PEI Update - Epidemiology and interventions

Polio Eradication Afghanistan

Poliovirus Epidemiology and Interventions Afghanistan

Meeting Technical Advisory Group March 24-25, 2011

Islamabad

Presentation outline

• Epidemiology

• Interventions 2010-11

• Challenges, Priorities and Plans

Map of Afghanistan by province and population density

Pakistan

Uzbakistan

Turkmanistan

Iran

Tajikistan

China

Dot = 20,000 Pop

Northeast

Northern

Western

Southern

Southeast

Central

Eastern

Regions - 7

Province - 34

Districts – 329

Target <5 years-7.8 mil

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Classification 2009 2010 2011

Reported AFP cases

1477 1572 278

Confirmed 38 25 1

Compatible 11 5 0

cVDPV2 1 5 1

Discarded 1427 1537 203

Pending - - 73

Comparison of AFP Cases by Classification 2009-2011 Afghanistan

Compared to 2009, there is reduction in number of confirmed cases by 34%

Data up to 16 Mar 2011

$

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Distribution of polio cases 2009-2011 Afghanistan

RegionConfirmed cases2009 2010 2011

Central 1 0 0

East 2 3 0

South east 0 0 0

South 34 19 01

North 0 0 0

Northeast 0 1 0

West 1 2 0

Country 38 25 01

2009

2010

2011

P1

P3


Polio virus Circulation is localized, mainly in high districts of Kandahar and Helmand Province

Although sporadic cases detected from East and N.East but no evidence of established circulation

Distribution of confirmed cases in Afghanistan 2008-11 and Area of 13 High Risk Districts

HilmandNimroz

Kandahar

Uruzgan

Zabul

RegGarmser

Dishu

Chahar Burja

Chakhansur

Day Kundi

Panjwayi

Nad Ali

Khash Rod

Maruf

Gizab

Washer

Daman

Chora

Spin Boldak

Baghran

Shorabak

Kijran

Arghistan

Naw Zad

Shahristan

Qalat

Maywand

NeshKajaki

Shah Wali Ko

Daychopan

Shamulzayi

Kang

Arghandab

Shinkay

DihrawudTirin Kot

Ghorak

Musa Qala Shahjoy

Khas Uruzgan

Atghar

Mizan

Shahidi Hass

Khakrez

Nahri Sarraj

Lashkar Gah

Zaranj

Tarnak Wa JaSangin

Kandahar

Naway i Bara

Despite number of rounds poliovirus is isolated at regular intervals indicating continued circulation with a shift from P3 to P1 type in 2010 -11

Almost 80-90% of the confirmed cases reported from the 13 High Priority Districts. Target Population of these districts is 54% of the region and 9% of the Country .

AFP Cases with isolation of cVDPV2 reported during 2010-11 Southern Region Afghanistan

2010 cVDPV2

2011 cVDPV2


Five cVDPV2 cases reported during Jun-Dec 2010 and one in 2011 Nad Ali Dist Helmand Almost 30-50 % of the target remain inaccessible in most of the rounds. SIAs coverage also ranged between 18-60%

Routine vaccination coverage among AFP cases <24 months is 9%

tOPV used in July SNIDs only in NadAli. An additional round with tOPV in 4 districts followed by tOPV in November NIDs.

3 rounds of accelerated routine EPI are planned in 2011. First round completed and 7700 children below 1 year vaccinated with tOPV.

Guidance from TAG is requested

Hilmand

Kandahar

Urozgan

Zabul

Nimroz

Characteristics of polio cases 2010-11 Afghanistan

• The Median age of all polio cases is 18 months ranging from (4-144)

• The Median OPV dose of all confirmed polio cases is 4 while among non polio cases it is 13

• 14 out of 21cases in the southern provinces have not received OPV through routine while 8 cases have not received any OPV dose.

• In 2010, 17 cases are of P1 type and 8 cases of P3 type. One case reported for 2011 is also P1 type

• Genetic study of most cases reported from South are indicating indigenous circulation of the virus while cases reported from East, North East and the recent 2011 case from Kandahar matches closely with circulation across the border in Pakistan.


Cross border Epidemiological situation and Risks Afghanistan 2010-11

•Continues circulation of virus in KPK Pakistan is posing great risk of virus transmission to the Eastern and Southeastern regions of the country

•Polio outbreak in Tajikistan and transmission of virus to Afghanistan was another epidemiological risk during 2010

Transmission, High risk & non transmission zones Afghanistan 2011

• Transmission zone

South & Farah: with on going virus circulation

• High Risk zone

East, South eastern regions: Risk of virus transmission from across the border

• Non Transmission Zone:

Central , north , northeast. Western region: no evidence of established virus transmission. Transmission

High Risk

Non-Transmission

Out of the house (FM) Surveys (Transmission , Non Transmission &High risk Zones) Feb 2010 to Jan 2011

PCA- Proportion of clusters by Transmission, High risk and non-transmission zone by FM, Afghanistan 2010-2011

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%M

ay

Jun

Jul

Oct

Nov

De

c

Jan

-11

May Ju

n

Jul

Oct

No

v

De

c

Jan-

11

Ma

y

Sep Oct

Nov

Pe

rce

nta

ge

<90 90-94 95+Data up to 16 Mar 2011

Transmission Zone High Risk Zone Non-Transmission Zone

Routine Vaccination of AFP cases 6-23 Months by Region, 2007-Mar 2011 Afghanistan

0%

20%

40%

60%

80%

100%Y

07Y

08Y

09Y

10Y

11

Y07

Y08

Y09

Y10

Y11

Y07

Y08

Y09

Y10

Y11

Y07

Y08

Y09

Y10

Y11

Y07

Y08

Y09

Y10

Y11

Y07

Y08

Y09

Y10

Y11

Y07

Y08

Y09

Y10

Y11

Y07

Y08

Y09

Y10

Y11

3+ DOSES 2 DOSES 1 DOSE UNVACC

South+Farah SoutheastEast Central West North Northeast Badakhshan


Steps Taken: SIAs Activity Afghanistan 2010-11Feb-SNID Mar-NID May-NID Jun-Mop up + SNID

Jul-SNID Sep-Mop up Oct-NID Nov-NID Dec-SNID

tOPV mOPV1bOPV3 Not included

•Two rounds of NIDs with bOPV and two with tOPV conducted in 2010. Also 4 rounds of SNIDs with bOPV•Afghanistan introduced De-worming: Using house to house network of polio vaccination teams targeting 4.6 million children of age 2-5 years of age in October NIDs

Jan- Mop up

Feb-SNID Mar-NID May-NID Jun-SNID 2011

2010


Steps Taken at Strategy and Policy level , PEI Afghanistan 2010-11

At the strategy and policy level

• Policy and Dialog Group chaired by H.E Minister of Public Health Afghanistan, meeting regulalrly and discussing the policy and strategy issues.

• Informal consultative Group (ICG) mainly for 13 high priority districts. Chaired by DG preventive medicine. WHO and Unicef also member.

• Establishment of PIT for Joint planning, monitoring and resource sharing

• Integrating de worming with polio campaigns to increase demand for vaccination.

• H.E Minister of Public Health Signed MoU with ARCS on their involvement in PEI

Steps Taken : Access and Staff Safety, PEI Afghanistan

• Maintained close coordination with ICRC and assigned DSTs, DC through ICRC in selected districts

• Hiring Local Access Negotiators

• Keeping neutrality of the program

• Promote selection of local staff to be acceptable for community

• Coordination with ISAF and ANA

Overall trend of inaccessible children in number and %age Southern region 2009 & 2011

2009 2010-2011

Month Target # inaccessible % Month Target # inaccessible %

Jan 1249321 235794 19 Feb 1298495 126748 10

March 1249321 182786 15 March 1298495 90233 7

April 1249321 187442 15 May 1298495 82782 6

May 1249321 212784 17 June 1298495 80510 6

June 1249321 95078 8 July 1298495 82500 6

Jul 1249321 62912 5Oct 1298495 109563 8

sep 663290 30788 5 Nov 1298495 92763 7

Oct 1249321 147325 12 Dec 1298495 96986 7

Nov 1249321 105449 8Jan ,2011 1330742 72423 5.4

Dec 1249321 153220 12

Steps Taken: Improve Campaign Quality in 13 HRDs, Afghanistan

• District Specific Plans for all 13 HR districts completed in August, 2010 at Kandahar

• Strengthening District SIAs Management by assigning District Managers in all 13 Districts by September 1, 2010

• Capacity building trainings completed for key SIAs Staff in 13 high risk District in July 2010 by special training consultants.

• Maintain and expanding involvement of BPHS NGO as implementing partner in 4 districts of Farah and 2 districts of Kandahar in 2010.

Trend of Vaccination from May -2010 to Jan-2011 SIAs in 13 high risk districts of Southern Region, 2010, Afghanistan

(Coverage Adjusted for Inaccessible children)

Steps Taken: Cross border Coordination, PEI AfghanistanCovering the target children on the move crossing

border from Pakistan and Afghanistan

Permanent Vaccination Posts • Permanent posts vaccinated almost

around 1 mil <5 years old children in 2010

Returnees • Almost 8000 children of Returnees

are vaccinated in 2010

Nomads• Special Vaccination Teams and plans;

Almost 13500 children are vaccinated by South East region during June 2010 rounds

Coordination• Maintaining high level coordination

and SIAs are synchronized with Pakistan

Steps Taken in Non transmission zone, 2010 Afghanistan

Preparedness and response :

• Two rounds on Mop up in the North east and Balkh province of Northern region using mOPV1

• Establishment of 4

vaccination posts between the borders of AFG TAJ and one post with Uzbekistan

• Continue risk prediction analysis

• Strengthening AFP

surveillance Activity

Nov 10Districts >=95%

Districts 90-94%

Districts <90%

Range

FMBalkh Kunduz Takhar Badak

75-100 89-100 87-100 93-100

Range

FMBalkh Kunduz Takhar Badak

85-100 89-99 93-100 88-98Oct-10

Gornyi Badakhshan

KulyabSukhandariya

Kurgan-Tube

Districts of Republic Subordination

Dushanbe City

Balkh

Badakhshan

Baghlan

TakharKunduz

Uzbekistan Border

Tajikistan Border

Priorities and Plans 2011, PEI Afghanistan

• Priority 1: 13 High Risk Districts– Efforts of improve access (ICRC, NGOs, ARCS)

– High risk cluster approach

– SIADs and Accelerated EPI (CHW)

– Special communication plans

• Priority 2: Maintain PEI under difficult security situation– Continuation of sensitive surveillance

– Alternate ways of monitoring

– Window of opportunity

• Priority 3: Ensuring PEI services among underserved population– IDPs, Nomads, Returnees and other mobile groups

• Priority 4: Strengthening Community bases surveillance

• Priority 5: Preparedness and timely response

• Priority 6: New partnerships (ARCS, Animal Health) and advocacy

• Priority 7: Using PEI Network to Strengthen Routine EPI

THANK YOU

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