In recent years, Pakistan has made considerable progress in reducing wild poliovirus type 1 (WPV1) transmission. Following an explosive outbreak in 2014, the Pakistan Polio Eradication Initiative (PEI) shifted to a government-led, ‘one team’ approach, aligning partner support within the multidisciplinary, multi-agency initiative to transform it into a truly data-driven programme. What followed was a steady and successful reduction in the number of children paralysed by polio – from 306 in 2014 to just 12 in 2018.
However, in 2019 the programme witnessed a significant spread of the virus. In 2019, 147 polio cases across all provinces were reported. In addition, circulating vaccine-derived poliovirus type 2 (cVDPV2) was detected in the country for the first time since 2016, with the number of children it has paralysed in 2019 were 22.
In light of this recent upsurge, the programme faces critical, often interrelated challenges. At a fundamental level, there is a lack of trust in vaccination and the polio eradication programme by families and communities in Pakistan, many of whom are impoverished and underserved. Lacking basic needs, they view frequent visits from polio eradication workers with suspicion. Because immunity against poliovirus is built up through repeated rounds, and since vaccination must be coordinated across the entire country to ensure no child is left unprotected, frequent campaigns can produce ‘polio fatigue’ among caregivers and frontline workers (FLWs) alike. Additionally, many caregivers don’t understand the risks of refusing the vaccine for their children, as the eradication effort’s success at reducing cases is misunderstood and poliovirus is mistakenly deemed a low risk. Mistrust in vaccination from polio campaigns, combined with misperceptions around the true risk of polio to Pakistan, have unfortunately provided fertile ground for misinformation and propaganda, which in recent years have also been fuelled by social media. In April 2019, propaganda against vaccines and the polio programme spread quickly and widely through social media in Peshawar, ultimately leading to the immediate interruption of the April National Immunisation Day (NID).
The eradication effort is further challenged by weakened essential immunisation (EI) services, poor water and sanitation (WASH), and a high prevalence of malnutrition. These contribute to a natural environment rife for virus circulation, which can be tied to the outbreak of cVDPV2 as well as lowered immunity to WPV1. Massive population movement within the country and across the border with Afghanistan continues to play a leading role in virus transmission. Added to these challenges, leadership transitions in government at all levels (federal, provincial, divisional, and districts) can also present difficulties, as a potential lack of unity on the importance of eradication cast polio immunisation as a partisan or political issue that can divide communities – and further vex the encounter on the doorstep between vaccinators and caregivers.
To face these challenges, the programme must re-strategize. A management review performed by McKinsey, alongside meetings convened by the Prime Minister, the President of Pakistan, and Global Polio Eradication Initiative (GPEI) advisory groups, have all helped to identify key transformations in the delivery of life-saving vaccines that, alongside improvements in core objectives and activities, will once again place Pakistan firmly on the path toward becoming polio-free.
This National Emergency Action Plan (NEAP) for Polio Eradication 2020 outlines bold strategies to ensure poliovirus transmission is interrupted. The Pakistan programme has aligned the 2020 NEAP with GPEI goals outlined in the Polio Endgame Strategy, 2019 – 2023, with a particular emphasis on building synergy with the Expanded Programme on Immunization (EPI) and Integrated Service Delivery (ISD).
Overall, the 2020 NEAP introduces a number of interventions, innovations and modifications to respond to both persistent challenges and new or unfolding epidemiological risks.
The following strategic decisions are offered as course corrections for the 2020 calendar year:
The Pakistan programme has shifted to a more comprehensive approach. The structure of the Emergency Operations Centre (EOC) reflects an increased focus on communications to address community resistance and generate vaccine demand. New Communication for Eradication (C4E) activities have been developed to improve trust in the PEI and in vaccines. Strategies have been devised to engage stakeholders and influencers, dispel misconceptions around vaccine safety and efficacy, and address the root causes for refusals.
The programme has added a dedicated area of work for building synergy with EPI to increase EI coverage across Pakistan, as well as building ISD capacities to address broader health needs through an expanded package of health, nutrition, and WASH services. These interventions will increase access to and utilisation of health services in communities affected by many types of deprivations.
Modifications to the schedule, structure and spacing of supplementary immunisation activities (SIAs) will address community concerns about repeated campaigns; relieve FLW fatigue; ensure sufficient time for campaign preparation, including social mobilisation and community engagement (CE); and improve implementation through concerted capacity building.
Specifically, there will be three (3) NIDs and three (3) Subnational Immunisation Days (SNIDs) in 2020.
Campaign duration for mobile teams (MT) will be a three-day campaign with a two-day catch-up (3+2). Campaign duration will remain the same for community-based vaccination (CBV) and special mobile team (SMT) areas, which is a five-day campaign with two-day catch-up (5+2). There will be no extended catch-up activities anywhere in the country.
Additionally, Pakistan’s SIA schedule has been aligned with the SIA schedule in Afghanistan, as coordination between these two countries is critical to interrupting poliovirus within and across the epidemiological block.
To refocus frontline efforts for maximum impact, a new district risk category has been introduced: super high-risk Union Councils (SHRUCs), those Union Councils (UCs) that have a dense and dynamic population where poliovirus circulates persistently. The programme has identified 40 SHRUCs in Tier 1 districts which will receive ’laser-focused’ interventions.
Additionally, the programme has refined the scope of CBV areas. To maximize vaccinator efficiency in SHRUCs and Tier 1 districts, the CBV model will be scaled down: the current 595 CBV UCs in Tier 1 and 2 will be reduced to 374 UCs in Tier 1 only. This will enable management teams to oversee the CBV workforce more efficiently and maintain focus on SHRUCs and core reservoir districts.
The 2020 NEAP also introduces transformations in structure, data, processes and human resources which have resulted from a comprehensive review of management and communication undertaken in 2019. The management review identified several challenges that included: human resource and accountability issues (multiple parallel lines of authority, overlaps and gaps in performance of roles, lack of clear ownership, evidence of overstaffing in some areas, ineffective performance management, lack of motivation); lack of critical thinking in campaign planning and execution (campaign processes follow a formulaic procedure rather than problem solving); inefficient data collection, reporting and use, as well as data misuse (used punitively to criticize lower management); and challenges in ensuring appropriate training delivery. The management review called for a revision of roles and responsibilities, organisational structures, operational processes, and data collection and use – and a realignment of the programme at all levels, particularly at the district and UC levels. All actions to address these challenges have been incorporated in this NEAP.