Washington Global Health Alliance Discovery Series David Heymann, MD June 19, 2008 'Challenges and Controversies in Polio Eradication'

1. Polio Eradication: Challenges and Controversies

2. Smallpox: Variola Major 20% - 40% case fatality 100% permanent facial scarring 2.7 million deaths, 1967

3. Challenge, 1967: Smallpox endemic in 31 countries or territories Endemic Importation Transmission interrupted

6. Intensified search: smallpox eradication, 1967–1978 WHO Smallpox Recognition Card

7. Simplified containment: smallpox eradication, 1967–1978 Multipuncture vaccination by bifurcated needle

8. Smallpox eradication: global partnership to detect/contain every case Ethiopia Somalia

9. Smallpox, the last endemic infection, Somalia, October 1977

10. Smallpox, the last human infection, Birmingham, Uninted Kingdom, November 1978

11. Smallpox Eradication: Certified 1980

13. Smallpox virus: officially remains in 2 WHO Collaborating Centres CDC (ATLANTA) KOLTSOVO (SIBERIA)

17. Strategy 1: routine childhood immunization Routine childhood immunization in national immunization programmes High level advocacy and political engagement

18. Reality: weak national immunization programmes Routine Polio Coverage, by Region

19. Strategy 2: national immunization campaigns 2002: 100 countries

20. Reality: inability to sustain campaigns when external resources decrease 2003: <20 countries, fewer campaigns

21. Specialised Reference Laboratory Regional Reference Laboratory National/ Sub-national Laboratory Strategy 3: clinical/laboratory surveillance of acute flaccid paralysis

22. Virus linked to common ancestor, West and Central Africa, 2004

24. Challenge: suspension of polio immunization, Nigeria, August 2003 Polio Vaccines - Western Countries Exploit Developing Ones Says Kano State Governor Shekarau BYLINE: Daily Trust BODY: The Kano State governor, Malam Ibrahim Shekarau, has asserted that the people's objections to polio vaccines has confirmed the exploitative actions of western nations towards developing countries.

25. 6 polio endemic countries 18 countries with imported virus Wild virus type 1 Wild virus type 3 International spread of polio from Nigeria, 2003-2005

26. Increased political commitment, West and Central Africa Nigerian President Obasanjo & African Union President Konare launch Kano campaign, 2004 Rotary/UN mediation mission, Côte d'Ivoire, February 2005

27. Coordinated Africa-wide vaccination campaigns 2004 Jan – May 2005 June 2005 5 Rounds of synchronized National Immunization Days, Oct 2004 - May 2005

31. Standing recommendation, International Health Regulations: August 2004

32. * data as on 10th September 2005 Challenge: polio a disease of vaccinated children in high population density countries 7 - 9 doses 27% 4 - 6 doses 27% >=10 doses 46% Vaccination status, children with polio, Uttar Pradesh, India 2005

33. Limited protection from trivalent oral polio vaccine: virus competition Percent John TJ, Devararjan LV, Balasubramanyan A. Immunization in India with trivalent and monovalent oral poliovirus vaccines of enhanced potency. Bull WHO 1976;54:115-7.

35. Monovalent oral polio vaccine types 1 and 3 (mOPV1 and mOPV3) Monovalent oral polio vaccine: greater herd immunity for fewer doses

36. Effective use of mOPV1, India, 2005 Type1 polio 2005 data as of 25 Sept 2005 mOPV mOPV mOPV tOPV tOPV tOPV mOPV *13 high risk districts, West Uttar Pradesh 0 2 4 6 8 10 12 14 16 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2004 2005

37. Wild poliovirus type 1 Sabin poliovirus type 1 2004 2005 Poliovirus isolated from sewage, Egypt, August 2004 – August 2005 year

38. Protective efficacy by dose, tOPV and OPV by country, 2005 - 2007

39. Direct protection against type 1 polio in children <5 years Impact on immunity to type 1 polio India and Nigeria 2005 2006 2007 2005 2006 2007

40. Type 1 Polio paralysis worldwide, 4 June 2008 Endemic countries Wild virus type 1 New importations (2008) Persistent imports (2006-7)

41. Type 3 Polio Cases at 4 June 2008 Endemic countries Wild virus type 3 New importations (2008) Persistent imports (2006-7)

42. Risks to polio eradication: June 2008 Active conflict Autonomous areas Lack of political & societal engagement Very efficient transmission

43. Polio outbreak, China, 2004 Polio outbreak 2 cases

44. Dilemma: circulating vaccine-derived polioviruses (cVDPVs) Philippines 2001 3 cases Madagascar 2002 4 cases China 2004 2 cases Indonesia 2005 46 cases Nigeria 2006-7 89 cases Hispaniola 2000 22 cases

47. Vaccine-associated risks to polio eradication from OPV iVDPV 28 identified <1 decreases ( since 1963) cVDPV 1* per year 10 increases VAPP 2-4/million 1 st dose 250-500 stable Frequency Annual Evolution Risk to date burden over time *based on current understanding After interruption of wild poliovirus, continued use of OPV will compromise the goal of a polio-free world. Expert Consultation on Vaccine-derived Polioviruses (VDPVs), Sept 2003, Geneva

49. VAPP 2-4/million birth cohort 250-500 stable iVDPV 19 identified <1 decreases ( since 1963) cVDPV 1* per year 10 increases IPV sites 1 accident (1990s) <1 decreases lab accident 1 investigation NK decreases deliberate 0 NK unknown Frequency Annual Evolution Risk to date burden over time Vaccine-associated and other risks to polio eradicatyion

51. Worldwide containment, wild poliovirus: status 2007 Polio endemic Survey not yet started Conducting survey Reporting completion of survey and inventory of laboratories with wild poliovirus materials

52. 2008-9 Funding Gap: US$ 525m of $1.3b budget ‘ Other’ includes: the Governments of Angola, Austria, Australia, Belgium, Czech Republic, Finland, Hungary, Iceland, Ireland, Italy, Liechtenstein, Luxembourg, Malaysia, Monaco, Namibia, New Zealand, Nigeria, Oman, Pakistan, Portugal, Qatar, Republic of Korea, Russian Federation, Saudi Arabia, Singapore, Spain, Switzerland, Turkey, the United Arab Emirates; African Development Bank; AG Fund; American Red Cross; De Beers, Inter-American Development Bank, Central Emergency Response Fund (CERF), International Federation of Red Cross and Red Crescent Societies, Oil for Food Programme, OPEC Fund, Sanofi Pasteur; Saudi Arabian Red Crescent Society, Smith Kline Biologicals, UNICEF National Committees, UNICEF Regular and Other Resources, United Arab Emirates Red Crescent Society, WHO Regular Budget and Wyeth. Domestic Resources 14% Non-G8 OECD/ Other 8% Multilaterals 15% Private Sector 15% Cost of eradication (1988-2009) US$ 6 Billion G8 48%

53. Smallpox Eradication: Certified 1980, cost US $300 million

54. Persons living with HIV infection, 2006: >40 million 3 million deaths during 2003 20 million deaths since 1981 Smallpox vaccine cannot safely be used in HIV-infected persons

56. Spread of polio from India and Nigeria: 27 previously polio-free countries in 2003-7 The Risk

57. The public good

59. Polio staff by region, 2008 Region International Staff National Staff Total FT ST* FT ST* SSA NPO APW AFRO 31 120 5 572 355 14 0 1097 AMRO 1 0 0 3 0 2 0 6 EMRO 13 83** 7 19 439 0 457 935 EURO 2 1.5 2 2 0 2 0 9.5 SEARO 13 12 5 11 1151 0 0 1192 WPRO 2 0 0 0 1 0 0 3 HQ 23 12 11.5 4.5 0 0 0 51 TOTAL 85 145.5 30.5 611.5 1946 18 457 3293.5

60. Micro-planning and mapping for Immunization campaigns in rural Pakistan