Introduction:
Striving to survive in 2020, amid the crisis of novel global pandemic, Covid-19, one should not forget the ancient, crippling virus, Polio, having its homage in our beloved country. Corona which has taken more than 1.5 lac lives and have infected millions, it pains me to pen down that more than 350,000 have lost their healthy lives to another virus. Today, only three countries are attached to this ominous disease which includes Pakistan, to some extent Nigeria and Afghanistan. Pakistan was hit by this disease 26 years ago in 1994. Polio is highly infectious, consisting of serotypes 1, 2, and 3. transmission contributing to majority of the cases especially in regions with poor hygiene and sanitation. The successful eradication of wild poliovirus therefore rests on Pakistan’s immunisation programme and strategy.

Pakistan still has 147 cases in 2019 and 39 in 2020 which shows that there’s some lack in effectiveness and efficiency of the program as it is facing various challenges due to its situational, financial, cultural, religious and other perspectives. There has been a decline in Polio Cases from 20,000 every year in 1990’s to only eight cases in 2018. But the issue lies in the fact that, if the virus is circulating even in one child, no child is safe from this crippling virus.

Discussion:
Polio Eradication program is basically a public-private led partnership by The Government of Pakistan, headed by partners including World Health Organization, United Nations Children’s Fund (UNICEF), Bill and Melinda Gates Foundation, Rotary International and the US Centres for Disease Control and Prevention (CDC).

“Polio is one of the few diseases we can eradicate in the world in the next few years. This is a priority of the United Nations and I am extremely happy to see it is a clear priority for the Government of Pakistan,” said Mr. Guterres.

Mr. Guterres issues a very praising and motivational comment for Pakistan’s Polio program. But, let’s throw a light on current progress of the program. Pakistan’s Expanded Programme on Immunisations (EPI) was formally initiated in 1978 after the WHO launched its Expanded Programme on Immunisation in 1974 . National EPI policy is regulated by the guidance of the National Immunisation Technical Advisory Group (NITAG), which makes evidence-based recommendations to improve the programme. Program’s objective is to optimize immunization of OPVs to children under 5 years by procuring OPVs and providing services necessary for polio campaigns, therefore contributing to the eradication of Polio in Pakistan. Annually the target for vaccinating children under age 5 is around 39 Million. OPV and GPEI budget brings the overall cost to of strategy to US $5.1 billion.

The Polio eradication program which is at its last stages that is end game strategy 2019-2023 has sorted out three challenges majorly including inaccessibility, insecurity, conflict, weak or fragile health systems, Operational, management and resource risks but after critically analyzing the program, more challenges can be sorted out in the way of program completion towards its closeout phase i.e. zero policy. Closely looking at Pakistan’s challenges a consistent problem that is arising is safety and security concerns. Till now over 100 polio workers have been killed due to various reasons. With life threats of polio frontline workers, the program seems unable to achieve its target in the time frame. Even after spending billions of rupees in awareness campaigns, there’s still awful parental perception. Parents refuse to get their children immunized as observed in Karachi in the last two latest SIAs. Pashtuns from low as well as high income group refuse to get their children vaccinated. In, Islamic Republic of Pakistan, with strong religious influence, sardars and Mullahs makes the Pashtuns avoid or refuse vaccinating their children. Keeping the geography and culture of Pakistan we can deduce that there is strong correlation between low immunization completion and negative socioeconomic factors adding poverty and illiteracy.

The icing on the top is its geographical challenges whether it is the Himalayan Range and glaciers of the north to harsh terrain of Baluchistan in the south with poor health safety. Cultural differences, densely populated areas, poor management and operational deficits adds to it. Another important perspective to this is concerns regarding OPV efficacy. Frequent power outages and the scarcity of equipment in Pakistan have made it difficult to maintain the cold chain necessary for OPV efficacy and has contributed to the alarming rise of cVDPVs as well as wild poliovirus-induced poliomyelitis among vaccinated children. Families lack access to basic services and children receive little or no protection against disease.

Poor immunization services, combined with high rates of malnutrition and a lack of safe water and sanitation, create conditions that allow the virus to thrive and paralyse vulnerable children with low immunity. Mobility and mass migration between Afghanistan and Pakistan makes several children inaccessible for polio workers. Weak and Fragile healthcare infrastructure in Pakistan that has been evident in Covid Pandemic as well. Technical Challenges arise when vaccines become ineffective in areas with poor sanitation and high-density population. Lack of efficient and reliable laboratory network is also seen.

For every challenge a project should have multiple strategies to deal with it. Pakistan has devised National Emergency Action Plan for polio eradication program 2018-2019 outlining the planning and strategies to handle polio vaccination and spreading of this virus. Pakistan Programme revisited its strategy and put forward the Extension of the National Emergency Action Plan 2018-2019. This program has been in constant control under the stakeholders. It has completed its three stages of initiation, planning and is working more effectively on execution and control. For this to happen they have collaborated with EPI and ISD with interventions that can improve lives and perception regarding polio Programme.

Furthermore, there is revised modalities in campaign, to reduce community fatigue and have better campaigns quality including community engagement and social mobilization strategies. They are incorporating new case response to ensure timely decisions in affected areas. As, we have entered polio endgame strategy, whose strategy can be explained in three words, eradication, integration, certification and containment. Afghanistan Pakistan hub is being created with collaboration of both countries only polio can be eradicated. Expanded partnership with WASH and other programs can generate better results.

Conclusion:

However, one cannot completely negate the fact that Pakistan has climbed some steps up and have lowered its numbers. Pakistan has made important progress towards stopping poliovirus transmission in the country. Case numbers are the lowest they have ever been, while immunity gaps among children continue to decline. An array of approaches and tools are implemented to help Pakistan reach the finish line of zero polio cases. Better project can add Pakistan to Polio free country as well. Hopefully!

Footnotes:

[1] Conflict and Health Research Group, King’s Centre for Global Health, King’s College London, Suite 2.13 Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK

[2] Owais A, Khowaja AR, Ali SA, Zaidi AK. Pakistan’s expanded programme on immunization: An overview in the context of polio eradication and strategies for improving coverage. Vaccine. 2013;31(33):3313–9.

References:
1. Ghafoor, S., & Sheikh, N. (2016). Eradication and Current Status of Poliomyelitis in Pakistan: Ground Realities. Journal of Immunology Research, 2016, 1–6. doi: 10.1155/2016/6837824
2. Hussain, S. F., Boyle, P., Patel, P., & Sullivan, R. (2016). Eradicating polio in Pakistan: an analysis of the challenges and solutions to this security and health issue. Globalization and health, 12(1), 63. https://doi.org/10.1186/s12992-016-0195-3
3. Weekly Epidemiological Record . Polio vaccines: WHO position paper, January 2014. Geneva: World Health Organization; 2014.
4. Aylward B, Tangermann R. The global polio eradication initiative: lessons learned and prospects for success. Vaccine. 2011;29:D80–5. doi: 10.1016/j.vaccine.2011.10.005
5. Garon JR, Orenstein WA. Overcoming barriers to polio eradication in conflict areas. Lancet Infect Dis. 2015;15(10):1122–4. doi: 10.1016/S1473-3099(15)00008-0
6. Pakistan. (2020, March 21). Retrieved from https://www.who.int/countries/pak/en/
7. Polio eradication a UN priority, says Guterres in Pakistan visit | UN News. (n.d.). Retrieved from https://news.un.org/en/story/2020/02/105764
8. Polio. (n.d.). Retrieved from https://www.unicef.org/pakistan/polio
9. Pakistan. (n.d.). Retrieved from http://polioeradication.org/where-we-work/pakistan/
10. User, S. (n.d.). Eradication Strategy. Retrieved from https://www.endpolio.com.pk/polioin-pakistan/eradication-strategy
11. Rehman, A. U., Sahir, I., Yaqoob, I., & Zulfiqar, S. (2020, January 7). Factor Affecting Polio Eradication Program in Pakistan. Retrieved from https://www.hilarispublisher.com/abstract/factor-affecting-polio-eradication-program-in-pakistan-21200.html
12. Polio Eradication and Endgame Strategic Plan 2013–2018. (n.d.).
13. Andrade, G. E., & Hussain, A. (2018, October 27). Polio in Pakistan: Political, Sociological, and Epidemiological Factors. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6318131
14. Kanwal, S., Hussain, A., Mannan, S., & Perveen, S. (2016, March). Regression in polio eradication in Pakistan: A national tragedy. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26968287
15. Shah, S. Z., Saad, M., Rahman Khattak, M. H., Rizwan, M., Haidari, A., & Idrees, F. (2016). “Why we could not eradicate polio from pakistan and how can we?”. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28718581
16. Larson, N. (2014, May 5). WHO declares polio ‘public health emergency’ (Update).
17. Hyland, R., Doan, M., & O’Leary, A. (n.d.). Pakistan’s Rise to Zero