Report on the Meeting of the Technical Advisory Group (TAG) on Polio Eradication in Pakistan [June 2020]

"There is an opportunity - now - to reframe the polio program as a key component of the broader health and economic COVID-19 response and recovery processes, merging the benefits each aims to bring to communities, and thereby facilitating the goal of complete interruption of poliovirus transmission."

A virtual meeting of the Technical Advisory Group (TAG) was held in the context of the COVID-19 pandemic, during which time the Polio Eradication Initiative (PEI) in Pakistan was also coping with co-circulation of both Wild Poliovirus type-1 (WPV1) and circulating Vaccine-Derived Poliovirus type-2 (cVDPV2). Not only has the COVID-19 pandemic caused a pause in the implementation of much-needed Supplementary Immunisation Activities (SIAs), but it has further delayed the roll-out of a comprehensive transformation of the Pakistan polio programme, including new strategies to overcome longstanding management and community acceptance challenges. Meanwhile, international and local experiences indicate that COVID-19 will continue to impact hardest on the economically poorest, marginalised communities, who are the core people among whom the PEI needs to achieve breakthroughs to build trust.

As the TAG report details, since the August 2019 TAG, an outbreak of cVDPV2 originated in Gilgit-Baltistan (GB), quickly spread to different parts of Khyber Pakhtunkhwa (KP), is now present in all provinces of Pakistan, and has spread across the border to the East Region of Afghanistan. Furthermore, the dramatic increase in WPV1 cases and positive environmental samples in 2019 has continued in 2020. Widespread WPV1 transmission is ongoing, with detection across the country and multiple areas of uninterrupted transmission (particularly, Karachi and Quetta Block), expansion to previously polio-free areas of Sindh and Punjab, and South KP becoming a new WPV1 reservoir due to the uninterrupted outbreak. (The TAG recommends that the programme undertake thorough operational, social, political, and epidemiological analyses to clearly identify factors hindering control of the outbreak in South KP and that a multidisciplinary team of experts from international, national, provincial, and district levels be set up to stop the outbreak.)

In this context, strategic programme objectives until end-2020 include: Eliminate cVDPV2 in 2020 through multiple large-scale campaigns without exacerbating COVID-19; address the surge and geographic expansion of WPV1 through targeted campaigns and outbreak response; and complete the transformation of polio eradication programme to successfully eliminate WPV1.

The National Emergency Operations Center (NEOC) submitted 15 questions to the TAG in advance of the meeting, which was conducted in 2 sessions: a full day on June 11 2020 for country team (national and provincial) presentations and focused discussions, followed by a feedback session to the Minister of Health on June 15 2020. The interval between the 2 sessions allowed for further consultations, facilitating the participatory process and inclusiveness of the TAG recommendations.

One of the categories of questions is concerned with SIA resumption and SIA plan for the 2nd half of 2020. The TAG is alarmed by negative impact of COVID-19 on Essential Immunisation (EI) performance; between March and April 2020, it is estimated that there were approximately 200,000 additional children not vaccinated with bivalent Oral Polio Vaccine (bOPV) (0,1,2,3) and Inactivated Polio Vaccine (IPV), and all other EI vaccines are affected, particularly measles. The TAG stressed that restarting SIAs requires additional planning time for: understanding community perceptions, monitoring COVID-19 impact on household and community attitudes, supplying face masks and hand sanitizer, making micro-plan adjustments, and conducting training. Notably, resumption of SIAs will also require development of a mass media narrative and communications plan that explains the rationale for SIA resumption in context of COVID-19 and embeds PEI in the broader national public health and COVID-19 recovery response. Furthermore, resumption of SIAs must have the highest level of political commitment and support.

While the Pakistan PEI should not assume COVID-19 will generate a more positive environment for vaccination, the TAG contends that the programme can benefit from aligning itself with COVID-19 recovery initiatives and take advantage of the opportunity to use the polio programme's widespread presence to be seen as advocates for communities by monitoring the reach and efficacy of national initiatives and referring households to wider public health opportunities (e.g., EI, nutrition).

To that end, the TAG stresses that the Communication Strategic Framework needs to be adjusted to support SIA resumption. There is also an urgent need for the programme to radically reorient its model of community engagement, as there has been an overemphasis on projection of polio messages, working through paid intermediaries, rather than listening and responding to communities. Pashtun communities and the most affected sub-tribes should be at heart of efforts to improve community engagement, trust, and SIA access and quality; the design and delivery of community engagement and dialogue processes with specific sub-tribes should be led by relevant Pashtun individuals and organisations. Specific TAG recommendations on the communication strategy include:

• Urgently operationalise a community engagement strategy prioritising the Pashtun population areas by:
  • Identifying relevant Pashtun actors with proven track record in community engagement and with linkages with groups in the highest-risk areas;
  • Developing a "short-list" of community engagement interventions informed by evidence-based review of community engagement methodologies (e.g., participatory action research, participatory development design, community-led monitoring and evaluation, human-centred development); and
  • Designing and testing pilot interventions with these partners to assess effectiveness, including against rates of SIA coverage and missed children - starting with the most-affected Pashtun groups and sub-tribes.
• Revise the approach to communications measurement by:
  • Developing a methodology to measure "community trust", and embed it as a core indicator of PEI progress that is both reportable at the most senior levels of the national programme and including in reports to TAG along with proportion of missed children; and
  • De-emphasising "refusal" and processes (like meetings held) as communication measures.

In conclusion, the TAG notes that "Pakistan has demonstrated unprecedented levels of political commitment and capacity in response to the COVID-19 national crisis....The high-level political leadership and commitment characterizing Pakistan's response to COVID-19 is the most effective and practical way to achieve PEI's core objectives."