Deliberations of the 23 rd IEAG July 2011

Questions to the IEAG 1.What is the significance of the current polio epidemiology – is this progress real? 2.What are the implications of the ensuing high transmission season for the current polio situation? 3.What are the risks for continued polio transmission in India? 4.How should these risks be effectively addressed to ensure that the gains made so far are further consolidated to achieve polio eradication?

Questions to the IEAG 5.What should be the number, timing, scope and vaccine type for SIAs during the remaining months of 2011 and early 2012? 6.How should the current communication gains be maintained and what are the specific communication challenges at this stage of polio eradication? 7.How should the program begin to prepare for the next phase of polio eradication?

Q1: What is the significance of the current polio epidemiology – is this progress real?

A Snapshot of Polio Situation in India P1 wildP3 wild 1 case to date in 2011 vs. 24 cases at same point in serotype in 2011 vs. 2 in genetic cluster in 2011 vs 5 in No sewage WPV since Nov

WPV cases during previous 12 months, India N=2 Dec 2010 – June 2011* N=11 Jun 2010 – Nov 2010 N=0 N=7 Type 1 Polio Type 3 Polio West Bengal is the only state with wild virus in 2011

WPV1 cases in endemic states, Uttar Pradesh Bihar 2011* Longest indigenous WPV1 transmission free period simultaneously in both endemic states Cross-border transmission with Nepal

Q2: What are the implications of the ensuing high transmission season for the current polio situation?

IEAG Conclusion 2: There is a high risk that any residual or imported wild poliovirus will manifest between July & November.

Monthly incidence of WPV1 cases, High transmission season Any residual WPV transmission is likely to be detected in the coming high season for polio

Q3: What are the risks for continued polio transmission in India?

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

RISK 1: Undetected Virus within India Highest risk areas (a) historic reservoirs, (b) orphan virus areas, (c) recent/recurrent re- infected areas Districts with ‘Orphan’ viruses,

Rest of India (N= 48) Non epidemic UP* (N= 56) * non epidemic UP excludes Moradabad, JP Nagar, Badaun, Kanshiram Nagar, Bareilly and Rampur districts *Data as on 10 July 2011 RISK 2: Movement of Viruses in Migrants Migration status WPV1 cases,

Data in WHO HQ as of 14 Jun 2011 wild virus type 1 wild virus type 3 RISK 3: Importation of Viruses into India Polio-infected districts globally, last 6 months Virus that originated in India can return by the same routes!

Q4: How should these risks be effectively addressed to ensure that the gains made so far are further consolidated to achieve polio eradication?

4 essential elements of risk management: 1.enhance routine OPV3, esp. in west UP, WB 2.enhance surveillance 3.ensure outbreak preparedness plans 4.extra OPV campaigns in highest risk areas IEAG Conclusion 4:

Risk Mgmt 1: improve routine EPI, with priority to lagging reservoir & 'amplification' areas, building on recent best practices (e.g. session & community monitoring activities) RI Augmentation Muskan % Full Immunization coverage Bihar

Routine Immunization: 1.Particular attention to those reservoir or amplication areas with lagging OPV3 (e.g. west UP, West Bengal). 2.Re-emphasize critical importance of ANM and Medical Officer vacancies in these areas. 3.Continue to build on convergence of polio & routine EPI activities (e.g. microplanning, communications, migrant/marginalized pops). Risk Management 1

Surveillance: 1.complete the planned serosurvey (August) 2.expand environmental sampling as planned 3.enhance surveillance among migrant populations (e.g. enrolling appropriate reporting sites/informers) 4.sustain state-level reviews for quality assurance (esp. reservoirs/amplification areas) Risk Management 2

Howrah, 2011 Murshidabad, 2010 bOPVmOPV1 JanFebMarAprMayJunJulAugSepOctNovDec WPV1 notified 07 Feb 2011 WPV1 notified 12 Feb Number of WPV 5 weeks 17 weeks 1 week 7 weeks WPV1 WPV3 Risk Mgmt 3: build on best practices to refine WPV/cVDPV emergency preparedness plans

Emergency Preparedness Plans: 1.ensure all states complete plans & that these are shared/reviewed centrally 2.ensure the identified risk areas have follow-up risk mitigation activities 3.conduct simulation exercises in highest risk areas in August 2011 (reservoirs, recently infected areas & amplification sites) 4.Ensure minimum buffer stock of 40 million bOPV and 10 million tOPV doses (review 6 monthly) Risk Management 3

Q5: What should be the number, timing, scope and vaccine type for SIAs during the remaining months of 2011 and early 2012?

IEAG Conclusion 5: Additional OPV campaigns are essential to protect the 'reservoir' and 'amplication' areas going into the 2011 high season.

2011: additional OPV Campaign in August to reduce risk of high season amplification of any residual or imported virus SNID SepOctNovDecJulAug SepNov bOPV SNID Aug SNID

NID tOPV MarAprMayJunJanFeb SNID (bOPV) Endemic & risk states NID tOPV/bOPV SNID (bOPV) Endemic & risk states 2012: procure sufficient vaccine for aggressive OPV schedule in 1 st half of 2012, then prepone/postpone based on epidemiology SNID (bOPV) Endemic & risk states SNID (bOPV) Endemic & risk states

Q6: How should the current communication gains be maintained & what are the specific communication challenges at this stage of polio eradication?

IEAG Conclusion 6: The current plan to maintain communications gains is endorsed, recognizing that the greatest challenges are (a) ensuring rapid, high-quality emergency response & (b) building on the polio capacity to improve child health.

From Every Child, Every Time to Your Child, Every Time to My Child, Every Time New Personalized Branding of the Polio Communications Approach

1.Roll out the new communications approach (incl. major emphasis on routine immunization & other convergence messaging). 2.Sustain the SMNet in UP and Bihar, and consolidate capacity in West Bengal. 3.All states should have a media & IEC as key elements of WPV emergency response plans (incl. designated government spokesperson!) Recs: Communications

Q7: How should the program begin to prepare for the next phase of polio eradication?

IEAG Conclusion 7: Given the recent eradication progress, and the long timelines for post-eradication planning, this work should be intensified esp. in the absence of high season transmission.

1.intensify implementation of the Global Action Plan for Poliovirus Containment (targeting completion of phase 1 by end-2012) 2.accelerate research & product development agenda (e.g. mucosal immunity, mathematical modeling, safe & affordable IPV approaches) 3.consider convening special IEAG-NTAGI session in late 2011 Recs: Post-eradication planning

Conclusion

India is definitely on the right path to finish eradication. HOWEVER, a more aggressive approach is essential to manage the risks along this path!

Towards a polio-free India Rukhsar. Let's ensure she is the last polio case in India!