Why is polio spreading?

The refusal by parents to get their children vaccinated against polio in Pakistan is only a minor contributory factor explaining the rise in the number of polio cases among children, say health experts.

In the past few weeks several polio cases have been detected in the conflict-affected Federally Administered Tribal Area (FATA) and in the North West Frontier Province (NWFP).

The most recent case was that of an Afghan child - taking the number of cases in the NWFP and FATA this year to 28, Pakistani media reported. Officials said the case was confirmed by the National Institute of Health. The nine-month-old child had received seven doses of polio drops during special campaigns but did not get vaccinated during routine immunisation.

According to the World Health Organization (WHO), the number of polio cases this year as of 5 October was 70, of which half were registered in August and September. In 2007, 32 cases were detected, and 40 in 2006.

Pakistan, Nigeria, India and Afghanistan are the only four countries in the world where the debilitating disease remains endemic.

Photo: Ibrash Pasha/IRIN

Many children have not been immunised against polio due to insecurity, say health workers (a school torched in Swat)

Insecurity - a major cause

Health workers attribute the recent rise in the number of cases to the fighting between the Pakistani army and Islamist militants.

“There are many factors that are beyond the control of the polio programme, including the security situation in NWFP/FATA and southern Afghanistan. Recently we have seen cases in Swat. The vaccinators have not been able to go to some of these areas to immunise children for nearly a year due to the security situation,” said Nima Abid, WHO’s polio team leader in Pakistan.

The biggest hurdles in the NWFP range from “insecurity and the low proportion of female teams, to pockets of refusals, and lack of independent monitoring, due again to insecurity in the area”, said Abid, who also cited other factors: “Poor service delivery in some districts and agencies, very variable routine immunisation coverage, pockets of refusals in a few key districts, rapid turnover of district health leaderships, and low public demand for immunisation.”

“Poor sanitation and high population density, which lead to a high prevalence of diarrhoeal disease and enteroinfections, also interfere with the uptake of the oral polio vaccine in the intestines of children. All these factors have hampered the eradication efforts,” Abid said.

Refusals

“Refusal is a significant problem in only a few districts and agencies like, Killa Abdullah, Bajaur, Mohamand, Swat and few others. Overall less than 1 percent of the targeted children are missed because of refusals, so it cannot be the [main] cause of the resurgence [in the number] of polio cases. An independent study of refusals highlighted that management and service delivery issues were also an issue,” she said.

Photo: Zofeen Ebrahim/IRIN

A child afflicted with polio getting receiving physiotherapy treatment

UNICEF-sponsored meeting

Attention must be given to the main reasons for missed children [during anti-polio drives],” said Chris Morry, a UN Children’s Fund (UNICEF) communication specialist, at a recent communication review meeting organised by UNICEF.

Mubina Agboatwala, in charge of the polio clinic at Karachi’s Civil Hospital, said at the meeting that it was all down to campaign fatigue, noting that some houses had been missed out during house-to-house calls.

“This is not just true for Sindh but all across Pakistan,” she said, adding: “Strict monitoring is the only solution.”

That sentiment was echoed by Abid. “Good selection of team and field supervisors as well as close monitoring by district management is crucial for successful campaign implementation,” she said.

NWFP’s minister for health, Syed Zahir Ali Shah, expressed concern about the growing number of polio cases and called for a policy review given that the polio cases were not only arising in inaccessible areas.

However, Abid pointed out that the polio programme in Pakistan was not a failure as significant strides had been made since it was launched in 1994, when the caseload was over 1,000.

ze/at/cb