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Pakistan: National Emergency Action Plan for Polio Eradication 2018/2019 (1st July 2018 - 30th June 2019)

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Pakistan
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Govt. Pakistan
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Executive Summary

In the past three years, Pakistan has made tremendous progress towards polio eradication, with its lowest ever number of confirmed wild poliovirus (WPV) cases reported last year. This progress comes as intensive planning and coordination has yielded many pathbreaking strategies: from community-based vaccination (CBV) to new surveillance methods for eradication; from a strong operational platform and full organisational accountability, to innovations in monitoring and evaluation that give visibility into the programme’s toughest challenges.

Yet even with this progress, Pakistan remains one of only two countries still reporting WPV cases; the other country is neighbouring Afghanistan. In 2017, 8 and 14 cases were reported from Pakistan and Afghanistan, respectively. As of June 2018, a total of 13 cases–3 from Pakistan and 10 from Afghanistan – have been reported. All cases in Pakistan were detected in Dukki, a rural district in Balochistan.

These cases make clear that neither Pakistan nor Afghanistan can eradicate polio without the other, and all of Pakistan remains at risk as long as WPV continues to circulate in either Pakistan or Afghanistan.

Until both countries reach and sustain ‘zero’ polio, the programme cannot celebrate. While the decline in the number of WPV cases demonstrates positive progress, the continued reporting isolation of WPVs from environmental surveillance (ES) samples in Peshawar and Karachi provides sobering evidence of persistent transmission in many parts of the country. Despite the reduction in the overall percentage of positive samples in the past 12 months, the distribution of sporadic positive samples across multiple geographic areas and epidemiological blocks and the persistent isolation of WPV from environmental samples in some core reservoirs indicate continued challenges to eradication.

Programme assessments also point to underlying operational issues that have created gaps in the quality of supplementary immunization activities (SIAs), seen in the proportion of unvaccinated and undervaccinated children.

Under the National Emergency Action Plan (NEAP) 2017/2018, 5 National Immunization Days (NIDs) and 5 Subnational Immunization Days (SNIDs) were conducted. While the proportion of targeted children remaining unvaccinated among recorded missed children declined dramatically to approx. 3% at the beginning of 2016, that proportion has gradually increased in the last two years and is now at approx. 6%. Looking to independent third-party post-campaign monitoring (PCM) data, there were variations in campaign performance. In Punjab, vaccination coverage remained above 90% throughout the low season and was ≥95% in April and May 2018. In Khyber Pakhtunkhwa (KP) and what was formerly the Federally Administered Tribal Areas (FATA), coverage was ≥ 90% in 7 of 9 and 8 of 9 campaigns, respectively. Coverage was ≥90% for 3 of 10 campaigns in Balochistan, 6 of 10 in Sindh, 3 of 8 in Islamabad, zero of 6 in Azad Jammu and Kashmir (AJK), and 2 of 6 in Gilgit Baltistan (GB).

Performance was equally varied in the highest-risk districts. In Karachi, the proportion of Union Councils (UCs) passing lot quality assurance sampling (LQAS) remained <80% for most towns throughout 2017 and 2018. In Quetta block, the proportion of UCs passing LQAS in both Quetta and Killa Abdullah was <80% between July and December 2017, though performance gains were observed in the second half of the 2017/2018 NEAP cycle. Consistent good performance was observed in both Khyber and Peshawar with the proportion of UCs passing LQAS remaining above 90%.

An assessment of 2017/2018 essential immunization (EI) in CBV Union Councils in Tier 1 districts was conducted in March-May 2018. The findings continue to highlight persistent gaps in EI coverage in the most critical districts. Coverage for Pentavalent 3 and IPV 1 remained extremely low in Killa Abdullah and Pishin, very low in Quetta, Khyber and parts of Karachi, and low in Peshawar and some parts of Karachi. These unacceptably low levels of EI coverage in the highest-risk districts hinder reaching and sustaining poliovirus eradication. Addressing the underlying challenges to improving EI coverage is beyond the scope of the polio programme and requires instead an ‘all government’ intervention. Using the established polio management, oversight and accountability structures to strengthen EPI performance is necessary if progress is to be made.

Under NEAP 2017/2018, the programme took additional measures to assess capacity in reaching all high-risk and mobile populations (HR&MPs). Detailed surveys of HR&MP groups were carried out in more than 60 districts with a high proportion of HR&MPs and a recurrent history of WPV transmission. A clear and granular profile of HR&MPs emerged: who they are, where they come from, where they go, and when they go. The surveys have been extremely useful in assessing the potential risk posed by HR&MPs, particularly as HR&MP groups were found to be systematically missed by the programme. However, where HR&MPs were undervaccinated, settled populations were also affected, indicating operational issues were the main problem. The finding gives clear direction: fixing operational issues at the district and sub-district level will support efforts with HR&MP-related issues, as outlined in the HR&MP Vaccination Strategy.

Quantitative and qualitative assessments all suggest that the programme is at a point where street-by-street knowledge of missed children and local community dynamics are the most important information the programme has and can use to cover the ‘last mile’ to eradication.

Community engagement remains the most critical factor in addressing remaining coverage gaps in the core reservoirs. Direct or hidden refusals associated with misconceptions and religious or other beliefs are the primary reasons for the non-vaccination of remaining missed children in these areas. The expansion and deployment of full-time, local, and mostly female vaccinators in all Tier 1 districts has created new opportunities for direct community engagement at the household level. The Sehat Muhafiz philosophy, which positions frontline workers (FLWs) as a community resource and as local and trusted health workers, and focused on identifying, tracking and covering missed children, has brought substantial benefits.

Surveillance also continues to be crucial to the eradication effort. In the past two years, the surveillance system was enhanced through the implementation of the Surveillance for Eradication Work Plan. Focused strategic planning, frequent field reviews, supportive missions, and quarterly reviews have transformed surveillance in all provinces. Furthermore, the concept of ‘green is not always green’ – meaning good indicators are not always equivalent to good surveillance – has helped refocus the programme on the basics of surveillance: a well-trained team conducting active and passive surveillance and, where necessary, innovating to enhance timely reporting.
Investments in new technology, such as the development of new, web-based surveillance data system and the full rollout of mobile phone data collection for active surveillance, has improved the quality and timeliness of data. In 2018/2019, maintaining a highly sensitive surveillance system will be a critical priority and thus has become newly designated as a separate area of work.

Governments at all levels continue to lead the way in polio eradication. This ‘all-government’ approach to eradication has been effective in solving problems and driving success. In the last three years, the ‘one team under one roof’ concept has worked well to bring collaboration and coherence to a multi-level, multi-disciplinary, and multi-agency organisation. Additionally, the Emergency Operations Centre (EOC) network is now mature and provides a strong platform for the programme. Transforming this new national asset into a national institution will be a priority for NEAP 2018/2019.

Yet as a third year of heavy investments and intensive push comes to an end, the fight to rid Pakistan of polio must not relent. Despite the programme’s achievements, steep challenges remain. Sustaining peak performance across all high-risk districts remains difficult. In 2017/2018, the programme was unable to simultaneously maintain high performance across all high-risk districts. Addressing chronic operational issues will be critical to success in the year ahead – and to completing the ‘last mile’ toward a polio-free Pakistan.

The way forward is clear. For 2018/2019, the programme will continue to implement the basic core strategies that have delivered substantial progress: comprehensive vaccination through four NIDs and five SNIDs; sensitive poliovirus surveillance throughout the country; and thorough monitoring and data analysis to drive decision making. To finally achieve eradication, the programme will increase its focus on both high-risk population groups settled in core reservoirs and other high-risk districts, and high-risk and mobile populations.

For core reservoir and high-risk districts

  • Enhance quality and reach of the immunization strategies where appropriate to increase overall population immunity.

  • Implement a comprehensive ‘Communication for Eradication’ strategy based on interactive approaches and focusing efforts on listening to the community and finding ways to address specific issues.

  • Fully implement corridor action plans and consolidate coordination with the Afghan polio eradication program on strategy and operational harmonization.

  • An option for expanding targeted age group for vaccination in critical areas especially among the seropositive older age group will be considered during the course of the next low transmission season.

  • Increase investment in EI coverage, especially through targeted support in low-performing tier 1 districts.

For high-risk and mobile populations:

  • Update HR&MP Strategic Plan incorporating lessons learned last year to identify and target this population in areas where they contribute most to poliovirus transmission.