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WHO-EM/XXX/###/E
Report on the
Meeting of the Technical Advisory Group on Poliomyelitis Eradication in Pakistan
Islamabad, Pakistan 21–22 March 2012
WHO-EM/XXX/###/E
Report on the
Meeting of the Technical Advisory Group on Poliomyelitis Eradication in Pakistan
Islamabad, Pakistan 21–22 March 2012
© World Health Organization 2012All rights reserved.
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Document WHO-EM/XXX/###/E/YY.ZZ/PPP
CONTENTS
1. INTRODUCTION.............................................................................................................1
2. OPENING SESSION........................................................................................................1
3. SUMMARY OF TECHNICAL PRESENTATIONS AND DISCUSSIONS.....................1
Augmented National Emergency Action Plan...................................................................2
Implementation status of the recommendations of the last TAG meeting.........................2
Epidemiological situation..................................................................................................3
Balochistan........................................................................................................................3
Federal Administrative Tribal Areas (FATA).....................................................................4
Khyber Pakhtunkhwa Province.........................................................................................5
Sindh Province...................................................................................................................6
Punjab Province.................................................................................................................7
Azad Jammu & Kashmir (AJK)........................................................................................8
Gilgit Baltistan (GB).........................................................................................................9
Polio Eradication Initiative (PEI): Communication Strategies..........................................9
Engaging High Risk Groups for Polio Eradication...........................................................9
Polio Eradication and the Media.....................................................................................10
Over all Questions asked to the TAG..............................................................................10
3. CONCLUSIONS & RECOMMENDATIONS......................................................................11
Conclusion.......................................................................................................................11
TAG Recommendations...................................................................................................12
Overarching Recommendations:.....................................................................................12
Additional Province Specific Recommendations............................................................14
1. PROGRAMME....................................................................................................................182. LIST OF PARTICIPANTS...................................................................................................20
WHO-EM/XXX/XXX/E
1. INTRODUCTION
The Pakistan Technical Advisory Group (TAG) on Poliomyelitis eradication met in Islamabad on 21-22 March at a time when Polio eradication has been declared to be 'a programmatic emergency for global public health', with 3 countries, namely Pakistan, Nigeria & Afghanistan driving global transmission of polioviruses. The objectives of the meeting were to review progress towards poliomyelitis eradication, after a quarter of the launch of the augmented National Emergency Action Plan. This is the first meeting of the Pakistan specific TAG, as previously it was combined for Afghanistan and Pakistan. The objective of separate TAGs is to provide more focus and in depth review of these country programs.
Pakistan is the only one of the three above countries that has reported an increased incidence of poliomyelitis in the last three consecutive years. In addition, Pakistan has reported 50% of global cases to date in 2012. The main reason for that is an evident deterioration of immunization status in key high risk areas in this country.
The programme and list of participants are attached as Annexes.
2. OPENING SESSION
Professor David M. Salisbury, the chairman of the TAG opened the meeting, highlighted with concern the critical situation that Pakistan is through for polio eradication and the threat that the country poses to the efforts for global polio eradication. Dr Guido Sabatinelli, WHO Representative in Pakistan welcomed all participants and thanked the Government of Pakistan for hosting the meeting and acknowledged the continued support of polio partners, namely, Rotary International, USAID, UNICEF, CDC and Bill & Melinda Gates Foundation, JICA and World Bank. The WR also read a message from Dr Ala Alwan, the Regional Director for WHO Eastern Mediterranean Region. The RD, in his message, acknowledged the efforts made by the Government to achieve the target of polio eradication and referred, specifically, to the augmentation of the National Emergency Action Plan (NEAP) for polio eradication and the efforts being made to ensure its implementation at all levels. He however; stressed and hoped for the urgent and spot on implementation of the plan.
The meeting was then addressed by the Federal Secretary Ministry for Inter-provincial Coordination (Cabinet Division), who welcomed the participants and acknowledged that the TAG is meeting at a very crucial time. He reiterated the strong commitment of the Government to convert the present situation to a success in achieving the target of polio eradication.
3. SUMMARY OF TECHNICAL PRESENTATIONS AND DISCUSSIONS
Dr Bruce Aylward, Assistant Director General WHO in his presentation reaffirmed that polio eradication remains WHO’s top priority in Pakistan. He presented to the meeting the latest developments in polio eradication, globally, and referred to success as well as to the challenges that the program has been facing. He underscored the elimination of India from the list of the polio endemic countries which marks a major step towards global polio eradication.
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He highlighted the profound drop in WPV3 which may be on its way to be eradicated. He however highlighted that the Pakistan is one of the only 2 countries globally which reported type-3 polio cases during the last 6 months. He also referred to the exportation of the WPV-1 from Pakistan to China which reinforces the fact that no part of the globe is free f the risk until the global eradication is achieved. He shared the upcoming important timelines; that include finalizing the national emergency plans by end of March 2012, SAGE review of consolidated plan in April and the World Health Assembly debate in May 2012. Dr Aylward raised two points for the consideration of TAG, a) Does the Augmented National Emergency Action Plan (NEAP) address all issues required to reach the OPV coverage levels needed to stop transmission in Pakistan; and b) What changes are needed to optimize NEAP implementation in each province?
Augmented National Emergency Action Plan
Member of the National Task Force for Polio Eradication
In Pakistan, Balochistan, Sindh and Federally Administered Tribal Areas (FATA) contributed a substantial proportion of upsurge of polio cases reported during 201. The Augmented National emergency Action Plan (A-NEAP) was endorsed by the National Task Force of Polio Eradication and Ms. Shahnaz Wazir Ali, Assistant to the Prime Minister on Social Sector has been appointed as the National Focal Person for polio eradication. The A-NEAP authorizes the government District Managers (DC, DCO, PAs) to lead the SIAs and holds them accountable for its quality. It also focuses involving the public representatives and stresses adequate preparations for SIAs at the UC level. Key recent steps in the light of the A-NEAP include abolishment of the zonal supervisors, nomination of the UC medical officers, strict actions against the sub-optimal performers at all levels and deferment of SIAs in case of inadequate preparations. Moreover renowned religious leaders, political figures and social workers have also been taken onboard. The A-NEAP has provided momentum to the program which needs to be carried on and the Government is fully committed for this.
Implementation status of the recommendations of the last TAG meeting
Coordinator Prime Minister’s Polio Monitoring and Coordination Cell
All the SIAs activities were conducted as per the advice of the TAG using the appropriate type of the OPV. Case response activities using bOPV were carried out in response to detection of all WPV-1 cases outside the known persistent transmission zones in 2011. In addition, large scale, intensive mop-ups were carried out in central southern Sindh, North Sindh, southern Punjab & southern KP. Khyber agency reported two P3 cases; SIADS were conducted in Khyber agency using bOPV only in the accessible areas; inaccessible areas could not be reached. He referred the implementation status of the province specific recommendations to the provincial teams.
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Epidemiological situation
WHO Senior Coordinator
In 2011, Pakistan reported 198 cases (196 WPV1 and 2 WPV3) from 60 infected districts which was the largest number of cases reported since 2000. The majority of cases during the last 3 years were reported from the known transmission zones of Federally Administered Tribal Areas (FATA) and associated areas of the Central Khyber Pakhtunkhwa (KP) province, Quetta Block (Quetta, Pishin and Killa Abdullah) in Baluchistan province and Karachi. Following the explosive outbreak in 2011; the 15 cases in 2012 may represent the tail end of this outbreak except FATA which carries on reporting both polio cases of both serotypes.
The key epidemiologic characteristics of polio cases include that majority below 2 years of age with predominance in males, 77% are from Pashto speaking families, 23% belong to refusal families, 88% live in multiple family dwellings, more than half the cases are inadequately immunized, some of them having not received any doses of OPV, among the polio cases Pashto speaking cases had larger proportions of un-immunized and under-immunized children in 2010 and 2011as compared to other ethnicities and 63% of the polio cases reported from FATA belonged to areas which could not be visited by the vaccination teams for long time due to insecurity. Nearly 30% of the non-polio AFP cases reported from FATA and Balochistan each were reportedly either un-immunized or under-immunized against polio. This warrants urgent attention to address these children. In fact, more than 70% polio cases were either reported from or genetically linked to the three transmission zones.
It is important to highlight though that the LQAS results indicate marginally better performance at this point in time as compared to last year which may possibly be the result of the recent thrust provided by the A-NEAP. The TAG was asked for guidance on the scale of the SNIDs.
Balochistan
Provincial EPI Manager
Districts with persistent transmission 53 cases representing (73%) of the cases in Balochistan, Kila Abdullah, Pishin and Quetta 22, 16 and 15 cases respectively, while Nasirabad/Jaffarbad Block escaped infection due to satisfactory vaccination coverage. Most of the cases are in localized Teshils, all the 15 cases in Quetta are in Quetta city, out of the 22 confirmed polio cases in Kila Abdulah district 13 in Chamman, and out of the 16 confirmed polio cases in Pishin 15 are from PISHIN Tehsil.
The AFP surveillance in Balochistan showed that 30% of the confirmed P1 are with ZERO OPV doses and 48% are with 7+ doses and LQAs in Pishin is rejected at 80% in the last 2 SIAS and according January SIAs market survey only Quetta reached 90%.
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Reasons for failure include inadequate preparations for quality campaigns; deficient micro-plans, inappropriate AICs & teams selection/training, lack of accountability, misuse of resources, political interference protecting poor performers & pockets of refusals.
Government of Balochistan has shown high level of commitment, four meetings are conducted in the Chief Minister office out of which 2 are chaired by the CM. In the line of implementation of the NEAP 4 Steering Committee meetings has been chaired by the Chief Secretary (CS), CS directed all DCs to lead PEI in their respective districts. At the level of management, a highly committed additional secretary for health has been assigned as the provincial polio focal persons, replacement of four non performing DHOs, and replaced old tier of Zonal Supervisors (ZS) by MOs as UC in charge.
The province has restructured the program and attained new strategy by conduction SIAs in two phases to ensure quality of SAIs in Quetta Block. At the UC level in the HRD, WHO has deployed 57 UCPWs providing technical support for SIAs. UNICEF has established the ComNet 8 DHSOs, 31 UCOs and 192 SMs have been deployed in field supporting social mobilization in addition to the media activities. All mobile (nomadic and seasonal) and cross bored population has been considered in micro planning. A media orientation workshop was arranged for the prominent health journalists in Q4 of 2011. Meetings with Parliamentarians from High Risk Districts and who exhibited their active support in form of District and Union Council level inaugurations
Religious leader seminars and all parties conference involving leadership of all prominent political parties were held in Pishin and Killah-Abdullah. Only in January –Feb campaign 344 Community meetings, 127 Madrissa/School Sessions, 435 Mosque announcements and 53 UC level inaugurations were held by Communication staff in the HRUCs of HRDs. Two high risk UCs in the high risk districts of Quetta Block are being source out to PPHI from the next round.
The province has the plan to increasing the number of technical supporting staff in HRDs to improve the campaign preparations, piloting outsourcing of PEI campaigns to local NGOs in 4 UCs in High risk districts, completion of the establishment of Polio Control Room at Provincial and district level, media engagement, and more Involvement of parliamentarians, religious & political leaders. Details of the action plan for the next six months are available at annex----.
Federal Administrative Tribal Areas (FATA)
Secretary Administration & Coordination
FATA has reported 59 polio cases with large number from Khyber Agency, followed by North Waziristan, FR Kohat & Lakkimarwat. Major challenges are insecurity and management in the accessible areas. Currently the Inaccessible areas remain 25% in Orakzai ranges to 2% in FR Peshawar. The state of inaccessibility at the end of December 2011 reaches to 8% contributing with major inaccessibility by Khyber Agency 30% followed by Orakzai Agency which is mentioned above. Management issues and lack of accountability do
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persist in the areas like Landikotal and Jamrud Tehsil of Khyber Agency and specially Miranshah of North Waziristan. Lack of Ownership at the agency health team is quiet evident. None of the Agency achieved the target level of 95% coverage, ranges from 82% in Kurram Agency to 54% in FR Bannu. All these factors contributed to the current prevailing situation of polio outbreak in 2011.
NEAP indicators in 2012 as compared to 2011 are improving like the UPEC Committee ranges from 63% in Dec to 82% in March. Civil Military Coordination Committee meetings held in each Agency by due time, 12 days before campaign. Secretary A&C and Commissioners monitored the activities in the field. Accountability started with transfer of Agency Surgeons in Mohmand Agency and Kurram Agency due to poor Performance. Besides this, involvement of Parliamentarians, wide range of social Mobilization activities were conducted which include School and College Health Sessions, local Jirgas of the tribal elders and community representative, games competition and local Polio Walks.
To strengthen and implement the A-NEAP in the FATA particularly to improve the access and quality of campaign, Health directorate consider the actions that include deployment of “Transit Teams” (Bara, Bajour, Mohmand) for mobile population and for IDP’s of Orakzai & South Waziristan, involvement of religious organization, addressing the refusal, enhancement of routine vaccination by celebrating Mother Child Health days, holding medical camps, further strengthening Cross Border Points vaccination points, holding a grand tribal elders & Ulema Jirga in April 2012, engaging Polio Ambassadors, further involvement of Teachers in UPEC and in teams during campaign – especially female teachers and transparency in making payments to the field staff.
Khyber Pakhtunkhwa Province
Secretary Health
The actions needed for implementation of the Augmented National Emergency Action Plan as reflected by the fact that two meetings of the Provincial Task Force by the Chief Secretary had already happened. UPECs have been re-notified in all of the 970 union councils and bank account numbers of 50% of vaccination team members. At the advocacy level new steps include decision of the Standing Committee on Health of Provincial Assembly to have polio eradication and immunization program as its permanent agenda and inclusion of the Chairman of Committee into the Task Force at the provincial level and Chairman of the District Development Advisory Committee (DDAC) as member of the District Polio Eradication Committees. It was also reported that mechanism of establishing provincial polio control room at the provincial level with close coordination with the district health teams had been in place since May last year and a deferment mechanism since June last year. In June 2011, seven districts had their SIAs delayed due to insufficient number of quality teams.
As a result of the above, there is remarkable change in the indicators of process and outcome. The proportion of the union councils having their meetings within time-line has increased from 61% in March 2011 to 100% in January 2012 (both months had NIDs); and percent of the UCs failing to achieve target (95%+ children vaccinated among checked by
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independent monitors with proof of finger-mark) dropped from 51% to 17% in the same period respectively in the persistent transmission districts. Partners’ support at the UC level in the highest risk UCs was acknowledged.
The province and FATA have close collaborative mechanisms for coordinated operations. For instance, in response to the first type-3 wild poliovirus in 2011, conducted SIADS campaigns in 4 districts. Ahead of the recent crisis of exodus from Bara, district commissioners alerted local teams to intensify transit point teams strategies and district teams to focus in the areas having IDPs camp and off-camp IDPs. A WHO consultant found 11 missed children in a sample of 104 children checked at households level, all of them were new arrivals (not missed by teams) but reflecting high volume of movement. There has been no isolation of wild poliovirus type-3 from AFP cases or sewage water sampling in 2011 and 2012 so far.
The report stressed that performance of the province may be considered keeping in view the fact that in 2011 alone; the highest number of casualties due to terrorist activities was in Khyber Pakhtunkhwa. In 512 different terrorist attacks there were 820 deaths and 1,684 injuries.
Key strategic focus in the near future envisaged includes: a) building capacity of the UPEC Chairman and how to facilitate them for performing their functions; b) speed and quality of the UC level data flow to the district especially the monitoring data in the pre-campaign implementation phase; and, c) DCOs’ training for clarifying the areas to be focused by them and sustain their engagement and enthusiasm until completion of polio eradication.
The Secretary requested that partners may intensify their support in all infected districts in 2011 and 2012 so far and urgently inform the provincial government their intended support by end-March 2012 so that provincial government’s mechanism for invoking the local resource generation may be invoked. Communications strategies were requested to address clustering of refusals and modified to create demand for vaccination.
Sindh Province
Secretary Health
The province reported 2 WPV-1 cases from 2 districts in 2012 (as of 21 March) compared to 6 WPV-1 cases from 5 districts in the same period of 2011. There were improvements in SIAs vaccination coverage (assessed by IM, MS, LQAS) in December 2011 and January 2012 campaigns compared to previous rounds but inconsistent at UCs level.
The province is maintaining the implementation of the strategies of A-NEAP : Governmental oversight and leadership improved since January 2012 but gaps in ownership and accountability persist, NEAP indicators showed improvement in campaign preparation and implementation but inconsistent, strategy to vaccinate migrant, nomads and children on-move prepared and approved, all milestones by January 2012 were achieved and the milestones by March 2012 are on track. The main significant innovative intervention is the
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partnership with EDHI Foundation. The pilot of the partnership implementation is in process in UC-4 of Gadap.
The major challenges are: sub-optimal coverage of children on-move and inefficient implementation of the strategy to vaccinate children of migrant and nomads, poor campaigns preparation and implementation in Gadap Town of Karachi is a significant risk to any achievement in the Sindh, outside the province and globally, lack of meaningful accountability at all levels, disconnect between the Deputy Commissioners and Health Departments and clustering of vaccinators in city areas, and frequent strike of contract base vaccinators and LHWs.
Punjab Province
Special Secretary Health
In 2011, Punjab province reported 9 polio cases in 8 districts in addition to detecting wild virus healthy nomad children & environmental sampling. So far in 2012 one polio case has been detected in district Jhang, and positive environmental samples have been found in 3 main urban centers of Punjab. The province participated in a rigorous International Surveillance Review in 2011 and the main conclusion was that “the AFP surveillance system in Punjab is sensitive enough to detect any poliovirus circulation …and there is minimal chance of missing transmission”. The province has demonstrated improvement in campaign quality over the past year. This has been demonstrated by decreasing proportion of monitored UC evaluated at less than 95% coverage by IM and more UCs “not rejected at 95%” for LQAS. All scheduled SIAs and timely case response immunization campaigns were implemented following the detection of wild polio virus.
At the Provincial level there is a functional Provincial Steering Committee lead by Chief Secretary that has held regular meetings during the past year. There is an operational Provincial Polio Control Room in the EPI Cell and in the district EDO (H) offices. There has also been increased involvement of parliamentarians as demonstrated by their participation in inaugurations and DPEC meetings. At District level DCOs are deeply involved in Supplementary Immunization Activities (SIAs). They are chairing District Polio Eradication Committee (DPEC) meetings (95% of all districts DCO chaired DPEC for March SNID). The DPEC meeting is conducted 10 days prior to every campaign (95% of all DPEC were conducted 10 days before the March SNID). During the DPEC the DCO delegates duties to the line departments. He also makes a careful review of the previous campaign and holds the district workers accountable for their work. The Chief Secretary has instructed all DCO to establish a PCR in their offices.
At the Union Council level the UPEC meetings are conducted 15 days prior to the campaign (96% of UC conducted timely UPEC meetings before March SNID). There is increasing leadership from MO and 94% took a leading role in the UPEC meetings. UC Secretary also participated in the UPEC; 82% co-chaired the UPEC meeting in March SNID. Team composition is meeting NEAP recommendations in that 95% or more of all UC have the
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recommended age, female composition, government accountable worker, and local member. Training is also conducted for vaccination teams one week prior to start of campaign.
Punjab has ensured nomadic settlements are identified and mapped on microplans for SIA and these are updated prior to every campaign. In January 2012 NID over 223,000 nomadic children were vaccinated. The Short Interval Additional Dose has been implemented in nomadic populations throughout Punjab in the latter half of the year after scheduled campaigns. There are over 2000 transit teams posted at transportation hubs throughout Punjab to vaccinate children during SIAs. In addition there have been strengthened social mobilization activities for nomadic populations.
The main challenges that Punjab faces are: Sustaining a motivated work force, Ensuring uniform coverage of +95% in every Union Council in every SIA, Achieving and maintaining above 80% routine EPI coverage in every Union Council of all districts, and Sustaining the highly sensitive AFP surveillance system to ensure no AFP case is missed, especially in urban areas that have isolated wild virus from environmental sources
The goal of Punjab is to interrupt polio virus circulation in 2012 through involving parliamentarians, ensuring strong intersectoral collaboration, and strengthening ownership of the PEI at the UC level in order to sustain high quality polio campaigns and improve routine EPI coverage. Punjab will also maintain the sensitive AFP surveillance system in order to guide vaccination activities. Lastly, the hard work and dedication of the vaccination teams who vaccinate millions of children during campaign days will continue to be firmly acknowledged.
Azad Jammu & Kashmir (AJK)
Director Health
Department of Health has introduced certain measures for the implementation of A- NEAP at different levels. At the provincial level, an officer of the status of Additional Secretary has been nominated as Focal Point at Prime Minister Secretariat, Provincial steering committee has been nominated and Polio Control Room has been established in office of the Provincial Program Manager EPI Muzaffarabad AJK.
At the district level, in all district of AJK focal point (Deputy Commissioner) has been nominated and functionalized since January/February round 2012, DPEC has been constituted and functionalized, Polio Control Room has been established in DC office as well as in the office of the District Health Offices. At the UC level, members of UPEC has been nominated and functionalized in all UCs of AJK, community has been mobilized through Mosques, Schools and campaign Inauguration, UC micro plans were review and revised where needed, 80 % to 95% mobile teams have local female and accountable workers, and 95-100% team members and supervisors were trained according to standardized module.
The way forward includes continuous monitoring and improving performance of NEAP indications.
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Gilgit Baltistan (GB)
Director Health
GB remained Polio free since, 1998 but the province was infected by importation from Swat in 2011.The DoH in collaboration with its partners like WHO, UNICEF responded timely and conducted almost 4-5 immunization campaigns in the infected district (Diamer) and adjacent areas of the bordering district Gilgit as well. Result further spread of virus was contained and no further Polio case has been reported since then.
The main issue in immunization is that of routine EPI in the province, and the department is trying to improve that with the assistance of its partners because this is the most important strategy in PEI and to maintain the polio free status in future. Another important strategy is that of AFP surveillance and due to non availability of fulltime ADHOs/DScs the same task is being looked after by the DHO. So there is a need to strengthen the surveillance system as well so that early detection of AFP cases could be ensured in the field
The UPEC meetings were held in all the districts, 96 % meetings were chaired by UCMO/Senior health official, 26 % co chaired by UC Secretary, 97 percent micro plans were reviewed while 96 percent teams had one local member and 86 percent teams had at least one female mobile team member in the province. The DCOs and EDO H attended these meetings. The campaign was conducted in all the UCs except few because of inaccessibility due to snow. The province achieved 96 % coverage based on finger marking.
Polio Eradication Initiative (PEI): Communication Strategies
Health Education Advisor / UNICEF Communications Officer
The presentation revisited last year’s TAG recommendations and progress made against them, followed by communication objectives and milestones of the augmented NEAP. The presentation further illustrated efforts taken by UNICEF in conjunction with the decisions of the National Communication Technical Committee for increased ownership and accountability through advocacy; social mobilization and community engagement through COMNet and local partnerships; strategic shift for more data driven communication supported by data reporting/M&E system (PRiME) and social research such as the recent KAP survey the findings of which were also shared. The presentation also highlighted the rebranding of the mass media campaign to redefine polio in the eyes of the public through introduction of a new concept, engagement of celebrities to ask as polio spokespersons and public-private partnerships for polio eradication.
Engaging High Risk Groups for Polio Eradication
High Risk Populations Coordinator
The presentation after giving brief background of NEAP Communication Objective for High Risk Groups (HRG) describes which are the HRG for polio and describes the current
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strategies in use to reach these HRGs and finally the proposed strategic shifts. The main HRGs identified were Pashtuns and other groups (Afghan Refugees, Nomadic Populations, Seasonal migrants, brick kiln workers and IDPs) labelled as addition HRGs were also discussed. The notion was supported by presenting facts & figures including social/ethnic fact, social and epidemiological data. Refusal for polio vaccination was identified as one of the major factors for being high risk group. The strategy to deal with the HRGs proposed in NEAP including; mobile populations and clusters of refusal families are mapped using social data, families on the move are mobilized for OPV, partners from the medical and religious community actively participate in social mobilization and families in inaccessible areas are mobilized and children vaccinated, was discussed in details progress so far was discussed and further steps to be taken were elaborated.
Polio Eradication and the Media
UNICEF Media Consultant
TAG presentation on media strategy was needed in the wake of negative media coverage of OPV. The presentation consisted of an overview of Pakistani media and a sketch of journalist professionals in Pakistan.
After developing this context it analysed the negative media coverage and its impact. A survey of print media coverage before and after the negative TV coverage (Feb. 5 th to March 12th) proved that the TV programs were isolated incidences and not a campaign. A plan of action was presented for media engagement and management, including capacity building of journalists on PEI/EPI, lobbying the case of polio with editorial decision makers, and most importantly creating demand for polio through enhanced social ownership. A multi-pronged, simultaneous strategy for mass media and its professionals was proposed to shift the focus from awareness to ownership.
Over all Questions asked to the TAG
The TAG was requested for guidance and advice on the following key areas of the Program:
1. Why did Pakistan experience a significant upsurge of cases in 2011?2. Does the augmented National Emergency Action Plan (a-NEAP) give Pakistan a firm
platform to achieve interruption of poliovirus transmission?3. What additional steps could be taken to usefully review the implementation of the
NEAP?4. What additional measures, including innovations, can be undertaken in the highest risk
districts?5. How can synergies be developed between polio and routine EPI?
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3. CONCLUSIONS & RECOMMENDATIONS
The TAG was alarmed with the fact that Pakistan and Nigeria keep on reporting high number of polio cases despite the fact that the world has reported the least number of polio cases over the last 4 months. The TAG also noted with concern that Pakistan (along with Nigeria and Afghanistan); is driving the global WPV transmission which is reinforced by the fact that about 50% of the global cases in 2012 are reported from Pakistan.
Transmission of WPV in Pakistan remains essentially linked to the transmission zones and the dramatic upsurge in 2011 is due to the fact that not enough children were immunized especially in the high risk areas. Transmission persists in these zones due to
Inability to access children for immunization due to conflict Continued problems with the quality of SIAs and hence with the consistent failure to
reach children with vaccine.
As well, an average polio cases in Pakistan is aged less than 2 years, under-immunized, from a Pashto speaking family, lives in a high risk district, an immediately neighbouring district, or a migrant/minority area.
It is obligatory to immunize more children more consistently with special focus on the high risk districts in the transmission zones. There are some signs of early marginal progress including massively enhanced oversight at the national and provincial level, engagement of the district administration and spotting of clear indicators and milestones. Enhanced oversight has resulted in improved process indicators in some of the high risk districts, marginal improvement in the coverage rates as measured by the LQAS, identification of the program blocks and measures to overcome, placement of the communication network and gradual improvement of access in FATA over the last 6 months.
Despite all the marginal improvements; there are some serious which keep Pakistan in danger of being the last reservoir of wild poliovirus. These include:
stall or slip on implementing the augmented A-NEAP failure to further improve quality in High Risk Districts especially failing districts
like Pishin and Gadap failure to take opportunities to reach children in FATA and neighbouring KP failure to create demand & acceptance in highest risk areas/groups esp. Pashtuns
Conclusion
The augmented NEAP provides a platform to take Pakistan to polio eradication; the challenge is to fully and consistently implement the NEAP.
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TAG Recommendations
The recommendations below should be taken in the context of the strategies and actions detailed in the National Emergency Action Plan.
Overarching Recommendations:
1.Engagement:
a. The commitment of the National & Provincial Governments to polio eradication could be made more explicit through the contribution of financial resources to the initiative
b. The national programme should deliberately plan to engage national and provincial parliamentarians, universities, professional bodies, community and religious organizations, and the private sector in a broad coalition of support for polio eradication
2.Maintaining Focus
a. Concentrate on the high risk districts & union councils in known transmission zones; without ignoring everywhere else.
b. Immediately scale up special operational and communication strategies for high risk groups (Pushtun strategy; Migrant & mobile populations strategy; Transit strategy - implementation plan by April)
c. Continued close monitoring of implementation indicators of the A-NEAP in HRDs (by DPECs, UPECs, Provincial and National Task Force)
3.Quality at the ground level
a. Indicators on the appropriateness and quality of vaccinator teams should be closely monitored at UC & district levels
b. The engagement, motivation, training, and support of vaccinators should be a priority especially in high risk areas
c. A system of recognition of high performing vaccinators should be instituted to recognize the contribution made by dedicated individuals
4.Improving information for action
a. Disaggregate indicator data to better define problems at different implementation levels.
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b. Develop a simple template to enable oversight committees to easily follow indicators of NEAP implementation
c. Special investigation process to define the operational & social reasons for missing children & to inform corrective plans (by May)
5.Innovating
a. Short interval rounds should be utilized for outbreak response and in the newly accessed areas/populations.
b. Special tactics should be used for newly accessed / special populations including expanded age groups (up to 15 years and higher) targeted with OPV and polio-plus delivery.
c. Partnerships for service delivery ('in sourcing') should be used for communications, immunization and monitoring
6.Improving communications
a. TAG endorsed the outline of the media action plan and urged its rapid roll out.
b. Communication strategies, including through ComNet, should be explicitly & closely linked to social data from KAP, IM and other sources.
c. Communications & operations teams must operate in conjunction in planning, implementation, & monitoring.
d. Social information from special investigations of the reasons for missing children should be used to inform actions in response.
7.Improving SIA monitoring
a. LQAS may be expanded in the high risk districts
b. Independent Monitoring (IM) process may be reviewed by the end of April and the guidelines may possibly be revised prior to May round
c. Partnerships on IM (pilot with Health Services Academy in April) in selected areas & expansion if experience is good
8.Synergies between PEI & EPI
a. Potential synergies should be explored between the PEI and EPI. These include: a) harmonization of polio and RI Microplans; b) awareness & demand creation through interpersonal & other communication channels used for polio; c)
WHO-EM/XXX/XXX/EPage 14
monitoring of the routine immunization sessions & vaccine availability during the polio activities monitoring including the community surveys.
9.SIA Strategy and schedule
a. The basic strategy may remain to conduct 4 NIDs and 4 SNIDs.
b.The scale / size of the SNIDs should been between 30-50% of the target population (aged < 5 years); with special focus on the transmission zones.
c. Trivalent OPV (tOPV) is to be used in 2 NIDs; bOPV in all other rounds.
d.Timings of the SIAs are to be flexible and should take account of seasonality and epidemiological developments.
e. More vaccination rounds should be conducted in the low transmission season.
f. Additional rounds must be considered in the key areas like persistent transmission zones, newly accessible populations
g.Case response and Mop-up vaccination campaign should continue outside transmission zones
10. Research
a. Seroprevalence surveys in known transmission zones to assess immunity in high risk populations
b. Operations research especially looking at the impact of innovations
c. Social and communications research especially in high risk groups
Additional Province Specific Recommendations
Balochistan
a. The geographical priority remains the Quetta Block with particular focus on districts Pishin which is failing despite repeated efforts and marginal improvements in Quetta and Killa Abdullah.
b. Operations:
i. Community & age appropriate vaccinators must be ensured
WHO-EM/XXX/XXX/EPage 15
ii. Permanent transit teams should be put in place at key transit points to cover the children on the move
iii. There must be a strong protection and guard against re-establishment of failed systems; that of the zonal supervisors
iv. Capacity of the newly appointed UC Medical officers should be built on the preparations, implementation and supervision of the SIAs
c. Minority, migrant and mobile communities must be given adequate focus during the vaccination and surveillance activities
Federally Administered Tribal Areas (FATA)
a. Geographical priorities are Khyber Agency and North Waziristan tribal agencies.
b. Permanent teams should be put in place at key transit points especially to and from Khyber & North Waziristan tribal agencies and Afghanistan
c. The program must be vigilant and ready to act to exploit the opportunities to vaccinate inaccessible populations e.g. large population displacements and newly accessible areas etc.
d. Mass / house to house vaccination should target expanded age groups in all newly accessed areas / populations (can go to < 15 years or whole population)
e. Short interval rounds should continue for the newly accessed areas / populations and among the displaced population (living in camps) coming from the areas which remained inaccessible for vaccination teams for long time
f. OPV campaigns should be coupled with other interventions to enhance the coverage and acceptance among the communities
g. High vaccination coverage must be ensured in all the accessible areas in FATA and FR areas
Khyber Pakhtunkhwa
a. Peshawar and Nowshera districts in the central part of the province are the current geographical Priority
b. Operations:
i. Appropriate and motivated vaccinators must be ensured to in the vaccination teams during the SIAs
ii. Partnerships with private sectors and the NGOs/CBOs should be used to support SIAs implementation
iii. Permanent teams should be put in place at key transit points especially those having large population movement with FATA
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c. Migrant / mobile populations including the displaced persons and refugees; must be given adequate focus during the SIAs and for surveillance activities. Any opportunities (even outside the SIAs) must be grabbed efficiently to vaccinate these populations
Sindh
a. All the high risk town (of Karachi) and the districts remain the geographical priority; particularly the Gaddap town Karachi which has been persistently failing despite repeated efforts.
b. Operations:
i. Community appropriate vaccinators must be ensured (particularly among the high risk ethnic and religious group) across the province with special focus in the high risk towns / districts especially in Gadap town
ii. Partnerships with private sectors and the NGOs/CBOs should be used to support SIAs implementation
iii. Permanent teams should be put in place at key transit points especially those having large population movement with FATA, Balochistan and KP
c. Migrant / mobile populations particularly the Pashto speaking populations and nomadic groups must be given adequate focus during the SIAs and for surveillance activities.
Punjab
a. High risk districts in the southern Punjab and urban slums in Lahore, Faisalabad and Rawalpindi are the current geographical priorities.
b. Permanent teams should be put in place at key transit points especially those having large population movement with FATA, Balochistan and KP.
c. Migrant / mobile populations particularly the Pashto speaking populations and nomadic groups must be given adequate focus during the SIAs and for surveillance activities.
Islamabad
a. UC and area level micro-plans should be immediately revised and there should be a mechanism regular updating of these plan before every SIA ensuring all the
WHO-EM/XXX/XXX/EPage 17
settlements are part of thee plans in order to be properly covered during each round
b. Permanent transit posts should be put in place to cover the children on the move especially those from KP, FATA.
c. All migrant / mobile populations especially the Pashto speaking communities must be give adequate focus to achieve high vaccination coverage during SIAs.
d. The slums in the peripheries of Islamabad (CDA and ICT) must be ensured to be part of the micro-plans and be covered well during the SIAs
AJK and Gilgit Baltistan
a. The overall priority is to maintain high level of population immunity through:
i. High quality SIAs
ii. Strong routine immunization program
b. Migrant / mobile populations particularly the Pashto speaking populations and nomadic groups must be given adequate focus during the SIAs
A sensitive AFP Surveillance must be ensured through regular review of the network and necessary revision / updating to make sure any introduction of wild poliovirus does not remain undetected.
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PROGRAMME
Wednesday, 21 March 2012
08:00 – 08:30 Registration08:30 – 08:40 Opening and introduction of participants 08:40 – 08:50 Welcome remarks 08:50 – 09:05 Address by the WHO Representative09:05 – 09:20 Global Polio Emergency Action Plan & Independent Monitoring Board (IMB) report
on Pakistan09:20 – 09:45 Augmenting national management and oversight of the NEAP
Followed by Discussion 09:45 – 10:00 Implementation status of the recommendations of the last TAG meeting 10:00 – 10:50 Epidemiological situation in Pakistan
DiscussionImplementation status of the NEAP by province 11:10 – 12:20 Baluchistan
Discussion12:20 – 13:30 Khyber Pakhtunkhwa
Discussion14:30 – 15:40 Sindh
Discussion15:40 – 16:50 Punjab
Discussion16:50 – 18:00 FATA
Discussion18:00 – 19:00 Internal TAG Meeting
Thursday, 22 March 2012Implementation status of the NEAP in non infected regions 08:30 – 09:00 AJK 09:00- 09:30 Gilgit Baltistan09:30- 10:30 Progress in implementing communications strategies
Discussion10:45 – 11:20 Short Interval additional dose – Impact and lessons learnt
Discussion11:20 – 12:00 Islamabad ( ICT & CDA)
Discussion12:00 – 12:40 Independent Monitoring (IM) & Lot Quality Assurance Sampling (LQAS) – connect
with the epidemiological situation, identification of gaps and improving the data credibilityDiscussion
WHO-EM/XXX/XXX/EPage 19
12:40 - 13:20 Progress in implementing the High Risk StrategyDiscussion
14:20 – 15:00 Creating an engaged mediaDiscussion
15:00 – 15:30 Cross Border CoordinationDiscussion
15:30 – 16:30 Internal TAG meeting16:30 – 18:00 Concluding session:
- Conclusions and recommendations - Concluding remarks by Madam Shahnaz Wazir Ali
WHO-EM/XXX/XXX/EPage 20
LIST OF PARTICIPANTS
MEMBERS OF THE TAG
Professor David M. SalisburyDirector of ImmunizationDepartment of Health510, Wellington House133-155, Waterloo Rd.,London SE1 8 UGUNITED KINGDOM
Dr Steve CochiActing Director, Global Immunization DivisionCenter for Global HealthCenters for Disease Control and Prevention1600 Clifton Road, NE—Mailstop A-04Atlanta, GA 30333USA
Dr Hyam Nicola Bashour Professor and chair, Department of Family and Community MedicineFaculty of MedicineDamascus UniversityP.O. Box 9241DamascusSYRIA
Dr Yu WangDirector of China CDCChinese Center for Disease Control and Prevention155 Changbai Road Changping DistrictBeijing 102206PEOPLES REPUBLIC OF CHINA
Dr Emmanuel Adebayo AbanidaDirector Disease Control & ImmunizationNational Primary Health Care Development AgencyPlot 681/682, Port-Harcourt Crescent off Gimbiya StreetArea 11, Garki Abuja, Federal Capital TerritoryNIGERIA Dr M. H. WahdanAFG & PAK TAG Member Alexandria
Unable to attend
WHO-EM/XXX/XXX/EPage 21
EGYPT
Dr. Olen KewMolecular Virology SectionCentres for Disease Control and PreventionAtlantaUSA
Dr Raymond Bruce AylwardRepresentative of Director General for Polio, Emergencies & Country Collaboration (PEC)WHO/HQ/PEA PECGenevaSWITZERLAND
Mr Chris MorryProgramme DirectorThe Communication InitiativeVictoria, British ColumbiaCANADA
Dr Ghulam Naqshband Haji Mir Khan Aram Dean of Herat Medical Faculty & Head of Pediatric Department;and Chairman of the National Certification CommitteeHeratAFGHANISTAN
NATIONAL TAG MEMBERSProfessor Tariq BhuttaChairman of NCCGovernment of PakistanPunjabPAKISTAN
Professor Tahir Masood AhmadProfessor of Paediatrics and Dean Children Hospital & The Institute of Child HealthLahorePAKISTAN
Professor Iqbal Ahmad MemonFellow American Board of Pediatrics, FRCP (C)Professor of Pediatrics, Dow University of Health Sciences KarachiPAKISTAN
GOVERNMENT OF PAKISTAN
WHO-EM/XXX/XXX/EPage 22
Ms Begum Shahnaz Wazir AliSpecial Assistant to Prime Minister on Social Sector and National Focal Person For Polio EradicationIslamabad
Mr Khushnood Akhtar LashariPrincipal Secretary to the Prime MinisterIslamabad
Mr Anisul Hasnain MusviSecretary, Ministry of Inter-Provincial Coordination (IPC-Division),Cabinet BlockIslamabad
Dr Azra Fazal PechuhoMember of the National Task Force on Polio Eradication in PakistanIslamabad
Dr Altaf BosanNational CoordinatorPrime Minister’s Polio Monitoring & CoordinationCellIslamabad
Dr Zahid LarikNational Programme Manager Expanded Programme on ImmunizationIslamabad
Mr. Mazhar Nisar SheikhHealth Education AdvisorPrime Minister’s Polio Monitoring & Coordination CellIslamabad
Mr. Salman SharifMolecular BiologistRegional Reference Laboratory (RRL)National Institute of HealthIslamabad
ISLAMABAD
Eng. Farkhand Iqbal
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Chairman (invited for concluding session only)Capital Development Authority (CDA)Islamabad
Mr. Tariq PeerzadaChief Commissioner (invited for concluding session only)Islamabad Capital Territory (ICT)Islamabad
Mr. Mansoor Ali KhanDeputy Director General CDA(Focal Person for Polio Eradication; CDA Islamabad)
Mr. Amer Ali Deputy Commissioner ICT(Focal Person for Polio Eradication; ICT Islamabad)
PUNJAB
Mr. Nasir Mahmood Khosa Chief Secretary (invited for concluding session only) Government of Punjab
Mr. Dawood Mohammad Bareach Special Secretary Health (coming for 2nd day only) Government of PunjabMinistry of Health
Dr Tanveer Ahmed ShaikDirector EPI Ministry of Health
SINDH
Mr Syed Hashim Raza ZaidiSecretary HealthMinistry of Health
Dr Mazhar Ali KhamisaniProject Director EPIMinistry of Health
KHYBER PAKHTUNKHWA
Mr. Muhammad IshfaqSecretary HealthMinistry of HealthDr Janbaz AfridiDeputy Director EPIMinistry of Health
WHO-EM/XXX/XXX/EPage 24
FATA
Mr. Abid MajeedSecretary Administration & CoordinationFATA
Dr Qasim AfridiDeputy Director EPIFATA
BALOCHISTAN
Mr. Asmat Ullah KakarSecretary HealthMinistry of Health
Dr M. Yousaf BizanjoProvincial EPI CoordinatorMinistry of Health
AZAD JAMMU & KASHMIR
Dr Shabbir Ahmed DarDirector Admin and CoordinationHealth Secretariat
Dr Adil HameedDirector CDC AJKMinistry of Health
GILGIT-BALTISTAN
Dr Iqbal RasoolProvincial Programme Officer-EPIHealth Secretariat
DONOR/PARTNER AGENCIES
UNICEF/HQ and CO
Mrs Karen AllenDeputy RepresentativeUNICEF – PakistanIslamabadPAKISTAN
Ms Sherine GuirguisCommunication Specialist - PolioNew York
WHO-EM/XXX/XXX/EPage 25
USA
Mr Jalaa AbdelwahabHealth Specialist, Health SectionNew York USA
Mr Dennis KingTeam Leader for Polio Program UNICEF – PakistanIslamabadPAKISTAN
Mr Rustam HaydarovCommunications Officer UNICEF – PakistanIslamabadPAKISTAN
Dr Shamsher KhanHigh Risk Populations Coordinator UNICEF – PakistanIslamabadPAKISTAN
Dr Altaf Ullah KhanMedia Consultant UNICEF – PakistanIslamabadPAKISTAN
CENTRES FOR DISEASE CONTROL AND PREVENTION
Dr Zundong YinAssociate Research FellowCDCBeijingCHINA
USAID
Ms Ellyn OgdenWorldwide Poliomyelitis Eradication CoordinatorWashington DCUSA
Aaron Schubert Deputy Director, HealthIslamabad
WHO-EM/XXX/XXX/EPage 26
PAKISTAN
ROTARY INTERNATIONAL
Mr Robert ScottChairman, International PolioPlus CommitteeRotary InternationalIllinois USAMr Aziz Memon Chairman, Polio-Plus NationalImmunization Committee for PakistanIslamabadPAKISTAN
BILL & MELINDA GATES FOUNDATION
Mr Michael Galway1
Senior Programme OfficerVaccine Deliver, Global HealthBill & Melinda Gates Foundation (BMGF)SeattleUSA
Dr Waqar Ajmal Representative Bill & Melinda Gates Foundation (BMGF)IslamabadPAKISTAN
WORLD BANK
Dr. Kumari Vinodhani Navaratne Task Team LeaderIslamabadPAKISTAN
Dr. Tayyeb MasudSenior Health SpecialistIslamabadPAKISTAN
EMBASSY OF JAPAN (GOVT. OF JAPAN)
Mr. Kaoru MagosakiCounselor and Head of the Economic and Development Section
1 Awaiting confirmation
WHO-EM/XXX/XXX/EPage 27
JICA
Mr Takatoshi NishikataCountry RepresentativeIslamabadPAKISTAN
IDB
Mr Birama B SidibeVice President, OperationsIslamic Development BankJeddah
HEART-FILE ORGANIZATION
Dr Sania NishtarPresident,HEART-FILE,IslamabadPAKISTAN
FELTP
Dr Rana Jawad AsgharResident AdvisorNICP Building National Institute of Health Islamabad
IMBMr Niall FryIndependent Monitoring BoardGlobal Polio Eradication InitiativeIslamabad PAKISTAN
WHO SECRETARIAT
WHO/EMRO
Dr Ezzeddine Mohsni,Coordinator Disease Elimination and EradicationDr Tahir P. Mir, Polio Regional AdvisorDr Ibrahim Kardany, Communication Consultant
WHO/HQ
Dr Hamid Jafari, Director of Global Polio Eradication InitiativeMr Chris Maher, Coordinator, Strategy Implementation and MonitoringMrs Sona Bari, Communication Officer
WHO-EM/XXX/XXX/EPage 28
Dr Naveed Sadozai, Medical Officer
WHO/PAKISTAN
Dr Guido Sabatinelli, WHO RepresentativeDr Elias Durry, Medical Officer/Senior Polio CoordinatorDr Ni’ma Abid, Medical Officer/ Team LeaderDr Zubair Mufti, Medical Officer
WHO/Provincial Team Leaders
Dr Deborah Bettels, Medical Officer/Provincial Team Leader, PunjabDr Salah Tumsah, Medical Officer/Provincial Team Leader, SindhDr Abdelwahab Al Anesi, Medical Officer/Provincial Team Leader, BalochistanDr Obaid-ul-Islam Butt, Medical Officer/Provincial Team Leader, KPKDr Sarfraz Afridi, Medical Officer/Provincial Team Leader, FATADr Tahir Malik (Islamabad)Dr Sardar Auranzgeb (Islamabad)Dr Saria Yunis (Islamabad)Dr Hadia Mirza (Islamabad)Dr Mariam Mallick (Islamabad)Mr Muzaffar Khan (Islamabad)Ms Meaza Tadesse (Islamabad)Mr Bilal Zaheer (Islamabad)Dr Hanqing He, STOP Team (Sindh)Ms Nima Abid (UNICEF, Islamabad)Mr SardarTalat, USAID (Islamabad)Dr Aslam Chaudhri, Bill & Melinda Gates Foundation (BMGF)Dr Ahmed Ali ShaikhBill & Melinda Gates Foundation (BMGF)Dr Imtiaz Ahmed, Bill & Melinda Gates Foundation (BMGF)Dr Masood Jogazai Bill & Melinda Gates Foundation (BMGF)Ms. Zarghuna Qaiyum Khan Assistant Economic Advisor, Japan EmbassyMr. Tsunenori Aoki, Deputy Director, JICA HQMs. Mitsuru Kayama, Senior Country Officer, JICA HQMs. Tomoyuki Nagita, JICA PakistanMr. Sohail Ahmad, JICA PakistanMrs Leslie Robert, Journalist, Science Magazine, USA