feedback from the panel technical consultation on polio eradication in pakistan 15 th february 2015
TRANSCRIPT
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