WHO-EM/XXX/###/E
Report on the
Meeting of the Technical Advisory Group on
Poliomyelitis Eradication in Pakistan
Islamabad, Pakistan
21–22 March 2012
WHO-EM/XXX/###/E
Report on the
Meeting of the Technical Advisory Group on
Poliomyelitis Eradication in Pakistan
Islamabad, Pakistan
21–22 March 2012
© World Health Organization 2012
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Document WHO-EM/XXX/###/E/YY.ZZ/PPP
CONTENTS
1.
INTRODUCTION ............................................................................................................ 1
2.
OPENING SESSION ........................................................................................................ 1
3.
SUMMARY OF TECHNICAL PRESENTATIONS AND DISCUSSIONS .................... 1
Augmented National Emergency Action Plan .................................................................. 2
Implementation status of the recommendations of the last TAG meeting ........................ 2
Epidemiological situation ................................................................................................. 3
Balochistan ........................................................................................................................ 3
Federal Administrative Tribal Areas (FATA) .................................................................... 4
Khyber Pakhtunkhwa Province......................................................................................... 5
Sindh Province .................................................................................................................. 6
Punjab Province ................................................................................................................ 7
Azad Jammu & Kashmir (AJK) ........................................................................................ 8
Gilgit Baltistan (GB) ......................................................................................................... 9
Polio Eradication Initiative (PEI): Communication Strategies ......................................... 9
Engaging High Risk Groups for Polio Eradication ........................................................... 9
Polio Eradication and the Media ..................................................................................... 10
Over all Questions asked to the TAG .............................................................................. 10
3. CONCLUSIONS & RECOMMENDATIONS ..................................................................... 11
Conclusion ...................................................................................................................... 11
TAG Recommendations .................................................................................................. 12
Overarching Recommendations: ..................................................................................... 12
Additional Province Specific Recommendations ........................................................... 14
1. PROGRAMME ................................................................................................................... 18
2. LIST OF PARTICIPANTS................................................................................................... 20
WHO-EM/XXX/XXX/E
1. INTRODUCTION
The Pakistan Technical Advisory Group (TAG) on Poliomyelitis eradication met in
Islamabad on 21-22 March at a time when Polio eradication has been declared to be 'a
programmatic emergency for global public health', with 3 countries, namely Pakistan, Nigeria
& Afghanistan driving global transmission of polioviruses. The objectives of the meeting were
to review progress towards poliomyelitis eradication, after a quarter of the launch of the
augmented National Emergency Action Plan. This is the first meeting of the Pakistan specific
TAG, as previously it was combined for Afghanistan and Pakistan. The objective of separate
TAGs is to provide more focus and in depth review of these country programs.
Pakistan is the only one of the three above countries that has reported an increased
incidence of poliomyelitis in the last three consecutive years. In addition, Pakistan has
reported 50% of global cases to date in 2012. The main reason for that is an evident
deterioration of immunization status in key high risk areas in this country.
The programme and list of participants are attached as Annexes.
2. OPENING SESSION
Professor David M. Salisbury, the chairman of the TAG opened the meeting, highlighted
with concern the critical situation that Pakistan is through for polio eradication and the threat
that the country poses to the efforts for global polio eradication. Dr Guido Sabatinelli, WHO
Representative in Pakistan welcomed all participants and thanked the Government of Pakistan
for hosting the meeting and acknowledged the continued support of polio partners, namely,
Rotary International, USAID, UNICEF, CDC and Bill & Melinda Gates Foundation, JICA
and World Bank. The WR also read a message from Dr Ala Alwan, the Regional Director for
WHO Eastern Mediterranean Region. The RD, in his message, acknowledged the efforts
made by the Government to achieve the target of polio eradication and referred, specifically,
to the augmentation of the National Emergency Action Plan (NEAP) for polio eradication and
the efforts being made to ensure its implementation at all levels. He however; stressed and
hoped for the urgent and spot on implementation of the plan.
The meeting was then addressed by the Federal Secretary Ministry for Inter-provincial
Coordination (Cabinet Division), who welcomed the participants and acknowledged that the
TAG is meeting at a very crucial time. He reiterated the strong commitment of the
Government to convert the present situation to a success in achieving the target of polio
eradication.
3. SUMMARY OF TECHNICAL PRESENTATIONS AND DISCUSSIONS
Dr Bruce Aylward, Assistant Director General WHO in his presentation reaffirmed that
polio eradication remains WHO’s top priority in Pakistan. He presented to the meeting the
latest developments in polio eradication, globally, and referred to success as well as to the
challenges that the program has been facing. He underscored the elimination of India from the
list of the polio endemic countries which marks a major step towards global polio eradication.
WHO-EM/XXX/XXX/E
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He highlighted the profound drop in WPV3 which may be on its way to be eradicated.
He however highlighted that the Pakistan is one of the only 2 countries globally which
reported type-3 polio cases during the last 6 months. He also referred to the exportation of the
WPV-1 from Pakistan to China which reinforces the fact that no part of the globe is free f the
risk until the global eradication is achieved. He shared the upcoming important timelines; that
include finalizing the national emergency plans by end of March 2012, SAGE review of
consolidated plan in April and the World Health Assembly debate in May 2012. Dr Aylward
raised two points for the consideration of TAG, a) Does the Augmented National Emergency
Action Plan (NEAP) address all issues required to reach the OPV coverage levels needed to
stop transmission in Pakistan; and b) What changes are needed to optimize NEAP
implementation in each province?
Augmented National Emergency Action Plan
Member of the National Task Force for Polio Eradication
In Pakistan, Balochistan, Sindh and Federally Administered Tribal Areas (FATA)
contributed a substantial proportion of upsurge of polio cases reported during 201. The
Augmented National emergency Action Plan (A-NEAP) was endorsed by the National Task
Force of Polio Eradication and Ms. Shahnaz Wazir Ali, Assistant to the Prime Minister on
Social Sector has been appointed as the National Focal Person for polio eradication. The ANEAP authorizes the government District Managers (DC, DCO, PAs) to lead the SIAs and
holds them accountable for its quality. It also focuses involving the public representatives and
stresses adequate preparations for SIAs at the UC level. Key recent steps in the light of the ANEAP include abolishment of the zonal supervisors, nomination of the UC medical officers,
strict actions against the sub-optimal performers at all levels and deferment of SIAs in case of
inadequate preparations. Moreover renowned religious leaders, political figures and social
workers have also been taken onboard. The A-NEAP has provided momentum to the program
which needs to be carried on and the Government is fully committed for this.
Implementation status of the recommendations of the last TAG meeting
Coordinator Prime Minister’s Polio Monitoring and Coordination Cell
All the SIAs activities were conducted as per the advice of the TAG using the
appropriate type of the OPV. Case response activities using bOPV were carried out in
response to detection of all WPV-1 cases outside the known persistent transmission zones in
2011. In addition, large scale, intensive mop-ups were carried out in central southern Sindh,
North Sindh, southern Punjab & southern KP. Khyber agency reported two P3 cases; SIADS
were conducted in Khyber agency using bOPV only in the accessible areas; inaccessible areas
could not be reached. He referred the implementation status of the province specific
recommendations to the provincial teams.
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Epidemiological situation
WHO Senior Coordinator
In 2011, Pakistan reported 198 cases (196 WPV1 and 2 WPV3) from 60 infected
districts which was the largest number of cases reported since 2000. The majority of cases
during the last 3 years were reported from the known transmission zones of Federally
Administered Tribal Areas (FATA) and associated areas of the Central Khyber Pakhtunkhwa
(KP) province, Quetta Block (Quetta, Pishin and Killa Abdullah) in Baluchistan province and
Karachi. Following the explosive outbreak in 2011; the 15 cases in 2012 may represent the tail
end of this outbreak except FATA which carries on reporting both polio cases of both
serotypes.
The key epidemiologic characteristics of polio cases include that majority below 2 years
of age with predominance in males, 77% are from Pashto speaking families, 23% belong to
refusal families, 88% live in multiple family dwellings, more than half the cases are
inadequately immunized, some of them having not received any doses of OPV, among the
polio cases Pashto speaking cases had larger proportions of un-immunized and underimmunized children in 2010 and 2011as compared to other ethnicities and 63% of the polio
cases reported from FATA belonged to areas which could not be visited by the vaccination
teams for long time due to insecurity. Nearly 30% of the non-polio AFP cases reported from
FATA and Balochistan each were reportedly either un-immunized or under-immunized against
polio. This warrants urgent attention to address these children. In fact, more than 70% polio
cases were either reported from or genetically linked to the three transmission zones.
It is important to highlight though that the LQAS results indicate marginally better
performance at this point in time as compared to last year which may possibly be the result of
the recent thrust provided by the A-NEAP. The TAG was asked for guidance on the scale of
the SNIDs.
Balochistan
Provincial EPI Manager
Districts with persistent transmission 53 cases representing (73%) of the cases in
Balochistan, Kila Abdullah, Pishin and Quetta 22, 16 and 15 cases respectively, while
Nasirabad/Jaffarbad Block escaped infection due to satisfactory vaccination coverage. Most of
the cases are in localized Teshils, all the 15 cases in Quetta are in Quetta city, out of the 22
confirmed polio cases in Kila Abdulah district 13 in Chamman, and out of the 16 confirmed
polio cases in Pishin 15 are from PISHIN Tehsil.
The AFP surveillance in Balochistan showed that 30% of the confirmed P1 are with
ZERO OPV doses and 48% are with 7+ doses and LQAs in Pishin is rejected at 80% in the
last 2 SIAS and according January SIAs market survey only Quetta reached 90%.
WHO-EM/XXX/XXX/E
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Reasons for failure include inadequate preparations for quality campaigns; deficient
micro-plans, inappropriate AICs & teams selection/training, lack of accountability, misuse of
resources, political interference protecting poor performers & pockets of refusals.
Government of Balochistan has shown high level of commitment, four meetings are
conducted in the Chief Minister office out of which 2 are chaired by the CM. In the line of
implementation of the NEAP 4 Steering Committee meetings has been chaired by the Chief
Secretary (CS), CS directed all DCs to lead PEI in their respective districts. At the level of
management, a highly committed additional secretary for health has been assigned as the
provincial polio focal persons, replacement of four non performing DHOs, and replaced old
tier of Zonal Supervisors (ZS) by MOs as UC in charge.
The province has restructured the program and attained new strategy by conduction
SIAs in two phases to ensure quality of SAIs in Quetta Block. At the UC level in the HRD,
WHO has deployed 57 UCPWs providing technical support for SIAs. UNICEF has
established the ComNet 8 DHSOs, 31 UCOs and 192 SMs have been deployed in field
supporting social mobilization in addition to the media activities. All mobile (nomadic and
seasonal) and cross bored population has been considered in micro planning. A media
orientation workshop was arranged for the prominent health journalists in Q4 of 2011.
Meetings with Parliamentarians from High Risk Districts and who exhibited their active
support in form of District and Union Council level inaugurations
Religious leader seminars and all parties conference involving leadership of all
prominent political parties were held in Pishin and Killah-Abdullah. Only in January –Feb
campaign 344 Community meetings, 127 Madrissa/School Sessions, 435 Mosque
announcements and 53 UC level inaugurations were held by Communication staff in the
HRUCs of HRDs. Two high risk UCs in the high risk districts of Quetta Block are being
source out to PPHI from the next round.
The province has the plan to increasing the number of technical supporting staff in
HRDs to improve the campaign preparations, piloting outsourcing of PEI campaigns to local
NGOs in 4 UCs in High risk districts, completion of the establishment of Polio Control Room
at Provincial and district level, media engagement, and more Involvement of parliamentarians,
religious & political leaders. Details of the action plan for the next six months are available at
annex----.
Federal Administrative Tribal Areas (FATA)
Secretary Administration & Coordination
FATA has reported 59 polio cases with large number from Khyber Agency, followed by
North Waziristan, FR Kohat & Lakkimarwat. Major challenges are insecurity and
management in the accessible areas. Currently the Inaccessible areas remain 25% in Orakzai
ranges to 2% in FR Peshawar. The state of inaccessibility at the end of December 2011
reaches to 8% contributing with major inaccessibility by Khyber Agency 30% followed by
Orakzai Agency which is mentioned above. Management issues and lack of accountability do
WHO-EM/XXX/XXX/E
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persist in the areas like Landikotal and Jamrud Tehsil of Khyber Agency and specially
Miranshah of North Waziristan. Lack of Ownership at the agency health team is quiet evident.
None of the Agency achieved the target level of 95% coverage, ranges from 82% in Kurram
Agency to 54% in FR Bannu. All these factors contributed to the current prevailing situation
of polio outbreak in 2011.
NEAP indicators in 2012 as compared to 2011 are improving like the UPEC Committee
ranges from 63% in Dec to 82% in March. Civil Military Coordination Committee meetings
held in each Agency by due time, 12 days before campaign. Secretary A&C and
Commissioners monitored the activities in the field. Accountability started with transfer of
Agency Surgeons in Mohmand Agency and Kurram Agency due to poor Performance.
Besides this, involvement of Parliamentarians, wide range of social Mobilization activities
were conducted which include School and College Health Sessions, local Jirgas of the tribal
elders and community representative, games competition and local Polio Walks.
To strengthen and implement the A-NEAP in the FATA particularly to improve the
access and quality of campaign, Health directorate consider the actions that include
deployment of “Transit Teams” (Bara, Bajour, Mohmand) for mobile population and for IDP’s
of Orakzai & South Waziristan, involvement of religious organization, addressing the refusal,
enhancement of routine vaccination by celebrating Mother Child Health days, holding
medical camps, further strengthening Cross Border Points vaccination points, holding a grand
tribal elders & Ulema Jirga in April 2012, engaging Polio Ambassadors, further involvement
of Teachers in UPEC and in teams during campaign – especially female teachers and
transparency in making payments to the field staff.
Khyber Pakhtunkhwa Province
Secretary Health
The actions needed for implementation of the Augmented National Emergency Action
Plan as reflected by the fact that two meetings of the Provincial Task Force by the Chief
Secretary had already happened. UPECs have been re-notified in all of the 970 union councils
and bank account numbers of 50% of vaccination team members. At the advocacy level new
steps include decision of the Standing Committee on Health of Provincial Assembly to have
polio eradication and immunization program as its permanent agenda and inclusion of the
Chairman of Committee into the Task Force at the provincial level and Chairman of the
District Development Advisory Committee (DDAC) as member of the District Polio
Eradication Committees. It was also reported that mechanism of establishing provincial polio
control room at the provincial level with close coordination with the district health teams had
been in place since May last year and a deferment mechanism since June last year. In June
2011, seven districts had their SIAs delayed due to insufficient number of quality teams.
As a result of the above, there is remarkable change in the indicators of process and
outcome. The proportion of the union councils having their meetings within time-line has
increased from 61% in March 2011 to 100% in January 2012 (both months had NIDs); and
percent of the UCs failing to achieve target (95%+ children vaccinated among checked by
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independent monitors with proof of finger-mark) dropped from 51% to 17% in the same
period respectively in the persistent transmission districts. Partners’ support at the UC level in
the highest risk UCs was acknowledged.
The province and FATA have close collaborative mechanisms for coordinated
operations. For instance, in response to the first type-3 wild poliovirus in 2011, conducted
SIADS campaigns in 4 districts. Ahead of the recent crisis of exodus from Bara, district
commissioners alerted local teams to intensify transit point teams strategies and district teams
to focus in the areas having IDPs camp and off-camp IDPs. A WHO consultant found 11
missed children in a sample of 104 children checked at households level, all of them were
new arrivals (not missed by teams) but reflecting high volume of movement. There has been
no isolation of wild poliovirus type-3 from AFP cases or sewage water sampling in 2011 and
2012 so far.
The report stressed that performance of the province may be considered keeping in view
the fact that in 2011 alone; the highest number of casualties due to terrorist activities was in
Khyber Pakhtunkhwa. In 512 different terrorist attacks there were 820 deaths and 1,684
injuries.
Key strategic focus in the near future envisaged includes: a) building capacity of the
UPEC Chairman and how to facilitate them for performing their functions; b) speed and
quality of the UC level data flow to the district especially the monitoring data in the precampaign implementation phase; and, c) DCOs’ training for clarifying the areas to be focused
by them and sustain their engagement and enthusiasm until completion of polio eradication.
The Secretary requested that partners may intensify their support in all infected districts
in 2011 and 2012 so far and urgently inform the provincial government their intended support
by end-March 2012 so that provincial government’s mechanism for invoking the local
resource generation may be invoked. Communications strategies were requested to address
clustering of refusals and modified to create demand for vaccination.
Sindh Province
Secretary Health
The province reported 2 WPV-1 cases from 2 districts in 2012 (as of 21 March)
compared to 6 WPV-1 cases from 5 districts in the same period of 2011. There were
improvements in SIAs vaccination coverage (assessed by IM, MS, LQAS) in December 2011
and January 2012 campaigns compared to previous rounds but inconsistent at UCs level.
The province is maintaining the implementation of the strategies of A-NEAP :
Governmental oversight and leadership improved since January 2012 but gaps in ownership
and accountability persist, NEAP indicators showed improvement in campaign preparation
and implementation but inconsistent, strategy to vaccinate migrant, nomads and children onmove prepared and approved, all milestones by January 2012 were achieved and the
milestones by March 2012 are on track. The main significant innovative intervention is the
WHO-EM/XXX/XXX/E
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partnership with EDHI Foundation. The pilot of the partnership implementation is in process
in UC-4 of Gadap.
The major challenges are: sub-optimal coverage of children on-move and inefficient
implementation of the strategy to vaccinate children of migrant and nomads, poor campaigns
preparation and implementation in Gadap Town of Karachi is a significant risk to any
achievement in the Sindh, outside the province and globally, lack of meaningful
accountability at all levels, disconnect between the Deputy Commissioners and Health
Departments and clustering of vaccinators in city areas, and frequent strike of contract base
vaccinators and LHWs.
Punjab Province
Special Secretary Health
In 2011, Punjab province reported 9 polio cases in 8 districts in addition to detecting
wild virus healthy nomad children & environmental sampling. So far in 2012 one polio case
has been detected in district Jhang, and positive environmental samples have been found in 3
main urban centers of Punjab. The province participated in a rigorous International
Surveillance Review in 2011 and the main conclusion was that “the AFP surveillance system
in Punjab is sensitive enough to detect any poliovirus circulation …and there is minimal
chance of missing transmission”. The province has demonstrated improvement in campaign
quality over the past year. This has been demonstrated by decreasing proportion of monitored
UC evaluated at less than 95% coverage by IM and more UCs “not rejected at 95%” for
LQAS. All scheduled SIAs and timely case response immunization campaigns were
implemented following the detection of wild polio virus.
At the Provincial level there is a functional Provincial Steering Committee lead by Chief
Secretary that has held regular meetings during the past year. There is an operational
Provincial Polio Control Room in the EPI Cell and in the district EDO (H) offices. There has
also been increased involvement of parliamentarians as demonstrated by their participation in
inaugurations and DPEC meetings. At District level DCOs are deeply involved in
Supplementary Immunization Activities (SIAs). They are chairing District Polio Eradication
Committee (DPEC) meetings (95% of all districts DCO chaired DPEC for March SNID). The
DPEC meeting is conducted 10 days prior to every campaign (95% of all DPEC were
conducted 10 days before the March SNID). During the DPEC the DCO delegates duties to
the line departments. He also makes a careful review of the previous campaign and holds the
district workers accountable for their work. The Chief Secretary has instructed all DCO to
establish a PCR in their offices.
At the Union Council level the UPEC meetings are conducted 15 days prior to the
campaign (96% of UC conducted timely UPEC meetings before March SNID). There is
increasing leadership from MO and 94% took a leading role in the UPEC meetings. UC
Secretary also participated in the UPEC; 82% co-chaired the UPEC meeting in March SNID.
Team composition is meeting NEAP recommendations in that 95% or more of all UC have the
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recommended age, female composition, government accountable worker, and local member.
Training is also conducted for vaccination teams one week prior to start of campaign.
Punjab has ensured nomadic settlements are identified and mapped on microplans for
SIA and these are updated prior to every campaign. In January 2012 NID over 223,000
nomadic children were vaccinated. The Short Interval Additional Dose has been implemented
in nomadic populations throughout Punjab in the latter half of the year after scheduled
campaigns. There are over 2000 transit teams posted at transportation hubs throughout Punjab
to vaccinate children during SIAs. In addition there have been strengthened social
mobilization activities for nomadic populations.
The main challenges that Punjab faces are: Sustaining a motivated work force, Ensuring
uniform coverage of +95% in every Union Council in every SIA, Achieving and maintaining
above 80% routine EPI coverage in every Union Council of all districts, and Sustaining the
highly sensitive AFP surveillance system to ensure no AFP case is missed, especially in urban
areas that have isolated wild virus from environmental sources
The goal of Punjab is to interrupt polio virus circulation in 2012 through involving
parliamentarians, ensuring strong intersectoral collaboration, and strengthening ownership of
the PEI at the UC level in order to sustain high quality polio campaigns and improve routine
EPI coverage. Punjab will also maintain the sensitive AFP surveillance system in order to
guide vaccination activities. Lastly, the hard work and dedication of the vaccination teams
who vaccinate millions of children during campaign days will continue to be firmly
acknowledged.
Azad Jammu & Kashmir (AJK)
Director Health
Department of Health has introduced certain measures for the implementation of ANEAP at different levels. At the provincial level, an officer of the status of Additional
Secretary has been nominated as Focal Point at Prime Minister Secretariat, Provincial steering
committee has been nominated and Polio Control Room has been established in office of the
Provincial Program Manager EPI Muzaffarabad AJK.
At the district level, in all district of AJK focal point (Deputy Commissioner) has been
nominated and functionalized since January/February round 2012, DPEC has been constituted
and functionalized, Polio Control Room has been established in DC office as well as in the
office of the District Health Offices. At the UC level, members of UPEC has been nominated
and functionalized in all UCs of AJK, community has been mobilized through Mosques,
Schools and campaign Inauguration, UC micro plans were review and revised where needed,
80 % to 95% mobile teams have local female and accountable workers, and 95-100% team
members and supervisors were trained according to standardized module.
The way forward includes continuous monitoring and improving performance of NEAP
indications.
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Gilgit Baltistan (GB)
Director Health
GB remained Polio free since, 1998 but the province was infected by importation from
Swat in 2011.The DoH in collaboration with its partners like WHO, UNICEF responded
timely and conducted almost 4-5 immunization campaigns in the infected district (Diamer)
and adjacent areas of the bordering district Gilgit as well. Result further spread of virus was
contained and no further Polio case has been reported since then.
The main issue in immunization is that of routine EPI in the province, and the
department is trying to improve that with the assistance of its partners because this is the most
important strategy in PEI and to maintain the polio free status in future. Another important
strategy is that of AFP surveillance and due to non availability of fulltime ADHOs/DScs the
same task is being looked after by the DHO. So there is a need to strengthen the surveillance
system as well so that early detection of AFP cases could be ensured in the field
The UPEC meetings were held in all the districts, 96 % meetings were chaired by
UCMO/Senior health official, 26 % co chaired by UC Secretary, 97 percent micro plans were
reviewed while 96 percent teams had one local member and 86 percent teams had at least one
female mobile team member in the province. The DCOs and EDO H attended these meetings.
The campaign was conducted in all the UCs except few because of inaccessibility due to
snow. The province achieved 96 % coverage based on finger marking.
Polio Eradication Initiative (PEI): Communication Strategies
Health Education Advisor / UNICEF Communications Officer
The presentation revisited last year’s TAG recommendations and progress made against
them, followed by communication objectives and milestones of the augmented NEAP. The
presentation further illustrated efforts taken by UNICEF in conjunction with the decisions of
the National Communication Technical Committee for increased ownership and
accountability through advocacy; social mobilization and community engagement through
COMNet and local partnerships; strategic shift for more data driven communication supported
by data reporting/M&E system (PRiME) and social research such as the recent KAP survey
the findings of which were also shared. The presentation also highlighted the rebranding of
the mass media campaign to redefine polio in the eyes of the public through introduction of a
new concept, engagement of celebrities to ask as polio spokespersons and public-private
partnerships for polio eradication.
Engaging High Risk Groups for Polio Eradication
High Risk Populations Coordinator
The presentation after giving brief background of NEAP Communication Objective for
High Risk Groups (HRG) describes which are the HRG for polio and describes the current
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strategies in use to reach these HRGs and finally the proposed strategic shifts. The main
HRGs identified were Pashtuns and other groups (Afghan Refugees, Nomadic Populations,
Seasonal migrants, brick kiln workers and IDPs) labelled as addition HRGs were also
discussed. The notion was supported by presenting facts & figures including social/ethnic
fact, social and epidemiological data. Refusal for polio vaccination was identified as one of
the major factors for being high risk group. The strategy to deal with the HRGs proposed in
NEAP including; mobile populations and clusters of refusal families are mapped using social
data, families on the move are mobilized for OPV, partners from the medical and religious
community actively participate in social mobilization and families in inaccessible areas are
mobilized and children vaccinated, was discussed in details progress so far was discussed and
further steps to be taken were elaborated.
Polio Eradication and the Media
UNICEF Media Consultant
TAG presentation on media strategy was needed in the wake of negative media coverage
of OPV. The presentation consisted of an overview of Pakistani media and a sketch of
journalist professionals in Pakistan.
After developing this context it analysed the negative media coverage and its impact. A
survey of print media coverage before and after the negative TV coverage (Feb. 5th to March
12th) proved that the TV programs were isolated incidences and not a campaign. A plan of
action was presented for media engagement and management, including capacity building of
journalists on PEI/EPI, lobbying the case of polio with editorial decision makers, and most
importantly creating demand for polio through enhanced social ownership. A multi-pronged,
simultaneous strategy for mass media and its professionals was proposed to shift the focus
from awareness to ownership.
Over all Questions asked to the TAG
The TAG was requested for guidance and advice on the following key areas of the
Program:
1. Why did Pakistan experience a significant upsurge of cases in 2011?
2. Does the augmented National Emergency Action Plan (a-NEAP) give Pakistan a firm
platform to achieve interruption of poliovirus transmission?
3. What additional steps could be taken to usefully review the implementation of the
NEAP?
4. What additional measures, including innovations, can be undertaken in the highest risk
districts?
5. How can synergies be developed between polio and routine EPI?
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3. CONCLUSIONS & RECOMMENDATIONS
The TAG was alarmed with the fact that Pakistan and Nigeria keep on reporting high
number of polio cases despite the fact that the world has reported the least number of polio
cases over the last 4 months. The TAG also noted with concern that Pakistan (along with
Nigeria and Afghanistan); is driving the global WPV transmission which is reinforced by the
fact that about 50% of the global cases in 2012 are reported from Pakistan.
Transmission of WPV in Pakistan remains essentially linked to the transmission zones
and the dramatic upsurge in 2011 is due to the fact that not enough children were immunized
especially in the high risk areas. Transmission persists in these zones due to
 Inability to access children for immunization due to conflict
 Continued problems with the quality of SIAs and hence with the consistent failure to
reach children with vaccine.
As well, an average polio cases in Pakistan is aged less than 2 years, under-immunized,
from a Pashto speaking family, lives in a high risk district, an immediately neighbouring
district, or a migrant/minority area.
It is obligatory to immunize more children more consistently with special focus on the
high risk districts in the transmission zones. There are some signs of early marginal progress
including massively enhanced oversight at the national and provincial level, engagement of
the district administration and spotting of clear indicators and milestones. Enhanced oversight
has resulted in improved process indicators in some of the high risk districts, marginal
improvement in the coverage rates as measured by the LQAS, identification of the program
blocks and measures to overcome, placement of the communication network and gradual
improvement of access in FATA over the last 6 months.
Despite all the marginal improvements; there are some serious which keep Pakistan in
danger of being the last reservoir of wild poliovirus. These include:




stall or slip on implementing the augmented A-NEAP
failure to further improve quality in High Risk Districts especially failing districts
like Pishin and Gadap
failure to take opportunities to reach children in FATA and neighbouring KP
failure to create demand & acceptance in highest risk areas/groups esp. Pashtuns
Conclusion
The augmented NEAP provides a platform to take Pakistan to polio eradication; the
challenge is to fully and consistently implement the NEAP.
WHO-EM/XXX/XXX/E
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TAG Recommendations
The recommendations below should be taken in the context of the strategies and actions
detailed in the National Emergency Action Plan.
Overarching Recommendations:
1. Engagement:
a. The commitment of the National & Provincial Governments to polio eradication
could be made more explicit through the contribution of financial resources to
the initiative
b. The national programme should deliberately plan to engage national and
provincial parliamentarians, universities, professional bodies, community and
religious organizations, and the private sector in a broad coalition of support for
polio eradication
2. Maintaining Focus
a. Concentrate on the high risk districts & union councils in known transmission
zones; without ignoring everywhere else.
b. Immediately scale up special operational and communication strategies for high
risk groups (Pushtun strategy; Migrant & mobile populations strategy; Transit
strategy - implementation plan by April)
c. Continued close monitoring of implementation indicators of the A-NEAP in
HRDs (by DPECs, UPECs, Provincial and National Task Force)
3. Quality at the ground level
a. Indicators on the appropriateness and quality of vaccinator teams should be
closely monitored at UC & district levels
b. The engagement, motivation, training, and support of vaccinators should be a
priority especially in high risk areas
c. A system of recognition of high performing vaccinators should be instituted to
recognize the contribution made by dedicated individuals
4. Improving information for action
a. Disaggregate indicator data to better define problems at different implementation
levels.
WHO-EM/XXX/XXX/E
Page 13
b. Develop a simple template to enable oversight committees to easily follow
indicators of NEAP implementation
c. Special investigation process to define the operational & social reasons for
missing children & to inform corrective plans (by May)
5. Innovating
a. Short interval rounds should be utilized for outbreak response and in the newly
accessed areas/populations.
b. Special tactics should be used for newly accessed / special populations including
expanded age groups (up to 15 years and higher) targeted with OPV and polioplus delivery.
c. Partnerships for service delivery ('in sourcing') should be used for
communications, immunization and monitoring
6. Improving communications
a. TAG endorsed the outline of the media action plan and urged its rapid roll out.
b. Communication strategies, including through ComNet, should be explicitly &
closely linked to social data from KAP, IM and other sources.
c. Communications & operations teams must operate in conjunction in planning,
implementation, & monitoring.
d. Social information from special investigations of the reasons for missing
children should be used to inform actions in response.
7. Improving SIA monitoring
a. LQAS may be expanded in the high risk districts
b. Independent Monitoring (IM) process may be reviewed by the end of April and
the guidelines may possibly be revised prior to May round
c. Partnerships on IM (pilot with Health Services Academy in April) in selected
areas & expansion if experience is good
8. Synergies between PEI & EPI
a. Potential synergies should be explored between the PEI and EPI. These include:
a) harmonization of polio and RI Microplans; b) awareness & demand creation
through interpersonal & other communication channels used for polio; c)
WHO-EM/XXX/XXX/E
Page 14
monitoring of the routine immunization sessions & vaccine availability during
the polio activities monitoring including the community surveys.
9. SIA Strategy and schedule
a. The basic strategy may remain to conduct 4 NIDs and 4 SNIDs.
b. The scale / size of the SNIDs should been between 30-50% of the target
population (aged < 5 years); with special focus on the transmission zones.
c. Trivalent OPV (tOPV) is to be used in 2 NIDs; bOPV in all other rounds.
d. Timings of the SIAs are to be flexible and should take account of seasonality and
epidemiological developments.
e. More vaccination rounds should be conducted in the low transmission season.
f. Additional rounds must be considered in the key areas like persistent transmission
zones, newly accessible populations
g. Case response and Mop-up vaccination campaign should continue outside
transmission zones
10.
Research
a. Seroprevalence surveys in known transmission zones to assess immunity in high
risk populations
b. Operations research especially looking at the impact of innovations
c. Social and communications research especially in high risk groups
Additional Province Specific Recommendations
Balochistan
a. The geographical priority remains the Quetta Block with particular focus on
districts Pishin which is failing despite repeated efforts and marginal
improvements in Quetta and Killa Abdullah.
b. Operations:
i. Community & age appropriate vaccinators must be ensured
WHO-EM/XXX/XXX/E
Page 15
ii. Permanent transit teams should be put in place at key transit points to cover
the children on the move
iii. There must be a strong protection and guard against re-establishment of
failed systems; that of the zonal supervisors
iv. Capacity of the newly appointed UC Medical officers should be built on the
preparations, implementation and supervision of the SIAs
c. Minority, migrant and mobile communities must be given adequate focus during
the vaccination and surveillance activities
Federally Administered Tribal Areas (FATA)
a. Geographical priorities are Khyber Agency and North Waziristan tribal agencies.
b. Permanent teams should be put in place at key transit points especially to and
from Khyber & North Waziristan tribal agencies and Afghanistan
c. The program must be vigilant and ready to act to exploit the opportunities to
vaccinate inaccessible populations e.g. large population displacements and
newly accessible areas etc.
d. Mass / house to house vaccination should target expanded age groups in all
newly accessed areas / populations (can go to < 15 years or whole population)
e. Short interval rounds should continue for the newly accessed areas / populations
and among the displaced population (living in camps) coming from the areas
which remained inaccessible for vaccination teams for long time
f. OPV campaigns should be coupled with other interventions to enhance the
coverage and acceptance among the communities
g. High vaccination coverage must be ensured in all the accessible areas in FATA
and FR areas
Khyber Pakhtunkhwa
a. Peshawar and Nowshera districts in the central part of the province are the
current geographical Priority
b. Operations:
i. Appropriate and motivated vaccinators must be ensured to in the vaccination
teams during the SIAs
ii. Partnerships with private sectors and the NGOs/CBOs should be used to
support SIAs implementation
iii. Permanent teams should be put in place at key transit points
especially those having large population movement with FATA
WHO-EM/XXX/XXX/E
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c. Migrant / mobile populations including the displaced persons and refugees; must
be given adequate focus during the SIAs and for surveillance activities. Any
opportunities (even outside the SIAs) must be grabbed efficiently to vaccinate
these populations
Sindh
a. All the high risk town (of Karachi) and the districts remain the geographical
priority; particularly the Gaddap town Karachi which has been persistently
failing despite repeated efforts.
b. Operations:
i. Community appropriate vaccinators must be ensured (particularly among
the high risk ethnic and religious group) across the province with special
focus in the high risk towns / districts especially in Gadap town
ii. Partnerships with private sectors and the NGOs/CBOs should be used to
support SIAs implementation
iii. Permanent teams should be put in place at key transit points
especially those having large population movement with FATA, Balochistan
and KP
c. Migrant / mobile populations particularly the Pashto speaking populations and
nomadic groups must be given adequate focus during the SIAs and for
surveillance activities.
Punjab
a. High risk districts in the southern Punjab and urban slums in Lahore, Faisalabad
and Rawalpindi are the current geographical priorities.
b. Permanent teams should be put in place at key transit points
especially those having large population movement with FATA, Balochistan and
KP.
c. Migrant / mobile populations particularly the Pashto speaking populations and
nomadic groups must be given adequate focus during the SIAs and for
surveillance activities.
Islamabad
a. UC and area level micro-plans should be immediately revised and there should
be a mechanism regular updating of these plan before every SIA ensuring all the
WHO-EM/XXX/XXX/E
Page 17
settlements are part of thee plans in order to be properly covered during each
round
b. Permanent transit posts should be put in place to cover the children on the move
especially those from KP, FATA.
c. All migrant / mobile populations especially the Pashto speaking communities
must be give adequate focus to achieve high vaccination coverage during SIAs.
d. The slums in the peripheries of Islamabad (CDA and ICT) must be ensured to be
part of the micro-plans and be covered well during the SIAs
AJK and Gilgit Baltistan
a. The overall priority is to maintain high level of population immunity through:
i. High quality SIAs
ii. Strong routine immunization program
b. Migrant / mobile populations particularly the Pashto speaking populations and
nomadic groups must be given adequate focus during the SIAs
A sensitive AFP Surveillance must be ensured through regular review of the network
and necessary revision / updating to make sure any introduction of wild poliovirus does not
remain undetected.
WHO-EM/XXX/XXX/E
Page 18
PROGRAMME
Wednesday, 21 March 2012
08:00 – 08:30
Registration
08:30 – 08:40
Opening and introduction of participants
08:40 – 08:50
08:50 – 09:05
09:05 – 09:20
Welcome remarks
Address by the WHO Representative
Global Polio Emergency Action Plan & Independent Monitoring Board (IMB) report
on Pakistan
Augmenting national management and oversight of the NEAP
Followed by Discussion
09:20 – 09:45
09:45 – 10:00
10:00 – 10:50
Implementation status of the recommendations of the last TAG meeting
11:10 – 12:20
 Baluchistan
 Discussion
 Khyber Pakhtunkhwa
 Discussion
 Sindh
 Discussion
 Punjab
 Discussion
 FATA
 Discussion
Internal TAG Meeting
Epidemiological situation in Pakistan
Discussion
Implementation status of the NEAP by province
12:20 – 13:30
14:30 – 15:40
15:40 – 16:50
16:50 – 18:00
18:00 – 19:00
Thursday, 22 March 2012
Implementation status of the NEAP in non infected regions
08:30 – 09:00
 AJK
09:00- 09:30
 Gilgit Baltistan
09:30- 10:30
Progress in implementing communications strategies
Discussion
10:45 – 11:20
Short Interval additional dose – Impact and lessons learnt
Discussion
11:20 – 12:00
Islamabad ( ICT & CDA)
Discussion
12:00 – 12:40
Independent Monitoring (IM) & Lot Quality Assurance Sampling (LQAS) – connect
with the epidemiological situation, identification of gaps and improving the data
credibility
Discussion
WHO-EM/XXX/XXX/E
Page 19
12:40 - 13:20
Progress in implementing the High Risk Strategy
Discussion
14:20 – 15:00
Creating an engaged media
Discussion
Cross Border Coordination
Discussion
Internal TAG meeting
Concluding session:
- Conclusions and recommendations
- Concluding remarks by Madam Shahnaz Wazir Ali
15:00 – 15:30
15:30 – 16:30
16:30 – 18:00
WHO-EM/XXX/XXX/E
Page 20
LIST OF PARTICIPANTS
MEMBERS OF THE TAG
Professor David M. Salisbury
Director of Immunization
Department of Health
510, Wellington House
133-155, Waterloo Rd.,
London SE1 8 UG
UNITED KINGDOM
Dr Steve Cochi
Acting Director, Global Immunization Division
Center for Global Health
Centers for Disease Control and Prevention
1600 Clifton Road, NE—Mailstop A-04
Atlanta, GA 30333
USA
Dr Hyam Nicola Bashour
Professor and chair, Department of Family and
Community Medicine
Faculty of Medicine
Damascus University
P.O. Box 9241
Damascus
SYRIA
Dr Yu Wang
Director of China CDC
Chinese Center for Disease Control and Prevention
155 Changbai Road Changping District
Beijing 102206
PEOPLES REPUBLIC OF CHINA
Dr Emmanuel Adebayo Abanida
Director Disease Control & Immunization
National Primary Health Care Development Agency
Plot 681/682, Port-Harcourt Crescent off Gimbiya Street

Unable to attend
WHO-EM/XXX/XXX/E
Page 21
Area 11, Garki Abuja, Federal Capital Territory
NIGERIA
Dr M. H. Wahdan
AFG & PAK TAG Member
Alexandria
EGYPT
Dr. Olen Kew
Molecular Virology Section
Centres for Disease Control and Prevention
Atlanta
USA
Dr Raymond Bruce Aylward
Representative of Director General for
Polio, Emergencies & Country Collaboration (PEC)
WHO/HQ/PEA PEC
Geneva
SWITZERLAND
Mr Chris Morry
Programme Director
The Communication Initiative
Victoria, British Columbia
CANADA
Dr Ghulam Naqshband Haji Mir Khan Aram
Dean of Herat Medical Faculty & Head of Pediatric Department;
and Chairman of the National Certification Committee
Herat
AFGHANISTAN
NATIONAL TAG MEMBERS
Professor Tariq Bhutta
Chairman of NCC
Government of Pakistan
Punjab
PAKISTAN
Professor Tahir Masood Ahmad
Professor of Paediatrics and
Dean Children Hospital &
The Institute of Child Health
Lahore
PAKISTAN
Professor Iqbal Ahmad Memon
Fellow American Board of Pediatrics, FRCP (C)
Professor of Pediatrics, Dow University
of Health Sciences
WHO-EM/XXX/XXX/E
Page 22
Karachi
PAKISTAN
GOVERNMENT OF PAKISTAN
Ms Begum Shahnaz Wazir Ali
Special Assistant to Prime Minister on
Social Sector and National Focal Person
For Polio Eradication
Islamabad
Mr Khushnood Akhtar Lashari
Principal Secretary to the Prime Minister
Islamabad
Mr Anisul Hasnain Musvi
Secretary, Ministry of Inter-Provincial
Coordination (IPC-Division),
Cabinet Block
Islamabad
Dr Azra Fazal Pechuho
Member of the National Task Force on Polio
Eradication in Pakistan
Islamabad
Dr Altaf Bosan
National Coordinator
Prime Minister’s Polio Monitoring & Coordination
Cell
Islamabad
Dr Zahid Larik
National Programme Manager
Expanded Programme on Immunization
Islamabad
Mr. Mazhar Nisar Sheikh
Health Education Advisor
Prime Minister’s Polio Monitoring & Coordination Cell
Islamabad
Mr. Salman Sharif
Molecular Biologist
Regional Reference Laboratory (RRL)
National Institute of Health
Islamabad
WHO-EM/XXX/XXX/E
Page 23
ISLAMABAD
Eng. Farkhand Iqbal
Chairman (invited for concluding session only)
Capital Development Authority (CDA)
Islamabad
Mr. Tariq Peerzada
Chief Commissioner (invited for concluding session only)
Islamabad Capital Territory (ICT)
Islamabad
Mr. Mansoor Ali Khan
Deputy Director General CDA
(Focal Person for Polio Eradication; CDA Islamabad)
Mr. Amer Ali
Deputy Commissioner ICT
(Focal Person for Polio Eradication; ICT Islamabad)
PUNJAB
Mr. Nasir Mahmood Khosa
Chief Secretary (invited for concluding session only)
Government of Punjab
Mr. Dawood Mohammad Bareach
Special Secretary Health (coming for 2nd day only)
Government of Punjab
Ministry of Health
Dr Tanveer Ahmed Shaik
Director EPI
Ministry of Health
SINDH
Mr Syed Hashim Raza Zaidi
Secretary Health
Ministry of Health
Dr Mazhar Ali Khamisani
Project Director EPI
Ministry of Health
KHYBER PAKHTUNKHWA
Mr. Muhammad Ishfaq
WHO-EM/XXX/XXX/E
Page 24
Secretary Health
Ministry of Health
Dr Janbaz Afridi
Deputy Director EPI
Ministry of Health
FATA
Mr. Abid Majeed
Secretary Administration & Coordination
FATA
Dr Qasim Afridi
Deputy Director EPI
FATA
BALOCHISTAN
Mr. Asmat Ullah Kakar
Secretary Health
Ministry of Health
Dr M. Yousaf Bizanjo
Provincial EPI Coordinator
Ministry of Health
AZAD JAMMU & KASHMIR
Dr Shabbir Ahmed Dar
Director Admin and Coordination
Health Secretariat
Dr Adil Hameed
Director CDC AJK
Ministry of Health
GILGIT-BALTISTAN
Dr Iqbal Rasool
Provincial Programme Officer-EPI
Health Secretariat
DONOR/PARTNER AGENCIES
UNICEF/HQ and CO
Mrs Karen Allen
Deputy Representative
UNICEF – Pakistan
Islamabad
WHO-EM/XXX/XXX/E
Page 25
PAKISTAN
Ms Sherine Guirguis
Communication Specialist - Polio
New York
USA
Mr Jalaa Abdelwahab
Health Specialist, Health Section
New York
USA
Mr Dennis King
Team Leader for Polio Program
UNICEF – Pakistan
Islamabad
PAKISTAN
Mr Rustam Haydarov
Communications Officer
UNICEF – Pakistan
Islamabad
PAKISTAN
Dr Shamsher Khan
High Risk Populations Coordinator
UNICEF – Pakistan
Islamabad
PAKISTAN
Dr Altaf Ullah Khan
Media Consultant
UNICEF – Pakistan
Islamabad
PAKISTAN
CENTRES FOR DISEASE CONTROL AND PREVENTION
Dr Zundong Yin
Associate Research Fellow
CDC
Beijing
CHINA
USAID
Ms Ellyn Ogden
Worldwide Poliomyelitis Eradication Coordinator
Washington DC
USA
WHO-EM/XXX/XXX/E
Page 26
Aaron Schubert
Deputy Director, Health
Islamabad
PAKISTAN
ROTARY INTERNATIONAL
Mr Robert Scott
Chairman, International PolioPlus Committee
Rotary International
Illinois
USA
Mr Aziz Memon
Chairman, Polio-Plus National
Immunization Committee for Pakistan
Islamabad
PAKISTAN
BILL & MELINDA GATES FOUNDATION
Mr Michael Galway1
Senior Programme Officer
Vaccine Deliver, Global Health
Bill & Melinda Gates Foundation (BMGF)
Seattle
USA
Dr Waqar Ajmal
Representative
Bill & Melinda Gates Foundation (BMGF)
Islamabad
PAKISTAN
WORLD BANK
Dr. Kumari Vinodhani Navaratne
Task Team Leader
Islamabad
PAKISTAN
Dr. Tayyeb Masud
Senior Health Specialist
Islamabad
PAKISTAN
1
Awaiting confirmation
WHO-EM/XXX/XXX/E
Page 27
EMBASSY OF JAPAN (GOVT. OF JAPAN)
Mr. Kaoru Magosaki
Counselor and Head of the Economic and Development Section
JICA
Mr Takatoshi Nishikata
Country Representative
Islamabad
PAKISTAN
IDB
Mr Birama B Sidibe
Vice President, Operations
Islamic Development Bank
Jeddah
HEART-FILE ORGANIZATION
Dr Sania Nishtar
President,
HEART-FILE,
Islamabad
PAKISTAN
FELTP
Dr Rana Jawad Asghar
Resident Advisor
NICP Building
National Institute of Health
Islamabad
IMB
Mr Niall Fry
Independent Monitoring Board
Global Polio Eradication Initiative
Islamabad
PAKISTAN
WHO SECRETARIAT
WHO/EMRO
Dr Ezzeddine Mohsni,Coordinator Disease Elimination and Eradication
Dr Tahir P. Mir, Polio Regional Advisor
WHO-EM/XXX/XXX/E
Page 28
Dr Ibrahim Kardany, Communication Consultant
WHO/HQ
Dr Hamid Jafari, Director of Global Polio Eradication Initiative
Mr Chris Maher, Coordinator, Strategy Implementation and Monitoring
Mrs Sona Bari, Communication Officer
Dr Naveed Sadozai, Medical Officer
WHO/PAKISTAN
Dr Guido Sabatinelli, WHO Representative
Dr Elias Durry, Medical Officer/Senior Polio Coordinator
Dr Ni’ma Abid, Medical Officer/ Team Leader
Dr Zubair Mufti, Medical Officer
WHO/Provincial Team Leaders
Dr Deborah Bettels, Medical Officer/Provincial Team Leader, Punjab
Dr Salah Tumsah, Medical Officer/Provincial Team Leader, Sindh
Dr Abdelwahab Al Anesi, Medical Officer/Provincial Team Leader, Balochistan
Dr Obaid-ul-Islam Butt, Medical Officer/Provincial Team Leader, KPK
Dr Sarfraz Afridi, Medical Officer/Provincial Team Leader, FATA
Dr Tahir Malik (Islamabad)
Dr Sardar Auranzgeb (Islamabad)
Dr Saria Yunis (Islamabad)
Dr Hadia Mirza (Islamabad)
Dr Mariam Mallick (Islamabad)
Mr Muzaffar Khan (Islamabad)
Ms Meaza Tadesse (Islamabad)
Mr Bilal Zaheer (Islamabad)
Dr Hanqing He, STOP Team (Sindh)
Ms Nima Abid (UNICEF, Islamabad)
Mr SardarTalat, USAID (Islamabad)
Dr Aslam Chaudhri, Bill & Melinda Gates Foundation (BMGF)
Dr Ahmed Ali ShaikhBill & Melinda Gates Foundation (BMGF)
Dr Imtiaz Ahmed, Bill & Melinda Gates Foundation (BMGF)
Dr Masood Jogazai Bill & Melinda Gates Foundation (BMGF)
Ms. Zarghuna Qaiyum Khan Assistant Economic Advisor, Japan Embassy
Mr. Tsunenori Aoki, Deputy Director, JICA HQ
Ms. Mitsuru Kayama, Senior Country Officer, JICA HQ
Ms. Tomoyuki Nagita, JICA Pakistan
Mr. Sohail Ahmad, JICA Pakistan
Mrs Leslie Robert, Journalist, Science Magazine, USA