PREVALENCE AND CONTROL OF POLIO MYELITIS IN

PAKISTAN

Prof. Dr. K.A.Karamat
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Introduction
Tremendous progress has been made in the global fight against polio since 1988,
when the World Health Assembly resolved to eradicate the disease. The number of polio
cases worldwide has decreased from 350,000 in 1988, to 784 cases in 2003. Three-
quarters of all cases globally are linked to a handful of polio hot spots in Nigeria,
Pakistan, Afghanistan and India. After about twenty years effort that has galvanized more
than 200 countries, 20 million volunteers, and an international investment of US$3
billion, the success or failure of the Global Polio Eradication Initiative, the worlds
largest public health campaign, is now within reach. Never before has the world been so
close to success, with only four countries remaining polio-endemic.
Ministry of Health (Pakistan) started National Immunization Days (NID) during
1994 to join the global Polio Eradication (PE) efforts. In the beginning, every year, 2
rounds of nation wide campaign (National Immunization Days or NIDs) were carried out
to give Polio drops to all children below 5 years of age. Almost a workforce of 500,000
including volunteers, apart from health staff, remain busy in this national effort. Since
1998 the strategy has been slightly modified i.e. (i) instead of fixed points the health
teams make house to house visits to give polio drops to children under 5 years of age and
(ii) instead of one day, the campaign is extended over 3-4 days. Apart from NIDS, the
campaign of Polio Eradication is being strengthened through; Sub-national Immunization
Days (SNIDs) in high-risk areas/districts; (ii) mopping-up campaign whenever/wherever
a case of Polio/Acute Flaccid Paralysis (AFP) is detected; and (iii) cross border Polio
vaccination with Afghanistan. In 2008, the world has its best and perhaps last chance
to stop polio forever. There is a historic, one-time only opportunity to stop transmission

1
Senior Consultant (Health) Planning Commission
2
of poliovirus. If the world seizes this opportunity and acts immediately, no child will ever
again know the crippling effects of this devastating disease.
Polio in Pakistan
Hundreds of cases used to occur in the past but by intensive vaccination the
number of cases was brought down to 53 in the year 2004-2005 and to 28 in 2005-2006
because a lot of stress was given to routine immunization, sense of ownership, strict
surveillance and accountability. Two fresh cases of polio virus detected this month (J une
2008), one in Kohat and the other in Karachi- have once again highlighted the two main
reasons why the country continues to miss out on attaining the elusive polio-free status.
The victims have no history of routine immunization and the case detected in Karachi
belongs to a migrant family having come from South Waziristan.[2]. Fifteen cases have
been reported till J une 2008. Five of these cases were among children under 2 years, 4
cases were among children between 2 years and 5 years and the remaining 5 cases were
in children aged 5 years and over. Only 2 cases had received 3 routine doses. However,
11 of them had received 7 or more doses and 2 were refusals and had received zero doses.
Ten cases are from Sindh, 3 from NWFP and 2 from Balochistan. The upsurge in Sindh is
attributable to weak routine immunization and failure to improve the service delivery, as
indicated by the fact that 42% of the children were due to no teams going to their houses,
a rate which is more than double that in any other province in Pakistan. There is a need to
establish a polio eradication emergency cell and activate the provincial steering
committee, as well as to create accountability and oversight system, not only in Sindh but
also in other provinces.

No. of cases of polio reported in 2008 is at Annex-A and those up to 2007 are at
Annex-B.

Poliovirus Epidemiology - 2008

The majority of population in Pakistan continues to live in areas without polio
cases. Of the 15 confirmed polio cases, there are 13 type- 1 and 2 type-3 cases this year.
It is important to highlight that 10 out of 13 type 1 cases are from Sindh province and one
3
from NWFP and two from Balochistan. The two type-3 cases are localized in Nowshera
district of NWFP.

There are 14 districts to date in 2008 that had polio cases. Of note is that 67% of
districts this year did not have a case last year. Karachi, Nowshera, Killa Abdullah and
J acobabad districts had confirmed polio cases in both 2008 and 2007. These four districts
have been included in all targeted supplementary immunization activities in 2007 and
2008 and the presence of cases this year indicates gaps in the quality of vaccination
activities (Annex-D).

More than half of the newly infected districts in 2008 are outside the known
transmission zones. This reinforces the fact that all polio-free areas remain at risk until
endemic circulation is interrupted with high general population immunity through routine
immunization and SIAs. Of concern is the fact that a common feature among the cases in
these new districts is that routine immunization coverage is often far below (0% to 72%)
of the target range (Annex E&G).

Epidemiological and genetic data confirms endemic circulation of type-1 virus in
Sindh, NWFP and Balochistan, though circulation appears to be restricted in NWFP and
Balochistan to the central and north-western areas respectively. However, this also
reinforces the fact that there continue to be performance gaps in vaccination activities.
There are a few isolates which have long limbs on the genetic tree (Kila Abdullah,
Nawab Shah & Kohat, for instance), indicating potential gaps in surveillance sensitivity.
Both type-3 cases are related with each other and are genetically linked to cases in
southern Afghanistan. In Afghanistan, endemic circulation is largely restricted to the
southern region of Afghanistan, where both virus sero-types are present. However, a
recent type-3 case in the eastern region shows extension of P3 circulation from the
southern region to this area. This is relevant, given the sharing of virus between southern
Afghanistan and Pakistan.



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The epidemiological profile of cases shows:


Majority of cases are young children aged below 3 years (56%) though a shift to
older children is observed (43% >35 months in 2008 compared to 10% in 2006 &
34% in 2007);

Majority of cases (12/14; 86%) had OPV doses. Only 2(14%) cases are zero dose
(\due to refusal of parents);

Only 2(14%) cases had 3 routine OPV doses;

89% are from low social-economic backgrounds and 70% have illiterate parents.

70% live in urban slums or large rural populations;

79% live in multi-family dwellings;

71% had history of injection and

43% of cases had first contact with an informal health care provider.


Vaccination monitoring data shows that operational issues continue to exist in
Sindh and Balochistan largely due to lack of accountability. Though the access issues
persist in parts of NWFP and FATA, the appearance of cases in accessible areas
highlights gaps in vaccination activities.

High quality vaccination activities at union council and local levels through
improving SIAs and routine EPI activities are vital for interrupting poliovirus circulation.

SNIDs in high risk areas were organized from 10-12 J une 2008 using mOPV1

An emergency Technical Consultation Meeting was held on 24-25 J une 2008 in
Karachi mainly focusing on Sindh

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The Federal Health Minister and National Assembly reiterated commitment to
stop polio & expressed concern on recent surge of polio cases

Virus isolation

Isolation and identification of poliovirus from the faeces is the best current
method to confirm the diagnosis of poliomyelitis. WHO, in collaboration with several
other institutions, has developed a global network of laboratories to provide this service.
Molecular techniques are available to characterize fully the poliovirus. Maintaining a
reference bank of the molecular structure of known viruses allows the geographic origin
of new isolates to be traced. When countries are polio-free or almost polio-free, it is
necessary to determine whether the virus was imported or indigenous. The laboratory will
also determine whether isolated viruses are wild or vaccine-like.

The laboratory network will play a key role in certification of polio eradication by
verifying the absence of wild poliovirus circulation. In addition to AFP surveillance, this
may include stool surveys of healthy children in high risk areas and environmental
surveillance. The laboratory network can perform potency tests on polio vaccine if
circumstances indicate possible failure. In selected situations, a laboratory might
participate in epidemiologic serosurveys if knowledge of the antibody status of the
population is important.
Polio Vaccines
Polio vaccines are one of the greatest medical success stories of the 20th century.
Before polio vaccines were developed, no illness inspired more dread and outright panic
than polio did. Sometimes called infantile paralysis, polio struck the nation every summer
and fall with increasingly virulent epidemics. By the mid-1950s mass immunizations
began to slow polio's spread. In 1979, the last case of natural, or "wild-type" polio,
occurred in the United States.
Even though polio has been eradicated from the US and the Western Hemisphere,
it still afflicts children and adults in other parts of the world. A single infection brought
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into the US by someone from a country where polio still persists could possibly lead to
polio epidemics again if we were not protected. That is why we continue to vaccinate.
There are two types of polio vaccine: 1) trivalent oral (live, attenuated) polio
vaccine (OPV) and 2), inactivated or killed polio vaccine (IPV).Trivalent oral polio
vaccine consists of live, attenuated polioviruses, and is a safe and effective vaccine.
Although in 2005 it was claimed that the type-2 and type-3 viruses are almost eradicated,
so single virus vaccine (Monovalent) for type-1 virus was used in some rounds. However
it is clear from the data (Annex-A) that the type-3 virus is still rampant. According to
estimates, more than 32 million children are vaccinated in each round. The estimated cost
of Polio Vaccine is almost US$ 30 million annually (This used to be met through grants
by donors but they have stopped it now).Distribution of OPV for the year 2007-08 is at
Annexure C. The special procurement of Monovalent vaccine needs reconsideration as
the Trivalent vaccine is effective against all the three types of polio virus.
Vaccination is the best way to prevent polio.
Today, most children in the US receive 4 doses (injections) of inactivated polio
vaccine (IPV) according to the following schedule:
2 months old
4 months old
Between 6 and 18 months
A booster between 4 and 6 years
IPV is 90% effective after 2 doses and 99% effective after 3 doses. Because the
vaccine contains inactivated (killed) poliovirus, it cannot cause polio. The most common
side effects are pain, swelling, or redness at the injection site; fever, loss of appetite,
fussiness and drowsiness. Most adults do not need the polio vaccine because they were
vaccinated as children. But there are 3 groups of adults who should consider vaccination
because they are at higher risk than the general adult population.
People who are traveling to areas of the world where polio still commonly occurs
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Laboratory workers who might handle poliovirus
Health-care workers treating patients who may have polio
IPOL (Poliovirus Vaccine Inactivated) is given to infants (as young as 6 weeks of
age), children, and adults to prevent polio caused by poliovirus Types 1, 2, and 3. As with
any vaccine, vaccination with IPOL vaccine may not protect 100% of individuals. There
are risks associated with all vaccines. IPOL vaccine should not be given to persons who
have had a serious allergic reaction after a previous dose of the vaccine. When
administering an intramuscular injection, like IPOL vaccine, in people with bleeding
disorders, caution should be exercised because they may develop a serious bruise or
collection of blood at the injection site.
If the world is to secure its twenty years investment in polio eradication, and
protect all children from the threat of this disease, each and every child under five must
be reached with polio vaccine during upcoming campaigns in the key endemic countries.

OPV is the vaccine recommended by WHO for polio eradication

WHO currently recommends a formulation of trivalent OPV for types 1,2, and 3,
respectively, for both routine and supplementary immunization. Three doses of OPV will
protect at least 80-85% of immunized children from paralytic disease. Lower levels of
immunity, especially for type 3, may occur in developing countries, particularly if OPV is
administered during the rainy season.
OPV is given by mouth and its cost is low. The vaccine produces both intestinal and
serologic immunity. As a result, children immunized with OPV are unlikely to spread
wild polio virus to other children. When administered during a mass campaign, OPV can
interrupt wild poliovirus transmission in the community. A disadvantage of OPV is that,
for every 10 million doses administered, approximately 3 children will experience
vaccine-associated paralytic polio.





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Inactivated or killed polio vaccine (IPV)

Inactivated polio vaccine prevents paralytic polio by producing sufficient
antibodies in the serum to prevent the poliovirus from entering the nervous system. IPV
poses no risk of vaccine-associated paralysis. However, compared to OPV, it produces
lower levels of intestinal immunity. Consequently, a person immunized with IPV is more
likely to spread wild polio virus to other children, compared to a person immunized with
OPV. IPV is more expensive than OPV, must be injected by trained personnel, and
requires additional equipment and supplies.

Vaccine schedule

WHO currently recommends that children receive four doses of OPV before one
year of age. In endemic countries, a dose should be given at birth or as close to birth as
possible. This is called the birth dose, or zero dose. The other three doses should be
given at least four weeks apart and usually at the same time as DPT. If the zero dose is
not given, then a fourth dose of OPV should be given at least one month after the third
one, for example at the time of measles immunization. One dose of OPV from most
manufacturers consists of 2 drops of vaccine administered directly into the mouth.

Contraindications

Children with congenital immune deficiencies, or who are iatrogenically
Immunocompromised (e.g. cancer patients) should receive IPV. Otherwise there are no
contraindications for administration of OPV. If OPV is given to a child with diarrhoea,
the dose should be repeated one month later.

Vaccine storage and transport

OPV is the least stable of the EPI vaccines. It can loose potency if exposed to
temperatures above 8C. Storage at temperatures below -15C halts deterioration in
vaccine potency. OPV should preferably be kept in a freezer (below -15C) at central and
regional levels. OPV can be kept in a refrigerator (between 0C and 8C) at district and
health centre levels, except when distribution is not imminent, in which case it should be
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stored in a freezer (below -15C), if possible. The shelf life (i.e. expiry date) indicated on
the OPV vaccine vials is valid for storage in freezers (below -15C). OPV can however
be kept up to 12 months in refrigerators (between 0C and 8C). Repeated freezing and
thawing does not affect the titre of the vaccine.

The vaccine vial monitor

Since the beginning of 1996, all vials of Oral Polio Vaccine procured through
UNICEF come with a Vaccine Vial Monitor (VVM). This heat sensitive label gradually
and irreversibly changes colour as the vaccine is exposed to heat. It warns the health
worker when a vial of OPV should be discarded because the vaccine is likely to have
been degraded by exposure to heat.
The Global Polio Eradication Initiative
The Global Polio Eradication Initiative is spearheaded by WHO, Rotary
International, CDC and UNICEF. It includes:
- governments of countries affected by polio

- private foundations (e.g. the United Nations Foundation, the Bill & Melinda Gates
Foundation)

- development banks (e.g. the World Bank)

- donor governments (e.g. Australia, Austria, Belgium, Canada, Denmark, Finland,
Germany, Ireland, Italy, J apan, Luxembourg, the Netherlands, New Zealand, Norway,
the United Kingdom, and the United States of America)

- the European Commission

- humanitarian and nongovernmental organizations (e.g. the International Red Cross and
Red Crescent societies)

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- corporate partners (e.g. Aventis Pasteur)

- volunteers in developing countries.
From 1988-2005, an estimated 5 million people who would otherwise have been
paralysed are walking because of the Global Polio Eradication Initiative. Through polio
eradication efforts, a significant investment has been made in strengthening health service
delivery systems in many countries. Hundreds of thousands of health workers have been
trained, millions of volunteers have been mobilized to support immunization campaigns,
and cold-chain transport equipment has been refurbished.
The final push: finishing the job
If polio is to be eradicated, each and every child must be vaccinated against polio
during upcoming immunization programs in the remaining polio-endemic
countries. Never before has so much commitment and effort been focused on this
final push to rid the world of polio forever
Pakistan Polio Eradication Initiative (PEI) is a high priority public health programme
of the Government of Pakistan, which is fully committed to the goal of Global Polio
Eradication. Pakistan has adopted the globally recommended four key strategies for PEI
that include establishing a sensitive surveillance system, holding National Immunization
Days (NIDs), mop-up campaigns in the terminal phases and strengthening EPI. Pakistan
began holding annual two-round (NIDs) in 1994. Surveillance for acute flaccid paralysis
(AFP) - was initiated in 1995 and by 1999 Pakistan was meeting global targets for several
key indicators of surveillance quality.

In 2000, to strengthen the quality of surveillance in problem districts, and to assist
districts in planning and implementing immunization campaigns WHO hired additional
surveillance officers. Now Pakistan has a well-established surveillance system involving
pediatricians, clinicians, field surveillance officers and the polio laboratory. Through
intensive efforts of all the AFP surveillance system has made rapid progress in the last
two years and has reached the global certification standards at national, provincial and
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district level. Surveillance is providing a clear epidemiological understanding of
poliovirus transmission, high-risk populations, reservoir districts and hence driving the
program decisions.

Active surveillance
Active surveillance started in September 2001. Prioritized sites are visited weekly
and others on monthly basis. Surveillance Officers both from the Government and WHO
in all provinces got training and then the process started with an incremental approach
from the populous districts expanding to the other districts. Weekly visits are maintained
to all sites where AFP cases may present for treatment/rehabilitation in the prioritized
districts. Active case finding is carried out by searching through indoor and outdoor
records especially of the Pediatric and Neurology departments. Liaison with pediatrician
at the hospital is strengthened and also feedback is given to them on previously reported
cases.

Community Based Case reporting by involving the PHC Workers
Lady Health Workers (LHWs), are Primary Health Care (PHC) workers, based in
the communities who have started to report AFP cases to the surveillance system. The
catchment area of every LHW is 200 houses having a population of about 1000
individuals. Presently there are 95000 LHWs in Pakistan with a proportion of 40 to 60 for
urban to rural areas. Government has planned to expand this program to cover the whole
country with 200,000 LHWs in a phased manner. Guidelines for LHWs and trainers (in
Urdu) and reporting instruments have been developed. A special referral slip with a red
line on the top has been designed for LHWs to refer the AFP case to the nearest Health
Facility, which would immediately inform the E.D.O, Health for notification and
necessary case response activities.




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Strengthening Routine Immunization

High routine immunization coverage of infants with at least three doses of oral
polio vaccine (OPV) is one of the basic strategies of polio eradication. Regional
coverage of infants with at least three doses of oral polio vaccine (OPV3) has remained
around 80 % for the past few years. However coverage level of less then 80% occurred in
Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen- the endemic countries and
those in which importation resulted in epidemics.

High routine immunization coverage is crucial for maintaining polio-free status
after successful eradication. The epidemic resulting from importation in Somalia, Sudan,
and Yemen compared with the sporadic cases that followed importations in other
countries, like the Islamic Republic of Iran, Saudi Arabia and Syrian Arab Republic,
highlights the importance of maintaining high routine coverage.
The Regional polio eradication initiative continues to emphasize the need to maintain
high coverage and has contributed in a number of ways to strengthening routine
immunization.

All poliomyelitis eradication staff is involved in the strengthening of routine
immunization and in surveillance of vaccine-preventable disease.

A substantial amount of poliomyelitis eradication resources have been utilized for
strengthening the physical infrastructure for routine immunization.

The strategic planning process introduced for poliomyelitis eradication activities,
and the lesson learned from it, have been used in other initiatives in support of
routine immunization services, such as in the process of application from support
from the Global Alliance for Vaccine and Immunization (GAVI).

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Routine immunization has benefited from poliomyelitis eradication efforts in
other areas, such as in programme management, improved coordination and
enhancement of political awareness and support.

Action Taken
Government of Pakistan has taken a strong notice of the rise in polio cases in
Pakistan. The Minister of Health emphasized that a system of proper screening and
efficient selection of polio teams be strictly enforced to ensure an effective
implementation of the programme. The government will make maximum efforts to
achieve the target of a polio-free Pakistan in the shortest possible time. Over 80,000
teams are spread out across the country, carrying out the task. During the last National
Immunization Drive, camps were set up at toll plazas across Pakistan, leading to
successful immunization of over 32,000 children. A comprehensive mechanism devised
jointly with the WHO is in place to counter cross-border transmission of the polio virus.
Polio currently exists only in Asia (Afghanistan, India, and Pakistan) and Africa
(primarily Nigeria). In 2006, there were 1,906 cases of polio in 16 countries, according to
the global polio Eradication initiative. Many organizations have been working hard
toward eradicating polio including WHO, United Nations Childrens Fund (UNICEF),
the Centre for Diseases Control and Prevention (CDC), Rotary international, and many
other international and national groups. Strategies include house-to-house vaccination on
National Immunization Days, and a strong committed highest percentage of routine
immunization against seven killer diseases including Polio vaccination. [3]

Routine Immunization in Sindh

Targets of EPI in Sindh are to reach 90% routine coverage and eliminate neonatal tetanus
by 2008. With regard to routine coverage, the reported provincial coverage rate with 3
OPV doses decreased from 78% in 2006 to 72% in 2007 and was only 70% in the first 5
months of 2008. There are significant variations in coverage between districts, with some
of them reporting coverage rates less than 5% while others reach 94% with the majority
around 70%.
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The challenges facing promotion of routine immunization include lack of public
demand and the fact that a third of existing health facilities are without EPI centres. Lack
of accountability at all levels, shortage of vehicles and vaccinators and frequent transfer
of EDOs and THOs are also major challenges.

Communication Initiatives in Sindh
There are five main challenges for cessation of circulation of polio in Sindh: lack
of sustained political commitment; high-risk and hard-to-reach populations; inadequate
interpersonal communication skills of teams; gaps in service delivery; and low level of
population awareness. A number of actions have been taken to address these constraints.
There is increasing political commitment as evidenced by awareness and inauguration of
activities by senior officials. Social mapping of districts in Sindh has helped greatly in
reaching high risk areas and cooperation with traffic police has assisted in covering target
children on the move. Interpersonal communication skills were improved through team
training, which has led to reduction in the proportion of missed children from one round
to the other. The efforts to improve service delivery through involving medical and
nursing students in campaigns and achieving support of Pediatric Associations have
resulted in accessing some of the persistently difficult to reach communities such as the
Agha Khan communities during campaigns. Efforts are ongoing to improve community
awareness including recruitment of communication officers, enhanced cooperation with
the media and involvement of religious leaders.

Reaching Inaccessible Population in NWFP

There are a number of inaccessible population and security-compromised areas in
NWFP/FATA along the borders with Afghanistan and in the district of Swat. A
multiplicity of initiatives and methods have been used to facilitate vaccination of children
in these areas, including inclusion of polio eradication efforts in peace agreements,
holding special jirgas, communication with tribal and religious leaders, use of local
vaccinators and supervisors, using every possible opportunity to vaccinate children,
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establishment of vaccination posts at the border crossings with Afghanistan and close
coordination between the two countries to reach children by the most accessible route,
and the principle adopted by the team of not giving up until all the targeted children are
vaccinated. These strategies have resulted in continued reduction in the proportion of
inaccessible children in NWFP. Advocacy efforts have been successful in obtaining the
support of religious leaders. As well, media are now strongly supporting eradication.

Meeting the Challenges in Punjab

The challenges in polio-free Punjab are different than those in other provinces
with viral circulation. The main challenge is to maintain strong political commitment and
good quality surveillance, as well as maintain high population immunity through
strengthening routine immunization, especially in areas with low routine immunization,
and conducting at least 4 rounds of supplementary immunization activities of good
quality. Several initiatives are ongoing in Punjab such as the polio card and the strong
partnership with the education department, which has boosted effective social
mobilization, as well as implementation of an active method for detecting missed
children.

Campaign and Surveillance Quality in Balochistan
Balochistan province is the least populous and has large areas with a scattered population.
Surveillance data indicate that K. Abdullah and Pischine remain P3 reservoirs, and
circulating viruses are linked with the viruses in southern Afghanistan. With regard to
campaign quality, the gap between finger-marking and recall data is closing. However,
there are still several union councils in Pischine and K. Abdullah where coverage is low

The reasons for slow progress in polio eradication efforts in Balochistan include: serious
management issues in some districts such as K. Abdullah; significant pockets of refusals
which remain uncovered after supplementary immunization activities, especially in
endemic areas; and performance gaps. As an example, during the past 6 months the
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Secretary Health has changed four times and the province has been without a Director
General Health since February 2008.

Cross Border Transmission
Pakistan-Afghanistan Block has emerged as a single poliovirus reservoir sharing the
poliovirus lineages. Continuous movement of people and poliovirus with them, back and
forth across border has necessitated close coordination and collaboration between the two
countries.

Information is shared regularly between Pakistan and Afghanistan programs by email,
telephone and frequent meetings. Surveillance data is shared on weekly basis through
electronic mail.

Emergency preparedness plan for the influx of Afghan Refugees was prepared at the
country level due to war in Afghanistan. AFP surveillance for the Afghan Refugees is
incorporated in the plan.

Campaign dates in the two countries are synchronized. Permanent fixed vaccination
posts have been established at the entry/exit points on borders.

Organization of AFP Surveillance includes the establishment of National Surveillance
Cell (NS CELL) with the provincial desks in Islamabad to coordinate the AFP
surveillance activities at the National level. NS CELL is carrying out core functions
(detection, confirmation, analysis, response) and support functions (training, supervision,
communication, resource management). Four provincial desks have been created in the
cell looking after all the four provinces, AJ K and FANA. WHO has also recruited
Surveillance Officers (SOs) at the district level. The job of these field officers is to
establish active Surveillance both in public and private sector health facilities for AFP
cases by frequently visiting hospitals, rehab centers, GPs pediatricians and community
leaders. Their work is also to ensure the quality of the data.

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COLD CHAIN & VACCINE MANAGEMENT


Vaccine cold chain, the backbone of EPI has been in place and functioning for
many years at different levels. Pakistan cold chain system needs some special attention at
the moment. All the elements of the cold chain system must be strengthened and
developed to an optimum standard to ensure vaccine potency, quality and safety from the
vaccine manufacturer to the children/women. Unless concerned people in each level of
the cold chain system entrust themselves to work as a team we may not be able to achieve
our goal of preventing, eliminating, controlling and eradicating the EPI vaccine
preventable diseases.
The objective is to ensure that health staff have safe, quality and potent vaccines
available, in the right quantities, at the right place and at the right time to immunize
children and women.
COLD CHAIN is a system that will ensure the potency, quality and safety of
vaccines by maintaining their correct temperature from the time they are released from
the vaccine manufacturer until they are administered to the children and women. The
major elements of cold chain and their role in the cold chain system are as follows:

Personnel, are EPI and cold chain staff who use and maintain the equipment,
provide the immunization services and manage the cold chain.

Equipment, are the cold rooms, freezer rooms, chest freezers, absorption
refrigerators, cold boxes, vaccine carriers, ice packs, thermometer, cold chain
monitor card, generators and refrigerated vehicles that are used to maintain the
correct temperature, safe storage and transportation of vaccines.

Procedures, are guides for vaccine management, vaccine store management,
cold chain logistics, and repair and maintenance of cold chain equipment.
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Cold Chain System for Pakistan



Vaccine manufacturer Cold Chain is a system
Comprising of:
National Vaccine Store, 1.People (supervisor,
Federal EPI Cell, Islamabad storekeeper, cold
Chain technician
Provincial Vaccine Store vaccinator etc)
Punjab, Sindh, NWFP, Balochistan 2.Cold chain equipment
(cold/freezer rooms,
District Vaccine Store freezer, cold box,
Vaccine carrier, ther-
Tehsil, RHC, BHU, FC facility mometer etc.)
3.Procedures (recor-
Vaccinators/EPI service ding form, vaccine
providers handling, distribution
transportation links
etc.)
Working together to ensure
Safe and Potent Vaccines
From
Manufacturer
To
Children and Women


Cold Chain & Vaccine Management

Vaccine arrival

a. Vaccine Arrival Report is used to check the integrity of vaccines on arrival in the
country of destination or local destination by verifying that the cold chain has
been properly maintained throughout the period of transport.

b. Vaccines, diluent and vaccine/diluent combinations must be stored at
recommended temperature. If there is an uncertainty about the correct
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temperature for a particular vaccine it must be stored in a cooler or refrigerator but
not in a freezer.
c. To eliminate the cause of vaccine wastage due to incorrect storage temperature,
temperature of every cold chain equipment has to be continuously monitored and
recorded. This process will detect the early occurrence of cold chain failure and
will avoid further loss of potency to the vaccines. Staff should be trained on how
the devices work, how to read the temperature correctly and how to maintain it.
d. Cold chain equipment at each level may vary depending on the storage volume
and duration of storage. National level and provincial level have the biggest
vaccine requirements therefore must need high storage capacity cold chain
equipment.
e. It is important that each level should be able to determine the vaccine
requirements and to have a sufficient stock for the entire immunization schedule
including campaign activities. Once the vaccine requirements are known the
vaccine storage volume, refrigerating capacity and icepack freezing capacity
could be determined.
f. Freeze dried vaccine is one of the two different forms of vaccine. It is a freeze-
dried powder that must be mixed with a liquid (diluent) in a process called
reconstitution before it can be used.

g. Expired vaccines are those that have been stock piled in the refrigerator/freezer
and have not been used prior to their expiry date. This type of vaccine wastage is
avoidable if proper vaccine stock management is applied.

h. Vaccines are sensitive biological substances and must be handled carefully to
avoid damage during transport and distribution. Satisfactory transport
arrangements should be in place for moving vaccine from one level to another
including maintenance of correct temperatures during transport.
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j. There are a number of development and updates in cold chain and these are
crucial for the successful implementation of EPI cold chain. All of these should
be disseminated to the field. Management should ensure that all concerned staff
should have an adequate formal or in-service training in cold chain and vaccine
management.

Laboratory Containment of Wild Polioviruses and Potential Infectious
Material
The success of global Polio eradication program is dependent on all countries of
the world being able to demonstrate that wild polioviruses circulation among their
populations has been interrupted and that all laboratory sources of wild polioviruses have
been found and safely contained. The only possible indigenous sources of wild poliovirus
are laboratories, which are in possession of wild poliovirus infectious or potentially
infectious materials. In this respect WHO had suggested all the countries to develop
laboratories containment system for wild polioviruses and other potential materials within
their countries. To carry out the task the country should nominate the National
Coordinator for laboratory containment of wild polioviruses and potential infectious
materials.

Pakistan has made substantial progress towards polio eradication since the start of
the program in 1994, with clear evidence of decreasing poliovirus diversity and intensity
of transmission. Number of polio cases has dropped from several thousand in 1994 and
early 2000 to 28 in 2005. They were 32 in 2007. Indicators for AFP surveillance system
for polio Eradication are reaching at the certification standered since the year 2001 at the
country level and high vaccination coverage rates have been reported in several
Supplementary Immunization Activities (SIAs). Routine immunization programme has
variable performance and great attention is being paid to improve this through multi
pronged strategies including optimizing experience gained in Polio Eradication Initiative
(PEI). The achievements in PEI so far is through political commitment, dedicated
leadership, appropriate community and social mobilization and support of members of
21
civic society and most importantly parents of the children. Pakistan and its two
neighboring countries Afghanistan and India are three of the four remaining polio
endemic countries in the world.

Laboratory survey and inventory

This phase covers the period when the number of Polio-free countries and
Regions are increasing, but wild polioviruses continue to circulate somewhere in the
word. During this phase, countries will have to accomplish the following tasks:

1. Survey all biomedical laboratories to identify those with wild poliovirus
infectious or potential infectious materials and encourage destruction of all
unneeded materials.

2. Develop an inventory list of laboratories that retain such material and report to the
Regional Certification Commission.

3. Instruct laboratories dealing or retaining wild poliovirus infectious or potential
infectious material to initiate to implement enhanced biosafety level-2 (BSL-
2/polio) measures for safe handling

4. Plan for Global Certification.

Global Certification

This phase begins when one year has elapsed without isolation of wild poliovirus
anywhere in the country. During this phase countries will ensure to:

1. Notify biomedical laboratories that poliovirus transmission has been interrupted.

2. Instruct laboratories on the National Inventory to choose one of the following
three options:
22

Render materials non-infections for poliovirus or destroy them under appropriate
conditions

Transfer wild poliovirus infectious and potential infectious materials to
laboratories capable or meeting the require biosafety standards.

Implement biosafety requirements appropriate for laboratory procedure being
carried out (BSL-2/polio or BSL-3/polio).

3. Document completion of all containment requirements for global certification.

Post Global Certification

It is anticipated that the containment requirements for global certification will
remain in force together with concurrent immunization policies. At some time in the
future, international advisory bodies are expected to re-examine post certification
immunization policies in the light of research outcomes, post eradication experiences,
containment assessments and assurances of the surveillance, vaccine stocks and
emergency response plans would be adequate and enough if polio re-emerge. If oral polio
vaccine (OPV) immunization is stopped, with or without universal replacement with
inactivated polio vaccine (IPV), the biosafety requirements for both wild and OPV
viruses will become more stringent than those outlined in this document, consistent with
the consequences of inadvertent transmission of poliovirus from the laboratory to an
increasingly susceptible global community.

DISCUSSION
Polio is a highly contagious disease that is caused by a virus that primarily lives in
the intestines and human feces. The poliovirus is spread from person-to- person primarily
through oral contact with the feces of an infected person (for example, by changing
diapers); it can also spread through contaminated food or water, especially in areas with
poor sanitation systems. There have also been cases that have been transmitted by direct
23
oral contact or by droplet spread. Once inside the body, the poliovirus multiplies in the
throat and intestinal tract, then travels through the bloodstream where it infects the brain
and spinal cord. Surprisingly, 95% of all individuals infected with Polio have no apparent
symptoms. Another 4%-8% of infected individuals have symptoms of minor, non specific
nature, such as sore throat, nausea, vomiting, and other common symptoms of any viral
illness. About 1%-2% of infected individuals develop nonparalytic aseptic (viral)
meningitis, with temporary stiffness of the neck, back, and/or legs. Less than 1% of all
Polio infections results in the classic flaccid paralysis where the patient is left with
permanent weakness or paralysis of legs, arms, or both. Among those paralyzed, 5% to
10% die when their breathing muscles become immobilized.[1]
Pakistans remote northwestern frontier province, one of the few remaining
hotspots of polio in the world, has been a major focus of efforts to eradicate the disease.
Now, however, health workers in Pakistan face a new obstacle: political fallout from the
US-led war on terror. Local tribal and religious leaders have convinced thousands to
refuse polio vaccinations in the belief that the vaccine is an American scheme aimed at
the sterilization of Muslims. In other cases, some local authorities demand benefits from
the Pakistani government before allowing vaccinations to proceed. Health workers in
Pakistan have made great strides in fighting polio, vaccinating 6 million people in
J anuary 2008. If they cannot overcome these new political obstacles, however, the
disease may survive to spread again.

Pakistan is committed to achieve the Millennium Development Goals (MDG)
through the Health Sector Reforms (HRS) by focusing on provision of basic health
service to the people at their doorsteps. A huge network has been established in the
country for this purpose. It includes 5270 BHUS, 552 RHCS, 946 Hospitals, 130,000
Doctors, 35000 Nurses and 100,000 Lady Health Workers. The major thrust has been to
provide quality care and reduce infant, child and maternal mortality. Health is one of the
major interventions for human development and poverty reduction. To achieve the MDG,
various National Programs have been launched which are meant to reduce morbidity and
mortality.
24
Potential complications of polio
Polio can lead to muscle paralysis that results in deformities of the hips, ankles,
and feet. Although many of the deformities can be corrected with surgery and physical
therapy, these treatments often arent available options in the developing countries where
polio still exists.
Other complications associated with the prolonged hospital stay as a result of the
paralysis caused by polio infection involve the lungs, kidneys, and heart:
Pulmonary edemaA potentially life-threatening condition that fills the lungs
with fluid and prevents them from absorbing oxygen
Aspiration pneumoniaAn inflammation of the lungs that is caused by inhaling
stomach contents into the lungs
Urinary tract infectionsBacterial infections that can permanently damage the
kidneys if not treated promptly
Kidney stonesUsually form when urine becomes too concentrated; they may
cause ongoing urinary tract infections or kidney damage
Intestinal obstructionA partial or complete blockage of the bowel that
prevents food from moving through the intestinal tract; severe obstructions can
lead to potentially life-threatening complications
MyocarditisAn inflammation of the thick muscular layer of the heart that can
lead to chest pain, an abnormal heartbeat, or congestive heart failure; it can also
cause blood clots to form, which greatly increases the risk of stroke
Cor pulmonaleA heart condition that occurs when the right side of the heart
cant pump hard enough to compensate for prolonged high blood pressure in the
arteries and veins in the lungs
Immunity

Protective immunity against poliovirus infection develops by immunization or
natural infection. Immunity to one poliovirus type does not protect against infection with
25
other poliovirus types. Immunity following natural infection or administration of live oral
polio vaccine (OPV) is believed to be lifelong. The duration of protective antibodies after
administration of inactivated polio vaccine (IP) is unknown. Infants born to mothers with
high antibody levels against poliovirus are protected for the first several weeks of life.
Natural, or wild-type, polio has not occurred in the US since 1979, or in the
Western Hemisphere since 1991. However, children and adults who havent been
vaccinated against polio could get the disease if they travel to a country where polio still
exists or where outbreaks have recently occurred or come into contact with infected
travelers from countries where polio still occurs. Because no cure for polio exists, the
focus is on increasing comfort, speeding recovery, and preventing complications. Today,
supportive treatments for polio include:
Antibiotics for secondary infection
Analgesics for pain
Portable ventilators for breathing
Moderate exercise
A nutritious diet
Recommendations

1. Ownership and commitment

a. Further gains in polio eradication will only be possible through full
ownership and accountability of the national officers at all levels.

b. To Ensure that Polio eradication becomes a standing agenda item at the
inter-ministerial meetings of Federal and Provincial Ministers of Health.

c. To Establish/activate polio Provincial Steering Committees in each
Province.

26
d. To Establish/activate district polio task forces under the chairmanship of
DCOs

e. To Monitor the security situation closely, and prepare and maintain
contingency plans to ensure vaccination of the moving children.

2. Supplementary Immunization Activities

a). It is essential to ensure the best quality performance during supplementary
immunization activities.

b). Ensure selection of competent and qualified Area-in-Charges whose
performance should be monitored.

c). Ensure proper vaccination team selection with respect to age and
appropriate proportion of females.

d). Ensure proper training of vaccinators.

e). Ensure campaign monitoring is carried out in a credible way:

3. Surveillance

(a). Ensure the quality of stool specimens by the investigating officers.

(b). Continue to hold monthly provincial surveillance meetings, and use them
as a forum also to discuss campaign achievements.

(c). Conduct surveillance reviews regularly.


27
4. Communication

(a). Continue the excellent progress made in developing effective
communication and expand it to include other elements of EPI and child
survival.

(b). Build communication capacity within the structures of Federal and
Provincial authorities.

(c). Target communication activities to high-risk areas where there is a need to
reach non-immunized children.

(d). Continue to conduct research into factors behind refusals and use the
findings to modify the present strategies.

5. Routine Immunization

Consider child immunization a priority and use the increasing skills in
communication to strengthen commitment of the national authorities, non-governmental
organizations and particularly the public, who should be demanding vaccination for their
children. Maximum emphasis may be put on routine immunization which includes three
doses of Polio Vaccine in the first year of life.

6. Analysis of the data of last 5 years according to the gender, age, percentage of
routine immunization in each affected district may be carried out to come to conclusion
regarding the reason of failures and occurrence of these cases.

7. The Antibody titre against polio may be carried out on all these cases of 2008,
which have been supposedly given many doses of polio vaccine and still got the
disease.
28

8. National and Provincial Funding commitment for action plans for E.P.I. and Polio

9. Strategies to resolve Provincial and District Management Challenges


10. Establishment of National Inter-Provincial Programme monitoring and crisis
management body


Acknowledgements:

Author is grateful to the encouragement and contribution made by Deputy Chairman,
Planning Commission and Member (SS). The information provided by Mr. Qadir Bux
Abbasi, and Dr. Hussain Bux Memon (EPI), Dr. Mushtaq A. Khan, and Dr. Amjad,
(N.H.P.U), Dr. Obaidul Islam, Senior Surveillance Officer, W.H.O. and Dr. Azhar
Abid of UNICEF is acknowledged.















29


REFERENCES

1) World Health Statistics 2008, World Health Organization.
2) Polio Eradication initiative, National surveillance Cell, Federal EPI, 2008.
3) The News, Two More Polio cases on 19.6.2008
4) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5712a3.htm
5) http://www.polioeradication.org/content/general/current_monthly_sitrep.asp
6) http://www.health.gov.pk/
7) http://www.who.int/mediacentre/factsheets/fs114/en/
8) Emergency Technical Consultation on Polio Eradication (TAG Meeting) Karachi
24-25 J une 2008
9) AFP Surveillance, Annual report 2001, National Surveillance Cell, Federal EPI
Ministry of Health Pakistan
10) National Surveillance Bulletin, issue 6, J une 2008, WHO Office, Islamabad
Pakistan
11) Global Polio Eradication initiative Strategic Plan 2004-08 CDC, UNICEF, WHO
12) Communication for Polio Eradication and routine immunization. Checklists and
easy reference guide. Who/Polio/02-06/WHO.UNICEF 2006
13) Field guide 1996 Global Programme for Vaccines and Immunization Polio
Eradication, WHO Geneva 1997
14) Daily News, 21 August 2008
15) Pakistan Social and living standards measurement Survey (PSLM) 2006-07
Government of Pakistan






30

Annex-A
POLIOMYLITIS CASES TILL JUNE 2008
Province/Region Distract Name
Polio Virus
Type
No. Cases Total Districts Total Cases
Punjab Last Confirmed Polio Case seen in September 2007 -
Hyderabad Type 1 1
Nawabshah Type 1(Contact) 1
Shikarpur Type 1 1
North Karachi Town Type 1 1
Mirpurkhas Type 1 1
Naushero Feroz Type 1 1
J acobabad Type 1 1
Dadu Type 1 1
SITE Town Karachi Type 1 1






Sindh
Sanghar Type 1 1
10 10
Nowshera Type 3 1
Nowshera Type 3 1
NWFP
Kohat Type 1 1

2

3
Killa Abdullah Type 1 1 1 Balochistan
Pishin Type 1 1
2
1
FATA
Last Confirmed Polio Case seen in December 2007
AJK Last Confirmed Polio Case seen in June 2000
-
FANA Last Confirmed Polio Case seen in J anuary 1998
-
Islamabad Last Confirmed Polio Case seen in December 2003
-
Total 14 15

Source: Federal EPI Cell, Ministry of Health






31
Annex-A-1
2008 UPDATE:
Total number of confirmed polio cases (to date) =31
25 type-1 cases (12 from Sindh, 6 from NWFP, 4 from Balochistan, 2 from
Punjab and 1 from Islamabad)
06 type-3 cases (all from NWFP/FATA; 2 from Nowshera, 2 from Bajour Agency
and 2 from Peshawar)

Confirmed polio cases by province, district & by type in 2008 to date
Province/
Region
District Name Poliovirus Type No.
Cases
Total
Districts
Total Cases
Okara NSL 1 1 Punjab
Sheikhupura NSL 1 1
2

2

Hyderabad NSL 1 1
Nawabshah NSL 1 (Contact) 1
Shikarpur NSL 1 1
North Karachi
Town
NSL 1 1
Mirpurkhias NSL 1 1
Naushero
Feroze
NSL 1 1
J acobabad NSL 1 1
Dadu NSL 1 1
SITE Town
Karachi
NSL 1 1
Sanghar NSL 1 1
Gadap Town NSL 1 1






Sindh
Khairpur* NSL 1 1






12






12
Nowshera NSL 3 (Contact) 1
Nowshera NSL 1 1
Kohat NSL 1 1
Swat NSL 1 1
Swat NSL 1 1
Peshawar NSL 3 1
Mardan NSL 1 1
Peshawar NSL 3 1
Dir Upper NSL 1 1





NWFP
Dir Upper* NSL 1 1





6





10
Bajour NSL 3 1 FATA
Bajour NSL 3 1
1 2
Killa Abdullah NSL 1 1
Pishin NSL 1 1
Ziarat NSL 1 1

Balochistan
Loralai NSL 1 1
4 4
AJ K Last Confirmed Polio Case seen in J une 2000 -
FANA Last Confirmed Polio Case Seen in J anuary 1998 -
Islamabad Islamabad NSL1 1 1 1
Total 26 31
NSL: Non-Sabin Like
32
Poliomyelitis Case 2000-2007 Annex-B


Source: Federal EPI Cell, Ministry of Health














Month/Years 2000 2001 2002 2003 2004 2005 2006 2007
January 10 9 4 6 4 4 0 5
February 7 3 4 7 3 0 2 1
March 1 4 4 7 4 2 0 1
April 11 4 9 14 1 1 1 0
May 13 3 3 7 4 3 5 2
June 22 4 6 7 3 2 4 2
July 16 7 2 8 4 3 4 0
August 23 18 11 11 10 2 3 2
September 27 24 20 14 2 3 6 4
October 30 20 14 7 8 2 8 1
November 24 16 7 10 2 3 6 6
December 15 7 6 5 8 3 1 8
Total 199 119 90 103 53 28 40 32
33
Annex-C
OPV Distribution for the Year 2007
Rounds Punjab Sindh NWFP Balochistan AJK FANA ICT Total
Feburary
07 SNIDs
264,755 308,925 239,365 78,675 ----- ----- ---- 891,720
March 07
SNIDs
195,800 256,190 181,110 66,900 ------ ----- ---- 700,000
24-26 April
07
955,000 455,000 375,000 130,000 37,500 13,000 13,000 1,978,500
10-14 May
07 SNIDs
192,700 251,300 191,400 65,060 ----- ----- ----- 700,460
19-21 J une
07
180,900 278,100 181,350 65,100 ----- ----- ----- 705,450
7-9 August
NIDs
955,000 455,000 375,000 129,000 38,400 12,500 12,100 1,977,000
24-26 Sept
07 Spl
camp.
---- 40,000 150,000 70,000 ----- ----- ----- 260,000
30
th
Oct to
1
st
Nov
NIDs
955,000 455,000 375,000 129,000 38,400 12,500 12,100 1,977,000
11-13 Dec
07 SNIDs
224,000 337,000 194,000 65,000 ----- ----- ----- 820,000

OPV Distribution for the Year 2008
Rounds Punjab Sindh NWFP Balochistan AJK FANA ICT Total
22-24 J an 08
NIDs
955,000 455,000 375,000 129,000 38,400 12,500 12,100 1,977,000
8-10 April 08
SNIDs
218,500 445,500 260,000 78,500 ---- ---- ---- 1,002,500
May 07 NIDs 950,000 450,000 360,000 130,000 38,500 12,500 12,850 1,953,850
34

Annex-D
40 Tot22)
3 QUETTA
4 KABDULAH
3 J AFARABAD
32 Tot(18) 1 NFEROZ 28 TOTAL(18)
1 PISHIN 2 KHIKORANGI 1 SIBI
2 NSIRABAD 1 KHIGIQBAL 1 KABDULAH
1 LORALAI 1 KHIGADAP 1 J AFARABAD
15 Tot(14) 1 LASBELA 1 UMERKOT 2 QUETTA
1 PISHIN 3 KABDULAH 2 SUKKUR 1 PISHIN
1 KABDULAH 1 THATTA 1 SHIKARPUR 1 MUSAKHEL
1 SHIKARPUR 2 KHIBALDIA 1 SANGHAR 1 KSAIFULAH
1 SANGHAR 1 KHAIRPUR 1 J ACOBABAD 2 LARKANA
1 NFEROZ 5 KAMBAR 1 GHOTKI 1 SANGHAR
1 NAWABSHAH 2 J ACOBABAD 1 MUZFARGARH 1 J ACOBABAD
1 MIRPURKHAS 1 GHOTKI 1 MULTAN 1 GHOTKI
1 KHISITE 1 DGKHAN 2 WAZIR-N 1 MULTAN
1 KHINORTH 1 WAZIR-S 1 LAKKIMRWT 6 DGKHAN
1 J ACOBABAD 1 SWAT 1 KHYBER 1 RYKHAN
1 HYDERABAD 1 PESHAWAR 1 DIRLOWER 2 KHANEWAL
1 DADU 2 NOWSHERA 1 DIKHAN 1 TANK
2 NOWSHERA 4 MARDAN 6 BANNU 2 PESHAWAR
1 KOHAT 2 KHYBER 4 BAJ OUR 2 BAJ OUR
2008 DISTRICT 2007 DISTRICT 2006 DISTRICT 2005 DISTRICT
Distribution of Polio Cases by District, 2005-2008*
* Afp.rec Data as of 26-06-2008



P1 Wild = 19
Distribution of Polio Cases by Sero-type & District,
2005-2008*
P1 Wild = 27
P3 Wild = 01
2005
No. Districts with Wild poliovirus cases =18
Provincial Boundary
Districts Boundary
No. Districts with Wild poliovirus cases =22
P1 Wild = 20
2006
P3 Wild = 20
2007
P3 Wild = 13
No. Districts with Wild poliovirus cases =18
Cases randomly placed
in Tehsils.
* Afp.rec Data as of 26-06-2008
No. Districts with Wild poliovirus cases =14
P1 Wild = 13
P3 Wild = 02
2008





35


36
Annex-F

Confirmed polio cases by month & by year (2000-2008) todate

Month/Year 2000 2001 2002 2003 2004 2005 2006 2007 2008
J anuary 10 9 4 6 4 4 0 5 2
February 7 3 4 7 3 0 2 1 1
March 1 4 4 7 4 2 0 1 0
April 11 4 9 14 1 1 1 0 6
May 13 3 3 7 4 3 5 2 5
J une 22 4 6 7 3 2 4 2 2
J uly 16 7 2 8 4 3 4 0 15
August 23 18 11 11 10 2 3 2
September 27 24 20 14 2 3 6 4
October 30 20 14 7 8 2 8 1
November 24 16 7 10 2 3 6 6
December 15 7 6 5 8 3 1 8
Total 199 119 90 103 53 28 40 32 31