Article on Polio

PREVALENCE AND CONTROL OF POLIO MYELITIS IN PAKISTAN

Prof. Dr. K.A.Karamat1

Introduction

Tremendous progress has been made in the global fight against polio since 1988,

when the World Health Assembly resolved to eradicate the disease. The number of polio

cases worldwide has decreased from 350,000 in 1988, to 784 cases in 2003. Three-

quarters of all cases globally are linked to a handful of polio hot spots in Nigeria,

Pakistan, Afghanistan and India. After about twenty years effort that has galvanized more

than 200 countries, 20 million volunteers, and an international investment of US$3

billion, the success or failure of the Global Polio Eradication Initiative, the worlds

largest public health campaign, is now within reach. Never before has the world been so

close to success, with only four countries remaining polio-endemic.

Ministry of Health (Pakistan) started National Immunization Days (NID) during

1994 to join the global Polio Eradication (PE) efforts. In the beginning, every year, 2

rounds of nation wide campaign (National Immunization Days or NIDs) were carried out

to give Polio drops to all children below 5 years of age. Almost a workforce of 500,000

including volunteers, apart from health staff, remain busy in this national effort. Since

1998 the strategy has been slightly modified i.e. (i) instead of fixed points the health

teams make house to house visits to give polio drops to children under 5 years of age and

(ii) instead of one day, the campaign is extended over 3-4 days. Apart from NIDS, the

campaign of Polio Eradication is being strengthened through; Sub-national Immunization

Days (SNIDs) in high-risk areas/districts; (ii) mopping-up campaign whenever/wherever

a case of Polio/Acute Flaccid Paralysis (AFP) is detected; and (iii) cross border Polio

vaccination with Afghanistan. In 2008, the world has its best and perhaps last chance

to stop polio forever. There is a historic, one-time only opportunity to stop transmission

1 Senior Consultant (Health) Planning Commission

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of poliovirus. If the world seizes this opportunity and acts immediately, no child will ever

again know the crippling effects of this devastating disease.

Polio in Pakistan Hundreds of cases used to occur in the past but by intensive vaccination the

number of cases was brought down to 53 in the year 2004-2005 and to 28 in 2005-2006

because a lot of stress was given to routine immunization, sense of ownership, strict

surveillance and accountability. Two fresh cases of polio virus detected this month (June

2008), one in Kohat and the other in Karachi- have once again highlighted the two main

reasons why the country continues to miss out on attaining the elusive polio-free status.

The victims have no history of routine immunization and the case detected in Karachi

belongs to a migrant family having come from South Waziristan.[2]. Fifteen cases have

been reported till June 2008. Five of these cases were among children under 2 years, 4

cases were among children between 2 years and 5 years and the remaining 5 cases were

in children aged 5 years and over. Only 2 cases had received 3 routine doses. However,

11 of them had received 7 or more doses and 2 were refusals and had received zero doses.

Ten cases are from Sindh, 3 from NWFP and 2 from Balochistan. The upsurge in Sindh is

attributable to weak routine immunization and failure to improve the service delivery, as

indicated by the fact that 42% of the children were due to no teams going to their houses,

a rate which is more than double that in any other province in Pakistan. There is a need to

establish a polio eradication emergency cell and activate the provincial steering

committee, as well as to create accountability and oversight system, not only in Sindh but

also in other provinces.

No. of cases of polio reported in 2008 is at Annex-A and those up to 2007 are at

Annex-B.

Poliovirus Epidemiology - 2008 The majority of population in Pakistan continues to live in areas without polio

cases. Of the 15 confirmed polio cases, there are 13 type- 1 and 2 type-3 cases this year.

It is important to highlight that 10 out of 13 type 1 cases are from Sindh province and one

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from NWFP and two from Balochistan. The two type-3 cases are localized in Nowshera

district of NWFP.

There are 14 districts to date in 2008 that had polio cases. Of note is that 67% of

districts this year did not have a case last year. Karachi, Nowshera, Killa Abdullah and

Jacobabad districts had confirmed polio cases in both 2008 and 2007. These four districts

have been included in all targeted supplementary immunization activities in 2007 and

2008 and the presence of cases this year indicates gaps in the quality of vaccination

activities (Annex-D).

More than half of the newly infected districts in 2008 are outside the known

transmission zones. This reinforces the fact that all polio-free areas remain at risk until

endemic circulation is interrupted with high general population immunity through routine

immunization and SIAs. Of concern is the fact that a common feature among the cases in

these new districts is that routine immunization coverage is often far below (0% to 72%)

of the target range (Annex E&G).

Epidemiological and genetic data confirms endemic circulation of type-1 virus in

Sindh, NWFP and Balochistan, though circulation appears to be restricted in NWFP and

Balochistan to the central and north-western areas respectively. However, this also

reinforces the fact that there continue to be performance gaps in vaccination activities.

There are a few isolates which have long limbs on the genetic tree (Kila Abdullah,

Nawab Shah & Kohat, for instance), indicating potential gaps in surveillance sensitivity.

Both type-3 cases are related with each other and are genetically linked to cases in

southern Afghanistan. In Afghanistan, endemic circulation is largely restricted to the

southern region of Afghanistan, where both virus sero-types are present. However, a

recent type-3 case in the eastern region shows extension of P3 circulation from the

southern region to this area. This is relevant, given the sharing of virus between southern

Afghanistan and Pakistan.

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The epidemiological profile of cases shows:

Majority of cases are young children aged below 3 years (56%) though a shift to older children is observed (43% > 35 months in 2008 compared to 10% in 2006 &

34% in 2007);

Majority of cases (12/14; 86%) had OPV doses. Only 2(14%) cases are zero dose (\due to refusal of parents);

Only 2(14%) cases had 3 routine OPV doses;

89% are from low social-economic backgrounds and 70% have illiterate parents.

70% live in urban slums or large rural populations;

79% live in multi-family dwellings;

71% had history of injection and

43% of cases had first contact with an informal health care provider.

Vaccination monitoring data shows that operational issues continue to exist in

Sindh and Balochistan largely due to lack of accountability. Though the access issues

persist in parts of NWFP and FATA, the appearance of cases in accessible areas

highlights gaps in vaccination activities.

High quality vaccination activities at union council and local levels through

improving SIAs and routine EPI activities are vital for interrupting poliovirus circulation.

SNIDs in high risk areas were organized from 10-12 June 2008 using mOPV1

An emergency Technical Consultation Meeting was held on 24-25 June 2008 in Karachi mainly focusing on Sindh

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The Federal Health Minister and National Assembly reiterated commitment to stop polio & expressed concern on recent surge of polio cases

Virus isolation Isolation and identification of poliovirus from the faeces is the best current

method to confirm the diagnosis of poliomyelitis. WHO, in collaboration with several

other institutions, has developed a global network of laboratories to provide this service.

Molecular techniques are available to characterize fully the poliovirus. Maintaining a

reference bank of the molecular structure of known viruses allows the geographic origin

of new isolates to be traced. When countries are polio-free or almost polio-free, it is

necessary to determine whether the virus was imported or indigenous. The laboratory will

also determine whether isolated viruses are wild or vaccine-like.

The laboratory network will play a key role in certification of polio eradication by

verifying the absence of wild poliovirus circulation. In addition to AFP surveillance, this

may include stool surveys of healthy children in high risk areas and environmental

surveillance. The laboratory network can perform potency tests on polio vaccine if

circumstances indicate possible failure. In selected situations, a laboratory might

participate in epidemiologic serosurveys if knowledge of the antibody status of the

population is important.

Polio Vaccines

Polio vaccines are one of the greatest medical success stories of the 20th century.

Before polio vaccines were developed, no illness inspired more dread and outright panic

than polio did. Sometimes called infantile paralysis, polio struck the nation every summer

and fall with increasingly virulent epidemics. By the mid-1950s mass immunizations

began to slow polio's spread. In 1979, the last case of natural, or "wild-type" polio,

occurred in the United States.

Even though polio has been eradicated from the US and the Western Hemisphere,

it still afflicts children and adults in other parts of the world. A single infection brought

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into the US by someone from a country where polio still persists could possibly lead to

polio epidemics again if we were not protected. That is why we continue to vaccinate.

There are two types of polio vaccine: 1) trivalent oral (live, attenuated) polio

vaccine (OPV) and 2), inactivated or killed polio vaccine (IPV).Trivalent oral polio

vaccine consists of live, attenuated polioviruses, and is a safe and effective vaccine.

Although in 2005 it was claimed that the type-2 and type-3 viruses are almost eradicated,

so single virus vaccine (Monovalent) for type-1 virus was used in some rounds. However

it is clear from the data (Annex-A) that the type-3 virus is still rampant. According to

estimates, more than 32 million children are vaccinated in each round. The estimated cost

of Polio Vaccine is almost US$ 30 million annually (This used to be met through grants

by donors but they have stopped it now).Distribution of OPV for the year 2007-08 is at

Annexure C. The special procurement of Monovalent vaccine needs reconsideration as

the Trivalent vaccine is effective against all the three types of polio virus.

Vaccination is the best way to prevent polio.

Today, most children in the US receive 4 doses (injections) of inactivated polio

vaccine (IPV) according to the following schedule:

2 months old 4 months old Between 6 and 18 months A booster between 4 and 6 years

IPV is 90% effective after 2 doses and 99% effective after 3 doses. Because the

vaccine contains inactivated (killed) poliovirus, it cannot cause polio. The most common

side effects are pain, swelling, or redness at the injection site; fever, loss of appetite,

fussiness and drowsiness. Most adults do not need the polio vaccine because they were

vaccinated as children. But there are 3 groups of adults who should consider vaccination

because they are at higher risk than the general adult population.

People who are traveling to areas of the world where polio still commonly occurs

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Laboratory workers who might handle poliovirus Health-care workers treating patients who may have polio

IPOL (Poliovirus Vaccine Inactivated) is given to infants (as young as 6 weeks of

age), children, and adults to prevent polio caused by poliovirus Types 1, 2, and 3. As with

any vaccine, vaccination with IPOL vaccine may not protect 100% of individuals. There

are risks associated with all vaccines. IPOL vaccine should not be given to persons who

have had a serious allergic reaction after a previous dose of the vaccine. When

administering an intramuscular injection, like IPOL vaccine, in people with bleeding

disorders, caution should be exercised because they may develop a serious bruise or

collection of blood at the injection site.

If the world is to secure its twenty years investment in polio eradication, and

protect all children from the threat of this disease, each and every child under five must

be reached with polio vaccine during upcoming campaigns in the key endemic countries.

OPV is the vaccine recommended by WHO for polio eradication WHO currently recommends a formulation of trivalent OPV for types 1,2, and 3,

respectively, for both routine and supplementary immunization. Three doses of OPV will

protect at least 80-85% of immunized children from paralytic disease. Lower levels of

immunity, especially for type 3, may occur in developing countries, particularly if OPV is

administered during the rainy season.

OPV is given by mouth and its cost is low. The vaccine produces both intestinal and

serologic immunity. As a result, children immunized with OPV are unlikely to spread

wild polio virus to other children. When administered during a mass campaign, OPV can

interrupt wild poliovirus transmission in the community. A disadvantage of OPV is that,

for every 10 million doses administered, approximately 3 children will experience

vaccine-associated paralytic polio.

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Inactivated or killed polio vaccine (IPV)

Inactivated polio vaccine prevents paralytic polio by producing sufficient

antibodies in the serum to prevent the poliovirus from entering the nervous system. IPV

poses no risk of vaccine-associated paralysis. However, compared to OPV, it produces

lower levels of intestinal immunity. Consequently, a person immunized with IPV is more

likely to spread wild polio virus to other children, compared to a person immunized with

OPV. IPV is more expensive than OPV, must be injected by trained personnel, and

requires additional equipment and supplies.

Vaccine schedule WHO currently recommends that children receive four doses of OPV before one

year of age. In endemic countries, a dose should be given at birth or as close to birth as

possible. This is called the birth dose, or zero dose. The other three doses should be

given at least four weeks apart and usually at the same time as DPT. If the zero dose is

not given, then a fourth dose of OPV should be given at least one month after the third

one, for example at the time of measles immunization. One dose of OPV from most

manufacturers consists of 2 drops of vaccine administered directly into the mouth.

Contraindications Children with congenital immune deficiencies, or who are iatrogenically

Immunocompromised (e.g. cancer patients) should receive IPV. Otherwise there are no

contraindications for administration of OPV. If OPV is given to a child with diarrhoea,

the dose should be repeated one month later.

Vaccine storage and transport OPV is the least stable of the EPI vaccines. It can loose potency if exposed to

temperatures above 8C. Storage at temperatures below -15C halts deterioration in

vaccine potency. OPV should preferably be kept in a freezer (below -15C) at central and

regional levels. OPV can be kept in a refrigerator (between 0C and 8C) at district and

health centre levels, except when distribution is not imminent, in which case it should be

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stored in a freezer (below -15C), if possible. The shelf life (i.e. expiry date) indicated on

the OPV vaccine vials is valid for storage in freezers (below -15C). OPV can however

be kept up to 12 months in refrigerators (between 0C and 8C). Repeated freezing and

thawing does not affect the titre of the vaccine.

The vaccine vial monitor Since the beginning of 1996, all vials of Oral Polio Vaccine procured through

UNICEF come with a Vaccine Vial Monitor (VVM). This heat sensitive label gradually

and irreversibly changes colour as the vaccine is exposed to heat. It warns the health

worker when a vial of OPV should be discarded because the vaccine is likely to have

been degraded by exposure to heat.

The Global Polio Eradication Initiative

The Global Polio Eradication Initiative is spearheaded by WHO, Rotary International, CDC and UNICEF. It includes:

- governments of countries affected by polio

- private foundations (e.g. the United Nations Foundation, the Bill & Melinda Gates

Foundation)

- development banks (e.g. the World Bank)

- donor governments (e.g. Australia, Austria, Belgium, Canada, Denmark, Finland,

Germany, Ireland, Italy, Japan, Luxembourg, the Netherlands, New Zealand, Norway,

the United Kingdom, and the United States of America)

- the European Commission

- humanitarian and nongovernmental organizations (e.g. the International Red Cross and

Red Crescent societies)

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- corporate partners (e.g. Aventis Pasteur)

- volunteers in developing countries.

From 1988-2005, an estimated 5 million people who would otherwise have been

paralysed are walking because of the Global Polio Eradication Initiative. Through polio

eradication efforts, a significant investment has been made in strengthening health service

delivery systems in many countries. Hundreds of thousands of health workers have been

trained, millions of volunteers have been mobilized to support immunization campaigns,

and cold-chain transport equipment has been refurbished.

The final push: finishing the job

If polio is to be eradicated, each and every child must be vaccinated against polio during upcoming immunization programs in the remaining polio-endemic

countries. Never before has so much commitment and effort been focused on this

final push to rid the world of polio forever

Pakistan Polio Eradication Initiative (PEI) is a high priority public health programme

of the Government of Pakistan, which is fully committed to the goal of Global Polio

Eradication. Pakistan has adopted the globally recommended four key strategies for PEI

that include establishing a sensitive surveillance system, holding National Immunization

Days (NIDs), mop-up campaigns in the terminal phases and strengthening EPI. Pakistan

began holding annual two-round (NIDs) in 1994. Surveillance for acute flaccid paralysis

(AFP) - was initiated in 1995 and by 1999 Pakistan was meeting global targets for several

key indicators of surveillance quality.

In 2000, to strengthen the quality of surveillance in problem districts, and to assist

districts in planning and implementing immunization campaigns WHO hired additional

surveillance officers. Now Pakistan has a well-established surveillance system involving

pediatricians, clinicians, field surveillance officers and the polio laboratory. Through

intensive efforts of all the AFP surveillance system has made rapid progress in the last

two years and has reached the global certification standards at national, provincial and

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district level. Surveillance is providing a clear epidemiological understanding of

poliovirus transmission, high-risk populations, reservoir districts and hence driving the

program decisions.

Active surveillance Active surveillance started in September 2001. Prioritized sites are visited weekly

and others on monthly basis. Surveillance Officers both from the Government and WHO

in all provinces got training and then the process started with an incremental approach

from the populous districts expanding to the other districts. Weekly visits are maintained

to all sites where AFP cases may present for treatment/rehabilitation in the prioritized

districts. Active case finding is carried out by searching through indoor and outdoor

records especially of the Pediatric and Neurology departments. Liaison with pediatrician

at the hospital is strengthened and also feedback is given to them on previously reported

cases.

Community Based Case reporting by involving the PHC Workers Lady Health Workers (LHWs), are Primary Health Care (PHC) workers, based in

the communities who have started to report AFP cases to the surveillance system. The

catchment area of every LHW is 200 houses having a population of about 1000

individuals. Presently there are 95000 LHWs in Pakistan with a proportion of 40 to 60 for

urban to rural areas. Government has planned to expand this program to cover the whole

country with 200,000 LHWs in a phased manner. Guidelines for LHWs and trainers (in

Urdu) and reporting instruments have been developed. A special referral slip with a red

line on the top has been designed for LHWs to refer the AFP case to the nearest Health

Facility, which would immediately inform the E.D.O, Health for notification and

necessary case response activities.

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Strengthening Routine Immunization

High routine immunization coverage of infants with at least three doses of oral

polio vaccine (OPV) is one of the basic strategies of polio eradication. Regional

coverage of infants with at least three doses of oral polio vaccine (OPV3) has remained

around 80 % for the past few years. However coverage level of less then 80% occurred in

Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen- the endemic countries and

those in which importation resulted in epidemics.

High routine immunization coverage is crucial for maintaining polio-free status

after successful eradication. The epidemic resulting from importation in Somalia, Sudan,

and Yemen compared with the sporadic cases that followed importations in other

countries, like the Islamic Republic of Iran, Saudi Arabia and Syrian Arab Republic,

highlights the importance of maintaining high routine coverage.

The Regional polio eradication initiative continues to emphasize the need to maintain

high coverage and has contributed in a number of ways to strengthening routine

immunization.

All poliomyelitis eradication staff is involved in the strengthening of routine

immunization and in surveillance of vaccine-preventable disease.

A substantial amount of poliomyelitis eradication resources have been utilized for strengthening the physical infrastructure for routine immunization.

The strategic planning process introduced for poliomyelitis eradication activities, and the lesson learned from it, have been used in other initiatives in support of

routine immunization services, such as in the process of application from support

from the Global Alliance for Vaccine and Immunization (GAVI).

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Routine immunization has benefited from poliomyelitis eradication efforts in other areas, such as in programme management, improved coordination and

enhancement of political awareness and support.

Action Taken Government of Pakistan has taken a strong notice of the rise in polio cases in

Pakistan. The Minister of Health emphasized that a system of proper screening and

efficient selection of polio teams be strictly enforced to ensure an effective

implementation of the programme. The government will make maximum efforts to

achieve the target of a polio-free Pakistan in the shortest possible time. Over 80,000

teams are spread out across the country, carrying out the task. During the last National

Immunization Drive, camps were set up at toll plazas across Pakistan, leading to

successful immunization of over 32,000 children. A comprehensive mechanism devised

jointly with the WHO is in place to counter cross-border transmission of the polio virus.

Polio currently exists only in Asia (Afghanistan, India, and Pakistan) and Africa

(primarily Nigeria). In 2006, there were 1,906 cases of polio in 16 countries, according to

the global polio Eradication initiative. Many organizations have been working hard

toward eradicating polio including WHO, United Nations Childrens Fund (UNICEF),

the Centre for Diseases Control and Prevention (CDC), Rotary international, and many

other international and national groups. Strategies include house-to-house vaccination on

National Immunization Days, and a strong committed highest percentage of routine

immunization against seven killer diseases including Polio vaccination. [3]

Routine Immunization in Sindh

Targets of EPI in Sindh are to reach 90% routine coverage and eliminate neonatal tetanus

by 2008. With regard to routine coverage, the reported provincial coverage rate with 3

OPV doses decreased from 78% in 2006 to 72% in 2007 and was only 70% in the first 5

months of 2008. There are significant variations in coverage between districts, with some

of them reporting coverage rates less than 5% while others reach 94% with the majority

around 70%.

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The challenges facing promotion of routine immunization include lack of public

demand and the fact that a third of existing health facilities are without EPI centres. Lack

of accountability at all levels, shortage of vehicles and vaccinators and frequent transfer

of EDOs and THOs are also major challenges.

Communication Initiatives in Sindh There are five main challenges for cessation of circulation of polio in Sindh: lack

of sustained political commitment; high-risk and hard-to-reach populations; inadequate

interpersonal communication skills of teams; gaps in service delivery; and low level of

population awareness. A number of actions have been taken to address these constraints.

There is increasing political commitment as evidenced by awareness and inauguration of

activities by senior officials. Social mapping of districts in Sindh has helped greatly in

reaching high risk areas and cooperation with traffic police has assisted in covering target

children on the move. Interpersonal communication skills were improved through team

training, which has led to reduction in the proportion of missed children from one round

to the other. The efforts to improve service delivery through involving medical and

nursing students in campaigns and achieving support of Pediatric Associations have

resulted in accessing some of the persistently difficult to reach communities such as the

Agha Khan communities during campaigns. Efforts are ongoing to improve community

awareness including recruitment of communication officers, enhanced cooperation with

the media and involvement of religious leaders.

Reaching Inaccessible Population in NWFP

There are a number of inaccessible population and security-compromised areas in

NWFP/FATA along the borders with Afghanistan and in the district of Swat. A

multiplicity of initiatives and methods have been used to facilitate vaccination of children

in these areas, including inclusion of polio eradication efforts in peace agreements,

holding special jirgas, communication with tribal and religious leaders, use of local

vaccinators and supervisors, using every possible opportunity to vaccinate children,

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establishment of vaccination posts at the border crossings with Afghanistan and close

coordination between the two countries to reach children by the most accessible route,

and the principle adopted by the team of not giving up until all the targeted children are

vaccinated. These strategies have resulted in continued reduction in the proportion of

inaccessible children in NWFP. Advocacy efforts have been successful in obtaining the

support of religious leaders. As well, media are now strongly supporting eradication.

Meeting the Challenges in Punjab

The challenges in polio-free Punjab are different than those in other provinces

with viral circulation. The main challenge is to maintain strong political commitment and

good quality surveillance, as well as maintain high population immunity through

strengthening routine immunization, especially in areas with low routine immunization,

and conducting at least 4 rounds of supplementary immunization activities of good

quality. Several initiatives are ongoing in Punjab such as the polio card and the strong

partnership with the education department, which has boosted effective social

mobilization, as well as implementation of an active method for detecting missed

children.

Campaign and Surveillance Quality in Balochistan Balochistan province is the least populous and has large areas with a scattered population.

Surveillance data indicate that K. Abdullah and Pischine remain P3 reservoirs, and

circulating viruses are linked with the viruses in southern Afghanistan. With regard to

campaign quality, the gap between finger-marking and recall data is closing. However,

there are still several union councils in Pischine and K. Abdullah where coverage is low

The reasons for slow progress in polio eradication efforts in Balochistan include: serious

management issues in some districts such as K. Abdullah; significant pockets of refusals

which remain uncovered after supplementary immunization activities, especially in

endemic areas; and performance gaps. As an example, during the past 6 months the

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Secretary Health has changed four times and the province has been without a Director

General Health since February 2008.

Cross Border Transmission Pakistan-Afghanistan Block has emerged as a single poliovirus reservoir sharing the

poliovirus lineages. Continuous movement of people and poliovirus with them, back and

forth across border has necessitated close coordination and collaboration between the two

countries.

Information is shared regularly between Pakistan and Afghanistan programs by email,

telephone and frequent meetings. Surveillance data is shared on weekly basis through

electronic mail.

Emergency preparedness plan for the influx of Afghan Refugees was prepared at the

country level due to war in Afghanistan. AFP surveillance for the Afghan Refugees is

incorporated in the plan.

Campaign dates in the two countries are synchronized. Permanent fixed vaccination

posts have been established at the entry/exit points on borders.

Organization of AFP Surveillance includes the establishment of National Surveillance

Cell (NS CELL) with the provincial desks in Islamabad to coordinate the AFP

surveillance activities at the National level. NS CELL is carrying out core functions

(detection, confirmation, analysis, response) and support functions (training, supervision,

communication, resource management). Four provincial desks have been created in the

cell looking after all the four provinces, AJK and FANA. WHO has also recruited

Surveillance Officers (SOs) at the district level. The job of these field officers is to

establish active Surveillance both in public and private sector health facilities for AFP

cases by frequently visiting hospitals, rehab centers, GPs pediatricians and community

leaders. Their work is also to ensure the quality of the data.

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COLD CHAIN & VACCINE MANAGEMENT

Vaccine cold chain, the backbone of EPI has been in place and functioning for

many years at different levels. Pakistan cold chain system needs some special attention at

the moment. All the elements of the cold chain system must be strengthened and

developed to an optimum standard to ensure vaccine potency, quality and safety from the

vaccine manufacturer to the children/women. Unless concerned people in each level of

the cold chain system entrust themselves to work as a team we may not be able to achieve

our goal of preventing, eliminating, controlling and eradicating the EPI vaccine

preventable diseases.

The objective is to ensure that health staff have safe, quality and potent vaccines

available, in the right quantities, at the right place and at the right time to immunize

children and women.

COLD CHAIN is a system that will ensure the potency, quality and safety of

vaccines by maintaining their correct temperature from the time they are released from

the vaccine manufacturer until they are administered to the children and women. The

major elements of cold chain and their role in the cold chain system are as follows:

Personnel, are EPI and cold chain staff who use and maintain the equipment, provide the immunization services and manage the cold chain.

Equipment, are the cold rooms, freezer rooms, chest freezers, absorption refrigerators, cold boxes, vaccine carriers, ice packs, thermometer, cold chain

monitor card, generators and refrigerated vehicles that are used to maintain the

correct temperature, safe storage and transportation of vaccines.

Procedures, are guides for vaccine management, vaccine store management, cold chain logistics, and repair and maintenance of cold chain equipment.

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Cold Chain System for Pakistan Vaccine manufacturer Cold Chain is a system Comprising of: National Vaccine Store, 1.People (supervisor, Federal EPI Cell, Islamabad storekeeper, cold Chain technician Provincial Vaccine Store vaccinator etc) Punjab, Sindh, NWFP, Balochistan 2.Cold chain equipment (cold/freezer rooms, District Vaccine Store freezer, cold box, Vaccine carrier, ther- Tehsil, RHC, BHU, FC facility mometer etc.) 3.Procedures (recor- Vaccinators/EPI service ding form, vaccine providers handling, distribution transportation links etc.) Working together to ensure Safe and Potent Vaccines From Manufacturer To Children and Women Cold Chain & Vaccine Management

Vaccine arrival

a. Vaccine Arrival Report is used to check the integrity of vaccines on arrival in the

country of destination or local destination by verifying that the cold chain has

been properly maintained throughout the period of transport.

b. Vaccines, diluent and vaccine/diluent combinations must be stored at

recommended temperature. If there is an uncertainty about the correct

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temperature for a particular vaccine it must be stored in a cooler or refrigerator but

not in a freezer.

c. To eliminate the cause of vaccine wastage due to incorrect storage temperature,

temperature of every cold chain equipment has to be continuously monitored and

recorded. This process will detect the early occurrence of cold chain failure and

will avoid further loss of potency to the vaccines. Staff should be trained on how

the devices work, how to read the temperature correctly and how to maintain it.

d. Cold chain equipment at each level may vary depending on the storage volume

and duration of storage. National level and provincial level have the biggest

vaccine requirements therefore must need high storage capacity cold chain

equipment.

e. It is important that each level should be able to determine the vaccine

requirements and to have a sufficient stock for the entire immunization schedule

including campaign activities. Once the vaccine requirements are known the

vaccine storage volume, refrigerating capacity and icepack freezing capacity

could be determined.

f. Freeze dried vaccine is one of the two different forms of vaccine. It is a freeze-

dried powder that must be mixed with a liquid (diluent) in a process called

reconstitution before it can be used.

g. Expired vaccines are those that have been stock piled in the refrigerator/freezer

and have not been used prior to their expiry date. This type of vaccine wastage is

avoidable if proper vaccine stock management is applied.

h. Vaccines are sensitive biological substances and must be handled carefully to

avoid damage during transport and distribution. Satisfactory transport

arrangements should be in place for moving vaccine from one level to another

including maintenance of correct temperatures during transport.

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j. There are a number of development and updates in cold chain and these are

crucial for the successful implementation of EPI cold chain. All of these should

be disseminated to the field. Management should ensure that all concerned staff

should have an adequate formal or in-service training in cold chain and vaccine

management.

Laboratory Containment of Wild Polioviruses and Potential Infectious

Material The success of global Polio eradication program is dependent on all countries of

the world being able to demonstrate that wild polioviruses circulation among their

populations has been interrupted and that all laboratory sources of wild polioviruses have

been found and safely contained. The only possible indigenous sources of wild poliovirus

are laboratories, which are in possession of wild poliovirus infectious or potentially

infectious materials. In this respect WHO had suggested all the countries to develop

laboratories containment system for wild polioviruses and other potential materials within

their countries. To carry out the task the country should nominate the National

Coordinator for laboratory containment of wild polioviruses and potential infectious

materials.

Pakistan has made substantial progress towards polio eradication since the start of

the program in 1994, with clear evidence of decreasing poliovirus diversity and intensity

of transmission. Number of polio cases has dropped from several thousand in 1994 and

early 2000 to 28 in 2005. They were 32 in 2007. Indicators for AFP surveillance system

for polio Eradication are reaching at the certification standered since the year 2001 at the

country level and high vaccination coverage rates have been reported in several

Supplementary Immunization Activities (SIAs). Routine immunization programme has

variable performance and great attention is being paid to improve this through multi

pronged strategies including optimizing experience gained in Polio Eradication Initiative

(PEI). The achievements in PEI so far is through political commitment, dedicated

leadership, appropriate community and social mobilization and support of members of

21

civic society and most importantly parents of the children. Pakistan and its two

neighboring countries Afghanistan and India are three of the four remaining polio

endemic countries in the world.

Laboratory survey and inventory

This phase covers the period when the number of Polio-free countries and

Regions are increasing, but wild polioviruses continue to circulate somewhere in the

word. During this phase, countries will have to accomplish the following tasks:

1. Survey all biomedical laboratories to identify those with wild poliovirus

infectious or potential infectious materials and encourage destruction of all

unneeded materials.

2. Develop an inventory list of laboratories that retain such material and report to the

Regional Certification Commission.

3. Instruct laboratories dealing or retaining wild poliovirus infectious or potential

infectious material to initiate to implement enhanced biosafety level-2 (BSL-

2/polio) measures for safe handling

4. Plan for Global Certification.

Global Certification This phase begins when one year has elapsed without isolation of wild poliovirus

anywhere in the country. During this phase countries will ensure to:

1. Notify biomedical laboratories that poliovirus transmission has been interrupted.

2. Instruct laboratories on the National Inventory to choose one of the following

three options:

22

Render materials non-infections for poliovirus or destroy them under appropriate conditions

Transfer wild poliovirus infectious and potential infectious materials to laboratories capable or meeting the require biosafety standards.

Implement biosafety requirements appropriate for laboratory procedure being carried out (BSL-2/polio or BSL-3/polio).

3. Document completion of all containment requirements for global certification.

Post Global Certification

It is anticipated that the containment requirements for global certification will

remain in force together with concurrent immunization policies. At some time in the

future, international advisory bodies are expected to re-examine post certification

immunization policies in the light of research outcomes, post eradication experiences,

containment assessments and assurances of the surveillance, vaccine stocks and

emergency response plans would be adequate and enough if polio re-emerge. If oral polio

vaccine (OPV) immunization is stopped, with or without universal replacement with

inactivated polio vaccine (IPV), the biosafety requirements for both wild and OPV

viruses will become more stringent than those outlined in this document, consistent with

the consequences of inadvertent transmission of poliovirus from the laboratory to an

increasingly susceptible global community.

DISCUSSION

Polio is a highly contagious disease that is caused by a virus that primarily lives in

the intestines and human feces. The poliovirus is spread from person-to- person primarily

through oral contact with the feces of an infected person (for example, by changing

diapers); it can also spread through contaminated food or water, especially in areas with

poor sanitation systems. There have also been cases that have been transmitted by direct

23

oral contact or by droplet spread. Once inside the body, the poliovirus multiplies in the

throat and intestinal tract, then travels through the bloodstream where it infects the brain

and spinal cord. Surprisingly, 95% of all individuals infected with Polio have no apparent

symptoms. Another 4%-8% of infected individuals have symptoms of minor, non specific

nature, such as sore throat, nausea, vomiting, and other common symptoms of any viral

illness. About 1%-2% of infected individuals develop nonparalytic aseptic (viral)

meningitis, with temporary stiffness of the neck, back, and/or legs. Less than 1% of all

Polio infections results in the classic flaccid paralysis where the patient is left with

permanent weakness or paralysis of legs, arms, or both. Among those paralyzed, 5% to

10% die when their breathing muscles become immobilized.[1]

Pakistans remote northwestern frontier province, one of the few remaining

hotspots of polio in the world, has been a major focus of efforts to eradicate the disease.

Now, however, health workers in Pakistan face a new obstacle: political fallout from the

US-led war on terror. Local tribal and religious leaders have convinced thousands to

refuse polio vaccinations in the belief that the vaccine is an American scheme aimed at

the sterilization of Muslims. In other cases, some local authorities demand benefits from

the Pakistani government before allowing vaccinations to proceed. Health workers in

Pakistan have made great strides in fighting polio, vaccinating 6 million people in

January 2008. If they cannot overcome these new political obstacles, however, the

disease may survive to spread again.

Pakistan is committed to achieve the Millennium Development Goals (MDG)

through the Health Sector Reforms (HRS) by focusing on provision of basic health

service to the people at their doorsteps. A huge network has been established in the

country for this purpose. It includes 5270 BHUS, 552 RHCS, 946 Hospitals, 130,000

Doctors, 35000 Nurses and 100,000 Lady Health Workers. The major thrust has been to

provide quality care and reduce infant, child and maternal mortality. Health is one of the

major interventions for human development and poverty reduction. To achieve the MDG,

various National Programs have been launched which are meant to reduce morbidity and

mortality.

24

Potential complications of polio

Polio can lead to muscle paralysis that results in deformities of the hips, ankles,

and feet. Although many of the deformities can be corrected with surgery and physical

therapy, these treatments often arent available options in the developing countries where

polio still exists.

Other complications associated with the prolonged hospital stay as a result of the

paralysis caused by polio infection involve the lungs, kidneys, and heart:

Pulmonary edemaA potentially life-threatening condition that fills the lungs with fluid and prevents them from absorbing oxygen

Aspiration pneumoniaAn inflammation of the lungs that is caused by inhaling stomach contents into the lungs

Urinary tract infectionsBacterial infections that can permanently damage the kidneys if not treated promptly

Kidney stonesUsually form when urine becomes too concentrated; they may cause ongoing urinary tract infections or kidney damage

Intestinal obstructionA partial or complete blockage of the bowel that prevents food from moving through the intestinal tract; severe obstructions can

lead to potentially life-threatening complications

MyocarditisAn inflammation of the thick muscular layer of the heart that can lead to chest pain, an abnormal heartbeat, or congestive heart failure; it can also

cause blood clots to form, which greatly increases the risk of stroke

Cor pulmonaleA heart condition that occurs when the right side of the heart cant pump hard enough to compensate for prolonged high blood pressure in the

arteries and veins in the lungs

Immunity Protective immunity against poliovirus infection develops by immunization or

natural infection. Immunity to one poliovirus type does not protect against infection with

25

other poliovirus types. Immunity following natural infection or administration of live oral

polio vaccine (OPV) is believed to be lifelong. The duration of protective antibodies after

administration of inactivated polio vaccine (IP) is unknown. Infants born to mothers with

high antibody levels against poliovirus are protected for the first several weeks of life.

Natural, or wild-type, polio has not occurred in the US since 1979, or in the

Western Hemisphere since 1991. However, children and adults who havent been

vaccinated against polio could get the disease if they travel to a country where polio still

exists or where outbreaks have recently occurred or come into contact with infected

travelers from countries where polio still occurs. Because no cure for polio exists, the

focus is on increasing comfort, speeding recovery, and preventing complications. Today,

supportive treatments for polio include:

Antibiotics for secondary infection Analgesics for pain Portable ventilators for breathing Moderate exercise A nutritious diet

Recommendations 1. Ownership and commitment

a. Further gains in polio eradication will only be possible through full

ownership and accountability of the national officers at all levels.

b. To Ensure that Polio eradication becomes a standing agenda item at the

inter-ministerial meetings of Federal and Provincial Ministers of Health.

c. To Establish/activate polio Provincial Steering Committees in each

Province.

26

d. To Establish/activate district polio task forces under the chairmanship of

DCOs

e. To Monitor the security situation closely, and prepare and maintain

contingency plans to ensure vaccination of the moving children.

2. Supplementary Immunization Activities

a). It is essential to ensure the best quality performance during supplementary

immunization activities.

b). Ensure selection of competent and qualified Area-in-Charges whose

performance should be monitored.

c). Ensure proper vaccination team selection with respect to age and

appropriate proportion of females.

d). Ensure proper training of vaccinators.

e). Ensure campaign monitoring is carried out in a credible way:

3. Surveillance

(a). Ensure the quality of stool specimens by the investigating officers.

(b). Continue to hold monthly provincial surveillance meetings, and use them

as a forum also to discuss campaign achievements.

(c). Conduct surveillance reviews regularly.

27

4. Communication

(a). Continue the excellent progress made in developing effective

communication and expand it to include other elements of EPI and child

survival.

(b). Build communication capacity within the structures of Federal and

Provincial authorities.

(c). Target communication activities to high-risk areas where there is a need to

reach non-immunized children.

(d). Continue to conduct research into factors behind refusals and use the

findings to modify the present strategies.

5. Routine Immunization

Consider child immunization a priority and use the increasing skills in communication to strengthen commitment of the national authorities, non-governmental

organizations and particularly the public, who should be demanding vaccination for their

children. Maximum emphasis may be put on routine immunization which includes three

doses of Polio Vaccine in the first year of life.

6. Analysis of the data of last 5 years according to the gender, age, percentage of routine immunization in each affected district may be carried out to come to conclusion

regarding the reason of failures and occurrence of these cases.

7. The Antibody titre against polio may be carried out on all these cases of 2008, which have been supposedly given many doses of polio vaccine and still got the

disease.

28

8. National and Provincial Funding commitment for action plans for E.P.I. and Polio 9. Strategies to resolve Provincial and District Management Challenges

10. Establishment of National Inter-Provincial Programme monitoring and crisis management body

Acknowledgements:

Author is grateful to the encouragement and contribution made by Deputy Chairman,

Planning Commission and Member (SS). The information provided by Mr. Qadir Bux

Abbasi, and Dr. Hussain Bux Memon (EPI), Dr. Mushtaq A. Khan, and Dr. Amjad,

(N.H.P.U), Dr. Obaidul Islam, Senior Surveillance Officer, W.H.O. and Dr. Azhar

Abid of UNICEF is acknowledged.

29

REFERENCES

1) World Health Statistics 2008, World Health Organization.

2) Polio Eradication initiative, National surveillance Cell, Federal EPI, 2008.

3) The News, Two More Polio cases on 19.6.2008

4) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5712a3.htm

5) http://www.polioeradication.org/content/general/current_monthly_sitrep.asp

6) http://www.health.gov.pk/

7) http://www.who.int/mediacentre/factsheets/fs114/en/

8) Emergency Technical Consultation on Polio Eradication (TAG Meeting) Karachi

24-25 June 2008

9) AFP Surveillance, Annual report 2001, National Surveillance Cell, Federal EPI

Ministry of Health Pakistan

10) National Surveillance Bulletin, issue 6, June 2008, WHO Office, Islamabad

Pakistan

11) Global Polio Eradication initiative Strategic Plan 2004-08 CDC, UNICEF, WHO

12) Communication for Polio Eradication and routine immunization. Checklists and

easy reference guide. Who/Polio/02-06/WHO.UNICEF 2006

13) Field guide 1996 Global Programme for Vaccines and Immunization Polio

Eradication, WHO Geneva 1997

14) Daily News, 21 August 2008

15) Pakistan Social and living standards measurement Survey (PSLM) 2006-07

Government of Pakistan

30

Annex-A

POLIOMYLITIS CASES TILL JUNE 2008

Province/Region Distract Name Polio Virus

Type No. Cases Total Districts Total Cases

Punjab Last Confirmed Polio Case seen in September 2007 - Hyderabad Type 1 1 Nawabshah Type 1(Contact) 1 Shikarpur Type 1 1 North Karachi Town Type 1 1 Mirpurkhas Type 1 1 Naushero Feroz Type 1 1 Jacobabad Type 1 1 Dadu Type 1 1 SITE Town Karachi Type 1 1

Sindh

Sanghar Type 1 1

10 10

Nowshera Type 3 1 Nowshera Type 3 1

NWFP

Kohat Type 1 1

2

3

Killa Abdullah Type 1 1 1 Balochistan Pishin Type 1 1

2 1

FATA Last Confirmed Polio Case seen in December 2007

AJK Last Confirmed Polio Case seen in June 2000 -

FANA Last Confirmed Polio Case seen in January 1998 -

Islamabad Last Confirmed Polio Case seen in December 2003 - Total 14 15 Source: Federal EPI Cell, Ministry of Health

31

Annex-A-1 2008 UPDATE: Total number of confirmed polio cases (to date) = 31 25 type-1 cases (12 from Sindh, 6 from NWFP, 4 from Balochistan, 2 from

Punjab and 1 from Islamabad) 06 type-3 cases (all from NWFP/FATA; 2 from Nowshera, 2 from Bajour Agency

and 2 from Peshawar) Confirmed polio cases by province, district & by type in 2008 to date Province/ Region

District Name Poliovirus Type No. Cases

Total Districts

Total Cases

Okara NSL 1 1 Punjab Sheikhupura NSL 1 1

2

2

Hyderabad NSL 1 1 Nawabshah NSL 1 (Contact) 1 Shikarpur NSL 1 1 North Karachi Town

NSL 1 1

Mirpurkhias NSL 1 1 Naushero Feroze

NSL 1 1

Jacobabad NSL 1 1 Dadu NSL 1 1 SITE Town Karachi

NSL 1 1

Sanghar NSL 1 1 Gadap Town NSL 1 1

Sindh

Khairpur* NSL 1 1

12

12

Nowshera NSL 3 (Contact) 1 Nowshera NSL 1 1 Kohat NSL 1 1 Swat NSL 1 1 Swat NSL 1 1 Peshawar NSL 3 1 Mardan NSL 1 1 Peshawar NSL 3 1 Dir Upper NSL 1 1

NWFP

Dir Upper* NSL 1 1

6

10

Bajour NSL 3 1 FATA Bajour NSL 3 1

1 2

Killa Abdullah NSL 1 1 Pishin NSL 1 1 Ziarat NSL 1 1

Balochistan

Loralai NSL 1 1

4 4

AJK Last Confirmed Polio Case seen in June 2000 - FANA Last Confirmed Polio Case Seen in January 1998 - Islamabad Islamabad NSL1 1 1 1 Total 26 31 NSL: Non-Sabin Like

32

Poliomyelitis Case 2000-2007 Annex-B

Source: Federal EPI Cell, Ministry of Health

Month/Years 2000 2001 2002 2003 2004 2005 2006 2007

January 10 9 4 6 4 4 0 5

February 7 3 4 7 3 0 2 1

March 1 4 4 7 4 2 0 1

April 11 4 9 14 1 1 1 0

May 13 3 3 7 4 3 5 2

June 22 4 6 7 3 2 4 2

July 16 7 2 8 4 3 4 0

August 23 18 11 11 10 2 3 2

September 27 24 20 14 2 3 6 4

October 30 20 14 7 8 2 8 1

November 24 16 7 10 2 3 6 6

December 15 7 6 5 8 3 1 8

Total 199 119 90 103 53 28 40 32

33

Annex-C

OPV Distribution for the Year 2007

Rounds Punjab Sindh NWFP Balochistan AJK FANA ICT Total

Feburary

07 SNIDs 264,755 308,925 239,365 78,675 ----- ----- ---- 891,720

March 07

SNIDs 195,800 256,190 181,110 66,900 ------ ----- ---- 700,000

24-26 April

07 955,000 455,000 375,000 130,000 37,500 13,000 13,000 1,978,500

10-14 May

07 SNIDs 192,700 251,300 191,400 65,060 ----- ----- ----- 700,460

19-21 June

07 180,900 278,100 181,350 65,100 ----- ----- ----- 705,450

7-9 August

NIDs 955,000 455,000 375,000 129,000 38,400 12,500 12,100 1,977,000

24-26 Sept

07 Spl

camp.

---- 40,000 150,000 70,000 ----- ----- ----- 260,000

30th Oct to

1st Nov

NIDs

955,000 455,000 375,000 129,000 38,400 12,500 12,100 1,977,000

11-13 Dec

07 SNIDs 224,000 337,000 194,000 65,000 ----- ----- ----- 820,000

OPV Distribution for the Year 2008

Rounds Punjab Sindh NWFP Balochistan AJK FANA ICT Total

22-24 Jan 08

NIDs 955,000 455,000 375,000 129,000 38,400 12,500 12,100 1,977,000

8-10 April 08

SNIDs 218,500 445,500 260,000 78,500 ---- ---- ---- 1,002,500

May 07 NIDs 950,000 450,000 360,000 130,000 38,500 12,500 12,850 1,953,850

34

Annex-D

40Tot22)3QUETTA

4KABDULAH

3JAFARABAD

32Tot(18)1NFEROZ28TOTAL(18)

1PISHIN2KHIKORANGI1SIBI

2NSIRABAD1KHIGIQBAL1KABDULAH

1LORALAI1KHIGADAP1JAFARABAD

15Tot(14)1LASBELA1UMERKOT2QUETTA

1PISHIN3KABDULAH2SUKKUR1PISHIN

1KABDULAH1THATTA1SHIKARPUR1MUSAKHEL

1SHIKARPUR2KHIBALDIA1SANGHAR1KSAIFULAH

1SANGHAR1KHAIRPUR1JACOBABAD2LARKANA

1NFEROZ5KAMBAR1GHOTKI1SANGHAR

1NAWABSHAH2JACOBABAD1MUZFARGARH1JACOBABAD

1MIRPURKHAS1GHOTKI1MULTAN1GHOTKI

1KHISITE1DGKHAN2WAZIR-N1MULTAN

1KHINORTH1WAZIR-S1LAKKIMRWT6DGKHAN

1JACOBABAD1SWAT1KHYBER1RYKHAN

1HYDERABAD1PESHAWAR1DIRLOWER2KHANEWAL

1DADU2NOWSHERA1DIKHAN1TANK

2NOWSHERA4MARDAN6BANNU2PESHAWAR

1KOHAT2KHYBER4BAJOUR2BAJOUR

2008DISTRICT2007DISTRICT2006DISTRICT2005DISTRICT

Distribution of Polio Cases by District, 2005-2008*

* Afp.rec Data as of 26-06-2008

P1 Wild = 19

Distribution of Polio Cases by Sero-type & District,2005-2008*

P1 Wild = 27P3 Wild = 01

2005

No. Districts with Wild poliovirus cases =18

Provincial BoundaryDistricts Boundary


P1 Wild = 20

2006

P3 Wild = 20

2007

P3 Wild = 13No. Districts with Wild poliovirus cases =18

Cases randomly placed in Tehsils.

* Afp.rec Data as of 26-06-2008


P1 Wild = 13P3 Wild = 02

2008

36

Annex-F Confirmed polio cases by month & by year (2000-2008) todate Month/Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 January 10 9 4 6 4 4 0 5 2 February 7 3 4 7 3 0 2 1 1 March 1 4 4 7 4 2 0 1 0 April 11 4 9 14 1 1 1 0 6 May 13 3 3 7 4 3 5 2 5 June 22 4 6 7 3 2 4 2 2 July 16 7 2 8 4 3 4 0 15 August 23 18 11 11 10 2 3 2 September 27 24 20 14 2 3 6 4 October 30 20 14 7 8 2 8 1 November 24 16 7 10 2 3 6 6 December 15 7 6 5 8 3 1 8

Total 199 119 90 103 53 28 40 32 31

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