"The IMB's championship of the people factors and the use of social data are bearing fruit, ranging from valuing and training vaccinators, to really understanding why parents are avoiding having their children immunized, to empowering women as health workers in their communities. As we have described, though, the Polio Programme is paying a heavy price for not listening properly to what the social data are telling it in some key areas."
This report follows the 14th meeting of the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI), July 20-21, London, United Kingdom (UK). The report makes an assessment of the progress of the Polio Programme with 6 months to go before the declared GPEI deadline (end of December 2016), by which time transmission of the poliovirus should be interrupted everywhere in the world. (The IMB meeting took place before the identification of new wild poliovirus (WPV) cases in northeast (Borno) Nigeria.) The IMB entitled its last report "Now Is the Time for Peak Performance" (see Related Summaries, below), but there remain threats to meeting the deadline, such as the fact that Pakistan still has 4 core reservoirs (Khyber Pakhtunkhwa (KP), Federally Administered Tribal Areas (FATA), Sindh, Balochistan) and Afghanistan also has 4 such reservoirs (Nangarhar, Kunar, Kandahar, Helmand). While there are very positive features of the work that the 2 governments and the GPEI in-country staff have done since the last IMB Report, "there are very serious weaknesses that are placing the entire endeavour in jeopardy."
For example, the level of joint working between the governments of Pakistan and Afghanistan is still falling below that required to interrupt polio transmission in the border areas and from the large reservoirs of infection that span the 2 countries. The low degree of political engagement in Northern Sindh is a major barrier to eliminating polio from that part of Pakistan, and the Polio Programme in many parts of Karachi has been chronically underperforming. The number of missed children in the inaccessible eastern area of Afghanistan has increased from 26,000 in March 2016 to 130,000 in May 2016. In the southern region of Afghanistan, the proportion of missed children has hardly changed in 2 years, and the proportion of refusals continues to be the highest of all polio-affected countries (and has been stagnant for 4 years). "The apparent intractability of a situation, in a [US]$1billion a year programme, in which an area of 1.5 Km in Eastern Afghanistan with a population of 1000 people has been responsible for 20% of the entire world's polio cases in 2016 is extraordinary; the area has been inaccessible to polio immunization teams for four years."
Successful programmes elsewhere have used modern social mobilisation tools. The Afghanistan Polio Programme is continuing to use male vaccinators from outside despite it being well known that matching of a vaccinator's characteristics with the religious and cultural composition of the local population is vital to acceptance; the failure of the GPEI to scale up within Afghanistan the use of local female health workers is a serious failing, in the IMB's estimate. The proportion of female vaccinators and social mobilisers in Afghanistan is 12%, despite potential benefits of women's participation are very clear from improved programme performance in Pakistan. (The IMB suggests that the World Health Organization (WHO) Eastern Mediterranean Office (EMRO) should appoint a senior female official to its Polio Programme team. She should be charged with rapidly strengthening the role and capacity of female workers in the successful delivery of polio and routine immunisation.) In general, "[t]here seems to be either a lack of openness or a lack of situational awareness in the Afghanistan Polio Programme that, taken together with the other concerns, suggests an inappropriate reliance on ending transmission in Pakistan and a 'good enough' performance philosophy."
The IMB is also concerned that surveillance functions of the Polio Programme have been given much less emphasis than immunisation activities. They find it alarming that the Polio Programme has failed to meet the standards for dealing with outbreaks of vaccine-derived polioviruses (particularly so in Guinea and Madagascar). "Slow reactions and delayed decision-making when viruses are discovered could be the Polio Programme's downfall unless it learns quickly from these dysfunctions." The list of countries with low levels of immunity to polio and inadequate surveillance, included in the report, is lengthy; the IMB asserts that the Polio Programme is not gaining from the beneficial pressures that flow from maintaining a publicly prominent Red List. The IMB states the the Polio Programme has a wide range of innovative quantitative social data, but their use is not mainstreamed at all levels. What is needed are qualitative data (e.g., identification of the root cause of the rejected vaccination opportunity) so that findings on parental and community attitudes can be used to generate definitive and transformational improvement in performance. The IMB references a "sophisticated new data platform" that has been created for Emergency Operations Centres (EOCs), suggesting that this platform needs to be fully utilised by all partners.
With regard to vaccines themselves, the IMB notes that the April 2016 global oral polio vaccine (OPV) switch will have left many countries with large supplies of redundant trivalent vaccine. "The IMB is particularly concerned that communication about the rationale for the oral polio vaccine switch may not have been adequate to reach all relevant personnel in countries." There is a risk that an ill-informed local decision maker, mindful of waste and costs, might deploy the trivalent vaccine in immunisation campaigns; it is not clear whether the GPEI has eliminated this source of risk. After polio eradication has been officially certified, the OPV will still be in use, even though the GPEI will have been disbanded. It is not clear that there is a plan for this eventuality.
Based on its assessment of the situation, the IMB offers several recommendations, many of which focus on the importance of collaboration and communication in creating "an unrelenting focus on the smaller areas where the virus is still present, where children are being repeatedly missed where immunity levels are low, and where surveillance is weak." For example, the IMB suggests that Nigeria's Presidential Task Force should reconvene, and the Executive Governors of each of the states should publicly reconfirm their commitment to the actions agreed in the Abuja Commitment. The IBM further recommends that a very high-level GPEI leader who is perceived as politically neutral should be appointed to work out of the Geneva, Switzerland office to strengthen the cohesiveness of the joint working of the Pakistan and Afghanistan governments. "The GPEI leadership should make an intervention to urgently engage with the political leadership in Northern Sindh to establish a clear commitment and ownership of the goals of the Polio Programme....Political engagement secured by end-September 2016."
With regard to assessment issues, the IMB urges the United Nations Children's Fund (UNICEF) to specially commission rapid qualitative data gathering to provide an in-depth understanding of the reasons for poor performance on social indicators in communities within the Pakistan-Afghanistan Core Reservoirs. A report of the findings should be with the IMB by end-September 2016. In a similar time frame, each EOC - both national and regional - should designate one team member to regularly gather soft intelligence from the field to identify situations where monitoring data are providing a falsely positive picture. This person should be someone who is completely trusted by field workers, who can speak to him or her on condition of anonymity, and who can feed back synthesised information to the EOC team; the information should be used for learning and improvement and on no account for retribution against any fieldworker. In addition, the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, United States (US) should facilitate the Polio Programmes in Pakistan and Afghanistan in undertaking a full process mapping of Acute Flaccid Paralysis (AFP) reporting and assessment. "It should be well informed with detailed local knowledge of the current situation and sufficiently granular to take account of context-specific aspects of the process that will vary from place to place. An action plan, informed by this work, should be immediately implemented in Karachi, as a pilot, and its impact monitored."
"The process of implementing the GPEI standards for responding to outbreaks should be urgently reviewed at high level....It should involve a thorough examination of the working relationships and decision-making between the headquarters of the United Nations GPEI Partners and their Regional and Country Offices....Lessons learned report to be ready by end October 2016."
Recent Polio Items from Childsurvival.net, sent to The Communication Initiative on August 28 2016; and "Int'l Body Commends Pak Anti-Polio Progress", July 23 2016 and "IMB Concerned over Changes in Polio Plan Leadership in Sindh", July 26 2016 - both accessed on August 29 2016.