Yet another end-polio deadline lapses despite 'tremendous turnaround' in situation

Poor campaign quality in some areas remains key irritant; TAG report terms Karachi
as biggest threat to polio-free goal; sees Islamabad too as being on the brink of an outbreak

Islamabad

The health and polio leadership in Pakistan needs to stop harping the tune of a "tremendous turnaround" in the polio situation as proclaimed in the recent meeting of the National Assembly Standing Committee on Government Assurances, because going by the final report of the 17th meeting of the Technical Advisory Group (TAG) for Polio Eradication, the country's polio eradication landscape continues to be plagued with mighty challenges including "poor campaign quality," "programmatic surveillance failures," "continued wild poliovirus transmission in pockets of unreached populations and among consistently missed children," and lack of aggressive efforts to overcome the "immunity gap."

The report, which has been exclusively obtained by this scribe from international channels, describes Karachi as the biggest remaining threat to interruption of poliovirus transmission in Pakistan by May 2016-the current goal of the National Emergency Action Plan (NEAP). While advising the polio programme to pay particular attention to areas with evidence of poliovirus transmission, TAG has flagged "continued poor campaign quality" in Sukkur and ironically in Islamabad too, as being "of particular concern."

It may be recalled that the 17th TAG meeting was held in Islamabad on January 28-29, 2016 to assess progress towards polio eradication; to develop consensus on remaining gaps; and to advise on measures that the polio programme can take to keep the country on track to interrupt poliovirus transmission.

The report reflects several areas of concern that need to be overcome if the eradication deadline is to be met. To begin with, it mirrors the concern of TAG members over the poor quality of Supplementary Immunization Activities (SIAs) in Islamabad, and clearly warns that the potential for an outbreak in the capital city is increasing. This concern stems from the fact that of the 22 lots assessed in Islamabad during three months before the publishing of the report, only 9 (41%) passed, indicating consistent below par performance.

Even though no polio case was detected in Islamabad during 2015, environmental surveillance indicates wild poliovirus (WPV) presence in both Islamabad as well as Rawalpindi.

"TAG is concerned by the poor quality of SIAs in Islamabad. Considering that there are high-risk populations socially connected to core reservoir areas and living in crowded neighbourhoods with poor sanitation, the potential for an outbreak in the capital city is increasing," the report forewarns.

Expressing concern over surveillance gaps in Karachi, northern Sindh, parts of Balochistan, Khyber-Pakhtunkhwa, FATA, and parts of Gilgit-Baltistan, the report has emphasized that "any identification of the circulation of indigenous orphan viruses should be considered a major programmatic surveillance failure," and has stressed that all gaps be comprehensively addressed by end of May 2016.

According to the report's findings, of the 54 cases reported in 2015, 38 (70%) were from tier 1 districts namely, Peshawar, Tank, Quetta, Pishin, Killa Abdullah, Gulshan, Baldia, Gadap, Khyber Agency, and north and south Waziristan.

The proportion of environmental samples positive for WPV decreased from 35% in 2014 to 20% in 2015. The number of circulating clusters declined from 16 in 2014 to 8 in 2015. However, despite the overall progress, surveillance data, including genetic sequencing results, indicate persistent WPV circulation in the three remaining core reservoirs: the city of Karachi, Khyber-Peshawar Corridor and Quetta block

The report points out that while the May 2016 goal of poliovirus interruption is achievable, it is at risk unless there is further reduction in immunity gaps.

"The virus is still successfully seeking out unprotected children, especially in core reservoirs. At this stage of the eradication effort, timely detection of transmission is critical and poor surveillance, especially in parts of Karachi and Quetta block, is unacceptable," the report states.

The report calls for further increase in population immunity for interruption of transmission. "Any failure to sustain the commitment to polio eradication by government and partners, or any reduction in the provision of adequate protection for polio teams, will cause the eradication effort to fail. Similarly, poor quality campaigns due to problems of access, security, or operational delivery will cause the failure to meet its target," it states.

TAG has recommended that the national authorities further improve political commitment; and continue to implement the accountability framework for sustained performance improvements. To this effect, it has advised that the Emergency Operation Centres (EOCs) engage local governments in monitoring and supervision of union council level staff, and that integrated rapid response units be established at the national and provincial EOCs to support local teams in responding to poliovirus events, whenever needed.

TAG has also recommended that the programme develop and implement district-specific action plans for districts showing consistent poor performance.

According to the TAG report, data from Acute Flaccid Paralysis (AFP) surveillance indicates the risk of polio is highest (78%) for children less than 2 years of age, and those belonging to underserved and margizalised population groups.

Presenting a province-wise analysis, the report mentions that while the immunity gap has decreased in Balochistan and the overall risk has been reduced, persistent transmission in Quetta block continues to pose risks to many districts. "Since September 2015, there has been steady improvement in the quality of SIAs in Quetta and satisfactory performance in Pishin. However, the results in Killa Abdullah have been profoundly substandard and TAG remains concerned that the current performance in Killa Abdullah will prevent getting Balochistan to zero-polio by May 2016," the report warns.

In addition to the Quetta block, Loralai and the districts neighbouring northern Sindh and southern Punjab remain at risk from imported cases. TAG has recommended more aggressive work to further close the immunity gap if potential outbreaks are to be avoided.

With reference to the Federally Administered Tribal Areas (FATA), TAG has congratulated the FATA team for improving access to children in South Waziristan, FR Bannu and parts of Khyber Agency; for focused implementation of a successful SIA in Khyber and other agencies; and for the complete shift away from 'hujra' vaccination to house-to-house vaccination. One major success story has been the implementation of Continuous Community Protected Vaccination (CCPV).

TAG has also appreciated the close coordination under the leadership of the Commissioner of Peshawar between Khyber and Peshawar teams including micro-synchronisation efforts along the common boundary.

However, at the same time, TAG has noted with concern, the threat represented by continued WPV transmission in pockets of unreached populations and among consistently missed children, as well as the low proportion of females (<10%) among frontline workers and the low levels of lot quality assurance sampling (6% in CCPV areas) in the agencies.

In Khyber-Pakhtunkhwa, TAG has observed improvement in campaign quality in many union councils. However, it has also noticed inconsistent and mostly suboptimal quality in non-CCPV union councils. TAG is also troubled that gaps identified by the findings of the external surveillance review are yet to be fully addressed.

With reference to Sindh, the TAG report mentions Karachi as an amplifier of imported and indigenous virus as of January 2016, and concludes that the city remains the biggest threat to the aim of interrupting transmission by May 2016. Interior Sindh (Sukkur and Shikarpur) in general and Karachi in particular have persistently led down national efforts for polio eradication.

"The worst-case scenario for Sindh and Pakistan is re-established transmission in the central Pakistan riverine heartland straddling the three provinces. The primary risks in this area are inadequate surveillance, poor management and lack of a coordinated high quality response," the report states.

The report identifies continued surveillance gaps in areas with ongoing transmission as a major worry. However, on a positive note, it has appreciated the efforts of the Sindh team to turn around the situation specifically through the creation of the Karachi Task Force and the Karachi Action Plan, which enabled better campaign performance in December and resulted in a single phase campaign for the first time in four-years with outstanding security protection.

The report commends Punjab for maintaining high population immunity through implementation of good quality SIAs and the execution of a strong routine immunisation programme. "The threat of polio to Punjab will cease only after the last transmission chain in Pakistan and Afghanistan is broken. High-risk migrant populations especially those connected socio-linguistically with populations in areas of ongoing transmission, pose a particular threat," the report highlights.

Coming to Gilgit-Baltistan and Azad Jammu Kashmir, both are seen as having maintained high-quality performance in SIAs throughout 2015, thereby reducing the risk of large-scale outbreaks following importation. "However, substandard surveillance in some districts, especially in Gilgit-Baltistan, are of concern," the report states.

TAG has commended the commitment of the security forces in ensuring that campaigns are conducted in a safe environment, and has regretted the loss of lives incurred among polio programme security support workers.

To end the back-and-forth transmission between Afghanistan and Pakistan, TAG has urged both countries to continue holding cross-border meetings to monitor the implementation of agreed actions;?to improve coordination at the micro level between KP/FATA and eastern/southeastern regions of Afghanistan;?and to continue reviewing the supplementary immunisation calendar together with?full synchronisation.

Since the NEAP expires in May 2016, TAG has suggested that a new plan for 2016-2017 be presented to it in its next meeting proposed for mid-2016.

The year 2015 saw the lowest number of polio in endemic countries and the fewest number of cases of confirmed WPV cases in recorded history.

As the last remaining two countries with indigenous transmission, all eyes are now on Pakistan and Afghanistan: of the 73 WPV cases reported in 2015, 54 (74%) were from Pakistan. "The world is tantalisingly close to permanently defeating the poliovirus and Pakistan can make humanity reach that goal," the report concludes.