Today’s Session on Polio Endgame

SAGE, 14 April, 2015 Outline of the Session

Four Presentaons – Each followed by discussion 1. Progress towards wild poliovirus eradicaon 2. Progress towards eliminaon of persistent cVDPV2 3. Proposed recommendaons for OPV2 withdrawal 4. Progress report on preparedness for OPV2 withdrawal For Consideraon by SAGE

Decisions: • Assessment of cVDPV2 eliminaon and confirmaon of OPV2 withdrawal date in October • Proposed process for verificaon of poliovirus containment in facilies Informaon: • Progress towards wild poliovirus eradicaon • Progress report on withdrawal of OPV2 in April 2016 Oct 2014 SAGE: cVDPV2 Transmission & Timeline for OPV2 Withdrawal Trigger for OPV2 Withdrawal: Propose change from a date to WG assessments of persistent cVDPV2 eliminaon WG Assessment WG Assessment SAGE Decision on OPV2 Withdrawal date Compleng The Endgame

Global Polio Eradicaon

SAGE, April 14, 2015 Outline

• Progress toward wild poliovirus eradicaon • GPEI Priories in 2015 • Update on polio legacy planning Wild Poliovirus type 1 Cases, 2014

306

Endemic countries Infected countries 359

Israel = Env. positive isolates (2013 , N=136 ; 2014, N=14 , last 30 Mar 2014) Gaza = Env. positve isolates (2013, N= 7 ; 2014, N=1, Jan )

*Data as of 7 April 2015 Wild Poliovirus Cases, Last 6 months

Last Case Iraq, 7 April, 2014 Syria: 21 Jan Israel (Env.): 30 March

Last Case , 24 Jul

Last Case Cameroon, 9 Jul Last Case Somalia, 11 Aug Equatorial Guinea: 3 May Ethiopia: 5 Jan

No WPV Reported in Africa or Middle East Progress in Endemic Countries WPV1 Cases, 2012-14* 350 306 300

250

200

Cases 150 103 100 93 53 55 37 50 28 14 6 0 Afghanistan Nigeria Pakistan 2012 2013 2014

*Data as of 7 April 2015 (including advance notifications as of this date) Trends in LQAS results -

NIGERIA

2014: 5 cases; lots in 41 LGAs at 2013: 15 cases; lots in 7 LGAs at ≥90% ≥90%

Makoda Kunchi Dambaa Dawakin-Tofa Tofa Rimin- Gazewa Gado Kabo MadobiKura Dawakin- Kudu Gaya 2014 Garum- Kiru Mallam Garko 6 cases Tudun- Wada

Last Case in Nigeria: 24 July LQAS coverage <60% 60-80% 80-90% ≥90% Doguwa Risks in Nigeria

• Insecurity and conflict in the northeast • Elecons • Loss of polical commitment • Complacency YTD WPV1 Cases, Afghanistan and Pakistan,

50 2014-15* 45 43 40 35 30 25 21 Cases 20 15 10 5 4 1 0 Afghanistan Pakistan 2014 2015

*Data as of 7 April 2015 (including advance notifications as of this date) Pakistan: Insecurity & Inaccessibility

Military operaon & Acve insurgency

Ban by local leaders WPV1 Cases in • N & S Waziristan Pakistan, 2014 N=306

Threats & fatal aacks on health workers • Peshawar Valley & Karachi Pakistan: WPV1 Cases, Last 6 months* n=101 Improving Accessibility • N & S Waziristan since June 2014 • Karachi Gadaap in recent weeks • Quality gaps: Focus on missed children 50 45 40 35 30 25 20 15 10 5 0 Oct Nov Dec Jan Feb Mar *8 Oct 2014 to 7 April 2015 Geng Pakistan on Track in 2015

• Naonal commitment, including the Military Can the Program • •Vaccinate everywhere? ‘Low Season’ plan with GPEI surge - Improving access • Monitor everywhere? - Restoring • Emergency operaons & management (EOC) • Enforce accountability? - EOCs starng to funcon • Track & vaccinate chronically missed children WPV1 Cases Afghanistan, 2014 N=28

Most Cases importaon related , but endemic strain persists in Southern Region Ensuring Progress in Afghanistan

• Accelerate Engagement with new leadership • Maintain dialogue with non-state actors • Ensure program neutrality • Reduce missed children in South & East Public Health Emergency of Internaonal Concern Internaonal exportaon of poliovirus in 2014

February

January April June August September October March

March Prevenng Internaonal spread

• Public Health Emergency of Internaonal Concern (PHEIC) declared by DG, WHO, on 5 May 2014; extended 31 July, 13 November & 3 March 2015

• New emphasis on regional cooperaon and cross-border coordinaon As of July 31

Countries with circulang Countries currently wild poliovirus, but NOT exporng wild • Pakistan the only exporng currently exporng poliovirus country, as of 5 April Program Priories in 2015 • Get Pakistan/Afghanistan back on track • Intensify surveillance for poliovirus • Reduce risk in Africa & Middle East • Prevent internaonal spread, build stronger outbreak response capacity • Ensure preparedness for OPV2 withdrawal • Launch legacy planning Progress in Legacy Planning 2014-2015

– Development of an ‘Evidence Base’ • Outlines Capabilies, Funcons, Assets & Contribuons of polio eradicaon efforts to other health priories – Pilot Planning Studies conducted in DRC & Nepal • To learn how transion planning could work in different sengs – Dra Transion Guidelines • To guide countries in the development of legacy transion plans – Dra Global Framework • Outlines a proposed phased approach to legacy planning including process, roles and responsibilies and a suggested meline Global Framework - Phased Approach

1. Review and endorsement of the Framework through WHO governing bodies; 2. Iniang legacy planning in a phased manner, beginning with a small group of countries; 3. Member States engagement in the process, including discussion at RCMs and engagement with naonal level stakeholders; 4. Donor engagement with the process, parcularly at the country level. 5. A country-convened planning and implementaon process supported by country and global level stakeholders, as appropriate. Three stages to this are envisaged: i. Planning & Decision ii. Preparaon iii. Execuon Proposed process, roles and responsibilies

Three key stages for Legacy rollout in each country, ideally completed by 2018 Given asset base and current epidemiology, legacy planning may require more time for completion in certain geographies

Should be a country-level and -led process, bringing together GPEI agency offices, government and key donors/other stakeholders

Phase of Transition Planning & Decision Preparation Execution

• Definition of project oversight • Formation of project oversight • Implementation of revised contracts structure team • Transfer of assets / capabilities • Selection of transition • MoUs with recipient institutions • Monitoring & Evaluation Activities opportunities, cost assessment • Revision of contracts • Ongoing monitoring of transitioned • Creation of operation and • Capacity building assets / capabilities communication strategies • Donor engagement

Leadership Country government

Transition Donor Consortium Assistance

Professional Project Management Team Project management Asset recipients Roles and responsibilities responsibilities Rolesand Technical Agencies and other stakeholders Recipients assistance

26 Proposed transion ming: Must link with broader organizaonal melines for polio resourcing

ABSOLUTE TIMELINE - INDICATIVE

2014 2015 2016 2017 2018 2019

Stakeholder engagement needed to raise awareness Global of need for country-level planning Eradicaon WHA RCMs Cerficaon Phase Country examples

Transition DRC Planning & planning Nepal Preparaon & Execuon Decision underway India Sudan Angola Ethiopia Bangladesh All other polio- Planning & Somalia Indonesia Preparaon & Execuon free and recent S. Sudan Myanmar Decision outbreak Egypt Chad Timeline contingent upon eradication status

Nigeria Planning & Current Preparaon & Execuon Pakistan Decision Legacy transition phase Legacytransition endemics Afghanistan Timeline contingent upon eradication status

27 Evidence Base – Contribuons to other priories Supporng Health Systems Esmated me allocaon Crical acvies and contribuons of of polio workers1 polio programme (not exhausve)

Other programs • Naonal planning and local staff training Disasters and crises Roune • Technical assistance Health systems strengthening 4% Immunizaon • Monitoring of field acvies 1% • Communicaon and community engagement MNCH, Nutrion 5% 2% Sanitaon & Hygiene 1% 1% Child health days 4% New vaccine intro • Surveillance for vaccine preventable diseases, e.g. measles, rubella, yellow fever, neo-natal Roune immunizaon 26% tetanus, JE Surveillance • Acvies including front-line training, case detecon, laboratory support and case reporng

Measles & rubella 12%

• Country supply chain management, e.g. Supply Chain – Vaccine procurement – Cold chain maintenance Polio 43% Resources & • Polio funds provide crical support to naonal Capacity and local WHO / UNICEF offices

Overall 1.Data based on survey of staff in DRC, Nepal, India, Somalia, and Ethiopia. Source: Polio Legacy Survey Polio country personnel time at ~22% for RI and ~46% for RI+related1 activities in RI focus countries

Estimated time allocation of polio personnel by country

100% 5% 5% 5% 6% 7% 4% 1% 7% 7% 4% 2% 5% 6% 5% 16% 5% 16% 9% 4% 7% 11% 11% 4% ~46% time 75% 9% 21% 7% 18% 5% 14% 8% spent on RI- 13% 7% 18% 9% related 32% 28% 22% 17% activities 50% 23% 22% 14% 26% 74% 64% 15% 54% 25% 44% 44% 46% 40% 39% 37% 29% 27%

0% Afghanistan Angola Chad DRC Ethiopia India Nigeria Pakistan Somalia South Overall Sudan

n 30 19 8 24 7 106 173 86 9 5 467

Polio eradication Child health days or weeks Natural disasters and humanitarian crises Roune Immunizaon Maternal, newborn, and child health and nutrition Other diseases or program areas Measles and rubella Health systems strengthening New vaccine introducon Sanitation and hygiene

1: RI-related activities are: RI, M&R, NVI, CHD, MNCH+N, HSS Source: RI IMG Polio Survey; Polio Legacy Survey Legacy Planning Priories 2015 • Establish oversight mechanism to monitor progress • Support country and regional transion planning • Decide on appropriate structures to support countries • Support the process in priority countries & regions • Ensure process links with exisng naonal/regional plans • Iniate/Connue Instuonal Resource Planning • For the three major phases of the iniave • Process underway (template for planning developed) • Finalize Global Framework and supporve documents • Framework to be finalized soon by GPEI • Toolkit under development with supporve materials

Summary – 2015 a defining year

• Unprecedented progress in Africa, risks remain • Pakistan: geng back on track, sll an internaonal risk • Strategic Priories: Surveillance, risk reducon, response capacity • Preparedness for OPV2 withdrawal • Legacy: Roll out guidance & tools, support planning • Financial & polical support essenal for the Endgame THANK YOU!