Polio Background Information - Ministry of Public Health Afghanistan

Polio Background Information

National Polio Eradication Initiative of Afghanistan

2014-2015

 

Background:

Vaccination is one of the efficient and cost-effective interventions to reduce mortality and morbidity among children under-5 years of age. Populations with high vaccination coverage are prevented from the fatality and disability caused by vaccine preventable diseases. Vaccination is one of the key interventions towards achieving Millennium Development Goals; the Goal that aims at reduction of under-5 mortality and morbidity rates.

Polio Eradication Initiative (PEI), a global-scale public health intervention of almost two decades, made significant progress by sparing millions of children from lifelong paralysis. One major achievement recently, is the success in India—passing more than two years without evidence to any child paralyzed by polio thereby reducing the number of endemic countries from 123 in 1988 to 3 in 2013 as a consequence of global efforts with investment of over 7 billion US$. 

During the 65th World Health Assembly in May 2012 polio was announced as a public health emergency and based on that the only 3 remaining countries worldwide, namely Afghanistan, Nigeria and Pakistan have been called upon to prepare National Emergency Action Plans (NEAP). In response to this resolution, Afghanistan Ministry of Public Health in consultation with its partners has developed a National Emergency Action Plan (NEAP) to gear up the efforts with more aggressive, innovative and measureable approaches. In September 2012, H.E The Former President of Afghanistan Hamid Karzai endorsed and signed the National Emergency Action Plan for Afghanistan. This has been a milestone activity in Afghanistan for Polio Eradication Initiative (PEI) which has started in 1994. Hence, the PEI has become not only a health priority but also a national emergency program.

The commitment of Islamic Republic of Afghanistan to support the PEI has shown some key elements that would lead to success of the national implementation of actions. Support and participation by HE President during the implementation of PEI are good examples to demonstrate those commitments. Today we have reached the last phase of the polio eradication, a phase that requires each and every child to receive two drops of Oral Polio Vaccine in all locations in the country, including very remote areas.

OPV team vaccinating target children in a Nomadic settlement

Poliomyelitis is one the dangerous diseases of the childhood which causes disability and death among children. The disease is caused by wild polio virus. After taking the contaminated food and water the viruses enter to the human body through Oro-fecal and then the virus multiply in the small intestine. After that the viruses enter to the blood system, invade the nervous system and causes flaccid paralysis. There is no treatment for poliomyelitis even in developed countries. The only prevention is to vaccinate all eligible aged children by administering two drops of OPV through routine EPI program and every supplementary immunization activities round.

Afghanistan is one of only three countries — alongside Nigeria and Pakistan — where polio is still endemic Wild polio cases are detected and reported through a nationwide community based AFP surveillance network.

Table below is indicating the recent four years (2011, 2012, 2013 and 2014) confirmed polio cases

No

Country

2012

2013

2014(* as of 25 Feb. 2015)

2015 (* as of 25 Feb.2015)

1

Afghanistan

37

14

28

1

2

Pakistan

58

93

306

9

3

Nigeria

122

53

6

0

Total

 

217

160

340

10

Polio Circulation Currently:

Polio Eradication in Afghanistan is has shown a steady progress. In 2012, Afghanistan reported total of 37 confirmed polio compared to 80 cases reported in 2011 in the country; a significant decrease of more than 50% and also the number of infected districts reduced from 34 in 2011 to 21 districts in 2012. In 2013, 14 confirmed Polio cases are reported compared to 37 cases reported in 2012; a reduction of around 62%. Out of these 14 cases 12 are reported from Kunar and Nangarhar provinces of the eastern region, one case from Nad Ali district of Helmand province and the last case was reported from district 15 of Kabul city with onset of paralysis on 24 November 2013.

 In 2014 (as of 25 February 2015) Afghanistan reported 28 confirmed cases. Out of these eight cases, three case are reported from Achin, Behsud and Mohmandara districts of Nangarhar province, two from Alingar district of Laghman province, one from Ghazi Abad of Kunar, one from Deh-Rawat district of Urozgan province, one from Qalat of Zabul, one from Khak-e-Safeed of Farah, one from Ali-sher of Khost, two from Barmal of Paktika, one case from Giro district of Ghazni province, 5 from Kandahar city, three from Panjwai district of Kandahar and one each from Spin Boldak, Shah Wali koat, Zehrai, Spin Boldak and Arghandab districts of Kandahar province and one each case from Nahr-e-Saraj and Garmser districts of Helmand province.

The most recent confirmed case and the first case of 2015 is reported from Reg district of Helmand province. The case is a 36 month old female child with onset of paralysis on 21-January 2015. All of the 28 cases of 2014 and this one case of 2015 are of type 1 polio virus.

Genetic analysis of wild polioviruses reported in 2012, 2013 and 2014 shows that they closely match with the circulation in bordering areas of Pakistan indicating huge population movement between the two countries which make them as one epidemiological block in terms of poliovirus circulation.                          

Below map (Figure 1) is indicating the geographical distribution of polio confirmed cases and genetic analysis for year 2014 in both countries; Afghanistan and Pakistan.

In the context of recent evidence of poliovirus circulation in Eastern region, MoPH has revised the list of low performing districts (LPDs) and has included all Kunar province and 6 districts of Nangarhar to enhance focus and provide additional support for vaccination in these areas to stop the poliovirus outbreak in Eastern region by the end of 2014. It has to be mentioned that five district of Kandahar province (Spin Boldak, Panjwai, Maiwand, Shahwalikot and Kandahar city), five districts of Helmand province (Lashkergah, Musaqala, Nadali, Sangin and Nehr Siraj) and three districts of Uruzgan province (Tirinkot city, Dehrawood and Shaheed Hasas), will also be the focus to interrupt the transmission.

The figure 2, below also indicates that there was more than 60% reduction in the number of polio confirmed cases countrywide in year 13 (1392) compared to 2012(1391), while the decrease was more significant in the Southern Region.

Actions and Steps Taken:

Government of Afghanistan is taking steps to ensure implementation of emergency action plan through concerted efforts with active engagement from every discipline of our society; particularly Civil Society Organizations, parliamentarians, Journalists, teachers, Mullah Imams, religious leaders and negotiations with community leaders. Our aim is to vaccinate every child, reach every community, village or settlements irrespective of their any political, cultural, tribal or religious affiliation

Office of the Former President had advised the provincial governors, particularly Governors of Kandahar, Helmand, Uruzgan and Farah provinces to ensure high vaccination coverage and report to the Office of the President. Advisor on Health Affairs is nominated as focal person for Polio Eradication and has to directly report on progress to the President.  An Inter-Ministerial Task Force on Polio Eradication is established under the chairmanship of Minister of Public Health. All ministries, particularly Education, Labor and Social Welfare, Hajj and Auqaf, Information and Culture and Ministry of Rural Rehabilitation and Development are members of this committee aiming to update cabinet regularly on progress.

Ministry of Public Health along with its partner, WHO and UNICEF, conducted four rounds of the National Immunization Days (NIDs) in March, May, August and October 2014. Almost 8.9 million children less than 5 years of age were targeted all over the country to administer the Oral Polio Vaccine (OPV). More than 64,000 service providers were involved in this campaign. Vitamin A and De-worming tablets (Albendazole) was also administered alternately in each of the NIDs. 

Four rounds of Sub-National Immunization Days were conducted in 2014 in all Southern, Eastern and South-Eastern regions and Farah province of Western Region. Total target of children in these areas was almost 3.6 million children. Bivalent Oral Polio Vaccine (bOPV) was administered in these rounds to vaccinate all the eligible children.  Eight additional rounds of vaccination were implemented in selected reservoir and low performing districts of South, South-East and Eastern Region.

20% of target children were still missed due to insecurity situation. Vit-A, which is very important and has a key role in the children’s growth and increasing the immunity level has also been administered to all eligible children (6-59 months) in two NIDs.

Permanent Polio Teams (PPTs) have also been established in two districts of Kandahar (Kandahar city and Spin Boldak) three districts of Helmand (Lashkergah, Nadali and Marja) and two districts of Farah province (Balablook and Khaksafid ), The PPTs are vaccinating the under five years children regularly four times a  year and reporting to MoPH on monthly basis.

Community awareness network has also been established and some key personnel have been hired to increase the community awareness through community elders, Mullah Imams and other influencers, which in turn is expected to increase the community demand regarding the vaccination.

Thirteen fixed Cross Border OPV points have been established to ensure the coordination of polio activities between Afghanistan and Pakistan along the border between two countries. Six of the CB-OPV points are in Nangarhar and Kunar provinces of the Eastern region (Torkham, Sarkani, Marawara, Dangam and Narai), 3 CB-OPV Points in Kandahar and Zabul provinces of the Southern region (Spin Boldak, Maroof and Shamalzai) and 4 CB-OPV points in Khost and Paktika provinces of the South-Eastern region (Babrak thana, Gholam khan, Angur hada, Gumruk and Thana Sokhta).

Two drops of OPV are being administered to a child under-5 years of age

It is worth mentioning that every year more than 1.2 million under five years of children are vaccinated by the entire above mentioned Cross border OPV teams.

Cross border meeting have been conducted on quarterly basis between Eastern, South-Eastern and Southern regions EPI/PEI teams and Pakistan EPI teams and all important issues as well as progress of PEI have been discussed in these important meetings. Two national coordination meeting has also been held, one in Kabul in 2012 (1391) and one in Islamabad in 2013 between both countries ministries of public health for more coordination of PEI.

Establishment of DEMT in 13 High Risk Districts (LPDs) of the Southern Region:

In all 13 High Risk Districts of the Southern region an expert and well trained person has been recruited as a district EPI/PEI manager for better management of the PEI/EPI activities in the district. The District EPI/PEI manger is responsible for all PEI/EPI activities at district level.

Routine EPI Activities:

Delivery of the Routine Immunization program services which is one of the basic strategies for the polio eradication in the country is carried out against eight vaccine preventable diseases (tuberculosis, Polio, diphtheria, Pertusis, tetanus, hepatitis-B , influenza and measles). All routine services are being provided free of charge through 1,400 EPI fix centers in the entire country for eligible children (under-2 years old) and eligible women (15-45years). The strategies for Routine EPI service delivery include; 1.Fix EPI center, 2.Outreach, 3.Pulse activities).

Coverage percentage of Penta-3 (diphtheria, Pertusis, tetanus, hepatitis-B, Influenza) in 1391 by districts is shown in the map below.

Coordination with ARCS:

As it is known that Afghan Red Crescent Society (ARCS) has a wide network of CBFA volunteers throughout the country and Ministry of Public Health has signed an agreement with the leadership of ARCS that indicates all of the volunteers of ARCS would play key roles and participate in PEI program as campaign staff.

Challenges:

There are many challenges that are affecting the polio eradication program in the country:

  • Long border between Afghanistan and Pakistan which imply for thousands of populations movement and crossing at both sides of the borders, thus humans can transmit the WPV across each sides.
  • Insecure situation especially in the Southern, South-Eastern and Eastern regions of the country that prevents the NIDs staff from reaching to some places and causes missed children among the target.
  • Dense populations, difficult geographical conditions and climatic situation are some of the other the factors that affect the PEI program from time to time.
  • Illiteracy and poor economic conditions in remote areas, which comprised 75% of the total population, are the other contributing factors affecting negatively the PEI program in the country.
  • Lack of Personnel, environmental hygiene and lack of access to safe drinking water are the main risk factors that also play key role in the transmission of the disease.
  • Migrations, mobile populations and IDPs that have been affected from insecurity in some parts of the country bring a risk for the transmission of WPV to polio free areas.

Conclusion:

The Polio eradication is a national commitment that we are entering to the end stage to eradicate the polio. There is a strong need for a sound and close collaboration between various governmental departments of Afghanistan and between Afghanistan and Pakistan as such.

Our kind requests from the Cabinet Meeting of H.E Ministers are as follows:

Presence of WPV is the same kind of challenge for children of Afghanistan and Pakistan. Thus, the collaboration and coordination between the Presidents of both countries for eradicating the polio has highlighted the importance of this issue in both countries. Hence, we propose that this important issue that has been taken at the level of the two Presidents of both countries to be followed up and required services to be delivered by the Government of Afghanistan.

Honorable Ministry of Haj can play a very key role in raising community awareness by sharing the importance of polio vaccine through Mullah Imams, religious leaders of the community and mosques, especially during the Friday prayer.

Honorable Ministry of Information and Culture can play an important role in raising awareness through the mass media, audio and print alike, for the activities in the field with a focus on the Southern Region of the country.

Honorable Ministry of Rural Development can play an essential role through its rural development committee to support and monitor the PEI program in the field.

Honorable Ministry of Education can play a key role in carrying out the NIDs messages through its well established and widespread network of schools. All the teachers could inform their students to pass on the NIDs messages to their respective families as well as actively participate in NIDs.

According to the agreement between World Health Organization (WHO) and Honorable Ministry of Public Health, two organizations have been working jointly to develop National Emergency Action Plan (NEAP) that would announce the PEI as an emergency program for Ministry of Public Health.

Following the approval of the aforementioned action plan, each department will be responsible to fully support and participate in the polio eradication program. Also particular attention will focus on polio affected areas. The progress on PEI program will be monitored and assessed according to the pre-identified criteria and indicators. In conclusion as National Emergency Action Plan clearly foresees the PEI is a national responsibility of all sectors.

The Ministry of Public Health commits itself to provide PEI quarterly reports of all achievements and challenges and will submit reports regularly to H.E President’s office. A brief report will also be offered and shared with H.E Ministers’ Cabinet Meeting in the future.