Health and economic consequences of different options for timing the coordinated global cessation of the three oral poliovirus vaccine serotypes.

BACKGROUND: World leaders remain committed to globally-coordinated oral poliovirus vaccine (OPV) cessation following successful eradication of wild polioviruses, but the best timing and strategy for implementation depend on existing and emerging conditions. METHODS: Using an existing integrated global poliovirus risk management model, we explore alternatives to the current timing plan of coordinated cessation of each OPV serotype (i.e., OPV1, OPV2, and OPV3 cessation for serotypes 1, 2, and 3, respectively). We assume the current timing plan involves OPV2 cessation in 2016 followed by OPV1 and OPV3 cessation in 2019 and we compare this to alternative timing options, including cessation of all three serotypes in 2018 or 2019, and cessation of both OPV2 and OPV3 in 2017 followed by OPV1 in 2019. RESULTS: If Supplemtal Immunization Activity frequency remains sufficiently high through cessation of the last OPV serotype, then all OPV cessation timing options prevent circulating vaccine-derived poliovirus (cVDPV) outbreaks after OPV cessation of any serotype. The various OPV cessation timing options result in relatively modest differences in expected vaccine-associated paralytic poliomyelitis cases and expected total of approximately 10-13 billion polio vaccine doses used. However, the expected amounts of vaccine of different OPV formulations needed changes dramatically with each OPV cessation timing option. Overall health economic impacts remain limited for timing options that only change the OPV formulation but preserve the currently planned year for cessation of the last OPV serotype and the global introduction of inactivated poliovirus vaccine (IPV) introduction. Earlier cessation of the last OPV serotype or later global IPV introduction yield approximately $1 billion in incremental net benefits due to saved vaccination costs, although the logistics of implementation of OPV cessation remain uncertain and challenging. CONCLUSIONS: All countries should maintain the highest possible levels of population immunity to transmission for each poliovirus serotype prior to the coordinated cessation of the OPV serotype to manage cVDPV risks. If OPV2 cessation gets delayed, then global health leaders should consider other OPV cessation timing options.

The differential impact of oral poliovirus vaccine formulation choices on serotype-specific population immunity to poliovirus transmission.

BACKGROUND: Prior analyses demonstrated the need for some countries and the Global Polio Eradication Initiative (GPEI) to conduct additional supplemental immunization activities (SIAs) with trivalent oral poliovirus vaccine (tOPV) prior to globally-coordinated cessation of all serotype 2-containing OPV (OPV2 cessation) to prevent the creation of serotype 2 circulating vaccine-derived poliovirus (cVDPV2) outbreaks after OPV2 cessation. The GPEI continues to focus on achieving and ensuring interruption of wild poliovirus serotype 1 (WPV1) and making vaccine choices that prioritize bivalent OPV (bOPV) for SIAs, nominally to increase population immunity to serotype 1, despite an aggressive timeline for OPV2 cessation. METHODS: We use an existing dynamic poliovirus transmission model of northwest Nigeria and an integrated global model for long-term poliovirus risk management to explore the impact of tOPV vs. bOPV vaccine choices on population immunity and cVDPV2 risks. RESULTS: Using tOPV instead of bOPV for SIAs leads to a minimal decrease in population immunity to transmission of serotypes 1 and 3 polioviruses, but a significantly higher population immunity to transmission of serotype 2 polioviruses. Failure to use tOPV in enough SIAs results in cVDPV2 emergence after OPV2 cessation in both the northwest Nigeria model and the global model. Despite perceptions to the contrary, prioritizing the use of bOPV over tOPV prior to OPV2 cessation does not significantly improve serotype 1 population immunity to transmission. CONCLUSIONS: Immunization leaders need to focus on all three poliovirus serotypes to appropriately manage the risks of OPV cessation in the polio endgame. Focusing on population immunity to transmission to interrupt WPV1 transmission and manage pre-OPV cessation risks of cVDPVs, all countries performing poliovirus SIAs should use tOPV up until the time of OPV2 cessation, after which time they should continue to use the OPV vaccine formulation with all remaining serotypes until coordinated global cessation of those serotypes.

Anti-poliovirus activity of protease inhibitor AG-7404, and assessment of in vitro activity in combination with antiviral capsid inhibitor compounds.

The National Research Council has recommended that at least one, preferably two, polio antiviral drugs be developed as a supplement to the tools currently available for control of polio outbreaks post-eradication. The primary application of such drugs is expected to be the resolution of chronic poliovirus excretion in persons with primary immunodeficiency disorders. We have assessed the in vitro activity of AG-7404 (also known as "compound 1"), an inhibitor of picornaviral 3C protease, against a large panel of programmatically important poliovirus strains and its activity in combination with two poliovirus capsid inhibitors, V-073 and BTA798. AG-7404 was active against all viruses in this panel, with EC50 values ranging from 0.080 to 0.674 µM. Similarly, BTA798 was active against all viruses in this panel, with EC50 values ranging from 0.003 to 0.591µM. By comparison, values for V-073 were 0.003-0.126 µM. BTA798 was active against V-073-resistant variants with an alanine to valine change in VP3 at position 24. However, BTA798 was inactive against the V-073-resistant strains with amino acid substitutions at VP1 amino acids 194 (equivalent to 192 in type 3) and 236. As expected from its different mechanism of action, AG-7404 was fully active against all V-073-resistant variants, with EC50 values ranging from 0.218 to 0.819 µM, compared to values of 0.202-0.407 µM for the V-073-susceptible parental strains. In vitro drug combination experiments demonstrated synergy between AG-7404 and either V-073 or BTA798, whereas the combination of the two capsid inhibitors acted additively.

StralSV: assessment of sequence variability within similar 3D structures and application to polio RNA-dependent RNA polymerase.

BACKGROUND: Most of the currently used methods for protein function prediction rely on sequence-based comparisons between a query protein and those for which a functional annotation is provided. A serious limitation of sequence similarity-based approaches for identifying residue conservation among proteins is the low confidence in assigning residue-residue correspondences among proteins when the level of sequence identity between the compared proteins is poor. Multiple sequence alignment methods are more satisfactory--still, they cannot provide reliable results at low levels of sequence identity. Our goal in the current work was to develop an algorithm that could help overcome these difficulties by facilitating the identification of structurally (and possibly functionally) relevant residue-residue correspondences between compared protein structures. RESULTS: Here we present StralSV (structure-alignment sequence variability), a new algorithm for detecting closely related structure fragments and quantifying residue frequency from tight local structure alignments. We apply StralSV in a study of the RNA-dependent RNA polymerase of poliovirus, and we demonstrate that the algorithm can be used to determine regions of the protein that are relatively unique, or that share structural similarity with proteins that would be considered distantly related. By quantifying residue frequencies among many residue-residue pairs extracted from local structural alignments, one can infer potential structural or functional importance of specific residues that are determined to be highly conserved or that deviate from a consensus. We further demonstrate that considerable detailed structural and phylogenetic information can be derived from StralSV analyses. CONCLUSIONS: StralSV is a new structure-based algorithm for identifying and aligning structure fragments that have similarity to a reference protein. StralSV analysis can be used to quantify residue-residue correspondences and identify residues that may be of particular structural or functional importance, as well as unusual or unexpected residues at a given sequence position. StralSV is provided as a web service at http://proteinmodel.org/AS2TS/STRALSV/.

Evaluation of response scenarios to potential polio outbreaks using mathematical models.

Appropriate response to polio outbreaks represents an important prerequisite for achieving and maintaining global polio eradication. We use an existing dynamic disease transmission model to evaluate the impact of different aspects of immunization campaigns in response to polio outbreaks occurring in previously polio-free areas. This analysis yields several important insights about response strategies. We find that delay in response represents a crucial risk factor for occurrence of large outbreaks and we characterize the tradeoffs associated with delaying the initial response to achieve better population coverage. We also demonstrate that controlling most potential outbreaks will likely require at least three immunization rounds, although the impact of the optimal interval between rounds varies. Finally, long after oral poliovirus vaccine cessation the choice of target age groups during a response represents an important consideration.

Global surveillance and the value of information: the case of the global polio laboratory network.

Effective control and eradication of diseases requires reliable information from surveillance activities, including laboratories, which typically incur real financial costs. This article presents data from a survey we conducted to estimate the costs of the Global Polio Laboratory Network (GPLN), which currently supports aggressive global surveillance for acute flaccid paralysis (AFP) to detect circulating polioviruses. The Global Polio Eradication Initiative (GPEI) of the World Health Organization (WHO) provides resources for some of the laboratory network costs, but the total cost of the network remains relatively poorly characterized given the limited documentation of national contributions. We surveyed network laboratories to quantify AFP surveillance support costs and provide data for cost estimates of potential posteradication surveillance policies related to the laboratories. We estimate that the GPLN currently requires millions (US dollars 2002) in total support annually, and that half of the support for national and regional reference laboratories comes from external donors through the WHO or bilateral agreements and half from within nations that host those laboratories. The article also presents the framework for considering the value of information from this global surveillance network and suggests that the expected value of surveillance information from the GPLN currently exceeds its costs. We also provided important insights about how the value of information may change after successful eradication of wild polioviruses.