GLOBAL POLIO ERADICATION INITIATIVE (GPEI)
STATUS REPORT
25 SEPTEMBER 2014
World Health Organization
Geneva, Switzerland
Rotary International
Evanston, Illinois USA
Centers for Disease Control and Prevention
Atlanta, Georgia USA
UNICEF
New York, New York USA
The boundaries and names shown and designations used on all maps in this document do not imply the expression of any opinion
whatsoever on the part of the Global Polio Eradication Initiative spearheading partners (the World Health Organization, Rotary
International, CDC or UNICEF) concerning the legal status of any country, territory, city or area or of its authorities, or concerning
the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there
may not yet be full agreement.
GPEI Partner Status Report - 25 September 2014
EXECUTIVE SUMMARY!
Since April 2014, Nigeria continues to have a low incidence of wild poliovirus type 1 (WPV1) cases; stopping all
WPV transmission in Africa in 2014 remains a possibility. More than 22 months have passed without detection of
wild poliovirus type 3 (WPV3) anywhere. The WPV1 outbreak in Syria (most recent case: 21 January) spread to
Iraq (most recent case: 7 April). The outbreak in Central Africa has persisted more than six months, with spread
from Cameroon to Equatorial Guinea, and the risk for further spread, as evidenced by cases in eastern Cameroon
and positive environmental sampling in Brazil linked to Equatorial Guinea. These events plus the spread from
Pakistan to Afghanistan in early 2014 led to the declaration of a Public Health Emergency of International
Concern on 5 May; recommendations were extended on 3 August. The WPV1 outbreak in the Horn of Africa has
continued, with the latest reported case occurring in August 2014 in Mudug, Somalia among pastoralist families.
The WPV1 outbreak in Pakistan centered in the Federally Administered Tribal Areas (FATA) is escalating rapidly;
vvaccination of displaced persons at transit points and within host communities has been scaled up immensely.
Surveillance performance indicators and/or genomic sequence analysis have provided evidence of lapses in
surveillance in most of these countries and many countries in proximity.
Afghanistan: Ten WPV1 cases have been reported to date in 2014. For the past year, polio cases occurred
primarily in the Eastern Region linked to importation from Pakistan. The occurrence in December 2013 and May
2014 of indigenous-lineage WPV1 cases in the Southern Region, after 20 months without detection revealed
continued surveillance gaps. Environmental surveillance recently began at selected sites in several cities and
WPV1 was detected for the first time in specimens taken in Kandahar and Nangarhar Provinces in July 2014.
Access to children has improved: the programme now has access to the Watapur District in Kunar after four years
of exclusion, and Helmand Province, closed to vaccination since March 2014, is once again conducting
supplemental immunization activities (SIAs). Inaccessibility again is a relatively small problem (0.55% of targeted
population of 8.9M) and primarily limited to the Eastern Region. Although relatively small in number, the
proportion of targeted children under 5 years of age missed because of refusals in the Southern Region continues
to be the highest globally. Social and cultural norms are a critical barrier, preventing vaccination of newborn, sick,
and sleeping children.
Pakistan: The outbreak of WPV1 and circulating vaccine-derived poliovirus type 2 (cVDPV2) in FATA has
continued to expand since the last report, with Pakistan having recorded 166 cases in 2014 as of 23 September,
compared with 28 during the same period last year. The number of reported cVDPV2 cases has decreased in
2014 compared with this time in 2013; the most recent case was in June. Environmental surveillance shows WPV1
transmission to be more widespread than last year. The government’s recent reluctance to actively engage in
polio eradication, including delaying the signing of an Islamic Development Bank loan, has contributed to
Pakistan’s problems. Despite the major setbacks in Pakistan, some successes have occurred. The program scaledup its already large transit-point vaccination network to reach the large number of children displaced out of
North Waziristan because of military actions there. Outside of key reservoirs of FATA, adjoining KP and Karachi,
the program is not seeing major outbreaks of polio, despite certain internal WPV importations. The threat of
violence against polio vaccination teams and security personnel has continued in parts of Karachi and greater
Peshawar.
Nigeria: Nigeria has continued to intensify its programme, pushing innovation and accountability, and
administering inactive poliovirus vaccine (IPV) SIAs in selected areas to accelerate interruption of WPV
transmission. Only six WPV1 cases have been reported in Nigeria so far this year, and WPV3 has not detected
for more than 22 months. Since late last year, WPV transmission appears to have been isolated to two areas,:
Borno/Yobe and the “Kano transmission zone,” consisting of southern Kano State and adjoining local government
areas (LGAs) of Kaduna and Bauchi. Activities are being further intensified in the latter zone, possibly the only
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GPEI Partner Status Report - 25 September 2014
place in Nigeria now with ongoing WPV1 transmission. At the same time, cVDPV2 transmission has continued, in
part because of a strategic decision to focus on WPV elimination early in the year and to delay trivalent oral
poliovirus vaccine (tOPV) subnational immunization days (SNIDs) to August and November of this year. Nineteen
cVDPV2 cases have been recorded so far in 2014 and environmental surveillance has shown transmission across
the north. Ongoing violence and conflict in Borno and Yobe state continue to affect the scope and quality of SIAs.
Horn of Africa: The focus of the outbreak in the South/Central Zone of Somalia was brought under control last
year, and WPV1 hasn’t been reported in Kenya since July 2013 or in Ethiopia since January 2014. However, the
detection of cases among pastoralists in the Mudug Region of Puntland in May, June and August exposes ongoing
transmission in rural Somalia while raising the possibility that bordering areas in Ethiopia may also be at risk. The
Somalia programme is now taking additional measures to reach pastoralist children. The security situation has not
improved in large sections of South Central Somalia, and the upcoming larger military operations could further
create opportunities for increased violence against civilian and humanitarian actors
Central Africa: Since mid-November 2013, Cameroon has been responding to a WPV1 outbreak after imported
WPV1 that had circulated undetected for more than two years. The programme has been slow to respond. The
occurrence of cases in Cameroon up to July 2014 and the geographic spread to Equatorial Guinea show that SIA
quality has been weak and that improvements are still needed; surveillance weaknesses also continue. Equatorial
Guinea has also been slow to respond. Surveillance is completely inadequate; SIAs still leave many children
unimmunized. Serious surveillance limitations in surrounding countries limit confidence of no further spread to date.
In both Cameroon and Equatorial Guinea, enhanced Government ownership and leadership is essential.
Syria and Iraq: From the beginning of the outbreak, the programme has considered this outbreak to be regional,
and has treated it as such, including surveillance improvements and several rounds of SIAs in neighboring
countries. The most recent case in Syria was in January 2014. Iraq has reported two cases so far, in February and
April. Surveillance in both countries has been of variable quality. Significant instability is expected.
Israel, the West Bank and Gaza: Since January 2014, bivalent oral poliovirus vaccine (bOPV) has been
incorporated into the childhood immunization schedule in Israel. Environmental sampling from all sites has been
negative for WPV1 since the week of March 30. No human cases of WPV1 were detected.
Countries at Risk: Countries at highest risk for transmission, according to current risk assessments, are in
West/Central Africa (particularly Central Africa), the Horn of Africa and the Middle East. The WHO African
Regional Office has been following up with the highest risk countries in Central Africa to follow through on
recommendations from a regional Technical Advisory Group meeting held in July. In addition, two rounds of
synchronous SIAs will be held throughout West and Central Africa in September and November of this year
except in the four West African countries affected by Ebola disease. Countries at risk in the Middle East have
been undertaking risk mitigation activities since late 2013.
Vaccine supply: Supply of both bOPV and tOPV has continued to be tight but well-managed through mid-2014
as no priority SIAs were deferred because of short supply. There is now sufficient buffer to meet planned
increased demand in the second half of 2014. IPV supply has also been tight in 2014; nearly all available IPV
was planned for introduction in routine immunization. The programme is finalizing plans for IPV use in SIAs in the
three endemic countries. OPV supplies for 2015 are considered adequate, with a larger buffer available.
Financing: Against the US$ 5.5 billion budget for 2013-2018, the best-case funding gap for the entire period is
US$ 494 million. As of July 2014, the Initiative has cash on hand of US$ 908 million against the total budget of
US$ 1.1 billion for 2014
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GPEI Partner Status Report - 25 September 2014
Table of Contents
EXECUTIVE SUMMARY .......................................................................................................... I!
ACRONYMS AND ABBREVIATIONS .....................................................................................V!
INTRODUCTION ................................................................................................................... 1!
COMMUNICATION AND SOCIAL MOBILIZATION ............................................................... 2!
ACCESSIBILITY AND SECURITY............................................................................................. 9!
ENDEMIC COUNTRIES ........................................................................................................ 12!
Afghanistan ............................................................................................................................................ 12!
National polio overview .................................................................................................................. 12!
Virology ............................................................................................................................................... 13!
Poliovirus sanctuaries and risk areas .............................................................................................. 15!
Communication and social mobilization ......................................................................................... 19!
Programme information .................................................................................................................... 21!
Performance indicators...................................................................................................................... 27!
Synopsis ................................................................................................................................................ 29!
Pakistan ................................................................................................................................................... 30!
National polio overview.................................................................................................................... 30!
Virology ............................................................................................................................................... 31!
Poliovirus sanctuaries and risk areas .............................................................................................. 32!
Communication and social mobilization ......................................................................................... 41!
Programme information .................................................................................................................... 45!
Performance indicators...................................................................................................................... 47!
Synopsis ................................................................................................................................................ 49!
Nigeria .................................................................................................................................................... 50!
National polio overview.................................................................................................................... 50!
Virology ............................................................................................................................................... 52!
Poliovirus sanctuaries and risk areas .............................................................................................. 56!
Communication and social mobilization ......................................................................................... 62!
Programme information .................................................................................................................... 66!
Performance indicators...................................................................................................................... 69!
Synopsis ................................................................................................................................................ 71!
NON-ENDEMIC COUNTRIES ............................................................................................... 72!
Horn of Africa Outbreak ..................................................................................................................... 72!
Somalia ................................................................................................................................................ 73!
Ethiopia................................................................................................................................................. 74!
Central Africa outbreak ....................................................................................................................... 76!
Cameroon ............................................................................................................................................ 77!
Equatorial Guinea .............................................................................................................................. 77!
Middle East outbreak ........................................................................................................................... 78!
Syria...................................................................................................................................................... 78!
Iraq........................................................................................................................................................ 79!
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GPEI Partner Status Report - 25 September 2014
Middle East outbreak Response ...................................................................................................... 79!
Other Countries/Areas with Detection of Active Poliovirus Transmission ................................... 82!
Israel; the West Bank and Gaza .................................................................................................... 82!
Countries at Risk .................................................................................................................................... 83!
Countries with recent poliovirus transmission ................................................................................. 83!
High-Risk Priority countries ............................................................................................................... 85!
Mitigating activities ............................................................................................................................ 86!
VACCINE SUPPLY AND MANAGEMENT ............................................................................ 87!
STAFFING AND CAMPAIGNS IN 2014 ............................................................................... 91!
FINANCING ........................................................................................................................ 94!
Global Polio Eradication Initiative Financing Situation .................................................................. 94!
Funding Gap ....................................................................................................................................... 94!
Cash Gap............................................................................................................................................. 95!
IMB Recommendations .......................................................................................................................... 95!
Rotary Support ...................................................................................................................................... 99!
ANNEX: LIST OF FIGURES ................................................................................................ 100!
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GPEI Partner Status Report - 25 September 2014
ACRONYMS AND ABBREVIATIONS
AFP
AGEs
aVDPV
bOPV
C4D
CAR
CDC
CMAM
COMNet
cVDPV
DRC
EOC
FATA
FLW
GPEI
HoA
ICN
IDPs
IMB
IPC
IPV
IVR
KP
acute flaccid paralysis
anti-government elements
ambiguous vaccine-derived poliovirus
bivalent (types 1 and 3) oral poliovirus
vaccine
Communication for Development
Central African Republic
U.S. Centers for Disease Control and
Prevention
community-based management of
acute malnutrition
Community Mobilizer Network
(Pakistan)
circulating vaccine-derived poliovirus
Democratic Republic of the Congo
Emergency Operations Centre
(Nigeria)
Federally Administered Tribal Areas
(Pakistan)
frontline worker
Global Polio Eradication Initiative
Horn of Africa
Immunization Communication Network
(Afghanistan)
internally displaced persons
Independent Monitoring Board
inter-personal communication
inactivated poliovirus vaccine
interactive voice response
Khyber Pakhtunkhwa (Pakistan)
LGA
LPD
LQAS
mOPV
NGO
NID
NPAFP
OPV
POB
POLIS
PTPs
SIA
SIAD
SMS
SNID
STOP
tOPV
TP
UC
UN
UNICEF
UPEC
VCM
VDPV
VTS
WHO
WPV
local government area (Nigeria)
low performing districts
lot quality assurance sampling
monovalent oral poliovirus vaccine
non-governmental organization
national immunization day
non-polio acute flaccid paralysis
oral poliovirus vaccine
Polio Oversight Board
polio information system
permanent transit posts
supplementary immunization activity
short-interval additional dose
short message service
subnational immunization days
Stop Transmission of Polio
trivalent oral poliovirus vaccine
transit point
Union Council (Pakistan)
United Nations
United Nations Children's Fund
Union Council Polio Eradication
Committee (Pakistan)
volunteer community mobilizer
vaccine-derived poliovirus
vaccination tracking system (Nigeria)
World Health Organization
wild poliovirus
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GPEI Partner Status Report - 25 September 2014
GPEI Partner Status Report: 25 September 2014
INTRODUCTION
This fifth GPEI Partner Report on progress towards polio eradication brings together input, analysis, and
interpretation from the World Health Organization (WHO), Rotary International, the U.S. Centers for Disease
Control and Prevention (CDC), and the United Nations Children’s Fund (UNICEF). The report examines both
wild poliovirus (WPV) and circulating vaccine-derived poliovirus (cVDPV), with a focus on the key poliovirus
'sanctuaries' and risk areas in the three remaining polio-endemic countries (Afghanistan, Pakistan, and
Nigeria) and indicators of progress towards the goals of the GPEI Polio Eradication and Endgame Strategic
Plan 2013–2018. The report includes data about ongoing WPV outbreaks in the Horn of Africa (HoA),
Central Africa and the Middle East; the detection of WPV in environmental samples; and an evaluation of
countries at risk for importation. The WPV and cVDPV data represent cases with onset through 2 September
as of 9 September 2014 (with noted exceptions) and with genomic sequence analysis through 20 August
2014. Analyses of WPV sanctuaries include data from acute flaccid paralysis (AFP) surveillance over the prior
12 months. For the analysis of standard surveillance and immunization indicators* by province/state for
endemic countries, analyses include non-polio AFP (NPAFP) cases within the following onset intervals: 1) 16
February 2013 to15 August 2013, 2) 16 August 2013–15 February 2014, and 3) 16 February 2014–15
August 2014. For countries at risk, analysis includes AFP cases with onset of 16 August 2013–15 August
2014. Vaccine supply, human resource, financing and key programme information are reported as of 9
September 2014.
Figure 1. WPV sanctuaries in polio-endemic countries, and countries and areas with wild poliovirus
transmission within the prior 12 months, 19 September 2014
Source: GPEI
The$boundaries$and$names$shown$and$designations$used$on$this$map$do$not$imply$the$expression$of$any$opinion$whatsoever$on$the$part$of$the$Global$Polio$
Eradication$Initiative$spearheading$partners$(WHO,$Rotary$International,$CDC$or$UNICEF)$concerning$the$legal$status$of$any$country,$territory,$city$or$area$
or$of$its$authorities,$or$concerning$the$delimitation$of$its$frontiers$or$boundaries.$Dotted$and$dashed$lines$on$maps$represent$approximate$border$lines$for$
which$there$may$not$yet$be$full$agreement.$$$
* Standard AFP surveillance performance indicators by province/state for this report include the following: 1) detection of at least two non-polio AFP (NPAFP)
cases per 100,000 population aged <15 years annually and 2) adequate stool specimen collection from >80% of AFP cases (two specimens collected >24
hours apart within 14 days of paralysis onset, shipped on ice or in frozen packs to a WHO-accredited laboratory, and arriving in good condition). Standard
immunization performance indicators by province/state for this report are: 1) <10% of children aged 6-35 months with NPAFP with an OPV dose recall
history of 0 doses, and 2) >80% of children aged 6-35 months with NPAFP with an OPV dose recall history of 4 or more doses.
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GPEI Partner Status Report - 25 September 2014
COMMUNICATION AND SOCIAL MOBILIZATION
New insights in 2014 show that now, more than ever, communication with caregivers and communities can
make or break the ability to reach every last child. Field data and recent polling by the Harvard School of
Public Health show a clear picture of where success has taken place and the main social obstacles that must
be overcome to finish the job in 2015.
Acceptance of the oral
Figure 2. Proportion of targeted children missed due to refusal, January 2013–
poliovirus vaccine (OPV)
August 2014
has reached the highest
levels ever seen in
Nigeria and Pakistan. As
long as a vaccinator
reaches the doorstep,
99% of parents in most
parts of these two
countries accept the
vaccine for their children.
When children are not
vaccinated in any of the
endemic countries, they
are largely missed
because of being outside
the household (which
may reflect covert noncompliance in part), poor
inter-personal
communication (IPC) skills
at the doorstep or being
inaccessible to
vaccination teams
Source: UNICEF
because of insecurity.
There is a proportion of
children who are also missed due to teams not visiting planned households, which should also be reviewed and
reduced.
Whereas communication programmes in the past have focused almost exclusively on refusals and generating
demand for vaccination, the role of communications has been changing rapidly in 2014 to address the critical
remaining challenges in the programme: inaccessibility and insecurity, population movement, children out of
the house, apathetic vaccinator practices and poor vaccination team performance.
The rise in refusals in Khyber Pakhtunkhwa (KP) by nearly 80% between May and June, however, is a
reminder that parents’ tolerance for repeated vaccinations is finite and cannot be taken for granted. Each of
Nigeria’s six polio-affected families this year refused OPV for their child at least once before the onset of
paralysis; four of the six families categorically refused OPV vaccination for their children and are zero-dose.
Nearly 15% of Pakistan’s polio victims this year have come from refusal families—triple last year’s
proportion.
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GPEI Partner Status Report - 25 September 2014
We must continue to provide new and fresh ways to convince parents that the threat of polio remains serious,
an increasingly difficult point to prove with so few visible reminders of risk. We must be equipped to offer
more than just a
message.
Figure 3. Missed children in high-risk areas of endemic countries, October 2013–
August 2014
Outbreaks pose
complex challenges
of their own, forcing
the programme to
fight polio on
multiple fronts with
limited resources
and time, and in
areas where
mechanisms
previously put into
place to eradicate
polio have long
been deactivated.
Fresh outbreaks
have largely meant
starting back up
from zero in staffing,
tools and emergency
response
procedures.
Outbreaks also
mean intensified
communication challenges, including creating demand for the vaccine among a population that hasn’t seen
polio in years or even decades, and where only a single case or a small number of cases may have emerged.
Local solutions are needed for localized challenges, yet the toughest challenges persist across the endemic
and outbreak countries alike. In its May 2014 report, the Independent Monitoring Board (IMB) identified three
key areas for improvement in communication and social mobilization: 1) measuring and raising the standard
of social mobilizers’ performance, 2) enhancing vaccinators’ IPC skills for difficult conversations, and 3)
creating common ground on the value of social mobilization in addressing the programme’s greatest
challenges.
Renowned external expertise is now on board to support these and other efforts. More than 30 organizations
with expertise ranging from polling and data management, training, innovation and advertising have been
brought on as partners through long-term agreements that allow UNICEF and WHO to contract and
implement quickly. Harvard and Johns Hopkins Universities, BBC Media Action and Seed Scientific are a few
examples of global partnerships being harnessed to solve the most chronic and localized challenges identified
below.
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GPEI Partner Status Report - 25 September 2014
MEASURE AND RAISE THE STANDARD OF SOCIAL MOBILIZER’S PERFORMANCE
The size and scale of social mobilization networks continue to rise in order to tackle the remaining challenges
of the programme. More than 15,000 social mobilizers are now working and redeployed to the highest risk
areas to maintain demand for OPV and ensure that all children are vaccinated, whether they are missed
because of refusal or other reasons. Most social mobilizers are also promoting broader health activities in
support of polio.
This vital link to
parents and
communities—the very
people who will
determine the fate of
eradication—provides
an unprecedented
opportunity to open
doors for vaccination
where it matters most.
The skills, flexibility
and accountability of
this workforce in the
face of ever-changing
social and operational
challenges will be
critical to the GPEI’s
success in the next—
and hopefully last—
low season.
Figure 4. Number of social mobilization networks, January 2013–August 2014
Social mobilization
networks have been
rising consistently for the past two years to meet a growing need to build community support in the highest risk
areas. Recruitment, deployment and training have taken place simultaneously in each country to ensure that
people are in place quickly. More than 6,000 permanent mobilizers and supervisors were recruited in one
year alone in Nigeria. Amidst an urgency to deploy these frontline workers, training suffered.
Although training is provided across each network, there has so far been no standard package of
development that each tier of mobilizers is expected to receive before deployment. Skills are currently
imparted through on-the-job experience, supervisor support and training courses, delivered as they become
available—with varying length and quality at field level. Few mechanisms are in place to evaluate whether
the trainings have imparted the required skills to each mobilizer successfully, or to the network as a whole.
To equalize skills across all layers of the networks, UNICEF has developed a learning framework that outlines
the skills and curriculum required for each tier of social mobilizers—from community, sub-district, district and
state/provincial level. Customized modules will be delivered to each tier depending on their core functions. A
professional training company has been hired to adapt existing content into interactive, participatory adultlearning methodology that imparts skills and knowledge together. This package will be preceded by a basic
IPC training for all frontline workers (see below) which should be ready for the field before the 2015 low
season.
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GPEI Partner Status Report - 25 September 2014
Short message service (SMS) and Interactive Voice Response (IVR) technology has been developed to monitor
motivation and training delivery in critical areas. Short surveys delivered through mobile phones—and voiceautomated for illiterate workers—consists of three short questions asking whether a mobilizer has recently
received payment, training and a recent visit from his or her supervisor. These data can be mapped in realtime and reviewed online globally—along with other campaign indicators—to better understand key drivers
of performance. This technology is now being piloted and will be useful not only to make immediate
corrections, but also to pinpoint where revised training and coaching is most critically needed.
What distinguishes an exceptional mobilizer from a mediocre or non-performing mobilizer is a mix of
knowledge, skills, profile, commitment and motivation. Ultimately, performance comes down to whether a
frontline worker is able to gain the trust of the person on the other side of the door. We know this trust is
hardest to build in
Figure 5.
areas that are
already predisposed to
conflict, insecurity
and dysfunctional
health systems.
The way frontline
workers are
equipped to do
their job must
involve not only
tools to build
knowledge and
skills, but also
passion and
motivation to
overcome the
many obstacles
that remain in key
sanctuaries and
risk areas.
For these reasons,
a motivational
Source: UNICEF
system is embedded in the learning strategy that offers personal incentives to innovate, invest in personal
development and share experience and lessons with fellow workers or staff. When the system is complete,
mobilizers can aspire to be a ‘black belt’ in IPC, data collection, health or any other relevant topic and collect
points, stars, belts or other symbols that visibly demonstrate their excellence. These visible ‘awards’ can offer
prestige and credibility when workers meet a parent at a doorstep as well as serve towards advancement
opportunities within a high performing network and hopefully beyond in local health systems.
All of these variables will be monitored in each country and globally through a standard performance
dashboard, shown in Figure 5. These data, along with other indicators monitoring the rest of the programme,
will flow upwards from district level into a system that will house global performance data online across all
countries. This database will enable information to flow more quickly down to the field for action, as well as
upwards for strategic decision making at provincial, national and global levels. The new system will greatly
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GPEI Partner Status Report - 25 September 2014
enhance clarity on performance. The key will be to incorporate these data into local and global GPEI
oversight forums and use the information for rapid action on the ground, where it matters most.
ENHANCE VACCINATOR’S IPC SKILLS FOR DIFFICULT CONVERSATIONS
Polio eradication will be won or lost by frontline workers. A trusted vaccinator succeeds in getting parents to
open their doors. A skilled vaccinator does not leave a household without finding and vaccinating every child
in the house. A knowledgeable vaccinator can explain to confused parents why he/she must vaccinate their
children today, even if they have already done so many times before. An exceptional vaccinator will
communicate other health behaviors and be welcomed eagerly when he or she returns the next month.
Trust in frontline workers—and in the polio programme more broadly—is unfortunately lowest in the areas it
is needed the most: Borno and the Federally Administered Tribal Areas (FATA). This finding is confounded
partially by the fact that fewer parents in these locations have recently seen a vaccinator compared with
parents elsewhere in the country. Even among parents who have seen vaccinators, a favorable opinion of
vaccinators is significantly lower than elsewhere in each country.
The gender and demographic profile of frontline workers are closely associated with their ability to foster
trust. According to recent polls, 32% percent of mothers and fathers in FATA said they prefer at least one of
the vaccinators who arrive at their doorstep to be a woman. Only 8% in Borno, and less than 5% in the rest
of Nigeria, want to see
Figure 6. Poll Responses Regarding Trust in Vaccinators, Nigeria and Pakistan
two men arrive at their
doorstep.
Nigeria has responded to
these community
preferences in the profile
of both social mobilizers
and vaccinators. Although
the GPEI in Pakistan has
generally been able to
ensure that more than
80% of vaccination teams
include at least one
woman, success in
recruiting female social
mobilizers has not been
comparable. The
Community Mobilizer
Network (COMNet) has
maintained their female
proportion of mobilizers
around 20% for more
than one year. This raises questions about the COMNet recruitment strategy as well as the coordination and
sharing of lessons learned between vaccinator and mobilizer selection—an area that requires further
integration in all countries.
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GPEI Partner Status Report - 25 September 2014
In the southern region of Afghanistan, the opposite trend can be seen, with a slight increase in female social
mobilizers over the past few months, but a general decrease in female vaccinators (except for a ‘one-off’
surge in March). Female mobilizers and vaccinators do exist in urban cities such as Jalalabad; in fact, they are
the majority there. The reported 0% in Figure 7 for Eastern Afghanistan reflects that data are not recorded
or monitored by the Afghanistan programme. This will need to be revised as the Immunization Communication
Network (ICN) continues to
expand.
Figure 7.
An IPC module has
already been developed
by UNICEF to introduce
inactivated poliovirus
vaccine (IPV) into routine
immunization, and is
available for use in
country. A professional
training company has
been hired by UNICEF to
adapt the existing IPC
module in the WHO-led
vaccinator training to be
more interactive and skillbuilding. Given the scale
and impact that a more
skilled frontline workforce
can have, the module for
IPC training of vaccinators is prioritized for roll out by November 2014, followed by the social mobilizer
training mentioned above.
A growing body of evidence suggests that mobile phones, SMS, IVR and Android applications can also help
build the capacity of community health workers. One example is BBC Media Action Trust’s Mobile Academy
for community health workers in India, which delivers voice training and interactive quizzes via mobile phones.
UNICEF is adapting these lessons to strengthen interpersonal training for frontline staff.
Supplementary educational applications have been developed that reinforce IPC skills and key health
messages through SMS and IVR. This “mHero” application—part of a customized social media package
designed exclusively for polio training—tests new trainees on key knowledge learned after training courses,
and is followed up later with behavioral questions once workers are in the field. This approach will
complement UNICEF’s face-to-face training package, and has already been added to a new integrated
health training that has been piloted with frontline staff in Katsina and Kaduna states in Nigeria. To see an
example of the initial mHero Knowledge and Training application, click this link.
∗
An advertising agency has also been hired to translate polling data into easy-to-remember messages that can
be delivered more innovatively by frontline workers. By the end of the year, informational videos can be
transmitted and broadcast to frontline workers via Multimedia Message Service and Bluetooth to help aid
their difficult conversations with parents. Frontline workers can use these videos for their own learning as well
as to interact more systematically with parents and members of the community.
∗
!https://www.dropbox.com/s/7ps1ft9gw31j2z9/Polio%20Knowledge%20Training%20Application%20Schematic.pdf?dl=0!!
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GPEI Partner Status Report - 25 September 2014
CREATE COMMON GROUND ON THE VALUE OF SOCIAL MOBILIZATION IN ADDRESSING THE
PROGRAMME’S GREATEST REMAINING CHALLENGES
The IMB has challenged the GPEI to have more honest discussions about the role of social mobilization in
addressing the programme’s remaining challenges. Several face-to-face discussions have taken place on this
issue since the last report: 1) in June at the face-to-face Polio Partners Group and Polio Oversight Board
(POB) meetings on the need to better integrate operations and communications in global presentations and
during programme implementation, particularly for access; 2) with the Bill and Melinda Gates Foundation and
CDC at partner review meetings on the future direction and relevance of social mobilization networks in the
highest risk areas; and 3) with WHO at the margins of the Global Polio Management Team on defining the
role of communications—external communications and Communications For Development (C4D)—to facilitate
access. The latter was among the first formal meetings to bring together colleagues from access, operations,
communications and both of these complementary arms of communication (external and frontline). It was a
positive progression in integrating not only operations and communications, but also integrating these two
parts of the communications field that rarely intersect programmatically, but should as the enabling
environment for the programme moves increasingly more fluidly between local and global spheres.
These meetings focused on how communications should play a role rather than if communications should play a
role, which is a positive indicator that the partnership sees the value of communications. What remains an
underlying challenge is how to move these discussions from positive views to positive actions.
The C4D Specialist in WHO’s Country Support Team—as well as WHO’s own C4D Specialist—have been
bridges built between intentions, plans and implementation, though both organizations require a more
fundamental culture shift to ensure that these two parts of the programme work together systematically.
Since the last report, social data have been incorporated as a standing set of slides in the monthly InterAgency Country Support Group. The role of community engagement and demand has formally been
incorporated within the strategic access framework of the GPEI and endorsed by the POB. A GPEI working
group has been working collaboratively on analyzing and rehabilitating, if required, the reputation of OPV
on the internet, particularly within influential online and social media platforms that have in the past maligned
the reputation of OPV. Agreement has been established to ensure that UNICEF’s PolioInfo and WHO’s Polio
Information System (POLIS) global database can exchange data and integrate seamlessly on a common
website once they are both built. Despite the moves to revise modules, agreed-upon timelines have not yet
materialized on operationalizing the updated vaccinator training.
CDC continues to be an integral partner to identify, train and deploy Stop Transmission of Polio (STOP)
volunteers where critical needs exist in the programme, and this support has extended to Ebola until July. CDC
has further operationalized its support by facilitating a new partnership with Voice of America Pashto, which
will significantly enhance the ability to reach Pashtun communities with more creative content.
Rotary continues to be instrumental in promoting and facilitating health camps, particularly in Pakistan, as well
as rehabilitation centers for polio-affected children.
ROTARY’S EFFORTS TO RAISE POLIO AWARENESS
Update on communications strategy
Rotary continues integrated communications for polio: traditional media relations, expanded digital (including
social) media efforts, celebrity engagement (more than 100 celebrities worldwide at all levels), and special
events—currently focused on World Polio Day (24 October) as keystone for many events.
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Rotary’s Online Museum
Rotary communications staff are working on a digital storytelling platform to expand on the efforts already
underway at www.endpolio.org/stories to gather stories of those whose lives have been affected by the fight
to end polio, including volunteers, health workers, Rotarians, polio survivors, and other supporters. The final
product will be an online “museum” of sorts telling the story of the global engagement around the issue.
World Polio Day
This year, Rotary is hosting its second annual World Polio Day Livestream event, featuring speakers including:
Minda Dentler, an inspiring polio survivor triathlete; a video message and song from Rotary polio
ambassador Ziggy Marley; TIME Magazine science/technology editor Jeffrey Kluger; and—closing out the
evening—a special concert from a rising pop star, who is one of Rotary’s newest ambassadors for polio
eradication. In addition to these English-language events, the Rotary International communications team will
be conducting media outreach in target countries globally to raise awareness and encourage people to
donate and share their stories.
Rotary International will also support other World Polio Day events that same week in:
• Atlanta, GA at the U.S CDC on 21 October – CDC Director Dr. Tom Friedan and Rotary International
President Gary Huang will be among the participants
• Strasbourg, France: 21October at the European Parliament
• Pakistan, where monuments will be illuminated with the “End Polio Now” message
ACCESSIBILITY AND SECURITY
The extent to which security continues to influence the ability of the GPEI to operate and access all children
continues and, in some cases, has deteriorated considerably. The markedly different contexts of Nigeria and
Pakistan are changing and are not likely to improve in the immediate- to medium-term. Similarly, the security
situation in outbreak countries, particularly Iraq and Syria, has further worsened, resulting in both countries
being considered as “L3 emergencies” within the United Nations (UN), the classification for the most severe,
large-scale humanitarian crises. The added complication of the current Ebola outbreak has the possibility of
adding another level of disruption to GPEI activities in West Africa.
A number of significant events have made it difficult to conduct GPEI activities and access to key geographies
has decreased. While the election period in Afghanistan did not have the level of violence expected, the
south and east of the country witnessed increased population movements due to the military operations in
Pakistan. The more significant issue was in Helmand Province where the area was fully inaccessible to GPEI
activities from March to July. Although a large degree of effort at various levels occurred, not least from both
UNICEF and WHO country offices, access has only just been granted with campaigns held in August.
Pakistan has also witnessed a high degree of turmoil since June when the military launched an operation into
North Waziristan in attempt to deal with anti-government elements. This operation has led to almost 1 million
people migrating into the surrounding areas, including Afghanistan. This has provided the GPEI with a unique
opportunity to reach children previously unvaccinated. However, this movement has resulted in spread of the
virus to host communites and sporadically elsewhere.
The security situation in Nigeria, especially in the Northeast, has continued to deteriorate. The Government
reports that inaccessibility due to insecurity declined from 100% in March 2013 to approximately 23%
currently. Despite an improvement, the situation has worsened from the 14-16% low seen in March 2014. This
situation is predominantly due to the insurgency and subsequent military action in the Northeast. Communal
violence is also present, especially in the Middle Belt. Insurgent activities have resulted in the Government’s
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State of Emergency remaining in place since May 2013. The insurgency has regional ramifications on security
and population movement, particularly to those countries directly neighbouring Nigeria. In early August, the
Office for the Coordination of Humanitarian Affairs reported that the insurgency in the Northeast of the
country had forced nearly 650,000 people from their homes, an increase of nearly 200,000 since May. The
GPEI’s ability to fully monitor campaigns in the key area of Borno has been further hampered by the current
ban by aviation authorities on commercial flights and by the lack of transport alternatives.
While the security situation in specific areas of endemic and outbreak countries is challenging, the GPEI has
continued to respond. Earlier this year, the GPEI agreed and the IMB reemphasized that it is important for
GPEI partners to share common analyses and approaches to access and security, and to ensure sharing of all
relevant information and insights as a basis for the development of common implementation strategies. Interagency coordination and accountability mechanisms will be critical to the success of all access strategies. To
that end, UNICEF and WHO have sought to improve collaboration with partners to seek multifaceted
measures to reach every child. The most significant strategic development has been the agreed-upon
coordinated approach that includes initial analysis, methods to facilitate access, and the development of
appropriate delivery approaches. There is agreement that community acceptance, trust and demand
generation are the foundation for ensuring security for polio vaccination efforts and health workers. Once the
political and conflict-related challenges that underpin the vaccination bans or attacks on polio vaccination
efforts are being addressed, it is then essential to understand and respond to the perspectives of parents and
communities on reaching all children.
This overall strategy provides breadth to the way in which delivery strategies are implemented and three
main approaches are involved. The first approach is analyzing the situation through data and information from
various components—political, social, security/conflict, epidemiological and polio campaign data. Collecting
and analyzing these diverse strands of information allows the GPEI, for example, to understand the root
causes for opposition to polio vaccination efforts and concerns of the beneficiary communities, and help map
the key influencers and processes to reach them.
The second approach involves the development of appropriate, area-specific access tactics based on the
analysis that has been conducted, and the available channels to discuss and develop these access tactics. The
POB endorsed four programmatic tactics. They include:
• Negotiated Access. This is the primary tactic and includes the engagement of religious and community
leaders, tribal elders and tribal structures; engagement of national and provincial governments and their
agencies, including military and law enforcement authorities; engagement of third party influencers, both
local and international; and indirect engagement of non-state armed groups to allow the conduct of
required number of SIAs to help stop WPV transmission.
• Opportunistic Vaccination Strategies. Smaller scale and low-profile activities to reach and vaccinate
children. These are important initiatives, but not likely sufficient to stop poliovirus transmission. They
include: permanent transit point vaccinations; ramping up routine Expanded Programme on Immunizations
(EPI); self-vaccination initiatives; immunization by local non-governmental organizations (NGOs) and
humanitarian organizations; and initiatives for nomadic and other mobile or displaced populations.
Provision of broader health interventions creates opportunities for vaccination through increasing demand
and ensuring the security of workers.
• Protected Vaccination Campaigns. This is the engagement of military and local law enforcement to
provide protection to health workers and support the polio eradication activities. The GPEI understands
that military or local law enforcement forces will not be directly involved in administering vaccines, and
that the use of military will be time-limited and as a last resort. In areas completely under the control of
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•
military authorities, no health or humanitarian activities are possible without the support and approval of
military leadership.
Engaging communities. Ensuring communities want and trust vaccination efforts (IPV and OPV) will
maximize the potential to reach all children once access is achieved. This is achieved through seeding
demand for immunization and health services though radio, TV and IPC where possible, and the
development and implementation of targeted social mobilization and C4D initiatives.
The third approach involves the full exploitation and integration of social mobilization and C4D initiatives of
this last programmatic tactic into the programme planning and delivery strategies to ensure the greatest
levels of access to children and communities. Broadly, these include the following:
• Community Acceptance. To create the conditions of community trust and acceptance that will enhance
security for health workers, and develop multiple local channels to secure and sustain access to the last
remaining children. This tactic targets those who can influence change at the community level to accept
polio vaccination efforts.
• Demand-generation. To help address the key concerns of the parents, promote the role of vaccinators
and local health workers, and create demand for immunization services and health interventions. This tactic
targets families, parents, vaccinators and health workers.
• Improved Service Delivery. To improve the programme’s ability to understand the various social factors
and help deliver quality services that respond to community demands. This tactic targets programme staff,
third party organizations, local governments and can ensure that any opportunistic vaccination efforts are
of the highest quality and help reach the greatest numbers of children from previously inaccessible areas.
Looking forward to the remainder of the year and beyond into 2015, further strategic shifts continue to be
developed:
• Operationalizing a fully integrated approach to engaging communities at all levels, address
community demands and secure access, including convergence strategies
• Moving from a Joint Security Approach to a Joint Access Approach to capture the multifaceted
strategy to reach every last child
• Providing proactive analytical and wider research capability to support programme delivery.
Ensuring that data are available to all decision makers and used for action
• Focusing on addressing specific inaccessibility issues—scenario-based approach/emerging threats/
political instability/population movements/Western & Central Africa/HoA/Middle East/Pakistan/
Afghanistan
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ENDEMIC COUNTRIES
AFGHANISTAN
Figure 8. WPV and cVDPV cases, Afghanistan, 2013 and 2014 to date*
NATIONAL POLIO
OVERVIEW
The number of WPV1 cases in
Afghanistan decreased from
37 in 2012 to 14 in 2013; ten
cases have been reported to
date in 2014 (as of September
23, 2014) compared with four
cases during the same period in
2013, the majority of which
have occurred in the Eastern
Region. Two cases occurred in
the Southern and, South Eastern
regions, and one case occurred
in the Western region. During
the last 12 months, most
reported cases were
importations from Pakistan.
SIAs have primarily used
bivalent (types 1 and 3) oral
poliovirus vaccine (bOPV)
Source: WHO
during the reporting period.
Two national immunization days
(NIDs) in 2014 used trivalent
oral poliovirus vaccine (tOPV)
and one short-interval
additional dose (SIAD) SIA
used monovalent OPV1
(mOPV1). Seven SIAD SIAs and
two subnational immunization
days (SNIDs) have been
Source: WHO
*Data as of 9 September 2014
conducted to date in 2014;
most included the low performing districts (LPDs) of the Southern Region as well as several rounds of case
response vaccinations. After a hiatus in access since March 2014, access to Helmand was granted in late
August and one SIA was conducted during the last week of August to be followed by three SIAs in the entire
province. Lot quality assurance sampling (LQAS) surveys indicated improvements in campaign quality during
2014 compared with 2013. “Permanent polio teams” that provide OPV to children on a continual basis
started to use tOPV in March 2013. Currently, 65 permanent polio teams are working in 11 LPDs in the
Southern Region. IPV is being introduced in LPDs in the October 2014 NID using fixed posts. A plan is in place
to introduce IPV into the routine immunization schedule in the entire country in mid- to late-2015. Remaining
challenges include access in Kunar in the East (one previously inaccessible district had breakthrough
negotiations and full access beginning in June). In addition, the exodus of internally displaced persons (IDPs)
from Waziristan during June–July 2014 posed a risk for WPV importations into Afghanistan. In response, nine
mobile vaccination teams were established to deliver routine immunizations to displaced populations. More
than 40,000 children were vaccinated with tOPV when entering Afghanistan; most had never previously
received OPV (i.e., most were zero-dose). The number of border crossing points was increased from four to
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GPEI Partner Status Report - 25 September 2014
eight and the target age group for polio vaccination at border crossing points and IDP camps was increased
to <10 years. In addition, three rounds of SIAs have been conducted between June and August 2014 in the
Southeast Region using bOPV.
VIROLOGY
WPV1 from five genetic clusters (R4A1, R4B1, R4B2, R4B5, and R4B6) were isolated from 12 August 2013
through 11 August 2014. Two viruses were detected in Southern Afghanistan (R4B1 clusters), representing
local transmission. The other WPV cases are related to WPV importation from Pakistan. Six (35%) of the17
WPV1 in Afghanistan had less-than-expected genetic linkage to other viruses from Afghanistan or Pakistan,
indicating surveillance gaps in either Afghanistan or Pakistan. These orphan viruses were detected in four
separate locations, including Kabul. Two orphan viruses from cases in the South Region were indigenous viruses
that had been circulating undetected for >20 months, indicating both ongoing endemic transmission and
surveillance gaps. Four orphan viruses from cases were imported from Pakistan. Environmental surveillance in
Afghanistan began in September 2013. Currently, Afghanistan has nine environmental surveillance sites; two
each in Kandahar, Helmand, and Nangarhar Provinces which were initiated in late 2013/early 2014 and
three sites in Kabul were added in June 2014. WPV1 was detected for the first time in specimens taken in
Kandahar and Nangarhar Provinces in July 2014. To date, no sites had VDPV detected.
No cVDPVs were detected during April 2013 to March 2014. However, isolation of VDPV from an
immunodeficient patient during November 2013 needs close monitoring and follow-up. The last known
emergence of cVDPV2 in Afghanistan was in early 2013 with three cases detected.
1. Seventeen WPV1 cases were detected in the past 12 months; all were in
four provinces in the east bordering Pakistan, except three that mapped
in the Southern and Western Regions.
2. Although the numbers of cases have declined, the proportion of orphan
viruses has increased, involving separate geographic locations.
3. No cVDPVs were detected during this time period.
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Figure 9. Wild poliovirus type 1 (WPV1) by genetic cluster and circulating vaccine-derived poliovirus type 2
(cVDPV2) by emergence, Afghanistan & Pakistan, 2013 and 2014 to date*
2013
2014
WPV1
cVDPV2
Source: CDC
* Data as of 20 August 2014
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POLIOVIRUS SANCTUARIES AND RISK AREAS
SOUTHERN SANCTUARY
Figure 10. WPV and cVDPV cases, Southern Sanctuary, 3 September 2013 to 2 September 2014*
Afghanistan has one WPV sanctuary,
Helmand and Kandahar Provinces,
which historically were the main
reservoir of endemic WPV transmission.
Within that area, the country has 11
LPDs because of inaccessibility,
confirmation of endemic circulation in
the previous two years, weak or
declining SIA quality, low level of
awareness of SIAs, and a
disproportionally high percentage of
young children with NPAFP who have
never received OPV. In May 2014, the
number of LPDs for this sanctuary
increased from 11 to 16.
Source: WHO
*Data as of 9 September 2014
Notes regarding Afghanistan’s lot quality assurance
sampling (LQAS) survey results (see next page):
Decision rules of 0–3, 4–8, 9–19 and 20–60 for
sample sizes of 60 provide a reasonable assessment
of SIA quality at 90% (High Pass), 80% (Pass) and
60% (Low) thresholds (or Fail if below) for
programmatic purposes under the assumption of
moderate variability in cluster-level results.
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GPEI Partner Status Report - 25 September 2014
Figure 11. WPV and cVDPV cases by week of onset, Southern Sanctuary (Helmand and Kandahar Provinces),
Afghanistan, 3 Sept 2013 to 2 Sept 2014*
Source: CDC
*Data as of 9 September 2014
Figure 12. LQAS survey results by SIA, Southern Sanctuary, Afghanistan, Sept 2013 to Aug 2014
Note: The “n=” numbers shown above each month represent the number of districts for which data are available.
Data from October and November 2013 include all available data from Kandahar and Helmand. LQAS data from February 2014 were only available from the
11 low performing districts. LQAS data from March, June, and August 2014 include all available data from Kandahar; LQAS was not conducted in Helmand.
Figure 13. Proportion of NPAFP cases 6-35 months, by OPV status, Southern Sanctuary, Afghanistan**
Source: WHO
**Data as of 2 September, 2014
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EASTERN RISK AREA
Figure 14. WPV and cVDPV cases, Eastern Risk Area, 3 September 2013 to 2 September 2014*
WPV from Pakistan has been imported into the
east of Afghanistan during 2012–2014. In turn,
the six provinces Nangarhar, Kunar, Laghman,
Nuristan, Khost, and Paktya have been designated
as the “Eastern Risk Area.” Six districts in the area
were designated as LPDs in 2014.
Source: WHO
*Data as of 9 September 2014
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Figure 15. WPV and cVDPV cases by week of onset in the Eastern Risk Area (Kunar, Nangarhar, Laghman,
Nuristan, Khost, and Paktya Provinces), Afghanistan, 3 Sept 2013 to 2 Sept 2014*
Source: CDC
*Data as of 9 September 2014
Figure 16. LQAS survey results by SIA in the Eastern Risk Area Afghanistan, Sept 2013 to Aug 2014
Note: The “n=” numbers shown above each bar month represent the number of districts for which data are available.
Figure 17. Proportion of NPAFP cases 6-35 months, by OPV status, Eastern Risk Area, Afghanistan**
Source: WHO
**Data as of 2 September 2014
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COMMUNICATION AND SOCIAL MOBILIZATION
Figure 18.
PERFORMANCE
In Afghanistan,
parents rarely turn
a vaccinator away
because they don’t
believe in OPV or
think it’s unsafe.
They turn
vaccinators away
because they
remain unconvinced
that polio is a
threat serious
enough to warrant
waking a sleeping
child, or to bring a
newborn out of the
house before social
Source: UNICEF
norms permit.
Doubt remains among parents that OPV is safe enough to risk giving it to a sick child. Newborn, sick and
sleeping concerns may not represent overt objections to the programme or vaccine but it does highlight gaps
in training of frontline workers, the inability of social mobilizers to assuage parental concerns and the lack of
a comprehensive revisit strategy.
In the 11 LPDs of Southern Afghanistan—where immunity gaps are second only to Borno and FATA—refusal
rates have remained at nearly the same “high risk” classification for the past two years. Despite being low in
absolute numbers, the lack of progress on refusal rates in Southern LPDs, and the inability to identify clustered
refusals pose a significant threat to interrupting transmission. But the absent children who are left unvaccinated
after campaigns are even more critical. More than 5% of all children in the South are missed because they
are out of the house and unreached with follow-up, 2% in the East. Significant shifts in the operational
strategy, such as compilation of tally sheet results and a thorough revisit strategy to find and vaccinate missed
children after campaigns, is central to reaching every child in Afghanistan.
Though an intensely complex working environment, underlying reasons for the alarmingly high rates of missed
children and poor performance in these districts are not clear. Tracking and monitoring need to be
systematically introduced and followed up with localized revisit strategies; these strategies have been
successfully applied in several areas of Southern Afghanistan. In Aug 2013 12,574 of the 37,307 children
who were recorded as “not available” remained unvaccinated, whereas in Aug 2014, with a revisit protocol,
35,350 children out of 41,002 who were “not available” were vaccinated on the fourth day revisit. These
basic protocols can significantly improve the quality.
In Afghanistan, social mobilizers are not permanent, and recruitment for at least part of the network is done
afresh each month. This constant cycle of recruitment, training and campaign activities puts a burden on the
management level of the programme and the level of training that can be provided in just one day is very
basic. It is unclear whether ICN—and in fact all frontline workers—have the appropriate IPC skills to make an
impact on newborn, sick and sleeping children, and whether skills exist across the spectrum of frontline workers
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GPEI Partner Status Report - 25 September 2014
to address the reasons for missed children. This issue should be considered as matter of priority for the six
districts in the South with consistently low coverage.
Figure 19. Proportion of missed children and missed because of refusal among targeted children in
selected LPDs in Southern Afghanistan, October 2013 to August 2014,
Source: UNICEF
COMMUNICATION FOR ACTION
In some of the most complex and insecure areas, ICN’s main function is to facilitate access on large and small
scales. Of the ICN’s 11 Provincial Communication Officers, two were recruited mainly to support access (North
Helmand and Farah) during all campaigns. Of the current 53 LPDs in the East and South (19 newly
designated since May 2014; previously 32 LPDs, 21 in the East and 11 in the South), nine District
Communication Officers (seven in the 10 LPDs in Kunar; and two in the nine LPDs considered top priority in
Kandahar province) were recruited for their community standing and ability to reach and negotiate access
with among anti-government elements (AGEs). As a result, the conventional strategy of pre-campaign houseto-house mobilization, vaccination and finger markings do not take place in these areas. Instead, the non-state
entities agree to allow children and caregivers to assemble in designated health facilities, mosques and other
central locations so the children may be vaccinated. These specialized arrangements are facilitated by the
ICN in these districts where children might otherwise be left unreached.
The recent access negotiations in Helmand Province and in Watapur District (Kunar Province) were brokered
at the community level by ICN staff. ICN helped identify many local objections, in particular to the profile of
frontline staff by speaking with local commanders and community leaders and ensuring their input in selecting
vaccinators and social mobilizers. In the Kajaki area of Helmand, this meant changing 13 of 17 cluster
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GPEI Partner Status Report - 25 September 2014
supervisors and in Helmand’s Musa Qala district, frontline workers from outside the community were replaced
with local workers.
This quiet and constant negotiation on the ground, along with high-level discussions with senior leadership,
meant access to children in Helmand in August for the first time since March of this year, and sustained access
since May to children in Watapur District, Kunar Province, inaccessible for four years.
While a non-permanent workforce provides unique challenges, the relative flexibility of the ICN conversely
allows it to respond quickly to changing circumstances on the ground. With no campaigns in Helmand from
March to August, the ICN workforce was reduced. Once access was regained, more than 1,300 social
mobilizers were reactivated to respond and support the campaign. Seeing increased missed children in the
East Region, Batikot and Shinwar LPDs, the ICN deployed 150 new social mobilizers to these new priority
districts. To help support the IDP influx from North Waziristan, ICN added more social mobilisers in Khost.
RECRUITING WOMEN
Recruitment of female social mobilizers, though improving, is a major challenge. In Kandahar, involvement of
female social mobilizers created suspicion among male community leaders who suspected access to households
for spying. It reportedly also forced changes in vaccinator profile as it is considered inappropriate for
unmarried men and women to be in public together, leaving female frontline workers clustering together in
groups for safety and community acceptance, but in the process reducing efficiency. Though it is critical that
female social mobilizers be available to facilitate access to households and female caregivers, their profile,
selection and acceptance by the community is crucial. The Afghanistan team is in the process of identifying a
realistic minimum standard for the gender mix of social mobilizers while simultaneously identifying other
opportunities to engage mothers in culturally acceptable ways, such as through shrine activities, mothers’
meetings, and hospitals.
PROGRAMME INFORMATION
ACCESSIBILITY AND SECURITY
During February through September, the security environment in Afghanistan has been dominated by a few
major factors—presidential elections, seasonal fighting trends, Ramadan, internal leadership struggle among
AGEs, and Pakistan military operations in North Waziristan. The South and Eastern Regions, the areas in
which the virus predominantly circulates, continue to produce the highest number of security incidents per month
that, to some degree, has an impact on the ability to implement the programme.
Traditionally, security incidents in Afghanistan rise steadily month-on-month until August where they then begin
to reduce as winter approaches and reach a low in February. No significant deviation has occurred from this
pattern so far this year, although a reduction of incidents was seen in July because of Ramadan. A
continuation of this normal trend is anticipated for the remainder of the year; however, security incidents will
likely be higher than previous years because of the contested outcome of the elections and planned
withdrawal of deployed international military by December 2014.
The prolonged presidential election period has caused uncertainty and high level of security incidents. Results
of the process should be known in mid- to late-September, but the chances of instability and ethnicity-based
violence is expected to increase given lack of support for the UN audit process among one of the candidates
and by both their powerful backers. The parliamentary elections will begin almost immediately after this,
ensuring that the security environment continues to be influenced by the political process. Bi-lateral security
agreements by NATO members have not been signed owing to the lack of a clear winner in the presidential
elections, thereby creating greater security vacuum that is being exploited by the AGEs.
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The Pakistan military operations along border areas with Afghanistan have also caused security challenges
within the country. There have been numerous reports of fighters moving into South East Afghanistan and
beyond, and it is assessed that many of these fighters were able to move relatively freely among displaced
persons, before heading deeper into other regions of Afghanistan. In some areas in the Eastern region of
Afghanistan, it is assessed that these factions have affected the leadership of local AGEs and may result in a
more hardline approach to humanitarian activities, including polio programme activities.
SECURITY INCIDENTS AGAINST THE POLIO PROGRAMME
Eight incidents and four fatalities occurred directly involving the Afghanistan polio programme during
February through September 2014. The majority have occurred in the Southern Region, traditionally the most
volatile Region in country with abduction of staff for short periods being the most common type of incident.
Analysis indicates that this is generally criminally motivated rather than a concerted effort to prevent the polio
programme from operating. There is no evidence of a concerted effort to prevent polio vaccination through
violence in Afghanistan.
Figure 20.
Source: UNICEF
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GPEI Partner Status Report - 25 September 2014
INACCESSIBILITY
Since August, access has improved substantially in Afghanistan with inaccessibility registering 0.55% of the
total target population. Limited campaigns were conducted during July because of Ramadan, with fewer
attempts to access and resulting in artificially low inaccessibility figures. Results mentioned below refer to
inaccessibility involving vaccination teams, not monitoring teams. Inaccessible districts continue to match areas
where security incidents are consistently high, and where the UN Security Levels System deems as high or
extreme threat.
Figure 21. Proportion of Missed Children due to Inaccessibility among Targeted Children <5 years of
age, by Region, Afghanistan, October 2013 to August 2014
Source: UNICEF
Southern Region has seen two areas that demonstrated significant improvements in inaccessibility.
Inaccessibility for the Region is assessed to have returned to pre-March 2014 levels of approximately 1% of
the 1.55 million children under 5 years of age.
Notable successes have occurred in Afghanistan to reduce inaccessibility:
• For most of the reporting period, Helmand Province was classified as 100% inaccessible with
approximately 700,000 children in the target population. After dialogue at several levels, and
subsequent changes in some personnel, access was gained in August. A single cluster in Sangin District
retains inaccessibility because of ongoing fighting.
• Kandahar Province, Southern Region has demonstrated pockets of inaccessibility, which was
particularly poor in Shawalikot and Mianashin Districts. Local dialogue held by access negotiators,
District Communication Officers, and District Polio Officers led to improved access for vaccination
teams.
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•
•
•
Issues remain in Ghorak District, Kandahar Province, where significant fighting is taking place. Afghan
National Security Forces control the District Admin Centre (DAC), and AGEs control the surrounding
areas. Inaccessibility now currently sits at 14% of the 8,811 target population and the focus now is
for dialogue in Kandahar Province to address this area.
East Region has elicited a sustained level of inaccessibility of approximately 2% of the 936,000
target population. Watapur District, Kunar Province is a success story in the area having been
inaccessible for more than four years. Progressive local level dialogue with key actors, led by District
Communication Officers, and District Polio Officers resulted in access being granted for vaccinators in
May 2014. This access has continued to be granted.
The effect of displaced persons moving from Pakistan into South East Region of Afghanistan (Khost
Province) has caused no substantial access problems. An isolated case of 26,000 children being
missed was rectified within days through local level dialogue. The movement of these people from
North Waziristan can be viewed as an opportunity to vaccinate those previously missed.
Figure 22. Inaccessible areas, 2014 WPV1 cases, and the estimated proportion of children affected during the
August 2014 SIA - Eastern Risk Area and Southern Sanctuary, Afghanistan
Source: WHO
*Data as of 9 September 2014
Page 24
GPEI Partner Status Report - 25 September 2014
OWNERSHIP
National
National EPI Committee Weekly Meetings
National
held
with minutes available
National
EPI Dialogue
CommitteeGroup
Weekly
Meetings
Polio
Policy
Quarterly
held
with
minutes
available
Meetings held with minutes available
Polio PolicyQuarterly
DialogueMeeting
Group Quarterly
President's
with
Meetings held
Governors
heldwith minutes available
President's Quarterly
Meeting
with
Inter-Ministerial
Task Force
Quarterly
Governorsheld
held
Meetings
Inter-Ministerial Task Force Quarterly
Meetings held
Regional
Regional/Provincial EPI Management Teams
RegionalMeetings held
Monthly
EPIminutes
Management
*Regional/Provincial
Held fortnightly ** No
availableTeams
Monthly Meetings held
Q4 '13
Q1 '14
Q2 '14
Q3 '14
Yes
Q4
'13
Yes*
Q1
'14
Yes*
Q2
'14
Yes*
Q3
'14
Yes
Yes
Yes*
Yes
Yes*
Yes
Yes*
Yes
Yes
No
Yes
No
Yes
No
Yes
No
No
No
No
Yes
No
Yes
No
Yes
No
Q4 '13
Yes
Q1 '14
Yes
Q2 '14
Yes
Q3 '14
Yes
Q4
'13
Yes
Q1
'14
Yes
Q2
'14
Yes
Q3
'14
Yes
Yes
Yes
Yes
* Held fortnightly ** No minutes available
Percent of Southern Region low performing districts meeting preparedness indicators
OWNERSHIP (CONTINUED)
Indicator: District Coordination Committee Meetings Held (yes / no)
Percent of Southern Region low performing districts meeting preparedness indicators
Low
Performing
Region
Districts Meetings
Dec Held
'13 (yes
Jan
'14
Feb '14
Mar '14
Indicator:
DistrictSouthern
Coordination
Committee
/ no)
Apr '14
May '14
Jun '14
Jul '14
Aug '14
8
Dec '13
100
8
8
Jan '14
100
8
8
Feb '14
100
8
5
Mar '14
60
5
5
Apr '14
80
5
5
May '14
80
5
5
Jun '14
80
5
Jul '14
5
Aug '14
80
5
Preparedness indicator met
Shahwalikot
100
Yes
100
Yes
100
Yes
60
Yes
80
Yes
80
Yes
80
Yes
80
Yes
Maiwand
Shahwalikot
Panjwai
Maiwand
Boldak
Panjwai
Bust (Lashkar Gah)
Boldak
Nahesaraj
Bust (Lashkar Gah)
Nadali
Nahesaraj
Sangin
Nadali
Kandahar
Sangin
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No*
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No campaign
No data
Yes
Yes
Districts Participating
Low Performing Southern Region Districts
Preparedness indicator met
Districts Participating
Kandahar
Abbreviations: EPI=Expanded
Program
No*
Yes on Immunization
Yes
Yes
Yes
Source: Afghanistan Campaign Dashboard, WHO-Afghanistan
No campaign No data
Abbreviations: EPI=Expanded Program on Immunization
* Meeting in Kandahar is not at district level but is the Provincial Coordination Committee Meeting which is held regularly before each campaign.
Source: Afghanistan Campaign Dashboard, WHO-Afghanistan
* Meeting in Kandahar is not at district level but is the Provincial Coordination Committee Meeting which is held regularly before each campaign.
Note: Results for 9 of the 11 Low Performing Districts were available at the time of this report. The 2 districts missing are Arghandab and Khakrez.
HUMAN RESOURCES
Location$
Number$of$
Number$(%)$of$
Number$(%)$of$
Salary$per$
vaccination$ vaccination$teams$with$ vaccination$teams$with$a$ vaccinator$/$day
teams
a$female$member
local$member
PEI$
Coordinator
Number$of$current$GPEI$staff
Provincial$Polio$
District$$$$$$$$$$
Total
Officer
Polio$Officer
Kandahar$and$
3,254
164$(5%)
2,992$(92%)
$5.00
3
20
20
43
Helmand
Nangarhar,$Kunar,$
Laghman$and$
2,846
140$(5%)
2,789$(98%)
$4.00
0
11
12
23
Nuristan$
*UNICEF$supports$40$District$communication$Officers$and$two$Provincial$Polio$Communication$Officers$in$Kandahar$and$Helmand.$In$the$Eastern$Region,$UNICEF$
support$22$District$communication$officers$and$three$Provincial$Polio$Communication$officers.$
Page 25
GPEI Partner Status Report - 25 September 2014
ROTARY INTERNATIONAL’S WORK IN AFGHANISTAN
Rotary has a small presence in Afghanistan, but remains active in the following targeted ways:
•
•
•
•
•
Representing Rotary at all government Poliovirus Epidemiology and Intervention activities, and advocate
at the local level with the authorities, including the Haj and Auqqaf religious department, police, education
department and local Governors.
Working with local influential figures and community leaders to help address refusals and change
perceptions of the programme.
Helping to reach children by providing funds for cross-border shelters on both the Afghanistan and
Pakistan side of the border.
Providing the funding and supervising the building of a dry vaccination storage facility that is being used
by EPI for enhanced routine immunization.
Providing funds for additional vaccinators to help address immunization requirements for travelers to
India.
Page 26
GPEI Partner Status Report - 25 September 2014
PERFORMANCE INDICATORS
IMMUNIZATION AND SURVEILLANCE
Figure 23. Six-month standard immunization indicators among children aged 6–35 months with NPAFP and
annualized surveillance indicators by province, Afghanistan and Pakistan February 2013 to August 2014
Source: CDC
*Data as of 2 September 2014
Page 27
GPEI Partner Status Report - 25 September 2014
GPEI POLIO ERADICATION AND ENDGAME STRATEGIC PLAN 2013–2018, AFGHANISTAN
STRATEGIC
PLAN
OBJECTIVE
OUTCOME INDICATORS (2013)
RESULTS
All wild poliovirus transmission
stopped by the end of 2014
STATUS
NA*
All cVDPV cases in 2013 were either a
continuation of the 2009 emergence or imported
from Pakistan. There are no identified cVDPV
cases in 2014 to date.
NA
Achieve and maintain an
NPAFP rate of › 2/100,000 in
all states/provinces of high-risk
countries and maintain an
NPAFP rate of › 2/100,000 in
all states/provinces
In the last 12 months, the national NPAFP rate
was 11.53/100,000, an absolute 2% increase
from the previous year. All provinces have
maintained a NPAFP rate >2/100,000.
Met
Achieve and maintain adequate
stool sample collection in
80% of cases in all states/
provinces
Nationally, 94% of AFP cases had adequate
stool specimen. All provinces have maintained
adequate stool collection in >80% of AFP cases
during the previous 12 months, which represents
a slight increase from 97% the previous rolling
year.
Met
LQAS passed at 80% threshold
in all high-risk areas
LQAS assessments continue to be limited. Using
available data, of the LQAS assessments
conducted in the Southern Sanctuary and Eastern
Risk Area, 62% have passed the 80% threshold.
Not Met
Establish full safety and security
framework
A security management plan is in place as part
of the overall security framework. Improvement
of dialogue with anti-government elements (AGE)
in the Southern Region resulted in improved
access to children during SIAs in the South.
Improvements also occurred in the Eastern Region
following improved coordination with AGE,
through intermediaries.
Established
All current cVDPV outbreaks
stopped by end-2013
More than 6 months have passed since the most
recent cVDPV case.
All new cVDPV outbreaks
stopped within 120 days
OUTPUT INDICATORS (2013)
Poliovirus
Detection and
Interruption:
Complete
the
interruption
of wild
poliovirus
transmission
globally and
more
rapidly detect
and interrupt
any new
outbreaks due
to vaccinederived
polioviruses
Met
* Not applicable
Page 28
GPEI Partner Status Report - 25 September 2014
SYNOPSIS
•
•
•
•
•
•
Epidemiology: Case counts decreased 62% in 2013 compared with 2012. However, as of 23 September
during 2014 to date there were ten WPV cases compared with four cases during the same time period in
2013. Three WPV1 cases occurred in the Southern region in late 2013 and early 2014, indicating that
the endemic spread of WPV1 transmission in this part of Afghanistan continues. The viruses from the two
cases had circulated undetected for more than 20 months, suggesting a surveillance gap. Seventeen of the
22 WPV cases that occurred in Afghanistan during 2013–2014 to date were reported in eastern
provinces bordering the KP and FATA Sanctuaries in Pakistan. Afghanistan will continue to remain at very
high risk for importation of WPV as long as transmission continues in Pakistan. No cVDPV cases have been
detected during 2014 to date.
Immunization: From August 2013 to August 2014, the proportions of children missed in SIAs as measured
by independent monitoring ranged from 5% to 13% (as high as 59% in LPDs). NPAFP data from the
endemic Southern Region suggest improvements in vaccination coverage during the previous 12 months
overall, except in Helmand province where SIA vaccinations were suspended during March–July 2014.
Vaccinations resumed in Helmand during late August and three SIA rounds are planned. NPAFP data
suggest a drop in vaccination coverage in the Eastern region (the proportion of zero-dose children
increased from 1% in 2012 to 5.9% in 2013). Nationally, during 2014 to date, none of the NPAFP cases
ages 6–23 months were in zero-dose children compared with 1.7% of cases during 2013. The circulation
of cVDPV2 into early 2013 highlighted weaknesses in the routine immunization system in the Southern
Region that appear to have been mitigated by tOPV SIAs and permanent polio team use of tOPV.
Security: The security situation continues to disrupt the ability to operate but despite this, the access
situation in the South has steadily improved since 2012. Negotiations through the International Committee
of the Red Cross and through the ICN in the Southern Region have been successful in reducing the number
of children missed because of inaccessibility, including again gaining access in Helmand in late August.
Credible channels of communication have been established to engage the AGE leadership systematically
through intermediaries.
Surveillance: AFP performance indicators and virologic data had in the past suggested substantial
surveillance gaps. In the most recent period, stool specimen adequacy has improved and virologic
evidence suggested improved performance after 2010. However, detection of six divergent (>1.5% from
closest link) WPV1 viruses in late 2013/2014 in Helmand, Kabul, Laghman, Nangarhar, and Uruzgan
suggests some potential gaps in surveillance in the areas which need to be addressed.
Ownership: At the national level, indicators suggest strong ownership within the Ministry of Public Health
but variable ownership elsewhere. There is concern whether the new government, when established, will
take ownership of the programme. Even now, however, meetings of the Inter-Ministerial Task Force and of
high-level governors with the President have been postponed consistently. Ownership is strong among
health leaders at the provincial levels but variable at the district level.
Community demand: Vaccine refusal accounted for up to 25% of missed children among all current 16
LPDs in the Southern Region and represented up to 5% of targeted children in some critical districts.
Trends indicate a decline in community demand from previous levels on average in the 11 LPDs, from
2.3% in January to 1.5% in July 2013. In November 2013 16% of children missed in SIAs in Afghanistan
were due to refusals. Among missed children in different regions the proportion due to refusals varied
from 11% in the East, 13.5% in the South and 19% in the Southeast.
Page 29
GPEI Partner Status Report - 25 September 2014
PAKISTAN
NATIONAL POLIO OVERVIEW
Figure 24. WPV and cVDPV cases, Pakistan, 2013 and 2014 to date*
The number of WPV cases in Pakistan
increased from 58 in 2012 to 93 in
2013, driven by an uncontrolled
outbreak in FATA since May 2013. As of
23 September, there have been 166
cases in 2014, compared with 28 for
the same time period in 2013. During
2013–2014, 70% of cases occurred in
FATA (mainly North Waziristan Agency)
and most of the remainder in KP with
other cases in Punjab, and Sindh. Cases
and environmental surveillance indicate
continued circulation in Sindh and KP
during 2013–2014. Case numbers in
Punjab decreased in the first quarter of
2014 but increased again in the second
quarter compared with 2013. No
WPV3 has been detected in Pakistan
since April 2012. There were 19 cVDPV
cases in 2014 to date (17 cases from
FATA and two from KP), compared with
25 cases during the same time period in
2013. Eleven SIAs have been conducted
during 2014 to date. SIAs have
primarily used bOPV; tOPV has been
used in the March NID and tOPV and
monovalent OPV type 1 (mOPV1) have
been used in select areas during SIADs
and SNIDs. Violence against healthcare
workers has continued sporadically and,
Source: WHO
*Data as of 9 September 2014
although this has adversely affected
vaccination in specific locations, the
programme has largely been able to maintain population immunity in those areas where access is not
impeded. Because of security concerns, the programme has been unable to conduct LQAS in the majority of
the country except for Karachi, where it has been used sporadically. Nonetheless, a successful series of oneday, once-a-week SIAs for 12 consecutive Sundays was completed without violence in and around Peshawar
earlier this year, with strong political commitment.
In response to military activity in Waziristan and the surge of IDPs from the area, 15 “Permanent Transit
Posts” (PTPs) were established in South KP and three in Frontier Region Bannu to vaccinate IDPs from North
Waziristan. Approximately 625,375 individuals (355,140 below 5 years of age) have been vaccinated
between 30 May and 31 August, 2014. Among these 380,629 (192,889 below 5 years of age) were
vaccinated at key PTPs in FR Bannu, Bannu, Hangu and Kurram Agency.
Page 30
GPEI Partner Status Report - 25 September 2014
ENVIRONMENTAL SURVEILLANCE
Environmental surveillance is ongoing at 30 sites throughout the country, including in two of the three poliovirus
sanctuaries (all but FATA) and the Quetta Risk Area. The frequency of detection of WPV from several
environmental sites declined in late 2012 and 2013 but increased in 2014. In 2012, 92 of 239 samples
(38%) were positive. In 2013, 20% were positive, and in 2014 to date 33% were positive. In 2014, WPV1
was isolated with increasing frequency (57% of samples in 2014 compared to 24% in 2013) from several
areas in Sindh, namely Baldia, G.Iqbal, Gadaap, and Hyderabad. WPV1 was isolated sporadically from
environmental specimens from Rawalpindi and Quetta in 2013 and from many specimens from various Lahore
sites during the second quarter of 2014. No WPV3 viruses have been detected in environmental specimens
since October 2010. cVDPV was detected in environmental specimens from Sindh in March through May 2014
but has not been detected again since then; the last case of cVDPV detected in Sindh was in July 2013.
VIROLOGY
(See also maps of WPV1 by genetic cluster and cVDPV2 in the Afghanistan section of this document, Figure 9,
page 14). Five genetic clusters of WPV1 were represented in specimens from polio cases and environmental
specimens in the past 12 months. Viral genetic diversity and levels of virus circulation were highest in FATA.
Wild virus has been exported from FATA to other parts of the country and Afghanistan. The number of cases
in Punjab increased as virus spilled over from FATA. WPV1 viruses were detected from environmental samples
in four provinces (Balochistan, KP, Punjab, and Sindh). One cluster of virus is localized to a specific geographic
location; a single R2A virus was found in environmental specimens in Quetta in late 2013.
VDPV emergence has resulted in cVDPV2 cases in Killa Abdullah district of the Quetta block, Balochistan, with
onset of the first case on 30 August 2012. The most recent cVDPV2 case in Balochistan was in June 2013.
cVDPV2 originating in Killa Abdullah spread to North Waziristan in FATA in April 2013, causing the ongoing
outbreak. This emergence group includes 16 cases from 2014; the onset of the most recent case was 23 June
2014. The first cVDPV2 from Pakistan environmental specimens was isolated from Karachi Gadaap in week
16 of 2013, and the most recent was isolated 20 May 2014 (related to North Waziristan emergence cluster;
the most recent isolate from the Kabul emergence cluster was on 14 March). A separate emergence group (N.
Waziristan) consists of five cases from 26 August 2013 to 11 January 2014. Two independent ambiguous
VDPV2 (aVDPV2s) were detected in AFP cases in FATA in the past 12 months.
The potential for surveillance gaps exists at the sub-national level, as evidenced by chains of transmission that
were detected only from environmental surveillance. The percentage of WPV1 isolates (from AFP surveillance)
with much less genetic linkage than expected has declined from 21% in 2009 to 5% in 2012 and 5% during
the reporting period (9/178 isolates from AFP cases).
1. Both WPV1 and cVDPV2 circulation increased during 2013–2014 compared with 2012,
due principally to ongoing outbreaks in FATA.
2. Viral genetic diversity and levels of virus circulation were highest in FATA in 2013.
3. The percentage of WPV1 isolates with less genetic linkage than expected has remained
stable from 2012 to the present. However, detection of long-standing WPV circulation only
by environmental surveillance provides virologic evidence of gaps in AFP surveillance.
Page 31
GPEI Partner Status Report - 25 September 2014
Figure 25. WPV1 and cVDPV2 cases and environmental isolates by genetic cluster (WPV1) and emergence
(cVDPV2), Pakistan, 12 August 2013 to 11 August 2014*
WPV1
cVDPV2
Source: CDC
* Data as of 20 August 2014
POLIOVIRUS SANCTUARIES AND RISK AREAS
At the time of this report, Pakistan has three designated virus sanctuaries and one risk area:
1.
2.
3.
4.
Federally Administered Tribal Areas (FATA) Sanctuary
Central and Southern districts of Khyber Pakhtunkhwa province (KP) Sanctuary
Karachi Sanctuary
Quetta Risk Area
The Quetta block (Quetta, Killa Abdullah, and Pishin) had been included as a sanctuary previously. Evidence
suggests that indigenous poliovirus is no longer circulating there since late 2013, although poor performance
indicators indicate ongoing risk. This area is now considered to be the Quetta Risk Area.
Page 32
GPEI Partner Status Report - 25 September 2014
FATA POLIOVIRUS SANCTUARY
Figure 26. WPV and cVDPV cases, FATA Sanctuary, 3 September 2013 to 2 September 2014*
Source: WHO
*Data as of 9 September 2014
LQAS surveys provide an assessment of SIA quality through a limited sample obtained from random cluster
sampling. LQAS surveys in many areas affected by conflict or security problems in Pakistan have not been
conducted at all, to avoid raising the visibility of the programme, or are not conducted in randomly selected
areas but rather in areas selected based on feasibility regarding the security situation. This will lead to
correspondingly biased results that may overstate SIA quality.
Other notes regarding LQAS:
• Pakistan has continued to use “old” decision rules (‘O’) of 0-5, 6-7, 8-12 and ≥13 for samples of five clusters of 10
children (50) and six clusters of 10 (60) for testing at thresholds of 95%, 90%, and 80%. These rules overstate SIA
quality. Please refer to discussion of methodological limitations in previous reports.
• “New” decision rules (‘N’) of 0, 1-2, 3-6, and 7-50 for sample sizes of 50 and 0, 1-3, 4-8, and 9-60 for sample sizes
of 60 provide a more reasonable quality assessment at 95% (High Pass), 90% (Pass), and 80% (Low) thresholds (or
Fail if below) for programmatic purposes under the same assumption of variability.
Page 33
GPEI Partner Status Report - 25 September 2014
!
Figure 27. WPV cases by week of onset and environmental surveillance results, FATA Sanctuary, Pakistan,
3 Sept 2013 – 2 Sept 2014*
Source: CDC
*Data as of 9 September 2014
Note: An aVDPV case recently re-classified as a cVDPV case is not included in Figure 27. Since June 2012, SIAs have not been
conducted in North or South Waziristan or in parts of Khyber Agency.
Figure 28. Proportion of Union Councils with LQAS survey results by SIA, FATA Sanctuary, Pakistan,
Sept 2013 to Aug 2014
Note: LQAS not conducted in FATA from March to August 2014. Since June 2012, SIAs have not been conducted in North or South Waziristan
or in parts of Khyber Agency.
Figures 29. Proportion of NPAFP cases 6 to 35 months, by OPV status, FATA Sanctuary, Pakistan**
Source: WHO
**Data as of 2 September 2014
Page 34
GPEI Partner Status Report - 25 September 2014
OWNERSHIP
Percent of Union Councils with indicators met for each campaign
Jan '14 R1 Jan '14 R2 Feb '14 R1 Feb '14 R2 Mar '14 R1 Mar '14 R2 Apr '14 R1 Apr '14 R1 May '14 R1 May '14 R2
FATA Sanctuary
UPEC meeting held
Jun '14
53
39
77
58
32
72
26
UPEC chaired by UCMO
100
100
100
100
100
100
100
Microplan Validated
94
94
95
95
94
92
77
≥1 Government member
87
90
92
88
87
72
≥1 Local member
99
99
97
98
97
82
≥1 Female member
13
12
14
14
14
11
Jul '14
Percent of teams with indicators met for each campaign
Abbreviations: UPEC=Union Council Polio Eradication Committee
No campaign
UCMO=Union Council Medical Officer
No data
Source: Pakistan National Emergency Action Plan Indicators, WHO-Pakistan
------------------------------------------------------------------------------------------------------------------------CENTRAL AND SOUTHERN KHYBER-PAKHTUNKHWA SANCTUARY
Figure 30. WPV and cVDPV cases, KP Sanctuary, 3 September 2013 to 2 September 2014*
This reservoir consists of Central
KP (Peshawar, Nowshera, Swabi,
Charsaddah, Mardan districts)
and Southern KP (Bannu, Tank,
Lakki Marwat districts). Data to
follow are presented for the
entire province.
Source: WHO
*Data as of 9 September 2014
Page 35
GPEI Partner Status Report - 25 September 2014
Figure 31. WPV cases by week of onset and environmental surveillance results, KP Sanctuary, Pakistan,
3 Sept 2013 to 2 Sept 2014*
Source: CDC
*Data as of 9 September 2014
Figure 32. Proportion of Union Councils with LQAS survey results by SIA, KP Sanctuary, Pakistan, Sept 2013
to Aug 2014
Note: LQAS not conducted in KP from March to August 2014.
Figure 33. Proportion of NPAFP cases 6 to 35 months, by OPV status, KP Sanctuary, Pakistan**
Source: WHO
**Data as of 2 September 2014
Page 36
GPEI Partner Status Report - 25 September 2014
OWNERSHIP
Percent of Union Councils with indicators met for each campaign
Jan '14 R1 Jan '14 R2 Feb '14 R1 Feb '14 R2 Mar '14 R1 Mar '14 R2 Apr '14 R1 Apr '14 R1 May '14 R1 May '14 R2
KP Sanctuary
UPEC meeting held
UPEC chaired by UCMO
Jun '14
26
Jul '14
53
73
46
84
68
85
99
100
100
100
100
100
100
100
100
17
85
72
Microplan Validated
71
≥1 Government
80
95
76
≥1 Local
78
99
100
≥1 Female
53
63
49
Percent of teams with indicators met for each campaign
Abbreviations: UPEC=Union Council Polio Eradication Committee
No campaign
UCMO=Union Council Medical Officer
No data
Source: Pakistan National Emergency Action Plan Indicators, WHO-Pakistan
-------------------------------------------------------------------------------------------------------------------------
KARACHI POLIOVIRUS SANCTUARY
Figure 34. WPV & cVDPV cases and environmental surveillance results, Karachi Sanctuary, 3 September 2013
to 2 September 2014*
All of Karachi is currently
serving as the WPV reservoir
within Sindh.
Source: WHO
*Data as of 9 September 2014
Page 37
GPEI Partner Status Report - 25 September 2014
Figure 35. WPV cases by week of onset and environmental surveillance results, Karachi Sanctuary, Pakistan,
3 Sept 2013 to 2 Sept 2014*
Source: CDC
*Data as of 9 September 2014
Figure 36. Proportion of union councils with LQAS survey results* by SIA, Karachi Sanctuary, Pakistan, Sept
to Aug 2014
Figure 37. Proportion of NPAFP cases 6 to 35 months, by OPV status, Karachi Sanctuary, Pakistan**
Source: WHO
**Data as of 2 September 2014
Page 38
GPEI Partner Status Report - 25 September 2014
OWNERSHIP
Percent of Union Councils with indicators met for each campaign
Jan '14 R1 Jan '14 R2 Feb '14 R1 Feb '14 R2 Mar '14 R1 Mar '14 R2 Apr '14 R1 Apr '14 R1 May '14 R1 May '14 R2
Sindh
UPEC meeting held
89
Jun '14
Jul '14
100
94
99
78
50
UPEC chaired by UCMO
100
100
100
100
100
Microplan Validated
99
99
98
100
86
≥ 1 Government member
96
98
97
97
86
≥ 1 Local member
98
99
98
99
84
≥ 1 Female member
92
92
93
91
78
Percent of teams with indicators met for each campaign
Abbreviations: UPEC=Union Council Polio Eradication Committee
No campaign
UCMO=Union Council Medical Officer
No data
Source: Pakistan National Emergency Action Plan Indicators, WHO-Pakistan
Data shown above are for all of Sindh Province
_________________________________________________________________________________
QUETTA RISK AREA (THE THREE HIGH-RISK DISTRICTS OF QUETTA, KILLA ABDULLAH, AND
PISHIN)
Figure 38. WPV and cVDPV2 cases, Quetta Risk Area, 3 September 2013 to 2 September 2014*
All endemic WPV circulation within
the Quetta block has apparently
been interruped. Pishin, Killa
Abdulah and Quetta now consitute
a risk zone for reintroduction of
WPV.
Note: an additional case in
Quetta block (in Quetta district)
with onset in August was
recently confirmed.
Source: WHO
*Data as of 9 September 2014
Page 39
GPEI Partner Status Report - 25 September 2014
Figure 39. WPV cases by week of onset and environmental surveillance results, Quetta Risk Area, Pakistan
3 Sept 2013 to 2 Sept 2014*
Source: CDC
*Data as of 9 September 2014
Figure 40. Proportion of Union Councils with LQAS survey results* by SIA, Quetta Risk Area, Sept 2013 to
Aug 2014
Note: LQAS not conducted in Quetta from May to August 2014.
Figure 41. Proportion of NPAFP cases 6 to 35 months, by OPV status, Quetta Risk Area, Pakistan**
Source: WHO
**Data as of 2 September 2014
Page 40
GPEI Partner Status Report - 25 September 2014
OWNERSHIP
Percent of Union Councils with indicators met for each campaign
Jan '14 R1 Jan '14 R2 Feb '14 R1 Feb '14 R2 Mar '14 R1 Mar '14 R2 Apr '14 R1 Apr '14 R1 May '14 R1 May '14 R2
Balochistan
UPEC meeting held
9
Jun '14
48
29
66
34
85
100
UPEC chaired by UCMO
100
100
100
99
100
100
100
Microplan Validated
69
88
92
90
100
100
66
≥ 1 Government member
69
49
≥ 1 Local member
96
75
≥ 1 Female member
52
75
Jul '14
17
Percent of teams with indicators met for each campaign
90
64
90
84
Abbreviations: UPEC=Union Council Polio Eradication Committee
UCMO=Union Council Medical Officer
81
69
87
52
100
89
92
62
51
53
27
67
No campaign
No data
Source: Pakistan National Emergency Action Plan Indicators, WHO-Pakistan
Data shown above are for all of the Balochistan Province
-------------------------------------------------------------------------------------------------------------------------
COMMUNICATION AND SOCIAL MOBILIZATION
HIGH DEMAND, BUT CRACKS
ARE SURFACING
Figure 42.
Despite Pakistan’s challenges, the
overwhelming majority of
Pakistan’s parents and caregivers
willingly vaccinate their children
in polio campaigns. Until April
2014, the aggregate high-risk
area refusal proportion had
fallen more than 80% since 2013
to just 0.1% - the lowest
proportion of polio-endemic
countries globally.
However, parents in KP and
Karachi are starting to show their
fatigue. The refusal proportion in
Pakistan has gone back up to
January 2013 levels,
predominantly because of
repeated dose refusals in these two areas.
Nearly 15% of 2014’s cases now come from refusal families, compared with 5.5% last year. Although the
refusal proportion is still miniscule among targeted children, the data show that refusal families are clustered
in under-vaccinated communities, and can be extremely dangerous. All polio cases come from families with no
formal education. This, together with Harvard polling data showing that 11% of all parents in FATA have
never heard of polio or a disease that causes paralysis, demonstrates that more must be done to reach these
families with more targeted communication methods: innovative voice, inter-personal or electronic messages
and dialogue.
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GPEI Partner Status Report - 25 September 2014
In Bannu District, where most IDPs from North Waziristan settled following the military operation, refusals are
being reported from all Union Councils (UCs), with 29 UCs reporting end of campaign refusal rates above
3%. The primary reasons for refusals since June have been “repeated campaign”, misconceptions and
religious. A focus group discussion held with IDPs based in Bannu in July revealed that parents wanted more
information about the effectiveness and ingredients of the vaccine. Most parents who were refusing
understood the consequence of not vaccinating but were prepared to take the risk. Refusals have reportedly
already come down from their peak of 15,000 in July to 9,000 by end of August
REACHING CHILDREN ON THE MOVE
This year, to date, 74% of all polio cases are from four tribal groups of FATA’s North and South Waziristan,
where 290,000 children have been inaccessible because of a militant ban on polio vaccination since June
2012. The military operation launched in May has resulted in the mass exodus of displaced people from
North Waziristan, providing the programme with its long-awaited opportunity to vaccinate these children.
UNICEF’s COMNet, which was already working in North and South Waziristan to facilitate the use of
functioning health centers and encourage self-vaccination by caregivers of unprotected children, has travelled
out with these families to FR Bannu and neighboring districts and is actively engaging these communities for
polio vaccination.
UNICEF’s four provincial offices have adopted an ‘All for FATA’ approach to identify the four priority tribal
groups that dominate poliovirus transmission wherever they are throughout the country. UNICEF’s goal is to
build community trust and to ensure that the tribal groups are reached with language- and issue-specific
messaging, are identified and included in microplans, and reached during campaigns and in transit.
To ensure immediate
response to the large scale
displacement from North
Waziristan, 241 mobilizers
were trained and deployed
in FATA and South KP
districts of FR Bannu, Bannu,
Lakki Marwat, DI Khan,
Kohat and Hangu.
Figure 43.
Close coordination with
Afghanistan to track
immunization and security in
border areas has contributed
to the now-high coverage
across the borders. All this
groundwork has contributed
to near-universal acceptance
of the vaccine at transit
points, refugee and IDP
camps and among nearby
host communities. Nearly two million were vaccinated at transit points in June 2014, and more than one million
have been vaccinated each month since January of this year.
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GPEI Partner Status Report - 25 September 2014
REACHING MISSED CHILDREN IN ACCESSIBLE AREAS
With refusals no longer a primary reason for missing children, UNICEF has focused much of its attention to
reaching and facilitating immunization of the approximately 100,000 children in accessible areas missed
because of poor campaign quality. Many of these children are missed at the doorstep because they are out
of the home or the district, because vaccinators have the wrong profile (too young, not from the local
community) or they lack the IPC skills to identify all children in the household or convince the caregiver to bring
all children to the doorstep for vaccination.
Multi-layered social data down to the UC level helps UNICEF identify and increasingly reach children who are
‘Not Available’ in campaigns. Literacy levels, media preferences, seasonal migration patterns, routes and
livelihood choices are analyzed and strategies redesigned to ensure that vaccine is available at the right time
and place to maximize each chance to reach every child.
On average,
more than 70%
of children can
be found within
their district
when
vaccinators
arrive, and can
be recovered
with adequate
revisit and outof-house
vaccination
strategies. Most
children are
visiting
relatives and
should be
reached at
other
households.
Figure 44. Summary of information on unavailable children, Pakistan February–June
2014
The IMB in May
challenged
COMNet to
double its initial
absence recovery rate of 40%. Since then, COMNet has been fairly consistent in recovering more than 60%
of children absent, but the figures fluctuate, indicating that this is not yet a systematic standard across the
network. Absence conversion has been included as a key performance indicator as part of frontline worker
performance monitoring. Given the social and operational strategies needed to recover children out of the
house, all partners must be held accountable for raising this conversion rate.
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GPEI Partner Status Report - 25 September 2014
ENGAGING COMMUNITIES FOR ACCESS
The Pakistan programme has rejected the mentality of “waiting for access to open up” before acting, and has
focused on proactive efforts that allow access to children even in the most challenging circumstances. Until
August, 74,000 children under age five remained in South Waziristan, but door-to-door campaigns could only
access 8,000 (11%) of them. Two months ago, COMNet staff identified religious influencers and held a series
of meetings with the Taliban/Mujahedeen for accessing the remaining 66,000 inaccessible Wazir children
Figure 45.
with door-to-door
campaigns. At the
same time, more than
20 COMNet staff
have been working in
South Waziristan to
help caregivers
facilitate selfadminister OPV inside
their homes for those
who could not be
reached with
campaigns. From
March to July, 1,184
children were selfvaccinated and many
more families
sensitized about the
importance of
vaccination.
In July, COMNet also
facilitated free health
camps operated by the military and Government health authorities, which vaccinated 2,054 children. They
also performed a cold chain inventory of the 22 registered health facilities in South Waziristan, of which only
half were found to have functional EPI centers.
The negotiations with the Taliban also bore fruit in August, with access to 91% of the children <5 years of
age in South Waziristan achieved through health facility-based vaccination. Agreement was also granted for
door-to-door polio vaccination in the 13 previously inaccessible areas. Campaigns are to start in September.
ENGAGING WOMEN
UNICEF is adding a fourth tier of female community mobilizers to the COMNet structure as an innovative
approach to raising the proportion of female mobilizers. More than 500 Female Community Mobilizers will
be hired in the next quarter to focus specifically on mothers, and on reaching newborns and children under
age 2 years within households. The Female Community Mobilizers will be deployed in top priority high-risk
areas where children are being consistently missed during campaigns.
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GPEI Partner Status Report - 25 September 2014
PROGRAMME INFORMATION
ACCESSIBILITY AND SECURITY
Pakistan remains a politically volatile country during 2013-14 with no signs that stability is on the horizon as
political protests continue across the country and Islamabad, in particular. In June 2012 various Pakistan
Taliban elements issued a ban on polio vaccinations citing numerous reasons, including the belief that the polio
programme was a cover for a U.S. spying campaign and the ongoing use of drone strikes. This led to North
Waziristan as well as large areas in South Waziristan becoming completely inaccessible to polio workers.
Figure 46. Inaccessible areas during the August 2014 SIA and 2014 WPV1 and cVDPV cases,
Pakistan*
Source: WHO
*Data as of 9 September 2014
In all of Pakistan, between June 2012 and January 2014, 24 killings occurred (10 each in 2012 and 2013
and four in 2014) that could be reasonably attributed to the victims’ connection with polio. In addition, there
were 36 deaths, mainly of security escorts, where the link to polio is unclear. Also, numerous reported cases of
intimidation serve to create fear and panic among polio workers leading to areas becoming inaccessible.
In June, the Pakistan Military launched Operation Zarb-e-Azb in North and South Waziristan to drive militant
factions out of those areas. Many such operations have been conducted previously with varying degrees of
success. This current operation has led to almost a million IDPs appearing in the settled areas around
Waziristan and neighboring Afghanistan. This has created opportunities to access children from North
Waziristan who have been unvaccinated for two years but it has also led to the threat of the spread of polio
from North Waziristan across other areas of Pakistan and Afghanistan. SIAs targeting IDPS were successfully
implemented in southern KP districts and FATA agencies.
It is vital that the local context of the security and access situation is fully understood and that such information
is acted upon immediately. In this regard, analysis that has been carried out in the FR Bannu, where children
Page 45
GPEI Partner Status Report - 25 September 2014
were missed in four areas for ‘security reasons’ and fear, revealed reasons different from those of the
neighboring areas. A plan has been put in place to gain access to these missed children.
Local COMNet staff have proven to be successful in understanding local security and accessibility issues. In
particular, work is being developed to facilitate the easy and rapid two-way flow of information between
polio workers (including COMNet staff) with higher levels, which will allow warnings to be raised in a timely
manner and for local cases of inaccessibility to be addressed immediately. This approach, which has been
proven effective in reducing community/parental refusals will greatly assist in improved reporting on security
and accessibility.
HUMAN RESOURCES
Location (sanctuary)
FATA *
KP (province)
KP (High risk districts:
Peshawar, Charsadda,
Mardan, Nowshehra, Lakki
Marwat)
Karachi (three high-risk
towns: Baldia, Gadap, and
Gulshen Iqbal)
Quetta (Quetta, Killa
Abdullah, and Pishin districts)
Total number of
house to house
vaccination teams
Number (%) of house to
Number (%) of
Salary per
house vaccination teams
house to house
with at least one female vaccination teams vaccinator per day
member
with a local member
2,169
299 (14%)
2118 (98%)
$3.50
19,358
10043 (52%)
16530 (85%)
$2.50
Remarks
$1.00 additional, since FATA is a region with security
hazard
See below for high risk districts
Peshawar (since February 2014), Mardan, Charsadda and
Swabi (since April 2014) are conducting SIAs in one day
and paying $5.00 per day, while Lakki Marwat in 3 days
9,424
5543 (59%)
9424 (100%)
$5.00
2,887
2,773 (96%)
2,757 (95%)
$5.00
Karachi is implementing the SIAs in one day since mid
March 2014
1,609
877 (55%)
1,421 (88%)
$5.00
$2.5 paid through Partner (WHO) and $2.5 paid by the
provincial Government
* Accessible areas only
ROTARY INTERNATIONAL’S WORK IN PAKISTAN
Rotarians in Pakistan have developed a targeted strategy for outreach related to polio eradication activities
in alignment with the National Emergency Action Plan. This involves Rotarians participating in high level
meetings with the President, district heads, and health ministers, as well as outreach to corporate and NGO
partners to help build broader support for the programme. Rotarians have worked with Coca Cola Pakistan
to raise awareness through billboards, and at the reverse-osmosis water filtration plants in high-risk areas. A
new partnership with Telenor provides e-monitoring through the use of cell phones for female health workers,
community mid-wives, and health facility managers.
Rotarians are helping to raise awareness among influential persons in high-risk communities through polio
orientation and planning workshops, as well as Ulema polio awareness workshops. The Speaking Book
project has served as an educational tool for use at polio resource centers and in schools.
Rotarians in Pakistan have addressed the inaccessibility issue in high-risk areas through the development of
Polio Resource Centers, which are organized in collaboration with local NGOs. They provide social
mobilization and health services along with polio vaccines. Nine centers have reached more than 111,000
children and helped convert more than 8,500 refusals. The resource centers are located in the following
communities:
• Killa Abdullah
• Pashin
• Loralai
• Gulshan Town-Karachi
Page 46
GPEI Partner Status Report - 25 September 2014
•
•
•
•
•
Mirpurkhas
Nowshera
Peshawar City
Peshawar Khairun Nas
Turbat
Rotary Clubs have also created permanent immunization centers in 14 areas, mostly located in Karachi and
Lahore, and established permanent transit posts in 10 areas, with four additional transit posts in process,
which have helped to cover more than 9 million children. The transit posts are located at the following points:
• Super Highway-Karachi (two posts)
• National Highway- Karachi
• Zoological Garden-Karachi City
• Mandi More-Rawalpindi
• Attock-G.T Road
• Killa Abdullah
• Chaman- Pak Afghan Border
• Torkhum- Pak Afghan border
• Jaccobabad-Sindh
• Gujranwala- Punjab
Rotarians are working on developing mobile vaccination services at railways, and in collaboration with WHO
and the provincial government, planning to reach children located in high-rise buildings and public places
through the installation of 18 kiosks, with an additional 60 planned.
PERFORMANCE INDICATORS
IMMUNIZATION AND SURVEILLANCE
(See Figure 23, Six-month standard immunization indicators among children aged 6–35 months with NPAFP
and annualized surveillance indicators by province, Afghanistan and Pakistan February 2013 to August 2014,
on page 28).
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GPEI Partner Status Report - 25 September 2014
GPEI POLIO ERADICATION AND ENDGAME STRATEGIC PLAN 2013–2018, PAKISTAN
STRATEGIC!
PLAN!
OBJECTIVE!
OUTCOME!INDICATORS!
(2013)!
RESULTS!
All!wild!poliovirus!transmission!
!!
stopped!by!the!end!of!2014!
!
Poliovirus!
Detection!and!
Interruption:!
Complete!
the!
interruption!
of!wild!
poliovirus!
transmission!
globally!and!
more!
rapidly!detect!
and!interrupt!
any!new!
outbreaks!due!
to!vaccineM
derived!
polioviruses!
!
All!new!cVDPV!outbreaks!
stopped!within!120!days!
Most!cVDPV!cases!in!2013!were!continuation!
of!2012!emergence.!After!a!new!emergence!in!
North!Waziristan,!all!reported!cases!occurred!
within!5!months!from!first!to!most!recently!
confirmed!case.!
OUTPUT!INDICATORS!(2013)!
!!
Achieve!and!maintain!an!
NPAFP!rate!of!›!2/100,000!in!
all!states/provinces!of!highM
risk!countries!and!maintain!an!
NPAFP!rate!of!›!2/100,000!in!
all!states/provinces!!
National!NPAFP!rate!during!16!August!2013!to!
15!August!2014!period!was!5.6/100,000,!a!0.4%!
decrease!from!the!previous!rolling!year.!Only!
75%!of!provinces!have!maintained!NPAFP!
>2/100,000!this!time,!compared!with!87.5%!
the!previous!rolling!year.!
Achieve!and!maintain!
adequate!stool!sample!
collection!in!80%!of!cases!in!all!
states/provinces!!
LQAS!passed!at!90%!threshold!
in!all!highMrisk!areas!
Establish!full!safety!and!
security!
framework!!
All!current!cVDPV!outbreaks!
stopped!by!endM2013!
Nationally!the!proportion!of!AFP!cases!with!
adequate!stool!was!93%,!marking!an!absolute!
3%!increase!from!the!previous!period.!All!
provinces!have!maintained!adequate!stool!
collection!in!>80%!of!AFP!cases!during!16!
August!2013!to!16!August!2014.!This!
represents!an!absolute!12.5%!increase!from!
the!previous!year.!
Over!the!last!12!months,!of!the!649!LQAS!
assessments!conducted!in!the!sanctuaries!and!
risk!area,!4%!have!passed!at!the!90%!threshold!
and!22%!have!passed!at!the!80%!threshold.!
Performance!has!been!particularly!poor!in!
Quetta.!
A!plan!to!provide!security!to!UN!polio!workers!
has!been!developed!and!is!supported!by!all!
stakeholders.!A!framework!for!operating!in!
insecure!areas!has!been!incorporated!into!the!
current!version!of!the!National!Emergency!
Action!Plan.!Discussions!and!efforts!with!
provincial!and!national!authorities!continue!to!
enhance!security!for!all!government!health!
workers!involved!in!SIAs,!
Circulation!in!2012!and!2013!after!!emergence!
in!2012!was!not!interrupted!by!endM2013!
STATUS!
NA*!!
NA!!
!!
Not Fully Met!
Met!
Not!Met!
Established!!
Not!Met!
* Not applicable
Page 48
GPEI Partner Status Report - 25 September 2014
SYNOPSIS
•
•
•
•
•
•
Epidemiology: An ongoing outbreak of WPV1 and cVDPV2 in the population from North Waziristan that
started around April 2013 and has caused a surge in cases and exportation to Afghanistan and other
parts of Pakistan. There are more than four times as many WPV1 cases during 2014 to date as there was
during the same time period in 2013. During 2014, 93% of cases were reported among children aged
<36 months. Among them, 67% received no OPV doses from routine or supplemental immunizations.
During 2014, WPV1 cases were reported in 21 (13%) of 157 districts compared with 15 (10%) districts
in 2013. Most WPV1 cases reported during 2014 were from FATA and KP (71% and 18% respectively),
57% of cases in FATA were from North Waziristan. The incidence of cVDPV cases has decreased in 2014
with most cases occurring in FATA (FR Bannu and North Waziristan); however isolation continued from
environmental surveillance sites in Sindh.
Immunization: Polio vaccination has not resumed in North Waziristan but immunization activities targeted
populations displaced by military action in North Waziristan. Through the use of transit posts, border
vaccination teams, and vaccinations at IDP camps, children leaving North Waziristan were vaccinated. In
FATA, during 2014 to date, 61% of non-polio AFP cases ages 6–23 months were zero-dose children and
25−34% of children were inaccessible during SIAs. The ongoing detection of cVDPV among cases and in
environmental specimens indicates the presence of immunity gaps than remain mainly in populations that
have been inaccessible.
Security: Pakistan’s political and security situations will remain unstable for the foreseeable future.
However, the population movements resulting from the current military offensive has provided the
opportunity to vaccinate the majority of hard-to-reach children located particularly in North Waziristan.
The remaining pockets of inaccessibility should now be the focus to help interrupt WPV transmission in
Pakistan. The completion of 12 consecutive Sunday vaccination campaigns in Peshawar earlier this year
provides an example of how, with strong political commitment, SIAs can be carried out without violence.
To conduct similar large scale “protected campaigns” in the high-risk UCs of Karachi, high-level
commitment and support from both the political parties in control of Sindh province and Greater Karachi is
critical. Engagement with the Military is also necessary to be able to fully exploit access to Bara Tehsil in
Khyber Agency, and to get a better sense of when the Military might provide access to conduct
vaccination activities in North Waziristan. This engagement should follow the agreed protocols of the
POB-endorsed approach. i.e., military or local law enforcement forces will not be directly involved in
administering vaccines, and that the use of military will be time-limited and considered as a last resort
Surveillance: Although overall strong, some indicators suggest decreased surveillance performance. The
percentage of WPV1 isolates with less genetic linkage than expected has decreased since 2012.
Detection of long-standing WPV circulation only by environmental surveillance provides virologic evidence
of gaps in AFP surveillance. Analysis of NPAFP cases and surveillance indicators suggests some underreporting of cases in FATA.
Ownership: The high degree of political commitment in KP is encouraging and has already produced
concrete results. The declining number of UPEC meetings held in each area, particularly in FATA and
Quetta, is concerning. On 12 September, the Government of Pakistan signed a loan agreement with the
Islamic Development Bank for program implementation. Although encouraging, the lengthy delay in
signing resulted in the scaling back of SIAs scheduled in September. The decision of the Prime Minister on
the IMB and Technical Advisory Group recommendations to establish federal and provincial emergency
operations centers is still pending.
Community Demand: Despite Pakistan’s challenges, the overwhelming majority of Pakistan’s parents and
caregivers willingly vaccinate their children in polio campaigns. More than 99% of parents in most parts
of the country accept vaccine for their children if vaccinators reach the doorstep. However, parents in KP
and Karachi are starting to show their fatigue. The refusal rate has increased by 80% over the past 3
months in these two areas, predominantly because of repeated doses. Nearly 15% of Pakistan’s 2014’s
cases now come from refusal families, compared with 5.5% last year. Although the refusal proportion is
still miniscule, the data show that refusal families are clustered in under-vaccinated communities, and can
be extremely challenging.
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GPEI Partner Status Report - 25 September 2014
NIGERIA
NATIONAL POLIO OVERVIEW
Figure 47. WPV and cVDPV cases, Nigeria, 2013 and 2014 to date*
The number of WPV cases in Nigeria
decreased from 122 in 2012 to 53 in
2013. As of 9 September 2014, there were
six WPV cases year-to-date, compared
with 46 during the same period in 2013.
No WPV3 has been detected since
November of 2012.
Since September 2012, no WPV cases have
been reported in the Northwest (Sokoto,
Zamfara as well as Kebbi) and since 9
September 2013, WPV cases have been
limited to Kano State (most recent case, 24
July 2014) and Borno/Yobe (19 April
2014). The most recent WPV cases have all
occurred in rural local government areas
(LGAs) in southern Kano, in what the
programme considers a “transmission zone”
cVDPV case numbers have increased, from
eight in 2012 and four in 2013 to 19 so far
in 2014, 13 of which have occurred since
May. Seven of these cases have occurred
in Kano and 12 in Borno. Environmental
surveillance has repeatedly detected
cVDPVs in Sokoto and Borno since mid2013 and sporadically in Kano and in
Kaduna more recently.
Throughout 2013 and continuing into 2014,
Nigeria implemented a broad array of
innovations in its polio programme, with
substantial improvement in SIA quality as
measured by LQAS, especially in Kano
State. Among the 85 highest-risk LGAs in
Source: WHO
*Data as of 9 September 2014
northern Nigeria, >80% have achieved the
“≥80%” threshold on LQAS (i.e., eight or fewer missed children out of 60) since January and >90% have
achieved this threshold since May.
Much of the programme’s attention is currently focused on two transmission zones: the “Kano” zone, which
includes non-urban LGAs in the south of the state as well as LGAs in north-eastern Kaduna State and northwestern Bauchi State, and the Borno/Yobe zone. In Kano State, operations are being led by a very assertive
emergency operations Centre (EOC) headquartered in Kano City. A number of changes have been made to
the programme, such as:
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GPEI Partner Status Report - 25 September 2014
1) An extensive, state-wide walk-through microplanning exercise earlier this year resulted in an almost
50% reduction in the target population for SIAs (children under 5 years of age).
2) The programme has been treating any new WPV case as an outbreak. After the July case in Sumaila
LGA, the EOC moved temporarily to the affected LGA and rapidly organized together with the
national programme three outbreak response SIAs to supplement the SNIDs already scheduled.
3) A Vaccination Tracking System (VTS) technology uses the GPS in mobile phones to monitor the
geographical movements of vaccination teams across Kano. This tool improves accountability by
ensuring that teams are in their assigned areas and provides another means of understanding
campaign quality, identifying areas that have been missed. The VTS shows increased geocoverage in
Kano—from 82% of the microplan area in February 2013 to 90% in August 2014.
4) A “Hard-to-Reach” project was rolled out in May in 751 settlements from 109 wards across 27 LGAs.
This project aims to deliver at least four doses of polio vaccine to all children 0–59 months of age in
these hard-to-reach and underserved settlements. Alongside its goal of increasing overall immunity in
these vulnerable areas by June 2015, the project is also delivering basic health services to these
communities, which are outside of the reach of existing health facilities. A similar initiative is underway
in five other states—Bauchi, Borno, Yobe, Kaduna and Katsina—targeting more than 2,500
settlements.
The national programme is looking into implementing additional measures, including “directly observed polio
vaccination” to improve team performance in areas with poor performance or a history of non-compliance
and “health camps” to help build community confidence in the programme. Additionally, 15 hard-toreach/rural LGAs around the border of Kano state have been selected for a 3-month PEI/routine
immunization intensification between September and December 2014. The intensification efforts will include
accelerating routine immunization activities, increasing supervision in SIAs, and strengthening surveillance.
In Borno and Yobe, and recently in northern parts of Adamawa, insecurity continues to be an overriding
factor, particularly in a band of LGAs south of Maiduguri stretching from Yobe to Cameroon. The programme
has continued innovations previously described, including permanent health teams, transit-point vaccination,
vaccination in camps for IDPs, “hit and run” vaccination (rapid implementation of short-interval SIAs to take
advantage of openings in inaccessible zones), and “health camps” (fixed-point vaccination centers providing a
variety of health services during SIAs). A strategy that will be expanded before the end of the year is the
vaccination of children at malnutrition treatment centers in Borno, linked to communities by referrals from over
550 volunteer community mobilizers (VCMs). In addition, for the first time in Nigeria, IPV was included as part
of SIAs in Borno (entire state) and Yobe (selected wards in seven LGAs). The campaign took place in two
phases, in June and August. The target group was 1.7 million children 14 weeks to 59 months old.
While much of the programme’s attention has been set on interrupting the last remaining chains of WPV1
transmission by the end of 2014, cVDPV circulation has expanded. Nigeria has experienced a prolonged
outbreak of cVDPV2 since 2005, peaking at 155 cases in 2009. By early 2012, a series of tOPV SIAs had
mostly but not entirely stopped new emergences from that outbreak but did not eliminate the dominant
lineage. cVDPV2 currently circulating in Nigeria is from both that outbreak and from a 2012–2013 cVDPV2
outbreak in Chad that spread to Nigeria and Cameroon. Driving the cVDPV outbreak in Nigeria is the
extremely low routine immunization coverage in the north and the almost exclusive use of bOPV during SIAs
between April 2013 and June 2014 (with no planned SIA during Ramadan in July, except in parts of the
North-Central sanctuary). Additionally, because of violence during the prior month, Borno and Kano did not
participate in the March 2013 tOPV SIA. To address low poliovirus 2 immunity, the programme conducted a
tOPV SIA in August 2014 and plans a second in November. tOPV was also used in Borno during the
December 2013 SIA, in selected areas of Borno in February and May 2014, and in Adamawa in February
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GPEI Partner Status Report - 25 September 2014
2014. In addition, the programme has used IPV throughout Borno and parts of Yobe. Nigeria’s Expert Review
Committee recently recommended that IPV also be used in southern Kano to boost population immunity and
accelerate interruption of WPV transmission.
The polio programme supports targeted effort to improve routine immunization in key areas, including 76
LGAs in the endemic northern States with weak routine immunization coverage and at high risk of cVDPVs.
Capacity building to improve Reaching Every Ward implementation is underway in Taraba and Adamawa.
AFP surveillance performance indicators have steadily improved in Nigeria in recent years, with the national
NPAFP rate now exceeding 13 per 100,000 children <15 years of age per year and a national stool
adequacy proportion of 97%. In Both Borno and Yobe, NPAFP reporting rates are increased over last year,
to 14.7 per 100,000 children <15 years per year in Borno and 12.4 per 100,000 children <15 years per
year in Yobe, and stool adequacy proportions exceed 98%.
In upcoming months, Nigeria faces two potential disruptions to its polio programme: the general elections in
early 2015 and the threat of further importations or spread of Ebola. In addition, the programme has a
funding gap of US $22 million for 2014 and $178 million for 2015.
VIROLOGY
During August 2013 through August 2014 the number of genetic lineages declined compared with the
previous 12-month period. Four clusters (N5A1, N5A2, N5A3 and N7B) were active, associated with cases
during 2013 whereas only one cluster (N5A3) was detected from AFP cases during 2014 and one other
(N5A1) detected through environmental surveillance. Cluster N5A3 detection was localized to only two NorthCentral/Northeast Sanctuary states (Kano and Yobe) in 2014. The most recent isolate corresponded to an
AFP case in Kano with onset date of 24 July 2014 and closely related to local circulation within the state.
Between August and December 2013, three WPV1 cluster N7B viruses were detected, circulating within Borno
state in the Northeast sanctuary and one virus was detected in Kano state. The most recent case in cluster N7B
was in Borno with onset date 15 December 2013. Orphan viruses were detected in five AFP cases, three in
cluster N5A3 and two in cluster N7B. An additional WPV1 orphan virus (cluster N5A1) was detected in an
environmental sample from Kaduna state collected 5 May 2014.
During the reporting period, two WPV1 were isolated from environmental specimens collected in two sites.
The WPV1 isolated from Kaduna environmental samples was detected in early May 2014, an orphan virus
related to a lineage in cluster N5A1 circulating in Kano in 2013 and Katsina in 2012. The only other WPV1
detected in environmental samples was from Borno in week 42 (October) of 2013 and was from cluster N7B.
Genomic sequence analysis reveals continued surveillance gaps, including some chains of WPV transmission
during 2013 and 2014 that went undetected for more than a year. Viruses from AFP cases from three states
(Borno, Kaduna, and Yobe) had less genetic linkage than expected with sensitive AFP surveillance. Nationally,
the percentage of WPV1 isolates with much less genetic linkage than expected declined substantially from
88% (7 of 8 positives) during 2010 to 13% (12 of 103) during 2012 but it has increased to 33% (2 of 6)
during the reporting period.
1. The genetic diversity of WPV1 strains has declined during August 2013 through August
2014 compared with the previous 12-month period.
2. WPV1 isolation from environmental specimens remained low during the reporting
period.
3. Virologic data indicate continued gaps in AFP surveillance.
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GPEI Partner Status Report - 25 September 2014
Figure 48. Wild poliovirus type 1 (WPV1) by genetic cluster and circulating vaccine-derived poliovirus type 2
(cVDPV2) by emergence, Nigeria, 2013 and 2014 to date*
2013
2014
WPV1
cVDPV2
Source: CDC
*Data as of 20 August 2014
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GPEI Partner Status Report - 25 September 2014
Figure 49. WPV1 cases and environmental isolates by genetic cluster, Nigeria, 12 August 2013 to 11
August 2014*
Source: CDC
*Data as of 20 August 2014
CIRCULATING VDPV2 IN WEST AND CENTRAL AFRICA
cVDPV2 emergence in Nigeria: The number of cVDPV2 cases associated with circulating Nigerian lineages
(from Nigerian emergences) increased substantially during 2014. Seven cases were detected in two states;
Kano (6 cases) and Borno (1 case). The last case detected corresponded to an AFP case in Kano with onset
date 22 June 2014. From all AFP cases, 14% had less genetic linkage than expected with sensitive AFP
surveillance. Environmental sampling detected 64 cVDPV2s in five states (Borno, Kaduna, Kano, Katsina, and
Sokoto) from the Nigerian emergence group 2005-8, which has been circulating for more than nine years.
Additionally, independent aVDPV2 emergences occurred in four states (cases in Kano and Federal Capital
Territory, and environmental samples in Kano, Sokoto, and Kaduna) during 2014.
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GPEI Partner Status Report - 25 September 2014
Figure 50. cVDPV2 in Nigeria and Niger by emergence, 12 August 2013 to 11 August 2014*
Source: CDC
* Data as of 20 August 2014
cVDPV2 emergence in Chad: VDPV2 emergence in Chad in 2012 affected Nigeria, Niger and Cameroon.
During the reporting period, 17 new cases (five in 2013 and twelve in 2014) were detected in Nigeria (and
one detected in Niger in 2014 representing a Nigerian child), corresponding to the emergence group A of the
2012 Chad cVDPV2 outbreak. Most cases were detected in Borno, in addition to cases in Adamawa and
Kano states. The latest case had onset date of 21 June 2014. During 2014, sentinel environmental sites in
Borno identified more than 30 samples with viruses genetically linked to the Chad cVDPV2 group A outbreak.
The only other environmental site reporting viruses linked to this emergence was in Kano state. During the
reporting period, there were no cases reported from Cameroon. One AFP case was reported in Niger with
onset date 14 May 2014.
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GPEI Partner Status Report - 25 September 2014
POLIOVIRUS SANCTUARIES AND RISK AREAS
At the time of this report, Nigeria has two virus sanctuaries and one risk area:
1. North-Central Sanctuary (Kano, Katsina, Jigawa, and Kaduna)
2. Northeast Sanctuary (Borno and Yobe)
3. Northwest Risk Area (Sokoto and Zamfara)
Although WPV cases have not been identified in Katsina and Kanduna since 2012, these states with Kano and
Jigawa formed a common reservoir of linked WPV clusters until that time that often led to circulation in Bauchi
state. The Northwest states of Sokoto and Zamfara do not appear to have circulating WPV; these states are
now referred to as the Northwest Risk Area.
NORTH-CENTRAL SANCTUARY
Figure 51. WPV and cVDPV cases, North-Central Sanctuary, 3 September 2013 to 2 September 2014*
Notes regarding Nigeria’s LQAS
survey results (see next page).
Decision rules of 0–3, 4–8, 9–19, and
20–60 for sample sizes of 60 in
Nigeria provide a reasonable
assessment of SIA quality at 90%
(High Pass), 80% (Pass), and 60%
(Low) thresholds (or Fail if below) for
programmatic purposes under the
assumption of moderate variability in
cluster-level results.
Source: WHO
Data as of 9 September 2014
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GPEI Partner Status Report - 25 September 2014
Figure 52. WPV and cVDPV cases by week of onset and environmental surveillance results, North-Central
Sanctuary (Kano, Katsina, Jigawa, and Kaduna), Nigeria, 3 Sept 2013 to 2 Sept 2014*
Source: CDC
*Data as of 9 September 2014
Data not Available
Figure 53. Proportion of LGAs with LQAS survey results by SIA, North-Central Sanctuary, Nigeria, Sept 2013
to Aug 2014
The October round was a combined measles OPV-measles campaign.
Figure 54. Proportion of NPAFP cases 6 to 35 months, by OPV status, North-Central Sanctuary, Nigeria**
Source: WHO
**Data as of 9 September 2014
Page 57
GPEI Partner Status Report - 25 September 2014
OWNERSHIP
Percent of LGAs meeting indicators 1 week pre-campaign
North Central Sanctuary
Percent of LGAs meeting indicators 3 days pre-campaign
Jan '14 Mar '14 Apr '14 May '14 Jun '14 Jul '14 Aug '14 Jan '14 Mar '14 Apr '14 May '14 Jun '14 Jul '14 Aug '14
# of LGAs participating
128
128
128
128
128
128
128
128
128
128
128
128
% of LGA task force met
79
78
95
99
100
99
98
99
100
100
100
100
% of LGA counterpart funding released
34
34
35
34
34
0
71
84
88
66
82
0
State task force met
yes
yes
yes
yes
no
yes
yes
yes
yes
State counterpart funding released
no
no
no
no
no
no
yes
no
no
Jigawa
Kano
State task force met
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
State counterpart funding released
no
yes
yes
yes
no
yes
yes
yes
yes
yes
Kaduna
State task force met
No
yes
no
yes
yes
yes
yes
yes
yes
yes
yes
State counterpart funding released
No
no
no
no
no
no
yes
yes
yes
yes
yes
State task force met
yes
yes
yes
yes
yes
yes
yes
State counterpart funding released
no
no
no
no
yes
yes
yes
Katsina
Abbreviations: LGA=Local Government Area
No campaign
Source: Nigeria Polio Campaign Dashboard, WHO-Nigeria
No data
-------------------------------------------------------------------------------------------------------------------------
NORTHEAST SANCTUARY
Figure 55. WPV and cVDPV cases, Northeast Sanctuary, 3 September 2013 to 2 September 2014*
Source: WHO
*Data as of 9 September 2014
Page 58
Source: WHO
**Data as of 9 September 2014
GPEI Partner Status Report - 25 September 2014
Figure 56. WPV and cVDPV cases by week of onset and environmental surveillance results, Northeast
Sanctuary (Borno and Yobe), Nigeria, 3 Sept 2013 to 2 Sept 2014*
Source: CDC
*Data as of 9 September 2014
Data not Available
Figure 57. Proportion of LGAs with LQAS survey results by SIA, Northeast Sanctuary, Nigeria, Sept 2013 to
Aug 2014
The October round was a combined measles OPV-measles campaign.
Figure 58. Proportion of NPAFP cases 6 to 35 months, by OPV status, Northeast Sanctuary, Nigeria**
Source: WHO
**Data as of 2 September 2014
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GPEI Partner Status Report - 25 September 2014
OWNERSHIP
Percent of LGAs meeting indicators 1 week pre-campaign
Northeast Sanctuary
Percent of LGAs meeting indicators 3 days pre-campaign
Jan '14 Mar '14 Apr '14 May '14 Jun '14 Jul '14 Aug '14 Jan '14 Mar '14 Apr '14 May '14 Jun '14 Jul '14 Aug '14
# of LGAs participating
128
44
44
44
44
44
44
44
44
44
44
44
44
% of LGA task force met
79
61
39
98
59
39
61
39
39
57
59
39
% of LGA counterpart funding released
34
0
59
98
59
95
98
39
59
98
98
95
State task force met
no
yes
yes
no
yes
yes
yes
yes
State counterpart funding released
no
yes
yes
yes
yes
yes
yes
yes
State task force met
yes
yes
yes
yes
yes
yes
yes
State counterpart funding released
no
no
no
yes
yes
yes
yes
Borno
Yobe
Abbreviations: LGA=Local Government Area
No campaign
Source: Nigeria Polio Campaign Dashboard, WHO-Nigeria
No data
_________________________________________________________________________________
NORTHWEST RISK AREA
Figure 59. WPV and cVDPV2 cases, Northwest Risk Area, 3 September 2013 to 2 September 2014*
Source: WHO
Data as of 9 September 2014
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GPEI Partner Status Report - 25 September 2014
Figure 60. WPV and cVDPV cases by week of onset and environmental surveillance results, Northwest Risk
Area (Sokoto and Zamfara), Nigeria 3 Sept 2013 to 2 Sept 2014*
Source: CDC
*Data as of 9 September 2014
Data not Available
Figure 61. Proportion of LGAs with LQAS survey results by SIA, Northwest Risk Area, Nigeria, Sept 2013 to
Aug 2014
The October round was a combined measles OPV-measles campaign.
Figure 62. Proportion of NPAFP cases 6 to 35 months, by OPV status, Northwest Risk Area, Nigeria**
Source: WHO
**Data as of 2 September 2014
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GPEI Partner Status Report - 25 September 2014
OWNERSHIP
Percent of LGAs meeting indicators 1 week pre-campaign
Northwest Risk Area
Percent of LGAs meeting indicators 3 days pre-campaign
Jan '14 Mar '14 Apr '14 May '14 Jun '14 Jul '14 Aug '14 Jan '14 Mar '14 Apr '14 May '14 Jun '14 Jul '14 Aug '14
# of LGAs participating
37
37
37
37
37
37
37
37
37
37
37
37
% of LGA task force met
65
62
100
41
100
100
100
100
100
100
100
100
% of LGA counterpart funding released
49
14
0
3
0
3
65
22
19
0
65
3
Sokoto
State task force met
yes
no
no
yes
yes
yes
yes
State counterpart funding released
no
no
no
no
no
yes
yes
Zamfara
State task force met
yes
no
yes
yes
yes
yes
yes
State counterpart funding released
no
no
no
no
no
yes
no
Abbreviations: LGA=Local Government Area
Source: Nigeria Polio Campaign Dashboard, WHO-Nigeria
No campaign
No data
-------------------------------------------------------------------------------------------------------------------------
COMMUNICATION AND SOCIAL MOBILIZATION
Stopping transmission in Nigeria is the condition for a polio-free Africa, yet the Nigeria programme also has
to keep an eye on its neighboring countries. Re-importation from the ongoing Central Africa Outbreak
remains a real threat. If Ebola spreads outside of Lagos and Rivers States, especially to northern Nigeria, this
would present a new and significant threat as well.
Harvard polling data shows a difference between levels of knowledge, trust and exposure to misinformation
about the vaccine in Borno, as compared to high-risk areas elsewhere in Nigeria. In Borno, 37% of parents
thought paralysis from polio was curable (vs. 24% in other high-risk areas polled in Nigeria). The percentage
of parents in Borno who were not aware that OPV must be taken every time it’s offered to maximize
protection against the disease was 35% (versus 29% elsewhere in Nigeria).
Obstacles to trust are especially pronounced in Borno where 48% of parents said they’d heard negative
rumors about the vaccine. However, only 4% of these believed the rumors they’d heard. But these rumors are
likely to only be a visible symptom indicating more important underlying issues and a negative community
sentiment/discourse about OPV and the polio programme. Only 85% of parents in Borno said they gave their
children vaccine the last time they saw vaccinators, the lowest rate cited by parents anywhere in the world.
Less than 48% of Borno parents said they trust the vaccinators “a great deal,” while elsewhere in Nigeria the
rate was 70%.
VOLUNTEER COMMUNITY MOBILIZERS
Nigeria’s VCM network is now the largest social mobilization network in the world. In the last quarter, the
number of VCMs rose by more than 1,200 mobilizers alone. In addition to this vast community network of
nearly 10,000 at settlement level, a management layer of 1,000 supervisors are in place at ward and district
levels. Outside the formal network, more than 224 religious focal points facilitate access to more than 17,000
religious leaders and teachers, traditional leaders are actively engaged and 1,400 polio survivors help
maintain a healthy level of risk perception within their local communities, putting a human face to the
poliovirus.
Nigeria’s mobilizers are increasingly active in generally inaccessible areas and can have a huge impact on
community acceptance there. Between UNICEF and CORE, more than 800 are already working in Borno and
Yobe. The VCMs are even more effective when they’re trained to offer broader skills in other key areas of
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GPEI Partner Status Report - 25 September 2014
child and maternal health. These skills can make them indispensable advisors in communities where organized
health care is weak or non-existent.
In accessible and inaccessible areas alike, VCMs show communities that polio drops are part of an overall
approach to caring for the whole child. This entry point has helped meet community demands for broader
health services and has increased acceptance rates substantially. Nigeria has had a consistently declining
refusal rate for the past two years, and now has the lowest rate globally according to Independent
Monitoring data.
Beyond refusals, Nigeria’s results in reducing missed children are impressive, particularly in Kano. In Kano—
where nearly half the VCM network is placed—the community has been an important contributor to success.
BUILDING A BIGGER AND BETTER WORKFORCE
As the Nigerian
programme has scaled
up over the years,
thousands of frontline
workers, social
mobilizers and
vaccinators alike have
had different levels
and quality of training.
The rapid scale up,
turnover of staff,
responsibility and size
of these workforces
mean Nigeria must
remain vigilant to
ensure that workers
follow standards of
excellence, particularly
as the programme
continues to innovate
and introduce new
approaches in these
critical few months.
Figure 63.
Although health camps have been implemented with varying scale and scope over the last year, frontline
workers had not received formalized training on integrated health. In July, Nigeria was the first country to test
the newly developed global training curriculum for integrated health. A two-day training of trainers was
conducted in Kaduna and Katsina States, attended by VCM staff and nearly 150 State Health Coordinators.
The training consisted of a basic integrated health package on primary health care interventions focused on
maternal, newborn, and child health. Content covered IPC applied to the introduction of IPV,
water/sanitation/hygiene (WASH), malaria, pneumonia, diarrheal diseases, and a basic human rights module.
More than 900 participants were trained in this first phase.
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GPEI Partner Status Report - 25 September 2014
PERFORMANCE MANAGEMENT
To adequately identify high and low performers, Nigeria is implementing a revamped performance
evaluation system, which includes data collection against the global performance dashboard, and
dissemination through a data platform that will integrate all data sources for the programme into one
database for more cohesive, sophisticated analysis.
As part of this system, UNICEF will collect programme data with GPS coordinates for faster mapping of
performance and skills together. A monthly performance management dashboard will be used to more closely
monitor performance of staff.
The IVR system will be used as an additional way of getting direct feedback from supervisees on how
supervision is going. This system initiates a 360° evaluation system for the first time as well, instilling
accountability for good management in addition to good performance on the ground.
While this more systematic approach is being implemented, the programme has been using a simple
performance management system that tracks performance based on a ‘three strikes’ system. To date, 447
VCMs, 66 ward supervisors, 65 polio survivors, nine LGA consultants and four religious focal points have been
terminated for poor performance. Conversely four Ward Supervisors were promoted to LGA consultants for
good performance, as well as four LGA consultants to cluster consultants, and four cluster consultants to state
leads.
Figure 64. Number of children vaccinated in specific demand-creation
In an effort to ensure proper team
exercises, 10 high-risk states, Nigeria January to August 2014
selection, partner staff have
assumed oversight of the ward level
team selection committees. Partner
staff at local levels participate in the
committees to ensure that frontline
workers are vetted for profile and
skillset. The partnership is
responsible for monitoring and
reviewing the performance of any
frontline worker, irrespective of
which agency has hired them.
FOCUS ON THE HARD TO REACH
Through Nigeria’s Hard to Reach
mobile outreach project, 3200
underserved villages receive the
polio vaccine four times a year,
along with other health- and lifesaving interventions.
Routine immunization is provided, together with free medicine to fight malaria and diarrhea. Adults are also
treated, especially pregnant mothers. These temporary services are welcomed enthusiastically by communities
within the context of a weak healthcare system. So far, attendance has been exceptional. This year, more
than 414,000 people in Kano alone will benefit from health camps offering vital primary services during
polio campaigns.
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GPEI Partner Status Report - 25 September 2014
In between campaigns, the VCMs
record newborns in their
settlements, attend the naming
ceremony of the baby (usually on
the 7th day after birth), and give
the first dose of OPV for 90% of
these children. Today, on average,
in the 10,000 settlements covered
by the VCM Network, 3,100 births
are tracked every week, 2,700
children are given the first dose of
OPV, and 2,800 children are linked
to health facilities for routine
immunization services. More than
100,000 newborns across the
country have been tracked this way
since the data started flowing in 34
weeks ago. In Kano, nearly 80%
of expected newborns are
recorded and vaccinated at birth.
COMMUNITY-BASED
MANAGEMENT OF ACUTE
MALNUTRITION (CMAM)
Community Mobilizers are also
trained to identify signs of
malnutrition in children and refer
them to CMAM centers to receive
proper treatment. Polio drops are
in turn administered at these
centers, reaching children whose
immunity is especially low. The
CMAM initiative, like the health
camps, serves a twofold aim. It
simultaneously helps reach hard-toreach children, and allows workers
to take tangible action on behalf
of the whole child—thereby
building trust.
Figure 65. Numbers of newborns registered and vaccinated by VCMs,
Kano, May to August 2014
Figure 66. Number of children vaccinated at CMAM centers and number
receiving the first OPV dose, 10 high-risk states, Nigeria, January to
August 2014
Today a total of 575 CMAM
centers are operational in the 11
high-risk states of Northern
Nigeria, which in many cases also
provide therapeutic food and counselling, vitamins, deworming, routine vaccines and OPV in addition to
therapeutic food. Scale-up is in progress, with particular focus on Borno state.
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GPEI Partner Status Report - 25 September 2014
The CMAM is also reaching children who might otherwise be completely missed. Among approximately 5,000
children who were vaccinated at CMAM centers in August, 10% received polio vaccine for the first time
(Figure 66).
PROGRAMME INFORMATION
ACCESSIBILITY AND SECURITY
The security/ humanitarian situation in the
Northeast Nigeria sanctuary (Borno and
Yobe States and northern parts of
Adamawa) remains critical as fighting has
intensified between the Nigerian military and
insurgents. The Nigerian Governmentimposed State of Emergency, introduced in
May 2013 and due to expire in May 2014,
likely will remain in force for the foreseeable
future. Insurgents continue to attack strategic
towns. Other insurgency targets include
political and religious figures. Continued
instances of reprisal attacks against the
civilian population, including kidnapping,
have been reported.
Armed conflict in the
southern and eastern
areas of Borno, in
southern Yobe, and
more recently in
Adamawa state has led
to increased rural to
urban movement of IDPs
in these states, and
forced others to seek
refuge in Cameroon and
Chad.
Figure 67. Insecurity Levels in Nigeria, August 2014
Figure 68. Inaccessible areas, WPV1 cases, and the estimated number of children
affected during the August 2014 SIA—Northeast Sanctuary, Nigeria
Other major security
incidents outside of this
region may also be
attributed to the
insurgency as it seeks to
expand its operations.
For example, since the
end of April 2014, a
number of attacks have
occurred, attributed to insurgent activity outside of Borno and Yobe.
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GPEI Partner Status Report - 25 September 2014
Figure 69. Inaccessible Settlements in Borno and Yobe Provinces, Nigeria, August 2014
In addition, there appears to be an ever-evolving change to tactics used by the insurgents. For example, on 9
June, a female suicide bomber, the first in Nigeria’s history, detonated explosives at a military barracks in
Gombe, killing one soldier and herself. In July, bombs exploded in Kaduna after the Ramadan sermon by a
prominent sheikh, killing more than 30 people. Additionally, Boko Haram appears to have adopted a
kidnapping strategy and took hostage a German NGO worker in Adamawa on 16 July 2014. This increases
the perception of fear for frontline workers and implementing partners to deliver the programme.
Although the insurgency’s recent operations in the Middle Belt and Lagos are of immediate concern, the
longer-term threat for Nigeria remains firmly in the Northeast. Since April, insurgents have been sealing
Borno’s road and bridge connections to Cameroon, Adamawa and Yobe and taking towns to the south and
north east of Maiduguri.
Because of the deteriorating security situation in the Northeast, the UN Security Management Team has
continued to limit UN staff movement in Yobe and Borno, preventing the GPEI’s ability to fully monitor
eradication efforts. Seven out of the 17 LGAs in Yobe remain inaccessible to UN Staff whereas in Borno, only
two out of 29 LGAs remain totally accessible to UN Staff. Other security threats remain acts of criminality,
communal violence in the Middle Belt and Northwest geopolitical zone of the country, as well as politicallymotivated violence in the central and southern areas.
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GPEI Partner Status Report - 25 September 2014
INCIDENTS INVOLVING POLIO PERSONNEL
During August 2014, in isolated incidents a polio worker was beaten during an IPD in Kano State, and
another was a victim of armed robbery in Sumaila LGA, also in Kano. These incidents are not believed to be
selected targeting of polio personnel, but rather as a result of local tension and opportunity crime,
respectively. Although the motivations for the attack are unclear, in June, suspected Boko Haram insurgents
dressed in military uniform were reported to have attacked a health camp team at Sasawa village in
Damaturu, Yobe. The perpetrators seized and destroyed all the vaccines and other equipment.
Although the programme in Nigeria continues to reach more children overall, the lack of accessibility in Borno
and Yobe continues to hamper polio immunization. Since April 2014 the number of missed children due to
inaccessibility has risen from 0.4% to 1.6% in Yobe and from 16% to 23% in Borno.
HUMAN RESOURCES
Location
(sanctuary or risk area)
Northwest
(Sokoto and Zamfara)
Total number of
vaccination teams
Number (%) of
Number (%) of
Salary per
Number of current
vaccination teams with a vaccination teams vaccinator / day
GPEI staff
female member
with a local member
Number of additional GPEI
staff needed (if surge is
planned)
4,884
4,884 (100%)
4,884 (100%)
$4.32
307
8
30,328
30,328 (100%)
30,328 (100%)
$4.32
1089
16
3,554
3,416 (96%)
3,554 (100%)
$4.32
346
3
North central
(Kano, Katsina, Jigawa, and
Kaduna)
Northeast
(Borno and Yobe)
Source: WHO
ROTARY INTERNATIONAL’S WORK IN NIGERIA
Rotarians in Nigeria have focused their efforts on the following social mobilization activities:
•
•
•
•
•
•
Providing ‘plus’ items such as soap that are used as incentives during “immunization plus days”
Engaging traditional leaders in the supervision of IPDs and resolution of non-compliance
Addressing broader health needs through the provision of first aid kits for Almajiri and Islamiya
schools
Providing 21,000 doses of medicine used during health camps
Delivering ‘plus’ items for IPV Introduction in Borno state as well as for use during SIAs as above
Developing a newsletter, website, and media pages to help raise awareness and highlight the role of
Rotary’s PolioPlus Ambassadors
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GPEI Partner Status Report - 25 September 2014
PERFORMANCE INDICATORS
IMMUNIZATION AND SURVEILLANCE
Figure 70. Six-month standard immunization indicators among children aged 6-35 months with AFP and
annualized surveillance indicators by state, Nigeria, February 2013 to August 2014
Source: CDC
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GPEI Partner Status Report - 25 September 2014
GPEI POLIO ERADICATION AND ENDGAME STRATEGIC PLAN 2013–2018, NIGERIA
STRATEGIC!
PLAN!
OBJECTIVE!
OUTCOME!INDICATORS!
(2013)!
RESULTS!
All!wild!poliovirus!transmission!
!The!most!recent!WPV!!
stopped!by!the!end!of!2014!
Poliovirus!
Detection!and!
Interruption:!
Complete!
the!
interruption!
of!wild!
poliovirus!
transmission!
globally!and!
more!
rapidly!detect!
and!interrupt!
any!new!
outbreaks!due!
to!vaccineM
derived!
polioviruses!
!
NA*!!
All!new!cVDPV!outbreaks!
stopped!within!120!days!
Circulation!of!cVDPV!imported!from!Chad,!as!
evidenced!by!cases!and!environmental!
isolation,!was!not!stopped!within!120!days!of!
confirmation.!
OUTPUT!INDICATORS!(2013)!
!!
Achieve!and!maintain!an!
NPAFP!rate!of!›!2/100,000!
children!<15!years!of!age!in!all!
states/provinces!of!highMrisk!
countries!and!maintain!an!
NPAFP!rate!of!›!2/100,000!in!
all!states/provinces!!
From!16!August!2013!to!16!August!2014,!the!
national!NPAFP!rate!was!11.8/100,000,!an!
absolute!2.1%!increase!from!the!previous!year.!
One!hundred!percent!of!provinces!have!been!
maintaining!NPAFP!>2/100,000!since!the!last!2!
rolling!years.!
Met!
Achieve!and!maintain!
adequate!stool!sample!
collection!in!80%!of!cases!in!all!
states/!provinces!!
During!the!last!12!months,!98%!of!AFP!cases!
nationally!had!an!adequate!stool!specimen.!
This!is!an!absolute!2%!increase!from!last!rolling!
year.!All!provinces!in!Nigeria!have!been!
maintaining!adequate!stool!collection!in!>80%!
of!AFP!cases!since!the!last!2!rolling!years.!
Met!
LQAS!passed!at!80%!threshold!
in!all!highMrisk!areas!
In!the!last!12!months!in!the!85!highest!risk!
LGAs,!>80%!have!been!achieving!the!80%!
threshold,!and!since!May,!>90%!have.!
Establish!full!safety!and!
security!framework!!
All!current!cVDPV!outbreaks!
stopped!by!endM2013!
*
STATUS!
A!UN!security!management!and!enhancement!
plan!has!been!developed!and!funded.!The!
national!programme!has!developed!a!specific!
operational!plan!with!innovative!strategies!to!
vaccinate!children!in!highly!insecure!LGAs!of!
Borno.!An!Emergency!Operations!Center!has!
been!established!in!Borno.!
There!have!been!2014!environmental!isolations!
of!indigenous!strain!from!emergence!in!2005!
and!a!recent!case;!imported!Chad!A!emergent!
strain!continued!circulation!into!2014.!Virologic!
evidence!indicates!ongoing!surveillance!gaps.!
Not!met!!
!!
Not!Met!in!2013!
Met!in!2014!
Established!!
Not!Met!
* Not Applicable
Page 70
GPEI Partner Status Report - 25 September 2014
SYNOPSIS
•
Epidemiology: Only six WPV1 cases have been reported so far in 2014. No WPV cases have been
reported in the Northwest sanctuary for two years and none in the Northeast for five months. WPV1
transmission may be limited to a single zone comprised of southern Kano State and adjoining areas of
Kaduna and Bauchi States. WPV3 has not been detected since 10 November 2012. cVDPV cases have
increased in both Kano and Borno, and environmental sampling has detected cVDPVs across most of the
north.
• Immunization: LQAS data continue to show improvement. Since May, more than 90% of high-risk LGAs
have achieved coverage at the ≥80% level. In June and August, IPV was used for the first time in SIAs in
Nigeria, covering 1.7 million children less than 5 years old in all of Borno and selected areas of Yobe.
• Security: Insecurity continues to limit access in Borno and Yobe States, although the programme’s data
show improvement in access through March, with a larger number of children able to participate in SIAs
until some regression in access during later SIAs. The overall security situation does appear to be
deteriorating in the Northeast and insurgent groups reportedly holding key geographic areas particularly
south of the Borno state capital hampers the ability to deliver programme elements safely and securely.
• Surveillance: AFP surveillance performance indicators have steadily improved in Nigeria in recent years,
with the national NPAFP rate now exceeding 13 per 100,000 children < 15 years of age per year and a
national stool adequacy proportion of 97%. In Both Borno and Yobe, AFP reporting rates are increased
over last year, to 14.7 per 100,000 children <15 years per year in Borno and 12.4 per 100,000
children <15 years per year in Yobe, and stool adequacy proportions exceed 98%.
• Ownership: There is strong political support for polio eradication, but it needs to be sustained and
intensified to drive the program to a successful conclusion. The Presidential Task Force on Polio Eradication
has only met once in more than a year, and tracking the ‘Abuja Commitments’ shows a decline in the level
of participation of state Executive Governors. Tracking data indicate that Local Government Area
Chairmen are failing to maintain strong overview over immunization activities, with low participation rates
in ‘evening review meetings’ during polio campaigns.
• Community Demand: Independent monitoring data continue to show relatively low rates of vaccine refusal
in Nigeria. However, anecdotal reports from southern Kano State suggest that vaccine refusal may be
more common than suggested by these data, or masked by the number of children reported as ‘absent’
when vaccinators visit the home. Three of the five cases reported in Kano this year were in families that
refused to allow their children to be vaccinated.
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GPEI Partner Status Report - 25 September 2014
NON-ENDEMIC COUNTRIES
HORN OF AFRICA OUTBREAK
Figure 71. WPV cases by week of onset in the Horn of Africa, 2013–2014 to date*
Source: CDC
*Data as of 9 Sept 2014
The WPV1 outbreak in the HoA started in April 2013. The first case was identified in Banadir (Mogadishu)
Somalia in May 2013 with subsequent cases identified in Kenya and Ethiopia. The last reported case in
Kenya had onset on 14 July 2013. As of 9 September 2014, the most recent WPV1 case linked to this
outbreak in the sub-region occurred in Somalia on 11 August 2014, >12 months after confirmation of the first
case of the HoA outbreak.
Figure 72. WPV1 and cVDPV Cases in the Horn of Africa, 2013-2014 to date*.
Source: WHO
*Data as of 9 September 2014
Among the three countries, time from outbreak confirmation to the onset of the latest case exceeded six
months only in Somalia. In 2013, the outbreak accounted for 54% of the polio cases globally. In addition to
the polio outbreak during 2013–2014, HoA countries have been affected by measles outbreaks, armed
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GPEI Partner Status Report - 25 September 2014
conflict in the Republic of South Sudan, which caused the rapid migration of South Sudanese into Kenya and
Ethiopia, and ongoing African Union military activities in Somalia against Al Shabaab militants which result in
fluctuations in areas of accessibility, particularly in South Central Somalia.
SOMALIA
The outbreak was confirmed on 9 May 2013 when WPV1 was identified from a case with an onset of 18
April. So far, Somalia has had a total of 199 confirmed WPV1 cases (194 cases in 2013 and five cases in
2014). The most recent case was
Figure 73. WPV cases and inaccessible children in Somalia in the
from Hobyo district, Mudug
August 2014 SIA
Region (onset 11 August 2014).
Four cases reported earlier in
2014 were from nearby Jariban
district in Mudug region. No new
WPV cases have been reported
from Banadir region, the
epicenter of the Somalia
outbreak, since 19 July 2013.
Among the 199 cases, 88% were
among children aged <5 years
and two (1%) cases were aged
>15 years (27 and 29 years of
age). During 2013–2014, 55
cases (28%) were in accessible
areas, 50 cases (26%) were in
inaccessible areas, 48 (24%)
were in partially accessible
areas, and 46 (23%) were in
accessible areas with security
challenges. During 2014 to date,
the overall NPAFP rate was 7.8
per
100,000 children <15 years
Source: WHO
Data as of 9 September 2014
of age per year and stool
adequacy was 96.5%.
Five cases (aged 18 months to 29 years) have been detected in 2014, all in the Mudug Region of Somaliland
in two bordering districts: (Jariban, 4 cases, and Hobyo, 1 case). All of the cases have occurred in pastoralist
families residing in hamlets outside larger settlements and were missed during previous SIAs during 2013 and
2014. Of these cases, none had received an SIA dose of OPV and only one had received a single dose
through the EPI program, in a neighboring city.
Outbreak response to the four May/June cases included three SIAs during June-August targeting the Mudug
region and all of Puntland. Three additional SIAs will be conducted during September-October (entire Mudug
region, accessible parts of Galgadud and two districts of Bari [Eyl and Burtinle]) in response to the more
recent cases. The programme is currently taking steps to identify pastoralist communities and to incorporate
them into SIAs through means of improved microplanning, enhanced mapping through use of satellite images,
and outreach to community leaders and elders.
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GPEI Partner Status Report - 25 September 2014
In 2013, 10 rounds of SIAs were administered, some targeting all age groups or children up to 10 years of
age and some conducted at short intervals. In 2014 12 SIA rounds have been implemented to date targeting
children up to 5 years of age (seven rounds), up to 10 years of age (two rounds), and all groups (one round).
In addition, four SIADs are implemented in each newly accessible district of the South Central Zone. In the
newly accessible districts, to date, four rounds have been conducted in Huddur and Mahas districts,
respectively, with the last round occurring in July. SIAs in Bhurdubu are currently underway, and rounds in
Wajid district are awaiting availability of cold chain supplies and vaccine. Efforts to access children in
inaccessible areas are ongoing with involvement of local NGOs and low profile vaccinations. District
accessibility is closely monitored and SIAs are implemented within one week of gaining access. Efforts to
expand independent monitoring to all accessible districts are ongoing with involvement of local NGOs and
professional groups. Challenges exist in identifying qualified independent monitors in some accessible districts.
ETHIOPIA
The most recently reported case occurred in the Somali Region of Ethiopia on 5 January 2014. Six SIAs have
been conducted thus far in 2014 and two NIDs are scheduled later in the year. Suboptimal surveillance in the
Dollo Zone of the Somali Region makes it uncertain that transmission has been interrupted. Microplanning
needs to address the nomad/pastoralist communities that are often missed in SIAs.
COMMUNICATION AND SOCIAL MOBILIZATION
Independent monitoring
data in the HoA (where
collected) confirms levels
of polio campaign
awareness between 85%
to more than 90% across
the region, especially in
the areas where significant
investments in social
mobilization have been
made. Yet, once
disaggregated by subdivisions, a number of
geographical areas of
concern exist, even within
the “green” districts. This
includes the Somali region
in the Dollo zone of
Ethiopia, Dhusamareb,
Hargeysa and Baidoa in
Somalia, and almost the
whole Coastal province of
Kenya.
Figure 74. Polio Campaign Awareness by Province/State, Horn of Africa
Although refusals across the region overall remain less than 1% of targeted children, this acceptance of
vaccination should not be taken for granted; rather, this positive perception of polio vaccination must continue
to be maintained until all outbreak transmission is finished.
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GPEI Partner Status Report - 25 September 2014
MUDUG REGION
The response to the recent outbreak in Mudug, Somalia has been supported with significant social mobilization
and communication efforts.
Independent Monitoring data for Mudug region and Harvard Opinion Research Poll for Puntland provided
proxy information that campaign awareness in this region varied greatly from more than 90% to 41% in
localized areas. A joint investigation into the affected community in Jariban showed there was a positive
attitude towards immunization and health services, but a gap in services. Media coverage here is extremely
low, with a short-wave BBC broadcast serving as the main source of information for communities. Because of
limited mass communication channels across this region, social mobilization efforts have been significantly
enhanced, deploying over 100 social mobilizers in Mudug and more than 1,300 in Puntland alone.
Public loudspeakers mounted on vehicles are now a main source of campaign announcement, with five new FM
radio stations airing 720 spots before each campaign. Islamic influencers and clan elders have been fully
mobilized to provide campaign support and entry points to madrassas, duqsies, and mosques.
Communication messages have been changed from health information to risk communication—more urgent
and immediate, with clear calls for immediate action. The parents of a polio-affected child have given a
testimonial that helps explain the proximity and personal risk for polio to the community. These strategies
have contributed to wide acceptance of polio vaccine during the last three rounds.
STRATEGIES TO IMPROVE SIA QUALITY, ACCESS AND REACH POPULATIONS ON THE MOVE
The main challenge to reaching all children in the Mudug region, similar to the affected areas of the Somali
Region of Ethiopia, is the pastoral lifestyle of the local communities. Many young children live in small satellite
settlements away from the main village. The coverage of children in these satellite settlements has been
inadequate. To overcome this challenge, the program is taking a number of steps that include deployment of
additional human resources for planning and monitoring and ensuring completeness of microplans to cover all
settlements. A number of strategies are being applied to assure full microplan coverage which includes close
coordination with village and tribal elders on listing all settlements, on the ground and aerial validation of
settlements and triangulation of these data with high resolution satellite imaging.
While Jariban district was accessible yet hard to reach, 27 districts in South-Central Zone remain partially or
completely inaccessible. GPEI partners in the HoA are expanding their capacity to: a) understand the reasons
why particular regions/districts/specific areas present access challenge and what specific threats exist at the
most local levels, b) map influencers who control communities, c) understand who is opposed to the programme
and why, and d) come up with mitigation measures that are best suited to reduce the level of residual risk and
possibly improve access. Since May, access has been gained in four new districts in South Central, opening up
access to 25,000 children.
The use of Independent Monitoring data for action has been steadily improving in the region. All countries
except Somalia where this process is still on-going, have adopted analysis of missed children for the category
“child absent”. Now countries are able to collect, analyze and use these data for action. The most significant
reasons children are missed when they are absent are because they are in pastures, market places, or schools
(varied by countries).
Recognizing the need to focus on mobile populations, including pastoralists, GPEI partners in the HoA have
begun to better understand these complex groups, their movement patterns and design flexible country-based
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GPEI Partner Status Report - 25 September 2014
strategies and action plans to reach them more consistently. Thorough engagement with the key stakeholders
in the migration has resulted in action plans and practical strategies.
Cross-border communication platforms for the Somali population have been engaged to support SIAs,
including BBC Somali Service, Voice of America Somalia, and Star FM Kenya. All of these stations broadcast
across the Somali populated areas of Somalia, Ethiopia, and Kenya. Evaluation of the BBC Somali service
project and anecdotal evidence from the field demonstrate importance of these media channels to reach farflung populations.
CENTRAL AFRICA OUTBREAK
Figure 75. WPV1 and cVDPV Cases in the Central Africa, 2013–2014 to date*
Source: WHO
*Data as of 9 September 2014
Figure 76. Population movements within and from CAR as of 9 September 2014,
The WPV1 outbreak in
2014the Central African Republic
Central Africa was
discovered in October 2013 in
Cameroon with subsequent
spread to Equatorial Guinea. To
date, there have been 14
WPV1 cases (nine in Cameroon,
five in Equatorial Guinea). As of
9 September 2014, the most
recent WPV1 case this outbreak
occurred in Cameroon in a
refugee from the Central
African Republic (CAR) with
onset on 9 July 2014. The most
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GPEI Partner Status Report - 25 September 2014
recent case in Equatorial Guinea had onset on 3 May 2014.
The ongoing outbreak in Cameroon and Equatorial Guinea puts CAR, Democratic Republic of the Congo
(DRC), Congo and Gabon at risk because of population movement in the area and low population immunity.
More than 500,000 people travel in and out of Cameroon alone each year. This intense population movement
(social, commercial, refugees, IDPs, etc.), coupled with poor AFP surveillance makes the possibility of
undetected transmission in both Gabon and CAR quite high. The complex humanitarian crisis in CAR also
increases the risk of polio transmission in the region.
Gabon and Congo conducted nationwide campaigns in June/July 2014, and the CAR conducted campaigns in
the west along the borders with Cameroon and Chad in August and September. A synchronized campaign
was to be held 18-23 September in Cameroon, CAR, Congo, DRC, Equatorial Guinea and Gabon. A regional
outbreak coordinator for Central Africa was appointed in August.
Figure 77. WPV cases by week of onset in Central Africa, 2013-2014 to date*
CAMEROON
*Data as of 9 September 2014
Since October 2013, nine WPV1 cases have been reported from West, North West, Centre, Adamaoua and
East regions, with onset of paralysis ranging from 1 October 2013 to 9 July 2014. The latest case was in a
child who was a refugee from the CAR who had been vaccinated twice during campaigns in the refugee
camp. The genetic sequencing of the more recent WPV1 strain suggests it has been circulating undetected in
Cameroon for about one year.
Thus far in 2014, Cameroon has conducted seven nationwide immunization campaigns. SIA quality by LQAS
data has improved slightly in the last two campaigns compared with campaigns earlier in the year. In
addition to the paucity of national human resources and high level attention allocated to the outbreak
response, the main reasons for sub-optimal coverage initially related to poor quality of microplans. This was
addressed to a large extent through training and updating of microplans in mid-2014. Low visibility of
campaigns and low awareness levels among parents about the campaigns remains a significant reason for
gaps in coverage. The second three-month outbreak response assessment has been conducted during 16-25
September. Surveillance training at the regional level was conducted in August and is being rolled out to the
districts in September. A full-time country outbreak coordinator was identified in July 2014.
EQUATORIAL GUINEA
As of 9 September 2014, five WPV1 cases have been confirmed, the most recent with onset 3 May 2014.
Response to the outbreak has been challenging. At the beginning of the outbreak, surveillance was poor, with
only 2 AFP cases having been reported in the prior 5 years, and the country had been five years without an
SIA. Equatorial Guinea conducted national campaigns in April, May, August, and September. These
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GPEI Partner Status Report - 25 September 2014
campaigns have been of insufficient quality. AFP surveillance remains poor; training was conducted in August
for 100 persons who will begin surveillance soon. Although cases have been detected through searches during
SIAs, a rapid national polio case search in health facilities and communities that was recommended by the
Central Africa Technical Advisory Group in July has not yet been implemented. Government commitment has
been variable. While the Ministry of Health has been engaged and committed, the upper levels of
government have not been. The government so far has offered to fund only the most recent SIA (the 5th
outbreak response SIA) and the November SIA, but not the two in between. The government has also been
unresponsive to the partnership’s concerns about the difficulty of obtaining necessary visas. This latter problem
has hampered efforts to bring in outside experts to assist in the response.
COMMUNICATION AND SOCIAL MOBILIZATION
Challenges in identifying and deploying staff to Central Africa—compounded now by the Ebola crisis—in
addition to overstretched GPEI resources continue to affect the response in Central Africa. Government
commitment, delayed financial flows and limited national oversight underline more systemic, underlying
challenges.
MIDDLE EAST OUTBREAK
SYRIA
On 28 October 2013, the Minister of
Health of the Syrian Arab Republic
announced that after 15 years of
absence, polio had returned to the
Middle East. Thirteen cases due to
WPV1 were confirmed from Deir Al
Zour province in Syria. Genetic
sequencing indicates that the virus,
originating from Pakistan, likely had
been circulating in Syria for nearly a
year before detection (and is linked to
WPV1 detected in environmental
samples collected in Egypt in December
2012, and in Israel, the West Bank and
Gaza during February 2013–March
2014).
Since that time, as of 31 August 2014, a
total of 36 cases have been confirmed
in Syria, with the most recently reported
confirmed case of polio occurring on 21
January 2014. Syria, being the primary
outbreak zone, has conducted eight
NIDs to date with the most recent one in
June 2014 and one SNID in August
2014. During the June NID, estimated
coverage, determined by postcampaign monitoring, was 89%. The first
Figure 78. WPV cases in Syria and Iraq, 2013-2014 to date*
Source: WHO
Source: WHO
*Data as of 9 September 2014
*Data as of 9 September 2014
Page 78
GPEI Partner Status Report - 25 September 2014
mass vaccination campaign using tOPV was launched by the Ministry of Health, Syria on 24 October 2013,
within five days of WHO’s polio alert. An estimated 2.4 million children were vaccinated during the campaign
that extended for four weeks because of conflict and logistic challenges. The Syrian government fast-tracked
the registration of bOPV in November 2013 and it has been used in all subsequent SIAs. No WPV cases have
been detected in Syria since the 2014 case with 21 January onset. During 2014 to date, the annualized
NPAFP rate is 3.0 per 100,000 children < 15 years of age per year and the proportion of AFP cases with
adequate specimens is 90%.
Figure 79. WPV and AFP cases by week of onset in Syria (n=36) and Iraq (n=2, WPV), 2013–2014 to date*
Source: GPEI Eastern Mediterranean Region/MENA
*Data as of 8 September 2014
IRAQ
Iraq confirmed the first WPV1 case since 2000 in a 6-month old, intentionally unvaccinated child in Baghdad
who had onset of paralysis on 10 February 2014. In April 2014, the second case was reported in Baghdad.
Genetic sequencing indicates the viruses are most closely related to virus detected in December 2013 in
Hasakeh, Syrian Arab Republic. In August 2014, Iraq conducted its tenth SIA since October 2013, most of
which used tOPV; the last two SIAs in June and August used bOPV. During the August NID, 1,872,684 children
under 5years of age were vaccinated with post-campaign monitoring coverage of 92 %; 142,448 were
children in IDPs camps. Subsequent campaigns will use bOPV. The majority of zero-dose NPAFP cases
reported during 2013 and 2014 were from Baghdad. During 2014, the annualized NPAFP rate was
4.2/100,000 children <15 years of age and sample adequacy proportion was 89% compared with an
NPAFP rate of 3.1/100,000 children and stool adequacy of 84% during 2013. Two provinces have NPAFP
rates below 2/100,000 children per year.
MIDDLE EAST OUTBREAK RESPONSE
Since WPV cases were first found in Syria, the outbreak has been considered to be regional and the
outbreak response has been targeted accordingly. During November 2013–August 2014, 35 SIAs have
been carried out in seven countries. The regional outbreak response is currently being coordinated out of
Amman, Jordan. The most recent review of the response was conducted in early September. In the 11
Page 79
GPEI Partner Status Report - 25 September 2014
months since Syria’s polio outbreak began, the programme has reached more than 25 million children with
the polio vaccine in the region’s largest-ever mass immunization campaign. During the most recent
campaigns, the vast majority of children across the Middle East were reached, with estimated coverage
more than 90% in Syria, and Iraq. Jordan and Lebanon lag behind, with estimated 88% and 78%
coverage respectively. There is need to focus on further improvements in the quality of the campaigns
guided by independent post-campaign monitoring; post-campaign monitoring has been conducted more
regularly since March 2014, particularly in Syria and Iraq. The March review also showed the need to
strengthen communication to raise awareness and especially the importance of taking polio vaccine each
time it is offered during the multiple campaigns planned, and to address surveillance gaps.
A plan for “phase 2” of the regional response is being implemented (see Figure 80) and envisions activities
through at least December 2014. During the second phase of the outbreak response, the key challenge is
to reach the hardest-to-reach—those pockets of children that continue to be missed, especially in Syria’s
besieged and conflict areas and in remote and conflict-affected areas of Iraq. Coordinating a response of
this unprecedented scale presents daily challenges. The vaccine must be delivered swiftly and repeatedly
to tens of millions of children across seven countries. Thousands of mobile teams must go door-to-door.
Health centers, where they are functioning and where families are able to reach them, must also have
vaccine as well as cross-border refugee registration stations and other sites where populations on the move
can be reached. Additionally, the declining security in Syria and Iraq specifically necessitates creative
means to access areas previously reachable through the health network.
Figure 80. Supplemental immunization activities in response to the Middle East outbreak, January–November
2014
Country</
Territory
Egypt
Total<SIAs<completed< Total<SIAs<completed<in<
from<Oct<2013
2014
NID
SNID
2
NID
1
SNID
2014<SIA<activities
Jan
1
SNID
Iraq
2
1
3
3
5:Jan
tOPV
Jordan
2
1
Feb
SNID<
4:Feb
tOPV
1
Mar
Apr
May
SNID
NID
NID
10:Mar
6:10<Apr
19:23<Oct
tOPV
tOPV
NID
NID
NID
SNID
Syria
2
2
2
6
2
6:10<Mar
6:10<Apr
13:17<May
15:19<Jun
tOPV
tOPV
tOPV
Nov
SNID
10:14<Aug
NID
NID
14:18<Sep
19:23<Oct
bOPV
tOPV
bOPV
SNID
SNID
NID
NID
2:Mar
8:12<Jun
10:14<Aug
26:29<Oct
30<Nov:3<Dec
tOPV
tOPV
tOPV
tOPV
NID
NID
SNID
SNID
SNID
NID
NID
10:15<Mar
14:19<Apr
15:21<Jul
15:21<Aug
15:21<Sep
15:21<Oct
15:21<Nov
tOPV
tOPV
bOPV
bOPV
bOPV
tOPV
tOPV
NID
NID
NID
NID
NID
SNID
NID
NID
5:Jan
2:Feb
2:6<Mar
6:10<Apr
4:8<May
15:19<June
31<Aug:4<Sep
19:23<Oct
23:27<Nov
bOPV
bOPV
bOPV
tOPV
bOPV
4
1
Oct
bOPV
17:23<Feb
bOPV
bOPV
SNID
SNID
SNID
7:13<Apr
21:27<May
5:11<Jun
NID
1
Sep
NID
tOPV
Palestine<
(OPT)
Aug
NID
SNID
Turkey
Jul
tOPV
tOPV
Lebanon
Jun
tOPV
tOPV
tOPV
bOPV
SNID
bOPV
SNID
tOPV
tOPV
NID
NID
tOPV
tOPV
12:Jan
tOPV
SNID
Completed)activity
NID<
Ongoing)or)Planned)activties
COMMUNICATION AND SOCIAL MOBILIZATION
An estimated 765,000 children <5 years of age currently live in hard-to-reach areas within Syria and lack
regular access to vaccines. When aid convoys have managed to enter besieged areas they have carried OPV
as a priority item. However, even when children are physically accessible, they may not receive the vaccine
because of ongoing violence. Despite the heavy fighting and inaccessibility in many areas, seven vaccination
campaigns took place between December 2013 and June 2014 through cooperation with local partners and
Page 80
GPEI Partner Status Report - 25 September 2014
volunteers. They were held in schools and health centers, on public buses, and through house-to-house
vaccination.
During prolonged outbreak response efforts, like Syria, it is always a challenge to keep interest in vaccination
high—among caregivers, as well as Governments and healthcare workers. Post- campaign monitoring data
from Syria has shown a slight, but consistent increase in missed children between March (7% missed) and June
(11% missed). This trend in
Figure 81. Reasons for Non-Vaccination among Missed Children in Jordan,
caregiver demand is a
Syria, Lebanon and Iraq, December 2013–June 2014
significant contributor to
missed children here,
largely due to the fixed site
strategy that relies on
parents bringing children
for vaccination during each
campaign. Where children
are accessible, more than
65% of children in the
region who don’t receive
OPV during campaigns are
missed because parents are
unaware of campaigns and
do not take their children to
vaccination centers, do not
prioritize polio vaccination
among other survival
challenges, or do not see
the need to ensure that
children receive multiple
doses of the vaccine.
Source: UNICEF
Additionally, accessibility
has been a challenge in Syria and is the largest barrier to vaccination.
In Lebanon, children are missed almost entirely because of social reasons. The vast majority of refusals are
due to physicians telling caregivers that children do not need vaccination during campaigns if they have
received their routine doses. Caretakers place greater trust in private healthcare to public services, so
vaccinators are often turned away at the door. Substantial communication efforts have been underway since
April including a mass media campaign launched with private sector pediatricians endorsing OPV and the
campaigns. Two high-profile media events were held for journalists in Beirut and Tripoli to launch this media
campaign in collaboration with pediatric associations. This work is done in parallel with religious mobilization,
social mobilization in predominantly Syrian neighborhoods, and information/education/communication
materials provided in private clinics and hospitals.
In Iraq, the August campaign marked the first major humanitarian intervention in conflict-affected areas. More
than 3.7 million out of an intended 3.97 million children were vaccinated with no major threats to health
workers or security incidents. A mass communication campaign has been launched in Iraq to raise risk
perception and keep polio high on a crowded humanitarian agenda. Journalists, religious leaders, and youth
groups have been engaged to support the polio campaigns. However, approximately 600,000 children are
inaccessible in Ninewa and Salah al Din Governorates.
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GPEI Partner Status Report - 25 September 2014
UNICEF’s Regional Office for
Figure 82. Facsimle of Proposed Street Drawing to Raise Public Awareness
the Middle East is launching
about Polio in Syria
a region-wide mass media
campaign in September that
seeks to heighten perceived
risk for polio through a series
of emotional TV spots
featuring a child’s love for his
brand new sneakers in which
he can no longer run and
play. New shoes, a symbol of
pride for many in the Middle
East, demonstrate what can
be lost by not vaccinating
children. The TV campaign
also features prominent
Mock-up of a potential street drawing for Syria, as part of UNICEF’s Regional Communications Campaign.
“Don’t allow polio to paralyze your children s’ dreams”
pediatricians from the region
Source: UNICEF
endorsing OPV. The
campaign is bolstered by school kits, billboards, and street drawings such as the one shown in the photo.
OTHER COUNTRIES/AREAS WITH DETECTION OF ACTIVE POLIOVIRUS
TRANSMISSION
ISRAEL; THE WEST BANK AND GAZA
In June 2013, the Israel Ministry of Health notified WHO that WPV1 had been detected in sewage samples
taken in May in a Bedouin town in the Southern District of Israel, part of their extensive environmental
surveillance network. Retesting and further sampling in June revealed WPV1 presence in sewage samples
taken at this and other sites in the Southern District. Samples were positive during the weeks of 3 February
2013–30 March 2014. These positives were primarily in samples taken at sites in the Southern District, but
also included samples taken from sites in the Central District and sporadically samples taken from sites in the
Ashkelon, Jerusalem and Tel Aviv Districts. Stool surveys in July 2013 identified WPV1 in a high proportion of
specimens obtained through convenience sampling at health facilities from children under 10 years of age
residing in the Southern District who had been fully-vaccinated with IPV. Genomic sequencing and
phylogenetic analysis suggests that this WPV1 originated from Pakistan and is similar to WPV transiently
detected in environmental specimens in Egypt in December 2012 and found circulating in Syria, suggesting
broad transmission in the Middle East starting in 2012. No clinical polio cases (WPV-associated AFP) have
been identified. In Israel, only IPV has been administered in routine childhood immunization since 2005.
Childhood vaccination coverage with 4 doses of IPV is very high (92%–98%). A schedule of IPV/OPV was
used from 1990 until 2005. After the WHO-led consultation in June that recommended at least two SIAs with
bOPV for the child cohorts vaccinated only with IPV, the Ministry of Health initiated a campaign on 4 August
2013 to administer bOPV to all children aged >2 months born since 2004 in the Southern District of Israel.
Two weeks later, the Minister of Health expanded the campaign nationally when WPV1 was detected in
sewage samples outside the Southern District. By mid-October 2013, about 70% of the target population had
been vaccinated with a dose of bOPV, including about 90% in the Bedouin towns of the Southern District.
WPV1-positive samples cultures continued to be identified from samples taken at selected sewage sampling
points serving several Southern District communities with Arab populations. Vaccination with a second bOPV
dose was recommended in October for children only in those communities and reached about 30% of the
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GPEI Partner Status Report - 25 September 2014
target population. In January 2014, childhood immunization with bOPV at 6 and 18 months of age was
initiated (without substantial catch-up for older cohorts), reaching >90% coverage at age-appropriate visits.
With a sporadic positive sample in Tel Aviv along with some other sporadically positive sites in the Southern
District in February 2014, only one collection site (Ar’ara) in the Southern District remained positive after midFebruary. The Ar’ara site was intermittently positive for the samples collected during December through
March, with the last identified in the sample collected in the week of 30 March.
In the West Bank and Gaza, a sequential IPV/OPV schedule was introduced in 1990 and remains in use.
WPV1 was intermittently detected in sewage samples taken at routinely tested sites in the West Bank in July
through October 2013 and in Gaza in August 2013 through January 2014, the most recent being taken on 5
January 2014. Full SIAs were conducted with tOPV in the West Bank and the Gaza during November and
December 2013. No polio cases have been identified in the West Bank and Gaza.
COUNTRIES AT RISK
COUNTRIES WITH RECENT POLIOVIRUS TRANSMISSION
Countries that have stopped transmission of indigenous WPV are subject to the risk of WPV importation from
remaining reservoirs. Depending on the level of immunity in the population, outbreaks can result. Although
substantial epidemics resulted after WPV1 importation into Tajikistan and other countries in the European
Region in 2010 and into China in 2011, the primary risk of outbreaks remains in the WPV-endemic regions of
WHO — the African (AFR) and the Eastern Mediterranean (EMR) Regions. Many outbreaks in polio-free
countries occurred in the “WPV importation belt” of the African Continent — a band of countries from West
Africa to the HoA with outbreaks from the West African B (WEAF-B) WPV1 genotype originating from
Nigeria. Additional outbreaks occurred in South/Central African countries due to South Asian (SOAS) WPV1
genotype originating from India. The 2013–2014 WPV1 outbreaks in the HoA, Central Africa, and the
Middle East demonstrate the ongoing risk for spread after importation from Nigeria, Afghanistan and
Pakistan, even in the face of preventive SIAs in some areas. Additionally, emergence and transmission of
cVDPVs have occurred in some of these same outbreak countries as well as other countries in AFR
(Mozambique) and EMR (Yemen) with compromised population immunity. There are 29 previously polio-free
countries in AFR (Angola, Benin, Burkina Faso, Burundi, Cameroon, CAR, Chad, Congo, Côte d’Ivoire, DRC,
Ethiopia, Equatorial Guinea, Gabon, Guinea, Kenya, Liberia, Mali, Mauritania, Mozambique, Niger, Senegal,
Sierra Leone, [South] Sudan, Togo and Uganda) and EMR (Iraq, Somalia, Syria, Yemen) in which WPV and/or
cVDPV transmission has occurred since 2009 that are subject to ongoing risk for poliovirus transmission.
Here presented are surveillance performance indicators and dose-histories in NPAFP cases (reflecting
immunity status) in 50 countries — the three WPV1-endemic countries plus the 29 previously-listed polio-free
countries with WPV and/or cVPDV outbreaks and 18 selected neighboring countries (Djibouti, Eritrea, Egypt,
Gambia, Ghana, Guinea-Bissau, Iran, Israel [in the WHO European Region], Jordan, Lebanon, Libya, Malawi,
Namibia, Rwanda, Sudan, Turkey [in the WHO European Region], Tanzania, Zambia). We also present an
overview of the assessment of risk of WPV transmission based on NPAFP dose history, history of outbreaks
and proximity to transmission, indicators of routine immunization system delivery and other factors that were
recently evaluated by Risk Assessment Task Team comprised of WHO, CDC and the Institute of Disease
Modelling (Global Good) along with the Bill and Melinda Gates Foundation and UNICEF to arrive at a
consensus on which countries are at highest risk in the AFR and EMR as well as selected countries of other
regions. Lastly, mitigating activities in 2014 are briefly reviewed.
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GPEI Partner Status Report - 25 September 2014
SURVEILLANCE PERFORMANCE
An article simultaneously published 25 April 2014 in CDC’s Morbidity and Mortality Weekly Report and
WHO’s Weekly Epidemiologic Record assessing surveillance indicators for 2012–2013 highlighted a
deterioration of surveillance indicators from 2012 to 2013 among the 30 countries evaluated, primarily in
AFR countries and primarily due to a decrease in the proportion of AFP cases with collection of adequate
specimens.
Updating those indicators for the 50 countries evaluated here for the time period of this report, 27 (84%) of
32 countries with poliovirus cases during 2009–2014 and 14 (78%) of 18 neighboring countries met the
national target of an annual rate of ≥2 NPAFP cases per 100,000 population aged <15 years. The five
Figure 83. AFP surveillance indicators at first administrative level, for AFP cases with onset 16 August
2013–15 August 2014, 50 selected AFR, EMR and European Region countries
Source: CDC
countries with cases from poliovirus transmission where the NPAFP rate indicator did not meet the national
target were all from the AFR region: Benin (1.45), Central African Republic (1.26), Gabon (0.99), Liberia
(1.58) and South Sudan (0.75). The four neighboring countries that didn’t meet the national target for this
indicator include one in AFR: Malawi (1.5); one in EMR: Djibouti (1.4); and two in EUR: Israel (1.5), and Turkey
(1.2).
The national target of ≥80% of AFP cases with adequate stool specimens was met by 42 (84%) of 50
countries over the last 12 months. The eight countries where the stool adequacy rate indicator did not meet the
target were five in AFR: Equatorial Guinea (8%), Ethiopia (78%), Gabon (10%), Guinea-Bissau (67%), and
Malawi (75%); two in EMR: Lebanon (69%), and Syria (75%); and one in EUR: Israel (77%).
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GPEI Partner Status Report - 25 September 2014
Figure 83 presents composite surveillance indicators for the previous 12 months at a sub-national level
(state/province) for 32 countries reporting poliovirus (WPV or cVDPV) cases from transmission during 2009–
2014 and 18 selected neighboring countries highlighting sub-national weaknesses that are masked by overall
national data. These data suggest that suboptimal surveillance limited the prompt detection of outbreaks in
most of the countries affected by importations in 2013–2014 which would have allowed more timely
outbreak response activities and potentially limited the extent of each outbreak. Sub-national AFP surveillance
quality was variable, noting a failure to meet one or both indicators in major areas of several countries in
close proximity to Nigeria, including Benin, Cameroon, Central African Republic (CAR), Congo, Equatorial
Guinea, Gabon, Mali, and Niger. In addition, there were notable deficiencies in parts of several countries in
the HoA, including Ethiopia, Eritrea, South Sudan, and Uganda. The other countries that reported a failure to
meet one or both indicators in major areas are: Angola, Burkina Faso, Liberia, Mauritania, Mozambique,
Senegal, Tanzania, Togo, Iraq, Pakistan, and Syria. Additionally, indicators may be met in areas that
nonetheless have substantial weaknesses in case detection.
IMMUNIZATION STATUS
Figure 84 presents immunization status indicators at a sub-national level for these 50 countries. The
immunization status of children was assessed using dose history for children 6–35 months of age with NPAFP
over the previous 12 months and looked at the proportion of children with no history of OPV doses (0-dose)
and the proportion with >4 OPV doses. Despite SIAs in this period in most of these countries, a high number of
countries have numerous sub-national areas in which <80% of children have >4 OPV doses, and many of
those areas have >10% of children with 0-dose history. Most of the same countries with limited sub-national
indicators of surveillance exhibit substantial weaknesses in population immunity and ongoing risk for further
spread of WPV, particularly in Central Africa and the HoA.
Validity and interpretation of data is of concern when dose history is missing for ≥20% of NPAFP cases, as in
eight countries in AFR: Malawi (55% [26 of 47]), Namibia (50% [13 of 26]), Senegal (37% [36 of 97]),
Mozambique (31% [48 of 156]), Central African Republic (30% [14 of 47]), Zambia (29% [23 of 80]),
Ethiopia (28% [131 of 461]), Benin (24% [36 of 147]); and one country in EMR: Jordan (24% [4 of 17]).
HIGH-RISK PRIORITY COUNTRIES
In September 2014, GPEI recently repeated a cross-agency review of vulnerability and factors affecting risk
for exposure (Risk Assessment Task Team). This risk assessment is to be revised quarterly and forms the basis
for prioritization of countries for SIAs and other mitigating activities. In addition, some countries included in
outbreak response plans in the HoA (e.g., portions of Kenya, Uganda, Djibouti, Yemen, South Sudan) and the
Middle East (e.g., Jordan, Lebanon, portions of Turkey) are at least as vulnerable as other countries currently
assessed as high or medium high on the risk list. The outbreak response in those areas is not limited solely to
interrupting transmission in countries affected by the outbreak but is also working to reduce the risk of
importation in unaffected countries in the area. Outside of those two outbreak response zones, countries
considered to be at the highest risk for polio outbreaks are the following eight countries:
Central Africa outbreak zone: Chad, Congo, CAR, portions of the Democratic Republic of the Congo (DRC)
and Gabon; Other: Benin, Niger, and Mali.
The Outbreak Risk Mitigation Task Team has decided to prioritize among the high-risk countries and focus on
Congo, CAR, Gabon and Niger.
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GPEI Partner Status Report - 25 September 2014
Many other countries are considered at potential risk, and are also recommended to undertake national or
subnational SIAs as appropriate to mitigate risks. These include, among others, the Philippines and Ukraine.
The latter has a worsening immunity gap that is chronically based on low trust in government and the
immunization programme, as well as acutely low vaccine supply due to lack of financing; further compounded
by the current conflict and political crisis; mitigating this gap in Ukraine will be problematic but contingencies
are being examined.
Figure 84. Immunization status at first administrative level, for children 6-35 months of age with
NPAFP cases with onset 16 August 2013–15 August 2014, 50 selected AFR, EMR and European
Region countries
Source: CDC
MITIGATING ACTIVITIES
The global SIA schedule was reviewed in late April 2014, and the partnership decided to increase the
number of SIAs planned for the second half of 2014 in at-risk countries. Increasing SIA number/frequency,
however, is only one means of attempting to reduce risk. To address other priorities in mitigating risk, such as
improving SIA quality and enhancing surveillance, GPEI has recently created the Outbreak Risk Mitigation
Task Team to work with the African Regional Office in planning activities in these approaches.
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GPEI Partner Status Report - 25 September 2014
VACCINE SUPPLY AND MANAGEMENT
INTRODUCTION
In 2014 so far, UNICEF has been able to supply both OPV and IPV for the programme to implement all
planned immunization campaigns without any delays or cancellation of activities.
The IMB report of May 2014 made a specific recommendation on increasing the OPV supplier base in
Nigeria and Pakistan. This report also expressed concerns regarding the quality of in-country vaccine stock
management and the need to finalize national plans for use of IPV in SIAs. Significant progress has been
made on expanding the bOPV supplier base in Nigeria, but not in Pakistan. Plans have been developed for
some IPV use in SIA in 2014 and IPV was supplied to Afghanistan, Nigeria and Pakistan keeping supply
provisions intact for planned IPV introduction in routine immunization.
UNICEF continues to implement pilots to improve in-country vaccine management but progress remains a
challenge as it is not yet viewed as a priority among all emergency activities in affected countries. There are
also challenges with data quality and vaccine inventory systems. With inputs from partners, UNICEF has
developed an internal technical guidance note on vaccine management during polio SIAs. UNICEF also
collaborated with CDC to include a training module on polio vaccine management during SIA into the STOP
team training of the 44th team, which was conducted in June 2014.
OPV SIA: SUPPLY AND DEMAND FOR SECOND HALF-2014 – Q1 2015
Since May 2014, because of additional awards made in Q4 2013, the supply situation has dramatically
improved for OPV, with sufficient buffer to meet potential increases in demand for the second half of 2014.
As of September 2014, global OPV supply for the second half of 2014 is sufficient including the availability
of buffer into Q1 of 2015 (see Figure 85). Additionally, after approval of the final 2014 SIA calendar by
the Eradication Management Group and Polio Steering Committee in May 2014, stress testing for supply
availability was conducted and supply should be sufficient through Q1 2016.
UNICEF is in the process of making awards to manufacturers for additional supply of bOPV and tOPV in
2015 to maintain a minimum of a 40 million dose buffer of bOPV and 30 million dose buffer of tOPV.
Since 2012, UNICEF has been working with Pakistan and Nigeria country offices to accelerate/increase the
number of licensed products to increase security of supply and allowing further flexibility in managing
demands globally and in these two countries. For Nigeria, there has been licensure of additional bOPV
suppliers (two products licensed, two more in the process of finalizing registration). Nigeria has also been
accepting delivery of non-license vaccine against issuance of import waivers on a campaign-by-campaign
basis, including from Indian manufacturers. Licensure is no longer a limitation for supply allocation but if
granted would expedite supply.
Progress for Pakistan has been limited. UNICEF is working with Pakistan to increase the supplier base but this
has been unsuccessful in additional registered products. There are still only two suppliers licensed for both
tOPV and bOPV. This continues to constrain the bOPV supplier base for Pakistan.
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GPEI Partner Status Report - 25 September 2014
Figure 85. OPV monthly demand vs. balance supplies: July 2014 to March 2015 (Projected)
IPV IN SIAS: SUPPLY UPDATE
The requirements of the IPV tender concluded in Q1 2014 were based on projected demand for introduction
in routine immunization (objective 2). Delays in IPV introduction plans reduced the IPV requirements in 2014
and increased availability for SIAs in 2014. This enabled the programme to allocate 5.4 million IPV doses for
SIAs in endemic countries in 2014. This quantity has been divided as follows:
•
•
•
Afghanistan
Nigeria
Pakistan
0.6 million doses
2.1 million doses
2.7 million doses of which 1.7 million doses has been funded
In Pakistan, all 400,000 IPV doses which have been already delivered remain unused due to delays in
government decision in conducting IPV SIAs. On the other hand, encouraged by the successful implementation
of IPV in SIA in Borno and Yobe, Nigeria Expert Review Committee has recommended further use of IPV in
campaigns in selected LGAs of Kano. The Nigeria country team is working out the additional IPV doses
required.
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GPEI Partner Status Report - 25 September 2014
Because of delay in licensure and reduced supply availability 2014-2015, global IPV supply will be very
constrained in order to meet the upcoming planned routine immunization introductions. Adding SIA
requirements leads to a projected moderate supply gap for 2014-2015. The Immunization System
Management Group has agreed to allocate specified quantifies of IPV doses for use in campaigns (4-7
million doses in 2015) but is requesting that the programme communicates the plans and needs for 2015 as
soon as possible. The Eradication Management Group has developed clear criteria to guide countries on IPV
use in SIAs and has communicated this to the three endemic countries with a request to provide detailed plans
for IPV SIAs in 2014 and 2015 with the Immunization Systems Management Group and Supply Division which
will be reviewed against the projected IPV introduction plans by end of September 2014.
IN-COUNTRY VACCINE MANAGEMENT AND STOCK INVENTORY
The recent IMB report expressed concerns regarding the in-country vaccine stock
management. They indicated that this “is wasteful, potentially constraining the
amount of vaccine that can be deployed elsewhere. Tighter inventory control
would help significantly.” In an effort to improve in-country vaccine management
especially during polio SIAs, UNICEF, in collaboration with partners, is now
leading several initiatives. Most of these are initial pilots and low-cost initiatives
that build on existing opportunities.
•
•
•
•
•
UNICEF, with inputs from partners, regional offices and country offices,
has developed a “Guidance note on vaccine management during polio
campaigns” which lays out key programmatic roles and responsibilities
at different levels and identifies priorities, processes, indicators and
tools. This is being rolled out gradually with focus on the endemic
countries.
Stock inventory reporting template: West and Central Africa Regional Office have also piloted a
UNICEF Headquarters (HQ) template for reporting on national and sub-national polio vaccine
utilization and stocks in countries. This has been helpful to account for available vaccine stocks prior to
further procurement orders by the country. Nigeria specifically has also been strengthening efforts on
stock inventory and was able to use surplus OPV doses to cover the needs of a full SNID in May,
2014.
Building in country capacity: In collaboration with CDC, UNICEF HQ has developed and delivered a
curriculum for the first training session on vaccine management targeting STOP (44th batch- June
2014) team members. STOP consultants are deployed to the field in the high priority countries to
support eradication activities. This has been well received and we plan to continue building on it and
to develop an interactive web-based training module that also links this to the guidance note. .It would
be critical to continue this effort as part of integrating vaccine management training into the overall
curriculum.
Cold chain capacity: members of the COMNet in Pakistan have been trained on conducting a cold
chain inventory and have completed this exercise and collected and analyzed the data for all high
risk districts in the country. These data have been critical to highlight gaps in the system and advocate
with local and provincial authorities on the importance of urgently addressing these gaps to strengthen
cold chain for polio SIAs and routine immunization in general. Most recently, in July, this was used to
assess cold chain capacity and status of health facilities in South Waziristan.
Vaccine management and cold chain and logistics indicators: UNICEF's internal polio management
dashboard for the endemic countries uses two such indicators—but the challenge is in getting the
whole programme and relevant structures at various levels to adopt and use such indicators to monitor
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GPEI Partner Status Report - 25 September 2014
this area of work. Some developments occurred with inclusion of vaccine management indicators in
Pakistan’s revised National Emergency Action Plan in 2014.
PRIORITY AREAS OF FOCUS IN NEXT 3-6 MONTHS
The programme continues to invest resources in vaccine supply management and the following areas still
require further work by the partnership.
•
Availability, quality and use of polio vaccine utilization data during SIAs by the programme at various
levels. It is critical for country teams to be fully engaged with this work and ensure that the vaccine
management and cold chain data are being collected regularly and used and the need to do so is not
viewed as a duty of one partner or agency. The minimum requirement would be for the programme to
review, analyze and use the following data and include it in all GPEI data platforms:
o Number of OPV doses delivered, used and remaining after each SIA at district, provincial and
national level
o Available polio vaccine stock by type of (tOPV, bOPV, IPV) on a monthly basis
o Number of sites reporting vaccine stock-outs during each SIA by district level
These data should be incorporated into regular reports from countries.
•
•
•
Focus on cold chain and vaccine logistics systems: GPEI partners will be looking at opportunities for
strengthening cold chain and logistics systems in the highest risk areas in the priority countries utilizing
polio infrastructure in place and using these data to advocate with local authorities to address existing
gaps
GPEI is updating the 2015-2016 calendar for both OPV and IPV SIAs and incorporate considerations
to mitigate any risk for outbreaks ahead of the tOPV to bOPV switch in routine immunization.
Continued need for close and joint monitoring of supply and demand and ensure that all vaccines are
supplied in time for planned SIAs (OPV and IPV) and that requests for vaccines outside of the
approved SIA calendar are assessed and decided on by appropriate global bodies before any
allocations are made.
Many of the efforts related to SIA activities will also contribute to strengthening the overall vaccine
management, cold chain and logistics systems in countries, as well as to the improvement of routine
immunization and facilitating the tOPV to bOPV switch.
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GPEI Partner Status Report - 25 September 2014
STAFFING AND CAMPAIGNS IN 2014
Consultants
GPEI consultants by deployment, 2014
WHO Paid
Consultants
BMGF
Sponsored
Afghanistan
12
12
Cameroon
51
CAR
2
Country
Chad
Congo
10
3
DRC
5.5
Djibouti
3
Equatorial Guinea
19
Ethiopia
24
Gabon
6
Iraq
12
Jordan
25
16
Kenya
26
2.5
Nigeria
38
22
Pakistan
9
27.5
1
Niger
Somalia
South Sudan
7
Switzerland
8
Syria
Turkey
9
2.5
Uganda
Yemen
WHO Headquarters
Total
11
256
110
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GPEI Partner Status Report - 25 September 2014
Staffing & SIA Campaigns 2014
1
Country#Staffing#for#Polio
Region
Country
Afghanistan
Endemic# Pakistan
Nigeria
Algeria
Angola
Benin
Botswana
BurkinaAFaso
Burundi
Cameroon
CapeAVerde
CentralAAfricanA
Republic
Chad
Congo
CôteAd'Ivoire
DemocraticA
RepublicAofAtheA
Congo
Eritrea
Ethiopia
AFR
UNICEF
WHO
2
NIDs
SNIDs
5
Polio#Program#
3#
CDC#Staff#&#
NSTOP
Supporting#
partners
3
32
1
209
Rotary
6
7
8
Core
Surge
Surge#&#Soc#
Core
Mob
9
STOP
272
28
2,892
7
4
35,842
9
22,173
$62.2
485
70
1,771
3
5
171,584
12
133,290
$146.2
25
314
2297
33
9,844
29
$273.4
2
117,925
9
191,680
0
0
0
0
3
80
5
4
7
4
$0.0
6
2
14,206
0
0
$11.7
2
3
9,855
0
0
$4.7
1
0
0
0
0
16
6
3
$0.2
2
4
25,440
0
0
$12.0
9
1
0
0
0
0
$0.0
4
7
31,304
4
15,050
$18.4
2
125
0
0
$0.2
2
948
5
3,026
$3.3
$16.2
0
1
Costs (USD,#
millions)
239
3
0
9
1
3
35
1
4
9
15
16
6
93
2
No.
Target#
(thousand)
145
0
1
No.
Target#
(thousand)
8
0
1
Total#No.
41
0
EquatorialAGuinea
Gabon
Gambia
Ghana
Guinea
GuineaSBissau
Kenya
Liberia
Madagascar
Malawi
Mali
Mauritania
Mozambique
Namibia
Niger
Rwanda
Senegal
SierraALeone
SouthAAfrica
SouthASudan
Swaziland
Tanzania
Togo
Uganda
Zambia
Zimbabwe
2014#Polio#Campaigns
4
CDC
0
6
11
73
35
9
4
16
14
3
11,189
2
3,769
4
4
4,122
0
0
$3.2
4
3
23,034
0
0
$10.2
20
2
28,761
1
6,424
$39.0
0
0
0
0
$0.3
2
21,737
6
20,201
$30.1
3
43
18
18,688
1
7
0
6
1,598
1
4
$2.6
1
1
3
1,991
0
0
$1.4
0
2
810
0
0
$0.6
0
2
11,431
0
0
$5.2
3
0
0
0
0
$0.0
2
0
2
576
0
0
$0.7
3
9
2
17,137
5
21,784
$24.6
$0.0
0
0
5
2
0
2
7
4
3
2
0
3
7
13
3
7
4
0
0
0
0
0
9
1
0
0
0
0
$0.5
0
2
0
0
0
0
$0.3
6
4
4
3
21,563
1
3,503
$8.5
0
1
3
2
1,214
0
0
$1.4
0
5
2
0
0
0
0
$0.6
0
4
0
0
0
0
0
$0.4
5
21
4
4
22,323
3
7,337
$17.6
0
3
2
0
0
0
0
$0.3
0
3
2
2
4,977
0
0
$2.5
0
7
3
0
0
0
0
$0.0
0
8
0
0
0
0
$0.7
0
446
0
3
0
7
3
5
3
12
0
0
6
1
3
1
12
4
12,374
0
0
$12.3
0
0
0
0
$0.2
0
0
0
0
0
$0.8
1
2
3,944
0
0
$2.0
4
2
9,714
1
3,806
$6.4
9
0
0
0
0
$0.9
3
0
0
0
0
$0.4
1
1
2
18
Page 92
!
GPEI Partner Status Report - 25 September 2014
1
Country#Staffing#for#Polio
Region
AMR
EMR
EURO
SEAR
WPR
All
Country
CDC#Staff#&#
NSTOP
Haiti
Djibouti
Egypt
Iran
Iraq
Jordan
Lebanon
Somalia
Sudan
SyrianFArabF
Republic
Yemen
EMRO
Kyrgyzstan
RussianF
Federation
Tajikistan
Turkey
Uzbekistan
Bangladesh
India
Indonesia
Myanmar
Nepal
Cambodia
China
Phillipines
VietFNam
Total
2014#Polio#Campaigns
WHO4
CDC
Supporting#
partners
Rotary
6
UNICEF
7
8
Core
Surge
Surge#&#Soc#
Core
Mob
1
11
2
SNIDs5
NIDs
9
STOP
Total#No.
No.
Target#
(thousand)
No.
Polio#Program#
Target#
(thousand)
Costs3#(USD,#
millions)
4
0
0
0
0
1
2
250
1
51
$0.4
2
25,891
0
0
$2.2
2
$0.0
1
5
28,642
4
8,220
$4.2
6
3
1
3
2,784
2
350
$2.4
6
2
4
2,843
3
200
$4.6
2
8
15,707
7
5,958
$26.0
0
2
12,311
1
4,427
$13.9
9
21,980
1
1,846
$9.0
4
20,707
0
0
$6.3
0
0
0
0
$0.01
0
0
2
1,173
$0.0
2
2,087
0
0
$0.3
0
0
4
2,011
$0.7
0
0
0
0
$0.03
1
185
4
40
15
12
69
37
5
17
15
1
4
1
2
2
21
103
4
32
1160
17
6
11
9,125
0
$2.5
273,372
$46.6
0
0
0
0
$1.6
0
0
0
0
$0.8
1
4,803
0
0
$2.1
0
0
0
0
$0.0
0
0
0
0
$0.0
2
27,247
0
0
$0.0
0
0
0
0
$0.0
127
1,133,457
87
729,655
$846.1
57
1
3
279
0
3
49
1
11
0
362,483
50
0
245
0
2
3360
3202
255
42332
184
0
1. Does not include staff at other levels
2. Includes National Immunization Days (NIDs), Subnational Immunization Days (SNIDs), Mop ups, and Child Health Days (CHDs)
3. Includes AFP surveillance, Social Mobilization, Technical Assistance, OPV, and Operational Costs. Costs for CHDs and CDC programmes
not included
4. The number in yellow background was not updated since last report (April 2014)
5. Concurrent SNIDs in different geographical areas were counted separately
6. CDC secondees to WHO country offices and contractors are also counted as WHO core staff
7. Includes both volunteers and paid staff.
8. Includes international and national technical staff
9. Stop Transmission of Polio (STOP) round 44, deployed July-December, 2014. One STOP volunteer was assigned to Papua New Guinea
(WPR).
Page 93
!
GPEI Partner Status Report - 25 September 2014
FINANCING
GLOBAL POLIO ERADICATION INITIATIVE FINANCING SITUATION
FUNDING GAP
Against the US$ 5.5 billion budget for 2013-2018, the best-case funding gap for the entire period is
US$ 494 million (Table GPEI Funding Gap as of July 2014, below).
The best case funding gap represents the difference between the total costs budgeted in the endgame plan
less a) pledges made at the 2013 vaccine summit, b) pledges made after the summit, and c) projections for
donors who have not made publically announced funding commitments but who have historically provided
support and have indicated that they will continue to do so.
GPEI Funding Gap as of July 2014
Funding Gap
2013-2018
2013-2018
USD millions
Feb 2013
Jul 2014
(pre-Vaccine Summit)
(Millions)
(Millions)
Funding Required (FRRs)
$5,525
$5,525
Confirmed Funding
$ 395
$1,986
Pledged Funding
$
-
$2,698
Projected Funding
$3,100
$ 347
'Best Case' Funding Gap
$2,030
$ 494
Source. GPEI.
This level of commitment from donors over the entire period of the plan represents a historic shift in the way
the Initiative is funded and has enabled stronger forward planning, more discipline in budget control and
supported a faster response to the two major outbreaks of 2013.
It is important to note that pledged funding does not represent cash available to the Initiative. Changes in
political leadership or economic downturns present a risk that pledges will not be honored. In addition, none
of the donors who pledged at the Vaccine Summit were in a position to make a full payment of the pledges
immediately and the timing of the operationalization of pledges has an impact on programme
implementation.
Page 94
GPEI Partner Status Report - 25 September 2014
CASH GAP
The cash gap represents the GPEI’s internal operating position in the near term based upon cash available for
expenditure. As of July 2014, the Initiative has cash on hand of US$ 908 million against the total budget of
US$ 1.1 billion for 2014 (Figure 86).
Figure 86: GPEI Cash Gap for 2014 as of July 2014
The remaining cash gaps for 2014 are in budget categories for SIAs and emergency response. The majority
of these gaps will be covered from forthcoming contributions from GPEI partners (Bill and Melinda Gates
Foundation, CDC supplements, and private philanthropists).
The cash gap projections for 2015 will be developed once the 2015 SIA calendar (currently being finalized
by the Eradication Management Group) is approved.
IMB RECOMMENDATIONS
In its Ninth Report of May 2014, the IMB recommended that current concerns and unease about the
transparency and communication of the polio eradication budget are properly and openly addressed and
suggested that this might best be achieved by a frank discussion at the Polio Oversight Board.
In order to better understand these issues, a follow-up call was held with members of the IMB secretariat.
Following this, the topic was also discussed at the 16 June 2014 meeting of the Polio Partners Group. The
outcome of these conversations resulted in the identification of 5 key issues to be addressed:
1.
2.
3.
4.
5.
More details on allocations and cash gaps against budget lines
Clear reporting on domestic contributions
Reporting on expenditure against budgets
Split of costs for polio eradication versus routing immunization
More information on IPV introduction (GAVI vis-à-vis GPEI budget; whether all vaccine costs are
included in the GPEI budget)
These issues and next steps were presented and discussed during the Finance and Budget update at the 20
June POB meeting. The POB chair noted that the Finance Working Group should develop ways to provide
more clarity both in reporting and communication on expenditures, future funding and cash gaps, including a
Page 95
GPEI Partner Status Report - 25 September 2014
more detailed breakdown of the gaps, the projected contributions that could close the gaps and the risks to
realizing the projected contributions. The POB made a recommendation that the GPEI should provide more
detailed and regular financial reporting to donors, including financial expenditures. In addition, the POB
supported the introduction of a semi-annual budget and cash-flow review during their meetings.
The following initial steps have been taken to address the 5 key issues above:
1. More details on allocations and cash gaps against budget lines – the following two charts will be
introduced in the July 2014 FRR
Page 96
GPEI Partner Status Report - 25 September 2014
2. Clear reporting on domestic contributions – this information is found in the Vaccine Summit reporting
table in the July 2014 FRR; information on trends in domestic funding will also be introduced in the
July FRR:
Confirmed&
Confirmed&
Funds&Committed&
New&Funding&
Funding&against&
Funding&against&
by&April&2013&
received&since&Feb&
the&GPEI&FRRs,&as&
the&GPEI&FRRs,&as&
Vaccine&Summit
2014&
of&February&2014
of&31st&July&&2014
G8&&&EC
Canada
$243.53
$65.08
$37.64
$102.72
$6.50
$5.80
$8.16
$13.96
$151.70
$53.96
$0.00
$53.96
$9.70
$457.00
$90.60
$14.80
$296.31
$129.85
$6.44
$1.33
$60.73
$21.24
$297.64
$190.58
$34.55
$34.55
$34.55
$0.53
$0.53
$0.53
$6.50
$0.70
$252.45
$6.63
$0.70
$12.45
$0.05
$0.14
$0.02
$0.35
$15.00
$0.05
$0.05
$0.02
$0.35
$15.00
$1.00
$120.00
$1.00
$12.00
$12.00
$1.00
$24.00
Bill6&6Melinda6Gates6Foundation
Korean6Foundation6for6International6Healthcare/6
Community6Chest6of6Korea
$1,800.00
$363.77
$47.88
$411.65
$1.00
$2.00
Private6Philanthropists/High6Networth6Individuals
$335.00
$51.20
$27.10
$78.30
$76.81
$0.75
$156.45
$0.07
$3.55
$160.00
$0.07
$24.00
$227.00
$64.50
$10.00
$24.00
$137.28
$22.75
$10.00
$12.92
$36.92
$137.28
$40.75
$10.00
$50.00
$50.00
$50.00
$4.27
$10.40
$10.40
$7.30
$10.00
$0.90
$6.54
$10.00
$0.67
$22.80
$6.54
$10.00
$0.67
$28.30
European6Commission
Germany
Japan
United6Kingdom
USA
NonTG8&OECD&Countries
Australia1
Finland
Ireland
Luxembourg
Norway2
Other&Donor&Countries
Brunei6Darussalem
Isle6of6Man
Liechtenstein
Monaco
Saudi6Arabia
Private&Sector/&NonTGov't&Donors
Al6Ansari6Exchange
Abu6DhabiRCrown6Prince
3
3
Rotary6International
UN6Foundation
Multilateral&Sector
GAVI/IFFIm6
Islamic6Development6Bank/6Government6of6Pakistan
UNICEF6
World6Bank6(Grant6to6Afghanistan)
World6Bank6Investment6Partnership,6Bank6Portion
World6Health6Organization
Domestic&Resources
Angola
Bangladesh
Nepal
Nigeria
TOTAL
1
4
$40.00
$4,041.85
$1,517.06
$0.35
$160.00
$0.23
$6.63
$1.05
$172.45
$0.05
$0.05
$0.02
$0.58
$15.00
$2.00
$18.00
$5.50
$401.83
$1,918.89
6In6June620146Prime6Minister6Tony6Abbot6reaffirmed6the6pledge6of6806million6USD6towards6the6Polio6Eradication6Strategic6Plan6and6Endgame
36
Funds6for620136under6the6$3556Million6Challenge6Grant6from6the6Bill6&6Melinda6Gates6Foundation6to6Rotary6International6is6reflected6in6both6the6
Bill6and6Melinda6Gates6Foundation6and6Rotary6International6contribution6lines,6though6the6contribution6is6only6counted6once6in6the6GPEI6totals.6The6
same6applies6for6a6$506million6grant6for62013R2015.6In62013,6Rotary6pledged6up6to6$1756million6for62013R2018,6which6will6be6matched62:16by6the6Bill6
&6Melinda6Gates6Foundation.6Contributions6from6both6under6this6match6scheme6will6be6reflected6as6and6when6funds6are6confirmed.6Rotary's6
contributions6to6the6GPEI6are6through6the6Rotary6Foundation.
Page 97
GPEI Partner Status Report - 25 September 2014
3. Reporting on expenditure against budgets – this report is being finalized for publication during
October 2014. Effective in 2015, this information will be a regular segment of the annual report.
4. Split of costs for polio eradication versus routine immunization – the July 2014 FRRs have an
expanded section on costs that contribute to routine immunization (RI) strengthening, and will include
the following chart:
Budget Category and
Funding Channels
Technical Assistance GPEI*
IMG Technical assistance
2014 - 15**
One-time RI strengthening
activities 2013 GPEI
TOTAL RI Strengthening
GPEI Budget Category
Core Functions and
Infrastructure: Technical
Assistance (WHO)
Core Functions and
Infrastructure: Ongoing Quality
Improvement
Core Functions and
Infrastructure: Ongoing Quality
Improvement
Total 2013-2018
$228M
$5M
$8M
$241M
*In 10 priority countries: 50% of field staff time at sub-national levels; 25% at national levels.
**Costing included under the IMG work plan/IPV introduction
5. More information on IPV introduction (GAVI vis-à-vis GPEI budget; whether all vaccine costs are
included in the GPEI budget) – As with routine immunization, there is an expanded section on IPV
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GPEI Partner Status Report - 25 September 2014
introduction in the July 2014 FRR which addresses these concerns, and includes the follow table
detailing budgetary information:
6.
IPV Introduction Budget
Category and Funding
Channels
Vaccine costs: GAVI
Introduction grants: GAVI
Introduction support: GPEI
GPEI Budget Category
Immunization Activities:
IPV in Routine Immunization
Immunization Activities:
IPV in Routine Immunization
Immunization Activities:
Total 2014-2018
$342M
$46M
$45M
IPV in Routine Immunization
IMG Technical assistance
•!!!!!!!!!IPV: GAVI/GPEI
•!!!!!!!!!RI Strengthening:
GAVI/GPEI
•!!!!!!!!!tOPV/bOPV switch:
GPEI
TOTAL
Core Functions and
Infrastructure: Ongoing Quality
Improvement
$50M
$483M
After publication of the July 2014 FRR and the WHO/UNICEF expenditure report, there will be follow-up
discussions with key stakeholders to assess progress on these efforts and further refine response strategies.
Additional work will be undertaken in the next period to refine the reporting further and address the request
of the POB chair for inclusion of additional information in subsequent FRRs.
ROTARY SUPPORT
Rotary continues to draw from its global volunteer network to raise awareness and funds for the Global Polio
Eradication Initiative. As a result of these enhanced efforts and in partnership with the Gates Foundation,
Rotary committed US$105 million in funding for polio eradication in calendar year 2013 and expects to do
the same in 2014.
Rotarians continue to advocate with donor governments to help meet critical funding needs, both within the
polio affected countries and in key donor markets. Rotary’s advocacy efforts have largely focused on the
following key markets, the US, UK, Canada, Japan, Australia, Germany, and the EU. Of note, the Prime
Minister of Australia announced a pledge of A$100 million at Rotary’s convention in June 2014 for global
polio eradication efforts.
Page 99
GPEI Partner Status Report - 25 September 2014
ANNEX: LIST OF FIGURES
Figure 1. WPV sanctuaries in polio-endemic countries, and countries and areas with wild poliovirus
transmission within the prior 12 months, 19 September 2014
Figure 2. Proportion of targeted children missed due to refusal, January 2013–August 2014
Figure 3. Missed children in high risk areas of endemic countries, October 2013-August 2014
Figure 4. Number of social mobilization networks, January 2013–August 2014
Figure 5. UNICEF performance dashboard for frontline workers, Endemic countries, Sept 2014
Figure 6. Poll Responses Regarding Trust in Vaccinators, Nigeria and Pakistan
Figure 7. Gender profile of frontline workers, July 2013-June 2014
Figure 8. WPV and cVDPV cases, Afghanistan, 2013 and 2014 to date*
Figure 9. Wild poliovirus type 1 (WPV1) by genetic cluster and circulating vaccine-derived poliovirus type 2
(cVDPV2) by emergence, Afghanistan & Pakistan, 2013 and 2014 to date*
Figure 10. WPV and cVDPV cases, Southern Sanctuary, 3 September 2013 to 2 September 2014*
Figure 11. WPV and cVDPV cases by week of onset, Southern Sanctuary (Helmand and Kandahar Provinces),
Afghanistan, 3 Sept 2013 to 2 Sept 2014*
Figure 12. LQAS survey results by SIA, Southern Sanctuary, Afghanistan, Sept 2013 to Aug 2014
Figure 13. Proportion of NPAFP cases 6-35 months, by OPV status, Southern Sanctuary, Afghanistan**
Figure 14. WPV and cVDPV cases, Eastern Risk Area, 3 September 2013 to 2 September 2014*
Figure 15. WPV and cVDPV cases by week of onset in the Eastern Risk Area (Kunar, Nangarhar, Laghman,
Nuristan, Khost, and Paktya Provinces), Afghanistan, 3 Sept 2013 to 2 Sept 2014*
Figure 16. LQAS survey results by SIA in the Eastern Risk Area Afghanistan, Sept 2013 to Aug 2014
Figure 17. Proportion of NPAFP cases 6-35 months, by OPV status, Eastern Risk Area, Afghanistan**
Figure 18. Trends in missed children in accessible, high-risk areas in Afghanistan, Oct 2013-Aug 2014
Figure 19. Proportion of missed children and missed because of refusal among targeted children in selected
LPDs in Southern Afghanistan, October 2013 to August 2014,
Figure 20. Polio related security incidents in Afghanistan, Feb-Sep 2014
Figure 21. Proportion of Missed Children due to Inaccessibility among Targeted Children <5 years of age, by
Region, Afghanistan, October 2013 to August 2014
Figure 22. Inaccessible areas, 2014 WPV1 cases, and the estimated proportion of children affected during
the August 2014 SIA - Eastern Risk Area and Southern Sanctuary, Afghanistan
Figure 23. Six-month standard immunization indicators among children aged 6–35 months with NPAFP and
annualized surveillance indicators by province, Afghanistan and Pakistan February 2013 to August 2014
Figure 24. WPV and cVDPV cases, Pakistan, 2013 and 2014 to date*
Figure 25. WPV1 and cVDPV2 cases and environmental isolates by genetic cluster (WPV1) and emergence
(cVDPV2), Pakistan, 12 August 2013 to 11 August 2014*
Figure 26. WPV and cVDPV cases, FATA Sanctuary, 3 September 2013 to 2 September 2014*
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GPEI Partner Status Report - 25 September 2014
Figure 27. WPV cases by week of onset and environmental surveillance results, FATA Sanctuary, Pakistan, 3
Sept 2013 – 2 Sept 2014*
Figure 28. Proportion of Union Councils with LQAS survey results by SIA, FATA Sanctuary, Pakistan, Sept 2013
to Aug 2014
Figures 29. Proportion of NPAFP cases 6 to 35 months, by OPV status, FATA Sanctuary, Pakistan**
Figure 30. WPV and cVDPV cases, KP Sanctuary, 3 September 2013 to 2 September 2014*
Figure 31. WPV cases by week of onset and environmental surveillance results, KP Sanctuary, Pakistan,
Sept 2013 to 2 Sept 2014*
3
Figure 32. Proportion of Union Councils with LQAS survey results by SIA, KP Sanctuary, Pakistan, Sept 2013 to
Aug 2014
Figure 33. Proportion of NPAFP cases 6 to 35 months, by OPV status, KP Sanctuary, Pakistan**
Figure 34. WPV & cVDPV cases and environmental surveillance results, Karachi Sanctuary, 3 September
2013 to 2 September 2014*
Figure 35. WPV cases by week of onset and environmental surveillance results, Karachi Sanctuary, Pakistan, 3
Sept 2013 to 2 Sept 2014*
Figure 36. Proportion of union councils with LQAS survey results* by SIA, Karachi Sanctuary, Pakistan, Sept to
Aug 2014
Figure 37. Proportion of NPAFP cases 6 to 35 months, by OPV status, Karachi Sanctuary, Pakistan**
Figure 38. WPV and cVDPV2 cases, Quetta Risk Area, 3 September 2013 to 2 September 2014*
Figure 39. WPV cases by week of onset and environmental surveillance results, Quetta Risk Area, Pakistan
3 Sept 2013 to 2 Sept 2014*
Figure 40. Proportion of Union Councils with LQAS survey results* by SIA, Quetta Risk Area, September 2013
to August 2014
Figure 41. Proportion of NPAFP cases 6 to 35 months, by OPV status, Quetta Risk Area, Pakistan**
Figure 42. Key social characteristics, polio cases, 2013-14*
Figure 43. Transit vaccination in Pakistan
Figure 44. Summary of information on unavailable children, Pakistan February–June 2014
Figure 45. Location of areas where COMNet succeeded in negotiating access in South Waziristan
Figure 46. I Inaccessible areas during the August 2014 SIA and 2014 WPV1 and cVDPV cases, Pakistan*
Figure 47. WPV and cVDPV cases, Nigeria, 2013 and 2014 to date*
Figure 48. Wild poliovirus type 1 (WPV1) by genetic cluster and circulating vaccine-derived poliovirus type 2
(cVDPV2) by emergence, Nigeria, 2013 and 2014 to date*
Figure 49. WPV1 cases and environmental isolates by genetic cluster, Nigeria, 12 August 2013 to 11 August
2014*
Figure 50. cVDPV2 in Nigeria and Niger by emergence, 12 August 2013 to 11 August 2014*
Figure 51. WPV and cVDPV cases, North-Central Sanctuary, 3 September 2013 to 2 September 2014*
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GPEI Partner Status Report - 25 September 2014
Figure 52. WPV and cVDPV cases by week of onset and environmental surveillance results, North-Central
Sanctuary (Kano, Katsina, Jigawa, and Kaduna), Nigeria, 3 Sept 2013 to 2 Sept 2014*
Figure 53. Proportion of LGAs with LQAS survey results by SIA, North-Central Sanctuary, Nigeria, Sept 2013
to Aug 2014
Figure 54. Proportion of NPAFP cases 6 to 35 months, by OPV status, North-Central Sanctuary, Nigeria**
Figure 55. WPV and cVDPV cases, Northeast Sanctuary, 3 September 2013 to 2 September 2014*
Figure 56. WPV and cVDPV cases by week of onset and environmental surveillance results, Northeast
Sanctuary (Borno and Yobe), Nigeria, 3 Sept 2013 to 2 Sept 2014*
Figure 57. Proportion of LGAs with LQAS survey results by SIA, Northeast Sanctuary, Nigeria, Sept 2013 to
Aug 2014
Figure 58. Proportion of NPAFP cases 6 to 35 months, by OPV status, Northeast Sanctuary, Nigeria**
Figure 59. WPV and cVDPV2 cases, Northwest Risk Area, 3 September 2013 to 2 September 2014*
Figure 60. WPV and cVDPV cases by week of onset and environmental surveillance results, Northwest Risk
Area (Sokoto and Zamfara), Nigeria 3 Sept 2013 to 2 Sept 2014*
Figure 61. Proportion of LGAs with LQAS survey results by SIA, Northwest Risk Area, Nigeria, Sept 2013 to
Aug 2014
Figure 62. Proportion of NPAFP cases 6 to 35 months, by OPV status, Northwest Risk Area, Nigeria**
Figure 63. Trends in missed children, Kano state, Nigeria, Jun 2013-Jun 2014
Figure 64. Number of children vaccinated in specific demand-creation exercises, 10 high-risk states, Nigeria
January to August 2014
Figure 65. Numbers of newborns registered and vaccinated by VCMs, Kano, May to August 2014
Figure 66. Number of children vaccinated at CMAM centers and number receiving the first OPV dose, 10
high-risk states, Nigeria, January to August 2014
Figure 67. Insecurity Levels in Nigeria, August 2014
Figure 68. Inaccessible areas, WPV1 cases, and the estimated number of children affected during the August
2014 SIA—Northeast Sanctuary, Nigeria
Figure 69. Inaccessible Settlements in Borno and Yobe Provinces, Nigeria, August 2014
Figure 70 Six-month standard immunization indicators among children aged 6-35 months with AFP and
annualized surveillance indicators by state, Nigeria, February 2013 to August 2014
Figure 71. WPV cases by week of onset in the Horn of Africa, 2013–2014 to date*
Figure 72. WPV1 and cVDPV Cases in the Horn of Africa, 2013-2014 to date*.
Figure 73. WPV cases and inaccessible children in Somalia in the August 2014 SIA
Figure 74. Polio Campaign Awareness by Province/State, Horn of Africa
Figure 75. WPV1 and cVDPV Cases in the Central Africa, 2013–2014 to date*
Figure 76. Population movements within and from CAR as of 9 September
Figure 77. WPV cases by week of onset in Central Africa, 2013-2014 to date*
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GPEI Partner Status Report - 25 September 2014
Figure 78. WPV cases in Syria and Iraq, 2013-2014 to date*
Figure 79. WPV and AFP cases by week of onset in Syria (n=36) and Iraq (n=2, WPV), 2013–2014 to date*
Figure 80. Supplemental immunization activities in response to the Middle East outbreak, January–November
2014
Figure 81. Reasons for Non-Vaccination among Missed Children in Jordan, Syria, Lebanon and Iraq,
December 2013–June 2014
Figure 82. Facsimile of Proposed Street Drawing to Raise Public Awareness about Polio in Syria
Figure 83. AFP surveillance indicators at first administrative level, for AFP cases with onset 16 August 2013–
15 August 2014, 50 selected AFR, EMR and European Region countries
Figure 84. Immunization status at first administrative level, for children 6-35 months of age with NPAFP cases
with onset 16 August 2013–15 August 2014, 50 selected AFR, EMR and European Region countries
Figure 85. OPV monthly demand vs. balance supplies: July 2014 to March 2015 (Projected)
Figure 86: GPEI Cash Gap for 2014 as of July 2014
Page 103