POLIO ERADICATION

june 2014

Benefit Risks as evolution of time

OPV vs. IPV

POLIO ERADICATION | 2

POLIO ERADICATION | 3

The fight against poliomyelitis has been lasting for more than 60 years

1938 1955

USA:

1st IPV

Jonas Salk

Thomas Francis Trial

Cutter Incident

1908

Landsteiner

(Vienna)

Discovery

of Polio virus

1988

GPEI

UNICEF

WHO

US-CDC

Rotary

1963

USA:

1st OPV (t)

Albert Sabin

USSR

VAPP

1982

Inst. Mérieux:

e-IPV

Kolda Trial

40/8/32

1952

USA:

57, 000

cases

21, 000

paralysed

children are

the most

affected

POLIO ERADICATION | 4

The vaccine race: two approaches Sabin / OPV - Salk / IPV

Albert Sabin, OPV (left), Jonas Salk, IPV (right)

All elements of the debate are already there

for the next 60 years

PolioEradication

June2014

The birth and life of GPEI

POLIO ERADICATION | 6

The 80s:Large Operations around Vaccine

● 1980 Certification of smallpox eradication

● 1983 First Meeting for the next eradication

● Scepticism and enthusiasm

● Measles or polio?

● 1984 Launch of the EPI

● 5% coverage estimated in poor countries

● Debate : Horizontal or Vertical programs

● Little progress in improving coverage

● 1988 Polio!

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● Feasibility more at reach than measles

● USA

● Seasonality

● OPV cheaper, most abundant than measles vaccine

● Rotary fund…for polio, not for measles

● Prestigious sponsors

● A Legitimate Champion: Ciro De Quadros

…and what a champion!

Why polio?

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The eradication strategymodel PAHO / « Ciro »

● Well articulated program, with strong strategic pillars :

● High routine coverage

● Systematic monitoring flaccid paralysis

● Regular campaign (SIA)

● Mop-up campaign (0 to 5 years)

● The Strategy is besed exclusively upon OPV :

● Cheap, many suppliers, easy to administrate

● Supposed to provide gut immunity

● Transmission of vaccine virus to the environment (seen as an important

advantage at that stage)

● Rare vaccine contamination, acceptable ...

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0

50

100

150

200

250

300

350

400

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

0

100

200

300

400

500

600

700

800

Polio cases[thousands]

1995PAHO

Polio free

1980 1999

1999Type 2 eradicated

2000Objective

Polio Eradication!

1988 GPEI Launch

Budget polio[Million US$]

Polio Eradication:

June2014

From OPV to IPV

POLIO ERADICATION | 11

2000 2009The Lost Decade?

0

50

100

150

200

250

300

350

400

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

0

100

200

300

400

500

600

700

800

Polio cases[thousands]

1995PAHO

Polio free

1999Type 2 eradicated

2000Objective

Polio Eradication!

1988 GPEI Launch

Budget polio[Million US$]

POLIO ERADICATION | 12

Polio Cases[thousands]

0

2

4

6

8

10

12

14

16

18

20

1998 2000 2002 2004 2006 2008 2010

Budget polio[Million US$]

0

100

200

300

400

500

600

700

800

2005mOPV1

Budget

Forecast

(2003)2002

EURO areaPolio Free

2001Lowest

Polio level

2000WPRO area Polio Free

20001st C-VDPV

2000 2009The Lost Decade?

POLIO ERADICATION | 13

2005 The Egyptian CrisisThe arrival of a new OPV Vaccine

December 2004 :1 case

12 environmental positive samples

(2003)

February 2006 :

Egypt Polio Free

New weapon

Confidence settles down : GPEI & Industry !

May 2005 :

Arrival of mOPV1 in Egypt

10 millions US$ (WHO & UNICEF)

mOPV1

tOPV

Fra

cti

on

of

ch

ild

ren

pro

tecte

d a

gain

st

the

po

lio

vir

us ty

pe 1

(%

)

POLIO ERADICATION | 14

2000 2009Failure of monovalent

Wild polio cases 2001-2009

0

500

1000

1500

2000

2500

3000

2001

2002

2003

2004

2005

2006

2007

2008

2009

WPV1 WPV3

Polio cases[thousands]

2000WPRO area Polio Free

0

2

4

6

8

10

12

14

16

18

20

1998 2000 2002 2004 2006 2008 2010

2005mOPV1

2009:bOPV

2002EURO areaPolio Free

20001st C-VDPV

POLIO ERADICATION | 15

Budget polio[Million US$]

2009 2013: we touch the Bi-OPV limits,

Polio cases [thousands]

2000WPRO areaPolio Free

0

2

4

6

8

10

12

14

16

18

20

1998 2000 2002 2004 2006 2008 2010

0

100

200

300

400

500

600

700

800

2005mOPV1

2009:bOPV

2002EURO areaPolio Free

2001Lowest

Polio level

POLIO ERADICATION | 16

222 Cases1352 Cases1740 Cases

0

500

1000

1500

2000

2500

2008 2010 20120

200

400

600

800

1000

1200

1400

1600

Polio Cases[number]

Budget polio[Million US$]

2013

Budget

Forecast

Type 3 Control

2010 2013

2009 20132011

1604 Cases 650 Cases 416 Cases

Polio Eradication:

June2014

The “End Game”…

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2000 / 2001:The strange epidemic in Hispaniola… c-VDPV*

Genetic reshuffle of Sabin strain > 1%

● Controlled by OPV…

● Debate among “poliologists” :

● How big?

● So what?

THIS IS THE END OF OPV AS UNIQUE ERADICATION TOOL

Hispaniola Island

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From 2000 to 2012, 20 c-VDPV (12 type 2; 6 type 1; 2

type 3) are the cause of more than 500 paralysis cases

DOR / HAITI

2000-01

cVDPV1

FILIPINO

2001

cVDPV1

CHINA

2004

cVDPV1

NIGERIA

2005-12

cVDPV2

CAMBODIA

2005-06

cVDPV3

MYANMAR

2006-07

cVDPV1

NIGERIA

2009-10

cVDPV2

SOMALIE

2008-11

cVDPV2

DR CONGO

2008-12

cVDPV2

INDEIA

2009-10

cVDPV2

ETHIOPIA

2008-09

cVDPV2

YEMEN

2011

cVDPV2

AFGHANISTAN

2010-11

cVDPV2

CHAD

2010-12

cVDPV2

ETHIOPIA

2009-10

cVDPV3

INDONESIA

2005

cVDPV1

MADAGASCAR

2001-02

cVDPV2

MOZAMBIQUE

2011

cVDPV1

MADAGASCAR

2005

cVDPV2

NIGERIA

2006

cVDPV2

POLIO ERADICATION | 20

The new plan for the endgame

● Focus on last endemic area:

● “Customized plan" for Afghanistan, Pakistan and Nigeria

● Concept of sanctuary for high-risk districts

● New vaccine strategy

● New objectives

Birth 12

months

18

months6

weeks

10

weeks

14

weeks

tOPV tOPV tOPV tOPV tOPV

bOPV bOPV IPV

POLIO ERADICATION | 21

Polio Eradication : Results and Endgame

0

50

100

150

200

250

300

350

400

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

0

100

200

300

400

500

600

700

800

Polio cases[thousands]

1995

PAHO area

Polio Free

1988

GPEI Launch

Budget polio[Millions US$]

2004 2006 2008 2010 2012

2005mOPV1

2009bOPV

900

1000

2014 2016 2018

2015

Switch from tOPV

to bOPV

2018

OPV

Cessation

450 1999

Type 2 eradicated

2012

Type-3

control

2014

IPV for all

coutry

500

2000Objective

Polio Eradication !

Polio eradicated

2000-2004Strategic plan

2004-2008Strategic plan

2009Strategic plan

2010-2012Strategic plan

2013-2018Polio Eradication

Endgame

1988-2000First Strategy

POLIO ERADICATION | 22

Conclusions

● Eradication seems on track

● IPV = 1st and last polio vaccine

● Human adventure, « Never in the field of human conflict was so much

owed by so many to so few » (Churchill, 20 August 1940)

● Industrial issues have played a continuing role

● Initial choice of OPV

● Continuous supply of OPV doses up to 2.5 billion per year

● Introduction of IPV after required industrial investment

● Eradication success or failure?

● Delay or miracle?

● Improvisation or great adjustment?

● Waste or resource mobilization that would never have existed otherwise?

Thank You