Health experts aim for zero transmission by targetting children at bus stations and border crossings with vaccinations
One worker leans toward the driver to ask a question as another reaches into a cooler to prepare the vaccine. Among the crush of passengers in the van, they identify one child who has not yet been vaccinated.
He is quickly innoculated with two drops of oral polio vaccine, and his little finger is stained with purple ink to indicate that he’s received his dose. He cries as the vaccinator hurriedly passes him back through the window. The van speeds off, fading back into the dizzying hum of traffic, as the vaccinators look for the next car and child.
This scene plays out thousands of times a day at transit posts like this one — makeshift vaccination clinics set up at bus stops, border crossings, army posts, and police checkpoints across the country in an effort to reach children who are on the move.
Here in Pakistan, home to almost all of the world’s polio cases just a few years ago, these moving targets require a vaccination strategy as agile and stubborn as the virus itself. At hundreds of sites, teams of health workers verify that every child passing through receives the vaccine.
Another child, another family, another generation is protected, and Pakistan moves one step closer to having zero polio cases.
Polio - a worldwide scourge
At the start of the 20th century, polio was a common childhood disease. In some cases the illness - caused by the poliomyelitis virus attacking the nervous system - would be no worse than a fever or a headache. But in a small but significant percentage of cases, paralysis would develop in different parts of the body. Sometimes it would affect just a toe. Sometimes a child might temporarily or permanently lose the use of their legs (hundreds of thousands suffered this fate worldwide every year), while others might be blinded by eye paralysis. In some cases, paralysis would develop in the chest and breathing muscles, leading to death through suffocation.
In the 1950s and 60s the development of an injectable vaccine for polio brought the spread of the disease under control in industrial countries such as Britain and the United States. The fight against polio was accelerated in 1961, by the development of an oral vaccine that could be given on a lump of sugar.
But the disease was still common in developing countries across Africa, Asia and Latin America. In 1988, when the Global Polio Eradication Initiative began, more than a thousand children each day were being left paralysed by the disease. In that same year, the World Health Assembly adopted a resolution to eradicate the disease completely by the year 2000.
Since then, more than 2.5 billion children have been immunised against polio, in a campaign built on the commitment of 20 million volunteers working across 200 countries. Their work has been supported by an international investment of more than $14bn dollars.
Polio has now has been eradicated from most of the world, across the Americas, western pacific and Europe.
Africa had gone nearly two years without a case of the disease when Nigeria experienced an outbreak last summer which left four children paralysed. However, progress against the outbreak seems promising, with no new cases reported since August.
If the virus is wiped out, polio will become only the second human-hosted virus to be eradicated since the end of smallpox in 1980.
And that goal is now in sight. While Afghanistan and Pakistan are the last holdouts of the virus, a passionate and innovative campaign is overcoming all obstacles to reach every child with the vaccine.
Pakistan - a campaign in crisis
In 2014, Pakistan’s effort to wipe out polio was in crisis. Political pressure to root out the virus was being tested, reports of violence against vaccinators were common, and perceptions that the country was an incubator of the disease grew. Massive population movement and displacement had pushed the anti-polio campaign to its limit.
Reports of the disease spiked to alarming levels. The explosive outbreak that year totalled 306 reported cases, up from 93 the previous year. Pakistan had 82% of the world’s cases of polio in 2014. One newspaper editorial at the time called the epidemic Pakistan’s “badge of shame”.
The government effectively declared war on polio, condemning the outbreak as a national disaster. “The motivation and the commitment of the vaccinators on the frontline and government officials became stronger,” says Aziz Memon, chair of Rotary’s Pakistan PolioPlus committee. “We had more reason to say, ‘Yes, we need to get rid of this disease and fulfil the promise we made to the children of this country: no child in the future will be crippled by this disease.’”
Routine vaccination campaigns that immunise children door-to-door were no longer enough. Calling it a “paradigm shift in strategy,” senator Ayesha Farooq, who leads the anti-polio strategy for the prime minister in Pakistan, says the revitalised programme focuses heavily on children who have routinely missed vaccinations. “Despite the fact we were receiving 80% coverage in every campaign, the other 10-20% that we were missing out on were sustaining the virus,” she says.
A refugee crisis creates an opportunity for vaccinators
For nearly four years, from 2012-15, half a million children in the federally administered tribal areas in northwestern Pakistan were inaccessible to vaccinators.
The mountainous, semiautonomous region, including North Waziristan, was controlled by militant groups such as the Taliban, which prohibited polio vaccinations. These areas were not under-vaccinated; the children were not immunised at all. This fuelled the 2014 outbreaks, with about 70% of cases coming from the tribal areas.
After a sweeping military offensive in 2015 pushed the Taliban out, more than 1 million civilians fled to neighboring areas and across the border into Afghanistan. The military action created a refugee crisis, putting tens of thousands of people in camps for the internally displaced.
Still, it also cleared the way for vaccinators to inoculate hundreds of previously inaccessible children, says Dr Malek Sbih, leader of WHO’s strategy of vaccinating children as they travel.
“The military operation provoked an enormous exodus of people from the region, inside and outside the borders. It’s unfortunate. But fortunately for us, it gave us the opportunity to reach 265,000 kids,” he says.
Even today the country’s high rate of population movement – travellers headed to religious festivals, migrant workers, nomads – poses a daily challenge to the polio campaign.
Pakistan and the GPEI partners had more than 200,000 trained and dedicated frontline vaccinators fan out to Karachi, Khyber Pakhtunkhwa and Quetta – the three core reservoirs of wild poliovirus.
The campaign installed more than 600 permanent transit posts across the country. These kiosks operate year-round and provide millions of vaccinations to children and families who are on the move.
None are more important than those operating along the 1,500-mile (roughly 2,500km) boundary between Afghanistan and northern and western Pakistan, a porous border that accounts for 90% of Pakistan’s population movement.
Recently the two governments agreed to work closely on synchronised immunisation campaigns. Because Pakistan and Afghanistan are part of the same epidemiological block, Farooq says, “we have to work in tandem with our Afghan partners to eradicate polio from the region altogether. We need to build immunity so that there is no cross-border importation.”
In July, Rotary bolstered this effort by opening a kiosk at the Friendship Gate, a border checkpoint in the Chaman area in northern Baluchistan. Along with migrants, each day, between 10,000 and 15,000 Pakistani and Afghan traders pass through the gate.
More than 1,000 children are vaccinated at this Friendship Gate point each day. In total, this kiosk strategy has vaccinated more than 68 million children who would otherwise be missed.
Challenging fear and intimidation
Public mistrust and intimidation by militant groups played a part in many parents’ refusal to have their children vaccinated. To counteract the intimidation, Rotary opened eight polio resource centres to build community trust in high-risk areas. The centres, in addition to giving polio vaccinations, sponsor health camps that offer immunisations against measles and other diseases, as well as free medical examinations, medicine and eyeglasses.
Rotary trained local, permanent vaccinators, mostly women, and they have reduced the number of refusals from 87,000 in March 2014 to 23,000 in March 2016 — a refusal rate of less than 1%.
“What we’ve seen is our female vaccinators are driving every single operational gain that is being made,” says Aidan O’Leary, head of Unicef’s polio campaign. It also helps that these vaccinators come from the community. “They know all the mothers and their children. They know when parents are available and when is the best time to reach them.”
Rotary also worked with leading Islamic scholars to form the Pakistan Ulema PolioPlus Committee, which is strongly behind efforts to rid the country of polio. “The committee is doing a wonderful job at holding workshops and gathering Islamic leaders to educate them about how important these polio drops are,” Rotary’s Memon says. “We are telling them that 52 other Muslim countries have eradicated polio with the same polio drops.”
Virologist Shoukat Ullah, who is also a mufti, an Islamic legal expert empowered to rule on religious matters in his community, says outreach to Muslim leaders can make a “huge impact”.
In his city of Nowshera, Ullah attends community gatherings and Friday prayer ceremonies to talk to families and other Muslim leaders about the benefits of polio vaccinations. “People will follow their Islamic scholars,” he says. “Community members will help volunteer … if asked by scholars. We can make a big difference in the perception of polio and any cultural barriers.”
The global footprint of polio has never been smaller. While Pakistan is hoping that its last case of polio occurred in 2016, significant challenges remain. “We look forward to the continued support of Rotary in crossing the finish line,” says Farooq. “We are close to finally ridding this country, the region, and globe of this menacing disease.”
The number of new infections has dropped from 306 in 2014 to 56 in 2015, a decrease of 82.
But refusals happen. About two in 10 vehicles flagged down do not participate in any vaccinations. Whether it’s for religious reasons, or because parents insist that their child has already received the vaccination, team members have to be ready to convince families that the drops they have in their hands are critical to making history.
“With polio eradication,” says O’Leary, “there’s no other health programme in the world that I’m aware of where your goal is zero in everything you do.”
Ryan Hyland is a senior writer at Rotary International.
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