Deliberations of the IEAG 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.

cases in 159 districts 225 cases in 87 districts 134 cases in 43 districts cases in 35 districts cases in 114 districts cases in 99 districts 2007 Polio Cases - India

Yes, polio cases in India have not fallen…BUT P1 wildP3 wild * data as on 30 th October 2009

…the geographic scope of both type 1 & 3 continues to be further reduced Type 1 = 8 states Type 3 = 10 states Type 1 = 5 states Type 3 = 5 states

About 100 blocks in west UP & central Bihar now hold the key to eradication in all India HR Blocks WPV WPV 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) PeriodNovember 2007April 2009 Age groups6-9 mths36-59 mths6-9 mths Sero-positive P181%99.8%99% Sero-positive P263.%97.%72% Sero-positive P371%93%48%

% seropositive 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=47,37819,09481,283113,044130,29052,243122,161 % unimmunized 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, *

Preliminary data on studies of poliovirus in older age groups West UP AFP samplingType 1Type 3 Polio cases with extended sampling1533 Number with results available34* Number of extended contact samples Number of contacts positive for WPV <5 years 5 to 15 years over 15 years % 9.6 % 5.9 % % 9.7 % 0.0 % Kosi River community sampling (N = 798)Type 1Type 3 Number positive for WPV <5 years 5 to15 years over 15 years % 1.4%.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 mOPV3 Jul & Oct mOPV3 Oct mOPV3 Oct

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 bOPVtOPV Target (mn) Vaccine (mn) bOPVtOPV Target (mn) Vaccine (mn)

IEAG Recommendation: SIAs, 2010 AugSepOctNov NIDs SNID Endemic & risk states mOPV1 tOPV/bOPV Dec SNID HR Zones UP/Bihar bOPV (1&3) MarAprMayJunJulJanFeb mOPV MOP-UPs Infected Districts mOPV3 SNID HR Zones UP/Bihar SNID Endemic & 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 to decide scope of SNIDs beyond July.

Impact of ongoing targeting of SIAs Children vaccinated in campaigns, India, Number of children (millions) 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 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 2 nd 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, *** 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.