Eighteen-month-old Usman Ali from Balochistan’s Zhob district is one of the 56 unfortunate children in Pakistan who contracted poliovirus in 2024, the most recent of these cases detected just this week. Including Usman, as many as 26 of these children belong to Balochistan, where cases have been confirmed in several districts: Chaman and Killa Abdullah along the Afghanistan border, as well as provincial capital Quetta, Dera Bugti, Jhal Magsi, Killa Saifullah, Kharan, Chagai, Noshki, Loralai, and Jaffarabad.
Usman’s father, 40-year-old rickshaw driver Mir Wali, is the sole breadwinner for his extended family that lives hand to mouth, which includes his four other children. They live in Sohrab Goth, a slum on the outskirts Zhob, which lacks proper sanitation, clean drinking water, electricity, and access to primary education. Open defecation in Sohrab Goth puts the lives of around 2,000 other children at risk for poliovirus transmission. This is a critical concern, as the Polio Eradication Programme operates under the idea that every unvaccinated or missed child is a potential carrier of the poliovirus, capable of affecting up to 200 others
Polio, also known as poliomyelitis, is an infectious disease caused by a virus that invades the nervous system after multiplying in the intestine, and results in irreversible paralysis. After the onset of symptoms in Usman’s case, World Health Organisation surveillance officials collected his specimens on June 28 and sent them to the National Institute of Health (NIH) in Islamabad. On July 19, the lab report revealed that the child had been infected with the poliovirus.
For Mir Wali, his son’s polio diagnosis has compounded his family’s struggle to make ends meet. Cradling the child in her lap amid sizzling heat, Usman's mother, an illiterate housewife, says her son had been suffering from a high fever, and she found weakness in both lower limbs. The ailing child was rushed to a private clinic in the town, but a minor illness led to his permanent disability. “My youngest son will not be able to walk and play for his entire life,” she laments, tears rolling down her cheeks.
Vaccine status
According to health officials, not a single vaccination card has been found at Usman’ s house. Although a finger mark was visible during the case investigation, his mother says, the child was not immunised during the last anti-polio drive, the Outbreak Response (OBR) campaign, which suggests, the child’s finger had been marked without administering anti-polio drops. The evidence shows the child received neither an injectable vaccine (IPV) nor the oral (OPV) doses. The vaccination history revolves around the ‘zero dose’ and ‘fake finger marking’.
Dr Nayyar Loni, Immunisation Officer at WHO, says the leading cause behind the Sohrab Goth case is a ‘fake finger mark’ carried out by the polio teams on the request of child’s parents, as he was suffering from fever. The polio teams deny the allegation.
“The community is completely unaware of the importance of vaccination and the crippling nature of poliovirus. Most of the families try to hide their children during the vaccination campaigns,” Dr Loni explains. Another cause, he adds, is mismanagement on the part of relevant government officials. “None of the officials are taking the anti-polio programme seriously. Moreover, the teams also showed negligence and poor performance. The child was not even recorded as a refusal, but his finger was marked,” he shares.
Although Usman' s family has not traveled recently, his mother says dozens of children from the Bawar village in neighboring Loralai visited Sohrab Goth to attend a wedding ceremony recently. In June 2024, the NIH lab revealed in a report that sewage samples collected from Loralai contained wild poliovirus (WPV) type-1.
Deputy Provincial Coordinator of the Expanded Programme on Immunisation (EPI) in Balochistan, Dr Zafar Khosti, says static sites have been established across the province. “It is now the responsibility of the parents to get their children vaccinated against various diseases, including polio.”
“Complete polio eradication is a distant dream, until routine vaccination is improved and vaccination of all under-five children is ensured," he adds.
Routine Immunisation
Routine vaccination is the regular vaccination of under-five children against various vaccine-preventable diseases. It is considered to be the gold standard for preventing diseases, including polio. The vaccination programme, started back in the 1970s in Pakistan, aims at protecting children from poliomyelitis, infant tuberculosis, diphtheria, whooping cough, neonatal tetanus, hepatitis-B, pneumonia, haemophilus influenza, measles and rubella. Regrettably, vaccination coverage is often low in nomadic communities as compared to the urban population. Sohrab Goth also houses a nomadic population that seasonally migrates between Zhob, Loralai, Dera Ismail Khan, Bannu, Punjab, and other parts of the country. This community has been identified as High Risk Mobile Population (HRMP) for the poliovirus.
High-Risk Mobile Population
In the northern part of Balochistan, Zhob (Fort Sandeman) holds not only historical but also geographical importance, as it shares borders with Afghanistan and the tribal region of South Waziristan. The ancient district also falls on the international route of Afghan nomads, locally known as ‘Kochis’ who travel between the Afghanistan-Pakistan border areas (after border-fencing) and the plains of Punjab. Twice a year, they pass through Zhob.
Dr Amin, N-STOP officer at polio eradication programme says, the Kochis (HRMP) are known for their higher risk of contracting and transmitting poliovirus due to their inter-province mobility.
“HRMP influx starts in March, while the out-flux starts in October. The community comes from the warm parts of Southern Punjab, Bannu, Lakki Marwat, and various districts of Sindh through both formal and informal routes. Prior to vaccinating HRMP children, a proper mapping is carried out, and the motorcycle teams vaccinate HRMP children. Still, HRMP compromises the quality of the campaign," he explains.
Twin cases
Usman' s story is not unique; he is the second unfortunate child in the same Sohrab Goth settlement diagnosed with poliovirus.
Another resident, Akhter Muhammad, had only two daughters after 12 years of marriage. That is until 2015, when he was blessed with twin sons. The boys’ grandmother intended to save them from ‘evil eyes’ and kept them indoors most of the time. So when the vaccinators would show up in the area to administer anti-polio drops, she would not let them immunise the newborns. The health officials had recorded the parents as a ‘silent refusal’, because the twins had not received even a single dose of the anti-polio vaccine.
In 2017, saving the children from ‘evil eye’ and misconceptions against vaccines resulted in the paralysis of one of the twins, then two-year-old Habibur Rehman. He is now battling a life-long disability.
Misconceptions
Misconceptions about vaccines are the main driving force behind the refusals, particularly in the rural communities. Both misconception and vaccination hesitancy have been identified as significant barriers in the way of polio eradication efforts. Numerous myths and misconceptions commonly echoed by people to justify their resistance lead to vaccine refusals and hesitancy in every nook and cranny of Balochistan.
In a study, published by Dr Muhammad Samsoor Zarak and other health experts in 2019 in the Eastern Mediterranean Health Journal (EMHJ) – an official journal by the WHO highlighted that misconceptions about the vaccine was the leading cause behind the refusal, accounting for 56.4% of cases. Additionally, 16% of refusals were based on religious grounds.
The frontline polio workers have bitter experiences while handling the chronic refusal parents and community elders as well. Halima is one of the thousands of frontline polio workers who has been associated with the polio eradication programme in Balochistan for the last couple of years, says that some people believe the vaccine carries ‘unknown’ ingredients that may cause ‘infertility’ and ‘impotence’. They term the entire campaign part of the ‘family planning’ programme aimed at 'sterilising’ their children.
“Some religious refusals are of the view that the anti-polio campaign is a ‘Western conspiracy’ and demand proof of vaccine safety during vaccination. It has also been experienced that in certain areas, the conservative-minded religious scholars have ill-informed opinions against vaccines and during Friday's sermons, prohibit people from getting their children vaccinated,” she reveals.
Countering misconceptions and debunking myths, the UNICEF-funded ComNet has hired communication officers and other staff across Balochistan for social mobilisation at the district level. Their key role is to minimise disinformation, build trust among the communities, provide a conducive environment to the frontline health workers and sensitise parents about the crippling nature of the poliovirus.
Decades-long history
Back in the 1980s, the World Health Assembly launched the Global Polio Eradication Initiative, setting the goal of eradicating polio by 2000. Pakistan carried out the first National Immunisation Days (NIDs) in 1994. The global initiatives and significant progress finally bore fruit; now poliovirus has been eradicated from all over the world, except from Pakistan and Afghanistan , which are the last two endemic countries.
Coordinator National Emergency Operation Center Captain (retd) Muhammad Anwarul Haq says the steps taken in neighboring Afghanistan regarding polio are worth emulating. “Our goal is aligned. The NEOCs of both countries are in close coordination and contact to carry out synchronised campaigns in the coming months,” he shares.
Other concerns
Beside the misconception and vaccine hesitancy, low vaccination coverage, security concerns, cultural and social barriers, scattered populations, inaccessibility and hard-to-reach areas, and population movement or migration are also contributing factors hindering the polio eradication efforts.
Like elsewhere in the country, indigenous wild poliovirus transmission also persists in Balochistan. The poverty-hit province forms 44 per cent of the total area of the country. Quetta bloc, comprising the provincial capital Quetta, Chaman, Killa Abdullah, Pishin, and Mastung districts, have been identified as high-risk areas for poliovirus circulation.
Dr Muhammad Samsoor Zarak, who is undergoing Internal Medicine Training at Northwest Medical Center in Arizona, US, has been associated with the World Health Organisation in Balochistan for a couple of years. He says the eradication of the poliovirus continues to face numerous challenges at the operational, systemic and geopolitical levels, affecting both polio workers and the effective execution of vaccination campaigns. Moreover, law and order issues significantly compromise the quality of anti-polio drives.
“The YB3A genetic cluster of WPV1 (a specific type of polio virus) has been documented in both neighboring countries, Pakistan and Afghanistan. This strain was initially identified in Pakistan in 2021, eradicated, but later re-emerged from Afghanistan in 2024, indicating cross-border transmission,” he highlights, adding that it is imperative for both governments to collaborate closely, develop concrete and unified plans to combat the virus. Regular meetings involving all stakeholders are essential for planning and monitoring the eradication efforts to ensure comprehensive and sustained results.
Health experts say a multi-dimensional and integrated approach with community engagement and social mobilisation can bear fruit in overcoming vaccine hesitancy and fostering acceptance of the polio vaccine. In addition to educating communities about the importance of polio vaccination, public awareness initiatives can also dispel myths in society and pave the way to completely eradicate polio from the country.
“Overcoming the challenges of polio eradication in Pakistan and Afghanistan requires coordinated interventions, minimising parental misconceptions, strengthening vaccination infrastructure, addressing security concerns, managing cross-border migration, and enhancing bilateral cooperation. By tackling these issues head-on, we can move closer to a polio-free world,” Dr Zarak suggests.
Rafiullah Mandokhel is a Balochistan-based freelance journalist. He can be reached at: mandokhail.rafi@gmail.com
All facts and information are the sole responsibility of the author