Polio, a disease that still lingers in parts of the world, spreads with quiet persistence. Picture this: a sip of water or bite of food, unknowingly contaminated by traces of feces from an infected person, becomes the virus’s way in. Polio also spreads through close contact, as the infected can shed the virus in their stool or saliva. This ongoing threat is a stark reminder of why sanitation and vigilance remain crucial in the fight to eradicate it.
In communities with limited access to clean water and adequate sanitation facilities — critical for proper waste disposal, handwashing, and maintaining hygiene — the risk of infectious diseases significantly increases for children under five, who are particularly vulnerable. In conflict-affected and unstable regions like Afghanistan and Pakistan, restricted access to healthcare services further heightens the risk, leaving families continually threatened by the resurgence of diseases like polio.
Since the virus spreads via the fecal-oral pathway, poor sanitation — including contaminated water sources and inadequate sewage systems — plays a significant role in polio transmission. The virus’ presence in feces means there's a heightened risk of water and food sources becoming contaminated in areas with open defecation. Children who consume contaminated water or food are particularly vulnerable, especially if they are unvaccinated. The absence of adequate sanitation infrastructure often perpetuates a cycle of infection, allowing the virus to circulate within communities, drive new outbreaks and hinder eradication efforts.
Where is Polio Still Endemic?
Despite remarkable progress in the global fight against polio, two countries — Afghanistan and Pakistan — continue to bear the heavy burden of this disease. The Taliban-led government in Afghanistan has a complicated history with polio vaccination campaigns, having banned door-to-door vaccinations in 2018 due to security concerns and violence against health workers. The ban left approximately 3.3 million children unvaccinated and contributed to a rise in polio cases, which spiked from 29 in 2019 to 56 in 2020. However, in November 2021, the Taliban reversed its position and supported vaccination efforts, allowing organizations like the UN and WHO to immunize millions of children in hard-to-reach areas and educate communities about polio.
Despite this progress, polio eradication efforts experienced another setback when the Taliban-led government again suspended all polio vaccination without any official reason in September 2024. This suspension raises concerns about the potential resurgence of polio in Afghanistan and its spillover effects into neighboring Pakistan.
While Pakistan has made progress in eradicating polio — reporting only six cases in 2023 compared to 20 in 2022 and just one in 2021 — challenges remain. The country has also experienced waves of violence from Afghan Taliban loyalists targeting health workers and Pakistani police officers guarding vaccination teams, particularly in the northwest of the country. Through the Pakistan Polio Eradication Program, vaccination teams were able to reach and vaccinate nearly 33 million children under the age of five across 116 districts earlier this year. However, the country now faces a potential resurgence of the virus and increased resistance to vaccination programs, exacerbated by the suspension of polio vaccination campaigns by the Taliban government in Afghanistan and the geographical ties between the two countries.
Integrated Approaches: The Excalibur the World Needs to Eradicate Polio
Think of King Arthur’s sword, Excalibur — double-edged, sharp, and imbued with legendary power, wielded to protect his realm and uphold noble ideals. In much the same way we face polio — an insidious threat that demands our own version of Excalibur: a unified effort combining the power of vaccination and sanitation initiatives to create strong, healthy communities.
One notable integrated initiative that adopted this approach is the Afghan Community-Led Total Sanitation (AC-CLTS) program, which operated between 2019 and 2020 in high-risk areas like Loya Wala and Manzil Bagh in Kandahar province, where polio transmission rates and vaccine refusal were high.
Just like Arthur and his knights uniting for a noble cause, this collaboration brought together Afghanistan’s Ministry of Public Health, provincial health departments, and UNICEF. Their mission was clear: eliminate open defecation and improve local sanitation practices while promoting polio vaccination. The initiative mobilized community groups to implement “community-triggering” events that educated families about the connection between sanitation and polio while addressing polio vaccine hesitancy.
Through follow-up visits, health workers ensured improved hygiene practices were sustained, leading to an increased uptake of the polio vaccine in targeted communities. They learned that just as Arthur’s sword defended his kingdom, improved sanitation could protect their children from the threats of polio. By the end of 2020, a total of 200 triggered communities were declared open defecation free (ODF), there was an increase in demand for vaccinations as more parents agreed to vaccinate their children against polio - significantly reducing the likelihood of the virus spreading through contaminated water sources. The success of initiatives like AC-CLTS in Afghanistan illustrates the power of integrated approaches, where vaccination and sanitation improvements work hand-in-hand to protect communities.
Similar models are also found in partnerships like those between the Global Polio Eradication Initiative (GPEI) and its partners in Afghanistan to integrate polio services with other primary healthcare programs to amplify health impacts in areas where sanitation and vaccines are urgently needed. This collaborative effort with the humanitarian groups in the country resulted in nearly 2 million polio vaccines being delivered to nearly 70,000 hard-to-reach children who would have otherwise remained inaccessible during standard vaccination campaigns between January 2023 and February 2024.
In Pakistan, the first two phases of a new three-phase initiative called "Reaching the Unreached," (RUR), led by the Federal Directorate of Immunisation (FDI) between July and September 2023 delivered polio vaccines alongside routine immunizations, reaching nearly 27,000 children under the age of two with missed and overdue vaccinations in 69 hotspot of vaccine resistance areas of southern Khyber Pakhtunkhwa (KP). By the end of March 2024, the third phase of RUR commenced, successfully reaching more than 223,000 children with oral polio vaccine (OPV), including over 6,000 who received the vaccine for the first time.
A Holistic Approach to Eradicating Polio for Good
As the world stands at the brink of eradicating polio, we need to reinforce our commitment to a future where no child lives in fear of polio. With successful programs like the AC-CLTS initiative and GPEI’s $4.8 billion investment, we can see that eradicating polio requires more than vaccines. lt demands an Excalibur — a collaborative approach that unites health services with sustainable sanitation solutions.
Just as King Arthur united his kingdom under a common purpose, we can join our efforts to eradicate polio for good. Whether through spreading awareness, advocating for better infrastructure, or replicating integrated models at the grassroots level in endemic countries and countries at risk of an outbreak, we can create resilient environments that protect vulnerable populations from polio and forge a path toward a polio-free world.