# Presentation: 684863

## OPV Stockpiling in the United States 

- Trudy V. Murphy, M.D.
- National Immunization Program
- Centers for Disease Control and Prevention
- February 5, 2003

## Is the US at Risk of an Outbreak of Poliomyelitis? 

- US has high vaccination coverage
- 1995 -1999 National Immunization Survey, parents of 1.9% - 3.1% of children reported child had no poliovirus vaccine by 19-35 months of age
- Western Hemisphere certified free of indigenous wild poliovirus in 1994

**Notes:**
Good morning. 

The multi-state investigation of intussusception among recipients of rotavirus vaccine was lead by the National Immunization Program and has been a collaborative effort of the Centers for Disease Control and the State and Local Health Departments of the 19 states listed here.  CA, GA, IN, IL, MD, MI, MN, MO, NC, NE, NJ, NY, OH, PA, SC, TN, TX, VA, and WI.  

## Outbreaks of Poliomyelitis in Countries with High Vaccine Coverage

- Pockets of under-vaccination 		-Religious communities
- 		-Vaccine objectors
- 		-Refugees, immigrants

- Patriarca P. JID 1997;175;S165

**Notes:**
Good morning. 

The multi-state investigation of intussusception among recipients of rotavirus vaccine was lead by the National Immunization Program and has been a collaborative effort of the Centers for Disease Control and the State and Local Health Departments of the 19 states listed here.  CA, GA, IN, IL, MD, MI, MN, MO, NC, NE, NJ, NY, OH, PA, SC, TN, TX, VA, and WI.  

## Potential Sources of Neurovirulent Polioviruses

- Eradication of polioviruses incomplete
- Endemic areas
- Vaccine-derived strains
- Laboratory containment
- The U.S. remains at risk of an outbreak of poliomyelitis

- Patriarca P. JID 1997;175;S165

**Notes:**
Good morning. 

The multi-state investigation of intussusception among recipients of rotavirus vaccine was lead by the National Immunization Program and has been a collaborative effort of the Centers for Disease Control and the State and Local Health Departments of the 19 states listed here.  CA, GA, IN, IL, MD, MI, MN, MO, NC, NE, NJ, NY, OH, PA, SC, TN, TX, VA, and WI.  

## Emergency Response to an Outbreak of Poliomyelitis in U.S. 

- Inactivated (IPV) and live attenuated oral (OPV) poliovirus vaccines induce similar levels of individual protection after three doses
- IPV and OPV differ in their risks and effectiveness when used to control an outbreak of poliomyelitis

## OPV Vaccine of Choice in Outbreak Settings

- Public health goal is to eradicate outbreak strain
- Extensive experience using mass campaigns demonstrates OPV interrupts transmission polioviruses
- Interferes with or reduces replication of outbreak strain at mucosal level

## OPV Halts Circulation of Poliovirus

- OPV used in Albania, 1996:
- 80% population vaccinated in mass campaign
- 90% decrease in cases within 2 weeks
- No case poliomyelitis after second mass campaign

- Prevots R. CID 1998;26:419

**Notes:**
Good morning. 

The multi-state investigation of intussusception among recipients of rotavirus vaccine was lead by the National Immunization Program and has been a collaborative effort of the Centers for Disease Control and the State and Local Health Departments of the 19 states listed here.  CA, GA, IN, IL, MD, MI, MN, MO, NC, NE, NJ, NY, OH, PA, SC, TN, TX, VA, and WI.  

##  IPV and Outbreaks of Poliomyelitis

- No example of successful control of an outbreak using IPV
- Countries that use all-IPV for routine vaccination, used OPV for control of outbreaks (Netherlands, Finland)

- Hovi T, Lancet 1986;1:1427; Oostvogel PM. Lancet 1994;344:665

**Notes:**
Good morning. 

The multi-state investigation of intussusception among recipients of rotavirus vaccine was lead by the National Immunization Program and has been a collaborative effort of the Centers for Disease Control and the State and Local Health Departments of the 19 states listed here.  CA, GA, IN, IL, MD, MI, MN, MO, NC, NE, NJ, NY, OH, PA, SC, TN, TX, VA, and WI.  

## Challenges of Response to an Outbreak of Poliomyelitis

- Vaccine acceptance among objectors may not be optimal regardless of type
- Risk of VAPP after OPV is established, but less than the risk of poliomyelitis in an outbreak

## Challenges of Response to an  Outbreak of Poliomyelitis

- IPV is vaccine of choice for
- immediate vaccination
- the immunodeficient and their contacts
- adults (usually)
- persons refusing OPV

## U.S. Uses IPV for Routine Poliovirus Vaccination

- In January 2000, the ACIP recommended IPV for routine vaccination against poliomyelitis to avoid the rare but established risk of vaccine associated paralytic poliomyelitis (VAPP)
- OPV no longer is manufactured in U.S.

## Options for Obtaining OPV

- Administer remaining U.S. licensed, expired OPV as investigational new drug (IND), given adequate potency, sufficient supply
- Establish stockpile of non-U.S. OPV
- Administer under IND
- Administer as U.S. licensed product

## Desirable Characteristics of OPV Product for U.S. Stockpile

- Trivalent OPV
- Extensive (global) use, meets U.S. or WHO standards for safety, potency
- ~ 4,000,000 doses; available on staggered timeline
- Rotation with OPV in active market to avoid replacing expired vaccine

## Status of U.S. OPV Stockpile

- Interim stockpile of licensed, expired Wyeth-Lederle OPV (IND)
- First solicitation for non-U.S. made OPV
- Planned second solicitation for non-U.S. made OPV
- Hurdles to establish U.S. OPV stockpile

## Potential Interim Stockpile  Wyeth-Lederle OPV (Expired) 

- ~800,000 doses, expired Nov. 2002
- Potency test ~quarterly; Sept. 2002
- CDC application for IND incomplete
- Manufacturer requests no release of OPV unless Government approves request for indemnification (Public Law 85-804) and contract reflects approval by Secretary of HHS

## First Solicitation for StockpileNon-U.S. Made OPV

- Initiated June 1999; preference for product licensed in U.S.
- One respondent
- Product required IND
- Lacked desirable characteristics
- Liability issues unresolved
- Negotiations ended February 2002

## Second Solicitation for StockpileNon-U.S. Made OPV

- CDC intends to issue in near future
- 4,000,000 doses, trivalent OPV
- IND use (U.S. license preferred)
- One year; option 9 additional years
- Liability issues remain

## OPV under IND Covered byNational Childhood Vaccine Injury Act

- OPV listed in Vaccine Injury Table
- Vaccine taxed on use
- No distinction made between investigational and approved vaccines for purposes of injury compensation
- Final determination resides with court

- August 2001

## Hurdles to Establish OPV Stockpile for Emergency Use in the U.S.

- Manufacturer interest
- Future demand for OPV uncertain
- Requirements to obtain IND (U.S. license) perceived as onerous, expensive
- Assurance of full indemnification
- CDC to hold IND
- Protocol, IRB

## Conclusion

- All groups recommend OPV to control an outbreak of poliomyelitis; use of OPV is supported by experience and scientific evidence
- A stockpile of OPV meeting FDA requirements for use is the foundation for preparedness in the event of an outbreak of poliomyelitis in the U.S.

**Notes:**
Good morning. 

The multi-state investigation of intussusception among recipients of rotavirus vaccine was lead by the National Immunization Program and has been a collaborative effort of the Centers for Disease Control and the State and Local Health Departments of the 19 states listed here.  CA, GA, IN, IL, MD, MI, MN, MO, NC, NE, NJ, NY, OH, PA, SC, TN, TX, VA, and WI.