Clinical Microbiology and Infection 24 (2018) 6e7
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Hot topic
Polio eradication challenges in Pakistan
The Global Polio Eradication Initiative was launched in 1988, when the wild type polio virus was present in 125 countries, paralysing 350 000 people per year. Since then, immunization efforts have reduced the number of polio cases by more than 99% and today wild type polio virus is found only in Afghanistan, Pakistan, and Nigeria [1]. Although the number of wild type polio cases is much reduced, the deadline for interrupting the transmission of wild type polio virus by the end of December 2016 has not been achieved. The major barriers to eradicating polio in Pakistan are persistently missed children during vaccination drives, a high percentage of environmental water samples testing positive for polio virus, vaccine refusal, misconceptions about the polio vaccine, killing of polio workers, and low performing districts. The Pakistan polio programme has performed well since the start of 2015. The number of wild type polio virus cases declined from 306 in 2014 to 54 in 2015, and to 20 in 2016 [2]. So far three cases have been reported from the country in the year 2017, including one from the Lodran district in Punjab, one from the Diamir district in Gilgit-Baltistan, and one from the Chaman district of Killa Abdullah. Not one single case of polio has been reported from the core reservoir of Peshawar-Khyber and Karachi in the past 12 months [2]. In a recent polio vaccination drive, more than 38 million children under the age of 5 were vaccinated in Pakistan [2]. A major concern for polio eradication in Pakistan is the number of children missed during vaccination drives. The children who are not available at the time of vaccination are categorized into three groups. The first group comprises children who were in school in the immediate locality, the second group comprises children who are in the wider district, and the third group comprises children who are further afield. The children in the first two groups can be reached with local cooperation and visited on their return home. The real problem is the third group: children who are far afield in another part of Pakistan or Afghanistan. In low season 2017, the number of children who missed vaccination even after attempts to re-visit them is 858 000. The number of unvaccinated children is very high, posing a serious threat to the polio eradication challenge [3]. Pakistan and Afghanistan are coordinating to reduce the number of missed children. Both countries have agreed to vaccinate children under 10 on all the border points between the two countries and to conduct polio vaccination campaigns on the same day. Officials from both countries have participated as observers in each other's Technical Advisory Group (TAG) meetings on polio. TAG members have urged the National High Commissioners for Refugees (UNHCR) to facilitate the polio eradication programmes of both countries in vaccinating repatriating populations [4].
Despite the record low number of wild type polio cases in 2017, the environmental surveillance system indicates that the virus remains a serious threat to children, with 18% of environmental water (sewerage or other waste water) samples testing positive for wild type polio virus in May 2017. The positive environmental samples were detected from Islamabad, Punjab, Sindh, KP, and Baluchistan [2]. The polio programme in Quetta block is still well below peak performance. There are a number of challenges in Quetta including large population movements, hard to get female polio workers, high refusal rate, few resources, weak public services, and conservative culture [3]. The polio programme in Pakistan has recruited community mobilizers to reduce the number of refusal cases. In early 2017, there were reports of 3000 parental refusal cases from the Sindh province of Pakistan [5]. A couple of refusal cases from the educated community of Islamabad were also published in a Pakistani newspaper [6]. There are different misconceptions about the polio vaccine in Pakistan. Some people think that the polio vaccine is not Islamic (haram) [7], it produces impotency, or it is substandard. A knowledge, attitude, and practice survey designed jointly by Harvard School of Public Health and the Pakistan polio programme was conducted at high-risk polio districts in 2016 and 2017. The results of the 2017 survey showed that the overall circulation of destructive rumours about polio vaccine has decreased from 59% to 44%, while in Baluchistan the circulation of destructive rumours has decreased from 95% to 61% [8]. Religious leaders, school teachers, tribal elders, and local female community workers are also engaged in polio awareness and vaccination drives in different districts of Pakistan. A laboratory controlled by the Drug Regulatory Authority of Pakistan has tested polio vaccine and declared it Halal (Islamic) [9]. Religious scholars also issued a Fatwa that the polio vaccine is Halal [7] and there are no religious or health-related issues with these vaccines. The security situation in Pakistan was much improved by the military operation Zarb-e-Azab in North Waziristan Agency, started in April 2014. The operation destroyed the hideouts and safe havens of terrorists in the area. Currently, there is no district banned for the entry of polio workers. There are certain sleeper cells of terrorists involved in the killing of polio workers. The most recent attack on polio workers took place on 1 July 2017 in the North West province of Pakistan. More than 100 people have been killed in such attacks since December 2012 [10]. Despite the attacks, Pakistan is determined to eradicate polio from the country. The Pakistani government is showing a strong political commitment to make Pakistan polio-free. The newly appointed Prime
https://doi.org/10.1016/j.cmi.2017.09.008 1198-743X/© 2017 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Hot topic / Clinical Microbiology and Infection 24 (2018) 6e7
Minister Shahid Khaqan Abbasi said ‘It is a matter of survival of our next generation; hence we take full ownership of polio eradication from the country’ [11]. An independent monitoring board also praised the efforts of Health Minister and the Prime Minister's Focal Person on polio eradication, and the provincial secretaries for running a high performing polio programme. The recent innovation in the polio programme is the formation of divisional level task forces run by divisional commissioners [3]. The high number of missed children is a major hurdle to eradication of polio from Pakistan. There is an urgent need for validated record of nomadic children, visiting guests, newborns, still missed and persistently missed children. The missed children can be reached by micro planning, aggressive follow-up, communitybased vaccination, and vaccine administration at different entry and exit points. The vaccine refusal cases can be reduced by different approaches of targeted community engagements including household visits by a range of influencers, mosque announcements, Jirgas, community meetings, and Fatwas by religious leaders in support of polio vaccine [8]. The media should help to raise awareness about polio vaccination and its safety [9]. Pakistan is working hard to eradicate polio but still efforts are needed to reduce the number of missed children and remove the misconceptions about polio vaccination.
[3] Every last virus. 14th Independent monitoring board of the global polio eradication initiative report. Published June, 2017. http://endpolio.com.pk/images/ Stories/14th-IMB-report-final.pdf (accessed June 29, 2017). [4] Wasif S. Coordinated Pak-Afghan efforts for polio eradication bear fruits. The Express Tribune. Published April 9, 2017 https://tribune.com.pk/story/ 1378570/coordinated-pak-afghan-efforts-polio-eradication-bear-fruit/ (accessed June 25, 2017). [5] Bhatti MW. 3000 persistently missed children hampering anti-polio efforts. The News; Feb 26, 2017 (accessed April 15, 2017), https://www.thenews. com.pk/print/188768-3000-persistently-missed-children-hampering-antipolio-efforts. [6] Junaidi I. Polio refusal cases among well-educated people baffle officials. Dawn News; April 1st, 2017 (accessed June 25, 2017), https://www.dawn.com/ news/1324148. [7] Riaz F, Waheed Y. Islam and Polio. Lancet Inf Dis 2014;14:791e2. [8] National emergency action plan for polio eradication 2017/2018. Published July 8, 2017. Downloaded from http://polioeradication.org/wp-content/ uploads/2016/07/NEAP-2017_2018_v6.pdf Accessed September 1, 2017. [9] Junaidi I. Lab tests show polio vaccine is not ‘Haram’. Dawn News; Jan 14, 2015 (accessed June 23, 2017). https://www.dawn.com/news/1156931. [10] Polio worker shot dead in NW Pakistan. The Nation; July 2, 2017 (accessed July 2, 2017), http://nation.com.pk/national/02-Jul-2017/polio-worker-shotdead-in-nw-pakistan. [11] PM Abbasi for early convening of meeting on Polio eradication. Parliament Times; August 15, 2017 (accessed August 29, 2017), http:// dailyparliamenttimes.com/pm-abbasi-early-convening-meeting-polioeradication/.
Y. Waheed* Foundation University Medical College, Foundation University Islamabad, Pakistan
Transparency declaration The author does not have any conflict of interest. The author did not receive any funding for this study. References [1] Hussain SF, Boyle P, Patel P, Sullivan R. Eradicating polio in Pakistan: an analysis of the challenges and solutions to this security and health issue. Global Health 2016;12:63. [2] Pakistan Polio update. Published May, 2017. http://endpolio.com.pk/images/ polio-briefer/pakistan-polio-update-may-2017.PDF (accessed July 1, 2017).
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Corresponding author. Y. Waheed, Foundation University Medical College, Foundation University Islamabad, DHA I, Islamabad, Pakistan. E-mail address:
[email protected]. 17 July 2017 Available online 28 September 2017 Editor: G. Greub
