Rakima Sanaullah, a vaccinator, is looking forward to her meeting with the mothers of young children in the narrow alleys of Quetta's Abdul Wadood Road. It will be after a hiatus of almost five months when she last went to administer polio drops to the children living in that area in February.

After February, there was supposed to be another nationwide anti-polio campaign in April but it was put off due to Covid-19. As a result of that pause, some 40 million Pakistani children under the age of five missed out on getting vaccinated.

The vaccination drives are restarting but this time around, Sanaullah knows that things will be done a little differently. "We will not be able to stay anywhere for too long, or go inside any rooms of any of the houses that we go to, or accept food or drink that people usually offer when one visits," she says, speaking over the telephone from Quetta.

Sanaullah is among the 8,000 vaccination workers who will be carrying out the campaign starting from July 20. While the broader campaign is to last for a period of four days, in Karachi and Quetta, it will go on for a period of five days. It will cover a total of 169 union councils. 23 of Karachi, 44 in Faisalabad, 14 in Attock, 78 in South Waziristan, and 10 in Quetta, with the goal to vaccinate up to 767,000 children.

'A much bigger danger to our children than Covid-19'

Senior pediatrician, Dr D S Akram is most relieved at this news. "Polio is a much bigger danger to our children than Covid-19." For each case of paralytic polio, she explains, there will always be at least 10 non-paralytic infections in other children and hence resumption of the anti-polio campaign in some union councils should be considered an emergency.

She says these "focused" campaigns should definitely happen, otherwise "we will have outbreaks of polio in many more tehsils", adding that the environmental samples taken from the sewerage system had shown the widespread incidence of the virus — both of the wild and the vaccine-derived variety.

Pakistan and Afghanistan are the only two countries in the world where polio is still endemic. In 2019, Pakistan reported 147 new cases. In comparison, only 12 and eight cases had emerged in 2018 and 2017, respectively.

And 2019 too had not been without its share of challenge for the Pakistan polio eradication cell, with the country witnessing a resurgence of vaccine-derived poliovirus type-2 (cVDPV2), which was thought to have been eradicated.

This year, from January to July, 59 children have already been afflicted with the wild polio virus.

"We saw a peak in 32 cases last December followed by month-on-month decline till March," informs Dr Rana Muhammad Safdar, Coordinator of the National Emergency Operations Centre, Pakistan Polio Eradication Programme.

But with the suspension of vaccination drives in light of Covid-19, the goal of eradicating polio has also experienced a setback of sorts.

Following SOPs will be critical, will also require parents' cooperation

Restarting the campaign is aimed at mitigating the situation and targeting the more high-risk areas. But vaccinating in the time of Covid-19 requires a different approach. And for this reason, all the vaccinators who will be carrying out field visits this week have been given proper training on how to operate during the coronavirus outbreak.

"I will shower, wear fresh, clean clothes before I report for duty," says Aasia Panezai, another vaccinator, also from Quetta. "In the field we have to wear gloves and a mask (that needs to be changed every four hours)," she says, adding that they have to keep using sanitisers before and after visiting each home.

Even to knock on the gate or to ring the doorbell, vaccination workers have to use a marker or a pen and not their hands, she adds.

Despite the scorching heat, Sanaullah is not perturbed about wearing the mask, saying she already wears the niqab so wearing a mask is not going to be that hard. And she is confident that by following all the standard operating procedures (SOPS) she will be "100% protected" from the coronavirus.

"Of course, in the end we have to accept Allah's plan, but I am taking all precautions for the sake of my four daughters as well as for other family members," she adds.

Sanaullah aims to vaccinate over 190 children "but who knows how many newborns will be added this time," she says.

Dr Akram, who heads the Health Education & Literacy Programme (Help), a non-governmental organisation working on immunisation and child health, assuages Sanaullah's fears, saying: "If proper SOPs are followed and polio workers wear adequate personal protective equipment (PPE), it should be safe."

She further suggests that local workers should be employed so that they do not have to travel too far.

The SOPs are not too cumbersome, but do require cooperation from the parents. For example, Panezai says that parents will be requested to hold their children and open their mouths as the health workers have been instructed to keep a distance and not to touch the child at all. "We have been asked to keep to at least a metre's distance," says Panezai.

But when it comes to marking the fingers, while the parents will hold the child's thumb steady, she says she will have to get a little closer and it might become difficult to keep that required distance.

Gap in immunisation and fears of upsurge

Dr Safdar seems satisfied with the plans that have been put in place to take the latest campaign off the ground after months of "sleepless nights" were spent working out the details on how to restart vaccination drives safely.

He is however still afraid that polio may see an upsurge. "When there is too big a gap in immunisation, not just for polio, but for any other vaccine preventable disease, chances of outbreaks increase," he says.

"Our routine vaccination has also suffered," admits Dr Akram, adding that that was the reason doctors were witnessing "cases of measles, and diptheria in all the provinces".

Dr Safdar emphasises that it is "imperative for parents to ensure vaccination of all eligible children both in routine as well as during the door-to-door campaigns".

Therefore, if everything goes as planned, the government aims to launch a nationwide campaign as soon as it gets the opportunity to do so. "We are equally worried about routine immunisation campaigns as those are suffering due to Covid-19. I fear for the outbreak of vaccine preventable diseases, such as measles," says Dr Safdar.

'No other choice'

Dr Zulfiqar Bhutta, founding director of the Karachi-based Aga Khan University's Institute for Global Health and Development, is glad that the first step has been taken to resume vaccination.

"I don't think we had any other choice or we would run the risk of decades of gains evaporating," Dr Bhutta says, suggesting that there was a need for "routine immunisation systems to be rebuilt with fresh vigour and new ideas".

Welcoming the move to restart the anti-polio campaign even if it cannot be nationwide at this time, Pakistan's former focal person for polio eradication Senator Ayesha Raza Farooq believes precious time was still wasted on this front and "without putting the vaccinators and polio workers at risk".

She says weeks went by after the government ended the lockdowns and all those weeks could have been used to ensure children were vaccinated. "If the government can open malls and markets, if it can open tourism, then why did it take so long to begin the vaccination drives when most children below the age of five are still at home?"

Dr Safdar has a response to this.

He says "we had to ensure that there was a slowdown in the Covid-19 trend" before we could send the vaccinators out in the field.

"Brainstorming and consensus building on revised operating modalities, developing guidance material and training, getting endorsement by the technical advisory group, and more importantly, availability of all logistics, including the PPE, it all takes time," he says.

How to polio team engaged in Covid-19 response

For those who think otherwise, the polio team was not sitting idle while the state was battling the pandemic.

"The entire programme staff remained effectively engaged in Covid-19 response," explains Dr Safdar. And this contribution was acknowledged by all stakeholders including the communities. He adds that the president, the prime minister, and the chief of army staff had also repeatedly expressed their worries with respect to potential risks arising because of inadequate routine immunisation services and the pause in door-to-door campaigns.

A feather in their cap was the 1166 helpline which was first set up in February 2020 for polio but was quickly adapted for Covid-19 so those in need of information and assistance could reach out.

And from a few hundred daily phone calls that were handled by 55 trained agents in its early days, the number of calls on the helpline increased to over 70,000 in a day. At this point, the helpline is being managed by 250 agents in the three cities of Karachi, Lahore, and Islamabad. The helpline currently operates in two shifts that in total last from 8am to midnight every day, seven days a week.

A number of the calls that come are about polio and the rest are for other vaccine-related diseases. "The ones about polio vary from complaints about vaccinators or requests for vaccinators to visit the caller's area, which we address immediately, and also follow up by calling the person to confirm if the polio team reached them or if their complaint was resolved," says Huma Shaukat, Project Manager for the Sehat Tahaffuz Helpline, adding: "It is also helping us vaccinate some of the missed children."

There are also people who call the helpline to inquire about the polio vaccine itself in order to know more about it. "The helpline has played a vital role in reaching out to parents who had never got their children vaccinated. It has helped us build trust with communities and has helped us address some of the misconceptions," says Shaukat.

The other set of calls are for other diseases with a majority related to queries about corona. "We have up to 20 doctors who handle callers directed to them by the helpline who suspect that they have symptoms of Covid-19.

With successful national campaigns, first in December 2019 and then again in February 2020, Dr Safdar is confident that the current drive will accomplish its goals. In addition to that, he is already planning anti-polio campaigns to take place in the months of October, November and then in December, with a gap of only five weeks in between these months, in order to cover for lost ground.

The header image by Reuters shows vaccinators wearing protective masks as they get their temperature checked during an anti-polio campaign in a neighbourhood in Karachi on July 20, 2020.