Table 1 Summary of GHD Recommendations for Polio in Pakistan

Increased access to vaccines

Supply Chain: Frequent power outages in Pakistan, especially in rural areas, make it difficult to maintain the required temperature for proper polio vaccine transport and storage; polio vaccine requires refrigeration to maintain the cold chain, and improper temperatures can render vaccine ineffective. A vaccine campaign’s efficacy is hampered when ineffective and expired vaccines are given to populations, particularly those in hard to reach areas. If a cold chain breaks down at the domestic level, money, time, and lives are potentially at risk.

Access: A fundamental priority is to increase access to free, effective, and easily administered polio vaccine to tackle remaining polio transmission avenues.

Supply Chain: Improving vaccine cold storage in tandem with enhanced regulatory control can improve vaccine efficacy. This includes use of random unscheduled inspection of health centers that store vaccine to monitor for compliance to cold chain storage that can further support the eradication process by identifying weaknesses in the vaccine supply chain.

Access: Public health centers offer the oral polio vaccine free of cost and in August 2015, Pakistan started an injectable polio vaccine program with plans to vaccinate 6 million children^a. Although the new injectable vaccine is more expensive than the OPV and requires a health care professional to administer, it can be more effective than OPV because only a single dose engenders immunity. Moreover, IPV has less chance to produce vaccine-derived polio virus and its related paralysis.

Improving water and sanitation in affected areas

FATA and other affected border areas are facing a serious water scarcity problem as the region lacks dams for water storage resulting in poor sanitary conditions. The combination of lack of literacy, false cultural beliefs and reduced water supply in border areas have resulted in reduced hand washing, even though Islam emphasizes the practice of frequent handwashing in the Quran to reduce disease risk. Tainted water and poor sanitary conditions transmit fecal–oral route infections like polio, hepatitis-A, and typhoid, and must be addressed in any comprehensive vaccine diplomacy efforts.

Access to clean drinking water must be prioritized as a fundamental human right and as a function of ensuring global health security and ending polio. Partner organizations such as Rotary International, UNICEF, RESULTS (an organization whose goal is to end poverty in the world), the UN Foundation, the Global Poverty Project, the World Bank and the Bill and Melinda Gates Foundation can help provide vulnerable populations with water treatment plants that ensure safe water supply. These efforts should integrate with Polio eradication efforts and should be specifically targeted for polio at-risk areas including border and rural communities.

Enhancing environmental surveillance

Environmental surveillance has detected polio virus in all provinces in Pakistan, although positive environmental samples decreased from 38% in 2014 to 16% in 2017.^b Laboratory tests on sewage indicate the presence of under-immunized or unimmunized children who can transmit the virus and contribute to its continuing spread.^c These children might have been immunized with expired and thus ineffective polio vaccines if the cold chain was not maintained during transport, while administering the vaccine, or if the children were missed cases.

To better quantify if these polio virus environmental trends are perpetuating, continued environmental surveillance of wastewater and sewage must be a priority. Positive environmental samples can serve as a proxy indicator for missed or unimmunized children that are not captured by other surveillance methods.

Mobilizing community and religious leaders

Mobilization of the community and religious leaders is important in health promotion efforts and achieving higher vaccine coverage. Religious leaders and the Imam Masjid (the worship leader of a mosque) can play a vital role in motivating people and improving community participation in polio eradication programs. The people of FATA and other affected border areas live in communities with strong religious beliefs and are oftentimes more conservative than Pakistani populations that live in other provinces. Additionally, community health workers need to be appropriately trained and incentivized.

Religious Leaders: The Imam and other religious leaders can help educate their communities that immunizing children and adults will eradicate polio. In this sense, religious leaders may be more persuasive and effective champions by practicing informal and grassroots vaccine diplomacy than national politicians or health staff due to the familiarity with culture and customs specific to affected areas of Pakistan that remain reservoirs for polio transmission.^d Fatwas (religious decisions) from Saudi Arabia in 2014, supporting polio vaccination and delivery of messages direct to the FATA and other border communities can also enhance community engagement, buy-in from religious leaders, and increase vaccination participation to ensure better compliance with polio eradication programs.^e

Community Health Workers: Strengthening community health staff capacity through mandatory workshops on how to administer polio vaccines are also vital steps toward countrywide eradication. This includes ensuring there are appropriate incentives for health workers and a reliable monthly salary so that campaigns can be successfully carried out. Female staff availability in areas where women observe the hijab can also break down cultural barriers, support religious beliefs, and thereby enhance polio vaccination coverage. For example, a study using smart phone monitoring showed that increasing incentives for senior vaccinators could lead to increased vaccination coverage.^f

Assisting Internally Displaced Persons

Movement of people between different regions internal to a country as a result of armed conflict, generalized violence or violation of human rights is termed “internal displacement of people.” Internally displaced people (IDP) are at particular risk for higher rates of unimmunized children, including in populations from south and north Waziristan, where conflict and displacement has created an immunity gap.^g The percentage of children missed due to polio teams not showing up is highest in FATA and Baluchistan.^g Pockets of unimmunized children are chronically missed because of internal migration and displacement in these conflicted areas.^g Internal displacement also has the potential to threaten broader disease transmission to larger cities like Karachi, Lahore, and Islamabad, when unimmunized IDPs are resettled and introduced into new communities.

Recognition of the human and health rights of IDPs and the unique health and security risks they face is important. This begins with clarification of their legal status and their right to access health services. IDPs should be prioritized in Polio eradication and vaccination interventions as an at-risk group. These groups should also be assessed for their risk of polio transmission in the context of forced migration or political displacement.

Effective health promotion and communication

Public service and mass media campaigns broadcast over radio can improve the regional population’s knowledge about benefits of polio vaccination. Announcements from religious leaders on both radio and digital channels such as YouTube can act as a powerful health promotion and vaccine awareness tool if utilized properly.

People in border areas communicate more frequently through mobile phones compared to traditional mass media forms such as television broadcast. In response, mobile applications using m-health (mobile Health) interventions have been deployed to help polio eradication teams increase their vaccination coverage in affected areas.^h Mobile phones are thus changing the way people access data and allowing public health interventions to expand to communities that may be remote or hard to engage with. In Pakistan in 2010, for example, mobile SMS-based service enabled parents to report missed cases of polio vaccine coverage.^h