National Emergency Action Plan for Polio Eradication 2016 – 2017

NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION

ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017

NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION

ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Design and layout: www.paprika-annecy.com CONTENTS

Acronyms �� v

Preface �� vi

Executive summary ��viii

Background and context �� 1

Progress during the implementation of NEAP 2015-2016 �� 3

High-risk areas and population groups �� 5 Geographical high-risk areas �� 5 High-risk population groups �� 5

Challenges in access �� 6

Lessons learned in the 2015-2016 period �� 8

Challenges for NEAP 2016-2017 �� 8

Goal �� 9

Strategic approach �� 9

Objectives �� 9

Targets and milestones �� 9

Governance and coordination �� 10

Leadership and coordination �� 10 At the national level ��10 At the regional, provincial and district levels ��11

Management of the Polio Eradication Initiative �� 12 Emergency Operations Centres ��12

Key strategies �� 14

Focus on high-risk areas �� 14

Supplementary immunization activities �� 14 Inactivated polio vaccine ��14

iii NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Enhancing campaign quality �� 14 Microplan revision ��15 Front-line worker selection, motivation and capacity building ��16 Intensified supportive supervision ��17 Revisit strategy ��17 Enhanced monitoring ��18 Campaign coordination and review meetings �� 20

Community health volunteer strategy �� 22

Data collection, collation, transmission and use �� 22 Data collation, analysis and dashboard �� 23 Use of mobile technology to fast-track data transmission �� 23

Strategies for access-challenged areas �� 23 Areas inaccessible for vaccination �� 23 Areas accessible with limitations ��24

Complementary vaccination activities �� 24 Permanent Transit Teams ��24 Permanent Polio Teams ��25 Cross-border Teams ��25 Special campaigns for nomads and other underserved population groups ��25

Building demand in immunization �� 25 Data collection and generation of evidence �� 27

Surveillance �� 27 Acute flaccid paralysis surveillance �� 27 Environmental surveillance �� 28

Response to any new polio case �� 29 Response to detection of poliovirus type 2 �� 29

Effective vaccine and cold chain management �� 30

Cross-border coordination �� 31

Evaluation �� 31

Routine immunization strengthening �� 31

Operations �� 32

Mobilization �� 32

Transition planning �� 32

List of annexes �� 33

iv NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Acronyms

AFP Acute flaccid paralysis BPHS Basic package of health services CBT Cross-border Team cVDPV Circulating vaccine-derived poliovirus DDM Direct Disbursement Mechanism EOC Emergency Operations Centre EPI Expanded Programme on Immunization FLW Front-line worker ICM Intra-campaign monitor/monitoring ICN Immunization Communication Network IPV Inactivated polio vaccine IVR Interactive Voice Response LPD Low-performing district LQAS Lot Quality Assurance Sampling M&A Monitoring and Accountability MoPH Ministry of Public Health mOPV2 Monovalent oral polio vaccine type 2 NCC National Certification Committee NEAP National Emergency Action Plan NID National Immunization Day OPV Oral polio vaccine PCM Post-campaign monitoring PEI Polio Eradication Initiative PEMT Provincial EPI Management Team PPT Permanent Polio Team PTT Permanent Transit Team RCC Regional Certification Commission SIA Supplementary immunization activity SNID Subnational Immunization Day TAG Technical Advisory Group UNICEF United Nations Children’s Fund VHR Very high risk WHO World Health Organization WPV Wild poliovirus WPV1 Wild polio virus type 1

For NEAP 2016-2017: • LPD 1 and 2 districts have been renamed “very high-risk (VHR) districts” and LPD 3 “high‑risk districts”; and • Post-campaign assessment has been renamed “post-campaign monitoring”.

v NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Preface

2015/2016 was a challenging year for polio of this historic moment on the global scale eradication in Afghanistan, with the country and also for the sustained development still reporting cases of wild poliovirus. of improved public health in Afghanistan. However, reflecting back over the past year, We have launched an “all-out” effort to finish we have witnessed significant progress in polio, with focused attention, resources and our efforts that make us more optimistic activities in the remaining reservoirs of the than ever before, despite all the challenges country. The 2016-2017 NEAP is a significant we still face. document for guiding the coordinated efforts of all polio eradication partners. The next year We are at a critical juncture in the programme will be one where we focus on consolidating and the eyes of the world are on us. I am all our efforts. This document is a reflection encouraged to hear that in the past few of the lessons learnt in the past year and it months there has been unprecedented outlines how we intend to build on recent political commitment under the leadership successes, reverse setbacks, measure results, of His Excellency the President and strong create an enabling environment, and maintain support of His Excellency the Chief Executive neutrality, underpinned by a strong focus on to strengthen polio eradication efforts in accountability of all stakeholders. We know Afghanistan. With the establishment of the that we are still missing too many children to Emergency Operations Centres (EOCs) in stop transmission. Our vision for the next year late 2015 to drive the implementation of is to reach every child, everywhere. Our mission the National Emergency Action Plan for is to reduce chronically missed children and Polio Eradication (NEAP), we have seen to close persistent immunity gaps. unprecedented coordination and oversight of polio efforts. The EOC’s mission is to I would like to appreciate and recognize the lead and manage Afghanistan’s effort to efforts of hundreds of thousands of people stop poliovirus transmission by the end of who are at the frontline of Afghanistan’s fight 2016 by ensuring every child, every time, to stop polio. Nearly every month, thousands everywhere receives polio vaccine as set out of health care workers in every corner of the in the NEAP. This will be achieved through country strive to reach every child, despite the strong coordination between government risks and challenges. We must pay special and partners, real-time use of data to drive tribute to those who have been injured or lost action, and full accountability at all levels their lives in the past year – they are the real of the programme. I am encouraged by the heroes of the programme and we will strive new initiatives that have recently been put to ensure an end of polio in their honour. in place in an effort to reduce the number of missed children. We are now starting to We are committed to re-doubling our efforts see results and these efforts must be further to stop transmission of wild poliovirus by strengthened in 2016/2017 to ensure that we the end of 2016, building on recent gains. put an end to polio in Afghanistan. Afghanistan’s fight against polio is at a critical moment and intensified polio eradication As we near the achievement of interrupting activities in the next few months will determine wild poliovirus in Afghanistan, the Ministry of if eradication of the poliovirus will be achieved Public Health is fully aware of the significance by end of this year. Working together we must

vi NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 be more focused on finding concrete and in these efforts. The Ministry of Public sharp solutions to overcome the remaining Health recognizes that this global effort, bottlenecks. I am optimistic Afghanistan with major global implications, requires the will succeed. intensification of all efforts during this revised NEAP. Working together with our partners, The Government of Afghanistan is grateful for I am confident that we will soon deliver on the support of the international community our promise of a polio-free world.

Sincerely,

Dr. Ferozuddin Feroz Minister of Public Health

vii NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Executive summary

Afghanistan and Pakistan are the two The national polio eradication programme remaining polio endemic countries in the made significant progress in 2015/2016 through world and form one epidemiological block the consistent implementation of the NEAP, with two epidemiological corridors, an eastern guided by strong government leadership corridor and a southern corridor. Most areas of and strengthened coordination between Afghanistan are polio-free, but wild poliovirus partners, following the establishment of the (WPV) continues to circulate particularly Emergency Operations Centres (EOCs). Since in Eastern and Southern regions. To date the establishment of the EOCs, a national level Afghanistan has reported a total of six WPV and three regional EOCs, coordination with the cases in three districts of which four are from Pakistan polio eradication programme has a small geographical area of Shigal Wa Sheltan also been strengthened at all levels. District in Kunar Province of Eastern Region; an area which has remained inaccessible for In 2015/2016 Afghanistan implemented vaccination activities since 2012. an intensive SIA schedule and a number of new initiatives to further improve SIA During implementation of the National quality were put in place during the second Emergency Action Plan for Polio Eradication half of the NEAP implementation period. 2015-2016 (NEAP) an extensive risk These initiatives included the roll-out of a categorization process was undertaken new FLW training curriculum; a modified and five provinces (i.e. Kandahar, Helmand, revisit strategy; the development of district Farah, Kunar and Nangarhar) were identified profiles and district-specific plans; in-depth having a higher risk of sustaining poliovirus investigation of reasons for failed lots in LQAS; transmission. Disaggregated district-level strategic use of inactivated polio vaccine analysis shows that 47 districts, which have (IPV); and microplan validation and revision. been responsible for over 84% of cases over the The national polio eradication programme past seven years, are at very high risk. There is focused the implementation of these initiatives also strong indication that mobile populations in the 47 very high risk districts and they are such nomadic groups and seasonal/economic starting to translate into improvements in migrants play an important role in sustaining the quality of SIAs and the immunity profile and spreading poliovirus transmission. of non-polio of acute flaccid paralysis cases.

Access to children for vaccination remains a The NEAP for polio eradication has been challenge in stopping the transmission of WPV. updated for the July 2016 to June 2017 Districts are classified in four categories as period, guided by the key lessons learned per their access status; category one being during the implementation of the previous fully accessible, two - partially accessible, NEAP. The programme continues to focus three - accessible with limitations, and four attention and resources on high-risk areas - fully inaccessible. Although the number of and populations to achieve the goal of stopping inaccessible children varies from campaign the transmission in Afghanistan by the end of to campaign, over the past year the access December 2016, with no further cases from deteriorated particularly in Eastern and January 2017 onwards. Northeastern regions.

viii NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 The strategic approaches to achieve the goal further strengthening of the revisit strategy; will include maintaining programme neutrality and enhancing systematic monitoring and and gaining access to all children with OPV, coordination during all phases of every irrespective of the area where they reside; campaign. All data collected from the various implementation of alternate strategies in sources will be analysed and displayed through inaccessible areas; focusing on identified high- a series of dashboards to guide evidence- risk provinces and districts and areas where based decision-making. children are persistently missed; underpinning all strategies by ensuring strong household The national polio eradication programme and community engagement; and enhancing continues to work towards its aim to vaccinate accountability of all stakeholders, at all levels. all children regardless of where they live by maintaining programme neutrality, through Afghanistan’s national polio eradication continuous mapping of accessibility, and on- programme continues to enjoy strong going negotiations to gain access. A range of support from the country’s highest political special complementary vaccination activities leadership. At the national level, a number such as Permanent Polio Teams, Cross- of bodies continue to govern and oversee the borders Teams, and special campaigns for implementation of the NEAP including the Polio nomads and other underserved populations Steering Committee and Polio High Council. will continue being implemented to ensure that The Ministry of Public Health plays the lead both children living in inaccessible areas and role in polio eradication efforts supported by children on the move are reached with vaccine. various line ministries and engagement of provincial and district governors through the Intensive efforts will be made to increase Office of the Presidential Focal Point for Polio. household and community engagement to The national EOC, led by the National Focal reduce missed children and build demand for Point for Polio, has overall responsibility for immunization through full-time engagement the stewardship of the programme and the of the Immunization Communication Network EOCs continue to manage the daily operation in the very high risk districts. Strengthening of Afghanistan’s polio eradication programme. partnerships with key influences will help to overcome issues of mistrust at the local level. The focus of the NEAP 2016-2017 will be to consolidate and strengthen the quality of the The AFP surveillance in Afghanistan generally new initiatives that are starting to yield results. meets global standards and an external While maintaining focus on the very high surveillance review conducted in June 2016 risk districts, the national polio eradication concluded that ‘circulation of WPV/cVDPV programme will not lose sight of other high is unlikely to be missed in Afghanistan’. risk districts. An intense OPV SIA schedule The recommendations made by the review team and IPV SIA plan will be implemented while will guide further improvements in the system. aiming to enhance campaign quality and reduce number of missed children. Interventions Every new polio case will be responded to as planned include microplan revision, improved per the existing SOPs and for outbreaks in FLW selection, motivation, and capacity areas contiguous with Pakistan there will be building; intensified supportive supervision; joint analysis, planning, response, monitoring,

ix NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 and reporting of case response. The national polio eradication programme will continue to strengthen cross-border coordination with the Pakistan team at all levels through regular face-to-face meetings, VCs, synchronization of SIA dates, streamlined cross-notification of AFP cases, uniform communication interventions of the cross-border transit points, and information sharing on high-risk population movements including returnee refugee populations.

Though Afghanistan still remains polio endemic and is prioritizing the implementing the activities to stop transmission, the country will start planning for the transition of polio assets beyond certification.

x NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Background and context

Afghanistan remains one of only two polio the national and regional levels in late 2015 to endemic countries in the world; the other intensify, guide and coordinate the efforts of is Pakistan. The two countries form one all partners for NEAP implementation under epidemiological block. Polio eradication is one roof. at the top of Afghanistan’s health agenda. In 2015/2016, the Government of Afghanistan Most areas of Afghanistan are polio-free, scaled up its efforts to accelerate polio but wild poliovirus (WPV) continues to circulate eradication in the country amidst multiple, in some parts of the country, particularly in complex challenges, including increasing Eastern and Southern regions (Figure 1). conflict and insecurity in many parts of In 2015, Afghanistan reported 20 polio cases the country. (due to WPV) in 16 districts of the country, compared to 28 cases in 19 districts in 2014. The National Emergency Action Plan for Polio To date in 2016, the country has reported a total Eradication (NEAP) continues to serve as the of six WPV cases in three districts. It is important guiding document for polio eradication activities to highlight that four of the cases in 2016 are in Afghanistan. A number of new developments from a small geographical area of Shigal Wa have taken place during the low season for Sheltan District in Kunar Province (Eastern polio transmission to accelerate progress Region), which has remained inaccessible for towards stopping transmission. Emergency vaccination activities since 2012. Operations Centres (EOC) were established at

Figure 1. Confirmed wild poliovirus cases in Afghanistan by region, 2014-2016.

Confirmed cases Region 2014 2015 2016 Central 0 0 0 East 6 10 4 2014 South-East 4 0 0 District= 19 South 17 4 2 WPV=28 North 0 1 0 North-East 0 0 0 West 1 5 0 Country 28 20 6 2015 District= 16 WPV= 20

Infected Districts Non Infected Districts

2016 District= 3 WPV= 06

1 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Afghanistan has continued to expand its contributed 84% of all WPV polio cases in environmental surveillance system, which now the past seven years. comprises 14 sampling sites in five provinces. In 2015, a total of 19 WPV isolates were Afghanistan continued to implement an reported from environmental samples. To date intensive SIA schedule in 2015/2016; led by in 2016, no wild or vaccine-derived poliovirus the national EOC, a number of new initiatives has been detected in environmental samples. to further improve SIA quality were put in place during the low transmission season An extensive risk categorization process (end of 2015 and early 2016). These initiatives was undertaken in 2015, based on poliovirus included the roll-out of a new front-line epidemiology and other factors. A total worker (FLW) training curriculum; a modified of 47 districts were classified as low- revisit strategy; the development of district performing districts (LPDs priority 1 and 2, profiles and district-specific plans; the in- now renamed “very high-risk districts”), based depth investigation of reasons for “lot failure” on the epidemiology of WPV transmission, in Lot Quality Assurance Sampling (LQAS) poor routine immunization and supplementary surveys; the strategic use of inactivated immunization activity (SIA) coverage, gaps in polio vaccine (IPV); and microplan validation population immunity and access challenges and revision. due to insecurity. These 47 districts have

Figure 2. Vaccination status of non-polio acute flaccid paralysis cases in children aged 6-59 months in high-risk provinces, 2014-2016 Nangarhar Kunar Kandahar Helmand Farah 100% 90% 80% 70% 65 60% 102 99 40 14 136 65 37 137 48 50 50% 137 66 27 17 40% 30% 16 20% 20 18 3 10% 5 2 14 10 17 6 3 4 2 1 1 16 10 4 11 5 4 0% 4 14 15 16 14 15 16 14 15 16 14 15 16 14 15 16 Zero dose 1-3 doses 4-6 doses 7+ doses Data up to 02 Jul 2016

2 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 The national polio eradication programme The NEAP for polio eradication has been has focused the implementation of these updated for the July 2016 to June 2017 period initiatives in the 47 prioritized districts. to further enhance polio eradication efforts These initiatives are starting to translate into and ensure that Afghanistan achieves the goal improvements in the quality of SIAs. Between of stopping WPV transmission. The focus of November 2015 and May 2016, the number NEAP 2016-2017 will be to consolidate and of failed lots assessed through LQAS in very strengthen the quality of the new initiatives that high-risk districts has decreased from 42% are starting to yield results. These initiatives to 17%. will be supplemented by full-time household and community engagement approaches, Over time, the immunity profile (the history prioritizing all activities in the very high- of oral polio vaccine (OPV) doses received) of risk (VHR) districts (formerly categorized as non-polio acute flaccid paralysis (AFP) cases LPD 1 and 2). In 2016/2017, emphasis will has continued to show improvement, as shown also be placed on the implementation of an in Figure 2 for five high-risk provinces. accountability framework at all levels.

Afghanistan shares a long border with Progress during the Pakistan, forming one common reservoir implementation of NEAP of poliovirus circulation. There are two 2015-2016 epidemiological corridors: an eastern corridor that extends from the greater Peshawar- The national polio eradication programme Khyber area of Khyber Pakhtunkhwa Province made significant progress in 2015/2016, and the Federally Administered Tribal Area through the consistent implementation of in Pakistan into Nangarhar and Kunar the NEAP, guided by strong government provinces of Eastern Region, Afghanistan. leadership and strengthened coordination The southern corridor extends from the Quetta between partners, following the establishment block of Baluchistan province, Pakistan, of the EOCs (Table 1). into Kandahar and Helmand provinces of southern Afghanistan. During the January 2016 meeting of the Technical Advisory Group (TAG), experts Since the establishment of the polio eradication acknowledged the significant improvement EOCs, coordination with the Pakistan national in programme oversight, management and polio EOC has been strengthened, including coordination through the establishment regular cross-border coordination meetings at of national and regional EOCs, which all levels; harmonization of the target age group has greatly strengthened the partnership for cross-border vaccination; improved cross- between government, United Nations notification of AFP cases; microplanning and agencies and other polio partners. The TAG sharing of data from districts on both sides of the noted significant programmatic progress, border; production of common communication while cautioning that eventual interruption materials and messages used in both countries; of WPV transmission will require progress and synchronization of campaign dates. to be further fast-tracked.

3 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Table 1. Progress of the National Emergency Action Plan 2015-2016 Area Progress • Polio Steering Committee formed and the first meeting chaired by H.E. the President of the Islamic Republic of Afghanistan • Involvement of line ministries and partnership building with relevant departments enhanced by regular meeting of Polio High Council • EOCs established at the national level and in three high-risk regions, including Eastern, Western and Southern • Governance of the Polio Eradication Initiative restructured to ensure smooth communication Governance and between regional and national levels coordination • Roles and responsibilities of Polio High Council, Presidential Focal Point, Minister of Public Health Focal Point and EOCs clearly defined to avoid overlap • Neutrality of the national polio eradication programme maintained • Provincial Polio Coordination units in five high-risk provinces established • Coordination among implementing partners strengthened under government leadership • Various managers at different levels sanctioned and relieved from their positions due to poor performance • Method of identifying LPDs modified; 47 LPDs identified as very high risk, responsible for 84% of Focus on LPDs cases in past seven years (very high-risk • Interventions for improving quality of SIAs prioritized and focused particularly on LPDs districts) • District profiles and district-specific plans developed for 47 LPDs 1 and 2 • Revisit strategy modified to include a fourth revisit day, and scaled up nationally • Microplan validation and revision completed in 37 of 47 LPDs Improving quality • FLW training module revised, and FLWs throughout the country trained using the new curriculum of SIAs • Supportive supervision from the national level standardized and strengthened • Post-campaign review conducted, followed by corrective action to resolve local problems, to improve SIA quality • Intra-campaign monitoring strengthened, with real-time data transfer using Interactive Voice Response (IVR) technology. Monitoring • Post-campaign assessment (henceforth called “post-campaign monitoring”) strengthened by expanding it to include all clusters in VHR districts • LQAS expanded to all priority VHR districts, wherever feasible and where security permits • Pre-, intra- and post-campaign evaluation data collected, processed and presented in a timely manner through pre-, intra- and post-campaign dashboards Data flow and • Administrative coverage data and intra-campaign monitoring information in five priority provinces utilization collected in a timely fashion and used for action • Post-SIA monitoring data available to the national polio eradication programme within 10 days of the end of every campaign Access in security • Threat of ban on SIAs in Southern Region successfully averted on three occasions compromised • Systematic reporting on accessibility shared with partners areas • Programme neutrality maintained • Review of Permanent Transit Team (PTT) and Permanent Polio Team (PPT) strategies conducted Complementary • PPTs reactivated in Southern Region vaccination • PTT strengthened and deployed in newly inaccessible areas activities • Cross-border Team (CBT) operations harmonized with Pakistan • Findings from Harvard “Knowledge, Attitudes and Practices” study used for guiding communication strategy Communication • Immunization Communication Network (ICN) expanded and terms of reference modified to engage and social for whole month mobilization • Religious leaders sensitized through the Ulama Conferences on Polio Eradication at national level and in Southern and Eastern Regions • Ongoing social mobilization embedded in district-specific plans Cross-border • Quarterly face-to-face meetings and videoconferences conducted between both national level teams coordination with • Monthly meetings conducted at regional and provincial levels Pakistan • SIA calendar synchronized between both countries • AFP surveillance sensitivity maintained, with all key indicators meeting global standards at national and regional levels Surveillance • Reporting network further expanded • AFP focal persons reoriented • Surveillance review conducted in June 2016 • Global guidelines for vaccine vial monitor and cold chain and logistics rolled out Cold chain • Training of cold chain officers in prioritized regions conducted in June 2016 and vaccine • Switch from trivalent oral polio vaccine to bivalent oral polio vaccine conducted successfully on management 23 April 2016

4 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 High-risk areas and population groups population immunity and the presence of The national polio eradication programme refugees and internally displaced persons, continues to focus attention and resources on Afghanistan has identified five provinces that high-risk areas and populations to achieve the have a higher risk of sustaining poliovirus goal of stopping the transmission of WPV. Certain transmission. The five high-risk provinces geographical areas and population groups are that are a priority are: Kandahar, Helmand, more vulnerable to polio transmission and Nangarhar, Kunar, and Farah. they have played a vital role in sustaining the transmission over time. Disaggregated district-level analysis shows that certain districts have an increased risk of polio transmission; at very high risk are Geographical high-risk areas 47 districts that have been responsible for Based on poliovirus epidemiology and other over 84% of cases over the past seven years factors, including access to implement SIAs, (Figure 3).

Figure 3. Risk level in districts of polio transmission, 2016

Very High Risk High Risk Other

High-risk population groups being transmitted from one area to another Epidemiological data of polio cases and genetic through the different groups of people who analysis of isolated viruses show that there are continuously on the move. Strong evidence is sharing of poliovirus circulation among indicates that mobile/migrant populations play distant areas within the country as well as an important role in sustaining and spreading across the border with Pakistan. This indicates poliovirus transmission. the sustained transmission of the virus. It is

5 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Mobile and migrant populations vary in different weather and the availability of silage for parts of the country (Figure 4). Some common their livestock; and types are: • Seasonal / economic migrants - who belong • nomadic populations – who have low to varying socio-economic groups and socioeconomic status and are largely migrate according to the seasons to support dependent on their livestock, moving from their livelihood. one place to another depending on the

Figure 4. Mobile population movements in Afghanistan.

Movement due to law and order and security issues

Cross-border movement

Nomads/Afghan refugee movement

Seasonal worker movement

Challenges in access campaign, but with limitations in programme Access to children for vaccination remains a oversight and management. challenge in stopping the transmission of WPV. A large number of children are missed from Four categories designate the access status vaccination during SIAs due to insecurity, mostly of districts, as follows: because of the inability of vaccination teams to reach children in security-compromised areas. Category 1 – Fully accessible: These districts In certain areas it is possible to implement the are fully accessible for all components of Polio Eradication programme implementation.

6 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Category 2 – Partially accessible: While The cause of Category 2 and 4 inaccessibility vaccination campaigns are conducted in some is usually active fighting nearby or local parts of these districts, other areas are not authorities’ “bans” on immunization campaigns. accessible to campaigns. The number of inaccessible children, and the area of inaccessibility, varies from campaign Category 3 – Accessible with limitations: to campaign, owing to the dynamic security The implementation of vaccination campaigns situation on the ground. In Category 3 districts, is possible in these districts. However, obtaining accurate and objective information the movement of non-resident supervisors and on the quality of campaigns remains one of monitors is not without risk; there are limitations the most critical challenges. and restrictions on effective implementation and monitoring of the performance of all Although the number of inaccessible children phases of SIA implementation - including FLW varies from campaign to campaign due to the selection, training, supervision, and monitoring continuously evolving security situation, Table 2 of campaign activities. highlights the number of children in inaccessible areas during SIAs over the past year. Access Category 4 – Inaccessible: These districts deteriorated in this period, particularly in are totally inaccessible for vaccination Eastern and North-Eastern Regions. campaign implementation.

Figure 5. Status of accessibility in districts by category, May 2016

Category 1 Category 2 Category 3 Category 4

7 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Table 2. Inaccessible children during SIAs, June 2015 to May 2016 2015 2016 Regions June August Oct Nov Dec Jan Feb Mar Apr May Central 17 523 East 32 799 51 327 61 910 57 232 138 359 41 744 22 938 25 869 30 555 131 781 North 18 880 22 756 3 376 North-East 6 386 173 818 65 583 97 997 146 810 106 281 165 332 South 584 751 17 830 15 562 51 105 43 423 12 335 7 079 11 684 56 662 22 811 South-East 450 830 1 793 2 020 91 380 380 400 West 26 935 672 0 AFGHANISTAN 662 458 95 925 79 266 306 931 181 874 119 662 128 394 184 363 193 878 323 700

Lessons learned in the 2015-2016 Regions and focus to a greater degree on period rapidly improving quality in all security- The key lessons learned during the challenged areas. implementation of NEAP 2015-2016 are helping • FLWs are the cornerstone of high- to guide the development of NEAP 2016-2017. quality campaigns. Continued focus and These lessons include: accountability should be placed on ensuring • Strong coordination at all levels, with clear the right selection, providing high-quality accountability, is critical to achieve results. training and sustaining their motivation. Results can be attained most effectively by working as one team to deliver one plan. Challenges for NEAP 2016-2017 • The programme needs to continuously adapt The national polio eradication programme to the rapidly changing security context. continues to face a number of It must particularly focus on devising and challenges, including: implementing alternative approaches to gain • a volatile security situation in many access to children in the inaccessible areas of areas, resulting in the inability to access Eastern and North-Eastern Regions, in view children in key regions of the country, of the developments that have increased particularly in Eastern, Southern and inaccessibility in these areas. North‑Eastern Regions; • The programme needs to put more emphasis • the maintenance of strict programme to strictly maintain neutrality. neutrality to ensure vaccination activities • Refocusing on programmatic basics and reach every child across the country; ensuring high-quality of activities yields • limited supervision and monitoring in certain results. New approaches and innovations areas of high-risk provinces, resulting in are needed to overcome challenges, suboptimal campaign quality; but they should be targeted to address • the full implementation of the accountability particular issues. framework at all levels; • Experience from other countries should • the sustained motivation and commitment be adapted to the local context. Tailoring of FLWs and of all stakeholders; and issue-specific plans to the local context is an • a possible funding gap. effective approach to reach more children. • The programme should strive beyond just gaining access in Southern and Western

8 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Goal

To stop WPV transmission in Afghanistan by poliovirus type 1 (WPV1) cases from January the end of December 2016, with no new wild 2017 onwards.

Strategic approach

1. Maintain programme neutrality and 3. Focus on identified high-risk provinces gain access to all children with OPV, and districts and areas where children irrespective of the area where they reside; are persistently missed; 2. Implement alternate strategies, i.e. 4. Underpin all strategies by ensuring strong use PolioPlus interventions and the PTT, household and community engagement; and particularly in inaccessible areas; 5. Enhance accountability of all stakeholders, at all levels.

Objectives

1. To interrupt the circulation of indigenous 4. To rapidly and effectively respond, WPV1 in Southern Region, Afghanistan by in coordination with Pakistan, to any the end of December 2016; importation of WPV1 and/or emergence 2. To interrupt WPV1 circulation in Eastern of vaccine-derived poliovirus type 2 into Region by the end of December 2016; polio-free areas of Afghanistan to prevent 3. To rapidly increase population immunity the establishment of virus circulation; and in high-risk provinces and districts 5. To maintain high-quality surveillance across by conducting high-quality SIAs and the country, and to ensure all provinces complementary vaccination activities; reach and maintain surveillance quality indicators that meet global standards.

Targets and milestones

1. Conduct five SIAs in the second half of 2016 4. Fully operationalize a full-time Immunization and five in the first half of 2017: Communication Network (ICN) in all VHR a. reaching over 90% of children during districts by the end of September 2016; each SIA as per the monitoring data; and 5. Maintain an annual non-polio AFP rate of b. improving the quality of campaigns >2 cases/100 000 under 15 years of age, particularly in very high risk districts, with adequate stool specimens collected with >90% LQAS lots accepted at 80% from >80% of AFP cases in every district and <5% missed children; across the country; and 2. Complete one IPV-OPV SIA in all VHR 6. Fully implement the accountability districts by the end of September 2016; framework by the end of August 2016. 3. Revise microplans of all VHR districts by the end of September 2016;

9 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Governance and coordination

A significant focus of NEAP 2015-2016 was to At the national level, a number of bodies continue improve national polio eradication programme to govern and oversee the implementation of the management and operational implementation. NEAP. These include: An overall governance framework for the • The Polio Steering Committee: The Steering national Polio Eradication Initiative (PEI) in Committee is the highest forum used by Afghanistan was established to encourage the national leadership to support the polio evidence-based decision-making, improved programme. The Committee is chaired by situational awareness, early problem detection the President of the Islamic Republic of and a coordinated response by both government Afghanistan, and its members are the Chief and partners. Executive of the Islamic Republic of Afghanistan and cabinet members. Meetings of the national The updated NEAP 2016-2017 strongly Steering Committee take place on a biannual emphasizes the importance of PEI governance basis to ensure that the eradication programme in Afghanistan, with clearly defined roles is seen and treated as a national public health and responsibilities, supported by a defined emergency, with full support from all line accountability framework. ministries whenever and wherever required. The forum brings all involved parties under As highlighted in NEAP 2015-2016, and to the umbrella of the accountability framework. ensure data-driven and quick evidence-based It provides overall oversight to the national decision-making and timely communication, polio eradication programme in Afghanistan. the governance of the PEI was restructured • The Polio High Council: The Polio High Council during the second half of 2015, by assigning the meets during the first week of every quarter. core role of PEI management to the national It is chaired by the Presidential Focal Point polio EOC. The following section outlines the for Polio Eradication, with the participation of renewed governance and coordination structure. the Minister of Public Health, line ministries and departments (Table 3), the polio team and Leadership and coordination representatives of donor and partner agencies. • The Presidential Focal Point for Polio At the national level Eradication: The President of the Islamic Afghanistan’s national polio eradication Republic of Afghanistan assigned a Focal programme enjoys strong support from the Point for Polio Eradication to represent the country’s highest political leadership. H.E. presidential office, provide required day-to-day the President of the Islamic Republic of support through line ministries and governors, Afghanistan maintains direct oversight of polio and regularly update the President on the eradication efforts. The President monitors programme’s progress. The Presidential Focal and oversees the implementation of the NEAP Point has regular meetings with line ministries through the national Polio Eradication Steering and departments and the governors of the Committee and the Presidential Focal Point high-risk provinces to ensure multisectoral for Polio Eradication. In the first Steering support for the polio eradication programme Committee meeting of 2016, the President at the national and provincial levels. Recently emphasized the importance of maintaining the the office of the Presidential Focal Point neutrality of the polio programme and other enhanced the accountability of governors and health initiatives. line ministries.

10 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 • The Ministry of Public Health (MoPH) plays At the regional, provincial and district levels the lead role in polio eradication efforts in • Recently, the provincial and district governors’ the country, with the overall responsibility engagement in the polio programme has to coordinate and communicate with all increased, particularly in the high-risk partners. The MoPH ensures the effective provinces of Southern, Eastern and Western leadership and coordination of the bodies Regions. Multisectoral meetings chaired by established to manage and oversee the national the provincial governors have been conducted polio eradication programme. The Minister of before each campaign round in Kandahar, Public Health has a Senior Adviser acting as Helmand, Nangarhar and Kunar. Focal Point for PEI, who directly oversees the • During the second half of 2016, the polio day-to-day management of the programme on team will ensure that provincial and district behalf of the Minister of Public Health. The Polio polio task forces (multisectoral meetings) are Focal Point ensures that all Ministry of Public fully functional in all five priority provinces Health departments provide full support to the and 47 VHR districts. The terms of reference programme. He is authorized to hold everyone for provincial and district task forces will be in the MoPH structure accountable for their role revised and operationalization will begin by in polio eradication. The MoPH will continue to the August NIDs. provide the overall leadership of the national EOC.

Table 3. Engagement of line ministries and departments in the national polio eradication programme

Line Department Area of Engagement

Ministry of Public Health • Bednet distribution to the community will be coupled with vaccination in very high-risk and Malaria Department high-risk districts

• Conducting PolioPlus and health camp interventions in Category 2 and Category 4 Basic Package of inaccessible districts Health Services • Increasing the number of outreach and mobiles sessions in areas where house-to-house (BPHS) implementer vaccination is not possible nongovernmental • Working closely with BPHS implementer NGOs to improve routine immunization coverage in organizations (NGOs) the 47 VHR districts

• Engaging school students and teachers in the social mobilization and tracking of missed Ministry of Education children at the community level • Engaging Village Education Shuras in the monitoring and accountability of the programme

Afghan Red Crescent • Introducing M&A officers in VHR districts Society • Health camps and mobile clinic activities in the inaccessible areas

Afghanistan • Supporting remote monitoring through mobile technology Telecommunication • Tracking post-campaign monitors in the field through mobile technology Regulation Authority

Ministry of Rural • Supporting the EOC in recruiting M&A officers Rehabilitation • Engaging village Shuras in polio SIAs

Ministry of Hajj and • Helping the PEI to clear misconceptions based on religion and persuading communities to Awqaf (Religious accept vaccination through the engagement of religious scholars Affairs)

11 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Management of the Polio commanding relationship with all regional Eradication Initiative EOCs, Regional Expanded Programme on Immunization (EPI) Management Teams and Emergency Operations Centres Provincial EPI Management Teams (PEMTs). The daily operation of Afghanistan’s polio eradication programme is managed by The national EOC has overall responsibility for Emergency Operations Centres (EOCs). the stewardship of the national polio eradication In line with the recommendations of the programme. It defines the strategies, identifies global Independent Monitoring Board and the high-risk areas, develops the tools needed, TAG, and to ensure quick evidence-based evaluates the programme and tracks the decision-making and timely communication, performance of districts. It will continue to EOCs were established at the national level ensure that all the strategies developed at the and in the country’s priority regions during the national level are shared with the provinces and last quarter of 2015. Three regional EOCs are undergo consultation before finalization. While functional in Eastern, Southern and Western the regional EOCs have some autonomous Regions (Figure 6). An EOC is a coordination decision-making power, their main role is to body that brings all implementing partners of coordinate and execute the strategies set at the PEI under a single roof to plan, organize the national level. and implement polio eradication activities. It maximizes the use of existing PEI assets The EOC structure will be further rather than creating a parallel structure. strengthened by • consolidating task team modality at EOCs bring together all polio partners to national level work in the same physical setting for better • conducting weekly videoconferences between coordination, information sharing, quick National and Regional EOCs decision-making and joint management of • monthly tracking of NEAPimplementation the national polio eradication programme. status To ensure timely communication between districts, provinces and regions, and the In addition to EOCs, provincial coordination national level, EOCs cut through all bureaucratic units were established during the first quarter red tape. After their establishment, polio of 2016 in the five priority provinces (Kandahar, eradication became a nationally-driven effort. Helmand, Nangarhar, Kunar and Farah) to The national EOC has a direct reporting and support data management.

12 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Figure 6. Governance framework for the national Polio Eradication Initiative in Afghanistan.

President

Minister of Presidential Public health focal point

National Polio Focal Point

NEOC

All line department of Line Ministries Governors MoPH

REOCs REMTs

PEMTs PEMTs

13 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Key strategies

Focus on high-risk areas OPV SIA schedule: two NIDs and three An analysis of past cases in Afghanistan has Subnational Immunization Days (SNIDs) in shown that more than 80% of cases have the second half of 2016, and two NIDs and come from five provinces: Kandahar, Helmand, three SNIDs in the first half of 2017. The SIA Nangarhar, Kunar and Farah. These are dates will be synchronized with Pakistan. considered the high-risk provinces. For every new case, the programme will conduct Further disaggregated district level analysis three case response campaigns targeting at shows that 47 of the country’s districts have least 500 000 children surrounding the area been responsible for 84% of cases over the where the case was detected. past seven years. These districts have thus been categorized as the VHR districts. Another Inactivated polio vaccine 49 districts are at relatively lower risk; they are All the VHR districts that have IPV SIAs considered the high-risk (HR) districts. planned for 2015/2016 will complete them by the third quarter of 2016. IPV campaigns will The geographical focus for NEAP 2016-2017 also be planned for every newly accessible takes into consideration this risk categorization. area that has been inaccessible for more than The five high-risk provinces and 47 VHR districts six months and/or missed three vaccination will receive special focus and will be given opportunities. Currently, 276 000 target priority for the key strategic interventions. District profiles and district-specific action children aged less than 5 years in 31 districts plans have been developed, based on the meet this criterion. The programme will also particular local issues and challenges. consider using IPV in selected areas, if any The district profiles and specific plans will new transmission is detected in a high-risk be further strengthened and updated after area with security challenges. every SIA, to address the challenges and/or bottlenecks identified during each campaign. In 2017, the programme aims to conduct IPV- OPV SIAs in the VHR districts where these While maintaining focus on the VHR districts, campaigns have not been conducted in 2015- the programme will not lose sight of the 49 high 2016, including selected parts of Kabul. risk and the non-high risk districts and will continue to improve quality in these areas. Enhancing campaign quality Figures from the post-campaign monitoring An analysis to identify the high-risk districts survey show that, in 2015, around 7% of target will be conducted again in December 2016 children were missed owing to gaps in the to adjust to changing epidemiology and quality of campaigns. The proportion of missed emerging scenarios. children was even higher in Southern Region where approximately 10% of children were Supplementary immunization missed during each round of SIA. LQAS results activities show that around 30% of lots across the country In 2016/2017, the national polio eradication were rejected during any given round of SIAs programme will continue to follow an intense in 2015.

14 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Improvement in the recent past has been while, in focused areas, the proportion of failed significant with the proportion of rejected lots was reduced from 40% to less than 20% lots reduced from 30% to 12% in the country (Figure 7).

Figure 7. Progressive improvement in SIA quality LQAS results, Quarter 1-Quarter 2, 2016

National VHR districts 100% 100% 13 90% 15 90% 5 20 26 8 80% 80% 10 10 70% 70% 60% 56 60% 36 17 50% 50% 37 50 9 17 40% 40% 13 30% 30% 20% 20% 21 33 7 7 10% 13 17 10% 5 2 0% 0% Feb_16 Mar_16 Apr_16 May_16 Feb_16 Mar_16 Apr_16 May_16

Accepted to 90% Accepted to 80% Rejected to 80%

The national polio eradication programme 47 VHR districts, they are being revised using has identified a number of interventions to geographic information system maps and improve the quality of campaigns. These will field validation. The aim of this exercise is to be prioritized in the five high-risk provinces ensure that: and VHR districts. • all the settlements are included in microplans; • there is a rational distribution of workload The focus of the programme is now on identifying of vaccination teams, supervisors and clusters of chronically missed children and district coordinators; refusals, and on ensuring that communication • team and supervisor maps are available and operational plans are aligned to address for all areas, including major landmarks the local issues at cluster level. and social components, i.e. the location of key influencers and mobilizers, important The key interventions for improving quality sites (mosques, schools, markets, gathering are outlined below. places), high-risk population groups, etc.; and • the microplans include information and Microplan revision plans for vaccination at major transit points Microplans of all the districts will be updated as well as for mobile population groups regularly to include new settlements. In all where applicable.

15 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 In June 2016, the process of updating the Improving team selection microplans in the VHR districts had been All FLWs should be selected from and within completed in 37 districts and was under way communities based on merit. This prerequisite in 10. The process will be completed in the applies to both accessible and access remaining VHR districts by the end of the third compromised areas. quarter of 2016. Efforts will be made to engage female The microplan validation process will be vaccinators, preferably community health reviewed and strengthened even further workers (CHWs) wherever available and feasible. in 2016/2017 to improve quality. Microplan validation using the revised methodology will Each two-member team should comprise at be conducted in a phased manner in all 49 least one member who can read and write. high-risk districts in the last quarter of 2016 and repeated in the 47 VHR districts in the Improving the quality of training first quarter of 2017. • All vaccinators will be trained, using the revised curriculum, ahead of every second SIA. Front-line worker selection, motivation • The quality of training in VHR districts will be and capacity building monitored from the provincial and regional Front-line workers (FLWs) and their supervisors levels with feedback to the national level; and are the key polio field staff, who actually deliver • The national EOC will track training polio immunization services to the population. attendance and quality (training attendance Poor team performance often manifests itself must be over 90%). as recordings of “child absent” and “household not visited” during campaigns. Efforts in Monitoring and performance management the next year will focus on improving team performance by ensuring FLWs are carefully • The performance of vaccinators and selected using a transparent and criteria-based supervisors will be tracked over subsequent approach, are equipped with the appropriate campaigns, particularly in the VHR districts. skills, information and materials to optimally • In line with the accountability framework, perform their job, and are kept motivated. the well-performing FLWs will be recognized and incentivized and the poor performers In the first half of 2016, the FLW training will be sanctioned. curriculum was revised based on the results of a training needs assessment undertaken Ensuring the timely payment of FLWs in 2015. All FLWs across the national polio There have been concerns regarding payment eradication programme were trained in this to FLWs both in the terms of the amount and new curriculum, which was founded on adult timeliness of distribution. FLW rates were learning principles. therefore revised in the second quarter of 2016 to ensure parity across the country. In 2016/2017, the programme will pay particular attention to improving the selection process Currently, the programme uses two financial of FLWs and enhancing their capacity through transaction methods. One is the Direct ongoing training. Major relevant activities Disbursement Mechanism (DDM), which will include: makes payments available directly to target beneficiaries using the banking system or

16 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 mobile phone technology (M-Paisa). The other The quality of supervision by front-line is cash distribution following a cash transfer supervisors (cluster supervisors) will also be to the local polio partners’ joint account. enhanced by: Currently 17% of beneficiaries are paid • rationalizing the workload of cluster through the DDM. The distribution of cash to supervisors by ensuring each covers a FLWs in provinces and localities should only maximum of five teams; be undertaken in the presence of financial • providing them with intensive training on committee representatives. supportive supervision techniques; • enhancing their supervision by District In 2016/2017, the national polio eradication Coordinators and intra-campaign programme will: monitors (ICM); • aim to ensure the payment of vaccinators • analysing all supervisory checklists at the within 30 days of the end of every campaign; provincial level; and • track the payment of vaccinators from the • tracking performances by cluster supervisor national level and take corrective action in area, including all components (i.e. post- case of delayed payment; campaign monitoring (PCM), training • apply a strict “zero-tolerance” policy related attendance and missed children). to any misappropriation of payments and PEI resources; and • continue expanding DDM in phase-wise Revisit strategy manner where feasible. In early 2016, as recommended by the TAG, the national polio eradication programme Intensified supportive supervision modified and expanded the revisit strategy, whereby vaccination teams revisit households Supervision of all phases of a campaign will be where one or more resident children were intensified by systematically engaging national-, missed from vaccination during the first regional- and provincial-level programme team visit. Key changes in the revised revisit staff, including EOC members, for supervision strategy include: in the field – particularly in the five high- risk provinces and VHR districts. To meet • strengthening the team revisit during this demand, the following interventions will campaign days through improved planning, be implemented: closer monitoring and supervision; and • identification of national- and regional-level • increasing the time gap between the first monitors from different agencies, who will be visit and revisits during and after campaigns: trained in supportive supervision, the use of >>days 1-3: campaign days – the team is to standardized tools and programme oversight; return to follow up and vaccinate all missed • deployment of these monitors to high-risk children in the afternoon after a break provinces to oversee and take corrective (after 14:00), following the same route as action during the pre-campaign phase and in the morning to maximize the amount of for the whole duration of the campaign; and time to reach missed children and/or for • concurrent feedback and corrective action the caregiver to return; at the local level along with daily feedback to >>day 4: one-day break – to ensure adequate regional and national EOCs. A final debrief planning for the post-campaign revisit; at the national level will be held focusing on >>day 5: post-campaign revisit day – to fall the follow-up actions discussed during the on a Friday to maximize the number of post-campaign review meeting. children and caregivers found at home; and

17 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 >>before the next campaign – ICN mobilizers • introduction of disaggregated information to follow up on outstanding missed children. on “children missed due to refusals” to differentiate between hard-core refusals Supervision and ICM have been modified to and children missed due to being “new born, incorporate the revised revisit strategy. sick or sleeping”; • availability of PCM and LQAS data to the The national polio eradication programme programme within 10 days of the end of will further strengthen the revisit strategy by: every campaign; and • fully implementing this strategy across the • deployment of M&A officers in selected country; and VHR districts. • tracking the impact of the revisit strategy by performing a disaggregated data analysis The programme will continue to systematically and taking corrective action as required. monitor key activities throughout the campaign cycle to guide corrective action to improve Enhanced monitoring SIAs in ongoing and subsequent campaigns. It is very important to systematically monitor The data team at the EOC will collect information all phases of every campaign (pre-, intra- and from the provinces and update the campaign post-campaign) to take corrective action to dashboards on a timely basis. improve the quality of SIAs in ongoing and subsequent campaigns. To further understand the situation on the ground for corrective action, M&A officers are being There is an established system of ICM and of deployed in the VHR districts. This deployment post-campaign monitoring which includes post- aims to strengthen the monitoring of pre-, campaign monitoring surveys, LQAS surveys intra- and post-campaign activities to ensure and “out-of-house” surveys. The latter check that there are no impediments to implementing the vaccination status of children found out of high-quality SIAs. These independent officers their homes (i.e. at school, in markets, etc.). are being deployed to collect and verify timely and reliable information in the districts for The national polio eradication programme has transmission directly to the national EOC. strengthened monitoring through the: • use of IVR technology for real-time data To date, 11 M&A officers are working in selected collection from ICM; districts of Kandahar and there is a plan to • revision of the ICM checklist and guidelines; fast-track expansion to all 47 VHR districts. • expansion of LQAS to all VHR districts, The national EOC will have four M&A focal wherever feasible and where security permits; persons to collect, compile and present the • surveying of 100% of the clusters (supervisory information to the EOC for corrective action. area) during the PCM in VHR districts where accessible; sampling of 50% of clusters in To further strengthen the monitoring other districts; mechanism and use of information for corrective • monitoring of monitors performing PCM; action, specific activities are envisioned. • detailed field investigation of all lots failed in LQAS and the team areas where more than • Pre-campaign monitoring: three children were missed among the 10 >>National-level monitors will be deployed houses surveyed by a PCM; to priority provinces and VHR districts

18 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 to monitor the pre- and intra-campaign the quality of monitoring. A total of 5% of phases during every SIA. monitors/surveyors will be cross-checked >>Standardized checklists will be used and by provincial polio officers/provincial the concurrent feedback system will be communication officers and district polio further strengthened. officers/district communication officers >>Pre-campaign dashboard: The national EOC during monitoring activities. In addition, will receive regular feedback from regions 5% of forms submitted will be validated in and provinces on the preparatory status of the field for correctness. Any discrepancy campaigns and ensure corrective action will be documented including the corrective is taken as needed, including possible action taken. postponement of a campaign based >>The performance of monitors will be tracked on preparedness. over the rounds and a “zero-tolerance” policy will be applied for any defaulters. • Intra-campaign monitoring: >>The PCM data will be made available to >>The selection and training of ICM staff the programme within 10 days of the end will be improved to ensure well-trained, of campaigns. high-quality ICM. >>A detailed analysis of PCM data, including >>The number of ICMs in the 47 VHR districts the reasons for missed children by district, will be increased to have one per five will be used during the post-campaign cluster supervisors. review meeting for corrective action. >>ICM data will be collected in real time using >>In any team area where PCM detects >3 IVR technology in the VHR districts and missed children among the 10 houses shared immediately for corrective action. surveyed, a detailed field investigation will >>Intra-campaign dashboards will be made be conducted by a joint team (UNICEF, fully functional and used for corrective WHO, MoPH) using a standardized tool to action on a daily basis. identify and document the key root causes >>Complete ICM data will be collected of the poor performance and to plan for and analysed at the national and corrective action in subsequent campaigns. regional levels for corrective action in The concerned area will be recovered to subsequent campaigns. reach the children missed. >>ICM data will be used during the >>In districts containing areas with both evening meeting and post-campaign government and anti-government elements, review meetings. the PCM will be conducted in both areas of influence (if allowed) and the results will • Post-campaign monitoring: be analysed separately. >>PCM will continue to target 100% of clusters in the 47 VHR districts and 50% of clusters • LQAS: in other districts. >>LQAS will be further expanded to include >>The selection and training of post-campaign all VHR and HR districts wherever the monitors in the five high-risk provinces will security situation allows. be directly overseen at the national level. >>The current system of LQAS surveyor >>The system of monitoring the monitors (in- engagement will be reviewed; if necessary process and after the monitoring) will be and feasible, third parties (contractors) institutionalized to ensure quality. This will will be engaged. include using mobile technology to verify

19 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 >>To ensure high quality LQAS, 10% of surveyors Campaign coordination and review will be cross-checked by provincial polio meetings officers/provincial communication officers Campaign coordination and review meetings during monitoring activities. In addition, are needed during the pre-campaign phase 10% of completed forms will be validated to ensure good preparedness, during the in the field for correctness. Any discrepancy campaign to take concurrent corrective will be documented including the corrective action and after the campaign to review the action taken. lessons learned to improve the quality of >>For every failed lot in LQAS, a detailed field subsequent campaigns. investigation will be conducted by a joint team (UNICEF, WHO, MoPH) within seven Pre-campaign coordination meetings days using a standardized tool to identify and document the key root causes of the • Prior to a vaccination campaign, coordination poor performance and to plan for corrective meetings will be held at the national, regional action in subsequent campaigns. Concerned and provincial levels, with the participation areas will be recovered to reach missed of polio partners and representatives of the children and lots failing repeatedly will provincial health office and BPHS NGOs. be further investigated and interventions • Depending on the frequency of campaigns, modified to ensure improvement of quality. coordination meetings will be conducted >>LQAS results will be available to the between two and four weeks before programme within 10 days of the end each campaign. of campaigns. • At the national level, the meetings will focus on: • Out-of-house surveys: >>support to regions and provinces to ensure >>Out-of-house surveys at marketplaces or good quality preparation; other public areas will be continued and >>lessons learned from past campaigns and enhanced in the five high-risk provinces. corrective action to be taken; >>They are particularly important in >>the calendar of activities at the national access-challenged areas where they will and regional levels; and be emphasized. >>the deployment of national monitors to provide support in the preparatory phase. • Innovative technology for monitoring: >>Mobile technology will be used to monitor • Pre-campaign preparedness will be the post-campaign and LQAS monitors. monitored on a daily basis by the national >>IVR technology will be used to collect real- EOC, using the pre-campaign dashboard. time information from ICMs. >>The key components tracked will >>Mobile technology will be used to fast- be microplanning, FLW training, track PCM and LQAS data from the five social mobilization and vaccine and high-risk provinces. logistics availability. >>Remote monitoring using telephonic >>The state of readiness will be assessed surveys will be conducted in access- 10, seven, three and one day(s) prior to compromised areas to assess coverage. every campaign. >>Mobile technology will be used to track the >>The required corrective action will be taken performance of ICM. with support from the national EOC and will include the deployment of additional national monitors.

20 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 >>If any district is found to be inadequately >>The primary focus of these task force prepared by three days before meetings will be to ensure the full implementation, the national EOC will engagement of all line departments and postpone the campaign and provide support to strengthen accountability at all levels. to ensure full preparedness. Provincial task force meetings will be: --held two weeks before every campaign; and • At the regional level, the meetings will --followed by district task force meetings, focus on: which will take place one week before >>the development of a schedule of activities, every campaign. including training plans; >>a plan of action to address the challenges Intra-campaign review meetings (evening identified in previous campaigns; and meetings) >>the deployment of regional and provincial • The national polio eradication programme staff to support field preparation. has been conducting evening review meetings with campaign organizers and monitors • The meetings in high-risk regions and (including intra-campaign monitors) at the provinces will be attended or supported by district level at the end of each campaign day to representatives from the national EOC. review the day’s activities and plan corrective • Provincial and district task force meetings action to respond to the problems identified. will be held before every campaign, chaired by • In the first half of 2016, the programme provincial and district governors, respectively. enhanced its focus on closely tracking >>Participants in the provincial task force will the evening review meetings. The focus in include the PEI/EPI team, the provincial 2016/2017 will be to improve the quality of public health director, representatives of these meetings. A standard matrix will be line ministries and departments, and the used to record the findings of the evening governors of the high-risk districts. review meetings and to note the actions to >>The primary focus of these task force be taken to respond to the reported issues meetings will be to ensure the full and problems. engagement of all line departments and • Intra-campaign reviews will also be conducted to strengthen accountability at all levels. at the national, regional and provincial levels, Provincial task force meetings will be: during which the core team will review --held two weeks before every campaign; and the progress and key challenges and take --followed by district task force meetings, necessary corrective action. which will take place one week before • Daily feedback will be collected from ICM every campaign. (data) and national and regional monitors • Provincial and district task force meetings in the field, along with operational feedback will be held before every campaign, chaired by from EOCs and the PEMT. provincial and district governors, respectively. >>Participants of the provincial task force will Post-campaign review meetings include the PEI/EPI team, the provincial • Post-campaign reviews are conducted at the public health director, representatives of national, regional and provincial levels to line ministries and departments, and the identify the key challenges encountered during governors of the high-risk districts. the campaign and to develop a plan of action to address them in subsequent campaigns.

21 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 • It is envisioned that post-campaign review Data collection, collation, meetings will be conducted at the national, transmission and use regional and provincial levels within 15 days Data and analysis provide the foundation of the end of each campaign. for evidence-based decision-making and • In the five high-risk provinces, these meetings corrective action that will address persistent will include representatives from the national gaps in national polio eradication programme EOC for support and input. performance. Afghanistan’s programme • The campaign data, including pre-, intra- and collects different streams of data during post-campaign information, will be reviewed the various campaign phases and uses to identify key issues to inform updated the information for corrective action and plans of action. These plans will be shared accountability. Dashboards have been developed with the national EOC. These meetings will to easily visualize, analyse and track the key also serve to update the district profiles and indicators in the pre-, intra- and post-campaign district specific action plans for each of the phases (Table 4). 47 VHR districts. • The national EOC will track the outcomes of The key data streams and information collected these meetings and follow up on progress and analysed by the national polio eradication and the support required. programme are as follows: • Pre-campaign: Community health volunteer >>information on preparations, including strategy training, microplanning, social mobilization, The national polio eradication programme has vaccine and logistics delivery; and initiated an innovative approach to improve >>pre-campaign coordination the quality of campaigns in selected areas. meeting information. The community health volunteer approach deploys local female and male permanent • Intra-campaign: community volunteers to conduct social >>administrative coverage including missed mobilization and to reach and vaccinate children covered during revisits; continuously missed children. >>intra-campaign monitoring data; and >>data and information on evening meetings. This strategy is being piloted in Behsud district in Nangarhar province with promising results. • Post-campaign: As recommended by the TAG in January 2016, >>PCM data; another pilot is being planned in Spin Boldak >>LQAS results; in Kandahar province, which exemplifies the >>out-of-house survey results; and challenges of VHR districts. >>administrative coverage data.

The TAG also recommended that the results of these pilots should inform the decisions regarding possible future expansion.

22 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Table 4. National polio eradication programme data, source and timeline Data Source Timeline Pre-campaign Campaign preparation EOC/PEMT 2 weeks, 1 week, daily in last week Coordination meeting EOC/PEMT 10 days before SIA Intra-campaign Administrative coverage EOC/PEMT Next day afternoon ICM EOC/PEMT Next day afternoon Evening meeting EOC/PEMT Next day afternoon Post-campaign Administrative coverage EOC/PEMT 10 days after SIA PCM WHO 10 days after SIA LQAS WHO 10 days after SIA Out-of-house survey WHO 10 days after SIA Compiled ICM data EOC/PEMT 10 days after SIA Access data EOC/PEMT 10 days after SIA

Data collation, analysis and dashboard establishing permanent vaccination points All the data collected from the various sources around inaccessible areas and implementing will be fed into an EOC database where it will PolioPlus initiatives. be analysed and displayed through a series of dashboards to guide decision-making. In 2016/2017, the ground rule of strictly The team responsible for the EOC database will maintaining the neutrality of the programme include representatives from the government will be upheld throughout all polio activities and partners. and during its day-to-day management.

Use of mobile technology to fast-track data Areas inaccessible for vaccination transmission In Category 2 and 4 districts, the national The national polio eradication programme polio eradication programme will continue to has started using IVR technology to transfer reinforce the following interventions: data in real time from ICM in selected areas. • negotiating at different levels through neutral The use of mobile technology for the real-time and credible mediators to help gain access data transfer of administrative coverage, ICM, to children in inaccessible areas; PCM and LQAS will be explored and expanded • mapping accessibility at the cluster- and by December 2016. village-levels, and conducting campaigns in all accessible areas; Strategies for access-challenged • deploying PTTs at the entry and exit routes of areas inaccessible areas, and vaccinating all eligible The national polio eradication programme has children to create a firewall of immunity worked towards its aim to vaccinate all children around the inaccessible areas; regardless of where they live by maintaining • using a three-phased approach of Short programme neutrality, negotiating at different Interval Additional Dose strategy, with one levels through local mediators, conducting round of OPV-IPV, to boost the immunity catch-up campaigns in newly accessible areas, of children in the newly opened areas,

23 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 and increasing the age group of one of the • sharing feedback on the gaps in quality of campaigns to target children aged up to operations including reasons thereof with 10 years; the relevant authority; • scaling up PolioPlus initiatives (adding other • exploring the possibility of engaging other services in conjunction with the polio vaccine, neutral parties for monitoring; and e.g. EPI services, outreach health services, • monitoring remotely the quality of campaigns hygiene kits and bednets; depending on the using mobile technology. local context and community demand) in and around inaccessible areas to respond Complementary vaccination to other felt needs in these communities activities where feasible, and to pull people out of The national polio eradication programme inaccessible areas; continues to implement a range of special • providing IPV-OPV at health facilities complementary vaccination activities to ensure surrounding areas inaccessible for more that specific populations on the move are than a year; and reached during and between polio campaigns. • promoting ongoing community engagement Complementary vaccination activities activities, including with local elders. include special activities planned around the inaccessible areas, at busy points and at border An updated report will be shared with polio crossings, and for nomadic populations. Efforts partners after each SIA, highlighting the will be made in 2016/2017 to improve the quality location and size of the inaccessible areas, of these activities and to expand their scale the assumed underlying causes, and an outline and scope according to programmatic need. of actions taken and planned to regain access. The strategies include: Accessibility at cluster level will be tracked over the rounds and areas inaccessible for Permanent Transit Teams more than two SIAs will be treated as high PTTs vaccinate children on the move and risk areas. those moving in and out of inaccessible areas. PTTs vaccinated a total of 6.3 million children The country will develop a contingency plan to in 2015, whereas they had already vaccinated address any increase in inaccessibility. 3.8 million children in the first four months of 2016. The number of PTTs was revised from Areas accessible with limitations 62 in 2015, to 264 in 2016. The national polio eradication programme will In 2016/2017, the national polio eradication intensify efforts in the areas where vaccination programme will: campaigns are feasible but with limitations in • continue to assess and modify the number oversight and programme management due and location of PTTs according to the needs of to insecurity and interference (Category 3). the programme and the evolving accessibility The main interventions planned are: situation; and • negotiating at all levels with key authorities • strengthen PTT supervision and monitoring, and stakeholders on the quality of campaigns closely tracked by the national EOC on a and the independence of monitoring; monthly basis. • deploying M&A officers in the 47 VHR districts, including those with the specific challenge of providing information on key indicators;

24 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Permanent Polio Teams The programme has also a mechanism in PPTs provide OPV to target age children on a place to vaccinate returnee refugees. continuous basis in their assigned catchment area, over and above planned house-to-house In 2016/2017, the national polio eradication programme aims to: vaccination during SIAs. • develop special population (nomad) plans at In 2016/2017, the national polio eradication the provincial level, shared with the country office, specifying the point of entry to the area, programme will: duration of stay, next destination, number • review the performance of the existing PPTs of families and number of eligible children; and modify as required; and • conduct specific campaigns targeting this • track and monitor the output of PPTs through population group; and regional EOCs. • ensure returnee refugee populations will be vaccinated at entry points with OPV and IPV. Cross-border Teams A total of 16 points have been identified The vaccine utilization reports of the PTTs, along the border with Pakistan where large PPTs and CBTs will be submitted on a monthly numbers of children cross on a regular basis. basis to ensure the information guides accurate CBTs provide OPV on a permanent basis to all vaccine forecasting. children crossing on either side of the border. The target age for children’s vaccination at Building demand in immunization these points has been increased to those aged Intensive efforts will be made to increase 10 years and fingermarks are applied to the household and community engagement left thumb. approaches in the prioritized high-risk districts to reduce missed children and build demand In 2016/2017, the national polio eradication for overall immunization. Child absence programme aims to: remains the major reason for missing children • continue CBTs; nationwide and across all priority provinces, • modify the number of teams as per workload; according to PCM data. In April 2016, children • monitor CBT performance by independent not available represented around 75% of missed monitors; and children in Kandahar, 90% in Helmand, 60% • ensure full synchronization with vaccination in Nangarhar and 75% in Kunar, recognizing operations across the border in Pakistan. that non-availability may be used as an excuse to covertly refuse vaccination in some areas. In Kandahar and Helmand, an alarming number Special campaigns for nomads and other of districts consistently show over 8% absolute underserved population groups refusals (Baghran, Garmser, Reg, Khakrez, Special campaigns in South-Eastern, Southern Shahwalikot, Panjwayi, Miyanshin, Arghestan, and Western Regions will target the nomads etc.). This is nearly 10 times the global average who enter Afghanistan from Pakistan and in polio priority countries. Addressing the move widely in the country before returning to unsupportive social context rooting refusals Pakistan. Their routes and movement periods and children not available in Afghanistan, are known to regional polio teams so the dates and in particular in Southern Region, will be of the special campaigns targeting the children the number one priority of the communication of nomadic groups are adjusted accordingly. focus in the coming year.

25 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Afghanistan’s polio communication framework >>including social elements as part of the identifies the main strategic objectives, integrated microplan as prioritized in the principles and approaches that will guide all VHR districts; communications work, including media and >>spearheading household and community advocacy, social mobilization, and household and engagement by the over 8 000 members community engagement, and partnerships with of the ICN, and conducting field work by religious leaders and medical professionals, fully trusted, capable and professional the development of education and edutainment FLWs to mobilize caregivers, religious and materials, and the training and empowerment community leaders, and key influencers of FLWs and civil society. By bringing all to understand, accept and support the communication interventions under one work of vaccinators and uptake of OPV; strategic umbrella, the programme will ensure this engagement will not only happen during that they are integrated, complementary vaccination days, but will be a constant and mutually supportive of the operational conversation with the community that feeds strategies to reduce the number of missed back into making the programme even more children in Afghanistan. effective (the ICN will not be deployed in areas that are implementing the community Understanding that building trust is the health volunteer strategy and vice versa); cornerstone of successful community >>assessing the impact of ICN on reduction engagement, the main strategic thrust will be of missed children following October to create an enabling environment to facilitate campaign and onwards; acceptance and trust in the vaccine during >>following up rigorously on the register of and between campaigns. Communication all missed children during and between activities will aim to shape an environment campaigns by members of the ICN, where continuous vaccination against polio and ensuring vaccination in coordination is embraced and accepted as an important with the local health facility; and social and individual goal by all community stakeholders. Experience has shown that >>conducting detailed analysis of children significant impact can be achieved by developing missed due to ‘not available’, particularly in locally appropriate communication plans that Kandahar. Sample of these will be surveyed include targeted household and community to identify real reasons and to develop an engagement approaches during and between intervention plan. polio campaigns. • strengthening partnerships with key Key activities include: influencers, including religious leaders, • focusing on reducing chronically missed health workers and other stakeholders, children through strengthened household to help overcome issues of mistrust and and community engagement approaches suspicion at the local level by: that include: >>in 2016/2017, placing focus on expanding >>developing an evidence-based the engagement of religious leaders at all communication plan as part of the specific levels in a more systematic way, particularly plan in every very high-risk district, including at the local level in the VHR districts, a focus on activities in high-risk clusters building on the National Islamic Ulama to address the locally-specific reasons for Group platform that was established in missed children; early 2016;

26 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 >>mapping and including local scholars in public trust and support for local the district-specific plans, with district health-service delivery, during and focal persons ensuring the engagement between campaigns; of key religious leaders across the district; >>placing increased emphasis on creating a >>holding workshops at the national and truly national programme that incorporates provincial levels to ensure the consistent other sectors, stakeholders and voices, engagement of key religious leaders; including medical professionals, as well >>continuing to disseminate programme as the Ministries of Education and of Rural information and guidance to inform Development, which have pledged their religious leaders about the importance support to the polio programme through of immunization. Through their Islamic the Polio High Council; efforts will focus teachings, religious influencers will on ensuring full support of these and facilitate broader support for polio and other sectors, including nongovernmental child health; organizations; and >>strategically incorporating the voices of >>focusing on ensuring the participation of key religious influencers into mass media community influencers, including medical content and platforms to expand the public doctors, religious scholars, community narrative on immunization; and elders and polio survivors and their families. >>organizing workshops to seek the support of doctors and other health workers in the Data collection and generation of evidence programme at all levels. The effective implementation of the previous • improving external relations and components relies on continuously updated partnerships to promote an environment evidence. Critical data collection includes of trust by: the study of the attitudes and behavioural >>creating partnerships with media and other issues that create barriers to the vaccination stakeholders to strengthen communication campaigns, as well as the assessment of and media interaction to ensure a better the effectiveness of ongoing interventions, understanding of polio eradication, especially specific social mobilization models, and facilitating improved partnerships partnerships and tools, to continuously improve with media by: the network’s operations. The focus will be on: --holding regular media briefings and • the implementation of a second study to trainings, ensuring regular interactions further understand shifts in attitudes and with key reporters, editors and talk show perceptions; and hosts; and • third-party monitoring – both qualitative and --engaging editors of religious publications quantitative – of communication interventions in social mobilization and advocacy for in VHR districts. polio vaccination in high-risk areas to complement the engagement of religious Surveillance leaders and institutions in advocacy and community engagement; Acute flaccid paralysis surveillance Surveillance for AFP is the gold standard for >>developing and disseminating awareness- detecting cases of poliomyelitis. Environmental raising materials for print and electronic surveillance adds to the sensitivity and detection media platforms to encourage increased of WPV.

27 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 The AFP surveillance system in Afghanistan • further strengthening of active surveillance generally meets global standards. The findings visits with closer supervision and tracking of an external review of the system in the from the regional and national levels; country, conducted during the second quarter • continuing to search for suspected AFPs of 2015, confirmed that AFP quality remains during SIAs which will be strengthened strong and exceeds global standards in further in vaccinator trainings; and most areas. However, a number of smaller • exploring alternate modes/routes, problems and issues were identified that affect as a contingency, for specimen shipment to surveillance sensitivity mainly at the provincial Regional Reference Laboratory. level and below. Environmental surveillance Certain measures were taken to strengthen the Currently Afghanistan is conducting AFP surveillance system, especially in hard- environmental surveillance at 14 sites in five to-reach and security-compromised areas. provinces as follows: Nangarhar (three), Kunar Also, active AFP case searches were conducted (one), Kandahar (three), Helmand (four) and frequently in areas where AFP surveillance is Kabul (three). suspected to be weak. The active search for AFP cases has also been introduced as one In 2015, a survey was conducted to investigate of the tasks vaccinators and transit teams the possibility of expanding environmental undertake during vaccination activities. sampling sites. In 2016-17, the programme will review the existing sites for their An external surveillance review was conducted appropriateness and explore the possibility in June 2016 and the review team concluded of expanding environmental surveillance to that ‘circulation of WPV/cVDPV is unlikely to be the areas surveyed without compromising the missed in Afghanistan’. The recommendations quality at existing sites. made by the review team will guide further improvements in the system. National Certification Committee The key interventions planned to strengthen The National Certification Committee AFP surveillance in 2016/2017 are: (NCC) is composed of independent experts, • review and expansion of the reporting network as outlined in the terms of reference adopted as needed, with emphasis placed on health- by the Eastern Mediterranean Regional care service providers catering to high-risk Certification Commission. The NCC meets population groups, insecure areas, high-risk twice a year to review the overall polio situation, areas and districts with a low non-polio assess the status of requirements for the AFP rate, and conducting a health facility certification process and prepare for the contact analysis of all AFP cases, particularly eventual presentation of national polio-free inadequate cases, to guide the expansion of documentation to the Regional Certification the reporting network; Commission (RCC). • analysing surveillance data in a disaggregated manner down to the district level and by The NCC will continue to undertake field visits security status to identify gaps to take in keeping with the RCC protocol, will prepare corrective action; and submit the Afghanistan Annual Progress Report on Certification to the RCC, and will

28 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 participate in and present the report during of three SIA campaigns after the last case in the RCC annual meetings. the area has been detected.

Response to any new polio case The country will develop a generic response plan for any outbreak in an inaccessible area. A National Rapid Response Team conducts detailed case and epidemiological investigations For outbreaks in areas contiguous with Pakistan, whenever a polio case is confirmed. The team there will be joint analysis, planning, response, consists of representatives from the MoPH, monitoring, and reporting of case response. WHO, UNICEF, the Centers for Disease Control and Prevention, and the Bill & Melinda Gates Foundation with expertise in epidemiological Response to detection of poliovirus type 2 investigations and the management of outbreak In line with the global guidelines, the detection response activities. of any poliovirus type 2 – wild, vaccine-derived or even Sabin (four months post-switch) – will The National Rapid Response Team reports to be notified as required under the International the national EOC and is expected to: Health Regulations (2005). • conduct the detailed investigation of any new polio case within 72 hours of notification by In response to the detection of any type 2 the lab and produce a narrative report within poliovirus, the following actions will be taken: three days of completing the investigation; • investigation and risk assessment: • in coordination with the national EOC, support >>enhancing surveillance in all the provincial and regional teams in planning for concerned areas; any case response; and >>conducting a rapid field investigation; • provide feedback to the national EOC on >>conducting a risk assessment as per the additional support required. global Standard Operating Procedures, with the nature of the virus (e.g. WPV, Every new polio case will be responded to vaccine-derived or Sabin) and strength according to the following approach: of evidence of circulation (e.g. confirmed, • detailed epidemiological and probable or possible) determining the case investigation; potential risk of further poliovirus type 2 • three SIAs after the date of onset, covering at transmission (for type 2 isolates, unlike least 500 000 children in the surrounding area: type 1 or 3 isolates, the transmission >>first campaign to be conducted within classification (not typology) determines two weeks; response); and >>preferably one of the three campaigns to >>conducting an additional investigation be conducted with IPV, if the area is high to determine whether trivalent OPV or risk and has not received an IPV-OPV SIA monovalent oral polio vaccine type 2 in 2015/2016; (mOPV2) is still being used, or the potential >>target age to depend on epidemiology; and for a containment breach; >>national-level monitors to support and monitor pre-, intra- and post-campaign • response: phases of all response SIAs. >>beginning preparations for a vaccination response upon receiving initial sequencing The national EOC will produce a report on results (not waiting for a complete the outbreak response after the completion

29 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 epidemiologic investigation or final procedures to ensure effective vaccine classification of an isolate); management at all levels; >>implementing an initial vaccination • ensure forecasting, planning and timely response using mOPV2 (from a global delivery of all vaccines and non-vaccine stockpile), targeting 500 000 children aged items to service delivery points; under 5 years, within 14 days of receiving • secure resources required for all the planned the initial sequencing results; SIAs, including complementary vaccination >>depending on the further classification activities and case responses, as well as of the virus and the transmission risk cold chain equipment for the entire NEAP analysis, conducting additional SIAs implementation period; targeting a minimum of 2 million children • receive regular feedback on vaccines and cold approximately every two to three weeks; and chain from the EOC Vaccine Management >>using IPV-mOPV2 in one of the SIAs in Task Team, which will also provide weekly the outbreak area and IPV alone for an update during the EOC plenary meetings; expanded high-risk subpopulation. • implement global guidelines for cold chain logistics and vaccine management before, To conduct the response vaccination as during and after polio campaigns for effective described above, Afghanistan will apply to vaccine and cold chain management; and WHO to access mOPV2 and IPV from the • ensure vaccine utilization reports are global stockpile. submitted by the PEMTs to National EPI within 14 days of implementation of SIAs Effective vaccine and cold chain and on monthly basis for complementary management vaccination activities, to be able to assess the vaccine wastage rates and provide feedback To maintain effective vaccine and cold chain as needed; and management in the country, the national polio • enhance the skills of cold chain staff at eradication programme will: national and provincial levels in vaccine • task the national vaccine and cold chain and cold chain management through management committee to oversee the capacity building. technical and administrative processes/

30 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 Cross-border coordination

As already highlighted, Afghanistan and Pakistan • streamlined cross-notification of AFP cases form one common reservoir of poliovirus to ensure timely communication and the circulation. The national polio eradication sharing of detailed information on WPV programme will continue to strengthen cross- case investigations; border coordination with the Pakistan team • uniform communication interventions of at all levels. As agreed by the national teams the cross-border transit points and regular of both countries, the following activities will sharing of media/communication plans to be carried out: ensure consistent messaging; • weekly communication between the identified • timely information sharing on high-risk cross-border focal points of the Afghanistan population movements, including nomads, and Pakistan national EOCs; displaced populations, new immigrations • biannual face-to-face meeting and national and returnees; and EOC videoconferences; • development of a contingency plan to • monthly meetings of relevant provincial and ensure returnee refugee populations will be regional teams from both countries; vaccinated at entry points with OPV and IPV. • synchronization of SIA dates and communication of any changes in the dates;

Evaluation

In view of the current critical stage of the the end-of-term evaluation guiding the national polio eradication programme, development of the next NEAP; and to ensure that progress is being made against >>a surveillance review will be conducted the NEAP, the programme’s performance will in June 2017 to assess the ability of the be evaluated using the following methods: system to detect transmission; • operational evaluation: >>internal evaluations of NEAP 2016-2017 • population immunity evaluation: progress will be conducted in January >>indirect evaluation through an assessment 2017 (midterm) and June 2017 (end of of the vaccination status of non-polio AFP term), involving national and international cases; and experts and key stakeholders, with the >>direct evaluation through a serological results of the midterm review helping to survey conducted in the first quarter of make mid-course corrections and with 2017 in Kandahar.

Routine immunization strengthening

Efforts to strengthen routine immunization that the prioritized VHR districts for polio also will sustain the gains achieved by regular report low RI coverage and have high numbers supplementary immunization activities through of unimmunized or under-immunized children. to certification. It is important to highlight Continued emphasis in 2016/2017 will be to

31 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 reduce the number of un- and under-immunized Mobilization children in the prioritized VHR districts by Efforts include: regularly engaging the polio infrastructure • ensuring that during all relevant meetings and undertaking operations and mobilization with key stakeholders at the community efforts. The polio infrastructure will provide level, information on RI and the scheduled support, where feasible, in monitoring, training dates of outreach sessions are highlighted; and mobilization. • identifying the low RI coverage areas during household visits and missed children tracking Operations by FLWs to find areas where RI coverage is The terms of reference of all polio field staff low, and informing district and provincial will be reviewed to ensure that up to 20% of teams; and their time is earmarked for RI activity support, • as the role of the ICN will be expanded in particular for: beyond polio SIAs, focusing on the tracking • monitoring fixed and outreach sessions; and of newborns by the mobilizers, informing the • training health workers. parents and family members of all newborns • Staff will receive orientation and training on about RI vaccines and giving them the details their responsibilities by the end of the third of the EPI fixed centres, vaccinator contacts quarter of 2016 and performance indicators and dates of outreach. will be set and measured.

Transition planning

Although Afghanistan still remains polio Key actions to achieve this involve the endemic and is prioritizing the implementation following interventions: of activities to achieve Objective 1 of the global • structure: appointing a transition committee Polio Eradication & Endgame Strategic Plan before end of quarter three 2016 to oversee (poliovirus detection and interruption), it is the planning, chaired by a senior government important for the country to start planning representative, which would include participants for the transition of polio assets beyond from implementing partners, donors and other certification. Enabling the transition of polio key stakeholders in the health sector; assets to support other basic public health • management: identifying a focal person within functions, wherever possible, will be a priority. the national EPI to manage the development of A plan must be put in place to guide the the transition plan and ensure that a work plan transition of polio staff and infrastructure to is in place by the first quarter of 2017; support the country’s other health priorities, • asset mapping and stakeholder workshop: with with governmental or other sources of funding. the support of the PEI implementing partners, ensuring that asset mapping is conducted and The National EPI, MoPH, will take the lead a transition planning workshop is held in the in developing these plans, engaging donors fourth quarter of 2016; and and other key stakeholders in the process. • follow-up: ensuring that a draft plan is developed Transition Planning Guidelines will be used and shared with partners and donors for input to develop these plans, with support from the by the second quarter of 2017. Transition Management Group.

32 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017 List of annexes

I. Very high risk districts and high risk districts map II. Very high risk districts and high risk districts list III. SIA calendar July 2016 – June 2017 IV. IPV-OPV plan July 2016 – June 2017 V. NEAP 2016-2017 work plan VI. Accountability framework

33 NATIONAL EMERGENCY ACTION PLAN FOR POLIO ERADICATION | ISLAMIC REPUBLIC OF AFGHANISTAN 2016-2017