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Current challenges and plan for next 6 months to interrupt polio virus transmission

Dr. Najibullah SafiDG Preventive Medicines, MoPH

Technical Advisory Group Meeting24-25 January 2016

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Current issues and challenges

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Program management• New EOC structure

– Realignment of the program and data flow as per new management structure

• Streamlining the oversight and management structures

• Need to strengthen program management and oversight in provinces

• Sub-optimal involvement of BPHS implementing NGOs

Access• Increased inaccessibility – particularly due to

deteriorating situation in eastern region following the emergence of new groups

Feb'

14 S

NID

Mar

'14

NID

May

'14

NID

Jun'

14 S

NID

Aug'

14 N

ID

Sep'

14 S

NID

Oct

'15

NID

Nov

'14

SNID

Feb'

15 S

NID

Mar

'15

NID

May

'15

NID

Jun'

15 S

NID

Aug'

15 N

ID

Oct

'15

SNID

Nov

'15

NID

Dec

'15

SNID

Dec

'15

LPD0%

2%4%6%8%

10%

Percentage of inaccessible target children in SIAs - ER 2014 - 2015

Region

Perc

enta

ge o

f tar

get c

hild

ren

73217

19885

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Access Cont. • Southern region: access to conduct quality campaign is

often used as political leverage for unrelated issues• Quality of manpower: interference in selection• In some areas, capacity to supervise and monitor is limited• Tracking of internally displaced population is not yet

systematic

SIA can not be conducted

SIA can be conducted in only some of the area

SIA can be conducted with limitations

SIAS can be conducted in all areas of the district

District_boundaries.shp1234

Provincial_boundries.shp

Nov 2015 NID

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Quality of campaign• Chronically missed children in accessible areas (Kandahar,

Helmand and Farah):– Quality of manpower selection– Quality of training for vaccinators – Suboptimal revisit strategy

• Use of monitoring data (ICM and PCA) for program correction is still suboptimal

• Quality of PCA in Kunar is a concern

• Ability to conduct LQAS in selected areas as per sampling methodology is compromised due to security challenges

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Communication• High levels of awareness but lack of knowledge

about the disease and ongoing mistrust, particularly in the east

• Challenge in reaching audience, particularly women

• Sub-optimal data quality in monitoring performance of ICN network

• Limited activities between campaigns at cluster/district level

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Cross-border coordination• Coordination between east/south east region and

FATA/KP is not regular

• Face-to-face meetings at national level are not happening regularly

• Coordination of communication approaches between Afghanistan and Pakistan is not systematic

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Epidemiology and surveillance• Orphan virus in environmental surveillance from

Nengarhar (only virus in 2015 as compared for 4 in 2014)

• Low stool adequacy in Nimroz and Kandahar provinces

• Repeated importations from Pakistan

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Vaccine management and cold chain

• Sub-optimal RI coverage in high risk provinces

• Vaccine utilization reports not systematically received from the provinces

• Denominator issues result in last-minute additional vaccine requests from provinces

• SOPs for vaccine and cold chain management not followed in the field as required

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Plan for next 6 months to interrupt polio virus transmission

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Oversight, coordination and management• Strengthen engagement of political leadership at

provincial/district level to enhance program oversight

• Further engage line ministries through office of presidential focal point for polio

• Make EOCs fully functional with dashboards and strong accountability framework by mid-Feb

• Systematically engage BPHS NGOs in program (CHWs, ICM and EOC) at provincial/district levels

• Establish polio coordination units in 5 priority provinces by end-Feb

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National emergency action plan

• Full implementation of NEAP and close monitoring of progress through EOCs

• Use of NEAP activity tracker dashboard

• Review of NEAP implementation in mid-February and adjustment of action plan accordingly

• Develop NEAP 2016/2017 by May 2016

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Interventions in LPDs

LPD category

Specific SIAs Increased resources Monitoring

LPD 1 LPD SIAs 1 DPO (possibly one PPO) and 1 DCO

Decreased Vaccinator to supervisor ratio

M and A offcers

LQAS in each campaign National level monitors Increased post campaign

monitors Close tracking of Preparation

and activity LPD 2 LPD SIAs 1 DPO and 1 DCO

Decreased Vaccinator to supervisor ratio

M&A officers

LQAS in each campaign Increased post campaign

monitors Close tracking of Preparation

and activity LPD 3 LPD SIAs Fill existing vacancies, if any

M&A officers to be considered

PCA and ICM to be continued. 25% of LPD 3 target for LQAS

in each campaign on rotation

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Supplementary immunization activities

• Implement 6 SIAs synchronized with Pakistan in first half of 2016 and OPV-IPV SIAs in 28 high risk districts

• Ensure highest quality of activities in all 47 (LPD 1&2) high risk districts:1. Fast track micro plan revision to complete in all high

risk districts by end of Q1 20162. Roll out revised training methodology by end-Feb 20163. Operationalization of updated revisit strategy country

wide (strengthen daily revisit & 5th day revisit) by March NID

- Day 4 for the planning of revisit

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Supplementary immunization activities Conti. 4. Use of PCA data to identify and address chronically

missed children5. Streamline flow and use of ICM information using mobile

technology for concurrent correction6. Direct oversight of 19 priority 1 high risk districts by

national level monitors

• Introduce CHV approach in one LPD in southern region in Feb– Phased expansion in poor performing priority 1 districts in

east and south by May NIDs

• Review and improve quality of PCA in Kunar• Fully implement IPV SIA plan for Q1 of 2016• Tracking displaced population for immunization

12-15 Jan-LPDs 16-19 Feb-SNIDs

19-22 Apr-SNIDs

15-18 Mar-NIDs

17-20 May-NIDs 7-10 Jun-LPDs

tOPV bOPV

SIA Schedule for Q1 - Q2 20162 NIDs, 2SNIDs and 2 LPD campaigns during the low transmission season / fully synchronized with PAK SIAs

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Plan of IPV SIAs - Q1 2016PHASE Districts Dates Target

PopulationDoses

required

Phase 1 Nangarhar-Achin, Lalpura, MomandaraFarah (Balabaluk, Gulistan)Herat (Shindand)

31st Jan to 6th Feb 2016

180,243 212,686

Phase 2 Nangarhar-(Batilkot, Dehbala, Kot)Kandahar (10 districts)

28th Feb to 5th Mar 2016

261,443 308,503

Phase 3 Helmand (Kajaki, Nawa-e Barakzaly, Nawzad, Sangin, Washer, Lashkargah, Nadali/Marja, Nahre Siraj, Musaqala)

27th Mar to 2nd April 2016

371,298 438,132

Total 812,984 959,321

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Communication

• Strengthen communication HR capacity • Create a more focused enabling environment to

promote trust in vaccination– Expand radio partnerships focused on high risk districts

• Scale up household and community engagement approaches, including between campaigns– Standardized ICN structure/activities throughout high risk

districts– Monthly district-specific communication action plans

• Improve monitoring of communication approaches• Equip CHVs and FLWs with IPC training and polio plus

materials

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Inaccessible areas

• Develop and implement area specific plans for eastern and southern regions, and for the rest of country, by mid-Feb

• Maintain program neutrality

• Continue negotiations through partners for full access in high risk districts

• Sub-district-level mapping of access and area specific approaches completed for high risk districts of eastern region by mid-Feb

• Engage NGOs who have access for delivery of vaccine and monitoring of campaign

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Inaccessible areas Cont.

• Systematic engagement of local communities and elders; ensure use of locally appropriate vaccinators

• Explore feasibility of delivering OPV combined with other services (e.g. health camps) by end-Feb

• Review and strengthen permanent vaccination points by end-Feb

• Maintain preparedness to conduct SIAs (including IPV SIAs) when any area becomes accessible

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Cross border coordination

• Quarterly VC between Afghanistan - Pakistan national EOCs with bi-annual face-to-face meeting

• Fortnightly TC at regional level with regular exchange of information

• Sharing of information on cross-border population movements to ensure coordinated vaccination

• Synchronized communication approaches between Afghanistan - Pakistan at border sites

• Produce and analyse data as per epidemiological blocks from Feb 2016

Synchronized SIAs in Pakistan & Afghanistan in 2011AFGHANISTAN PAKISTAN

NIDs SNIDs SNIDs NIDs

Series1 NID 11-14 Jan 2016

LPD7-10 Jun

SIA schedule AFG & PAK, 1st semester 2016

LPD 12-15 Jan

SNID 15-18 Feb 2016

NID 15-18 Mar

SNID 19-22 Apr

NID 14-17 Mar 2016

SNID 18-21 Apr 2016

NID 17-20 May SNID 16-19 May, 2016

SNID 16-19 Feb

LPDs

bOPVtOPV

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Vaccine management

• Ensure vaccine availability for all planned SIAs, complimentary immunization activities (CB, PTTs, PPTs) and sufficient buffer stock to address case responses

• Functionalise systematic delivery of vaccine utilization reports from the provinces

• Strengthen capacity of provincial and district-level SIA service providers to ensure SOPs for vaccine and cold chain management during SIAs are followed

• Update cold chain equipment requirement for SIAs bi-annually

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Surveillance• Explore expansion of environmental sampling sites and

expand by end of Q1 2016

• Track quality of surveillance in inaccessible and security compromised areas through disaggregated data analysis and disaggregate analysis of surveillance data by district

• Conduct reason analysis of low stool rate in Kandahar and Nimroz and take corrective action

• Conduct Surveillance review in Q2 of 2016

• Tracking displaced population for surveillance

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Questions to the TAG

• Is the 6-month plan presented, appropriate to achieve interruption of polio transmission?

• What should the target age group be for cross-border vaccination?

• Is the plan to introduce the CHV approach in the southern

region and phased expansion to poor performing priority 1 districts appropriate?

• Does the TAG endorse the plan presented for reaching children in inaccessible areas?

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THANK YOU