Despite COVID-19, Pakistan and Afghanistan Make Good Progress in Eradicating Polio
Polio workers protest against WHO retrenchments.

ISLAMABAD – Despite the 18-month COVID-19 pandemic, Pakistan and Afghanistan have observed a sharp decline in polio cases which the health authorities attribute to their effective back-to-back anti-polio drives.

Officials leading the polio eradication programme believe that the decline occurred due to uninterrupted polio vaccination campaigns, improved security and the polio field teams’ accessibility to the population in high-risk areas.

However, despite a remarkable decline in poliovirus cases, officials believe that ‘vaccine refusal and hesitancy’ by parents remains a bigger challenge than COVID in completely eradicating the virus.

Pakistan and Afghanistan, both members of the World Health Organization’s (WHO) Eastern Mediterranean Region, are the only two countries in the world still fighting to eradicate wild polio virus as a cause of the crippling disease.    

In August 2020, Nigeria achieved zero wild poliovirus cases, leaving Africa to be certified by WHO as a free of the wild poliovirus

However, some 16 countries in Africa are still experiencing periodic outbreaks of vaccine-derived polio cases (cVDPV2). While rare, vaccine-derived polioviruses cases can occur when the weakened live virus in the oral polio vaccine passes among under-immunized populations and, over time, changes to a form that can cause acute disease.  If a population is adequately immunized with polio vaccines, it will be protected from both wild polio and circulating vaccine-derived polioviruses.

A WHO report on the global battle to eradicate polio was the subject of a wide-ranging discussion Saturday at the World Health Assembly – with WHO and other member states commending Pakistan and Afghanistan and Africa on the progress seen – while also highlighting the uphill battle still faced to completely eradicate both wild and vaccine-derived forms of the disease. Member states also called upon WHO to remain committed to polio eradication – including building the capacity of national health teams to gradually take over the roles of the WHO-supported Global Polio Eradication initiative.

“We are accountable to children,” said WHO Polio Director Aidan O’Leary, in describing the challenges still faced to eradicate the last remaining cases of wild poliovirus – along with tackling vaccine derived cases that continue to circulate not only in Africa and Asia, but other regions as well.

‘Last Mile’ in Pakistan ? 

On both sides of the shared 2,640 kilometer border, Pakistan and Afghanistan are focused on both forms of the virus – working alongside about dozen international health and donor agencies.

Speaking to Health Policy Watch ahead of the WHA, key Pakistani health officials expressed hope that the wild poliovirus could soon be eradicated altogether in that country.

“This is our last mile and hopefully we will achieve zero cases in 2022,” said National Coordinator Dr. Shehzad Baig.  He told  Health Policy Watch that the last three anti-polio campaigns had been very effective reaching 90 to 95% of targets in  eradicating the virus from the country – and if that track record can be maintained then the eradication target can be met.

He said that the silver lining of the COVID-19 pandemic’s lockdown rules meant that children had been easier to reach: “Mostly children in high-risk areas remained at home and were accessible to polio teams for vaccination,” said Baig.

Stability in Pakistan’s security situation since last year also contributed to effective anti-polio drives, he said adding: “Since November, there was no security challenge for 286,000 field polio workers accessing areas for polio drives in security risk regions,” he said.

A WHO report submitted to the World Health Assembly (WHA) on Saturday, stated that WPV transmission is ongoing in traditional reservoirs in the northern corridor (Peshawar/Khyber), Karachi and the southern corridor (Quetta block, Balochistan), with expansion of virus to previously polio-free areas (Punjab and Sindh), and detection of virus across the country.

It also said that circulating vaccine-derived poliovirus type 2 continues to spread geographically, notably in Khyber Pakhtunkhwa, with ongoing breakthrough transmission complicated by a large nationwide accumulation of populations susceptible to type 2 poliovirus. 

Afghanistan also Sees Progress – But Poor Reporting May be Factor 

In Afghanistan, reports of polio virus cases were also on the decline this year as compared to 2020 – although surveillance remains an issue, particularly in areas where the reach of the central government is weak, officials cautioned.

Just one wild polio virus case has been reported so far in Afghanistan so far in 2021, as compared to 56 in 2020, according to the Independent Monitoring Board, an international body monitoring the performance of the polio programs by the countrie. And only 38 cases of circulating vaccine-derived poliovirus type 2 (cVDPV2) had been reported in Afghanistan, in contrast to 308 cases in 2020. 

In the wake of three WPV cases in November 2020, some 54 cross-border teams and 288 permanent transit teams (PTTs) were deployed across Afghanistan, the IMB said. The teams vaccinated 79,489 adults and 538,674 children.  Wild Polio Virus type 1 is endemic to the southern and eastern regions of Afghanistan, but  WPV, along with more vaccine derived cases, can encroach previously polio-free areas in the north and west of the country in the absence of containment vaccine campaigns. And those had been suspended in the first six months of the pandemic.    

In Pakistan, cases so far in 2021 have declined even more dramatically.  According to the official data of Pakistan Polio Eradication Program (PPEP), the country saw 84 Wild Polio Virus (WPV) cases and 83 circulating vaccine-derived poliovirus type 2 (cVDPV2) virus cases in 2020 (the IMB says the number of vaccine derived cases in 2020 was even higher – 135). 

This year, there has been just one WPV case reported so far, and no cVDPV2 cases.

Speaking at the WHA, the Afghan representative said, however, that still 3.5 million children are missing from the country’s vaccination campaigns. Afghanistan also urged the global community for more financial support to expand the immunization campaigns in the security risk areas.

Setbacks at Start of Pandemic Followed by Renewed Vaccine Drives  

In both countries, campaigns were initially suspended for the first six months of the year.  For instance in Pakistan,  after the first surge of COVID-19 pandemic, the country’s polio programme had to suspend its scheduled April National Immunization Drive (NID) –  which meant that around 40 million children missed the polio drops.

That followed on interruptions in vaccine drives in 2019, as well, after attacks on polio teams occurred in the country’s southern and western regions.  As a result, around 250,000 children missed the polio drops as a result leading to 134 polio cases reported in 2019.

However, after the decline of the first COVID-19 wave, Pakistan’s polio programme, led by Dr Rana Muhammad Safdar, then National Coordinator on Polio Program now the Director General of Pakistan’s Health Ministry, rebounded. It conducted two national and three sub-national anti-polio drives between July and December  2020 to cover the immunity gaps. Then, in 2021 the country conducted another national drive to vaccine 40 million children with polio drops.

Impact of CIA’s Fake Polio Campaign

Pakistani efforts to eliminate polio were seriously undermined a decade ago when the US Central Investigation Agency (CIA) conducted a widely-criticized fake polio campaign as part of its intelligence gathering operations on the whereabouts of Osama Bin Laden in Abottabad; the al-Qaeda leader was finally ambushed and killed by US troops in his compound on 2 May 2011.

Following the disclosure of the CIA mission, the Taliban also launched an intense anti-vaccine propaganda campaign on both sides of the Pakistani-Afghan border. Polio teams were attacked in both countries by the militants, and several field workers were killed.

It is likely that these factors eroded parental confidence in vaccines and health workers and declines in vaccination rates. 

Cross Border Transmission and Vaccine Hesitancy    

To this day, parental refusal remains a bigger challenge in both Afghanistan and Pakistan than cross border transmission of the virus, said Baig.

He said that the ratio of parents’ refusal from polio drops fluctuates between 2% and 5% in different areas of Pakistan.

Meanwhile, Dr Faisal Sult, the Special Assistant to the Prime Minister (SAPM) on health, warned, however, that “we have been close before and lowered our guard and polio surged back, so rather than congratulate ourselves on efforts to date, we need to double our efforts and drive harder than ever if we are to truly protect Pakistan’s, and the world’s children from this devastating disease.”

He also stressed the need for a coordinated whole of government approach encompassing nutrition, primary health care and water and sanitation.

Risk of Resurgence

Despite the sharp decline in the polio cases in Pakistan, polio officer Anil Kumar from Sindh province believes that the risk of resurgence remains as dedicated polio vaccine teams are gradually reduced or reassigned – in Pakistan as well as worldwide.

Kumar criticized the recent WHO moves to abolish around 850 posts of national polio officers – even while the virus lingers in the country.

The cutbacks have come as part of a gradual WHO move to phase out its huge and costly ground support for the polio elimination programme – with an eye to the day when the world reaches polio eradication.

However, the strategy has been controversial among countries which have relied heavily upon the polio teams to conduc other vaccine drives too. And indeed, over the past several years, WHO has shifted gradually from talking about outright staff cuts to a more gradual integation of WHO-supported polio teams with other national immunization efforts – as part of developing stronger national immunization capacity.

In the wake of COVID, which saw national polio teams also supporting COVID  testing, tracking and containment followed by a groundswell of needs for vaccine teams generally, that approach has been validated.

But even so, countries like Pakistan say that the reality on the ground doesn’t always match the rhetoric in Geneva.

In Sindh province, one key at-risk region, the Deputy Commissioner (DC) of the Umerkot district wrote a letter to the WHO team lead in the province appealing for the retention of its lost polio officers.

In March 2021, polio workers staged a protest outside WHO’s Pakistan country office, demanding a restoration of the 850 cancelled posts. But the head of WHO’s Pakistan country office, Dr Palitha Mahipala, turned down their demand.

Warned Kumar, “some of the posts have been abolished in high-risk areas where there is still a chance of resurgence of the virus.” 





Image Credits: Pakistan Polio Eradication Program.

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