Analysis of population immunity to poliovirus following cessation of trivalent oral polio vaccine

Abstract

Background: The global withdrawal of trivalent oral poliovirus vaccine (OPV) (tOPV, containing Sabin poliovirus strains serotypes 1, 2 and 3) from routine immunization, and the introduction of bivalent OPV (bOPV, containing Sabin poliovirus strains serotypes 1 and 3) and trivalent inactivated poliovirus vaccine (IPV) into routine immunization was expected to improve population serologic and mucosal immunity to types 1 and 3 poliovirus, while population mucosal immunity to type 2 poliovirus would decline. However, over the period since tOPV withdrawal, the implementation of preventive bOPV supplementary immunization activities (SIAs) has decreased, while outbreaks of type 2 circulating vaccine derived poliovirus (cVDPV2) have required targeted use of monovalent type 2 OPV (mOPV2).

Methods: We develop a dynamic model of OPV-induced immunity to estimate serotype-specific, district-level immunity for countries in priority regions and characterize changes in immunity since 2016. We account for the changes in routine immunization schedules and varying implementation of preventive and outbreak response SIAs, assuming homogenous coverages of 50% and 80% for SIAs.

Results: In areas with strong routine immunization, the switch from tOPV to bOPV has likely resulted in gains in population immunity to types 1 and 3 poliovirus. However, we estimate that improved immunogenicity of new schedules has not compensated for declines in preventive SIAs in areas with weak routine immunization. For type 2 poliovirus, without tOPV in routine immunization or SIAs, mucosal immunity has declined nearly everywhere, while use of mOPV2 has created highly heterogeneous population immunity for which it is important to take into account when responding to cVDPV2 outbreaks.

Conclusions: The withdrawal of tOPV and declining allocations of resources for preventive bOPV SIAs have resulted in reduced immunity in vulnerable areas to types 1 and 3 poliovirus and generally reduced immunity to type 2 poliovirus in the regions studied, assuming homogeneous coverages of 50% and 80% for SIAs. The very low mucosal immunity to type 2 poliovirus generates substantially greater risk for further spread of cVDPV2 outbreaks. Emerging gaps in immunity to all serotypes will require judicious targeting of limited resources to the most vulnerable populations by the Global Polio Eradication Initiative (GPEI).

Keywords: Disease Modeling; Polio; Population immunity.

Fig. 1.

Immunity and SIA schedule in Banadir, Somalia. The bars in the top panel indicate dates of SIAs including Banadir. The plot at the bottom indicates the resulting immunity estimates to each serotype, under 50% and 80% coverage assumptions.

Fig. 2.

Cumulative population targeted with OPV SIAs in GPEI-funded countries, by year, in the WHO African Region and Eastern Mediterranean Region.

Fig. 3.

Estimated Immunity to types 1 and 2 poliovirus, January 2016, 2018 and 2020, WHO African Region and Eastern Mediterranean Region. Colors indicate district-level (2nd administrative unit) immunity estimates under the 50% coverage assumption¹. ¹The publication of this map does not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any territory, city, or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. WHO does not endorse or approve the sub-national boundaries in this map.

Fig. 4.

Province-level (first administrative unit) type 1 poliovirus immunity estimates in January 2016, 2018, and 2020, for the Democratic Republic of the Congo (COD), Ethiopia (ETH) and Nigeria (NGA), using either the 50% or 80% coverage assumptions. Example immunity targets (80% and 90%) shown in dotted lines.

Fig. 5.

National-level type 1 poliovirus immunity estimates for countries in the WHO African and Eastern Mediterranean Regions, using the 50% coverage assumption. Colors indicate the WHO-UNICEF best estimates of national immunization coverage (WUENIC)[23] for the 3rd dose of oral poliovirus vaccine (pol3) in 2016.