Eradicating polio in Pakistan: a systematic review of programs and policies

Figures & data

Figure 1. Poliovirus case count in Pakistan: 1994 – 2020 [20–24,118]

Figure 2. Prisma

Figure 3. Overview of polio policies and programs in Pakistan

Table 1. Polio program and policy analysis table

Policies/Programs/Strategies/Plans
GLOBAL
GPEI Emergency Action Plan 2012–2013 (2011)	Description	The GPEI developed the GPEI Emergency Action Plan 2012–2013 for Nigeria, Pakistan, and Afghanistan. The goal of this plan was to help get the GPEI back on track in the endemic regions through an emergency approach. The plan builds upon the strategies highlighted in the GPEI Strategic Plan 2012-2012, and was focused on developing appropriate leadership, oversight, accountability and surge capacity at global, national and sub-national level to support a transformational change.
	Classification	Global initiative
National Stop Transmission of Polio (N-STOP) programme (2012)	Description	Piloted in Nigeria, N-STOP is a CDC-WHO collaborative program which supports eradication efforts in polio priority countries, by strengthening local surveillance, training local health professionals, and deploying public health professionals accordingly. The National Stop Transmission of Polio (N-STOP) program was established in Pakistan in 2012; 16 public health professionals were deployed as part of Pakistan’s N-STOP program.
	Classification	Global initiative
Islamic Advisory Group Adopts Anti-Polio Plan (2015)	Description	The Islamic Advisory Group for Polio Eradication (IAG) adopted a new action plan that sought to help eradicate polio in the remaining Muslim nations. The meeting was hosted by Al Azhar in Cairo and was attended by Islamic scholars and experts of the IAG. Specific to Pakistan, the IAG aimed to enhance the work of the National Islamic Advisory Group for Polio Eradication in Pakistan, through increased advocacy and communication activities, and also planned to organize for members of the IAG to visit and interact with religious institutions in priority areas of Pakistan.
	Classification	Global initiative
NATIONAL
Pakistan Polio Eradication Programme (1994)	Description	The Pakistan Polio Eradication Program, a public–private partnership between the Government of Pakistan and partners from the GPEI (WHO, UNICEF, BMGF, Rotary International, and CDC), was launched in 1994. The initiation of polio eradication efforts was signified by the first set of supplementary immunization activities (SIAs) through National Immunization Days (NIDs).
	Classification	National programmatic action
Trivalent OPV (1994–2016)	Description	Trivalent OPV (tOPV) was the only vaccine used in SIAs between 1994-2004, after which a combination of monovalent and bivalent vaccines were used. The trivalent vaccine was withdrawn globally in 2016.
	Classification	National programmatic action
Acute Flaccid Paralysis (AFP) surveillance begins (1995)	Description	The program began conducting acute flaccid paralysis (AFP) surveillance in 1995. As part of the AFP surveillance, AFP cases in children aged less than 15 years were reported to surveillance bodies and further investigated as possible polio cases
	Classification	National programmatic action
AFP surveillance becomes fully functional (1998)	Description	AFP surveillance was fully functional by 1998, after provincial staff were provided training and computerized case listings were introduced.
	Classification	National programmatic action
Synchronization of Pakistan and Afghanistan SIAs (1998)	Description	To ensure comprehensive coverage of border regions and children in transit, immunization activities in Pakistan and Afghanistan were synchronized.
	Classification	National programmatic action
Stop Transmission of Polio (STOP) program (1999)	Description	The STOP program is a collaborative program run by the CDC, WHO, and UNICEF. In 1999, the Stop Transmission of Polio (STOP) program was launched; international health professionals were sent to Pakistan on 3 to 5 months assignments to assist with polio eradication activities and improve the quality of surveillance activities.
	Classification	National programmatic action
House-to–house vaccination strategy implemented (1998–1999)	Description	During the implementation of the 1998-1999 subnational immunization days (SNIDs) in Pakistan, a house-to-house vaccination approach was introduced. The house-to–house vaccination approach was expanded further in 2000, and became a core aspect of Pakistan’s polio eradication strategy.
	Classification	National programmatic action
First ‘Partnership for Polio Eradication’ project (2003–2006)	Description	In 2003, the First Partnership for Polio Eradication project was implemented by the Government of Pakistan. [24] This project was funded by the World Bank, and the objective of this project was to support the supply to the Government of Pakistan (GoP) of 50% of the Oral Polio Vaccine (OPV) needed for Supplemental Immunization Activities during 2003–2005. Project funds were transferred to UNICEF, who was responsible for vaccine procurement and delivery, as per an agreement between the Government of Pakistan and UNICEF. The project financed the procurement of 371 million oral polio vaccines (OPV) for SIAs held between 2003 to 2006, and roughly 30 million children were immunized in each round.
	Classification	National programmatic action
First National EPI policy (2005)	Description	In 2004, the National EPI Advisory Group (NEAG) developed the first National EPI policy, which was adopted by the former Ministry of Health in 2005. The new EPI policy introduced new vaccines and technologies, and aligned its goals with priorities set at the global and regional level. Specific to vaccinations, the policy introduced new strategies for immunizations and vaccine preventable disease (VPD) surveillance.
	Classification	National policy formation and modifications
Monovalent OPV (2005–2010)	Description	Monovalent OPV (mOPV) was introduced in Pakistan in 2005 (mOPV1) and 2007 (mOPV3), and were used until the introduction of bivalent OPV in 2010.
	Classification	National programmatic action
Second ‘Partnership for Polio Eradication’ project (2006-2008)	Description	In 2006, the Second Partnership for Polio Eradication project was implemented by the Government of Pakistan, an extension of the initial project implemented in 2003. The second project was also financed by the World Bank, and vaccine procurement and delivery was also handled by UNICEF. The second project financed the procurement of approximately 590 million doses of OPV to children between 2006 to 2008. Approximately 30 million children were immunized in each round of SIAs.
	Classification	National programmatic action
Finger-marking in polio campaigns (2008)	Description	Finger-marking was introduced into polio campaigns in 2008 to objectively measure polio quality. This measure was intended to complement parental recall and other methods used to identify previously vaccinated children.
	Classification	National programmatic action
Inter-Provincial Committee for Polio (IPCP) (2009)	Description	In 2009, the Federal Ministry of Health established the Inter-Provincial Committee for Polio (IPCP), which was chaired by the Federal Minister of Health. The ICPC was responsible for managing inter–sectoral coordination, monitoring the engagement of officials working at district and union council levels, and bringing together all provincial health ministers in order to collectively address challenges experienced when implementing polio eradication strategies.
	Classification	Federal alliance
EPI Policy revised to involve LHWs (2009)	Description	In 2009, the EPI policy was revised and provided guidelines highlighting greater involvement of lady health workers (LHWs) in immunization programs. The revised EPI policy specified that LHWs who are trained in EPI will deliver vaccination services, and LHWs who are not trained in EPI will assist the vaccinator by organizing vaccination services and mobilizing community members.
	Classification	National policy formation and modifications
Third ‘Partnership for Polio Eradication’ project (2009–2014)	Description	In 2009, the third ‘Partnership for Polio Eradication’ project was implemented by the Government of Pakistan, the final extension of the initial project implemented in 2003. The third project was also financed by the World Bank, and UNICEF continued to be responsible for vaccine procurement and delivery. The third project ensured timely supply and procurement of OPV for polio campaigns conducted between 2009-2014, and approximately 32 million children were immunized in each round of SIAs.
	Classification	National programmatic action
Environmental surveillance (2009)	Description	Surveillance activities were expanded in 2009, when environmental surveillance was implemented. Sewage testing began in Lahore and Karachi, and enabled virus transmission to be monitored so that poliovirus reservoirs could be identified.
	Classification	National programmatic action
Bivalent OPV (2010–present)	Description	Bivalent OPV (bOPV) containing wild polioviruses 1 and 3 was introduced in 2010. bOPV replaced tOPV in 2016, and continues to be used today,
	Classification	National programmatic action
Decentralization of Pakistan’s health care system (2010)	Description	The passing of the 18th Amendment to the Constitution by the National Assembly of Pakistan in 2010 resulted in the decentralization of Pakistan’s federal health care system. As a consequence, the Federal Ministry of Health was devolved, and health care responsibilities were transferred from federal to provincial authorities.
	Classification	National policy formation and modifications
National Emergency Action Plan (NEAP) (2011-2020)	Description	The National Emergency Action Plan (NEAP) was developed and launched in 2011. After limited success of the NEAP 2011, and Augmented NEAP was launched in 2012, with the goal of stopping poliovirus transmission by the end of 2012. The goal of ending transmission was not achieved, thus followed the implementation of a yearly NEAP in 2013. This is an annual strategic plan which has been released every year to date, and outlines the program’s eradication strategy, priorities, and innovations. The NEAP includes coordination with and support from GPEI partners.
	Classification	National programmatic action
PM’s Polio Monitoring & Coordination Cell (2011)	Description	The Prime Minister’s Polio Monitoring & Coordination Cell was established in 2011. The purpose of this new Cell was to monitor and coordinate polio-eradication activities nationwide. The specific duties of the Cell included the following: 1) To liaise on a regular basis with the Provincial Monitoring Cells, Provincial health departments, National and Provincial EPI teams, Chief Secretaries office, DCOs, EDOs Health and other relevant departments and organizations to regularly monitor the progress of the Polio Eradication Initiative and provide feedback to the Prime Minister. 2) To facilitate and ensure the establishing of Polio Monitoring Cells at the Provincial level in line with announcement made by the Prime Minister on 14 January 2011. 3) To provide guidance, technical input and situation analysis to the National Task Force on Polio Eradication led by the Prime Minister.
	Classification	Federal alliance
National Task Force on Polio Eradication (2012)	Description	The President of Pakistan declared polio eradication a national emergency, and established the National Task Force on Polio Eradication in 2012. The Task Force was to be chaired by the Prime Minister, and constituted of provincial chief ministers and chief secretaries.
	Classification	Federal alliance
National Vaccine Management Committee (NVMC) (2012)	Description	In 2012, a National Vaccine Management Committee (NVMC) was established at the federal level, with representation from EPI, WHO, and UNICEF. The Committee was responsible for supporting vaccine management and reporting, including vaccine storage, transport, and utilization. The Committee was developed in response to the recommendations made by UNICEF, after they conducted a vaccine management review which highlighted issues with vaccine storage and wastage, and cold chain maintenance.
	Classification	Federal alliance
Revision of security operations (2012)	Description	After a series of attacks on polio workers and vaccination campaigns in 2012, the program adapted and began to operate under a new security framework, with intensified security operations in place for frontline health workers.
	Classification	National programmatic action
Section 144 of the Criminal Procedure Code invoked (2012)	Description	Section 144 of the Criminal Procedure Code was invoked for the first time during a polio campaign in Pakistan in 2012, by the District Coordination Officer (DCO) of Faisalabad. Section 144 was implemented to counteract vaccine refusals, and made it a criminal offense for parents to refuse vaccinating their children during polio campaigns. Furthermore, under Section 188 of the Pakistan Penal Code, action could be taken against parents who refused to let health teams vaccinate their children against polio during the anti-polio campaigns. According to press releases, this seems to be the first time that the law held non-compliant caregivers accountable, however Section 144 was also implemented in other cities such as Peshawar (2014), Charsadda (2015), and Mardan (2020).
	Classification	National policy formation and modifications
Polio communication approach shifted as an Islamic responsibility (2013)	Description	The polio communication approach saw a shift in 2013; with support from UNICEF, the Government of Pakistan began to emphasize polio vaccination as an Islamic responsibility.
	Classification	National programmatic action
Fatwa issued urging parents to immunize their children (2013)	Description	A prominent Pakistani religious scholar, Maulana Sami Ul Haq, issued a Fatwa (Islamic ruling) urging parents to immunize their children against poliovirus.
	Classification	National programmatic action
Emergency Operations Center (EOC) (2014)	Description	The Government of Pakistan launched the Emergency Operations Centers (EOC), at both the federal and provincial levels. These centers were to be supported by Polio Eradication Committees at the district and union-council levels, and were responsible for timely monitoring of activities, and responding to the needs of local areas in a prompt and effective manner.
	Classification	Federal alliance
International Ulama Conference on Polio Eradication (2014)	Description	The International Ulama Conference on Polio Eradication was held in 2014, and had representation from Pakistan, Saudi Arabia, Egypt, and other Islamic nations. At this conference, the Ulama of Pakistan issued a Fatwa declaring the use of polio vaccine completely permissible under Islamic Sharia, and they also reassured the community that the polio vaccine does not contain any harmful ingredients, further endorsing its use.
	Classification	National programmatic action
Revision of National EPI Policy (2015)	Description	The revised EPI policy was released in 2015, and outlined the following objectives: 1) To affirm the commitment of the Government of Pakistan (GOP) to provide safe, effective and cost-effective vaccination against Vaccine Preventable Diseases (VPDs). 2) To set national standards and guidelines for immunization aligned with the global goals and evidence base, and encourage the program for generation of local evidence for vaccination against VPDs.
	Classification	National policy formation and modifications
IPV introduced into the national EPI (2015)	Description	According to the revised national EPI policy, one dose of IPV was introduced into the routine immunization schedule.
	Classification	National policy formation and modifications
Revision of security plans to include armed forces (2015)	Description	Ongoing attacks against polio workers led to the revision of the program’s security plan in 2015. Minister for National Health Services Saira Afzal Tarar chaired an emergency high level polio security meeting, which was attended by representative of Armed Forces, Ministry of Interior. Secretary, and Ministry of National Health Services. The outcomes of this meeting were as following: 1) A post incident inquiry be conducted in the event of any polio–related attack. These inquires will be conducted by a team consisting of a Ministry of Interior representative, an official from the intelligence agencies, a District Police Officer representative, and an expert representing the polio program. This inquiry should determine the case, fix responsibilities if a lapse in security arrangements was identified, and make recommendations to avoid recurrence of such events. 2) Provinces will be allowed to seek help from civil armed forces or armed forces to ensure security cordoning of campaign areas.
	Classification	National policy formation and modifications
National Immunization Support Project (NISP) (2016)	Description	In 2016, the National Immunization Support Program (NISP) was implemented, with the goal of providing the Government of Pakistan with additional funding to strengthen the national EPI program. The NISP has the following objectives: 1) Increase the equitable coverage of services for immunization against vaccine preventable diseases (VPD), including poliomyelitis, for children between 0 and 23 months in Pakistan, 2) Improve immunization services through strengthening Routine Immunization and introduce Systems Strengthening approach, 3) Interruption of transmission of indigenous wild Poliovirus by the end of 2015 and certification of a Polio Free Pakistan by the end of 2018.
	Classification	National programmatic action
Polio Endgame Strategy 2019–2023 (2019)	Description	The GPEI launched the Polio Endgame Strategy 2019-2023 in 2019. The Endgame Strategy outlines the strategic plan for eradicating polio globally, with a particular focus on the polio-endemic countries. The plan highlights that complete polio eradication will require prompt detection and interruption of polio transmission, strong immunizations systems and integration of polio surveillance with other VPD surveillance systems, and the ultimate containment of all polioviruses.
	Classification	National programmatic action
PROVINCIAL
‘Sehat ka Insaf’ (health justice) campaign – Khyber Pakhtunkhwa (2014)	Description	The Pakistan Tehreek-e-Insaf (PTI) political party launched the ‘Sehat ka Insaf’ campaign in Khyber Pakthunkhwa in 2014, with the goal of protecting children against nine vaccine-preventable diseases, including polio. The campaign was initially launched in Peshawar and reached approximately 30,000 families, costing the PTI government roughly 20 billion rupees.
	Classification	Provincial action
‘Sehat Ka Ittehad’ (health unity) program – Khyber Pakhtunkhwa (2015)	Description	The ‘Sehat Ka Ittehad’ program was launched in Khyber Pakhtunkhwa in 2015. The ‘Sehat Ka Ittehad’ program was aimed at providing polio vaccination, and vaccinations against other diseases such as measles and diarrhea, to children in FATA and other regions of Khyber Pakthunkhwa, who had not been vaccinated due to inaccessibility or security reasons.
	Classification	Provincial action
Khyber Pakhtunkhwa Immunization Support Project (2015)	Description	The Khyber Pakhtunkhwa Immunization Support Project (KPISP) was launched in Khyber Pakhtunkhwa in 2015. KPISP was aimed at providing additional funding to support the province’s existing EPI program, and increasing coverage of VPD, including polio, among children.
	Classification	Provincial action

Figure 4. Quality of AFP surveillance in Pakistan: 2000-2020 [118]

World Health Organization. Polio case count [ cited 2021 January 11]. Available from: https://extranet.who.int/polis/public/CaseCount.aspx

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