The document outlines the current challenges facing Afghanistan's polio eradication program and presents a 6-month plan to address these challenges and interrupt polio virus transmission. The plan focuses on strengthening program management and oversight; improving access, quality of campaigns, and cross-border coordination; and conducting supplementary immunization activities synchronized with Pakistan. Key elements include engaging political and community leaders, operationalizing an emergency action plan, targeting high-risk districts, and developing innovative approaches for reaching children in inaccessible areas. The TAG is asked to provide feedback on the appropriateness and feasibility of the 6-month plan.

1. Current challenges and plan for next 6 months
to interrupt polio virus transmission
Dr. Najibullah Safi
DG Preventive Medicines, MoPH
Technical Advisory Group Meeting
24-25 January 2016
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2. Current issues and challenges
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3. Program management
• New EOC structure
– Realignment of the program and data flow as per new
management structure
• Streamlining the oversight and management
structures
• Need to strengthen program management and
oversight in provinces
• Sub-optimal involvement of BPHS implementing NGOs
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4. Access
• Increased inaccessibility – particularly due to
deteriorating situation in eastern region following the
emergence of new groups
0%
2%
4%
6%
8%
10%
Feb'14SNID
Mar'14NID
May'14NID
Jun'14SNID
Aug'14NID
Sep'14SNID
Oct'15NID
Nov'14SNID
Feb'15SNID
Mar'15NID
May'15NID
Jun'15SNID
Aug'15NID
Oct'15SNID
Nov'15NID
Dec'15SNID
Dec'15LPD
Percentageoftargetchildren
Percentage of inaccessible target children in SIAs - ER
2014 - 2015
Region
73217
19885

5. Access Cont.
• Southern region: access to conduct quality campaign is
often used as political leverage for unrelated issues
• Quality of manpower: interference in selection
• In some areas, capacity to supervise and monitor is
limited
• Tracking of internally displaced population is not yet
systematic
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SIA can not be conducted
SIA can be conducted in only some of the area
SIA can be conducted with limitations
SIAS can be conducted in all areas of the district
District_boundaries.shp
1
2
3
4
Provincial_boundries.shp
Nov 2015 NID

6. Quality of campaign
• Chronically missed children in accessible areas
(Kandahar, Helmand and Farah):
– Quality of manpower selection
– Quality of training for vaccinators
– Suboptimal revisit strategy
• Use of monitoring data (ICM and PCA) for program
correction is still suboptimal
• Quality of PCA in Kunar is a concern
• Ability to conduct LQAS in selected areas as per
sampling methodology is compromised due to
security challenges
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7. Communication
• High levels of awareness but lack of knowledge about
the disease and ongoing mistrust, particularly in the
east
• Challenge in reaching audience, particularly women
• Sub-optimal data quality in monitoring performance
of ICN network
• Limited activities between campaigns at
cluster/district level
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8. Cross-border coordination
• Coordination between east/south east region and
FATA/KP is not regular
• Face-to-face meetings at national level are not
happening regularly
• Coordination of communication approaches between
Afghanistan and Pakistan is not systematic
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9. Epidemiology and surveillance
• Orphan virus in environmental surveillance from
Nengarhar (only virus in 2015 as compared for 4 in
2014)
• Low stool adequacy in Nimroz and Kandahar
provinces
• Repeated importations from Pakistan
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10. Vaccine management and cold chain
• Sub-optimal RI coverage in high risk provinces
• Vaccine utilization reports not systematically received
from the provinces
• Denominator issues result in last-minute additional
vaccine requests from provinces
• SOPs for vaccine and cold chain management not
followed in the field as required
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11. Plan for next 6 months to interrupt polio
virus transmission
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12. Oversight, coordination and management
• Strengthen engagement of political leadership at
provincial/district level to enhance program oversight
• Further engage line ministries through office of
presidential focal point for polio
• Make EOCs fully functional with dashboards and strong
accountability framework by mid-Feb
• Systematically engage BPHS NGOs in program (CHWs,
ICM and EOC) at provincial/district levels
• Establish polio coordination units in 5 priority provinces
by end-Feb
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13. National emergency action plan
• Full implementation of NEAP and close monitoring of
progress through EOCs
• Use of NEAP activity tracker dashboard
• Review of NEAP implementation in mid-February and
adjustment of action plan accordingly
• Develop NEAP 2016/2017 by May 2016
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14. Interventions in LPDs
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LPD
category
Specific SIAs Increased resources Monitoring
LPD 1 LPD SIAs  1 DPO (possibly one PPO) and
1 DCO
 Decreased Vaccinator to
supervisor ratio
 M and A offcers
 LQAS in each campaign
 National level monitors
 Increased post campaign
monitors
 Close tracking of Preparation
and activity
LPD 2 LPD SIAs  1 DPO and 1 DCO
 Decreased Vaccinator to
supervisor ratio
 M&A officers
 LQAS in each campaign
 Increased post campaign
monitors
 Close tracking of Preparation
and activity
LPD 3 LPD SIAs  Fill existing vacancies, if any
 M&A officers to be considered
 PCA and ICM to be continued.
 25% of LPD 3 target for LQAS
in each campaign on rotation

15. Supplementary immunization activities
• Implement 6 SIAs synchronized with Pakistan in first
half of 2016 and OPV-IPV SIAs in 28 high risk districts
• Ensure highest quality of activities in all 47 (LPD 1&2)
high risk districts:
1. Fast track micro plan revision to complete in all high
risk districts by end of Q1 2016
2. Roll out revised training methodology by end-Feb 2016
3. Operationalization of updated revisit strategy country
wide (strengthen daily revisit & 5th day revisit) by
March NID
- Day 4 for the planning of revisit
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16. Supplementary immunization activities Conti.
4. Use of PCA data to identify and address chronically
missed children
5. Streamline flow and use of ICM information using
mobile technology for concurrent correction
6. Direct oversight of 19 priority 1 high risk districts by
national level monitors
• Introduce CHV approach in one LPD in southern region
in Feb
– Phased expansion in poor performing priority 1 districts
in east and south by May NIDs
• Review and improve quality of PCA in Kunar
• Fully implement IPV SIA plan for Q1 of 2016
• Tracking displaced population for immunization
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17. 12-15 Jan-LPDs 16-19 Feb-SNIDs
19-22 Apr-SNIDs
15-18 Mar-NIDs
17-20 May-NIDs 7-10 Jun-LPDs
tOPV bOPV
SIA Schedule for Q1 - Q2 2016
2 NIDs, 2SNIDs and 2 LPD campaigns during the low transmission
season / fully synchronized with PAK SIAs

18. Plan of IPV SIAs - Q1 2016
PHASE Districts Dates Target
Population
Doses
required
Phase 1 Nangarhar-Achin, Lalpura,
Momandara
Farah (Balabaluk, Gulistan)
Herat (Shindand)
31st Jan to 6th
Feb 2016
180,243 212,686
Phase 2 Nangarhar-(Batilkot,
Dehbala, Kot)
Kandahar (10 districts)
28th Feb to 5th
Mar 2016
261,443 308,503
Phase 3 Helmand (Kajaki, Nawa-e
Barakzaly, Nawzad,
Sangin, Washer,
Lashkargah, Nadali/Marja,
Nahre Siraj, Musaqala)
27th Mar to 2nd
April 2016
371,298 438,132
Total 812,984 959,321
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19. Communication
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• Strengthen communication HR capacity
• Create a more focused enabling environment to
promote trust in vaccination
– Expand radio partnerships focused on high risk districts
• Scale up household and community engagement
approaches, including between campaigns
– Standardized ICN structure/activities throughout high
risk districts
– Monthly district-specific communication action plans
• Improve monitoring of communication approaches
• Equip CHVs and FLWs with IPC training and polio plus
materials

20. Inaccessible areas
• Develop and implement area specific plans for eastern
and southern regions, and for the rest of country, by
mid-Feb
• Maintain program neutrality
• Continue negotiations through partners for full access
in high risk districts
• Sub-district-level mapping of access and area specific
approaches completed for high risk districts of eastern
region by mid-Feb
• Engage NGOs who have access for delivery of vaccine
and monitoring of campaign
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21. Inaccessible areas Cont.
• Systematic engagement of local communities and
elders; ensure use of locally appropriate vaccinators
• Explore feasibility of delivering OPV combined with
other services (e.g. health camps) by end-Feb
• Review and strengthen permanent vaccination points
by end-Feb
• Maintain preparedness to conduct SIAs (including IPV
SIAs) when any area becomes accessible
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22. Cross border coordination
• Quarterly VC between Afghanistan - Pakistan national
EOCs with bi-annual face-to-face meeting
• Fortnightly TC at regional level with regular exchange of
information
• Sharing of information on cross-border population
movements to ensure coordinated vaccination
• Synchronized communication approaches between
Afghanistan - Pakistan at border sites
• Produce and analyse data as per epidemiological blocks
from Feb 2016
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23. Synchronized SIAs in Pakistan & Afghanistan in 2011
AFGHANISTAN PAKISTAN
NIDs SNIDs SNIDs NIDs
NID 11-14 Jan 2016
LPD
7-10 Jun
SIA schedule AFG & PAK, 1st semester 2016
LPD
12-15 Jan
SNID 15-18 Feb 2016
NID 15-18 Mar
SNID 19-22 Apr
NID 14-17 Mar 2016
SNID 18-21 Apr 2016
NID 17-20 May SNID 16-19 May, 2016
SNID 16-19 Feb
LPDs
bOPV
tOPV
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24. Vaccine management
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• Ensure vaccine availability for all planned SIAs,
complimentary immunization activities (CB, PTTs, PPTs)
and sufficient buffer stock to address case responses
• Functionalise systematic delivery of vaccine utilization
reports from the provinces
• Strengthen capacity of provincial and district-level SIA
service providers to ensure SOPs for vaccine and cold
chain management during SIAs are followed
• Update cold chain equipment requirement for SIAs bi-
annually

25. Surveillance
• Explore expansion of environmental sampling sites and
expand by end of Q1 2016
• Track quality of surveillance in inaccessible and security
compromised areas through disaggregated data
analysis and disaggregate analysis of surveillance data
by district
• Conduct reason analysis of low stool rate in Kandahar
and Nimroz and take corrective action
• Conduct Surveillance review in Q2 of 2016
• Tracking displaced population for surveillance1/24/2016 25

26. Questions to the TAG
• Is the 6-month plan presented, appropriate to achieve
interruption of polio transmission?
• What should the target age group be for cross-border
vaccination?
• Is the plan to introduce the CHV approach in the
southern region and phased expansion to poor
performing priority 1 districts appropriate?
• Does the TAG endorse the plan presented for reaching
children in inaccessible areas?
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27. THANK YOU
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