Polio Eradication Program in India: Actions in PostEradication Phase

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Polio Eradication Program in IndiaActions in
Post-Eradication Phase

• By
• Prasanta 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.
• prasant20012001_at_yahoo.co.in, 91-11-22716998
• 91-9873247997, 91-9818473935

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Polio Eradication Program in IndiaActions in
Post-Eradication Phase---------------------------
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• 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.

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Polio Eradication Program in IndiaActions 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 2005. 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 5th June, 2006
  
• Total Polio Cases 2004 134
  
• Total Polio Cases 2005 65
• Total Polio Cases 2006(as on 5th June,06) 36

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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.

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Contd.

• Policy makers are to primarily formulate
  policies related to
• routine and supplemental immunization,
• outbreak response (including whether to
  create a stockpile),
• surveillance and
• 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.

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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.

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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

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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.

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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.

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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.

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Contd.

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

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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.

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Contd.

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

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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,

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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.

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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

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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.

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• 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).

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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.

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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.

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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.

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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, 69367 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. www.medscape.com

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PEP in IndiaActions in Post-Eradication Phase

• THANKS
• For any query I may me contacted through my
  e-mails
• pkssaahhaa_at_hotmail.com
• prasant20012001_at_yahoo.co.in