Involve the community, eradicate polio

AKU, Peshawar Medical College conduct study on polio threats in conflict-hit areas of Pakistan

KARACHI: The threat of polio in conflict-hit areas of Pakistan can be reduced through a package of community-based strategies that integrate maternal child health services and routine immunisations, according to a new study, 'Community Engagement and Integrated Health and Polio Immunisation Campaigns in Conflict-Affected Areas of Pakistan: a Cluster Randomised Controlled Trial', which was published in The Lancet Global Health.

The research conducted by health experts from Aga Khan University (AKU) in partnership with Peshawar Medical College, London School of Hygiene and Tropical Medicine and Canada's Centre for Global Child Health at the Hospital for Sick Children, Toronto, tested a range of interventions in 387 insecure areas of the country in Bajaur, Karachi and Kashmore, where children are especially vulnerable to contracting polio: a disease that has been eradicated throughout the world except in  Pakistan, Afghanistan and Nigeria.

Challenges to polio eradication such as children not being present at home during immunisation drives, health care workers being denied access to particular areas or being unable to cover all homes in an area, distrust of vaccination activity among the population and fatigue caused by recurrent polio-focused immunisation drives were identified by researchers, which they said lead to new cases of polio being reported in the country every year.



The interventions to expand coverage of the polio vaccine in insecure areas included the introduction of pictorial health awareness campaigns, community mobilisation and engagement through local volunteers and the running of holistic health camps after national immunisation drives that addressed the unmet need for mother and child health services in these areas.

These steps enabled low-cost but accurate health information to be disseminated as well as vaccinations to be provided to over 50,000 families. The steps also helped address the problem of children being missed in national drives and alleviated the potential hesitancy of those refusing polio vaccines delivered through frequent door to door immunisation campaigns

"Ensuring that no child is missed in polio vaccination campaigns is especially challenging in areas in Bajaur and parts of Karachi where the law and order situation limits access to vaccinators," said Dr Sajid Soofi, associate professor in paediatrics and child health at AKU. "There is also widespread suspicion of immunisation activities across the country, which is why one of the approaches we tested involved building trust within communities," he added.



Dr Saeed Anwar, an associate professor in community health sciences at Peshawar Medical College, said that health care teams, comprising community mobilisers from the area, were trained to deliver accurate information about immunisation to parents and local health care providers during the course of study spanning four years.

This included focused sessions with community leaders, religious figures, teachers and other prominent officials at the union council level.

Speaking about the value of these approaches, Dr Anwar said, "By employing local influencers to manage projects and by focusing on personalised sessions with local stakeholders we were able to gain access to previously unreachable areas and thereby protect more children from this preventable disease".



The study also disproved a theory that providing an anti-polio injection - the inactivated poliovirus vaccine (IPV) - alongside polio drops - the oral poliovirus vaccine - would result in opposition from the community, he maintained, adding that researchers noted that data showed that eight out of 10 families agreed to their child receiving the IPV when it was delivered as part of a comprehensive health package that provided vital hygiene, nutrition and antenatal services to mothers and children.

"Since the eradication of polio is a national and global imperative, we worked closely with the World Health Organisation (WHO), UNICEF, Bill and Melinda Gates Foundation, as well as federal and provincial governments to generate evidence that can help achieve the objectives of the National Emergency Plan and the WHO's Polio Eradication Initiative," said senior author of the study Professor Zulfiqar A Bhutta, founding director of AKU's Centre of Excellence in Women and Child Health and the chair in global child health at the Centre for Global Child Health in Toronto.

"Our package of interventions enabled us to boost coverage of the oral polio vaccine by 8.5% in areas where there was previously fierce opposition to immunisation campaigns," he explained.



"Our steps to organise temporary health camps providing broad-based health services ensured that we reached two-thirds of the targeted children and families and helped us to provide booster injections to ensure that every child stayed on track with the four-dose schedule needed to eradicate polio," added Dr Bhutta.

"The eradication of polio worldwide requires global partnerships that combine medical expertise with strong community health research capabilities," said Pakistan Country Head for the WHO Dr Mohammad Assai. "Working in partnership with a range of universities and multilateral organisations has helped us generate evidence to strengthen immunisation systems and to expand vaccine coverage so that the world stays on track with targets under the global Polio Eradication and Endgame Strategic Plan which aims to eradicate the disease by 2018."