Deliberations of the IEAG

18-19 November 2009

IEAG Issues – Federal & State Gov'ts

• Why isn't epidemiology for type 1 and type 3 fully meeting IEAG projections despite intensity of activities (in terms of cases)?

• Given the very highly focal nature of polio now in India, can the scope of national & sub-national activities be reduced to better target efforts?

• Recognizing the importance of improving routine immunization can the work of 'B-teams', esp. in reservoir areas, be merged with 'Village Health & Nutrition Days' to optimize health impact?

IEAG Issues - Independent Evaluation

• What are the implications of the Evaluation's finding that the major barrier now in India is the incomplete nature of gut mucosal immunity coupled with the uniquely high force of infection seen in west UP and central Bihar?

• How should the recommendations of the Evaluation be translated into specific research and SIA activities?

The epidemiologic, virologic,

genetic, operational &

technical evidence do suggest

that India is still on the right

path to finish eradication.

2002 2003

1600 cases in 159 districts

225 cases in 87 districts

134 cases in 43 districts

2004

66 cases in35 districts

2005

676 cases in114 districts

2006

874 cases in99 districts

2007

Polio Cases - India

Yes, polio cases in India have not fallen…BUT

P1 wild P3 wild* data as on 30th October 2009

…the geographic scope of both type 1 & 3continues to be further reduced

2008 2009

Type 1 = 8 states

Type 3 = 10 states

Type 1 = 5 states

Type 3 = 5 states

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About 100 blocks in west UP & central Bihar now hold the key to eradication in all India

HR Blocks

WPV1 - 2008

WPV1 - 2009

WPV3 – 2004 & 2005

What is so special about

these 100+ blocks?

What has been so special about these 100+ high risk blocks?

1. Persistent gaps in OPV coverage

2. Suboptimal seroconversion to tOPV

3. Incomplete gut mucosal immunity

4. Very high force of infection

Challenges to Polio Eradication, India

Who is sustaining transmission?

Very young: definitely

Migrants: yes

Older children: maybe(?)

How do we know young children are still transmitting polio?

Age-distribution of confirmed cases

WPV1 polio cases

WPV3 polio cases

Is young child immunity improving?Comparison of Moradabad 2007 & 2009

Study Seroprevalence study(N=923)

Baseline 5 arm study (N=1002)

Period November 2007 April 2009

Age groups 6-9 mths 36-59 mths 6-9 mths

Sero-positive P1 81% 99.8% 99%

Sero-positive P2 63.% 97.% 72%

Sero-positive P3 71% 93% 48%

0

10

20

30

40

50

60

70

80

90

100

6 to 11 12 to 23 24 to 59

type 1 type 2 type 3

% s

erop

ositi

ve

N = 140 N = 330 N = 317

Is young child immunity improving across west UP (Sept 2008-Aug 2009)?

Is gut mucosal immunity improving through use of mOPV vaccines in India?

How important are migrants to eradication? WPV1 cases by migration status, 07-09*

Rest of India

(N= 31)

* data as on 30 october 2009

Non epidemic UP*

(N= 54)

*Non epidemic UP excludes Moradabad, JP Nagar,Badaun, Kanshi ram nagar, Bareilly and Rampur dists of UP

Source of data : NPSP monitoring

N= 47,378 19,094 81,283 113,044 130,29052,243 122,161

% u

nim

mun

ized

66,005 65,491

Are migratory/ mobile communities getting better vaccinated (UP)?

*data 3 November 2009

Are older children contributing to transmission of wild poliovirus?

Age of vaccine-virus excretion, 2005-2009*

Preliminary data on studies of poliovirus in older age groups

West UP AFP sampling Type 1 Type 3

Polio cases with extended sampling 15 33

Number with results available 3 4*

Number of extended contact samples 105 148

Number of contacts positive for WPV

<5 years

5 to 15 years

over 15 years

1

5

2

5.3 %

9.6 %

5.9 %

4

6

0

10 %

9.7 %

0.0 %

Kosi River community sampling (N = 798) Type 1 Type 3

Number positive for WPV

<5 years

5 to15 years

over 15 years

3

3

1

1.9%

1.4%

.2%

2

2

0

1.2%

.9%

0.0%

Recommendations

Three things are absolutely essential at this critical point:

1) sustain intense effort to close coverage gaps in highest risk groups (young children & migrants) & highest risk blocks.

2) introduce bOPV to close type 3 humoural & mucosal immunity gaps

3) immediately research the impact of new tools to boost mucosal immunity in different age groups.

mOPV1

IEAG Endorses SIA Plan for Nov & Dec 2009

Nov Dec

Mix of mOPV1 & mOPV3

mOPV3 will be used in the UP Districts that have not conducted 2 type 3 rounds in the past 6 months

All data suggest type 3 is very sensitive to 2 x mOPV3 & should come under control quickly

* data as on 31 October 2009

mOPV3Jul & Oct

mOPV3Oct

mOPV3Oct

IEAG Rec: Scale of NIDs

• Maintain nationwide scope for Jan-Feb 2010

• Planning to scale down 2011 NIDs should be based on (a) routine OPV3 (e.g. >85% to minimize VDPV risks), & (b) importation risk (based on history).

• An analysis of these risk factors should be presented at the next IEAG to guide finalization of 2011 NID plans.

IEAG Recommendation: NIDs, Jan-Feb 2010

bOPV tOPV

Target (mn) 12.2 161.3

Vaccine (mn)

15.9 206.3

bOPV tOPV

Target (mn) 29.1 144.4

Vaccine (mn)

37.8 184.4

IEAG Recommendation: SIAs, 2010

Aug Sep Oct Nov

NIDs

SNIDEndemic & risk states

mOPV1tOPV/bOPV

Dec

SNIDHR Zones UP/Bihar

bOPV (1&3)

Mar Apr May Jun JulJan Feb

mOPV MOP-UPsInfected Districts

mOPV3

SNIDHR Zones UP/Bihar

SNIDEndemic & risk states

IEAG Recommendation: bOPV

Given the importance of bOPV in the India eradication strategy, priority should be given to national licensure of all national & off-shore bOPV products as soon as they become available

NOTE: GSK bOPV currently the only licensed & bOPV pre-qualified product.

IEAG Rec: Scale of SNIDs

• Maintain planned scope for at least Apr-Jun 2010, recognizing (a) continued risk of spread of type 3 outbreak in west UP, and (b) uncertainty on dates of bOPV introduction and its impact.

• The IEAG should review the epidemiology, bOPV impact and seroprevalence data by mid-2010 to decide scope of SNIDs beyond July.

7008639021026

0

200

400

600

800

1000

1200

2007 2008 2009 2010

Impact of ongoing targeting of SIAsChildren vaccinated in campaigns, India, 2007- 10

Num

ber

of c

hild

ren

(mill

ions

)

Year

Impact of IEAG SIA recommendation: type 1 immunity

Impact of IEAG SIA recommendation: type 3 immunity

IEAG Recommendation: Mop-ups

From Nov 2009 to May 2010:– mop-up WPV1 anywhere in India

– mop-up WPV3 outside west UP or central Bihar

From June 2010:

– mop-up any WPV 1 or 3 anywhere in India.

mOPVs are the vaccine of choice for mop-ups.

Mgnt, speed of response & extent per IEAG recs.

IEAG Rec: SIA Operations (1)

• The IEAG concurs with GoI and state proposals to expand the 'B-team' activities to deliver a broader range of interventions through Village Health & Nutrition Days (VHNDs).

• However, the IEAG proposes that this approach be introduced in a phased manner to understand both the operational issues and the impact, if any, on OPV/SIA coverage.

IEAG Rec: SIA Operations(2)

• Geographic Focus: high risk blocks of west UP and central Bihar.

• Demographic Focus: high risk groups which include young children and migrant populations.

• Other Operational Issues: use work on JE & planned measles campaigns to assess logistics of (a) an OPV round in older children, (b) an IPV round in young children, if either are needed.

IEAG Recs: Comms & Social Mobilization

In the context of the Oct 2009 Communications Review:

• endorses the 3 principles of the 2010-13 Strategy (incl. promotion of RI, zinc, breastfeeding, hygiene/sanitation).

• IEAG stresses the continued focus of the SMNet on migrants & nomads, with intensified transit mobilization linked to improved operations coverage to reach all mobile groups (e.g. beyond trains).

• IEAG welcomes the new district/block communications profiles (esp. to deal with resistence) and supports the rapid roll-out of this tool.

IEAG Recs: Research

• Conduct seroprevalence surveys in Jan & June 2010 in 'core districts' of west UP & Kosi River, Bihar to document bOPV impact & guide strategy.

• Give high priority to study mucosal immunity & impact of bOPV vs. bOPV+IPV in west UP (different age groups; target – March 2010).

• Based on analysis of full enhanced surveillance data, consider implications for further studies in west UP & the Kosi River area, Bihar.

• Environmental sampling: initiate the Delhi sampling & expand sites to include Patna.

• 1 vs. 2 stool sample collection from AFP cases: given lab workloads, NPSP to analyze whether gains in the sensitivity of WPV detection continue to warrant collection of a 2nd specimen.

IEAG Recs: Poliovirus Surveillance

• IEAG is impressed with the data from Bihar demonstrating that real progress can be achieved on routine, during an intensive eradication effort.

• IEAG recommends documenting and disseminating the findings from Bihar to areas struggling to improve routine.

IEAG Recs: Routine Immunization

Evaluated Coverage Estimates of Fully Immunized children in Bihar and UP, 1992-2008

11 12

21

32.838

41.4

55.26

20 2026

23

3730

0

10

20

30

40

50

60

70

80

90

100

NFHS I (1992-93) NFHS II (1998-99) DLHS II (2002-04) NFHS-III (2005-06) CES (2006-07) DLHS (2007-08) Survey by ***FRDS

Bihar UP Linear (Bihar)

*** Immunization Survey carried out by SHSB outsourced to FRDS (Formative Research & Development Services) in the 2nd, 3rd & 4th quarter of 2008 (completed in 30 randomly selected districts).

Data sources: NHFS, DLHS, CES & FRDS

Percent Fully Immunized

Conclusion

India is on the right path to

finish eradication.

The new tools & tactics will

help states to accelerate and

ensure eradication.

The key to success will be

continued innovation, building on

the current successes, the results

of ongoing programme evaluation

and new research.

Recognizing the speed with which

the programme is generating new

information, the IEAG is available

to meet as soon or as often as GoI

might request.