The Evolution, Facilitators, Barriers, and Additional Activities of Acute Flaccid Paralysis Surveillance Platform in Polio Eradication Programme Bangladesh: A Mixed-method Study

"Robust multi-sectoral collaboration between ministries, the involvement of other stakeholders like NGOs [non-governmental organisations[ and development partners and strong political commitments were among the contributors to the polio program in Bangladesh."

The Global Polio Eradication Initiative (GPEI) helped develop the standard acute flaccid paralysis surveillance (AFP) system worldwide. AFP is the sudden onset of weakness or paralysis of limbs often associated with fever that occurs in polio and other diseases with a similar features. AFP surveillance can complement any disease surveillance system. For example, the AFP surveillance team in Bangladesh also served as frontline health workers for the COVID-19 response. This study outlines AFP surveillance evolution in Bangladesh, its success and challenging factors, and its potential to facilitate other health goals.

This study is a part of the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) project. A sequential explanatory mixed-method study design was used to map, synthesise, and disseminate lessons learned from the global polio eradication effort in Bangladesh. The study includes a grey literature review, online and in-person surveys, and key informant interviews (KIIs).

Based on the data gathered, the paper outlines the evolution of AFP surveillance in Bangladesh, which was introduced in 1990 through the existing government structure. Bangladesh achieved certified standards for ten AFP surveillance performance indicators in 2001. Due to effective AFP surveillance, Bangladesh detected 18 imported cases of wild poliovirus type 1 (WPV1) in 2006 from western Uttar Pradesh, India, and contained the outbreak through extensive surveillance and supplementary immunisation activities (SIAs). Survey responses and KIIs highlighted that AFP surveillance led by the government under the Expanded Program on Immunization (EPI) and supported by the World Health Organization (WHO) successfully contributed to the decrease in poliomyelitis cases and in attaining polio-free status for Bangladesh in 2000. 

Examples of factors driving the success of AFP surveillance:
 

• Multi-sectoral collaboration, support, and activities: Both free survey responses and KIIs signify that the strong collaboration and social engagement among all relevant ministries, local government, political leaders and parties, civil society and local non-governmental organisations (NGOs), professional EPI workforce, polio laboratory team, and the WHO Surveillance Medical Officer (SMO) network provided technical and financial support, facilitated AFP surveillance implementation, and kept Bangladesh polio free.
• Social environments: Most survey respondents mentioned that the community setting, and context were major contributing external factors to successful AFP surveillance. To increase case notification and awareness, the government trained and mobilised community volunteers and local NGO workers in Upazilas and districts named "key informants". These informants included frontline primary healthcare workers, BRAC volunteers, Imams of local mosques, Union Council members, village doctors, local healers, EPI outreach sites caretakers, oral rehydration salt and contraceptive depot holders, schoolteachers, and scouts. All KII respondents acknowledged their valuable contribution in identifying AFP cases.
• High political commitment: Since 1971, political instabilities have taken place, including conflicts, strikes, and shutdowns threatening the overall development of the country. Fortunately, the government was highly committed to polio eradication efforts, including AFP surveillance, from the beginning. Around 17% of survey respondents informed political factors, which includes any political or high-level support either from local or national government, as a primary contributor.

On the other hand, high population growth, hard-to-reach areas, people residing in risky zones, and polio transition planning were significant challenges.

Bangladesh is also utilising these polio surveillance assets for other vaccine-preventable diseases, as outlined in the article.

Thus, this study emphasises the central role AFP surveillance played in Bangladesh's achievement of polio-free status by serving as an early warning system for the presence of the poliovirus. "The government should recognize the value of polio transition plan and secure the ownership over the programme and funding and strengthen their technical capacity for sustaining the polio free status and smooth transitioning of polio assets to other health priorities."