Pakistan Polio Eradication Programme Update Independent Monitoring - PowerPoint PPT Presentation

Government of Pakistan Ministry of National Health Services, Regulations & Coordination Pakistan Polio Eradication Programme Update Independent Monitoring Board (IMB), Seventeenth Meeting, London 1 – 3 October, 2019

Outline • Current epidemiology • SIAs performance • Challenges and programmatic reviews • Outline of NEAP 2020 • New Pakistan Polio Programme pillars • 2019/20 Low Season SIAs schedule 2

CURRENT EPIDEMIOLOGY 3

Pakistan WPV1 cases, 1994 – 2019 3000 Number of polio cases in Pakistan has decreased from 2635 2555 estimated 20,000 per year in early 1990s to 66 so far in 2019 2500 2000 1802 1500 1155 1000 558 500 341 306 199 198 144 119 117 103 90 89 93 66 53 58 54 39 28 32 20 12 8 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 4

Number 10 20 30 40 50 60 0 Jan Mar May 2010 Jul Sep Nov Jan Mar May 2011 Pakistan WPV1 cases, 2010 – 2019* Jul Sep Nov Jan Mar May 2012 Jul Sep Nov Jan Mar May 2013 Jul Sep Nov Jan Mar May 2014 Jul WPV1 Sep Nov Jan Mar May 2015 Jul Sep Nov Jan Mar May 2016 Jul Sep Nov Jan Mar May 2017 Jul Sep Nov Jan Data as of 24-09-2019 Mar May Jul Sep 2018 Nov Jan Mar May Jul Sep

Pakistan-Afghanistan WPV1 cases and ES+, 2019 • 66 WPV1 cases reported in 2019, of which 58 cases reported outside core reservoirs. • Explosive outbreak across KP, and especially intense in southern KP . • Transmission persists in core reservoirs of Peshawar , Karachi and Quetta block , but is particularly intense in Karachi where all 11 ES sites are WPV1+. • Extensive spread of virus transmission outside core reservoirs (detected through environmental surveillance), with entrenched transmission in Lahore .

WPV1 geographical distribution of 2018 and 19 Infected Infected districts/Towns/Agencies/Areas districts/Towns/Agencies/Areas On the basis of WPV isolation On the basis of WPV isolation • WPV cases = 04 • WPV cases = 21 • Sewage water = 21 (no WPV case) • Sewage water = 24 (no WPV case) 2019 2018 • Total = 25 • Total = 45 Source Source Source AFP Surveillance AFP Surveillance P1 = 66 P1 = 06 Compatible = 0 Compatible = 01 cVDPV Cases = cVDPV Cases = - - cVDPV Env = - cVDPV Env = - Sewage water Sewage water Disputed Territory Disputed Territory Grab = 210 Grab = 78 BMFS = 07 BMFS= 14 Provincial Boundary Districts Boundary Cases randomly placed in districts * Afp.rec Data as of 23-09-2019

Molecular epidemiology of WPV Increase in genetic diversity in second half of 2018 • Genetic diversity plots are based on statistical and evolutionary models and represent estimated mean values from AFP cases from Jan 2010 – July 2019 • The skyline plot summarizes changes in genetic diversity over time; the shaded areas are the confidence intervals of the estimates • Upswings after the mid-years reflect high- season transmission • Genetic diversity appears to be higher in second half of 2018 than in 2016 or 2017 (low and high season peaks)

Fraction of positive environmental samples Intensity peaks in the first quarter of 2019 80 70 70 60 60 50 50 40 Number 40 30 30 20 20 10 10 0 0 Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Data as of 24-09-2019 Samples Collected Positive Samples

Environmental surveillance results, Pakistan (last 52 weeks) Q1 2019 highlight pan-Karachi circulation 10

Environmental surveillance results, Pakistan (last 52 weeks) Widespread ES+ Outside Core Reservoirs 11

Distribution of WPV cases by quarter, 2017 – 2019 40 35 30 25 20 38 15 22 10 5 6 2 1 2 3 1 2 4 5 0 Q-1 (2017) Q-2 (2017) Q-3 (2017) Q-4 (2017) Q-1 (2018) Q-2 (2018) Q-3 (2018) Q-4 (2018) Q-1 (2019) Q-2 (2019) Q-3 (2019) Proportion of positive ESS by quarter, 2017-2019 100% 90% 80% 67 104 114 70% 126 129 60% 130 136 141 146 148 147 50% 40% 30% 59 83 82 20% 51 45 10% 29 27 28 22 22 21 0% Q-1 (2017) Q-2 (2017) Q-3 (2017) Q-4 (2017) Q-1 (2018) Q-2 (2018) Q-3 (2018) Q-4 (2018) Q-1 (2019) Q-2 (2019) Q-3 (2019) Data as of 24-09-2019

SIA PERFORMANCE 13

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 45.00 0.00 5.00 Jan-18 Feb-18 Jan-18 Mar-18 Feb-18 Apr-18 Mar-18 May-18 Apr-18 Jul-18 BALOCHISTAN May-18 Aug-18 Jul-18 BALOCHISTAN SIAs quality: missed children – admin data Sep-18 Aug-18 Nov-18 Sep-18 Dec-18 Nov-18 Jan-19 Dec-18 Feb-19 Jan-19 Mar-19 Feb-19 Apr-19 Mar-19 Jun-19 Still-Not available/NA (Jan-18 – June-19) Apr-19 Jan-18 Jun-19 Feb-18 Jan-18 Proportion of Still NA children against target children Mar-18 Feb-18 Proportion of Still NA children against Recorded Missed Apr-18 Mar-18 May-18 Apr-18 Jul-18 May-18 Aug-18 Jul-18 KP Sep-18 Aug-18 Nov-18 KP Sep-18 Dec-18 Nov-18 Jan-19 Dec-18 Feb-19 Jan-19 Mar-19 Feb-19 Apr-19 Mar-19 Jun-19 Apr-19 Jan-18 Jun-19 Feb-18 Jan-18 Mar-18 Feb-18 Apr-18 Mar-18 May-18 Apr-18 Jul-18 May-18 Aug-18 PUNJAB Jul-18 Sep-18 Aug-18 PUNJAB Nov-18 Sep-18 Dec-18 Nov-18 Jan-19 Dec-18 Feb-19 Jan-19 Mar-19 Feb-19 Apr-19 Mar-19 Jun-19 Apr-19 Jan-18 Jun-19 Feb-18 Jan-18 Mar-18 Feb-18 Apr-18 Mar-18 May-18 Apr-18 Jul-18 May-18 Aug-18 Jul-18 SINDH Sep-18 Aug-18 SINDH Nov-18 Sep-18 Dec-18 Nov-18 Jan-19 Dec-18 Feb-19 Jan-19 Mar-19 Feb-19 Apr-19 Mar-19 Jun-19 Apr-19 Jun-19

10.00 12.00 0.00 2.00 4.00 6.00 8.00 10 20 30 40 50 60 70 80 90 0 Jan-18 Jan-18 Feb-18 Feb-18 Mar-18 Mar-18 Apr-18 Apr-18 May-18 May-18 Jul-18 BALOCHISTAN Jul-18 BALOCHISTAN Aug-18 SIAs quality: missed children – admin data Aug-18 Sep-18 Sep-18 Nov-18 Nov-18 Dec-18 Dec-18 Jan-19 Jan-19 Feb-19 Feb-19 Mar-19 Mar-19 Apr-19 Apr-19 Jun-19 Jun-19 Jan-18 Jan-18 Feb-18 Feb-18 Mar-18 Proportion of Still Refusal children against Recorded Refusal Proportion of Still Refusal children against target children Still refusals (Jan-18 J – June-19) Mar-18 Apr-18 Apr-18 May-18 May-18 Jul-18 Jul-18 Aug-18 Aug-18 KP Sep-18 KP Sep-18 Nov-18 Nov-18 Dec-18 Dec-18 Jan-19 Jan-19 Feb-19 Feb-19 Mar-19 Mar-19 Apr-19 Apr-19 Jun-19 Jun-19 Jan-18 Jan-18 Feb-18 Feb-18 Mar-18 Mar-18 Apr-18 Apr-18 May-18 May-18 Jul-18 Jul-18 Aug-18 PUNJAB Aug-18 PUNJAB Sep-18 Sep-18 Nov-18 Nov-18 Dec-18 Dec-18 Jan-19 Jan-19 Feb-19 Feb-19 Mar-19 Mar-19 Apr-19 Apr-19 Jun-19 Jun-19 Jan-18 Jan-18 Feb-18 Feb-18 Mar-18 Mar-18 Apr-18 Apr-18 May-18 May-18 Jul-18 Jul-18 Aug-18 SINDH Aug-18 SINDH Sep-18 Sep-18 Nov-18 Nov-18 Dec-18 Dec-18 Jan-19 Jan-19 Feb-19 Feb-19 Mar-19 Mar-19 Apr-19 Apr-19 Jun-19 Jun-19

SIAs quality: LQAS Results 2017 – 18 and 20181 – 9 16

SIAs quality: LQAS Pass, July 2017J – June 2019 • 90% or above is pass rate target • Balochistan and Sindh have not met this target in 2018/2019 • Trend in declining pass rates in KP and Punjab since mid-2018 100 90 80 70 60 50 40 30 20 10 0 Islamabad Balochistan KP Punjab Sindh Jul 17 Sep Oct Nov Dec Jan18 Feb Mar Apr May Jul 18 Aug Sep Nov Dec Jan19 Feb Mar Jun Red line indicates beginning of NEAP Year 2018/2019 Islamabad was not part of June 2019 campaign 17

100% 10% 20% 30% 40% 20% 40% 60% 80% 0% 0% JAN-18 JAN-18 Feb-18 Feb-18 Mar-18 Mar-18 Apr-18 Apr-18 May-18 May-18 BALOCHISTAN BALOCHISTAN Jul-18 Jul-18 Refusal Proportion in missed children (2018 – 2019) Aug-18 Aug-18 Sep-18 Sep-18 Nov-18 Nov-18 Dec-18 Dec-18 Jan-19 Jan-19 Demand Feb-19 Feb-19 Mar-19 Mar-19 JAN-18 JAN-18 Fatigue Feb-18 Feb-18 Mar-18 Mar-18 Apr-18 Apr-18 SIAs quality--LQAS; HospDr May-18 May-18 Reason for missed; Refused % Jul-18 Jul-18 KP KP Aug-18 Aug-18 Religion % of Refusal Sub categories Sep-18 Sep-18 Nov-18 Nov-18 Dec-18 Dec-18 Rumour Jan-19 Jan-19 Feb-19 Feb-19 Mar-19 Mar-19 Security JAN-18 JAN-18 Feb-18 Feb-18 Mar-18 Mar-18 Apr-18 Sick Apr-18 May-18 May-18 Jul-18 PUNJAB Jul-18 Already Vacc PUNJAB Aug-18 Aug-18 Sep-18 Sep-18 Nov-18 Nov-18 Dec-18 Dec-18 Unknown Jan-19 Jan-19 Feb-19 Feb-19 Mar-19 Mar-19 JAN-18 JAN-18 Feb-18 Feb-18 Mar-18 Mar-18 Apr-18 Apr-18 May-18 May-18 SINDH Jul-18 SINDH Jul-18 Aug-18 Aug-18 Sep-18 Sep-18 Nov-18 Nov-18 Dec-18 Dec-18 Jan-19 Jan-19 Mar-19 Mar-19

CHALLENGES & PROGRAMMATIC REVIEWS 19

Main challenges facing Pakistan PEI in 2019 20

Programmatic reviews and assessments – External communication review, April 2019 – Internal communication consultation commissioned by the NEOC, May 2019 – McKinsey management review in tier-1 districts, May 2019 – High Level Program Review/consultation by Minister, June 2019 – TAG meeting, August 2019 – Super-high risk UCs programme review, September- October 2019 21