Suleman Chauhdary
LAHORE MIRROR — Discussing Pakistan’s political and economy issues at a global health forum, the Independent Monitoring Board (IMB) has expressed its concerns that in Pakistan; various factors are still contributing to the complexity of the polio situation, including shifts in the political landscape; overall rates of immunisation, poor sanitary conditions, and insecurity are major challenges to interrupt the wild poliovirus transmission by the end of 2023.
IMB working on behalf of Global Polio Eradication Initiative (GPEI) analyses the weaknesses and deficits in the Polio Programmer’s functioning at global level in its new report “CLOSING IN ON ZERO: ADAPTING TO COMPLEXITY AND RISK ON THE PATH TO END POLIO,” has assessed and analysed progress with polio eradication.
The Polio Eradication Strategy 2022-2026, delivering on a Promise set 2023 as a target year to interrupt all remaining type 1 wild poliovirus transmission and circulating type 2 vaccine-derived poliovirus transmissions with the aim of reaching eradication by 2026.
The IMB report says the process of changing governments in Pakistan has previously had a negative impact on the Polio Programme. Federal elections are scheduled to take place later in 2023. Elections in Pakistan come with the mobilisation of the district commissioners, the police force and the army, for election duty report further said. IMB reported, situation can affect the polio calendar and all the necessary programmatic activities such as the timing of planned vaccination campaigns, training and surveillance.
The IMB says Polio Programme will come under pressure because it can no longer have the usual level of support from the army and the police with election activities happening, the report further said.
Any true re-establishment of wild poliovirus in these former reservoirs would be disastrous to polio eradication in Pakistan and for the world. Robust, rapid and geographically well scaled outbreak responses are essential. So too are strong well-coordinated continuous activities to build immunity.
The report cites Quetta is a special case among the former reservoirs. The others, notably Karachi, have been confronted by the return of poliovirus and have withstood the challenge it says. Report said Quetta Block has not yet been tested in this way, Programme’s performance in Quetta has not shown substantial improvement.
It states despite the presence of geospatial satellite imagery to track populations of children, there are still parts of Baluchistan where external monitors have not been. In particular, the areas bordering with Iran have received hardly any monitoring visits IMB said.
Independent-Monitoring-Board-IMB
There are areas of Baluchistan where very few campaign rounds have been carried out it says. This all highlights gaps in oversight. Essential immunization in these areas remains poor; improved immunity levels are the primary line of defence against poliovirus transmission. In the informal discussions over coffee and lunch at the July 2023 IMB meeting, many people expressed a lack of confidence in this province’s level of resilience if poliovirus returned, report reads.
The Polio Programme has been heavily focusing on south Khyber Pakhtunkhwa (KPK) but it also needs to turn its gaze intensively to Quetta. It is a weaker part of the Pakistan Polio Programme – weak in the sense of the government’s engagement, weak in partnerships and capacities.
Despite commendable efforts and substantial investments, Pakistan continues to see a concerning prevalence of polio detections. Endemic transmission persists in the south districts of KPK, where the virus has a stubborn hold
Report said operating environment in south KPK is complex and threatening.
A remarkable 200 plus boycotts of the polio vaccination programme, with diverse sources of grievance and demands, were running at the beginning of 2023.Serious insecurity problems have also persistently led to delayed, attenuated or cancelled vaccination campaigns it reads.
Reports says there are still many uncertainties in assessing the KPK Polio Programme’s status and difficulties in establishing why, for example, campaign quality is low for a particular vaccination round. The Polio Programme team could not give the IMB an absolute assurance that fake finger marking had been eliminated because they said that they found it very difficult to detect “collusion”.
The IMB did not feel that a clear and certain path to interruption of wild poliovirus transmission in south KPK had been set out.Many of the actions are ad- hoc and opportunistic. Different approaches are being tried, some successfully, some not.
Boycotts and refusals, fuelled by misinformation and disaffection with governmental services, are a significant roadblock to the progress of polio eradication in Pakistan; most are occurring in KPK province. Stopping transmission in KPK province will be tough even in 2024. The IMB cannot yet see a convincing path to interrupting transmission in this province.
The IMB does not have full confidence in the resilience of the Baluchistan Polio Programme. Making interruption of wild poliovirus transmission in 2024 feasible also requires major strengthening of the performance of the Polio Programme in Baluchistan. This should be of equal priority to the work in south KPK.
The south districts of KPK province continue to be places of endemic transmission. In 2020, the country achieved a substantial overall reduction in polio cases; however, a setback came in 2022, especially in KPK in 2023, there was a decline in reported cases, although some environmental samples still indicate the presence of the wild poliovirus in the south of this province says the latest IMB report.
A resurgence of wild poliovirus in 2022 led to a burst of cases, primarily in south KPK, which spread to other areas. Concerted efforts towards the end of the year successfully contained it. The challenges to completely interrupting wild poliovirus transmission in Pakistan, as scheduled by the end of 2023, are formidable.
IMB said environmental testing, a wild poliovirus strain originating in Afghanistan was identified, emphasising the ever-present risk of cross-border spread. A positive environmental sample in Karachi, in May 2023, was also unexpected because this big city, a traditional polio hotspot, had been poliovirus-free for approximately one year.
This immediately raised concerns about whether campaign quality and vaccine coverage were providing the level of resilience for Karachi to withstand poliovirus importations that could lead to re-established transmission. It was an orphan virus; an unwelcome reminder of the programme’s vulnerability read the IMB report.
According to report there are still detections occurring in south KPK in a hugely complex operating environment. The root causes of the barriers to sustainable further gains are quite profound, including severe insecurity and large numbers of boycotts of the Polio Programme in response to unmet wider demands by communities and interest groups. This last reservoir of endemic polio in Pakistan is an area fraught with complexities and challenges that make polio eradication tough.
Report says in the south of KPK there have been multiple campaigns to reach the children who have been persistently missed. IMB sources report that every campaign has been a struggle, with children being missed; for example, 5,000 were missed in the March 2023 campaigns, but the number jumped to 30,000 in May 2023.
In three of the critical districts – Tank, Lakki Marwat and Bannu – progress has been made, showing a slight increase in immunity estimates it reads. IMB report said this suggests a higher proportion of children protected against polio. Conversely, in North Waziristan, South Waziristan and Dera Ismail Khan, immunity has shown a marginal decline during the same period.
All the recent attention has focused on making a breakthrough in the province’s 69 most at-risk councils. In a strategic shift, the Polio Programme in Pakistan has decided to do monthly polio campaigns and focus on reaching consistently missed children through a more targeted approach.
Estimates reveal a significant gap in coverage, with an alarming 60,000 children being missed (in reality, likely to be higher) in south KPK, excluding those who are in the Mehsud belt. The latter is a vast region covering some of the high-risk districts where vaccination campaigns have been unattainable for a long time.
The IMB has found data analysed by the TAG, highlighted an adverse trend in south KPK, whereby over 60% of refusals are attributed to missed visits to households or incomplete vaccination within the visited households. Other assessments put the proportion closer to 75% to 80% of children being missed by polio vaccination teams.
Again, the reasons cited are wide-ranging and encompass insecurity, boycotts, clustering of refusals and frontline teams missing houses or children within houses. These difficulties have persisted across the last 10 rounds of vaccination, pointing strongly to systemic management weaknesses that must be addressed urgently.
The emergence of boycotts of polio vaccination is a worrying development, boycotts have received less attention compared to other root causes of programmatic failures.There were 218 active boycotts in KPK in January 2023.
This is a staggering statistic. Boycotts happen when people, who know that the government is very serious about polio eradication, use their agreement to vaccination as leverage to get their demands met.
For example, in Bannu West Block in North Waziristan,KPK province, there was a campaign by the Pashtun leadership for the community to share in a gas and oil discovery described as containing the country’s largest hydrocarbon reserves.
Analysis of recent boycotts showed that 31% were linked to job-related concerns, while another 16% were triggered by grievances about lack of basic necessities such as health care, electricity and water supply. Approximately 40% of boycotts were associated with multiple demands, ranging from land disputes to the lack of mobile phone networks, illustrating a complex web of challenges faced by these communities.
In south KPK, programmatic stability is fragile in the presence of threats from insurgency, tribal conflicts and political unrest. These factors, together with a difficult terrain, create a hostile and unsettling environment, making it incredibly difficult for local law enforcement authorities to maintain control.
Beyond the immediate threats of violence, underlying poverty, lack of education and limited opportunities for the person living in such communities can fuel resentment and draw some people into the orbit of extremist groups.
This background, combined with the challenges of border security linked to human and narcotics trafficking, weave together to form an enormously complex security situation. The operation of the Polio Programme must be seen in this context if solutions to the current performance problems are to be found.
The effect of the security situation on the Polio Programme in south KPK can be tangible and immediate. Real and present dangers of violence and refusal surround them, compounded by misinformation about, and mistrust of, vaccination campaigns. Insecurity has led to loss of campaign quality, including instances of the fake finger marking of children.
If wild poliovirus transmission is to be stopped in Pakistan, the remarkable recent achievement of clearing long-established poliovirus reservoirs and sanctuaries in the country must also stand the test of time. There has to be no hiding place left for any poliovirus in these large and complex areas.
The most polio-vulnerable area in Sindh province is Karachi because of its demography, its size, its migration patterns, its past reluctance to address some of the programmatic cultural barriers and its long history of intractable poliovirus transmission.
In the light of this, the reduction of poliovirus transmission in Karachi has been formidable. However, amid these gains, a lingering concern arises from the discovery of a positive environmental sample in May 2023. It is estimated to have been circulating undetected (an “orphan” virus) somewhere in the environment for approximately four years.
The devastating flood, in 2022, in Sindh, resulted in the migration of a large population from the various districts of the province to Karachi. The city was saved from that flooding and people moved to it as a safe haven. Also, during the last two years, many Afghans have settled in Karachi.
Roughly estimated, there are three to four million Afghans living there. While the local Polio Programme has been transformative in Karachi, there is still substantial community resistance. For example, in very poor slum areas of the city, communities are resentful about the pressure to administer a polio vaccine to their children when they do not have clean drinking water, adequate sanitation, schools or general health facilities available in their neighborhood.
The polio context in Baluchistan province has some similarities to KPK, including the level of persistently missed children, refusals and zero-dose children. The security situation has worsened with back-to back attacks targeting security personnel in the region.
