deliberations of the ieag 18-19 november 2009. ieag issues – federal & state gov'ts why...
TRANSCRIPT
IEAG Issues – Federal & State Gov'ts
• Why isn't epidemiology for type 1 and type 3 fully meeting IEAG projections despite intensity of activities (in terms of cases)?
• Given the very highly focal nature of polio now in India, can the scope of national & sub-national activities be reduced to better target efforts?
• Recognizing the importance of improving routine immunization can the work of 'B-teams', esp. in reservoir areas, be merged with 'Village Health & Nutrition Days' to optimize health impact?
IEAG Issues - Independent Evaluation
• What are the implications of the Evaluation's finding that the major barrier now in India is the incomplete nature of gut mucosal immunity coupled with the uniquely high force of infection seen in west UP and central Bihar?
• How should the recommendations of the Evaluation be translated into specific research and SIA activities?
The epidemiologic, virologic,
genetic, operational &
technical evidence do suggest
that India is still on the right
path to finish eradication.
2002 2003
1600 cases in 159 districts
225 cases in 87 districts
134 cases in 43 districts
2004
66 cases in35 districts
2005
676 cases in114 districts
2006
874 cases in99 districts
2007
Polio Cases - India
…the geographic scope of both type 1 & 3continues to be further reduced
2008 2009
Type 1 = 8 states
Type 3 = 10 states
Type 1 = 5 states
Type 3 = 5 states
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About 100 blocks in west UP & central Bihar now hold the key to eradication in all India
HR Blocks
WPV1 - 2008
WPV1 - 2009
WPV3 – 2004 & 2005
What has been so special about these 100+ high risk blocks?
1. Persistent gaps in OPV coverage
2. Suboptimal seroconversion to tOPV
3. Incomplete gut mucosal immunity
4. Very high force of infection
Challenges to Polio Eradication, India
Who is sustaining transmission?
Very young: definitely
Migrants: yes
Older children: maybe(?)
How do we know young children are still transmitting polio?
Age-distribution of confirmed cases
WPV1 polio cases
WPV3 polio cases
Is young child immunity improving?Comparison of Moradabad 2007 & 2009
Study Seroprevalence study(N=923)
Baseline 5 arm study (N=1002)
Period November 2007 April 2009
Age groups 6-9 mths 36-59 mths 6-9 mths
Sero-positive P1 81% 99.8% 99%
Sero-positive P2 63.% 97.% 72%
Sero-positive P3 71% 93% 48%
0
10
20
30
40
50
60
70
80
90
100
6 to 11 12 to 23 24 to 59
type 1 type 2 type 3
% s
erop
ositi
ve
N = 140 N = 330 N = 317
Is young child immunity improving across west UP (Sept 2008-Aug 2009)?
How important are migrants to eradication? WPV1 cases by migration status, 07-09*
Rest of India
(N= 31)
* data as on 30 october 2009
Non epidemic UP*
(N= 54)
*Non epidemic UP excludes Moradabad, JP Nagar,Badaun, Kanshi ram nagar, Bareilly and Rampur dists of UP
Source of data : NPSP monitoring
N= 47,378 19,094 81,283 113,044 130,29052,243 122,161
% u
nim
mun
ized
66,005 65,491
Are migratory/ mobile communities getting better vaccinated (UP)?
*data 3 November 2009
Are older children contributing to transmission of wild poliovirus?
Age of vaccine-virus excretion, 2005-2009*
Preliminary data on studies of poliovirus in older age groups
West UP AFP sampling Type 1 Type 3
Polio cases with extended sampling 15 33
Number with results available 3 4*
Number of extended contact samples 105 148
Number of contacts positive for WPV
<5 years
5 to 15 years
over 15 years
1
5
2
5.3 %
9.6 %
5.9 %
4
6
0
10 %
9.7 %
0.0 %
Kosi River community sampling (N = 798) Type 1 Type 3
Number positive for WPV
<5 years
5 to15 years
over 15 years
3
3
1
1.9%
1.4%
.2%
2
2
0
1.2%
.9%
0.0%
Three things are absolutely essential at this critical point:
1) sustain intense effort to close coverage gaps in highest risk groups (young children & migrants) & highest risk blocks.
2) introduce bOPV to close type 3 humoural & mucosal immunity gaps
3) immediately research the impact of new tools to boost mucosal immunity in different age groups.
mOPV1
IEAG Endorses SIA Plan for Nov & Dec 2009
Nov Dec
Mix of mOPV1 & mOPV3
mOPV3 will be used in the UP Districts that have not conducted 2 type 3 rounds in the past 6 months
All data suggest type 3 is very sensitive to 2 x mOPV3 & should come under control quickly
* data as on 31 October 2009
mOPV3Jul & Oct
mOPV3Oct
mOPV3Oct
IEAG Rec: Scale of NIDs
• Maintain nationwide scope for Jan-Feb 2010
• Planning to scale down 2011 NIDs should be based on (a) routine OPV3 (e.g. >85% to minimize VDPV risks), & (b) importation risk (based on history).
• An analysis of these risk factors should be presented at the next IEAG to guide finalization of 2011 NID plans.
IEAG Recommendation: NIDs, Jan-Feb 2010
bOPV tOPV
Target (mn) 12.2 161.3
Vaccine (mn)
15.9 206.3
bOPV tOPV
Target (mn) 29.1 144.4
Vaccine (mn)
37.8 184.4
IEAG Recommendation: SIAs, 2010
Aug Sep Oct Nov
NIDs
SNIDEndemic & risk states
mOPV1tOPV/bOPV
Dec
SNIDHR Zones UP/Bihar
bOPV (1&3)
Mar Apr May Jun JulJan Feb
mOPV MOP-UPsInfected Districts
mOPV3
SNIDHR Zones UP/Bihar
SNIDEndemic & risk states
IEAG Recommendation: bOPV
Given the importance of bOPV in the India eradication strategy, priority should be given to national licensure of all national & off-shore bOPV products as soon as they become available
NOTE: GSK bOPV currently the only licensed & bOPV pre-qualified product.
IEAG Rec: Scale of SNIDs
• Maintain planned scope for at least Apr-Jun 2010, recognizing (a) continued risk of spread of type 3 outbreak in west UP, and (b) uncertainty on dates of bOPV introduction and its impact.
• The IEAG should review the epidemiology, bOPV impact and seroprevalence data by mid-2010 to decide scope of SNIDs beyond July.
7008639021026
0
200
400
600
800
1000
1200
2007 2008 2009 2010
Impact of ongoing targeting of SIAsChildren vaccinated in campaigns, India, 2007- 10
Num
ber
of c
hild
ren
(mill
ions
)
Year
IEAG Recommendation: Mop-ups
From Nov 2009 to May 2010:– mop-up WPV1 anywhere in India
– mop-up WPV3 outside west UP or central Bihar
From June 2010:
– mop-up any WPV 1 or 3 anywhere in India.
mOPVs are the vaccine of choice for mop-ups.
Mgnt, speed of response & extent per IEAG recs.
IEAG Rec: SIA Operations (1)
• The IEAG concurs with GoI and state proposals to expand the 'B-team' activities to deliver a broader range of interventions through Village Health & Nutrition Days (VHNDs).
• However, the IEAG proposes that this approach be introduced in a phased manner to understand both the operational issues and the impact, if any, on OPV/SIA coverage.
IEAG Rec: SIA Operations(2)
• Geographic Focus: high risk blocks of west UP and central Bihar.
• Demographic Focus: high risk groups which include young children and migrant populations.
• Other Operational Issues: use work on JE & planned measles campaigns to assess logistics of (a) an OPV round in older children, (b) an IPV round in young children, if either are needed.
IEAG Recs: Comms & Social Mobilization
In the context of the Oct 2009 Communications Review:
• endorses the 3 principles of the 2010-13 Strategy (incl. promotion of RI, zinc, breastfeeding, hygiene/sanitation).
• IEAG stresses the continued focus of the SMNet on migrants & nomads, with intensified transit mobilization linked to improved operations coverage to reach all mobile groups (e.g. beyond trains).
• IEAG welcomes the new district/block communications profiles (esp. to deal with resistence) and supports the rapid roll-out of this tool.
IEAG Recs: Research
• Conduct seroprevalence surveys in Jan & June 2010 in 'core districts' of west UP & Kosi River, Bihar to document bOPV impact & guide strategy.
• Give high priority to study mucosal immunity & impact of bOPV vs. bOPV+IPV in west UP (different age groups; target – March 2010).
• Based on analysis of full enhanced surveillance data, consider implications for further studies in west UP & the Kosi River area, Bihar.
• Environmental sampling: initiate the Delhi sampling & expand sites to include Patna.
• 1 vs. 2 stool sample collection from AFP cases: given lab workloads, NPSP to analyze whether gains in the sensitivity of WPV detection continue to warrant collection of a 2nd specimen.
IEAG Recs: Poliovirus Surveillance
• IEAG is impressed with the data from Bihar demonstrating that real progress can be achieved on routine, during an intensive eradication effort.
• IEAG recommends documenting and disseminating the findings from Bihar to areas struggling to improve routine.
IEAG Recs: Routine Immunization
Evaluated Coverage Estimates of Fully Immunized children in Bihar and UP, 1992-2008
11 12
21
32.838
41.4
55.26
20 2026
23
3730
0
10
20
30
40
50
60
70
80
90
100
NFHS I (1992-93) NFHS II (1998-99) DLHS II (2002-04) NFHS-III (2005-06) CES (2006-07) DLHS (2007-08) Survey by ***FRDS
Bihar UP Linear (Bihar)
*** Immunization Survey carried out by SHSB outsourced to FRDS (Formative Research & Development Services) in the 2nd, 3rd & 4th quarter of 2008 (completed in 30 randomly selected districts).
Data sources: NHFS, DLHS, CES & FRDS
Percent Fully Immunized
India is on the right path to
finish eradication.
The new tools & tactics will
help states to accelerate and
ensure eradication.
The key to success will be
continued innovation, building on
the current successes, the results
of ongoing programme evaluation
and new research.