POLIO PROGRAM PAKISTAN

POLIO PROGRAM IN PAKISTAN
1 Preamble
The third meeting of the Technical Advisory Group (TAG) on Polio Eradication in Pakistan was convened in Geneva, Switzerland, from 8 to 10 May 2002, with the objectives to review progress towards interrupting wild poliovirus transmission, to analyze the current status of the program, to review whether or not planned activities are appropriate, and to elaborate recommendations to improve important technical and managerial aspects of the program.
The TAG was impressed by the high quality of analyses presented by the team that clearly described the current epidemiology of poliovirus and the improving quality of AFP surveillance and supplementary immunization campaigns. The presentations demonstrated the strength of the team in Pakistan and its ability to fully analyze data and use the information for programmatic action.
The TAG reviewed progress since its last meeting in November 2001 and noted with satisfaction that the recommendations made during the meeting in have been largely implemented:
• A SNID round in January targeting high-risk areas and NIDs in March and April have been implemented with improved quality according to the SIA plan for early 2002 endorsed by TAG
• High-risk population groups and areas that remain reservoirs for poliovirus were better defined and targeted
• Strategies have been developed to focus social mobilization activities in high-risk communities
• Government commitment has remained strong at the national level and continues to improve in all provinces. The number of districts where commitment remains weak is declining
• Partnership between WHO, UNICEF and other agencies is stronger. The TAG acknowledges the outstanding contributions of other partners particularly Rotary International, the governments of Japan, UK, and USA, CDC, and ICRC, in the ongoing efforts to eradicate poliomyelitis from Pakistan.

2 Current situations
Significant progress towards polio eradication has continued in Pakistan
• Surveillance data provide clear evidence of reduction in the number of polio cases and restriction of virus transmission to well defined foci in each province in 2001. A total of 116 confirmed polio cases were reported from 39 districts in 2001 compared with 199 cases from 59 districts in 2000. This is coupled with reduction in genetic diversity of wild P1 and P3 isolates and elimination of a substantial number of viral lineages that were circulating in 1999 and 2000.
• Only 11 cases have been reported up to mid-April 2002. Most of these cases occurred before NID rounds in March and April and have been reported from reservoirs that were active in 2001
• The quality of AFP surveillance improved further in 2001 and indicators of performance were generally high in all provinces. Data from the robust surveillance system in Pakistan is providing a sound basis for decision making
• Surveillance and SIA monitoring data analyses have identified high-risk minority groups that constitute special risk for the program
• The quality of SIAs has improved, particularly in some high-risk areas
• Efforts to recruit a strong WHO team leader for NWFP are still ongoing

Polio Eradication, Pakistan, 1999 to April, 2002

Year Total AFP Non AFP with Adequate confirmed Infected
Cases rate Specimen cases Districts

1999 1329 1.24 69% 558(324) 76
2000 1144 1.52 71% 199(199) 59
2001 1565 2.1 83% 116(116) 39
2002 673 2.0 87% 11(11) 10

3 Risks
The TAG considers the following to be the main risks to interruption of wild poliovirus transmission in Pakistan:
• Failure to reach high-risk populations in upcoming campaigns
• Escalation of conflict and deterioration of security situation in the region
• Persistence of transmission in reservoirs shared with Afghanistan
• Inability to balance other program priorities resulting in a loss of program focus
• Complacency and over-confidence during the critical final phase
• Inability to maintain vital staff in critical areas

4 Conclusions and recommendations
Conclusions.
Transmission of wild poliovirus in Pakistan has become increasingly focal. There is early evidence that several virus reservoirs have been successfully eliminated during 2001. Foci of transmission, however, are dispersed and remain active in each province. The quality of surveillance system is generally high and the TAG is confident of the current epidemiology of poliovirus in Pakistan. Despite recent changes in senior staff, the laboratory continues to function efficiently and is providing reliable and timely data. Appropriate program decisions are being made based on sound analyses of surveillance and campaign monitoring data.
Based on excellent analyses of data presented and the encouraging reduction in geographic and genetic restriction in virus circulation, the TAG considers that interruption of wild poliovirus transmission before the end of 2002 is feasible in Pakistan, provided steps are taken to address the risks identified above.
The quality of SIAs in Pakistan has improved in most areas. Extensive efforts to monitor the quality of SIAs, particularly in high-risk areas, have been instrumental in improving campaign quality.
There is evidence of strong political commitment at all levels. The growing government commitment has been critical to the overall improvement in program performance. The improved coordination between WHO and UNICEF has also contributed significantly to the progress.
Recommendations
Supplementary Immunization Activities (SIAs):
1. The TAG endorses plans to conduct NID rounds in September and October 2002 taking into consideration national elections in October, and encourages continued strong efforts to synchronize all SIAs with Afghanistan, including effective cross-border coordination.
2. A highly focused immunization campaign targeting active virus reservoirs should be conducted in June. This should be followed by a larger immunization round in July. The June-July targeted campaigns followed by NIDs present a real opportunity to interrupt virus transmission in Pakistan.
Achieving high quality during the targeted rounds should be the top program priority. Failure to do so may compromise the effectiveness of NIDs and may allow spread of virus transmission from reservoirs to polio-free districts during the high-transmission season (August-October).
3. The TAG endorses the high-risk area approach. Special attention should be focused on quality of implementation in high-risk communities during all SIAs.
4. The Communication and Social Mobilization Plan for Polio Eradication and EPI is appropriate and well conceived. WHO and UNICEF should ensure that the plan is implemented soon, particularly to reach the high-risk communities and minority groups in the upcoming campaigns. Implementation of the plan in high-risk areas should be closely monitored.
5. The program should prepare to rapidly conduct appropriate mopping-up campaigns in response to poliovirus isolates beginning in early 2003.
6. Campaign monitoring should continue and be designed to document the impact of corrective actions or innovations introduced to improve campaign quality.
7. Efforts to coordinate surveillance and SIAs with Afghanistan should continue. The team leaders for WHO and UNICEF should ensure that cross-border coordination remains an integral part of their program operations.
Surveillance:
8. The program should continue the detailed analysis of AFP surveillance data. The periodic internal reviews of the system have been beneficial and should continue. Given the current strengths of the surveillance system and the need to conduct intensive immunization campaigns in coming months, an international review of the AFP surveillance system should only be considered in mid to late 2003.
9. Attention should continue to be given to AFP surveillance quality in NWFP to ensure uniformly high standards of performance.

Government commitment and enabling factors
10. Joint efforts by Federal Ministry of Health and partner agencies should continue to secure the commitment of district leadership (Nazims and counselors) and line departments, particularly in those high-risk districts where program ownership and accountability remain sub-optimal.
11. Efforts should continue to recruit staff for vital positions. All partners should consider recruitment of a WHO team leader for NWFP a high program priority.
12. Adequate number of national and international experts should be deployed immediately in critical areas to ensure success of the upcoming campaigns.


Evaluations

Communication Support for the Pakistan Polio Eradication Initiative
Presented at: The Technical Advisory Group (TAG) Meeting on Communication for Polio Eradication
June 22-24 2005

This PowerPoint presentation was part of a June 2005 joint United Nations Children's Fund (UNICEF)/World Health Organisation (WHO) meeting dedicated to examining communication in the context of the final global push to eradicate polio. At this meeting, country-specific presentations were made by communication practitioners in 16 of the 21 countries which have experienced cases of wild poliovirus in 2004 and/or in 2005 (to June). The total number of global poliovirus cases increased from 784 cases in 2003 to 1,255 cases in 2004, with 1,004 cases reported to August 9 2005 (548 for the same period in 2005). Communication strategies presented at this meeting were primarily focused on:
1. Analysing the results of programs implemented to June 2005, and
2. Detailing the planned communication program for the next 6 to 12 month period, designed to support a reversal of the above trend and achievement of the goal of eradicating polio worldwide.
According to this presentation, Pakistan (one of 6 polio endemic countries), has experienced a consistent decrease in the number of poliovirus cases since 2003 as follows: 103 cases (2003), 53 cases (2004), and 10 cases to June 2005 vs 16 cases for the same period in 2004 (a 40% decrease). The communication strategy is two-fold, and is designed to:
1. Maintain high levels of polio immunisation coverage in the general population via broad advocacy and program support communication, ensuring ongoing policy, awareness and commitment from the national to the community level; and
2. Provide intensive, targeted support activities based on the premise that, in order to effect the eradication of polio, the communication strategies must reach the persistent, low-level transmission virus reservoirs that are typically characterised by: impoverished families, living in multi-family homes, parents with no formal education, and children under 2 years old.
Mass media in Pakistan is utilised extensively to ensure wide coverage, with celebrity polio ambassadors including entertainers, sports figures, religious figures and political leaders making both personal and media appearances. Television has been reported as the most trusted source of information among all the mass media, and reaches over 89% of the population.

Messages are data driven. For example, one focal message designed to increase the proportion of caregivers understanding that oral polio vaccine (OPV) is safe for a child with fever or diarrhoea resulted in an increase of from 70% to 80% of those surveyed (from Dec 2004 to May 2005).

Polio program communication has been gain-framed, using positive messages and vivid materials with a recognised "two-drop" logo and tag line, which have a reported 86% unprompted recognition. Materials are available in local language print and electronic media, with regionally appropriate images. The logo has also been incorporated into the Expanded Program of Immunisation (EPI) messages.

In high-risk districts, process indicators include micro-planning, training, supervision and increasing the number of women vaccinators. Outcome indicators focus on coverage and known/suspected presence of the polio virus. District specific plans are developed with federal team assistance, and increased numbers of social mobilisation personnel including Communication Campaign Support Persons (CCSPs), Grassroots Mobilisers (GMs), Social Mobilisation Teams (SMTs), and women vaccinators. Specific activities are designed to reach female child caregivers, 55% of whom have been identified as being directly involved in decision making for the immunisation of their children.

Research methods and indicators are detailed in this presentation, including federal communication monitors, 3rd party campaign monitors, micro-studies and intensive coverage surveys in high-risk districts. A three phase National Research Effort is currently underway, with the final phase (Phase Three) to be completed in September 2005. Final evaluation indicators from this research will be used to evaluate the program to date, and to guide activities in 2006.

The detailed research methods and indicators in this presentation include assessments as to whether discussions regarding OPV have been held (55% have discussed OPV with people in their community), and with whom; exposure to Polio Eradication Initiative (PEI) messages (nearly 70% report interpersonal as one source of polio/OPV information); attitude toward the safety of OPV (93% feel OPV is safe), and many more.

An evaluation of the High-Risk Strategy, comprising activities focused on reaching female child caretakers to improve access to children under one year of age is also detailed.

Finally, a summary of the follow-up to the Peer Review Panel recommendations from the prior year meeting held in New Delhi, India is provided (see also 2004 Peer Review Group Comments [PDF]).

In summary, this presentation indicates that there have been improvements in all aspects of both the campaign and surveillance over the past two years, as well as a steady decrease in virus transmission. A key remaining challenge is the acknowledged immunity gap in children under one year of age. All activities are directed towards increasing coverage in this group, including recognition that mothers are an important missing link in accessing these children.

National Immunisation Days (NIDs) are planned for June, August and September 2005, with Supplementary NIDs (SNID's) planned in November 2005. Four NIDs and 2 SNIDs are planned for 2006. However there is still a funding gap for both 2005 (US$1.7 million) and 2006 (US$3.6 million), reflecting the US$600,000 per NID cost, which must be filled in order for these planned activities to take place.

Dr Abdul Aziz Awan