IMED2007_Heymann.pdf - International Society for Infectious ...
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Polio Eradication: completing the job,<br />
guaranteeing the investment<br />
February 2007<br />
World Health Organization 1
Polio eradication:<br />
scientific basis <strong>for</strong><br />
eradication<br />
February 2007<br />
World Health Organization 2
Polio eradication:<br />
scientific basis <strong>for</strong><br />
No reservoir in nature<br />
Easy-to-administer<br />
and effective vaccine<br />
eradication<br />
Feasibility of eradication proven in<br />
industrialized countries<br />
Up to 600 – 1000 asymptomatic<br />
infections <strong>for</strong> each child with paralysis<br />
February 2007<br />
World Health Organization 2
Estimated polio situation,<br />
1988<br />
350 000 children<br />
125 countries<br />
Inequitable access to polio<br />
vaccine<br />
February 2007<br />
World Health Organization 3
World Health Assembly<br />
Resolution:<br />
polio eradication by year 2000<br />
FORTY-FIRST WORLD HEALTH ASSEMBLY GENEVA, 2-13 MAY<br />
WHA41.28 Global eradication of poliomyelitis by the year 2000<br />
1. DECLARES the commitment of WHO to the global eradication of poliomyelitis by<br />
the year 2000;<br />
2. EMPHASIZES that eradication ef<strong>for</strong>ts should be pursued in ways which strengthen<br />
the development of the Expanded Programme on Immunization as a whole, fostering<br />
its contribution, in turn, to the development of the health infrastructure and of<br />
primary health care;<br />
February 2007<br />
World Health Organization 4
Strategy 1:<br />
routine childhood immunization<br />
Routine childhood immunization in<br />
national immunization programmes<br />
February 2007<br />
High level advocacy and<br />
political engagement<br />
World Health Organization 5
Reality: weak national immunization<br />
programmes<br />
Region Routine PT3Polio<br />
Coverage, by Region<br />
February 2007<br />
World Health Organization 6
Strategy 2: national immunization<br />
campaigns<br />
2002: 100 countries<br />
February 2007<br />
World Health Organization 7
Reality: inability to sustain campaigns<br />
when external resources decrease<br />
2003:
Strategy 3: clinical/laboratory<br />
surveillance of acute flaccid paralysis<br />
Specialised Reference Laboratory<br />
Regional Reference Laboratory<br />
National/ Sub-national Laboratory<br />
February 2007<br />
World Health Organization 9
Virus linked to common ancestor, West and<br />
Central Africa, 2004<br />
February 2007<br />
World Health Organization 10
Polio-funded staff by region,<br />
2006<br />
Region<br />
<strong>International</strong> Staff<br />
FT<br />
ST*<br />
FT<br />
ST*<br />
National Staff<br />
SSA<br />
NPO<br />
APW<br />
Total<br />
AFRO<br />
31<br />
120<br />
5<br />
572<br />
355<br />
14<br />
0<br />
1097<br />
AMRO<br />
1<br />
0<br />
0<br />
3<br />
0<br />
2<br />
0<br />
6<br />
EMRO<br />
13<br />
83**<br />
7<br />
19<br />
439<br />
0<br />
457<br />
935<br />
EURO<br />
2<br />
1.5<br />
2<br />
2<br />
0<br />
2<br />
0<br />
9.5<br />
SEARO<br />
13<br />
12<br />
5<br />
11<br />
1151<br />
0<br />
0<br />
1192<br />
WPRO<br />
2<br />
0<br />
0<br />
0<br />
1<br />
0<br />
0<br />
3<br />
HQ<br />
23<br />
12<br />
11.5<br />
4.5<br />
0<br />
0<br />
0<br />
51<br />
TOTAL<br />
85<br />
145.5<br />
30.5<br />
611.5<br />
1946<br />
18<br />
457<br />
3293.5<br />
February 2007<br />
World Health Organization 11
AFP reporting rate world-wide,<br />
2004 and 2005<br />
April 2004 – March 2005<br />
April 2003 – March 2004<br />
< 0.5 0.5 -1<br />
> 1 No AFP Surveillance<br />
February 2007<br />
Data<br />
World<br />
in WHO<br />
Health<br />
HQ as<br />
Organization<br />
of 19 Apr 2005<br />
12
Stool collection rate world-wide,<br />
2004 and 2005<br />
April 2004 – March 2005<br />
April 2003 – March 2004<br />
< 60% 60% -80%<br />
> 80% No AFP Surveillance<br />
February 2007<br />
Data<br />
World<br />
in WHO<br />
Health<br />
HQ as<br />
Organization<br />
of 19 Apr 2005<br />
13
Micro-planning and mapping <strong>for</strong><br />
immunization campaigns<br />
February 2007<br />
World Health Organization 14
Polio eradication progress<br />
1988<br />
350 000 children<br />
125 countries<br />
Inequitable access to<br />
polio vaccine<br />
1988 - 2003<br />
February 2007<br />
World Health Organization 15
Polio eradication progress<br />
1988<br />
350 000 children<br />
125 countries<br />
Inequitable access to<br />
polio vaccine<br />
2003<br />
784 children<br />
6 countries<br />
Equitable access to<br />
polio vaccine<br />
1988 - 2003<br />
February 2007<br />
World Health Organization 15
Polio eradication progress<br />
1988<br />
350 000 children<br />
125 countries<br />
Inequitable access to<br />
polio vaccine<br />
2003<br />
784 children<br />
6 countries<br />
1988 - 2003<br />
Equitable access to<br />
polio vaccine Type 2 wild poliovirus last transmitted in 1999<br />
February 2007<br />
World Health Organization 15
Challenge: suspension of polio<br />
immunization, Nigeria, August 2003<br />
Polio Vaccines - Western Countries Exploit Developing<br />
Ones Says Kano State Governor Shekarau<br />
BYLINE: Daily Trust<br />
BODY:<br />
The Kano State governor, Malam Ibrahim Shekarau, has<br />
asserted that the people's objections to polio vaccines<br />
has confirmed the exploitative actions of western<br />
nations towards developing countries.<br />
February 2007<br />
World Health Organization 16
<strong>International</strong> spread of polio from Nigeria,<br />
India<br />
2003-2006<br />
ongoing<br />
6 months<br />
Wild virus type 1<br />
Wild virus type 3<br />
Wild virus type 1 & 3<br />
February 2007<br />
World Health Organization 17
<strong>International</strong> spread of polio from Nigeria,<br />
India<br />
2003-2006<br />
ongoing<br />
6 months<br />
Wild virus type 1<br />
Wild virus type 3<br />
Wild virus type 1 & 3<br />
February 2007<br />
World Health Organization 17
<strong>International</strong> spread of polio from Nigeria,<br />
India<br />
2003-2006<br />
ongoing<br />
6 months<br />
Wild virus type 1<br />
Wild virus type 3<br />
Wild virus type 1 & 3<br />
February 2007<br />
World Health Organization 17
<strong>International</strong> spread of polio from Nigeria,<br />
India<br />
2003-2006<br />
ongoing<br />
6 months<br />
Wild virus type 1<br />
Wild virus type 3<br />
Wild virus type 1 & 3<br />
24 countries, 70 events<br />
Number of importations from Nigeria<br />
viral origin: 58 (83%)<br />
Number of importations from India<br />
viral origin: 12 (17%)<br />
February 2007<br />
World Health Organization 17
Contribution of outbreaks in re-infected<br />
areas to total children paralyzed, 2005<br />
400<br />
200<br />
000<br />
800<br />
600<br />
400<br />
200<br />
0<br />
Total<br />
Re-infected areas<br />
February 2007<br />
World Health Organization 18
Change in laboratory algorithm: decrease in time to<br />
confirmation by 50%<br />
February 2007<br />
World Health Organization 19
Control of international spread<br />
Reduce importation risk:<br />
<strong>International</strong> Health Regulations (IHR):<br />
establishing new standing<br />
recommendation on OPV <strong>for</strong> travellers<br />
from all infected areas<br />
Saudi Arabia requires proof of OPV <strong>for</strong><br />
entry visas in advance of standing<br />
recommendation<br />
February 2007<br />
World Health Organization 20
Number of children paralyzed, international<br />
spread, 2003-2006<br />
Number of cases<br />
1200<br />
1000<br />
800<br />
600<br />
400<br />
200<br />
Total: 1452 cases<br />
0<br />
2003 2004 2005 2006<br />
February 2007<br />
World Health Organization 21<br />
Data in HQ as of 09october 2006
Financial consequences,<br />
internatioanl spread 2003-2006<br />
Millions US $<br />
250<br />
200<br />
150<br />
Total: US$ 450<br />
Million<br />
Op Costs<br />
Vaccine<br />
100<br />
50<br />
0<br />
2003 2004 2005 2006<br />
February 2007<br />
World Health Organization 22<br />
Data in HQ as of 14 November 2006
Polio in vaccinated children: high<br />
population density countries<br />
Vaccination status, children with polio,<br />
Uttar Pradesh, India 2005<br />
4 - 6 doses<br />
27%<br />
>=10 doses<br />
46%<br />
7 - 9 doses<br />
27%<br />
* data as on 10th September 2005<br />
February 2007<br />
World Health Organization 23
Limited protection from trivalent oral<br />
polio vaccine: virus competition<br />
100<br />
90<br />
89<br />
96<br />
80<br />
70<br />
65<br />
67<br />
67<br />
Percent<br />
60<br />
50<br />
40<br />
30<br />
29<br />
50<br />
31<br />
52<br />
Dose 1<br />
Dose 2<br />
Dose 3<br />
20<br />
10<br />
0<br />
Poliovirus type 1 Poliovirus type 2 Poliovirus type 3<br />
ohn TJ, Devararjan LV, Balasubramanyan A. Immunization in India with trivalent and<br />
monovalent oral poliovirus vaccines of enhanced potency. Bull WHO 1976;54:115-7.<br />
February 2007<br />
World Health Organization 24
Monovalent oral polio vaccine:<br />
greater herd immunity <strong>for</strong> fewer<br />
doses<br />
Monovalent oral polio vaccine types 1 and 3<br />
(mOPV1 and mOPV3)<br />
February 2007<br />
World Health Organization 25
Improvement in protection:<br />
monovalent oral polio vaccine<br />
trials<br />
Decrease in<br />
competition among<br />
three virus types<br />
Marked increase in<br />
level of protection<br />
with 1 st dose<br />
February 2007<br />
100<br />
75<br />
50<br />
25<br />
0<br />
34%<br />
tOPV<br />
61%<br />
mOPV1<br />
Protection against type 1 polio after<br />
one birth dose of mOPV1 vs. one dose<br />
tOPV (Egypt)<br />
World Health Organization 26
Poliovirus isolated from sewage,<br />
Egypt, August 2004 – August 2005<br />
12<br />
Wild poliovirus type 1<br />
Sabin poliovirus type 1<br />
10<br />
8<br />
6<br />
4<br />
2<br />
0<br />
32<br />
34<br />
36<br />
38<br />
40<br />
42<br />
44<br />
46<br />
48<br />
50<br />
52<br />
2<br />
4<br />
6<br />
8<br />
10<br />
12<br />
14<br />
16<br />
18<br />
20<br />
year<br />
2004 2005<br />
22<br />
24<br />
26<br />
February 2007<br />
World Health Organization 27
Polio world-wide, active transmission,<br />
1 January 2007<br />
1,968 cases, 2006<br />
district with type 1 polio<br />
Reservoir areas with types 1 and 3 polio<br />
February 2007<br />
World Health Organization 28
Polio in reservoir areas 2007:<br />
local problems/local solutions<br />
100%<br />
80%<br />
Probable<br />
missed children<br />
per round<br />
in polio-infected<br />
areas (%)<br />
60%<br />
40%<br />
20%<br />
Intense<br />
trasmission<br />
Insecure<br />
areas<br />
Poor quality<br />
operations<br />
0%<br />
India Afgh/Pak Nigeria<br />
February 2007<br />
World Health Organization 29
Polio campaign quality<br />
deteriorated in west UP in 2005<br />
'Unsearched' Houses (%)<br />
12<br />
8<br />
4<br />
& early 2006<br />
> 1 million houses<br />
being missed in<br />
west Uttar Pradesh<br />
at end-2005<br />
0<br />
Jan<br />
Feb<br />
Apr<br />
May<br />
Jul<br />
Oct<br />
Nov<br />
Jan<br />
Feb<br />
Apr<br />
May<br />
Jun<br />
Aug<br />
Sep<br />
Nov<br />
Jan<br />
Feb<br />
Apr<br />
May<br />
Jun<br />
Moradabad<br />
J P Nagar<br />
2004 2005 2006<br />
February 2007<br />
World Health Organization 30
and vaccine virus isolation dropped<br />
arkedly among minority population<br />
Muslims<br />
Hindus<br />
4<br />
2<br />
0<br />
8<br />
6<br />
4<br />
2<br />
14<br />
2006 = 2%<br />
12<br />
2006 = 8%<br />
10<br />
8<br />
6<br />
4<br />
2<br />
0<br />
Jan-Mar 05 Apr-Jun 05 Jul-Sep 05<br />
Oct-Dec<br />
05<br />
Jan-Mar 06 Apr-Jun 06<br />
0<br />
Jan-Mar 05 Apr-Jun 05 Jul-Sep 05<br />
Oct-Dec<br />
05<br />
Jan-Mar 06<br />
February 2007<br />
World Health Organization 31
Accelerated campaign strategy,<br />
India, 2007<br />
100%<br />
90%<br />
80%<br />
70%<br />
60%<br />
50%<br />
40%<br />
Closing immunity gap in<br />
the young<br />
mOPV1 rounds every 4<br />
weeks & mOPV1 at birth<br />
IMMUNE<br />
30%<br />
20%<br />
10%<br />
SUSCEPTIBLE<br />
0%<br />
0 to 4 5 to 8 8 to 12 13 to 16 17 to 20 21 to 24 25 to 28 29 to 32 33 to 36<br />
Age range<br />
February 2007<br />
World Health Organization 32
New Initiatives by Government of<br />
India<br />
New Manpower & Infrastructure:<br />
– 2200 more doctors (800 appointed)<br />
– 73,000 new ASHA workers (46,000 trained)<br />
New Strategies:<br />
– mOPV1 campaigns every month<br />
– mOPV1 birth dose (72% coverage in pilot areas)<br />
– IPV on limited basis in 1-2 rounds in late 2007<br />
– mOPV3 used in intermittant localized campaigns<br />
Renewed Government Ownership and funding<br />
February 2007<br />
World Health Organization 33
Cross-Border Strategies:<br />
Afghanistan & Pakistan<br />
February 2007<br />
President Karzai<br />
establishes polio action group to<br />
coordinate all ministries<br />
Afghanistan and Pakistan Ministers<br />
announce synchronized, cross-border<br />
activities, Nov 2006<br />
World Health Organization 34
Immunization Plus Days,<br />
Nigeria 2006-2007<br />
Fixed Sites:<br />
• 5 days<br />
• mOPV1, measles, DPT<br />
• deworming medicine, bednets, etc<br />
Mobile Teams (house-to-house):<br />
• 5 days<br />
• mOPV1, social mobilization.<br />
February 2007<br />
World Health Organization 35
Trend in zero-dose Children, Nigeria, 2006<br />
(from WHO data on non-polio AFP cases)<br />
2 nd Quarter<br />
3 rd Quarter<br />
1 st Quarter<br />
Missed<br />
Children<br />
> 20%<br />
10-19%<br />
< 10 %<br />
February 2007<br />
World Health Organization 36
Systematic engagement of Muslim<br />
societies<br />
Muslim Leader Conclave<br />
Northern India<br />
Community Dialogues<br />
Northern Nigeria<br />
February 2007<br />
World Health Organization 37
Polio outbreak, China, 2004<br />
Polio outbreak<br />
2 cases<br />
February 2007 World Health Organization 38
Dilemma:<br />
circulating vaccinederived<br />
polioviruses (cVDPVs)<br />
Hispaniola<br />
2000<br />
22 cases<br />
Madagascar<br />
2002<br />
4 cases<br />
Indonesia<br />
2005<br />
46 cases<br />
China<br />
2004<br />
2 cases<br />
Philippines<br />
2001<br />
3 cases<br />
February 2007 World Health Organization 39
iVDPV and long-term excretion<br />
known to WHO<br />
<br />
<br />
32 cases identified during 40<br />
years use of OPV<br />
type 1, type 2, type 3<br />
Europe, USA , Japan ,<br />
Argentina , Taiwan , Iran,<br />
Zimbabwe<br />
3 known to be presently<br />
excreting<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
February 2007<br />
World Health Organization 40
Vaccine derived polio viruses:<br />
definitions<br />
iVDPV is a virus with >1% drift from parent OPV strains by full<br />
VP1 sequence, isolated from a patient either<br />
– with evidence of immune deficiency, or<br />
– with multiple isolates over several months<br />
cVDPV is a virus with >1% difference from parent OPV strains<br />
by full VP1 sequence homology found by AFP surveillance<br />
– consistent with an extensive period of virus excretion or<br />
transmission<br />
– generally in a areas with low OPV coverage rates<br />
February 2007<br />
World Health Organization 41
Vaccine-associated risks<br />
to polio eradication from OPV<br />
Frequency Annual Evolution<br />
Risk to date burden over time<br />
<br />
<br />
<br />
<br />
<br />
based on current understanding<br />
February 2007<br />
World Health Organization 42
Vaccine-associated risks<br />
to polio eradication from OPV<br />
Frequency Annual Evolution<br />
Risk to date burden over time<br />
After interruption of wild poliovirus,<br />
<br />
<br />
continued use of OPV will compromise<br />
<br />
the goal of a polio-free world.<br />
<br />
<br />
Expert Consultation on Vaccine-derived<br />
Polioviruses (VDPVs), Sept 2003, Geneva<br />
based on current understanding<br />
February 2007<br />
World Health Organization 42
OPV cessation after<br />
certification of polio<br />
eradication<br />
Risk of VDPV<br />
cVDPV<br />
emergence<br />
0<br />
Years after<br />
1 2 3 4 5<br />
last wild<br />
poliovirus<br />
Potential Target Date<br />
<strong>for</strong> OPV Cessation<br />
February 2007<br />
Routine immunization and<br />
campaigns,<br />
AFP surveillance<br />
Vaccine stockpile and<br />
response mechanism,<br />
AFP surveillance (IHR)<br />
World Health Organization 43
Vaccine-associated and<br />
other risks to polio eradicatyion<br />
Frequency Annual Evolution<br />
Risk to date burden over time<br />
<br />
<br />
<br />
<br />
<br />
IPV sites 1 accident (1990s)
Laboratory specimens of<br />
poliovirus after eradication<br />
<br />
Polio virus widespread in laboratories throughout<br />
the world:<br />
– Known wild poliovirus<br />
– Known Sabin poliovirus<br />
– Potential infectious materials (wild<br />
and Sabin poliovirus)<br />
– Wild and Sabin poliovirus used<br />
in production of inactivated polio<br />
vaccine (IPV)<br />
February 2007<br />
World Health Organization 45
Worldwide containment, wild<br />
poliovirus: status 2006<br />
Survey not yet advised<br />
Survey not yet started<br />
Conducting survey<br />
Reporting completion of<br />
survey and inventory of<br />
laboratories with wild<br />
poliovirus materials<br />
February 2007<br />
World Health Organization 46
Cost of polio eradication, 1988 – 2006<br />
(US$ 4 billion)<br />
Multilateral Sector<br />
16%<br />
Germany<br />
Japan<br />
Canada<br />
France<br />
USAID<br />
USCDC<br />
G8<br />
49%<br />
GAVI/IFFIm<br />
European<br />
Commission<br />
UK<br />
World Bank/India<br />
Netherlands<br />
Denmark<br />
WB Investment<br />
Partnership <strong>for</strong> Polio<br />
Norway<br />
Sweden<br />
Private Sector<br />
17%<br />
UN Foundation<br />
Gates Foundation<br />
Rotary <strong>International</strong><br />
Other<br />
2007-08 Funding Gap<br />
US$ 575 million<br />
Non-G8 OECD/<br />
Other 18%<br />
‘Other’ includes: the Governments of Austria, Australia, Belgium, Finland, Ireland, Italy, Luxembourg, Malaysia, Monaco, New Zealand, Oman, Portugal, Qatar, Republic of<br />
Korea, Russian Federation, Spain, Switzerland, Saudi Arabia, the United Arab Emirates; AGFund, De Beers, Inter-American Development Bank, <strong>International</strong> Federation of Red<br />
Cross and Red Crescent Societies, Millennium Fund, Oil <strong>for</strong> Food Programme, OPEC Foundation, Sanofi Pasteur, Saudi Arabian Red Crescent <strong>Society</strong>, Smith Kline Biologicals,<br />
UNICEF National Committees, UNICEF Regular Resources, United Arab Emirates Red Crescent <strong>Society</strong>, WHO Regular Budget and Wyeth.<br />
February 2007<br />
World Health Organization 47
Challenges <strong>for</strong> the polio<br />
eradication endgame -<br />
summary<br />
As long as wild poliovurus continues to circulate, all countries are at<br />
risk<br />
The vaccine used to eradicate polio previously (tOPV) is less effective<br />
in tropical countries, monovalent vaccines are being used<br />
VDPV and VAPP will become an unacceptable human risk, and a threat<br />
to polio eradication, once transmission of wild poliovirus has been<br />
interrupted; OPV cessation must there<strong>for</strong>e occur<br />
Laboratory specimens of poliovirus (wild and Sabin) will be a threat to<br />
polio eradication unless effectively contained in laboratories<br />
A global mechanism <strong>for</strong> polio surveillance and response after<br />
certification of eradication is in place<br />
February 2007<br />
World Health Organization 48
Smallpox: Variola Major<br />
20% - 40% case<br />
fatality<br />
100% permanent<br />
facial scarring<br />
2.7 million deaths,<br />
1967<br />
February 2007<br />
World Health Organization 49
Challenge: Smallpox<br />
endemic in 31 countries or territories, 1967<br />
Endemic<br />
Importation<br />
Transmission<br />
interrupted<br />
February 2007<br />
World Health Organization 50
Intensified search:<br />
smallpox eradication, 1967–1978<br />
WHO Smallpox Recognition Card<br />
February 2007<br />
World Health Organization 51
Simplified containment:<br />
smallpox eradication, 1967–1978<br />
1978<br />
Multipuncture vaccination<br />
by bifurcated needle<br />
February 2007<br />
World Health Organization 52
Smallpox eradication programme:<br />
detecting/containing every case<br />
Ethiopia<br />
Somalia<br />
February 2007<br />
World Health Organization 53
Smallpox eradication certified world-<br />
wide, 1980<br />
February 2007<br />
World Health Organization 54
Persons living with HIV infection,<br />
2006: >40 million<br />
February 2007<br />
3 million deaths during 2003<br />
20 million deaths since 1981<br />
World Health Organization 55
Persons living with HIV infection,<br />
2006: >40 million<br />
Smallpox vaccine cannot safely<br />
be used in HIV-infected persons<br />
February 2007<br />
3 million deaths during 2003<br />
20 million deaths since 1981<br />
World Health Organization 55
THE CHALLENGE:<br />
Complete polio eradication<br />
while the window of<br />
opportunity remains open<br />
February 2007<br />
World Health Organization 56
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