Feedback from the PanelTechnical Consultation on

Polio Eradication in Pakistan

15th February 2015

Panel acknowledges the GoP

request for this Technical

Consultation, at a critical

juncture for Pakistan, half-way

through the all important low

season

Panel recognizes theoverall heightened commitment of the GoP to eradicate polio in 2015 & formation of PM’s Focus Group, Cabinet Committee on Immunization & Ministerial Committee

Panel also recognizes the meticulous planning process for the low transmission season and the Bhurban (II) Workshop for finalizing the plan and developing national

consensus

ContextGlobal WPV Cases during the last 6 months

Endemic country

Wild poliovirus type 1Afghanistan 04-Dec-14 8 10

Pakistan 17-Jan-15 28 83

EMR 17-Jan-15 36 93

Global 17-Jan-15 36 93

NA - Date of onset is prior to rolling 6-month period.

CountryOnset of

most recent case

Number of districts

Total WPV (All type1)

ContextMid-Term Review of Low Season Plan Implementation

• Is the low season plan being implemented as per envisaged alignment towards achieving the desired goals; what are the key gaps?

• Advise to improve reservoir specific plan implementation during the remaining low season?

• What would it take to make the reservoir specific plans contribute effectively towards a national success?

Findings / Conclusions

Overall ImpressionEpidemiology-1

• Pakistan has the highest number of annual polio cases during the last decade

• Known reservoirs remain the key culprits

• There was spill over with minimal viral establishment

WPV Cases 2014

• Outbreaks in Quetta Block & South KP are concerning

• Central Pakistan; a possible WPV hide-out

Overall ImpressionEpidemiology-2

Central Pakistan

WPV Cases, Balochistan 2014

WPV Cases, South KP 2014

Orphan virus

• Configuration of the Plan seems appropriate– Cornerstones, key approaches, SIAs schedule & reservoir

specific strategies well poised

• If implemented fully, the Plan has the capacity to stop WPV circulation by the end 2015

• Given the population dynamics, immediate Simultaneous & synchronized implementation by all geographical areas, is of utmost importance for success

Overall ImpressionThe Bhurban Plan

• Panel recognizes the establishment of the EOCs at the national & provincial levels – with overall improving program oversight &

accountability mechanisms• Panel also commends the steps taken towards

the key assumption of the plan that “all children will be reached everywhere in the country”

Overall ImpressionPlan Implementation Status

• However, the implementation status of reservoir plans was not presented in a way that the Panel would have liked (except FATA)– Would have been good to see concrete

implementation status against each key component of the plan

Overall ImpressionPlan Implementation Status

2014 Now

North Waziristan

South Waziristan

Khyber Agency (Bara)

Peshawar

Charsadda (Shabqadar)

Karachi (high risk)

Overall ImpressionAccess Situation in Key Areas with Security Challenges

Accessible partially accessibke Inaccessiblke

Overall ImpressionImplementation Status of the Key Elements of Low Season Plan

Punjab KP FATA Sindh Balochistan

Vaccinating everywhere(Security perspective)

Tracking of Chronically Missed Children

Monitoring

Accountability

Community Ownership/ Civil Society engagement

Quality & Morale of FLW

Polio Plus

Administering IPV on track /

implemented partial / in progress of track / not implemented

Province Specific FindingsPunjab – 1

• Panel recognizes the enhanced commitment from the highest level provincial leadership– Overall robust monitoring & accountability

• Panel commends:– the focus on routine immunization– Use of innovative approaches to reach maximum

children & monitoring

• There is persistent viral transmission in Lahore (environmental samples) indicating pockets of missed populations

• Segregated estimates of missed children among migrants/mobiles populations and for high risk communities were not shared in the presentation

Province Specific FindingsPunjab – 2

• Panel recognizes the commitment of the political leadership

• Opportunity to reach the NW populations was well grabbed through transit vaccination & targeted SIAs

• The initiative “Sehat ka Ittehad” provides a good platform for synchronized implementation with FATA

Province Specific FindingsKhyber Pakhtunkhwa - 1

• Information on tracking of missed children in key areas of Peshawar & South KP was not presented– Background data provided to the Panel indicates a good start to

the low season (in terms of reaching persistently missed children)

• Panel noted with concern that KPK is the only province with local WPV circulation that has not kicked off the IPV-OPV SIAs– Opportunity still there to vaccinate the NW & Bara IDPs

• Parts of Peshawar still face difficulties due to security– Four campaigns missed in some parts (target: 19000)

Province Specific FindingsKhyber Pakhtunkhwa – 2

• Polio remains in three tribal agencies & adjacent FR areas

• Panel commends the efforts for accessing persistently missed populations– Recent resumption of door to door

SIAs in SW & Hujra vaccination in NW & FR Bannu is encouraging, indeed

– >70,000 reached for the first time in more than 2 years’ time in SW

• Good insight of the team about the local issues and their mapping is acknowledged

Province Specific FindingsFATA - 1

• Panel noted with concern that Low Season Plan implementation has not kicked off in Khyber Agency (Bara and parts of Jamrud in particular)– Infection from Bara has spread to Jamrud tehsil– There is potential risk of spread of infection to

Bajour and Mohmand Agencies

Province Specific FindingsFATA - 2

• With ongoing WPV circulation, Karachi may become the most dangerous polio reservoir in the country with potential to amplify & export– Unless urgent steps are taken

• Program oversight / accountability seems to have started scaling up very recently

• FCVs / FCMs initiative in line with the Bhurban Plan, is encouraging– >64,000 vaccinated in areas previously

unreachedBut some areas are still not been vaccinated due to Security/Access

Province Specific FindingsKarachi-1

WPV cases – Sindh, 2014

Children still being missed in critical areas

Province Specific FindingsKarachi-2

Campaign # UCs Covered Target

Coverage Missed ChildrenSpot

Survey

LQAS

n % NA Refusal No. Lots

Pass % War-ning % Fail %

NID Jan 15 188 2,236,582 2,237,989 100% 17,337 9,686 90% 26 7

(27%)12

(46%)7

(27%)

NID Dec 14 188 2,211,218 2,178,795 99% 14,818 9,629 91% 17 6

(35%)6

(35%)5

(29%)

SIAD Nov 14 97 846,413 808,470 96% 8,795 5,912 92% 13 6

(46%)5

(38%)2

(15%)

SNID Nov 14 97 829,684 826,503 100% 6,996 5,053 91% 7 1

(14%)5

(71%)2

(29%)

• Enabling environment for all vaccinators still lacking– Operational & Security Plans not fully hand

in hand– Three SIAs missed since November 2014 in

parts of Karachi due to security related issues

Province Specific FindingsKarachi - 3

• A new outbreak; possibly intensifying– Kila Abdullah, the epicentre

• Balochistan has demonstrated the capacity to stop WPV transmission– Stopped twice

• Available data indicates pockets of missed children due to operational reasons & refusals

Province Specific FindingsQuetta Block

Recommendations

Timeline6 – 8 weeks from now

Early high season starts in late April

Panel Reiterates the Assumption of the Bhurban Plan that “All the

children everywhere are reachable during the low season”

This is the foundation

• The Plan has all the necessary ingredients; it needs proper implementation & tracking

• In the light of provincial presentations; Panel feels that the plan is not being meticulously followed up / tracked

Overarching RecommendationsStick to the Bhurban Plan

• Paradigm from now must be the “Chronically Missed Children”; not the ones reached

• Tracking through all possible sources– PTPs, health camps, AFP data monitoring

• Disaggregation UC by UC & House by house– Local plans should be developed to reach these children

between campaigns– Reason-wise (break down not available) recording &

tracking

• Include coverage of Zero dose children among the key performance indicators

Overarching Recommendations (cont.)

Chronically Missed Children

Quality

• Intra-campaign & post campaign monitoring, both are vital

• Intra-campaign monitoring to be immediately strengthened as per NEAP and Bhurban plan

• Maintain LQAS & out of house Survey as post campaign assessments– LQAS should be on a standardized and a randomized

approach– Start disaggregating the reasons & track

Overarching Recommendations (cont.)

Monitoring

• EOCs should establish a dashboard to review campaign performance, with a set of consistent performance indicators

• National guidelines on vaccination response to failed LQAS lots should be followed & results documented

Overarching Recommendations (cont.)

Monitoring

• Place frontline workers at the center of the eradication campaign– Particularly in high risk UCs

• Establish a retention, training & motivational plan for appropriate recruitment locally

• Implement a strategic, holistic communication campaign to elevate the status of frontline workers in the community

• local community volunteers (FCVs, FCMs, LHCWs)• Ensure timely payment to all vaccinators

– urgent thorough situational review & immediate fixation for late payments

Overarching Recommendations (cont.)

Quality of Vaccinators

• Area appropriate customized security plans should be put in place, that facilitate the operational plans– Covering implementation & monitoring –Coordinated & timely preparation– Better coordination between federal &

provincial level

Overarching Recommendations (cont.)

Security

• Assign permanent EOC coordinators in all provincial EOCs

• Enhance security coordination under the umbrella of EOC– One full time security forces/army representative

in EOC

Overarching Recommendations (cont.)

Accountability

• Urgent steps should be taken to ensure all the high risk / migrant communities are included in the UC micro-plans of Lahore & Rawalpindi

• The problem of language / culture in-appropriate teams must be overcome immediately

• Proper implementation of Mobile population strategy in the entire province, especially the south Punjab

• Continue efforts to improve routine EPI particularly in HRUCs

Recommendations, Punjab

• The initiative “ Sehat Ka Ittehad” should be utilized to ensure– Improving access and community trust– tracking of missed children due to all reasons (insecurity,

performance .. )– Stringent accountability for performance

• Missed children data tracking must be immediately streamlined & maintained

• IPV-OPV SIAs must immediately be implemented in Peshawar & Bannu– NW IDPs should get the IPV dose before returning– Bara IDPs before returning or during repatriation

Recommendations; KP

• Plans for conducting door to door SIAs in Bara and Jamrud should be implemented in letter and spirit– Khyber puts the entire central KP & FATA at risk

• House to house vaccination, in North Waziristan (areas with population) & FR Bannu

• Panel endorses the plan for vaccination during repatriation & emphasizes its proper implementation and monitoring

• The UAE – PAP payment mechanism for the front-line workers should be urgently streamlined

Recommendations, FATA

• The improving EOC should have political support to achieve accountability

• Security & communication plans should aim to produce enabling ground environment for the vaccinators– Operational, security & communication plans synchronization

• IPV-OPV SIAs to be implemented in the remaining high risk UCs

• Panel endorses the SIAs strategy for the eight super high risk UCs (Feb – Mar)– However, reaching the chronically missed children holds the key

– not just vaccinating the same kids

Recommendations, Karachi

Vaccination Status of AFP Cases (NP AFP aged 6-35 months)Karachi; 2010 – 2014

109 128 98 76

55

11 118

4

5

44

47

7

3 2 26

7

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010

2011

2012

2013

2014

Case

s (%

)

7 +0 DOSE 1-3 4 TO 6

• Good local initiatives (permanent polio teams); but there is need to provide better evidence of impact on access & coverage – Strengthen ground-up accountability

• Cross border coordination with southern Afghanistan team should be maintained ensure all communities are reached

• The high risk UCs / tehsils focus to be enhanced during rest of the low season

Recommendations, Balochistan

Central Pakistan

• There is urgent need to have a coordinated initiative to identify & fix the gaps in vaccination activities & surveillance– Panel endorses the suggestion for

coordination process

• Document progress from NOW

• EOC to evaluate progress in implementation of Bhurban Plan in 8 weeks

• Propose TAG evaluation of implementation in June

Recommendations, Evaluation

Twelve Weeks Left… .

The Bhurban Plan addresses all the hurdles; provided that it is

implemented fully

Thank You