1. Polio Endgame Strategy in India Considerations and Way Forward WHO-India, NPSP 15 March 2012

2. Outline of the presentation Background/Context Considerations Possible Way forward

3. Context No WPV2 in India since 1999 tOPV used in RI and during NIDs bOPV used in most SNIDs since Jan 2010 Areas and populations with low routine immunization coverage All cVDPVs in India due to type 2 in setting of low immunity to type 2

4. Last wild poliovirus cases by type, India WPV2 24/10/1999 Aligarh (UP) WPV1 13/01/2011 Howrah (WB) WPV3 22/10/2010 Pakur (JH)

5. Current pattern of vaccine use-India tOPV –EPI schedule: 6,10,14 wks Birth dose for institutional births –SIAs: 2 NIDs with tOPV each year bOPV –Introduced in Jan 2010 –Used extensively during SNIDs in high risk states/ areas 70.4% <60 60 - 70 70 - 80 >= 80 Assessed tOPV3 coverage by CES 2009

6. cVDPV cases, India 2009-2011 cVDPV cases detected in 2009-10 100% due to type 2 District Type 2 200920102011 Badaun300 Bulandshahar200 Ghaziabad010 Meerut200 Moradabad200 Pilibhit400 Shahjahanpur210 Total1520

7. Low seroprevalence against poliovirus type 2 Results from different serosurveys Moradabad Nov 2007 (N=121) AFP cases UP Nov 08 – mid 09 (169) Moradabad May 2009 (N=534) UP & Bihar Aug 2010 (N=1280) UP & Bihar Aug 2011 (N=1246) Age 6-7 mo6-11 mo6-7 mo 6-11 mo Type 1 78% 96.5% 99%98%98.5% Type 2 56% 33.7% 75%65%85% Type 3 69% 42.6% 49%77%88.2%

8. cVDPV type 2 Uttar Pradesh 2009 2010 2011 Number of cases c VDPV type 2 tOPV < 25% 25 to 50% 50 to 75% >= 75% tOPV sNID tOPV NID tOPV sNID tOPV NID Evaluated OPV3 coverage by district – DLHS 3 (2007-08) and cVDPVs

9. iVDPV & aVDPV cases, India 2009 to 2012* *: data as on 10 March 2012 iVDPVaVDPV ambiguous VDPV (aVDPV): origin uncertain e.g. single isolate from single AFP case, non-immunodeficient person

10. Managing the risk of VDPVs

11. tOPV-bOPV switch in India? Considerations Pre-switch increase in type 2 immunity Rapidly improve routine immunization coverage Use of IPV in conjunction with bOPV/tOPV to reduce risk of emergence and consequences of cVDPV Availability of vaccines –IPV availability for use in routine immunization –bOPV availability for routine immunization and SIAs Management of post-switch risks of type 2 VDPVs cVDPV type 2 circulation stopped everywhere & switch synchronised globally

12. Pre-switch boosting of type 2 immunity Switch soon after tOPV NIDs Improve RI, particularly DTP3 and OPV3 coverage Adding a dose of IPV in RI for infants prior to switch

13. IPV introduction Benefit – impact on RI ? Timing/Age/Doses/Route – follow global SAGE recs ? Frequency: 2 doses in known cVDPV risk areas? Modelling and Research in the India context may help optimise strategy for India

14. bOPV availability Licensure and pre-qualification of additional manufacturers to meet requirements of India pre and post-switch bOPV assessment study to support licensure of additional manufacturers

15. Post-switch VDPV type 2 risk management Heightened surveillance to detect post- switch Sabin type 2 (not just VDPV type 2!) Stockpile/ Capacity to produce mOPV2 at short notice Certification standard surveillance to continue beyond certification

16. NID 0 JanMarMayJulSepNovJanMarMayJulSepNovJanMarMayJulSepNovJanMarMay Polio Endgame Strategy-India, Possible Way Forward 2011201220132014 Last WPV case Polio certification IPV NID tOPV NID Post- switch Sabin type 2 risk mgt. tOPV- bOPV switch NID Certification standard surveillance, improved RI coverage PQ/ licensing, stockpile Modelling, Research, Development

17. Conclusions India can be in a position to move ahead with polio endgame strategy Careful planning and consideration of risks required before implementation Earliest possible timing for tOPV-bOPV switch: Qtr.1 2014 Lessons from tOPV-bOPV switch significant for subsequent withdrawal of all OPV from programme