1 Polio Strategic Plan India Expert Advisory Group July 2011 Impact & prospects at the half-way point

2 Recap of Major Elements of the New Strategic Plan

West Uttar Pradesh HR block s =41 Central Bihar High-Risk Blocks New Tactics: high risk 'blocks' & migrants, India

New Tactics: sub-national & local leaders, Nigeria

1 st bivalent OPV campaign Afghanistan 16 Dec 2009

Pakistan President Zardari launches new plan (24 Jan '11) Angola President Dos Santos meets UNICEF ExD on new plan (Jan '11) DR Congo President Kabila meets WHO DG on new plan (7 Feb 2011)

7 Impact of the Strategic Plan at July 2011

8 Key Developments - Progress Polio-infected districts, last 6 Months wild virus type 1 wild virus type 3 India: 6 months with no polio case for 1 st time in history! Nigeria: 95% drop in cases sustained for > 18 months Smallest type 3 infected area & cases in history

9 Polio cases due to type 3 wild virus (at 13 July 2011)

10 Major Risks

11 Polio Cases in Endemic Countries Year-to-Date

Persistent outbreaks in the 3 're-established transmission' countries* * infected-districts, last 6 months Chad DR Congo Angola Virus that originated in India can return by the same routes!

13 < 11 – 1.9 >= 2 Pop under 15 yrs <100,000 Data in WHO/HQ as of 07 Jun 2011 Non Polio AFP Sample Collection < 50%50 – 79% >= 80% Pop under 15 yrs <100,000 Persistent performance gaps in recently infected areas.

Polio Financing, US$665 million funding gap

15 Summary

16 At the mid-point in the new Polio Strategic Plan, there is strong evidence that full application will stop all polio transmission.

17 Strong progress globally, but India still faces major risks Re-infected country Endemic country with WPV Wild virus type 1 Wild virus type 3 Wild Polioviruses Globally, last 4 months 22 Feb – 21 Jun 2011

18 Undetected low season transmission Return of Indian viruses from Africa New importations from reservoirs Risks to India's US$1 Billion Investment in Polio Eradication

19 What extra actions could protect very high risk areas through the 2011 high season? How to ensure preparedness for a rapid, massive response to a new or persistent virus? How to enhance surveillance in very high risk areas to rapidly detect a new or residual virus? Is there a robust Emergency Preparedness plan for polio with a state-by-state risk assessment? Potential IEAG Priorities

20

21 Circulating Vaccine-derived Poliovirus last 6 months cVDPV2 (13 cases) cVDPV1 (0 case) cVDPV3 (0 case) cVDPV monthly distribution of cases by country

22 Institutionalizing Best Practices (examples) OPV campaign quality & impact: district-specific planning process (HR areas) public tracking of sub-national leaders actions scaled-up role of traditional/local leaders short-interval additional dose (SIAD) strategies mobile population & transit strategies bivalent OPV operational research (e.g. serosurveys)

23 Institutionalizing Best Practices (examples) OPV campaign monitoring: standardized Independent Monitoring Lot Quality Assurance Sampling (LQAS) serologic surveys Poliovirus surveillance: Rapid field reviews (insecure areas, new import., orphan virus) Environmental surveillance Enhanced performance standards (e.g. AFP rate >2)

24 Major Lessons immunity thresholds differ virus persists in smaller areas & pops than thought new mOPVs harder to optimize than thought int’l spread & outbreaks largely predictable District-specific plans & oversight Population-specific approaches Bivalent OPV 'Importation belt' tactics Key Elements of the New Strategic Plan

25 Major Milestones at 24 March 2011 mid-2010: all 2009 importations interrupted Achieved (15/15) within 6 months: all new (2010) imports interrupted Achieved/on-track end-2010: all re-established viruses interrupted. Achieved: Sudan Off-track: DR Congo Missed: Angola, Chad end-2011: 2 of 4 endemic countries interrupted. On-track: India, Nigeria, Afghanistan Off-track: Pakistan

26 Genetic Clusters of Poliovirus Virologic Progress in Africa

27 RCCs: elim of cVDPV2 Roadmap for VDPV Elimination Implementation Biosafety Outbreak response * for areas facilities with type II PV/WPVs, high RI coverage with > 2 doses IPV; for areas with high cVDPV2 risk >1 dose IPV; other areas subject to SAGE IPV WG recs. Validation/ Certification Policy 12 mos Decisions Routine Immunization Surveillance Timeline 0-12 mos? Critical Events 6 months after last WPV in main African reservoir? 6 months after last WPV in the world? Last polio case in main Asian reservoir EB DG/WHO announce SAGE WPV erad. RCCs (3) GCC 30 mos bOPV cessation 6 mos 0-18 mos? 6 mos OPV IPV AFP Env. Increased environmental sampling (Event-based) Prepare enhanced type 2 biosafety (inventory, BSL2) GAP III for all WPVs Enhanced type 2 biosafety VDPV elim. RCCs (6) GCC WHA RCCs assess WPV2 elim & no persistent cVDPV2s(?) GAP III for all PVs DG/WHO announce Prepare nat'l OPV producers? Ensure min 50m IPV/year? SIAs tOPV/bOPV/mOPVs 1 or 2 dose IPV?* tOPV 1 dose IPV?* bOPV (with tOPV restart option) tOPV pulse in HR areas? bOPV/mOPVs Uncertainty mOPV1,2,3 +/- IPV IPV +/- mOPVs? mOPVs/tOPV DG/WHO announce