GPEI-Innovation Series: Two countries, one team

The border between Pakistan and Afghanistan is no barrier to the poliovirus. Close cultural and linguistic ties connect the two countries. Populations move fluidly across these borders. Each year, the virus moves with them.

Afghanistan and Pakistan have seen significant progress in the last 18 months in their efforts to stop polio. But both countries have been close before, and have been thwarted: the virus has found pockets of unvaccinated children where it can hide, regroup, and stage a comeback. Despite historically low levels of polio over the last few months, cases of paralysis and positive samples found through environmental surveillance show us that the virus has not yet been stopped.

A new approach

Armed with this knowledge, Pakistan and Afghanistan have taken a new approach. Since June 2015, the two have been coordinating major programme activities, as success in one country depends on success in the other. Monthly polio immunization campaigns have been synchronized so that no child on either side of the border can fall through the cracks, the Emergency Operations Centres (EOCs) of each country – which house the government and partners of the Global Polio Eradication Initiative to coordinate eradication activities – interact with one another on a weekly basis, and the highest level political and administrative leadership meet face to face every six months, to resolve challenges and to develop plans to address the remaining hurdles.

A common communications strategy has synchronized messaging at the border and – with radio being the main source of news for 70% of Afghans and 50% of Pakistanis in border areas – the programme has coordinated radio programming on the leading border channels, producing weekly health shows and using popular soap operas to create Pashto-language programming on polio and children’s health.

This innovative approach is paying dividends. The polio eradication programmes in both countries are working closely together to coordinate vaccination campaigns, surveillance, and to track population movements.

The three ‘corridors’ of polio transmission

Three ‘corridors’ are serving to allow the virus to travel with population movements between countries: via the Torkham border crossing from Peshawar and Khyber in Pakistan to Nangarhar, Kunar and Laghman in east Afghanistan, and via the Friendship Gate border crossing from Pakistan’s Quetta Block to the Greater Kandahar area in south Afghanistan. Population immunity in these transmission corridors have been gradually improving in the last year, shown by the vaccination status of non-polio AFP cases.

Wild polio increasingly seems to be travelling down a central corridor between southern Khyber Pakhtunkhwa and the Federally Administered Tribal Areas in Pakistan travelling across rugged, smaller border crossings to Paktika, Paktia and Khost provinces in the south east of Afghanistan.

Mobile populations

At the most recent Inter-Country Coordination Meeting in Islamabad, Pakistan, the Afghanistan National EOC Director underscored the importance of reaching and vaccinating populations on the move, whether at formal or informal locations.

While Torkham in the northwest and Friendship Gate in the south are the main border crossing points between the reservoirs – with more than one million children under 5 crossing these points each year – the smaller informal crossings are considerably more challenging to reach and vaccinate children.

Pakistan and Afghanistan are working to strengthen coordination on the communities moving through these locations, to ensure that all children under 5 are vaccinated wherever they are. The programmes are strengthening their disease surveillance at community level, mapping out mobile groups and ensuring they’re included in immunization microplans, and working with leaders and influential figures to understand their movements better.

Stronger together

The new polio cases in the central corridor have reinforced the idea that neither Pakistan nor Afghanistan can eradicate polio alone, with the virus travelling between the two. At the Islamabad meeting, the National EOC coordinator for Pakistan highlighted the fact that neither programme was where it intended to be by this time in 2016, and these strategies tailored to addressing specific challenges were essential to end the virus for good.

Two vaccinators climb onto a truck to deliver polio vaccines to a family travelling across Torkham border into Afghanistan. © WHO/S. Ramo

The significant improvements in the programme quality in the southern and eastern corridors can be attributed to a relentless focus on improving campaign quality and the innovative approach of the two countries working as one team across the border.

Pakistan and Afghanistan are learning from the programme’s experiences in other countries. If this progress can be maintained in the traditional corridors between the long-time polio reservoirs, and the programme can move quickly to rapidly increase immunity in the new, central corridor, the programme has the opportunity to strike out polio in two countries with one blow, working together to ensure that no poliovirus can find a hiding place along the porous border between them.

The Global Polio Eradication Initiative (GPEI) is highlighting the innovations that are helping to bring us closer to a polio-free world. Find out about other new approaches driving the polio eradication efforts by reading more in the Innovation Series.

Dr Raul Bonifaco, Punjab team leader, demonstrating how to examine a child with acute flaccid paraysis. © WHO

In the last stages of polio eradication, a sensitive surveillance system that can detect every single poliovirus is indispensable to find it in its last hiding places. In Pakistan, surveillance for cases of acute flaccid paralysis (AFP), subsequent testing and supplementary environmental sampling from the environment are informing the progress made towards eradication.

The poliovirus has proven to be a constant and resilient foe, continuing to show up in several areas of Pakistan. However, transmission is the lowest it has ever been. So far in 2016, fewer children have been paralysed by polio than at any other year in history, with the virus limited to a few areas in just three countries – Pakistan, Afghanistan and Nigeria. Pakistan has made strong progress in identifying and vaccinating missed children in the country’s most challenging areas, resulting in historical low numbers of cases this year. This remarkable achievement is especially visible in the core reservoir districts where persistent transmission has been the norm.

Training surveillance officers

The training of dedicated surveillance officers is key to ensuring Pakistan’s surveillance system is built strongly for eradication. A recent training for 32 district surveillance officers from across Pakistan highlighted the importance of effective AFP and environmental surveillance in tracking down the virus. World Health Organization’s National Surveillance Coordinator, Dr Tahir Malik said the training is essential to ensure surveillance officers down to the district level are highly skilled in identifying and investigating cases. “This is critical not only to orient new surveillance officers but also for old officers to bring alignment in surveillance procedures”. He further explained, “After training we expect from the participants to fully understand poliovirus epidemiology, AFP surveillance, but also in detail its components and mechanics in Pakistan.”

“The training, which also covered specifics on the role of laboratory, surveillance indicators, healthy children sampling and environmental surveillance, aims to bring all officers on one page in terms of programme priorities,” Dr Tahir said.

Constantly improving

Supported by contributions from the Canadian Government, the training is part of the programmes surveillance improvement plan that was recommended by the Technical Advisory Group (TAG) for Polio Eradication in Pakistan, to place a greater emphasis on disease surveillance including scaling up the workforce of dedicated staff, realigning environmental surveillance sites and ensuring surveillance targets are met by including private and informal health sectors, pushing for timely investigation, and reprioritizing reporting sites to focus on silent UCs and Tehsils.

“Make the paediatrician your friend, talk continuously to the community, walk, move, sensitise, orient, visit facilities and care providers. Surveillance is not beautiful graphs on a laptop, it is hard field work,” says TAG chair Jean-Marc Olive to District Surveillance Officers. ©WHO

The Chairman of the TAG Jean-Marc Olive, who was visiting Pakistan during the training, addressed the Surveillance officers from Punjab, Balochistan, FATA and KP. “Make the paediatrician your friend, talk continuously to the community, walk, move, sensitise, orient, visit facilities and care providers. Surveillance is not beautiful graphs on a laptop, it is hard field work,” he said. “Be proud of what you do for the children of Pakistan.”

The 2016-2017 National Emergency Action Plan for polio eradication also highlights the intensification of surveillance as a critical activity so that virus signal are picked up as early as possible and response initiated rapidly and aggressively. In response, the programme is working to engage private clinics, traditional healers and pharmacies to make it more likely that all cases of polio will be reported and immediate case response can be launched when needed.

Environmental surveillance

In addition, there has been an increase in the work being done for environmental surveillance. The number of sites that test for presence of the virus in sewage water has been increased to 43 sites across Pakistan’s highest risk areas and environmental samples are being taken more frequently, which is proving to support the programme to detect and track the virus, a critical step as the country edges closer to stopping transmission.

Leaving no stone unturned

Once Pakistan is able to demonstrate that no poliovirus is present, both from AFP surveillance and supplementary environmental surveillance, for three consecutive years, the country will be declared polio-free. Until that time Pakistan will continue to leave no stone unturned in pursuit of the virus and no child unvaccinated and vulnerable.

Canada is one of the leading supporters of the Global Polio Eradication Initiative’s goal of eradicating the disease by 2018, and this year again extended its support to polio eradication in Pakistan with a renewed commitment of Can$40 million. The contribution, in part made through WHO, continues to contribute to the efforts to strengthen the monitoring and surveillance of the virus to track it down to its last hiding place.

outbreakresponse — A child in northern Nigeria receives a dose of the oral polio vaccine. Vaccination teams are going to great lengths to protect every last child against polio. UNICEF/T.Moran

Experts from across the Global Polio Eradication Initiative (GPEI) partnership convened an emergency meeting in Abuja, Nigeria, from 3 – 5 November. Led by senior epidemiologists from the governments of Nigeria and neighbouring countries, the group examined a detailed review of the current impact of the outbreak response, and identified area-specific challenges and prioritized operational plans accordingly.

The detection of new wild poliovirus type 1 (WPV1) cases in Borno, Nigeria, in August – the first detected on the African continent in more than two years – has prompted an unprecedented response. The outbreak was immediately declared by both the Government of Nigeria and governments of surrounding countries to be national and regional public health emergency. This opened the way for a regional outbreak response, mobilizing emergency resources from across the public and civil society sectors.

Thousands of health workers across the region have been mobilized and trained, and in Borno alone more than 1.7 million children have been vaccinated. But many more continue to be un- or under-immunized, either due to operational deficits in outbreak response implementation, hampered access due to insecurity or large-scale population movements within countries.

Unless these missed children are rapidly reached, the risk remains that the current outbreak could spread further, including internationally, and cause more preventable, incurable paralysis.

Access and reaching populations everywhere

Insecurity, geographical challenges and difficulties with communication in some of the hardest to reach areas are providing barriers to reaching all children. Internally displaced persons (IDPs), refugees and nomads are particularly vulnerable groups, with insecurity blocking transit routes and the ability to accurately predict population size ahead of vaccination campaigns reduced. Due to population displacement, detailed micro-plans are frequently disrupted.

outbreakresponse1 — Children across northern Nigeria and other countries in the Lake Chad region must be protected rapidly against polio to end the outbreak. UNICEF/T.Moran

Cross-border coordination, embedding the response within the broader humanitarian emergency context, and innovating rapidly to adapt strategies to local challenges is what has stopped similar outbreaks with similar challenges elsewhere in the world.

Yet despite these challenges, the GPEI can draw on a vast array of experience from running outbreak responses in similar settings, most recently in the Middle East, Central Africa and the Horn of Africa from 2013-2015. These existing, proven strategies are rapidly adapted to the evolving environment. Permanent vaccination teams are now in place, as and when an area becomes accessible, to rapidly implement ‘mini’ vaccination campaigns in between larger-planned activities. Such teams are also critical to reach populations as they leave inaccessible areas. Children in both formal and informal IDP camps are a particular focus for the delivery of the polio vaccine alongside other humanitarian and basic health needs.
Assuming that many children living in conflict-affected areas will not have been vaccinated for several years, the target age group has been raised to protect children over 5 years of age.

The Volunteer Communication Network of vaccination advocates within communities has been expanded to cover Internally Displaced Populations living in camps and host populations, while Koranic School teachers have been engaged to address non-compliance and the mobilization of women and youth to ensure local protection for vaccination teams.

outbreakresponse2 — Volunteer community mobilizers wearing distinctive blue hijabs are working in IDP camps and host communities to identify unvaccinated children, pregnant women and those with severe acute malnutrition. UNICEF/T.Moran

Coordinating across borders

While cases of polio have only been found in Borno, extensive population movement, insecurity and previous cross border population movements require the outbreak response to cover the entire Lake Chad region. Cameroon, the Central African Republic (CAR), Chad, Nigeria and Niger are working together to track population movements and addressing the challenges inherent in accessing some hard-to-reach areas in each country, including sourcing communication equipment to operate where there is a lack of telecommunication network, closed borders in some places and language barriers. Efforts are being intensified to map out the seasonal movement of nomads, identifying resting places and water points with the support of nomadic community leaders in order to improve micro-planning to inform the response. In Chad, vaccination campaigns are providing livestock vaccines alongside polio vaccines to children in order to increase uptake in nomadic communities.

It is not insecurity alone that leads to hampered access. Sometimes it is simply a more natural phenomenon: the rains! The rainy season in the region typically runs from June to mid-October. Some areas are completely cut off from roads and other transport networks as a result of the associated flooding. With the rainy season now over, many areas and populations will be able to be reached with polio vaccine and other urgent health services.

Stopping outbreaks in such challenges settings is possible

There is no doubt that running an outbreak response with such challenges is far more complex, dangerous, costly and slower than under normal circumstances. However, what is equally clear is that the plans being intensified and implemented across the region are having an impact, and will continue to have an impact. Cross-border coordination, embedding the response within the broader humanitarian emergency context, and innovating rapidly to adapt strategies to local challenges is what has stopped similar outbreaks with similar challenges elsewhere in the world.

The groundwork set by this first phase of the outbreak response has set for reaching previously missed children in late 2016 and throughout 2017.

With continued leadership of political, health and community leaders at the local, national and regional levels alongside the international development community, this outbreak will be stopped and children across Africa protected against polio.

Last week, global political commitment to eradicating polio was affirmed at the World Health Assembly (WHA) in Geneva. During the polio agenda item, member states discussed progress made in the last year and the remaining hurdles that stand in the way of polio eradication.

In her opening address to the WHA, Dr Margaret Chan, Director General of WHO, said polio eradication has never been so close to the finish line. “During the short span of 2 weeks in April, 155 countries successfully switched from trivalent to bivalent oral polio vaccine, marking the largest coordinated vaccine withdrawal in history. I thank you and your country teams for this marvellous feat,” she said.

Member states reviewed the latest global epidemiology, noting the strong progress made across Africa with no case of wild poliovirus in approaching two years. Delegates from Afghanistan and Pakistan, the final remaining polio endemic countries, outlined the steps they are taking to ensure that transmission is interrupted as a matter of urgency. With fewer missed children than ever before and just 74 cases across the two in 2015, achieving eradication has never appeared to be such an achievable target.

Many member states spoke to reaffirm their commitments to fulfilling the objectives of the resolution passed at the last WHA to commit to ending polio once and for all. Michel Zaffran, Director of Polio Eradication at WHO, stated that strong progress had been made against all four objectives of the Polio Eradication and Endgame Strategic Plan.

Delegates also commended the historic achievement of the switch, warning that shortages of the inactivated polio vaccine and potential outbreaks of type 2 vaccine-derived polioviruses would be some of the major challenges of the coming year. They also expressed appreciation for the global contingency plans put in place to adequately manage the risks associated with the supply shortage, notably the availability of the stockpile of monovalent oral polio vaccine type 2.

Gavi, the Vaccine Alliance, supported the interjections of several member states highlighting the importance of ramping up transition planning in countries to prepare for the end of the polio infrastructure after eradication. “To be sustainable, the decision on which polio assets to sustain must be fully led and driven by countries themselves, based on national ownership, national plans and investments,” said the Gavi spokesperson.

Rotary international spoke to affirm that their 1.2 million volunteers worldwide remain fully committed to polio eradication. “We have three key challenges remaining,” said the Rotarian speaker. “First, we have to interrupt polio in Pakistan and Afghanistan. Second, we must avoid complacency. An additional US $1.5 billion is needed through 2019 to sustain high levels of immunity, repeatedly reaching more than 400,000,000 children in up to 60 countries and carrying out high quality surveillance to protect progress. Finally we must fully leverage the physical and intellectual assets of polio eradication so that they can benefit broader public health priorities.”

Sir Gustav Nossal – winner of the Albert Einstein World Award of Science and former Chairman of the WHO’s vaccines and biologicals program oversight committee – has added his support to the Global Poverty Project’s The End of Polio campaign.

Delivery of the Global Polio Eradication Initiative’s 2011-12 strategic plan is currently threatened by a $590 million funding gap, The End of Polio campaign is working to build public support for eradication efforts.

Three of the four countries in which polio remains endemic are members of the Commonwealth of Nations, and the campaign is working to make polio a priority issue at this year’s Commonwealth Heads of Government Meeting in Perth, before building global advocacy efforts to secure additional funding commitments from donor countries.

With more than 2,000 supporters signed on already, the campaign is off to a very successful start! Please add your voice at www.theendofpolio.com

News Category: Endemic countries