title: Characterization of outbreak response strategies and potential vaccine stockpile needs for the polio endgame.
abstract: BACKGROUND
  Following successful eradication of wild polioviruses and planned globally-coordinated cessation of oral poliovirus vaccine (OPV), national and global health leaders may need to respond to outbreaks from reintroduced live polioviruses, particularly vaccine-derived polioviruses (VDPVs). Preparing outbreak response plans and assessing potential vaccine needs from an emergency stockpile require consideration of the different national risks and conditions as they change with time after OPV cessation.
  
  
  METHODS
  We used an integrated global model to consider several key issues related to managing poliovirus risks and outbreak response, including the time interval during which monovalent OPV (mOPV) can be safely used following homotypic OPV cessation; the timing, quality, and quantity of rounds required to stop transmission; vaccine stockpile needs; and the impacts of vaccine choices and surveillance quality. We compare the base case scenario that assumes aggressive outbreak response and sufficient mOPV available from the stockpile for all outbreaks that occur in the model, with various scenarios that change the outbreak response strategies.
  
  
  RESULTS
  Outbreak response after OPV cessation will require careful management, with some circumstances expected to require more and/or higher quality rounds to stop transmission than others. For outbreaks involving serotype 2, using trivalent OPV instead of mOPV2 following cessation of OPV serotype 2 but before cessation of OPV serotypes 1 and 3 would represent a good option if logistically feasible. Using mOPV for outbreak response can start new outbreaks if exported outside the outbreak population into populations with decreasing population immunity to transmission after OPV cessation, but failure to contain outbreaks resulting in exportation of the outbreak poliovirus may represent a greater risk. The possibility of mOPV use generating new long-term poliovirus excretors represents a real concern. Using the base case outbreak response assumptions, we expect over 25% probability of a shortage of stockpiled filled mOPV vaccine, which could jeopardize the achievement of global polio eradication. For the long term, responding to any poliovirus reintroductions may require a global IPV stockpile. Despite the risks, our model suggests that good risk management and response strategies can successfully control most potential outbreaks after OPV cessation.
  
  
  CONCLUSIONS
  Health leaders should carefully consider the numerous outbreak response choices that affect the probability of successfully managing poliovirus risks after OPV cessation.
authors.affiliation: Kid Risk, Inc., 10524 Moss Park Rd., Ste. 204-364, Orlando, FL, 32832, USA. rdt@kidrisk.org.
authors.forename: Radboud J
authors.initials: RJ
authors.lastname: Duintjer Tebbens
authors.affiliation: Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Pallansch
authors.affiliation: Global Immunization Division, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Steven G F
authors.initials: SG
authors.lastname: Wassilak
authors.affiliation: Global Immunization Division, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Stephen L
authors.initials: SL
authors.lastname: Cochi
authors.affiliation: Kid Risk, Inc., 10524 Moss Park Rd., Ste. 204-364, Orlando, FL, 32832, USA.
authors.forename: Kimberly M
authors.initials: KM
authors.lastname: Thompson
mesh_terms: D004189:Disaster Planning; D004196:Disease Outbreaks / Q000517:prevention & control; D006801:Humans; D007391:International Cooperation; D011051:Poliomyelitis / Q000517:prevention & control*; D011055:Poliovirus Vaccine, Oral / Q000600:supply & distribution*; D012308:Risk Management; D014611:Vaccination / Q000379:methods
chemical_list: D011055:Poliovirus Vaccine, Oral
keywords: Eradication; Polio; Risk management; Stockpile; Vaccine