Eradicating Polio in Pakistan: A Systematic Review of Programs and Policies

"[I]t is essential that one considers the web of factors that have thwarted Pakistan's polio eradication efforts....Situating...resistance to polio vaccination within its larger backdrop is essential to understanding and shifting beliefs."

Established in 1994, the Pakistan Polio Eradication Programme has made efforts to halt polio transmission, including yearly campaigns wherein roughly 260,000 health workers go door to door to ensure every child under five years of age is vaccinated against polio. However, Pakistan continues to be affected by wild poliovirus type 1 (WPV1) and circulating vaccine-derived poliovirus type 2 (cVDPV2). This systematic literature review presents: (i) a timeline highlighting distinct polio-related policies, programmes, and activities implemented in Pakistan since 1994, and (ii) barriers and facilitators associated with polio eradication activities in Pakistan.

The researchers conducted a systematic search of indexed peer-reviewed literature published between January 1 2000 and July 30 2020 in Embase and Medline databases. For the gray literature search, they searched the websites of 25 stakeholders that are involved in delivering polio eradication or public health activities across Pakistan.

Selected elements of Pakistan's polio journey:

• 1994-2001: Early days of polio eradication - The start of the war after the September 11 2001 attacks against the United States (US) increased insecurity and conflict in Afghanistan and bordering regions of Pakistan. Drone strikes began in the newly merged districts of Khyber Pakhtunkhwa (known at that time as the Federally Administered Tribal Area - FATA), which intensified the belief that vaccination programmes had an underlying ulterior motive.
• 2003-2006: First partnership for polio eradication - In October 2005, the Kashmir Earthquake struck; this environmental disaster impacted the delivery of polio vaccination campaigns in affected regions.
• 2006-2008: Second partnership for polio eradication - In 2008, finger–marking was introduced in to polio campaigns to objectively measure the quality and reach of campaigns.
• 2009-2012: Third partnership for polio eradication - Osama Bin Laden was located through a fake hepatitis vaccine programme conducted by the American Central Intelligence Agency (CIA), in collaboration with a local Pakistani physician. This incident deepened community mistrust toward vaccine programmes, including polio vaccination programmes, and, for many, confirmed their belief that polio eradication campaigns were a ploy by the CIA. In July 2012, in North and South Waziristan in FATA, local leaders issued a complete ban on immunisation campaigns that continued into 2013. In response to increasing case rates and brewing vaccine hesitancy, 2012 saw the establishment of various new initiatives. For one thing, the President of Pakistan declared polio eradication a national emergency.
• 2013-present: yearly national emergency action plans (NEAPs) - In 2013, in response to growing religious opposition to polio vaccination, the polio communication strategy began to emphasise polio vaccination as an Islamic responsibility. In response to misconceptions about vaccines being incompatible with the Islamic Shariah Law, the Islamic Advisory Group (IAG) adopted a new anti-polio action plan that incorporated advocacy and communication activities in 2015. In 2019, with only two polio endemic countries remaining (Pakistan and Afghanistan), the Global Polio Eradication Initiative (GPEI) launched the Polio Endgame Strategy 2019-2023.

Summary of barriers and facilitators to the delivery and uptake of polio vaccination in Pakistan:

• Caregiver beliefs, knowledge, and experiences:
  • Several articles cited misbeliefs and misperceptions about polio vaccination as a barrier to increasing vaccination rates. The beliefs were of two different types; demographic, geopolitical, and religious concerns on the one hand, and misbeliefs about when a child could be vaccinated, on the other. The former, which are more commonly cited, were often characterised in the literature as rumours about polio vaccination. Demographic concerns were focused on the potential fertility impacts of the polio vaccine on increasing sterility; geopolitical anxieties concerned the true motive underlying the vaccination campaign, which at their heart revealed suspicions about the desire to shrink the Muslim population as part of a foreign agenda; and questions about the religious permissibility of the polio vaccine were related to the belief that haram (impermissible) ingredients such as pig byproducts were used in the polio vaccine. Analysis of polio resistance among Pakhtuns has illustrated that misperceptions and belief in rumours mirror larger political debates in Pakistan.
  • Several studies highlighted limited knowledge of immunisation schedules and the need for multiple polio vaccinations as leading to incomplete polio vaccination. The type of information caregivers received - and the source - was also cited as an essential factor to polio vaccination. The literature describes the development of tailored messages specific to the needs of the local community as an important strategy to encourage polio vaccination. However, exposure to messaging about the benefits of polio vaccination is not sufficient, as several studies discussed the issue of community members' mistrust of the messaging. Furthermore, repeated polio campaigns contributed to community fatigue and fostered vaccine hesitancy. Frustrations with the lack of essential services such as poor water and sanitation also fostered mistrust in the Pakistani government and in some cases led to polio vaccine refusal.
• Polio programme: governance and oversight:
  • Staff morale and job satisfaction was highlighted as an issue in polio eradication efforts. Attacks on healthcare workers and increased insecurity exacerbated their dissatisfaction with their job. The hiring of locals as healthcare workers has proven to be a successful strategy, as it allows the leveraging of local knowledge; however, nepotism often played a role. Concerns related to the training of vaccinators have also been raised by caregivers and community members. Pre-campaign trainings have been critiqued for being ineffective and having low engagement from staff.
  • Government ownership of polio eradication through providing sustained oversight to activities and establishing strong partnerships with donors and experts has been deemed an important aspect of polio eradication activities. However, coordination between different levels of government is limited and inconsistent. Moreover, there is still a pressing need for engagement with other preventive health programmes, supportive government agencies, and the private sector. Issues related to access - e.g., constraints to caregivers' time and schedules, distance from a health facility - also acted as a barrier to vaccinating children.
• Pakistani context: climate and insecurity threats - Pakistan faces significant challenges related to environmental factors and insecurity. Improvements in the security situation in Shangla and Swat, and the subsequent increase of polio vaccination there, demonstrate the role of insecurity in polio vaccination rate.

More recently, inconsistent leadership has only worsened after the 2018 elections. Despite assurance that Senator Ayesha Raza Farooq, the Prime Minister's Focal Person for Polio Eradication, would continue in her position, she resigned after the election. The subsequent appointee, Babar Bin Atta, has since resigned and been accused of corruption.

Furthermore, in April 2020, polio vaccination campaigns and routine immunisation programmes across Pakistan were halted to mitigate the spread of COVID-19. Staff and resources from the polio program were redirected in the fight against COVID-19, which unintentionally increased the susceptibility of already vulnerable children to vaccine-preventable diseases (VPD) such as polio. "Although the government's response to COVID-19 has been lauded, it begs the question why has polio not had received the same political commitment."

The researchers assert that polio eradication efforts must be integrated with other preventive health services, particularly immunisation services. Addressing the underlying causes of polio refusals, including underdevelopment and social exclusion, can help counteract resistance to polio vaccination. "Such a strategy will be essential to engaging communities that are marginalized and disenfranchised....Moreover, the integration of polio activities within other preventive health services may present an opportunity for the generation of trust..."

Trust building is one of the themes the research highlight in their outline of research gaps and opportunities. They note that, despite mistrust of polio eradication efforts being cited in the literature for over a decade, there is limited research on how this trust can be cultivated by the polio programme. Further research on how to develop trust between communities and government agencies could have important impacts on polio activities, they argue. There is also the opportunity to interrogate efforts to engage religious leaders to encourage polio vaccination, which have not been able to entirely convince the public. "Literature on Islam and health practices has demonstrated that religious beliefs are consistently negotiated and contested....The question remains how then can that be leveraged to address vaccine hesitancy in Pakistan."

They also note that the literature has primarily focused on the beliefs and knowledge of caregivers; literature focusing on the perspectives of programme workers, partner organisations, and government representatives is limited. Thus, there is a key gap in our understanding of how to improve coordination and collaboration. Focused in-depth research in this area could generate key recommendations for policymakers.

In conclusion: "Pakistan has the potential to make large gains toward polio eradication in the next five years; however, this will require consistent leadership and political support of the program."