Until There Are None: Immunizing All Children in Key to Eradicating Polio

(Editor's note: This story originally was published in the 2018 Annual Progress Report of the TEPHINET Secretariat.)

TEPHINET, in close collaboration with CDC, continues to support N-STOP Pakistan to contribute, along with the Polio Eradication Initiative (PEI) partnership team, to achieving polio eradication in Pakistan.

28 days. That is when the cascade of intensive activities associated with Pakistan’s polio eradication campaign and the countdown to the next National Immunization Day (NID) will begin. For the Polio Eradication Initiative (PEI) partnership teams, including National Stop Transmission of Polio (N-STOP) officers, the next four weeks will be intense, with long hours, often in high risk areas with difficult terrain and security challenges.

The N-STOP program came to Pakistan in 2011 when the country declared polio a national emergency. It is one of several partners working on the Polio Eradication Initiative, a global program involving hundreds of thousands of field staff from the Government of Pakistan including provincial and district governments, the Department of Health, and staff from partner organizations including the World Health Organization, UNICEF, Bill and Melinda Gates Foundation, Rotary International, and others.

N-STOP is the result of collaboration among several organizations, including the Federal Ministry of National Health Services, Regulation and Coordination of the Government of Pakistan, the U.S. Centers for Disease Control and Prevention (CDC), the Expanded Program on Immunization (EPI) in Pakistan, provincial health departments in the country, and TEPHINET. Through CDC funding, TEPHINET provides operational support to the N-STOP program.

The Pakistan Field Epidemiology and Laboratory Training Program (FELTP), established in 2006, provides training to the N-STOP officers, who are public health professionals and medical doctors. Currently, 65 percent of the N-STOP workforce consists of FELTP Pakistan graduates; 9 percent consists of currently enrolled FELTP Pakistan fellows, and 26 percent consists of attendees of a four-week FELTP Pakistan basic screening course.

When the N-STOP program began, N-STOP officers were deployed in 16 high risk districts for six months. Now, there are 81 N-STOP officers deployed in all of Pakistan’s provinces and 61 of its high priority districts, including 12 officers at divisional and provincial levels.

N-STOP officers in Pakistan are instrumental in District Polio Control Rooms in bridging the gap between health department officials, district administration officials and PEI partnership staff in all phases of an immunization campaign, including planning and preparation, implementation, and post-campaign monitoring and evaluation.

In the planning and preparation phase, they will start their days at 8:30 a.m. at the District Polio Control Rooms/Emergency Operation Centers (EOC) with pre-campaign activities. This is a huge effort which requires teamwork and close coordination to implement activities, review results and assess failures of the last campaign before moving on to preparations of supplementary immunization activity (SIA) plans.

During campaigns, N-STOP officers start their day at 7:30 a.m. with team deployment, field monitoring and supervision of campaign activities. They will continue to work up to 11:30 p.m. after the facilitation and completion of district evening review meetings. In the post-campaign days that follow, they contribute to post-campaign evaluations including LQAS (Lot Quality Assurance), continue to coordinate and make plans for tracking missed children in the campaign, and devise strategies for reaching and vaccinating them.

At an efficient and steady pace, District Polio Control Room officers will move into planning for the next campaign, which includes formulating a timeline and assigning responsibilities. After the team assesses needs for the next campaign, trainings will begin so that staff are adequately prepared for the vaccination campaign. Close collaboration and effective communication are critical.

On day one of the campaign, N-STOP officers will start their day from the District Polio Control Room. Teams coordinate and then go into the communities to support frontline polio teams and supervise and monitor the quality of immunization campaigns--often through challenging terrain and with limited security--to ensure that that every child is vaccinated against polio, also often providing basic public health education on immunization simultaneously. Many SIAs are now synchronized with Pakistan’s neighbor Afghanistan, another of the three remaining countries where polio is endemic (Nigeria is the third).

“As N-STOP officers, we have a challenging job,” says Dr. Aftab Kakar, N-STOP Officer from Quetta Block core reservoir and team lead in the EOC in Balochistan. “It involves a lot of coordination. We are involved in all parts of the EOC cycle of the campaign and the post-campaign review to identify remaining gaps and start preparations for the next campaign.”

All of the planning, collaborating and strategizing is driven by the goal of eradicating polio.

“Our goal is to reach and vaccinate every child in Pakistan against polio,” says Brigadier (R) Dr. Kamal Soomro, national coordinator of the N-STOP program. “We want to achieve a polio-free Pakistan.”

The Pakistan Field Epidemiology and Laboratory Training Program has been a tremendous benefit to N-STOP.

“FELTP graduates are public health professionals and trained field epidemiologists, and their skills can be utilized in any kind of public health emergency,” says Dr. Mumtaz Ali Laghari, deputy team lead for N-STOP, who is a 2011 FELTP graduate. “FELTP graduates have certain skills which make them distinct from any other technical resource persons in the fight for polio eradication.”

FELTP Pakistan and its graduates have been recognized for their excellent training and strong skills. In 2016, the program received the 2016 CDC Director’s Award for Excellence in Epidemiology and Public Health Response as an acknowledgement of the superb leadership of FELTP Pakistan in building a skilled workforce capable of conducting real-time disease surveillance and responding effectively based on sound epidemiological principles.

“FELTP Pakistan provides a learning platform to train and equip public officials in the government sector who will play a future role in public health,” says Dr. Shumaila Rasool, technical support officer for N-STOP at Sindh EOC for Polio Eradication. “FELTP graduates are able to mitigate risk in an area where public health has traditionally been quite neglected.”

Polio eradication in Pakistan is guided by four core strategies:

• Strengthening routine immunizations: Increase the number of children who are receiving all of their essential childhood immunizations.
• Supplemental immunization activities (NIDs/SNIDs): Reach every child (with a special focus on persistently missed children).
• Surveillance: Perform surveillance of acute flaccid paralysis (AFP), a hallmark of polio, in children to identify new cases of polio.
• Mop-up immunization campaigns: Engage in door-to-door immunizations in specific areas where polio is known or suspected to still be circulating.

While the program has grown in reach and resources, N-STOP officers, along with all PEI partnership teams, still experience significant challenges. Rising vaccine hesitancy in parents in epidemiological core reservoir areas is one of the biggest challenges to overcome to achieve the goal of eradication.

“While working in Pakistan, there’s not just one challenge--there are many,” says Laghari. “Pakistan is not a small country, and it has all of the difficult terrain you can think of. At the same time there are significant challenges with security in certain pockets of the country.”

Despite challenges, the success of the program has mirrored its growth due to the high commitment, sacrifice, and courage of frontline polio workers and the critical security support provided by law enforcement agencies.

According to Pakistan’s polio eradication program, there has been a 96 percent reduction in cases of polio in Pakistan since 2014. In that year, Pakistan experienced 306 cases. In 2019--just five years later--there have only been six cases of polio reported in Pakistan.

With success comes continued vigilance in polio eradication. One challenge to meeting that goal is that many children and their families in Pakistan are highly mobile.

“We are reaching the majority of children, but we are not reaching every child each time because of the complicated mix of parental hesitancy to vaccinate and the high mobility of people in Pakistan from place to place,” says Soomro. “We are employing many different strategies to reach persistently missed children.”

One way Pakistan’s polio eradication program is tackling the challenge of mobile populations is by setting up permanent cross-border transit points (on the Pakistan-Afghanistan border), across the country at provincial and district borders, and at other important transit points such as bus stops, railway stations, airports and highways. In January 2019 alone, 1.5 million children were vaccinated at permanent transit points, and a total of 39.4 million children were vaccinated during the January 2019 National Immunization Days. Yet, if just one child in any country has polio, children in all parts of the country remain at risk.

“We understand the world is looking at us with high concern,” says Laghari. “Pakistan holds the key to eradication. We are ready and committed to finish the job.”