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Epidemiological update Polio Eradication Pakistan

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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Epidemiological update Polio Eradication Pakistan

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  1. Epidemiological update Polio Eradication Pakistan 17 September 2007

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. P1 Wild = 49 P3 Wild = 22 High Risk Variable Risk Security Risk Areas & Polio Cases 2006 Boundaries: District Provincial Country

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. < 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

  18. < 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

  19. 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

  20. 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

  21. WILD POLIO CASES 2006 Routine EPI Coverage in Children aged 11 to 23 months May-June 2006 Source: Contech International

  22. 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

  23. 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

  24. 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

  25. 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)

  26. 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

  27. 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

  28. 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

  29. 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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