Report: Technical Consultation on Polio Eradication in Afghanistan and Pakistan (Muscat, Oman)

This report was generated following a technical consultation on polio eradication in Afghanistan and Pakistan, held in Oman from October 1-2, 2007. The objectives of the meeting included:

1. Reviewing progress towards polio eradication in the two countries, with a focus on the past six months.
2. Reporting on progress against recommendations put forward during the last Technical Advisory Group on polio eradication (TAG) meeting, held in Islamabad, Pakistan in April 2007.
3. Discussing planned activities for the remainder of 2007 and early 2008.
4. Making the necessary technical recommendations to enable the programme to achieve global polio eradication milestones set by stakeholders during a consultation in Geneva in February 2007.

This meeting included representation from major implementing and donor organisations involved in the polio eradication initiative (PEI) in both countries, including the World Health Organisation (WHO), the United Nations Children's Fund (UNICEF), the Technical Advisory Group on polio eradication (TAG), the Centres for Disease Control (CDC), and the United States Agency for International Development (USAID), among others.

The two-day meeting consisted of a programme of presentations that delivered a global overview as well as detailed updates and discussions from the Pakistan and Afghanistan country teams. The sessions addressed the following main topics, highlights from which are given below:

Epidemiological Situation

Globally: It was noted that there has been more than a 50% decrease in type 1 polio (WPV1)-infected districts in each of the four endemic countries (Afghanistan, Pakistan, India, and Nigeria.) Although the average number of polio vaccine doses per child in endemic zones was reported to be nearly comparable to that of polio-free zones, it was emphasised that the percentage of zero-dose children in endemic areas is particularly high in Nigeria and Southern Afghanistan.

Data regarding virus importation and circulation was summarised, and indicated that of the 34 WPV importations in 2006 only three are continuing, with an additional five importations reported in 2007. The impact of monovalent oral polio vaccine (mOPV1) on type 1 polio was also discussed, and shown to have a 2- to 4-fold higher per dose efficacy than the trivalent vaccine (tOPV). It was also noted that the global programme is still operating under a financial short-fall of 60 million US dollars.

Pakistan: A total of 13 WPV cases were reported in Pakistan through the end of September 2007, as compared with 23 in the same period in 2006. The were geographically restricted for the most part to the areas between Balochistan and Northern Sindh provinces.

Afghanistan: A total of 10 WPV cases were reported in Afghanistan through the end of September 2007, as compared with 28 in the same period in 2006. These cases remain concentrated in the provinces of Hilmand, Kandahar, Laghman, and Nangarhar.

Two cross-border zones of active virus transmission are seen to exist across the two countries, and virologic profiling has allowed for the identification and tracking of these WPV genetic sub-clusters. In assessing progress against the Geneva milestones for eradication, it was noted that the two countries are generally on schedule with respect to their number of infected districts. Immunisation activities in each of the countries were also enumerated and praised, with a focus on the concentrated efforts made to address recommendations of the previous TAG meeting.

Communication Reviews

A pair of polio communication reviews were conducted two weeks prior to the Oman consultation - one in each country under discussion. The outcomes and recommendations of those meetings were presented. For both countries, it was strongly recommended that future communication activities should include data-driven strategies and more rigorous measurement of impact. In the case of Afghanistan, emphasis was placed on the development of a comprehensive communication strategy at national and provincial levels, and the need for increased human capacity to support social mobilisation and communication activities.

Conclusions

The consultation noted four major conclusions:

1. There have been impressive efforts by the two countries. Of particular note were: sustained political commitment; continued improvements in quality of immunisation activities; cross-border coordination between the two countries; and convening of communication reviews in both countries.
2. WPV transmission is currently focal in two main areas:
   
   1. Pakistan's Northwest Frontier Province (NWFP) and Federally Administered Tribal Areas (FATA); and
   2. the corridor for mobile populations between Southern Afghanistan to Balochistan/Northern Sindh in Pakistan.
3. Important challenges remain, including: volatile security situations; the threat of virus exchange through mobile populations; and increased percentages of refusals in some areas.

Recommendations

The consultation reviewed the recommendations put forward by the last TAG meeting, and suggested programme adjustments for the upcoming six months pertaining to: planned immunisation activities and vaccine types; communication reviews; surveillance; and resources. Highlights include:

• A detailed schedule of national and sub-national level vaccination rounds for each country
• A request that immediate communication priorities will address young children, mobile populations, and issues related to refusals
• Monthly mapping of Southern Afghanistan to support surveillance activities in the area
• Establishment of a reserve stock of 8 million doses of vaccine for each country, to be able to respond to cases emerging outside of zones of transmission