Keeping conservative norms of the community in mind, a vaccinator and two social mobilisers have set up an outreach vaccination site away from the community’s residential family compound in a hut made of straw and jute, dedicated to guests, in this village Rajanpur district. The site is located far from the city centre in the riverine area close to Mithankot where the five Punjab rivers.

This is the last day of a special 10-day Inactivated Polio Vaccination (IPV) campaign. Wearing wool scarfs and caps, vaccinators look fatigued but not fazed by the extreme cold and in the midst of Covid-19 pandemic. Relieved by the fact that most of the children have been vaccinated, they are a little late to start the day’s work. Soon the calm gives way to jitters as the last 24 children fail to turn up at the vaccination site. The vaccinator rises the alarm and calls the social mobilisers to send for the Not Available (NA) children.

“The children were away, visiting their grandmother in a remote village. I had informed their parents about the revisit today and the location of the vaccination site. We will go see and bring the children over. I will check if there are any concerns to address,” says Majida Bibi the lead social mobiliser in the area.

After going over the names and addresses of the children the two social mobilisers are on their way wearing masks as per SOPs.

Half an hour later they are seen coming back with five children in the arms of their caregivers.

“Hold the child’s arms tight”, the vaccinator asks a grandfather accompanying the crying child as social mobilisers look on.

The grandfather holds the child tight. The vaccinator, sanitizes his hands, prepares the dose and administers the vaccine in the upper portion of the right arm using a jet injector which is painless.

One-by-one, the vaccinator keeps calling out names of children for vaccination. After around more than two hours the team has vaccinated 18 children in the area using the Inactivated Polio Vaccine.

Rajanpur is one of the most impoverished districts of the Punjab. Hard-to-reach areas and lawlessness have impacted polio teams’ work in the past.

As per Annual Studies of Education Report released in 2011, the district ranked last in the province on literacy indicator.

Most of the health and nutrition indicators are dismally low. As per MICS 2018 survey, child stunting stands at 47 percent.

Together with neighbouring Dera Ghazi Khan, it has the lowest Expanded Programme on Immunization coverage across the Punjab leaving children at the risk of polio and other vaccine-preventable diseases.

Keeping movement pattern of the populations from one field to another in search of livelihoods in consideration, it is not surprising to see children missing critical vaccination.

Even in this village most of the children available were seen flocking to the site in groups with their grandmothers or grandfathers.Very rarely are they accompanied by their parents as younger adults of the village have been busy in sugarcane harvesting.

An IPV campaign is not a cake walk. Before the start of the special IPV campaign, the government was apprehensive about its success as the mode of vaccination was facility-based and outreach unlike house-to-house vaccination done in the case of the oral polio drops. A campaign with IPV could give rise to more parental apprehensions about the use of oral polio drops.

Of the parents who were reluctant to have their children vaccinated, most questioned the efficacy of injectable polio vaccine, especially when polio drops were also available. In addition, fear of injectors, too much emphasis on polio and adverse effects following immunization sowed hesitance in the caregivers.

“The community is wary of the pain caused by an injection. They relate it with the redness or fever caused in the aftermath of injection. Some parents also ask about the significance of the IPV when polio drops are also being administered”, says Abu Bakr who is in chrage of the campaign in the union council.

“Some of them are very apprehensive about too much emphasis on polio,” he says.

“The hospital is located across the river. They find it hard to go that far,” adds Abu Bakr.

A woman in the mid-50s carrying a child to the site complains about the absence of a hospital in the area. “If polio teams can come to vaccinate children in this village why can the government not set up a hospital here so that the local population can avail basic healthcare facilities?” she asks.

The IPV in combination with the OPV drops has worked wonders around the globe to build immunity in children and save them from the risk of polio.

When OPV is given to a child, that child develops immunity in the gut (intestines), which is required to stop person-to-person spread of the virus. The OPV has been and is still the main vaccine used to eradicate polio.

Conflict, political instability, hard-to-reach populations, and poor infrastructure continue to pose challenges to eradicating the disease. Every country offers a unique set of challenges requiring local solutions.

The IPV is given through an injection by a trained vaccinator at the designated health facility or health site/camp. When IPV is given to a child, that child develops immunity in the blood. IPV protects the individual child. IPV together with the OPV is the best combination to boost immunity in the gut.

“The fractional dose of the IPV in this campaign will help boost the immunity of children most-at-risk against the polio virus. This is an effort to stop polio transmission in Pakistan,” says Sundas Irshad, head of the polio programme in the Punjab.

“The IPV and the OPV are completely safe and very effective. It is in the best interests of the child to receive both polio vaccines, and all vaccinations and health services,” says the head of the polio programme.

Pakistan Medical Association’s Dr Ashraf Nizami corroborates the view of the Punjab polio programme head about the use of the IPV. He says no serious adverse events have been reported following vaccination with the IPV, whether used alone or in combination with other vaccines. “Minor reactions – the skin might become a bit red and tender, may occur following the IPV, as sometimes happens after a child has received vaccines,” the PMA representative says.

The Punjab has reported 14 polio cases in 2020. In 2019 the provincial tally had stood at 12. Out of the 26 polio cases in two years, 17 have been reported from Lahore (7), DG Khan (9) and Rajanpur (1). The prevalence of polio virus has also been proven in almost all polio environment sampling sites.

Since the halt in campaigns due to Covid-19 in March, the Punjab has seen increased incidence of children falling prey to the polio virus. The halt deprived millions of children of the critical oral polio vaccine, leaving them vulnerable to the virus.

The government then planned the special campaign in selected union councils of Lahore, DG Khan and Rajanpur in which all children between 4 and 59 months of age were provided a dose of IPV.

As per government data, the polio programme achieved more than 100 percent coverage in the campaign. Overall 0.91 million children were administered polio vaccine injections in the 10-day campaign. Over 0.63 million children were administered polio vaccine in Lahore alone. During the campaign, over 0.16 million and 0.11 million children were vaccinated in DG Khan and Rajanpur, respectively. “The execution of the campaign was a major success,” says Sundas Irshad, the Punjab Polio Programme head.

There are only two countries that have not stopped polio transmission: Pakistan and Afghanistan.

There has also been success in eradicating certain strains of the WPV virus. The last case of Type 2 was reported in 1999. Its eradication was announced in September 2015. It resurfaced in 2018 in Northern Areas of Pakistan and spread to other parts of the country. The most recent case of Type 3 was observed in November 2012.

Tackling the last 1 percent of polio cases has proved difficult. Conflict, political instability, hard-to-reach populations and poor infrastructure continue to pose challenges to eradicating the disease. Every country offers a unique set of challenges that require local solutions.

The writer is a Communication Officer, Polio in Rajanpur. He works with the district heath management team to mobilise communities against the paralytic disease. Additional reporting for the piece has been done by Communication Officer Polio DG Khan, Kalim Tahir, with the support of the EOC communication team in Lahore