As World Polio Day is celebrated across the globe, Pakistan remains one of only two countries on the World Health Organisation's (WHO) list of polio-endemic countries.
Although the number of polio cases in Pakistan during 2015 is reported to be 38 till October ─ down from 224 during the previous year according to the polio control cell ─ the country has been struggling to combat the number of refusals it receives, the spread of polio via air and land routes as well as what appears to be the declining quality of the immunisation campaign.
Polio which can cause life-long paralysis can be prevented with a simple vaccination.
A report last year quoted Adviser to Sindh Chief Minister Shahnaz Wazir Ali saying polio cannot be tackled "on a part-time basis."
"You have to have your nose to the ground and pursue it relentlessly. It requires close and rigorous coordination down to the union council level ─ from seeing that procurement is done on time to ensuring the quality of campaign."
Earlier this year, officials working with polio in Balochistan had said that over 50 per cent of polio cases in the province occurred due to the refusal of parents to allow administration of the vaccine to their children. Parents may refuse vaccination for a number of reasons, including religious beliefs and socio-cultural attitudes.
Rumours that the polio vaccine drive is a front for espionage or a conspiracy to sterilise Muslims have made inhabitants of lesser-developed parts of the country more wary of allowing immunisation.
The claims were propagated by the Taliban, who stepped up attacks targeting polio immunisation teams after Pakistani doctor Shakeel Afridi was recruited by the Central Intelligence Agency to set up a hepatitis immunisation drive as part of efforts to track down Al Qaeda chief Osama Bin Laden.
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In addition, polio teams comprise a very small number of female staff ─ only 20pc of polio team staff in Balochistan is female, Dr Javahir Habib, Unicef’s communication specialist for Balochistan had said in 2014.
“In such situations sometimes the women of the household may lie and say they do not have children to avoid speaking to male staff members or that the children are at their grandparents. This greatly limits our access to the children,” Habib explained.
In order to remedy the problem, the government has attempted to take religious scholars on board. In September, the Ministry of National Health Services again sought clerics’ cooperation to ensure the success of nine polio campaigns planned for this season.
The KP provincial health department in Feb 2015 began tackling refusals by issuing arrest warrants for parents and guardians who defied vaccination of their children under the Sehat Ka Ittehad (Alliance for Health) initiative. Parents were freed after they submitted an undertaking that they would not oppose immunisation.
Following implementation of these measures, only 23,000 refusal cases were recorded in KP in Feb 2015 against the 47,000 cases in Jan 2015.
Last year, restrictions were imposed on Pakistani air travellers flying in and out of the country preventing them from boarding international flights without a polio certificate with a year-long validity proving they had been vaccinated.
The purpose of these measures was to prevent the 'export' of polio to other countries after strains of the virus originating in Pakistan had been found in China, Syria and Tel Aviv, raising fears the disease may resurface globally.
There are reports, however, that many travellers have been able to acquire certificates without being administered the anti-polio vaccine.
Experts have pointed out that the spread of polio via land routes is currently the largest challenge faced by the country, especially in light of repatriation of temporarily displaced persons and refugees from militancy-stricken areas, as well as migration between rural and urban areas.
In 2014, a Punjab government official speaking on condition of anonymity as they were not authorised to speak on the issue, had said that about 2,500 families have migrated from northern areas to the province which is “a cause of major concern for the administration.”
“We have started thinking more strategically. It is difficult to track the migrating families so we strictly enforce administering of vaccine doses at all transit points but more needs to be done to map out a solution,” the official added.
Unicef's team leader for polio in KP Dr Bilal Ahmed the same year had said the government had planned vaccination campaigns at three levels ─ intra-district/agency, inter-district/agency and inter-provincial transit points.
These teams vaccinate children under five years of age, between five and 10 years and above 10 years in order to raise community immunity against polio virus.
There are around 203 transit points in KP, 218 in Sindh, 180 in Punjab and 53 each in Fata and Balochistan.
National Chair Polio Plus Committee Rotary International Club Dr Aziz Memon earlier this month said that the number of 'missed' children was a greater concern than the number of refusals, and called for complete coverage of children at transit points.
Cases have also surfaced in Sindh of children contracting the crippling disease despite being administered the vaccine previously.
This may be due to low community immunity against the virus ─ or even malnutrition, which may render the vaccine ineffective. However, one of the leading reasons for previously immunised children contracting the disease is poor quality assurance of polio vaccines.
Inconsistent cold chains and low-level education of workers are reasons why the efficacy of polio vaccines may be unpredictable.
According to experts, each vial of the Oral Polio Vaccine has a vaccine vial monitor (VVM) having four stages that indicate if the vaccine has been exposed to heat ─ which can make it ineffective.
The VVM comes in stage one, which remains constant as long as the vaccine is not exposed to heat. With continued exposure to heat, the VVM moves to stages two, three and finally to stage four.
“The government needs to impose strict accountability for good quality campaigns and as far as the issue of cold chain management goes, it is still not being taken seriously,” WHO Emergency Coordinator for Polio in Pakistan Dr Elias Durry told Dawn.com in 2014.
Pakistan in August formally launched an injectable polio vaccine. More than four million children will benefit from the inactivated polio vaccine (IPV), which will be incorporated into the country's routine immunisation schedule and given to children alongside other jabs.
Saira Afzal Tarar, state minister of National Health Services Regulation and Coordination, had hailed the IPV introduction as a landmark.
“We are hopeful that we will intercept the virus by 2016."