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
Confirmed Polio Cases By Poliovirus Type, 2011-2013*
NID SNID
42
40
38
36
34
32
30
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
Vaccine Type
mOPV1
mOPV3
* Data source AFP 25/04/2013
2013
2012
2011
Months / Years
Trivalent
Virus Type
Bivalent
NSL3
NSL1
NSL1 & NSL3
Comparison of polio cases by province/region
2011 & 2013*
No. of polio cases
Region/ Province
BALOCHISTAN
FATA
SINDH
K.PAKHTUNKHWA
PUNJAB
G.BALTISTAN
PAKISTAN
* Data source AFP 25/04/2013
2011
2012
2013
73
59
33
23
9
1
4
20
4
27
2
1
2
3
1
0
198
58
6
Decline in
2012 as
compared to
2011 %
95%
66%
88%
+17%
78%
0%
71%
Last polio
case
02-Oct-12
10-Nov-12
15-Mar-13
12-Feb-13
07-Feb-13
11-Aug-12
15-Mar-13
Polio cases 2012 – 2013*
2012
2013
Total no. of infected districts = 28
Total no. of infected districts = 06
P1 = 55
P3 = 2
P1 = 06
cVDPV cases (2)
P1+P3 = 1
cVDPV cases (16)
Wild POLIO CASES
PROVINCE
KP
FATA
BALOCHISTAN
SINDH
GBALTISTAN
PUNJAB
Pakistan
n
27
20
4
4
1
2
58
ONSET OF
LAST CASE
30-Nov-12
03-Nov-12
02-Oct-12
09-Sep-12
06-Aug-12
21-May-12
30-Nov-12
Last WPV3 case: 18th April 2012
Last WPV3 positive Env. Sample: 7th Oct. 2010
Cases randomly placed in districts
* Data source AFP 03/04/2013
Provincial Boundary
Districts Boundary
Wild POLIO CASES
PROVINCE
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
Environmental Surveillance, Pakistan
Data as of 30-04-2013
Environmental Surveillance by Province
Balochistan
Punjab
Khyber Pakhtunkhwa
Sindh
Data as of 30-04-2013
Summary Environmental Surveillance- Pakistan
X
Wild poliovirus type 1 (WPV1)
Wild poliovirus type 3 (WPV3)
Mixture WPV1 & WPV3
No WPV Isolated
Under process
Scheduled sampling, sample not collected
No sampling scheduled
SUMMARY
Total Sites = 23
Total Samples Collected (2011-2012-2013) = 530
Total Samples with results available = 513
Total samples positive for Wild PV (2011-2012-2013) =
237 (136+88+13)
(WPV1= 237)
The Last Low Season ?
• 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
Headlines
Dec 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
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)
*
Rest of the
Country
Province
*
*
* Partial (high Risk Populations / areas)
*
AJK
BALOCHISTAN
FATA
GBALTISTAN
ISLAMABAD
KP
PUNJAB
SINDH
Grand Total
*
Priority-1
718,845
1,305,151
1,815,138
3,193,607
782,544
7,815,285
Target population
Priority-2 Priority-3
282,660
133,301
Priority-4
690,428
1,149,235
44,634
169,228
232,454
1,058,565 1,372,326
865,184
3,240,943
276,075 9,281,813
2,881,137
106,169 3,730,382
7,695,759 1,932,505 15,886,270
SIAs: Jan to Apr 2013
Jan 14-16
SNIDs
(38% of the
target)
Jan 28-30
SNIDs
(35% of the
target)
*
Feb 18-20
SNIDs
Mar 4-6
SNIDs
(48% of the
target)
(30% of the
target)
* *
* *
Mar 25-27
SIAs
Apr 5-7
SIAs
(23% of the
target)
(7% of the
target)
* Partial (high Risk Populations / areas)
Priority1
Apr 15-17
NIDs
Priority2
Priority3
Priority4
Trend of children reached in Priority1 areas
SIAs Dec 2012 – Mar 2013
Children reached Dec 2012 - Mar 2013 in Priority1
KP
% children reached
% children reached
Sindh
Balochistan
% children reached
% children reached
FATA
Dec SNIDs (1st round)
Dec SIAs (2nd round)
Jan (1st round)
Jan (2nd round)
Feb
Mar (1st round)
Mar (2nd round)
Number of SIAs conducted in 2013 (1st Jan to 31st Mar)
Priority-1
Priority-2
Priority-3
Priority-4
NIDs in April except north & south
Waziristan and Gaddap Town
No. of SIAs by Quarter – FATA
Jan 2012 – Mar 2013
LQAS Results of Priority-1 Districts
Year
SIAs
Total Lots
Oct (15-17)
Passed for 95%
Total Lots
2012 Nov (18-20)
Passed for 95%
Total Lots
Dec (17-19)
Passed for 95%
Total Lots
Jan (28-30)
Passed for 95%
Total Lots
Feb (18-20)
Passed for 95%
Total Lots
2013 Mar (04-06)
Passed for 95%
Total Lots
Mar (25-27)
Passed for 95%
Total Lots
Apr (15-17)
Passed for 95%
n
n
%
n
n
%
n
n
%
n
n
%
n
n
%
n
n
%
n
n
%
n
n
%
Punjab
7
5
71%
8
8
100%
Sindh*
5
3
60%
3
3
100%
KP
13
13
100%
5
4
80%
FATA
9
6
67%
5
2
40%
Balochistan
7
2
29%
6
2
33%
Pakistan
41
29
71%
27
19
70%
LQAS could not be conducted
6
5
83%
20
19
95%
16
16
100%
12
11
92%
11
10
91%
3
3
100%
4
4
100%
3
3
100%
4
4
100%
3
3
100%
*LQAS could not be conducted in Karachi since
December, 2012
18
8
44%
21
11
52%
15
10
67%
25
13
52%
44
25
57%
<80%
10
10
100%
8
8
100%
15
15
100%
21
15
71%
17
12
71%
5
0
0%
6
0
0%
10
3
30%
80% - 89%
37
26
70%
58
42
72%
55
44
80%
62
43
69%
79
50
63%
>90%
Multi-district Case Response Activities in 2013
Mardan* polio case (Target: 1.7
million children in 4 districts)
Round1: 25-27 Feb
Round2: 11-13 Mar
Round3: 25-27 Mar
Round4: 5-7 Apr
Round5: 15-17 Apr
*Mardan is part of the central KP reservoir
targeted with intensified SIA strategy
Bannu polio case (Target: 0.7 million
children in 6 districts and 2 FRs)
Round1: 18-20 Feb
Round2: 4-6 Mar
Round3: 11-13 Mar
Malakand polio case (Target: 1.5 million
children in 6 districts)
Round1: 11-13 Mar
Round2: 18-20 Mar
Round3: 25-27 Mar
Mianwali polio case (Target: 0.6 million
children in 5 districts)
Round1: 11-13 Mar
Round2: 18-20 Mar
Round3: 25-27 Mar
Jaffarabad VDPV case (Target: 0.7
million children in 4 districts)
Round1: 11-13 Mar
Round2: 18-20 Mar
Round3: 1-3 Apr
Bin Qasim polio case(Target:
44,000 children in 1*town)
Round1: 11-13 Feb
Round2: 20-22 Mar
Round3: Could not be conducted
District with WPV and VDPV
Dadu polio case (Target: 1.7 million
children in 7 districts)
Round1: 15-17 April
Round2: 29 April – 1 May
Round3: 15-17 May
Recorded Missed Children* Due to Refusals
*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
Routine Vaccination status€ of Non polio AFP cases
aged 06-23 months 2011 to 2013*
Punjab
0 DOSE
€As per recall of parents
*Source AFP.rec: Data as of 25-04-2013
Sindh
KP
1 DOSE
€ As per recall of parents
2 DOSES
FATA
3 DOSES
Balochistan
AJK/ISB/GB
Pakistan
Target
^ Including AFP Cases pending for classification
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 priority1 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
AFP Cases reporting by Month, 2009-2013*
800
750
700
650
600
550
Cases (n)
500
450
400
350
300
250
200
150
100
50
2009
2010
2011
2012
Mar
Jan
Nov
Sep
Jul
May
Mar
Jan
Nov
Sep
Jul
May
Mar
Jan
Nov
Sep
Jul
May
Mar
Jan
Nov
Sep
Jul
May
Mar
Jan
0
2013
@ Non-polio AFP rate of 2/100,000 children < 15 years
*Afp.rec Data as of 25-04-2013
Key Surveillance Indicators; 2011-2013*
Non Polio AFP rate Up to Week No. 16 ended on 20 h April, 2013
* Afp.rec Data as of 25-04-2013
Target
Non Polio AFP Rate By Province/Regions, 2011-2013*
Non polio AFP cases/100,000 children <15 years
11
10
9
8
7
6
5
4
3
2
1
0
Punjab
Sindh
Khybe r Pak htoonk haw
Non Polio AFP rate Up to Week No.14 ended on 06h April, 2013
FATA
Balochis tan
2011
2012
AJK
Gilgit-Baltis tan
Is lam abad
Pak is tan
2013
Target Non-Polio AFP Rate 2/ 100000 < 15 years of the age
Percent AFP Cases with Adequate Specimens
By Province/Regions, 2011-2013*
100
AFP Cases with Adequate Specimens (%)
90
80
70
60
50
40
30
20
10
0
Punjab
* Data source AFP 11/04/2013
Sindh
KhyberPakhtoonkhaw
FA TA
2011
Balochistan
2012
2013
A JK
Gilgit-Baltistan
Islamabad
Pakistan
Non-Polio AFP Rate by District
2013*
Percent AFP Cases with Adequate
Specimens,
By District – 2013*
Population density
0.00 - 0.99
1 – 1.99
≥2
0% - 59 %
60% - 79%
≥ 80 %
No AFP Case reported
Non Polio AFP rate Up to Week No.14 ended on 06h April, 2013
* Data source AFP 11/04/2013
2000 children under 15 years of age
Long Chain (orphan) WPV Isolates (AFP & Environment)
2009-2013**
2009 (28)
2010 (24)
Year
2011 (15)
Total No. of WPV isolates
(AFP + Environment)
2012 (10)
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
**Data Source Afp/Afp Lab: 25-04-2013
Environmental Surveillance Network
• 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
Province
District
BALOCHISTAN
KP
PUNJAB
SINDH
One site
QUETTA
PESHAWAR
FAISALABAD
LAHORE
MULTAN
RAWALPINDI
HYDERABAD
KARACHI
SUKKUR
PAKISTAN
No. of Sites
3
2
2
3
3
1
1
6
2
23
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
Way Forward – Surveillance (2)
• 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
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
More than ever
Thank you!