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SERTIFIKASI GLOBAL dan POLIO ENDGAME

ismoedijanto
pokja akhli surveilans polio

Kilas balik (1)
• WHA th 1988 : memutuskan /merekomendasikan GPEI
(Global Polio Eradication Initiative) dg target th 2000.
• Dilakukan imunisasi serentak dg OPV dalam NID, di
Indonesia th 1995,1996,1997. negara yg tertinggal
menularkan ke negara yg sdh bebas.
• Diragukan bisa eradikasi ok adanya VAPP dan VDPV, terakhir
adanya klb WPV di Suriah (dari Pakistan) dan WPV1
Palestina di limbah lingkungan .
• Namun WHO tetap dg rencana semula dan per region akan
dibantu RCC untuk mempercepat bebas polio. Polio liar P2
dan P3 sdh hilang , upaya pada eradikasi P1 .

Kilas balik (2)

• Imunisasi adalah alat untuk mengendalikan penyakit menular
dan bekerja dengan jalan:
– Membuat bayi menjadi kebal (serokonversi)
– Mempertahankan kekebalan dengan suntikan booster terus menerus
– Membuat cakupan imunisasi tinggi sehingga terbentuk herd immunity
– Herd immunity menahan dan menolak transmisi atau penularan
– Herd immunity akan menyurut dan memicu timbul KLB
– Cakupan imunisasi harus tetap tinggi, sehingga tidak ada immunization
gap dan akumulasi penduduk yang tidak kebal
– Gap terjadi bila terbentuk sela populasi yg sensitif (cohort yang tidak
diimunisasi) dan tidak ada jendela waktu tanpa kekebalan ( dewasa
yang tidak diimunisasi tetapi tidak sakit ok waktu bayi herd immunity
tinggi) . Contoh Jawa Timur difteri pada dewasa.

poliklinik. KLB terjadi akibat akumulasi penduduk yang tidak kebal • KLB menjadi sering dengan kasus yang besar • KLB main jarang dengan jumal kasus yang menurun • Kasus menghilang dari tempat praktek. diluar kelaziman – Eradication march: • Endemisitas tinggi: tiap hari ada kasus dimana saja • Kasus menurun. . kasus terabaikan • Active surveillance – Active : mencari di RS dengan HRR atau pencarian mingguan atau community dengan melibatkan lembaga sosial. Kilas balik (3) • Surveilans adalah alat untuk mengetahui adanya KLB: – Bertindak sebagai sensor adanya bahaya penyakit untuk masyarakat – Mengamati kejadian secara pasif dengan mencermati laporan – Peka terhadap laporan yang “aneh”. dengan reporting sites yang sangat banyak.

Kemajuan yang besar menuju eradikasi global (AFRO serta EMRO) bebas polio • Penurunan > 99.9% semua kasus • Tinggal 3 negara endemic polio • poliovirus type 2 terakhir tahun 1999 • Polio virus type 3 tidak dilaporkan sejak 2014 • Tinggal 2 WHO Regions yang belum sertifikasi bebas • Polio virus type 1 sudah mencapai titik rendah .

Eradikasi Virus Polio liar. 1988-2012 400 Polio300 cases (thousands) 200 2012 100 Kasus Polio tipe Kasus Polio 2 di dunia terakhir di India 0 1985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 .

India 5. Myanmar 7. DPR korea 4. Thailand 9. Timor Leste . South East Asia Regional Office (SEARO) road to polio free region certification 1. Nepal 8. indonesia 6. Bhutan 3. Bangladesh 2.

India January 2011 .Recent Rukshar Khatoon Developments West Bengal.

19 tahun kemudian 27 maret 2014 SEARO bebas kasus polio .Setelah berupaya sejak tahun 1995.

WHY • HARUS MELAKUKAN PIN • MENGGANTI Topv dengan Bopv • MENGGUNAKAN IPV .

– Conduct simulation exercise of the national plan for polio outbreak preparedness and response. – To prepare annual updates of their national documentation for polio eradication and submit to the NCCPE for review. namun kita mempunyai tugas …. risk registry and risk mitigation activities. . • The NCCPE of all countries should advocate with the national government on the following. – Maintain a buffer stock of OPV so that the minimum qualities of vaccines are available at country level in an emergency response at earliest. – Continue doing risk assessment.

. but the accumulation of susceptible population due to low immunization coverage keeping the country at a high risk of polio importation and outbreak. usulan untuk Indonesia maret 2014 (1) • Indonesia • There were clear evidences of two main gaps: – 1) reduced routine immunization coverage – 2) gaps in AFP surveillance. • The commission is concerned about the declining trend of the programme performance in a populous country. The RCCPE supports the statement by the NCCPE that the there is no evidence of wild poliovirus circulation in the country during the past three years. Though there is no wild poliovirus has been reported after the outbreak was stopped in 2006.

supplementary immunization and high quality AFP surveillance. usulan untuk Indonesia Maret 2014 (2) • The RCCPE recommends that • The NCCPE should advocate with the national government for their attention and take urgent action to improve programme quality and population immunity everywhere in the country through strengthening routine immunization. • The NCCPE should advocate with national government to facilitate cross border collaboration with neighboring countries as a risk mitigation activity. .

Setelah sertifikasi • Cakupan polio yg rendah • Gap imunisasi yg tetap tinggi • Peningkatan cakupan imunisasi rutin gagal • Kinerja surveilans yg cenderung turun • Selesai nya demonstrasi suntikan IPV Jogya .

. PIN .Solusi sebelum ke IPV……….

2011–2015 13.000 children under 15 years of age 16 Data as of 10 Aug 2015 .94 12.84 6.12 and above SEAR Minimum Target * Number of discarded AFP cases per 100.49 12.38 7.Non-polio AFP Rate* SEAR.50 13.

17 Data as of 10 Aug 2015 . 2011-2015 Minimum Target Percent *Percentage with 2 specimens 24 hours apart and within 14 days of paralysis onset.Percent Adequate Stool Specimen Collection* SEAR.

2009-2013 N=170 immunization gap Indonesia N=164 N=43 N=258 N=281 N=277 N=303 N=194 Data as of 09 Sep 2013 N=78 N=98 N=103 Percent of Non-Polio AFP Cases Under Immunized for OPV N=100 N=44 . SEAR. N=881 N=847 N=909 N=862 N=535 N=30908 N=33081 N=35175 N=33691 N=17434 N=800 N=762 N=931 N=987 N=491 N=170 N=137 (6 Months to 5 Yrs).

2011-2015 N=253 N=170 N=164 N=145 N=158 N=44 N=277 N=303 Percent of Non-Polio AFP Cases Under Immunized for OPV N=291 Data as of 10 Aug 2015 N=236 N=97 N=103 N=100 N=76 N=80 N=35 . SEAR. 19 N=909 N=862 N=794 N=838 N=472 N=35175 N=33691 N=30571 N=28749 N=11491 N=931 N=987 N=964 N=898 (6 Months to 5 Yrs).

2012 Low Risk Medium Risk High Risk .Risk analysis for SEAR countries for transmission following WPV importation into polio-free areas.

2012 Low Risk Medium Risk High Risk Data as of 31 Dec 2012 .Sub-national risk analysis for SEAR countries for transmission following WPV importation into polio-free areas.

Myanmar. SEARO) Medium risk High risk . SEARO and WPRO: Sub-national Polio Risk Assessment: 2012 • Cross-border meeting China. Viet Nam planned 2013 Low risk (WPRO. Thailand. Laos.

2015) ** Percentage with 2 specimens 24 hours apart and within 14 days of paralysis onset. Surveillance Indicators by Province Indonesia.33 Percent Adequate Stool Specimen Collection ** Adequate Stool specimen = 94% Provinces reporting AFP cases= 30 (85%) Adequate Stool Specimen Collection < 60% 60% – 79% > 80% No AFP Case * Number of discarded AFP cases per 100. 2015 Non-polio AFP Rate* Non-Polio AFP Rate <1 1 – 1. Data as of 10 Aug 2015 .000 children under 15 years of age (annualized by week 32. 23 Note: Some AFP cases may still be pending final classification.99 >2 No Non-Polio AFP Case Total AFP Cases = 618 Non-Polio AFP Rate = 1.

Data as of 10 Aug 2015 . 2014 Non-polio AFP Rate* Non-Polio AFP Rate <1 1 – 1.000 children under 15 years of age ** Percentage with 2 specimens 24 hours apart and within 14 days of paralysis onset. Surveillance Indicators by Province Indonesia. 24 Note: Some AFP cases may still be pending final classification.43 Percent Adequate Stool Specimen Collection ** Adequate Stool specimen = 89% Provinces reporting AFP cases= 34 (100%) Adequate Stool Specimen Collection < 60% 60% – 79% > 80% No AFP Case * Number of discarded AFP cases per 100.99 >2 No Non-Polio AFP Case Total AFP Cases = 1765 Non-Polio AFP Rate = 2.

polio end game: mengapa bOPV dan IPV ? .

Previous 6 Months2 .cVDPV Cases1.

GPEI optimis bisa tercapai th 2018. AFRO • RCC dibentuk untuk mendorong region memberantas polio di semua negara anggotanya dan mencegah penularan. SEARO. namun negara endemis kurang (tinggal 3) dan kasus sangat menurun. yang belum bebas polio: EMRO. bisa untuk peny lain . Capaian dan kendala secara umum • Telah ada 4 region yg bebas polio: PAHO. EURO dan WPRO. – Adanya klb importasi inter dan antar region – Review dan validasi dokumen negara – Review dan validasi internasional ke negara masing2 – Mendorong imunisasi dan s afp masing2 negara • KLB polio setelah sertifikasi bebas polio tetap terjadi. • SEARO : bukti adanya komitmen pimpinan pusat dan lokal serta peran serta masyarakat tinggi.

UPDATE ON POLIO P2 sdh tidak ada sejak 1999 P3 sdh tidak dilaporkan sejak 2014 P1 sudah sangat rendah cVDPV P2 menjadi polio liar baru Sabin bisa jadi liar kembali .

Vaccine-associated paralytic poliomyelitis* : lumpuh ok OPV +Birth cohort in countries using OPV *Overall risk .

arti dari KLB cVDPV. muncul cVDPV dan VAPP sebagai polio “liar” baru Type 1 (79 cases) Type 2 (478 cases) Type 3 (9 cases) . 2000-2012: polio liar sdh hampir punah.

Tipe 2 komponent dari tOPV harus dihentikan karena menyebabkan > 90% dari circulating vaccine derived poliovirus (cVDPV) pada beberapa tahun terakhir ini *as of 31 December 2014) .

Revised goal for ERAPO: to complete the eradication and containment of all wild. vaccine- related and Sabin polioviruses. .

Penemuan baru yang merubah endgame • type 2 cVDPV is the main 'post-eradication' problem. • New 'IPV' options allow all countries 33 to . • Vaksin bivalent baru (bOPV) terbukti lebih efisien dari vaksin tOPV untuk kekebalan wP1 & wP3 (P2 sdh tidak ada) • merupakan opsi pilihan untuk mengganti tOPV.

2014 Endemic countries Infected countries 359 Israel = Env. last 30 Mar 2014) Gaza = Env. Jan ) . positive isolates ( 2014. positve isolates (2014. N=14 . N=1.Kasus Polio virus tipe 1. 2014 306 Tidak ada kasus polio liar yang terlaporkan di Afrika atau Timur Tengah sejak 11 Agustus.

Kasus Polio liar tipe 1. 350 2012-15* 303 300 2012 2013 2014 2015 250 Tidak ada kasus polio 200 liar yang terlaporkan Cases di Nigeria sejak 24 Juli 150 2014 100 93 53 55 50 37 28 14 6 6 0 Afghanistan 103 Nigeria Pakistan 12 6 6 0 6 6 6 6 6 4 *Data per 18 August 2015 : .

Update terkini ttg cVDPVs : polio 2 Circulating Vaccine-Derived Poliovirus Oubreaks (cVDPVs) 2000-2010 Type 1 (79 cases) Type 2 (450 cases) Type 3 (9 cases) Since 2009. 97% of cVDPV cases are due to type 2 (& 40% of VAPP) 36 .

a new country • 1 case in Equatorial Guinea . All rights reserved . territory.) The boundaries and names shown and the designations used in the maps in this document do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country.No new cVDPV case *New district. city or area or of its authorities.No new WPV case cVDPV .  WHO 2014. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. or concerning the delimitation of its frontiers or boundaries. a new country cVDPV • 1 case in Nigeria 2013 Wild poliovirus . 1 Case was previously reported by advance notification on 28 January but does not yet appear in EMRO official data (awaiting sequencing. governorate and country refer to areas that was previously without WPV in 2014. Highlights of New Wild Poliovirus and cVDPV Cases 2014 Wild poliovirus 4 new officially reported WPV1 cases Data in WHO HQ as of • 2 cases and 2 new district* in Pakistan 18 March 2014 • 1 case in Cameroon.

mencegah cVDPV2 – Memberikan minimal satu dosis IPV. What next • Menggunakan IPV untuk mengganti OPV – Untuk mencegah cVDPV dan VAPP • IPV dalam bentuk vaksin kombinasi – Dalam bentuk pentavalent atau hexavelent • Selama transisi: – Mengganti tOPV dengan bOPV. primming P2 – Meningkatkan imunisasi rutin sampai cakupan >90% – Mempertahankan surveilans AFP agar KLB terdeteksi .

– 95% dari kasus cVDPV ok type 2 • Kasus poliovirus liar type 3 paling rendah selama ini • SAGE Working Group merekomendasikan endgame strategy baru (Sabin 2 cessation) and new polio vaccines. ~40% dari vaccine-associated paralytic poliomyelitis (VAPP) global berasal dari Sabin type 2 (100-200 cases annually). Bagaimana selanjutnya ? Apa yang berubah ? • poliovirus liar type 2 terakhir di temukan di India th 1999 • Lebih dari 10 tahun tanpa poliovirus liar type 2 – Namun . .

Tipe Virus Polio .

Schematic description of tOPV: 3 rings of protection technical rationale for use of at least one dose Type 1 against types 1. 2. and 3 of IPV as part of the Endgame Strategy Type 2 Type 3 bOPV + tOPV-bOPV IPV bOPV + IPV switch IPV adds protection bOPV against type 2 & boosts 2 rings of protection immunity to 1 & 3 against types 1 and (enhancing bOPV effect) 3 Potential Type 2 outbreak mOPV2 mOPV2 requiring mOPV2 bOPV + mOPV2 Protection against bOPV + IPV + mOPV2 type 2 provided by bOPV & mOPV2 effect is supplementary use enhanced in an IPV of mOPV2 in the population thus setting of an facilitating outbreak outbreak control .

India.Bivalent OPV Efficacy & Use Seroconversion after 2 x bOPV bivalent OPV use vs. tOPV. 2008-2009 as of Sept 2011 Introduced Dec 09-Aug 11 Planned by end-2011 Type 1 Type 3 42 .

ok ada interferensi intestinal antar polio Sabin P1. 43 .P3 contoh di India : tOPV 3x kekebalan sekitar 60% • mOPV dan bOPV terbukti cepat – meningkatkan antibodi – Menekan transmisi.P2. namun memunculkan cVDPV terutama yg P2 – Sabin harus dihentikan meskipun “jasa” nya sangat besar • Karena cVDPV muncul sebagai “polio liar baru” WHA merekomendasikan menghentikan OPV. Mengapa b OPV dan IPV • tOPV menimbulkan antibodi secara lambat dan sequential. menghilangkan outbreak secara cepat – mOPV memunculkan WPV 3 sehingga terpaksa menggunakan bOPV (P1 dan P3) – India cepat hilang kasusnya sekalipun cakupannya belum 90%.

Perubahan epidemiologik 2013 • VDPV= OPV yg de attenuated dalam usus manusia • Semula eradikasi ditujukan WPV. baik WPV maupun VDPV • Environmental surveillance : mencari cVDPV tapi ketemu WPV di Israel • Endgame jadi synchronized WPV dan OPV . namun kini termasuk cVDPV dan bahkan oral polio vaccine OPV – Sabine • VAPP dan cVDPV setara dengan WPV secara epidemiologik • Terjadi KLB di daerah cakupan rendah dan miskin.

OPV2 harus dihentikan agar tidak berubah menjadi cVDPV2 • Shift dari tOPV ke bOPV (polio1 dan 3) untuk imunisasi rutin • Primming polio2 dg IPV. kini semua sekaligus • mOPV dan bOPV lebih cepat mengatasi KLB dibanding tOPV • Ok WPV2 sdh lenyap th 1999. • Memperkuat imunisasi rutin dan SAFP harus mampu mendeteksi peredaran polio . Perubahan strategi • Semula WPV baru VDPV.

Potential benefits of 'at least 1 IPV dose prior to OPV2 cessation' a) prevent polio if exposed to a VDPV2 or WPV2 b) improve response to mOPV2 in an outbreak c) reduce transmission of a reintroduced type 2 d) boost immunity to WPV1 & 3 .

• Bilamana strategy berhasil. 47 . penggunaan IPV jangka panjang dapat diperluas dan diperlama sampai tidak ada virus polio apapun beredar.e. • IPV sendirian dapat digunakan menuju end game dengan IPV dalam hexavalent sebagai kunci 'post-eradication'. tOPV-bOPV switch could be prior to 2015).Some Implications for IPV: must be used • OPV should be replace by IPV • Transsisi selama end game • IPV dapat dipercepat penggunaannya (i.

A new 'Endgame' strategy: parallel instead of sequential risk management Last wild polio case trivalent OPV cessation Years 0 2 4 6 8 10 12 Sequential risk Wild virus Certification & VDPV elimination & Post-OPV management eradication containment validation surveillance Parallel risk Wild virus Certification & management eradication containment VDPV2 elimination & Post-OPV validation surveillance OPV2 cessation bivalent OPV 1&3 & IPV introduction (bOPV) cessation 48 .

Potential polio policies for each phase Eradication Global certification Now 2014-15 2018-19 tOPV bOPV Stop all OPV IPV introduction Hexavalent introduction IPV for bOPV in routine Hexavalent IPV for acceleration immunization + routine immunization 1 dose IPV .

Objective 2 of The Plan addresses the Endgame through three distinct
stages

2019-2020

2016
Withdraw
• of bOPV & routine OPV
Switch use
Before end
• tOPV to bOPV
2015

Introduce
• at least one dose of IPV
• into routine immunization

Ongoing STRENGTHENING of routine immunization services
2/23/17 50

Penggunaan IPV: Rekomendasi SAGE

IPV tidak menggantikan dosis OPV

Kubu optimis eradikasi akan dicapai • Sejak tahun 1999 tidak ada WPV2 • Kemungkinan menghilangkan baik WPV3 maupun WPV1 dengan bOPV atau mOPV terbuka • Menghilangkan VAPP dan cVDPV dengan IPV • Polio hanya hidup di usus manusia • Penelitian Yogya : setelah 6 bulan penggunaan IPV . tidak beredar lagi polio Sabin (vaksin) di limbah • Pengamatan selama 4 tahun tidak di jumpai adanya Sabin dari luar propinsi pada limbah sentral Yogya • Transmisi dan imunitas tergantung pada tiap negara .

pertussis • Perlu waktu lama sebelum imunisasi polio dan surveilans AFP bisa dihentikan .Kubu pesimis : mengingatkan ada kendala eradikasi • Imunitas intestinal bisa menurun. sehingga dapat dihuni virus polio lagi • Setelah sertifikasi tercapai akan terjadi penurunan kegiatan imunisasi dan surveialans • Cakupan imunisasi suntikan rendah di beberapa negara • Maintenance program ? KLB difteri. campak.

All rights reserved Data in WHO HQ as of 01 Sept 2015 . Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. city or area or of its authorities. Highlights of New Wild Poliovirus and VDPV Positive Results From AFP surveillance Wild poliovirus No new WPV case VDPV 2 new cVDPV1 cases • 2 cases in Ukraine.  WHO 2015. territory. a new1 country 1 New country refers to an area without cVDPV1 in 2015 The boundaries and names shown and the designations used in the maps in this document do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country. or concerning the delimitation of its frontiers or boundaries.

Wild Poliovirus & cVDPV Cases1. 1 Onset of paralysis 02 September 2014 – 01 September 2015 2 Data in WHO HQ as of 01 Sept 2015 . Previous 12 Months2 Wild poliovirus type 1 cVDPV type 1 cVDPV type 2 Endemic country Excludes viruses detected from environmental surveillance.

Previous 6 Months2 Wild poliovirus type 1 Endemic country Excludes viruses detected from environmental surveillance. 1 Onset of paralysis 02 March – 01 September 2015 2 Data in WHO HQ as of 01 Sept 2015 . Wild Poliovirus Cases1.

cVDPV Cases1. 1 Onset of paralysis 02 March – 01 September 2015 2 Data in WHO HQ as of 01 Sept 2015 . Previous 6 Months2 cVDPV type 1 cVDPV type 2 Endemic country Excludes viruses detected from environmental surveillance.

3/100.000 person-years with VC of 84% • 2. Lancet 1998. Balraj V. Indian J Med Res 2004. OPV in several field intervention studies • Intervention study in Tamil Nadu (1987-1992) by ICMR • 2. John R.4/100.B69:393-422 59 John TJ. Samuel R.000 person-years in the year following introduction in each block John TJ.John and co-workers demonstrated in India that IPV induced higher and consistent immune response vs.5 million received OPV: incidence dropped from 9 to 0. J.5 million received IPV: incidence dropped from 14 to 0.119:1-17 .000 person-years with VC of 95% • Intervention study in Mumbai slums (1988-1991) by R.000 population over a 3-year period from 1988 to 1990 • Incidence dropped to 0/100. Proc Indian Natl Sci Acad 2003.352:58-61 John TJ.Patel • Successive introduction of IPV in 3 blocks of 100.

IPV introduction program in the Yogyakarta province of Indonesia: High impact on vaccination coverage.571.865 with an annual birth cohort of 52. Stakeholder meeting. PV circulation and seroprevalence • Switch from an OPV-only to an IPV-only schedule (“condensed 3+1”) in Sept 2007 in a population of 3. 25 – 26 April 2012 60 .723 • No drop in vaccination coverage rates during 4 consecutive years of follow up (remained > 95%) • Environmental sampling (inlet sewage) – Maintenance of absence of WPV circulation – Very rapid decrease of isolated PV with only 5 samples with Sabin like and no VDPVs (but 24 out of the 55 months period of F/U were missed) • Seroprevalence and dose 3-to-dose 4 seroconversion survey done on 188 infants revealed 100% SP post-dose 3 and increase in GMT from dose 3 to dose 4 IPV Introduction Project in Yogyakarta.

China (3). intensity. Mexico. UK. duration and genetics of PV excretion after OPV vaccination / challenge • Several types of IPV-containing vaccines – IPV stand-alone – wP-based combinations – aP-based combinations 61 . Brazil.IPV-followed-by-OPV regimen have been the most documented • 13 trials done with several types of IPV-containing vaccines in 7 countries since 1986 – USA (5). 3+1 or 3+0 regimen • No OPV given at birth in all cases • Several types of study design – Non-randomized descriptive-only licensing or launch studies or RCTs between sequential schedules and IPV-only and / or OPV-only schedules – Some trials have investigated prevalence. Taiwan & Guatemala • 1 or 2 IPV followed by 1 or 2 OPV administered as 2+1.

IPV-followed-by-OPV regimen is the most relevant from a Public Health perspective • Address the VAPP issue • Combine the full benefit of both vaccines in terms of breath of immune responses (mucosal and humoral) • The incorporation of at least one dose of IPV at the start of the immunization schedule increase post-primary series Ab levels compared to OPV-only schedules • I-I-O primary series during the first year of life schedule is the best performer in terms of absolute post-primary series antibody levels (versus OPV-only) • Two doses of IPV during the first year of life schedule is able to reduce prevalence. intensity and duration of PV excretion following an early OPV vaccination / challenge compared to 1st time OPV-recipients • Hypothesis that prior IPV might result in faster excretion of revertant virus after PV infection (by OPV) is not confirmed 62 .

pre-terms 63 . 3+0. adolescents.and post-licensure clinical trials or intervention studies done in more than 50 countries since 1977 • Product performances documented – In primary immunization in infant / toddlers • IPV-only regimen (2+1. adults and elderly – In special populations: HIV+. IPV-containing vaccines have demonstrated excellent and consistent immunogenicity profile whatever conditions of use • Extensive database with various IPV-containing products (15) used in many countries • More than 300 pre. bone-marrow transplanted. 3+1) • IPV-followed-by-OPV sequential regimen • IPV-only regimen supplemented by OPV NIDs or by OPV SIAs • Mixed / Combined – IPV / OPV regimen • OPV-followed-by-IPV sequential regimen • All these regimen completed or not with OPV at birth – As a polio vaccine in adolescents and adults with unknown vaccination histories with a 2- dose regimen – As a polio immunity booster in pre-school children.

seroprotection against poliovirus • 89-100% against type 1 • 92-100% against type 2 • 70-100% against type 3 • Immunogenicity expectedly reinforced after 3rd dose – In 48 trials involving >6000 subjects. IPV-containing products do induce seroconversion and seroprotective levels in almost all subjects after two doses • Immunological priming documented after 1st dose • High immunogenicity after 2nd dose – In 30 trials involving >4500 subjects. 95-100% seroprotection rates against all 3 types 64 .

Inclusion of IPV • Protection against possible cVDPV type 2 only through IPV under new plan • The most medically.and epidemiologically-sounded regimen is the IPV-followed-by-OPV sequential schedule made of « I – I – O – O » given as a “3+1” • Switching to aP-IPV combos is by essence adopting an IPV-only regimen • The clinical performance of the WHO-proposed regimen is not yet fully documented 65 .