The time is ripe for Pakistan to eradicate polio from within its confines. It is an opportunity that should not be wasted
POLIO is a crippling disease, especially in children in whom it can be the source of lifelong paralysis. The poliovirus is highly contagious, and in places where vaccination rates are low, it can spread easily from child to child.
Eradication of this disease has been a global priority since 1988, when the World Health Assembly resolved to eradicate polio by the year 2000. A lot of progress has taken place since and there has been a 99 per cent decline in polio cases. The number of polio infected countries too has dropped from 125 in 1988 to just seven in 2002. Of these, Pakistan, India and Nigeria have the most number of cases. In fact, it is highly likely that by the end of 2003, these three will be the only remaining countries in the world with the polio virus. However, it will be highly embarrassing for these three if they are unable to achieve the eradication of polio by 2005, the revised target date for achieving the global goal.
Pakistan joined the global commitment of completely wiping out polio with the launching of the first National Immunization Days (NIDs) in 1994. Around the same time the foundations were laid for a surveillance system to detect polio cases and circulation of poliovirus. Since then, substantial progress towards polio eradication has occurred in Pakistan, especially following intensive eradication efforts in 2000. Compared with thousands of cases reported annually, right upto the late 1990s, only 90 cases of polio were reported in 2002 through a very sensitive surveillance system.
Moreover, the geographic extent of virus circulation has also been restricted significantly, resulting in only 33 of 126 districts reporting cases during 2002. The active zones of transmission in 2002 were northern Sindh, Quetta and its adjacent border districts in Balochistan, greater Peshawar Valley and Southern NWFP, and Southern Punjab.
Although the two annual rounds of NIDs conducted from 1994 through 1998, using fixed site vaccination, led to the reduction of polio cases, these campaigns were clearly insufficient to terminate virus circulation due to three main reasons:
* A significant proportion of children were not being reached by the fixedpost strategy.
* The national average coverage rate with routine vaccination of infants with polio vaccine was low with wide variations in provincial and district coverage rates; and
* Rapid accumulation of unvaccinated infants in the period between annual NIDs.
Beginning in late 1999, the eradication effort was therefore intensified by first changing from a fixed site to a predominantly house-to-house vaccine delivery strategy to reach every child. At the same time, the frequency of NIDs and Sub-National Vaccination Campaigns (SNIDs) was increased and better planning, training and monitoring was made available in order to improve the quality of mass campaigns.
Of note, Sindh took the lead in conducting the first province-wide house-to-house vaccination campaign in Pakistan.
While impressive progress has continued well into 2003, the quality of immunization campaigns has remained sub-optimal in a few districts within the active virus transmission zones of 2002, particularly in Sindh and NWFP. A total of 50 polio cases have been reported to date, from 23 districts, from all over Pakistan. Of these, half the cases have occurred in Sindh. This number is higher than what was seen last year at this time.
In other words, after achieving so much in recent years, Pakistan, and particularly Sindh, may be facing a setback in its progress towards completing eradication of this crippling disease.
Is the persistence of polio in Sindh due to failure of the eradication strategy or does it represent a failure to implement the strategy?
This is the key question that requires careful consideration by the Government of Sindh and its partners at this critical stage. The strategies used in Sindh have been applied successfully in many countries including Bangladesh, China and Nepal in Asia, and Sudan, Congo and Ethopia in Africa. In fact, the same strategies have been quite effective in most districts of Pakistan, including those in Sindh.
Close review of both qualitative and quantitative campaign monitoring data indicates that persistence of polio in districts of northern Sindh in early 2003, and the recent resurgence of cases in Thatta, are due to poor campaign performance, resulting in many children being missed during NIDs and SNIDs vaccination rounds. While there is always room to fine-tune a campaign through better micro-planning and training, and more effective supervision, districts with poor performance are consistently characterized by lack of commitment, weak leadership and sub-optimal campaign management by local authorities.
Conversely, program ownership, accountability for performance and strong management within the district have been the most important indicators of program success in districts that no longer harbour poliovirus.
From the start of the polio eradication initiative, there has been a high level of commitment from the Government and political leaders of Pakistan. Additionally, the support provided by international agencies like Who, Unicef, Rotary International Centres for Disease Control and Prevention (CDC), Government of Japan, DFID, USAid, etc. has made it possible for Pakistan to achieve the success that it has to date.
Although the commitment of federal and provincial governments has also intensified during the last 18-24 months, this has translated variably into effective involvement of district leadership and management. Pakistan and the world have never been more closer to the goal of eradicating polio, as they are today. Considering the unprecedented support of global partners, the strong international will and the success to date, failure to eradicate polio in Pakistan, especially due to performance gaps in Sindh, would be a tremendous loss of opportunity and an enormous embarrassment for the province and the country.
Eradication of polio in essence is a national movement and is therefore a collective responsibility of every all citizens, government departments, political leaders and the elected Nazims of all tiers. Despite the political, infrastructural and logistical challenges, further strained by a longstanding drought and recent floods in Sindh, I have full confidence that the district leadership and management teams in the province will accept this challenge with valor.
I am convinced that strong engagement of Executive District Officers (Health) and effective mobilization of District Nazims and District Coordination Officers, within the districts will be a key to achieving the target.
From now on I also intend to personally monitor the progress towards polio eradication in Sindh and ensure full support and cooperation from the Government of Sindh in general and the office of the Governor in particular.
The goal of polio eradication has challenged our ability to serve our citizens and protect our children from preventable diseases. The lessons learned, the capacity built and the skills acquired during the course of polio eradication should form a basis on which the province should strengthen its routine childhood immunization program (EPI).
These are exciting times for the control of vaccine-preventable diseases in children and the Government of Pakistan has acquired the necessary technical and funding support to broaden and strengthen its routine EPI as can be seen by the recent introduction of Hepatitis B vaccination in the routine immunization schedule. With unprecedented international, technical and funding support, and government resources and national commitment currently available, opportunities to reduce childhood mortality and morbidity abound, only if we commit ourselves to manage these resources appropriately. Achieving high immunization coverage of infants will be an important objective yardstick by which our citizens and partners will measure our ability to protect and serve our people. We must hold ourselves accountable for meeting these targets.
The time is ripe for Pakistan to eradicate polio from within its confines. It is an opportunity that should not be wasted 
