From fake vaccination records to targeted killings of health workers, global health organizations face a range of challenges as they work to eradicate polio in Pakistan. The country remains one of only two countries worldwide, alongside neighboring Afghanistan, where polio is endemic, or regularly occurring. As of December 3, Pakistan has reported 59 cases of polio in 2024.
Polio, a highly infectious viral disease, spreads from person to person through fecal-oral transmission or, less commonly, from droplets from a sneeze or cough of an infected person or by a common vehicle such as contaminated water or food.
Though there is no cure, polio is preventable with safe and effective vaccines that provide lifelong protection. Despite this, low vaccination coverage among children under five has long been a challenge in Pakistan, driven by factors like misinformation, security threats, and logistical barriers. These gaps in coverage are critical, as vaccinating young children is essential to stopping the virus's transmission. For detailed information on these issues, read our explainer on polio in Pakistan.
In October, a nationwide vaccination campaign aimed to reach over 45 million children under five. However, several districts delayed their campaign start until mid-November, and the WHO is currently validating the number of children missed in that campaign.
The Pakistan Polio Eradication Programme conducts multiple mass vaccination drives every year, with the next one scheduled for mid-December, which aims to reach more than 44 million children.
To gain deeper insights into the fight against polio, Global Citizen spoke with Dr. Zubair Mufti Wadood, a senior epidemiologist in the polio department at the World Health Organization headquarters in Geneva. He discussed the current challenges in eradicating polio in Pakistan, the importance of community engagement, and how political decisions by the Taliban in neighboring Afghanistan are impacting Pakistan’s efforts to eradicate this disease.
Dr. Zubair Mufti Wadood, a senior epidemiologist in the polio department at the World Health Organization, is photographed discussing the quality of campaigns with local public health experts.
What is the current situation of polio in Pakistan, which tends to be seasonal?
We have seen a steep rise in polio cases, particularly in the last few months, which was the higher transmission season since polio is a social disease, and these monsoon summer months are very favorable for transmission. We have seen the most cases between July and September to October and are now entering the low transmission season.
While the eradication of polio is a public health issue, it’s often closely tied to political will. Can you explain how and why politics intersects with vaccination campaigns?
In Pakistan, a political transition has continued over the last 18 months or so at the national and provincial levels, and sometimes, changes at the political level lead to a period where the focus on polio can be disturbed. Having said that, after the elections in early 2024 and the new government taking over, we have seen improved and enhanced political ownership and political supervision of the program.
Political oversight is the first step in eradicating polio. The Global Polio Eradication Initiative [GPEI] is advocating in a focused way with the highest political leadership in Pakistan to make sure that polio is high on the agenda. The GPEI, the WHO, and other partners, like the Bill and Melinda Gates Foundation, are trying to keep contact with the political leadership and make quarterly visits [to advocate for prioritizing polio].
Secondly, political ownership and oversight at the operational level are key to implementing not just campaigns but high-quality campaigns. When political will gets translated at the operational level to the district level leadership, deputy commissioners, divisional commissioners, health leadership, and district health officers, they start to really exercise all their power into campaigns; that's when the difference can be seen.
Why is political will, and, in turn, community ownership of polio vaccination campaigns essential in eradicating this disease?
It’s very important to have this overarching component of effective community ownership and engagement so that communities are on board. One of the challenges we recently encountered in Pakistan relates to community ownership. Some reports in certain geographies indicated the communities were not on board with vaccination campaigns. There were also reports of fake vaccinations where fingerprints indicate a vaccination occurred when the child was not vaccinated. [Editorial note: Using a fingerprint to replace a signature is common in areas where the population is not literate.] So, that challenge is something that can be addressed once the communities are on board.
A health worker, right, marks a door of makeshift after administering the polio vaccine to children in a neighborhood of Lahore, Pakistan, June. 3, 2024.
What can you tell us about these falsified documents indicating more children have been vaccinated than those who were?
This vaccine hesitancy is limited to geographies and certain population pockets, particularly in the Sindh, Balochistan, and Khyber Pakhtunkhwa provinces, where this falsification of vaccination records has been observed. Additionally, there have been factors like dwelling insecurity and attacks on health workers during polio campaigns. Unfortunately, some have lost their lives in the line of duty, ranging from frontline vaccinators up to the supervisors level. There have also been community boycotts of the polio vaccination, whereby they use this as a bargaining chip in seeking social development initiatives. There are also situations where the teams go door-to-door [to vaccinate]. Still later, assessments and careful, in-depth evaluations have shown that people didn't allow their children to be vaccinated, but they were recorded as vaccinated.
All these factors indicate that up to 700,000 children were missed in certain campaigns. This is really a significant number, especially when they exist in pockets and when they are in clusters because polio transmits in clusters of unimmunized children.
In the last few years in neighboring Afghanistan, there have been many changes regarding how vaccination campaigns are implemented due to restrictions by the Taliban, such as suspending door-to-door vaccinations and, instead, hosting the vaccination campaigns in mosques or other sites, which limit the reach of these campaigns. What are the implications of these political decisions?
From the perspective of polio in this region, it transmits through epidemiological corridors such as the northern corridor which runs between Afghanistan and Pakistan. Making progress in one part of this epidemiological block and not the other is always a risk to the entire epidemiological block. So, if there is progress in Pakistan, and Afghanistan does not have the same kind of progress, it won't drive us toward our goal of stopping transmission and eradication.
Now, for the Afghanistan program, which has gone from door-to-door campaigns to other strategies like mosque-to-mosque strategies, it is really a great concern. The WHO is advocating for Afghanistan to return to door-to-door vaccinations. In Afghanistan, experience shows that a door-to-door strategy can reach the maximum number of children. At the same time, site-to-site [vaccination sites] and mosque-to-mosque vaccination campaigns are not able to reach the number of children and achieve the coverage that is required for eradication. These strategies may involve up to 50% to 70% of children, but that won’t achieve eradication. We need to reach over 90% of children for vaccination campaigns, especially in these reservoirs.
What can potentially happen if low vaccination coverage trends continue in Afghanistan, consequent to regression from door-to-door campaigns, is there will be buildup of unimmunized and under-immunized children, and polio transmission may intensify. And if there is progress on the Pakistan side with regression on the Afghan side, this whole epidemiological block remains at risk. Efforts from the GPEI have been focusing on maintaining collaboration between the two countries and two country programs as it's in the interest of everyone.
What would it take to finally eradicate polio in Pakistan?
To eradicate polio, a strategy with five key components is needed. After political oversight and political ownership, the third component is to keep an eye on areas in Pakistan that are outside of these core reservoirs so that if the virus appears elsewhere, there's a strong outbreak response to stop this transmission.
The fourth component relates to implementing all our campaign operations in the bordering areas of Afghanistan and all the programmatic assessments, including field assessments. These border areas are sometimes vulnerable, especially as some children are on the move with their families. So collaboration between the two programs to implement synchronized vaccination activities to reach those populations living in the bordering areas and also those moving across in different ways and for several reasons, including economic, cultural, and other reasons.
The last component is to enhance collaboration with the routine immunization program to jointly reach zero-dose communities and zero-dose children and also offer them routine immunization, polio vaccines, and other antigens. That serves two purposes: it’s another way of enhancing population immunity, and it also helps gain community acceptance by ensuring we protect children from other vaccine-preventable diseases.
A health worker administers a polio vaccine to a child in a neighbourhood of Lahore, Pakistan, Oct. 28, 2024.
The COVID-19 pandemic showed us how viruses can spread globally. Yet, polio, which is only endemic in Pakistan and Afghanistan, may not be on the radar of people who live in other regions and continents since it may not seem like a threat. What is your perspective?
If you look at the recent epidemiology in the last two years, we have seen wild poliovirus type one from Afghanistan and Pakistan detected in southeast Africa in early 2022. Still, in our epidemiological analysis and the analysis of the poliovirus in the lab, this virus was transmitting somewhere for nearly two years. Then it got detected in Malawi, and then subsequently Mozambique. The moment polio exists [anywhere], it causes a risk everywhere.
Editor’s Note: This article is part of a content series that was made possible with funding from the Bill and Melinda Gates Foundation.