A United Front: Afghanistan And Pakistan's Collaborative Effort To Immunize Their Nations

Afghanistan and Pakistan are the only two remaining countries with endemic wild poliovirus type 1 (WPV1) transmission. Both countries have been working towards eradicating polio, with Pakistan making significant progress since the launch of its Polio Eradication Programme in 1994. The programme has seen a massive decline in polio cases, from approximately 20,000 every year in the early 1990s to only eight cases in 2018. Afghanistan, on the other hand, has been facing challenges in its immunization efforts due to conflict, the Taliban regime, and other disruptions to its health services. Despite these challenges, there has been some progress, with a decrease in the number of WPV1 cases and an increase in the number of children vaccinated. Both countries have been working together to synchronize their immunization activities and cross-border communication to eradicate polio.

Synchronizing immunization activities

In recent years, there has been a decline in the number of WPV1 cases in both countries. Afghanistan reported two WPV1 cases in 2022 as of September 30, compared to one case during the same period in 2021. Similarly, Pakistan has made significant progress, with only eight polio cases reported in 2018, down from approximately 20,000 cases every year in the early 1990s.

To further reduce the number of cases and eradicate polio, synchronizing immunization activities between the two countries is crucial. The Technical Advisory Group (TAG) for Afghanistan and Pakistan, which met in October 2022, acknowledged the progress made by both countries' polio programmes despite the challenges posed by the humanitarian crisis in Afghanistan and the flooding in Pakistan. The group also emphasized the high level of sustained political commitment to polio eradication in both countries.

One of the key achievements highlighted by TAG was the increased access to children for vaccination. In Afghanistan, nationwide campaigns since the political transition have allowed the polio programme to reach almost 10 million children, 3.5 million of whom were previously inaccessible. In Pakistan, intensified vaccination activities and strategic approaches helped reach missed children.

To further synchronize immunization activities, the following strategies have been implemented:

• Greater coordination between the two countries' polio eradication programmes, including synchronization of immunization activities and data sharing on key population movements.
• Implementation of jointly developed plans and cross-border communication activities.
• Synchronization of immunization calendars: both countries have endorsed the 2023 polio supplementary immunization activities' calendars.
• Continued use of strategies to integrate gender and social behavioural change communication into the programmes to reach every last child.

By working together and synchronizing their immunization activities, Afghanistan and Pakistan are making significant progress towards interrupting poliovirus transmission and achieving the goal of zero polio cases.

The role of Emergency Operations Centres (EOCs)

Emergency Operations Centres (EOCs) are critical in responding to public health emergencies. They are a central command and control "coordination structure" responsible for managing emergency response, emergency preparedness, emergency management, and disaster management functions at a strategic level during an emergency. EOCs are secure locations that provide space for centralized monitoring, control, and command of an emergency event. They are often activated when emergencies require resources beyond what local capabilities can handle, during lengthy crisis situations, when major policy decisions are needed, or when local or state emergencies are declared.

EOCs are designed to bring together staff from multiple agencies, offices, sectors, and organizations to work directly and collaboratively, sharing information in real time, and formulating a joint plan of action. They are equipped with the necessary personnel, equipment, and communication technology the government needs during an emergency response. The team inside an EOC may handle crisis communication, such as press inquiries or calls from family members of victims, conduct incident stabilization management, and ensure business continuity to the extent possible.

EOCs have five sections to manage operations: Management, Operations, Planning and Intelligence, Logistics, and Finance and Administration. The Management section has overall responsibility for managing and directing all EOC activities, including developing, implementing, and reviewing strategic decisions. The Operations section represents on-scene emergency responders and provides coordination between the EOC and field operations. The Planning and Intelligence section is responsible for receiving, evaluating, and analyzing all disaster information, providing updated status reports, and conducting damage assessments. The Logistics section is in charge of procuring supplies, personnel, and material support necessary for emergency responses. Finally, the Finance and Administration section handles cost accountability, purchase authorizations, documentation, and risk assessment.

In the context of immunization efforts, EOCs have played a crucial role in the fight against polio and other infectious diseases. For example, EOCs have been established in Nigeria, Afghanistan, and Pakistan to re-energize polio eradication activities. These centers have helped track disease outbreaks and the resources deployed to address them in real time, providing direct accountability for vaccinations and surveillance. EOCs have also been used to address other public health threats, such as the Ebola outbreak in Nigeria, where the EOC organized a quick and successful response.

EOCs are particularly important in countries with weak health infrastructure and limited resources, as they offer the government a central command post where disparate groups can coordinate and develop consensus around appropriate actions. They are also valuable in improving the health and safety of their own countries and containing diseases globally by facilitating quicker, better-synchronized, and more effective emergency responses.

The importance of cross-border coordination

Cross-border coordination is crucial in the fight against polio and other diseases, as evidenced by the collaboration between Afghanistan and Pakistan. The two countries are the last remaining polio-endemic countries, and their synchronized efforts are vital to eradicating the disease. Cross-border coordination ensures that immunization activities are well-organized and that resources are efficiently utilized. It also helps in maintaining high levels of political commitment and involves the active participation of law enforcement and security agencies.

Cross-border coordination plays a significant role in strengthening the overall response to disease outbreaks. By working together, countries can share information, exchange data, and develop joint strategies to combat the spread of diseases. This coordination is especially important for neighboring countries with shared borders and frequent population movements, as it helps in containing the disease and preventing its spread across borders.

Furthermore, cross-border coordination allows for the synchronization of immunization activities and the implementation of jointly developed plans. It also enables the sharing of best practices and the development of consistent approaches to disease prevention and control. This collaboration ensures that vulnerable populations, such as children under five, are protected regardless of their location.

In addition to health benefits, cross-border coordination has economic advantages. By working together, countries can reduce the economic strain caused by protectionist trade and travel restrictions. It also promotes international trade and collaboration, which can lead to economic growth and development.

Moreover, cross-border coordination facilitates the free movement of essential supplies and health workers across borders. This is crucial during disease outbreaks, as it ensures that life-saving resources can reach the areas that need them the most without any hindrance.

Finally, cross-border coordination strengthens the relationship between countries and promotes regional cooperation. It fosters a sense of shared responsibility and encourages countries to work together towards a common goal. This collaboration can have long-lasting positive effects on various aspects of international relations.

The impact of political transitions

Afghanistan has experienced a tumultuous history of political transitions, with the most recent one occurring in August 2021, when the Afghanistan government was fully replaced by the Taliban de facto government. This political transition has had a significant impact on the country's immunization efforts, particularly in the fight against polio.

Impact on Immunization Efforts

The political transition in Afghanistan has had a mixed impact on immunization efforts. On the one hand, it has provided an opportunity to reach previously inaccessible children with vaccinations. For example, since the political transition, nationwide campaigns have allowed the polio program access to almost 10 million children, 3.5-4.5 million of whom were previously unreachable. This has resulted in a substantial reduction in the number of unreached children.

Challenges and Limitations

However, the political transition has also brought about certain challenges and limitations. Firstly, there are still restrictions on how supplementary immunization activities (SIAs) are conducted, particularly in the critical South Region provinces of Kandahar, Helmand, and Uruzgan. These restrictions have hindered efforts to vaccinate all children and achieve the goal of interrupting wild poliovirus type 1 (WPV1) transmission.

Secondly, the quality of data on SIA implementation is limited due to the low accuracy of reported coverage data. This affects the ability to make informed decisions and adjustments to the immunization programs.

Future Prospects

Despite these challenges, there is a window of opportunity to interrupt WPV1 transmission in Afghanistan. With continued and expanded SIAs throughout the country, including in high-risk provinces, there is a possibility of ending WPV1 transmission before the end of 2023. Additionally, the full synchronization and coordination of Afghanistan's polio eradication program with that of Pakistan can help improve the overall success of immunization efforts in the region.

The need for community engagement

Community engagement is critical to the success of immunization programs. It is important to note that the success of an immunization program depends on high rates of acceptance and coverage. Community engagement can address demand-side barriers while also mobilizing the community to advocate for better service delivery. Participatory engagement of communities can help identify barriers to vaccination at the local level and thus might lead to more sustainable solutions in a manner which a top-down approach cannot achieve.

Community engagement can be used to identify the most vulnerable groups and tailor immunization services to their needs. For example, in the context of immunization, community engagement can be used to identify and address the specific concerns of ethnic minorities, who are often more vaccine-hesitant. It can also be used to improve access to and understanding of information, especially for those with limited English literacy skills.

Community engagement can also be used to increase demand for vaccination among hesitant population groups. For example, in Israel, a public relations campaign was launched to encourage vaccination among ultra-orthodox Jewish communities, with religious leaders sharing pictures of their own vaccinations. In the UK, a campaign was launched to tackle false vaccine information shared among ethnic minority communities, providing content designed to be shared via WhatsApp and Facebook community groups.

Community engagement can also be used to improve the implementation of immunization services. For example, in the context of polio eradication, community engagement has been used to gain access to previously unreachable children in Afghanistan.

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