program: background and 2016update Pakistan as a major obstacle in global end topoliomyelitis INFECTIOUS DISEASES

brazjinfectdis2016;20(5):518–520

w w w . e l s e v ie r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Letter

to

the

editor

Pakistan

as

a

major

obstacle

in

global

end

to

poliomyelitis

program:

background

and

2016

update

DearEditor,

Thepersistenceofpolio(poliovirus)inPakistantilldatehas givenrisetoseriousglobalpublichealthconcerns.Pakistanis oneofthetwocountries(Afghanistanbeingthesecond)where thestatusofpolioisstillendemic.1_{Eventhesituationinwar}

strickenAfghanistanhasimprovedefficientlyin2015.1_Now,

PakistanisaheadofAfghanistanintermsofnumberofpolio cases1_{andonwardtransmissiontoothercountries.}2,3

Inthepast,severalfactorscontributedtothefailureofpolio viruseradicationfromthecountry.TheturmoilinAfghanistan sincetheRussianinvasionhasaffectedAfghanistanandits neighbors,particularlyPakistan.TheareasofPakistaninthe vicinityofPak-Afghan border including Federally Adminis-tered Tribal Area (FATA)and thenorthernprovince Khyber Pakhtunkhwa(KP) havesuffered immensely.Consequently, thisscenarionotonlyresultedincrossbordermovementof people due toporous natureof the border contributing to thespread ofinfectionbetweenthe twocountriesbut also causedinaccessibilityofhealthmonitoringorganizationsto thoseareas.Further,thereislackofproperknowledgeabout the infection in dwellers of the region. Still, many people assume that the providedanti-polio vaccine may result in reproductivesterilityandinfertility.Othermaydenyitby pre-sentingtheargumentthatthevaccineinducespolioinhealthy individuals.Thisconcernhasdevelopeddueto misconcep-tionregardingthevaccine-derivedpoliocases.1_{Overall,these}

circumstances have made it very difficult to carry on the immunizationandvaccinationprogramssmoothly.Insevere events, polio vaccination teams have been attacked and stoppedforcefullyfromtheirservices.

Theconcernsofglobalcommunityregardingtheexistence ofpoliovirusinPakistanincreasedwhenseveralcasesofpolio virusinothercountriesshowedcloselinkagewithviralstrain circulatinginPakistan.In2013,thepoliofreeSyriaobserved anoutbreakoftheinfection3_{after1999.Thepolioviralstrain}

wasidentifiedaswildtype1ofPakistaniorigin.Earlier,Egypt, PalestineandIsraelhadconfirmedtheexistenceofthesame straininsewagedrains.3_{InJune2014,thesameviralstrainwas}

detectedinAfghanistan,2 _{andPakistanbecametheprimary}

focusofinternationalcommunityasasourceofinfection dis-semination.

ThefailureofPakistantocurbthevirustriggeredserious complicationsforitsresidentsintermsoftradeand travel. Manycountrieshaveshowntheirreservationsandpolio vac-cination hasbeen made mandatoryfor person of any age departingoutofthecountry.Recently,thegovernmentof Pak-istangearedupthepaceofimmunizationprogramstodeliver thefinalpunch.Polioteamsarenowescortedbypolice person-neltofacilitatetheprocess.AsofJune15,2016,thereckoned poliocasesinthecountrywere11,whichisfarlessthanthe numberofregisteredcasesin2015(24cases)tillsametimeof theyear1_{(Fig.1).Thelatestinformation}4_{retrievedon3July,}

2016revealedanewcaseincreasingthetollofpoliocasesin 2016to12(Fig.2).Itisobviousthatthewaraffectedprovince, KPisstilltheleadinghotspotforthepoliovirusfollowedby numberofcasesinSindhprovince(Fig2).Comparedtothe pastyears,thesituationinotherregionsofthecountryhas improvedconsiderably(Fig2).Nevertheless,theinformation presented(Fig2) revealsthenumber ofpoliocasestillJuly period.Itisexpectedthatthepolioincidencetollwillincrease in theupcoming months.Although, the healthmonitoring agenciesareoptimisticthatwiththecurrentpacethepolio virus could bewiped out completelyby2018as per World HealthOrganization(WHO)agenda.5_{However,withtherecent}

statusofKPandSindhprovince,apparentlythisseemsvery difficultbuttimewillunveilthereality.

InprospectofPakistancurrentscenario,thereisaneedfor immediateattentionandemergencybasedmeasures.These includespeedinguptheongoingcampaignsinfavorof anti-polio vaccination and immunization by health and social organization. As partofthe anti-polio management policy, initiativesshouldbetakentoincreaseawarenessofthe pub-lic, particularly inremote and backward areas ofKP, FATA and Sindh.In acountry wherethe influenceof religionis remarkableinpeople routinelifeand decisionmaking,the roleofrenownedreligiousscholarsandclericswouldbe phe-nomenalinmotivatingthepublictowardtheobjective.Most importantly,immunedeficienciesshouldbestrictlyinquired before administering the vaccine and possible alternative

b r a z j i n f e c t d i s . 2 0 1 6;20(5):518–520

519

Countries WPV cVDPV WPV cVDPV WPV cVDPV WPV cVDPV NA NA NA NA NA NA NA 29-May-16 26-Apr-16 09-Feb-15 14-Dect-15 11-Jan-16 22-Aug-15 05-Oct-15 16-May-15 07-Jul-15 6 11 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 24 2 0 20 0 2 7 8 10 2 1 2 2 54

Year-to-date 2016 Year-to-date 2015 Total in 2015 Onset of paralysis of most recent case

Afghanistan Pakistan Guinea Lao PDR Madagascar Myanmar Nigeria Ukraine

Fig.1–StatusofPakistaninworldwidepolioincidencecases.1

Province 2009 2010 2011 9 2 7 10 30 68 179 25 0 0 306 54 0 0 7 16 17 12 4 11 65 0 0 0 93 5 2 0 7 0 1 0 0 12 4 27 20 4 1 0 58 33 23 59 73 1 0 198 2012 2013 2014 2015 2016 7 27 24 74 12 0 0 144 17 12 29 20 11 0 0 89 Punjab Sindh KPK Fata Balochistan Gilgit-Baltistan Azad Jammu & Kashmir Total

Fig.2–Provincewisepolioincidencecasesfrom2009toJuly2016inPakistan.4

strategies should be devised by WHO for individuals with knownimmune deficiencies(people withHIVand primary immune-deficiencies).Thisisimportantinordertominimize thechancesofinfectioninimmuno-compromisedpeopleand nullifyanypossibleargumentregardingvaccineinducedpolio casesinhealthyindividuals,whichcansabotagetheoverall cause.Lastly,the global community should assist Pakistan healthsectorin combatingthe menace tillits final end to achievethedreamofapoliofreeworld.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1.GlobalPolioEradicationInitiative.Poliothisweek;2016. Availableat:http://www.polioeradication.org/

dataandmonitoring/poliothisweek.aspx[accessed21.06.16]. 2.WorldHealthOrganization.WHOstatementonthesecond meetingoftheInternationalHealthRegulationsEmergency Committeeconcerningtheinternationalspreadofwild poliovirus;2014.Availableat:http://www.who.int/ mediacentre/news/statements/2014/polio-20140505/en/ [accessed21.06.16].

3.TheLancetInfectiousDiseases.Awake-upcallforpolio eradication.LancetInfectDis.2014;14:1.

520

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4.EndPolioPakistan.Poliocasesinprovinces;2016.Available from: http://www.endpolio.com.pk/polioin-pakistan/polio-cases-in-provinces[accessed03.07.16].

5.GlobalPolioEradicationInitiative.Polioeradicationand endgamestrategicplan2013–2018;2016.Availableat:http:// www.polioeradication.org/resourcelibrary/strategyandwork. aspx[accessed21.06.16].

AbdulWaheedKhan∗_{,ShahidAli, SyedShujaitAli}

University of Swat, Center for Biotechnology and Microbiology, Odigram,Pakistan

∗_{Correspondingauthor.}

E-mailaddress:khanibge@yahoo.com(A.W.Khan). Received3July2016

Accepted16July2016

Availableonline12August2016

1413-8670/©2016SociedadeBrasileiradeInfectologia. PublishedbyElsevierEditoraLtda.Thisisanopenaccess articleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.bjid.2016.07.009