Pakistan: National Emergency Action Plan for Polio Eradication 2016–2017
The information presented in the document is based on the most recent and best available data at the time of publication. The EOC may update and, where necessary, modify the analysis and data in order to ensure the most current and accurate perspective is available to all.
Pakistan and Afghanistan remain the last nations in the world known to have wild poliovirus (WPV). In the past year, Pakistan took giants strides towards closing the immunity gap and interrupting transmission. This can be seen by a number of different indicators.
First, the number of confirmed wild poliovirus (WPV) cases in Pakistan has declined by 82%: from the 306 confirmed cases seen during the outbreak of 2014 to 54 cases in 2015, and it continues to decline in 2016 (Figure 1). With only 13 confirmed cases reported as of June 2016, this year represents a 59% decline in case count compared to a similar period in 2015 (Figure 2).
Second, the country observed a decrease in the proportion of environmental specimens confirmed for WPV: from 35% in 2014 to 20% in 2015, and now that proportion stands at 10% in the first half of 2016.
Third, Pakistan saw a reduction of circulating genetic clusters—from 16 in 2014 to eight in 2015—indicating reduced genetic diversity. Deeper analysis of genetic variations of viruses has shown that, for the first time ever, WPV1 genetic diversity fell during the 2015 high season. In previous years it had risen, sometimes sharply, as the high season progressed. Now, as of June 2016, only three clusters were identified.
Fourth, the proportion of non-polio acute accid paralysis (NPAFP) cases in children between 6 months and ve years of age who reported as ‘zero’-OPV dose has declined from 24% in 2014, to 4% in 2015, and now 2% as of June 2016.
This progress was achieved through dogged pursuit of a one-month, one-bOPV campaign strategy throughout the low season. At the heart of Pakistan’s vaccination efforts was a dedicated and uncompromising focus on improved microplanning and aggressive same-day follow-up of recorded missed children. Improving the performance of frontline workers (FLWs) was a cornerstone of last year’s performance improvement plan, with noticeable impact to morale and motivation. Over the course of the low season, the programme reduced the proportion of “no teams” among recorded missed children in third-party post-campaign monitoring: from a peak of 52% in the November NID, to 18% in the May NID. This can be partly attributed to the diligent effort of many to improve the timeliness of payments to FLWs: over the course of the low season, 81% of districts paid their FLWs within one month of the start of the campaign.
The major paradigm shifts in the 2015 - 2016 NEAP from “coverage” to “no missed children” has driven programme operations with very encouraging results. The proportion of recorded missed children remaining unvaccinated at the end of each campaign was between 3% and 4% throughout 2016, decreasing from approximately 7% over a similar period last year (Figure 3). Except for the October SNID and May NID, the quality of the campaigns at the national level (as measured by third-party independent monitoring) has remained above the NEAP target of >90% (Figure 4). However, performance varied from province to province: Punjab met the NEAP target in all nine campaigns, Khyber Pakhtunkhwa and FATA in eight of nine campaigns, Sindh in seven of nine campaigns, and Balochistan in four of nine campaigns (Figure 4).
Additionally, in the high-risk Union Councils (UCs) of the most important districts, the implementation of a Community-Based Vaccination (CBV) strategy has provided the programme with an edge when it comes to delivering high-quality vaccinations in areas of most concern. As of the end of May 2016, there were 10,995 Community Health Workers vaccinating children in 472 Union Councils. The result has been an increase in the overall quality of campaigns to levels that were unprecedented in these Union Councils. This is evident in the trend of performance improvement observed in lot quality assurance sampling (LQAS) results from high-risk UCs (Figures 5 and 6).
In our efforts to use every tool available to nudge up immunity levels and stop persistent transmission in the core reservoirs, the programme carried out an aggressive combined bOPV/IPV campaign. Over the course of the low season, 1.2 million children between 4 months and 23 months received IPV vaccines, with 1.7 million children under 5 years of age receiving bOPV at the same time. Almost all IPV vaccines delivered to Pakistan for SIAs and routine immunisation have been—and are being—used. As measured by LQAS, the proportion of Union Councils in the core reservoirs obtaining an estimated coverage of 80% or more reached 100% in Khyber agency, 85% in Peshawar, 70% in Quetta Block and 51% in Karachi.
The programme has recognised the importance of reaching and vaccinating children in transit during SIAs, as well as reaching and vaccinating children in highly mobile migratory, nomadic or internally displaced populations. From January to April 2016, a total of 9.4 million children were vaccinated at Permanent Transit Points (PTPs). The proportion of ‘zero’-OPV dose children vaccinated in April and May was 0.8%.
The programme has made tremendous progress in ensuring careful monitoring of performance. Tools used for pre-campaign, intra-campaign, and post-campaign monitoring (PCM) have been standardized. Post campaign LQAS monitoring has expanded with the number of UCs assessed each round, which increased from 265 in January 2015 to 536 in January 2016. Equally important, pre- and intra-campaign monitoring has been expanded with the provision of real-time data to provinces and districts so course correction can be taken even before the completion of the campaign in question.
Underpinning all programmatic activity has been sustained Government commitment and oversight at every level. The Prime Minister’s continued direct oversight and active involvement through the National Task Force (NTF) and the Prime Minister’s Focus Group (PMFG) allowed the programme to heighten oversight and encourage accountability everywhere. Key oversight bodies are functioning well with strong leadership from senior Government Of cials and Ministers. Divisional Task Forces have emerged as crucial for oversight in key areas. Through the implementation of an Accountability and Performance Management Framework, the Government and its partners have ensured that “accountability at all levels” becomes a guiding principle throughout the programme. This has resulted in the rewarding of good performance and, where necessary, the active removal of underperforming senior governmental or partnership staff from positions of authority.
Yet despite these efforts, the virus remains in a few areas—speci cally, the core reservoirs that have sustained the infection for many years and periodically reseed the virus across the country.
In this National Emergency Action Plan (NEAP) for 2016 - 2017, the main objective is to stop transmission in the core reservoirs and maintain or increase population immunity against polio in the rest of the country. To achieve this, the programme has set up a multi-pronged strategy with a well-developed work plan to ensure all children are vaccinated and any circulating virus is detected quickly and responded to immediately.
In the NEAP 2016 - 2017, the programme will:
Conduct 5 NIDs and 4 SNIDs with remaining unvaccinated children <2% of recorded missed children that are not socially and geographically clustered, reaching 95% coverage by third- party post-campaign monitoring (PCM) and achieving a lot quality assurance sampling (LQAS) pass rate of ≥90%
Implement a combined bOPV/IPV campaign in Tier 1 districts and as many Tier 2 districts as possible, depending on IPV vaccine availability
Expand community-based vaccination (CBV) to 100% of Union Councils in Khyber, Peshawar, Quetta, Killa Abdullah, and Pishin, and ≥60% of the target population in Karachi
Focus on improving the quality of campaigns in Union Councils using mobile team strategy in Tier 1, Tier 2, and Tier 3 districts, with the aim of achieving and surpassing all key performance indicators
Improve routine immunisation service delivery in Union Councils bene tting from CBV, as measured by an IPV-1 coverage rate for infants raised to ≥80%. This too will be subject to adequate vaccine availability
Boost surveillance sensitivity by shifting the focus of the surveillance system from measuring “targets achieved” to monitoring, reporting on, and minimizing “AFP cases unreported” and “missed transmission.” Through this recalibrated strategy, the programme will improve the capacity and reach of its surveillance system and effectively transform from a polio programme to a “surveillance system for eradication”
The goal is simple and ambitious: stop polio transmission in Pakistan by the end of 2016.
The next opportunity to make progress on that goal arrives on the 25 July 2016, when the rst campaign of the new NEAP will be held.