1 Polio Eradication Program in India: Actions in Post-Eradication Phase By Prasanta K. SahaPrasanta K. Saha, M.Sc., FRSS(UK), CSTAT(UK) Sr. Consultant: National Council of Applied Economic Research, India [Former Chief Director: Ministry of Health & Family Welfare, & Additional Director General: Ministry of Statistics & Program Implementation, Govt. of India] ,

2 Polio Eradication Program in India: Actions in Post-Eradication Phase Under the Polio Eradication program of India, the most relevant issues-both technical and administrative, which will arise in post-eradication situation, are discussed in this lecture.

3 Polio Eradication Program in India: Actions in Post-Eradication Phase That Polio Eradication program in India is extraordinarily time-overrun is well known. Original target was the year 2000-revised as 2002-further revised as Unfortunately the last revised target of the year 2005 could also not be achieved.

4 Contd. It is evident from the factual positions that the whole matter is bordering uncertainty. Polio Cases in India as on 5 th June, 2006: Total Polio Cases 2004: 134 Total Polio Cases 2005: 65 Total Polio Cases 2006(as on 5 th June,06): 36

5 Contd. Location of most recent cases: Uttar Pradesh (23), Bihar (12) & Madhya Pradesh (1) Though WHO designed global eradication strategy in1988, India participated much late in 1995.

6 Contd. Serious Actions needed in Post- Eradication Phase First to characterize the actual factors that country-level policy makers must weigh to manage polio risks during the first 5 years after certification by WHO.

7 Contd. Policy makers are to primarily formulate policies related to (a) routine and supplemental immunization, (b) outbreak response (including whether to create a stockpile), (c) surveillance and (d) containment of Wild & Vaccine-Derived Polio Viruses (VDPVs).

8 Contd. Global certification will occur once all 6 Regions of World Health Organization (WHO) confirm no wild poliovirus under high-quality surveillance for at least 3 years and the Global Certification Commission becomes satisfied that sufficient laboratory containment exists.

9 Contd. Determination of reasons for high incidence of vaccine failure Answer to this query is derived from some of the reasons as revealed in various PPI rounds are as follows:

10 Contd. Expiry of effectiveness of a few vials of vaccine. Portable cold storage containing the vaccines not providing desired cool temperature Note: A few vials of Polio vaccines might have expired their effectiveness but that might have escaped notice of the health workers. It has been experienced that in rural areas

11 Contd. the portable cold storage containing the vaccines does not provide desired cool temperature as the ice kept inside gets melted after sometime and there is no scope of filling it with fresh ice because the same is not available in the locality [NPSU, WHO regional office, New Delhi may supplement with further information].

12 Contd. Even that great event of eradication of Polio takes place in India in near future, there are more serious concerns in the post -eradication phase which will need appropriate attention and actions. Those technical problems are narrated below:

13 Contd. As eradication process approaches finishing line, there is greater need for new polio vaccines. These new vaccines will be needed to create a stockpile for future outbreaks.

14 Contd. Experts may be aware: (1) After eradication there was again outbreak of Polio in China [ after 5 years], Hispaniola [after 6 years], the Philippines [ after 4 years], Madagascar [ after 3 years] and in Egypt [ perhaps, after 25 years].

15 Contd. (2) Effective bio-containment of all existing polio viruses is essential to minimize risk of accidental infections. Such arrangement is yet to be initiated in India.

16 Contd. OPV Cessation Plan: As concerned experts dealing with eradication program may be aware, after eradication, use of OPV [Oral Polio Vaccine] should be discontinued to minimize the possibility of mutated strains of vaccines leading to new out-breaks.

17 Contd. WHO has discovered that out-break in China was caused by Circulating Vaccine Derived Polio Virus (cVDPV) mutated from OPV. Normally after eradication, manufacturing of trivalent OPV gets stopped.

18 Contd. This plan will take into account the risk of reintroducing virulent poliovirus from a laboratory or a manufacturing unit.

19 Contd. So there is need of manufacturing mono-valent OPV [mOPV] ( WHO, perhaps, has granted license to some Indian company). A proper strategy is to be formulated to guarantee that Polio outbreak does not recur.

20 Contd. Recent discussions predominantly focused on stopping immunization as the ultimate goal of the eradication initiative and on characterizing related issues.

21 Contd. Policy Options for the First 5 Years Following Certification: From the analysis of the implications of delays in outbreak response, experts recommended: (a) maintaining active surveillance for at least 5 years after ceasing all polio vaccination, (b) minimizing delays in diagnosis and confirmation of an outbreak,

22 Contd. (c) restricting poliovirus work to a few high-level containment laboratories, (d) maintaining OPV manufacturing capacity, and (e) establishing a stockpile and a response protocol for outbreaks.

23 Contd. Routine Immunization Current policies: The decision to vaccinate routinely requires choosing both the type of vaccine for use and the schedule for vaccine administration. Currently, the WHO recommends that each child receive 4 doses of trivalent oral polio vaccine [tOPV]

24 Contd. (administered at 6, 10, and 14 weeks, with the fourth dose given either at birth or within the first year) in order to be fully protected against polio. Consistent with this recommendation, most countries perform primary vaccination (defined as the first 3 doses of polio vaccination) with tOPV.

25 Contd. Post-certification options: In the post-certification era, routine immunization policies include stopping vaccination altogether, using the same or a different vaccine, and changing or maintaining the vaccination schedule.

26 Containment Strategies Current policies: Containment strategies focus on reducing the risk of reintroduction of poliovirus into the environment, notably through vaccine manufacturing facilities and laboratories that handle materials that could contain poliovirus (wild or vaccine-related).

27 Contd. WHO recommends that laboratories handle wild poliovirus infectious or potentially infectious materials under biosafety level procedures. According to guidance of WHO policy, countries are required to complete a national inventory of wild poliovirus infectious materials and potentially wild poliovirus infectious materials before global certification of eradication.

28 Contd. Management of Chronic Excretors of Polioviruses Current policies: No known cases exist of chronic excretion of wild poliovirus. WHO reports have catalogued a cumulative experience consisting of a total of 19 immuno- deficient chronic excretors of vaccine-derived polioviruses (iVDPV) globally in more than 40 years of OPV use. These individuals lived in middle level to upper-level income countries, primarily in the United States and Europe.

29 Contd. Management of Chronic Excretors of Polioviruses: Current policies-continued Assessment of the sensitivity of the AFP surveillance system for detecting iVDPV is needed, given that prolonged excretion may occur prior to the development of paralysis. To manage the risk of reintroduction of poliovirus to the community from identified patients, countries may choose whether to conduct screening and/or offer education about strategies for minimizing exposure to others.

30 Contd. Acknowledgement: 1. ‘Nature’,Vol.434,April,2005: ‘ A global call for new polio vaccines’ 2. Dr. François Bompart, Aventis Pasteur, 2, avenue Pont Pasteur, Lyon Cedex 07, France. 3. Nalinee Sangrujee, PhD, MPH; Radboud J. Duintjer Tebbens, MS; and others: Medscape General Medicine: ‘Policy Decision Options During the First 5 Years Following Certification of Polio Eradication’.

31 PEP in India: Actions in Post-Eradication Phase THANKS For any query I may me contacted through my s: