By Heba Ijaz
Since Nigeria was declared endemic-free last year, Pakistan has become one of two remaining countries where polio is still an endemic viral infection.
Poliomyelitis is a highly infectious disease caused by the poliovirus that primarily affects children. The virus spreads mainly through the fecal-oral route, although transmission through oral and nasal secretions can also occur. It resides mainly in the throat and intestines, and in certain cases, can enter the bloodstream to invade the brain and spinal cord, leading to paralysis. Contaminated water and food sources along with poor personal hygiene are significant contributors to polio transmission. Two types of vaccines are available today: Oral Polio Vaccine (OPV) is a live attenuated version and Intravenous Polio Vaccine (IPV) is an inactivated version.
In 1974, the World Health Organization (WHO) implemented the Expanded Programme on Immunization (EPI) in response to reports showing that less than 5% of the world’s children were immunized within the first year of birth against 6 preventable diseases, including polio. In Pakistan, routine immunizations against polio were made mandatory in 1978, although active steps to eliminate polio were not taken until much later. The Polio Eradication Initiative was launched in 1994 and, with the implementation of national immunization days, the approximate number of reported cases of wild polio dropped from 2500 to 156 per year within 4 years. This consistent downward trend showed hope for polio eradication soon. However, limited outreach to families in underserved and rural areas, reservations against all-male vaccination teams (and barriers for women’s involvement in vaccination campaigns), and rising misconceptions about OPV due to a severe lack of education caused increasing absence of and resistance to treatment. To make matters worse, the Guardian released an article in 2011 accusing the C.I.A. of organizing a vaccination program in Abbottabad, Pakistan to gather information. A senior Pakistani doctor, who was later arrested and imprisoned, was recruited to manage the drive. Since then, militant groups have banned local vaccination teams from entering certain tribal areas, campaigned incessantly to promote suspicion within the general population about these “intelligence-gathering” vaccination drives, and openly targeted health workers, causing many to abandon their jobs in fear of their own safety. Consequently, polio cases in Pakistan began to rise. In 2014, 306 polio cases were reported, the highest number in Pakistan in over a decade and the highest worldwide in that year.
Over the past couple of years, active measures have been taken to engage and empower local communities to eradicate polio. Community and religious leaders are encouraged to advise people to get vaccinated, advertisements are used to educate people about the effects of polio, and more women are hired as health workers as a means to establish trust with families. Ongoing military operations against militant insurgencies in the Federally Administered Tribal Areas (FATA) have allowed vaccination teams to access areas that were once too dangerous to visit. Travel restrictions were placed by the WHO on Pakistanis who failed to provide proof of polio vaccinations upon request. Furthermore, in 2015, the federal government introduced injectable vaccines that would require only one dose to develop immunity (OPV required multiple doses). Although more expensive than OPV, it was launched with the hopes that it would be more effective in treating an additional 4 million children, bringing the country closer to its eradication goal. That same year, the provincial government in Khyber Pakhtunkhwa went so far as to issue arrest warrants for parents and guardians who refused vaccinations for their children; they were released once they had signed a guarantee that they would allow their children to be vaccinated. By the end of 2015, 54 cases of wild polio had been reported, and fewer are expected this year (2 cases have been reported as of February).
With the whole country now invested in eradicating polio and vaccines being administered to millions of infants each year, the finish line seems to be in sight. Looking back, it raises the question of why, despite almost no issues of donor funding, it has taken approximately 40 years to come this close to eradicating polio, a disease that has been preventable by vaccination for over half a century. As of last year, one in four deaths of children under 5 years was caused by vaccine-preventable diseases. In order to now address these horrifying occurrences more efficiently, the government needs to assess its shortcomings in responding to the polio endemic. Although using fear of arrest and travel restrictions may have engaged the public and resulted in an increase in demand for immunization, a better approach would be to implement effective public awareness and education campaigns to promote health and immunization in local communities. Programs in other countries, including now polio-free Nigeria, have shown time and again that community involvement at the local level (as well as the national level) is vital to disease eradication.
BBC Video on Pakistan’s ongoing battle with polio: https://www.youtube.com/watch?v=b5-MVm3Itdk
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