a report of the csis global health policy center Eradicating Polio in Afghanistan and Pakistan 1800 K Street, NW | Washington, DC 20006 Authors Tel: (202) 887-0200 | Fax: (202) 775-3199 April Chang E-mail: [email protected] | Web: www.csis.org Edgar Chavez Sadika Hameed Robert D. Lamb Kathryn Mixon August 2012 CHARTING our future Blank a report of the csis global health policy center Eradicating Polio in Afghanistan and Pakistan Authors April Chang Edgar Chavez Sadika Hameed Robert D. Lamb Kathryn Mixon August 2012 CHARTING our future About CSIS—50th Anniversary Year For 50 years, the Center for Strategic and International Studies (CSIS) has developed practical solutions to the world’s greatest challenges. As we celebrate this milestone, CSIS scholars continue to provide strategic insights and bipartisan policy solutions to help decisionmakers chart a course toward a better world. CSIS is a bipartisan, nonprofit organization headquartered in Washington, D.C. The Center’s more than 200 full-time staff and large network of affiliated scholars conduct research and analysis and develop policy initiatives that look to the future and anticipate change. Since 1962, CSIS has been dedicated to finding ways to sustain American prominence and prosperity as a force for good in the world. After 50 years, CSIS has become one of the world’s preeminent international policy institutions focused on defense and security; regional stability; and transnational challenges ranging from energy and climate to global development and economic integration. Former U.S. senator Sam Nunn has chaired the CSIS Board of Trustees since 1999. John J. Hamre became the Center’s president and chief executive officer in 2000. CSIS was founded by David M. Abshire and Admiral Arleigh Burke. CSIS does not take specific policy positions; accordingly, all views expressed herein should be understood to be solely those of the author(s). Cover photo: A boy is vaccinated against polio with ‘monovalent oral polio vaccine type 1’ (mOPV1) outside Poli Clinic in the Herat Bazaar neighbourhood of the southern city of Kandahar, photo by UNICEF Sverige, http://www.flickr.com/photos/unicefsverige/4415954257/. © 2012 by the Center for Strategic and International Studies. All rights reserved. Center for Strategic and International Studies 1800 K Street, NW, Washington, DC 20006 Tel: (202) 887-0200 Fax: (202) 775-3199 Web: www.csis.org embedd eradicating polio in afghanistan and pakistan April Chang, Edgar Chavez, Sadika Hameed, Robert D. Lamb, and Kathryn Mixon1 Polio has a real possibility of being eradicated worldwide. Efforts to eradicate the virus have proved largely successful, in part thanks to the Global Polio Eradication Initiative (GPEI), launched by the international community in 1988. GPEI is a partnership of governments, private foundations, development banks, humanitarian organizations, nongovernmental organizations, and corporate partners. It is led by the World Health Organization (WHO), Rotary International, the U.S. Centers for Disease Control and Prevention (CDC), and the UN Children’s Fund (UNICEF).2 The number of new cases has dropped in the past decade, even in countries where the virus has never been eradicated. India was removed from the WHO list of polio endemic countries in February 2012; its last reported case was in January 2011. Bangladesh recovered from an outbreak in 2006 and is considered polio free. In 2003, when polio was confined to only six countries, clerics in one of those countries, Nigeria, banned the vaccine, and as a result, the Nigerian strain spread to 16 countries worldwide, including Angola, Chad, and the Democratic Republic of the Congo, which had previously been declared polio free.3 GPEI battled new outbreaks in eight additional African countries in 2011 and successfully interrupted transmission in all of them. Today, there are only three countries in the world where the polio virus remains endemic: Afghanistan, Nigeria, and Pakistan.4 1 April Chang, Edgar Chavez, and Kathryn Mixon are research interns with the CSIS Program on Crisis, Conflict, and Cooperation. Sadika Hameed is a research associate with the CSIS Program on Crisis, Conflict, and Cooperation. Robert D. Lamb is director of the CSIS Program on Crisis, Conflict, and Cooperation. 2 Global Polio Eradication Initiative (GPEI), Financial Resource Requirements 2012–2013: As of 1 May 2012 (Geneva: World Health Organization [WHO], May 2012), http://www.polioeradication.org/Portals/0/ Document/FRR/FRR_ENG.pdf. 3 Jeffry Klugger, “The Taliban Halts Polio Vaccines—and Pakistan’s Kids Will Pay,” Time, June 19, 2012, http://world.time.com/2012/06/19/the-taliban-halts-polio-vaccines-and-pakistans-kids-will-pay/?iid=gs-x- mostpop1. 4 Associated Press, “India Declared Polio-free by World Health Org.,” CBS News, February 27, 2012, http://www.cbsnews.com/8301-202_162-57385542/india-declared-polio-free-by-world-health-org; WHO, “Polio Eradication in Bangladesh,” Newsletter of the Regional Office for South-East Asia of the World Health | 1 Afghanistan and Pakistan share a long, generally uncontrolled border traversing a region that has experienced repeated conflicts for more than three decades. Both countries have weak governments and poor health infrastructure. Significant cross-border activity, including the movement of refugees fleeing conflict, facilitates transmission of the polio virus. Since the launch of GPEI, newly reported cases of polio have declined steeply in both countries, due in part to coordination between the national and local governments and the international community, as well as the occasional engagement of armed insurgents, such as the Taliban. But that progress has reversed in the past few years. Between 2010 and 2011, the number of new cases in Pakistan increased from 144 to 198 and in Afghanistan from 30 to 76.5 The increase in new cases underscores the challenges that remain in both countries. The persistence of conflict in key polio sanctuaries limits the territorial coverage of vaccination teams, generates population displacements (within the two countries and across their borders) that contribute to the spread of the virus, and perpetuates conditions of poverty. Misunderstandings and rumors about the vaccine limit participation and acceptance in some communities. Because of the porous nature of the border, success in either country will depend in part on efforts made in the other. This paper reviews the eradication efforts in Afghanistan and Pakistan, including the challenges that both countries encounter and the strategies that are being used to overcome them. Surveillance of wild poliovirus cases is undertaken in both countries by monitoring children with acute flaccid paralysis (AFP), the main symptom of polio, and collecting stool specimens to be tested for the virus. Surveillance teams also collect social and demographic details about each potential case of polio, the vaccination status of the child, and the number of oral polio vaccine (OPV) doses received by non-polio AFP case patients. Separately, vaccination teams typically go from door to door to administer either a trivalent oral polio vaccination (tOPV) or a bivalent oral polio vaccine (bOPV), both of which contain live but weakened strains of the virus. Conflict and security are the biggest obstacles to monitoring and vaccination, but GPEI and its government partners are adapting programs to reach communities in need. Polio Eradication in Afghanistan Through 2004, reports showed that polio incidence in Afghanistan was in decline (see figure 1). When GPEI reported only 30 new cases in 2010, the program was widely hailed as effective and on the road to complete success. However, GPEI and the Afghan Ministry of Health reported 76 new cases at the end of 2011. The increase alarmed public health officials, who noted that some Organization, http://www.searo.who.int/LinkFiles/Advocacy_Efforts_Polio_Eradication_in_Bangladesh_ Aug07.pdf; Jennifer G. Cooke and Farha Tahir, Polio in Nigeria: The Race to Eradication (Washington, DC: CSIS, February 2012), http://csis.org/files/publication/120210_Cooke_PolioNigeria_Web.pdf. 5 GPEI, “Polio this week,” May 2, 2012, http://www.polioeradication.org/Dataandmonitoring/ Poliothisweek.aspx. 2 | eradicating polio in afghanistan and pakistan new cases were in provinces with no recent history of the disease.6 The recent increase of cases in Afghanistan is linked to the recent increases in Pakistan, and health officials consider the two countries to be part of the same epidemiological area. Figure 1: Reported Cases of Polio in Afghanistan (2000–2011) 7 140 120 100 80 60 40 20 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Several international actors have focused on the eradication effort in Afghanistan. The Afghan government, supported by members of GPEI, has spearheaded the effort to eradicate polio since 2001. One of the largest international donors to the eradication effort in Afghanistan is the government of Canada, which allotted nearly $60 million between 2009 and 2011. The Afghan Ministry of Public Health coordinates with GPEI and other international actors to set vaccination goals and agendas, and then works with teams at the provincial and district level to implement strategies to reach all children under five years of age. While most of Afghanistan remains polio free, the virus has proved most resilient in the southern provinces of Helmand and Kandahar, which are near the border with Pakistan, and in the northern province of Uruzgan. All are sites of persistent conflict, and 80 to 90 percent of confirmed cases over the last three years have come from “high-risk” districts within the southern provinces. Instability and violence in those areas, coupled with limited government oversight and 6 Rod Nordland, “After Years in Decline, Polio Cases in Afghanistan Triple in a Year,” New York Times, January 17, 2012, http://www.nytimes.com/2012/01/18/world/asia/after-years-of-decline-polio-cases-in- afghanistan-rise.html?_r=1. 7 WHO, “Afghanistan reported cases,” October 3, 2011, http://apps.who.int/immunization_monitoring/ en/globalsummary/timeseries/TSincidenceByCountry.cfm?C=AFG.