Polio Epidemiology

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Polio Epidemiology Situation Update
Afghanistan Polio Eradication Initiative

• TAG Meeting 1-2 June 2009

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Transmission localized in Southern Region since
2004
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Polio Virus Isolates By Type Month Transmission
Zone Afghanistan 05-09
Southern Region including Farah
A -3A
A -3A
A-3A
A -3D
A -3A
A-3D
B -4A
B -4A
B-1C
Eastern Region
Data up to 18 May 09
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Characteristics of cases
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Characteristics 1 Confirmed , Compatible NP
AFP cases Afghanistan 06- May 09
Data up to 9 May 09
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Characteristics 2 Polio Cases

• Six of the 7 polio cases (Jan to April 09), are
  from two provinces of Southern Region (Kandahar 4
  cases, Helmand 2 cases) one case is reported
  from Nuristan, Eastern Region.
• 06 polio cases from South are A-3A lineage
  Nuristan case is B-4A. Last B-4 A in Afghanistan
  was in 2007.
• All the polio cases are lt36 months age.
• All 6 SR cases have not received any dose through
  routine. None of these children had received more
  than 3 doses of OPV.

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Characteristics 3 Social characteristics of
confirmed cases 08-09
Average Distance from nearest Health Facility 20
Km (Range 1-80) Average Duration of Nomadic Stay
in the Areas 2 Months
Pharmacist,Policeman,Businessman etc
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Immunization Status
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Finger Mark Market Surveys (Transmission Non
Transmission Zones) January to April 2009
Percentage
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Major Challenges in Afghanistan

• Accessing children safety for vaccinators in
  key insecure areas
• Maintaining high immunity in polio-free areas of
  Afghanistan until all polio transmission is
  stopped
• High population movement between polio-endemic
  areas in Afghanistan Pakistan

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All remaining polio in Afghanistan in 2008 - 09
is in security-compromised areas!
UN Security Map 2005
By June 2005
UN Security Map 2009
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• Access problem - South
• Serious access problem in South through active
  conflict and 'climate of fear'
• Of 1.2 mil target children lt 5 yrs, 4 - 18 in
  'no access' areas each SIA round
• No mobility for UN staff anywhere in the Region
• much reduced supervision / monitoring / control

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Polio Cases Population lt 5 year by District,
Southern Region, 2004 - May 09
Helmand Province Nadeali, Lashkargah, Nauzad and
Mosaqala Districts Kandahar Province Panjwai,
Maywand, Kandahar and Shahwalikot
Districts Uruzgan Province Trinkot, Dehrewood
and Shaheedehesas Districts
70 of the polio cases are from these 11 Districts
Data up to 29 May 09
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An example of success in improving
accessMosaqala district Helmand Province

• Target children 50185
• All 18 clusters inaccessible since March 08.
• AGE very active military operations taking place
  off and on.
• In 08, AGE asked for health clinic in their area
  but found not feasible by MoPH in 2009, they
  asked for medicine which were provided
• Meetings with District Shura Elders. Finally
  PPO managed to find two DCs acceptable to AGE.
• All 18 clusters covered in March, April May
  2009 campaigns.
• Main risk to progress any change in Taliban
  district leadership.

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Nadeali district Helmand Province

• Target children - 80,980
• 13 /27 clusters inaccessible since March 08 all
  27 since Nov 08
• AGE very active and military operations taking
  place off and on fear of land mines in the
  field.
• Local negotiations resulted in Taliban agreement
  to conduct the campaign in March but couldnt due
  to active fight. In April poppy harvesting was
  the competing activity.
• Established transit teams on Lashkargah bridge in
  April 09
• BPHS NGO (Ibne Sina) is taking over the
  responsibility of Nadeali.

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Panjwai district Kandahar Province

• Target children 41875
• 6/13 clusters inaccessible since March 09.
• AGE active military operations continue off
  on.
• Meetings with Prov. Dist. Governors follow up
  meetings with Shura Elders were held with less
  impact.
• NRP helped to identify DCs CS
• Father of the recent polio case is helping in
  advocacy.
• Planning Immunization Week in the accessible area
  inviting the population from inaccessible
  clusters.

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Shahwalikot district Kandahar Province

• Target children 38000
• 18 clusters reportedly all covered.
• This district is a stronghold of AGE.
• 02 polio cases in 08 01 in 09
• Meeting with District governor and follow up
  meeting with Shura elders
• promised support for introducing reliable
  supervisors teams, reporting missed areas-but
  no positive outcome yet.
• Working on PCA data validation through NRP
  other reliable source.
• BPHS NGO AHDS taking over the responsibility from
  May round.

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Poorly performing districts but no access issues

• Kandahar, Spin Boldak, Shaga, Daman Arghandab
  districts
• District governors assured their support and had
  meeting with the Shura, local PEI teams and
  elders.
• Willing to support in team selection campaign
  monitoring
• Elders Shura members cooperated in most of
  these districts.
• Progress in these districts in next rounds will
  be monitored closely.
• Liaison with Governors, local elders and district
  Shura will continue to keep them updated about
  the PEI activities.
• Campaign implementation by AHDS in Spin Boldak,
  Shaga, Daman

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Risks in non transmission zone in Afghanistan
Gap Analysis / Risk of WPV by District in 2009

• Identify risk of WPV transmission in districts if
  it should be introduced
• Identify weak areas/factors
• Immunization (median opv doses 0 dose AFP
  cases, routine EPI, last three campaign data)
• Surveillance (Hot AFP cases, sex, adequacy,
  diagnosis, NSL, EV, SL)
• Pop. density movement
• Security access factors
• Plan implement actions addressing main reasons
  of weaknesses in the high lighted districts
• Monitor and review effectiveness and further
  action
• accordingly

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Gap Analysis / Risk in non-endemic areas by
district in 2009 on basis of 2007-2008 data
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SIAs Type of OPV - Afghanistan 2009
OPV measles Feb 7- 12
NID Jan 11-13
NID Mar 15-17
SNID Apr 12-14
NID Jul 26-28
NID Oct 11-13
SNID Jun 21-23
NID May 23-25
?
NID Nov 15-17
SNID Dec 13-15
tOPV
mOPV1
mOPV3
not covered due to insecurity
?
According to polio Epidemiology
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High-level political commitment andinnovative
approaches in Southern Region

• Continued high-level support
• President and Health Minister launching SIAs
• Dr Mojadidi Advisor to President on Health and
  Education continues to guide and monitor PEI
• SRSG is taking part in the launching of the
  campaign
• Provincial Governors launching campaign at the
  provincial level
• Polio Eradication was many times on the agenda of
  the Cabinet
• Recent Innovative Approaches
• Introduction of TV Posts at Lashkargah bridge
  other main CP among these districts.
• Conduct Immunization Weeks in the border
  accessible areas to attract children from the
  inaccessible areas of the district.

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Southern Region Improving SIA management

• Management
• MoU signed between MoPH BPHS NGO (AHDS, Ibne
  Sina)
• Kandahar districts Shahwalikot, Spinboldak, Dand
  Shega
• Helmand provinces Bust, Nadeali, Nawa,
  Nehresiraj
• Working on such MoU for the Farah province
• Such changes are recommended for the revised
  agreement
• How the existing funding will be linked with BPHS
  funding partners with MoPH??
• Appointment of District Public Health Officers
  (DPHOs) is in progress

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Southern Region Reducing access problems

• Coordination with military groups (ISAF, NATO) /
  Afghan national army provide info on dates /
  areas of SIAs
• Progress on Option 03 for DOT
• Meetings with ISAF/NATO, TFK, PCB Kandahar
• Recently met on May 26 09
• Continue ICRC-mediated coordination with
  Anti-Govt. Elements (Taliban) to obtain letter of
  support (facilitate access)
• Support from National Reconciliation Program
• Using community-based access negotiators
• Success in Mosaqala

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Summary

• Program is able to contain WPV circulation in the
  South rest of the country is without any
  established circulation.
• Campaign quality is overall inadequate in the
  south while vaccination status of children in
  other parts of country is satisfactory.
• Worsening security is impeding safe access to the
  children and supervisors can not go to the field
  to supervise the campaign quality.
• Children in other parts of Afghanistan and of
  neighboring polio free countries will be at risk
  till the job is completed in the South.

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Upcoming polio vaccination rounds in Afghanistan,
June December 2009

• June 2009 (campaign 21-23 June) SNIDs
• July 2009 (campaign 27-29 Jul) NIDs
• October 2009 (campaign 12-14 Oct) NIDs
• November 2009 (Campaign 15-17 Nov) - NIDs
• December 2009 (campaign 13-15 Dec) SNIDs

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Advise from the TAG

• What further approaches should be adopted to
  enhance the access to children in insecure areas
  for vaccination?
• Afghanistan Team will hold the meeting on June 30
  in Kabul to share the findings recommendations
  of the TAG. Representation of TAG is requested.

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Southern Region-OPV type used Polio virus
Isolates 2006 - May 2009
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Nauzad district Helmand Province

• Target children 39136
• All 18 clusters inaccessible since Jun 08.
• AGE very active military operations continue
  off and on.
• PPO identifed one DC for Nauzad acceptable to the
  AGE.
• 7/18 clusters with 15219 target children were
  accessed in March 09 NIDs
• MoPH changed this DC in April.
• In April, poppy harvesting was the competing
  activity.
• Team is trying to find Acceptable DC.
• Plan to raise Transit Vaccination Post at Mirza
  Khan check post (Crossing point for Nauzad, Musa
  Qilla, Baghran Kajaki)

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Maywand district Kandahar Province

• Target children 38553
• 6/26 clusters inaccessible since March 09.
  Military activity continues.
• Meetings with Prov. Dist. Governors follow up
  meetings with Shura Elders were held with less
  impact.
• TFK/PRT will share the Contacts program will
  approach them independently.
• Plan to raise TVP at Baghipul check post
  (crossing point for Ghorak, Khakrez also)

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Finger Mark Market Surveys (Transmission Non
Transmission Zones) January to April 2009
100
90
80
70
60
Percentage
50
40
30
20
10
0
Jan
March
April
East
South east
Median of other region
South/farah