Crossing the finish Line
for polio eradication in Afghanistan
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? Because the world came together. From parents to governments, from 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, we are now in 2019 and yet to cross the finish line to 100% eradicate the disease. 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, 21 wild poliovirus cases were reported in Afghanistan while 12 cases in Pakistan and zero in Nigeria, which means this country had the largest number of cases last year. However, it is important to know that those cases are mostly limited to small areas in the southern and eastern regions. In fact, 96% of the country is polio free and the virus is very geographically restricted. We should be aware that the measure of progress is not only in the number of cases, but also in the geographic restriction of those cases. And in this regard, Afghanistan has seen an incredible achievement over the past decade.
This progress could not have been possible without the country’s political commitment, the continuous support from major donors such as the Government of Japan and long-term efforts of the Global Polio Eradication Initiative (GPEI), the world’s largest private-public partnership for health which members include World Health Organization (WHO), the U.S. Center for Disease Control and Prevention (CDC), Rotary, 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 the polio eradication efforts. Rotarians in Japan alone fundraised more than 3.4 million USD in Fiscal Year 20181 to end polio. 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.”
Last mile, the hardest mile
“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 of vaccines. 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 when 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 of tomorrow. Thirdly, inaccessibility due to bans and active conflict remains a major concern. Since May 2018, a ban on the house-to-house immunization strategy in most of the Southern region, including Kandahar, Helmand and Uruzgan has led to an upsurge in the number of inaccessible children. Many children in these three provinces have missed five consecutive polio vaccination opportunities and are a risk of 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 are proven to be the most effective method to reach every child, so the restriction on the campaigns decreases the access to children. The fourth reason why eradication has been hampered is the high mobility of people in the eastern region which shares a border with Pakistan. There is ongoing transmission between Afghanistan and Pakistan, and despite the good monitoring and tracking system, due to the porous borders between the two countries, 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 together with partners, a framework of change has been developed to address the remaining challenges in Afghanistan. To overcome the social norms which cause refusals from some families, during nation-wide campaigns more than 70,000 front-line workers are recruited from their communities 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 national and provincial level to systematically guide, monitor and track progress of 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 a number of 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, site-to-site campaigns, adding polio to measles campaigns and expanding permanent transit teams are being implemented.
To reach out children on the move between Afghanistan and Pakistan, cross-border coordination has been improved with Pakistan to facilitate vaccination of moving populations between the two countries. Population movements are being tracked and mapped, and supplementary vaccination posts are being established at key gathering sites and border crossings. More than 100,000 children are immunized every month by the 15 cross-border teams.
On the right trajectory
It is not a 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 then, to 33 reported cases in 2018 – it is clear that eradication strategies work. It is the world’s concerted efforts that has made it happen. The world is in the right trajectory towards the 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.
1Fund raising amount during 1 July 2017 – 30 June 2018