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Indian Pediatr 2016;53: S28-S32 |
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Polio
Eradication and Endgame Plan – Victory within Grasp
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Manish Patel, *Lisa
Menning and #Pankaj
Bhatnagar
From Task Force for Global Health, Atlanta, GA, USA;
*World Health Organization, Geneva, Switzerland; and #World
Health Organization, New Delhi, India.
Correspondence to: Dr Manish Patel, Center for
Vaccine Equity, 325 Swanton Way, Decatur GA 30330,
Email: [email protected]
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Since the launch of the Global Polio
Eradication Initiative (GPEI) by the World Health Assembly (WHA) in
1988, the number of polio-endemic countries has decreased from 125 to 2
(Afghanistan and Pakistan). To secure the gains and to address the
remaining challenges, the GPEI developed the Polio Eradication and
Endgame Strategic Plan, 2013-2018 (the Plan), endorsed by all Member
States at the WHA in May 2013. One of the major elements that
distinguishes this Plan from previous GPEI strategies is the approach to
ending all polioviruses, both wild and vaccine-derived. Overall, the
Plan outlines four main objectives: (1) to stop all wild poliovirus
(WPV) transmission; (2) to introduce inactivated polio vaccine (IPV),
withdraw all oral polio vaccines (OPV), and strengthen immunization
systems in countries with weak immunization systems and strong polio
infrastructure; (3) to certify all regions as polio-free and safely
contain all poliovirus stocks; (4) and to mainstream the investment in
polio eradication to benefit other priority public health initiatives
for years to come. Implementing the Plan and meeting the milestones in a
timely manner will help to ensure that that the world remains
permanently polio-free.
Keywords: Endgame, IPV, OPV, oral polio vaccine, Poliovirus.
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India’s last polio case was reported on January 13, 2011. Three years
later, in March 2014, the Global Certification Commission officially
certified the World Health Organization’s (WHO) South-East Asia Region,
where India is located, polio-free [1]. India was once considered by
experts as the most challenging country for interrupting transmission of
polio, and in noting its immense success, enthusiasm was renewed among
partners, donors, and countries that indeed polio can be eradicated
globally. The road to polio eradication began nearly a century ago with
defining the disease burden, isolating and culturing the virus,
identifying the immunological mechanisms of protection, and developing
safe and effective vaccines to prevent disease. These early milestones
paved the path for polio eradication but the journey has not been
smooth, requiring creative and steady modifications in the vaccines,
policy, and implementation strategies [2-10]. Since the World Health
Assembly (WHA) announced a goal to eradicate polio in 1988 and created
the Global Polio Eradication Initiative (GPEI), polio cases have
declined dramatically from over 350,000 cases annually to only 359 cases
reported in 2014 [11]. To capitalize on the building momentum and the
latest tools and technologies, the WHA in May 2013 endorsed GPEI’s
Polio Eradication and Endgame Strategic Plan, 2013-2018 (the Plan),
which provides a detailed approach and concrete timeline for complete
eradication of polio [12].This renewed focus has already shown progress.
In September 2015, WHO declared the eradication of the wild type 2
poliovirus strain, one of the three strains responsible for paralyzing
children and adults since ancient times. In the same month, Nigeria was
removed from the list of polio endemic countries, leaving only
Afghanistan and Pakistan to interrupt wild poliovirus transmission.
The current Plan is different from previous
strategies because it provides direction and approaches for both the
eradication and containment of polio caused not only by wild viruses,
but also for paralytic cases that derive from oral polio vaccines (OPV)
[12,13]. The Plan also incorporates a strategy to use the backbone of
the polio effort for strengthening routine immunization (RI) systems and
delivering other health services to the world’s most vulnerable
children. The Plan outlines four objectives (Table I) that
comprehensively address eradication of polio, the endgame strategy,
containment, and the polio legacy process.
TABLE I Overview of The Polio Eradication and Endgame Strategic Plan, 2013-2018
Objective |
Description |
Key Activities and Milestones, 2013-2019 |
Objective 1 |
Poliovirus detection and interruption |
•Interruption by end 2016 (revised from end 2015) |
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•Eradication by end 2019 (revised from end 2018) |
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•Enhancing poliovirus surveillance |
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•Improving OPV campaign quality |
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•Revising outbreak response protocol & ensuring rapid
outbreak response |
Objective 2 |
IPV introduction, OPV withdrawal, |
• Access to IPV to all countries
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and strengthening immunization |
• Switch from tOPV to bOPV in all 155 OPV using
countries and territories in April 2016
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systems
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• Ensure both bOPV and IPV in routine immunization until
polio eradication |
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• Develop framework for using GPEI assets to improve
routine immunization and monitor their contributions in
10 countries with substantial polio resources |
Objective 3 |
Containment and certification |
• Implement appropriate containment of WPV type 2 in
essential laboratory and vaccine production facilities
by end 2015 |
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• Containment of type 2 OPV within 3 months of tOPV-bOPV
switch |
Objective 4 |
Legacy planning
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• Consultation, development of plan (end 2015),
implementation (beginning 2015- 2016) |
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• Core components of planning: |
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• Maintaining and mainstreaming polio functions |
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• Sharing lessons learned to improve child health |
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• Transition polio functions to improve child health |
*OPV denotes oral polio vaccine; tOPV denotes
trivalent OPV; bOPV denotes bivalent OPV; IPV denotes
inactivated polio vaccine; GPEI denotes Global Polio
Eradication Initiative |
Objective one of the Plan was to complete the
eradication of polio once and for all, with interruption of WPV
worldwide by end of 2015. This objective focuses on Pakistan,
Afghanistan, and Nigeria, the three countries that were polio endemic
when the Plan was established. Since then, GPEI has made substantial
progress towards eradication. In 2015, only 74 cases of wild polio virus
(WPV) were reported (from Pakistan (73%) and Afghanistan (27%), compared
to 359 in 2014 [11]. Importantly, no cases of WPV have been detected in
Nigeria since its last case on 24 July 2014, bringing the Africa region
closer than ever to being certified polio-free. Despite this progress in
Nigeria, immunity gaps still exist in both Pakistan and Afghanistan,
where polio cases continue to occur, continuing to threaten children
everywhere. That said, Pakistan has made substantial strides in the past
year, driven by an Emergency Operations Centre, improving access to
children in inaccessible areas, and working towards the Plan’s goal of
interrupting polio transmission in 2016, and achieving official
certification of eradication by 2019 [1]. Meanwhile, Afghanistan had
more cases in 2015 than in 2014. An Independent Monitoring Board (IMB)
has evaluated the GPEI Polio Oversight Board’s conclusion that
interruption of transmission is most likely to occur in 2016, leading to
eradication in 2019 [14]. IMB opined that this goal is possible but
would require Nigeria to adapt and maintain focus, Pakistan to continue
momentum, and Afghanistan to make immediate improvements in operational
structure of its program.
The second objective of the Plan addresses the
Endgame component to address the challenges of vaccine derived
polioviruses [15]. Oral polio vaccines (OPV) have been indispensable for
successful control of paralytic polio globally. However, use of OPV is
very rarely associated with cases of vaccine-related polio. First, the
live attenuated vaccine can also very rarely cause paralytic polio in
vaccinated individuals or close contacts (vaccine-associated paralytic
polio [VAPP]). In addition, individuals can shed slightly modified polio
vaccine viruses into the environment. Accumulation of mutations can
occur through circulation of these modified polio vaccine viruses in the
community, particularly in communities with lower population immunity to
polio. With sufficient mutations, these vaccine viruses may achieve the
same transmissibility and neurovirulence as WPV (circulating
vaccine-derived polioviruses [cVDPV]) [16]. Since the detection of the
last naturally occurring case of type 2 polio in October 1999 (in
Aligarh, India), the type 2 component of OPV has caused an estimated
1600-3200 cases of VAPP and over 600 cases of cVDPV2 [9]. Today, over
95% of all cVPDV cases are related to type 2 OPV. To address this
limitation associated with OPV use, the Plan calls for a phased
withdrawal of OPV globally. This phased withdrawal will begin with
removal of the type 2 component of OPV through a switch globally from
trivalent OPV (tOPV, containing antigens 1, 2, and 3) to bivalent OPV (bOPV,
containing only antigens 1 and 3) in 2016. Withdrawal of OPV may lead to
gaps in immunity that could risk the emergence of cVDPV or the
re-introduction of WPV. To manage these risks associated with OPV
withdrawal, beginning with removal of the type 2 component of OPV, WHO’s
Strategic Advisory Group of Experts (SAGE) has recommended that all
countries introduce at least one dose of the inactivated polio vaccine
(IPV) to routine immunization programs prior to the switch from tOPV to
bOPV. The need to introduce IPV into all OPV using countries globally in
a relatively short time represents a major and unprecedented challenge.
However, it is also a timely opportunity to improve collaborations
between global immunization partners and make efficient use of GPEI
resources to strengthen routine immunization services, particularly in
countries with the highest risk target populations and weak immunization
systems.Thus, the launch of Mission Indradhanush by the Government of
India with support from partners is an appropriate innovation to improve
routine immunization coverage and strengthen routine immunization
systems. Mission Indradhanush aims to immunize all children against
seven vaccine preventable diseases (diphtheria, pertussis, tetanus,
polio, tuberculosis, measles, and hepatitis B) by 2020.
Introduction of IPV alone is insufficient to reduce
the risks of cVDPV2 emergence after the tOPV-bOPV switch, and may not
prevent cVDPV2 emergence during the highest risk period of 6-12 months
after the switch [8]. Thus, all current cVDPV2 outbreaks must be
controlled in advance of the switch, which is on target with no
detections of cVDPV2 at the time of the switch in April 2016. Programs
with lower routine coverage have conducted tOPV campaigns to boost type
2 immunity before the switch, which further reduces risk. SAGE has
recommended a multipronged strategy that includes controlling and
aggressively responding to any VDPV outbreaks after the switch,
implementing appropriate containment of polioviruses, creating a global
stockpile of monovalent type 2 OPV (mOPV), and finalizing a protocol for
responding to type 2 outbreaks. The race between the disappearance of
the vaccine derived viruses and accumulation of susceptibles in the
population would determine the low but real risk of potential outbreaks
of type 2 vaccine derived viruses in the first 6-12 months after the
switch. In the longer term, type 2 virus would be contained only in a
few essential facilities with adequate safeguards to prevent release of
virus into the community. However, breaches in containment or potential
bioterrorism events are possible and could lead to re-introduction of
virus. There are a very limited number of immunodeficient individuals,
who are chronic excretors of polioviruses, who may also pose an
additional low risk of re-introduction but models suggest this risk to
be very low.
Research to develop and test candidate antiviral
drugs is ongoing. While indications for use have not yet been
determined, these drugs could possibly be useful in the Endgame for
reducing or stopping shedding of polioviruses by immunodeficient people
who are chronically shedding poliovirus, persons exposed to poliovirus
through breaches in containment, or perhaps even in communities exposed
to cVDPV outbreaks in the post-eradication era [17-21].The Plan also
recognizes that achieving gains towards eradicate and sustaining them
relies on a strong routine immunization system for delivery of childhood
vaccines. Thus, the Plan calls for GPEI to commit at least 50% of its
resources in 10 countries to strengthen routine immunization. The 10
selected countries that were deemed to have the highest polio risk and
greatest GPEI assets are: Afghanistan, Angola, Chad, the Democratic
Republic of the Congo, Ethiopia, India, Nigeria, Pakistan, Somalia, and
South Sudan.
Objective three of the Plan calls for all 194 WHO
Member States to certify polio eradication and to ensure that all
polioviruses are safely contained by 2018. As a first step, all member
states have committed to implementing appropriate containment of wild
poliovirus type 2 in essential laboratory and vaccine production
facilities by end of 2015, and of type 2 OPV within 3 months of the
tOPV-bOPV switch [22]. Following guidance provided in third Global
Action Plan to minimize poliovirus facility-associated risk
(GAPIII), all national authorities will need to certify that all
essential facilities they host meet the containment requirements. SAGE
has advised GPEI to develop a targeted advocacy and community plan to
engage key countries and stakeholders to ensure completion of
containment activities as outlined by GAPIII. As use of OPV is stopped
after polio eradication, containment of all polioviruses will ensure
that viruses are not inadvertently or intentionally released into a
polio-free world.
The fourth and final objective of The Plan is focused
on ensuring that the lessons learned and infrastructure of GPEI are
appropriately transferred to other priority global health initiatives
[23]. Legacy planning will help to guarantee that polio immunity is
sustained through the use of IPV for as long as it is deemed necessary.
The polio infrastructure and workforce contribute substantially to
immunization services beyond polio, and thus an important component of
legacy planning will be to avoid a vacuum in immunization programs after
polio eradication, and to adequately and responsibly transition these
resources into other public health priorities.
Inability to meet timelines of interrupting
transmission of polio according to The Plan can have immense risks to
the program primarily in terms of donor, partner, government, provider,
and parental fatigue with regard to sustaining this intensive
eradication effort against polio. Recently, the Polio Oversight Board
estimated that the delay in eradication to 2019 requires an additional
$1.5 billion and each additional year would cost another $1 billion to
the program. Beyond the financial cost, the credibility and the resolve
of donors, partners, and governments to maintain momentum may also be at
jeopardy with each additional year of delay in eradication of polio.
A fundamental reason for the global withdrawal of the
type 2 component of OPV is that the world has eradicated type 2
poliovirus – a truly monumental success for partners and countries
worldwide. Switching from tOPV to bOPV will prevent several hundred
unnecessary cases of vaccine-derived polioviruses per year. However, to
avoid jeopardizing the behemoth gains that the countries have made will
require interrupting transmission of WPV in Pakistan and
Afghanistan,introduction of at least one dose of IPV in all routine
immunization programs globally, implementing the synchronized tOPV-bOPV
switch in all 155 OPV using countries and territories in April 2016, and
coordinated planning for the polio legacy. Interrupting polio
transmission in India for over four years has provided many tools,
technologies, and the necessary grist and enthusiasm for donors,
partners, and countries to remain motivated and complete eradication of
polio once and for all. The Polio Eradication and Endgame Strategic
Plan, 2013-2018 provides the world with the vision and the framework
for capitalizing on these gains in India, and ending one of humanity’s
devastating diseases.
Contributions: All authors made
substantial contributions to the overall design of the manuscript. MP:
drafted the original perspective; LM, PB: critically reviewed and
revised subsequent versions. All authors have seen and approved the
final copy of the manuscript.
Funding: MP is supported by the Bill and
Melinda Gates Foundation; Competing interest: None stated.
References
1. Global Polio Eradication Initiative. Indedependent
Monitoring Board Report, October 2015. Available at
http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/13IMBMeeting/13IMB_Report_EN.pdf.
Accessed December 2, 2015.
2. Enders JF, Weller TH, Robbins FC. Cultivation of
the Lansing strain of poliomyelitis virus in cultures of various human
embryonic tissues. Science. 1949;109:85-7.
3. Sabin AB. Present position of immunization against
poliomyelitis with live virus vaccines. Br Med J. 1959;1:663-80.
4. Salk JE, Krech U, Youngner JS, Bennett BL, Lewis
LJ, Bazeley PL. Formaldehyde treatment and safety testing of
experimental poliomyelitis vaccines. Am J Public Health Nations Health.
1954;44:563-70.
5. Kew O, Morris-Glasgow V, Landaverde M, Burns C,
Shaw J, Garib Z, et al. Outbreak of poliomyelitis in Hispaniola
associated with circulating type 1 vaccine-derived poliovirus. Science.
2002;296:356-9.
6. Aylward RB, Maher C. Interrupting poliovirus
transmission – new solutions to an old problem. Biologicals.
2006;34:133-9.
7. Centers for Disease Control and Prevention.
Certification of poliomyelitis eradication—the Americas, 1994. MMWR Morb
Mortal Wkly Rep. 1994;43:720-2.
8. Grassly NC, Fraser C, Wenger J, Deshpande JM,
Sutter RW, Heymann DL, et al. New strategies for the elimination
of polio from India. Science. 2006;314:1150-3.
9. Jafari H, Deshpande JM, Sutter RW, Bahl S, Verma
H, Ahmad M, et al. Polio eradication. Efficacy of inactivated
poliovirus vaccine in India. Science. 2014;345:922-5.
10. Nathanson N, Kew OM. From emergence to
eradication: the epidemiology of poliomyelitis deconstructed. Am J
Epidemiol. 2010;172:1213-29.
11. Global Polio Eradication Literature. Available at
http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx.
Accessed December 01, 2015.
12. Global Polio Eradication Initiative. Polio
Eradication & Endgame Strategic Plan 2013-2018. WHO/POLIO/13.02.
Available at
http://www.polioeradication.org/Portals/0/Document/Resources/StrategyWork/PEESP_EN_US.pdf
2013. Accessed, December 2, 2015.
13. Sutter RW, Platt L, Mach O, Jafari H, Aylward RB.
The new polio eradication end game: rationale and supporting evidence. J
Infect Dis. 2014;210 Suppl 1:S434-8.
14. Bahl S, Kumar R, Menabde N, Thapa A, McFarland J,
Swezy V, et al. Polio-free certification and lessons
learned—South-East Asia region, March 2014. MMWR Morb Mortal Wkly Rep.
2014;63:941-6.
15. Patel M, Zipursky S, Orenstein W, Garon J,
Zaffran M. Polio endgame: the global introduction of inactivated polio
vaccine. Expert Rev Vaccines. 2015;14:749-62.
16. Kew OM, Sutter RW, de Gourville EM, Dowdle WR,
Pallansch MA. Vaccine-derived polioviruses and the endgame strategy for
global polio eradication. Annu Rev Microbiol. 2005;59:587-635.
17. Meeting of the Strategic Advisory Group of
Experts on Immunization, April 2012 - conclusions and recommendations.
Wkly Epidemiol Rec. 2012;87:201-16.
18. Meeting of the Strategic Advisory Group of
Experts on Immunization, November 2012 - conclusions and
recommendations. Wkly Epidemiol Rec. 2013;88:1-16.
19. Meeting of the Strategic Advisory Group of
Experts on Immunization, April 2013 - conclusions and recommendations.
Wkly Epidemiol Rec. 2013;88:201-6.
20. Meeting of the Strategic Advisory Group of
Experts on Immunization, November 2013 - conclusions and
recommendations. Wkly Epidemiol Rec. 2014;89:1-20.
21. Meeting of the Strategic Advisory Group of
Experts on Immunization, April 2014 - conclusions and recommendations.
Wkly Epidemiol Rec. 2014;89:221-36.
22. Previsani N, Tangermann RH, Tallis G, Jafari HS.
World Health Organization Guidelines for Containment of Poliovirus
Following Type-Specific Polio Eradication - Worldwide, 2015. MMWR.
2015;64:913-7.
23. Cochi SL, Freeman A, Guirguis S, Jafari H, Aylward B. Global
polio eradication initiative: lessons learned and legacy. J Infect Dis.
2014;210:S540-6.
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