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Sutter RW, Eisenhawer M, Molodecky NA, Verma H, Okayasu H. Inactivated Poliovirus Vaccine: Recent Developments and the Tortuous Path to Global Acceptance. Pathogens 2024; 13:224. [PMID: 38535567 PMCID: PMC10974833 DOI: 10.3390/pathogens13030224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 04/21/2024] Open
Abstract
Inactivated poliovirus vaccine (IPV), available since 1955, became the first vaccine to be used to protect against poliomyelitis. While the immunogenicity of IPV to prevent paralytic poliomyelitis continues to be irrefutable, its requirement for strong containment (due to large quantities of live virus used in the manufacturing process), perceived lack of ability to induce intestinal mucosal immunity, high cost and increased complexity to administer compared to oral polio vaccine (OPV), have limited its use in the global efforts to eradicate poliomyelitis. In order to harvest the full potential of IPV, a program of work has been carried out by the Global Polio Eradication Initiative (GPEI) over the past two decades that has focused on: (1) increasing the scientific knowledge base of IPV; (2) translating new insights and evidence into programmatic action; (3) expanding the IPV manufacturing infrastructure for global demand; and (4) continuing to pursue an ambitious research program to develop more immunogenic and safer-to-produce vaccines. While the knowledge base of IPV continues to expand, further research and product development are necessary to ensure that the program priorities are met (e.g., non-infectious production through virus-like particles, non-transmissible vaccine inducing humoral and intestinal mucosal immunity and new methods for house-to-house administration through micro-needle patches and jet injectors), the discussions have largely moved from whether to how to use this vaccine most effectively. In this review, we summarize recent developments on expanding the science base of IPV and provide insight into policy development and the expansion of IPV manufacturing and production, and finally we provide an update on the current priorities.
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Affiliation(s)
| | - Martin Eisenhawer
- Polio Eradication Department, World Health Organization, 1211 Geneva, Switzerland; (M.E.); (H.V.)
| | - Natalia A. Molodecky
- Polio Surge Capacity Support Program, The Task Force for Global Health, Inc., Decatur, GE 30030, USA;
| | - Harish Verma
- Polio Eradication Department, World Health Organization, 1211 Geneva, Switzerland; (M.E.); (H.V.)
| | - Hiromasa Okayasu
- Division of Healthy Environments and Population, Regional Office for the Western Pacific, World Health Organization, Manila 1000, Philippines
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Biya O, Manu JI, Forbi JC, wa Nganda G, Ikwe H, Sule A, Edukugho A, Shehu A, Aliyu N, Barau ND, Wiesen E, Sutter RW. Notes from the Field: House-to-House Campaign Administration of Inactivated Poliovirus Vaccine - Sokoto State, Nigeria, November 2022. MMWR Morb Mortal Wkly Rep 2023; 72:1290-1291. [PMID: 37991997 PMCID: PMC10685385 DOI: 10.15585/mmwr.mm7247a3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
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Sharma AK, Verma H, Estivariz CF, Bajracharaya L, Rai G, Shah G, Sherchand J, Jones KAV, Mainou BA, Chavan S, Jeyaseelan V, Sutter RW, Shrestha LP. Persistence of immunity following a single dose of inactivated poliovirus vaccine: a phase 4, open label, non-randomised clinical trial. Lancet Microbe 2023; 4:e923-e930. [PMID: 37774729 DOI: 10.1016/s2666-5247(23)00215-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/27/2023] [Accepted: 07/04/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The polio eradication endgame required the withdrawal of Sabin type 2 from the oral poliovirus vaccine and introduction of one or more dose of inactivated poliovirus vaccine (IPV) into routine immunisation schedules. However, the duration of single-dose IPV immunity is unknown. We aimed to address this deficiency. METHODS In this phase 4, open-label, non-randomised clinical trial, we assessed single-dose IPV immunity. Two groups of infants or children were screened: the first group had previously received IPV at 14 weeks of age or older (previous IPV group; age >2 years); the second had not previously received IPV (no previous IPV group; age 7-12 months). At enrolment, all participants received an IPV dose. Children in the no previous IPV group received a second IPV dose at day 30. Blood was collected three times in each group: on days 0, 7, and 30 in the previous IPV group and on days 0, 30, and 37 in the no previous IPV group. Poliovirus antibody was measured by microneutralisation assay. Immunity was defined as the presence of a detectable antibody or a rapid anamnestic response (ie, priming). We used the χ2 to compare proportions and the Mann-Whitney U test to assess continuous variables. To assess safety, vaccinees were observed for 30 min, caregivers for each participating child reported adverse events after each follow-up visit and were questioned during each follow-up visit regarding any adverse events during the intervening period. Adverse events were recorded and graded according to the severity of clinical symptoms. The study is registered with ClinicalTrials.gov, NCT03723837. FINDINGS From Nov 18, 2018, to July 31, 2019, 502 participants enrolled in the study, 458 (255 [65%] boys and 203 [44%] girls) were included in the per protocol analysis: 234 (93%) in the previous IPV group and 224 (90%) in the no previous IPV group. In the previous IPV group, 28 months after one IPV dose 233 (>99%) of 234 children had persistence of poliovirus type 2 immunity (100 [43%] of 234 children were seropositive; 133 [99%] of 134 were seronegative and primed). In the no previous IPV group, 30 days after one IPV dose all 224 (100%) children who were type 2 poliovirus naive had seroconverted (223 [>99%] children) or were primed (one [<1%]). No adverse events were deemed attributable to study interventions. INTERPRETATION A single IPV dose administered at 14 weeks of age or older is highly immunogenic and induces nearly universal type 2 immunity (seroconversion and priming), with immunity persisting for at least 28 months. The polio eradication initiative should prioritise first IPV dose administration to mitigate the paralytic burden caused by poliovirus type 2. FUNDING WHO and Rotary International.
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Affiliation(s)
- Arun K Sharma
- Department of Pediatrics, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | | | - Luna Bajracharaya
- Department of Pediatrics, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Ganesh Rai
- Department of Pediatric Medicine, Kanti Children's Hospital, Kathmandu, Nepal
| | - Ganesh Shah
- Department of Pediatrics, Patan Hospital, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Jeevan Sherchand
- Department of Microbiology, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | | | - Smita Chavan
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Laxman P Shrestha
- Department of Pediatrics, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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Sharma AK, Verma H, Estivariz CF, Bajracharaya L, Rai G, Shah G, Sherchand J, Jones KAV, Mainou BA, Chavan S, Jeyaseelan V, Sutter RW, Shrestha LP. Persistence of immunity following a single dose of inactivated poliovirus vaccine: a phase 4, open label, non-randomised clinical trial. The Lancet Microbe 2023. [DOI: org/10.1016/s2666-5247(23)00215-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2023] Open
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Aziz AB, Verma H, Jeyaseelan V, Yunus M, Nowrin S, Moore DD, Mainou BA, Mach O, Sutter RW, Zaman K. One Full or Two Fractional Doses of Inactivated Poliovirus Vaccine for Catch-up Vaccination in Older Infants: A Randomized Clinical Trial in Bangladesh. J Infect Dis 2022; 226:1319-1326. [PMID: 35575051 PMCID: PMC9574668 DOI: 10.1093/infdis/jiac205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/24/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The polio eradication endgame called for the removal of trivalent oral poliovirus vaccine (OPV) and introduction of bivalent (types 1 and 3) OPV and inactivated poliovirus vaccine (IPV). However, supply shortages have delayed IPV administration to tens of millions of infants, and immunogenicity data are currently lacking to guide catch-up vaccination policies. METHODS We conducted an open-label randomized clinical trial assessing 2 interventions, full or fractional-dose IPV (fIPV, one-fifth of IPV), administered at age 9-13 months with a second dose given 2 months later. Serum was collected at days 0, 60, 67, and 90 to assess seroconversion, priming, and antibody titer. None received IPV or poliovirus type 2-containing vaccines before enrolment. RESULTS A single fIPV dose at age 9-13 months yielded 75% (95% confidence interval [CI], 6%-82%) seroconversion against type 2, whereas 2 fIPV doses resulted in 100% seroconversion compared with 94% (95% CI, 89%-97%) after a single full dose (P < .001). Two doses of IPV resulted in 100% seroconversion. CONCLUSIONS Our study confirmed increased IPV immunogenicity when administered at an older age, likely due to reduced interference from maternally derived antibodies. Either 1 full dose of IPV or 2 doses of fIPV could be used to vaccinate missed cohorts, 2 fIPV doses being antigen sparing and more immunogenic. CLINICAL TRIAL REGISTRATION NCT03890497.
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Affiliation(s)
- Asma B Aziz
- Correspondence: Dr. Asma Binte Aziz, MBBS, MPH, PhD Research Fellow, International Vaccine Institute, SNU Research Park, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, South Korea ()
| | | | | | - Mohammad Yunus
- International Centre for Diarrheal Disease, Bangladesh, Dhaka, Bangladesh
| | - Samarea Nowrin
- International Centre for Diarrheal Disease, Bangladesh, Dhaka, Bangladesh
| | - Deborah D Moore
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Ondrej Mach
- World Health Organization, Geneva, Switzerland
| | | | - Khalequ Zaman
- International Centre for Diarrheal Disease, Bangladesh, Dhaka, Bangladesh
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Bashorun AO, Badjie Hydara M, Adigweme I, Umesi A, Danso B, Johnson N, Sambou NA, Fofana S, Kanu FJ, Jeyaseelan V, Verma H, Weldon WC, Oberste MS, Sutter RW, Jeffries D, Wathuo M, Mach O, Clarke E. Intradermal administration of fractional doses of the inactivated poliovirus vaccine in a campaign: a pragmatic, open-label, non-inferiority trial in The Gambia. Lancet Glob Health 2021; 10:e257-e268. [PMID: 34951974 PMCID: PMC8786671 DOI: 10.1016/s2214-109x(21)00497-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/19/2021] [Accepted: 10/11/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND A rapid increase in circulating vaccine-derived poliovirus type 2 outbreaks, and the need to reserve inactivated poliovirus vaccine (IPV) for routine immunisation, has increased the value of fractional dose IPV (fIPV) as a measure to prevent acute flaccid paralysis. However, the intradermal route of administration has been viewed as prohibitive to outbreak response campaigns. We aimed to establish the immunogenicity and safety of administering intradermal fIPV with a disposable syringe jet injector (DSJI) or an intradermal adaptor (IDA) compared with standard administration with a BCG needle and syringe (N&S). METHODS This pragmatic, non-inferiority trial was undertaken in a campaign setting in communities in The Gambia. Children aged 4-59 months without contraindication to vaccination were eligible. Children were not individually randomly assigned; instead, the vaccination teams were randomly assigned (1:1:1) to one of three administration methods. Parents and the field team were not masked, but laboratory personnel were masked. Baseline demographic and anthropometric data were collected from the participants. Public health officers experienced at intradermal immunisation, and nurses without experience, had 2 h of training on each of the administration methods before the campaign. Participants were vaccinated using the administration method in use by the vaccination team in their community. Poliovirus serum neutralising antibodies (SNA) were measured in children aged 24-59 months before and 4 weeks after vaccination. Adverse events and data on injection quality were collected from all participants. The primary outcome was the type 2 immune response rate (seroconversion in seronegative [SNA titre <8] children plus a 4-fold titre rise in seropositive children). Adjusted differences in the immune response between the DSJI or IDA group versus the N&S group were calculated with 97·5% CIs. A margin of -10% was used to define the non-inferiority of DSJI or IDA compared to N&S. Immunogenicity analysis was done per protocol. The trial is registered with ClinicalTrials.govNCT02967783 and has been completed. FINDINGS Between Oct 28 and Dec 29, 2016, 3189 children aged 4-59 months were recruited, of whom 3170 were eligible. Over 3 days, 2720 children were vaccinated (N&S, 917; IDA, 874; and DSJI, 929). Among 992 children aged 25-59 months with a baseline SNA available, 90·1% (95% CI 86·1-92·9; 281/312) of those vaccinated using the DSJI had an immune response to type 2 compared with 93·8% (90·6-95·8; 331/353) of those vaccinated with N&S and 96·6% (94·0-98·0; 316/327) of those vaccinated with IDA. All (53/53) type 2 seronegative children seroconverted. For polio type 2, non-inferiority was shown for both the IDA (adjusted difference 0·7% [97·5% CI -3·3 to 4·7], unadjusted difference 2·9% [-0·9 to 6·8]) and DSJI (adjusted difference -3·3% [-8·3 to 1·5], unadjusted difference -3·7% [-8·7 to 1·1]) compared with N&S. Non-inferiority was shown for type 1 and 3 for the IDA and DSJI. Neither injection quality nor the training and experience of the vaccinators had an effect on immune response. No safety concerns were reported. INTERPRETATION In a campaign, intradermal fIPV is safe and generates consistent immune responses that are not dependent on vaccinator experience or injection quality when administered using an N&S, DSJI, or IDA. Countries facing vaccine-derived poliovirus type 2 outbreaks should consider fIPV campaigns to boost population immunity and prevent cases of acute flaccid paralysis. FUNDING World Health Organization and the Medical Research Council.
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Affiliation(s)
- Adedapo O Bashorun
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Mariama Badjie Hydara
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Ikechukwu Adigweme
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Ama Umesi
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Baba Danso
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Njilan Johnson
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | | | - Sidat Fofana
- Ministry of Health, Government of The Gambia, Banjul, The Gambia
| | - Francis J Kanu
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | | | | | | | | | | | - David Jeffries
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Miriam Wathuo
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | | | - Ed Clarke
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia,Correspondence to: Dr Ed Clarke, Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, PO Box 273, The Gambia
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Ahmad M, Verma H, Deshpande J, Kunwar A, Bavdekar A, Mahantashetti NS, Krishnamurthy B, Jain M, Mathew MA, Pawar SD, Sharma DK, Sethi R, Visalakshi J, Mohanty L, Bahl S, Haldar P, Sutter RW. Immunogenicity of Fractional Dose Inactivated Poliovirus Vaccine in India. J Pediatric Infect Dis Soc 2021; 11:60-68. [PMID: 34791350 PMCID: PMC8865014 DOI: 10.1093/jpids/piab091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 09/17/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Following the withdrawal of Sabin type 2 from trivalent oral poliovirus vaccine (tOPV) in 2016, the introduction of ≥1 dose of inactivated poliovirus vaccine (IPV) in routine immunization was recommended, either as 1 full dose (0.5mL, intramuscular) or 2 fractional doses of IPV (fIPV-0.1mL, intradermal). India opted for fIPV. We conducted a comparative assessment of IPV and fIPV. METHODS This was a 4-arm, open-label, multicenter, randomized controlled trial. Infants were enrolled and vaccines administered according to the study design, and the blood was drawn at age 6, 14, and 18 weeks for neutralization testing against all 3 poliovirus types. RESULTS Study enrolled 799 infants. The seroconversion against type 2 poliovirus with 2 fIPV doses was 85.8% (95% confidence interval [CI]: 80.1%-90.0%) when administered at age 6 and 14 weeks, 77.0% (95% CI: 70.5-82.5) when given at age 10 and 14 weeks, compared to 67.9% (95% CI: 60.4-74.6) following 1 full-dose IPV at age 14 weeks. CONCLUSION The study demonstrated the superiority of 2 fIPV doses over 1 full-dose IPV in India. Doses of fIPV given at 6 and 14 weeks were more immunogenic than those given at 10 and 14 weeks. Clinical Trial Registry of India (CTRI). Clinical trial registration number was CTRI/2017/02/007793.
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Affiliation(s)
- Mohammad Ahmad
- Office of the WHO Representative to India, New Delhi, India,Corresponding Author: Mohammad Ahmad, MBBS, MD, National Professional Officer - Research, Office of the WHO Representative to India, 537, A Wing, Nirman Bhawan, Maulana Azad Road, New Delhi 110 011, India. E-mail:
| | | | | | | | | | | | | | - Manish Jain
- Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra, India
| | | | | | - Deepa K Sharma
- ICMR-National Institute of Virology, Pune, Maharashtra, India
| | - Raman Sethi
- Office of the WHO Representative to India, New Delhi, India
| | | | | | - Sunil Bahl
- South East Asian Regional Office of World Health Organization, New Delhi, India
| | - Pradeep Haldar
- Ministry of Health and Family Welfare, Government of India, New Delhi, India
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Molodecky NA, Jafari H, Safdar RM, Ahmed JA, Mahamud A, Bandyopadhyay AS, Shukla H, Quddus A, Zaffran M, Sutter RW, Grassly NC, Blake IM. Modelling the spread of serotype-2 vaccine derived-poliovirus outbreak in Pakistan and Afghanistan to inform outbreak control strategies in the context of the COVID-19 pandemic. Vaccine 2021; 41 Suppl 1:A93-A104. [PMID: 34629206 PMCID: PMC8463303 DOI: 10.1016/j.vaccine.2021.09.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 08/31/2021] [Accepted: 09/13/2021] [Indexed: 11/27/2022]
Abstract
Background Since July 2019, Pakistan and Afghanistan have been facing an outbreak of serotype-2 circulating vaccine derived poliovirus (cVDPV2) in addition to continued transmission of serotype-1 wild poliovirus (WPV1) and SARS-CoV-2 in 2020. Understanding the risks of cVDPV2 transmission due to pause of global vaccination efforts and the impact of potential vaccination response strategies in the current context of COVID-19 mitigation measures is critical. Methods We developed a stochastic, geographically structured mathematical model of cVDPV2 transmission which captures both mucosal and humoral immunity separately and allows for reversion of serotype-2 oral polio vaccine (OPV2) virus to cVDPV2 following vaccine administration. The model includes geographic heterogeneities in vaccination coverage, population immunity and population movement. The model was fitted to historic cVDPV2 cases in Pakistan and Afghanistan between January 2010-April 2016 and July 2019-March 2020 using iterated particle filtering. The model was used to simulate spread of cVDPV2 infection from July 2019 to explore impact of various proposed vaccination responses on stopping transmission and risk of spread of reverted Sabin-2 under varying assumptions of impacts from COVID-19 lockdown measures on movement patterns as well as declines in vaccination coverage. Results Simulated monthly incidence of cVDPV2 from the best-fit model demonstrated general spatio-temporal alignment with observed cVDPV2 cases. The model predicted substantial spread of cVDPV2 infection, with widespread transmission through 2020 in the absence of any vaccination activities. Vaccination responses were predicted to substantially reduce transmission and case burden, with a greater impact from earlier responses and those with larger geographic scope. While the greatest risk of seeding reverted Sabin-2 was predicted in areas targeted with OPV2, subsequent spread was greatest in areas with no or delayed response. The proposed vaccination strategy demonstrated ability to stop the cVDPV2 outbreak (with low risk of reverted Sabin-2 spread) by February 2021. Conclusion Outbreak response vaccination campaigns against cVDPV2 will be challenging throughout the COVID-19 pandemic but must be implemented urgently when feasible to stop transmission of cVDPV2.
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Affiliation(s)
- Natalia A Molodecky
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, UK; World Health Organization (WHO), Islamabad, Pakistan; National Emergency Operations Centre for Polio Eradication, Islamabad, Pakistan; World Health Organization (WHO), Geneva, Switzerland.
| | - Hamid Jafari
- World Health Organization (WHO), EMRO, Amman, Jordan
| | - Rana M Safdar
- National Emergency Operations Centre for Polio Eradication, Islamabad, Pakistan; Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
| | - Jamal A Ahmed
- World Health Organization (WHO), Islamabad, Pakistan; National Emergency Operations Centre for Polio Eradication, Islamabad, Pakistan; World Health Organization (WHO), Geneva, Switzerland
| | - Abdirahman Mahamud
- World Health Organization (WHO), Islamabad, Pakistan; National Emergency Operations Centre for Polio Eradication, Islamabad, Pakistan; World Health Organization (WHO), Geneva, Switzerland
| | | | - Hemant Shukla
- World Health Organization (WHO), EMRO, Amman, Jordan
| | - Arshad Quddus
- World Health Organization (WHO), Geneva, Switzerland
| | | | | | - Nicholas C Grassly
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, UK
| | - Isobel M Blake
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, UK
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Saleem AF, Mach O, Yousafzai MT, Kazi Z, Baig A, Sajid M, Jeyaseelan V, Sutter RW, Zaidi AKM. One-Year Decline of Poliovirus Antibodies Following Fractional-Dose Inactivated Poliovirus Vaccine. J Infect Dis 2021; 223:1214-1221. [PMID: 32798224 PMCID: PMC8030725 DOI: 10.1093/infdis/jiaa504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/04/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Fractional dose (one-fifth of full intramuscular dose) of inactivated poliovirus vaccine (fIPV) administered intradermally is used as IPV dose-sparing strategy. We compared the rate of decline of poliovirus antibodies (PVA) in recipients of 2 doses of fIPV or IPV. METHODS A community-based randomized controlled trial was conducted in Karachi, Pakistan. Children aged 14 weeks were randomized into fIPV or full IPV (study arms A, B) and received 1 vaccine dose at age 14 weeks and 1 at age 9 months. PVAs were measured at age 14, 18 weeks and 10, 21 months. RESULTS Seroprevalence of poliovirus type 2 antibodies in 170/250 (68%) children after 2 IPV or fIPV doses at age 10 months in A and B reached 100% vs 99% (P = .339), and at 21 months, 86% vs 67% (P = .004). Between age 10 and 21 months antibody log2 titers dropped from ≥ 10.5 to 6.8 in A and from 9.2 to 3.7 in B. CONCLUSIONS There was a significant decline in antibody titers 12 months following the second IPV dose. The slope of decline was similar for full IPV and fIPV recipients. The results provide further evidence that fIPV is a viable option for IPV dose-sparing. CLINICAL TRIALS REGISTRATION NCT03286803.
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Affiliation(s)
| | - Ondrej Mach
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | | | | | | | | | - Vishali Jeyaseelan
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | - Anita K M Zaidi
- Aga Khan University, Karachi, Pakistan
- Bill and Melinda Gates Foundation, Seattle, USA
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Resik S, Mach O, Tejeda A, Jeyaseelan V, Fonseca M, Diaz M, Alemany N, Hung LH, Aleman Y, Mesa I, Garcia G, Sutter RW. Immunogenicity of Intramuscular Fractional Dose of Inactivated Poliovirus Vaccine. J Infect Dis 2020; 221:895-901. [PMID: 31242300 DOI: 10.1093/infdis/jiz323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 06/25/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUNDS Intradermal (id) fractional inactivated poliovirus vaccine ([fIPV] one fifth of normal IPV dose) is safe and immunogenic; however, id administration is perceived as difficult. We compared fIPV immunogenicity administered id or intramuscularly (im). METHODS This noninferiority trial was conducted among polio vaccine-naive Cuban infants who received 2 IPV doses at 4 and 8 months of age. Infants were randomized into 4 arms: (A) fIPV, 0.1 mL im; (B) fIPV, 0.2 mL im; (C) fIPV, 0.1mL id; and (D) IPV, 0.5 mL im. Blood collected before and after vaccinations was tested for poliovirus-neutralizing antibodies. RESULTS A total of 196 of 214 (91.6%) enrolled children completed study. Seroconversion after 2 IPV doses in each arm were as follows: (A) 97.3% (90.6-99.7), 98.7% (92.7-99.9), and 90.5% (81.5-96.1) for serotypes 1, 2, and 3, respectively; (B) 97.2% (90.3-99.7), 100%, 95.8% (88.3-99.1) for serotypes 1, 2, and 3, respectively; (C) 89.3% (71.8-97.7), 92.9% (76.5-99.1), 82.1% (63.1-93.9) for serotypes 1, 2, and 3, respectively; and (D) 100%, 100%, 100% for serotypes 1, 2, and 3, respectively. Seroconversion with fIPV im was noninferior to fIPV id for all serotypes. CONCLUSIONS We demonstrated noninferiority of fIPV im compared with id when administered at 4 and 8 months of age. Further investigations in an earlier infant schedule should be pursued to explore fIPV im as option for dose-sparing strategy in countries reluctant to use fIPV id due to programmatic difficulties of id administration.
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Affiliation(s)
- Sonia Resik
- Pedro Kouri Institute of Tropical Medicine, Havana, Cuba
| | - Ondrej Mach
- Polio Department, World Health Organization, Geneva, Switzerland
| | - Alina Tejeda
- Provincial Center of Hygiene, Epidemiology and Microbiology, Camaguëy, Cuba
| | | | - Magile Fonseca
- Pedro Kouri Institute of Tropical Medicine, Havana, Cuba
| | - Manuel Diaz
- Pedro Kouri Institute of Tropical Medicine, Havana, Cuba
| | - Nilda Alemany
- Provincial Center of Hygiene, Epidemiology and Microbiology, Camaguëy, Cuba
| | - Lai Heng Hung
- Pedro Kouri Institute of Tropical Medicine, Havana, Cuba
| | - Yoan Aleman
- Pedro Kouri Institute of Tropical Medicine, Havana, Cuba
| | - Ileana Mesa
- Provincial Center of Hygiene, Epidemiology and Microbiology, Camaguëy, Cuba
| | - Gloria Garcia
- Provincial Center of Hygiene, Epidemiology and Microbiology, Camaguëy, Cuba
| | - Roland W Sutter
- Polio Department, World Health Organization, Geneva, Switzerland
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11
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Tagbo BN, Verma H, Mahmud ZM, Ernest K, Nnani RO, Chukwubike C, Craig KT, Hamisu A, Weldon WC, Oberste SM, Jeyaseelan V, Braka F, Mkanda P, Esangbedo D, Olowu A, Nwaze E, Sutter RW. Randomized Controlled Clinical Trial of bivalent Oral Poliovirus Vaccine and Inactivated Poliovirus Vaccine in Nigerian Children. J Infect Dis 2020; 226:299-307. [PMID: 33230550 PMCID: PMC9189759 DOI: 10.1093/infdis/jiaa726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/16/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We conducted a trial in Nigeria to assess the immunogenicity of the new bOPV + IPV immunization schedule and gains in type 2 immunity with addition of second dose of IPV. The trial was conducted in August 2016-March 2017 period, well past the tOPV-bOPV switch in April 2016. METHODS This was an open-label, two-arm, non-inferiority, multi-center, randomized controlled trial. We enrolled 572 infants of age ≤14 days and randomized them into two arms. Arm A received bOPV at birth, 6 and 10 weeks, bOPV+IPV at week 14 and IPV at week 18. Arm B received IPV each at 6, 10, 14 weeks and bOPV at 18 weeks of age. RESULTS Seroconversion rates for poliovirus types 1 and 3, respectively, were 98.9% (95%CI:96.7-99.8) and 98.1% (95%CI:88.2-94.8) in Arm A, and 89.6% (95%CI:85.4-93.0) and 98.5% (95%CI:96.3-99.6) in Arm B. Type 2 seroconversion with one dose IPV in Arm A was 72.0% (95%CI:66.2-77.3), which increased significantly with addition of second dose to 95.9% (95%CI:92.8-97.9). CONCLUSION This first trial on the new EPI schedule in a sub-Saharan African country demonstrated excellent immunogenicity against poliovirus types 1 and 3, and substantial/enhanced immunogenicity against poliovirus type 2 after 1 to 2 doses of IPV respectively.
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Affiliation(s)
- Beckie N Tagbo
- Institute of Child Health/Department of Paediatrics, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | | | | | - Kolade Ernest
- Department of Pediatrics and Child Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Roosevelt O Nnani
- Institute of Child Health, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Chinedu Chukwubike
- Institute of Child Health, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | | | | | | | | | | | | | - Pascal Mkanda
- World Health Organization, Regional Office for Africa, Brazzaville, DRC
| | | | | | - Eric Nwaze
- National Primary Health Care Development Agency, Enugu, Nigeria
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12
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de Deus N, Capitine IPU, Bauhofer AFL, Marques S, Cassocera M, Chissaque A, Bero DM, Langa JP, Padama FM, Jeyaseelan V, Oberste MS, Estivariz CF, Verma H, Jani I, Mach O, Sutter RW. Immunogenicity of reduced-dose monovalent type 2 oral poliovirus vaccine in Mocuba, Mozambique. J Infect Dis 2020; 226:292-298. [PMID: 33180924 PMCID: PMC9400415 DOI: 10.1093/infdis/jiaa704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/05/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Monovalent type 2 oral poliovirus vaccine (mOPV2) stockpile is low. One potential strategy to stretch the existing mOPV2 supply is to administer a reduced dose: one-drop instead of two-drops. METHODS We conducted a randomized, controlled, open-label, non-inferiority trial (10% margin) to compared immunogenicity following administration of one versus two-drops of mOPV2. We enrolled 9-22-months old infants from Mocuba district of Mozambique. Poliovirus neutralizing antibodies were measured in sera collected before and one month after mOPV2 administration. Immune response was defined as seroconversion from seronegative (<1:8) at baseline to seropositive (>1:8) after vaccination or boosting titers by >4-fold for those with titers between 1:8 and 1:362 at baseline. The trial was registered at anzctr.org.au (number ACTRN12619000184178p). RESULTS We enrolled 378 children and 262 (69%) completed per-protocol requirements. Immune response of mOPV2 was 53.6% (95% confidence interval [CI]: 44.9%-62.1%) and 60.6% (95% CI: 52.2%-68.4%) in 1-drop and 2-drops recipients, respectively. The non-inferiority margin of the 10% was not reached (difference=7.0%; 95%CI= -5.0-19.0). CONCLUSION A small loss of immunogenicity of reduced mOPV2 was observed. Although the non-inferiority target was not achieved, the Strategic Advisory Group of Experts on Immunization, recommended the 1-drop strategy as a dose-sparing measure if mOPV2 supplies deteriorate further.
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Affiliation(s)
- Nilsa de Deus
- Instituto Nacional de Saúde (INS) - Mozambique, Maputo, Mozambique
| | | | - Adilson Fernando Loforte Bauhofer
- Instituto Nacional de Saúde (INS) - Mozambique, Maputo, Mozambique.,Instituto de Higiene e Medicina Tropical - Universidade Nova de Lisboa, Lisboa, Portugal
| | - Selma Marques
- Instituto Nacional de Saúde (INS) - Mozambique, Maputo, Mozambique
| | - Marta Cassocera
- Instituto Nacional de Saúde (INS) - Mozambique, Maputo, Mozambique.,Instituto de Higiene e Medicina Tropical - Universidade Nova de Lisboa, Lisboa, Portugal
| | - Assucênio Chissaque
- Instituto Nacional de Saúde (INS) - Mozambique, Maputo, Mozambique.,Instituto de Higiene e Medicina Tropical - Universidade Nova de Lisboa, Lisboa, Portugal
| | | | - José Paulo Langa
- Instituto Nacional de Saúde (INS) - Mozambique, Maputo, Mozambique
| | | | | | | | | | - Harish Verma
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | - Ilesh Jani
- Instituto Nacional de Saúde (INS) - Mozambique, Maputo, Mozambique
| | - Ondrej Mach
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
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13
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Macklin GR, O'Reilly KM, Grassly NC, Edmunds WJ, Mach O, Santhana Gopala Krishnan R, Voorman A, Vertefeuille JF, Abdelwahab J, Gumede N, Goel A, Sosler S, Sever J, Bandyopadhyay AS, Pallansch MA, Nandy R, Mkanda P, Diop OM, Sutter RW. Evolving epidemiology of poliovirus serotype 2 following withdrawal of the serotype 2 oral poliovirus vaccine. Science 2020; 368:401-405. [PMID: 32193361 PMCID: PMC10805349 DOI: 10.1126/science.aba1238] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/11/2020] [Indexed: 11/02/2022]
Abstract
Although there have been no cases of serotype 2 wild poliovirus for more than 20 years, transmission of serotype 2 vaccine-derived poliovirus (VDPV2) and associated paralytic cases in several continents represent a threat to eradication. The withdrawal of the serotype 2 component of oral poliovirus vaccine (OPV2) was implemented in April 2016 to stop VDPV2 emergence and secure eradication of all serotype 2 poliovirus. Globally, children born after this date have limited immunity to prevent transmission. Using a statistical model, we estimated the emergence date and source of VDPV2s detected between May 2016 and November 2019. Outbreak response campaigns with monovalent OPV2 are the only available method to induce immunity to prevent transmission. Yet our analysis shows that using monovalent OPV2 is generating more paralytic VDPV2 outbreaks with the potential for establishing endemic transmission. A novel OPV2, for which two candidates are currently in clinical trials, is urgently required, together with a contingency strategy if this vaccine does not materialize or perform as anticipated.
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Affiliation(s)
- G R Macklin
- Centre of Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK.
- Polio Eradication, World Health Organization, Geneva, Switzerland
| | - K M O'Reilly
- Centre of Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - N C Grassly
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - W J Edmunds
- Centre of Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - O Mach
- Polio Eradication, World Health Organization, Geneva, Switzerland
| | | | - A Voorman
- Bill and Melinda Gates Foundation, Seattle, WA, USA
| | - J F Vertefeuille
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - J Abdelwahab
- United Nations Children's Fund (UNICEF), New York, NY, USA
| | - N Gumede
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
| | - A Goel
- Polio Eradication, World Health Organization, Geneva, Switzerland
| | - S Sosler
- Gavi (the Vaccine Alliance), Geneva, Switzerland
| | - J Sever
- Rotary International, Evanston, IL, USA
| | | | - M A Pallansch
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - R Nandy
- United Nations Children's Fund (UNICEF), New York, NY, USA
| | - P Mkanda
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
| | - O M Diop
- Polio Eradication, World Health Organization, Geneva, Switzerland
| | - R W Sutter
- Polio Eradication, World Health Organization, Geneva, Switzerland
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
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14
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Gamage D, Mach O, Ginige S, Weldon WC, Oberste MS, Jeyaseelan V, Sutter RW. Poliovirus Type 2 Seroprevalence Following Full- or Fractional-Dose Inactivated Poliovirus Vaccine in the Period After Sabin Type 2 Withdrawal in Sri Lanka. J Infect Dis 2020; 219:1887-1892. [PMID: 30649505 DOI: 10.1093/infdis/jiz026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/11/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In July 2016, Sri Lanka replaced 1 intramuscular dose of inactivated poliovirus vaccine (IPV) with 2 doses of intradermal fractional-dose IPV (fIPV) in its routine immunization schedule. We carried out a survey of seroprevalence of antipolio antibodies in children who received 2 fIPV doses and compared it with those who received 1 full IPV dose. METHODS Children born between March and December 2016 were randomly selected from 3 Sri Lankan districts (Colombo, Badulla, and Anuradhapura). Serum samples were collected and tested for presence of neutralizing antibodies to poliovirus types 1, 2, and 3. RESULTS Seroprevalence of antipolio antibodies was 100% in all districts for poliovirus type 1 and poliovirus type 3; it ranged between 90% and 93% for poliovirus type 2 (PV2) in children who received 1 full IPV dose and between 78% and 100% in those receiving 2 fIPV doses (P = .22). The median reciprocal titers of anti-PV2 antibodies were similar in children who received full-dose IPV and those who received fIPV (1:64 vs 1:45, respectively; P = .11). CONCLUSIONS Our study demonstrated not only that Sri Lanka succeeded in maintaining very high primary immunization coverage also but that it is feasible for a national immunization program to implement fIPV immunization and achieve high coverage with intradermal application. The seroprevalence of anti-PV2 antibodies did not decrease after the introduction of fIPV.
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Affiliation(s)
- Deepa Gamage
- Epidemiology Unit, Ministry of Health, Colombo, Sri Lanka
| | - Ondrej Mach
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | - Samitha Ginige
- Epidemiology Unit, Ministry of Health, Colombo, Sri Lanka
| | - William C Weldon
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - M Steven Oberste
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
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15
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Resik S, Tejeda A, Mach O, Fonseca M, Diaz M, Alemany N, Heng Hung L, Aleman Y, Mesa I, Garcia G, Sutter RW. Does Simultaneous Administration of Bivalent (Types 1 and 3) Oral Poliovirus Vaccine and Inactivated Poliovirus Vaccine Induce Mucosal Cross-immunity to Poliovirus Type 2? Clin Infect Dis 2019; 67:S51-S56. [PMID: 30376088 PMCID: PMC6206124 DOI: 10.1093/cid/ciy604] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Inactivated poliovirus vaccine (IPV) alone does not induce mucosal immunity. However, it was hypothesized that administration of IPV together with bivalent (types 1+3) oral poliovirus vaccine (bOPV) may stimulate mucosal cross-immunity to poliovirus type 2 (PV2). Methods Cuban infants were randomized to receive either one dose of IPV (Arm A); one dose of IPV with bOPV (Arm B) at about 6 months of age or no vaccine (Arm C). Subjects were challenged with one dose of trivalent OPV (tOPV); they were about 7 months old in arms A and B, and about 3 months old in arm C at a time of the tOPV challenge. Sera were collected before vaccination and 30 days after tOPV challenge and tested for presence of poliovirus neutralizing antibodies; stool samples were collected at days 0, 7, 14, 21 and 49 post-challenge and tested for presence of poliovirus. Results We enrolled 333 children. Excretion of PV2 following tOPV challenge was highest on day 7 (75 [CI 95% = 65-82%], 68 [CI 95% = 58-75%] and 73 [CI 95% = 63-80%] for study arms A, B, and C respectively); excretion decreased with every subsequent stool sampling; no significant differences either in proportion of PV2 excretion or in its duration were observed between study arms. Conclusions There was no reduction in excretion of PV2 after tOPV challenge in children who had received IPV with bOPV when compared to those who had received IPV alone or no vaccine. Polio eradication program cannot assume any PV2 mucosal response with the current polio immunization schedule. Clinical Trials Registration The trial was registered with the Australian New Zealand Clinical Trials Registry and allocated trial number ACTRN12616000169448.
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Affiliation(s)
- Sonia Resik
- Pedro Kouri Institute of Tropical Medicine, Havana, Cuba
| | - Alina Tejeda
- Provincial Center of Hygiene, Epidemiology and Microbiology, Camaguey, Cuba
| | - Ondrej Mach
- The World Health Organization, Geneva, Switzerland
| | - Magile Fonseca
- Pedro Kouri Institute of Tropical Medicine, Havana, Cuba
| | - Manuel Diaz
- Pedro Kouri Institute of Tropical Medicine, Havana, Cuba
| | - Nilda Alemany
- Provincial Center of Hygiene, Epidemiology and Microbiology, Camaguey, Cuba
| | - Lai Heng Hung
- Pedro Kouri Institute of Tropical Medicine, Havana, Cuba
| | - Yoan Aleman
- Pedro Kouri Institute of Tropical Medicine, Havana, Cuba
| | - Ileana Mesa
- Provincial Center of Hygiene, Epidemiology and Microbiology, Camaguey, Cuba
| | - Gloria Garcia
- Provincial Center of Hygiene, Epidemiology and Microbiology, Camaguey, Cuba
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16
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Sutter RW, Cochi SL. Inactivated Poliovirus Vaccine Supply Shortage: Is There Light at the End of the Tunnel? J Infect Dis 2019; 220:1545-1546. [PMID: 30958545 PMCID: PMC10547123 DOI: 10.1093/infdis/jiy739] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/21/2018] [Indexed: 10/05/2023] Open
Affiliation(s)
| | - Stephen L. Cochi
- Global Immunization Division, Centers for Disease Control
and Prevention, Atlanta, Georgia
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17
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Moffett DB, Llewellyn A, Singh H, Saxentoff E, Partridge J, Iakovenko M, Roesel S, Asghar H, Baig N, Grabovac V, Gurung S, Gumede-Moeletsi N, Barnor J, Theo A, Rey-Benito G, Villalobos A, Boualam L, Swan J, Sutter RW, Pandel E, Wassilak S, Oberste MS, Lewis I, Zaffran M. Progress Toward Poliovirus Containment Implementation - Worldwide, 2018-2019. MMWR Morb Mortal Wkly Rep 2019; 68:825-829. [PMID: 31557146 PMCID: PMC6762185 DOI: 10.15585/mmwr.mm6838a3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Among the three wild poliovirus (WPV) types, type 2 (WPV2) was declared eradicated globally by the Global Commission for the Certification of Poliomyelitis Eradication (GCC) in 2015. Subsequently, in 2016, a global withdrawal of Sabin type 2 oral poliovirus vaccine (OPV2) from routine use, through a synchronized switch from the trivalent formulation of oral poliovirus vaccine (tOPV, containing vaccine virus types 1, 2, and 3) to the bivalent form (bOPV, containing types 1 and 3), was implemented. WPV type 3 (WPV3), last detected in 2012 (1), will possibly be declared eradicated in late 2019.* To ensure that polioviruses are not reintroduced to the human population after eradication, World Health Organization (WHO) Member States committed in 2015 to containing all polioviruses in poliovirus-essential facilities (PEFs) that are certified to meet stringent containment criteria; implementation of containment activities began that year for facilities retaining type 2 polioviruses (PV2), including type 2 oral poliovirus vaccine (OPV) materials (2). As of August 1, 2019, 26 countries have nominated 74 PEFs to retain PV2 materials. Twenty-five of these countries have established national authorities for containment (NACs), which are institutions nominated by ministries of health or equivalent bodies to be responsible for poliovirus containment certification. All designated PEFs are required to be enrolled in the certification process by December 31, 2019 (3). When GCC certifies WPV3 eradication, WPV3 and vaccine-derived poliovirus (VDPV) type 3 materials will also be required to be contained, leading to a temporary increase in the number of designated PEFs. When safer alternatives to wild and OPV/Sabin strains that do not require containment conditions are available for diagnostic and serologic testing, the number of PEFs will decrease. Facilities continuing to work with polioviruses after global eradication must minimize the risk for reintroduction into communities by adopting effective biorisk management practices.
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18
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Gamage D, Mach O, Palihawadana P, Zhang Y, Weldon WC, Oberste MS, Gunasena S, Sutter RW. Boosting of Mucosal Immunity After Fractional-Dose Inactivated Poliovirus Vaccine. J Infect Dis 2019; 218:1876-1882. [PMID: 29982532 DOI: 10.1093/infdis/jiy389] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 06/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background Inactivated poliovirus vaccine (IPV) boosts mucosal immunity in persons previously vaccinated with oral poliovirus vaccine (OPV). We assessed whether fractional-dose IPV (fIPV, 1/5th of full dose) administered intradermally also boosts mucosal immunity. Methods Children 10-12 years old were enrolled in Sri Lanka and randomized to receive one dose IPV, fIPV, or no IPV vaccine. One month later, they received OPV challenge. Blood was collected at enrolment and before challenge; stool was collected at 3, 7, and 14 days post-challenge. Sera were analysed for presence of poliovirus neutralizing antibodies; stool was analysed for poliovirus. Results We analysed 304/309 (98%) enrolled subjects. There were 16/97 (16%), 9/99 (9%), and 72/95 (76%) subjects excreting poliovirus after challenge in the IPV, fIPV and "No IPV Vaccine" study arms, respectively (P < .001 for comparison of IPV [or fIPV] vs "No IPV Vaccine"; P = .1 for comparisons of fIPV vs IPV). Relative decrease in excretion prevalence was 80% and 88% to IPV and fIPV, respectively, compared with the "No IPV Vaccine" control arm. Conclusions Single fIPV dose boosted mucosal immunity to a similar degree as single full dose of IPV. This finding provides further evidence in support of fIPV for poliovirus outbreak response at the time of IPV global supply shortage. Clinical trials registration Australia New Zealand Clinical Trial Registry ACTRN12616000124437p.
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Affiliation(s)
- Deepa Gamage
- Epidemiology Unit, Ministry of Health, Colombo, Sri Lanka
| | - Ondrej Mach
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | | | - Yiting Zhang
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - William C Weldon
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - M Steven Oberste
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
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19
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Macklin GR, Grassly NC, Sutter RW, Mach O, Bandyopadhyay AS, Edmunds WJ, O'Reilly KM. Vaccine schedules and the effect on humoral and intestinal immunity against poliovirus: a systematic review and network meta-analysis. Lancet Infect Dis 2019; 19:1121-1128. [PMID: 31350192 DOI: 10.1016/s1473-3099(19)30301-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/04/2019] [Accepted: 04/18/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND The eradication of wild and vaccine-derived poliovirus requires the global withdrawal of oral poliovirus vaccines (OPVs) and replacement with inactivated poliovirus vaccines (IPVs). The first phase of this effort was the withdrawal of the serotype 2 vaccine in April 2016, with a switch from trivalent OPVs to bivalent OPVs. The aim of our study was to produce comparative estimates of humoral and intestinal mucosal immunity associated with different routine immunisation schedules. METHODS We did a random-effect meta-analysis with single proportions and a network meta-analysis in a Bayesian framework to synthesise direct and indirect data. We searched MEDLINE and the Cochrane Library Central Register of Controlled Trials for randomised controlled trials published from Jan 1, 1980, to Nov 1, 2018, comparing poliovirus immunisation schedules in a primary series. Only trials done outside western Europe or North America and without variation in age schedules (ie, age at administration of the vaccine) between study groups were included in the analyses, because trials in high-income settings differ in vaccine immunogenicity and schedules from other settings and to ensure consistency within the network of trials. Data were extracted directly from the published reports. We assessed seroconversion against poliovirus serotypes 1, 2, and 3, and intestinal immunity against serotype 2, measured by absence of shedding poliovirus after a challenge OPV dose. FINDINGS We identified 437 unique studies; of them, 17 studies with a maximum of 8279 evaluable infants were eligible for assessment of humoral immunity, and eight studies with 4254 infants were eligible for intestinal immunity. For serotype 2, there was low between-trial heterogeneity in the data (τ=0·05, 95% credible interval [CrI] 0·009-0·15) and the risk ratio (RR) of seroconversion after three doses of bivalent OPVs was 0·14 (95% CrI 0·11-0·17) compared with three doses of trivalent OPVs. The addition of one or two full doses of an IPV after a bivalent OPV schedule increased the RR to 0·85 (0·75-1·0) and 1·1 (0·98-1·4). However, the addition of an IPV to bivalent OPV schedules did not significantly increase intestinal immunity (0·33, 0·18-0·61), compared with trivalent OPVs alone. For serotypes 1 and 3, there was susbstantial inconsistency and between-trial heterogeneity between direct and indirect effects, so we only present pooled estmates on seroconversion, which were at least 80% for serotype 1 and at least 88% for serotype 3 for all vaccine schedules. INTERPRETATION For WHO's polio eradication programme, the addition of one IPV dose for all birth cohorts should be prioritised to protect against paralysis caused by type 2 poliovirus; however, this inclusion will not prevent transmission or circulation in areas with faecal-oral transmission. FUNDING UK Medical Research Council.
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Affiliation(s)
- Grace R Macklin
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK; Centre for Mathematical Modelling of Infectious Disease, London School of Hygiene & Tropical Medicine, London, UK; Polio Eradication Department, World Health Organization, Geneva, Switzerland.
| | - Nicholas C Grassly
- Department of Infectious Disease Epidemiology, St Mary's Campus, Imperial College London, London, UK
| | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | - Ondrej Mach
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | | | - W John Edmunds
- Centre for Mathematical Modelling of Infectious Disease, London School of Hygiene & Tropical Medicine, London, UK; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Kathleen M O'Reilly
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK; Centre for Mathematical Modelling of Infectious Disease, London School of Hygiene & Tropical Medicine, London, UK
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20
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Bandyopadhyay AS, Singh H, Fournier-Caruana J, Modlin JF, Wenger J, Partridge J, Sutter RW, Zaffran MJ. Facility-Associated Release of Polioviruses into Communities-Risks for the Posteradication Era. Emerg Infect Dis 2019; 25:1363-1369. [PMID: 31082331 PMCID: PMC6590745 DOI: 10.3201/eid2507.181703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The Global Polio Eradication Initiative continues to make progress toward the eradication target. Indigenous wild poliovirus (WPV) type 2 was last detected in 1999, WPV type 3 was last detected in 2012, and over the past 2 years WPV type 1 has been detected only in parts of 2 countries (Afghanistan and Pakistan). Once the eradication of poliomyelitis is achieved, infectious and potentially infectious poliovirus materials retained in laboratories, vaccine production sites, and other storage facilities will continue to pose a risk for poliovirus reintroduction into communities. The recent breach in containment of WPV type 2 in an inactivated poliovirus vaccine manufacturing site in the Netherlands prompted this review, which summarizes information on facility-associated release of polioviruses into communities reported over >8 decades. Successful polio eradication requires the management of poliovirus containment posteradication to prevent the consequences of the reestablishment of poliovirus transmission.
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Huyen DTT, Mach O, Thanh Trung N, Thai PQ, Thang HV, Weldon WC, Oberste MS, Jeyaseelan V, Sutter RW, Anh DD. Rapid Disappearance of Poliovirus Type 2 (PV2) Immunity in Young Children Following Withdrawal of Oral PV2-Containing Vaccine in Vietnam. J Infect Dis 2019; 220:386-391. [PMID: 30869149 PMCID: PMC9069936 DOI: 10.1093/infdis/jiz124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/13/2019] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Due to global shortage of inactivated poliovirus vaccine and withdrawal of oral vaccine containing poliovirus type 2 (PV2), a PV2-containing vaccine was not used in Vietnam May 2016 to October 2018. We assessed the population immunity gap to PV2. METHODS A cross-sectional survey in children aged 1-18 months was carried out in January 2018. One blood sample per child was analyzed for presence of poliovirus neutralizing antibodies. In children with detectable anti-PV2 antibodies, a second sample was analyzed 4 months later to distinguish between passive (maternally derived) and active (induced by secondary transmission or vaccination) immunity. RESULTS Sera were obtained from 1106/1110 children. Seroprevalence of PV2 antibodies was 87/368 (23.6%) at age 1-7 months, 27/471 (5.7%) at 8-15 months, and 19/267 (7.1%) at 16-18 months. Seroprevalence declined with age in the 1-7 months group; in the 8-18 months group there was no significant change with age. Four months later, 11/87 (14%), 9/27 (32%), and 12/19 (37%) remained seropositive in 1-7, 8-15, and 16-18 months age groups, respectively. CONCLUSIONS We found declining immunity to PV2, suggesting Vietnam is at risk for an outbreak of type 2 vaccine-derived poliovirus following virus importation or new emergence.
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Affiliation(s)
| | - Ondrej Mach
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | | | - Pham Quang Thai
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | | | - William C Weldon
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - M Steven Oberste
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | - Dang Duc Anh
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
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Affiliation(s)
- Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva CH-1211, Switzerland.
| | - Michel Zaffran
- Polio Eradication Department, World Health Organization, Geneva CH-1211, Switzerland
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Saleem AF, Mach O, Yousafzai MT, Khan A, Weldon WC, Steven Oberste M, Zaidi SS, Alam MM, Quadri F, Sutter RW, Zaidi AKM. Immunogenicity of Different Routine Poliovirus Vaccination Schedules: A Randomized, Controlled Trial in Karachi, Pakistan. J Infect Dis 2019; 217:443-450. [PMID: 29126173 DOI: 10.1093/infdis/jix577] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 11/01/2017] [Indexed: 11/14/2022] Open
Abstract
Background We assessed immunity against polioviruses induced with a new Pakistani poliovirus immunization schedule and compared it to alternative poliovirus immunization schedules. Methods Newborns were randomized to undergo vaccination based on 1 of 5 vaccination schedules, with doses administered at birth and at 6, 10, and 14 weeks of age. Arm A received inactivated poliovirus vaccine (IPV) at all time points. Arm B received bivalent oral poliovirus vaccine (bOPV) at all time points. Arms C and D received bOPV at the first 3 time points and bOPV plus IPV at the final time point (the current schedule). Arm E received trivalent OPV (tOPV) at all time points. At 22 weeks of age, all children received 1 challenge dose of tOPV, and children in arm D received 1 additional IPV dose. Sera were analyzed for the presence of poliovirus neutralizing antibodies at birth and 14 and 22 weeks of age. Results Seroconversion for poliovirus type 1 (PV1) at 22 weeks of age was observed in 80% of individuals in arm A, 97% in arm B, 94% in arm C, 96% in arm D, and 94% in arm E; for PV2, seroconversion frequencies were 84%, 19%, 53%, 49%, and 93%, respectively; and for PV3, seroconversion frequencies were 93%, 94%, 98%, 94%, and 85%, respectively. Conclusions The current immunization schedule in Pakistan induced high seroconversion rates for PV1 and PV3; however, it induced PV2 seroconversion in only half of study subjects. There is a growing cohort of young children in Pakistan who are unprotected against PV2; and this creates an increasing risk of a large-scale outbreak of poliomyelitis caused by circulating vaccine-derived PV2.
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Affiliation(s)
| | - Ondrej Mach
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | | | - Asia Khan
- Aga Khan University, Karachi, Pakistan
| | - William C Weldon
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - M Steven Oberste
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Syed S Zaidi
- National Institute of Health, Islamabad, Pakistan
| | | | | | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
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Sutter RW, Okayasu H, Kieny MP. Next Generation Inactivated Poliovirus Vaccine: The Future Has Arrived. Clin Infect Dis 2019; 64:1326-1327. [PMID: 28200099 DOI: 10.1093/cid/cix116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Marie-Paule Kieny
- Health Systems and Innovation Cluster, World Health Organization, Geneva, Switzerland
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Abstract
Pakistan began using inactivated poliovirus vaccine alongside oral vaccine in mass campaigns to accelerate eradication of wild-type poliovirus in 2014. Using case-based and environmental surveillance data for January 2014-October 2017, we found that these campaigns reduced wild-type poliovirus detection more than campaigns that used only oral vaccine.
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Verma H, Iliyasu Z, Craig KT, Molodecky NA, Urua U, Jibir BW, Gwarzo GD, Gajida AU, McDonald S, Weldon WC, Oberste MS, Braka F, Mkanda P, Sutter RW. Trends in Poliovirus Seroprevalence in Kano State, Northern Nigeria. Clin Infect Dis 2018; 67:S103-S109. [PMID: 30376090 PMCID: PMC6206109 DOI: 10.1093/cid/ciy637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Kano state has been a protracted reservoir of poliovirus in Nigeria. Immunity trends have been monitored through seroprevalence surveys since 2011. The survey in 2015 was, in addition, intended to assess the impact of use of inactivated poliovirus vaccine (IPV). Methods It was a health facility based seroprevalence survey. Eligible children aged 6-9, 12-15 and 19-22 months of age brought to the paediatrics outpatient department of Murtala Mohammad Specialist Hospital between 19 October and 6 November 2015, were screened for eligibility. Eligible children were enrolled after parental consent, history taken, physical examination conducted, and a blood sample collected to test for neutralizing antibody titres against the three poliovirus serotypes. Results Overall, 365 results were available in the three age groups. In the 6-9-month-old age group, the seroprevalence was 73% (95% confidence interval [CI] 64-80%), 83% (95% CI 75-88%), and 66% (95% CI 57-73%) for serotypes 1, 2, and 3, respectively. In the 12-15- and 19-22-month-old age groups, seroprevalence was higher but still remained <90% across serotypes. Seroprevalence to serotypes 1 and 3 in 2015 was similar to 2014; however, for serotype 2 there was a significant improvement. IPV received in supplemental immunization activities was found to be a significant predictor of seropositivity among 6-9-month-old infants for serotypes 1 and 2. Conclusions Seroprevalence for serotypes 1 and 3 remains low (<80%) in 6-9-month-olds. This poses a significant risk for poliovirus spread if reintroduced into the population. Efforts to strengthen immunization coverage are imperative to secure and sustain high population immunity.
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Affiliation(s)
| | - Zubairu Iliyasu
- Department of Community Medicine, Aminu Kano Teaching Hospital & Bayero University, Kano, Nigeria
| | | | | | - Utibeabasi Urua
- National Primary Health Care Development Agency, Abuja, Nigeria
| | - Binta Wudil Jibir
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Garba Dayyabu Gwarzo
- Department of Pediatrics, Aminu Kano Teaching Hospital & Bayero University, Kano, Nigeria
| | - Auwalu U Gajida
- Department of Community Medicine, Aminu Kano Teaching Hospital & Bayero University, Kano, Nigeria
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Jorba J, Diop OM, Iber J, Henderson E, Zhao K, Sutter RW, Wassilak SG, Burns CC. Update on Vaccine-Derived Polioviruses - Worldwide, January 2017-June 2018. MMWR Morb Mortal Wkly Rep 2018; 67:1189-1194. [PMID: 30359342 PMCID: PMC6290814 DOI: 10.15585/mmwr.mm6742a5] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Fournier-Caruana J, Previsani N, Singh H, Boualam L, Swan J, Llewellyn A, Sutter RW, Zaffran M. Progress Toward Poliovirus Containment Implementation - Worldwide, 2017-2018. MMWR Morb Mortal Wkly Rep 2018; 67:992-995. [PMID: 30188884 PMCID: PMC6132186 DOI: 10.15585/mmwr.mm6735a5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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29
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Blake IM, Pons-Salort M, Molodecky NA, Diop OM, Chenoweth P, Bandyopadhyay AS, Zaffran M, Sutter RW, Grassly NC. Type 2 Poliovirus Detection after Global Withdrawal of Trivalent Oral Vaccine. N Engl J Med 2018; 379:834-845. [PMID: 30157398 PMCID: PMC5985919 DOI: 10.1056/nejmoa1716677] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Mass campaigns with oral poliovirus vaccine (OPV) have brought the world close to the eradication of wild poliovirus. However, to complete eradication, OPV must itself be withdrawn to prevent outbreaks of vaccine-derived poliovirus (VDPV). Synchronized global withdrawal of OPV began with serotype 2 OPV (OPV2) in April 2016, which presented the first test of the feasibility of eradicating all polioviruses. METHODS We analyzed global surveillance data on the detection of serotype 2 Sabin vaccine (Sabin-2) poliovirus and serotype 2 vaccine-derived poliovirus (VDPV2, defined as vaccine strains that are at least 0.6% divergent from Sabin-2 poliovirus in the viral protein 1 genomic region) in stool samples from 495,035 children with acute flaccid paralysis in 118 countries and in 8528 sewage samples from four countries at high risk for transmission; the samples were collected from January 1, 2013, through July 11, 2018. We used Bayesian spatiotemporal smoothing and logistic regression to identify and map risk factors for persistent detection of Sabin-2 poliovirus and VDPV2. RESULTS The prevalence of Sabin-2 poliovirus in stool samples declined from 3.9% (95% confidence interval [CI], 3.5 to 4.3) at the time of OPV2 withdrawal to 0.2% (95% CI, 0.1 to 2.7) at 2 months after withdrawal, and the detection rate in sewage samples declined from 71.0% (95% CI, 61.0 to 80.0) to 13.0% (95% CI, 8.0 to 20.0) during the same period. However, 12 months after OPV2 withdrawal, Sabin-2 poliovirus continued to be detected in stool samples (<0.1%; 95% CI, <0.1 to 0.1) and sewage samples (8.0%; 95% CI, 5.0 to 13.0) because of the use of OPV2 in response to VDPV2 outbreaks. Nine outbreaks were reported after OPV2 withdrawal and were associated with low coverage of routine immunization (odds ratio, 1.64 [95% CI, 1.14 to 2.54] per 10% absolute decrease) and low levels of population immunity (odds ratio, 2.60 [95% CI, 1.35 to 5.59] per 10% absolute decrease) within affected countries. CONCLUSIONS High population immunity has facilitated the decline in the prevalence of Sabin-2 poliovirus after OPV2 withdrawal and restricted the circulation of VDPV2 to areas known to be at high risk for transmission. The prevention of VDPV2 outbreaks in these known areas before the accumulation of substantial cohorts of children susceptible to type 2 poliovirus remains a high priority. (Funded by the Bill and Melinda Gates Foundation and the World Health Organization.).
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Affiliation(s)
| | | | - Natalie A. Molodecky
- Department of Infectious Disease Epidemiology, Imperial College London,
London, UK
| | - Ousmane M. Diop
- Department of Infectious Disease Epidemiology, Imperial College London,
London, UK
| | - Paul Chenoweth
- Polio Eradication Department, World Health Organization, Geneva,
Switzerland
| | | | - Michel Zaffran
- Polio Eradication Department, World Health Organization, Geneva,
Switzerland
| | - Roland W. Sutter
- Polio Eradication Department, World Health Organization, Geneva,
Switzerland
| | - Nicholas C. Grassly
- Department of Infectious Disease Epidemiology, Imperial College London,
London, UK
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Abstract
Cuba eliminated polio in 1962 and was among the first countries to do so. Since then, only 20 cases of vaccine-derived paralytic poliomyelitis have been reported. Because Cuba used oral poliovirus vaccine exclusively in two mass campaigns usually in February and April each year, Sabin viruses were detected only within approximately 6-8 weeks after each annual campaign. This made Cuba a very attractive site to study the epidemiology of poliomyelitis in a tropical country without risk of secondary transmission of Sabin viruses for a large part of each year, an advantage over countries that used oral poliovirus vaccine continuously throughout the year in routine immunization programs. This report summarizes the unique scientific collaboration between Cuba's Ministry of Public Health and WHO, with participation by US scientists, in the global effort to eradicate polio. KEYWORDS Poliomyelitis, disease eradication, disease elimination, oral poliovirus vaccine, Sabin vaccine, inactivated poliovirus vaccine, Salk vaccine, Cuba, WHO.
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Affiliation(s)
- Sonia Resik
- Pedro Kourí Tropical Medicine Institute, Havana, Cuba
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31
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Razafindratsimandresy R, Mach O, Heraud JM, Bernardson B, Weldon WC, Oberste MS, Sutter RW. Assessment of poliovirus antibody seroprevalence in high risk areas for vaccine derived poliovirus transmission in Madagascar. Heliyon 2018; 4:e00563. [PMID: 29560473 PMCID: PMC5857717 DOI: 10.1016/j.heliyon.2018.e00563] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 02/06/2018] [Accepted: 02/27/2018] [Indexed: 11/24/2022] Open
Abstract
Background Vaccine-derived polioviruses (VDPV) outbreaks typically occur in areas of low poliovirus immunity. Madagascar successfully eradicated wild poliovirus in 1997; however, multiple VDPV outbreaks have occurred since then, and numerous vaccination campaigns have been carried out to control the VDPV outbreaks. We conducted a survey of poliovirus neutralizing antibodies among Malagasy children to assess performance of vaccination campaigns and estimate the risk of future VDPV outbreaks. Methods This was a random community survey in children aged 6-11 months, 36-59 months and 5-14 years of age in high risk areas of Madagascar (Mahajanga, Toliara, Antsalova, and Midongy-atsimo); and in a reference area (Antananarivo). After obtaining informed consent, basic demographic and vaccination history, 2 mL of peripheral blood were collected. Neutralizing antibodies against all three poliovirus serotypes were detected by using a standard microneutralization assay. Results There were 1500 children enrolled and 1496 (>99%) provided sufficient quantity of blood for analysis. Seroprevalence for poliovirus type 1 (PV1) was >90% in all age groups and study areas. PV2 seroprevalence ranged between 75-100%; it was lowest in the youngest age group in Midongy and Toliara. PV3 seroprevalence ranged between 79-100%. Seroprevalence in the reference area was not significantly different from polio high risk sites. Discussion Madagascar achieved high population immunity. In order to preserve these gains, routine immunization needs to be strengthened. Currently, the risk of new VDPV emergences in Madagascar appears low.
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Affiliation(s)
| | - Ondrej Mach
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | | | | | - William C Weldon
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, USA
| | - M Steven Oberste
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, USA
| | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
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Hussain I, Mach O, Hamid NA, Bhatti ZS, Moore DD, Oberste MS, Khan S, Khan H, Weldon WC, Sutter RW, Bhutta ZA, Soofi SB. Seroprevalence of anti-polio antibodies in children from polio high risk area of Afghanistan: A cross sectional survey 2017. Vaccine 2018; 36:1921-1924. [PMID: 29510918 PMCID: PMC5873527 DOI: 10.1016/j.vaccine.2018.02.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 11/29/2022]
Abstract
First ever immunity profile from Afghanistan on polio antibodies. Reflective findings of program coverage despite dismal security situation and other potential challenges. Identified Immunity gaps suggestive of more robust planning and implementation.
Background Afghanistan is one of the remaining wild-poliovirus (WPV) endemic countries. We conducted a seroprevalence survey of anti-poliovirus antibodies in Kandahar Province. Methods Children in two age groups (6–11 months and 36–48 months) visiting Mirwais hospital in Kandahar for minor ailments unrelated to polio were enrolled. After obtaining informed consent, we collected venous blood and conducted neutralization assay to detect poliovirus neutralizing antibodies. Results A total of 420 children were enrolled and 409/420 (97%) were analysed. Seroprevalence to poliovirus type 1 (PV1) was 97% and 100% in the younger and older age groups respectively; it was 71% and 91% for PV2; 93% and 98% for PV3. Age group (RR = 3.6, CI 95% = 2.2–5.6) and place of residence outside of Kandahar city (RR = 1.8, CI 95% = 1.2–2.6) were found to be significant risk factors for seronegativity. Conclusions The polio eradication program in Kandahar achieved high serological protection, especially against PV1 and PV3. Lower PV2 seroprevalence in the younger age group is a result of a withdrawal of live type 2 vaccine in 2016 and is expected. Ability to reach all children with poliovirus vaccines is a pre-requisite for achieving poliovirus eradication.
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Affiliation(s)
- Imtiaz Hussain
- Department of Peadiatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Ondrej Mach
- Polio Eradication Department, World Health Organization, Geneva, Switzerland.
| | | | - Zaid S Bhatti
- Department of Peadiatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Deborah D Moore
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, USA
| | - M Steven Oberste
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, USA
| | - Shahid Khan
- Department of Peadiatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Hasan Khan
- Polio Eradication Departments, World Health Organization, Kabul, Afghanistan
| | - William C Weldon
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, USA
| | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | - Zulfiqar A Bhutta
- Department of Peadiatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid B Soofi
- Department of Peadiatrics and Child Health, Aga Khan University, Karachi, Pakistan.
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Guindo O, Mach O, Doumbia S, Ekra DK, Beavogui AH, Weldon WC, Oberste MS, Sutter RW. Assessment of poliovirus antibody seroprevalence in polio high risk areas of West Africa. Vaccine 2018; 36:1027-1031. [PMID: 29358054 DOI: 10.1016/j.vaccine.2018.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/20/2017] [Accepted: 01/06/2018] [Indexed: 11/19/2022]
Abstract
We conducted a serological survey of anti-polio antibodies in polio high-risk areas of Mali, Guinea and Cote d'Ivoire to assess risk of future poliovirus outbreaks. Random community sampling of children 6-11 and 36-48 months-old was conducted; neutralizing antibodies against poliovirus were detected using microneutralization assay. We analysed 1059/1064 (99.5%) of enrolled children. Seroprevalence to poliovirus type 1 (PV1) across all age groups and locations ranged between 92 and 100%, for PV2 it was 77-100%, and 89-95% for PV3. PV2 seroprevalence in the younger age group in Guinea and Cote d'Ivoire was <80%. History of <4 polio vaccine doses and acute malnutrition were associated with seronegativity (OR = 2.1 CI95% = 1.5-3.1, OR = 1.8 CI95% = 1.1-3.3 respectively). The risk of poliovirus outbreak following importation is low because of high population immunity to PV1, however, due to large cohort of PV2 seronegative children any future detection of vaccine-derived poliovirus type 2 requires urgent response to arrest rapid spread.
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Affiliation(s)
- Oumar Guindo
- University Clinical Research Center (UCRC), University of Sciences, Techniques and Technology of Bamako, Bamako, Mali
| | - Ondrej Mach
- Polio Eradication Department, World Health Organization, Geneva, Switzerland.
| | - Seydou Doumbia
- University Clinical Research Center (UCRC), University of Sciences, Techniques and Technology of Bamako, Bamako, Mali
| | - Daniel K Ekra
- UFR Sciences Médicales, Université Felix H. Boigny, Abidjan, Cote d'Ivoire
| | - Abdoul H Beavogui
- Centre de Formation et de Recherche en Santé Rurale de Mafèrinyah, Conakry, Guinea
| | - William C Weldon
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, USA
| | - M Steven Oberste
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, USA
| | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
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Sutter RW. Unraveling the Mucosal Immunity of Inactivated Poliovirus Vaccine. J Infect Dis 2018; 217:344-346. [DOI: 10.1093/infdis/jix557] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 10/20/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
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Jorba J, Diop OM, Iber J, Henderson E, Sutter RW, Wassilak SGF, Burns CC. Update on Vaccine-Derived Polioviruses - Worldwide, January 2016-June 2017. MMWR Morb Mortal Wkly Rep 2017; 66:1185-1191. [PMID: 29095803 PMCID: PMC5689216 DOI: 10.15585/mmwr.mm6643a6] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
In 1988, the World Health Assembly launched the Global Polio Eradication Initiative (GPEI) (1). Among the three wild poliovirus (WPV) serotypes, only type 1 (WPV1) has been detected since 2012. Since 2014, detection of WPV1 has been limited to three countries, with 37 cases in 2016 and 11 cases in 2017 as of September 27. The >99.99% decline worldwide in polio cases since the launch of the GPEI is attributable to the extensive use of the live, attenuated oral poliovirus vaccine (OPV) in mass vaccination campaigns and comprehensive national routine immunization programs. Despite its well-established safety record, OPV use can be associated with rare emergence of genetically divergent vaccine-derived polioviruses (VDPVs) whose genetic drift from the parental OPV strains indicates prolonged replication or circulation (2). VDPVs can also emerge among persons with primary immunodeficiencies (PIDs). Immunodeficiency-associated VDPVs (iVDPVs) can replicate for years in some persons with PIDs. In addition, circulating vaccine-derived polioviruses (cVDPVs) can emerge very rarely among immunologically normal vaccine recipients and their contacts in areas with inadequate OPV coverage and can cause outbreaks of paralytic polio. This report updates previous summaries regarding VDPVs (3). During January 2016-June 2017, new cVDPV outbreaks were identified, including two in the Democratic Republic of the Congo (DRC) (eight cases), and another in Syria (35 cases), whereas the circulation of cVDPV type 2 (cVDPV2) in Nigeria resulted in cVDPV2 detection linked to a previous emergence. The last confirmed case from the 2015-2016 cVDPV type 1 (cVDPV1) outbreak in Laos occurred in January 2016. Fourteen newly identified persons in 10 countries were found to excrete iVDPVs, and three previously reported patients in the United Kingdom and Iran (3) were still excreting type 2 iVDPV (iVDPV2) during the reporting period. Ambiguous VDPVs (aVDPVs), isolates that cannot be classified definitively, were found among immunocompetent persons and environmental samples in 10 countries. Cessation of all OPV use after certification of polio eradication will eliminate the risk for new VDPV infections.
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Gofama MM, Verma H, Abdullahi H, Molodecky NA, Craig KT, Urua UA, Garba MA, Alhaji MA, Weldon WC, Oberste MS, Braka F, Muhammad AJG, Sutter RW. Survey of poliovirus antibodies in Borno and Yobe States, North-Eastern Nigeria. PLoS One 2017; 12:e0185284. [PMID: 28949979 PMCID: PMC5614605 DOI: 10.1371/journal.pone.0185284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/08/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Nigeria remains one of only three polio-endemic countries in the world. In 2016, after an absence of 2 years, wild poliovirus serotype 1 was again detected in North-Eastern Nigeria. To better guide programmatic action, we assessed the immunity status of infants and children in Borno and Yobe states, and evaluated the impact of recently introduced inactivated poliovirus vaccine (IPV) on antibody seroprevalence. METHODS AND FINDINGS We conducted a facility-based study of seroprevalence to poliovirus serotypes 1, 2 and 3 among health-seeking patients in two sites each of Borno and Yobe States. Enrolment was conducted amongst children 6-9 and 36-47 months of age attending the paediatrics outpatient department of the selected hospitals in the two states between 11 January and 5 February 2016. Detailed demographic and immunization history of the child was taken and an assessment of the child's health and nutritional state was conducted via physical examination. Blood was collected to test for levels of neutralizing antibody titres against the three poliovirus serotypes. The seroprevalence in the two age groups, potential determinants of seropositivity and the impact of one dose of IPV on humoral immunity were assessed. A total of 583 subjects were enrolled and provided sufficient quantities of serum for testing. Among 6-9-month-old infants, the seroprevalence was 81% (74-87%), 86% (79-91%), and 72% (65-79%) in Borno State, and 75% (67-81%), 74% (66-81%) and 69% (61-76%) in Yobe States, for serotypes-1, 2 and 3, respectively. Among children aged 36-47 months, the seroprevalence was >90% in both states for all three serotypes, with the exception of type 3 seroprevalence in Borno [87% (80-91%)]. Median reciprocal anti-polio neutralizing antibody titers were consistently >900 for serotypes 1 and 2 across age groups and states; with lower estimates for serotype 3, particularly in Borno. IPV received in routine immunization was found to be a significant determinant of seropositivity and anti-polio neutralizing antibodies among 6-9-month-old infants for serotypes 1 and 3, but demonstrated a non-significant positive association for serotype 2. Children receiving IPV through SIAs demonstrated significantly higher anti-polio neutralizing antibodies for serotypes 1 and 3. CONCLUSIONS The seroprevalence to poliovirus remains suboptimal in both Borno and Yobe States in Nigeria. The low seroprevalence facilitated the continued transmission of both wild serotype 1 and serotype 2 circulating vaccine-derived poliovirus detected in Borno State in 2016. Further efforts are necessary to improve the immunity status of these populations to ensure sufficient population immunity to interrupt transmission.
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Affiliation(s)
| | | | | | | | | | | | | | | | - William C. Weldon
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - M. Steven Oberste
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Macklin G, Liao Y, Takane M, Dooling K, Gilmour S, Mach O, Kew OM, Sutter RW. Prolonged Excretion of Poliovirus among Individuals with Primary Immunodeficiency Disorder: An Analysis of the World Health Organization Registry. Front Immunol 2017; 8:1103. [PMID: 28993765 PMCID: PMC5622164 DOI: 10.3389/fimmu.2017.01103] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/23/2017] [Indexed: 12/19/2022] Open
Abstract
Individuals with primary immunodeficiency disorder may excrete poliovirus for extended periods and will constitute the only remaining reservoir of virus after eradication and withdrawal of oral poliovirus vaccine. Here, we analyzed the epidemiology of prolonged and chronic immunodeficiency-related vaccine-derived poliovirus cases in a registry maintained by the World Health Organization, to identify risk factors and determine the length of excretion. Between 1962 and 2016, there were 101 cases, with 94/101 (93%) prolonged excretors and 7/101 (7%) chronic excretors. We documented an increase in incidence in recent decades, with a shift toward middle-income countries, and a predominance of poliovirus type 2 in 73/101 (72%) cases. The median length of excretion was 1.3 years (95% confidence interval: 1.0, 1.4) and 90% of individuals stopped excreting after 3.7 years. Common variable immunodeficiency syndrome and residence in high-income countries were risk factors for long-term excretion. The changing epidemiology of cases, manifested by the greater incidence in recent decades and a shift to from high- to middle-income countries, highlights the expanding risk of poliovirus transmission after oral poliovirus vaccine cessation. To better quantify and reduce this risk, more sensitive surveillance and effective antiviral therapies are needed.
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Affiliation(s)
| | - Yi Liao
- World Health Organization, Geneva, Switzerland.,University of Tokyo, Tokyo, Japan
| | | | | | | | - Ondrej Mach
- World Health Organization, Geneva, Switzerland
| | - Olen M Kew
- Centers for Disease Control and Prevention, Atlanta, GA, United States.,Taskforce for Child Health, Atlanta, GA, United States
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38
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Garon J, Sutter RW, Orenstein W. High population immunity reduces poliovirus community transmission. Lancet Infect Dis 2017; 17:1009-1011. [PMID: 28693855 DOI: 10.1016/s1473-3099(17)30417-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 06/21/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Julie Garon
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | - Walter Orenstein
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA 30322, USA.
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39
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Okayasu H, Sein C, Chang Blanc D, Gonzalez AR, Zehrung D, Jarrahian C, Macklin G, Sutter RW. Intradermal Administration of Fractional Doses of Inactivated Poliovirus Vaccine: A Dose-Sparing Option for Polio Immunization. J Infect Dis 2017; 216:S161-S167. [PMID: 28838185 PMCID: PMC5853966 DOI: 10.1093/infdis/jix038] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A fractional dose of inactivated poliovirus vaccine (fIPV) administered by the intradermal route delivers one fifth of the full vaccine dose administered by the intramuscular route and offers a potential dose-sparing strategy to stretch the limited global IPV supply while further improving population immunity. Multiple studies have assessed immunogenicity of intradermal fIPV compared with the full intramuscular dose and demonstrated encouraging results. Novel intradermal devices, including intradermal adapters and disposable-syringe jet injectors, have also been developed and evaluated as alternatives to traditional Bacillus Calmette-Guérin needles and syringes for the administration of fIPV. Initial experience in India, Pakistan, and Sri Lanka suggests that it is operationally feasible to implement fIPV vaccination on a large scale. Given the available scientific data and operational feasibility shown in early-adopter countries, countries are encouraged to consider introducing a fIPV strategy into their routine immunization and supplementary immunization activities.
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MESH Headings
- Antibodies, Viral/immunology
- Child
- Child, Preschool
- Humans
- Immunization, Secondary/economics
- Immunization, Secondary/methods
- Infant
- Injections, Intradermal/instrumentation
- Injections, Intradermal/methods
- Mass Vaccination/economics
- Mass Vaccination/instrumentation
- Mass Vaccination/methods
- Poliovirus/immunology
- Poliovirus Vaccine, Inactivated/administration & dosage
- Poliovirus Vaccine, Inactivated/economics
- Poliovirus Vaccine, Inactivated/immunology
- Poliovirus Vaccine, Inactivated/supply & distribution
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Affiliation(s)
| | - Carolyn Sein
- Research, Policy and Containment, Polio Eradication Department
| | - Diana Chang Blanc
- Expanded Programme on Immunization, Immunization, Vaccines and Biologicals Department, World Health Organization, Geneva, Switzerland
| | - Alejandro Ramirez Gonzalez
- Expanded Programme on Immunization, Immunization, Vaccines and Biologicals Department, World Health Organization, Geneva, Switzerland
| | | | | | - Grace Macklin
- Research, Policy and Containment, Polio Eradication Department
| | - Roland W Sutter
- Research, Policy and Containment, Polio Eradication Department
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Previsani N, Singh H, St. Pierre J, Boualam L, Fournier-Caruana J, Sutter RW, Zaffran M. Progress Toward Containment of Poliovirus Type 2 - Worldwide, 2017. MMWR Morb Mortal Wkly Rep 2017. [PMID: 28640795 PMCID: PMC5657795 DOI: 10.15585/mmwr.mm6624a5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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41
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Aghamohammadi A, Abolhassani H, Kutukculer N, Wassilak SG, Pallansch MA, Kluglein S, Quinn J, Sutter RW, Wang X, Sanal O, Latysheva T, Ikinciogullari A, Bernatowska E, Tuzankina IA, Costa-Carvalho BT, Franco JL, Somech R, Karakoc-Aydiner E, Singh S, Bezrodnik L, Espinosa-Rosales FJ, Shcherbina A, Lau YL, Nonoyama S, Modell F, Modell V, Barbouche MR, McKinlay MA. Patients with Primary Immunodeficiencies Are a Reservoir of Poliovirus and a Risk to Polio Eradication. Front Immunol 2017; 8:685. [PMID: 28952612 PMCID: PMC5468416 DOI: 10.3389/fimmu.2017.00685] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 05/26/2017] [Indexed: 12/25/2022] Open
Abstract
Immunodeficiency-associated vaccine-derived polioviruses (iVDPVs) have been isolated from primary immunodeficiency (PID) patients exposed to oral poliovirus vaccine (OPV). Patients may excrete poliovirus strains for months or years; the excreted viruses are frequently highly divergent from the parental OPV and have been shown to be as neurovirulent as wild virus. Thus, these patients represent a potential reservoir for transmission of neurovirulent polioviruses in the post-eradication era. In support of WHO recommendations to better estimate the prevalence of poliovirus excreters among PIDs and characterize genetic evolution of these strains, 635 patients including 570 with primary antibody deficiencies and 65 combined immunodeficiencies were studied from 13 OPV-using countries. Two stool samples were collected over 4 days, tested for enterovirus, and the poliovirus positive samples were sequenced. Thirteen patients (2%) excreted polioviruses, most for less than 2 months following identification of infection. Five (0.8%) were classified as iVDPVs (only in combined immunodeficiencies and mostly poliovirus serotype 2). Non-polio enteroviruses were detected in 30 patients (4.7%). Patients with combined immunodeficiencies had increased risk of delayed poliovirus clearance compared to primary antibody deficiencies. Usually, iVDPV was detected in subjects with combined immunodeficiencies in a short period of time after OPV exposure, most for less than 6 months. Surveillance for poliovirus excretion among PID patients should be reinforced until polio eradication is certified and the use of OPV is stopped. Survival rates among PID patients are improving in lower and middle income countries, and iVDPV excreters are identified more frequently. Antivirals or enhanced immunotherapies presently in development represent the only potential means to manage the treatment of prolonged excreters and the risk they present to the polio endgame.
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Affiliation(s)
- Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Necil Kutukculer
- Faculty of Medicine, Department of Pediatric Immunology, Ege University, Izmir, Turkey
| | - Steve G Wassilak
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Mark A Pallansch
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Samantha Kluglein
- Center for Vaccine Equity, Task Force for Global Health, Atlanta, GA, United States
| | - Jessica Quinn
- Jeffrey Modell Foundation, New York, NY, United States
| | - Roland W Sutter
- Research and Product Development, World Health Organization, Geneva, Switzerland
| | - Xiaochuan Wang
- Department of Clinical Immunology, Children's Hospital of Fudan University, Shanghai, China
| | - Ozden Sanal
- Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Tatiana Latysheva
- Department of Allergology and Immunotherapy, Institute of Immunology, Moscow, Russia
| | - Aydan Ikinciogullari
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Ewa Bernatowska
- Department of Clinical Immunology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Irina A Tuzankina
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Sciences, Yekaterinburg, Russia
| | | | - Jose Luis Franco
- Grupo de Inmunodeficiencias Primarias, Facultad de Medicina, Departamento de Microbiología y Parasitología, Universidad de Antioquia, Medellín, Colombia
| | - Raz Somech
- Pediatric Department A and the Immunology Service, Sheba Medical Center, Tel Hashomer, Jeffrey Modell Foundation Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elif Karakoc-Aydiner
- Division of Pediatric Allergy and Immunology, Marmara Medical Faculty, Istanbul, Turkey
| | - Surjit Singh
- Pediatric Allergy and Immunology Unit, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
| | | | | | - Anna Shcherbina
- Department of Clinical Immunology, Dmitry Rogachev Federal Research and Clinical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Yu-Lung Lau
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong.,Shenzhen Primary Immunodeficiency Diagnostic and Therapeutic Laboratory, Hong Kong University-Shenzhen Hospital, Shenzhen, China
| | - Shigeaki Nonoyama
- Department of Pediatrics, National Defense Medical College, Saitama, Japan
| | - Fred Modell
- Jeffrey Modell Foundation, New York, NY, United States
| | - Vicki Modell
- Jeffrey Modell Foundation, New York, NY, United States
| | | | - Mohamed-Ridha Barbouche
- Department of Immunology, Institut Pasteur de Tunis, University Tunis El-Manar, Tunis, Tunisia
| | - Mark A McKinlay
- Center for Vaccine Equity, Task Force for Global Health, Atlanta, GA, United States
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Resik S, Tejeda A, Diaz M, Okayasu H, Sein C, Molodecky NA, Fonseca M, Alemany N, Garcia G, Hung LH, Martinez Y, Sutter RW. Boosting Immune Responses Following Fractional-Dose Inactivated Poliovirus Vaccine: A Randomized, Controlled Trial. J Infect Dis 2017; 215:175-182. [PMID: 28073858 DOI: 10.1093/infdis/jiw492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/01/2016] [Indexed: 11/12/2022] Open
Abstract
Background Fractional-dose administration of inactivated poliovirus vaccine (fIPV) could increase IPV affordability and stretch limited supplies. We assessed immune responses following fIPV administered intradermally, compared with full-dose IPV administered intramuscularly, among adults with a history of oral poliovirus vaccine (OPV) receipt. Methods We conducted a randomized, controlled noninferiority trial in Cuba. fIPV or IPV were administered on days 0 and 28; serum was collected on days 0, 7, 28, and 56 for analysis by a neutralization assay. The primary end point was seroconversion or a ≥4-fold rise in antibody titer. The noninferiority limit was 10%. The secondary end point was safety, assessed by the number and intensity of adverse reactions. Results A total of 503 of 534 enrolled participants (94.2%) completed all study requirements. Twenty-eight days after the first dose, 94.8%, 98.0%, and 98.0% of fIPV recipients had an immune response to poliovirus types 1, 2, and 3, respectively, compared with 98.1% (P = .06), 98.0% (P = 1.00), and 99.2% (P = .45) in the IPV arm. Noninferiority was achieved on days 7, 28, and 56 for all serotypes. No serious adverse events were reported. Conclusion fIPV induced similar boosting immune responses, compared with full-dose IPV. This suggests that fIPV would be an effective strategy to boost population immunity in an outbreak situation. Clinical Trials Registration ACTRN12615000305527.
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Affiliation(s)
- Sonia Resik
- Pedro Kouri Institute of Tropical Medicine, Havana
| | - Alina Tejeda
- Provincial Center for Hygiene, Epidemiology, and Microbiology, Camaguey, Cuba
| | - Manuel Diaz
- Pedro Kouri Institute of Tropical Medicine, Havana
| | | | | | | | | | - Nilda Alemany
- Provincial Center for Hygiene, Epidemiology, and Microbiology, Camaguey, Cuba
| | - Gloria Garcia
- Provincial Center for Hygiene, Epidemiology, and Microbiology, Camaguey, Cuba
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43
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Anand A, Molodecky NA, Pallansch MA, Sutter RW. Immunogenicity to poliovirus type 2 following two doses of fractional intradermal inactivated poliovirus vaccine: A novel dose sparing immunization schedule. Vaccine 2017; 35:2993-2998. [PMID: 28434691 PMCID: PMC10423713 DOI: 10.1016/j.vaccine.2017.03.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The polio eradication endgame strategic plan calls for the sequential removal of Sabin poliovirus serotypes from the trivalent oral poliovirus vaccine (tOPV), starting with type 2, and the introduction of ≥1 dose of inactivated poliovirus vaccine (IPV), to maintain an immunity base against poliovirus type 2. The global removal of oral poliovirus type 2 was successfully implemented in May 2016. However, IPV supply constraints has prevented introduction in 21 countries and led to complete stock-out in >20 countries. METHODS We conducted a literature review and contacted corresponding authors of recent studies with fractional-dose IPV (fIPV), one-fifth of intramuscular dose administered intradermally, to conduct additional type 2 immunogenicity analyses of two fIPV doses compared with one full-dose IPV. RESULTS Four studies were identified that assessed immunogenicity of two fIPV doses compared to one full-dose IPV. Two fractional doses are more immunogenic than 1 full-dose, with type 2 seroconversion rates improving between absolute 19-42% (median: 37%, p<0.001) and relative increase of 53-125% (median: 82%), and antibody titer to type 2 increasing by 2-32-fold (median: 10-fold). Early age of administration and shorter intervals between doses were associated with lower immunogenicity. DISCUSSION Overall, two fIPV doses are more immunogenic than a single full-dose, associated with significantly increased seroconversion rates and antibody titers. Two fIPV doses together use two-fifth of the vaccine compared to one full-dose IPV. In response to the current IPV shortage, a schedule of two fIPV doses at ages 6 and 14weekshas been endorsed by technical oversight committees and has been introduced in some affected countries.
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Affiliation(s)
- Abhijeet Anand
- Centers for Disease Control and Prevention, Atlanta, Georgia.
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44
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Saleem AF, Mach O, Yousafzai MT, Khan A, Weldon WC, Oberste MS, Sutter RW, Zaidi AKM. Needle adapters for intradermal administration of fractional dose of inactivated poliovirus vaccine: Evaluation of immunogenicity and programmatic feasibility in Pakistan. Vaccine 2017; 35:3209-3214. [PMID: 28479178 PMCID: PMC5457301 DOI: 10.1016/j.vaccine.2017.04.075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 03/27/2017] [Accepted: 04/25/2017] [Indexed: 10/26/2022]
Abstract
Administration of 1/5th dose of Inactivated poliovirus vaccine intradermally (fIPV) provides similar immune response as full-dose intramuscular IPV, however, fIPV administration with BCG needle and syringe (BCG NS) is technically difficult. We compared immune response after one fIPV dose administered with BCG NS to administration with intradermal devices, referred to as Device A and B; and assessed feasibility of conducting a door-to-door vaccination campaign with fIPV. In Phase I, 452 children 6-12months old from Karachi were randomized to receive one fIPV dose either with BCG NS, Device A or Device B in a health facility. Immune response was defined as seroconversion or fourfold rise in polio neutralizing antibody titer 28days after fIPV among children whose baseline titer ≤362. In Phase II, fIPV was administered during one-day door-to-door campaign to assess programmatic feasibility by evaluating vaccinators' experience. For all three poliovirus (PV) serotypes, the immune response after BCG NS and Device A was similar, however it was lower with Device B (34/44 (77%), 31/45 (69%), 16/30 (53%) respectively for PV1; 53/78 (68%), 61/83 (74%), 42/80 (53%) for PV2; and; 58/76 (76%), 56/80 (70%), 43/77 (56%) for PV3; p<0.05 for all three serotypes). Vaccinators reported problems filling Device B in both Phases; no other operational challenges were reported during Phase II. Use of fIPV offers a dose-saving alternative to full-dose IPV.
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Affiliation(s)
| | - Ondrej Mach
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
| | | | - Asia Khan
- Aga Khan University, Karachi, Pakistan
| | - William C Weldon
- Polio and Picornavirus Laboratory Branch, Centers for Disease Control and Prevention, Atlanta, USA
| | - M Steven Oberste
- Polio and Picornavirus Laboratory Branch, Centers for Disease Control and Prevention, Atlanta, USA
| | - Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva, Switzerland
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Shirreff G, Wadood MZ, Vaz RG, Sutter RW, Grassly NC. Estimated Effect of Inactivated Poliovirus Vaccine Campaigns, Nigeria and Pakistan, January 2014-April 2016. Emerg Infect Dis 2017; 23:258-263. [PMID: 27861118 PMCID: PMC5324799 DOI: 10.3201/eid2302.161210] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In 2014, inactivated poliovirus vaccine (IPV) campaigns were implemented in Nigeria and Pakistan after clinical trials showed that IPV boosts intestinal immunity in children previously given oral poliovirus vaccine (OPV). We estimated the effect of these campaigns by using surveillance data collected during January 2014-April 2016. In Nigeria, campaigns with IPV and trivalent OPV (tOPV) substantially reduced the incidence of poliomyelitis caused by circulating serotype-2 vaccine-derived poliovirus (incidence rate ratio [IRR] 0.17 for 90 days after vs. 90 days before campaigns, 95% CI 0.04-0.78) and the prevalence of virus in environmental samples (prevalence ratio [PR] 0.16, 95% CI 0.02-1.33). Campaigns with tOPV alone resulted in similar reductions (IRR 0.59, 95% CI 0.18-1.97; PR 0.45, 95% CI 0.21-0.95). In Pakistan, the effect of IPV+tOPV campaigns on wild-type poliovirus was not significant. Results suggest that administration of IPV alongside OPV can decrease poliovirus transmission if high vaccine coverage is achieved.
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46
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Sutter RW, Modlin JF, Zaffran M. Completing Polio Eradication: The Case for Antiviral Drugs. J Infect Dis 2017; 215:333-334. [PMID: 27932609 DOI: 10.1093/infdis/jiw547] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 11/21/2016] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - John F Modlin
- Bill and Melinda Gates Foundation, Seattle, Washington
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47
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Okayasu H, Sein C, Hamidi A, Bakker WA, Sutter RW. Development of inactivated poliovirus vaccine from Sabin strains: A progress report. Biologicals 2016; 44:581-587. [DOI: 10.1016/j.biologicals.2016.08.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/29/2016] [Accepted: 08/30/2016] [Indexed: 12/12/2022] Open
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48
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Iliyasu Z, Verma H, Craig KT, Nwaze E, Ahmad-Shehu A, Jibir BW, Gwarzo GD, Gajida AU, Weldon WC, Steven Oberste M, Takane M, Mkanda P, Muhammad AJG, Sutter RW. Poliovirus seroprevalence before and after interruption of poliovirus transmission in Kano State, Nigeria. Vaccine 2016; 34:5125-5131. [PMID: 27591950 PMCID: PMC5036508 DOI: 10.1016/j.vaccine.2016.08.058] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/14/2016] [Accepted: 08/17/2016] [Indexed: 11/18/2022]
Abstract
Polio seroprevalence surveys help measure progress towards polio eradication. Nigeria program conducted multiple seroprevalence surveys in northern states. This article covers seroprevalence survey in Kano Nigeria in 2013 and 2014. Data represents levels before and after the interruption of poliovirus transmission. Significant improvement in seroprevalence in 2014 over 2013, but gaps continue. Good participation even by vaccine refusers in this health facility based project.
Introduction In September 2015, Nigeria was removed from the list of polio-endemic countries after more than 12 months had passed since the detection of last wild poliovirus case in the country on 24 July 2014. We are presenting here a report of two polio seroprevalence surveys conducted in September 2013 and October 2014, respectively, in the Kano state of northern Nigeria. Methods Health facility based seroprevalence surveys were undertaken at Murtala Mohammad Specialist Hospital, Kano. Parents or guardians of children aged 6–9 months, 36–47 months, 5–9 years and 10–14 years in 2013 and 6–9 months and 19–22 months (corresponding to 6–9 months range at the time of 2013 survey) in 2014 presenting to the outpatient department, were approached for participation, screened for eligibility and asked to provide informed consent. A questionnaire was administered and a blood sample collected for polio neutralization assay. Results Among subjects aged 6–9 months in the 2013 survey, seroprevalence was 58% (95% confidence interval [CI] 51–66%) to poliovirus type 1, 42% (95% CI 34–50%) to poliovirus type 2, and 52% (95% CI 44–60%) to poliovirus type 3. Among children 36–47 months and older, seroprevalence was 85% or higher for all three serotypes. In 2014, seroprevalence in 6–9 month infants was 72% (95% CI 65–79%) for type 1, 59% (95% CI 52–66%) for type 2, and 65% (95% CI 57–72%) for type 3 and in 19–22 months, 80% (95% CI 74–85%), 57% (49–63%) and 78% (71–83%) respectively. Seroprevalence was positively associated with history of increasing oral poliovirus vaccine doses. Conclusions There was significant improvement in seroprevalence in 2014 over the 2013 levels indicating a positive impact of recent programmatic interventions. However the continued low seroprevalence in 6–9 month age is a concern and calls for improved immunization efforts to sustain the polio-free Nigeria.
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Affiliation(s)
- Zubairu Iliyasu
- Department of Community Medicine, Aminu Kano Teaching Hospital & Bayero University Kano, Nigeria
| | | | | | - Eric Nwaze
- National Primary Health Care Development Agency, Abuja, Nigeria
| | | | - Binta Wudil Jibir
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Garba Dayyabu Gwarzo
- Department of Pediatrics, Aminu Kano Teaching Hospital & Bayero University, Kano, Nigeria
| | - Auwalu U Gajida
- Department of Community Medicine, Aminu Kano Teaching Hospital & Bayero University Kano, Nigeria
| | - William C Weldon
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - M Steven Oberste
- Centers for Disease Control and Prevention, Atlanta, GA, United States
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Jorba J, Diop OM, Iber J, Sutter RW, Wassilak SG, Burns CC. Update on Vaccine-Derived Polioviruses — Worldwide, January 2015–May 2016. MMWR Morb Mortal Wkly Rep 2016; 65:763-9. [DOI: 10.15585/mmwr.mm6530a3] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Craig KT, Verma H, Iliyasu Z, Mkanda P, Touray K, Johnson T, Walla A, Banda R, Tegegne SG, Yehualashet YG, Abba B, Ahmad-Shehu A, Takane M, Sutter RW, Nsubuga P, Muhammad AJG, Vaz RG. Role of Serial Polio Seroprevalence Studies in Guiding Implementation of the Polio Eradication Initiative in Kano, Nigeria: 2011-2014. J Infect Dis 2016; 213 Suppl 3:S124-30. [PMID: 26908720 PMCID: PMC4818560 DOI: 10.1093/infdis/jiv774] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nigeria was one of 3 polio-endemic countries before it was de-listed in September 2015 by the World Health Organization, following interruption of transmission of the poliovirus. During 2011-2014, Nigeria conducted serial polio seroprevalence surveys (SPS) in Kano Metropolitan Area, comprising 8 local government areas (LGAs) in Kano that is considered very high risk (VHR) for polio, to monitor performance of the polio eradication program and guide the program in the adoption of innovative strategies. METHODS Study subjects who resided in any of the 8 local government areas of Kano Metropolitan Area and satisfied age criteria were recruited from patients at Murtala Mohammed Specialist Hospital (Kano) for 3 seroprevalence surveys. The same methods were used to conduct each survey. RESULTS The 2011 study showed seroprevalence values of 81%, 75%, and 73% for poliovirus types 1, 2, and 3, respectively, among infants aged 6-9 months age. Among children aged 36-47 months, seroprevalence values were greater (91%, 87%, and 85% for poliovirus types 1, 2, and 3, respectively).In 2013, the results showed that the seroprevalence was unexpectedly low among infants aged 6-9 months, remained high among children aged 36-47 months, and increased minimally among children aged 5-9 years and those aged 10-14 years. The baseline seroprevalence among infants aged 6-9 months in 2014 was better than that in 2013. CONCLUSIONS The results from the polio seroprevalence surveys conducted in Kano Metropolitan Area in 2011, 2013, and 2014 served to assess the trends in immunity and program performance, as well as to guide the program, leading to various interventions being implemented with good effect, as evidenced by the reduction of poliovirus circulation in Kano.
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Affiliation(s)
| | | | - Zubairu Iliyasu
- Aminu Kano Teaching Hospital Bayero University, Kano, Nigeria
| | - Pascal Mkanda
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | - Kebba Touray
- World Health Organization, Country Representative Office
| | - Ticha Johnson
- World Health Organization, Country Representative Office
| | | | - Richard Banda
- World Health Organization, Country Representative Office
| | | | | | - Bashir Abba
- World Health Organization, Country Representative Office
| | | | | | | | | | | | - Rui G Vaz
- World Health Organization, Country Representative Office
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