Report of the Sixteenth Meeting of the Technical Advisory Group on Poliomyelitis Eradication in Afghanistan and Pakistan (TAG) [May 2024]

"The [polio] programme is clear about its challenges, fully recognizes gaps in implementation, and has the resilience and capabilities to address the critical gaps."

From May 22-25 2024, the 16th 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 over the past 11 months. Participants also: reviewed the implementation of outbreak response and advised modifications to understand reason(s) for wild poliovirus (WPV) type 1 (WPV1) circulation in historic reservoirs; reviewed strategies adopted by Afghanistan and Pakistan to map, track, and vaccinate migrant settlements and communities, especially in bordering districts, and provided guidance; and reviewed and suggested the supplementary immunisation activity (SIA) schedule for the remainder of 2024.

Since the last TAG (June 2023), the number of infected districts in both countries has increased (from 17 from October 2022 to June 2023, to 62 from July 2023 to May 2024). There are more WPV1 detections and more infected districts in the joint epidemiologic bloc in 2024 than in 2023. There is a major risk of historic reservoirs becoming endemic again, as well as continued endemic transmission in the East Region and a large-scale polio outbreak in the South Region. Outbreak response activities have prevented establishment of transmission in 18 of 32 districts/provinces (Pakistan = 17; Afghanistan = 1). Outbreak response to recent detections is ongoing in 14 districts/provinces (Pakistan = 10; Afghanistan = 4).

The TAG recognises the challenges in the operating environment in both countries, including: security, access; weak health and immunisation systems; large and unpredictable population movements; economic and humanitarian challenges; environmental change - natural disasters; political transitions; and complacency during periods of absence of virus.

However, there are opportunities for success, such as: enhanced political commitment from the highest leadership in both countries; resumption of house to house (H2H) access across all Afghanistan after a period of 6 years; progress toward elimination of the endemic YB3C cluster in Pakistan (not detected since November 2023); demonstration of clear understanding of challenges and new approaches to overcome them by the national and regional/provincial programmes; and the polio programme's human, technical, and financial resources to finish polio.

The TAG acknowledges substantial progress on social and behaviour change (SBC) analysis and strategy development. The key now is to prioritise most critical objectives and activities and to develop integrated SBC/operationals action plans. The problem of missed children - whether due to oral polio vaccine (OPV) refusal, children "NA" (not available), "Grey or 0/0 houses" (hidden children) or operational gaps - is a collective challenge that requires joint problem-solving in an integrated and holistic approach. To that end, the TAG recommends that the national emergency operations centre (NEOC) create best practice guidance for integrated microplanning and incorporating SBC and SIA/operational information and action in one document. 

The report delves into the epidemiology in both countries. It also looks at particular geographic areas, offering various communication-related observations and recommendations. Here are a few communication-related examples:
 

• Southern Khyber Pakhtunkhwa, Pakistan: There are concerning high numbers of missed children due to insecurity, boycotts, and programme quality issues. Stronger coordination and teamwork are needed. The TAG urges rapid development of a consensus on the SBC communication (SBCC) strategy and agreed-upon implementation plan.
• East Region, Pakistan: TAG recommendations include: continue to identify and map missed children, particularly refusals, to address clusters of under-vaccinated children with particular emphasis in border districts; encourage local officials to lead by example by publicly vaccinating their children; and optimise integration of operational and SBCC elements of micro-plans and coordination of activities.
• South Region, Afghanistan: Per the TAG, leadership should directly communicate with communities and health workers to indicate the full support of the government for H2H polio campaigns and the priority they give to the polio eradication programme. Community influencers and elders and local authorities should be part of the microplanning.
• Quetta Bloc, Pakistan: As of early 2023, multiple campaigns had been staggered or delayed due to insecurity and local protests concurrent with multiple introduction and local circulation of virus. Disruption of campaigns in Chaman and Kila Abdullah has continued except in the February 2024 SIA. Support of the top leadership and administration is urgently needed to implement high-quality SIAs in Chaman and Kila Abdulla.
• Karachi Bloc, including Hyderabad, Pakistan: The TAG suggests that the remapping of migrant populations and the profiling of reluctant and refusing families should be undertaken jointly by SBCC and operational teams in an integrated manner. The underlying reasons for insufficient improvement in vaccination of zero-dose children identified during campaigns and the overall RI coverage in the highest risk union councils (UCs) require a thorough investigation and urgent corrective measures.
• Peshawar Bloc (Peshawar and Khyber), Pakistan: The full extent of under-reported missed children due to operational problems, refusals, collusion, fake finger marking etc., should be assessed in all high-risk UCs, particularly among migrant settlements.

The report notes the importance of cross-border collaboration, suggesting that collaborators, for example:
 

• Use all available data sets to track cross border mobile groups, exchange information on migrants/returnees, and include them in micro-plans.
• Focus on identifying religious and community influencers who should be mobilised to facilitate vaccination of reluctant communities on both sides of the border.
• Undertake joint analysis of refusals and joint messaging among cross-border populations.
• Develop a plan for a cross-border Islamic scholars initiative.

In both countries, frontline workers (FLWs) should be engaged and supported by:
 

• Refreshing the FLW listening process and following through on recommendations;
• Holding a special series of listening sessions focused on solutions to the fake finger marking issue;
• Training all FLWs in SBC skills; and
• Ensuring human resources (HR) supports FLWs in cases of injury, harassment, and violence.

The TAG concludes that the target to stop transmission of all WPVs by the end of 2024 under the current circumstances is unrealistic; however, WPV interruption is possible during the next low season if the TAG recommendations are implemented urgently and comprehensively.