Report on the Meeting of the Technical Advisory Group on Poliomyelitis Eradication in Afghanistan and Pakistan

This 32-page World Health Organization (WHO) report emerges from a meeting of the Technical Advisory Group (TAG) on poliomyelitis eradication in Afghanistan and Pakistan, held in Cairo, Egypt, at the WHO Regional Office for the Eastern Mediterranean (EMRO), June 1-2 2009. The objectives of the meeting were to review progress towards polio eradication in the 2 countries (particularly during 2008), to discuss planned activities for 2009, and to make recommendations to address constraints facing the national programmes on their way to achieve the target. Participants included the delegations of Afghanistan and Pakistan and representatives of the core partners: the United States Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), the United Nations Children's Fund (UNICEF), WHO, and the Bill & Melinda Gates Foundation. Opening comments stressed the close relationship between the two countries epidemiologically and the importance of continuing and further strengthening joint and well-coordinated efforts between them.

A brief summary of the Pakistan epidemiological and polio communication situation follows:

There was a setback in polio eradication in Pakistan in 2008, with 117 cases reported from the 4 provinces, compared to the numbers reported in 2005, 2006, and 2007 (28 cases, 40 cases, and 32 cases, respectively). The main case load in 2008 was due to wild poliovirus type 1 (WPV1) outbreak in Punjab and wild poliovirus type 3 (WPV3) outbreaks in central North-West Frontier Province (NWFP)/Federally Administered Tribal Areas (FATA). Amongst the critical reasons for the outbreaks are: sub-optimal quality of campaign implementation in some districts, reduction in the number of campaigns in central and North Punjab, frequent population movement having inadequately immunised children from unsafe areas, and weak routine immunisation (RI) coverage. In 2009, to date, 17 confirmed cases have been reported. There are 2 distinct zones of transmission having ongoing circulation: central/northern NWFP/FATA and Karachi in Sindh province. The main reasons for continued circulation are: insecurity and extensive movement of internally displaced persons (IDPs); residual impact of the 2008 outbreak; and weak performance in key districts due to inadequate management.

According to UNICEF Pakistan, the majority of high-risk districts and agencies now have communications human resource capacity in place and have developed locally appropriate social mobilisation plans to address issues such as access, service delivery issues, refusals, lack of community demand for immunisation, and engagement. A multi-platform approach is being taken to address these communication challenges, including a focus on advocacy at all levels, a focus on high-risk districts and specific planning to address local challenges. Attention has been given to improving interpersonal communication (IPC) to improve awareness, as well as broad-based approaches to improve overall awareness. Particular emphasis has been placed on improving human resource capacity at the district level.

Data from knowledge, attitudes, and practices (KAP) studies are being used to guide planning in training as well as communications. For example, in Karachi, a key issue from the epidemiological data is the high number of cases within the Pashto communities, where there are closed communities due to inappropriate vaccinators and some refusals. Efforts have focused on mapping of these communities, working with the political parties, and recruiting local teams who can communicate with these communities with demonstrated impact. In South Waziristan, efforts have focused on overcoming access issues, refusals, and low awareness through the successful engagement of all local stakeholders. There has been some improvement in gaining access over the past year as well as reducing the number of refusals.

As UNICEF Pakistan reports, over the past year the polio eradication team has been working proactively with the media. As a result of one-to-one engagement, media trainings by respected members of the media, and the distribution of a weekly Polio Journal to more than 500 journalists, polio continues to make the headlines within a cluttered media environment. There has been a reduction in the number of uncontrolled or negative articles, and key issues - including lapses in immunisation campaign quality - are being highlighted through the media. As a result, polio continues to be on the health agenda and there is high political commitment at all levels. Ministers - including communications, information, and interior - are now actively participating in campaign activities, further generating increased media coverage. The national assembly and senate continue to raise questions about the programme and are interested in the actions being taken to overcome the challenges.

In the past year, the Prime Minister has inaugurated the campaign twice and launched the Prime Ministers Action Plan, which has reportedly fostered improved intersectoral collaboration, including with the media, Pakistan Telecommunications Authority, mobile phone operators, National Database & Registration Authority, and the Highway Motorway Police. The new initiatives, including the establishment of the National Polio Control Cell, are showing impact in terms of the number of children being immunised during every campaign. Mother and Child Weeks have been conducted in 29 districts, and the data show improvements in immunisation coverage as well as awareness about the importance of immunisation.

Overall, there has reportedly been demonstrated progress in the Pakistan communications programme, particularly in the area of using data to guide programme planning, especially at the district level. Given the ongoing service delivery issues, and based on the results of the recent training assessment, the team has worked to revise the training methodology and materials with the support of an independent training consultancy. This process was expected to be fully implemented by July 2009. Despite the interventions, refusals continue in some key districts. Efforts are ongoing to assess the reasons for refusals in order to develop appropriate strategies for overcoming this challenge in the districts where they continue to be clustered. Focus in the coming months will be on the implementation of the Prime Ministers Action plan to ensure more intersectoral engagement, particularly on the part of civil society organisations and the private sector.

A brief summary of the Afghanistan epidemiological and polio communication situation follows:

Polio virus circulation is localised in the southern part of Afghanistan; there is no evidence of transmission in rest of the country. A deteriorating security situation impedes access to the children in the southern region. In 2009, 6 polio cases are from southern region and one is from the eastern region. The main challenges include accessing children and safety for vaccinators in key insecure areas, maintaining high immunity in polio-free areas, and dealing with high population movement between polio-endemic areas in Afghanistan and Pakistan.

According to UNICEF Afghanistan, the polio communication strategy has been updated on the basis of the results of the January 2009 KAP study, as well as post-campaign assessment (PCA) data. Specifically: capacity gaps have been analysed and filled; communication data collection tools and indicators have been jointly reviewed and refined with WHO under the leadership of the Ministry of Public Health; data collection, management, and utilisation have been substantially improved; and advocacy efforts at district and sub-district levels have been strengthened to improve access to children under age 5 in security affected areas.

In more detail, the KAP study showed that though the general awareness about campaigns and the oral polio vaccine (OPV) was over 75%, there were critical knowledge gaps within the family regarding specific understanding of polio as a vaccine-preventable disease and the role of OPV in protecting susceptible under-5 children. The PCA coverage results for 2008 and early 2009 highlighted that 80% of 100,000 children missed during every campaign round in the endemic southern region (SR) were due to children being "absent" or "teams not reached".

Therefore, the communication strategy focuses on motivating and convincing families to keep children at home to receive OPV and on improving vaccinators' IPC skills to enable them to explain the importance of polio immunisation. The key strategies for the high-risk areas are community engagement and mobilisation at the village level and local-level advocacy. Community mobilisation is carried out by locally identified influencers - religious leaders, village elders, community health workers (CHW), and teachers from the same clusters - who work for one planning and orientation day, three days before the supplementary immunisation activity (SIA) campaign round, three days during the campaign, and one day to review results and challenges. The mobilisers engage with families before and during the SIA, preparing the ground for vaccinator teams, accompanying them, and participating in planning and daily review meetings during the SIAs to fine tune their day-to-day plans.

Data analysis showed clearly that young children and newborns that could not come to the door when vaccinators came were still being missed and women caregivers in the household were not in the communication loop. It was, therefore, decided in consultation with local-level partners to have a focused strategy to involve women in the polio campaigns and to ensure women-to-women communication. Women Courtyards are led by women CHWs, teachers, and influential women of the village. The courtyard leaders invite neighbourhood women to meet in the home environment of a respected village woman to meet and talk about the health of their children, including immunisation. The hope is that demand for polio and routine immunisation could be created through this enhanced knowledge and consultation - with a resulting increase in accountability at the family level for assuring that each child receives OPV drops during SIAs.

Radio, television, and print media channels are being used nationally to provide information about campaigns and to get editorial leverage using media briefings and the Polio Express newsletter. At the ground level, the media strategy relies on outreach to families through locally popular radio and TV channels. In order to meet the communication objectives on the service delivery side, the IPC component of the Training Module for vaccinators has been revised with updated messages and a focus on the requirement to give time to and engage with family members. Role plays and likely questions and answers have been included.

Concluding brief recommendations:

The TAG noted the progress made in both Pakistan and Afghanistan since its last meeting, particularly with regard to top-level government leadership, improvement in monitoring polio campaigns, and enhanced programme implementation in areas that had suffered importations, as well as in key reservoir areas. The TAG also noted the continued and strengthened cross-border collaboration between the two countries, as reflected by synchronised activities both for surveillance and campaigns, border meetings, immunisation at transit points, and the development of joint plans of action to overcome border issues.

The TAG reinforced the strategy decision of the October 2008 consultation to maintain 6 rounds of nationwide vaccination with trivalent OPV (tOPV), combined with supplementary national immunisation days (SNIDs) using monovalent OPVs (mOPVs), as appropriate, to interrupt viral circulation in reservoir areas. The TAG noted that, depending on the outcomes of a clinical trial that will be announced in the near future, it may be appropriate to replace up to 3 of the tOPV rounds with bivalent OPV (bOPV). Also, the TAG urged that cross-border collaboration should be further strengthened, that advances made in developing national and more localised communication activities should continue, and that both countries should continue to conduct annual internal and international reviews - establishing indicators to monitor and assess the impact of communication activities.