NWCP Wild Poliovirus Oral Polio Vaccine Question

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Global child health Julie Garon,1 Manish Patel2 1 Department of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA 2 Center for Vaccine Equity, Task Force for Global Health, Decatur, Georgia, USA Correspondence to Julie Garon, Department of Infectious Diseases, Emory University School of Medicine, 1462 Clifton Rd NE, Suite 446, Atlanta, GA 30322, USA; julie. [email protected] Received 23 August 2016 Revised 21 December 2016 Accepted 26 December 2016 Published Online First 17 January 2017 ABSTRACT The decades long effort to eradicate polio is nearing the final stages and oral polio vaccine (OPV) is much to thank for this success. As cases of wild poliovirus continue to dwindle, cases of paralysis associated with OPV itself have become a concern. As type-2 poliovirus (one of three) has been certified eradicated and a large proportion of OPV-related paralysis is caused by the type-2 component of OPV, the World Health Assembly endorsed the phased withdrawal of OPV and the introduction of inactivated polio vaccine (IPV) into routine immunisation schedules as a crucial step in the polio endgame plan. The rapid pace of IPV scale-up and uptake required adequate supply, planning, advocacy, training and operational readiness. Similarly, the synchronised switch from trivalent OPV (all three types) to bivalent OPV (types 1 and 3) involved an unprecedented level of global coordination and country commitment. The important shift in vaccination policy seen through global IPV introduction and OPV withdrawal represents an historical milestone reached in the polio eradication effort. BACKGROUND To cite: Garon J, Patel M. Arch Dis Child 2017;102:362–365. 362 The world is closer to achieving complete eradication of polio than ever before. As of 4 January 2017, only 35 cases of wild poliovirus (WPV) have been detected in 2016, compared with over 350 000 in 1988, the year when eradication effort had begun (see figure 1).1 WPV type 1 is the only wild-type strain (of types 1, 2 and 3) still in circulation. Oral polio vaccine (OPV) has largely been responsible for much of this success particularly in developing country settings due to its low cost, ability to be administered without specialised training and ability to induce intestinal mucosal immunity and thus interrupt transmission within populations in addition to protecting individuals.2 However, during replication in the gut of the vaccinee and subsequent chains of contact, the live-attenuated vaccine virus undergoes evolution through genetic reversions and possibly recombination with non-polio enterovirus C species. In very rare cases, the vaccine virus may regain neurovirulence causing paralysis in recipients or close contacts (called vaccine-associated paralytic polio (VAPP))2 and perhaps even acquire transmissibility characteristics leading to outbreaks (circulating vaccine-derived poliovirus (cVDPV)).2 Therefore, to eradicate polio completely—both wild and vaccine-derived viruses—the world must cease use of OPV once WPV transmission has been interrupted (ie, polio endgame). After eradication, immunity against polio will be provided by inactivated polio vaccine (IPV), an injectable vaccine that does not cause VAPP or cVDPVs and induces an excellent neuroprotective humoral immune response. However, compared with OPV, IPV is costlier, provides lesser intestinal immunity and is logistically more difficult to administer, particularly when targeting hard to reach populations.3 In addition, IPV on its own does not appear to be sufficient to halt poliovirus circulation and the risk of silent transmission is likely to be greater in IPV-only immunised populations, as occurred in Israel in 2013.4 As WPV cases continue to decrease, the world is in the midst of an historical shift in vaccine policy to ensure that no child is paralysed by polio ever again. This paper provides an overview of the polio endgame plan for paediatricians, infectious disease specialists and the global health community. GLOBAL POLIO ERADICATION INITIATIVE AND THE POLIO ERADICATION AND ENDGAME STRATEGIC PLAN 2013–2018 To date, global polio eradication efforts have included several general strategies leading to a dramatic reduction in the number of cases of WPV. Including polio vaccines, OPV and more recently IPV, into childhood routine immunisation schedules has been the foundation of the global eradication strategy. Active surveillance of children experiencing acute flaccid paralysis (AFP) including collection of stools followed by laboratory confirmation of poliovirus is a bedrock of the polio programme and has guided vaccination strategies. Ensuring high routine immunisation coverage for polio and other antigens has been an ongoing goal for vaccination programmes. Supplemental immunisation activities (SIAs), in which all children under 5 years of age are vaccinated in a mass caign regardless of vaccination status, have allowed more children to be reached and reduced pockets of unimmunised children. Periodic mop-up caigns provide further opportunities to vaccinate and serve to increase immunity in at-risk areas. To sustain the gains achieved so far and secure final eradication of polio, partners of the Global Polio Eradication Initiative (GPEI) launched the Polio Eradication and Endgame Strategic Plan, 2013–2018, outlining detailed steps and a distinct timeline for complete eradication of all types of polio (both wild and vaccine derived).5 The four objectives of the plan involve (1) completing eradication of WPV in its remaining strongholds; (2) a phased, global transition from OPV to IPV while strengthening routine immunisation systems; (3) ensuring containment of poliovirus in laboratories and facilities and (4) ensuring polio’s many resources and lessons are used for other health priorities. This paper will focus mainly on the second Garon J, Patel M. Arch Dis Child 2017;102:362–365. doi:10.1136/archdischild-2016-311171 Arch Dis Child: first published as 10.1136/archdischild-2016-311171 on 17 January 2017. Downloaded from http://adc.bmj.com/ on 23 June 2018 by guest. Protected by copyright. The polio endgame: rationale behind the change in immunisation Global child health objective of this plan, which includes introduction of IPV into routine immunisation programmes in all OPV-using countries, withdrawal of the type-2 component of OPV (ie, ‘the switch’) and strengthening of routine immunisation systems. RATIONALE FOR OPV WITHDRAWAL AND IPV INTRODUCTION OPV currently exists in five formulations: trivalent OPV (tOPV, containing all three polio types), bivalent OPV (bOPV, containing types 1 and 3) and monovalent OPV (mOPV, containing either types 1, 2 or 3). Surveillance has not detected any naturally occurring type-2 WPV since 1999 in Aligarh, northern India and in September, 2015, the Global Polio Eradication Certification Committee (GCC) certified the eradication of this serotype.6 In addition, the type-2 component of tOPV (OPV2) is associated with approximately 26%–31% of all VAPP cases leading to 100–200 cases a year.7 Since 1999, it is estimated from reports in the literature that anywhere from 1600 to 3200 people have experienced VAPP due to OPV2.8 OPV2 also plays a significant role in cVDPV cases as 683 cases were reported between 2000 and 2014, accounting for almost 90% of all cVDPVs.9 Also, the type-2 component of tOPV interferes with the immune response to types 1 and 3, and with type-1 WPV still in circulation, maximum efficacy of the vaccine is desired.2 10 For these reasons, the WHO Strategic Advisory Group of Experts on immunisation (SAGE) deemed the risks of tOPV to outweigh the benefits, necessitating the withdrawal of the type-2 component of tOPV. GPEI’s approach to OPV2 cessation has largely been about risk reduction—reducing risks associated with ongoing use of OPV and implementing measures to mitigate risks associated with cessation of OPV. To minimise the risk of type-2 outbreaks, GPEI considered a series of readiness criteria prior to the decision to proceed with the switch including eradicating type-2 WPV, stopping cVDPV2 outbreaks, introducing at least one dose of IPV, licencing bOPV, containment of WPV2, ensuring high type-2 immunity prior to the switch, stockpiling mOPV2 and preparing a postswitch type-2 surveillance and outbreak response protocol.11 Countries were advised by SAGE to comply with a globally synchronised switch from tOPV to bOPV in April, 2016, the month when poliovirus circulation is at its lowest in endemic countries.11 12 Synchronising the switch globally during a 2-week period reduced risks of cVDPV2 circulation or importation from an area with ongoing tOPV use to an area where type-2 immunity was reduced due to discontinuation of tOPV. Countries were to select 1 day (or several days for some large countries) within the 2-week window to complete the switch in all vaccine storage sites nationwide and validate through site visits thereafter that all tOPV had been removed from the cold chain. It was imperative that all countries stop tOPV production and shipment, scale-up bOPV supply, procurement and shipment, and ensure country preparations globally during the 6 months leading up to the switch. Until eradication and containment are confirmed, and perhaps even for some time after that point, some immunity against polioviruses will be necessary. Thus, IPV (which contains all three poliovirus types) is to provide some level of immunity to type 2 following OPV2 withdrawal. In 2014, WHO recommended that all 126 OPV-using countries introduce at least one dose of IPV intro routine immunisation schedules.13 As of November, 2016, 173 (89%) of 194 WHO member states were using at least one dose of IPV and the remaining countries have committed to introducing as soon as sufficient supply is available, likely in 2017.14 One dose of IPV leads to lower seroconversion rates (19%–46% against type 1, 32%–63% against type 2 and 28%–54% against type 3)15 than three or four doses, which provides nearly complete protection. However, data indicate nearly all children are ‘primed’ after one dose of IPV; that is, those who do not seroconvert after one dose of IPV may mount a rapid immune response within 7 days of subsequent exposure and thus theoretically could be protected against paralysis if exposed to poliovirus.16 Routine IPV administration may also facilitate interruption of transmission during cVDPV2 outbreaks through use of mOPV2 (stockpiled for posteradication type-2 outbreaks) as the population immunity may already be closer to herd immunity thresholds.10 IPV has also been shown to reduce duration and amount of viral shedding.15 17 IPV may aid in eradicating WPV by boosting immunity to types 1 and 3 polioviruses in individuals who have received bOPV or tOPV.10 11 Several additional factors warrant consideration for IPV. IPV also induces mucosal immunity but to a lesser extent than OPV, particularly with regard to intestinal immunity in developing country settings, where the faecal–oral route is the predominant mode of transmission.17 Studies of intradermal administration of fractional doses (1/5 of a full dose) of IPV found that two doses resulted in much higher seroconversion (98% in Cuba and 81% in Bangladesh) to type-2 poliovirus than one full dose (63% in Cuba and 39% in Bangladesh).16 18 19 For this reason, WHO has also endorsed the use of two fractional doses of IPV at 6 and 14 weeks for countries conserving limited vaccine supply, given the programmatic cost and logistical implications of intradermal administration (additional supplies and health worker training needed for intradermal administration) is considered.19 IPV also Garon J, Patel M. Arch Dis Child 2017;102:362–365. doi:10.1136/archdischild-2016-311171 363 Arch Dis Child: first published as 10.1136/archdischild-2016-311171 on 17 January 2017. Downloaded from http://adc.bmj.com/ on 23 June 2018 by guest. Protected by copyright. Figure 1 Progress in polio eradication from 1988 to 2016 (*as of 4 January 2017). (Data from The Global Polio Eradication Initiative. Data and Monitoring. 2016. http:// polioeradication.org/polio-today/ polio-now/wild-poliovirus-list/ (accessed 6 January 2016). Global child health IMPLEMENTATION OF IPV INTRODUCTION Introduction of IPV in 126 OPV-only using countries within a matter of a few years was an unprecedented and daunting task. To facilitate country buy-in, GPEI partners and supporting agencies developed advocacy tools such as policy papers, guidelines, case studies and information packets to communicate the complicated technical rationale behind IPV introduction to stakeholders.14 Detailed planning documents and templates were developed for adaptation and use in country. Specialised workshops took place in various locations worldwide to further raise awareness, share tools, support development of country introduction plans and assess planning progress. In-country missions from GPEI partners and trained consultants provided technical support and facilitated in the completion of IPV introduction plans. Countries exhibited an exemplary level of commitment to the introduction of IPV, with all countries either introducing at least one dose of IPV in 2015 or committing to introduce IPV prior to the switch. However, despite long-term agreements with two IPV manufacturers to meet increased demand, manufacturers encountered setbacks and challenges due to the rapid scale-up of complex production processes, leading to supply constraints globally. GPEI prioritised use of IPV in SIAs, stockpiling for outbreak response, and introductions in countries at high risk for polio. As of 7 November 2016, 173 countries (89% of the global birth cohort), including those at the highest risk of polio, have introduced IPV into routine immunisation schedules.14 Twenty countries (10% of the global birth cohort) delayed introduction until 2017 due to supply constraints. After careful evaluation of context-specific risks and implications, countries adapted to the situation through delayed or phased introductions, or consideration of a two-dose series of intradermal fractional administration of IPV, as recommended by SAGE. IMPLEMENTATION OF THE SWITCH In October, 2015, SAGE reviewed global epidemiological data for polio and the readiness criteria for the switch and confirmed 364 17 April to 1 May 2016 as the official dates during which all countries would switch from tOPV to bOPV.26 Similar to IPV introduction, extensive global-level, regional-level and countrylevel advocacy was required far in advance of these dates to ensure buy-in from country governments and partners. To facilitate this complex endeavour, GPEI partners developed and disseminated guidance documents and toolkits, held workshops and provided the necessary technical assistance and resources to countries before the switch. Guidelines for planning for the switch revolved around four key steps: planning, preparation, implementation and validation. Planning ensured that all countries established appropriate management/coordination mechanisms and secured adequate financing for switch activities. Countries conducted frequent tOPV vaccine inventories to inform vaccine forecasting, limit excess tOPV requiring disposal after the switch and avoid stock outs prior to the switch. Preparation activities included planning vaccine transport, collection and disposal, training of health workers and logisticians and developing communication strategies. On the day of the switch, all tOPV would be removed from the cold chain and placed in a designated area for disposal by appropriate means such as boiling, incineration, chemical inactivation, autoclaving or encapsulation. Finally, independent monitors would visit all vaccine distribution stores in the country as well as a sle of the fixed health facilities where vaccine is administered to ensure tOPV had been removed from the cold chain. Independent validation committees reviewed these data and provided confirmation of adequate tOPV withdrawal and/or recommendations for corrective actions needed by national authorities. WHO confirmed that by mid-May, 2016, all 155 OPV-using countries successfully discontinued use of tOPV. BEYOND THE ENDGAME AND CONTINUED USE OF IPV AND OPV Despite momentous recent achievements, the endgame is not without risks of re-emergence of cVDPV2 and WPV2. Risk of cVDPV2 emergence is greatest in the first 6–12 months after the switch due to the expected decline in humoral and intestinal immunity against type-2 poliovirus after OPV2 withdrawal even with the introduction of one dose of IPV.27 Longer term risks include reintroduction of type-2 poliovirus from a laboratory or manufacturing facility breach, as occurred in 2002–2003 in India.28 In addition, a risk exists that populations could be exposed to poliovirus through B-cell immune deficient individuals, who are known to have a higher risk or prolonged poliovirus excretion.29 Outbreak control protocols have been prepared and a large stockpile of mOPV2 is available, should an outbreak of wild or vaccine-derived polio be detected. Maintenance of strong AFP surveillance and utilization of targeted environmental surveillance will become increasingly important after eradication. Implementation of a comprehensive strategy to ensure containment of poliovirus, prioritising type-2 poliovirus, is currently underway.30 Two drug candidates for treatment of B-cell immune-deficient long-term excreters are in late-stage clinical trials with promising results in reduction of shedding among participants.31 Finally, numerous tools and technologies capable of making IPV production safer and development of stable OPV with less risk of reversion to infective virus are also being explored.10 32 All OPV is expected to be withdrawn after 2020, similarly to the 2016 switch, if transmission of type-1 WPV can be interrupted in Pakistan, Afghanistan and Nigeria in the coming year. Once all countries and regions have been certified polio free, Garon J, Patel M. Arch Dis Child 2017;102:362–365. doi:10.1136/archdischild-2016-311171 Arch Dis Child: first published as 10.1136/archdischild-2016-311171 on 17 January 2017. Downloaded from http://adc.bmj.com/ on 23 June 2018 by guest. Protected by copyright. has additional benefits when used during posteradication outbreaks of not reintroducing type-2 vaccine virus into the population, which is a concern when the live vaccine mOPV2 is used alone. Children having already received OPV will receive a boost in humoral and intestinal immunity after an additional dose of IPV, thus helping to interrupt transmission.20 While both the accelerated introduction of IPV globally and the synchronised switch from tOPV to bOPV are unprecedented in terms of timeframe, size and scope, many countries have experienced transitions in polio vaccines in the past. Most industrialised countries no longer experiencing WPV transmission transitioned to IPV-only schedules many years ago out of concern for VAPP and cVDPV’s. Some switched over at once, while others transitioned through a period of sequential use of OPV and IPV. For exle, the USA transitioned to a sequential schedule of two doses of IPV followed by two doses of OPV in 1997, followed by a transition to all-IPV in 2000.21–23 Many countries are familiar with the use of bOPV in caigns and with using different OPV formulations depending on global epidemiology of WPV. In India, transmission persisted in the underdeveloped and highly populated states of Bihar and Uttar Pradesh despite high coverage and multiple doses of vaccine, leading to the development of mOPV1, mOPV3 and bOPV, which had much higher efficacy per dose than tOPV.24 Use of these new vaccines in SIAs were innovations contributing to the elimination of polio in India, a monumental achievement in the eradication effort.25 Global child health Twitter Follow Julie Garon @JulieRGaron Contributors JG drafted the paper with input from MP. JG and MP contributed to writing and revision of the submitted manuscript. Funding JG and MP are supported by the Bill and Melinda Gates Foundation under grant OPP1095024. The authors have no other relevant affiliations or financial involvement with any organisation or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. 11 12 13 14 15 16 17 18 19 20 Competing interests None declared. Provenance and peer review Commissioned; externally peer reviewed. 21 22 REFERENCES 1 2 3 4 5 6 7 8 9 10 Global Polio Eradication Initiative > Data and monitoring > Polio this week > Wild poliovirus list [Internet]. [cited 2015 Apr 22]. http://www.polioeradication.org/ Dataandmonitoring/Poliothisweek/Wildpolioviruslist.aspx Sutter RW, Kew OM, Cochi SL, et al. 28—Poliovirus vaccine—live. In: Plotkin SA, Orenstein WA, Offit PA, eds. Vaccines (Sixth Edition) [Internet]. London: W.B. Saunders, 2013:598–645. http://www.sciencedirect.com/science/article/pii/ B9781455700905000355 Iqbal S, Shi J, Seib K, et al. Preparation for global introduction of inactivated poliovirus vaccine: safety evidence from the US Vaccine Adverse Event Reporting System, 2000–12. Lancet Infect Dis 2015;15:1175–82. Kopel E, Kaliner E, Grotto I. Lessons from a public health emergency—importation of wild poliovirus to Israel. N Engl J Med 2014;371:981–3. Global Polio Eradication Initiative. Polio Eradication #038; Endgame Strategic Plan 2013–2018 [Internet]. 2013. http://www.polioeradication.org/Portals/0/Document/ Resources/StrategyWork/PEESP_EN_US.pdf Global eradication of wild poliovirus type 2 declared [Internet]. Global Polio Eradication Initiative > News stories. 2015 (cited 6 October 2015). http://www. polioeradication.org/mediaroom/newsstories/Global-eradication-of-wild-poliovirustype-2-declared/tabid/526/news/1289/Default.aspx Platt LR, Estívariz CF, Sutter RW. Vaccine-associated paralytic poliomyelitis: a review of the epidemiology and estimation of the global burden. J Infect Dis 2014;210 (Suppl 1):S380–9. Report of the SAGE Polio Working Group Meeting 7–8 September 2015 [Internet] (cited 26 October 2015). http://www.who.int/immunization/sage/meetings/2015/ october/2_SAGE_WG_report_draft_Final_clean.pdf?ua=1 Global Polio Eradication Initiative > Data and monitoring > Polio this week > Circulating vaccine-derived poliovirus [Internet] (cited 6 April 2015). http://www. polioeradication.org/Dataandmonitoring/Poliothisweek/ Circulatingvaccinederivedpoliovirus.aspx Patel M, Zipursky S, Orenstein W, et al. Polio endgame: the global introduction of inactivated polio vaccine. Expert Rev Vaccines 2015;14:749–62. 23 24 25 26 27 28 29 30 31 32 33 Garon J, Patel M. Arch Dis Child 2017;102:362–365. doi:10.1136/archdischild-2016-311171 Garon J, Seib K, Orenstein WA, et al. Polio endgame: the global switch from tOPV to bOPV. Expert Rev Vaccines 2016;15:1–16. Agenda Item 15.2 Poliomyelitis. In Geneva, Switzerland: World Health Organization; 2015 (cited 18 June 2015). http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_ R3-en.pdf WER. Polio Vaccines: WHO position paper, January 2014 [Internet]. World Health Organization; 2014 Feb p. 73–92. Report No.: 9. http://www.who.int/wer/2014/ wer8909.pdf?ua=1 WHO|IPV Introduction, OPV Withdrawal and Routine Immunization Strengthening [Internet]. WHO (cited 6 January 2016). http://www.who.int/immunization/diseases/ poliomyelitis/endgame_objective2/en/ Estivariz CF, Pallansch MA, Anand A, et al. Poliovirus vaccination options for achieving eradication and securing the endgame. Curr Opin Virol 2013;3:309–15. Resik S, Tejeda A, Sutter RW, et al. Priming after a fractional dose of inactivated poliovirus vaccine. N Engl J Med 2013;368:416–24. Hird TR, Grassly NC. Systematic review of mucosal immunity induced by oral and inactivated poliovirus vaccines against virus shedding following oral poliovirus challenge. PLoS Pathog 2012;8:e1002599. Anand A, Zaman K, Estívariz CF, et al. Early priming with inactivated poliovirus vaccine (IPV) and intradermal fractional dose IPV administered by a microneedle device: a randomized controlled trial. Vaccine 2015;33:6816–22. Polio vaccines: WHO position paper—March, 2016 [Internet]. World Health Organization; 2016 Mar (cited 2016 Mar 30), p. 145–68 (Weekly Epidemiologic Record). Report No.: 91. http://www.who.int/wer/2016/wer9112.pdf?ua=1 Garon J, Orenstein W, John TJ. The need and potential of inactivated poliovirus vaccine. Indian Pediatr 2016;53(Suppl 1):S2–6. Hinman AR, Koplan JP, Orenstein WA, et al. Live or inactivated poliomyelitis vaccine: an analysis of benefits and risks. Am J Public Health 1988;78:291–5. Poliomyelitis prevention in the United States: introduction of a sequential vaccination schedule of inactivated poliovirus vaccine followed by oral poliovirus vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1997;46(RR-3):1–25. Alexander LN, Seward JF, Santibanez TA, et al. Vaccine policy changes and epidemiology of poliomyelitis in the United States. JAMA 2004;292:1696–701. Grassly NC, Fraser C, Wenger J, et al. New strategies for the elimination of polio from India. Science 2006;314:1150–3. Aylward B, Tangermann R. The global polio eradication initiative: lessons learned and prospects for success. Vaccine 2011;29(Suppl 4):D80–5. Meeting of the Strategic Advisory Group of Experts on immunization, October 2015—conclusions and recommendations [Internet]. World Health Organization; 2015 Dec (cited 17 December 2015), p. 681–700 (Weekly Epidemiologic Record). Report No.: 50. http://www.who.int/wer/2015/wer9050.pdf Tebbens RJD, Pallansch MA, Kew OM, et al. Risks of paralytic disease due to wild or vaccine-derived poliovirus after eradication. Risk Anal 2006;26: 1471–505. Deshpande JM, Nadkarni SS, Siddiqui ZA. Detection of MEF-1 laboratory reference strain of poliovirus type 2 in children with poliomyelitis in India in 2002 #038; 2003. Indian J Med Res 2003;118:217–23. Wood DJ, Sutter RW, Dowdle WR. Stopping poliovirus vaccination after eradication: issues and challenges. Bull World Health Organ 2000;78:347–57. World Health Organization. Guidelines for Containment of Poliovirus Following Type-Specific Polio Eradication—Worldwide, 2015 [Internet] (cited 20 October 2015). http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6433a5.htm?s_ cid=mm6433a5_w McKinlay MA, Collett MS, Hincks JR, et al. Progress in the development of poliovirus antiviral agents and their essential role in reducing risks that threaten eradication. J Infect Dis 2014;210(Suppl 1):S447–53. Bandyopadhyay AS, Garon J, Seib K, et al. Polio vaccination: past, present and future. Future Microbiol 2015;10:791–808. Cochi SL, Freeman A, Guirguis S, et al. Global polio eradication initiative: lessons learned and legacy. J Infect Dis 2014;210(Suppl 1):S540–6. 365 Arch Dis Child: first published as 10.1136/archdischild-2016-311171 on 17 January 2017. Downloaded from http://adc.bmj.com/ on 23 June 2018 by guest. Protected by copyright. that is, completed 3 years with no detection of WPV in the presence of WHO standard quality surveillance, the GCC will review documentation of surveillance and containment and declare the world polio free.5 Questions remain as to the length of time IPV will be administered beyond certification of eradication and the ideal dosing schedule for developing countries. The lessons learned from the unprecedented operational feat of IPV introduction, the switch and the polio eradication effort overall are many.33 Countless opportunities exist to transition the personnel, infrastructure, resources and functions to other health priorities. In doing so, we ensure that no child is paralysed by polio ever again and that polio’s legacy lives on.

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