With nearly all of the rest of the world on the brink of being free of polio, the disease's persistence in Pakistan has long challenged health experts both inside and outside the country. Last year, the 51 cases of wild poliovirus reported here represented the bulk of all 70 cases reported throughout the world.
Even so, last year's count is cause for optimism, since it was a huge drop from the 294 cases reported in Pakistan in 2014, and because it seems to be a product of some clever adjustments the country has made to its longstanding polio eradication program, with help from the Pakistani Army and smartphone-based technology.
Since 1978, the country has had an official Expanded Program on Immunization, in which vaccinators go door to door to immunize against many childhood and other diseases - tuberculosis, hepatitis, meningitis, measles and more. But when the goal became finally stamping out the last traces of polio, the regimen had to be ramped up to include more than these periodic household visits.
As part of the World Health Organization's Polio Eradication and Endgame Strategic Plan 2013-2018, for example, the government announced that April 25 will be a National Switch Day for updating the kind of vaccine used, to account for the fact that Types 2 and 3 of the polio virus appear to have already been eliminated in Pakistan, with only Type 1 remaining. Recognizing that, the WHO recommended a switch from a trivalent oral polio vaccine to a version that can target Type 1 more effectively.
The next milestone will be phasing out the oral vaccine, which is built from a weakened live virus, and replacing it with an inactive polio vaccine administered by injection. Starting in Punjab, that strategy will supplement the live-virus vaccine schedule with one dose of the inactive version, which eliminates even the small risk of contracting the disease from the live virus vaccine. One reason the inactive vaccine is coming into use only now is that it is five times more expensive than the live oral type. To overcome that obstacle, GAVI, a public-private organization funded by various countries, charities and international institutions, will help cover the cost. On Tuesday, GAVI and Unicef tweeted that the inactive vaccine is now available in all of Pakistan's provinces.
At the same time, Pakistan's government has supplied vaccinators with motorcycles, for which Britain's Fund for International Development, along with Unicef, will provide fuel allowances. Lack of fuel has been a popular excuse for vaccinators who miss their vaccine targets because they don't want to travel to the far-flung areas where they are most needed. Security for vaccinators is an even bigger issue, illustrated by the bombing last Wednesday of a polio eradication center in Quetta that killed 14 policemen during an immunization drive.
Indeed, a long campaign of disinformation spread by the Taleban helps explain why Pakistan's polio eradication program has not yet wiped out the disease. In 2006, the extremist group declared vaccination to be a Western plot to sterilize Pashtun children and stunt their growth. It threatened to kill parents who had their children immunized, and attacked polio vaccinators in Pakistan's tribal areas and in metropolitan Karachi. Celebrities joined campaigns to counter the propaganda, and religious leaders issued fatwas declaring that Islam permitted the immunization of children, but those efforts did nothing to stop the attacks.
In 2012, Taleban commanders and clerics affiliated with the movement also halted the immunization program in North Waziristan, in protest against American drone attacks that had followed the killing of Osama bin Laden by American Special Forces; subsequent revelations that the CIA had used a bogus vaccination program to capture DNA material from Bin Laden's relatives gave the Taliban additional ammunition with which to besmirch all vaccinators as spies for America.
But much of that changed last January, after the Taleban disrupted a three-day immunization drive in Sindh Province by killing three polio workers. First, vaccinators refused to work until they were given more protection. Then, the Pakistani Army provided the vaccinators with visible security.
By that point, the army had already begun a nationwide anti-militant campaign in the wake of an attack on an army-run public school. When the offensive drove militants out of North Waziristan's tribal areas and Karachi's no-go zones, parents finally lowered their resistance to immunizing their children. What followed was the 70% drop in new polio cases over the full year.
Nevertheless, the Taleban's efforts to fight the campaign continue, as do management problems within the national immunization campaign. Some officials have been accused of siphoning money from its programs, or of using expired vaccines, and some vaccination plans have had difficulty targeting vulnerable populations.
One effort to resolve that problem was the introduction in Punjab last year of a smartphone app on which the region's 3,700 vaccinators could keep track of their work. Now, instead of going household to household, they go to a center where children have been assembled for vaccination. The vaccinators then send the data via phone to a central office. Using this approach, vaccinators' attendance rates, which at times had been as low as 21%, have risen to 95% to 100%.
Officials also have analyzed satellite images to target population clusters, and have produced a color-coded map showing where vaccinations have and haven't reached children in need. By now, the rates of vaccination with the two types of antigens have risen beyond 70%, a critical threshold toward the goal of eradication.
Encouraged by those results, the Punjab government and the World Bank plan to invest in 10,000 more vaccinator smartphones, which will also capture a child's photo and the mother's cellphone number, enabling automatic reminders to a mother that a child is due for a vaccine scheduled near home.
The Punjab government is eager to share its technological know-how with the rest of the nation. One target area this year is remote Khyber Pakhtunkhwa. And if Sindh and Baluchistan follow suit, there's every chance that Pakistan can catch up quickly to the rest of the world. A polio-free Pakistan - and globe - may be coming sooner than you think.
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