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Published Date: 2019-07-15 14:37:57
Subject: PRO/EDR> Poliomyelitis update (59): Pakistan (KP,PB)
Archive Number: 20190715.6569236
POLIOMYELITIS UPDATE (59): PAKISTAN (KHYBER PAKHTUNKHWA, PUNJAB)
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A ProMED-mail post
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International Society for Infectious Diseases
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In this update:
[1] Pakistan (Khyber Pakhtunkhwa, Punjab): 4 new cases - media report and End Polio Pakistan
[2] Pakistan: falsification of vaccination records - media report
[3] Vaccination data manipulated - media report

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[1] Pakistan (Khyber Pakhtunkhwa, Punjab): 4 new cases - media report and End Polio Pakistan
Date: Sun 14 Jul 2019
Source: Samaa TV [edited]
https://www.samaa.tv/news/2019/07/four-more-polio-cases-surface-in-pakistan/


Another 4 polio cases surfaced in Khyber Pakhtunkhwa and Punjab provinces on [Sun 14 Jul 2019], bringing the total number of these cases to 45 this year [2019]. A 6 month old boy from Kala Khel union council of Khyber Pakhtunkhwa's Bannu district has been diagnosed with polio, according to the National Institute of Health. Anti-polio campaign workers visited the family during immunization campaigns, but the child could not be administered anti-polio vaccine as the parents reportedly hid him each time the volunteers visited them. With this new case, the total number of polio cases in the district has reached 17. Another polio case has surfaced in Khyber Pakhtunkhwa's Lakki Marwat district.

The NIH confirmed that one polio case each has been reported in Lahore and Jhelum [Punjab]. So far this year [2019], 35 polio cases have been reported in Khyber Pakhtunkhwa, followed by 5 cases in Punjab. Three cases of polio virus have emerged in Sindh, while 2 have emerged in Balochistan.

[byline: Khan Zamir]

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[The information in the above media report is consistent with the information on the End Polio Pakistan website (http://www.endpolio.com.pk/polioin-pakistan/polio-cases-in-provinces). As mentioned in a previous posting, while this year (2019) is already a major year for polio activity in Pakistan, the country has not yet entered the highest period of the year for polio transmission, so unless major vaccination efforts are successful in overcoming the antivaccination movements in the country, there is real fear of many more cases to come this year [2019].

For a map of Pakistan showing districts, see https://reliefweb.int/sites/reliefweb.int/files/resources/pak215_pakistan_districts_v5_a0_20181203.pdf.
HealthMap/ProMED-mail map of Pakistan: http://healthmap.org/promed/p/140
- Mod.MPP]

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[2] Pakistan: falsification of vaccination records - media report
Date: Mon 15 Jul 2019
Source: Pakistan Today [edited]
https://www.pakistantoday.com.pk/2019/07/15/fake-polio-markers-highlight-risks-to-pakistans-vaccination-drive/


Pakistan's polio eradication campaign has hit serious problems with an alarming spike in reported cases that has raised doubts over the quality of vaccination reporting and prompted officials to review their approach to stopping the crippling disease. The country is one of only 3 in the world where polio is endemic, along with neighboring Afghanistan and Nigeria, but vaccination campaigns have cut the disease sharply, with only a dozen cases last year [2018] compared with 306 in 2014 and more than 350 000 in 1988, according to Pakistani health officials.

However, there has been a worrying jump this year, with 41 cases recorded [now 45, see section [1] above], 33 [now 35] of them in the north western region of Khyber Pakhtunkhwa, where many people resent what they see as intrusive and coercive vaccination campaigns often involving repeated rounds of visits, officials say.

Just as alarming for health services, environmental sampling has shown the presence of the virus in areas across the country, a clear sign of gaps in vaccination, which must cover the entire population to be effective. Hopes that transmission of the disease could be ended this year [2019] have been abandoned. "We need to take the bull by the horns and accept there are problems," said Babar Atta, prime minister Imran Khan's point person on polio eradication.

As well as the difficulty in reaching very remote areas and keeping track of people moving through big cities like Karachi, there have been problems in collecting reliable data, exacerbated by resistance to efforts to force vaccination. Efforts to eradicate the disease have for years been undermined by opposition from some Islamists, who say immunization is a foreign plot to sterilize Muslim children or a cover for Western spies.

Local officials say parents suspicious of mass immunization campaigns have been getting hold of special markers, used by health workers to put a colored spot on the little fingers of children who have been vaccinated. "They themselves would mark the fingers of their children in case of an official visit to countercheck the vaccinated children," one official associated with an international organization told Reuters in the northwestern city of Peshawar. Officials estimate that so-called fake finger marking, sometimes in collusion with health workers, is hiding the true scale of refusal rates, and thus gaps in vaccination.

In some areas, as many as 8% of families may be refusing or avoiding vaccination, a level which would mean the disease is not eradicated. A senior official of the Health Department in Khyber Pakhtunkhwa said the exact data had been deliberately hidden by local health authorities nervous of being blamed for failing to ensure full coverage. "And the result of hiding figures has led us to face an epidemic-like situation today," he said.

Polio, transmitted through sewage, is a disease that can cause crippling paralysis, particularly in young children. The disease is incurable and remains a threat to human health as long as it has not been eradicated. Immunization campaigns have succeeded in most countries and have come close in Pakistan, but persistent problems remain. International observers have been watching the situation with alarm for some time. In October [2018], the Independent Monitoring Board, which oversees the global polio eradication effort, wrote in its annual report that there was "something seriously wrong with the program in Pakistan."

In April [2019], fueled by rumors on social media that children were being poisoned by the vaccinations, mobs rioted in Khyber Pakhtunkhwa, and at least 3 polio workers were killed. Even without violence, many people consider polio a "US disease". Facing more immediate threats such as a lack of clean water, many do not see why their families should be disturbed by what they consider intrusive foreign-sponsored campaigns.

Health workers, whose closeness to the communities they work in is vital in building trust, face difficult choices in remote areas where kinship and local power structures can often place them under severe pressure not to report cases of non-compliance. According to many officials, the stubborn hostility to the campaigns and the high levels of avoidance underline the problems with heavy-handed repeat visits by health workers and police going after families that refuse vaccination. "Why are the marker pens in the shops? Because parents want to buy them. They are sick and tired of repeated vaccinations," said Babar Atta.

Officials are now looking at more targeted approaches involving more persuasion and education in areas where there are problems overcoming resistance to vaccination. Oliver Rosenbauer, a spokesperson for the World Health Organization, said resistance to vaccination was hampering the eradication effort, although other factors, including the movement of people in Pakistan and across the border with Afghanistan, were potentially more important. He said officials were analyzing the series of problems confronting the program to build a new approach. "What is very clear to everyone is that if things keep going the way they're going, we're not going to eradicate polio in Pakistan," he said. "We can keep a lid on it, but that's not the aim. The aim is to eradicate it."

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[3] Vaccination data manipulated - media report
Date: Fri 12 Jul 2019
Source: Dawn [edited]
https://www.dawn.com/news/1493542


After a sudden rise in reported cases, the new leadership of the polio programme has reached a conclusion that data manipulation was done over the past few years as performance of the entire programme revolved around the data or numbers. Moreover, in the past, all the attention was given to controlling the disease and reducing the number of reported cases rather than eradication of the crippling disease's virus.

"Across the globe, it is observed that wherever 95% of children were vaccinated against polio, the virus was eradicated. Over the years, the staff of the polio programme claimed it had vaccinated over 99% of children and, in some cases, such as in January 2019, data showed that 101% of children were vaccinated. I believe that wrong data was given by the field staff, as their performance depended on the number of vaccinated children," the prime minister's focal person on polio Babar Bin Atta said while talking to Dawn.

He claimed that a new strategy had been adopted due to which within a year poliovirus would be restricted to a core reservoir of Peshawar. Mr Atta, to prove his point, said that in India, 95% of children were vaccinated continuously, and it achieved the target of becoming a polio-free country. "I have to admit that there was a communication gap between field workers and the management due to which field workers claimed that they had vaccinated over 99% of children. Moreover, parents had markers, which were used for marking on fingers, due to which the same results were observed during verifications, and fingers of children were observed marked. However, whenever a child was infected with polio, it was revealed that he/she was not vaccinated, and it was a refusal case," he said. He said that after the incident of Peshawar, it was decided that parents would not be pressured for vaccination. During campaigns it was observed that around 8% of the parents refused to vaccinate their children.

It is worth mentioning that during a nationwide polio campaign in April [2019], students of a school of Mashokhel were taken to the Hayatabad Medical Complex in Peshawar with the complaint that they suffered a reaction because of polio vaccine. However, it was revealed later that a drama was staged against the polio campaign, and all the children had no reaction. Some of the culprits involved in the drama were arrested, and legal action was taken against them.

"Last month we conducted a survey in Khyber Pakhtunkhwa, and it was revealed that over 40% of the population understands that multiple doses were required for the children, over 31% said no, while over 27% were not sure about it. It showed over 44% of the population was aware of the risk for their children of getting polio, while over 55% did not believe in it," he said. He also said that unfortunately, in the past, the programme was considered a disease-control programme rather than a virus-eradication programme. "The virus is very smart; it found children with a weak immunity level and paralysed them. When we tested paralysed children, it was proved that they did not have vaccine," he said.

"It is unfortunate that parents have kept markers at their homes, and they mark the fingers of their children on the starting day of a campaign. Then they claim that their children are vaccinated. In October 2017, there was a better situation in terms of reported cases compared to today, but the Independent Monitoring Board (IMB) on Polio stated that Pakistan should not continue fooling itself by believing that it has done the job," he said. Mr Atta said it had been decided to start the Polio Tahafuz Helpline from which not only assistance would be provided to parents, but a call would also be made, in the voice of Imran Khan, to every parent that polio vaccine is in the best interest of their children.

[byline: Ikram Junaidi]

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[From the media reports above, it is very clear that the Pakistani government is fully committed to the goal of polio eradication but is confronting serious challenges in getting the vaccination coverages needed to interrupt transmission of the poliovirus. As one observes the worldwide situation with vaccine-preventable diseases and the antivaccination movements, one sees that it is not just Pakistan that is paying the price of the antivaccination movement: the high-income as well as the middle- and lower-income countries are confronting major measles outbreaks clearly assisted by the antivaccination movement and false information campaigns about vaccinations. In many areas, parents are falsely hiding behind "religious exemptions" coming from religions that do not reject vaccines, and with religious leaders advocating vaccinations. I can't help but think that medical anthropologists and marketing specialists could be very helpful in coming up with strategies to "sell the concept" of the importance of the vaccines and debunk the false rumors that are circulating worldwide, not just in Pakistan, Afghanistan, and northern Nigeria. - Mod.MPP

HealthMap/ProMED map available at:
Pakistan: http://healthmap.org/promed/p/140]

See Also

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Poliomyelitis update (55): global (WPV1 & cVDPVs) 20190628.6541884
Poliomyelitis update (54): Pakistan (KP, KPTD) 20190627.6540866
Poliomyelitis update (53): Afghanistan (OZ) 20190626.6539747
Poliomyelitis update (52): global (WPV1, cVDPV) Ethiopia, Pakistan 20190621.6531966
Poliomyelitis update (51): Pakistan (KP, SD) 20190620.6530102
Poliomyelitis update (50): Afghanistan (OZ) 20190619.6528976
Poliomyelitis update (40): Central African Republic (MP,UK) cVDPV, WHO, RFI 20190529.6493464
Poliomyelitis update (30): (Afghanistan, Pakistan) social media 20190503.6454173
Poliomyelitis update (20): (Pakistan, Nigeria) isolates, real-time surveill. 20190315.6367838
Poliomyelitis update (10): (Afghanistan, Pakistan, Nigeria) positive environ. 20190131.6288339
Poliomyelitis update (01): global 20190104.6241814
2018
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Poliomyelitis update (62): (Nigeria, Niger) cVDPV2 20181228.6226490
Poliomyelitis update (01): global (Afghanistan) 20180105.5539242
2017
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Poliomyelitis update (47): Pakistan, global (Congo DR) 20171229.5526565
Poliomyelitis (01): Pakistan (GB), global, RFI 20170314.4898724
2016
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Poliomyelitis update (21): IPV shortage, global 20161231.4733243
Poliomyelitis update (01): India, VDPV, wild type-free 20160115.3939297
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