Crossing the finish line for polio eradication in Afghanistan
By Yu Sasaki
99.9 per cent
We are almost there! We can see the finish line – the goal we have been pursuing for so long – a world without polio. Over the last three decades, there has been a 99.9% decrease in wild poliovirus cases across the globe. How? The world came together. From parents to governments, community leaders to the United Nations, we worked together to put an end to this crippling and highly infectious disease. However, despite the major global investment, in 2019 we are yet to cross the finish line to complete polio eradication.
So, what is happening? We knew the last mile wouldn’t be an easy path, but should it be this hard? To answer these questions, it is worth looking back at the achievements so far and understanding challenges that we are facing today.
Achievements in Afghanistan
Afghanistan is one of the three polio endemic countries in the world, alongside Pakistan and Nigeria. In 2018, there were 21 wild poliovirus cases in Afghanistan making it the country with the largest number of cases last year, while 12 cases were reported in Pakistan and zero in Nigeria. It is important to note that those cases were mostly limited to small areas in the southern and eastern regions. In fact, 96% of the country is polio free and the virus is geographically restricted. In this regard, Afghanistan has seen an incredible achievement over the past decade.
This progress could not have been possible without political commitment, continuous support from major donors such as the Government of Japan and long-term efforts by the Global Polio Eradication Initiative(GPEI), the world’s largest private-public health partnership comprising of the World Health Organization (WHO), the U.S. Center for Disease Control and Prevention (CDC), Rotary International, the Bill and Melinda Gates Foundation, and UNICEF.
“We want this world to be polio-free.” said Dr. Yuji Matsumoto, Rotary International’s End Polio Now coordinator in Japan. “Rotarians have been tirelessly working on polio eradication efforts. We conduct advocacy activities for the Government of Japan in partnership with UNICEF Tokyo and Japanese NGOs, and many of us organize awareness-raising events about polio eradication in our communities.” As one of the spearheading partners of GPEI, Rotary builds awareness, conducts fundraising, and urges donor countries to support polio eradication efforts. To this end, Rotarians in Japan alone fundraised more than 3.4 million USD in 2018. Dr. Matsumoto continues, however: "Some people are starting to get worried if polio eradication is really happening. They ask me why it has taken so long."
The last mile, the hardest
“We have tremendously increased the immunization coverage in Afghanistan. UNICEF monitors progress everywhere in the country to ensure the quality of our immunization campaigns,” said Laurence Chabirand, Senior Immunization Specialist, UNICEF Afghanistan. “However, in southern and eastern regions, several factors hamper polio vaccination activities in different communities.”
One of the reasons is chronic social norms resulting in parental refusal to vaccinate. Some parents believe that vaccines are not safe, or not halal, and refuse to have their children vaccinated.
Secondly, families do not see the immediate necessity of immunization while they also lack access to basic services such as clean water and food. People sometimes demand water and food for today over vaccination to prevent possible diseases tomorrow.
Thirdly, inaccessibility due to bans and active conflict remains a major concern. Since May 2018, a ban on house-to-house immunization in most of the southern region, including Kandahar, Helmand and Uruzgan has led to more children becoming inaccessible. Many children in these three provinces have missed five consecutive polio vaccination opportunities and are at risk of contracting poliovirus. In countries like Afghanistan where health facilities are often scarce, house-to-house campaigns where social mobilisers and vaccinators visit each house to vaccinate children have proven to be the most effective method to reach every child.
The fourth reason why eradication has been hampered is the high mobility of people in the eastern region which shares a border with Pakistan. Due to a porous border between the two countries and despite a good monitoring and tracking system, there is a highly mobile population group that is difficult to trace and reach with immunization.
Strategic measures implemented
Under the leadership of the Ministry of Public Health, and together with partners, a framework of change has been developed to address the challenge of polio remaining in Afghanistan.
To overcome the social norms which cause refusals from some families, more than 70,000 front-line workers have been recruited from their communities in nation-wide campaigns to deliver vaccines house-to-house. The programme also works with influential people in the communities such as religious leaders who are trusted and can mobilize and convince people. Refusal Oversight Committees have been formulated at a national and provincial level to systematically guide, monitor and track the reduction of refusals.
Secondly, for those families who are deprived of basic services and therefore do not see the immediate need for immunization, UNICEF coordinates with other services related to health, water, sanitation, nutrition and education to go along with immunization services to increase the families’ demand.
Thirdly, UNICEF and our partners have implemented several contingency approaches in areas where house-to-house approaches are not permitted to enhance population immunity. UNICEF will continue to advocate for house-to-house campaigns as the most effective eradication approach. In the meantime, we are implementing site-to-site campaigns, adding polio to measles campaigns and expanding permanent transit teams.
To reach children on the move between Afghanistan and Pakistan, we have improved cross-border coordination with Pakistan to facilitate vaccination of moving populations between the two countries. We are tracking and mapping population movements and establishing supplementary vaccination posts at key gathering sites and border crossings. The 15 cross-border teams are immunizing more than 100,000 children every month.
On the right trajectory
It is no miracle that we have reduced wild poliovirus cases by more than 99% since 1988, from an estimated 350,000 cases in more than 125 endemic countries to 33 reported cases in 2018. Eradication strategies work. And concerted effort has made it happen. The world is on the right trajectory towards polio eradication, no matter how hard the path to conquer the last mile looks. We cannot stop here. If we do not finish the job now, it is estimated that within a decade, there could be as many as 200,000 new cases worldwide every year.
Having come this far, we must cross the finish line and make the world polio-free for the next generations.