1. Conclusions &
Recommendations
24th IEAG
March 2012

2. Context – a polio free India!
2010*
No WPV from any source since
January 2011
India is no longer an endemic
Last detected case January 2011
country!
* data as on 30 October 2010

3. But risks remain……

4. Questions to the IEAG
• What are the challenges that India is likely to face in
maintaining polio-free status?
• What lessons from other countries can be applied in
India to protect the programme gains?
• What strategies should India follow in 2012-2014 to
sustain polio-free status?
• Is isolation of VDPVs a concern for India?
• How should India plan for the polio endgame strategy?

5. Risks
• Importing WPV
• Development of cVDPVs

6. Lessons
• Its not over until its over
everywhere
• 'The price of freedom is
eternal vigilance'

7. Challenges
• Maintaining immunity
• Maintaining surveillance
• Readiness to respond
• Reducing risk
• Building on polio
• Preparing for the endgame

8. Maintaining immunity

9. Objectives of SIA strategy
• Maintain high levels of immunity
especially in high risk areas and
populations
• Protect against both WPV & VDPVs

10. Recommended SIA calendar, 2012
conducted planned
NID with tOPV SNID with bOPV

11. Recommended SIAs, 2013-14
2013 NID with tOPV SNID with bOPV
2014

12. Maintaining
surveillance

13. Surveillance performance indicators, last 6 months
Non-polio AFP rate Stool collection rate
14.3 AFP cases, Jan – Feb
# 86%
India
Less than 60%
60% to 69%
70% to 79%
80% and above
No AFP case

14. Recommendations: Surveillance
• Expand environmental surveillance: Punjab & Gujarat
• Conduct planned field reviews & act on gaps
– urgently address the issues identified in Andhra Pradesh
• Involve district / block level government staff in all
components of AFP surveillance
– response to AFP case reporting, sensitization of the existing
reporting network, regular review of surveillance database etc
• Laboratory human and financial resources should be
ensured to maintain high performance

15. Readiness to respond

16. Recommendations: Response
• The new state EPRPs should be reviewed and
evaluated by GOI and partners by the end of
April 2012
• National & state EPRPs should be updated at
minimum annually
– updates must include a full new risk analysis to
inform risk mitigation measures.
• Conduct simulations of the emergency
response plans at national and state levels

17. Recommendations: Planning for response
• State EPRPs must adequately address:
– Plans for overcoming staff vacancies in high risk areas;
– Systematic inclusion of high risk areas & populations for
RI strengthening;
– Timeline for harmonization of SIA and RI microplans in
high risk areas;
– Assignment of HR districts to Rapid Response Team
members (RRT) for regular review of RI, SIA and
emergency preparedness;
– Assessment of communication risks and social mapping;
– Identification of media spokesperson;
– Plans for procurement of logistics and IEC materials for
undertaking urgent mop-ups.

18. Reducing risk

19. Recommendations: Communications
• Maintain SMNet and other ground-level initiatives (e.g. through
ASHA & Anganwari Workers) in traditional polio reservoirs and
in newly emerging high-risk areas until risk is gone
• Appropriate social network research should be carried out in
key high risk areas to inform programme actions
• Document and share experience & best practices, including
elements of the SMNet, media engagement and utilization of
data for identification, tracking and engagement of high-risk
populations
• All communication efforts, including SMNet, at all levels adopt
promotion of routine immunization as a primary message in all
public communication

20. Recommendations: OPV supply
• All pre-qualified global OPV producers not yet licensed in India
should be encouraged to apply for & complete the licensing process
• Considering the risks to vaccine supply DCGI should fast track the
licensing process for already pre-qualified vaccines.
• GoI should continue to ensure a 50 million dose rolling emergency
stock (40 million bOPV & 10 million tOPV) to enable rapid response
• GoI should plan for a 24 month time frame for OPV procurement
• To facilitate timely procurement of OPV for SIAs only
– the standard vaccine shelf life can be reduced to 60%
– the requirement for primary vaccine vial packaging indicating the product is not
for sale be waivered (still required for secondary and outer packaging)

21. Reducing risk - importation
• Immunization of travellers at border crossing
points should continue until there is no longer
an epidemiological risk.
• Particular attention should continue to be paid
to border populations to ensure that they are
effectively covered by SIAs and routine
immunization.

22. Reducing risk - VDPVs
• All detected VDPVs should continue to be
thoroughly and rapidly investigated to determine
risk of circulation
• Any evidence of circulation - mop-up response!

23. Building on polio

24. Where are we missing the maximum
number of children?
69% of partially and
un-immunized
children in 6 states:
•Uttar Pradesh
•Bihar
•Madhya Pradesh,
Data not available
Below 5 %
•Rajasthan
5 % - 10 %
>10 % - 25%
•West Bengal
>25 %
•Jharkhand
Source: CES 2009; Full immunization of children surveyed 12-23 months

25. 2012-2013: Year of intensification of UIP

26. Recommendations: RI
• State EPRPs and Year of Intensification of UIP
plans to be consolidated and operationalized
– monitored timelines and milestones
– focus on high risk and migrant populations
– urban and peri-urban populations
• Focus on 239 high risk districts
• Conduct Immunization Weeks in in NE states, UP,
Bihar, MP, Rajasthan, Gujarat and Jharkhand
• Priority to ensuring ANMs and MOs are present in
HR areas in priority states

27. Recommendations:
• Surveillance for vaccine preventable diseases
should be expanded based on the experience &
structure of the AFP surveillance system
• The communications and operational experience of
polio eradication should inform other disease
control initiatives including measles elimination

28. Preparing for the
endgame

29. Recent developments
• SAGE Nov 2011: recommended that the endgame
strategy be based on phased rather than simultaneous
Sabin strain removal
• WHO Executive Board Jan 2012: requested Director-
General to develop comprehensive endgame strategy
and timeline based on phased Sabin strain removal
• SAGE Apr 2012: may consider an 'early switch' (by Apr
2014), preceded by universal introduction of at least 1
dose of IPV (ID or IM) at DPT3 contact.

30. IEAG Conclusion: 'Endgame'
Following the WHO Executive Board resolution of
January 2012 endorsing eventual replacement
of tOPV with bOPV globally, India should start
preparing appropriate policies, esp. on the role
of IPV, guided by and considering the global
recommendations of SAGE.

31. Recommendations: 'Endgame' planning (1)
1. The national immunization programme should now
begin incorporating into its planning:
(a) an eventual tOPV-bOPV switch globally,
potentially as early as April 2014, and
(b) eventual cessation of all remaining bOPV globally
at some point in the future (e.g. 2017-18 period).

32. Recommendations: 'Endgame' planning (2)
1. This planning should include consideration of
the introduction, in advance of a tOPV-bOPV
switch, of at least one dose of IPV (e.g. at
DPT3 contact), to boost population immunity
thereby reducing the risk of a type 2 cVDPV
emergence & the consequences of a potential
cVPDV.

33. Polio Endgame Strategy-India,
Potential Timeline tOPV-
bOPV
switch
Polio
Last WPV certification
case
NID NID NID NID NID NID NID NID
IPV intro? Post-
switch
VDPV
Modelling, Research, Development type 2
risk mgt.
Certification standard surveillance, improved RI coverage
0
J an Mar May J ul S ep Nov J an Mar May J ul S ep Nov J an Mar May J ul S ep Nov J an Mar May
2011 2012 2013 2014
tOPV NID

34. Recommendations: 'Endgame' planning (3)
1. convene a small consultation with IEAG members in
mid-2012, following the SAGE (April) and World
Health Assembly (May), to facilitate national
deliberations on the timing and IPV policy options
for a tOPV-bOPV switch.
2. begin examining the programmatic and cost
implications of adding at least 1 IPV dose to the
routine EPI schedule (e.g. at the DPT3 contact) in
advance of a global tOPV-bOPV switch.

35. Recommendations: 'Endgame' planning (3)
• include an examination of implications (pros/cons)
of delivering IPV as a fractional (1/5th) dose intra-
dermally (ID) vs. a full dose intramuscularly (IM).
• consolidate the considerable IPV study data already
existing in India, including from licensing trials, to
help inform policy options.
• finalize & start the planned trial to verify the
immunogenicity & programmatic feasibility of a
'bOPV + 1 dose of IPV (ID or IM)' routine schedule.

36. Recommendations: Research
1. implement the planned research agenda, giving
priority to:
(a) complete the mucosal immunity study,
(b) conduct a new seroprevalence survey,
(c) initiate the planned immunogenicity study with
bOPV from multiple manufacturers, and
(d) finalize the protocol for the trial to verify
immunogenicity, programmatic feasibility of a
'bOPV + 1 dose of IPV (ID or IM)' routine schedule.

37. Protecting the
investment

38. GoI, partners, & donors
must maintain the human,
material, & financial
infrastructure of polio
eradication until global
certification