Report on the Meeting of the Technical Advisory Group for the Eradication of Poliomyelitis in Afghanistan [May 2018]

This report summarises the discussions of the Technical Advisory Group (TAG) on Poliomyelitis Eradication in Afghanistan, May 30-31 2018 in Kabul. The objectives of the meeting were to: (i) review the status of polio eradication efforts, key challenges, and the way forward in Northern, Central, and Southern corridors; and (ii) make recommendations to overcome remaining obstacles in polio eradication in Afghanistan.

Globally, there has been significant progress - with the number of polio cases decreasing from 37 in 2016 to 22 in 2017. However, transmission of wild poliovirus (WPV) in Afghanistan's Northern and Southern transmission corridors has not been interrupted. At the time of TAG meeting, Afghanistan had reported 8 polio cases and 18 WPV type 1 (WPV1) positive environmental samples in 2018. Despite evidence of overall progress in reaching more children with immunisation, 6 of the 8 polio cases in 2018 had never been reached with polio vaccine. This shows that children are still being missed due to inaccessibility, continuing challenges in programme quality in both accessible and access-compromised areas, and clusters of refusals with the backdrop of low routine immunisation coverage in many high-risk areas. Along these lines, the TAG is very worried about recent bans by local authorities on house-to-house vaccination activities in large parts of Southern Region and the possibility of those bans expanding further.

There are reasons to be hopeful. The TAG appreciates the good progress made by the programme in Afghanistan despite all the challenges, particularly in improving the quality of campaigns in key areas. If accessibility improves and can be sustained, the programme is on the right track to achieve the goal of stopping transmission in Afghanistan. The reasons for continuing transmission are understood by the programme, and clear plans are in place to address gaps.

Some findings specific to advocacy and communication issues:

• The TAG feels that the highest level of the government remains committed, and the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the wider UN are fully committed and provide strong support to the Polio Eradication Initiative (PEI). The TAG also appreciates the establishment of new forums - i.e., Polio Executive Committee and Polio Policy Dialogue - to enhance coordination and information sharing between the government and implementing partners, and between implementing partners and the broader donor and partner community.
• The TAG notes that a range of activities are being undertaken to enhance vaccine acceptance, and the social data that the programme is collecting show that communications and social mobilisation activities are having a positive impact in many areas. However, more needs to be done to track impact of interventions on campaign quality, attitudes at household and community level, and rates of missed children and refusals.

Looking at the overall challenges, the Afghanistan programme proposed the following as a way forward to the TAG:

• Continued implementation of National Emergency Action Plan (NEAP) 2018 and tracking from national level on monthly basis.
• Intensification of dialogue with concerned parties at all levels, leveraging support of other agencies like the International Committee of the Red Cross (ICRC) for gaining full access and implementation of the NEAP.
• Close tracking of implementation of Northern and Southern corridor action plans in coordination with Pakistan.
• Pursuite of a cluster approach to address refusals, enhancing the engagement of appropriate influencers.
• Deployment of National Emergency Operations Centre (NEOC) focal points to oversee and support implementation in high-risk areas/ blind spots.

The TAG made the following recommendations:

1. Conduct a mid-term review of progress in implementing the 2018 NEAP and take corrective actions to address any identified gaps.
2. Fully implement the Northern and Southern Corridor action plans and jointly track status by the Afghanistan and Pakistan NEOCs through monthly video conferences. (A further face-to-face meeting on the common reservoirs should take place in the third quarter of 2018.)
3. Urgently undertake advocacy to gain house-to-house access to areas where restrictions on immunisation activity are being imposed.
4. Emphasise regular assessment of planning and functioning of permanent transit teams (PTTs) and cross-border teams (CBTs) to ensure that no opportunity is missed for vaccinating children on the move.
5. Assess the impact of initiatives under the 2018 NEAP and corridor action plans aimed at ensuring that all children are consistently reached with vaccine, and document and share the results of this assessment with TAG members by August 2018.
6. Implement a focused and cluster-specific approach for addressing missed children, informed by data being collected, including by the Immunization Communications Network (ICN).
7. Systematically document and analyse polio cases, positive environmental samples, and zero-dose and under-immunised acute flaccid paralysis (AFP) cases to identify key gaps in the programme, and use this information for corrective action.
8. Implement plans to intensify routine immunisation in the 29 focus districts as quickly as possible, based on the joint PEI-Expanded Programme on Immunization (EPI) accountability framework with indicators to monitor progress.