1. Polio Eradication Initiative Pakistan Meeting of the Independent Monitoring Board for GPEI; 7 th May 2013

2. Outline Current Situation Supplementary Immunization Activities Surveillance for Polioviruses

3. Current Situation

4. Months / Years NSL3 NSL1 NID SNID Virus Type Vaccine Type Cases (n) NSL1 & NSL3 mOPV1 TrivalentmOPV3 Bivalent 2011 2012 Confirmed Polio Cases By Poliovirus Type, 2011-2013* 2013 * Data source AFP 25/04/2013

5. Comparison of polio cases by province/region 2011 & 2013* Region/ Province No. of polio cases Decline in 2012 as compared to 2011 % Last polio case 201120122013 BALOCHISTAN734- 95% 02-Oct-12 FATA5920- 66% 10-Nov-12 SINDH3342 88% 15-Mar-13 K.PAKHTUNKHWA23273 +17% 12-Feb-13 PUNJAB921 78% 07-Feb-13 G.BALTISTAN110 0% 11-Aug-12 PAKISTAN198586 71% 15-Mar-13 * Data source AFP 25/04/2013

6. Polio cases 2012 – 2013* Last WPV3 case: 18 th April 2012 Last WPV3 positive Env. Sample: 7 th Oct. 2010 PROVINCE Wild POLIO CASES n ONSET OF LAST CASE KP312-Feb-13 PUNJAB17-Feb-13 SINDH222-Mar-13 PAKISTAN622-Mar-13 PROVINCE Wild POLIO CASES n ONSET OF LAST CASE KP2730-Nov-12 FATA2003-Nov-12 BALOCHISTAN402-Oct-12 SINDH409-Sep-12 GBALTISTAN106-Aug-12 PUNJAB221-May-12 Pakistan5830-Nov-12 Cases randomly placed in districts Provincial Boundary Districts Boundary * Data source AFP 03/04/2013 20122013 cVDPV cases (2) cVDPV cases (16)

7. Environmental Surveillance, Pakistan Data as of 30-04-2013

8. Balochistan Khyber Pakhtunkhwa Punjab Sindh Environmental Surveillance by Province Data as of 30-04-2013

9. SUMMARY Total Sites = 23 Total Samples Collected (2011-2012-2013) = 530 Total Samples with results available = 513 Total samples positive for Wild PV (2011-2012-2013) = 237 ( 136+88+13 ) (WPV1= 237) Scheduled sampling, sample not collected Wild poliovirus type 1 (WPV1) Wild poliovirus type 3 (WPV3) Mixture WPV1 & WPV3 Under process No sampling scheduled No WPV Isolated X Summary Environmental Surveillance- Pakistan

10. Program was set to fully utilize the low season – Consultative Workshop (Nov. 2012) - Gov/WHO/UNICEF with focus on reservoirs (Op/Com action plan) – Revision of NEAP for 2013 – Technical Expert Group Consultation (Dec. 2012) to review the NEAP 2013 – Closer collaboration with the Military on FATA – Prime Minster’s Task Force Meeting (Dec. 2012) Plans was seriously hampered by security situation – “New Reality” emerged – Security of front-line workers became paramount – The program put under serious & unprecedented threat The Last Low Season ?

11. Headlines Dec 18, 2012

12. Security Situational Analysis Attacks on Polio workers continue 16 Killed since Jul. 2012 (14 since Dec. 2012) – 11 polio workers and 3 escorting security personnel Series of threats to polio workers – Written and verbal by unknown elements – Teams chased in the field Government’s investigations inconclusive so far – No one claimed responsibility

13. Steps Taken Ensuring safety of polio workers – Emergency Op. Guidelines developed – Security component included in all micro-plans; with op. & comm. plans – Prov. Security Coordination Committees established (Chaired by Home Secretary) – DCs/DCOs were tasked in assessing security situation and provide necessary protection  DPEC and UPEC to include active participation of Law Enforcement Agencies Continue the campaigns with mitigation of security threats Partners support continues in SIAs monitoring & UC level support for HR UCs

14. Operating in Insecure Environment

15. Supplementary Immunization Activities (SIAs)

16. Prioritization of districts for low season SIAs (revised as of 30 th Apr.) (Feb – Apr 2013) Priority 1: Reservoirs/Core endemic areas: Central Khyber Pakhtunkhwa, FATA, High Risk Towns of Karachi, Quetta Block, Demographically Linked areas with the Reservoirs Rest of the Country * Partial (high Risk Populations / areas) Priority 2: High Risk Districts Other than the Reservoirs: Parts of Northern Sindh, Southern Punjab, Southern Khyber Pakhtunkhwa Priority 3: Other High Risk Areas: Infected Areas during last six months (outside reservoir and High Risk Belt) * * * * * * * Province Target population Priority-1Priority-2Priority-3Priority-4 AJK 690,428 BALOCHISTAN 718,845 282,660 133,301 1,149,235 FATA 1,305,151 GBALTISTAN 44,634 169,228 ISLAMABAD 232,454 KP 1,815,138 1,058,565 1,372,326 865,184 PUNJAB 3,193,607 3,240,943 276,075 9,281,813 SINDH 782,544 2,881,137 106,169 3,730,382 Grand Total 7,815,285 7,695,759 1,932,505 15,886,270

17. * * * * * SIAs: Jan to Apr 2013 Mar 4-6 SNIDs (30% of the target) * Partial (high Risk Populations / areas) Priority1 Priority2 Priority3Priority4 Mar 25-27 SIAs (23% of the target) Jan 14-16 SNIDs (38% of the target) Jan 28-30 SNIDs (35% of the target) Feb 18-20 SNIDs (48% of the target) Apr 15-17 NIDs Apr 5-7 SIAs (7% of the target)

18. Trend of children reached in Priority1 areas SIAs Dec 2012 – Mar 2013

19. Sindh KP FATA Balochistan Children reached Dec 2012 - Mar 2013 in Priority1 % children reached Dec SNIDs (1 st round) Jan (1 st round)Jan (2 nd round) Feb Dec SIAs (2 nd round) Mar (1 st round)Mar (2 nd round)

20. Priority-1 Priority-2 Priority-3 Priority-4 Number of SIAs conducted in 2013 (1 st Jan to 31 st Mar) NIDs in April except north & south Waziristan and Gaddap Town

21. No. of SIAs by Quarter – FATA Jan 2012 – Mar 2013

22. LQAS Results of Priority-1 Districts YearSIAsPunjabSindh*KPFATABalochistanPakistan 2012 Oct (15-17) Total Lotsn75139741 Passed for 95% n53136229 %71%60%100%67%29%71% Nov (18-20) Total Lotsn8355627 Passed for 95% n8342219 %100% 80%40%33%70% Dec (17-19) Total Lotsn LQAS could not be conducted Passed for 95% n % 2013 Jan (28-30) Total Lotsn631810-37 Passed for 95% n53810-26 %83%100%44%100%-70% Feb (18-20) Total Lotsn204218558 Passed for 95% n194118042 %95%100%52%100%0%72% Mar (04-06) Total Lotsn16315 655 Passed for 95% n1631015044 %100% 67%100%0%80% Mar (25-27) Total Lotsn 1242521 62 Passed for 95% n 1141315 43 %92%100%52%71%-69% Apr (15-17) Total Lotsn11344171079 Passed for 95% n1032512350 %91%100%57%71%30%63% *LQAS could not be conducted in Karachi since December, 2012 80% - 89%>90%<80%

23. * Bin Qasim polio case(Target: 44,000 children in 1 town) Round1: 11-13 Feb Round2: 20-22 Mar Round3: Could not be conducted Jaffarabad VDPV case (Target: 0.7 million children in 4 districts) Round1: 11-13 Mar Round2: 18-20 Mar Round3: 1-3 Apr Mianwali polio case (Target: 0.6 million children in 5 districts) Round1: 11-13 Mar Round2: 18-20 Mar Round3: 25-27 Mar Bannu polio case (Target: 0.7 million children in 6 districts and 2 FRs) Round1: 18-20 Feb Round2: 4-6 Mar Round3: 11-13 Mar Dadu polio case (Target: 1.7 million children in 7 districts) Round1: 15-17 April Round2: 29 April – 1 May Round3: 15-17 May District with WPV and VDPV Mardan* polio case (Target: 1.7 million children in 4 districts) Round1: 25-27 Feb Round2: 11-13 Mar Round3: 25-27 Mar Round4: 5-7 Apr Round5: 15-17 Apr *Mardan is part of the central KP reservoir targeted with intensified SIA strategy Malakand polio case (Target: 1.5 million children in 6 districts) Round1: 11-13 Mar Round2: 18-20 Mar Round3: 25-27 Mar Multi-district Case Response Activities in 2013

24. Recorded Missed Children* Due to Refusals *Remaining at the end of SIAs

25. Major Obstacle: Peshawar in Khyber Pakhtunkhwa Continued inconsistent performance in some HR areas Insecurity and targeted attacks Management issues Pockets of refusals

26. Risks: Hyderabad, Gaddap, Quetta Block Hyderabad – Inconsistent performance due to weak management & oversight – Some improvement recently – Intensified SIA strategy in Hyderabad division Gaddap – Continued insecurity, targeted attacks & threats – DCs providing leadership – security forces onboard Quetta Block – Ongoing management issues; including problems with DDM – Continued inconsistent performance

27. ^ Including AFP Cases pending for classification Punjab Sindh KP FATA Balochistan AJK/ISB/GB Pakistan Target Routine Vaccination status € of Non polio AFP cases aged 06-23 months 2011 to 2013* 0 DOSE 1 DOSE 2 DOSES 3 DOSES € As per recall of parents *Source AFP.rec: Data as of 25-04-2013

28. Summary – SIAs The momentum in 2012 is seriously shaken by targeted attacks on polio workers – SIAs missed in critical areas – Quality of implemented SIAs not consistent in priority- 1 areas Courageous stance by the Govt. partners and frontline workers – to continue SIAs Missed children tracking also hampered due to insecurity – Pockets of refusals in KP and Balochistan North & South Waziristan remain un-reached

29. Way Forward – SIAs Safety of polio workers – highest priority Enhanced and Systematic implementation missed children tracking mechanisms Improving communication strategies to mitigate the “new reality” Bridging between PEI & RI for synergy Strengthening civil-military partnership to reach the un-reached

30. Surveillance for Polioviruses

31. AFP Cases reporting by Month, 2009-2013* Cases (n) @ Non-polio AFP rate of 2/100,000 children < 15 years 2010 *Afp.rec Data as of 25-04-2013 2012 2013 20092011

32. Target Key Surveillance Indicators; 2011-2013* * Afp.rec Data as of 25-04-2013 Non Polio AFP rate Up to Week No. 16 ended on 20 h April, 2013

33. Non Polio AFP Rate By Province/Regions, 2011-2013* Target Non-Polio AFP Rate 2/ 100000 < 15 years of the age * Data source AFP 11/04/2013 Non Polio AFP rate Up to Week No.14 ended on 06 h April, 2013 Percent AFP Cases with Adequate Specimens By Province/Regions, 2011-2013*

34. 2000 children under 15 years of age 0.00 - 0.99 1 – 1.99 ≥ 2 Population density Non-Polio AFP Rate by District 2013* Percent AFP Cases with Adequate Specimens, By District – 2013* 0% - 59 % 60% - 79% ≥ 80 % No AFP Case reported * Data source AFP 11/04/2013 Non Polio AFP rate Up to Week No.14 ended on 06 h April, 2013

35. Year Total No. of WPV isolates (AFP + Environment) Long Chain (orphan) WPV Isolates from Polio Cases n% 20091072826 20102232411 2011334154 2012146107 2013170- Long Chain (orphan) WPV Isolates (AFP & Environment) 2009-2013** 2011 (15) 2010 (24) 2009 (28) 2012 (10) **Data Source Afp/Afp Lab: 25-04-2013

36. Environmental Surveillance Network ProvinceDistrictNo. of Sites BALOCHISTANQUETTA3 KPPESHAWAR2 PUNJAB FAISALABAD2 LAHORE3 MULTAN3 RAWALPINDI1 SINDH HYDERABAD1 KARACHI6 SUKKUR2 PAKISTAN23 23 collection sites in 11 large cities/towns Most extensive globally Covers all the provincial capitals and regional hubs Sampling sites selected strategically, biased to towards detecting polio viruses One site

37. Possible Reasons for decline in AFP reporting Intensified SIAs in 2012 & 2013 – Frequency and quality of active surveillance – Overall monitoring of the surveillance Inadequate Contribution of Health Department (ownership) – District surveillance Coordinators not fully functional – More dependence on partners Security situation in FATA

38. Way Forward – Surveillance (1) NEAP addendum on AFP Surveillance – Defining indicators and performance tracking mechanisms Desk review of district and sub-district level performance Review, appropriating and prioritization of the surveillance network Training of the Government and WHO Surveillance Staff Orientation of Healthcare Providers including informal ones and faith healers Engagement of medical and pediatric associations

39. Further Expansion in environmental surveillance Innovative approaches: – Community based surveillance initiative – Strengthening active AFP search during SIAs – Incentives for reporting in selective areas – Utilizing technology like text messages (sms) improving the reporting timeliness Way Forward – Surveillance (2)

40. Summary – Surveillance There is an overall drop in the number of reported AFP cases – Key indicators remain above the global standards AFP surveillance is complimented by an extensive environmental surveillance network Long chain (orphan) viruses have decreased over the years indicating functional surveillance for polioviruses

41. Thank you! More than ever