Hindawi Publishing Corporation

Journal of Immunology Research

Volume 2016, Article ID 6837824, 6 pages
http://dx.doi.org/10.1155/2016/6837824

Review Article
Eradication and Current Status of Poliomyelitis in Pakistan:
Ground Realities

Shazia Ghafoor and Nadeem Sheikh

Department of Zoology, University of the Punjab, QA Campus, Lahore 54590, Pakistan

Correspondence should be addressed to Nadeem Sheikh; s [email protected]

Received 11 May 2016; Accepted 23 June 2016

Academic Editor: Senthamil Selvan

Copyright © 2016 S. Ghafoor and N. Sheikh. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Pakistan is among the last three countries along with Afghanistan and Nigeria, where polio virus is still endemic. More or less,
with some fluctuations, numbers of reported cases in the past few years have shown a rising trend. Year 2014 pushed the country
into the deep sea of difficulties, as number of cases rose to red alert level of 328. Security situation has adversely affected the whole
immunization coverage campaign. In a country where 40 polio vaccinators have been killed since 2012, such a big number of cases
is not a surprising outcome. Worse perception of parents about polio vaccine as in Karachi and FATA, the high risk zones, makes
100% coverage a dream. Minor and perhaps delayed payments to polio workers make them frustrated, resulting in decline of trained
manpower for vaccination. Strong implementation of policies is required and those found guilty of attack on polio workers need
to be punished. Targeted community awareness programme, strong surveillance network, and involvement of influential religious
entities can help to root out polio disease from country. Present review is aimed at analyzing all barriers on the road to success in
eradication of polio from Pakistan.

1. Introduction is predominant, where substandard sanitary and health issues

prevail [3]. After infection, replication occurs in GIT (gas-
Poliomyelitis (family Picornaviridae), frequently abbreviated trointestinal tract) [4]. Global efforts need to be appreciated
as “Polio,” is among the most feared viruses of the twentieth for wiping out type two and type three serotypes, as there is
century in the world that resulted in commencement of global no known recorded case of type 2 since 1999 and type 3 since
initiative programme for the eradication of polio by WHO 2012. Type 1 is still in circulation [5].
in 1988. Polio being a positively stranded RNA enterovirus is The most heard GPEI (global polio eradication initiative)
well-known for its ability to affect a part of spinal cord (gray launched by WHO 27 years ago has achieved remarkable suc-
matter), leading to irreversible acute flaccid paralysis (AFP) cess in reducing the number of endemic countries from 125
mostly in children under five due to affected motor neurons, across the globe to only 3 including Pakistan, Afghanistan,
or can result in death if muscles of respiration or throat gets and Nigeria, where WPV (wild polio virus) transmission has
paralyzed but fortunately that is not quite often [1]. not yet been interrupted although numerical digit of cases
The three serotypes of polio virus, although they differ has dropped down by 99% in comparison to 350,000 new
in their virulence potential, affect human cell specifically cases per annum then (1988) [6–8]. Eradication programme
through PVR CD-155 receptors [2]. Paralysis rate with respect has faced much more operational problems in these countries
to the number of infections is variable from 1 per 200–2000 in comparison to the rest of the world [9–13]. World Health
cases of infection depending upon type of viral serotype. Assembly (WHA) has declared the crippling polio disease
Rate of fatality is usually from 5 to 10% in paralytic cases. as PHEIC (Global Public Health Emergency of International
Age and geographic location are two key parameters in this Concern) in May 2014 [14].
regard. VAP (vaccine associated poliomyelitis) has made the Polio is among the few strenuous challenges that Pakistan
situation more complicated. Fecal-oral mode of transmission is facing today. Expanded Programme on Immunization
2 Journal of Immunology Research

Immunization, the key to polio eradication, is facing hard-

ships like crude management, vague parental perception,
and restricted approach to vaccination facilities. Around 5.8
million children benefit every year from the EPI programme.
SIAs cover around thirty million children per round of
operation [2].
\

] 4. Role of EPI (Expanded Programme on

] Immunization) in Pakistan
]
Immunization services are largely provided by EPI in the
country whereas only 3% is contributed by privately owned
sector. Immunization is provided through permanent (6000
Movement across border centers) and mobile vaccination sessions by more than ten
Movement of Afghan refugees thousand vaccinators and 6000 LHVs (lady health visitors)
Movement of seasonal workers engaged in these immunization centers. SIAs and RIAs are
Figure 1: Map of Pakistan showing HPTZ (adopted and modified supplemented by approximately 100,000 LHVs [2].
from [23, 24]).
5. High Polio Transmission Zones (HPTZ)
(EPI) embarked on the health scenario in 1978 with its The sole exemplary mopping up of an epidemic from global
fundamental objective to vaccinate children against fatal dis- surface (smallpox) has revealed that military accuracy is
eases in their infancy. Polio eradication programme started indispensable during multiple synchronized immunization
officially in 1994. NIDs (National Immunization Days) and efforts. Three high polio transmission zones (HPTZ) across
surveillance resulted in decreasing number of cases markedly the country include Khyber Pakhtunkhwa (KPK) province
to double figure of just 28 in 2005 from 1155 recorded in 1997 along with FATA (Federally Administered Tribal Areas)
[15]. WHO has imposed mandatory vaccination for people sharing border with neighboring country Afghanistan (polio
traveling internationally from Pakistan which has maligned endemic) and Quetta block which is a part of Baluchistan
the image of country along with panic and stress among (geographically located southern to FATA) and the third
travelers [16]. Polio eradication is the question of life and zone, Karachi, a cosmopolitan city, in the south of Pakistan
death for Pakistan. In spite of all efforts, polio is still endemic along the Arabian Sea, harboring more than 14 million
in Pakistan. people, which is tragically polio victimized (Figure 1). Within
HTPZ, 33 districts are under spotlight being marked as
“highly endangered districts (hot spots for polio)” as, for
2. Immunization: Key to Polio Eradication one reason or another, 100% vaccination coverage is out of
OPV (oral polio vaccine) also called as Sabin’s vaccine and question there [23].
IPV (Inactivated Polio Vaccine), the two ways of immuniza-
tion have saved innumerable children [17]. Salk vaccine (IPV) 6. Why Polio Eradication Initiative Is
has inactivated polio virus. Straightforward administration Failing in Pakistan? Real Scenario behind
and long-standing immunization capability make Sabin vac- the Curtain
cine preferable. Trivalent polio oral vaccine having the three
known viral serotypes (attenuated) is in use in Pakistan Many reasons exist behind near failure of polio eradication
[2]. OPV is the most opted option for SIAs (Supplementary initiative in Pakistan. These multiple factors behind the
Immunization Activities) and RIAs (Routine Immunization curtain present the whole real scenario.
Activities) [18]. Pakistan is still aiming to switch over from
trivalent OPV to bivalent OPV as per recommendations of 6.1. War against Terrorism. War against terrorism has badly
Endgame Strategic Plan 2013–2018 by WHO [19]. affected FATA and KPK regions of the country that had
been invaded by stateless characters. The puzzle becomes
3. GPEI Strategic Plan for Eradication trickier as literacy rate among females is hardly 3%. Since
2004 these areas have been targeted by drone attacks that
Prudent pillars of GPEI, as learned from success stories lead to mass killings (1900–2900 people). Some parts of FATA
of several regional polio eradication campaigns, include remained unattended by polio campaign for 3 years due to
RIAs (Routine Immunization Activities), SIAs (Supplemen- security concerns and rumors against immunization. As per
tary Immunization Activities), polio case detection through reported by WHO, in 2011, a major proportion of population,
surveillance (AFP + environmental surveillance), and the almost 38% children, remained unapproachable for polio
fourth pillar being targeted wiping out activities [20, 21]. vaccination in Khyber Agency, a part of FATA, although the
In Pakistan, the first two are the focal points of eradication percentage in the next year (2012) was declined to 20% [23].
programme. RIA is the core pillar of eradication success [22]. Further, local religious personalities with their disliking point
Journal of Immunology Research 3

Statistical data showing attacks on polio workers from cards) are charged. Open vial policy is often misused for per-
2013 to 2015 sonal benefits. Delivery infrastructure through which polio
18
Number of polio workers

16 eradication initiative is implemented is underfinanced [34].

14 Shah et al. (2011) have reported that substandard performance
12
of EPI, insufficiently trained workers, and awful parental
attacked

10
8 awareness deprived almost 10–20% infants, who received
6 initial dose of TOV (Trivalent Oral Vaccine), of getting their
4 second and third booster doses [2].
2
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 6.4. Reduction in Vaccinator Number. Vaccinators and vol-
2013 unteers serving as frontline workers mainly contribute to the
2014 success of eradication campaign. Decrease of trained staff for
2015 vaccination in remote and security-threatened regions has
evolved as a crucial issue for EPI. Their number has declined
Figure 2: Showing number of attacks on polio workers during 3
years (2013–2015) adopted and modified from [25].
to almost half of the original number recommended by EPI
(at least two polio vaccinators per Union Council are required
while the real figure is around 1.3 in each Union Council) [35].
Polio workers refuse to work in conflict zones of the country
of view for polio vaccination and workers have substantially due to trepidation for life [36] that results in complaints
affected eradication process [26]. regarding absence of immunization teams. Financial support
in this regard to the workers is not appreciable. Irregular,
6.2. Life Threatening Attacks against Polio Frontline Workers. minor salaries, no encouragement, no incentives, stress, and
Life threatening attacks against polio vaccinators in Pakistan frustration are other major factors of lack in workforce [37,
[25] and Nigeria is a way adopted by fanatic groups to seek 38].
global attention due to sensitivity of the issue [27]. In a
country where almost 40 vaccinators have been killed in 6.5. Awful Parental Perception. Besides such unavoidable cir-
such attacks since July 2012, polio surge is not a surprising cumstances, refusal of parents to get their children immunize
outcome there (Figure 2). Such attacks result in temporary (up to 74%) is another key issue as observed in Karachi in the
cessation of the campaign. Having Polio vaccinators and last two latest SIAs. Pashtuns from low as well as high income
workers often back on duty after a short break of just few group refuse to get their children vaccinated. Due to scarcity
weeks is really commendable [28]. Since June 2012, regional of polio awareness, trust deficiency in vaccine efficacy, vac-
tribal leaders of North Waziristan Agency (a part of FATA) cine related misconceptions, and lack of confidence on polio
have prohibited polio immunization. The Independent Mon- workers, Pashtuns of low income group have been found to be
itoring Board (IMB) reported in February 2014 that health more reluctant in getting immunized in SIAs, of their children
officials responded slowly in grasping basic seriousness of in comparison to non-Pashtuns of low income group. Strong
the situation. Such kind of attitude by the officials may result influence of a religious person is one of the other factors that
in a situation where Pakistan would be the last endemic makes the Pashtuns avoid or refuse vaccinating their children.
country over the globe. It has become mandatory to punish Key to eradication lies in counseling the male members for
the responsible office bearer in this situation and flawless being the driving force in decision making [39, 40]. Thus
security needs to be provided to the frontline polio workers poor knowledge about vaccination is found to be the primary
in order to revive the campaign to eradicate polio in the cause and religious misperceptions present in some ethnic
affected areas [29]. Aid and immunization are often linked groups are likely to be the secondary cause of a large group
with foreign interests in Pakistan [30] which make all the of population that remain unimmunized [41].
exercise questionable and debatable at national level. LHVs
have been targeted in Swat region for being working for such 6.6. Polio Resurgence: A Nightmare. Statistical data analysis
campaigns and fostering contraceptives [31] for betterment of showed that Pakistan had 5 NIDs (National Immunization
the women in Pakistan. Days) rounds along with sub-NIDs that were two in number
in 2001 with 119 confirmed polio cases (Figure 3). Sind
6.3. Crummy Healthcare Systems. Malpractices in service province had the highest number of cases (25 cases) as
delivery and loopholes in prevailing health systems are compared to Baluchistan (20 cases), Punjab (18 cases), and
emerging as troublesome matters [23]. Poor healthcare sys- Khyber Pakhtunkhwa (22 cases). In the next year (2002) a
tem seems to be a major hurdle in immunization coverage falloff trend in numeric value of polio cases (90 confirmed
[32–34]. RI (Routine Immunization) rate is low [35]. Flaws cases) was seen. Year 2003 again showed a rising trend (103
in health system allow bundles of corruption both financially new cases of polio). For the next four years the number
and morally resulting in stealing of resources. Absence of staff showed variation between 59 and 32. Real difficulty started
from duty, lack of field operations, and even use of vaccines in year 2008 when number of cases touched triple figure
for privately run clinics affect service delivery in terms of of 118 cases. Reason behind that surge appeared to be that
quantity and quality. Free services (syringes and vaccination there is no conductance of SIAs due to security reasons in
4 Journal of Immunology Research

350 children vaccinated would likely strengthen eradication. The

question regarding vaccine efficiency is a big issue [44].
Confirmed polio cases

300
250 False propaganda against vaccine as a cause of castration has
200 made immunization extremely difficult. Achieving a polio-
150 free Pakistan depends on diverting the focus from federal
level engagements to frontline staff of eradication campaign
100
directly. Steps for supporting LHVs are inevitable includ-
50
ing increase in their remuneration and career development
0 opportunities. These LHVs and frontline vaccinators have
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
achieved importance as UN staff has been stopped from
working in the field, due to security reasons [26].
Figure 3: Number of confirmed polio cases (WPV + cVDP) in
Pakistan from 2001 to February 2016.
Pakistan is among the four states reported to export
WPV as roots of proximal polio cases in Afghanistan have
been traced back to Pakistan and in future that might affect
progressing polio campaign in that country. Even in genetic
areas near porous Pakistan and Afghanistan border and vast analysis of polio strains in Syria, certified as polio-free from
areas of FATA and KPK. Moreover immunization campaigns 1999 to 2013, polio strains were found to be of Pakistani
were intensely affected in Baluchistan and Sind provinces due origin and the same was the situation reported in waste
to political and administrative issues. For year 2009 a total waters in countries like Egypt, Israel, and Palestinian states
number of reported cases of wild polio viral strains were 89 until regional countries in Eastern Mediterranean WHO
[2]. Numerical and geographical resurgence spread trend is requested Pakistan to make sincere efforts to stop worldwide
predominant since 2007 and thereafter which is quite clear polio export [42]. Presence of polio virus in Pakistan has
from the situation of Punjab province harboring more than already affected China and Afghanistan [45]. Restriction to
60% population. It was polio-free in 2007 and unfortunately refugees movement within and across the border can be a
had 8 reported cases in year 2008 [42]. Vaccination coverage key to success [42]. Polio eradication campaign failure is a
has shown an increasing overall trend from 1980 to the first threat to travel and international economy [46]. Resurgence
decade of 21st century. Apparently the number of polio cases of polio has occurred in some countries with tumbling rate
should decrease and it was true until 2007 after which a rapid of vaccination and unsanitary conditions. Israel remained
rise was recorded despite expanding immunization coverage polio-free since 1988 (WPV transmission) until 2013 when
[22]. Geographical unstable law and order situation looted polio virus evidence was found in waste water samples [47].
that success and FATA became red zone for polio teams.
Moreover mass movement of local population from these
polio affected areas leads to sharp increase in wild polio virus 7. Recommendations and Possible Way Outs
cases to the highest number, with 144 cases in 2010 and 198 in
Amalgamation of several factors has greatly impeded polio
2011 [15]. Out of total (144) reported cases in 2010, again, 100
eradication success in Pakistan. Each contributing factor is
cases were from conflict-affected regions of western border
crucial for battle against eradication. China, Syria, and Iraq
of the country (FATA had 23 cases while the rest were from
had outbreaks due to polio virus export from Pakistan during
KPK) [2]. Significant progress was shown by Pakistan in year
recent years [16].
2012 as number value decreased to just 58 cases in comparison
to 198 cases of previous year [22]. Wild polio virus type 1
(WPV1) confirmed reported cases in year 2013 were 93 in (1) Despite various setbacks, the target is still not impos-
comparison to 58 cases of previous year [6]. In 2014 Pakistan sible. In India successful polio eradication has made
plunged into the deep sea of difficulties as the figure rose history and has become a source of inspiration for
to red alert level of 328 of polio cases. It was a setback for South Asian countries that elimination is possible,
eradication efforts. Year 2015 ended up with 56 WPV cases. even under tough circumstances. Financial aid and
Only two polio cases have been reported until February 2016. assistance should be there for resource-poor countries
Polio resurgence has become a nightmare for people being by GPEI and manufacturers of vaccines [17]. Indian
linked to achieving eradication goal (Figure 3) [43]. polio eradication success can be utilized by the rest
Three major curbs are identified on the road to success of endemic countries like Pakistan to achieve their
of polio eradication: the security concerns, parent’s refusal in remaining goals. Year 2010 proved to be a remarkable
vaccinating the children, and credibility of polio vaccine as year in Indian history, as use of bOPV (bivalent oral
well as effective campaign. Provincial government of KPK has polio vaccine) immunization strategy proved itself as
recently started a health related programme named “Sehat ka a giant leap on bumpy polio eradication road. Strong
Ittehad” to diminish political obstacles and resolve security surveillance network by trained staff [20] and effective
issues of vaccinators. Better hope remains for future as ground level delivery system made eradication a
Pakistani security personnel will guard the vaccinators in reality [48]. It is recommended to vaccinate each
future. One day polio campaign is also a positive sign so as child through high standard coverage rather than
to improve the security of the vaccinator. Implementation depending on NIDs only, which will help Pakistan to
of new legislation to arrest parents who refuse to get their eradicate polio [14].
Journal of Immunology Research 5

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