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Eradicating Polio in Pakistan: a Systematic Review of Programs and Policies eCommons@AKU Woman and Child Health Division of Woman and Child Health 5-10-2021 Eradicating polio in Pakistan: A systematic review of programs and policies Anushka Ataullahjan The Hospital for Sick Children, Toronto, Canada Hanaa Ahsan The Hospital for Sick Children, Toronto, Canada Sajid Bashir Soofi Aga Khan University, [email protected] Atif Habib Aga Khan University, [email protected] Zulfiqar Ahmed Bhutta Aga Khan University, [email protected] Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_wc Part of the Influenza Virus accinesV Commons Recommended Citation Ataullahjan, A., Ahsan, H., Soofi, S., Habib, A., Bhutta, Z. A. (2021). Eradicating polio in Pakistan: A systematic review of programs and policies. Expert Review of Vaccines, 1-18. Available at: https://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_wc/177 Expert Review of Vaccines ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ierv20 Eradicating polio in Pakistan: a systematic review of programs and policies Anushka Ataullahjan, Hanaa Ahsan, Sajid Soofi, Muhammad Atif Habib & Zulfiqar A. Bhutta To cite this article: Anushka Ataullahjan, Hanaa Ahsan, Sajid Soofi, Muhammad Atif Habib & Zulfiqar A. Bhutta (2021): Eradicating polio in Pakistan: a systematic review of programs and policies, Expert Review of Vaccines, DOI: 10.1080/14760584.2021.1915139 To link to this article: https://doi.org/10.1080/14760584.2021.1915139 © 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Published online: 10 May 2021. Submit your article to this journal Article views: 351 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ierv20 EXPERT REVIEW OF VACCINES https://doi.org/10.1080/14760584.2021.1915139 REVIEW Eradicating polio in Pakistan: a systematic review of programs and policies Anushka Ataullahjan a, Hanaa Ahsan a, Sajid Soofi b, Muhammad Atif Habib b and Zulfiqar A. Bhutta a,c aCentre for Global Child Health, The Hospital for Sick Children, Toronto, Canada; bCentre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan; cCentre of Excellence in Women and Child Health, Aga Khan University South-Central Asia, East Africa & United Kingdom ABSTRACT ARTICLE HISTORY Introduction: Established in 1994, Pakistan’s polio program demonstrated early success. However, Received 21 January 2021 despite over 120 supplementary immunization activities in the last decade, polio eradication efforts Accepted 7 April 2021 in Pakistan have been unable to achieve their objective of halting polio transmission. Variable govern­ ance, and inconsistent leadership and accountability have hindered the success of the polio program KEYWORDS Polio eradication; Pakistan; and the quality of the campaigns. Insecurity and terrorism has interrupted polio activities, and com­ polio vaccination; policy munity fears and misbeliefs about polio vaccinations continue to persist. analysis; service delivery Areas covered: The article consists of a systematic review of the barriers and facilitators associated with the delivery of polio eradication activities in Pakistan. We also provide a comprehensive review of the policy and programmatic decisions made by the Pakistan Polio Programme since 1994. Searches were conducted on Embase and Medline databases and 25 gray literature sources. Expert opinion: Polio eradication efforts must be integrated with other preventive health services, particularly immunization services. Addressing the underlying causes of polio refusals including under­ development and social exclusion will help counteract resistance to polio vaccination. Achieving polio eradication will require building health systems that provide comprehensive community-centered care, and improving governance and systems of accountability. 1. Introduction Roughly 20,000 wild poliovirus cases were reported in Pakistan in the early 1990s, however the polio program has The Global Polio Eradication Initiative (GPEI) was launched in reduced this by up to 99% [2]. Today, Pakistan continues 1988, with the goal of eradication and containment of all wild, to be affected by wild poliovirus type 1 (WPV1) and circu­ vaccine-related and Sabin polioviruses worldwide [1]. Polio eradication efforts began in Pakistan in 1994, through the lating vaccine-derived poliovirus type 2 (cVDPV2) [7]. launch of the Pakistan Polio Eradication Programme [2]. The A record low of eight cases was reported in 2017; however, Pakistan Polio Eradication Programme is a public–private part­ this was followed by an increase in subsequent years, with nership led by the federal government, and supported by GPEI 12 cases in 2018, 147 cases in 2019, and 84 cases in 2020 partners including WHO, UNICEF, BMFG, and CDC [3]. Despite (Figure 1). Polio transmission is highly active in certain core national efforts to eradicate polio, the transmission of wild reservoir districts, including Karachi, Peshawar, and the poliovirus is ongoing in Pakistan [4]. Quetta block. Polio cases have also been identified in Presently, Pakistan and Afghanistan are the only coun­ northern Sindh and Southern Punjab [4,8]. A large propor­ tries where the transmission of endemic wild poliovirus has tion of cases are among Pashto-speaking populations [9]. never stopped [5]. Given global interest in eradicating The polio program’s success is highly dependent on vacci­ polio, polio eradication initiatives have been funded nating high-risk mobile populations (HRMP) and internally through a diverse range of donors made up of national displaced persons (IDP), who often have inconsistent governments, private organizations/non-governmental access to the health system [10]. The polio program imple­ donors, and multisectoral partnerships. Since 1985, more ments numerous vaccination campaigns every year than US$ 17 billion has been donated to support the GPEI. wherein roughly 260,000 health workers go door-to–door Between 1985 and 2019, the Government of Pakistan con­ to ensure every child under five years of age is vaccinated tributed roughly US$387 million and US$121 million to the against polio [2]. During vaccination campaigns, special GPEI through loans provided by the Islamic Development attention is given to the core reservoir districts [4]. Bank and Japan International Cooperation Agency, respec­ Despite efforts by the Pakistani polio program, vaccina­ tively, and roughly US$ 58 million through assistance from tion bans, rumors, and conspiracy theories that polio eradi­ other national governments [6]. cation is enabling foreign bodies to destabilize the country CONTACT Zulfiqar A. Bhutta [email protected] Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada © 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 A. ATAULLAHJAN ET AL. polio program were redirected in the fight against COVID-19, Article highlights highlighting the strength of the program’s infrastructure [18,19]. This strategy has unintentionally increased the sus­ ● Polio eradication requires the intervention of multiple stakeholders at different levels of the health system ceptibility of already vulnerable children to vaccine- ● Variable governance and inconsistent leadership have compromised preventable diseases (VPD) such as polio [18]. Although the the functioning of polio eradication activities government’s response to COVID-19 has been lauded, it begs ● The morale of polio workers is low due to inconsistent pay, limited opportunities for promotion, and consistent threats of insecurity the question why has polio not had received the same ● Improved field monitoring during polio campaigns and through polio political commitment [19]. surveillance systems are needed Understanding the barriers and facilitators to service delivery, ● Misbeliefs and misperceptions about polio vaccination among com­ munity members continue to persist and the operational factors that influence functioning of the ● Integration of polio activities with other preventive health services polio program is essential to its success. This systematic review especially child health, nutrition and routine immunizations may will present the following: i) a timeline highlighting distinct address community resistance and increase program reach ● Terrorism and insecurity are still a consistent concern for the polio polio–related policies, programs, and activities implemented in program through blocking access to certain geographies and result­ Pakistan since 1994, and ii) barriers and facilitators associated ing in attacks on polio workers with the delivery of polio eradication activities in Pakistan. 2. Methods continue to be a barrier to polio eradication [11–13]. Access to children in security-compromised areas, and attacks on 2.1. Search strategy healthcare workers have created an insecure environment A systematic search of indexed peer-reviewed literature pub­ where the safety of both the providers and recipients has lished between 1 January 2000 to 30 July 2020 was conducted been jeopardized [14]. In addition to these demand-related in Embase and Medline databases
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