To Print: Click your browser's PRINT button. NOTE: To view the article with Web enhancements, go to: http://www.medscape.com/viewarticle/464841 Original Article Policy Decision Options During the First 5 Years Following Certification of Polio Eradication Nalinee Sangrujee, PhD, MPH; Radboud J. Duintjer Tebbens, MS; Victor M. Cáceres, MD, MPH; Kimberly M. Thompson, ScD Medscape General Medicine 5(4), 2003. © 2003 Medscape Posted 12/18/2003 Abstract and Introduction Abstract Policy makers face a number of difficult choices as they develop policies to ensure maintenance of a polio-free world following global eradication and certification. These policy decisions include choices about immunization, outbreak response (including whether to create a vaccine stockpile), surveillance, containment, management of chronic excretors, and investment in future research. This paper focuses on identifying the categories of decisions and characterizing the actual factors that country-level policy makers must weigh to manage polio risks during the first 5 years after certification. Building on a comprehensive literature review, we report the results of the first qualitative analysis to: (1) systematically characterize each type of decision and the relevant options during the first 5 years after certification, (2) clearly identify critical factors that influence the choices, and (3) specifically demonstrate the interdependence among the decisions to produce a reduced set of decision options. This paper explicitly focuses on the different perspectives of developed and developing countries in characterizing the options. While the management of polio risk in the postcertification period presents important challenges, this comprehensive approach helps simplify the process by focusing on critical decisions. Introduction Successful polio eradication efforts continue to move the world closer to eradication and certification as free of wild poliovirus. Global certification will occur once all 6 World Health Organization (WHO) regions report finding no wild poliovirus under high-quality surveillance for at least 3 years and the Global Certification Commission becomes satisfied that sufficient laboratory containment exists, [1,2] a milestone already achieved by 3 regions. The achievement of polio eradication and certification will soon lead policy makers to face difficult choices to ensure maintenance of a polio-free world. These choices primarily include policies related to: routine and supplemental immunization, outbreak response (including whether to create a stockpile), surveillance, and containment of wild and vaccine-derived polioviruses (VDPVs). The combination of discrete policy choices forms an overall strategy, with the best strategy from the policy maker's perspective striking an optimal balance among the risks, costs, and benefits. In the context of global discussions of postcertification risk management strategies, few efforts to date have comprehensively described the complexity of choices and placed them within the context of developing and evaluating an overall national strategy. This paper builds on prior work to help fill this void. Recent discussions predominantly focused on stopping immunization as the ultimate goal of the eradication initiative and on characterizing related issues. In March 1998, a WHO meeting on the scientific basis for stopping polio immunizations identified 4 strategies for stopping immunization that depended on the then unanswered question of whether VDPVs could persist in populations. [3,4] If VDPVs could persist, the preferred options would be to replace the current trivalent oral polio vaccine (tOPV) for a transition period or replace the tOPV indefinitely with either the enhanced inactivated polio vaccine (eIPV) or a new vaccine. If VDPVs could not persist, the preferred option involved a coordinated cessation of tOPV use, possibly including sequential removal of eradicated strains from tOPV (ie, using bivalent OPV [bOPV] or monovalent OPV [mOPV]). Following clear evidence of the persistence of VDPVs and associated outbreaks, [5] Wood and colleagues [6] concluded that "discontinuation of OPV in a synchronized way remains the most plausible" option. Subsequent publications presented similar vaccination options [7-13] and discussed whether and how immunization should be stopped, [14-16] with one study emphasizing the differences in decisions between developed and industrialized countries. [15] Another study summarized available data addressing the option of using monovalent vaccines as part of the immunization policy, [17] and a recent report noted the interdependence of countries' decisions. [18] In spite of clear recognition of the need for surveillance strategies, stockpiles, and contingency plans to respond to potential outbreaks in the postcertification era, [3,4,9,10,13,19,20] few articles have elaborated on these issues and related decision options. [10,21] Fine and colleagues [10] estimated the impact in the posteradication era of an outbreak in a population assuming various immunization and surveillance conditions Page 1 of 18 12/22/2003 file://C:\Documents%20and%20Settings\kimt\Local%20Settings\Temp\PE82DZSN.htm