ISLAMABAD – Pakistan’s last countrywide anti-polio drive of 2024 is set to conclude on 22 December but eradicating polio remains a challenge for the government, and this year’s surge in cases has resulted in calls for an independent audit of the program.

Pakistan and Afghanistan are the last two countries in the world battling to eliminate polio. In Pakistan, 63 polio cases have emerged this year in comparison to six in 2023, raising eyebrows about the strategies adopted by the government and international organizations working on polio eradication.

Shahzaib Khan, a health worker from the northern district of Mansehra in Pakistan’s Khyber Pakhtunkhwa province, is one of those grappling with these concerns.

Shahzaib, who works as a vaccinator in the health department, participated in the countrywide anti-polio drive with the target of vaccinating 44 million children five and under. Around 260,000 frontline workers are involved in the campaign.

As a frontline polio worker, he believes that the check-and-balance system at the district level has weakened, resulting in rising polio cases.

According to Khan, while the number of polio vaccination teams in each district has increased, there has been a reduction in those monitoring their performance at the district level. 

“Previously, these teams numbered up to 80 per district, but now the minimum has reduced to around eight, which has affected the standard of monitoring field teams,” Khan said.

Moreover, the long gaps between national polio campaigns allows the crippling disease to strengthen its roots, he added. For instance, in Naran, Khyber Pakhtunkhwa, the recent campaign was conducted after a seven-month hiatus.

Increase in cases

Aside from the, 63 cases have been reported this year, positive polio samples from 27 districts indicate a potential increase in cases in the coming days.

The highest number of cases has been reported in Balochistan, Pakistan’s southwestern province, with 26 cases, followed by Khyber Pakhtunkhwa with 18, Sindh with 17 and one case each from Punjab and the federal capital, Islamabad.

The polio elimination program faces major challenges from population migration, cross-border movement with Afghanistan and the refusal from some tribal communities and ultra-conservative groups in remote areas to allow vaccinations.

These communities, where the government also struggles to establish its writ, consider anti-polio drives as a ‘Western conspiracy’ against their children, allegedly believing it will harm the children’s fertility.

Polio teams in these areas are sometimes subject to armed attacks. During the recent seven-day national anti-polio campaign, two security personnel and five children were killed in such attacks in Balochistan and Khyber Pakhtunkhwa.

Conspiracy theories

Abdul Basit, a health department official from southern province of Sindh, noted that mistrust about the polio program exists among some communities and parents who either see the polio vaccine as a conspiracy or believe it is harmful to their children’s health.

In areas where security threats hinder polio teams, incidents of fake vaccination marking and data are common, he added. There is no national or provincial law to deal with parents who refuse polio drops for their children or those involved in falsifying data. 

Basit believes paediatricians can play a crucial role in educating parents about the positive effects of the vaccine, as they are often the first to be consulted when children fall ill. He would like to see a comprehensive strategy involving pediatricians at primary health centers to educate parents about the importance of the polio vaccine for their child’s future.

Prime Minister’s intervention 

Prime Minister Shahbaz Sharif, during a high-level meeting on polio, expressed confidence that the country would soon be free of polio, but he has also ordered a third-party audit of the polio campaign.

He has also directed top health officials to form a comprehensive strategy to reduce the immunity gap.

The Prime Minister’s Office in its statement reiterated its commitment to eradicating polio from the country through concerted efforts.

Meanwhile, former federal minister and public health expert Dr Nadeem Jan believes that the current immunity gap can be reduced within two years if there are changes in the polio program.

Jan said that while the high number of polio cases in a single year is concerning, the virus’s spread can be contained with a new approach. He proposes that Pakistan integrate the polio program with the routine immunization program.

“Routine immunization is already accepted within communities and does not face the same level of resistance as the polio program, therefore, the polio program should also be managed under the Expanded Program on Immunization (EPI),” said Jan.

Jan also stressed the need for a third-party audit of the program to ensure its effectiveness.

‘Significant failure’

However, Dr Abdul Ghafoor Shoro, general secretary of the Pakistan Medical Association (PMA), the country’s largest body representing physicians, has described the rise in cases as a failure of the program.

“This alarming trend indicates a significant failure in the polio eradication efforts, and PMA calls on the government to take immediate and decisive action to address this critical situation,” said Shoro.

He claims that the current approach, which appears reliant on a bureaucratic and foreign-funded system, has failed to contain the virus.

The PMA has demanded a comprehensive and transparent investigation into the reasons behind the resurgence of polio, including a thorough assessment of the existing polio eradication program, the role of the government, and the effectiveness of the current strategies.

The PMA also urged the government to immediately implement a robust and effective polio eradication strategy, increase public awareness campaigns and strengthen the surveillance system to ensure timely detection and response to new cases.

It also emphasized that adequate resources and support need to be provided to the polio eradication program, and those responsible for the failure to control the spread of the virus need to be held accountable.

Militancy and insecurity

The World Health Organization’s (WHO) regional polio eradication director Dr Hamid Jafari, told a webinar hosted by Global Polio Eradication Program that the current polio resurgence in Pakistan and Afghanistan is not comparable to the catastrophic levels witnessed decades ago, when over 20,000 children were paralyzed annually in Pakistan alone.

“By 2021 to 2022, Pakistan reported just one case of wild poliovirus, while Afghanistan recorded two. This is a dramatic improvement compared to the 176 cases reported in 2019 across both countries,” Jafari noted.

However, he explained that resurgence in polio is a predictable pattern in eradication efforts. “Until you completely eliminate the virus, it will resurge and come back,” he remarked.

Jafari highlighted several immediate causes for the recent rise in polio cases. These include the large-scale repatriation of Afghan nationals which triggered unpredictable population movements within Pakistan and across Afghanistan. 

Challenges such as militant insurgencies and insecurity have hindered vaccination campaigns in certain regions as “children in these insecure areas cannot be consistently vaccinated,” he explained.

Jafari also pointed to vaccine hesitancy and community boycotts driven by unmet expectations for broader services as significant obstacles.

This week, as part of a joint effort with partners, WHO is mobilizing over 380,000 health workers and volunteers to support the @GovtofPakistan on the vaccination of 44M children against polio, protecting them from a paralyzing disease that poses a global threat. #EndPolio pic.twitter.com/BmVpmx4wBi

— WHO Pakistan (@WHOPakistan) December 17, 2024

Despite these setbacks, both Pakistan and Afghanistan are actively working to counter the polio resurgence using measures such as remapping and identifying children who missed vaccinations, particularly among migrant and mobile populations, he added. 

Strategies also address vaccine fatigue and hesitancy by rebuilding community trust and confidence. Pakistan and Afghanistan are collaborating with their respective security forces to access children in insecure regions, he added.

“In Afghanistan, where door-to-door vaccination campaigns are not feasible, WHO is working closely with local authorities and communities to ensure children are mobilized for vaccination,” he said.

 Jafari expressed optimism about the future, stating that the current resurgence does not signify a return to high case levels: “Next year, we are confident we will come very close to elimination.”

He emphasized the importance of overcoming challenges in the virus’s remaining safe havens – insecure areas, mobile populations, and vaccine-hesitant communities.

National priority

The Prime Minister’s health coordinator,  Dr Mukhtar Ahmed Bharath said polio eradication is our first national priority under the leadership of the Prime Minister of Pakistan.

He said necessary measures are being taken on an emergency basis for the complete eradication of polio and an effective road map has been laid out for the success of the upcoming polio campaigns.

“All resources and capabilities will be utilized to stop the spread of polio virus and for high-risk areas, the federation and the provinces have jointly formulated an integrated strategy,” said Bharath.

“Complete eradication of polio is our national goal, and the cooperation of parents is very important to achieve this goal.”

The health ministry’s spokesperson Sajid Shah, told Health Policy Watch that that a high-level review meeting,  chaired by the Federal Secretary of Health and the Chief Secretary of Khyber Pakhtunkhwa, was held to discuss the current situation of polio and its related challenges.

The meeting resolved to take strict disciplinary action against those who make fake finger markings in anti-polio drives while special integrated strategy attention is being formulated for the high-risk areas.

“With all efforts from the government parents are requested to cooperate fully with the polio teams for the healthy future of their children,” said Shah.

Image Credits: Pakistan Polio Eradication Program .