Strategy to eradicate polio in Pakistan

Context

• Karachi city (Sindh Province)
• the Quetta block – Quetta, Pishin and Killah Abdullah districts (Balochistan Province)
• FATA and NWFP – three adjoining areas (called ‘agencies’) in the Federally Administered Tribal Areas (FATA) bordering Afghanistan, and the Peshawar district (North-West Frontier Province).

In total, only 11 of Pakistan's 152 districts, agencies and towns have persistent poliovirus transmission. Within these districts and agencies, the virus circulates primarily in a number of sub-district administrative units known as 'union-councils' (in the districts) or 'tehsils' (in the agencies). In addition, Pakistan and neighbouring Afghanistan repeatedly re-infect one other, due to the substantial population movements within and between the countries.

In 2009, the Government decided to accept only those supplementary immunization coverage results that were based on independent monitoring of 'finger-marked children'. This data provided a solid foundation for targeting additional resources to improve supplementary immunization quality and enhance accountability.

The expansion of environmental sampling to include the cities of Karachi and Lahore from mid-2009 provided additional data for monitoring virus transmission and targeting interventions.

At the same time, the Prime Minister launched a ‘Polio Action Plan’ with the direct engagement of His Excellency the President. An Inter-provincial Committee for Polio (IPCP) was established, chaired by the Federal Minister of Health and bringing together all provincial health ministers to overcome barriers to the implementation of polio eradication strategies.

Strategic approach in Asia

In Asia, persistent poliovirus transmission is highly localized in a few districts. The approach in Asia therefore focuses on district- and sub-district-specific plans to achieve exceptionally high coverage with very frequent supplementary immunization activities to boost population immunity to >95% – the threshold required to stop transmission in Asia.

Engaging local political and administrative leaders to ensure the quality of supplementary immunization activities is also important.

Strategic approach in Pakistan

Interrupting the remaining poliovirus transmission in Pakistan requires the following activities.

• Building on the lessons of 2009 and implementing district-specific plans to interrupt poliovirus transmission in the 11 districts, agencies or towns with persistent transmission.
• Supplementing district plans with regular national and subnational polio immunization days to maintain population immunity against importations in the polio-free areas.
• Refining social mobilization activities based on the issues which are particular to each district/agency/town.
• Improving coordination with neighbouring Afghanistan, in particular for tracking/mapping of population movements. Where necessary, additional temporary or permanent vaccination posts will be set up at key gathering sites and border crossings.

Karachi

In Karachi, district-specific plans focus on the three towns at highest-risk of persistent virus. To improve supplementary immunization coverage, the plans include:

• targeted advocacy with the political leadership of all ethnic groups
• hiring staff from the high-risk communities
• community-specific communications activities
• further engaging the private sector and local NGOs in new settlements and slums
• continuing to partner with academic institutions for independent monitoring.

Quetta block

In the Quetta block (Quetta, Pishin and Killah Abdullah) district-specific plans focus on:

• securing the direct oversight of the District Coordinating Officers
• engaging the leadership of the paramedic associations
• continuing effective cross-border collaboration
• securing community engagement and acceptance through direct advocacy with religious leaders.

The Federally Administered Tribal Areas (FATA) and North-West Frontier Province (NWFP)

• engaging all parties to support implementation of supplementary immunization activities
• employing community focal persons to support 'access negotiators' and community mobilization
• exploiting windows of opportunity to implement the Short Interval Additional Doses (SIAD) strategy with bivalent oral polio vaccine
• working with and through nongovernmental organizations
• increasing the use of other 'add-on' interventions, such as zinc supplementation.

Eradication targets

• End–2010: <10% missed children during at least two supplementary immunization activities in all towns of Karachi; <15% missed children during at least two supplementary immunization activities in all districts of the Quetta area and the persistent transmission districts of North-West Frontier Province and the Federally Administered Tribal Areas.
• End–2011: <10% missed children during at least 90% of supplementary immunization activities in the Quetta area and in the persistent transmission districts of North-West Frontier Province and the Federally Administered Tribal Areas; >90% of children with >3 doses of oral polio vaccine in Sindh and Punjab.
• End–2012: <10% missed children during each supplementary immunization activity in all districts; >90% of children with >3 doses of oral polio vaccine sustained in all provinces.
  

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