National Emergency Action Plan for Polio Eradication 2018/2019 [Pakistan]

"Communication has come to the fore, as the programme employs robust strategies and a clever use of media to address refusals during vaccination rounds and instill greater trust by parents, caregivers, and communities nationwide. This was no easy feat..." - Aamir Mehmood Kiyani, Federal Minister for National Health Services, Regulations and Coordination

Produced by the National Emergency Operations Centre (NEOC) for Polio Eradication, Islamabad, Pakistan, this document sets forth the National Emergency Action Plan (NEAP) for polio eradication in that country for the time period 2018-2019. As noted here, the Pakistan Polio Eradication Initiative (PEI) has made tremendous progress towards polio eradication in the past 3 years, with the lowest ever number of confirmed wild poliovirus (WPV) cases reported in 2017. It remains one of 2 countries in the world still reporting WPV cases; the other country is neighbouring Afghanistan. As of June 2018, a total of 13 cases - 3 from Pakistan and 10 from Afghanistan - have been reported. All 2018 cases in Pakistan have been reported from Dukki, a rural district in Balochistan.

Pakistan now has one of the highest polio vaccination acceptance rates in the world: over 95% self-declared coverage by caregivers, according to the latest Knowledge, Attitudes, and Practices (KAP) survey. Integrating communications and community engagement into the overall operations of the programme and aligning trust-building with tracking and covering missed children has been critical to this success. Past investments in recruitment, training, and supportive supervision has been paying off, as the KAP 2017 shows improved trust in frontline workers (FLWs) in the majority of polled caregivers (74%).

According to the NEOC, the next chapter of Pakistan's eradication story will require deeper analysis and an understanding of street-by-street barriers and customised, contextualised responses. As a first step in this direction and in response to Technical Advisory Group (TAG) 2017 recommendations, the NEOC commissioned focus group discussions (FGDs) to dig deeper into the reasons for refusals in core reservoir areas. The following are areas of concern highlighted in the FGDs:

• A perception that polio now presents a very low risk.
• A very complex set of reasons for refusal, misconceptions.
• Increased fatigue within the programme.
• Reports of too many campaigns and too many knocks.

In developing its NEAP 2018/2019 priorities, the programme reflected on the following:

• Vaccine safety and efficacy: A recurrent theme for refusals, issues around vaccine safety linger and more and more questions are asked around the efficacy of the vaccine as campaign intensity continues.
• Refusals and community resistance: The number of refusals has plateaued or are increasing.
• Campaign pressure: During the implementation of the previous NEAP, campaigns took place every 4 weeks in the core reservoirs, leaving little time for corrective actions, especially communication-related ones. Beyond these operational concerns, the programme is testing the limits of caregiver acceptance and goodwill – and this needs to be addressed in the upcoming 6-week cycle.
• Contextual communications: The planning and monitoring of the programme emphasised operational improvements, and little effort was spared for communication aspects. More FLWs will be equipped with communication skills so that they can effectively respond to the community resistance widely reported, specially, in the core reservoirs. The District Polio Control Room (DPCRs) and the provincial EOCs will adopt an accountability framework that focuses on the impact of the communication interventions.
• Frontline motivation and support: The local, female profile of the vaccinator remains the cornerstone in establishing trust with caregivers and the community. There is a need to continue motivating vaccination teams, building their capacity to sustain pressure and negotiate with the community and households whilst maintaining a supportive environment within which to work, so problems may be quickly surfaced for action.
• Refusal and defaulter data: Granular and systematic triangulation of data in the reservoirs and high-risk areas is essential to better locate pockets of geographical and social clusters of silent refusals and identify the most appropriate influencers to effective engage and convert.
• Traditional media: The situation is fragile, and, therefore, regular and proactive media engagement is required in order to shift the dominant, neutral media tone to a positive one to better handle communication during a crisis.
• Social media: The programme's social media engagement to date has been limited and rarely proactive. Moreover, an increasing threat from antivaxxer propaganda, spread through social media (particularly WhatsApp) and occasionally picked up by traditional media, has had a direct impact on the increasing number of refusals. To effectively address these challenges, the programme should strengthen its social media strategy by monitoring, analysing, and adopting an overall more proactive approach towards community engagement and crisis communication on social media, for example with regard to an adverse event following immunisation (AEFI).
• Influencer engagement: As much as possible, third-party voices including medical practitioners, religious leaders, community elders, prominent figures, celebrities, sports professionals, and polio survivors, as well as relevant institutions, should all be engaged - both offline and online - to support the programme messages.
• Crisis communication: The programme's earlier approach to crisis communication, specifically its handling of any type of false or negative information, has been indirect in its approach. The programme has rarely rebuffed, rebutted, or responded to allegations, so as to avoid giving unnecessary attention to adverse or oppositional voices. Whenever such content surfaced on either traditional or social media, the programme actively started posting and trending positive content, such as the endorsement of medical experts, religious scholars, celebrities, and community influencers who supported vaccines or refuted misconceptions by providing correct, sound, and scientifically-based information. This approach, however, has not been able to bear substantive results in stopping the circulation of propaganda content that is making rounds because of its sensational nature. More importantly, the allegations remain unanswered and pose a risk of re-emergence in other forms, especially as WhatsApp grows in significance and usage in resource-poor settings. The NEOC advises that, in light of the growing challenges to programme operations and reputation, the programme should develop a robust and proactive mechanism to handle crisis, including traditional media, social media, influencer engagement, and strengthened coordination with EPI (e.g., with regard to AEFI).

Thus, while virological trends have been largely positive, performance gains have not been consistently observed in immunisation activities in the last 12 months, according to the NEOC. The aggressive targets set for provinces by the NEAP 2017/2018 (see Related Summaries, below) have not been fully realised. This underperformance in some districts, especially over a long time in parts of interior Balochistan, did come back to haunt the programme in the form of outbreaks in Zhob division.

Specifically, one of the key lessons learned from the 2017/2018 experience is that community engagement remains the most critical asset for closing gaps in the core reservoirs.

• Direct or hidden refusals associated with misconceptions and religious or other beliefs are the primary reasons for the non-vaccination of remaining missed children in these areas.
• The expansion and deployment of full-time, local, and mostly female vaccinators in Tier 1 districts presented opportunities for direct community engagement at the household level.
• The Sehat Muhafiz (Guardians of Health) philosophy, which positions 260,000 FLWs to date as a trusted, local health resource, has brought substantial benefits through addressing refusals and identifying, tracking, and covering missed children.
• The programme is at a point where street-by-street knowledge of missed children and local community dynamics are the most important information for reaching children who are the hardest to vaccinate. Including community engagement activities in microplans and in discussions at meetings of the Union Council Polio Eradication Committee (UPEC) and District Polio Eradication Committee (DPEC) will be critical to ensure these pivotal programme inputs are properly explored and assessed at the local level.
• To further enhance the quality of engagement, the programme must consider more interactive communication approaches. The most high-risk families - intractable refusals, absences, and guest children - resist the promotional approach for a multitude of reasons and may require a listening approach not subjected to a scheduled timeframe.

In that light, the NEAP 2018/2019 has the goal of stopping all WPV transmission in Pakistan, once and for all, by: stopping poliovirus transmission in all remaining WPV reservoirs through focused, intensified national efforts and coordinated strategies across international borders; rapidly detecting, containing, and eliminating poliovirus from any newly infected areas; and protecting the overall health of populations by maintaining and increasing immunity to poliovirus infection through implementing quality supplementary immunisation activities (SIAs) and routine Expanded Programme on Immunization (EPI).

In order to achieve these strategic objectives, a set of guiding principles were articulated to guide all PEI staff, from FLWs to the NEOC. They focus on: effective collaboration, open communication, active and continuous improvement, dedication, integrity, commitment, agility, tenacity and boldness, individual and team recognition, organisational and individual responsibility, and national and organisational oversight on accountability.

To further sharpen the effectiveness of the NEAP's communication strategies, NEOC has embarked on a 'Communication for Eradication' (C4E) strategic plan, driven by high-quality epidemiological and social data, with a focus on those who were getting missed. This plan will be led by 2 new task teams: the Communication for Eradication Task Team, and the Media and Advocacy Task Team.

C4E priorities for 2018/2019:

• Develop communications and community engagement tailored to local issues
  • Build the necessary human resource and other support structure needed to address deficiencies, especially in the core reservoirs.
  • Develop communication risk-related analyses and algorithms, similar to one used for low-performing Union Councils (LPUCs).
  • Given the critical importance of social dynamics in high-risk areas, establish special investigation protocols with requisite tools that prioritise detailed social analysis and communication factors.
  • Create a Community Engagement Response Team that has the technical expertise to investigate and address challenges at a granular level.
  • Select and train a cadre of staff to specifically deal with repeat refusals in UCs with persistently missed children, as these require increased engagement and understanding.
  • Conduct a training needs assessment in priority UCs.
  • Develop context-specific and evidence-based communication approaches and information, education, and communication (IEC) for populations moving across the border with Afghanistan. Ensure the messages strongly resonate with parents and encourage vaccination of children in-transit and guest children at destination points.
  • Roll out motivational packages for FLWs (such as recognition and rewards) to help foster a sense of purpose and mission.
• Address global challenges and maintain high acceptance
  • Integrate social mobilisation tools into the microplanning process and ensure analysis of the reasons for missed children, still missed children, and persistently missed children are carefully reviewed and consistently addressed.
  • Respond to emerging issues from messages circulating in social media and establish a comprehensive approach that goes beyond Incident Management to promote regular, strategic conversation on priority platforms.
  • Place more emphasis on vaccine safety and efficacy, addressing repeated immunisation, repeated knocks, and campaign fatigue and dispelling low-risk perception and misperceptions around vaccination.
  • Engage in targeted mobilisation of influencers including health professionals, religious and community leaders, private sector, and celebrities.
  • Leverage community-based entertainment opportunities, such as sports and cultural events, to address campaign fatigue and community resistance.
• Ensure the C4E activities are on track to reach programme goals
  • Conduct regular reviews of the C4E Strategic Plan.
  • Develop and implement field review and field support mechanisms and capacity for the core National and Provincial EOC C4E teams.
  • Conduct monthly reviews for all core reservoirs at the provincial level and quarterly reviews for all core reservoirs at the national level.
  • Conduct half-yearly C4E internal consultations and yearly consultations involving international communications experts that assess the effectiveness of outlined C4E strategy.
  • Submit a detailed annual Work Plan for 2018/2019 that provides exact timelines for the implementation of activities.

Media and advocacy priorities for 2018/2019:

• To ensure policies and plans address and evolve with emerging programmatic needs, the programme will carefully increase its media visibility via a more proactive communication approach with traditional media, social media, and influencer engagement, while taking into account specific local contexts and conducting a thorough risk assessment before adopting a higher-visibility strategy.
• To address specific concerns around the issues of vaccine safety, efficacy, and repeated vaccination, the programme will review the existing messaging and audio-visual media content and develop any additional required material, in close collaboration with provinces, to meet local need.
• Keeping in mind that a successful strategy is built around reaching the right people at the best time with the most insightful content, the programme will sharpen its listening abilities through comprehensive and systematic monitoring and analysis of traditional and social media.
• Recognising the importance of social media as a powerful tool to build trust in polio vaccination and address people's concerns, the programme will take a more proactive approach towards social media engagement, community management, and social media influencers' engagement.
• To effectively respond to any crisis, the programme will shift its approach from response to preparation by: building the crisis communication capacity of programme spokespeople at the national and provincial levels; establishing clear standard operating procedures (SOPs) to guide the programme on roles, responsibilities, and response timelines and channels in the time of crisis; and developing a set of readily available templates and statements on key themes, such as AEFI, vaccine safety, and polio workers' security.
• The programme will conduct regular reviews of the media and advocacy strategy and submit a detailed annual Work Plan for 2018/2019 that provides exact timelines for the implementation of activities.

Among other aspects of programme performance, the NEAP discusses polio legacy transition planning, 3 main aspects of which include:

1. Maintaining and mainstreaming essential polio eradication activities into ongoing public health programmes in a polio-free Pakistan following the end of the initiative, with continued involvement of Global Polio Eradication Initiative (GPEI) partners and increased government involvement.
2. Ensuring that the knowledge generated and lessons learned during more than 2 decades of polio eradication activities are documented and shared with other functioning health initiatives.
3. Transitioning the capacities, assets, and processes - including human resources - that the initiative has created and engaged for polio eradication - to support other health priorities, where feasible, appropriate, or required.

As Pakistan is still in the phase of polio eradication, the planning for the polio transition is expected to start in the first quarter of 2019 at the earliest.