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Epidemiological update Polio Eradication Pakistan. 17 September 2007. Population Density Map, Pakistan. 1 Dot = 20000 people. Rivers/Lakes. District’s Boundary Provincial Boundary. CHINA. FANA. Pakistan = 174.06** Punjab = 93.48 Sindh = 39.40

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slide2

Population Density Map, Pakistan

1 Dot = 20000 people

Rivers/Lakes

District’s Boundary

Provincial Boundary

CHINA

FANA

Pakistan = 174.06**

Punjab = 93.48

Sindh = 39.40

NWFP = 22.94

FATA = 3.82

Balochistan = 8.30

AJK = 3.57

FANA = 1.27

Islamabad = 1.27

**Population in millions

Peshawar

AJK

Islamabad

NWFP/

FATA

AFGHANISTAN

Gujranwala

Lahore

Quetta

Punjab

Faisalabad

Multan

Balochistan

BHARAT

IRAN

Larkana

Sindh

Districts with high Pop Density

Hyderabad

Karachi

ARABIAN SEA

background
Background
  • Polio eradication efforts started in 1994, six years after launch of Global PEI
  • Pakistan is making progress
    • Number of cases down from an estimated 20 - 30,000 per year to 40 in 2006 & 13 to date in 2007
    • Geographical & genetic restriction of polioviruses
  • Sharing of poliovirus between Pakistan & Afghanistan
    • Mainly in populations moving between 2 countries and border areas
    • Strong coordination & collaboration led by the political leadership of both countries
  • Consistently high quality SIAs (>95%) at provincial level
  • AFP surveillance system and laboratory are reaching the international standards
slide4

Wild cases from 1994-1996 are estimated

Polio trends and significant milestones 1994-2007

NIDs started

AFP Surveillance

House to house campaigns

No. of Cases

High risk focus

mOPV1 & New Algorithm

Years

Data as of 08-09-2007

slide5

Confirmed Polio Cases By Sero-type, 2002-2007*

Cases (n)

^

2002

2003

2004

2005

2006

2007

Months / Years

^ Data incomplete

SNID/ Mopup (18)

NSL3

NSL1

NID (30)

* Afp.rec Data as of 08-09-2007

zones of poliovirus transmission
Zones of Poliovirus Transmission

Case reported from Australia genetically linked with NWFP/FATA

2007

1997

2003

No. Zones = 02

No. Zones = 06

No. Zones = 09

No polio case from Punajb since July 2006 (52% of the country population)

No WPV1 from reservoir area of north Sindh since late 2005

No case from FANA since 1998, AJK - 2000 and Islamabad - 2003

Confirmed Cases = 1155

Districts Infected = 90

Confirmed Cases = 13

Districts Infected = 09

Confirmed Cases = 103

Districts Infected = 49

Boundaries:

Confirmed Polio Cases

District

Provincial

slide7

Afghanistan & Pakistan isolates by genetic cluster & TypeJan-Aug 2007

Case reported from Australia genetically related with NWFP/FATA viruses

A - 3A

A - 3D

B - 4A

B - 1C

Boundaries:

District

Provincial

Country

Last Update: September 11, 2007

slide8

Sharing of polio viruses between Pakistan and Afghanistan

B-4A

A-3A

A-3B

A-3C

A-3D

B-1C

B-1D

2007 cases

Boundaries:

District

Provincial

slide9

P1 Wild = 49

P3 Wild = 22

High Risk

Variable Risk

Security Risk Areas & Polio Cases 2006

Boundaries:

District

Provincial

Country

slide10

P1 Wild = 01

P1 Wild = 10

Case reported from Australia genetically related with NWFP/FATA viruses

P3 Wild = 11

High Risk

Variable Risk

Security Risk Areas & Polio Cases 2007

Boundaries:

District

Provincial

Country

slide11

IDPs due to security reasons

Across Border Movement

Nomads/Afghan Refugees

Movement

Seasonal Migrants

HIGHLY MOBILE POPULATION

MOVEMENT IN PAKISTAN WITH SURROUNDING PROVINCES OF AFGHANISTAN

0.2 million children vaccinated from mobile populations in August 2007

slide12

Highly Mobile Population Movement in Southern Punjab

Coming from Zhob Estimated population is 1000(Nom*) aprox. Staying for 2-4 months

Coming from DG Khan estimated population is 840(Nom*) / 6933(Afg**) stay for 1 month

Nom* = Nomads Children < 5 years

Afg** = Afghan Refugees Children < 5 years

Coming from Bhawalpur Estimated population is 586(Nom*) aprox. Duration of stay is 1-5 months

Security Compromised Areas

Coming from Rajanpur and further going to Sindh. When they return they follow same path.

In Southern Punjab Basically

nomads and Afghan Refugees are coming from

Loralai, Kohlu, Zhob,

Musakhel (Balochistan), Peshawar,

Dir and Swat (NWFP) and after staying they

are moving toward Sindh,

Mirpurkhas, Umerkot and Tando Allah Yaar

Rivers

District Boundaries

Tehsil Boundaries

slide13

NWFP

Coming from Peshawar NWFP passing through Multan, MGarh, Lodhran estimated population is 1182 (Nom*)/4200(Afg**) aprox. Staying for 2-5 months especially April than go to Sadiqabad (RY Khan)

Coming from Zhob Estimated population is 1000(Nom*) aprox. Staying for 3-6 months further moving from M garh, Multan to Bhawalpur

Coming from Kohlu, through Barkhan, DG Khan and B nagar than further going through MGarh to Bhawalpur their estimated population is 840(Nom*) / 6933(Afg**) stay for 1 month further go to Rajanpur and return from same way

Coming from Kohlu, through Barkhan, DG Khan and Bnaga than further going through MGarh to Bhawalpur their estimated population is 840(Nom*)/ 6933(Afg**) stay for 1 month further go to Rajanpur and return from same way

Coming from Loralai, NWFP through DG Khan Estimated population is 586(Nom*) aprox. Duration of stay is 1-9 months Further take move to Sindh Umerkot

Coming from Balochistan and NWFP Estimated population is 3889(Nom*)/7000(Afg**) aprox. Staying for 2-3 months and go to Rajanpur

Coming from Loralai, NWFP through DG Khan Estimated population is 586(Nom*) aprox. Duration of stay is 1-9 months Further take move to Sindh Umerkot

Coming from Loralai, NWFP through DG Khan Estimated population is 586(Nom*) aprox. Duration of stay is 1-9 months Further take move to Sindh Umerkot

Estimated population is 3889(Nom*)/7000(Afg**) aprox. Staying for 2-3 months and go to Rajanpur

Coming from Rajanpur and further going to Sindh (Mirpurkhas, Umerkot, Tando Allah Yaar). When they return they follow same path.

Highly Mobile Population Movement

in Southern Punjab

Nom* = Nomads Children < 5 years

Afg** = Afghan Refugees Children < 5 years

Security Compromised Areas

In Southern Punjab Basically

nomads and Afghan Refugees are coming from

Loralai, Kohlu, Zhob,

Musakhel (Balochistan), Peshawar,

Dir and Swat (NWFP) and after staying they

are moving toward Sindh,

Mirpurkhas, Umerkot and Tando Allah Yaar

Rivers

District Boundaries

Tehsil Boundaries

significant epidemiological characteristics of wild polio cases pakistan 2006 07
Significant Epidemiological Characteristicsof Wild Polio Cases, Pakistan 2006-07*
  • There is significant shift in the age group of the cases
    • 46% cases > 35 months in 2007 compared to 10% in 2006
    • However, 46% of the cases < 12 months in 2007
    • The first ever reported adult case 22 years old.
  • Children from poor, illiterate families are at higher risk
    • 79% (42) cases from poor families
    • 92% (49) cases’ father & 96% (51) cases’ mother having no formal education
    • 66% (35) cases are living in multiple family dwellings
  • Majority of cases are from rural and urban slum areas
    • 66% (35) cases from rural areas
    • 30% (16) cases from urban slum

*Data as of 13/9/2007;

Total cases - 53

significant epidemiological characteristics of polio cases pakistan 2006 07
Significant Epidemiological Characteristicsof Polio Cases, Pakistan 2006-07*
  • Afghan Refugees are at high risk
    • 13% (7 of the provincial total) cases in NWFP/FATA are Afghan Refugees (ARs - 7% of total population in NWFP/FATA)
  • 57% (30) cases are Pashto speaking (13% of total population in the country)
    • 2 P1 cases of Karachi in 2007 Pashto speaking
  • 58% (31) cases have received ≥ 6 OPV doses
  • 53% (28) cases are males
  • 38% (5) cases have atypical clinical manifestation

*Data as of 13/9/2007;

Total cases - 53

the first adult polio case
The first adult polio case
  • WPV1 reported from Australia
    • 22 year old person spent his whole life in Pakistan until Jan’07
    • From an affluent family, good standard of living
    • Had shingles while in Australia in February 2007
    • Seen by 2 physicians in Pakistan; treated for G.E.
  • Onset in home district Gujrat with history of visit to NWFP in incubation period (3 overnights stay)
  • District Gujrat without polio case since 1997 and Swat since 2003
  • Genetic data shows that WPV1 isolated from case related with viruses circulating in NWFP/FATA and neighboring eastern region
    • The genetic cluster restricted in the above transmission zone
    • Only once reported outside, Karachi – 2003
  • Few issues
    • WPV circulating in healthy adults who are one of sources of transmission – importation
    • Reinforces AFP case definition
slide17

< 95 %

 95 %

SIA Coverage of under 5 years children

Jan 07

Apr 07

Aug 07

S. Wazirstan & Tank - consistently suboptimal coverage; known security issues

No Campaign

Jun 07

Feb 07

May 07

Mar 07

Boundaries:

District

Provincial

slide18

< 95 %

 95 %

SIA Coverage of under 6 months children

Jan 07

Apr 07

Aug 07

No Campaign

Consistently children below 6 months in areas bordering Afghanistan have sub optimal coverage

Feb 07

Mar 07

May 07

Jun 07

May 07

Boundaries:

District

Provincial

slide19

Coverage of High Risk Groups, Jacobabad,

Nov06-Aug07 Rounds

1 missed area

All unvaccinated children recorded & revisited

Miscellaneous: *Religious groups/new residential areas, ** Market area, *** Slum areas

slide20

0 DOSE

4 TO 6

7 +

1 TO 2

3

Vaccination status of ^Non-Polio AFP cases aged 6 - <36 months 2005 to 2007* (Base populationMay 2007 round areas)

Sindh

FATA

Balochistan

Punjab

NWFP

Cases (%)

* Data as of 08-09-2007

^ Including AFP Cases pending for classification

slide21

WILD POLIO CASES 2006

Routine EPI Coverage in Children aged 11 to 23 months May-June 2006

Source: Contech International

pakistan afghanistan cross border coordination
Pakistan-Afghanistan Cross Border Coordination
  • Immediate cross notification of cases
  • Joint risk analysis and planning
  • Synchronized SIAs
  • Mapping of Nomadic population
  • Regular provincial level coordination meeting
  • 9 additional cross border vaccination posts
  • 52500 children vaccinated each month
slide23

16-18

14-16

20-22

27-29

25-27

24-26

22-24

22-24

19-21

17-19

7-9

24-26

5-7

30 Oct -1 Nov

19-21

11-13

28-30

9-11

Synchronized SIAs Pakistan & Afghanistan - 2007

Pakistan

Afghanistan

18-20

NIDs

SNIDs

measles sias
Measles SIAs
  • 21,000 deaths and 21 million cases annually
  • The largest campaign targeting 63 million children aged 9 months to 13 years
    • 5 phases, 3 completed
  • OPV as ‘add on’ in high risk areas – greater acceptance (75% refusals in Bajour given OPV)
  • Polio infrastructure supporting measles activities
  • Overall high coverage has been reported
pei infrastructure epi 1
PEI Infrastructure & EPI - 1
  • Supporting measles and NNT surveillance through weekly active surveillance visits
    • Measles outbreak investigations
  • Improving service delivery for RI through SIAs monitoring
    • Improve micro planning & vaccine management
    • Registration of zero dose infants during SIAs
    • Using standardized checklist in selected districts
  • January 2007 Peshawar - 2851 children 6-24 months checked by CSPs for routine EPI Status (82% OPV3)
pei infrastructure epi 2
PEI Infrastructure & EPI - 2
  • Mohmand – special campaigns for routine in refusal areas (1300 children vaccinated)
  • 10% improvement in RI coverage in 3 districts of north Sindh due to tracing zero dose routine
  • Punjab: defaulter tracing during catch up
  • Supporting national public health emergencies
    • 2005 earthquake, 2007 floods & Avian Influenza
  • Facilitating research activities
    • Sentinel surveillance for bacterial meningitis
the way forward
The Way Forward
  • Continued focus on high risk areas
    • Interruption of WPV transmission in the 2 remaining transmission zones
    • Rapid & effective response to any WPV outside 2 transmission zones
  • Maintaining high general population protection through quality vaccination and surveillance activities
  • Sustaining communications activities
  • Improving routine immunization and optimizing experience of PEI
slide29

WPV1 case reported from Australia genetically related with viruses in NWFP/FATA

Expected Scenario for 2008 based on current WPV Epidemiology*

Peshawar27-06-2007

Nasirabad27-03-2007

Transmission Zone

Jacobabad13-05-2007

NSL1

NSL3

Compatible

Boundaries:

District

Provincial

*Data as of 20-08-2007

summary
Summary
  • Epidemiological & virological data shows Pakistan is close to interrupting virus transmission
  • Accessing populations living in security compromised areas & highly mobile populations are major challenges
  • Efforts being made to ensure consistently high quality vaccination activities
  • Polio infrastructure & approaches are being used for strengthening routine EPI
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