Getting to Zero:On the Verge of Polio Eradication

Ellyn Ogden, MPHUSAID Worldwide Polio Eradication Coordinator

May 17, 2017

1. Poliovirusdetection&interruption

2. OPV2withdrawal,IPVintroduction,immunizationsystemstrengthening

3. Containment&GlobalCertification

4. TransitionPlanning

Polio Eradication and Endgame Strategy

2

1988 2016

Progress in WPV eradication

37Casesin2016

PublicHealthEmergencyofInternationalConcern

declaredinMay2014andreconfirmedevery3monthssince

thattime

5casesin2017(AfghanistanandPakistan)asof10May2017

4Currentrolling6months:10November2016– 09May 2017Sameperiodpreviousyear:10November 2015– 09May 2016

Endemiccountry1Excludesvirusesdetectedfromenvironmentalsurveillance2Onsetofparalysis10November2016– 09May 2017

GlobalWildPoliovirus&cVDPVCases1,Previous6Months2

Wildpoliovirustype1cVDPVtype22

DatainWHOHQasof09May2017

Country Onset of most recent WPV1 case Current4 Same period

last year4 Current4 Same period last year4

Nigeria 0 0 0 0 0

AFR 0 0 0 0Pakistan 13-Feb-17 3 17 3 12Afghanistan 21-Feb-17 4 5 4 4

EMR 21-Feb-17 7 22 7 16

Global 21-Feb-17 7 22 7 16

Number of cases

10

1

1

0

Number of WPV1 cases

Number of WPV infected districts

cVDPV current 6 months2

Pakistan – AfghanistanLowestnumberofcaseseverinthe

epidemiologicalblock

PakistanandAfghanistan:Corridorsoftransmission—commonreservoirsspanningbordersbetweenAfghanistanandPakistaninvolving:1)selectedgeographic

areas,and2)demographic groups

Threemainsharedtransmissioncorridors/endemic zones:a) Southern/Western(Kandahar&Helmand—Quetta)b) SoutheastAfghanistan/SouthKP(Paktika—South Waziristan)c) Eastern/Northern(Nangahar&Jalalabad—Peshawar Valley)

4riskscenariosforfutureWPVtransmissionduetomovementofpeople,andGPEI action:• Movementwithinreservoir areas

• Areaswithhighpopulationmovementidentifiedand focused

• Emphasisonguestchildren (vaccinators,SMs,Supervisorsandmonitors)

• Straddlingpopulationsatborder areas• Mappingofareasandrelationsonother

sideof border• Inclusioninhighriskareaforincreased

focus• Nomads

• Routes,seasonality identified• Nomadspecificcampaigns,Nomadspecific

PTTs,Inclusionin SNID/NID• Returnees

• Vaccinationatborder,UNHCR/IOM centers• IPV(under5)andOPV(under 10)• Identificationofsettlementandinclusionin

microplan

Inaccessiblechildren:May2016- Mar 17400,000

300,000

200,000

100,000

0MayNID Aug NID Oct NID Mar NID2

South&West East North East Restof Afghanistan

Afghanistan

Pakistan

NigeriaandLakeChad

WPV1andVDPV2inNigeria,2016-20172016:• 4WPV1fromBorno.Dateofonsetof

lastcaseAugust21,2016• WPV1inBorno areorphansand

isolatedinsecuritycompromisedareasinnorthernpartofthestate

• 2cVDPV2casesbothfromcontacts(Borno andSokoto).

• LastcaseisfromBodinga LGAinSokoto StatewithdateofonsetSeptember28,2016

2017:• 10VDPV2isolatesfrom

environmentalsurveillancesites:• 6inSokoto• 2inGombe• 1inBauchi• 1inKatisna

• 1VDPV2wasisolatedfromahealthycontactinSokoto (50th Stoolsample)

• Nucleotidechangesrangefrom6- 10AllVDPV2isolatedin2017arenotcirculatingbyGPEIguidelines

THE OUTBREAK LED TO A MASSIVE REGIONALRESPONSE TARGETING 40+ MILLION WITH OPV MULTIPLE TIMES• Overall cost of the outbreak Aug-Dec: $140m

10

HornOfAfrica

HOAWILDPOLIOVIRUS (Type1)OUTBREAKS2004to 2013

2004-2008 Outbreak2009-2012 Outbreak

2013 Outbreak

2016??

2016??

Childrenininaccessibleareas,May2017

Accessstatus SouthSudan Somalia Yemen Sudan TotalinHOAPartiallyaccessibleareas

16,282 655,967 363,864 109,2221,145,335

CompletelyInaccessible

areas 296,320236,081

(comparedto400,000in2016)

51,972 142,532

726,905Total

populationU5in

securitychallenged

area

312,602(comparedto450,000in2016)

892,048

415,836(comparedto600,000in

2016)

251,754(comparedto305867in

2016)1,872,240

Yemen

S.Sudan

SudanSomalia

VDPVOutbreaks

GlobalCirculatingVaccine-derivedPoliovirusCases1,2,2000- 2017

DatainWHOHQasof09May2017

1ForcVDPVdefinitionsee http://polioeradication.org/wp-content/uploads/2016/09/Reporting-and-Classification-of-VDPVs_Aug2016_EN.pdf.Niger2006,Niger2009,Niger2010,Chad2010cVDPVsarelinkedtotheNigeriaoutbreak.Kenya2012cVDPVsarelinkedtotheSomaliaoutbreak.NigeriafiguresincludecaseswithWPV1/cVDPV2mixture:2005- 2,2006- 1,2007- 1,2008- 3,2009- 1,2011- 1;WPV3/cVPDV2mixture2007- 2.2InNigeria,1cVDPV2fromahealthychildcontactofaWPV1casenotincludedincountryorglobalcasecount. 3Figuresincludemultipleemergencesandtransmissionchains.

Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Onset of most recent case

Laos 8 3 11-Jan-16Madagascar 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 20 3 0

Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Onset of most recent case

Pakistan 16 48 22 2 1 17-Dec-16Nigeria 3 22 71 68 155 27 34 8 4 30 1 1(12) 28-Oct-16Guinea 1 7 14-Dec-15Myanmar 2 05-Oct-15South Sudan 2 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 12 2 0

Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 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 0 0

cVDPV type 13

cVDPV type 23

cVDPV type 33

1. Poliovirusdetection&interruption

2. OPV2withdrawal,IPVintroduction,immunizationsystemstrengthening

3. Containment&GlobalCertification

4. LegacyPlanning

Polio Eradication and Endgame Strategy

Introduction• atleastonedoseofIPVinto routineimmunization

Switch• tOPVtobOPV

Withdrawal• ofbOPV&routineOPVuse

Transitioning Away from tOPVin Three Stages

2015-2016

2016

2019-2020

Ongoing STRENGTHENING of routine immunization services

IMG, IPV Introduction and OPV Withdrawal

Data source: WHO/IVB Database, as of 08December 2016

Map production Immunization VaccinesandBiologicals (IVB),

World Health Organization

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 delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. ©WHO 2016. All rightsreserved.

Introduced* to date (173 countries or 89%)Introduction delayed to 2017/2018 (21 countries or 11%)

Not available

Not applicable

* Including partial introduction in India

Introduction delayed :Angola, Burkina Faso, Cabo Verde, Egypt, Eritrea, Ghana, Kyrgyzstan, Liberia, Malawi, Mongolia, Republic of Moldova (the), Rwanda, Sierra Leone, Tajikistan, Togo, Turkmenistan, United Republic of Tanzania (the), Uzbekistan, Viet Nam, Zambia, Zimbabwe

173countriesusing IPV

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 delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. ©WHO 2016. All rights reserved.

Data source: WHO/IVB Database, as of 11 April 2017 Map production Immunization Vaccines and Biologicals (IVB),

World Health Organization

Countries with delayed introduction (18 countries or 9.2%)

Countries with delayed resupply (17 countries or 8.8%)

Not available / Countries already introduced Not applicable

0 950 1,900

20

3,800Kil

CountrieswithIPVsupply disruptions

1. Poliovirusdetection&interruption

2. OPV2withdrawal,IPVintroduction,immunizationsystemstrengthening

3. Containment&GlobalCertification

4. TransitionPlanning

Polio Eradication and Endgame Strategy

figure 1: containment requirements

Phase I: Preparation for containment of poliovirus type 2

Phase II: Poliovirus type 2 containment period

Phase III: Final poliovirus containment

Global readiness

criteria met

OPV2 withdrawal

6 x Regional certification of

WPV eradication

bOPV cessation

Poliovirus- essential facilities

holding WPV

Inventory Destruction, Preparation for containment

IIa: WPV2 containment IIIa: Final containment of all WPV Containment certification

Poliovirus- essential

facilities holding OPV/Sabin only

(no WPV)

Destruction, Preparation for containment

IIb: OPV2/Sabin2 poliovirus containment Containment certification

IIIb:Final containment of all OPV/Sabin polioviruses

Poliovirus- non-essential

facilities

Destruction, Safe handling, No storage Adopt

safe measures

Safe handling of new samples potentially containing poliovirus material in poliovirus-non-essential laboratories

GlobalPolioLaboratoryNetwork– 146Laboratories Worldwide

*Includes 16 in process of implementation AFR: African RegionAMR: Americas RegionEMR: Eastern Mediterranean Region

EUR: European Region ITD: Intratypic differentiationSEAR: South Eastern Asia Region WPR: Western PacificRegion

b

AMRAFR

Laboratories WorldwideVirus Isolation Laboratory (43)

ITD Laboratory (70*)

Sequencing Laboratory (26)

Global Specialized Laboratory (7)

EUR

WPREMR

SEAR

World HealthOrganization

EMROandAFRONOTCertified80%oftheWorld’sChildrenliveinPolio-freeRegions

1. Poliovirusdetection&interruption

2. OPV2withdrawal,IPVintroduction,immunizationsystemstrengthening

3. Containment&GlobalCertification

4. TransitionPlanning

Polio Eradication and Endgame Strategy

Purpose:Definehowapolio-freeworldwillbesustained

26

Goal1: ContainPolioSources

Goal2:ProtectPopulations § Immunizepopulationsagainstunanticipatedpolioevents

Goal3:DetectandRespond

§ Detectanypoliovirusintroductionandrapidlyrespondtopreventtransmission

Goal4:ManageEffectivelyandMonitor

§ Ensureongoingpoliofunctionsareembeddedinexistingordevelopnewapproachestosustainthegoalsofpoliopost-certification

§ Ensurepotentialsourcesofpoliovirusareproperlycontrolledorremoved

Post-CertificationStrategyGoals

• RoutineImmunization• SIAQuality– Immunitygaps• AFPSurveillance– missed

transmission• EnvironmentalSurveillance• MobileandCross-border

populations• Securitycompromised/access• CommunityTrustinVaccines• Containment• IPVsupply• OPVsupply• Complacency• Funding• PoorTransitionPlanning

ProgramRisks

ReasonsforOptimism

• LowestNumberofCases

• Declininggeneticdiversity

• ExpandEnvironmentalSurveillance

• Risksareknownw/solutionspossible

• WindowsofOpportunityinInsecureAreas

• EvidenceBasedCommunications

• Technology:GIS,Mobilephones/remote

monitoring,babyregistries

• CostSavingsIdentified

• TransitionPlanningImproving

• Strongeroversight

• Country-ledeffortsandownership

• Accountabilityframeworks

GlobalPolioEradicationisthelargesteffortoutsideofarmedconflictintheworld.With20millionvolunteers,healthworkers,labtechs,vaccinators,mobilizersdedicatedtothecommongoalofpreventingchildhoodparalysis.

13MillionCasesofParalysisPrevented

Every Child Counts!

Thank You