A polio-free world after 60 years of vaccination ? HARRIE VAN DER AVOORT

18-11-2015

RVP ONDERZOEKSDAG, UTRECHT

Polio in the Netherlands

Two last epidemics: ◦ 1978: Polio 1 1992/93: Polio 3

Origin virus: India ⇒ Turkey ⇒ the Netherlands

All patients not vaccinated, most of them for religious reasons

Start IPV

↓

Prevention of polio in NL Since 1957: IPV in regular vaccination program

Vaccination is free of charge, but not obligatory

Intensive surveillance is necessary for early awareness and for measures to minimalize the risks:

◦ Regular EV surveillance nationwide ◦ Regular environmental surveillance in Biblebelt ◦ Weekly surveillance meetings at RIVM ◦ Extra activities in case of threats for import/circulation in NL

◦ Polio eradication is the only option to prevent new epidemics in NL

POLIO 1988-2014 4

Biological principles of virus eradication.

1) Virus causes acute, non-persisting infections

2) Humans are the only reservoir

3) Virus is transmitted only by infectious humans

or their waste (no transmitting vector)

4) Survival of virus in the environment is finite

5) Vaccination interrupts virus transmission

(Dowdle and Birmingham JID:1997,175,S286-292)

5 criteria for successful eradication

POLIO 1988-2014 5

Polio vaccines

IPV: Inactivated Polio Vaccine

OPV: Oral Polio Vaccine

Both vaccines contain

all three types of poliovirus virus

and provide excellent protection against disease,

but not against infection ◦

POLIO 1988-2014 6

Differences between IPV and OPV

◦ IPV OPV

◦ type vaccine inactivated live, attenuated

◦ administration injection oral

◦ combination with DPT Vit. A

◦ costs/dose $1.00 $0.08

◦ contra-indication no pregnancy immunodeficiency

POLIO 1988-2012 7

Differences between IPV and OPV ◦ IPV OPV

◦ antibody titers high high

◦ mucosal immunity no high

◦ adverse effects no reversion to neurovirulence

VAPP cases (2/1,000,000 primo vaccinations)

since 2002: > 25 VDPV epidemics by vaccine viruses with enhanced transmissibility

POLIO 1988-2012 8

VDPVs Virological characteristics:

>10 nucleotide changes in comparison to vaccine strain for type 1 and 3

6 or more nucleotide changes in comparison to vaccine strain for type 2

Origin: i-VDPV

prolongued infection in B-cell immuno-deficient OPV vaccinees

excretion usually stops spontaneously, but may last for > 10 years

often without disease

c-VDPV

prolongued circulation in non-/insufficiently vaccinated population

a-VDPV

none of above, f.i. isolate from environment

Pathogenicity and transmissibility : as for wildtype

POLIO 1988-2014

1988 350 000 cases 125 countries

Polio eradication 1988-2010

2010 1352 cases

4 endemic countries

10

Total: 223 WPV cases in 5 countries • WPV 1: 202 in 5 countries • WPV 3: 21 in 2 countries • Endemic countries (n=3): 217 (96.8% of cases) • Non-endemic countries : 6 cases

Total: 650 WPV in 16 countries WPV 1: 583 in 13 countries WPV 3: 67 in 7 countries (10% of total cases Endemic countries (n=4): 341 (52% of cases) Non-endemic countries : 309 cases Chad: 132 (20% of all cases)

GLOBAL POLIO LABORATORY NETWORK

Wild Poliovirus Cases1, 2013

Endemic country Poliovirus type 1

1Excludes cases caused by vaccine-derived polioviruses and viruses detected from environmental surveillance.

Data in WHO HQ as of 10 December 2013

W1 W3Cameroon 30-Oct-13 2 4 4Ethiopia 19-Sep-13 1 6 6Kenya 14-Jul-13 3 14 14Nigeria 08-Oct-13 29 51 51AFR Total 30-Oct-13 35 75 75Afghanistan 12-Nov-13 9 13 13Pakistan 26-Nov-13 20 74 74Somalia 09-Oct-13 46 183 183Syria 08-Oct-13 3 17 17EMR Total 26-Nov-13 78 287 287Total 26-Nov-13 113 362 362

Total WPV

Country Onset of most recent case

Number of districts

Virus Type

Cameroon 09-Jul-14 4 5Equatorial Guinea 03-May-14 4 5

Ethiopia 05-Jan-14 1 1

Nigeria 24-Jul-14 7 8AFR 24-Jul-14 16 19

Afghanistan 05-Nov-14 17 23Iraq 07-Apr-14 2 2

Pakistan 11-Nov-14 35 279

Somalia 11-Aug-14 4 7Syria 21-Jan-14 5 5EMR 11-Nov-14 63 316

Global 11-Nov-14 79 335

Onset of most recent case

Number of districtsCountry

Total WPV (All type1)

Wild Poliovirus Cases1, 2014

↑

POLIO 1988-2014 12

Last circulation in UP and Bihar

Large birth cohorts in between NIDs

240 block program in Moradabad (“cordon sanitaire”)

Use of bOPV very successful:

97% reduction in number of cases in 2010

Last case 11-1-2011

2014: declared polio free, 3 years after last case

INDIA

POLIO 1988-2014 13

mOPV vs. bOPV vs. tOPV

Polio 2 component dominates antibody production after tOPV administration

mOPV 1 or 3 and bOPV(1+3) more effective than tOPV in raising immunity against type 1 or 3 virus

Sutter et al. 2010

Wild Poliovirus & cVDPV Cases1, Previous 12 Months2

1Excludes viruses detected from environmental surveillance. 2Onset of paralysis 11 November 2014 – 10 November 2015

Endemic country

Wild poliovirus type 1 cVDPV type 1

cVDPV type 2

Data in WHO HQ as of 10 November 2015

Guinea NA 0 20-Jul-15 1Nigeria NA 0 16-May-15 2Madagascar NA 0 22-Aug-15 10AFR 0 22-Aug-15 13Pakistan 21-Oct-15 78 13-Dec-14 1Afghanistan 06-Sep-15 17 NA 0EMR 21-Oct-15 95 13-Dec-14 1Ukraine NA 0 07-Jul-15 2EUR 0 07-Jul-15 2Lao People's Democratic Republic

NA 0 07-Oct-15 3

WPR 0 07-Oct-15 3Global 21-Oct-15 95 07-Oct-15 19

Wild poliovirus cVDPV

Onset of most recent case

Total cVDPV*

*cVDPV1 in Madagascar, Ukraine, Laos, cVDPV2 in all other countries. NA: most recent case had onset of paralysis prior to rolling 12 months.

Country Onset of most recent case

Total WPV(All type1)

2015

POLIO 1988-2014 15

Non-acceptation of vaccine between 2003-2007

(fear for HIV/AIDS, infertility of girls).

Solution: vaccine produced in Indonesia

Only since second half 2009: new government, good coverage in NIDs

In 2011 no P1 and P3 for > 6 months, as a result of use of bOPV

In 2012 again P1 and P3 in the North, with risk for export to neighbouring countries

Since 2013 unprecedented success: no wild polio since 24-6-2014 !!!!!!!

NIGERIA

POLIO 1988-2014 16

Since 2007:: Taliban allows polio vaccinations

Afghan polio teams given access to Taliban areas

2010: Vaccination teams kidnapped and killed in AFG

2012-3: Similar incidents in PAK (>15 deaths)

Since 2012: military support for every vaccination team

Interference by instability and unsafe political situation

Polio circulation reduced to one province

Diplomacy at high level

PAK/AFG: One epidemiological block

Wild Poliovirus Cases1, Previous 6 Months2

Endemic country

Wild poliovirus type 1

1Excludes viruses detected from environmental surveillance. 2Onset of paralysis 11 May – 10 November 2015

Country Onset of most recent case

Number of infected districts

Total WPV (All type1)

Pakistan 21-Oct-15 7 15Afghanistan 06-Sep-15 6 9EMR 21-Oct-15 13 24Global 21-Oct-15 13 24

Data in WHO HQ as of 10 November 2015

cVDPV Cases1, Previous 6 Months2

Endemic country

cVDPV type 1

cVDPV type 2

1Excludes viruses detected from environmental surveillance. 2Onset of paralysis 11 May – 10 November 2015

CountryOnset of most recent case

Number of infected districts

cVDPV* cases

Guinea 20-Jul-15 1 1Nigeria 16-May-15 1 1Madagascar 22-Aug-15 4 9AFR 22-Aug-15 7 11Lao People's Democratic Republic 07-Oct-15 1 3

WPR 07-Oct-15 1 3Ukraine 07-Jul-15 1 2EUR 07-Jul-15 1 2EMR NA 0 0Global 07-Oct-15 9 16

*Madagascar, Ukraine & Laos serotype 1, Nigeria & Guinea serotype 2. NA: onset of paralysis of most recent case more than 6 months ago.

Data in WHO HQ as of 10 November 2015

Circulating Vaccine-derived Poliovirus Cases1, 2000 - 2015

1For cVDPV definition see http://www.polioeradication.org/Portals/0/Document/Resources/VDPV_ReportingClassification.pdf. Niger 2006, Niger 2009, Niger 2010, Chad 2010 cVDPVs are linked to the Nigeria outbreak. Kenya 2012 cVDPVs are linked to the Somalia outbreak. Nigeria figures include the following cases with WPV1/cVDPV2 mixture: 2005 - 2, 2006 - 1, 2007 - 1, 2008 - 3, 2009 - 1, 2011 - 1; WPV3/cVPDV2 mixture 2007 - 2. 2Figures include multiple emergences and transmission chains.

Data in WHO HQ as of 10 November 2015

Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Onset of most recent case

Laos 3 07-Oct-15Madagascar 1 10 22-Aug-15Ukraine 2 07-Jul-15Mozambique 2 02-Jun-11Myanmar 1 4 06-Dec-07Indonesia 46 26-Oct-05China 2 11-Nov-04Philippines 3 26-Jul-01DOR/Haiti 12 9 12-Jul-01Total type 1 12 12 0 0 2 46 1 4 0 0 0 2 0 0 1 15

Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Onset of most recent case

Guinea 1 1 20-Jul-15Nigeria 3 22 71 68 155 27 34 8 4 30 1 16-May-15Pakistan 16 48 22 0 13-Dec-14South Sudan 2 0 12-Sep-14Cameroon 4 12-Aug-13Niger 2 2 1 1 1 11-Jul-13Chad 1 12 4 12-May-13Afghanistan 5 1 9 3 13-Mar-13Somalia 1 6 1 9 1 1 09-Jan-13Kenya 3 29-Aug-12DRCongo 13 5 18 11 17 04-Apr-12China 2 06-Feb-12Yemen 9 05-Oct-11India 15 2 18-Jan-10Ethiopia 3 1 16-Feb-09Madagascar 1 4 3 13-Jul-05Total type 2 0 1 4 0 0 6 24 71 85 184 55 65 68 65 55 2

Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Onset of most recent case

Yemen 3 1 12-Jul-13Ethiopia 1 5 17-May-10Cambodia 1 1 15-Jan-06Total type 3 0 0 0 0 0 1 1 0 0 1 5 0 3 1 0 0

cVDPV type 12

cVDPV type 22

cVDPV type 32

cVDPV type 2 dominates

Country (no. isolates)

Category Type Genetic

distance Netherlands* (1) aVDPV 3 1,7 Turkey (2)** iVDPV 2 <1,0 Turkey (1)** aVDPV 2 <1,0

Turkey*** (1) iVDPV 3 >1,0 Ukraine (4) cVDPV 1 2,9

VDPV isolations in 2015 In EUROPE

* non-AFP refugee from Syria, arrived in 2014 ** These viruses are not related *** PID patient follow up sample

Status in 2015 Wild Poliovirus type 2: officially declared eradicated Wild Poliovirus type 3: no virus isolated since November 2012: eradicated ? India and SEARO region declared poliofree Nigeria and AFRO region free of polio for more than a year Only 2 endemic countries (one epidemiological block) left: PAK/AFG Use of Sabin strain as seed lots for IPV: sIPV Safe intradermal administration of IPV via needle-free jet injector with 1/5 of dose Polio program ready for next steps!

Status in 2015 Polio programme ready for next steps: Vaccine switch: from tOPV to bOPV No OPV type 2 anymore, but 3x b-OPV + 1x IPV Full attention to containment: all wildtype, all VDPV + all type 2 OPV

2013 2014 2015 2016 2017 2018

Virus detection & interruption

Last wild polio case

23

Certification

RI strengthening & OPV withdrawal

Containment & certification

Introduce IPV

Wild virus interruption

Outbreak response (esp. cVDPVs)

RI strengthening & OPV2 pre-requisites

OPV2 withdrawal

Legacy Planning

Finalize long-term containment plans

Complete containment & certification globally

Consultation & strategic plan

Initiate implementation of legacy plan

Last OPV2 use Major

Objectives

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Polio Eradication and Endgame Strategic Plan 2013-2018 and Legacy Planning

WHA Resolution, 2015

• Date for last OPV2 use

• Response protocol for type 2 virus (post-OPV2)

• Poliovirus containment

• International notification of all type 2 viruses

Global Polio Laboratory Network

5 readiness criteria for global tOPV withdrawal (by end-2015)

1. IPV: Introduction of at least one dose of inactivated poliovirus vaccine;

2. bOPV: Access to a bivalent oral polio vaccine that is licensed for routine immunization;

3. Surveillance and Stockpile: Implementation of surveillance and response protocols for type 2 poliovirus (including constitution of a stockpile of monovalent oral polio vaccine type 2);

4. Containment: Completion of phase I poliovirus containment activities, with appropriate handling of residual type 2 materials;

5. Verification: Verification of global eradication of wild poliovirus type 2.

Trigger for setting a date for the withdrawal of type 2 OPV: Absence of all persistent circulating vaccine-derived type 2 polioviruses

(cVDPV2) for at least six months

GAPIII: WHO poliovirus containment policy

Containment policy document (draft 2009): WHO global action plan to minimize poliovirus facility-associated

risk after eradication of wild polioviruses and cessation of routine OPV use (GAPIII)

• GAPIII (2009) addresses all 3 poliovirus strains together

1. Eliminate all wild poliovirus, 2. Stop vaccination with all 3 OPV strains simultaneously

• Endgame Plan introduces phased withdrawal of OPV

strains 1. Beginning with type 2 (tOPV-bOPV switch)

⇒ Need to revise GAPIII and align containment timelines with the Endgame Plan

2013 2009

Revised GAPIII: 3 new containment phases

1. Phase I: Global Coordination for Readiness (until end-2015)

2. Phase II: Global Poliovirus Type 2 Containment Period (2016 – 2018)

3. Phase III: Longterm Containment (2019 ➙)

2014

2. Phase I and Phase II a. timelines

2014 2015 2016 2017 2018 2019 2020 2021

Phase I: Global readiness coordination

Phase II: Poliovirus type 2 containment period

Phase III: Longterm poliovirus containment

6 x Regional certification of

WPV eradication

OPV2 withdrawal

bOPV cessation

Essential facilities holding WPV

IIIa: Final containment of all WPV

Inventory, Destruction, Preparation for containment

Certifica-tion

IIa: WPV2 containment

Essential facilities holding OPV/Sabin only (no WPV)

IIIb: Containment of all Sabin polioviruses IIb: OPV2/Sabin2 poliovirus containment

Destruction, Preparation for containment Certification

Non-essential facilities Safe handling of new samples potentially containing PV material in non-essential laboratories

Destruction, Safe handling, No storage

Adopt safe

measures

Global readiness

criteria met

NOW

Key questions requiring immediate answers): By end-2015: Is it essential for your facility to maintain stocks of WPV2? By end-July 2016: Is it essential for your facility to maintain stocks of OPV2/Sabin2? By end-2015: Is it likely that your facility will investigate new WPV2, VDPV2 isolates, or new faecal or respiratory samples originating from recent OPV-using countries? If the answer to all three questions is no: destroy/inactivate all wild and type 2 OPV viruses and all materials (possibly) containing these viruses

yes: 1

yes: 2

yes: 3

Containment activities ◦ Update of inventory: all wild, all VDPV, OPV2

◦ Destruction/inactivation of viruses and materials with viruses

◦ Destruction/inactivation of materials potentially containing these viruses

◦ Certification of absence of these materials

◦ Implementation of containment for institutions that want to keep viruses/materials

◦ Verification of correct containment according to GAP III

Containment activities

◦ New roles for National Polio Containment Officer (Central Co-ordinator) National Certification Authority (MOH, IGZ, other government entities) National Polio Certification Committee (independent body for final evaluation of all data and contact to Regional Certification Commission) WHO has only advisory role, no authority for certifcation within various countries RIVM has only advisory role, no authority for certification within NL

◦ In May 2015 World Health Assembly ( including NL) has adopted resolution on polio containment

◦ Action needed ASAP, time is short, task is not easy, but can be done

After 60 years of vaccination a polio-free world is in reach !!!