Polio Eradication and the “Endgame”

Why Eradicate Polio

 The biologic feasibility has been proven and incidence now is at global
record lows
 Switching to control would cost more than completing eradication.
Economic modeling has demonstrated eradication to be cost-effective,
particularly for low income countries
 Returning to routine immunization for control would result in 200,000
cases/year
 Political commitment is building, and heads of Governments are
directly engaged
 Demonstration that a combined global effort against a common
enemy, the poliovirus, can succeed, setting the stage for other global
health cooperative initiatives
 We have the tools

© 2012 Bill & Melinda Gates Foundation |

 Types of polioviruses

• 99% reduction in cases of wild poliovirus since 1988

• Type 1 (369 cases as of 31 December 2013†)
Wild • Type 2 (eliminated worldwide in 1999)
• Type 3 (none detected since November 2012)

• Vaccine-associated paralytic poliomyelitis (VAPP)**

VAPP** • Estimated ~250-500 globally per year
related
OPV

• Type 2 accounts for about 40% of VAPP

• Vaccine derived polioviruses (VDPV)

• Most are circulating VDPVs (cVDPVs)*
VDPVs* • ~58-184 per year since 2008 (through 31 Dec 2013)
• Type 2 cVDPVs account for 97% of cVDPVs

† More up-to-date numbers can be found at http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

*Other extremely rare VDPVs include primary immunodeficiency VDPVs (iVDPVs) and ambiguous VDPVs (aVDPVs)
**Refers to spontaneous reversion to neurovirulence of one of the attenuated viruses in OPV. VAPP occurs in OPV recipients or
their close contacts in contrast to cVDPVs which are widely transmitted in a community and are not likely to be related to contact
with a recent vaccine recipient.

Adapted from a slide from Walt Orenstein © 2012 Bill & Melinda Gates Foundation |
 Critical tools in polio eradication
 Disease Surveillance
• Acute flaccid paralysis (AFP) surveillance
− Indicators of quality
 At least 2/100,000 cases of non-polio AFP among children < 15 years of age, annually
 At least 80% of AFP cases investigated have at least two stools collected at least 24 hours apart within
14 days of paralysis onset and processed in an accredited laboratory
 Global accredited laboratory network

 Environmental Surveillance (sewage monitoring)

 Affordable Vaccines
 Coverage Monitoring
 Routine Coverage
 Immunization status of non-polio AFP cases
 Supplemental Immunization Coverage Monitoring
 Finger Marking
 Independent monitors

From “Introduction to Poliomyelitis”. Training of STOP Team 34, Atlanta, May 2010

© 2012 Bill & Melinda Gates Foundation |

Vaccines against Polio
Oral polio vaccine (Sabin) Inactivated polio vaccine (Salk)

© 2012 Bill & Melinda Gates Foundation |

 Eradication
In 1988, the World Health Assembly,
the governing body of the World Health
Organization (WHO) resolved
to eradicate poliomyelitis by the year 2000.

© 2012 Bill & Melinda Gates Foundation |

GPEI

 Founded in 1988, based on WHA Resolution

 Public-private partnership led by:
 4 spearheading partners
 National governments
 20 million volunteers
 2.5 billion children immunized
 > US $9B investment
 52 donors since 1988

© 2012 Bill & Melinda Gates Foundation |

Current Global Situation

© 2012 Bill & Melinda Gates Foundation | 11

 Wild Poliovirus Cases1, Previous 12 Months*

Onset of most Number of Total WPV

Country
recent case districts (all type1)

Cameroon 31-Jan-14 5 7
Equatorial Guinea 19-Mar-14 3 3
Ethiopia 05-Jan-14 1 10
Kenya 14-Jul-13 3 8
Nigeria 19-Apr-14 20 30
AFR 19-Apr-14 32 58
Afghanistan 06-Apr-14 11 16
Iraq 10-Feb-14 1 1
Poliovirus type 1 Pakistan 01-May-14 20 144
Somalia 20-Dec-13 45 169
Endemic country
Syria 21-Jan-14 12 36
Country with WPV case in previous 6 months EMR 01-May-14 89 366
Global 01-May-14 121 424
Country with WPV case 6-12 months ago
*21 May 2013 – 20 May 2014
1Excludes cases caused by vaccine-derived polioviruses and viruses detected from environmental surveillance.
© 2012 Bill & Melinda Gates Foundation |
Data in WHO HQ as of 20 May 2014
 Wild Poliovirus Cases by Type 2013 & 2014 - Year to Date Comparison

01 January - 20 May 1
Country Total 2013 Date of most
2013 2014
classification recent case
W1 W3 W1 W3 2014 W3
Endemic
Pakistan 93 0 8 0 66 0 01-May-14
Nigeria 53 0 22 0 3 0 19-Apr-14
Afghanistan 14 0 2 0 4 0 06-Apr-14
Total 160 0 32 0 73 0
Outbreak
Equatorial Guinea 0 0 0 0 3 0 19-Mar-14
Iraq 0 0 0 0 1 0 10-Feb-14
Cameroon 4 0 0 0 3 0 31-Jan-14
Syria 35 0 0 0 1 0 21-Jan-14
Ethiopia 9 0 0 0 1 0 05-Jan-14
Somalia 194 0 1 0 0 0 20-Dec-13
Kenya 14 0 1 0 0 0 14-Jul-13
Total 256 0 2 0 9 0
Global total 416 0 34 0 82 0
1
Data as of 21 May 2013 for 2013 data and 20 May 2014 for 2014 data.

Data in WHO HQ as of 20 May 2014

 Circulating Vaccine-derived Poliovirus Cases*, Previous 6 Months§

cVDPV1 (0 cases)
cVDPV2 (16** cases)
cVDPV3 (0 cases)

Monthly Distribution of Cases by Country

Number of cases

§21 Nov 2013 – 20 May 2014 *Circulating vaccine-derived poliovirus (cVDPV) is associated with 2 or more AFP cases. VDPV type 2 cases w ith greater than or equal to 6nt
difference from sabin in VP1; VDPV types 1 and 3 cases with greater than or equal to 10nt difference from sabin in VP1 are reported. Figures
exclude VDPV from non-AFP source. Figures may include different chains of transmission. **1 cVDPV2 (onset of paralyses 18 March) is not
Data in WHO HQ as of 20 May 2014 reflected on the map and chart as it is currently under cross-border investigation to determine the country of onset (Nigeria or Cameroon.)
 Political Instability in Endemic Areas

.
Courtesy: Waqar Ajmal, BMGF © 2012 Bill & Melinda Gates Foundation |
Source: http://www.impatientoptimists.org/Posts/2014/05/Polio-Eradication-Explainer

© 2012 Bill & Melinda Gates Foundation | 16

The Polio Eradication & Endgame Strategic
Plan 2013-2018

The Plan differs from

previous eradication
plans

“complete the eradication

and containment of all
wild, vaccine-related, and
Sabin polioviruses such
that no child ever again
suffers paralytic
poliomyelitis.”

© 2012 Bill & Melinda Gates Foundation |

GPEI Strategic Plan has four major objectives
 Objective 1: Interrupt wild poliovirus transmission by December 2014

 Objective 2: Introduce IPV and withdraw Type 2 OPV globally

 Objective 3: Certify eradication and WPV containment by 2018

 Objective 4: Plan for Polio’s legacy

May 30, 2014 ©2012

© 2011 Bill &
& Melinda
MelindaGates
GatesFoundation
Foundation | | 18
CONFIDENTIAL
GPEI Timelines

 2014-2015: introduce ≥ 1 dose of IPV for routine immunization in all countries

 2016: global replacement of tOPV with bOPV

 2019-2020: withdrawal of all OPV

Last wild polio tOPV-bOPV Global Stop

Anticipated case switch certification bOPV
timeline

2013 2014 2015 2016 2017 2018 2019-2020

Strengthen routine immunization

Phase in IPV IPV in routine immunization

Prepare tOPV-bOPV switch Prepare phasing out bOPV

© 2012 Bill & Melinda Gates Foundation |

19
 Polio “Endgame”: Post-Eradication Risks
 Re-Introduction of Wild Polio Viruses

• Break in laboratory containment

• Break in containment from IPV manufacturer
• Intentional release (Bioterrorism)
 Circulating Vaccine Derived Polio Viruses (cVDPVs)

 Vaccine-Associated Paralytic Polio (VAPP) if OPV continues to be

used

 Immune deficient persons who are chronic shedders (B-cell defects)

From “Introduction to Poliomyelitis”. Training of STOP Team 34, Atlanta, May 2010 20
© 2012 Bill & Melinda Gates Foundation |
 “Endgame”: Mitigating Post-Eradication Risks
 Global laboratory containment with destruction of viruses in non-
essential laboratories
 tOPV – bOPV shift, followed by cessation of the use of OPV
 Consider long term or some period of IPV use globally to assure
population immunity is maintained
• Need researchon making IPV affordable / more effective
− Fractional doses
− Make from non-wild virus sources / Sabin IPVs
− IPV’s role in inducing intestinal immunity
 Antiviral Drugs to treat identified chronic shedders
 Stockpiles of vaccines to use if polio returns

From “Introduction to Poliomyelitis”. Training STOP Team 34, Atlanta, May 2010

© 2012 Bill & Melinda Gates Foundation | 21

Source: http://www.impatientoptimists.org/Posts/2014/05/Polio-Eradication-Explainer

© 2012 Bill & Melinda Gates Foundation | 22

Source: http://www.impatientoptimists.org/Posts/2014/05/Polio-Eradication-Explainer

© 2012 Bill & Melinda Gates Foundation | 23

Source: http://www.impatientoptimists.org/Posts/2014/05/Polio-Eradication-Explainer

© 2012 Bill & Melinda Gates Foundation | 24

 Progress against Polio
 In 1988, polio was endemic in
125 countries and paralyzed
more than 1,000 children
worldwide every day.

 Today, there are only 3

countries where
transmission of polio hasn’t
stopped – Nigeria,
Afghanistan, Pakistan.

We are closer than ever in eradicating the disease

May 30, 2014 © 2012 Bill & Melinda Gates Foundation | 25

THANKS .. !

© 2012 Bill & Melinda Gates Foundation |