Pakistan's push against polio

With nearly all of the rest of the world on the brink of being free of polio, the disease’s persistence in Pakistan has long challenged health experts both inside and outside the country. Last year, the 51 cases of wild poliovirus reported here represented the bulk of all 70 cases reported throughout the world.

Even so, last year’s count is cause for optimism, since it was a huge drop from the 294 cases reported in Pakistan in 2014, and because it seems to be a product of some clever adjustments the country has made to its longstanding polio eradication programme, with help from the Pakistani Army and smartphone-based technology.

Since 1978, the country has had an official Expanded Programme on Immunisation, in which vaccinators go door to door to immunise against many childhood and other diseases — tuberculosis, hepatitis, meningitis, measles and more. But when the goal became finally stamping out the last traces of polio, the regimen had to be ramped up to include more than these periodic household visits.

As part of the World Health Organisation’s Polio Eradication and Endgame Strategic Plan 2013–2018, the government announced that April 25 will be a National Switch Day for updating the kind of vaccine used, to account for the fact that Types 2 and 3 of the polio virus appear to have already been eliminated in Pakistan, with only Type 1 remaining.

Recognising that, the WHO recommended a switch from a trivalent oral polio vaccine to a version that can target Type 1 more effectively.

Next milestone will be phasing out the oral vaccine, which is built from a weakened live virus, and replacing it with an inactive polio vaccine administered by injection. Starting in Punjab, that strategy will suppl-ement live-virus vaccine schedule with one dose of the inactive version, which eliminates even the small risk of contracting the disease from live virus vaccine.

One reason the inactive vaccine is coming into use only now is that it is five times more exp-ensive than the live oral type. To overcome that obstacle, GAVI, a public-private organisation funded by various countries, charities and international ins-titutions, will help cover the cost.

At the same time, Pakistan’s government has supplied vaccinators with motorcycles, for which Britain’s Fund for International Development, along with Unicef, will provide fuel allowances. Lack of fuel has been a popular excuse for vaccinators who miss their vaccine targets because they don’t want to travel to the far-flung areas where they are most needed. Security for vaccinators is an even bigger issue, illustrated by the bombing last Wednesday of a polio eradication centre in Quetta that killed 14 policemen during an immunisation drive.

Indeed, a long campaign of disinformation spread by the Taliban helps explain why Pakistan’s polio eradication progra-mme has not yet wiped out the disease. In 2006, the extremist group declared vaccination to be a Western plot to sterilise Pashtun children and stunt their growth. It threatened to kill parents who had their children immunised, and attacked polio vaccinators in Pakistan’s tribal areas and in metropolitan Karachi.
Celebrities joined campaigns to counter the propaganda, and religious leaders issued fatwas declaring that Islam permitted the immunisation of children, but those efforts did nothing to stop the attacks.

Security to vaccinators
But much of that changed last January, after the Taliban disrupted a three-day immunisation drive in Sindh Province by killing three polio workers. First, vaccinators refused to work until they were given more protection. Then, the Pakistani Army provided the vaccinators with visible security.

By that point, the army had already begun a nationwide anti-militant campaign in the wake of an attack on an army-run public school. When the offensive drove militants out of North Waziristan’s tribal areas and Karachi’s no-go zones, parents finally lowered their resistance to immunising their children. What followed was the 70 per cent drop in new polio cases over the full year.

Nevertheless, the Taliban’s efforts to fight the campaign continue, as do management problems within the national immunisation campaign. Some officials have been accused of siphoning money from its programmes, or of using expired vaccines, and some vaccination plans have had difficulty targeting vulnerable populations.

One effort to resolve that problem was the introduction in Punjab last year of a smartphone app on which the region’s 3,700 vaccinators could keep track of their work. Now, instead of going household to household, they go to a centre where children have been assembled for vaccination. The vaccinators then send the data via phone to a central office. Using this approach, vaccinators’ attendance rates, which at times had been as low as 21 per cent, have risen to 95 per cent to 100 per cent.

Encouraged by those results, the Punjab government and the World Bank plan to invest in 10,000 more vaccinator smartphones, which will also capture a child’s photo and the mother’s cellphone number, enabling automatic reminders to a mother that a child is due for a vaccine scheduled near home.

The Punjab government is eager to share its technological know-how with the rest of the nation. One target area this year is remote Khyber Pakhtun-khwa. And if Sindh and Baluch-istan follow suit, there’s every chance that Pakistan can catch up soon to the rest of the world.