Meeting Report of the Technical Advisory Group on Poliomyelitis Eradication in Afghanistan and Pakistan [June 2023]

"The goal of interrupting virus transmission is still within reach if the key enabling factors, i.e., political commitment, community support and support of law enforcement agencies come together cohesively to ensure adequate implementation of strategies with optimal quality to reach all children."

The year 2023 is a critical juncture for the Global Polio Eradication Initiative (GPEI) and marks 35 years since the programme embarked on its journey to eradicate poliovirus. In June 2023, the 15th meeting of the Technical Advisory Group (TAG) on Polio Eradication was held in Doha, Qatar, to evaluate the progress of polio eradication efforts in Afghanistan and Pakistan - the remaining two wild poliovirus (WPV) countries - over the past six months. Before the in-person meeting, pre-TAG consultations on key thematic areas, including social and behaviour change communication (SBCC), for example, were conducted virtually. This report provides an analysis of the TAG's deliberations, focusing on assessing the status of endemic zones in the East region of Afghanistan and southern districts of Khyber Pakhtunkhwa (KP) province of Pakistan, as well as outbreak districts and known historic reservoirs. Detailed attention is given to understanding the current WPV epidemiology and evaluating the surveillance and immunisation efforts of both country programmes, as well as understanding the risks that remain to end polio, once and for all. The present summary focuses on the communication-related elements of the meeting/report.

In October 2022, TAG recommended a major strategic shift, focusing on a new risk categorisation: (i) WPV1 endemic transmission zones, (ii) outbreak response zone, (iii) risk reduction districts, and (iv) districts to maintain population immunity against polio. Since then, both polio programmes have implemented most of the TAG's recommendations on surveillance, rapid outbreak response, campaign quality, and routine immunisation. Global polio eradication now depends on rapidly solving the remaining challenges in two small geographic areas with a combined total target of 2.2 million children (southern KP = 1,104,060 and East region = 1,144,312 children).

Per the TAG:

• Afghanistan should continue an aggressive supplementary immunisation activities (SIAs) schedule of progressively improving quality campaigns in the East region to interrupt transmission as soon as possible. One element of a quality SIA is pre-positioning information, education, and dommunication (IEC) materials and messages in appropriate language for rapid deployment. To enhance community acceptance and trust in the poliovirus vaccine, the programme is implementing a focused and integrated SBCC strategy in the East region that includes various interventions such as parental counseling, engagement with trusted influencers, a single-knock strategy, and engagement with female Madrassa.
• Pakistan should continue to employ innovative strategies to reach all children in southern KP, particularly in the 69 union councils recently identified with the most missed children. However, success in Pakistan depends on finding approaches that will work within the existing context. The programme should continue to pursue avenues for high-quality house-to-house (H2H) campaigns (which the TAG calls the most direct path to interrupting WPV type-1 transmission) in as many parts of southern KP as possible, while at the same time using alternative approaches in areas where reaching all children through H2H is compromised for one reason or another. The TAG acknowledges the tailored SBCC packages, including the introduction of female teams in areas where previously there was no participation of women and community engagement in slum areas, which have contributed to this country programme's ability to successfully respond to outbreaks.

With regard to both programmes, the TAG commended overall strengthened linkage between immunisation operations and SBCC, which is expected will enhance efforts to reach missed children, convert refusals, and build community trust. The TAG recommends further integration between SBCC and operations in multiple thematic areas, including microplanning, refusal conversion, and campaign planning - e.g., to maximise coverage in areas with mosque-to-mosque or site-to-site modality, utilise SBCC community dialogues and other co-design approaches, as needed, to determine fixed site delivery at times and places convenient to the community.

In Pakistan, the National Emergency Operations Centre (NEOC) formulated the Gender Working Group (GWG) to strengthen the efforts to overcome gender-related programme barriers. One of the projects initiated by the GWG is the "Female Frontline Workers Co-design Initiative". This initiative involved a consultative process that solicited inputs from frontline workers, the majority female. It started with surveying a representative sample of more than 2,600 women working in the highest-risk districts. Women answered questions about their experiences and challenges in the field, including the barriers to reaching children during campaigns and administering vaccines in homes, as well as their motivations and safety concerns. Based on the survey results, 14 in-person workshops were held across the country, bringing together hundreds of female frontline workers in dedicated listening sessions.

Given the complex operating environment and unique risks in Afghanistan and Pakistan, the TAG presented each country with a tailored set of recommendations aimed at finally interrupting polio transmission by the end of 2023. These recommendations also cover key cross-cutting programmatic areas, including increasing cross-border coordination, integrating the programme with other health initiatives, improving the participation of women in the polio workforce, and strengthening synergies with the Expanded Programme on Immunization (EPI). For example, in Pakistan, the TAG recommends that SBCC results should be measured beyond refusal reduction to ensure adequate resources dedicated to its broader role in reducing all forms of missed children, including:

• Strengthening social analysis, understanding community perceptions, and applying social intelligence to help shape the programme response;
• Prioritising areas with the highest epidemiological risk and virus circulation, and
• Conducting community-based rapid assessment and tracking community sentiment.

The TAG recommends further harmonisation between SBCC and operations - specifically, in designing programme delivery formats and schedules to ensure that both streams are mutually synergetic. An entry point should be joint micro planning using the insights and knowledge from the SBCC stream, with an enhanced focus on community acceptance. The TAG suggests leveraging insights from social and community listening, particularly in areas of community resistance and insecurity, to tailor operational activity to maximise local acceptability and uptake.

The GPEI Hub for Afghanistan and Pakistan will convene a virtual TAG consultation in November 2023 to review the status of the implementations of the recommendations provided, update on epidemiology, and advise additional recommendations, if required. The next joint in-person TAG is scheduled for mid-February 2024.