Report on the Meeting of the Technical Advisory Group on Poliomyelitis Eradication in Afghanistan and Pakistan [February 2008]

This report was generated following a technical consultation on polio eradication in Afghanistan and Pakistan, held in Cairo, Egypt from February 3-4, 2008. The objectives of the meeting included:

1. Reviewing progress towards polio eradication in the two countries, with a focus on 2007.
2. Discussing planned activities for 2008.
3. Making recommendations to enable the programme to address constraints facing the two national programmes.

This meeting included representation from major implementing and donor organisations involved in the polio eradication initiative (PEI) in both countries, including senior representation from both the Afghanistan and Pakistan governments, the World Health Organisation (WHO), the United Nations Children's Fund (UNICEF), the Technical Advisory Group on polio eradication (TAG), the United States Centres for Disease Control (CDC), the United States Agency for International Development (USAID) and Rotary International, among others.

The two-day meeting consisted of a programme of presentations and discussion looking at the epidemiological situation and programme activities in both countries. The sessions addressed the following main topics, highlights from which are given below:

Epidemiological situation:

It is to be noted that the detected wild viruses represent only the tip of the iceberg of circulating wild viruses in both countries.

Pakistan:
A total of 32 cases of poliomyelitis, nineteen due to wild poliovirus type 1, and thirteen due to type 3, were reported in 2007 as compared to forty cases in 2006 (twenty cases due to each of the WPV of type 1 and type 3). The main characteristics of the 2007 polio confirmed cases show that:

• Two thirds of the cases are under three years of age.
• Two thirds of the cases received no routine immunisation.
• 40% received less than four doses of OPV.

The main reasons behind the modest decrease in number of wild poliovirus cases in 2007 included the inaccessibility to children in security compromised areas, gaps in performance, pockets of refusals, and inadequate management in some districts.

Afghanistan:
As of February 2nd, 2008, a total of seventeen cases of poliomyelitis with onset in 2007 have been confirmed (eleven due to WPV3 and six due to WPV1). This shows a significant reduction in the number of reported type 3 cases from 2006 (twenty nine) and an increase in type 1 cases (two).

The polio cases reported from Southern Region were in general under immunised. Ten of the fifteen cases had less than 3 doses of OPV. Two of the ten infected districts in the southern region in 2007 were infected with both types of poliovirus, WPV1 and WPV3. The two Eastern Region cases, in contrast, were well immunised. All cases reported in Afghanistan were less than thirty months of age except one case - six years old.

Cross-Border:
The southern region of Afghanistan is part of a larger transmission zone extending into Baluchistan and northern Sindh in Pakistan, with extensions to Karachi and southern Punjab. This combined southern Afghanistan-Pakistan transmission zone accounts for the majority of cases reported in both countries, and has the localised transmission of persistent genetic lineages with multiple chains of transmission.

Immunisation Activities:

Pakistan:
In 2007, Pakistan implemented four National Immunisation Days (NIDs) and seven Sub-National Immunisation Days (SNIDs). Each NID involved the recruitment of more than 80,000 vaccination teams, 15,000 first level supervisors and another 4,000 higher levels of supervisors. The SNIDs generally cover 35-40% of the population and focus on transmission zones and high risk areas.

Post-campaign assessment coverage rates analysed for districts shows overall high rates. It was noted, however, that analysing coverage data by lower administrative levels shows clearly that in many districts, especially in the transmission zones and high-risk areas, more than 20% of the Union Councils (UCs) have coverage rates less than 95%. Retrospective analysis of coverage data by UC showed that this low coverage in certain areas has been ongoing for several consecutive rounds.

Afghanistan:
Afghanistan implemented four full NIDs and seven SNIDs in 2007. The SNIDs focussed on the transmission zones and high risk areas bordering Pakistan, i.e. Southern Region, South-Eastern Region, Eastern Region, and Faraha province of Western Region.

The critical issue for supplementary immunisation activity (SIA) quality remains the Southern Region. The national programme has documented the access issues in the Southern Region, round by round. Both epidemiological data and SIA quality data clearly indicate that large numbers of children continue to be missed in the Southern Region and neighbouring areas.

Communication/Social Mobilisation:

Pakistan:
Social mobilisation efforts since October 2007 have focused on ensuring that human resources for communication are in place at the provincial and district level. Priority has been given to ensuring that an issue-specific communication plan is in place in the high-risk districts and that district teams are trained in data-driven communications. A set of national communication indicators have been agreed and monitoring tools were used during the January campaign. Future focus will be on tracking trends and the impact of the communication interventions during NIDs. A communication review process is to be undertaken at the provincial level and upcoming research is planned to address service delivery.

Afghanistan:
The Afghanistan team has been scaling up human resources for communication at all levels though it is a major challenge to rapidly find well qualified people. A knowledge, attitudes, and practices (KAP) baseline study was undertaken to provide a baseline for measuring community attitudes, perceptions, and practices around behaviours related to polio (and routine) immunisation. The KAP also identified barriers that prevent families from getting their children immunised including gaps in service delivery at the health facilities and at the door step. A set of processes and impact indicators have been agreed to measure the impact of the communication strategy at all levels. The next step is to ensure a communication structure that is fully functional at all levels to implement the strategy.

A key issue continues to be the lack of access to priority areas; anti-government elements (AGE) control some areas which make insecurity a primary factor in not being able to reach children.

Communication challenges in Afghanistan are different from Pakistan. Refusals are not an issue. However, since there is a lot of movement between endemic areas in both countries, a distinct possibility of refusals creeping into Afghanistan cannot be ruled out.

Both countries presented specific experiences and approaches from activities focused on coordination of cross-border initiatives, maintaining the interest of political leaders, involving religious leaders, ensuring coverage of mobile populations, and working towards days of tranquility in Afghanistan.

Conclusion Highlights:

Polio cases remain confined to known transmissions zones and the majority of the population live in polio free areas. However, in spite of intensive programme activities both types 1 and 3 are circulating over wide geographical areas in both north and south Pakistan and adjacent areas in Afghanistan. This picture indicates the presence of sufficient inadequately immunised population groups which are permitting continued viral circulation due to poor quality campaigns (NIDs and SNIDs). As much as 40% of the polio confirmed cases in Pakistan were found to have received less than four doses of OPV and more than half the cases have not received any routine OPV doses. These facts, in addition to the epidemiologic investigation findings, confirm the possibility that some areas are being missed regularly not only in routine immunisation but also during SIAs.

The TAG is concerned that uneven planning and supervision management quality and SIA monitoring results, largely in high risk districts, are not proving credible. This lack of reliable monitoring can only lead to concealed problems and programme deficiencies, resulting in complacency.

Recommendations:

• Political commitment and support is required to improve operational management including performance review of district level officials to strengthen or replace ineffective management.
• Both countries need to ensure effective supervision, vaccinator selection and training and local involvement. Monitoring of rounds needs to be improved through finger marking, stronger independent monitors, and analysis of campaign data to the lowest administrative level.
• Security compromised areas should be mapped and monitored and the programme should be ready to take advantage of any opening on short notice.
• Buffer stocks of five million doses each of MPV1 and 3 should be retained for rapid response use in Pakistan and similar stocks of one million doses should be kept in Afghanistan.
• General population immunity should be assured through conducting four NIDs using trivalent vaccines in both countries.
• The TAG encouraged both countries to continue to implement the recommendations of the communication reviews as soon as possible and viewed the establishment of communication indicators as a particularly important development.
• The TAG recommended further communication reviews for 2008 though in a form modified to each country's needs and priorities.