By Dure Samin Akram, MD
I remember being vaccinated against smallpox as a child. We got the vaccine every two to three years to protect us during epidemics—and these were frequent enough. Thanks to a global immunization campaign by the World Health Organization (WHO), smallpox was declared eradicated in 1980; the last known case was in Somalia in 1977.
A global campaign to eradicate polio seems set to yield similar results. Last year, there were only eight reported cases worldwide, three of which were in Pakistan.
Pakistan started its National Program for Immunization in 1978. Initially, vaccination was given for five antigens: tuberculosis (TB), diphtheria, pertussis, tetanus, and polio. Measles vaccine was added later. This has increased over time to include nine antigens, including the injectable form of polio vaccine, in addition to the oral drops. As vaccines become more accessible, there is a corresponding decline in the prevalence of these diseases. With only three cases last year, eradicating polio in Pakistan in 2018 seems within reach. The effort and resources are being channeled toward this goal with a large part of the funding for immunization targeted towards polio eradication.
I remember the “bad old days,” when a whole room in the hospital where I worked was dedicated to neonates with tetanus. Now, most of these wards have been converted to play areas or to other purposes. As a medical student in the ‘60s, I frequently dealt with children with diphtheria and whooping cough. I recall my brother getting diphtheria, a serious infection of the nose and throat caused by the Corynebacterium diphtheriae. Children rarely get diphtheria anymore, though it remains endemic in Pakistan as well as many counties in Asia, the South Pacific, the Middle East, Eastern Europe, and in Haiti and the Dominican Republic.
Measles epidemics were also common in the ‘70s and ‘80s. Half our pediatric wards were dedicated to children with measles complications, including the flare-up of fulminant TB, which can follow a measles infection as the child’s immunity drastically decreases. The other rooms had children with perforated corneas due to Vitamin A deficiency and oedematous malnutrition which are also complications associated in the post-measles phase. Again, effective immunization programs and improved capacity in monitoring and treatment have dramatically reduced the number of people who become ill from infectious diseases and related complications.
Measles epidemics still occur, but they are limited in scale, duration, and infection-related complications. Deaths in children under five from infectious diseases in Pakistan are still unacceptably high. As many as 81 in 1000 children born do not live to see their fifth birthday (UNICEF, 2016), a higher rate than the low-income–country average at 73.1 and extremely high compared to figures from high-income countries at 5.3–9.6 per 1000 births.
Overall, Pakistan’s vaccination coverage is sub-optimal. Most of unimmunized children surprisingly live in busy cities. There are immunization clinics and vaccinators that do community outreach, but hidden in the numerous slums of all large cities are children that are not being reached. With the help of Gavi, the Vaccine Alliance, and other partners, there is a plan to fast track immunization in urban slums of nine large cities in Pakistan. We also have areas in cities and villages where misinformation related to vaccine side effects or about adulteration of vaccines with family planning medicines, producing infertility; this often results in refusal by parents to vaccinate their children based on religious grounds. Certain vaccines cause transient fever and pain at the site of the injection, and mothers sometimes hide their babies when a vaccinator visits their neighborhood for fear of such side effects.
Security hazards, especially for outreach polio teams, is another great challenge. Although the government provides security guards or police to accompany polio workers, there have been many instances of these volunteer women being shot at. Many polio workers, both male and female, and their guards have died over the last five to seven years. Conditions have drastically improved in the last two years, and therefore, polio campaigns have become more impactful.
Infrastructural challenges also contribute to difficulty reaching some children. Until recently, for example, electricity outages disrupted vaccine supply chains. New solar refrigerators now reach the most remote areas in Pakistan, and supply and outreach with vaccines has improved greatly.
Still, there is unmistakable momentum out of the joint effort between the government, Gavi, U.N. agencies, donors, and civil society organizations. There is a sense of urgency to reach every child whether hidden in city slums or in small villages in the deserts of Balochistan and Sindh. Pakistan can look forward to eradication of polio in our lifetime and to drastic reduction in the prevalence of childhood infections and infant mortality.
Samin Akram, MD, is a Pakistani pediatrician and an ACTION Media Champion