Evaluation of the Global Polio Eradication Initiative: Report on the Independent Evaluation of the Major Barriers to Interrupting Poliovirus Transmission in Afghanistan

This 49-page report details an independent, external evaluation of the Global Poliomyelitis Eradication Initiative (GPEI) that was carried out in response to a request from the Executive Board of the World Health Organization (WHO). The report is part of a package that consists of an Executive Summary and 5 full reports from 5 separate evaluation teams, focused on: Nigeria, India, Pakistan, Afghanistan, and the international spread of polio.

In brief, this evaluation finds that Afghanistan's polio eradication initiative (PEI) has achieved remarkable success in an increasingly challenging environment. For the majority of the Afghan population (84%), ongoing polio transmission has ceased. Indeed, the range of wild polio virus (WPV) reduced from 6 of 7 regions in 2000 to 4 regions in 2009; an independent evaluation in 2008 found that it is highly unlikely that polio cases are missed in the 4 regions assessed. Evaluators explain that these successes are due to "a very high level of political commitment, coordination by partners, and technical quality of PEI team work", including regular coordination with the PEI in Pakistan and maintenance of high quality and coverage of acute flaccid paralysis (AFP) surveillance, even in security-compromised areas.

Despite the contraction of the area of polio transmission, the annual number of confirmed cases is not diminishing, and appears to have remained static for the last 4 years: 18 cases reported during 2009 up until mid-August is consistent with the reported incidence in 2008. The reasons for this include non-health sector barriers, health system and service delivery barriers, community issues, and potential technical barriers. Conflict-related and customary movements of large populations between Pakistan and Afghanistan and between provinces within the country have the potential to introduce WPV into areas where it has long been absent.

The single most onerous barrier, according to evaluators, is a security situation that is unstable, unpredictable, and threatened by a range of armed factions. One communication-related implication of this situation is that there is "inadequate flexibility in accessing children safely. A number of examples of negotiation through different local intermediaries, including NGO [non-governmental organisation] district staff, hired negotiators, mullahs, and tribal elders, points to the success of discrete, local negotiations with anti-government elements through a flexible range of intermediaries. These examples also highlight that there is no single 'right way' to engage with communities in security-compromised areas."

"Direct provision of vaccination by uniformed personnel must be avoided and the neutrality of the PEI must be protected and promoted. High profile political endorsement of the polio eradication program may no longer be appropriate and, in some security-compromised provinces, may have a negative effect. All government associated initiatives, particularly successful ones, are potential targets for anti-government elements. Similarly, supplementary immunization activities (SIAs) should be de-linked from events that risk aligning the PEI with real or perceived political agendas; for example, UN [United Nations] Peace Day."

Furthermore, despite what appears to be high community awareness and acceptance, "polio vaccination is not perceived to be a high priority by most communities. Although male elders, mullahs, and teachers have been engaged to mobilise communities, greater efforts are needed to engage with individual male household heads to improve coverage of birth dose OPV and to ensure that mothers make all their children, including newborns, sleeping and sick children, available for SIAs. Excellent innovative strategies have been developed to mobilise women, however, their application may be confined to narrow geographic areas."

Health systems and technical barriers to polio eradication are explored in detail within the report as well.

A series of recommendations, with delineation of the organisation primarily responsible for each, is offered in the document. These include detailed short-term/immediate, medium-term, and longer-term suggestions related to:

• Promoting/maintaining the neutrality of the polio programme - e.g. "While ISAF [International Security Assistance Force] is a key stakeholder in some provinces/districts and should participate in planning and review meetings, continue to give careful consideration to the nature of their role in actual service delivery. Uniformed soldiers directly providing health services in security-compromised areas may fuel local suspicions that activities such as immunization are part of the ISAF/UN."
• Devolving responsibility for detailed district-by-district, cluster-by-cluster planning of Sub-National Immunisation Days (SNIDs), with flexible dates and flexible local approaches to achieving access to communities.
• Strengthening programme management - for example, by involving private practitioners and non-health service providers in both routine Expanded Programme on Immunisation (EPI) and SIAs, involving a broader range of stakeholders to enable adequate supervision and monitoring and evaluation (M&E), and developing communication strategies to improve the retention rate of routine immunisation cards.
• Adjusting the strategy of the polio programme from regular, frequent NIDs to focused SNIDs in high-risk areas (although "the implementation of this recommendation would need to proceed with the utmost caution..." to avoid re-introduction of WPV transmission). A few of the specific communication-related suggestions include:
  • "Continue to pilot and evaluate innovative methods of community mobilisation, such as 'women's courtyards', district and sub-district level volley-ball, football and cricket games, and cluster jirgas of community elders while recognising that such strategies may only be acceptable within relatively narrow geographic areas."
  • Work to engage individual male heads of households in efforts to mobilise community support for SIAs. "Consider piloting group education sessions in different regions for 'expectant fathers' either at health facilities or traditional meeting places, such as mosques. A key message is the importance of the birth dose of OPV [oral polio vaccine] (and HBV [Hepatitis B vaccine]), but could be combined with other important messages related to maternal and newborn health, such as early warning signs of labour and pregnancy complications, nutrition, and neonatal tetanus prevention."
• Increasing base level of immunity in children through strengthened routine EPI services.
• Conducting operational research to clarify the following issues: polio infection in children with high number of OPV doses; possible infection of some children by older children or adults returning from Pakistan; and high male:female ratio of reported AFP cases.
• Maintaining the high quality of AFP surveillance and strengthening the quality of the review of "inadequate" AFP cases. This could be achieved by ensuring in-person review by members of the Expert Review Committee (ERC) and/or strengthening the capacity of AFP focal points to collect sufficient clinical information for the ERC to make a firm diagnosis (e.g. through videos of clinical examinations and/or access to medical investigations and imaging). Lessons learned from individual cases about how to improve early detection should be shared with all surveillance system stakeholders.