EXPLORING THE ROLE OF ANTIVIRAL DRUGS IN THE ERADICATION OF POLIO

WORKSHOP REPORT

Committee on Development of a Polio Antiviral and Its Potential Role in Global Poliomyelitis Eradication

Board on Life Sciences

Division on Earth and Life Studies

NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Exploring the Role of Antiviral Drugs in the Eradication of Polio: Workshop Report EXPLORING THE ROLE OF ANTIVIRAL DRUGS IN THE ERADICATION OF POLIO WORKSHOP REPORT Committee on Development of a Polio Antiviral and Its Potential Role in Global Poliomyelitis Eradication Board on Life Sciences Division on Earth and Life Studies NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Exploring the Role of Antiviral Drugs in the Eradication of Polio: Workshop Report THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. CDC-200-2000-00629 between the National Academy of Sciences and the Centers for Disease Control and Prevention (CDC) and Contract No. HQ/05/076671 between the National Academy of Sciences and the World Health Organization (WHO). The content of this publication does not necessarily reflect the views or policies of the CDC or the WHO, nor does mention of trade names, commercial products or organizations imply endorsement by the U.S. Government. International Standard Book Number 0-309-10161-1 Cover: Upper left: Three-dimensional image of a poliovirus virion produced using an electron microscope and X-ray crystallography (courtesy of Robert Grant, Stéphane Crainic, and James Hogle, Harvard Medical School). Center: Egyptian stele with the first-known depiction of a polio victim (courtesy of Ny Carlsbert Glyptotek, Copehnagen), superimposed on the genetic sequence of the poliovirus (courtesy of Eckard Wimmer, State University of New York, Stonybrook). Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

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Exploring the Role of Antiviral Drugs in the Eradication of Polio: Workshop Report THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Exploring the Role of Antiviral Drugs in the Eradication of Polio: Workshop Report COMMITTEE ON DEVELOPMENT OF A POLIO ANTIVIRAL AND ITS POTENTIAL ROLE IN GLOBAL POLIOMYELITIS ERADICATION SAMUEL L. KATZ (Chair), Duke University Medical Center, Durham, North Carolina RAUL ANDINO, University of California, San Francisco DIANE JOSEPH-MCCARTHY, Wyeth Research, Cambridge, Massachusetts JOHN F. MODLIN, Dartmouth Medical School, Lebanon, New Hampshire NEAL NATHANSON, University of Pennsylvania School of Medicine, Philadelphia RICHARD J. WHITLEY, University of Alabama, Birmingham ECKARD WIMMER, Stony Brook University School of Medicine, Stony Brook, New York Staff ANN H. REID, Study Director FRANCES E. SHARPLES, Director, Board on Life Sciences JOSEPH C. LARSEN, Postdoctoral Research Associate ANNE F. JURKOWSKI, Program Assistant

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Exploring the Role of Antiviral Drugs in the Eradication of Polio: Workshop Report BOARD ON LIFE SCIENCES COREY S. GOODMAN (Chair), Renovis, Inc., South San Francisco, California ANN M. ARVIN, Stanford University School of Medicine, Stanford, California JEFFREY L. BENNETZEN, University of Georgia, Athens RUTH BERKELMAN, Emory University, Atlanta, Georgia DEBORAH BLUM, University of Wisconsin, Madison R. ALTA CHARO, University of Wisconsin, Madison DENNIS CHOI, Merck Research Laboratories, West Point, Pennsylvania JEFFREY L. DANGL, University of North Carolina, Chapel Hill PAUL R. EHRLICH, Stanford University, Stanford, California JAMES M. GENTILE, Research Corporation, Tucson, Arizona JO HANDELSMAN, University of Wisconsin, Madison ED HARLOW, Harvard Medical School, Boston, Massachusetts DAVID HILLIS, University of Texas, Austin, Texas KENNETH H. KELLER, University of Minnesota, Minneapolis RANDALL MURCH, Virginia Polytechnic Institute and State University, Alexandria GREGORY A. PETSKO, Brandeis University, Waltham, Massachusetts STUART L. PIMM, Duke University, Durham, North Carolina JAMES TIEDJE, Michigan State University, East Lansing KEITH YAMAMOTO, University of California, San Francisco Staff FRANCES E. SHARPLES, Director KERRY A. BRENNER, Senior Program Officer MARILEE K. SHELTON-DAVENPORT, Senior Program Officer EVONNE P. Y. TANG, Senior Program Officer ROBERT T. YUAN, Senior Program Officer ADAM P. FAGEN, Program Officer ANN H. REID, Program Officer DENISE GROSSHANS, Financial Associate ANNE F. JURKOWSKI, Program Assistant TOVA JACOBOVITS, Program Assistant

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Exploring the Role of Antiviral Drugs in the Eradication of Polio: Workshop Report Acknowledgments THIS REPORT IS A PRODUCT of the cooperation and contributions of many people. The committee would like to thank all the speakers and participants who attended the Workshop on Development of a Polio Antiviral and Its Potential Role in Global Poliomyelitis Eradication on November 1-2, 2005, and others who provided information and input. This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following for their review of this report: Craig Cameron, Pennsylvania State University Walter Dowdle, The Task Force for Child Survival and Development Christopher D. Earl, BIO Ventures for Global Health Diane E. Griffin, Johns Hopkins Bloomberg School of Public Health James M. Hogle, Harvard Medical School Karla Kirkegaard, Stanford University School of Medicine Amy K. Patick, Pfizer

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Exploring the Role of Antiviral Drugs in the Eradication of Polio: Workshop Report Bert L. Semler, University of California, Irvine School of Medicine P. Frederick Sparling, University of North Carolina School of Medicine Although the reviewers listed above have provided constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Donald S. Burke of the Johns Hopkins Bloomberg School of Public Health and Nicole Lurie of the RAND Corporation. Appointed by the National Research Council, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the author committee and the institution.

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Exploring the Role of Antiviral Drugs in the Eradication of Polio: Workshop Report Contents     SUMMARY   1 1   AN OVERVIEW OF THE POLIO ERADICATION CHALLENGE   7 2   PUBLIC HEALTH CONSIDERATIONS   13 3   POTENTIAL BIOLOGICAL TARGETS OF POLIO ANTIVIRAL DRUGS   19      Synopsis of Poliovirus Pathogenesis and Replication,   20      Targets for Polio Antivirals,   23      Basic Research Needs,   33 4   DEVELOPMENT OF ANTIVIRAL DRUGS FOR POLIOVIRUS   35      Potential Hurdles to Address at the Outset,   36      Identifying and Optimizing Potential Polio Antiviral Drugs,   37      Clinical Development,   41      The Importance of Developing More Than One Antiviral Drug,   43      Timelines and Costs,   44 5   IMPLEMENTATION AND RECOMMENDATIONS   47      Recommedations,   48

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Exploring the Role of Antiviral Drugs in the Eradication of Polio: Workshop Report     REFERENCES   51     APPENDIXES         A  Statement of Task   61     B  Committee Biographical Sketches   63     C  Workshop Agenda and Participant List   69