UNICEF SOUTH ASIA TARGET
No new polio case by end-2016
The world is certified polio-free at end-2019
I have no better work to do than protecting your child’s good health.”
UNICEF Social Mobilizer, Charsadda, Pakistan
Polio is a crippling and potentially fatal infectious disease.
For polio to be eradicated every child must be vaccinated multiple times for full immunity.
Even one unprotected country, community or child is a threat to this goal.
No new polio case by end-2016
The world is certified polio-free at end-2019
The Global Polio Eradication Initiative (GPEI)is the largest internationally coordinated public health effort in history. In 1988, when the world launched this effort to eradicate polio, more than 350,000 children in 125 countries were being paralyzed every year by the disease. Today, millions of children are walking without support due to the efforts of the front line workers who went door to door to vaccinate children.
Within the GPEI, UNICEF is the lead agency for communication and community engagement efforts, vaccine procurement and cold chain management. GPEI is led by national governments in partnership with the World Health Organization, Rotary International, the US Centers for Disease Control and Prevention and UNICEF. Underpinning the effort is a global network of more than 20 million volunteers worldwide who have collectively immunized nearly 3 billion children over the past 20 years.
As part of its communication and community engagement strategy for polio eradication, UNICEF’s goal is to raise awareness and create demand for vaccination. To achieve this goal, we need well-trained, highly motivated front line workers who come from the local community and have good inter personal communication skills. It also involves reaching parents with key campaign messages on immunization every time it is offered in the area. UNICEF also works to ensure that the right type of polio vaccine is available at the right time and in right quantities; and that the cold chain is functioning for all planned campaigns and case responses.
In 2016 only two countries, Pakistan and Afghanistan, remain endemic for wild poliovirus circulation. Nigeria was taken off the list of polio endemic countries in August 2015 because the country at that point had not reported any polio case for more than a year. However, recently three polio cases have been reported from Borno state in North East of Nigeria. In 2016 until September, Pakistan and Afghanistan have reported 22 polio cases, with 14 cases from Pakistan and 8 cases from Afghanistan. Continued circulation has been focused in small pockets of high-risk areas in the Peshawar-Khyber Agency corridor, Quetta block, Karachi, North Sindh, Kandahar, Helmand and Nangarhar.
36 cases were reported in the first half of 2015 versus 17 so far in 2016 (as of end-June)
1 - PAKISTAN
IPakistan made significant progress, with a drop in polio cases from 306 in 2014 to 54 in 2015, and only 14 cases from 10 districts till date in 2016. National and provincial Emergency Operation Centres (EOC) were established to coordinate the programme, and a new focused National Emergency Action Plan was developed with firm management, oversight and accountability mechanisms.
A coherent Low Transmission Season strategy was developed for implementation in the 2015-16 winter months, when it is easier to stop the virus. Nine well-planned and high-quality campaigns were conducted, implementing the paradigm shift for campaign performance from “covered” children to a relentless focus on “missed” children. Twelve high-risk Tier 1 districts were identified in the core polio transmission reservoirs, with targeted interventions including implementation of full-time female vaccinators and focused deployment of additional staff. A Rapid Response Unit was established to further enhance the capacity of the EOC network to respond to identified triggers. At the completion of the Low Season, more than 280 million doses had been delivered to under-5 children across the country.
In the core reservoirs, these approaches have seen cases reduced by half, with environmental surveillance from 39 sewage sites across the country confirming a dramatic reduction in the prevalence of wild poliovirus. Epidemiologically, the number of genetic clusters of the disease has fallen from 5 in third quarter of 2015 to just 1 by second quarter in 2016. Programmatically, all high-risk provinces, with the exception of Sindh, are seeing consistently high vaccination coverage, verified by third party monitoring.
Moreover, real risks remain: it is critical to sustain the necessary commitment to polio eradication by the government and partners at all levels and to ensure adequate protection for polio teams.
To sustain previous gains, the Pakistan polio programme is hiring more female vaccinators, for whom it is culturally acceptable to enter a house and vaccinate infant children. In two-person mobile team areas, a relentless focus on improving microplanning is improving accountability of teams and reduce missed children. These teams are now covering fewer houses to improve quality. The programme is also focusing on better understanding populations from neighboring Afghanistan who regularly travel between the countries and on occasion take the virus with them. Finally, the programme supports strengthening of routine immunization system to ensure all children, particularly for the introduction of one dose of the injectable Inactivated Polio Vaccine (IPV).
2 - AFGHANISTAN
Although Afghanistan and Pakistan remain polio-endemic, most of Afghanistan is now polio-free. However, wild poliovirus continues to circulate in some parts of the Eastern and Southern Regions. In 2016 until September, Afghanistan reported 8 confirmed polio cases in 5 districts of the country, compared to 20 cases in 16 districts in 2015.
In early 2016, Afghanistan reviewed its highest-risk areas and identified 47 high-risk districts that have been responsible for 84 percent of cases in the past seven years. These districts have weak routine immunization and face challenges like campaign quality and access due to insecurity. In these districts, the Immunization Communication Network (ICN) comprising of social mobilizers and cluster supervisors work full-time to address missed children during campaigns including refusal families. In between campaigns, they focus on referring defaulter and drop-out children to the nearest health facilities for routine immunization.
To improve accountability and performance, Emergency Operations Centres (EOC) have been established at the national- and three regional-levels; district-specific profiles and plans with operation and communication components have been developed for all the high-risk districts; and, national monitors are selected and trained at the EOC and sent for campaign monitoring in the high-risk provinces and districts. A comprehensive fifth-day revisit strategy has also been rolled out nationwide to cover children missed during campaigns.
As part of its efforts to stop wild poliovirus transmission, the Afghanistan programme is ensuring that frontline workers are local, female (where possible), paid on time; at least one team member is literate; and they are trained via a new curriculum. Vaccinators are required to conduct a comprehensive revisit strategy of children missed in the first phase of a campaign to ensure all children are covered and intensive intra- and post-campaign monitoring are conducted via mobile phone technology.
3 - INDIA
India was certified polio-free in 2014. In the post-polio era, UNICEF continues to work closely with the government and partners to maintain zero cases of polio and retain immunity to the disease. The UNICEF-funded and -managed Social Mobilization Network (SMNet), comprising 7,300 social mobilizers, continues to work in the highest-risk and hardest-to-reach areas of Uttar Pradesh, Bihar and West Bengal, reaching over 3 million households with 2.2 million under-5 children.
In 2015, the SMNet sustained more than 99 percent oral polio vaccine (OPV) coverage in its highest-risk areas. The SMNet engages more than 50,000 volunteers to mobilize their communities and build trust, while about 5,000 informers are engaged to notify the programme when migrant groups are on the move.
UNICEF’s robust, evidence-based communication strategies have created an environment in which parents accept repeated polio immunization for their children. By focusing on high-risk areas, using tailored materials and tools, and through broad advocacy and partnerships, UNICEF’s social mobilizers have assured near-complete community ownership of the polio programme.
In 2015, UNICEF signed an agreement with the National Ministry of Health and Family Welfare to fund the States of Uttar Pradesh (UP) and Bihar for progressive funding of the SMNet until March 2018, after which the UP Government will assume full ownership and funding of the network. This funding will allow the SMNet to continue supporting polio immunization campaigns, routine immunization sessions, integrated health and nutrition days, and support other child health initiatives. The SMNet will continue to promote lifesaving messages on early and exclusive breastfeeding, handwashing with soap, and the use of oral rehydration salts (ORS) and zinc for diarrhea management.
This support is seeing real results: in UP in areas where the SMNet are working, routine immunization coverage rates rose from 36 percent in 2009 to 79 percent by end-2014. In Bihar, Routine Immunization rates rose from 69 percent to 85 percent.
Community-based Vaccination in Pakistan
In previous years, efforts to control polio in high-risk areas of Pakistan were not successful in interrupting transmission despite vigorous implementation of a Short Interval Additional Dose strategy. The causes were many and complex: there were major setbacks in access and security, poor monitoring and supervision, and unreliable data, which altogether contributed to poor campaign rounds and an accumulation of persistently missed children.
The 2015 - 2016 National Emergency Action Plan (NEAP), after learning from recent successes in Karachi, implemented Community-Based Vaccination (CBV) in core reservoir districts with two primary objectives:
1. To improve campaign quality and access in the high-risk Union Councils (UC) of the reservoir districts through sustained community engagement and use of local, permanent vaccinators equipped with tools and knowledge needed to build community trust
2. To track and immunize the cohort of children persistently missed during vaccination campaigns in the high-risk UCs in Tier 1 districts, including those from underserved communities: nomadic families, seasonal laborers, migrants, slum-dwellers, and populations in transit, as well as the new birth cohort
At the end of May 2016, there were 10,955 Community Health Workers vaccinating children in 472 Union Councils. The National Polio Management Team plans to expand the CBV initiative to both cover as many Union Councils as possible within Tier 1 districts (located within the core reservoirs) and maintain CBV in Tier 2 districts where it is already in place. The community-based vaccination strategy will now become the backbone of the programme and NEAP implementation for Tier 1 districts.
Reaching inaccessible children in Afghanistan
One of the greatest threats to continued wild poliovirus is the growing conflict in Afghanistan which, as of May 2016, means 150,000 children are inaccessible to vaccinators in each immunization campaign. To tackle this, the program has focused its efforts to reach as many children as possible with vaccine, irrespective of the area in which they live. To achieve this, the programme ensures complete and non-negotiable neutrality, conducts ongoing negotiations at different levels through neutral and credible local mediators. It also conducts multiple catch-up campaigns as soon as areas become accessible, and places permanent vaccination points at all the entry and exit routes to vaccinate all eligible children and create a firewall of immunity around the area – a strategy which vaccinated more than 630,000 children in 2015. In addition, the programme implements ‘polio-plus’ strategies offering more than just polio, such as the provision of ‘dignity kits’ containing essential household and health supplies including soap, ORS, and mosquito nets to families at the borders of inaccessible areas to attract parents and their children to come out to receive the kits – and vaccination.
Leveraging polio assets to raise routine immunization coverage in India
In early 2015, the Government of India (GoI) launched an equity-based strategy, Mission Indradanush, which aimed to drastically increase India’s full immunization coverage to 90 percent by 2020 by targeting its most vulnerable and underserved communities. On the request of the Ministry of Health and Family Welfare and the state governments, UNICEF deployed over 500 SMNet members to large, traditionally non-polio states with poor Routine Immunization (RI) indicators – Chhattisgarh, Haryana, Madhya Pradesh and Rajasthan – covering over 2.1 million children. Additionally, over 200 members were deployed within the original SMNet states of Uttar Pradesh and Bihar to newer non-SMNet areas to support communication activities under Mission Indradanush. The results were impressive: 3,771 immunization sessions were monitored by SMNet in 52 districts, with RI coverage increased across the board, district-level communication plans updated in 94 percent of deployed districts, and 85 percent of families persuaded for immunization.
Pakistan and Afghanistan share a long, porous border, forming one common reservoir of polio virus circulation. Since the establishment of the Emergency Operations Centres in both countries, coordination between the countries has been strengthened at all levels. This includes regular in-person and weekly video conference meetings; harmonization of an expanded target age group (all children under 10) for cross border vaccination at 16 identified border crossings; synchronized immunization campaigns; cross-notification of all acute flaccid paralysis cases; a common communications campaign with common materials on both sides of the border; and, common microplanning and sharing of data along the border districts.
In Pakistan and Afghanistan, UNICEF is revamping its communication approach to place frontline workers at the centre of the programme to maximize the critical touchpoint between a vaccinator and a caregiver at the door step, creating an enabling environment where the vaccinator is recognized to be providing a trusted service, and the caregiver is systematically accepting that service.
In Pakistan, polio vaccinators have been rebranded as Sehat Muhafez or ‘Guardians of Health’ and supported through two comprehensive mass media campaigns dubbed “We are all Intertwined” and “Strangers no More”, which serve to engage social perceptions, norms and beliefs and generate an understanding that the vaccinator is a local person who is most likely known to you, who speaks your language and is a trusted part of your community. Mass media campaigns and activities are targeted to parents of children in the core reservoir zones, and complemented by a comprehensive ground-level community engagement strategy. All approaches are pre-tested and supported by a constant feedback loop via focus group discussions, media monitoring and bi-annual Knowledge, Attitude and Practices studies.
In Afghanistan, new advertisements have utilized popular celebrities, including cricketers and Pashto comedians, to support frontline workers in their attempts to reach every child with polio vaccine. Long-term partnerships have been established with Voice of America and the BBC, who host popular radio stations along the border areas with Pakistan and host weekly health shows and radio dramas featuring polio messaging. At the ground-level, district-specific plans have been rolled out, identifying key messages required by district and the best platforms for delivering those messages.
Afghanistan’s polio communication framework aims to build trust under one strategic umbrella that guides all communications work, including media and advocacy, social mobilization, household and community engagement, partnerships with religious leaders, medical professionals, and the training and empowerment of frontline workers and civil society. Communication activities aim to shape an environment where continuous vaccination against polio is embraced and accepted as an important social and individual goal by all community stakeholders.
Seeking the views of parents in Afghanistan and Pakistan
In a collaboration between the Harvard School of Public Health (HSPH) and UNICEF, researchers conduct annual polls in India and bi-annual polls in Pakistan and Afghanistan. The polls focus on parents and other caregivers of under-5 children in the areas at greatest risk for polio transmission. As the global polio eradication effort moves closer to its goal, such polls are part of global research to understand and respond to parents’ views and experiences of receiving polio vaccine. All three country programmes use the results of the polls to shape community engagement and mass-media responses to clearly identify issues, queries and knowledge gaps, helping to provide the requisite information to build trust and generate an enabling environment for vaccination.
Evaluation of the social mobilization network (SMNet) in India
PriceWaterhouseCoopers conducted an evaluation in 2015 of the SMNet, comparing the impact they had made across a decade with neighboring SMNet areas and determining several options for their future engagement. The evaluation (i) identified clear lessons and critical factors of the SMNet, namely the type of focused interpersonal communication and advocacy the social mobilizers conduct, their ability to leverage local partners/influencers, targeted capacity development and strong monitoring and supportive supervision system and supervisory structure; (ii) mapped the current location, size and scope of SMNet with potential difference in the future if it were to be adjusted to target Routine Immunization, Nutrition or RMNCH+A strategies; and (iii) based on the consultations, offered options for transition of the SMNet for each of the three states (both programmatic scope, geographical location and structure and role of the mobilizers).
Taking polio vaccine to every last child in Pakistan
Tahiranaz - Community Health Worker, Community-Based Vaccination Program, Peshawar District (Sheikh Muhammadi Union Council), Khyber Pakhtunkwa
“When I joined the polio campaign seven years ago, I was working as a part-time vaccinator for five days every month. I was not working in my own area, which made me feel unsafe. There were areas where polio workers were being attacked and even killed. I have faith in Allah and believe that my life should be to serve people. At the same time, I was scared as any human being would be.
These days, I am working in my own area. If I were to go one mile away, people would not know me. But inside this little area where I live, it is very different. I know the names of all the children, know who is pregnant and who is travelling to visit their relatives. In a small community, we know each other and all these things. Also, as I am working full time now, families are assured about my regular visits. They don’t like seeing new faces. To make sure I had my records right, my supervisor helped me to do a micro census. Before the campaigns, I went to every house and listed every child – their names, their father’s names and their addresses. Nothing was missed.
My husband is very supportive and proud of me. He said that our country is shamed by this polio disease because everyone who goes to the Haj must be vaccinated. Sometimes, he even used to accompany me to make me feel safe. He doesn’t have to do it anymore.
Earlier, there were just a few of us. Now there are more, and I hope many women will join us. I never forget the women I have worked with and all we have been through. This job provides great opportunity for women. It’s a great way to serve the public and in return you get respect.
www.polioeradication.org, accessed 3 April 2015.
www.iple.in/category/index/social-mobilization-network-1, accessed 3 April 2015.
PriceWaterhouseCoopers, Evaluation of Social Mobilization Network (SMNet) – Final Report, December 2015
Pakistan and Afghanistan 2016 National Emergency Action Plans