Report on the Meeting of the Technical Advisory Group (TAG) on Polio Eradication in Pakistan [October 2022]

"Success of eradicating polio in Afghanistan and Pakistan are mutually dependent on each other." Dr. Jean-Marc Olivé, TAG Chair



The Technical Advisory Group (TAG) on polio eradication in Pakistan convened from October 4-6 2022 in Muscat, Oman. This was the first face-to-face TAG meeting in three years and happened at a time when the country was conducting a massive flood response. The objectives of the meeting were to review the status of polio eradication efforts, key challenges, and programmatic gaps, as well as to provide technical guidance on programme priorities and required interventions, including the supplementary immunisation activity (SIA) calendar for 2023.



TAG noted a major shift in the epidemiology of poliovirus in Pakistan and recommended programmatic pivots to respond to this shift, leading to a new categorisation of risk with responses tailored to the risk category. For the first time ever, endemic transmission is restricted to seven districts in southern Khyber Pakhtunkhwa (KP) province. TAG also noted the drastic reduction in the number of genetic clusters that continue to circulate: from 11 in 2020 to just one in 2022. Epidemiological risks include the persistent circulation in the polio-endemic districts of southern KP and possible spillover and re-establishment of circulation in the historic reservoirs. TAG also underscored the continued risk of cross-border spread of the poliovirus to and from Afghanistan and missed transmission.



Thus, the endemic zone of southern KP is an absolute geographical priority. A multi-dimensional south KP plan is being implemented, keeping in view the complex security and social context of the area. Quality implementation of the new enhanced house-to-house (H2H) strategy, based on robust impact measurement, was recommended as the overarching priority to stop the remaining endemic transmission in southern KP. All programme operations, social behavioural change communication (SBCC), and administrative and security approaches should be in support of this strategy. Recommendations for southern KP SBCC include:

• Rapidly collect and confirm social evidence for different contexts in districts in southern KP to guide the design and implementation of relevant SIA and SBC strategies.
• Refine community engagement plans that are informed by social evidence to support the enhanced H2H modality, as per different contexts of southern KP, and increase community acceptance.
• Use different available social assets and opportunities to engage with local females - e.g., health workers such as traditional birth attendants and lady health workers - to maximise reach of persistently missed children.
• In specific circumstances, where the programme chooses alternative options fully delinked from the Global Polio Eradication Initiative (GPEI), such as provision of vaccination by a third party , ensure inclusion of SBC engagement interventions as part of the operations plans, which should be based on documented segmentation of community concerns.
• Segmentation can be done using existing data on missed children, households, and predominant community categories (e.g., intermittently missed, refusal due to oral polio vaccine (OPV)/trust concerns, refusal due to "other demands"). This approach can enable tailoring of SBC activities to special local challenges and evaluation of impact by segmented categories. For example, for those who have vaccine safety or other trust concerns, consider more intensive, female mobilisation and targeted communication.

More general recommendations for SBC and community engagement include:

• Consider external support to adapt SBCC strategies to the new risk environment, including by:
  • Intensifying strategy, implementation, and evaluation in "endemic interruption" and "outbreak control" areas, including tailored support to the enhanced H2H modality; and
  • Optimising existing strategy in "reduction of risk" areas - e.g., extending community engagement.
• Specify community engagement strategies and activities according to risk category and local analysis of barriers to vaccine delivery, including complementary vaccination activities, health camps, and integrated service delivery (ISD).
• Regularly evaluate all community engagement interventions against area performance data on coverage and missed/persistently missed children.
• Evaluate resource implications of all community engagement activities against prioritisation, availability, and potential impact.
• Fully implement plans to dialogue with frontline workers (FLWs) to understand their working experiences and motivations, and consider their suggested solutions as basis for FLW engagement strategy.
• Continue to promote routine immunisation (RI) as an integral part of the SBC strategy at all levels.

Fake finger-marking (FFM) is a significant concern within the programme and manifests deeper challenges - both operationally and in SBCC - between the programme, FLWs, and households. Progress has been made in gathering information that has provided new perspectives to understand what drives FFM. Recommendations include: Continue efforts to investigate and understand what drives FFM on both FLW and household sides and the approach of the programme towards households and communities that refuse vaccination; and, where causes are identified, ensure flexibility of integrated vaccination and SBC approaches to address them effectively.



The TAG offers several considerations related to gender, citing the recommendations from TAG 2021, which remain valid (see Related Summaries, below). They also suggest that prevention of sexual exploitation, abuse, and harassment (PRSEAH) should be fully implemented at all levels of the programme.



In conclusion, the TAG points to "a remarkable improvement in epidemiology despite the sobering number of polio cases....Given this progress, the TAG is confident that poliovirus interruption in Pakistan is technically possible within global timelines if its recommendations are rigorously implemented. Nonetheless, the window of opportunity to avoid a reinfection of all reservoirs in Pakistan is finite."