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Polio Eradication Initiative Pakistan
Meeting of the Independent Monitoring Board for GPEI; 7th May 2013
Outline
• Current Situation
• Supplementary Immunization Activities
• Surveillance for Polioviruses
Current Situation
02468
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Jan
Feb
Mar
Apr
May
Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
Months / Years
NSL3 NSL1
NID SNID
Virus Type
Vaccine Type
C
ases
(n
)
NSL1 & NSL3
mOPV1 TrivalentmOPV3 Bivalent
2011 2012
Confirmed Polio Cases By Poliovirus Type, 2011-2013*
2013
* Data source AFP 25/04/2013
Comparison of polio cases by province/region 2011 & 2013*
Region/ Province
No. of polio cases Decline in 2012 as
compared to 2011 %
Last polio case2011 2012 2013
BALOCHISTAN 73 4 - 95% 02-Oct-12FATA 59 20 - 66% 10-Nov-12SINDH 33 4 2 88% 15-Mar-13
K.PAKHTUNKHWA 23 27 3 +17% 12-Feb-13
PUNJAB 9 2 1 78% 07-Feb-13
G.BALTISTAN 1 1 0 0% 11-Aug-12PAKISTAN 198 58 6 71% 15-Mar-13
* Data source AFP 25/04/2013
Polio cases 2012 – 2013*
P1+P3 = 1
P3 = 2P1 = 55
Total no. of infected districts = 28
Last WPV3 case: 18th April 2012
Last WPV3 positive Env. Sample: 7th Oct. 2010
PROVINCE
Wild POLIO CASES
n ONSET OF LAST CASE
KP 3 12-Feb-13
PUNJAB 1 7-Feb-13
SINDH 2 22-Mar-13
PAKISTAN 6 22-Mar-13
P1 = 06
Total no. of infected districts = 06
PROVINCEWild POLIO CASES
n ONSET OF LAST CASE
KP 27 30-Nov-12FATA 20 03-Nov-12BALOCHISTAN 4 02-Oct-12SINDH 4 09-Sep-12GBALTISTAN 1 06-Aug-12PUNJAB 2 21-May-12Pakistan 58 30-Nov-12
Cases randomly placed in districts Provincial BoundaryDistricts Boundary * Data source AFP 03/04/2013
2012 2013
cVDPV cases (2)
cVDPV cases (16)
Environmental Surveillance, Pakistan
Data as of 30-04-2013
Balochistan Khyber Pakhtunkhwa
Punjab Sindh
Environmental Surveillance by Province
Data as of 30-04-2013
SUMMARYTotal Sites = 23Total Samples Collected (2011-2012-2013) = 530Total Samples with results available = 513
Total samples positive for Wild PV (2011-2012-2013) = 237 (136+88+13) (WPV1= 237)Scheduled sampling, sample not collected
Wild poliovirus type 1 (WPV1)Wild poliovirus type 3 (WPV3)
Mixture WPV1 & WPV3
Under process
No sampling scheduled
No WPV Isolated
X
Summary Environmental Surveillance- Pakistan
• Program was set to fully utilize the low season– Consultative Workshop (Nov. 2012) - Gov/WHO/UNICEF
with focus on reservoirs (Op/Com action plan)– Revision of NEAP for 2013– Technical Expert Group Consultation (Dec. 2012) to review
the NEAP 2013– Closer collaboration with the Military on FATA– Prime Minster’s Task Force Meeting (Dec. 2012)
• Plans was seriously hampered by security situation– “New Reality” emerged– Security of front-line workers became paramount– The program put under serious & unprecedented threat
The Last Low Season ?
HeadlinesDec 18, 2012
Security Situational Analysis
• Attacks on Polio workers continue• 16 Killed since Jul. 2012 (14 since Dec. 2012)
– 11 polio workers and 3 escorting security personnel• Series of threats to polio workers
– Written and verbal by unknown elements– Teams chased in the field
• Government’s investigations inconclusive so far– No one claimed responsibility
Steps Taken• Ensuring safety of polio workers
– Emergency Op. Guidelines developed– Security component included in all micro-plans; with op. &
comm. plans– Prov. Security Coordination Committees established
(Chaired by Home Secretary)– DCs/DCOs were tasked in assessing security situation and
provide necessary protection DPEC and UPEC to include active participation of Law Enforcement
Agencies
• Continue the campaigns with mitigation of security threats
• Partners support continues in SIAs monitoring & UC level support for HR UCs
Operating in Insecure Environment
Supplementary Immunization Activities (SIAs)
Prioritization of districts for low season SIAs (revised as of 30th Apr.)(Feb – Apr 2013)
Priority 1: Reservoirs/Core endemic areas: Central Khyber Pakhtunkhwa, FATA, High Risk Towns of Karachi, Quetta Block, Demographically Linked areas with the Reservoirs
Rest of the Country
* Partial (high Risk Populations / areas)
Priority 2: High Risk Districts Other than the Reservoirs: Parts of Northern Sindh, Southern Punjab, Southern Khyber Pakhtunkhwa
Priority 3: Other High Risk Areas: Infected Areas during last six months (outside reservoir and High Risk Belt)
**
**
**
*
ProvinceTarget population
Priority-1 Priority-2 Priority-3 Priority-4
AJK 690,428
BALOCHISTAN 718,845 282,660 133,301 1,149,235
FATA 1,305,151
GBALTISTAN 44,634 169,228
ISLAMABAD 232,454
KP 1,815,138 1,058,565 1,372,326 865,184
PUNJAB 3,193,607 3,240,943 276,075 9,281,813
SINDH 782,544 2,881,137 106,169 3,730,382
Grand Total 7,815,285 7,695,759 1,932,505 15,886,270
* *
*
* *
SIAs: Jan to Apr 2013Mar 4-6SNIDs(30% of the target)
* Partial (high Risk Populations / areas) Priority1 Priority2 Priority3 Priority4
Mar 25-27SIAs(23% of the target)
Jan 14-16SNIDs(38% of the target)
Jan 28-30SNIDs(35% of the target)
Feb 18-20SNIDs(48% of the target)
Apr 15-17NIDs
Apr 5-7SIAs(7% of the target)
Trend of children reached in Priority1 areas SIAs Dec 2012 – Mar 2013
Sindh KP
FATA Balochistan
Children reached Dec 2012 - Mar 2013 in Priority1%
chi
ldre
n re
ache
d%
chi
ldre
n re
ache
d
% c
hild
ren
reac
hed
% c
hild
ren
reac
hed
Dec SNIDs (1st round) Jan (1st round) Jan (2nd round) FebDec SIAs (2nd round) Mar (1st round) Mar (2nd round)
Priority-1 Priority-2
Priority-3 Priority-4
Number of SIAs conducted in 2013 (1st Jan to 31st Mar)
NIDs in April except north & south Waziristan and Gaddap Town
No. of SIAs by Quarter – FATAJan 2012 – Mar 2013
LQAS Results of Priority-1 DistrictsYear SIAs Punjab Sindh* KP FATA Balochistan Pakistan
2012
Oct (15-17)Total Lots n 7 5 13 9 7 41
Passed for 95% n 5 3 13 6 2 29% 71% 60% 100% 67% 29% 71%
Nov (18-20)Total Lots n 8 3 5 5 6 27
Passed for 95% n 8 3 4 2 2 19% 100% 100% 80% 40% 33% 70%
Dec (17-19)Total Lots n
LQAS could not be conductedPassed for 95% n%
2013
Jan (28-30)Total Lots n 6 3 18 10 - 37
Passed for 95% n 5 3 8 10 - 26% 83% 100% 44% 100% - 70%
Feb (18-20)Total Lots n 20 4 21 8 5 58
Passed for 95% n 19 4 11 8 0 42% 95% 100% 52% 100% 0% 72%
Mar (04-06)Total Lots n 16 3 15 15 6 55
Passed for 95% n 16 3 10 15 0 44% 100% 100% 67% 100% 0% 80%
Mar (25-27)Total Lots n 12 4 25 21 62
Passed for 95% n 11 4 13 15 43% 92% 100% 52% 71% - 69%
Apr (15-17)Total Lots n 11 3 44 17 10 79
Passed for 95% n 10 3 25 12 3 50% 91% 100% 57% 71% 30% 63%
*LQAS could not be conducted in Karachi since December, 2012
80% - 89% >90%<80%
*Bin Qasim polio case(Target: 44,000 children in 1 town)Round1: 11-13 FebRound2: 20-22 MarRound3: Could not be conducted
Jaffarabad VDPV case (Target: 0.7 million children in 4 districts)Round1: 11-13 MarRound2: 18-20 MarRound3: 1-3 Apr
Mianwali polio case (Target: 0.6 million children in 5 districts)Round1: 11-13 MarRound2: 18-20 MarRound3: 25-27 Mar
Bannu polio case (Target: 0.7 million children in 6 districts and 2 FRs)Round1: 18-20 FebRound2: 4-6 MarRound3: 11-13 Mar
Dadu polio case (Target: 1.7 million children in 7 districts)Round1: 15-17 AprilRound2: 29 April – 1 MayRound3: 15-17 May
District with WPV and VDPV
Mardan* polio case (Target: 1.7 million children in 4 districts) Round1: 25-27 FebRound2: 11-13 MarRound3: 25-27 MarRound4: 5-7 AprRound5: 15-17 Apr*Mardan is part of the central KP reservoir targeted with intensified SIA strategy
Malakand polio case (Target: 1.5 million children in 6 districts)Round1: 11-13 MarRound2: 18-20 MarRound3: 25-27 Mar
Multi-district Case Response Activities in 2013
Recorded Missed Children* Due to Refusals
*Remaining at the end of SIAs*Remaining at the end of SIAs
Major Obstacle: Peshawar in Khyber Pakhtunkhwa• Continued inconsistent performance in
some HR areas
• Insecurity and targeted attacks
• Management issues
• Pockets of refusals
Risks: Hyderabad, Gaddap, Quetta Block
• Hyderabad– Inconsistent performance due to weak management &
oversight– Some improvement recently– Intensified SIA strategy in Hyderabad division
• Gaddap– Continued insecurity, targeted attacks & threats– DCs providing leadership– security forces onboard
• Quetta Block– Ongoing management issues; including problems with
DDM– Continued inconsistent performance
^ Including AFP Cases pending for classification
Punjab Sindh KP FATA Balochistan AJK/ISB/GB Pakistan
Target
Routine Vaccination status€ of Non polio AFP cases aged 06-23 months 2011 to 2013*
0 DOSE 1 DOSE 2 DOSES 3 DOSES€ As per recall of parents
€As per recall of parents*Source AFP.rec: Data as of 25-04-2013€As per recall of parents*Source AFP.rec: Data as of 25-04-2013
Summary – SIAs• The momentum in 2012 is seriously shaken by
targeted attacks on polio workers– SIAs missed in critical areas– Quality of implemented SIAs not consistent in
priority-1 areas• Courageous stance by the Govt. partners and
frontline workers – to continue SIAs
• Missed children tracking also hampered due to insecurity– Pockets of refusals in KP and Balochistan
• North & South Waziristan remain un-reached
Way Forward – SIAs• Safety of polio workers – highest priority• Enhanced and Systematic implementation
missed children tracking mechanisms• Improving communication strategies to
mitigate the “new reality”• Bridging between PEI & RI for synergy• Strengthening civil-military partnership to
reach the un-reached
Surveillance for Polioviruses
0
50
100
150
200
250
300
350
400
450
500
550
600
650
700
750
800Ja
n
Mar
May Ju
l
Sep
Nov Jan
Mar
May Ju
l
Sep
Nov Jan
Mar
May Ju
l
Sep
Nov Jan
Mar
May Ju
l
Sep
Nov Jan
Mar
AFP Cases reporting by Month, 2009-2013*
Cas
es (
n)
@ Non-polio AFP rate of 2/100,000 children < 15 years
2010
*Afp.rec Data as of 25-04-2013
2012 20132009 2011
Target
Key Surveillance Indicators; 2011-2013*
* Afp.rec Data as of 25-04-2013
Non Polio AFP rate Up to Week No. 16 ended on 20 h April, 2013
Non Polio AFP Rate By Province/Regions, 2011-2013*
Target Non-Polio AFP Rate 2/ 100000 < 15 years of the age
0
1
2
3
4
5
6
7
8
9
10
11
Punjab Sindh Khyber-Pakhtoonkhaw
FATA Balochistan AJK Gilgit-Baltistan Islamabad Pakistan
No
n p
olio
AF
P c
as
es
/10
0,0
00
ch
ild
re
n <
15
ye
ars
2011 2012 2013
* Data source AFP 11/04/2013
Non Polio AFP rate Up to Week No.14 ended on 06h April, 2013
Percent AFP Cases with Adequate Specimens By Province/Regions, 2011-2013*
2000 children under 15 years of age
0.00 - 0.99
1 – 1.99
≥ 2
Population density
Non-Polio AFP Rate by District 2013* Percent AFP Cases with
Adequate Specimens, By District – 2013*
0% - 59 %60% - 79%
≥ 80 % No AFP Case reported
* Data source AFP 11/04/2013
Non Polio AFP rate Up to Week No.14 ended on 06h April, 2013
YearTotal No. of WPV
isolates(AFP + Environment)
Long Chain (orphan) WPV Isolates from Polio Cases
n %
2009 107 28 26
2010 223 24 11
2011 334 15 4
2012 146 10 7
2013 17 0 -
Long Chain (orphan) WPV Isolates (AFP & Environment) 2009-2013**
2011 (15)2010 (24)2009 (28)
2012 (10)
**Data Source Afp/Afp Lab: 25-04-2013
Environmental Surveillance Network
Province District No. of Sites
BALOCHISTAN QUETTA 3KP PESHAWAR 2
PUNJAB
FAISALABAD 2LAHORE 3MULTAN 3RAWALPINDI 1
SINDHHYDERABAD 1KARACHI 6SUKKUR 2
PAKISTAN 23
• 23 collection sites in 11 large cities/towns
• Most extensive globally• Covers all the provincial capitals
and regional hubs• Sampling sites selected
strategically, biased to towards detecting polio viruses
One site
Possible Reasons for decline in AFP reporting
• Intensified SIAs in 2012 & 2013 – Frequency and quality of active surveillance– Overall monitoring of the surveillance
• Inadequate Contribution of Health Department (ownership)– District surveillance Coordinators not fully
functional– More dependence on partners
• Security situation in FATA
Way Forward – Surveillance (1)
• NEAP addendum on AFP Surveillance– Defining indicators and performance tracking mechanisms
• Desk review of district and sub-district level performance
• Review, appropriating and prioritization of the surveillance network
• Training of the Government and WHO Surveillance Staff
• Orientation of Healthcare Providers including informal ones and faith healers
• Engagement of medical and pediatric associations
• Further Expansion in environmental surveillance
• Innovative approaches: – Community based surveillance initiative– Strengthening active AFP search during SIAs– Incentives for reporting in selective areas– Utilizing technology like text messages (sms)
improving the reporting timeliness
Way Forward – Surveillance (2)
Summary – Surveillance• There is an overall drop in the number of
reported AFP cases– Key indicators remain above the global standards
• AFP surveillance is complimented by an extensive environmental surveillance network
• Long chain (orphan) viruses have decreased over the years indicating functional surveillance for polioviruses
Thank you!
More than ever