Progress in Access and Oral Polio Vaccine Coverage Among Children Aged <5 Years in Polio Campaigns After the Political Change in Afghanistan

"This study reports significant progress in access to every child, in polio surveillance, and in overall OPV coverage in Afghanistan required for the final push to global polio eradication. It also identifies shortcomings in the implementation of the polio campaigns that should be promptly addressed..."



Warfare has long impeded routine immunisation coverage and the implementation of polio campaigns in polio-endemic Afghanistan. More specifically, armed conflict has resulted in the underimmunisation of the population in certain areas and children's inaccessibility during polio vaccination campaigns. These factors, together with the suboptimal quality of the polio campaigns in accessible areas and insufficient routine immunisation programmes, resulted in a continuous immunity gap against polio. This study describes progress in access to children under 5, oral polio vaccine (OPV) coverage among children under 5 in nationwide polio campaigns, and polio surveillance performance indicators after the Islamic Republic of Afghanistan collapsed to Taliban forces in August 2021.



The researchers obtained data on national immunisation days (countrywide polio campaigns) for the years 2020 to 2022 from the National Emergency Operations Center, Ministry of Public Health (MoPH), Afghanistan. Data on acute flaccid paralysis (AFP), wild poliovirus type 1 (WPV1), and circulating vaccine-derived poliovirus type 2 (cVDPV2). They obtained case numbers and polio surveillance performance indicators for the years 2015 to 2023 from the World Health Organization (WHO)'s Eastern Mediterranean Regional Office and Global Polio Eradication Initiative (GPEI) websites.



From 2015 to mid-July 2020, 74 of 126 (58.7%) WPV1 cases were reported from inaccessible areas. In November 2020, 34.1% of children under 5 were inaccessible; in November 2021 (the first postchange polio campaign conducted by the Taliban), all were accessible. From November 2020, under-5 OPV coverage of 69.9% rose steadily to 99.9% in the May 2022 campaign. The number of cVDPV cases fell from 308 (2020) to zero (2022). Recorded missed children shrank from 146,846 (2.4%) in November 2020 and 140,140 (2.4%) in January 2021 to 131,202 (1.8%) in June 2022. Under-5s' OPV refusals in house-to-house campaign areas also declined from 58,418 (0.9%) in November 2020 and 57,530 (1.0%) in January 2021 to 36,136 (0.5%) in May 2022 and 40,140 (0.6%) in June 2022. June 2022's house-to-house OPV coverage was 34.2% higher than non–house-to-house modalities. Nonpolio AFP and stool adequacy rates rose from 18.5/100,000 and 92.6% in 2020 to 24.3/100,000 and 94.4% in 2022, respectively.



In reflecting on the findings, the researchers note that, pre-2021, the Taliban leadership was not categorically opposed to polio vaccination. However, they modified campaign modalities in some areas to thwart the government's and government allies' intelligence gathering in areas under Taliban control, or to challenge the government's governance. The inaccessibility issue was resolved after the Taliban took control of the entire country.



Ranking after inaccessibility, OPV refusal is also a serious challenge to WPV1 eradication in Afghanistan, similar to several former polio-endemic countries' experiences. Parents/caregivers might refuse OPV administration to their children due to reasons including: religious grounds (e.g., belief that the vaccine contains haram [forbidden] ingredients such as pork, which a Muslim is not allowed to consume), campaign fatigue (frustration with multiple door knockings), shortages of other essential health and development services in high-risk areas, deployment of nonlocal staff, young male volunteers' presence, or shortage of female vaccinators/social mobilisers. The reduced rate of refusals may be due to the success of strategies adopted in 2020 and 2021 focusing on community engagement interventions across the country: women's inclusion in vaccination teams, use of mass and social media, and support from the Ministry of Haj and Auqaf (religious affairs), the Ministry of Education, and other ministries.



Looking forward, the researchers note that the house-to-house visit is considered the "gold standard and most accepted method of polio campaign implementation in low- and/or middle-income countries." But there are challenges in Afghanistan that lead some to suggest banning house-to-house visits in some parts of the country. First, some policymakers think that when very essential and needed healthcare services are lacking, going house-to-house does not help the new government to "look good". Second, some think that the mosque-to-mosque approach is popular and effective and that it claims high coverage. Third, some think that security incidents (casualties) may harm the new authorities' reputation in improving and maintaining peace and security. In addition, cross-border population movements and their settlement in polio-free areas of Afghanistan complicate the house-to-house approach. As suggested here, advocacy efforts should be intensified to persuade Taliban representatives to continue to allow house-to-house visits throughout Afghanistan. The successes shown in this study "must not be jeopardized by possible international sanctions on the new regime."



More broadly, as argued here, the GPEI needs to:

• Benefit from the improved security situation, maintain the momentum by conducting quality SIAs, and intensify advocacy for house-to-house polio campaigns.
• Meet the basic healthcare needs of this high-risk population and maintain and strengthen the healthcare system of Afghanistan.

In conclusion, this study finds that inaccessibility is no longer a challenge for polio eradication at this time in Afghanistan, and improved the AFP and environmental surveillance systems are less likely to miss any poliovirus circulation. However: "Polio communication interventions must intensify the polio campaign's efforts to promote and maintain vaccine acceptance and further convert refusals to acceptance by delivering other services addressing communities' essential needs. Allocation of further resources in this area may expedite the interruption of WPV transmission in Afghanistan."