their role to better engage local communities.
In the last 4 endemic countries, the Head of Government is now directly engaged in
completing eradication ...
On 28 February 2007, the Heads of Government of Afghanistan, India, Nigeria and
Pakistan sent personal envoys to lead their delegations to the Director-General's
Urgent Stakeholder Consultation on Polio Eradication at WHO, Geneva. This level
of government can marshal cross-ministerial, cross-sectoral support for new tactics to
reach every child in each infected area. In 2 of the 4 countries the impact of this
support is already evident in new pledges totalling USS 311 million in domestic
financing for polio activities.
Completing eradication will benefit the Millennium Development Goals (MDGs)...
The investment in GPEI pays major dividends beyond preventing 5 million polio
cases to date. Over 85% of the fulltime GPEI staff (approximately 3 400 people at 1
May 2007) work on other disease control activities for an average of 50% of their
time. This GPEI investment has helped avert 1.25 million deaths through Vitamin A
supplementation and 2.3 million deaths through measles mortality reduction
activities8; boost routine immunization and introduce new vaccines in GAVI-eligible
countries; respond to international health emergencies such as SARS and Avian
Influenza9; and facilitate a rapid response to humanitarian crises such as the South
Asia Tsunami in 2004 and the Pakistan earthquake in 2005. Further investing in
eradication will facilitate the continued integration of the GPEI's infrastructure and
operations with other activities, and prevent the harmful consequences of an
inadvertent collapse in GPEI support.
8 Wolfson LJ. Measles Initiative. Has the 2005 measles mortality reduction goal been achieved? A
natural history modelling study. Lancet 2007; 369(9557): 191-200.
9 Heymann DL, Aylward RB. Poliomyelitis eradication and pandemic influenza. Lancet 2006;
367(9521): 1462-4.
4
Immediate Actions to Intensify Polio Eradication Efforts (within 6 months)
Exploiting the new tools, tactics and commitments to accelerate polio eradication
during 2007-8 requires immediate action by all GPEI stakeholders. For endemic
countries, the priority is to increase the number of children vaccinated with the new
mOPVs in each polio-infected district during each campaign. At the international
level, the focus is on ensuring the GPEI has the financing and political support needed
to implement polio campaigns and surveillance of the highest possible quality.
National activities (polio-endemic countries)
1. Polio as a National Priority: a government mechanism will be established at
national and state/province levels to coordinate cross-ministerial and crosssectoral inputs regularly (at least every 2 months) and report to the head of
government. ’Polio officers' will implement the decisions of these bodies, with
overall responsibility for performance in their area.
2. Social Mobilization & Communications: a national-international review will
develop a comprehensive plan of action to engage communities in infected
districts, optimize mass media use, increase the role of local influencers and
proactively deal with rumours. Standard indicators will be analyzed during each
campaign, with a revision of the plan if appropriate.
3. Campaign Quality & Monitoring: to reach >95% of children in infected districts,
microplans will be redone to international standards with all areas mapped and
assigned to vaccinators acceptable to the community; local organizations and
NGOs will be engaged, especially religious and women's groups. Independent
teams will monitor campaigns in high-risk areas10 and report to the national polio
technical advisory body, hi infected districts, areas achieving <90% coverage will
be revisited and revaccinated.
4. Routine Immunization: coverage targets will be established for polio-infected
districts and, with key process indicators11, included in data reviewed during each
meeting of national technical advisory body.
5. Research & Introduction of New Tools: research to guide activities (e.g.
serosurveys, IPV studies, pilots of new interventions) will be identified by
technical advisory bodies and addressed within 6 months. New tools will be
rapidly introduced (e.g. by licensing at least 2 of each mOPVl and mOPV3).
6. Domestic Financing: 3-year eradication budgets will be established or updated,
domestic financing will be finalized, and a high-level national Interagency
Coordinating Committee (ICC) meeting will be convened 2 times per year with
development partners and the Ministry of Finance to discuss or clarify domestic
financing.
10 Highest risk areas for missing children during polio campaigns, as identified by a high burden of
disease, a high proportion of'never vaccinated children', historically poor campaign performance, etc.
11 Key process indicators may include the proportion of routine immunization positions that are vacant,
routine immunization sessions conducted and vaccine stockouts.
5
International activities (donors and partner agencies)
1. International Financing: development partners will include the 'Casefor
Completing Polio Eradication' in G8 meetings, meetings of the OECD-DAC, the
World Bank Development Committee, the Organization of Islamic Conference
(OIC) and Boards of the Global Alliance for Vaccines and Immunization (GAVI).
2. International Advocacy: the Director-General of WHO will travel to each of the 4
endemic countries to discuss the intensified eradication effort with the Head of
Government. The 'Case for Completing Polio Eradication' will also be brought to
the attention of the political leaders and organizations that support the GPEI,
through the summits of the G8, the Organization of Islamic Conference (OIC), the
African Union, the South Asian Association for Regional Cooperation (SAARC)
and the Commonwealth.
3. Enhancing the Safety ofPolio Workers & Volunteers: WHO, UNICEF and
relevant international stakeholders will assist national efforts to advocate for Days
of Tranquillity and/or other mechanisms to ensure the safe passage of vaccinators
to reach all children in insecure areas and areas of active conflict.
4. International Coordination of Campaigns: WHO and UNICEF will assist
countries to synchronize campaigns where this is needed to optimize coverage of
moving populations (e.g. Afghanistan/Pakistan, India/Nepal, Nigeria/Niger).
5. Limiting International Spread of Polio: WHO and UNICEF will assist reinfected
countries to implement rapid responses to polio outbreaks. WHO will also assist
in updating national immunization policy to reduce the risk of polio importations.
6
Milestones for an Intensified Polio Eradication Effort
Progress towards the following milestones will demonstrate whether the ’immediate
actions for an intensified eradication effort' are being implemented and achieving the
expected impact on stopping polio transmission in endemic and reinfected countries.
1. Endemic Countries: Reduction in Polio-Infected Districts
•
by end-2007 there should be a 50% reduction in the number of polio-infected
districts relative to 2006.
•
by end-2008 polio transmission should be interrupted or there should be at
least a further 50% reduction in the number of infected districts relative to
2007.
2. Endemic Countries: Increase in Protection Against Polio in Infected Districts12
•
by end-2007 the level of immunity against polio among children aged 6-35
months in infected districts should be at least at the level in polio-free districts.
•
by end-2008 the level of polio immunity among children aged 6-35 months in
infected districts should have been at least as high as in polio-free districts, for
at least 12 months.
3. Reinfected Countries: Rapid Cessation of New Polio Outbreaks
•
by end-2007, countries reinfected in 2006 will have implemented appropriate
response activities' 3 and interrupted transmission of the imported poliovirus.
•
by end-2008, any country reinfected in 2007 will have implemented response
activities and interrupted transmission of the imported poliovirus.
4. International Stakeholders: Closure of the Financing Gap14
•
by mid-2007 sufficient funding will have been pledged to finance all
eradication activities planned through end-2007.
•
by end-2007 sufficient funding will have been pledged to finance all
eradication activities planned through end-2008.
12 Measured by the vaccination status of non-polio acute flaccid paralysis (AFP) cases aged 6-35
months and, if appropriate, adjusted for differences in vaccine efficacy compared with polio-free areas.
13 World Health Assembly Resolution WHA59.1.
14 As outlined in the relevant edition of the Financial Resource Requirements of the Global Polio
Eradication Initiative (FRRs) at www.polioeradication.org.
7
Monitoring the Intensified Polio Eradication Effort
Stakeholders can monitor progress towards the milestones and activities of the
intensified eradication effort on the GPEI website www.polioeradication.org, and in
GPEI publications (e.g. PolioNews and the GPEI Annual Report).
In each endemic country, activities will be monitored and guided every 4-6 months by
the polio technical advisory body (the Expert Review Committee (ERC) in Nigeria;
the Technical Advisory Group (TAG) in Afghanistan and Pakistan; and the India
Expert Advisory Group (IEAG)). At the international level, activities will be
monitored by the Advisory Committee on Polio Eradication (ACPE) every 6 months
(with a face-to-face meeting every 12 months) and by regional advisory committees
each year.
The findings of the technical advisory bodies will be posted on the GPEI website
within 10 days of each meeting and will be reflected in the annual reports of the
Secretariat to the World Health Assembly. Follow-up stakeholder consultations will
be convened every 12 months.
8
A Call to Action to Finance an Intensified Eradication Effort, 2007-8
Implementing the ’immediate actions’ to intensify the GPEI requires a rapid injection
of multi-year flexible funding, without which the opportunity to eradicate polio will
be lost. As of 10 May 2007, the GPEI had a funding gap of US$ 540 million for
2007-8. Activities and staff will have to be cut back as early as July 2007 if USS 100
million of the funding gap is not secured by that time. A further USS 100 million of
the funding gap requirement is needed by November 2007.
Summary of externalfinancing required by major category of expenditure, 2007-8
(USS millions)15
2007-2008
2008
2007
Major Expenditures
Oral polio vaccine
$
227.98
$
176.09
$
404.07
Campaign operations
$
230.69
$
163.81
$
394.50
Outbreak response/ mOPV evaluation
$
50.00
$
35.00
$
85.00
Surveillance
$
61.09
$
59.47
$
120.56
Laboratory
$
8.37
$
8.45
$
16.82
Technical assistance
$
87.90
$
83.35
$
171.25
Certification and containment
$
12.00
$
12.00
$
24.00
Products for the post-eradication era
$
5.00
$
5.00
$
10.00
Vaccine for post-eradication stockpile
$
12.70
$
31.60
$
44.30
Subtotal
$
695.72
$
574.77
$
1,270.50
Contributions
$
493.80
$
237.73
$
731.53
Funding gap
$
201.92
$
337.04
$
538.97
Budget notes:
•
conducting additional campaigns to raise immunity in polio-free countries at
moderate risk of importations would cost an additional USS 110 million per year.
.
a 12-month delay in completing eradication in the Pakistan/Afghanistan reservoirs,
Nigeria or India would increase costs by a minimum of USS 45 million, USS 80
million and USS 140 million, respectively.
•
after interrupting wild poliovirus transmission globally, USS 661 million will be
required over the next 3 years for certification and post-eradication preparedness.
15 Details can be found in the Financial Resource Requirements of the Global Polio Eradication
Initiative (FRRs) at www.polioeradication.or2 .
9
I
Articles
Protective efficacy of a monovalent oral type 1 poliovirus
vaccine: a case-control study
Nicholas C Grossly,Jay Wenger, Sunita Durrani, Sunil BahIJagadish M Deshpande, Roland W Sutter, David L Heymann,R Bruce Aylward
Summary
Lancet 2007; 369:1356-62 Background A high-potency monovalent oral type 1 poliovirus vaccine (mOPVl) was developed in 2005 to tackle
Published online persistent poliovirus transmission in the last remaining infected countries. Our aim was to assess the efficacy of this
April 12,2007 vaccine in India.
001:10.1016/501406736(07)60531-5
See Comment pages 1321
and 1322
See Articlespage 1363
Departmentof Infectious
Disease Epidemiology, Imperial
college London, London, uk
(N C Crassly DPhil); National
Polio Surveillance Project,
WHO, New Delhi, India
(J Wenger MD, S Durrani BSc,
S Bahl MD); Enterovirus
Research Centre, Parel,
Mumbai, India
(J M Deshpande PhD); and
Global Polio Eradication
Initiative, WHO, Geneva,
Switzerland (R W Sutter MD,
D L Heymann MD,
R B Aylward MD)
Correspondence to:
Dr Nicholas C Crassly,
Department of infectious Disease
Epidemiology, imperial college
London, Norfolk Place, London
n.grassiy@imperiai.ac.uk
1356
Methods We estimated the efficacy of mOPVl used in supplementary immunisation activities from 2076 matched
case-control pairs of confirmed cases of poliomyelitis caused by type 1 wild poliovirus and cases of non-polio acute
flaccid paralysis in India. The effect of the introduction of mOPVl on population immunity was calculated on the
basis of estimates of vaccination coverage from data for non-polio acute flaccid paralysis.
Findings In areas of persistent poliovirus transmission in Uttar Pradesh, the protective efficacy of mOPVl was
estimated to be 30% (95% CI 19-41) per dose against type 1 paralytic disease, compared with 11% (7-14) for the
trivalent oral vaccine. 76-82% of children aged 0-23 months were estimated to be protected by vaccination against
type 1 poliovirus at the end of 2006, compared with 59% at the end of 2004, before the introduction of mOPVl.
Interpretation Under conditions where the efficacy of live-attenuated oral poliovirus vaccines is compromised by a
high prevalence of diarrhoea and other infections, a dose of high-potency mOPVl is almost three times more effective
against type 1 poliomyelitis disease than is trivalent vaccine. Achieving high coverage with this new vaccine in areas
of persistent poliovirus transmission should substantially improve the probability of rapidly eliminatingtransmission
of the disease.
Introduction
mass polio immunisation campaigns in India (April,
By early 2004, the transmission of indigenous wild 2005) and Egypt (June, 2005).6,7
poliovirus had been interrupted in all but six countries of
The efficacy of mOPVl has major implications for
world as a result of a concerted international international public health. The Global Polio Eradication
eradication effort.1
in four
four of
ofthese
these countries—Nigeria,
countries—Nigeria,Initiative has invested US$5 billion in eradication over a
effort.' In
eradication
Niger, Pakistan,
Pakistan, and
and Afghanistan—sustained
Afghanistan—sustained trans
trans- 20-year period and a key role is now proposed for
Niger,
mission was the result of a failure to immunise a monovalent vaccines in the strategic approach to
sufficiently high proportion of children against polio- interrupting the transmission of remaining indigenous
myelitis.2 However, In India and Egypt, poliovirus wild poliovirus and managing the risks of re-emergent
transmission persisted despite immunisation coverage transmission of poliovirus after global certification of
with four doses of the trivalent oral poliovirus vaccine of eradication.8,9
Especially important to the programme is the
more than 90% among children aged less than 5 years.5,4
In recognition of the grave threat that persistent effectiveness of the monovalent vaccine under field
transmission in India and Egypt posed to the Global conditions of poor sanitation and high population density,
Polio Eradication Initiative, the programme’s inter where a high prevalence of diarrhoeal disease and other
national oversight body urgently reviewed a range of infections have been shown to interfere with the efficacy
options in October, 2004, to enhance the effectiveness of of trivalent oral poliovirus vaccine as well as to favour the
vaccination in these areas. By that time, transmission of transmission of wild poliovirus.10-12 In Egypt, no indiwild type 2 poliovirus had been interrupted worldwide genous strain of wild poliovirus has been detected since
the introduction of mOPVl.6 Tn India, however, a polio
and type 3 poliovirus had been eliminated in Egypt and
all but one state of India. Consequently, the Advisory outbreak in 2006 allowed us to study the efficacy of this
Committee on Polio Eradication recommended the new vaccine under field conditions. Our aim was to
rapid development, licensing, and introduction of a new determine the protective efficacy of mOPVl in India and
monovalent oral type 1 poliovirus vaccine (mOPVl).1 explore the consequent implications of mOPVl for global
This new vaccine possesses five times the potency of polio eradication and post-eradication risk management,
licensed monovalent vaccines used in the early 1960s
(IxlO6 median cell culture infective doses [CCID50] vs Methods
200000 CCID5() per dose).5 Through an extraordinary Patientsand procedures
public-private development effort this new mOPVl was Since the introduction of mOPVl use in India in 2005,
licensed by April, 2005, in India and Egypt and used in vaccination efforts have focused on the northern states of
www.thelancet.com Vol 369 April 21, 2007
Articles
Investigators who enrolled patients
Australia—C Bladin, S Davis, R Gerraty, J Frayna, G Herkes, P Landau,
D Crimmins, D Schultz, S Read, G Hankey; Austria—W Soukop,
K Niederkorn, E Rumpl, W Lang; Brazil—A A Gabbai, E Ramacciotti,
M Friedrich, ERF Manenti, R J Gagliardi; Canada—L Berger, C Bradley,
A Mackey, M Mant, G Pineo; Colombia—M I Vergara; Czech
Republic—Z Kalita, M Bar, D Vaclavik, R Mikulik, J Neumann, E Ehler,
J Bauer, O Skoda; India—M V Padma, C U Velmurugendran, A Patel,
V Puri, S Ravat, A Shah, S Prabhakar, R Srinivasa, M Singh,
J M K Murthy; Israel—B Brenner, A S Berliner, G Lugassy, M Ellis;
Italy—C Fieschi, C Argentino, D Paternostro, G Micieli, D Imberti;
Mexico—J L Ruiz-Sandoval, A Arauz, L Leon-Flores, G Aguayo-Leytte,
J Villarreal-Careaga, C Cantu-Brito, J A Sagastegui-Rodriguez;
Poland—A Czlonkowska, D Filipczak, P Haug, H Kwiecinski, W Nyka,
J Pniewski, J Kozlowska-Staniczek, Z Stelmasiak,
A Kuczynska-Zardzewialy; South Africa—L Van Zyl, J Steyn,
J Engelbrecht, J Gardiner, F Maritz, L Jamjam, H F M Nortje, R Isaacs;
South Korea—J K Roh, M K Han, Y S Lee, B C Lee, J H Heo, D I Chang,
D J Shin; Turkey—S Bahar, B Ince, G Bakac, K Selekler, K Kutluk,
E Ogul, A Ozeren. USA—D Sherman, J Couch, R B Van Staven,
H Payne, B Dihenia, R Atkinson, J Bertoni, D Chiu, G Albers, K Levin,
J Graff, E Giraldo, N Papamitskas, A Lahiri, M Vengrow, J J Wang,
D Wang, E Skalabrin, V D P Bandi, D Honeycutt, A Kay, S Kishner,
K Sheinart, M Duerden, A Felix, M Goldstein, P Mazzeo, W 0‘Riordan,
J Rubin, E Albakri, R Dafer, S Etezadi, E Lader, W Felton, A Kloman,
D Pasupuleti, S Mallenbaum, J Kramer, M Concha, R Zweifler.
Contributors
All authors participated in the study design, collection of data,
interpretation of results, and writing and critically reviewing or revising
the report. All authors have seen and approved the final version of the
report, and were fully responsible for content and editorial decisions.
8
9
10
11
12
13
14
15
16
17
Conflict of interest statement
All authors were members of the PREVAIL study steering committee.
DS has received honoraria from Sanofi-Aventis for speaker bureau and
consultancy. CK has received honoraria for membership of speaker
bureaus for Boehringer-Ingelheim and Sanofi-Aventis, and from
Orgaiion for consultancy. WO'R was a principal investigator at a study
site for both PREVAIL and EXCLAIM studies (sponsored by
Sanofi-Aventis). GP has received honoraria from Sanofi-Aventis, Pfizer,
BMS, and Leo for consultancy. GA has been a member of scientific
advispry boards and a principal investigator in clinical trials funded by
AstralZeneca, Sanofi-Aventis, Novartis, and Boehringer Ingelheim.
18
19
20
Acknowledgments
21
This study was sponsored by Sanofi-Aventis. We thank the people who
agreed to participate in this trial and the study contributors, including
members of the steering committee. Editorial support for this article was
provided by Sanofi-Aventis.
22
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2
3
4
5
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Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous
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McCarthy ST, Turner J. Low-dose subcutaneous heparin in the
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Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P.
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Lensing AW, Buller HR, Prandoni P, et al. Contrast venography, the
gold standard for the diagnosis of deep-vein thrombosis:
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Kelly J. Rudd A, Lewis RR, Coshall C, Moody A, Hunt BJ. Venous
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456-64.
1355
Articles
Uttar Pradesh—where over 80% of all type 1 cases of
poliomyelitis in India in 2006 occurred—and Bihar.
Frequent rounds of vaccination with mOPVl have been
interspersed with use of trivalent vaccine to maintain
immunity to type 3 poliovirus. In the few districts with
continued reporting of type 3 poliomyelitis, monovalent
vaccine against type 3 (mOPV3) has also been used in up
to two immunisation rounds.
We extracted data for cases of type 1 poliomyelitis and
control individuals from the database of the National
Polio Surveillance Project, which detects and investigates
cases of acute flaccid paralysis in children aged less than
15 years in India. The National Polio Surveillance Project
is an active surveillance system that receives reports from
over 10 000 health-care institutions and 15 000 health-care
practitioners.13 All cases of acute flaccid paralysis undergo
standard clinical, epidemiological, and laboratory
investigations, including the collection of two stool
samples to test for wild poliovirus. Data were extracted for
patients in whom paralysis developed between January 1,
1997, and December 31, 2006. Laboratory confirmation of
suspected cases of poliomyelitis was not routinely done
before this time. Cases of acute flaccid paralysis without
information on vaccine doses received or that did not
have two adequate stool samples and had residual
paralysis compatible with poliomyelitis were excluded
from the analysis.
Institutional ethics approval was not sought since this
is not a prospective intervention study. The paper reports
an analysis of a National Surveillance database recording
use of standard vaccines licensed by the National
Regulatory Authority of the Government of India for use
in India. The database is anonymised and free of
personally identifiable information.
A case of type 1 poliomyelitis was defined as any case
of acute flaccid paralysis with virological confirmation of
type 1 wild poliovirus. Virological confirmation was done
by the national laboratory network supported by the
National Polio Surveillance Project. We estimated the
sensitivity of laboratory testing for type 1 poliovirus from
the consistency in results across the two stool samples
collected from each case of acute flaccid paralysis.14 The
tests are assumed to be 100% specific since virus is
grown in culture and all positive samples are sequenced
in the VP1 region of the viral genome to allow
differentiation of genotype and to identify any identical
sequences that would indicate potential cross
contaminationof samples.
Cases of acute flaccid paralysis from which wild
poliovirus was not isolated from stool samples were
defined as non-polio acute flaccid paralysis and could
have been caused by a wide range of conditions including
Guillain-Barre syndrome, trauma, and infection with
other enteroviruses.15 Control individuals were selected
from these cases of non-polio acute flaccid paralysis and
were matched to each case of poliomyelitis by district,
age of onset of paralysis (to within 1 month), and date of
www.thelancet.com Vol 369 April 21, 2007
I
onset of paralysis (to within 3 months). Matching criteria
were chosen to reduce differences in exposure to wild
poliovirus between cases and controls to a minimum,
and are consistent with criteria used previously to
estimate the efficacy of the trivalent vaccine.10 We
estimated the probability that a case of non-polio acute
flaccid paralysis was actually infected with type 1
poliovirus (ie, the risk of misclassification) from the
sensitivity and specificity of laboratory testing and the
prevalence of type 1 poliovirus among all reported cases
of acute flaccid paralysis.14
The number of doses of oral poliovirus vaccine reported
by the parent to have been received by each case and
control was extracted from the case investigation data,
Individuals who recorded dose information were masked
to the polio status of the child, which only became
available after virological testing of the stool samples.
These data do not differentiate between doses of oral
poliovirus vaccine received through routine immunisation services, which use only trivalent vaccine, and
supplementary immunisation activities, which use
trivalent or monovalent vaccine. We therefore estimated
the efficacy of mOPVl under the assumptions of
either 0% or 100% coverage by routine services. In the
first case, we assumed that none of the total reported
doses of vaccine were received through routine services.
In the second case, the first three doses reported by cases
and controls were assumed to have been trivalent vaccine
received through routine services. The number of doses
of monovalent and trivalent vaccine received by each case
and control through supplementary immunisation
activities was determined from their exposure to activities
with different vaccine types based on their district of
residence, date of birth, and date of onset of paralysis.
For example, a child born on November 22, 2004, in
Moradabad district in Uttar Pradesh, with date of onset
of paralysis of November 12, 2005, would have been
exposed to seven rounds ofsupplementaryimmunisation,
four of which were with mOPVl and the rest with
trivalent vaccine. To estimate the number of doses of oral
poliovirus vaccine of a particular type received by a child
with acute flaccid paralysis, we multiplied the number of
doses reported to have been received by the child by the
fraction of supplementary immunisation activities that
used vaccine of that type.
Statisticalanalysis
Vaccine efficacy was calculated by comparing the number
of doses received by cases with that of matched controls by
use of conditional logistic regression.16 The odds of
infection with paralytic poliovirus in India shows a
log-linear relationship with the number of doses of
trivalent vaccine received.10 This finding is consistent with
the mechanism of action of oral poliovirus vaccine, which
shows an all-or-nothing response to vaccination in terms
of protection against paralytic disease, with a probability
of protection per dose that is independent of the number
1357
I
Articles
Cases of
poliomyelitis
Matched cases
ofpoliomyelitis
Age (years)
<1
1820 (37%)
851(41%)
1-2
2471 (50%)
1051 (51%)
3-4
458 (9%)
141 (7%)
5+
217 (4%)
33 (2%)
Uttar Pradesh
2973 (60%)
1499 (72%)
Bihar
439 (9%)
204 (10%)
Rest of India
1554 (31%)
373 (18%)
Location
Period
1997-2001
2540 (51%)
816 (39%)
2002-2006
2426 (49%)
1260(61%)
Exposed to mOPVl, assuming
(a) no routine tOPV
534(11%)
451 (22%)
(b) first three doses routine tOPV
479 (10%)
405 (20%)
4966 (100%)
2076 (100%)
Total
Data are n (%). mOPVl=monovalentoral type 1 poliovirus vaccine. tOPV=trivalent
oral poliovirusvaccine.
Table 1: Characteristics of matched cases of type 1 poliomyelitis and all
reported cases of type 1 poliomyelitis, 1997-2006
of earlier doses.1718 We therefore estimated the log-odds of
a paralytic infection with type 1 poliovirus as a linear
function of the number of doses of vaccine of different
types:
ln(odds)=pmxm+ptx+E
see online for webappendix where (1-ePm) is the per-dose protective efficacy of mOPVl
against type 1 paralytic poliovirus, (1-eft)is the per-dose
protective efficacy of the trivalent vaccine against type 1
poliovirus, and xm and x, are the number of doses of
mOPVl and trivalent vaccine received, respectively. Each
matched case-control pair has a particular level of
exposure to wild poliovirus, E, which is unknown and
can be eliminated from the analysis by maximising the
Vaccine
Location
Vaccine efficacy
Trivalent
Rest of India
23% (17-29)
19% (8-29)
Bihar
No routine tOPV
First three doses routine tOPV
Monovalent
Monovalent
Uttar Pradesh
11% (7-14)
Rest of India
36% (0-72)
Bihar
18% (0-43)
Uttar Pradesh
30% (19-39)*
Rest of India
42% (0-71)
Bihar
19% (0-47)
31% (20-41)t
Uttar Pradesh
Date are efficacy (95% Cl). tOPV=trivalent oral poliovirusvaccine. ’Significantly better than trivalent vaccine in Uttar
Pradesh, p=0-0007. tSignificantlybetter than trivalent vaccine in Uttar Pradesh, p=0 0004.
Table 2: Estimated per dose protective efficacy of mOPVl and trivalent vaccine against paralysis by
type 1 poliovirus in India
1358
conditional likelihood.16 We estimated vaccine efficacy
separately for the states of Uttar Pradesh and Bihar, and
for the rest of India, by including an interaction term,
since the efficacy of trivalent vaccine in these two
northern states has been shown to be lower than in the
rest of India.10 We also examined the possibility of
interference between mOPVl and doses of trivalent
vaccine by testing for an interaction.
To examine the hypothesis of a constant efficacy per
dose for mOPVl, we also treated the estimated number
of doses received as a categorical variable, and this
unconstrainedmodel was compared with the model with
a constant per dose efficacy by use of the likelihood ratio
statistic. Potential differences in mOPVl efficacy by age
were also examined by the inclusion of an interaction
term for the age at onset of paralysis by 6-month
age-groups. We tested the robustness of the process used
to assign the vaccine type of each reported dose by
examining the estimated efficacy of oral poliovirus
vaccine irrespective of vaccine type before and after the
introduction of monovalent vaccine in 2005.
The overall effectiveness of mOPVl in Uttar Pradesh
was assessed by calculating the proportion of children
who were protected by vaccination against type 1
paralytic poliovirus, by 3-month age-groups, in the last
quarter of 2004 (ie, just before the introduction of
mOPVl) and the last quarter of 2006. This was estimated
from the number doses of mOPVl and trivalent vaccine
received by children with non-polio acute flaccid
paralysis, who are assumed to have the same level of
vaccine coverage as other children from the same
age-group and location, and the estimated efficacy for
each of these vaccines (see webappendix for further
details). A comparison was made with the estimated
proportion of children protected in the last quarter
of 2004 in the rest of India, where wild poliovirus
transmission had been interrupted for the previous
2 years and continued immunisation had maintained
the reproductive number below one, the threshold for
persistence.10 Immunity among 0-23-month-old
children in the rest of India at this time is therefore
indicative of exposure to vaccine virus alone, not wild
poliovirus. The implications of mOPVl for post
eradication risk management were assessed by calcu
lating the number of doses of mOPVl or of trivalent
vaccine required to achieve a level of protection
comparable with that which interrupted wild poliovirus
transmission and maintained polio-free status in the
rest of India.
All statistical analyses were implemented with the
statistical programminglanguage R.
Role of the funding source
The funding source had no role in the study design, data
collection, data analysis, data interpretation, or writing of
the report. All authors had full access to all the data. NCG
had final responsibility to submit for publication.
www.thelancet.com Vol 369 April 21, 2007
Articles
I
Results
stool samples was 97%, which is consistent with previous
122173 cases of acute flaccid paralysis were identified. Of estimates.1019 The prevalence of type 1 poliovirus among
these, 2580 did not have two adequate stool samples and all cases of acute flaccid paralysis was estimated to
had residual paralysis compatible with poliomyelitis and be 4-7% and the probability of misclassifying a child
were thus excluded from the analysis; a further 5773 cases paralysed by type 1 poliovirus as a non-polio acute flaccid
did not report the number of vaccine doses received and paralysis control to be 0 • 0017.
were also excluded. 4966 cases of type 1 poliomyelitis
Figure 1 shows the effect of mOPVl on the proportion
had complete dose information for the entire study of children protected by vaccination against type 1
period; of these, 2076 were matched with suitable paralytic poliovirus for Uttar Pradesh, assuming
controls (table 1). The age distribution of matched cases 0% routine coverage with trivalent vaccine. Similar
was much the same as that for all reported cases of results were found when we assumed that there was
poliomyelitis. There was a greater probability of finding 100% routine coverage with trivalent vaccine (webfigure 2). see online for webfigures 1 and 2
a matched control in Uttar Pradesh in recent years The number of doses of oral poliovirus vaccine received
because there were more reported cases of non-polio by children aged 0-23 months, as estimated from data
acute flaccid paralysis in this region compared with
A
other parts of India; in 2006, 388 (86%) cases of type 1
25 “I
poliomyelitis reported from Uttar Pradesh were matched
2006
2004
with a control. Between 438 and 460 matched controls
H tOPV □ tOPV
were exposed to at least one supplementary immunisation
ffl mOPV3
20 activity with mOPVl, depending on the assumed routine
■ mOPVl
coverage with trivalent vaccine.
c
We estimate that the protective efficacy of mOPVl in
15
Uttar Pradesh is 30% (95% CI 19-39) per dose under the
assumption of no routine coverage with trivalent vaccine
E
and 31% (20-41) under the assumption of 100% coverage
c
Is 10
of routine programmes with up to three doses of trivalent
vaccine (table 2). Both efficacy estimates are significantly
higher than that for trivalent vaccine against type 1
poliovirus in Uttar Pradesh, which we estimated to be
5
11% per dose, irrespectiveof the assumption about routine
coverage (p=0 • 0007 and 0 • 0004 for each assumption). The
0
estimate of mOPVl efficacy is largely independent of the
3
0
6
9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57
assumption about routine coverage with trivalent vaccine.
B
Therefore, our (conservative) point estimate of mOPVl
100 -1
efficacy is 30% per dose, with a CI of 19-41%, which spans
2006
2004
the intervals for our two estimates. In Bihar and the rest of
90 I I
□
India, there were insufficient cases ofpoliomyelitis in 2006
g 80 to allow us to estimate mOPVl efficacy precisely (table 2).
c
70 As expected, there was no significant interaction between
doses of mOPVl and of trivalent vaccine in protecting
60 "S
against paralytic type 1 poliovirus, since supplementary
£ 50 immunisation activities occured at least 4 weeks apart to
2_
c
avoid interference between vaccine virus doses (p=0-54
40 - s
and p=0 ■ 21 for each assumption).
g- 30 The estimated odds of infection with paralytic poliovirus
was found to fall exponentially with increasing number
20 n
of doses of mOPVl or trivalent vaccine, consistent with
10 the assumption of a constant vaccine efficacy per dose
(webfigure 1). Furthermore, the model with a constant
0
0
3
6
9 12 15 18 21 24 27 30 33 36 39 42
probability of providing protection per dose did not give a
Age (months)
significantly worse fit than the unconstrained model with
differing efficacy by number of vaccine doses previously Figure 1: The effect of monovalentvaccine on population immunity among children in Uttar Pradesh
received (likelihood ratio test p=0-9). The estimated Calculations assumethat all doses were received through supplementary immunisationcampaigns. (A) The mean
efficacy of mOPVl was not dependent on age at onset of number of doses of each type of oral poliovirus vaccine received by children in Uttar Pradesh by 3-month age-groups,
comparing the last quarter of 2004 with 2006. (B)The proportion of children in Uttar Pradesh who remained
paralysis.
unprotected by oral vaccine against type 1 paralytic poliovirus in the last quarter of 2004 and 2006, based on the
We estimated that the sensitivity of testing for type 1 estimated coverage and efficacy of monovalentand trivalent vaccines. mOPVl=monovalentoral type 1 poliovirus
poliovirus from cases of acute flaccid paralysis with two vaccine. mOPV3=monovalentoral type 3 poliovirus vaccine. tOPV=trivalent oral poliovirusvaccine.
l/>
in
_Q
CD
ijiiiitfiiliiiil.
I
n
www.thelancet.com Vol 369 April 21, 2007
1359
I
Articles
Discussion
g
mOPVl
2 100-|
I
..■o-
9080-
g
70-O'
p'
60-
o'
s 50o
.O-'
.o-
.O’
? X■
I
40-
J
30-
d.=-'
,|
20 -
.■
o
g.
10 -
oi0 1
2
K
3
1
I
I
I
IflI
I
4
5
6
7
8
10 11
9
I
I
I
12 13
I
I
14 15
Doses
Figure 2: Proportionof children protected against type 1 paralytic poliovirus
Based on vaccine efficacy estimates for Uttar Pradesh. The shaded areas
represent 95% Cl for the per dose efficacy estimates. mOPVl=monovalent oral
type 1 poliovirus vaccine. tOPV=trivalentoral poliovirusvaccine.
for cases of non-polio acute flaccid paralysis, shows a
marginal improvement, from an average of seven doses
in the last quarter of 2004 to eight doses for the same
period in 2006 (figure 1). However, there was a substantial
improvement in population immunity between the two
periods, since in 2006 about half of the doses received in
this age-group were mOPVl (45-69%, depending on
assumed coverage of routine services; figure 1 and
webfigure 2). Consequently, in the last quarter of 2004,
59% of children aged 0-23 months in Uttar Pradesh were
protected against type 1 poliovirus, compared with
76-82% of children in this age-group in the last quarter
of 2006. This finding is comparable with an estimated
81% of children aged 0-23 months protected against
type 1 poliovirus in the rest of India (excluding Bihar)
during the last quarter of 2004.
The overall protective efficacy of vaccine given to
children in Uttar Pradesh, irrespective of the inferred
vaccine type, was estimated to be 25% (95% CI 17-31) per
dose in 2006, compared with 9% (5-14) in the 5 years
preceding the distribution of monovalent vaccine
(p=0-0002). This increase in overall vaccine efficacy
following the introduction of mOPVl supports the notion
that this vaccine has greater efficacy than does trivalent
vaccine, irrespective of the process used to classify the
type of vaccine for each reported dose.
The greater efficacy of mOPVl leads to much more
rapid protection of children than with trivalent vaccine in
Uttar Pradesh (figure 2). Each child would need to receive
about five doses of mOPVl to achieve an estimated 78%
(range 61-87) level of vaccine-generated immunity, which
is comparable with that needed to interruptwild poliovirus
transmission in the rest of India. By contrast, 14 doses of
trivalent vaccine would be needed to reach such a level of
protection.
1360
Our results show that, in the state of Uttar Pradesh, the
monovalent vaccine is about three times more likely to
result in a protective immune response against type 1
paralytic poliomyelitis than is the trivalent vaccine,
irrespective of the assumption about routine immu
nisation. This increased efficacy is probably caused by the
absence of interference between the three Sabin vaccine
strains.20 Even balanced formulations of trivalent poliovirus
vaccines tend to result in preferential infection and
seroconversion to type 2 virus, especially in developing
countries, most likely explaining the global eradication of
wild type 2 poliovirus in 1999.
The relative efficacy of mOPVl is somewhat better than
expected from seroconversion studies after vaccine
administration, in which a relative rate of seroconversion
per dose of 2-2-5 was found.5 However, an estimated
per dose efficacy of 30% is substantially lower than an
overall seroconversion rate of72% (range 53-89) observed
in four small studies from developing countries,5 which
is probably the result of the higher prevalence of diarrhoea
and other infections in Uttar Pradesh. Such infections
can severely compromise the efficacy of live-attenuated
oral poliovirus vaccine, as has been shown for the
trivalent vaccine.1112 Vaccine quality is unlikely to be a
problem, since temperature-sensitive vaccine vial
monitors have been used in India since 1998, and routine
testing of samples of vaccine vials from the field have
found consistently high vaccine potency (i>106 CCID50
per dose). We were unable to generate precise estimates
of the efficacy of mOPVl outside Uttar Pradesh;
nevertheless, efficacy is probably higher in the rest of
India because of the lower prevalence of diarrhoea and
other infections.
Although the estimated per dose efficacy of mOPVl is
below that observed in other studies, its efficacy was
three times greater than that of the trivalent vaccine in
the same setting, which has important implications for
interrupting the remaining chains of wild poliovirus
transmissionin India as well as managingpost-eradication
risks.
risks. Most
Most importantly,
importantly, our
our estimate that 76-82% of
children aged
aged 0-23
0-23 months
months were
’
children
protected by vaccine
against type 1 paralytic poliovirus in Uttar Pradesh in the
last quarter of 2006 due to the use of mOPVl in over half
the supplementary immunisation activities compares
favourably with the estimated 81% achieved in the rest of
India (excluding Bihar) at the end of 2004 when endemic
transmission of type 1 wild poliovirus had been stopped
for 2 years and the reproductive number maintained
below the threshold for persistence.10 In both cases, actual
population immunity will be somewhat higher than these
estimates of primary vaccine-derived immunity, due to
natural exposure to wild poliovirus, secondary vaccine
virus transmission, and the presence of maternal anti
bodies that protect children in the first few months of life,
Although a proportion of the children who seroconvert
after immunisation with oral poliovirus vaccine can still
www.thelancet.com Vol 369 April 21, 2007
I
Articles
become infected with poliovirus, the observation of a
herd effect sufficient to interrupt transmission in the rest
of India is consistent with studies that show that the
duration and titre of viral excretion in children who
become infected after immunisation are substantially
reduced compared with unimmunised children.21-23 In
Uttar Pradesh, the proportion of children that need to be
protected to interrupt transmission could be higher than
in the rest of India, since higher population densities and
poorer sanitation probably result in a greater transmission
potential of wild poliovirus.
The higher per dose efficacy of mOPVl compared with
trivalent vaccine would facilitate a much more rapid
increase in population immunity during an outbreak
response in the post-eradication era. In the setting of
Uttar Pradesh, five doses of mOPVl would be needed to
protect about 80% of children against type 1 poliomyelitis
(figure 2). A comparable level of protection with trivalent
vaccine would require 14 doses. This lends support to the
idea ofthe stockpiling monovalentvaccines for managing
the risks associated with polioviruses in the post
eradication era, as proposed by the Advisory Committee
on Polio Eradication.6
Several factors could affect the precision of our estimate
of the field efficacy of mOPVl. The number of doses of
vaccine of different types recorded for each case of acute
flaccid paralysis relies on accurate reporting of doses
received and correct classification of the vaccine dose
administered. Any misreporting that might have occurred
is unlikely to have affected our estimate ofvaccine efficacy,
since more detailed follow-up of a subset of cases of
poliomyelitis in 2005 found no tendency towards under
reporting or over-reporting of doses. Misclassification of
vaccine doses received by individuals with acute flaccid
paralysis will lead to an underestimate of the true mOPVl
efficacy, since trivalent doses could erroneously be
recorded as mOPVl. Although such a misclassification
could have some effect on our estimate of mOPVl efficacy,
the proportion of children missed by each supplementary
immunisation activity is small (<5%) and exposure to
different types of such activities is strongly correlated
with the number of doses reported by individuals with
acute flaccid paralysis, suggesting misclassification—and
misreporting—is limited (webfigure 3). That mOPVl is
more effective than trivalent vaccine is lent strong support
by the increased estimated efficacy of oral poliovirus
vaccine in 2006, irrespective of vaccine type, compared
with the 5 years before its introduction. Before the
introduction of mOPVl, estimated vaccine efficacy based
on data gathered since 1997 did not change over time.10
Children with non-polio acute flaccid paralysis are a
suitable control group for the analysis since they come
from the same communities as reported cases of
poliomyelitis. The estimate of vaccine efficacy would be
biased if these children were in fact paralysed due to
infection with type 1 poliovirus. However, the estimated
probability of misclassification is very low; indeed, just
www.thelancet.com Vol 369 April 21, 2007
three cases of type 1 poliomyelitis would be expected to
be misclassified as controls over the entire period of the
analysis and less than one during 2005-06, when mOPVl
was in use. Although just under half the cases of type 1
poliomyelitis could be matched, the tendency to select
recent cases from Uttar Pradesh in the analysis of
efficacy does not introduce bias, since the analysis is
stratified by location and there has been no temporal
change in the efficacy of the trivalent vaccine.10
Furthermore, the estimate of mOPVl efficacy is largely
based on matched case-controls from the outbreak
in 2006 centred on Uttar Pradesh, when 86% of cases
were matched with controls. Indeed the estimated
efficacy ofmOPVl remains at 30% per dose (range 19-41)
when based on these cases alone.
Further studies are required to refine our understanding
ofthe field efficacy of mOPVl, and also monovalent vaccine
against type 3 poliovirus, and their role in interrupting the
final chains ofwild poliovirus transmission worldwide and
managing post-eradication risks. Seroconversion studies
after administration of trivalent vaccine and mOPVl
should be completed in India and elsewhere to assess the
relative immunogenicity of these vaccines in different
settings. However, most important to the elimination of
poliovirus from the four remaining endemic areas in the
world is achieving and sustaining high coverage with oral
poliovirus vaccine of the appropriate type in all geo
graphical areas and among all population subgroups. The
2006 outbreak of type 1 poliomyelitis in India, despite the
introduction of a substantially more efficacious vaccine
since mid-2005, serves as stark evidence of the need for
high coverage with multiple doses of vaccine as early as
possible in life in these areas. Achieving such coverage will
require sustained dialogue with local communities and
strong political commitment. If these conditions can be
met, the prospects are now very good for the elimination of
wild poliovirus transmission worldwide.
Contributors
NCG and RBA conceived the analysis and wrote the final manuscript,
NCG applied the analysis, JW coordinated surveillance of acute flaccid
paralysis, SD supported the analysis, SB supervised data collection, JMD
did the laboratory testing of cases, and DLH and RWS contributed to the
concept and review of the paper. All authors reviewed the analysis and
contributed to the writing of the paper.
Conflictof interest statement
See Online for webfigure 3
We declare that we have no conflict of interest.
Acknowledgments
Tliis work was supported by a Royal Society University Research
Fellowship to NCG. We thank C Fraser for discussion and anonymous
reviewers for suggestions to improve the manuscript.
References
1
World Health Organization. Conclusions and recommendations of
2
3
the Ad Hoc Advisory Committee on Poliomyelitis Eradication,
Geneva, 21-22 September 2004. Wkly Epidemiol Rec 2004; 79: 401-08.
World Health Organization. Progress towards global eradication of
poliomyelitis, 2003 and January-April 2004. Wkly Epidemiol Rec
2004; 79: 229-36.
World Health Organization. Progress towards poliomyelitis
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World Health Organization. Progress towards poliomyelitis
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Caceres VM, Sutter RW. Sabin monovalent oral polio vaccines:
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review of past experiences and their potential use after polio
eradication. Clin Infect Dis 2001; 33: 531—41.
World Health Organization. Conclusions and recommendations of
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the Advisory Committee on Poliomyelitis Eradication, Geneva,
11-12 October 2005. Wkly Epidemiol Rec 2005; 80: 409-16.
Graf H. Manufacturing and supply of monovalent oral polio
7
vaccines. Biologicals 2006; 34:141-44.
Aylward RB, Sutter RW, Cochi SL, Thompson KM, Jafari H,
8
Heymann D. Risk management in a polio-free world. Risk Anal
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Aylward RB, Sutter RW, Heymann DL. OPV cessation - the final
9
step to a "polio-free" world. Science 2005; 310: 625-26.
10 Crassly NC, Fraser C, Wenger J, et al. New strategies for the
elimination of polio from India. Science 2006; 314:1150-53.
11 The World Health Organization Collaborative Study Group on Oral
Poliovirus Vaccine. Factors affecting the immunogenicity of oral
poliovirus vaccine—a prospective evaluation in Brazil and the
Gambia. J Infect Dis 1995; 171:1097-106.
12 Posey DL, Linkins RW, Oliveria MJC, Monteiro D, Patriarca PA.
The effect of diarrhea on oral poliovirus vaccine failure in Brazil.
J Infect Dis 1997; 175: S258-63.
13 Banerjee K, Hlady WG, Andrus JK, Sarkar S, Fitzsimmons J,
Abeykoon P. Poliomyelitis surveillance: the model used in India for
polio eradication. Bull World Health Organ 2000; 78: 321-29.
14 Gary HE Jr, Sanders R, Pallansch MA. A theoretical framework for
evaluating the sensitivity of surveillance for detecting wild
poliovirus: I. Factors affecting detection sensitivity in a person with
acute flaccid paralysis. J Infect Dis 1997; 175 (suppl 1): S135-40.
4
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Marx A, Glass JD, Sutter RW. Differential diagnosis of acute flaccid
paralysis and its role in poliomyelitis surveillance. Epidemiol Rev
2000; 22: 298-316.
16 Clayton D, Hills M. Statistical models in epidemiology. Oxford:
Oxford University Press, 1993.
17 Sutter RW, Kew OM, Cochi SL. Poliovirus vaccine—live. In: Plotkin
SA, Orenstein WA, eds. Vaccines, 4th edn. Philadelphia, PA, USA:
Saunders, 2004: 651-705.
18 Halsey N, Galazka A. The efficacy of DPT and oral poliomyelitis
immunization schedules initiated from birth to 12 weeks of age.
Bull World Health Organ 1985; 63:1151-69.
19 Kohler KA, Deshpande JM, Gary HE, Banerjee K, Zuber PLF,
Hlady WG. Contribution of second stool specimen to increased
sensitivity of poliovirus detection in India, 1998-2000.
Epidemiol Infect 2003; 131: 711-18.
20 Patriarca PA, Wright PF, John TJ. Factors affecting the
immunogenicity of oral poliovirus vaccine in developing countries:
Review. Rev Infect Dis 1991; 13: 926-39.
21 Henry JL, Jaikaran ES, Davies JR, et al. A study of poliovaccination
in infancy: excretion following challenge with live virus by children
given killed or living poliovaccine. J Hyg (Lond) 1966; 64:105-20.
22 Onorato IM, Modlin JF, McBean AM, Thoms ML, Losonsky GA,
Bernier RH. Mucosal immunity induced by enhanced-potency
inactivated and oral polio vaccines. J Infect Dis 1991; 163:1-6.
23 Ghendon YZ, Sanakoyeva II. Comparison of the resistance of the
intestinal tract to poliomyelitis virus (Sabin’s strains) in persons
after naturally and experimentally acquired immunity. Acta Virol
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15
www.thelancet.com Vol 369 April 21, 2007
On 21 April 2007, a leading medical journal - The Lancet published a new study by Kim Thompson et al from Harvard
University, demonstrating that effective control of polio (eg
maintaining low numbers of polio cases) would cost more in the
long-term - both in human suffering and dollars - than finishing
eradication.
Below are answers to frequently asked questions relating to the
study.
What are the study's main findings?
•
•
.
•
•
•
Concerns about the high perceived costs of eradicating the
relatively low number of polio cases worldwide have led to recent
suggestions that it is time to shift from a goal of eradication to
control-abandoning eradication and allowing wild polioviruses to
continue to circulate-which proponents of control believe can
sustain the low number of cases. This paper urges explicit
consideration of the health and financial trade-offs associated with
this choice.
Comparing the numbers of expected cases and costs for 20 years
into the future for a range of eradication and control options, the
study finds that eradication is the best solution. As long as it is
technically achievable, eradication offers both lower cumulative
costs and cases than control in the long-term, even with the costs
of achieving eradication exceeding several billion dollars more.
The results suggest that control means a future with high costs and
low cases or with low costs and high cases. Low costs and low cases
is only an option if we continue to pay high costs in the short-term
until we eradicate.
Results from a dynamic model of endemic wild poliovirus
transmission in the populous Northern India states of Uttar Pradesh
and Bihar show that eliminating the virus requires that we increase
the immunization intensity.
Permanently reducing vaccination intensity even by a small
percentage will lead to a significant resurgence of polio incidence
and thousands of annual cases expected just in Uttar Pradesh and
Bihar.
This study demonstrates that acting based on concerns of incurring
high costs to prevent few polio cases will eventually lead to more
polio cases and much higher cumulative costs compared to
eradication followed by cessation of vaccination. A wavering
commitment to eradication is not a good option.
What are the study's main recommendations?
•
We should require stakeholders in the debate about whether to give
up or pursue the current option to eradicate polio to make their
1
•
•
assumptions about costs and cases of specific options explicit and
transparent.
We need to take a long-term perspective with respect to decisions
about global polio eradication. Failing to do so will not only put
children in developing countries at a higher risk of getting polio, but
in the long term will also hurt other public efforts in those countries.
Discussions about opportunity costs should consider the opportunity
costs that we will incur if we do not eradicate polio, which will
include real children paralyzed by the disease (predominantly in
low-income countries that already suffer from large disease burdens)
and real resources that we will continue to spend on polio control in
perpetuity that cannot be used for other public health interventions.
What do the cost-effectiveness ratios mean in this paper?
•
•
This paper sought to expose the weakness of thinking in terms of
high costs aimed at a disease with a now very low global number of
reported cases, which is the way that some non-economists appear
to be looking at the current situation for polio. To demonstrate this,
this paper modeled what would happen if we based decisions on a
naive understanding of cost-effectiveness ratios formulated as costs
per case. The demonstrative example in the paper shows that
basing decisions on a concern about high costs per case would
result in a failure to complete eradication, and ultimately yield
higher costs and more polio cases due to a wavering commitment.
This problem is one reason why economists use costs per case
prevented for cost-effectiveness ratios.
In the analysis for all of the low-income group countries, the study
notably does not present incremental cost-effectiveness ratios.
However, Figure 5 shows the costs and cases of the various
eradication and control options from which these could be derived.
The costs of achieving eradication are unknown and as stated in the
paper they are not included. Instead, the study focuses on
estimating the amount that we should be willing to spend to
achieve eradication. The results of the analysis of the amount that
we should be willing to pay to eradicate results can be correctly
interpreted as showing that from an incremental cost-effectiveness
perspective eradication dominates control as long as the costs of
eradication are less than a minimum of $3 billion ($2 billion if we
completely ignore treatment costs and outcomes in middle-income
countries). In addition, since all of the eradication scenarios yield
fewer cases than the control options (except for the bad option of
ORV without supplemental immunization activities after eradication
vs. high control options), we would obtain negative denominators
and thus negative and non-standard incremental cost-effectiveness
ratios (implying that we would save money to suffer worse health
outcomes). (Note: Another paper that provides estimates of
incremental cost-effectiveness ratios and incremental net benefits
for future polio risk management is currently submitted and
economists interested in reviewing that paper should contact
Professor Thompson to obtain a review copy. The embargo policies
2
of the journal to which that paper is submitted preclude posting
that manuscript and its detailed technical appendix or any public
distribution prior to its publication.)
How much will polio eradication actually cost?
We do not know the costs needed to finish eradication or the time
required, although with very few areas remaining endemic so long
as we sustain the commitment eradication appears close.
Is global polio eradication feasible?
•
•
One of the three wild poliovirus serotypes (type 2) was eradicated
globally in 1999. The GPEI has demonstrated the ability to interrupt
wild poliovirus in some of the most challenging regions, including
areas with high population density, poor sanitation, almost no
public health infrastructure, and civil or military conflict.
This paper assumes that "eradication is achievable provided that we
are willing to commit the necessary resources."
What is immunization intensity?
•
Immunization intensity is an indication of the level of effort aimed
at increasing population immunity. We define immunization
intensity specifically as the fraction of susceptible people who
become immune because of exposure to oral vaccine viruses per
year (i.e., from successful routine or supplemental oral poliovirus
vaccination, or secondary exposure to oral poliovirus vaccine).
Why are the costs of control in the endemic areas so high for
every modeled control option?
•
The study assumes that the control policies would involve sufficient
resources to effectively maintain the current incidence of
approximately 1,300 paralytic polio cases per year in endemic areas.
If not, we will likely see a rapid expansion of the endemic areas and
more frequent importation outbreaks into countries that are now
free of wild poliovirus transmission.
3
NOW, MORE THAN EVER: STOP POLIO FOREVER.
O ®3 unicef<&»
Global Polio Eradication Initiative
The Lancet: publication of monovalent oral polio
vaccine efficacy study
Interpretation and significance
Synopsis:
New Lancet publication: Fast Facts
On 12 April 2007, a leading
mOPV 1 three times as effective as trivalent OPV against
medical journal, the Lancet,
type 1 polio
published the results of a new
V Wide-scale use of mOPV 1 can raise population immunity
study1, showing increased efficacy
to levels necessary to stop indigenous type 1 polio in India
of monovalent oral polio vaccine
Key to success: reaching all children multiple times with
type 1 (mOPVl) over the
mOPVl!
traditionally-used trivalent OPV
against paralytic polio due to type 1 poliovirus. The results of this study have substantial
implications to the global polio eradication effort, and emphasizes the technical
feasibility of rapidly finishing polio once and for all.
Study results:
The study confirms the increased efficacy of mOPVl over trivalent OPV against type 1
polio. In a field study in Uttar Pradesh, India (one of only two remaining endemic states
in India), mOPVl was shown to be three times more effective than trivalent OPV at
protecting children against type 1 polio. The study estimates that 30% of children in this
key area of persistent wild poliovirus transmissionare fully protected against type 1 polio
after a single dose of mOPVl compared to only 11% of children after a single dose of
trivalent OPV.
Interpretation and significance:
Uttar Pradesh is arguably one of the most difficult places on earth to eradicate polio, due
to a number of programmatic and environmental challenges, including low levels of
routine immunization services, inadequate sanitation infrastructure, high population
density and large birth cohorts. Oral polio vaccines have been shown to be less effective
in areas such as Uttar Pradesh, due to high prevalence of diarrhoeal disease and other
intestinal infections thus facilitating intense transmission of wild poliovirus. Due to the
specific environmental challenges and compromised efficacy of trivalent OPV in Uttar
Pradesh, poliovirus transmission has continued to persist, despite high vaccination
coverage with trivalent OPV.
1 Crassly NC et al, Protective efficacy of a monovalent oral type I poliovirus vaccine: a case-control study.
The Lancet, 12 April 2007.
i
'I
NOW, MORE THAN EVER: STOP POLIO FOREVER.
Health
Organization
O
unicef<0>
Vaccination coverage versus population immunity:
Due to the challenging conditions in Uttar Pradesh, higher levels of population immunity
are required to interrupt polio transmission than were required in the rest of India. It is
estimated that on average 7 doses of trivalent OPV among children aged 0-23 months in
other parts of India succeeded in protecting at least 80% against paralysis and interrupted
poliovirus transmission, compared to only 59% protected in Uttar Pradesh at the end of
2004.
mOPVI use: markedly increases
population immunity with same
number of doses
The study shows that much higher
100
levels of population immunity can
80
be
achieved using mOPVI with the
70 -x.
% of children
Plan:
vaccination
same
coverage
aged < 2 years 60
Avg of
8 doses
protected
50
compared to use of trivalent OPV,
4 doses
Avg
mOPVI
against type 1
mOPVI
of?
40
resulting in
a
dramatically
polio
&
doses
4 doses
30
tOPV
compounded
impact
on
population
tOPV
20
immunity levels. It is estimated
10
that on average 4 doses of mOPV I
0 _
and 4 doses of trivalent OPV
2004 2006 2007
resulted in 79-82% of children
being protected at the end of 2006,
compared with only 59% of children protected by 7 doses of trivalent OPV alone. In
2007, an aggressive new tailored approach to eradication was launched in the country
aiming to administer 8 doses of mOPVI to every child aged 0-23 months in the
remaining endemic areas of the country. Based on the study results, this plan would lead
to a level of population immunity greater than that achieved in the other areas of India
that have already eradicated the disease. This is extremely significant, as it suggests that
repeated and large-scale administration of mOPVI could now rapidly interrupt the
remaining chains of type I polio transmission for the first time ever in these areas of
India.
Estimated level of population
immunity that
successfully stopped
type 1 polio in rest of India
I
Additional information:
Of further significance is the fact that in most areas of western Uttar Pradesh, including in
the five traditionally highest-risk districts centred around Moradabad, no new cases of
type 1 polio have occurred since October 2006. While it is too early to say if type 1 polio
transmission has been successfully interrupted in these highest-risk districts of western
Uttar Pradesh, it is clear that the levels of population immunity have been significantly
increased in these areas in the latter half of 2006.
Key to rapid success in India is now to further increase the quality of large-scale polio
immunization campaigns to reach every child with mOPVI, and sustain these levels until
transmission has been successfully interrupted throughout the country. mOPVI may
prove to be one of the most important new tools in finishing the job of polio eradication,
and protecting the global US$5 billion investment made in the Global Polio Eradication
Initiative.
2
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