25th Meeting of the India Expert Advisory Group
for Polio Eradication (IEAG)
Delhi, India, 3 May 2013
Conclusions and Recommendations
The twenty-fifth meeting of the India Expert Advisory Group (IEAG) was convened on 3 May 2013 in Delhi, with the following objectives:
1.To review progress on polio eradication since the twenty-fourth meeting of the IEAG in March 2012;
2.To make recommendations on strategies to ensure the maintenance of polio-free status in India.
3.To make recommendations on polio vaccination strategies during the post eradication phase.
The meeting was co-chaired by Mr. K. Desiraju, Secretary (Health and Family Welfare), Ministry of Health and Family Welfare, Government of India, and Dr Jagadish Deshpande, Director, Enterovirus Research Centre (ICMR), Mumbai. A list of IEAG members and the special invitees that attended the meeting is annexed. The IEAG was pleased to have the participation of Dr Jagdish Prasad, Director General Health Services, Ms. Anuradha Gupta, Additional Secretary& Mission Director, NRHM, Dr Rakesh Kumar, Joint Secretary, MoHFW, Government of India and representatives from the States of Bihar, Uttar Pradesh (UP) and West Bengal. In addition, core partner agencies (WHO, Rotary International, UNICEF, and CDC) were represented as were the Bill and Melinda Gates Foundation, USAID, CORE and DFID.
The IEAG met in the context of three major developments for India and globally:
India has now been free of polio for more than 24 months and the South East Asian Region has begun the process of certifying polio-free status;
Poliovirus circulation is rapidly declining globally; to date in 2013 only 3 countries have reported cases, and case numbers are less than half for the same period in 2012, itself the lowest year on record; the only country with wild poliovirus type 3 during the past 12 months being Nigeria.
Post-eradication policy issues for immunization aimed at keeping the world polio-free are assuming increasing importance.
The IEAG was posed the following questions by the Government of India:
1.Is the proposed number and scope of supplementary immunization activities (SIAs) in 2013-2014 sufficient to maintain high population immunity? What is the number and scope of SIAs that should be planned for 2015?
2.Is the emergency preparedness in the country adequate to respond rapidly and effectively to importation of wild poliovirus or emergence of circulating vaccine derived polio viruses (cVDPVs)?
3.Is poliovirus surveillance in India good enough to rapidly detect poliovirus circulation/importation?
4.What additional steps should India take to mitigate the risk of importations?
5.What are the next steps to finalize the timing of the inactivated polio vaccine (IPV) dose in the routine immunization schedule in India?
6.Are there other operational assessments required to optimize the switch from trivalent oral polio vaccine (tOPV) to bivalent OPV (bOPV) and IPV introduction?
7.Are the proposed research studies sufficient to mitigate risks due to potential gaps in bOPV supply for routine immunization (RI) and for IPV supply requirements for post-switch boosting?
8.Are the areas that the polio network is currently supporting in routine immunization appropriate? Are there any additional areas that the programme should be looking at to support broader immunization goals?
9.How does the IEAG recommend transitioning the polio human resources and skills to benefit other programmes, while maintaining a thorough response capacity for polio?
India has not reported any case of confirmed polio due to wild poliovirus (WPV) for more than 24 months; the last confirmed case due to the WPV had onset on13 January 2011. One case due to vaccine derived poliovirus (VDPV) has been detected each in 2012 and 2013. There is no evidence that any of these VDPVs were circulating or had any relationship with the circulating VDPVs (cVDPVs) detected in 2009 and 2010 in India. Since the last WPV case, an extremely high standard of surveillance quality has been maintained, along with a sustained high level of population immunity. The continued strong oversight and support to the polio eradication effort, in the absence of poliovirus circulation, reflects great credit on the Union and State governments for their strong commitment to completing eradication, including through the provision of substantial financial resources, implementation of previous IEAG recommendations and, most importantly, identifying and addressing programme weaknesses, and reaching high risk areas and populations with high quality immunization and surveillance activities. The challenge for India now is to remain polio-free until the global eradication of all circulating wild polioviruses.
The risks to India’s polio-free status remain the same as at the time of the 24th meeting of the IEAG, namely:
1. International importation of wild poliovirus. As noted previously, the most significant risk is the importation of wild poliovirus from remaining countries with endemic circulation. Despite the reduction in WPV transmission globally, the endemic zones of Pakistan, Afghanistan, and Nigeria continue to constitute a risk. Additionally, the possibility of outbreaks in non-endemic countries leading to spread that threatens India cannot be discounted.
2. The development of circulating vaccine derived polioviruses (cVDPVs). Although no circulating VDPVs have been detected in India since 2010, experience demonstrates that cVDPVs (particularly cVDPV type 2) can develop if there are pockets of population with very low immunity against polioviruses type 2. The regular use of tOPV in national campaigns in the past 3 years has reduced the risk of type 2 cVDPV emergence in India, but some level of risk remains.
IEAG Conclusions and Recommendations
The questions posed to the IEAG fall essentially into four groups; first is the issue of maintaining high levels of population immunity; second is the capacity to reduce the risk of importation, and to detect and respond to importations of wild poliovirus or outbreaks of cVDPVs; third is the development of post-eradication immunization policy; and fourth is maximizing the impact of polio eradication on broader immunization goals in India. The recommendations below aim to answer the questions posed to the IEAG by the Government of India and to outline the strategies and activities needed to mitigate the risks outlined above.
Annual serological surveys tracking the immunity levels of children in the highest risk areas of UP and Bihar show that the current regime of supplementary immunization activities, coupled with improvements in routine immunization in these areas, have led to the achievement and maintenance of high levels of immunity against all three poliovirus serotypes. The IEAG therefore continues to believe that both supplementary immunization and enhanced routine immunization are needed to maintain high population immunity against poliviruses until global eradication is achieved, to minimize the impact of any WPV importation, and to ensure that cVDPVs do not develop.
OPV Supplementary Immunization Activities (SIAs) Schedule
The IEAG recommended the following for the period from May 2013-2015.
Polio SIAs for the remainder of 2013:
• As per current national plans, three large scale SNIDs with bOPV, targeting all of UP, Bihar, Delhi and associated high risk areas of Haryana, Rajasthan, and Uttarakhand, and migrant/high risk areas in Maharashtra, Punjab, Gujarat, Jharkhand, and West Bengal.
Polio SIAs in 2014:
• As per previous IEAG recommendations, two NIDs with tOPV in all areas in 1st quarter of 2014
Three SNIDs with bOPV, ideally one in each of quarters 2, 3, and 4 of 2014 targeting all of UP, Bihar, Delhi, and associated high risk areas of Haryana, Rajasthan, and Uttarakhand, and migrant/high risk areas in Maharashtra, Punjab, Gujarat, Jharkhand, and West Bengal
Polio SIAs 2015: 2 NIDs+2/3 SNIDs
• Two NIDs with tOPV in all areas in 1st quarter of 2014
• Two to three SNIDs with bOPV (depending on global epidemiology) targeting all of UP, Bihar, Delhi, and associated high risk areas of Haryana, Rajasthan, and Uttarakhand, and migrant/high risk areas in Maharashtra, Punjab, Gujarat, Jharkhand, and West Bengal.
The timing of sub-national rounds should be at the discretion of the national programme and based on operational and epidemiological considerations.
Quality of supplementary immunization activities
It is absolutely essential that the current high quality of the Polio SIAs (Pulse Polio campaigns) be maintained to obtain the maximum possible benefit of SIAs on population immunity. State Governments should ensure that full attention is paid to maintaining the highest possible quality of SIA rounds, and quality should continue to be closely monitored and tracked at district, state, and national level.
Serological surveys to determine immunity levels
Detecting and responding to importations and outbreaks
The IEAG believes that the Acute Flaccid Paralysis (AFP) surveillance and laboratory system is performing at a very high standard and is adequate to provide early detection of importations and outbreaks. The IEAG also believes that the emergency response system put in place by Union and State Governments is currently adequate to generate a rapid and effective response. The main risk to maintaining the quality and effectiveness of surveillance and emergency response systems is complacency and the waning of a high state of alert over time.
Surveillance and laboratory
Reducing risks of importation
While the IEAG was not asked specifically about the certification process, presentations referring to that process were made. Given the critical importance of India’s input to the certification process in the region and globally, and the imminence of the Regional Certification Commission’s consideration of the regions status, the IEAG recommended:
Post-eradication policy and preparing for the endgame
With the preparations of the South-East Asian Region for regional certification of polio-free status early in 2014, the polio endgame planning for the post-eradication era in India and the region is therefore now a priority. This planning revolves around the sequential removal of oral poliovirus vaccines from routine use, the introduction of inactivated polio vaccine as a risk mitigation strategy prior to this process, and the eventual documentation of the absence of any live poliovirus outside appropriately contained facilities.
Planning for the tOPV/bOPV switch
The national immunization programme should incorporate into its planning the switch from tOPV to bOPV for routine and supplementary immunization, potentially in 2016, and the eventual cessation of use of bOPV at some point in the future. This will require assessment of vaccine needs and licensed supplies for bOPV.
IPV introduction process
The ICMR expert group should study the proposal for a routine single intramuscular dose of IPV at the DPT3 contact in order to facilitate introduction in 2015 in advance of the global tOPV/bOPV switch, and should finalize recommendations on the subject by the end of July 2013, taking into account the findings of the SAGE Polio Working Group meeting in June 2013.
Mitigating the risk of vaccine supply gaps
The Government of India and partners should carry out a cold chain assessment within the next 12 months taking into consideration requirements for all new vaccine introductions including IPV.
Building on Polio Eradication
The IEAG appreciated the clearly laid out plan for using polio networks and experience to support the improvement of routine immunization as part of the Government’s Year of Intensification of Immunization, and considers the areas of work outlined in the plan to be very appropriate. Substantial progress has already been made in these areas of work, in particular with the institutionalization of State and District Immunization Task Forces for immunization, in the incorporation of high risk communities into routine immunization microplans, building capacity of frontline workers on routine immunization and in the development of integrated communications strategies and use of the communications network to promote immunization. However, further work needs to be done to maximize the benefit of the polio infrastructure and experience for broader immunization goals. The achievements of the Government and partners in establishing the structures and skills necessary to eradicate polio from India is widely respected and rightly regarded as a model of how public health programmes can reach extremely high standards even under very difficult circumstances; it will be crucial to maintain these structures and skills through to global certification and the transition period beyond.
Strengthening Routine immunization
The IEAG endorsed the plans for using the polio network and experience to strengthen routine immunization, with a particular focus on high risk areas and groups, and urged the Government of India to extend the period of intensification of routine immunization beyond 2013.
Broadening the impact
Maintaining the capacity of the polio network
The IEAG urged the Government of India, partners, and donors, to invest in maintaining the human, material, and financial infrastructure of polio eradication until the process of eradication of all poliovirus globally, and the implementation of post-eradication immunization policy, is completed.
List of India Expert Advisory Group Members
List of Special Invitees