Getting to Zero: On the Verge of Polio Eradication. Ellyn Ogden, MPH USAID Worldwide Polio Eradication Coordinator May 17, PDF Free Download

Getting to Zero: On the Verge of Polio Eradication Ellyn Ogden, MPH USAID Worldwide Polio Eradication Coordinator May 17, 2017

Polio Eradication and Endgame Strategy 1. Poliovirus detection & interruption 2. OPV2 withdrawal, IPV introduction, immunization system strengthening 3. Containment & Global Certification 4. Transition Planning 2

Progress in WPV eradication 37 Cases in 2016 1988 2016 Public Health Emergency of International Concern declared in May 2014 and reconfirmed every 3 months since that time 5 cases in 2017 (Afghanistan and Pakistan) as of 10 May 2017

Global Wild Poliovirus & cvdpv Cases 1, Previous 6 Months 2 Country Onset of most recent WPV1 case Number of WPV1 cases Number of WPV infected districts Same period 4 Same period Current4 last year 4 Current last year 4 Nigeria 0 0 0 0 0 AFR 0 0 0 0 Pakistan 13-Feb-17 3 17 3 12 Afghanistan 21-Feb-17 4 5 4 4 EMR 21-Feb-17 7 22 7 16 cvdpv current 6 months 2 Number of cases 0 1 0 1 Wild poliovirus type 1 cvdpv type 2 2 Endemic country 1 Excludes viruses detected from environmental surveillance 2 Onset of paralysis 10 November 2016 09 May 2017 Global 21-Feb-17 7 22 7 16 4 Current rolling 6 months: 10 November 2016 09 May 2017 Same period previous year: 10 November 2015 09 May 2016 Data in WHO HQ as of 09 May 2017 1

Pakistan Afghanistan Lowest number of cases ever in the epidemiological block

Pakistan and Afghanistan: Corridors of transmission common reservoirs spanning borders between Afghanistan and Pakistan involving: 1) selected geographic areas, and 2) demographic groups Three main shared transmission corridors/endemic zones: a) Southern/Western (Kandahar & Helmand Quetta) b) Southeast Afghanistan/South KP (Paktika South Waziristan) c) Eastern/Northern (Nangahar & Jalalabad Peshawar Valley) 4 risk scenarios for future WPV transmission due to movement of people, and GPEI action: Movement within reservoir areas Areas with high population movement identified and focused Emphasis on guest children (vaccinators, SMs, Supervisors and monitors) Straddling populations at border areas Mapping of areas and relations on other side of border Inclusion in high risk area for increased focus Nomads Routes, seasonality identified Nomad specific campaigns, Nomad specific PTTs, Inclusion in SNID/NID Returnees Vaccination at border, UNHCR/IOM centers IPV (under 5) and OPV (under 10) Identification of settlement and inclusion in microplan

Inaccessible children: May 2016- Mar 17 400,000 300,000 200,000 100,000 0 May NID Aug NID Oct NID Mar NID2 South & West East North East Rest of Afghanistan Afghanistan Pakistan

Nigeria and Lake Chad

WPV1 and VDPV2 in Nigeria, 2016-2017 2016: 4 WPV1 from Borno. Date of onset of last case August 21, 2016 WPV1 in Borno are orphans and isolated in security compromised areas in northern part of the state 2 cvdpv2 cases both from contacts (Borno and Sokoto). Last case is from Bodinga LGA in Sokoto State with date of onset September 28, 2016 2017: 10 VDPV2 isolates from environmental surveillance sites: 6 in Sokoto 2 in Gombe 1 in Bauchi 1 in Katisna All VDPV2 isolated in 2017 are not circulating by GPEI guidelines 1 VDPV2 was isolated from a healthy contact in Sokoto (50 th Stool sample) Nucleotide changes range from 6-10

THE OUTBREAK LED TO A MASSIVE REGIONALRESPONSE TARGETING 40+ MILLION WITH OPV MULTIPLE TIMES Overall cost of the outbreak Aug-Dec: $140m 1 0

Horn Of Africa

HOA WILD POLIO VIRUS (Type1) OUTBREAKS 2004 to 2013 2016?? 2016?? 2004-2008 Outbreak 2009-2012 Outbreak 2013 Outbreak

Children in inaccessible areas, May 2017 Access status South Sudan Somalia Yemen Sudan Total in HOA Partially accessible 16,282 655,967 363,864 109,222 areas 1,145,335 Completely Inaccessible areas 296,320 Total population U5 in security challenged area 312,602 (compared to 450,000 in 2016) 236,081 (compared to 400,000 in 2016) 892,048 51,972 142,532 415,836 251,754 (compared (compared to 600,000 in to 305867 in 2016) 2016) 726,905 1,872,240 Yemen Somalia Sudan S. Sudan

VDPV Outbreaks

Global Circulating Vaccine-derived Poliovirus Cases 1,2, 2000-2017 cvdpv type 1 3 Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Onset of most recent case Laos 8 3 11-Jan-16 Madagascar 1 10 22-Aug-15 Ukraine 2 07-Jul-15 Mozambique 2 02-Jun-11 Myanmar 1 4 06-Dec-07 Indonesia 46 26-Oct-05 China 2 11-Nov-04 Philippines 3 26-Jul-01 DOR/Haiti 12 9 12-Jul-01 Total type 1 12 12 0 0 2 46 1 4 0 0 0 2 0 0 1 20 3 0 cvdpv type 2 3 Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Onset of most recent case Pakistan 16 48 22 2 1 17-Dec-16 Nigeria 3 22 71 68 155 27 34 8 4 30 1 1(1 2 ) 28-Oct-16 Guinea 1 7 14-Dec-15 Myanmar 2 05-Oct-15 South Sudan 2 12-Sep-14 Cameroon 4 12-Aug-13 Niger 2 2 1 1 1 11-Jul-13 Chad 1 12 4 12-May-13 Afghanistan 5 1 9 3 13-Mar-13 Somalia 1 6 1 9 1 1 09-Jan-13 Kenya 3 29-Aug-12 DRCongo 13 5 18 11 17 04-Apr-12 China 2 06-Feb-12 Yemen 9 05-Oct-11 India 15 2 18-Jan-10 Ethiopia 3 1 16-Feb-09 Madagascar 1 4 3 13-Jul-05 Total type 2 0 1 4 0 0 6 24 71 85 184 55 65 68 65 55 12 2 0 cvdpv type 3 3 Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Onset of most recent case Yemen 3 1 12-Jul-13 Ethiopia 1 5 17-May-10 Cambodia 1 1 15-Jan-06 Total type 3 0 0 0 0 0 1 1 0 0 1 5 0 3 1 0 0 0 0 Data in WHO HQ as of 09 May 2017 1 For cvdpv definition see http://polioeradication.org/wp-content/uploads/2016/09/reporting-and-classification-of-vdpvs_aug2016_en.pdf. Niger 2006, Niger 2009, Niger 2010, Chad 2010 cvdpvs are linked to the Nigeria outbreak. Kenya 2012 cvdpvs are linked to the Somalia outbreak. Nigeria figures include cases with WPV1/cVDPV2 mixture: 2005-2, 2006-1, 2007-1, 2008-3, 2009-1, 2011-1; WPV3/cVPDV2 mixture 2007-2. 2 In Nigeria, 1 cvdpv2 from a healthy child contact of a WPV1 case not included in country or global case count. 3 Figures include multiple emergences and transmission chains.

Transitioning Away from topv in Three Stages 2019-2020 2016 Withdrawal Switch of bopv & 2015-2016 routine OPV use topv to bopv Introduction at least one dose of IPV into routine immunization Ongoing STRENGTHENING of routine immunization services IMG, IPV Introduction and OPV Withdrawal

173 countries using IPV Introduced* to date (173 countries or 89%) Introduction delayed to 2017/2018 (21 countries or 11%) Not available Not applicable * Including partial introduction in India Introduction delayed : Angola, Burkina Faso, Cabo Verde, Egypt, Eritrea, Ghana, Kyrgyzstan, Liberia, Malawi, Mongolia, Republic of Moldova (the), Rwanda, Sierra Leone, Tajikistan, Togo, Turkmenistan, United Republic of Tanzania (the), Uzbekistan, Viet Nam, Zambia, Zimbabwe The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2016. All rightsreserved. Data source: WHO/IVB Database, as of 08 December 2016 Map production Immunization Vaccinesand Biologicals (IVB), World Health Organization

Countries with IPV supply disruptions 0 950 1,900 3,800 Kil Countries with delayed introduction (18 countries or 9.2%) Countries with delayed resupply (17 countries or 8.8%) Not available / Countries already introduced Not applicable Data source: WHO/IVB Database, as of 11 April 2017 Map production Immunization Vaccines and Biologicals (IVB), World Health Organization 2 The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2016. All rights reserved.

figure 1: containment requirements Phase I: Preparation for containment of poliovirus type 2 Phase II: Poliovirus type 2 containment period Phase III: Final poliovirus containment Global readiness criteria met OPV2 withdrawal 6 x Regional certification of WPV eradication bopv cessation Poliovirusessential facilities holding WPV Inventory Destruction, Preparation for containment Containment certification IIa: WPV2 containment IIIa: Final containment of all WPV Poliovirusessential facilities holding OPV/Sabin only (no WPV) Destruction, Preparation for containment Containment certification IIb: OPV2/Sabin2 poliovirus containment IIIb:Final containment of all OPV/Sabin polioviruses Poliovirusnon-essential facilities Destruction, Safe handling, No storage Adopt safe measures Safe handling of new samples potentially containing poliovirus material in poliovirus-non-essential laboratories

Global Polio Laboratory Network 146 Laboratories Worldwide b EUR AMR AFR EMR SEAR WPR Laboratories Worldwide Virus Isolation Laboratory (43) ITD Laboratory (70*) Sequencing Laboratory (26) Global Specialized Laboratory (7) *Includes 16 in process of implementation AFR: African Region AMR: Americas Region EMR: Eastern Mediterranean Region EUR: European Region ITD: Intratypic differentiation SEAR: South Eastern Asia Region WPR: Western Pacific Region World Health Organization

EMRO and AFRO NOT Certified 80% of the World s Children live in Polio-free Regions

Post-Certification Strategy Goals Purpose: Define how a polio-free world will be sustained Goal 1: Contain Polio Sources Ensure potential sources of poliovirus are properly controlled or removed Goal 2: Protect Populations Immunize populations against unanticipated polio events Goal 3: Detect and Respond Detect any poliovirus introduction and rapidly respond to prevent transmission Goal 4: Manage Effectively and Monitor Ensure ongoing polio functions are embedded in existing or develop new approaches to sustain the goals of polio post-certification 26

Program Risks Reasons for Optimism Routine Immunization SIA Quality Immunity gaps AFP Surveillance missed transmission Environmental Surveillance Mobile and Cross-border populations Security compromised / access Community Trust in Vaccines Containment IPV supply OPV supply Complacency Funding Poor Transition Planning Lowest Number of Cases Declining genetic diversity Expand Environmental Surveillance Risks are known w/ solutions possible Windows of Opportunity in Insecure Areas Evidence Based Communications Technology: GIS, Mobile phones/remote monitoring, baby registries Cost Savings Identified Transition Planning Improving Stronger oversight Country-led efforts and ownership Accountability frameworks

Global Polio Eradication is the largest effort outside of armed conflict in the world. With 20 million volunteers, health workers, lab techs, vaccinators, mobilizers dedicated to the common goal of preventing childhood paralysis. 13 Million Cases of Paralysis Prevented

Every Child Counts! Thank You

Getting to Zero: On the Verge of Polio Eradication. Ellyn Ogden, MPH USAID Worldwide Polio Eradication Coordinator May 17, 2017