HYDERABAD: Larkana has been in the spotlight since last month for all the wrong reasons.

First, it was because of HIV-positive cases in newborns and adults in Ratodero taluka and now the focus remains on the Pakistan Peoples Party stronghold after poliovirus infected a three-year-old girl in Dokri taluka.

The minor girl was well until April 17 when she had high-grade fever and weakness in the right arm and leg. Initially, her family took her to a faith healer, but later she was found infected with poliovirus. During investigations, health authorities found that the girl had travelled to Karachi’s Bin Qasim area in district Malir, considered to be a hotbed of poliovirus in Karachi.

The latest polio case in Larkana after Karachi must have set alarm bells ringing for the Sindh health authorities overseeing the poliovirus under a separate Emergency Operations Centre (EOC) for polio eradication and immunisation.

Frequent positive poliovirus environmental samples also remain a disturbing phenomenon. In addition to the EOC, routine vertical programme of immunisation under the Expanded Programme on Immunisation (EPI) was also there.

The EOC is part of a national-level set-up created in 2014 amidst foreign donors’ funding with government oversight at the federal and provincial levels. EOCs are overseeing anti-polio campaigns in collaboration with foreign partners.

Sindh has 49pc coverage figures with 12-23-month-old children receiving all basic vaccines

A Sindh government officer sits in Karachi as EOC coordinator to look after the national immunisation drive (NID) and Sub-National Immunisation Drive (SNIDs), which have been launched for certain specific areas in view of reports of NID.

Senator Ayesha Raza Farooq, ex-focal person of prime minister for polio eradication during the Pakistan Muslim League-Nawaz government, recently painted a bleak picture of the country’s efforts towards polio eradication in the last one year.

“Pakistan was supposed to be polio free in 2018, but that was not the case. In 2017, numbers were reduced from 20 in 2016 to eight in 2017. It was 306 in 2014 that were brought down to 254,” she had said while speaking in the Senate. “When PML-N government completed its termm there were only three cases in Dukki, Balochistan”.

An upward trend

Reports indicated that so far 15 confirmed poliovirus cases have been reported in Pakistan till May. This shows an upward trend. Sindh reports two cases with one each in Larkana and Karachi’s Lyari area. Punjab reported three cases in Lahore while rest are coming from Khyber Pakhtunkhwa. Positive environmental samples are in addition to these cases.

Sindh’s healthcare system remains somewhat fragile. It was evident from the fact that so far 9,082 people were screened in just one taluka of Larkana’s Ratodero and 393 of them were tested HIV positive. The number of HIV-positive cases would keep scaling up if such general screening is carried out in other districts and health authorities might run short of the WHO-recommended rapid test kits.

In terms of poliovirus, the High-Risk Mobile Population (HRMP) is a huge factor that is contributing to its spread in Sindh. The HRMP comprises people who frequently travel between core reservoirs of poliovirus like Karachi, Peshawar, Quetta, Qila Abdullah, Qilla Saifullah.

The HRMP has lowest polio vaccination acceptability as well as accessibility, according to officials. “A big component of HRMP — mainly Pakhtun community — has larger concentration in Karachi and Hyderabad,” said an official.

“Still miss children (SMCs), not available or refusal cases, remain constant in Karachi,” provincial EOC coordinator Umer Farooq Bullo said. “They are always one to two per cent of those children who are to be vaccinated.”

He added that permanent and temporary transit points had also been set up to cover these children for controlling HRMP.

‘Refusal’ remains a big challenge

Unending “refusals” among families and positive environmental sample of poliovirus in polio eradication campaign are two major challenges now.

Refusal is a case where parents plainly decline to have their child inoculated. They come up with different explanations inclusive of misconception and negative propaganda, drug’s efficacy and above all fear of male child’s infertility once vaccinated.

The backlog of refusals keeps increasing. Information of some health officials show families even in posh localities avoid vaccine on efficacy ground, saying they will get their children inoculated in private facilities.

“The community says vaccination is aimed at controlling their population under a foreign conspiracy. It raises different demands before agreeing to child’s vaccination,” said Halima Leghari, a central leader of the Lady Health Workers (LHWs).

She said that some communities often said village roads should be built first and then they would allow vaccination. “LHWs’ sexual harassment is a major stumbling block that hampers coverage. Only recently, LHWs in Pathan Colony were intimidated and harassed,” she said.

An environmental sample is testing of sewage collected from some designated sewerage pumping station in Sindh. It is analysed in a laboratory for genetic sequencing (GE).

“If environment is frequently positive it shows a localised trend of virus and its presence somewhere,” said a former EOC official. He explained that poliovirus survived in human gut. “Human body works as an amplification factor and individual concerned keeps shedding it wherever he/she is travelling,” he said.

According to a health official, 40 out of 73 environmental samples collected across Sindh were found positive. Hyderabad is reporting positive environmental samples constantly. Four such cases are reported this year against one in 2018. Same goes for Sukkur district and then comes Larkana.

Communities react harshly to multiple anti-polio campaigns

Polio eradication campaigns have been causing fatigue for the community, which often reacts harshly.

Around nine polio eradication campaigns took place recently, which tend to antagonise the community. LHW team visits a child if he/she is not found and there are cases where families often tend to avoid vaccination on different pretexts.

“Parents are fed up with back-to-back visits of LHWs and volunteers,” said a health official.

“This is forcing authorities to give some breathing space to community by withholding polio vaccination drive,” said an EOC official. “But simultaneously we fear that if such space is given it may lead to outbreak of virus so we are between the devil and the deep sea.”

Doctors said malnourishment among children made them vulnerable to poliovirus. During polio eradication campaign some vitamins A & D doses were given to overcome nutrients’ deficiency among children. Children under five are to be vaccinated primarily but according to EOC children under two are not to be missed come what may as this group is most vulnerable for poliovirus.

While Larkana is a regional centre its only public sector medical university is yet to get an infectious diseases ward, blood bank, pathology/diagnostic laboratory and physiotherapy unit.

“What a polio patient needs after being hit by the virus is physiotherapy which we lack,” says a university teacher.

Is EPI working?

Routine immunisation of children takes place under vertically-funded EPI in Sindh. It maintains the cold chain of polio vaccine.

According to the Pakistan Health Demographic Survey (PHDS) 2017-18, findings of which were released in January 2019, Sindh (49pc) has lowest coverage figures with children aged 12-23 months, receiving all basic vaccines.

Sindh is only ahead of Balochistan (29pc) while Punjab has ideal figures of 80pc, Khyber Pakhtunkhwa 55pc.

The 2012-13 measles outbreak was reported in Sindh’s upper districts with EPI figures claiming ideal vaccination coverage. But it was anybody’s guess why such outbreak was reported with over 200 deaths of children due to measles despite such an “impressive” coverage.

Under a recent decision two districts — Khairpur and Dadu — have been placed under the administrative control of the Pakistan Primary Healthcare Initiative (PPHI) for managing Sindh’s EPI component as well. And it also perhaps indicates that if coverage ratio improves or shows encouraging results in the two districts the PPHI may get more subsequently.

Published in Dawn, May 15th, 2019