Conclusions & Recommendations 24 th IEAG March 2012

2010 * * data as on 30 October 2010 Last detected case January 2011 Context – a polio free India! No WPV from any source since January 2011 India is no longer an endemic country!

But risks remain……

Questions to the IEAG What are the challenges that India is likely to face in maintaining polio-free status? What lessons from other countries can be applied in India to protect the programme gains? What strategies should India follow in to sustain polio-free status? Is isolation of VDPVs a concern for India? How should India plan for the polio endgame strategy?

Risks Importing WPV Development of cVDPVs

Lessons Its not over until its over everywhere 'The price of freedom is eternal vigilance'

Challenges Maintaining immunity Maintaining surveillance Readiness to respond Reducing risk Building on polio Preparing for the endgame

Maintaining immunity

Maintain high levels of immunity especially in high risk areas and populations Protect against both WPV & VDPVs Objectives of SIA strategy

Recommended SIA calendar, 2012 conducted planned NID with tOPVSNID with bOPV

Recommended SIAs, NID with tOPVSNID with bOPV

Maintaining surveillance

% Non-polio AFP rateStool collection rate Surveillance performance indicators, last 6 months # AFP cases, Jan – Feb

Expand environmental surveillance: Punjab & Gujarat Conduct planned field reviews & act on gaps –urgently address the issues identified in Andhra Pradesh Involve district / block level government staff in all components of AFP surveillance –response to AFP case reporting, sensitization of the existing reporting network, regular review of surveillance database etc Laboratory human and financial resources should be ensured to maintain high performance Recommendations: Surveillance

Readiness to respond

Recommendations: Response The new state EPRPs should be reviewed and evaluated by GOI and partners by the end of April 2012 National & state EPRPs should be updated at minimum annually –updates must include a full new risk analysis to inform risk mitigation measures. Conduct simulations of the emergency response plans at national and state levels

Recommendations: Planning for response State EPRPs must adequately address: –Plans for overcoming staff vacancies in high risk areas; –Systematic inclusion of high risk areas & populations for RI strengthening; –Timeline for harmonization of SIA and RI microplans in high risk areas; –Assignment of HR districts to Rapid Response Team members (RRT) for regular review of RI, SIA and emergency preparedness; –Assessment of communication risks and social mapping; –Identification of media spokesperson; –Plans for procurement of logistics and IEC materials for undertaking urgent mop-ups.

Reducing risk

Recommendations: Communications Maintain SMNet and other ground-level initiatives (e.g. through ASHA & Anganwari Workers) in traditional polio reservoirs and in newly emerging high-risk areas until risk is gone Appropriate social network research should be carried out in key high risk areas to inform programme actions Document and share experience & best practices, including elements of the SMNet, media engagement and utilization of data for identification, tracking and engagement of high-risk populations All communication efforts, including SMNet, at all levels adopt promotion of routine immunization as a primary message in all public communication

Recommendations: OPV supply All pre-qualified global OPV producers not yet licensed in India should be encouraged to apply for & complete the licensing process Considering the risks to vaccine supply DCGI should fast track the licensing process for already pre-qualified vaccines. GoI should continue to ensure a 50 million dose rolling emergency stock (40 million bOPV & 10 million tOPV) to enable rapid response GoI should plan for a 24 month time frame for OPV procurement To facilitate timely procurement of OPV for SIAs only –the standard vaccine shelf life can be reduced to 60% –the requirement for primary vaccine vial packaging indicating the product is not for sale be waivered (still required for secondary and outer packaging)

Reducing risk - importation Immunization of travellers at border crossing points should continue until there is no longer an epidemiological risk. Particular attention should continue to be paid to border populations to ensure that they are effectively covered by SIAs and routine immunization.

Reducing risk - VDPVs All detected VDPVs should continue to be thoroughly and rapidly investigated to determine risk of circulation Any evidence of circulation - mop-up response!

Building on polio

Data not available Below 5 % 5 % - 10 % >10 % - 25% >25 % Where are we missing the maximum number of children? 69% of partially and un-immunized children in 6 states: Uttar Pradesh Bihar Madhya Pradesh, Rajasthan West Bengal Jharkhand Source: CES 2009; Full immunization of children surveyed months

: Year of intensification of UIP

Recommendations: RI State EPRPs and Year of Intensification of UIP plans to be consolidated and operationalized –monitored timelines and milestones –focus on high risk and migrant populations –urban and peri-urban populations Focus on 239 high risk districts Conduct Immunization Weeks in in NE states, UP, Bihar, MP, Rajasthan, Gujarat and Jharkhand Priority to ensuring ANMs and MOs are present in HR areas in priority states

Recommendations: Surveillance for vaccine preventable diseases should be expanded based on the experience & structure of the AFP surveillance system The communications and operational experience of polio eradication should inform other disease control initiatives including measles elimination

Preparing for the endgame

Recent developments SAGE Nov 2011: recommended that the endgame strategy be based on phased rather than simultaneous Sabin strain removal WHO Executive Board Jan 2012: requested Director- General to develop comprehensive endgame strategy and timeline based on phased Sabin strain removal SAGE Apr 2012: may consider an 'early switch' (by Apr 2014), preceded by universal introduction of at least 1 dose of IPV (ID or IM) at DPT3 contact.

IEAG Conclusion: 'Endgame' Following the WHO Executive Board resolution of January 2012 endorsing eventual replacement of tOPV with bOPV globally, India should start preparing appropriate policies, esp. on the role of IPV, guided by and considering the global recommendations of SAGE.

1.The national immunization programme should now begin incorporating into its planning: (a) an eventual tOPV-bOPV switch globally, potentially as early as April 2014, and (b) eventual cessation of all remaining bOPV globally at some point in the future (e.g period). Recommendations: 'Endgame' planning (1)

2.This planning should include consideration of the introduction, in advance of a tOPV-bOPV switch, of at least one dose of IPV (e.g. at DPT3 contact), to boost population immunity thereby reducing the risk of a type 2 cVDPV emergence & the consequences of a potential cVPDV. Recommendations: 'Endgame' planning (2)

NID 0 JanMarMayJulSepNovJanMarMayJulSepNovJanMarMayJulSepNovJanMarMay Polio Endgame Strategy-India, Potential Timeline Last WPV case Polio certification IPV intro? NID tOPV NID Post- switch VDPV type 2 risk mgt. tOPV- bOPV switch NID Certification standard surveillance, improved RI coverage Modelling, Research, Development

3.convene a small consultation with IEAG members in mid-2012, following the SAGE (April) and World Health Assembly (May), to facilitate national deliberations on the timing and IPV policy options for a tOPV-bOPV switch. 4.begin examining the programmatic and cost implications of adding at least 1 IPV dose to the routine EPI schedule (e.g. at the DPT3 contact) in advance of a global tOPV-bOPV switch. Recommendations: 'Endgame' planning (3)

5.include an examination of implications (pros/cons) of delivering IPV as a fractional (1/5 th ) dose intra- dermally (ID) vs. a full dose intramuscularly (IM). 6.consolidate the considerable IPV study data already existing in India, including from licensing trials, to help inform policy options. 7.finalize & start the planned trial to verify the immunogenicity & programmatic feasibility of a 'bOPV + 1 dose of IPV (ID or IM)' routine schedule. Recommendations: 'Endgame' planning (3)

1.implement the planned research agenda, giving priority to: (a) complete the mucosal immunity study, (b) conduct a new seroprevalence survey, (c) initiate the planned immunogenicity study with bOPV from multiple manufacturers, and (d) finalize the protocol for the trial to verify immunogenicity, programmatic feasibility of a 'bOPV + 1 dose of IPV (ID or IM)' routine schedule. Recommendations: Research

Protecting the investment

GoI, partners, & donors must maintain the human, material, & financial infrastructure of polio eradication until global certification