November Issue 2015
The Last Mile
The expression on his face changed as he spoke on the phone. The visitors sitting in his room could guess that news from the other end was not exactly pleasant for Dr Rafiq Ahmed, District Officer Health (DHO), Rawalpindi. “Our polio team in UC 5, one of our high-risk areas, is facing resistance despite the police escort that we have provided them,” he shared after putting down the receiver.
“We have had very few refusals this year, hardly 300-400, as compared to 5,000 or more a few years ago. This is because this campaign is done after five months in high-risk areas as compared to an average of two in one month,” he said. “Frequent campaigns compromise quality,” he added, supporting a shift of focus to the quality of the campaign instead of quantity.
“It’s a pity that administering life-saving vaccines to children of your country can be such a dangerous job for which you have to risk your life,” says Samia Rasheed, who works as a lady health worker (LHW).
The LHW was referring to the killings of polio workers in the country that has invoked a deep sense of insecurity among these front-line health workers, who faced the brunt of attacks aimed at polio teams protecting children from the disease at the cost of their lives in high-risk polio districts. But the situation may be different now.
Last month, Pakistan introduced the Inactivated Polio Vaccine (IPV), an injection given at 14 weeks that has been included in the country’s routine immunisation (RI) schedule and will be administered to children along with other life-saving vaccines.
Adding IPV to the RI will help protect all populations most effectively against a possible polio re-emergence. It protects children against all three strains of the polio virus, and when used together with the oral polio vaccine (OPV), will further boost the child’s immunity. One dose of IPV is being introduced into the RI schedule at or after 14 weeks of age, said Dr Gilani
Vaccinators and LHWs working in the public health system have been trained in the management and administering of the new vaccine. This training includes teaching the field workers how to interact with parents, and address their concerns regarding the addition of an injection while the oral drops continue to be administered to their children.
Despite major challenges and remaining hurdles in some provinces, Pakistan is getting closer to polio eradication. There were 28 cases of polio in the first six months of this year compared to 94 in the same period, which means a 70% reduction in the cases.
Pakistan and Afghanistan are the last two countries where polio remains endemic. Even Nigeria has been given a clean chit. However, Nigeria introduced the vaccine earlier this year and Afghanistan is due to begin using IPV in the coming weeks. The introduction of IPV in all countries is seen as a critical step on the path to eradicating the disease.
The introduction of IPV will be one of the fastest rollouts in history. Out of 126 countries using only OPV, Pakistan is among the first 30 countries that have now introduced IPV and, according to an estimate, every year more than six million children will benefit from its introduction.
Previously, OPV had been used by Pakistan as part of the global polio eradication efforts. New evidence clearly demonstrates that just giving one dose of IPV as opposed to multiple doses of OPV is more effective, says Dr Kamal Fahmy, who works at the Eastern Mediterranean Region office of the World Health Organisation.
“IPV and OPV evoke different immune responses and when used together, maximise immunity to the polio virus. In areas of known polio virus transmission, IPV, in addition to OPV ,will provide the greatest possible protection against polio virus. Following immunisation with IPV, it is essential that parents continue to immunise their children with OPV every time it is offered, until polio is eradicated globally,” adds Dr Fahmy.
The international community has pumped millions into Pakistan’s polio programme. The Polio Eradication and Endgame Strategic Plan was developed to provide countries with a roadmap to help navigate this challenge. The plan calls on countries to make three important changes to their immunisation efforts: 1) to introduce one dose of IPV into RI schedules 2) to strengthen RI and 3) to eventually withdraw OPV.
Pakistan has the largest birth cohort (4.6 million) of all countries in the WHO Eastern Mediterranean region. Despite a slow decline in the past 10 years, the under-five mortality in Pakistan is still very high and immunisation coverage considerably low. The last Pakistan Demographic and Health Survey (PDHS 2012-13) demonstrates that only half of the children are fully immunised in Pakistan. The number varies considerably across geographic, social and cultural boundaries and there are marked variations in immunisation coverage across provinces and districts, and gender, which is alarming. For instance, the 2012-13 PDHS shows that the proportion of fully immunised children in Sindh and Balochistan has dropped since 2006-07, from 37 to 29 per cent and 35 to 16 per cent, respectively. It is startling to see that around one-fifth of infants and children in rural Balochistan did not receive any vaccination (PDHS 2012-13). However, Khyber Pakhtunkhwa and Punjab have shown slow but steady progress.
On the ground, vaccinators and LHWs working in the public health system have been trained to manage and administer the new vaccine and LHW Rasheed is “very positive” that after nearly 30 years of polio eradication efforts, “we can say the end is in sight.” In 1988, the year the World Health Assembly resolved to eradicate polio, there were an estimated 350,000 polio cases globally. Last year, there were only 359.
Every year, approximately three million children do not receive the full course of the most basic vaccines and immunisation coverage rates vary dramatically across Pakistan’s districts, provinces and regions.
The main risks pertaining to the introduction of IPV, as foreseen by Rasheed, is limited acceptance for giving three injections to a child in one visit, and not refusal as such. The DHO agrees that “the last mile” will be the hardest.
This article was originally published in Newsline’s November 2015 issue.