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October 24, 2020

Battling polio at the final frontier

Islamabad

October 24, 2020

Special Assistant to Prime Minister on Health

After more than 30 years of effort, Africa was finally declared free of (wild) polio virus in August. With this milestone, only Afghanistan and Pakistan are left as the last frontiers in the fight against wild polio virus. On the occasion of World Polio Day, it is important that we reflect on this reality and on the responsibility that rests on our shoulders to fight for a polio-free future for the children of Pakistan and the world at large. Pakistan’s journey towards Polio eradication has been marked with ups and downs. With gains made under the umbrella of the National Emergency Operations Centres Network from 2015 to 2018, success in eradication appeared to be within reach. Polio case numbers dwindled and in 2017, we reported only eight polio cases which was the lowest in the history of Pakistan. This triumph was shortlived as 2019 proved to be a significant setback. The year was marked by aggressive virus circulation as well as a sharp increase in refusals to the vaccine fuelled by the proliferation of anti-vaccine propaganda especially on social media platforms. These developments were poised to set back some of the hard earned efforts to protect Pakistan’s children from Polio, we had to rethink, re-strategise and innovate like never done before. The subsequent months included comprehensive reviews of operations, programme structures and staff, as well as forensic and detailed analysis of available data. This ultimately helped us launch a battle against polio afresh with renewed and reinvigorated energy. Learning from the past, system- based solutions were initiated focusing on improvements in essential immunization. Substantive progress was made to the “cold chain system” which ensures quality of the vaccine as well as the development of a state-of-the-art vaccine warehouse equipped with a top of the line temperature monitoring system. Leveraging technology improved campaign performance and polio surveillance, such as integrated software for data collection, the development and roll out of mobile apps for real-time data collection and segregation of data down to the Union Council level. High risk areas have been the centre for attention and efforts were made to develop holistic programming that addresses wider health needs and service delivery in these areas. Synergy was prioritised with the Essential Immunization (EI) program to strengthen the routine immunization system in conjunction with door-to-door polio campaigns. The renewed efforts started bearing fruits. The national vaccination campaigns at the end of 2019 and beginning of 2020 showed that the situation was improving with better vaccination coverage and greater trust and acceptance of the polio vaccine in previously resistant communities. B y the end of February 2020, the World and Pakistan were engaged heavily in the response against the COVID-19 pandemic. This has impacted amongst other things, the delivery of essential public health interventions such as polio campaigns. To minimise the potential spread of COVID-19, all planned polio eradication campaigns were suspended for a fourmonth period. Pakistan’s Polio Eradication Programme was in this period able to pivot its focus and step in as one of the first lead responders to the national COVID-19 response. The public health expertise and infrastructure built and embedded across the country through the programme helped to provide exceptional support to the country’s COVID-19 surveillance and response. For example, the same technology used to track polio cases was used to track COVID-19 cases and inform policy decisions on strengthening COVID-19 response and guide the Government’s interventions, like targeted / smart lockdowns as well as contact tracing around infected persons.. In addition, polio resources such as the 1166 helpline answered questions and provided information on COVID- 19 to the public. Due to the successful coordinated and coherent national response to COVID-19, the situation began to improve over the summer months and polio vaccination campaigns resumed with full force. Vaccinators were trained on COVID-19 preventative measures and strict rules were put in place to reduce any chance of COVID-19 infection amongst vaccinators and the community. From July to September 2020, three campaigns were conducted, helping to vaccinate up to 722,500 children in July, 33.6 million children in August and 39.1 million children in September. The programme picked up where it had left off before COVID-19 by continuing to critically analyse itself and all available data to improve its operations, and in turn drive up vaccination coverage, while engendering greater trust and demand for the polio vaccine. The journey to polio eradication has profound challenges. In certain areas the vaccination teams continue to miss children during campaign rounds due to various reasons, including refusals to getting vaccines by parents. The programme faces a lack of trust in vaccination especially in communities which are impoverished and underserved. Additionally, many caregivers don’t understand the risks of refusing the vaccine for their children, as the eradication effort’s success at reducing cases is misunderstood, and poliovirus is mistakenly deemed a low risk. The eradication effort is further challenged by gaps in essential immunization services, poor water, sanitation and hygiene (WASH), and a high prevalence ofmalnutrition. These factors contribute to a natural environment which enables virus circulation.Meanwhile, the threat of pandemic and 2nd wave lingers and could stand to impact the potential outreach of the programme in the coming months. To overcome these challenges, we will continue to implement a comprehensive vaccination schedule into 2021, prioritising the optimal vaccination coverage of children, especially within high risk areas for polio. If one thing became obvious in the struggle against COVID- 19, it was the value and impact of data driven, science based responses from a national platform with provincial buy-in and reach. Therefore, some new and disruptive ideas will need to be put in place. To this end, the program’s focus and response will be sharpened and more timely reactive to data from within communities about cases and about presence of the virus in environmental samples. This response will need to be early and without waiting for the next scheduled campaign. Some innovation and attention to detail on specific high risk areas will be deployed. We will also continue to implement and build upon the changes brought about in 2019, such as delivery of broader health services where required, the strengthening of the routine immunization system, and greater efforts to build trust in polio vaccination in those communities who continue to refuse the vaccine. We will build synergy in campaigns and operations with Afghanistan in order to manage the spread of the polio virus across the shared epidemiological block. Although we have some ground to cover yet, it is important to recognise how far we have come and the formidable efforts that Pakistan has already undertaken to protect our children from polio, saving over a million children since 1994. For more than 26 years, the programme’s over 250,000 gallant polio vaccinators have made it a personal mission to ensure that no child is left behind, no matter the odds or risks they have faced. This is a testament to how far Pakistan has come in this journey and a reflection of the collective resolve within our society to tackle the challenges that lie ahead. The fight against the COVID-19 pandemic illustrates this resolve better than anything. We will continue to use the same resolve to create a polio-free Pakistan.