Deliberations of the 23rd IEAG

13 - 14 July 2011

Questions to the IEAG

1. What is the significance of the current polio epidemiology – is this progress real?

2. What are the implications of the ensuing high transmission season for the current polio situation?

3. What are the risks for continued polio transmission in India?

4. How should these risks be effectively addressed to ensure that the gains made so far are further consolidated to achieve polio eradication?

Questions to the IEAG

5. What should be the number, timing, scope and vaccine type for SIAs during the remaining months of 2011 and early 2012?

6. How should the current communication gains be maintained and what are the specific communication challenges at this stage of polio eradication?

7. How should the program begin to prepare for the next phase of polio eradication?

Q1: What is the significance of

the current polio epidemiology

– is this progress real?

A Snapshot of Polio Situation in India

P1 wild P3 wild

1 case to date in 2011 vs. 24 cases at same point in 2010.

1 serotype in 2011 vs. 2 in 2010.

1 genetic cluster in 2011 vs 5 in 2010.

No sewage WPV since Nov 2010.

741

42 1

WPV cases during previous 12 months, India

N=2

Dec 2010 – June 2011*

N=11

Jun 2010 – Nov 2010

N=0N=7

Type 1 Polio

Type 3 Polio

West Bengal is the only state with wild

virus in 2011

WPV1 cases in endemic states, 2009-2011

2009 2010

Uttar Pradesh

Bihar

2011*

Longest indigenous WPV1 transmission free period simultaneously in both endemic states

Cross-border transmission with Nepal

Q2: What are the implications of the

ensuing high transmission season

for the current polio situation?

IEAG Conclusion 2:

There is a high risk that any

residual or imported wild

poliovirus will manifest between

July & November.

Monthly incidence of WPV1 cases, 2005-2011

High transmission season

Any residual WPV transmission is likely to

be detected in the coming high season for polio

Q3: What are the risks for continued

polio transmission in India?

Undetected low season transmission

Return of Indian viruses from Africa

New importations from reservoirs

Risks to India's US$1 Billion Investment in Polio Eradication

RISK 1: Undetected Virus within India

Highest risk areas

(a) historic reservoirs,

(b) orphan virus areas,

(c) recent/recurrent re- infected areas

Districts with ‘Orphan’ viruses,

2008-2011

Rest of India

(N= 48)

Non epidemic UP*

(N= 56)

* non epidemic UP excludes Moradabad, JP Nagar, Badaun, Kanshiram Nagar, Bareilly and Rampur districts*Data as on 10 July 2011

RISK 2: Movement of Viruses in MigrantsMigration status WPV1 cases, 2007-2011

Data in WHO HQ as of 14 Jun 2011

wild virus type 1

wild virus type 3

RISK 3: Importation of Viruses into IndiaPolio-infected districts globally, last 6 months

Virus that originated in

India can return by the

same routes!

Q4: How should these risks be effectively

addressed to ensure that the gains made

so far are further consolidated to achieve

polio eradication?

4 essential elements of risk management:

1. enhance routine OPV3, esp. in west UP, WB

2. enhance surveillance

3. ensure outbreak preparedness plans

4. extra OPV campaigns in highest risk areas

IEAG Conclusion 4:

Risk Mgmt 1: improve routine EPI, with priority to lagging reservoir & 'amplification' areas, building on

recent best practices (e.g. session & community monitoring activities)

11 11.6

18.6

32.838

41.4

5449

66.8 68

0

10

20

30

40

50

60

70

80

90

100

NFHS 21998-99

CES 2002 CES 2005 NFHS 32005-06

CES 2006-07

DLHS 07-08 FRDS2008/09

CES 2009-10 Unicef

FRDS 2010-11

HtHMonitoring

2011

RI Augmentation

Muskan

% Full Immunization coverage

Bihar

Routine Immunization:1. Particular attention to those reservoir or

amplication areas with lagging OPV3 (e.g. west UP, West Bengal).

2. Re-emphasize critical importance of ANM and Medical Officer vacancies in these areas.

3. Continue to build on convergence of polio & routine EPI activities (e.g. microplanning, communications, migrant/marginalized pops).

Risk Management 1

Surveillance:1. complete the planned serosurvey (August)

2. expand environmental sampling as planned

3. enhance surveillance among migrant populations (e.g. enrolling appropriate reporting sites/informers)

4. sustain state-level reviews for quality assurance (esp. reservoirs/amplification areas)

Risk Management 2

Howrah, 2011

Murshidabad, 2010bOPV mOPV1

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

WPV1 notified

07 Feb 2011

WPV1 notified

12 Feb 2010

1

123

45

6

7

2

3

456

7

Num

ber

of W

PV

5 weeks 17 weeks

1 week7 weeksWPV1

WPV3

Risk Mgmt 3: build on best practices to refine WPV/cVDPV emergency preparedness plans

Emergency Preparedness Plans:1. ensure all states complete plans & that these are

shared/reviewed centrally

2. ensure the identified risk areas have follow-up risk mitigation activities

3. conduct simulation exercises in highest risk areas in August 2011 (reservoirs, recently infected areas & amplification sites)

4. Ensure minimum buffer stock of 40 million bOPV and 10 million tOPV doses (review 6 monthly)

Risk Management 3

Q5: What should be the number,

timing, scope and vaccine type for SIAs

during the remaining months of 2011

and early 2012?

IEAG Conclusion 5:

Additional OPV campaigns are

essential to protect the 'reservoir'

and 'amplication' areas going into

the 2011 high season.

2011: additional OPV Campaign in August to reduce risk of high season amplification of any

residual or imported virusSNID

Sep Oct Nov DecJul Aug

Sep Nov

bOPV

SNID

Aug

SNID

NIDtOPV

Mar Apr May JunJan Feb

SNID (bOPV)Endemic & risk states

NIDtOPV/bOPV

SNID (bOPV)Endemic & risk states

2012: procure sufficient vaccine for aggressive OPV schedule in 1st half of 2012, then

prepone/postpone based on epidemiology

SNID (bOPV)Endemic & risk states

SNID (bOPV)Endemic & risk states

Q6: How should the current

communication gains be maintained & what

are the specific communication challenges

at this stage of polio eradication?

IEAG Conclusion 6:The current plan to maintain communications

gains is endorsed, recognizing that the

greatest challenges are (a) ensuring rapid,

high-quality emergency response & (b)

building on the polio capacity to improve

child health.

From Every Child, Every Time

to Your Child,Every Time

toMy Child,

Every Time

New Personalized Branding of the Polio Communications Approach

1. Roll out the new communications approach (incl. major emphasis on routine immunization & other convergence messaging).

2. Sustain the SMNet in UP and Bihar, and consolidate capacity in West Bengal.

3. All states should have a media & IEC as key elements of WPV emergency response plans (incl. designated government spokesperson!)

Recs: Communications

Q7: How should the program begin to

prepare for the next phase of polio

eradication?

IEAG Conclusion 7: Given the recent eradication progress,

and the long timelines for post-eradication

planning, this work should be intensified

esp. in the absence of high season

transmission.

1. intensify implementation of the Global Action Plan for Poliovirus Containment (targeting completion of phase 1 by end-2012)

2. accelerate research & product development agenda (e.g. mucosal immunity, mathematical modeling, safe & affordable IPV approaches)

3. consider convening special IEAG-NTAGI session in late 2011

Recs: Post-eradication planning

Conclusion

India is definitely on the right

path to finish eradication.

HOWEVER, a more aggressive

approach is essential to manage the

risks along this path!

Towards a polio-free India

Rukhsar. Let's ensure she is the last polio case in

India!