A dream to chase
The failure in eradicating polio is a cause for concern. According to last month’s media reports, the World Health Organisation (WHO) has ‘informally warned’ Pakistan to control the spread of polio, HIV/Aids and hepatitis on emergency basis, failing which it would be placed among the countries on ‘watch list’ where international travellers to and from the country would be required to inform the organisation about their movement.
The disease has already been eliminated in most of the world. With India’s name having been taken off the list of polio endemic countries this year, Pakistan is the world leader in polio cases, followed by Afghanistan and Nigeria. A few years ago, Pakistan seemed to be on the verge of eradicating polio, but unfortunately the dream could not materialise. A number of factors have led to the resurgence of the disease.
The most commonly cited is the failure of the immunisation teams to reach all children under the age of five. During the National Immunisation Days (NID) campaigns the health teams make door-to-door visits to administer polio drops to children. Unfortunately, during every campaign a number of children are missed. Sometimes this happens because the children are not at home at the time a team visits, other times a team may leave out homes due to the absence of correct data on the number of children to be immunised—since census in Pakistan is not been carried out at the stipulated ten year period .
Another obstacle is that the teams do not have enough women workers, and male health workers are not always welcome inside homes due to security reasons or where women observe purdah. In some cases it is the parents’ refusal to get their children immunised under the influence of the misguided notion spread by some clerics that vaccination is against religion and that it may cause infertility.
Lack of accountability and commitment of immunisation teams is also often cited as a factor. Given the rampant corruption in every field and non-commitment to their cause, it can be questioned whether the teams are really going and delivering vaccines or not. According to paediatrician Dr Mubina Agboatwala, “during the early days of the NID campaigns, there was a lot of enthusiasm and many people volunteered, but now it seems as if the enthusiasm has faded and it has become a routine matter. For the campaigns to be successful, proper monitoring is important.”
Another reason for the failure is the lack of routine immunisation. Given the incentives linked with the campaigns, people tend to rely more on NID as the main instrument of polio eradication and hence little attention is paid to routine immunisation. This has a far-reaching negative effect since immunisation acts as the foundation and includes protection against other diseases as well. “To eradicate polio, both Expanded Programme of Immunisation (EPI) and NDIs are important as children in areas where polio is still present need more doses for full immunisation,” says Dennis King, head of Unicef polio eradication programme in Pakistan.
Cross border movement of population across the Pak-Afghan border as well as the migration of people from areas where polio still exists due to conflict and floods is yet another roadblock towards a polio-free Pakistan. This, coupled with the health teams’ inability to access certain areas due to volatile security situations in many parts of the country, is cited as an important contributing factor.
There have also been cases where children contracted polio despite being vaccinated. Experts believe that for the vaccine to be effective it is important that proper cold chain is maintained i.e., the vaccine vials are stored at a certain temperature. This maintenance of cold chain is often questioned due to the long periods of load-shedding and power failures.
However, King believes that the cold chain is properly maintained and asserts that it is possible for the health worker to identify the vials which have been spoilt since the colour of the vaccine changes when exposed to heat.
In some quarters there have been allegations of using expired vaccine which obviously does not have the desired effect. King refutes this allegation too, asserting that Unicef procures the vaccine on behalf of the Government of Pakistan and has been doing so for the past 12 years and the same vaccine has been instrumental in eradicating polio from 99 per cent of the countries worldwide.
High levels of malnutrition, diarrhoea and poor sanitary conditions are also regarded as hurdles to polio eradication since despite receiving multiple doses of oral polio vaccine, some children are unable to develop immunity against the disease. King believes that in areas where these factors prevail “many more doses are required for the child to develop immunity to the disease.”
Dr Agboatwala disagrees with this opinion and asserts that polio virus is a type of enterovirus and 40 per cent of the children under five in Pakistan harbour it in their guts and it in no way hampers seroconversion.
Whatever the factors may be, there’s no doubt that they can be controlled with commitment and dedication. There is no justification that a disease that has been wiped out from most countries and which was brought under control in Pakistan as well cannot be completely eradicated now.