Afghanistan completes largest ever review of polio surveillance system – GPEI

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Sixteen of the 29 environmental monitoring sites in Afghanistan were visited by the review team, including four in Kandahar City. © WHO

Over the past two decades, the prospect of sending 16 polio experts to visit the provinces of Afghanistan would have been impossible, but from June 6-19, 2022, WHO’s polio eradication program in Afghanistan did just that. Their mission? Review the country’s polio surveillance system, assess its functionality at all levels, and make specific recommendations to maintain and improve the quality of surveillance.

“This was an extraordinary achievement by the WHO polio team in Afghanistan. The logistical and administrative challenges alone were enormous,” said Dr Luo Dapeng, WHO Representative in Afghanistan. “Afghanistan is one of the last countries where polio is endemic and we must do everything possible to prevent this virus from infecting other children.

The review was necessary for several reasons, one of which was to determine whether the steep decline in the number of children paralyzed by wild poliovirus in Afghanistan over the past eighteen months accurately reflected the reality on the ground. From 56 cases in 2020, the number fell to four in 2021. So far this year, two children have been crippled by the virus.

“It is important to show that the surveillance system has the strength and the ability to detect any poliovirus circulation that may be occurring,” said Dr Irfan Elahi Akbar, Polio Team Leader at WHO Afghanistan. “Because if we don’t detect cases, investigate them quickly and respond to them, more and more children will be paralyzed.

The last international oversight review team visited in 2016, meaning a review was also overdue. Insecurity and the polio program’s lack of access to much of the country meant that the small team could only visit a handful of locations, including the cities of Kabul, Herat, Kandahar, Jalalabad, Mazar- e-sharif and Kunduz.

This time, reviewers visited 76 districts in 25 of the country’s 34 provinces, interviewing 899 people, including volunteers from the community surveillance network of more than 46,000 people, including pharmacists, health workers community workers, religious healers, nurses, imams and bone repairers.

Following a desk review of the system late last year in which the Global Polio Eradication Initiative (GPEI) Partners Center in Amman analyzed existing national data, a physical visit was necessary in order to verify the results and to obtain as accurate a picture as possible of the standby system.

Examiners visited 76 districts in 25 of the country's 34 provinces, interviewing 899 people.  © WHO
Examiners visited 76 districts in 25 of the country’s 34 provinces, interviewing 899 people. © WHO

“A surveillance review is a very rigorous process of reviewing the records and documentation of acute flaccid paralysis cases [AFP, a sign that polio may be present] in children, talking to patients and their families, assessing the knowledge of the many people involved in the surveillance network, scanning hospital records, checking and rechecking data,” said Dr Khushhal Khan Zaman, who oversees the surveillance of poliomyelitis for WHO in Afghanistan.

The ultimate goal of Afghanistan’s polio eradication program is for the country to be certified polio-free, a long and meticulous process that relies on documentary evidence to show that there has been no transmission. of wild poliovirus for a period of at least three years since the last reported case. .

The reviewers’ assignment also included overseeing the collection and shipment of stool samples to the nearby Pakistan Regional Reference Laboratory, as well as ensuring that environmental monitoring protocols, involving the collection of sewage samples , are respected. Sixteen of the 29 environmental monitoring sites in Afghanistan were visited by the review team, including four in Kandahar City. The review team also met with the country’s AFP Expert Review Committee to better understand Afghanistan’s review process.

The review took place in June during a window that opened between a series of national polio immunization campaigns. Each campaign takes about 21 days to start. With access to all regions of the country, in the first six months of 2022, the Afghanistan program implemented five of the six campaigns planned for the year. Additional campaigns are planned for the remainder of 2022.

The logistics of getting examiners to Afghanistan and the provinces proved the biggest challenge, something akin to a game of snakes and ladders involving UN guesthouses, armored vehicles and the availability of security escorts. The influx of UN personnel into Afghanistan following the August 2021 transition has led to increased demand for all three. Each time a piece of the puzzle became unavailable, the organizing team of logistics, administration, security and travel personnel would delete their carefully constructed color-coded spreadsheet and start over. Fortunately, the logistics of the exam were largely a “One UN” effort with sister agencies stepping in to fill accommodation and transportation gaps where possible.

Perhaps the most significant support came from polio staff in the provinces who organized visits to 152 health facilities as well as interviews with hundreds of health workers, volunteers, patients and families. .

The review determined that Afghanistan’s surveillance system meets all targets for sensitivity and that the likelihood of undetected transmission of poliovirus is low. The recommendations, including the intensification of surveillance in the south and south-east of the country, are currently being implemented.

“After many visits to Afghanistan, this was the first time we could visit all the places we needed to review,” said Dr Jean-Marc Olive, leader of the surveillance review team. “It gave me great confidence that this massive effort was a thorough review of the country that clearly identified both achievements and remaining challenges to ensure that no WPVs will be missed.”

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