"Our focus remains on the basics of vaccination to ensure our heroic vaccinators are met with success on the doorstep and inside every home."
Produced by the National Polio Emergency Operations Centre (EOC), Islamabad, Pakistan, this document represents an update of the National Emergency Action Plan (NEAP) as developed and continually revised by the Pakistan Polio Eradication Initiative (PEI). In 2014, Pakistan recorded 306 cases of wild poliovirus; as of June 2017, there were only 3 cases (by this time in 2016, there were 13 cases). Over the course of the year, Pakistan implemented 5 national immunisation days (NIDs) and 4 sub-national immunisation days (SNIDs), and in the core reservoir districts, the implementation of the community-based vaccination (CBV) approach has been a boon for the programme. Across Pakistan, the oral polio vaccine (OPV) coverage rates increased from 85% in August 2016 to 92% in May 2017. Some programme innovations over the last few years have contributed to this achievement:
- The EOCs, housed under government leadership, are effectively working towards a single goal as "one team under one roof".
- Multiple hard and soft data sets now guide and inform decision making.
- Under the 2016-2017 NEAP, the surveillance system was enhanced through the implementation of a "Surveillance for Eradication" Work Plan.
- The paradigm shift toward focusing on missed children (rather than covered children) is compelling the programme to reach children who normally remain undetected, and unvaccinated.
- Over 250,000 frontline workers (FLWs) - praised for their dedication and commitment - remain at the centre of the polio eradication effort. There has been an increased focus on motivation and performance of vaccinators and other FLWs - including greater emphasis on training, timely payment, and supportive supervision.
- Performance management, oversight, and accountability has been strengthened.
Opening words in the report from the Federal Minister for National Health Services, Regulations and Coordination also point to commitment to polio eradication, which she says transcends any political consideration. "This broad political will offers reassurance, and ensures continuity and sustainability in the days ahead."
After exploring Pakistan's overall polio situation in depth, the report relects on progress, challenges, and lessons learned from NEAP 2016-2017. For example, community acceptance and demand are the bedrock for success:
- The communication strategy has delivered on the goal of increasing acceptance within the community and improving trust of vaccinators as they meet families door to door.
- Balancing the response to the epidemiological risk posed by circulating vaccine-derived poliovirus type 2 (cVDPV2) with the monthly bivalent OPV (bOPV) SIA schedule against a backdrop of campaign fatigue by communities and caregivers requires careful judgment.
- Calibrating the performance pressure for "zero polio" with voluntary coverage and conversion rather than punitive measures, so as to avoid transgressing social boundaries and promoting more complex forms of resistance to the programme, remains a must.
- More needs to be done to improve acceptance in small population pockets where community resistance has been flagged as a major concern by monitors.
Looking to the year ahead, the programme plans to continue its pursuit of pockets of missed children. The Quetta Block remains the primary focus, followed by Islamabad and Rawalpindi, Karachi, and the Peshawar-Khyber corridor. The goal of ensuring vulnerable populations - e.g., nomads, seasonal and economic migrants, and agricultural migrant labourers - are systematically mapped, incorporated in micro plans, and vaccinated has not been fully met. Furthermore, routine immunisation service delivery targets set by the programme in the previous NEAP have not been achieved. The programme will prioritise these activities in the 2017-2018 NEAP, which focuses on 3 core areas of work: (i) programme operations, (ii) risk assessment and decision support, and (iii) management, oversight, and accountability. The key deliverables for 2017-2018 are described, and 11 guiding principles are outlined, including: effective collaboration, open communication, active and continuous improvement, dedication, integrity, commitment, agility, tenacity and boldness, individual and team recognition, organisational and individual responsibility, and national and organisational oversight on accountability. Specific deliverables and quarterly milestones are also delineated.
In various areas of programme operations, core programme strategies, progress seen in 2016-2017, and priorities for 2017-2018 are explored. Some communication-related discussion points concern:
- Social mobilisation: The approach supports programme operations by promoting all vaccination, including polio, as a social norm that builds acceptance and trust for health workers by humanising them in all of communications. The Sehat Muhafiz (Guardians of Health) strategy also reinforces the paradigm shift to "no missed children". By portraying strengthened interpersonal communication between frontline vaccinators and caregivers, this communications strategy aims to reduce still and persistently missed children by ensuring that mass media efforts promote an enabling environment. The Harvard Opinion Research Program (HORP) at the Harvard T.H. Chan School of Public Health and the Pakistan programme have developed a collaboration for knowledge, attitudes, and practices (KAP) polling to support polio eradication and routine immunisation. (See Panel 2 on page 32). The poll's findings provide indirect evidence that recent programme communication efforts are effectively aligned with community sentiments, norms, and values (e.g., perceptions of vaccinators have improved, destructive rumours have decreased, local embededness has improved, and perceptions of supportive community norms have improved). Lessons learned:
- The survey indicates that, while household acceptance of OPV in Pakistan remains high, fatigue around "repeated visits" and the intent to vaccinate each time the vaccine is offered is starting to emerge as an issue across the core reservoirs and high-risk districts. Efforts in these areas should be maintained and enhanced to protect against backsliding. In the face of negative media, a negative experience with a health worker or with negative rumours or disapproving social pressure, individual compliance may easily be put at risk without a social environment that consistently supports vaccination.
- Misconception, demand, vaccine safety, fatigue, and religious refusals are key reasons for refusals. As the programme moves ever closer to interruption of transmission, tonality of messaging must keep both risk perceptions high while being clear about progress made.
- Balancing the response to the epidemiological risk posed by cVDPV2 with the monthly bOPV SIA schedule against a backdrop of campaign fatigue by communities and caregivers requires careful judgment.
- Voluntary coverage and conversion rather than punitive measures remains a must to avoid transgressing social boundaries that may generate more complex forms of resistance to the programme.
- Demand for services other than polio in under-served areas is an ongoing challenge for the programme. Planned revitalising and strengthening of Expanded Programme on Immunization (EPI) in the core reservoirs will help to address some of these demand issues.
- Continued granular and systematic triangulation of data in the reservoirs and high-risk areas is essential to better identify pockets of geographical and social clusters of silent refusals and the most appropriate influencers to effective engage and convert.
- The local, female profile of the vaccinator remains the cornerstone in building trust with caregivers and the community. There is a need to continue motivating vaccination teams, building their capacity to sustain pressure and negotiate with the community and households whilst maintaining a supportive environment within which to work so that problems may be quickly surfaced for action.
- Mass media: The Sehat Muhafiz approach is designed to present vaccination as a social norm against the backdrop of the interconnectedness of family, children, and the traditions that define a place and culture. The "Strangers No More" campaign seeks to directly support the building of acceptance and trust for the Sehat Muhafiz. Vaccinators are presented as fathers, mothers, and community members with lives and contributions not limited to their role in the polio programme. The campaign also balances a positive tonality of the strides made by the programme with heightened risk perception to keep awareness levels high. District-localised approaches are managed through targeted channel selection, with specific outreach to caregivers of persistently and still missed children under five years of age. Key mass media outlets include TV, radio, radio adaptations, cable channels, and print and outdoor media. Messaging has focused on repeated vaccination, vaccine efficacy and safety, disease awareness, and raising risk perception via personalities, paediatricians, and popular polio songs. All materials bear the Sehat Muhafiz branding. In terms of mass media effectiveness, polio awareness was 97.6%, the need for regular vaccination each time offered was 96.3%, knowledge of polio impact was 84.9%, and knowledge of whether polio is curable was 71.3%. Focus group discussions indicate that mosque announcements, community meetings, engagement of religious leaders, schools, and shopping malls are good communication channels.
- Targeted community engagement: Community and household engagement activities were primarily geared towards the caregivers and parents of still missed and persistently missed children, focusing on repeated campaigns and vaccine safety. A field workforce of CBV and almost 2,000 COMNet and religious support persons maintained an ongoing engagement to increase coverage and conversion of recorded missed children. Key activities included: community meetings, jirgas, mosque announcements, and household visits by a range of influencers; specific engagement in "posh areas"; information, education, and communication (IEC) material dissemination, interactive voice response (IVR) and automated SMS (short message service, or tex); and fatwas from key religious leaders in support of the programme. The vaccinator profile, knowledge, behaviour, and attitude remains the foundation towards effective interaction with caregivers on the doorstep and to the successful vaccination of each and every child within the home. The programme will continue to strengthen the recruitment, retention, supervision, motivation, and capacity building of local female vaccinators. KAP data disaggregated to the district level will be utilised to inform targeted capacity-building interventions in particular.
- Information management system: As of June 2017, pre-campaign, intra-campaign, and post-campaign data are fully accessible to the programme through the EOC online platform and the Integrated Disease Information Management System (IDIMS). However, the growing needs of the programme require further refinement of the available tools. One area where the programme has lagged behind its peers across the globe is in the use of 21st century public health mapping techniques to cultivate a spatial understanding of disease epidemiology and more effectively monitor vaccination strategies. With the full functionality of the EOC server in place, unleashing the full potential of these tools may now be a possibility.
- External communications: "Good coordination between stakeholders is key to good crisis management. Together, they establish facts as quickly as possible and disseminate factual information to media outlets through designated media focal points and spokesperson/s." Public engagement sought to build on the image of the polio programme's honest, responsive, and transparent communication that guided relations with the media throughout 2016-2017. Intensive media engagement of 1,200 reporters, producers, senior media managers, and spokespersons in a series of orientation sessions, training and media field trips resulted in large-scale media coverage amounting to approximately 10,580 print and electronic media stories. As a result, the tone of the media coverage throughout the low transmission season has been 97% positive and neutral. The impact of such media interventions helps to create an enabling environment that shapes social norms, perceptions and expectations to support vaccinators as they work to achieve repeated, successful campaigns in the polio high-risk areas. The English and Urdu "End Polio Pakistan" website has had 123,000-plus page views, with visits from 140 countries and 1,800 plus cities. The content of Facebook and Twitter received almost 1.3 million impressions, providing an opportunity to communicate regularly with a large pool of followers.
As noted here, as Pakistan moves towards eradication, it becomes critical to document and transition the knowledge, lessons learned, assets, and infrastructure accumulated by the programme. This goal of Polio Legacy Transition Planning (PLTP) is to sustain a polio-free Pakistan and to ensure that years of investments in polio eradication contribute to the delivery of a better public health system. In order to ensure complete focus on eradication, there will be no specific actionable priorities for the NEAP year 2017-2018; a more nuanced and detailed priorities will be included in the NEAP 2018-2019.
End Polio Pakistan website, October 12 2017.