Taimur Saleem  ( Class of 2009, Aga Khan University Medical College, Karachi, Pakistan )

Letter To Editor

Madam, Poliomyelitis is a disease for which prevention itself offers the best cure. Using polio vaccination as an ally, great strides have been made globally in eradicating this disease as evidenced by the reduction in the number of polio cases as well as the number of polio-endemic countries. In 2008, only four countries (Pakistan, Afghanistan, India and Nigeria) in the world remain polio-endemic; a remarkable reduction from more than 125 countries in 1988.¹ In 1994, EPI, in Pakistan developed stratagems to eradicate polio by the end of 2005. Additionally, enhanced surveillance for acute flaccid paralysis (AFP) cases was put into place along with synchronized cross border immunization campaigns with neighboring countries from time to time.² Though eradication measures have certainly gone a long way in reducing the number of polio cases in Pakistan, the country has yet to fulfill the criteria laid down by WHO for certification as a polio-free region. Sindh alone has been reporting one case per month since May, 2007.³ The difficulties that are stumbling Pakistan's final steps on the stairway to success could stem from restricted mobility of health care workers secondary to increasing political and military instability in some provinces, distrust among local groups towards vaccination, lack of accountability at various levels and incomplete coverage by national and subnational polio campaigns.⁴ Other possible reasons could include children receiving too many rounds of vaccinations (and therefore incurring the risk of vaccine associated paralytic polio) and continued influx of Afghan refugees into the country; Afghanistan itself being one of the remaining polio-endemic countries. A study conducted in Pakistan to assess the perceived barriers about vaccination among health managers and service providers about routine immunization revealed a perceived negative impact of national polio immunization days on routine immunization coverage.⁵ All of these problems need to be addressed at the earliest for the realization of the dream of a polio-free Pakistan. An area specific approach should be tailored to focus greater magnitude of resources and energy on the pockets reporting the highest number of polio cases. A proactive media strategy should be conceived to dispel any misconceptions harboured by the locals towards polio vaccination; it is imperative that the local populace owns these campaigns as their own. Intensive efforts should be directed to vaccinate child refugees entering Pakistan at the borders; vaccination stations can also be set up at various transit points in the country.⁶ We need to define eradication targets that can be met within the brackets of a stipulated time period; campaigns stretched over the course of decades run the risk of being marred by fatigue and failure.⁷

 Taimur Saleem
  Class of 2009, Aga Khan University Medical College, Karachi, Pakistan

1.  WHO - Poliomyelitis. [cited 2008 May 4]. URL: http://www.who.int/ mediacentre/factsheets/fs114/en/index.html
2.   Pakistan: world's largest ever house-to-house mop-up. Polio news. 1999 Jun;(4):2.
3.  No let-up in polio cases. Mukhtar Alam. Dawn. 2008 May 2.  Available from: URL: http://www.dawn.com
4.  Khabir Ahmad. Pakistan struggles to eradicate Polio. The Lancet Infectious Diseases 2007; 7:247.
5.  Mangrio NK, Alam MM, Shaikh BT. Is Expanded Programme on Immunization doing enough? Viewpoint of Health workers and Managers in Sindh, Pakistan. J Pak Med Assoc. 2008; 58:64-7.
6.  Arora NK, Dasgupta R, Sushant L. The polio eradication initiative in India: Need for evidence based actions. Indian J Med Res. 2007; 126: 500-1.
7.  Global eradication of polio: the case for "finishing the job". Bull World Health Organ. 2007; 85: 487-92.