Pakistan’s polio programme ‘no longer on track’

ISLAMABAD: Announcing yet again, a three-month extension in temporary international travel restrictions on Pakistan, the International Health Regulations Emergency Committee of the World Health Organisation (WHO) has recommended an urgent analysis of the startling increase in polio cases in Pakistan in order to understand the factors that have led to "the most serious deterioration in polio eradication seen since 2014."

"The government of Pakistan, the Polio Eradication Programme and community factors-all need to be included in such a review," reads the statement of the 21st IHR meeting regarding the international spread of poliovirus. While understanding that the recent political transition may have adversely affected delivery of the programme, the Committee has emphasised for the new government to renew its efforts because its polio eradication programme "is no longer on track." The IHR Committee has found that the spread of polio still constitutes a Public Health Emergency of International Concern (PHEIC), thereby necessitating extension of travel recommendations for another three months effective May 21, 2019.

Ever since June 2014, it is mandatory for travelers from Pakistan to produce a valid polio vaccination certificate to be able to embark on an international journey. The restriction is aimed at mitigating the potential risk of poliovirus exportation. With reference to Pakistan, the Committee has expressed grave concern over the "significant further increase" in wild poliovirus cases globally in 2019, "particularly in Pakistan," where 15 cases had been reported when it convened on May 14, 2019.

The political transition in 2018 stagnated the country's progress towards zero as cases increased to 12 in 2018. The situation continues to massively deteriorate in 2019 as the number has already risen to an unpardonable 20 in just five months, with an 18 month-old male child from Bannu being the latest victim to have been confirmed on May 29.

A province-wise breakup of polio cases reported so far in 2019 shows Khyber Pakhtunkhwa leading the count with 8 (Bannu: 6, Hangu: 1, DI Khan: 1), followed by six in KPTD (Khyber Agency: 1, Bajour Agency: 1, North Waziristan: 4) and three cases each from Punjab (Lahore city) and Sindh (Lyari, Gulshan Iqbal, Larkana). The situation is particularly embarrassing for the PTI government as 29 polio cases have been reported ever since it came into power (9 cases in the second-half of 2018 and 20 so far this year). It is pertinent to recollect that the One Team Under One Roof approach adopted by the network of Emergency Operation Centres had proven to be a game changer in reducing the polio case count from 306 in 2014 to 54 in 2015, 20 in 2016, and only 8 in 2017.

Pakistan is under global scrutiny for not one, but multiple reasons. These include detection of the first WPV1 exportation since 2014 in Iran. The virus is most closely linked to viruses found recently in Karachi. The fact that the exportation is outside the Pak-Afghan epidemiological block signals that the hard-fought gains of recent years can easily be reversed. Pakistan is also on the international radar because of the rising number of WPV1 cases; rising proportion of positive WPV1 environmental samples; clusters of cases in areas not considered high-risk; and increasing resistance to vaccination.

Moreover, issues related to the security environment (attacks on polio workers and policemen), rapid population growth, limited access to safe water and sanitation, high prevalence of malnutrition, and low routine immunization coverage have also hampered Pakistan's progress. The Committee has noted that poliovirus transmission in Pakistan remains widespread and that recent cases in Lahore indicate that the problem has transcended the high-risk corridors. It is convinced that unless urgent remedial steps are taken, the increased rate of infection during the low transmission season may herald even higher rates of infection in the high-transmission season. Current trends and data provide compelling evidence about Pakistan being on its way to losing a war it had almost won.