Polio Eradication Initiative Pakistan

Meeting of the Independent Monitoring Board for GPEI; 7th May 2013

Outline

• Current Situation

• Supplementary Immunization Activities

• Surveillance for Polioviruses

Current Situation

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Months / Years

NSL3 NSL1

NID SNID

Virus Type

Vaccine Type

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NSL1 & NSL3

mOPV1 TrivalentmOPV3 Bivalent

2011 2012

Confirmed Polio Cases By Poliovirus Type, 2011-2013*

2013

* Data source AFP 25/04/2013

Comparison of polio cases by province/region 2011 & 2013*

Region/ Province

No. of polio cases Decline in 2012 as

compared to 2011 %

Last polio case2011 2012 2013

BALOCHISTAN 73 4 - 95% 02-Oct-12FATA 59 20 - 66% 10-Nov-12SINDH 33 4 2 88% 15-Mar-13

K.PAKHTUNKHWA 23 27 3 +17% 12-Feb-13

PUNJAB 9 2 1 78% 07-Feb-13

G.BALTISTAN 1 1 0 0% 11-Aug-12PAKISTAN 198 58 6 71% 15-Mar-13

* Data source AFP 25/04/2013

Polio cases 2012 – 2013*

P1+P3 = 1

P3 = 2P1 = 55

Total no. of infected districts = 28

Last WPV3 case: 18th April 2012

Last WPV3 positive Env. Sample: 7th Oct. 2010

PROVINCE

Wild POLIO CASES

n ONSET OF LAST CASE

KP 3 12-Feb-13

PUNJAB 1 7-Feb-13

SINDH 2 22-Mar-13

PAKISTAN 6 22-Mar-13

P1 = 06

Total no. of infected districts = 06

PROVINCEWild POLIO CASES

n ONSET OF LAST CASE

KP 27 30-Nov-12FATA 20 03-Nov-12BALOCHISTAN 4 02-Oct-12SINDH 4 09-Sep-12GBALTISTAN 1 06-Aug-12PUNJAB 2 21-May-12Pakistan 58 30-Nov-12

Cases randomly placed in districts Provincial BoundaryDistricts Boundary * Data source AFP 03/04/2013

2012 2013

cVDPV cases (2)

cVDPV cases (16)

Environmental Surveillance, Pakistan

Data as of 30-04-2013

Balochistan Khyber Pakhtunkhwa

Punjab Sindh

Environmental Surveillance by Province

Data as of 30-04-2013

SUMMARYTotal Sites = 23Total Samples Collected (2011-2012-2013) = 530Total Samples with results available = 513

Total samples positive for Wild PV (2011-2012-2013) = 237 (136+88+13) (WPV1= 237)Scheduled sampling, sample not collected

Wild poliovirus type 1 (WPV1)Wild poliovirus type 3 (WPV3)

Mixture WPV1 & WPV3

Under process

No sampling scheduled

No WPV Isolated

X

Summary Environmental Surveillance- Pakistan

• Program was set to fully utilize the low season– Consultative Workshop (Nov. 2012) - Gov/WHO/UNICEF

with focus on reservoirs (Op/Com action plan)– Revision of NEAP for 2013– Technical Expert Group Consultation (Dec. 2012) to review

the NEAP 2013– Closer collaboration with the Military on FATA– Prime Minster’s Task Force Meeting (Dec. 2012)

• Plans was seriously hampered by security situation– “New Reality” emerged– Security of front-line workers became paramount– The program put under serious & unprecedented threat

The Last Low Season ?

HeadlinesDec 18, 2012

Security Situational Analysis

• Attacks on Polio workers continue• 16 Killed since Jul. 2012 (14 since Dec. 2012)

– 11 polio workers and 3 escorting security personnel• Series of threats to polio workers

– Written and verbal by unknown elements– Teams chased in the field

• Government’s investigations inconclusive so far– No one claimed responsibility

Steps Taken• Ensuring safety of polio workers

– Emergency Op. Guidelines developed– Security component included in all micro-plans; with op. &

comm. plans– Prov. Security Coordination Committees established

(Chaired by Home Secretary)– DCs/DCOs were tasked in assessing security situation and

provide necessary protection DPEC and UPEC to include active participation of Law Enforcement

Agencies

• Continue the campaigns with mitigation of security threats

• Partners support continues in SIAs monitoring & UC level support for HR UCs

Operating in Insecure Environment

Supplementary Immunization Activities (SIAs)

Prioritization of districts for low season SIAs (revised as of 30th Apr.)(Feb – Apr 2013)

Priority 1: Reservoirs/Core endemic areas: Central Khyber Pakhtunkhwa, FATA, High Risk Towns of Karachi, Quetta Block, Demographically Linked areas with the Reservoirs

Rest of the Country

* Partial (high Risk Populations / areas)

Priority 2: High Risk Districts Other than the Reservoirs: Parts of Northern Sindh, Southern Punjab, Southern Khyber Pakhtunkhwa

Priority 3: Other High Risk Areas: Infected Areas during last six months (outside reservoir and High Risk Belt)

**

**

**

*

ProvinceTarget population

Priority-1 Priority-2 Priority-3 Priority-4

AJK       690,428

BALOCHISTAN 718,845 282,660 133,301 1,149,235

FATA 1,305,151      

GBALTISTAN     44,634 169,228

ISLAMABAD   232,454    

KP 1,815,138 1,058,565 1,372,326 865,184

PUNJAB 3,193,607 3,240,943 276,075 9,281,813

SINDH 782,544 2,881,137 106,169 3,730,382

Grand Total 7,815,285 7,695,759 1,932,505 15,886,270

* *

*

* *

SIAs: Jan to Apr 2013Mar 4-6SNIDs(30% of the target)

* Partial (high Risk Populations / areas) Priority1 Priority2 Priority3 Priority4

Mar 25-27SIAs(23% of the target)

Jan 14-16SNIDs(38% of the target)

Jan 28-30SNIDs(35% of the target)

Feb 18-20SNIDs(48% of the target)

Apr 15-17NIDs

Apr 5-7SIAs(7% of the target)

Trend of children reached in Priority1 areas SIAs Dec 2012 – Mar 2013

Sindh KP

FATA Balochistan

Children reached Dec 2012 - Mar 2013 in Priority1%

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Dec SNIDs (1st round) Jan (1st round) Jan (2nd round) FebDec SIAs (2nd round) Mar (1st round) Mar (2nd round)

Priority-1 Priority-2

Priority-3 Priority-4

Number of SIAs conducted in 2013 (1st Jan to 31st Mar)

NIDs in April except north & south Waziristan and Gaddap Town

No. of SIAs by Quarter – FATAJan 2012 – Mar 2013

LQAS Results of Priority-1 DistrictsYear SIAs Punjab Sindh* KP FATA Balochistan Pakistan

2012

Oct (15-17)Total Lots n 7 5 13 9 7 41

Passed for 95% n 5 3 13 6 2 29% 71% 60% 100% 67% 29% 71%

Nov (18-20)Total Lots n 8 3 5 5 6 27

Passed for 95% n 8 3 4 2 2 19% 100% 100% 80% 40% 33% 70%

Dec (17-19)Total Lots n

LQAS could not be conductedPassed for 95% n%

2013

Jan (28-30)Total Lots n 6 3 18 10 - 37

Passed for 95% n 5 3 8 10 - 26% 83% 100% 44% 100% - 70%

Feb (18-20)Total Lots n 20 4 21 8 5 58

Passed for 95% n 19 4 11 8 0 42% 95% 100% 52% 100% 0% 72%

Mar (04-06)Total Lots n 16 3 15 15 6 55

Passed for 95% n 16 3 10 15 0 44% 100% 100% 67% 100% 0% 80%

Mar (25-27)Total Lots n 12 4 25 21   62

Passed for 95% n 11 4 13 15   43% 92% 100% 52% 71% - 69%

Apr (15-17)Total Lots n 11 3 44 17 10 79

Passed for 95% n 10 3 25 12 3 50% 91% 100% 57% 71% 30% 63%

*LQAS could not be conducted in Karachi since December, 2012

80% - 89% >90%<80%

*Bin Qasim polio case(Target: 44,000 children in 1 town)Round1: 11-13 FebRound2: 20-22 MarRound3: Could not be conducted

Jaffarabad VDPV case (Target: 0.7 million children in 4 districts)Round1: 11-13 MarRound2: 18-20 MarRound3: 1-3 Apr

Mianwali polio case (Target: 0.6 million children in 5 districts)Round1: 11-13 MarRound2: 18-20 MarRound3: 25-27 Mar

Bannu polio case (Target: 0.7 million children in 6 districts and 2 FRs)Round1: 18-20 FebRound2: 4-6 MarRound3: 11-13 Mar

Dadu polio case (Target: 1.7 million children in 7 districts)Round1: 15-17 AprilRound2: 29 April – 1 MayRound3: 15-17 May

District with WPV and VDPV

Mardan* polio case (Target: 1.7 million children in 4 districts) Round1: 25-27 FebRound2: 11-13 MarRound3: 25-27 MarRound4: 5-7 AprRound5: 15-17 Apr*Mardan is part of the central KP reservoir targeted with intensified SIA strategy

Malakand polio case (Target: 1.5 million children in 6 districts)Round1: 11-13 MarRound2: 18-20 MarRound3: 25-27 Mar

Multi-district Case Response Activities in 2013

Recorded Missed Children* Due to Refusals

*Remaining at the end of SIAs*Remaining at the end of SIAs

Major Obstacle: Peshawar in Khyber Pakhtunkhwa• Continued inconsistent performance in

some HR areas

• Insecurity and targeted attacks

• Management issues

• Pockets of refusals

Risks: Hyderabad, Gaddap, Quetta Block

• Hyderabad– Inconsistent performance due to weak management &

oversight– Some improvement recently– Intensified SIA strategy in Hyderabad division

• Gaddap– Continued insecurity, targeted attacks & threats– DCs providing leadership– security forces onboard

• Quetta Block– Ongoing management issues; including problems with

DDM– Continued inconsistent performance

^ Including AFP Cases pending for classification

Punjab Sindh KP FATA Balochistan AJK/ISB/GB Pakistan

Target

Routine Vaccination status€ of Non polio AFP cases aged 06-23 months 2011 to 2013*

0 DOSE 1 DOSE 2 DOSES 3 DOSES€ As per recall of parents

€As per recall of parents*Source AFP.rec: Data as of 25-04-2013€As per recall of parents*Source AFP.rec: Data as of 25-04-2013

Summary – SIAs• The momentum in 2012 is seriously shaken by

targeted attacks on polio workers– SIAs missed in critical areas– Quality of implemented SIAs not consistent in

priority-1 areas• Courageous stance by the Govt. partners and

frontline workers – to continue SIAs

• Missed children tracking also hampered due to insecurity– Pockets of refusals in KP and Balochistan

• North & South Waziristan remain un-reached

Way Forward – SIAs• Safety of polio workers – highest priority• Enhanced and Systematic implementation

missed children tracking mechanisms• Improving communication strategies to

mitigate the “new reality”• Bridging between PEI & RI for synergy• Strengthening civil-military partnership to

reach the un-reached

Surveillance for Polioviruses

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AFP Cases reporting by Month, 2009-2013*

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@ Non-polio AFP rate of 2/100,000 children < 15 years

2010

*Afp.rec Data as of 25-04-2013

2012 20132009 2011

Target

Key Surveillance Indicators; 2011-2013*

* Afp.rec Data as of 25-04-2013

Non Polio AFP rate Up to Week No. 16 ended on 20 h April, 2013

Non Polio AFP Rate By Province/Regions, 2011-2013*

Target Non-Polio AFP Rate 2/ 100000 < 15 years of the age

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Punjab Sindh Khyber-Pakhtoonkhaw

FATA Balochistan AJK Gilgit-Baltistan Islamabad Pakistan

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* Data source AFP 11/04/2013

Non Polio AFP rate Up to Week No.14 ended on 06h April, 2013

Percent AFP Cases with Adequate Specimens By Province/Regions, 2011-2013*

2000 children under 15 years of age

0.00 - 0.99

1 – 1.99

≥ 2

Population density

Non-Polio AFP Rate by District 2013* Percent AFP Cases with

Adequate Specimens, By District – 2013*

0% - 59 %60% - 79%

≥ 80 % No AFP Case reported

* Data source AFP 11/04/2013

Non Polio AFP rate Up to Week No.14 ended on 06h April, 2013

YearTotal No. of WPV

isolates(AFP + Environment)

Long Chain (orphan) WPV Isolates from Polio Cases

n %

2009 107 28 26

2010 223 24 11

2011 334 15 4

2012 146 10 7

2013 17 0 -

Long Chain (orphan) WPV Isolates (AFP & Environment) 2009-2013**

2011 (15)2010 (24)2009 (28)

2012 (10)

**Data Source Afp/Afp Lab: 25-04-2013

Environmental Surveillance Network

Province District No. of Sites

BALOCHISTAN QUETTA 3KP PESHAWAR 2

PUNJAB

FAISALABAD 2LAHORE 3MULTAN 3RAWALPINDI 1

SINDHHYDERABAD 1KARACHI 6SUKKUR 2

PAKISTAN 23

• 23 collection sites in 11 large cities/towns

• Most extensive globally• Covers all the provincial capitals

and regional hubs• Sampling sites selected

strategically, biased to towards detecting polio viruses

One site

Possible Reasons for decline in AFP reporting

• Intensified SIAs in 2012 & 2013 – Frequency and quality of active surveillance– Overall monitoring of the surveillance

• Inadequate Contribution of Health Department (ownership)– District surveillance Coordinators not fully

functional– More dependence on partners

• Security situation in FATA

Way Forward – Surveillance (1)

• NEAP addendum on AFP Surveillance– Defining indicators and performance tracking mechanisms

• Desk review of district and sub-district level performance

• Review, appropriating and prioritization of the surveillance network

• Training of the Government and WHO Surveillance Staff

• Orientation of Healthcare Providers including informal ones and faith healers

• Engagement of medical and pediatric associations

• Further Expansion in environmental surveillance

• Innovative approaches: – Community based surveillance initiative– Strengthening active AFP search during SIAs– Incentives for reporting in selective areas– Utilizing technology like text messages (sms)

improving the reporting timeliness

Way Forward – Surveillance (2)

Summary – Surveillance• There is an overall drop in the number of

reported AFP cases– Key indicators remain above the global standards

• AFP surveillance is complimented by an extensive environmental surveillance network

• Long chain (orphan) viruses have decreased over the years indicating functional surveillance for polioviruses

Thank you!

More than ever