Saturday, 24th of May 2014 Print






Weekly Epidemiological Record, 23 May 2014,

Conclusions and recommendations, Meeting of the Strategic  Advisory  Group of  Experts  on immunization,  April  2014

Also available, in French and English, at

Conclusions and  Recommendations

The Strategic Advisory Group of Experts  (SAGE) on immunization 1 met on 1–3 April  2014 in Geneva, Switzerland. This report  provides a summary of the discussions,  conclusions and recommendations.  





See below the fourth of ten postings on the meeting of the Strategic  Advisory  Group of  Experts  on immunization,  April  2014. For background documents for the SAGE meeting, go to


Following the large poliomyelitis outbreaks in the Middle East and the Horn of Africa in 2013, and an expanding outbreak in Central Africa in 2014, Member States  are voicing increasing concern about the international  spread of poliovirus and have requested additional  WHO guidance on recommendations for the vaccination of travellers from countries where poliovirus is  circulating. Upon reviewing the relevant scientific evidence, SAGE endorsed updates to the existing WHO  recommendations for travellers from polio-infected  countries in the WHO publication  International Travel  and Health (ITH) 2013 as follows:

1. Polio vaccination recommendations for travellers  from polio-infected countries should apply to all  residents and to visitors of all ages who spend  >4 weeks in the country. Several lines of evidence  demonstrate that older individuals play an important role in international spread of poliovirus, including observational and challenge studies and  documented cases of adult travellers excreting wild  poliovirus.

2. In addition to oral poliovirus vaccine (OPV), which  is currently recommended in ITH for the vaccination of travellers from polio-infected countries,  IPV can be used for booster doses. A recent study  from Moradabad, India, demonstrated that 1 dose  of bivalent OPV or IPV reduces excretion of poliovirus significantly in people previously given OPV.  For people who previously received only IPV, OPV  should be the choice for booster if available and  feasible. 

3. Resident travellers of all ages from polio-infected  countries should have received 1 documented  additional dose of OPV or IPV a minimum of  4 weeks and a maximum of 12 months before each  international travel. Evidence from a number of  studies demonstrates that immunologically-naive  populations usually attain a maximum immune  response within 4 weeks, and intestinal immunity  can wane within 12 months. Travellers embarking  on last minute/urgent travel that cannot be postponed should nevertheless receive 1 dose of OPV  or IPV before departure if they have not received  a documented dose of polio vaccine within the  previous 12 months. 

SAGE recognized the potential social and economic cost  associated with the implementation of these recommendations but believes that they would help decrease  the risk of outbreaks. In 2013, 60% of the all reported  polio cases resulted from long distance importations  from polio-endemic countries.

SAGE reviewed the status of IPV introduction globally,  which is 1 of the 5 major criteria for judging global  readiness for OPV2 withdrawal. 4 SAGE was informed of  the outcomes of the February 2014 UNICEF tender, in  which one IPV supplier has offered a price of  € 0.75 per  dose in 10-dose vials (approximately USD 1 per dose)  to GAVI-eligible countries and  € 1.5–2.4 per dose (approximately USD 2.1–3.3 per dose) for middle-income  countries, also in 10-dose vials; another manufacturer  offered a price of US$ 1.90/dose in 5-dose vials, for any  requesting country. SAGE concurred that these represent the best possible IPV prices in the near term and  constitute a firm basis for proceeding with the goal of  global IPV introduction by end-2015 as an integral part  of the polio endgame strategy. To date, of the 194 WHO  Member States, 71 (36%) have introduced IPV and  65 (34%) have decided or declared intent to introduce  IPV by end-2015. SAGE reaffirmed the need for all countries to have completed planning for IPV introduction  by end-2014. SAGE endorsed the proposed actions by  the Immunization Systems Management Group to further accelerate decision-making to introduce IPV in the  remaining OPV-using countries, particularly through  increased technical assistance, enhanced communications, and potential financial support mechanisms for  non-GAVI supported countries in special circumstances.  SAGE reinforced the importance of conducting a technical briefing on IPV introduction for OPV-using countries during the WHA in May 2014. SAGE reviewed the progress towards eventual confirmation of a specific date for global OPV2 withdrawal,  which requires the absence of persistent circulating  vaccine-derived poliovirus type-2 (cVDPV2) for at least  6 months globally. SAGE was alarmed by the persistent  VDPV2 circulation in northern Nigeria (since July 2005)  and Pakistan (since August 2012), noting that these  areas overlap with some of the last wild poliovirus  reservoirs in the world. Stopping circulation of both  WPVs and VDPVs requires addressing gaps in quality  of supplementary immunization activity (SIA), improving routine immunization coverage, increasing access,  and using an appropriate mix of trivalent and bivalent  OPV over the coming 10 months. SAGE emphasized that  the elimination of persistent cVDPV2s by late 2014/early  2015 must be a high priority for global eradication efforts to remain on-track for major milestones of the  Polio Eradication and Endgame Strategic Plan 2013– 2018. SAGE urged countries to correct the mix of OPV  being used in large scale immunization campaigns in  areas with persistent cVDPV2 to ensure that OPV2 can  be withdrawn during the 2016 low season for poliovirus  transmission, as originally scheduled. SAGE reviewed  and endorsed the broad outlines of the proposed approach for mitigating the risk of cVDPV2 emergence at  the time of OPV2 withdrawal, including IPV introduction, routine immunization strengthening and preventive trivalent OPV SIAs in Tier 1 and selected Tier 2  countries or parts of countries. The specifics of the approach will be further elaborated by the Working Group  for SAGE review in October 2014.