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Need for polio eradication efforts in Pakistan: Where to focus

To the Editor, Polio, a human enterovirus transmitted via fecal–oral route, is one of the major health concerns in developing countries. Muscle weakness leading to paralysis is the most common symptom associated with polio. Although most patients sometimes fully recover, about 2%–5% of children and 15%–30% of adults die due to respiratory failure. The paralysis rate is 1 per 200–2000 cases and depends on poliovirus serotypes. Historically, humans have been suffering from polio since ancient times until very recently. An ancient polio case was portrayed on an Egyptian stele during the 18th dynasty (1580–1350 BCE) depicting an adult with a withered flaccid leg with crutches which is like a modern paralytic poliomyelitis case. During the early 1900s, annual poliomyelitis epidemics occurred regularly in the United States until the introduction of inactivated poliovirus vaccine in 1955. In 1998, 350 000 polio cases were reported in endemic countries by World Health Assembly. In 2002, World Health Organization estimated a global burden of 250–500 vaccine‐associated paralytic poliomyelitis cases. Currently, polio has been successfully eradicated from the world except for three countries, that is, Pakistan, Nigeria, and Afghanistan where it is still endemic. In 2015, 30 wild‐type poliovirus (WPV) and 9 circulating vaccine‐derived poliovirus (cVDPV) cases were reported worldwide. Among endemic countries, Pakistan is thought to be the hub of endemic transmission of WPV. In general, fluctuations in polio cases were observed in Pakistan. For instance, during 2001, 119 cases were reported which in 2002 were reduced to 90 cases. In 2003, however, the number increased to 103 during the first half of the year but reduced to 55 during the second half. Later, the cases further soared in 2009–2010 to 198 and, in 2011–2012 to 223. In 2013, 16 reported polio cases still clearly indicated incomplete eradication. In 2014, 22 cVDPV and 116 WPV cases were reported while until December 2016, 21 WPV1 cases were reported. North Waziristan, Karachi, and few areas of FATA were among the endemic areas in Pakistan. During 2014, among 116 WPV cases, approximately 46% were due to vaccine refusal by few families. And most of these reported cases were from FATA and Baluchistan areas adjacent to Afghanistan. From 2007 to 2014, 645 paralytic polio cases were reported in Khyber Pakhtunkhwa and FATA regions. Among paralytic cases, the fatality rate ranged from 5% to 10%. For polio‐related fatality, the two main variables were age and geographic location. In Pakistan, lower literacy rates, security hazards, local religious believes, and political instability were major hurdles for poor polio eradication. In 2014 and 2015, the total number of polio cases were 306 and 54, respectively, with a new polio case been reported in Karachi in February 2016. While 8 and 12 cases were reported in 2017 and 2018, respectively. In Pakistan, polio eradication is far more challenging as poliovirus was found in almost all cities. Khyber Pakhtunkhwa, FATA, and the metropolitan city Karachi were among the high polio transmission zones. Although, efforts directed to eradicate polio have been made; however, several reasons still hamper the progress. In April 2019, National Immunization Days Campaign vaccinated about 37.6 million children in Pakistan. Still, several children were missed due to vaccine refusal caused by antivaccination propaganda circulating on social media. As a result, 18 WPV1‐positive environmental samples were reported between May and June 2019 in Pakistan. Although due to the efforts of the Government and NGOs, the cases have reduced; however, Pakistan still lags in complete polio eradication. Poor health infrastructure, discrepancies in vaccine coverage along political, religious, and socioeconomic barriers are limitations for preventing polio eradication in Pakistan. In highly sensitive areas, vaccination campaigns have been stopped due to the emergence of overt violence, deadly attacks, and insecurity of health workers; altogether impeding polio eradication. In Pakistan between December 2012 and February 2013, 16 members of the polio vaccination team and one law enforcement officer were killed by militants. As a result, many children were deprived of vaccination leading to increased polio cases and an inability to eradicate polio. To overcome these obstacles, innovative strategies with a particular focus on mentioned limitations are needed in endemic areas. Expanding vaccination program coverage, improving policies, and believes to overcome frequently encountered issues in specific regions might help further in polio eradication.