Progress Toward Poliomyelitis Eradication - Pakistan, January 2018-September 2019.

Afghanistan and Pakistan are the only countries that continue to confirm ongoing wild poliovirus type 1 (WPV1) transmission (1). During January 2018-September 2019 the number of WPV1 cases in Pakistan increased, compared with the number during the previous 4 years. This report updates previous reports on Pakistan's polio eradication activities, progress, and challenges (2,3). In 2018, Pakistan reported 12 WPV1 cases, a 50% increase from eight cases in 2017, and a 31% increase in the proportion of WPV1-positive sites under environmental surveillance (i.e., sampling of sewage to detect poliovirus). As of November 7, 2019, 80 WPV1 cases had been reported, compared with eight cases by the same time in 2018. An intensive schedule of supplementary immunization activities (SIAs)* implemented by community health workers in the core reservoirs (i.e., Karachi, Peshawar, and Quetta) where WPV1 circulation has never been interrupted, and by mobile teams, has failed to interrupt WPV1 transmission in core reservoirs and prevent WPV1 resurgence in nonreservoir areas. Sewage samples have indicated wide WPV1 transmission in nonreservoir areas in other districts and provinces. Vaccine refusals, chronically missed children, community campaign fatigue, and poor vaccination management and implementation have exacerbated the situation. To overcome challenges to vaccinating children who are chronically missed in SIAs and to attain country and global polio eradication goals, substantial changes are needed in Pakistan's polio eradication program, including continuing cross-border coordination with Afghanistan, gaining community trust, conducting high-quality vaccination campaigns, improving oversight of field activities, and improving managerial processes to unify eradication efforts.

Progress Toward Poliomyelitis Eradication - Pakistan, January 2017-September 2018.

Among the three wild poliovirus (WPV) serotypes, only WPV type 1 (WPV1) has been reported in polio cases or detected from environmental surveillance globally since 2012. Pakistan remains one of only three countries worldwide (the others are Afghanistan and Nigeria) that has never had interrupted WPV1 transmission. This report documents Pakistan's activities and progress toward polio eradication during January 2017-September 2018 and updates previous reports (1,2). In 2017, Pakistan reported eight WPV1 cases, a 60% decrease from 20 cases in 2016. As of September 18, 2018, four cases had been reported, compared with five cases at that time in 2017. Nonetheless, in 2018, WPV1 continues to be isolated regularly from environmental surveillance sites, primarily in the core reservoir areas of Karachi, Quetta, and Peshawar, signifying persistent transmission. Strategies to increase childhood immunity have included an intense schedule of supplemental immunization activities (SIAs), expanding and refining deployment of community-based vaccination implemented by community health workers recruited from the local community in reservoir areas, and strategic placement of permanent transit points where vaccination is provided to mobile populations. Interruption of WPV1 transmission will require further programmatic improvements throughout the country with a focus on specific underperforming subdistricts in reservoir areas.

Experiences and Lessons From Polio Eradication Applied to Immunization in 10 Focus Countries of the Polio Endgame Strategic Plan.

Nine polio areas of expertise were applied to broader immunization and mother, newborn and child health goals in ten focus countries of the Polio Eradication Endgame Strategic Plan: policy & strategy development, planning, management and oversight (accountability framework), implementation & service delivery, monitoring, communications & community engagement, disease surveillance & data analysis, technical quality & capacity building, and partnerships. Although coverage improvements depend on multiple factors and increased coverage cannot be attributed to the use of polio assets alone, 6 out of the 10 focus countries improved coverage in three doses of diphtheria tetanus pertussis containing vaccine between 2013 and 2015. Government leadership, evidence-based programming, country-driven comprehensive operational annual plans, community partnership and strong accountability systems are critical for all programs and polio eradication has illustrated these can be leveraged to increase immunization coverage and equity and enhance global health security in the focus countries.

Sexual Violence-Related Pregnancy Among Internally Displaced Women in an Internally Displaced Persons Camp in Northeast Nigeria.

Sexual violence is quite common in conflict situations and puts women at risk of unintended pregnancies. In the northeast region of Nigeria with the ongoing insurgency, a substantial number of women are kidnapped and subjected to forced marriages and repeated sexual assaults. This study set out to report on the disclosure and outcomes of sexual violence-related pregnancies (SVRPs) among women liberated from insurgents and relocated to one of largest Internally Displaced Persons (IDP) camps located in Borno State, northeast Nigeria. The clinic records of women with SVRP were reviewed. Forty-seven women with SVRP were identified by the health care providers using a snowball technique to reach as many of the women with SVRP as possible. The mean age of the participants was 15.3 years (SD = 3.4 years), and all the participants had spent 2 years or more in captivity. Most of the women first disclosed the pregnancy to their peers before disclosure to health care providers or family members. All the women initially requested to have the pregnancy terminated; however, abortion services are not offered in the clinic in line with the country's restrictive abortion laws. Following counseling and psychosocial support offered in the clinic, 19 (40%) of the women continued with the pregnancy and were delivered in the camp clinic while the remaining 26 women left the camp shortly after disclosure and pregnancy outcomes are not known. SVRP is not uncommon in humanitarian settings with its associated stigma and unwillingness among the survivors to keep the pregnancy. There is a need for further studies to provide more insight into the extent of this problem and help-seeking for SVRPs especially for women in such difficult circumstances to provide needed empirical information to drive advocacy efforts for more comprehensive services.

Quantifying movement patterns and vaccination status of high risk mobile populations in Pakistan and Afghanistan to inform poliovirus risk and vaccination strategy.

BACKGROUND: Stopping serotype 1 wild poliovirus transmission in Pakistan and Afghanistan requires ensuring all children <5 years of age are repeatedly vaccinated, including the large proportion living in mobile groups. Vaccinating children living in high-risk mobile populations (HRMPs) remains a priority for the polio programme. METHODS: In 2017-2018, group-level censuses were conducted in 43 districts of Pakistan, gathering information for all HRMP children <5 years of age residing in settlements. Demographic and mobility information was collected, including HRMP type, ethnicity, language, mode of transportation and movement patterns. Vaccination status was recorded for the most recent polio campaign. Proportion of HRMP children by demographic factors and mode of transportation was determined and the magnitude of movement was quantified based on the origin, previous and next locations. Magnitude of cross-border movement with Afghanistan was evaluated, as was primary crossing point. Vaccination status was evaluated for each district by demographic and mode of transportation information. RESULTS: In total, 188,130 HRMP children <5 years of age were assessed. The predominant HRMP type, ethnic group, language and mode of transport was Afghan refugees (27%), Pashtun (69%), Pashto (69%) and bus (52%). Overall, 84% of children originated outside of their current district, including 29% from Afghanistan. Previous and next locations, were reported outside of current location by 34% and 77% of children. Afghanistan was previous and next location for 5% and 11% of children, with 5.5% and 3% of children crossing the Afghanistan border in the past 6-months and next 3-months. Primary crossing route was Torkham (79%). Overall vaccination coverage was 98% (IQR: 96%-99%) and consistently >90% across HRMP type, ethnic group, language and mobility means. CONCLUSION: Large numbers of HRMPs were found across Pakistan, with substantial links throughout the country and with Afghanistan. While vaccination coverage of HRMPs was high, ensuring these populations are consistently vaccinated remains a priority.

Needle-free injectors for mass administration of fractional dose inactivated poliovirus vaccine in Karachi, Pakistan: A survey of caregiver and vaccinator acceptability.

The first large-scale vaccination campaign using needle-free jet injectors to administer fractional doses of inactivated poliovirus vaccine (fIPV) was conducted in Karachi, Pakistan, in February 2019. Data on acceptability of jet injectors were collected from 610 vaccinators and 4898 caregivers during the first four days of the campaign. Of those with prior needle and syringe experience, both vaccinators and caregivers expressed a strong preference for jet injectors (578/592 [97.6%] and 4792/4813 [99.6%], respectively), citing ease of use, appearance, and child's response to vaccination. Among caregivers, 4638 (94.7%) stated they would be more likely to bring their child for vaccination in a future campaign that used jet injectors. Mean vaccine coverage among towns administering fIPV was 98.7% - an increase by 18.4% over the preceding campaign involving full-dose IPV. Our findings demonstrate the strong acceptability of fIPV jet injectors and highlight the potential value of this method in future mass campaigns.