Tropical Health Matters

According to MinahHAli, polio is still with us as seen in this posting about polio challenges in the class blog of the course, Social and Behavioral Foundations of Primary Health Care at the Johns Hopkins Bloomberg School of Public Health

Image Source: UNHCR

After a much-desired decrease of polio cases in Pakistan, the recent increase in cases reported has been alarming. This latest surge coincided with the Afghan Refugee Crisis in Pakistan, showcasing the impact of government policies in the success of polio eradication.

What is Polio? Polio, also known as poliomyelitis, is a viral disease which affects nerves in the spinal cord or brain stem leading to paralysis and death in some cases. Poliovirus rapidly spreads either via feces or droplets from coughing/sneezing. Polio mainly affects unvaccinated children.

Why are Polio vaccination initiatives focused on Pakistan and Afghanistan? Are all polio cases the same? Pakistan and Afghanistan are the last two countries in the world which consistently report polio cases. Despite spending $9.3 billion over the course of 10 years (2013-2023) polio cases remain present in Pakistan.  According to WHO, Polio cases in Afghanistan can be traced back to one variant: YB3A. However, recently polio cases in Pakistan are now also from YB3A variant.

Image Source: CNN

What is the Afghan Refugee Crisis and how is it fueling the spread of polio? Pakistan is the largest host country for Afghan refugees since 1979 post-Soviet invasion. In 2019, Ministry of National Health Services, Regulation and Coordination in Pakistan, along with UNHCR, promised healthcare which included polio vaccination to Afghan refugees. However, due to increased security threats recently near the Pak-Afghan border these efforts have stopped.

Due to attacks on Pakistani soil which have been linked to Afghan terrorist groups, the Federal Government of Pakistan is currently forcibly relocated Afghan refugees back to Afghanistan. Due to this, many Afghans refugees refuse to seek healthcare in the fear of being reported and deported.

Why are the polio eradication programs failing? The political climate in Pakistan, especially in the Khyber Pakhtunkhwa province which borders Afghanistan, is tense; heightened insecurity, fueled with tribal conflicts amongst Pakistanis and Afghanis residing in the area is making polio vaccination programs “almost impossible”, according to polio eradication lead at Bill and Melinda Gates foundation.

By neglecting the on-going polio spread amongst Afghan refugees, Poliovirus is making its way into Pakistani citizens/communities.  It is imperative that the Ministry of National Health Services, Regulation and Coordination, as well as the provincial Khyber Pakhtunkhwa Government increase their efforts for polio vaccination- regardless of immigration status.

On August 20, 2024, Yasir Ahmed Posted this blog about polio challenges in the class blog of the course, Social and Behavioral Foundations of Primary Health Care at the Johns Hopkins Bloomberg School of Public Health

Pakistan and Afghanistan are the only countries in the world reporting wild type polio virus cases. Polio is a crippling disease that does not have any cure but it is preventable through immunization. The detection of wild-type virus in wastewater suggests 2024 target of ending all wild virus transmission will be missed. 6 cases were reported in 2023 and 14 have been reported this year so far.  According to a report by IMB, an estimated 300,000 children have been consistently missed in vaccination activities in Pakistan and in the East region of Afghanistan. Disinformation, false beliefs and mistrust on the government and administration, refusal, not understanding the importance of vaccines, and low general literacy and health literacy etc. are among the important factors contributing to these missed opportunities.

In addition to the above-mentioned factors, insecurity, movement across the porous 2400 kilometers long Pakistan-Afghan border, and poor water and sanitation and waste management are the contributing factors. I believe that the missed opportunities to reach and vaccinate these children has a major role in the spread of poliovirus along with poor water and sanitation in these areas.

The program uses four distinct risk tiers to classify areas according to the risk they present and to devise risk appropriate strategies. Core reservoir districts (or Tier 1 districts), high-risk districts (or Tier 2 districts), vulnerable districts (or Tier 3 districts), and low-risk districts (or Tier 4 districts). Most of the tier 1 and tier 2 areas are located on the western border aka Pakistan-Afghan border (upper parts on the map).

Pakistan Polio Eradication Program is an initiative that is driven by the largest surveillance network in the world (up to 339,521 trained and dedicated polio workers), quality data collection and analysis, behavioral change communication, laboratories, and epidemiologists and public health experts in Pakistan, working with experts and local and international stakeholders. The government started National Emergency Action Plan for Polio Eradication in 2010, which runs supplemental immunization activities on regular basis to reach every child in Pakistan. As a result, a huge decline in the number of polio cases is seen since the 90’s. The World Health Organization (WHO) and UNICEF along with other key partners of the Global Polio Eradication Initiative, has been a very supportive to the Government of Pakistan in polio eradication. Gavi the vaccine alliance, the Center of Disease Control (CDC), Rotary International, and Bill and Melinda Gates Foundation are important stakeholders that provides major financial, technical and field support.

A Polio-worker is pictured giving an oral polio vaccine during an immunization campaign.

Innovative approaches are required to reach the children missing vaccinations including:

• Expanding the network and improving data collection and surveillance, targeting the areas of high density with polio cases e.g., the tribal areas along the porous Pak-Afghan border.
• Mandatory vaccination at border crossing.
• Increased security for the polio workers.
• Taking local religious and community leaders and scholars on-board to counter disinformation and false beliefs.
• Continuation and strengthening of National Emergency Action Plan for Polio Eradication by the government of Pakistan.

Continued efforts and support from the local and international stakeholders as we are getting very close global polio eradication.

A May 28^th press release from the World Health Organization states that, “Togo eliminates trachoma as a public health problem.” The article explains that …

“Validation of trachoma elimination as a public health problem in Togo was based on evidence. Several population-based trachoma surveys were conducted starting from 2006 to 2017. The 2017 survey using WHO recommended methodology found that the prevalence of key indicators was below the WHO trachoma elimination threshold. There was also evidence that Togo’s health system is able to identify and treat new cases of late complications of trachoma.”

This raises the question, is Trachoma gone from Togo or does trachoma continue to exist at some low level whereby, as WHO notes, Togo has joined, “12 other countries that have been validated by WHO for having eliminated trachoma as a public health problem.”

This description of disease elimination contrasts sharply with the global concerns when “health authorities in Malawi have declared an outbreak of wild poliovirus type 1 after a case was detected in a young child in the capital Lilongwe. This is the first case of wild poliovirus in Africa in more than five years.” Wild polio virus had been declared eliminated in Africa, and just one case in one country grabs international attention.

Would one case of trachoma tomorrow receive the same concern in Togo? Apparently not according to the WHO definition, “Elimination of trachoma as a public health problem is defined as: (i) a prevalence of trachomatous trichiasis (TT) “unknown to the health system” of < 1 case per 1000 total population; and (ii) a prevalence of trachomatous inflammation-follicular (TF) in children aged 1–9 years of < 5%, in each formerly endemic district.”

So, while no cases of smallpox, guinea worm or polio would be tolerated after elimination has been declared, parents of a child who develops trachoma in Togo tomorrow would be told that your child’s case is only 1 in a 1000 and not of concern to public health. The caveat is though that “the health system (must be) able to identify and manage incident TT cases.” Presumably, if such management capacity does not exist, the disease in question could spread and elimination would be eliminated.

Another Neglected Tropical Disease, Lymphatic Filariasis, faces the same challenge in terms of elimination status. WHO explained in its guidance that, “In 1997, the 50th World Health Assembly resolved to eliminate LF as a public-health problem (resolution WHA50.29). In response, WHO proposed a comprehensive strategy for achieving the elimination goal that included interrupting transmission in endemic communities and implementing interventions to prevent and manage LF-associated disabilities The LF guidance stresses “Effective monitoring, epidemiological assessment and evaluation are necessary to achieve the aim of interrupting LF transmission,” or in a word Surveillance. There is clear concern for “absence of transmission” and worries about “recrudescence.”

While polio has a vaccine and guinea worm relies on providing safe community water, LF and Trachoma elimination depends on mass drug administration (MDA) at planned intervals until such time as transmission is reduced. All require a strong health system to implement, but the challenges of maintaining MDAs until such time as elimination has been validated is somewhat more challenging. In this context the communication is extremely important. Just because WHO validates the elimination of a disease as a public health problem, does not give policy makers license to ignore that disease. Advocacy is continually needed such that even after apparent elimination, neglected diseases will not be forgotten and health systems themselves not neglected.

As part of the course on Social and Behavioral Foundations in Primary Health Care, Muhammad N Asghar posted in the class blog. We have shared these thoughts below.

Pakistan is one of the three polio endemic countries and recent surge in cases shows that eradication of the disease demands an urgent change in strategy. A look at previous five year cases in Pakistan shows a positive progress in reduction of new polio cases; from 307(2014) to 12(2018), but new cases still appeared in almost every province. The reasons behind this country wide presence of disease can be attributed to internal displacement due to conflicts, weak health systems and operational and resource risks. But the alarming increase in number of new polio cases during 2019 has reversed the whole progress made so far as the number of new cases as of today stands at 53. 32 out of 53 cases are reported from KPK region, which had observed massive internal displacement during last decade but the number of IDPs has decreased from last two years due to stability in the region.

This recent surge in polio cases in the the province is mainly due to increase in vaccine refusals due to rumors regarding side effects caused by the vaccine on social media. Official sources reported that after rumors refusals to vaccinate increased by 85% in the province. But high number of cases in other provinces when compared with last year cases indicate that multiple factors are hindering the progress towards containment and eradication of the polio virus disease from the country, which can be attributed to homelessness and poor sanitation, operational issues for vaccine delivery, conflicts, cross border movement etc.

This situation demands urgent review of existing strategy for polio eradication as number of new cases are increasing rapidly. There is a need to work on multiple aspects to make the anti-polio drive successful; some key aspects include detailed geo-mapping of the population at basic level and identification of missed areas to ensure every child is vaccinated, involving community and religious leaders, NGOs, CSOs for confidence building and education of the community, expansion of partnership with nutrition, hygiene, water sectors, and robust rebuttal of rumors and strict action against those involved in such heinous activities etc. There is a new political government of helm, which is sensitive to the social sector issues and taking measures to provide homes, health facilities and education to the disadvantaged sections. International agencies (GPEI, WHO) shall coordinate with the political government to review the existing strategy for revamping it, so that not only the current surge can be contained but the disease can be eradicated from the country to achieve the target of polio free world.