Extension of the National Emergency Action Plan for Polio Eradication 2018/2019 [Pakistan]

"...too many knocks on the door and the rapid spread of misinformation on social media have had negative impacts on vaccine acceptance amongst parents and caregivers..."

Despite Pakistan's progress in reducing the number of wild poliovirus type 1 (WPV1) cases to 8 in 2017 and 12 in 2018, 2019 has seen a significant rise in the number of WPV1 cases (41 cases as of July 8 2019). One of the most intractable challenges the Pakistan Polio Eradication Initiative (PEI) is facing is refusals by parents and caregivers to immunise their children with the polio vaccine. In light of this challenge, the Pakistan programme has revisited its strategy and put forward this Extension of the National Emergency Action Plan 2018/2019 (NEAP), which will carry the programme forward from July to December 2019 (see Related Summaries, below).

The NEAP Extension allows the Pakistan programme to incorporate the goals outlined by the Global Polio Eradication Initiative (GPEI) in the Polio Endgame Strategy, 2019-2023, and to align with the Afghanistan programme for 2020/2021 planning, as coordination between the 2 countries is critical. The Extension introduces a number of modifications, interventions, and innovations identified to respond to persistent challenges, unfolding epidemiological risks, and new strategic approaches.

Community resistance to vaccination is increasing due in part to so-called "polio fatigue", which results when communities that are deprived of many basic services - i.e., water, sanitation, and hygiene (WASH) - grow weary of repeated knocks at the door for supplementary immunisation activities (SIAs). In addition, the spread of misinformation and propaganda, fuelled by social media, has stirred up mistrust in the oral polio vaccine (OPV) that has materialised as real resistance to, or even refusal of, vaccination. In April 2019, propaganda against the polio programme in Peshawar resulted in a record number of refusals, particularly in districts of Khyber Pakhtunkhwa (KP). Furthermore, inconsistent and suboptimal SIA campaign quality in some areas, massive population movements across the borders with Afghanistan and within the country, and inadequate delivery of essential immunisation services, are among the factors that have contributed to the currently expanding epidemiology.

To respond to these challenges, the Extension puts more emphasis on:

• Synergy and additional activities, which will initiate new collaborations with the Expanded Programme on Immunization (EPI) and integrated services delivery (ISD) so that communities that are vulnerable for polio also receive other critical interventions that are designed to improve their lives and positively impact their perception of the programme. The focus of the ISD synergy will be on collaborating with partners, donors, local government authorities, private agencies, and community-based or civil society organisations (CSO) that are actively involved in providing communities with WASH, nutrition, and health-related services.
• Communications, with dedicated task teams that will work to engage communities more effectively to increase vaccine acceptance and respond to external communication needs and crises. Key priorities for July-December 2019 are summarised in Figure 7 (page 14), Table 8 (page 16), and Appendix A, Table 4 but, in short, the overarching priority will be building trust in the polio programme, especially among those at highest risk of polio transmission. In addition, communications will work to address low trust in frontline workers (FLWs) due to concerns around the lack of technical knowledge to deliver safe vaccines and the appearance or hygiene and interpersonal skills of FLWs. To transform perceptions of parents and caregivers, the community engagement process is data driven from inception to completion. The programme will focus on the following key priorities over the next 6 months:
  • Increase focus on building public trust by managing public opinion (Perception Management Initiative [PMI]) - e.g., through a toll-free telephone line for direction engagement with the public.
  • Advocate broader support for the polio programme and develop policies and actions by communicating with relevant sectors at all levels - e.g., through orientation sessions with the multi-party parliamentarians forum.
  • Foster social mobilisation and community engagement through community influencer support and media outreach - e.g., through mosque- and school-based activities, media outputs, and social media campaigns.
  • Build caregiver and family knowledge, awareness, and motivation in support of polio vaccination - e.g., through identification and mobilisation of role model parents to mobilise other parents.
  • Strengthen crisis communication - e.g., through simulation of possible situations and the building of possible plans around them.
  • Synchronisation of and synergy for cross-border communication strategies to reach mobile populations and travellers crossing both countries' borders - e.g., through regular communication with the Afghanistan PEI.
  • Improve FLW motivation and capacity building - e.g., through an app with key updates and information, education, and communication (IEC) material.
  • Implement compelling, context-specific content development and dissemination in support of all components of the communication for development (C4D) strategy - e.g., through evidence-based IEC.
  • Oversee and coordinate communication management structures - e.g., through review of community-based vaccination (CBV), communications network (COMNet), CSOs, religious support persons (RSPs), and other communication cadres.

In addition, the Extension lays out plans to:

• Introduce a revised SIA campaign modality by spacing out SIA campaigns with at least a 6-week buffer designed to avert community fatigue with the polio programme and allow for activities to support community engagement, FLW capacity, social mobilisation strategies, and overall campaign quality.
• Elevate the risk tier level for a handful of districts that either have continued transmission or are close to persistently infected districts or districts with programmatic gaps.
• Define new case response and event response guidelines so the programme organises a focused and timely response to new WPV cases or positive environmental samples.
• Incorporate the latest guidelines for surveillance among high-risk and mobile populations and patients with primary immunodeficiency disorders.
• Streamline data collection by prioritising pre-campaign preparedness and retaining only one method of post-campaign evaluation: lot quality assurance sampling (LQAS) by third-party monitors. New mechanisms are also introduced to ensure the programme uses data effectively, reduces duplication, and maximises the impact of programme resources.
• Build upon the Accountability and Performance Management (APM) Framework to provide clearly defined and systematic mechanisms for the recognition of good performance and investigation, support, and sanctions for sub-optimal performance.

Across key priorities for the Extension, the programme also organises a special task team with representation from all areas of work and all task teams to encourage coordination, strengthen operations, and drive performance across all levels of the programme. This approach is put forward to close the remaining gaps and turn the tide toward polio eradication in Pakistan.