On Dec 31, the world missed the deadline for the 24-year-old Global Polio Eradication Initiative to halt all wild poliovirus transmission by the end of 2012. Set in 1988, WHO's original target—global eradication of polio by the year 2000—has been extended several times. With only 215 cases reported worldwide as of Dec 26, 2012—an encouraging contrast to 650 cases in 2011—success seemed close.
But recently, the global effort to eradicate polio has suffered devastating setbacks. In mid-December, nine health workers were shot dead while travelling from house to house to administer polio vaccine to children during the national anti-polio campaign in Pakistan. And on Jan 1, six female Pakistani aid workers and a male doctor were shot dead. The brutal attacks took place in several locations, including Khyber Pakhtunkhwa province, which in 2012 accounted for more than 40% of all Pakistan's polio cases and 46% of Pakistan's infected towns and districts; Karachi, the largest city in Pakistan with a population of 18 million; and Sindh province. The killing of the health workers was condemned as “senseless and inexcusable” by UN Secretary-General, Ban Ki-moon. Owing to the safety concerns, the UN was forced to halt its participation in the vaccination campaign, and the campaign itself has been suspended temporarily by the Government of Pakistan and the affected provinces.
In this tragedy, women and children are the main victims. Most of the health workers who were killed were women, and the youngest was a schoolgirl aged 17 years. Female health workers are standing fearlessly and selflessly on the frontline of Pakistan's war against polio, because culturally only women are allowed to enter into houses to talk to mothers and vaccinate their children. Last June, in Federally Administered Tribal Areas, the Pakistani Taliban banned polio vaccination in retaliation for the use of unmanned drones by the USA. It is of deep concern that women who stand for something big have become the Pakistani Taliban's target. Female polio health workers are one example; the schoolgirl Malala Yousafzai, whom the Taliban shot in the head in October for campaigning for access to education—another essential ingredient in promoting children's health—is another. More than 3·5 million Pakistani children have missed vaccinations as a result of the campaign's suspension. “Such attacks deprive Pakistan's most vulnerable populations—especially children—of basic life-saving health interventions”, said WHO and UNICEF in ajoint statement.
The effect of the killing of polio vaccine workers in Pakistan will have repercussions for its neighbour Afghanistan, which, together with Pakistan itself and Nigeria, is one of the remaining polio-endemic countries. Genetic analysis shows that two of the three chains of polio transmission in Afghanistan are from Pakistan. Other neighbouring countries have also been put at risk. For instance, polio broke out in China in 2011 for the first time since 1999 after being imported from Pakistan; 18 people were paralysed and one died. Heidi Larson, an anthropologist who studies public trust in vaccines and immunisation at the London School of Hygiene and Tropical Medicine, pointed out that the killings of health workers in Pakistan could be a “game changer” in the global efforts to eradicate polio, calling for a rethink of delivery strategies. She compared it with the 2003—04 immunisation boycott in northern Nigeria, led by religious and political leaders, who claimed that the oral polio vaccine could cause sterility. This boycott led to poliovirus not only rebounding in Nigeria, but also spreading to 15 African countries and to Indonesia. The boycott and its effect prompted discussions between WHO, the Organization of Islamic States, and local religious leaders to help address the rumours and contain the further spread of polio. Indeed, the insecurity of and inaccessibility to vaccination have become the major impediments to the final push for polio eradication. Last year, Kathleen O'Reilly and colleagues reported in The Lancet the effect of mass immunisation campaigns and new oral poliovirus vaccines on the incidence of polio in Pakistan and Afghanistan. They reported that decreases in vaccination coverage in parts of Pakistan and southern Afghanistan had severely restricted the effectiveness of bivalent oral poliovirus vaccines.
To eradicate polio, the work that the brave polio health workers died for must be continued in 2013. Furthermore, it is imperative not only to ensure immunisation workers' security, but also to address the determinants behind the shooting of polio health workers—ie, to win the hearts of the public, to go beyond the “polio only” agenda, and to enhance polio vaccination's integration into the routine health and immunisation programme.
WHO and partners hope that they can finally rid the world of polio. But insurgency, Taliban-initiated boycotts, and a US$1 billion funding deficit will not make it an easy task. Dara Mohammadi reports.
Bruce Aylward has reason to lay awake at night. As Assistant Director-General of WHO, he is heading the Global Polio Eradication Initiative, which, after 23 gruelling years and two failed attempts, is making another high-stakes swing at the eradication of polio.
“There was a bit of a false premise going around about the consequences of failure”, he tells The Lancet. “Many people had, for a long time, almost lied to themselves, saying that if eradication failed it wouldn't really matter, that we could just continue with cases at a very low level.”
He explains how outbreaks in Tajikistan and DR Congo in 2010—11 changed that perception. During the outbreaks, hundreds of children were left paralysed and, uncharacteristically for the virus, which usually affects only young children, many adults were also infected, with substantial proportions of them dying from the disease.
“People are starting to understand that over time we are again going to have over a quarter of a million children paralysed every single year if this programme fails”, he says. “And it's not going to be a gradual creep back up that nobody notices, we could have serious backlashes in places that have long been polio-free, with tremendous mortality rates in adults.” Continue