Crippled by resistance, dream of polio-free Pakistan teeters on tightrope

Pakistan is currently grappling with a growing polio crisis. This year, so far, there have been 56 confirmed cases of the wild poliovirus (WPV), according to the National Institute of Health (NIH) — an alarming jump from the six cases reported the previous year. As the number of infected children grows, health authorities and global organisations are sounding the alarm, calling for urgent action.

One major reason contributing to this sudden uptick in cases identified by the Global Polio Eradication Initiative (GPEI) is the forced repatriation of Afghan refugees, which has led to widespread displacement across Pakistan. This movement of people hampers vaccination efforts by disrupting established health services and causing children to miss immunisation campaigns.

Wild poliovirus (WPV type 1) continues to be endemic in Afghanistan and Pakistan, the only two countries where WPV transmission never stopped.

Afghanistan has reported 23 cases of the viral infection in 2024. Compounding the issue, in September the Taliban government in Afghanistan suspended door-to-door vaccination campaigns, citing security concerns. The decision has left many children vulnerable, not just in Afghanistan but also in Pakistan, because of the high volume and frequency of cross-border travel between the two countries.

“Afghanistan is the only neighbour from where Afghan people in large numbers come to Pakistan and then go back,” Anwarul Haq, the coordinator at the National Emergency Operation Centre (NEOC) for Polio Eradication, told the Associated Press in September.

The bulk of cases in the country have been reported from Balochistan, where 26 children have been infected so far, particularly in areas near the Pakistan-Afghanistan border. Six cases were reported in Killa Abdullah, three each in Quetta and Zhob, and two each in Chaman, Killa Saifullah, and Pishin. Nationally, 15 cases were reported in Khyber Pakhtunkhwa, 13 in Sindh, and one each in Punjab and Islamabad.

Role of religion and community beliefs

As is the case with several issues in the country, misguided beliefs and cultural misconceptions have played a significant role in the spread of the disease.

Vaccine hesitancy has taken root in many communities, fuelled by deep-seated misapprehensions and widespread misinformation, such as the belief that the vaccine could cause infertility or is part of a foreign conspiracy. This climate of distrust is particularly volatile in regions where health outreach is most needed.

In Karachi’s Gadap area, Shafiq*, an elderly resident, expressed doubts about polio immunisation.

Four cases have been detected in Karachi to date this year; two from Kemari district and one each from Karachi East and Malir districts. Overall Sindh has reported 13 cases, the second-highest number after Balochistan.

“These diseases didn’t exist in our time,” he claimed. “They started spreading after international organisations began giving our children these vaccines.”

According to the United Nations Children’s Fund (UNICEF), Pakistan used to report approximately 20,000 polio cases per year in the 1990s. After the launch of the country’s polio eradication programme in 1994, the numbers declined massively.

Shafiq argues that the polio vaccine is not mentioned in the Holy Quran and asserts that it is not "farz" (obligatory) for him to administer it to his grandchildren.

Prominent Islamic scholars such as Imtiaz Ahmed have taken a stand against these misconceptions. Ahmed, a religious scholar and author of The Easy Quran and several other religious books including the Biography of the Holy Prophet, says: “Islam encourages us to take all measures necessary to safeguard the health of our families. Vaccinations are not only permissible but a moral responsibility to protect our children and community from harm.”

Government officials need to redouble their efforts to collaborate with religious leaders of all sects and build trust among communities during immunisation campaigns.

This strategy has proven successful in Gilgit-Baltistan, where not a single case has been reported since 2017.

Experts attribute this progress to increased awareness among the population, high literacy rates, lack of vaccine refusals, and extensive community involvement during immunisation days.

“Announcements are made by the neighbourhood Jammat Khana to bring children for vaccination whenever a government campaign is launched,” said Aneela, a resident of Gilgit, who is a health worker and research assistant.

She has worked for polio campaigns in Gilgit and Sindh but never encountered any resistance from the community or authorities in her hometown. She recalls her family telling her that the people in her locality were eager to have their children vaccinated in the recent drive after hearing about the rise in cases in other provinces.

The Pakistani government launched a third anti-polio vaccination campaign aimed at protecting the most vulnerable population, which lasted from October 28 to November 3 and reached over 400,000 children under the age of five across the country.

Despite proactive efforts, resistance to vaccination is palpable in various communities. In Ibrahim Hyderi, a neighbourhood in Karachi’s Malir district, vaccine refusals have been reported which are often driven by family dynamics. Husbands and mothers-in-law often discourage mothers from getting their children vaccinated or even receiving the tetanus jab during pregnancy, according to health workers at the local primary care clinics.

Shehnaz*, a homemaker from Ibrahim Hyderi, said her mother-in-law had refused to allow community health workers to administer anti-polio drops to her two children, claiming they would cause fertility problems in the future.

While Christian families generally show acceptance towards vaccinations, others, particularly migrant families from the Bengali community, exhibit significant opposition, according to community health workers. Many do not trust the government with their children’s health, they added.

When contacted for comments, Senator Ayesha Raza Farooq, the Prime Minister’s Focal Person on Polio Eradication, a representative from the National Emergency Operations Centre, and Islamic scholar Mufti Munib ur Rehman did not provide a response to inquiries.

Why oral polio drops are Pakistan's vaccine of choice?

"Since poliovirus is mostly spread through the faecal-oral route and resides in the throat and gut where it replicates, it is pertinent to prime the mucosal immunity, and the role of the oral polio vaccine (OPV) is to ensure those living in high transmission areas have good mucosal immunity as it is the first line of defence against the virus," explained Dr Zaubina Kazi, a senior researcher at the Aga Khan University’s (AKU) Department of Paediatrics and Child Health.

"This is the reason it is still the vaccine of choice in Pakistan where there is uninterrupted wild poliovirus transmission."

As the global polio eradication efforts work towards novel and more effective strategies to eradicate polio, the picture looks very grim.
— Dr Zaubina Kazi

Dr Kazi has worked extensively on polio eradication and vaccines in the country and published several papers on polio and other childhood illnesses.

The OPV consists of the attenuated (weakened) poliovirus and was the mainstay of past anti-polio campaigns worldwide. It continues to be used in high-risk areas and outbreak settings.

The inactivated polio vaccine (IPV) strengthens the immune system through the blood and is the vaccine of choice in polio-free areas, Dr Kazi added. It is used in conjunction with OPV in some countries including Pakistan’s national immunisation programme.

"The strategic advisory group of experts (SAGE) for polio recommends the gradual phasing out of OPV and replacement with IPV as more countries become polio-free," she said.

There remain considerable gaps in immunity and supply issues with IPV, therefore fractional IPV (fIPV) dosing was introduced where 1/5th of the usual IPV dose was used, Dr Kazi said. Research has shown that two doses of fIPV are superior to a single dose of IPV.

A study conducted by AKU demonstrated that this dose-sparing strategy was comparable to the immunity provided by a full dose.

“As the global polio eradication efforts work towards novel and more effective strategies to eradicate polio, the picture looks very grim,” Dr Kazi warns, urging people to vaccinate their children.

Global response

The global health community is increasingly concerned by the resurgence of polio. The GPEI, in response to the escalating crisis, announced in October an extension of its strategic plan from 2022-2026 to 2029, along with a substantial increase in its budget. The Polio Oversight Board (POB) set the funding target for the extended 2022-2029 strategy at $6.9 billion, marking a significant increase from the previously estimated $4.8 billion. While $4.5 billion has already been pledged by donors, an urgent need for an additional $2.4 billion remains.

GPEI members also visited Pakistan on November 20—their second visit this year. The delegation evaluated strategies for closing immunity gaps and reaching children who have missed vaccinations and emphasised the need for ongoing efforts to improve routine immunisation and strengthen cross-border health collaboration.

The fight against polio in Pakistan stands at a crucial crossroads. As health authorities, communities, and global partners come together, the path toward eradicating this debilitating disease hinges on educating the public and fostering trust in vaccination efforts to ensure every child receives the protection they deserve from polio.

Dr Taneer Ahmed is a research specialist at the paediatrics and child health department of the Aga Khan University. She has previously worked as a science educator and health journalist.

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