Pakistan logs its first polio case of 2010

From The International News in Pakistan:

ISLAMABAD -- Having capped 2009 with the regretful figure of 89 polio cases, Pakistan’s first polio case of the year 2010 was confirmed by the National Institute of Health (NIH) here on Monday — right on the eve of inauguration of the first Sub-National Polio Immunisation Campaign of the year by President Asif Zardari.

Nine-month old Bushra, a type-1 case from Inam Khra Chinagi, Union Council Dama Dola, Bajaur Agency, is the first child to have been affected by polio this year. She had onset of the disease on January 1, and as far as her parents can recollect, she did not receive a single dose of polio vaccine. Detailed epidemiological investigations of the case are currently under process.

With Pakistan’s struggle against polio entering its 16th year, there are no indications yet of the disease being pushed to the annals of history — at least not in the foreseeable future. In the context of the latest case, it is essential to point out that Bajaur Agency reported the second highest number of polio cases (16) last year, preceded only by Swat, which had 20 cases. Children in Bajaur Agency in general and Mohmand in particular have not been accessible for vaccination on account of compromised security situation.

According to officials of the Expanded Programme on Immunisation (EPI), 11 vaccination campaigns were conducted in accessible parts of Bajaur Agency in 2009. Yet, more than 100,000 children-meaning over half of the target population — are persistently inaccessible to the vaccination staff for immunisation due to ongoing insecurity.

Current thinking within EPI focuses on requesting the health leadership of FATA and Bajaur Agency to pay urgent attention to oversight in a bid to improve the quality of vaccination activities in areas where accessibility is not an issue. For areas marked by difficult access, the government intends to continue with its policy of availing opportunities to vaccinate children, using locally appropriate vaccination strategies and engaging all levels of the civil society. Moreover, the Directorate of Health Services, FATA, may also be requested to supervise campaigns in Bajaur Agency.

However, in an enlightening analysis of Pakistan’s polio eradication scene, eminent public health specialist Dr. Sania Nishtar attributes “weaknesses in the delivery of services and broader issues of health systems governance” as a major factor in the country’s failure to achieve polio eradication. Titled ‘Pakistan, Politics and Polio,’ a soft copy of her article, which will be carried in the February 2010 issue of the World Health Organisation Bulletin, has been posted online ahead of its publication.

According to Dr. Sania, “Although the Polio Eradication Initiative is well-funded, the public infrastructure through which it is delivered remains under-financed. It is consistently observed that the system provides opportunities in many areas for institutionalized malpractice, primarily geared towards pilfering resources from the system. Staff misconduct is often ignored due to collusion between staff and inspectors. As a consequence, staff remain absent from duty, do not run field operations and divert vaccine for use in private facilities; service delivery is, therefore, undermined both qualitatively and quantitatively, and costs are levied for services that are meant to be provided for free.”

Dr. Sania makes a reference to “frequent anecdotal reports of vaccinators engaging in petty theft in the field, e.g., by charging money for vaccination cards and syringes that they receive at no cost and by selling part of the vaccine stock to private hospitals. The recent open-vial policy, under which the field vaccinator has the prerogative to open a multi-dose vial even for one child so as to maximise vaccination coverage, is particularly abused in this way.”

The public health specialist believes that “worsening governance, notably preferential treatment in staff deployment and rapid turn-over of programme managers” are also “partly responsible” for resurgence of polio from 2007 onwards. Dr. Sania is of the opinion that “the most important reason for the delay in interrupting poliovirus transmission in Pakistan relates to failure to vaccinate during Supplementary Immunisation Activities. Vaccination coverage in critical areas is not high enough to interrupt transmission and then to maintain that achievement.”

The author moves on to highlight the role of non-health sector issues such as access in war and conflict zones; refusal of parents to vaccinate their children; and problems with cross-border movement of nomadic populations from Afghanistan; as well as poor sanitation and lack of clean water as also contributing to the rise in polio cases. “With an average of 8 hours per day of electricity cuts due to load-shedding, maintaining the cold chain for vaccine storage may become a problem, although there is no direct evidence yet of its impact on results of the Polio Eradication Initiative,” she raises a highly pertinent point.

Dr. Sania calls upon Pakistan to draw lessons from China’s example in polio eradication by “developing a plan for grand national immunisation days, where the entire organisational force of the government should be put behind polio eradication.” She proposes that “the outreach drive in national immunisation days must go beyond traditional vaccinators to involve actors that can deliver services in disaster zones. Second, the government should commit to providing a maximum of resources to ensure a seamless supply chain that includes airlifting of vaccines, access to areas on horseback and possible imposition of a military curfew for the duration of the campaign. Third, through the creative use of quotes from the Quran, polio eradication can be presented as a ‘right to life’ issue. Improved understanding of religion may assist in negotiating access in areas where refusal is an issue and soliciting a ceasefire for vaccination campaigns.” As such, there are many uncharted options that the EPI can work on if polio eradication is what it is pursuing in earnest.