Pakistan may be on its way to finally ridding itself of polio, if a small environmental survey is truly representative of the country as a whole.
The polio virus, which only infects humans but can spread in the environment usually through contaminated sewage or water, has been eliminated through vaccination in all but two countries, Pakistan and Afghanistan.
Despite fears in 2014 that Pakistan was going backward on attempts to eradicate polio, there have been important breakthroughs in the past 18 to 24 months, with the number of reported polio case numbers falling by 70 percent and only 11 known cases of infection this year.
Samples taken of sewage and other possible environmental reservoirs of the virus in Pakistan have, for the first time ever, tested negative for the virus. In an email to Humanosphere, Oliver Rosenbauer, a spokesman for the World Health Organization’s Global Polio Eradication Initiative (GPEI), said it’s possible the virus could be eradicated from Pakistan “possibly even this year” if efforts are sustained.
These last two years are not without precedent in Pakistan. Rosenbauer added that 25 years ago around “30,000 children were paralyzed every single year by polio in Pakistan.” Progress has been so impressive that this number is now down to 16, with 11 reported in Pakistan and five in Afghanistan. Last year, fewer than 100 new cases were reported in both countries.
There are several reasons for the progress in Pakistan and Afghanistan. Community-health workers have worked tirelessly in reaching every child and changing negative perceptions about the vaccination. The government of Pakistan has established nearly 1900 health camps, which are crucial in extending outreach and identifying children at risk in low-coverage areas, such as the remote province of Chandiya in Dera Ghazi Khan in the Punjab region.
However, despite these “strengthening trends,” Rosenbauer said we need to be cautious in prophesizing the death knell for polio in the region. Firstly, he said that “there is always a four-to-six-week lag time for laboratory processing,” where there is still a window for previously negative environmental samples to turn into positives. Rosenbauer also advised caution ahead of the “high season for poliovirus transmission,” which starts in June, adding that “only then can we really see where we stand epidemiologically.”
The issue of outreach, often seen as one of the biggest hurdles in reaching every last child with vaccination, is a problem in a country of such a size as Pakistan’s. This was seen in India where it was previously thought near impossible for a country of more than 1 billion people to defeat the virus, due to the size. Often, in Pakistan, it is the case where “95 percent of children are vaccinated when, in the next district, 65 percent of children are vaccinated.”
Though Pakistan has lowered its transmission rates over the last year, “sustained commitment at federal and provincial level is required to increase the coverage of services and reach children who today miss out on life-saving vaccines,” according to a spokesman from Gavi, a international vaccine group. Rosenbauer agreed, adding that “there remain pockets of underimmunized children” in regions “where virus transmission is still geographically widespread.”
In the past, the problem of reaching every last child in remote parts of the country was compounded by attacks on WHO and community-health workers by the Taliban, in both Pakistan and Afghanistan. Not only has this created political insecurity, it has also allowed the Taliban to lead anti-vaccination campaigns, which has countered messages about the benefit of vaccinating children against polio. In 2014, the spread of misinformation was tantamount to the spread of the virus.
Political insecurity, especially at the border between both countries, can ensure that polio transmission can travel across borders unchecked. Added to this, “polio and routine immunization remain quite separate in Pakistan and Afghanistan,” the Gavi spokesman said, which makes monitoring and surveillance of the virus even more difficult. Experts conclude there must be a “convergence of the strategies, expertise and lessons between the two programs.”
Recently, however, a political agreement between the governments of both countries means that Pakistan and Afghanistan are now working closely on “synchronized immunization campaigns to ensure vaccination of all children on both sides of the border,” Shahram Tarakai told the Guardian. Tarakai is the health minister for Khyber Pakhtunkhwa, which is in the Peshawar Province which borders Afghanistan; Peshawar, along with Karachi, are thought to be the main two hubs for polio cases in Pakistan. Since this announcement there was another attack on several police officers who were escorting a team of polio vaccinators. It is unclear whether this agreement will ensure the protection of health workers and the spread of vaccination efforts in areas under duress from Taliban attacks.
Coordination of efforts in countries that are adjacent to one another are important, not just to ensure political will is in place, but also to ensure collaboration of “surveillance activities” to “reach populations on the move,” Rosenbauer said. The influx of 6 million Afghan refugees into Pakistan in recent years only makes vaccination even harder to monitor.
Beyond contiguous borders the issue of containing polio transmissions is crucial. WHO estimates that for “every year that Pakistan and Afghanistan does not complete the job, it costs the effort an additional estimated $800 million USD,” Rosenbauer said. The fight against polio is around $1.5 billion short of the funding it needs to meet targets to eradicate polio entirely by 2019, he said. Both agree that reaching this target means not only tackling polio where it is still endemic, but tackling it where it could be “re-introduced.” This means renewed calls of sustained funding to ensure that more does not need to be spent on tackling a resurgent virus. Rosenbauer cites the Middle East, Southeast Asia and previously endemic regions of Africa as being particularly at “high risk of re-infection,” where donors must carry on with the very same tactics that have increased vaccination coverage.
The worry is that without renewed funding, the world will again see “200,000 new cases every single year within 10 years,” Rosenbaeur said. Analysis at the GPEI have also claimed that $50 billion will be saved in economic productivity and associated treatments costs over the next 20 years. “The stakes are high,” Rosenbauer said, “but the rewards will be tremendous.”