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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

339,521 trained and dedicated polio workers work across Pakistan for polio eradication. The polio vaccine history of polio drops is critical for polio eradication.

Pakistan's Polio Eradication Roadmap

This article or video has been recorded by a subject / domain specialists with a proven track record of excellence in their area. 

Madeeha Syed

This article or video has been vetted and verified by Meri Sehat’s specialists. It contains citations and research from validated sources.

What Anti-Vaxxers Get Wrong About the Polio Vaccine

Overview

Polio is a thing of the past, right? You don&rsquo;t see it much in the news anymore and it&rsquo;s not something we really have to worry about. Well, anti-vaxxers would like you to think that this is true. But it isn&rsquo;t. Polio still exists today and, if you&rsquo;re not vaccinated against it, you could get polio or spread it to someone else who might die from it. It&rsquo;s important for everyone not just parents with children to know how vaccines work and why they&rsquo;re safe.&nbsp;

<div>&nbsp;</div>

Anti-Vaxxers  About  Polio Vaccine

The anti-vaccine movement is growing increasingly popular, despite the fact that many of its arguments are based on erroneous historical facts. Here are just a few:

<ul>
	<li>Vaccines aren&rsquo;t effective</li>
	<li>They do not cause infertility</li>
	<li>No, your government is not injecting you with nanochips to track you</li>
	<li><a href="https://merisehat.pk/disease/autism" target="_blank">They cause autism</a></li>
	<li>They&rsquo;re not necessary because polio hasn&rsquo;t been around for decades now</li>
</ul>

&nbsp;

It&rsquo;s important to remember that, as we speak, polio is still a problem in many countries. In fact, the World Health Organisation still refers to it as an &ldquo;endemic&rdquo; disease. Since 1988 , when the UN certified that polio had been eradicated in every country on Earth, there have been only 21 cases of wild poliovirus found globally: 16 in Somalia and five in Pakistan (the last case on this list occurred just this past September).

But while anti-vaxxers are right that vaccines can&rsquo;t prevent all disease outbreaks, they&rsquo;re wrong about why we need them at all. Because the truth is this: vaccines aren&rsquo;t just useful for preventing one infectious illness, they&rsquo;re also useful for preventing other diseases from spreading by stopping people from getting sick with them too. That&rsquo;s why some people think of vaccines as a sort of &ldquo;immunity insurance&rdquo; against outbreaks rather than just something you need when you actually start showing symptoms of an illness like measles or mumps (which are both very contagious). 
&nbsp;

Thimerosal is a preservative that prevents the growth of harmful bacteria in vaccines. It has been used since the 1930s, and thimerosal-free vaccines have been available for several years. There is absolutely no scientific evidence that links thimerosal to any health problems. In fact, all credible studies have shown just the opposite. In fact, it&rsquo;s safe to use as a preservative in food items, too!

Although many anti-vaxxers will try to tell you otherwise, thimerosal isn&rsquo;t dangerous or toxic at all. It&rsquo;s just an additive used by doctors and manufacturers alike in order to make sure our vaccinations remain effective while they&#39;re being stored and transported around the world!

<div>&nbsp;</div>

It&rsquo;s important to note that the polio vaccine does not cause cancer. Nor does it cause autism, any other brain defect, autoimmune disease, or death. The idea that vaccines are some kind of hoax like climate change denialism or flat-Earth-ism is a conspiracy theory with no basis in reality. We know this because there is plenty of evidence to prove that vaccines work and are safe for children (and adults). 
&nbsp;

Vaccines Are Safe

Polio Vaccine Is Important, Polio Vaccine Is Safe: You may be thinking that anti-vaxxers are a bunch of crazy people, but there&rsquo;s actually a lot to like about them. They&rsquo;re confident in their beliefs and not afraid to stand up for what they believe in. They&rsquo;re also highly educated, which makes them more likely than others to be able to articulate their beliefs effectively.

What anti-vaxxers get wrong about polio vaccines is that it&rsquo;s not just one type of vaccine; it&#39;s two types: oral polio vaccine (OPV) and inactivated polio vaccine (IPV). The OPV is commonly used in Pakistan due to its ease of administration. The oral polio vaccine also eradicates the need for the presence of a healthcare professional and highly sterile equipment. This has allowed Pakistan to conduct vaccinations on a mass level. Whereas the IPV on the other hand, requires the presence of proper healthcare workers, sterile equipment and multiple doses. IPV is far more effective than OPV but since we are on a mission to completely eradicate polio from the face of earth, whatever vaccine you can get your hands on, works.&nbsp;

Many countries stopped using OPVs long ago because they discovered that although it could prevent children from getting paralysed by wild versions of poliovirus, these viruses would still circulate around the community throughout childhood &mdash; which meant other kids might get infected anyway! The risk/benefit ratio was no longer proportionate. 
&nbsp;

Bottom Line

I hope that this has helped to clear up some of the misconceptions about polio vaccines. It is important to note that the polio vaccine is not a one-size-fits-all approach, and there are many factors involved in deciding whether or not you should receive it. However, these arguments do not mean that anti-vaxxers are wrong about everything: they are right in their belief that public health decisions should be made on the basis of science rather than fear mongering.&nbsp;

Umna Salah

Non-Alcoholic Fatty Liver Disease (NAFLD) In Pakistan

Introduction

Fatty liver disease is very common throughout the world. The condition is characterized by the storage and accumulation of extra fat in the liver. Mostly, there are no serious symptoms nor does it interfere with daily life activities. However, leaving the condition unattended may eventually cause liver damage.&nbsp;

&nbsp;

One particular type of fatty liver, called non-alcoholic fatty liver disease (NAFLD) has seen a global rise in cases and associated mortality. In the United States, NAFLD is a leading cause of chronic liver disease<a href="#accordion">[1]</a>. Moreover, it continues to be a leading cause of end-stage liver disease worldwide<a href="#accordion">[2]</a>. A population-based observational study revealed a global increase in cases from 391.2 million in 1990 to 882.1 million in 2017<a href="#accordion">[2]</a>. The highest case numbers were seen in East Asia, South Asia, North Africa, and the Middle East<a href="#accordion">[2]</a>.

&nbsp;

Obesity, unhealthy diet, lack of physical activity, and diabetes are some of the most established risk factors for non-alcoholic fatty liver disease (NAFLD)<a href="#accordion">[2]</a>. However, in recent years, the medical literature has reported an increase in cases among people without any of the mentioned risk factors. Called lean NAFLD, the fatty liver disease is seen to be affecting non-obese or lean individuals with a normal body mass index (BMI). As per a recent meta-analysis, approximately 40% of the global NAFLD population was found to be non-obese and a fifth were lean<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

Understanding Non Alcoholic Fatty Liver Disease In Pakistan

To fully understand how any condition affects your body, it is crucial to understand its functioning first.&nbsp;

&nbsp;

The liver is an essential organ and has crucial functions that involve the production of bile to aid in digestion, storage of iron for your blood, creation of immune factors as well as the removal of toxic substances from the body as it processes the nutrients obtained from food.&nbsp;

&nbsp;

Liver is also responsible for aiding your blood with substances that help it clot whenever there is an injury; clotting stops the body from losing any more blood.&nbsp;

&nbsp;

All of these functions get affected one way or another if your liver is not working fully. Every function associated with the liver is one way or another related to your body&rsquo;s immune system and basic functioning<a href="#accordion">[4]</a>.&nbsp; &nbsp; &nbsp;&nbsp; 
&nbsp;

Like the name suggests, it is simply extra fat in your liver. However, it can be of 2 main types:

&nbsp;

<ul>
	<li>Alcohol-induced fatty liver disease - As the name suggests, the disease is brought on due to heavy alcohol consumption.&nbsp;</li>
	<li>Nonalcoholic fatty liver disease (NAFLD) - The condition presents in the absence of alcohol consumption. With a global prevalence of 25%, it is a common cause of chronic liver disease worldwide<a href="#accordion">[5]</a>. Although the exact cause remains unclear, it has been linked to obesity, diabetes, and an unhealthy lifestyle. It can be further divided into:</li>
</ul>

&nbsp;

1. Simple Fatty Liver: This refers to fat in your liver without inflammation or damaged liver cells. This fatty liver does not cause noticeable issues and tends to go unnoticed. Most cases of fatty liver are like this.&nbsp;

2. Non-Alcoholic Steatohepatitis (NASH): This is a much more serious condition than just the conventional fatty liver. NASH involves inflammation and liver cell damage along with fat accumulation. NASH has been associated with causing fibrosis and cirrhosis. It makes up about 20% of the total cases of non-alcoholic fatty liver diseases<a href="#accordion">[6]</a>. 
&nbsp;

Despite the high prevalence of the issue in Pakistan, research suggests that people in high income countries are affected the most for e.g. In the US, the prevalence of fatty liver disease ranges from 10-46%. The higher rate is due to the obesity epidemic in the US<a href="#accordion">[7]</a>.&nbsp; &nbsp;

&nbsp;&nbsp;

In Pakistan, <a href="https://merisehat.pk/disease/obesity">obesity </a>does exist and while it may not be as hard of a hit as it is in the United States, it is still worrisome and does not get due attention. The rise in obesity coupled with poor health awareness and lifestyle choices, have led to a drastic increase in fatty liver issues in Pakistan as well. As per research, around 15% of Pakistan&rsquo;s population now suffers from nonalcoholic fatty liver disease<a href="#accordion">[8]</a>. However, it is important that NAFLD in Pakistan is seen in not only obese patients but also patients suffering from diabetes and dyslipidemia. Furthermore, a 2017 study conducted among a Pakistani cohort identified male gender and advanced age as major risk factors for metabolic disturbances linked to NAFLD<a href="#accordion">[9]</a>.

&nbsp;

Between 2013 and 2014, researchers in Peshawar, Pakistan analyzed the prevalence of NAFLD and NASH in hospitalized and ambulatory patients at Combined Military Hospital Peshawar Cantonment area. The overall prevalence of NAFLD was 47%, with Pathans demonstrating the highest numbers<a href="#accordion">[10]</a>. Moreover, NAFLD was more common among male patients, diabetics, hypertensive and older individuals<a href="#accordion">[10]</a>.

&nbsp;

Most patients with fatty liver have dyslipidemia even if they do not suffer from other contributing factors. The ever-increasing rate of nonalcoholic fatty liver disease in Pakistan requires multiple population-based studies to be carried out to determine the root cause, and the cultural and lifestyle impact on the disease and its development<a href="#accordion">[8]</a>. 
&nbsp;

Non-alcoholic fatty liver disease does not really have a lot of discomforting symptoms. You may experience tiredness or abdominal pain towards the upper right side.&nbsp;

&nbsp;

However, in the case of non-alcoholic steatohepatitis or cirrhosis, you may experience the following symptoms:

<ul>
	<li>Irritated palms</li>
	<li>Jaundice &ndash; yellowing of eyes and skin</li>
	<li>Swollen belly</li>
	<li>Enlarged blood vessels&nbsp;</li>
	<li>Bigger breasts in men 
	&nbsp;</li>
</ul>

This is probably the hardest part of the disease. There are no visibly discomforting symptoms that would make you see the doctor. However, it is also common to get to know about the condition while diagnosing some other issues.&nbsp;

&nbsp;

The diagnosis starts off with taking a health history. This is carried out through a series of questions that involve asking about your diet, medications, and any health conditions. It is followed by blood tests to assess if you have increased levels of liver enzymes (aminotransferase, alanine, or aspartate aminotransferase). Incidental abnormal liver enzymes commonly lead to a NAFLD diagnosis. However, in 80% of cases, the liver enzymes are in the normal range<a href="#accordion">[8]</a>. Therefore, proper screening programs with abdominal imaging are required for the diagnosis of NAFLD. Especially, in individuals with risk factors such as obesity, diabetes, and hypertension. Moreover, even non-obese or lean individuals should be kept in mind when screening for NAFLD.&nbsp;

&nbsp;

The most common method used for diagnosis is through ultrasounds and, in most cases, that is also how people get to know about the issue<a href="#accordion">[11]</a>.&nbsp; &nbsp; &nbsp; 
&nbsp;

There is no targeted medicine for the treatment of fatty liver disease. The best approach for maintenance is to monitor and maintain other contributing factors that revolve around lifestyle changes. The earlier you adopt these changes, the better:

&nbsp;

<ul>
	<li>No smoking</li>
	<li>No alcohol consumption</li>
	<li>Maintaining optimum weight&nbsp;</li>
	<li>Controlling other health issues, like diabetes, cholesterol, etc.</li>
	<li>Taking vitamin E 
	&nbsp;</li>
</ul>

Conclusion

The statistics in Pakistan are not as bad as other countries like the US; nevertheless, the numbers are increasing. Moreover, with the increasing obesity and unhealthy lifestyle trends in the country, the burden of NAFLD is expected to increase further. This poses a growing concern to public health. Therefore, there is a need for increasing awareness among the population and promoting a healthy lifestyle.&nbsp;

Key Points

<ul>
	<li>Fatty liver refers to the accumulation of fat on the liver. The two main types are alcohol-induced fatty liver disease and nonalcoholic fatty liver disease (NAFLD)</li>
	<li>NAFLD can be divided into&nbsp;simple fatty liver disease, which is common, and the less common non-alcoholic steatohepatitis, which is responsible for the formation of cirrhosis and fibrosis in people.</li>
	<li>Contributing factors include obesity, high LDL levels, diabetes, etc.</li>
	<li>There is no treatment, however, it can be maintained and prevented by taking care and maintaining a perfect BMI.</li>
	<li>With the increasing obesity and unhealthy lifestyle trends in the country, the burden of NAFLD is expected to increase further. Therefore, there is a need for increasing awareness among the population and promoting a healthy lifestyle.</li>
</ul>

[1] Kanwal F, Kramer JR, Duan Z, Yu X, White D, El-Serag HB. Trends in the Burden of Nonalcoholic Fatty Liver Disease in a United States Cohort of Veterans. Clin Gastroenterol Hepatol. 2016;14(2):301-8.e82. doi:10.1016/j.cgh.2015.08.010

[2] Ge X, Zheng L, Wang M, Du Y, Jiang J. Prevalence trends in non-alcoholic fatty liver disease at the global, regional and national levels, 1990-2017: a population-based observational study. BMJ Open. 2020;10(8):e036663. Published 2020 Aug 3. doi:10.1136/bmjopen-2019-036663

[3] Ye Q, Zou B, Yeo YH, et al. Global prevalence, incidence, and outcomes of non-obese or lean non-alcoholic fatty liver disease: A systematic review and meta-analysis. The Lancet Gastroenterology & Hepatology. 2020;5(8):739-752. doi:10.1016/s2468-1253(20)30077-7

[4] Fatty liver disease: Risk factors, symptoms, types &amp; prevention. Cleveland Clinic.

[5] Chrysavgis L, Ztriva E, Protopapas A, Tziomalos K, Cholongitas E. Nonalcoholic fatty liver disease in lean subjects: Prognosis, outcomes and management. World J Gastroenterol. 2020;26(42):6514-6528. doi:10.3748/wjg.v26.i42.6514

[6] Fowler P. Fatty liver disease: Nonalcoholic &amp; alcoholic steatohepatitis (NAFLD/AFLD). WebMD.

[7] Fatty liver disease. UCLA Health System.

[8] Abbas Z, Zaheer R. Non-alcoholic fatty liver disease: A real threat in Pakistan. Journal of the Pakistan Medical Association. 2020:1. doi:10.5455/jpma.95891

[9] Ghani RA, Saqlain M, Zafar MM, Jabeen S, Naqvi SM, Raja GK. Identification of Metabolic risk phenotypes predisposing to Non-Alcoholic Fatty Liver Disease in a Pakistani Cohort. Pak J Med Sci. 2017;33(1):121-126. doi:10.12669/pjms.331.11445

[10] Shah AS, Khan S, Rahim H, Chishti KA, Khan AG. Prevalence of non alcoholic fatty liver and Non alcoholic Steatohepatitis in Peshawar Cantonment, Khyber Pakhtunkhwa, Pakistan. Pak J Pharm Sci. 2018;31(1):193-198.

[11] Team THE. Everything you need to know about fatty liver. Healthline.

AL SHIFA CLINIC KARACHI

Syed Intisar Hussain

Heading Towards Polio Endgame

Poliomyelitis, or polio for short, is a fatal infection caused by the polio virus that predominantly affects children under 5 years of age<a href="#accordion">[1]</a>.. The virus attacks the spinal cord causing paralysis, a condition in which an individual is unable to move his or her body<a href="#accordion">[2]</a>. 
&nbsp;

The contagious <a href="https://merisehat.pk/disease/polio">polio virus</a> is transmitted from human to human. It typically inhabits an infected individual&#39;s throat and intestines. The virus can spread through direct contact with contaminated feces, through the oral-fecal route, and airborne droplets from the cough or sneeze of an infected individual. However, the latter is a less common route of transmission<a href="#accordion">[2]</a>.&nbsp;&nbsp;

&nbsp;

Unfortunately, 72% of individuals infected with poliovirus do not present with any alarming symptoms of the infection<a href="#accordion">[2]</a>. Thus, making it difficult to isolate these individuals who are at risk of transmitting the disease.&nbsp; 
&nbsp;

A quarter of people will have flu-like symptoms initially, such as fever, tiredness, nausea, headache, sore throat, and stomach aches<a href="#accordion">[2]</a>.These resolve on their own, over 2 to 5 days<a href="#accordion">[2]</a>. One out of 200 individuals is at the risk of developing irreversible paralysis, mostly in the lower limbs, which is why poliomyelitis is considered a crippling disease<a href="#accordion">[2]</a>.&nbsp; 
&nbsp;

Of these individuals who are paralyzed, 5 to 10% of them die because the disease rapidly progresses and attacks the respiratory muscles, robbing them of their ability to breathe<a href="#accordion">[2]</a>. Eventually, the infected person dies due to an inability to breathe<a href="#accordion">[1][2]</a>.&nbsp; 
&nbsp;

Moreover, even after individuals have fully recovered from the polio infection early in their life, they can still develop muscle weakness, muscle aches, or paralysis as adults. This condition is referred to as &#39;post-polio syndrome&#39; and occurs roughly 15-40 years after recovery<a href="#accordion">[2]</a>. It is seen in up to 40% of polio survivors<a href="#accordion">[3]</a>.&nbsp;

&nbsp;

Understanding Misconceptions About Polio Vaccine

Since this life-threatening infection currently has no potential cure, prevention is the only way to save oneself from this disabling disease. The Global Polio Eradication Initiative that commenced in 1988, has led to a 99% decrease in polio cases. Through successful vaccinations, 20 million people that were earlier at risk of paralysis, can walk today, which is a tremendous feat.&nbsp; 
&nbsp;

There existed three viral strains of poliovirus: type 1, type 2, and type 3 wild poliovirus, of which type 2 and type 3 have been completely eradicated. However, type 1 wild poliovirus remains and is yet to be eradicated, and remains endemic in Pakistan and Afghanistan<a href="#accordion">[1]</a>. If the poliovirus infection is not curbed in the two countries, it can result in the global resurgence of this deadly disease - a much-dreaded outcome. Therefore, it is imperative to wipe poliovirus from the face of this earth by providing immunizations (vaccinations) to everyone without discrimination.&nbsp;

&nbsp;

There are two vaccines available for the poliovirus. One of them is an Inactivated Polio Vaccine (IPV) which is injected intramuscularly (in the muscle) in the leg or arm of an individual. It has been in use across the United States since 2000. Another vaccine known as the Oral Polio Vaccine (OPV) is in use across several developing countries to protect them from this disabling disease<a href="#accordion">[2]</a>.Pakistan and Afghanistan are among the countries still using OPV for disease eradication. Unfortunately, the opposing views against the polio vaccine in both populations have made complete eradication of the disease difficult.&nbsp;

&nbsp;

One may question why the disease is still endemic in Pakistan and Afghanistan when it has been swept clean by every other country in the world. The answer lies in the fact that there has been a plethora of misconceptions and propaganda swirling around the oral polio vaccine claiming it to be un-Islamic and haram (something that is prohibited in Islam). Due to widespread misconceptions about the polio eradication campaigns, many polio campaign workers have faced strong resistance. Moreover, many parents are not willing to get their children vaccinated due to these misconceptions. These misconceptions state that the oral polio vaccine causes sterility and the composition of the vaccination makes it impermissible for Muslims. However, this is far from the truth. 
&nbsp;

<h5>Addressing Misconceptions, The Halal Way&nbsp;</h5>

In 2013, religious scholars, spiritual leaders, Muftis, and intellectuals collaborated with the Al-Azhar University in Egypt and confirmed that the oral polio vaccine does not affect the reproductive potential of an individual. This conference analyzed and cleared the doubts and suspicions linked to the use of the oral polio vaccine. A conclusion was reached in this conference that polio vaccines being used in Pakistan are safe and effective, the vaccine has no ingredient that causes infertility, and last but not the least, the vaccine contains nothing that is prohibited in Islam or is hazardous to health<a href="#accordion">[4].</a>&nbsp;Moreover, the trypsin present in the oral polio vaccine is halal (permissible in Islam)<a href="#accordion">[5]</a>. 
&nbsp;

<h5>Islamic Conference Summarized</h5>

On 27th February 2014, in Jeddah, the largest Islamic conference presided by the Grand Imam of Kaaba (Holy Mosque of Makkah) took place to address the challenges faced during polio eradication programs in the polio-endemic regions of the Islamic world<a href="#accordion">[6]</a>. In the meeting, it was stated that protection against a disease such as polio is obligatory and permissible under Islamic Shariah and those Muslims who do not support these preventive measures are putting the entire world at risk. Thus, causing harm to humanity which is un-Islamic<a href="#accordion">[6]</a>.&nbsp; 
&nbsp;

<h5>Islam On Health And Protecting Oneself Against Diseases</h5>

Furthermore, Islam itself propagates practices that are beneficial and protective for the individuals, and it negates impurity, sickness, and distress which are the features of poliovirus infection. Therefore, timely administration of the vaccine is the only prophylactic treatment available to prevent infection and curb the disease. In the light of Islam, it is binding upon every Muslim to play his or her part in the control of any widespread disease and to prevent it from progressing<a href="#accordion">[5]</a>. Additionally, it has been proved through Prophet Muhammad&#39;s (PBUH) saying as reported by Ibn Al-Qayyim that &quot;The Holy Prophet permitted seeking protection against contagious diseases&rdquo;<a href="#accordion">[7]</a>. As mentioned earlier, polio is a contagious disease and wiping it out is essential which is possible through the administration of the oral polio vaccine. 
&nbsp;

When a significant percentage of the community gets vaccinated against a particular disease, in this case polio, then the community develops &#39;herd immunity&#39;. This prevents the spread of the disease. Herd immunity works by impeding the transmission of the virus or any disease-causing organism for that matter. The majority of the immunized individuals in the community will not host the poliovirus or let it replicate upon entry into the body. Hence, putting an end to the transmission of the disease. But herd immunity develops only when 80 to 95 per cent of the population is immunized<a href="#accordion">[8]</a>.

&nbsp;

Consequently, to eradicate polio in Pakistan and Afghanistan, the communities need to extend their support to the Eradication of Polio campaign by getting their children immunized against poliovirus. Any negative presumptions regarding the oral polio vaccine should be dispelled by the society. These negative theories against the vaccine are providing hindrance to the complete eradication of the deadly, but preventable, poliovirus and putting the world at risk of disability. It takes only one traveler with polio to spread the disease in polio-free countries. Hence, it is imperative to act responsibly toward the duty of wiping polio from Pakistan and Afghanistan so that no child has to face a disability or die from this crippling disease. 
&nbsp;

Moreover, when nations become polio-free it greatly impacts the economic structure. Economic modelling estimates that the eradication of polio can save 40 to 50 billion USD in low-income countries like Afghanistan and Pakistan<a href="#accordion">[1]</a>. Thus, eradicating polio as a nation can help our country flourish by reducing the disease burden on our struggling healthcare system. Moreover, polio eradication is a step towards the betterment of the country and saves children from a lifelong crippling disease. 
&nbsp;

<ul>
	<li>Polio is a deadly infection that can cause irreversible paralysis and life-long disability.</li>
	<li>It largely affects children under 5 years of age.</li>
	<li>It is a contagious disease; hence, prevention is key.</li>
	<li>99% of the polio cases have been eradicated from all over the world, and the disease is currently endemic only in Pakistan and Afghanistan.</li>
	<li>Polio eradication campaigns have faced widespread resistance from society due to which global eradication of the disease has not yet been achieved.&nbsp; &nbsp;</li>
	<li>Several religious scholars have unanimously stated the polio vaccine is safe and without any potential to cause sterility. 
	&nbsp;</li>
</ul>

[1]."Poliomyelitis (polio) - WHO | World Health Organization.

[2]."What is Polio? - CDC."

[3]."Infectious diseases - Oxford Medicine

[4]."Pakistan Polio Eradication Programme | end polio

[5]."Islam and polio - The Lancet Infectious Diseases." 1 Sep. 2014,

[6]."Islamic scholars call for access to vaccinate children | Resources.

[7]."Taking vaccines against diseases."

[8]."Herd Immunity - virology blog." 12 May. 2008,

Nawal Adnan

<a href="https://merisehat.pk/disease/polio">Polio</a> is a crippling disease that mainly affects children below the age of 5 years and is caused by poliovirus. It is contagious, which means it can be transmitted from human to human.

&nbsp;

Polio is a global health concern. While the disease has been wiped off from most parts of the world through effective immunization campaigns, it remains endemic in Pakistan and Afghanistan. Nevertheless, it poses a serious threat to countries that have already eradicated the disease because a single person, who&rsquo;s infected with the poliovirus, can become a source of the global spread of the infection while traveling.&nbsp; 
&nbsp;

Understanding Pakistan's Fight Against Polio

Polio is a crippling disease that mainly affects children below the age of 5 years, and is caused by poliovirus. It is contagious, meaning it can be transmitted from human to human.&nbsp;

&nbsp;

The virus spreads through the fecal-oral route and very rarely through respiratory droplets when an infected person sneezes or coughs. Once the virus is inside the body, it reaches the intestines where it multiplies. Later, it invades the nervous system (spinal cord) and results in paralysis, a state of immobility of the body<a href="#accordion">[1][2]</a>. 
&nbsp;

Due to the disabling nature of the disease, polio eradication campaigns were launched worldwide to curb this highly infectious disease through immunization. There is no denying the fact that the eradication campaigns have been tremendously successful globally; the campaigns eradicated 99% of the polio infection.&nbsp;

&nbsp;

Although Pakistan is among the two polio-endemic countries, it has also worked significantly to eliminate polio from the region.&nbsp;

&nbsp;

This article will shed light on how Pakistan managed to pull off effective polio eradication campaigns throughout the years, despite a plethora of conspiracies, negative theories, and resistance by certain groups against the polio vaccine. Subsequently, there has been a massive reduction in polio cases in the region as compared to the pre-eradication era.&nbsp;

&nbsp;

Since Pakistan launched its Polio Eradication Program in 1994, the number of polio cases declined by 90%. There were roughly 20,000 polio cases each year in the early 1990s and, by 2018, this number had dropped to 8 cases, highlighting the significance of this initiative<a href="#accordion">[3]</a>.&nbsp;

&nbsp;

However, Pakistan needs to make it to 0 polio cases because as long as the virus keeps circulating in human reservoirs, the disease won&#39;t be eliminated and children will remain at risk of contracting the disabling infection. Therefore, it is the responsibility of every Pakistani to abide by the rules set by the polio eradication campaigns, and make the process easier for the vaccine administration to reach out to children in the door-to-door campaigns<a href="#accordion">[4]</a>.&nbsp; 
&nbsp;

Pakistan launched its Expanded Program of Immunization&nbsp;(EPI) in 1978. It involved immunization&nbsp;against vaccine-preventable diseases, including polio. Through EPI, only 2% of the population was vaccinated against polio in 1980, and by 1990 the polio vaccination coverage had reached 54% of the population<a href="#accordion">[5]</a>. 4 years later, in 1994, an independent polio eradication campaign was launched.&nbsp;&nbsp; 
&nbsp;

<h5>Pakistan&#39;s Polio Eradication Program - 1994</h5>

The first-ever polio eradication program was launched in Pakistan in 1994, and it was a collaborative effort between the Government of Pakistan (GoP) and the Global Polio Eradication Initiative (GPEI), partnered by WHO, UNICEF, BMGF, CDC, and Rotary International.&nbsp;

&nbsp;

Through this program, supplemental immunization activities (SIAs) were carried out during National Immunization Days (NIDs). Trivalent oral polio vaccine was administered during the SIAs and it proved to be effective against all the 3 strains of wild poliovirus. This was the first step towards creating a polio-free country. The CDC even predicted that Pakistan could be polio-free in the next 2-3 years following this program<a href="#accordion">[3]</a>. 
&nbsp;

<h5>Acute Flaccid Paralysis Surveillance - 1995&nbsp;</h5>

Acute flaccid paralysis (AFP) Surveillance was initiated in 1995. However, it became fully functional in 1998. Through this surveillance program, children under 15 years of age who had developed acute flaccid paralysis (AFP) were evaluated for polio infection.&nbsp;

&nbsp;

Evaluating polio cases through AFP surveillance is key to detecting polio cases in a given region as it signals the likelihood of the spread of the disease. The surest way to make the diagnosis of polio is to detect poliovirus in the stool sample of affected individuals. Upon detection of the virus, further investigations are carried out to identify the genetic type/strain of poliovirus causing the infection<a href="#accordion">[3][6]</a>.

&nbsp;

The AFP surveillance program started receiving undivided focus in 2000. As of now, Pakistan has a sensitive and highly effective AFP surveillance program at national, provincial, and district levels. Environmental surveillance has also been added to this program where sewage is checked to detect poliovirus.&nbsp;

&nbsp;

Pakistan is known to have the largest surveillance network in the world; there are 60 surveillance sites in 40 cities nationwide<a href="#accordion">[6]</a>. 
&nbsp;

<h5>Synchronization&nbsp;Of Pakistan And Afghanistan SIAs - 1998</h5>

Since Pakistan shares its border with Afghanistan and there is mass transit between the two all year round, there was a higher risk of the spread of polio in both the countries. Therefore, to ensure a comprehensive coverage of immunization between the two countries, this initiative was taken and vaccination activities in Pakistan and Afghanistan were synchronized<a href="#accordion">[3]</a>. 
&nbsp;

<h5>Stop Transmission Of Polio (STOP) Program - 1999</h5>

The STOP program was initiated in 1999 in Pakistan by the collaborative effort of WHO, CDC, and UNICEF. In this program, international healthcare professionals were deployed to Pakistan for 3-5 months to assist in the polio eradication activities, and to improve the quality of surveillance programs that were run in the country<a href="#accordion">[3]</a>. 
&nbsp;

<h5>House-To-House Vaccination Strategy - 1998-1999</h5>

A house-to-house vaccination strategy was implemented in 1998-1999 and expanded in 2000. This approach remains the cornerstone to the polio eradication strategy in Pakistan till date<a href="#accordion">[3]</a>. 
&nbsp;

<h5>March - 2001</h5>

Approximately 27 million children were vaccinated by March 2001 in hopes that the country would be polio-free by the end of the year<a href="#accordion">[5]</a>. 
&nbsp;

<h5>First &#39;Partnership for Polio Eradication&#39; Project - 2003-2006</h5>

GoP implemented the first &#39;Partnership for Polio Eradication&#39; project in 2003. The project was funded by the World Bank and the prime objective of this project was to facilitate Pakistan with the supply of 50% of the oral polio vaccine to be used during the period of 2003- 2005. The funds were transferred to UNICEF that was responsible for the procurement and distribution of the vaccines.&nbsp;

&nbsp;

During this period, 371 million oral polio vaccines were financed and in each round of immunization, 30 million children were vaccinated<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<h5>First National EPI Policy - 2005</h5>

In 2005, the first National EPI Policy was adopted by the GoP with the aim of introducing new strategies for surveillance, and to tackle vaccine preventable diseases including polio<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<h5>Monovalent Oral Polio Vaccine - 2005-2010</h5>

Monovalent oral polio vaccine was introduced in Pakistan against wild poliovirus strain type 1 in 2005, and against wild poliovirus type 3 in 2007. These monovalent oral vaccines were used until the introduction of bivalent oral polio vaccine in 2010<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

Second &#39;Partnership For Polio Eradication&#39; Project - 2006-2008

The second &#39;Partnership for Polio Eradication&#39; project was implemented in 2006. It was an extension of the first &#39;Partnership for Polio Eradication&#39; project that was held in 2003. The World Bank financed this project as well, and, likewise, UNICEF was responsible for the procurement and distribution of vaccines.&nbsp;

&nbsp;

From 2006-2008, 590 million oral polio vaccines were financed and 30 million children were vaccinated in each round of immunization. To optimize the polio campaigns and to improve quality, finger marking was introduced in 2008<a href="#accordion">[3]</a>. 
&nbsp;

<h5>Inter-Provincial Committee For Polio (IPCP) - 2009</h5>

The ICPC was chaired by the Federal Minister of Health in 2009, and the aim of the meeting was to address the challenges faced by the polio eradication campaigns at district and union council level<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<h5>EPI Policy Revised To Introduce Lady Healthcare Workers (LHWs) - 2009</h5>

The EPI policy was revised in 2009 and it stressed upon the induction of Lady Healthcare Workers (LHWs) for the polio eradication campaigns. The LHWs who were trained in EPI were expected to deliver immunization, while those who weren&#39;t trained were given the task to assist during the vaccination campaigns<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<h5>Third &#39;Partnership For Polio Eradication&#39; Project - 2009-2014</h5>

Similar to the previous two &#39;Partnerships for Polio Eradication&#39; project, this was also financed by WHO. UNICEF again was responsible for the supply of vaccine and its handling. During this project, 32 million children were immunized against polio in each round<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<h5>National Emergency Action Plan (NEAP) - 2011-2020</h5>

The National Emergency Action Plan was launched in 2011, and an augmented plan was later launched in 2012. The NEAP focused on devising an annual strategic plan for the eradication of polio campaign. It was supported by the GPEI partners<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<h5>PM&#39;s Polio Monitoring And Coordination Cell - 2011</h5>

The purpose of the PM&#39;s polio monitoring and coordination cell was to keep a check on the polio activities happening in the country as all the activities were reported to the Prime Minister<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<h5>National Task Force On Polio Eradication - 2012</h5>

Eradication of polio was considered a national emergency by the President of Pakistan. Subsequently, the National Task Force on Polio Eradication was launched in 2012 and was chaired by the Prime Minister<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<h5>National Vaccine Management Committee (NVMC) - 2012</h5>

The National Vaccine Committee (NVCM) was established under the Federal government and it included EPI, WHO, and UNICEF. This committee was responsible for vaccine management and vaccine storage. The formation of the committee was in response to UNICEF&#39;S recommendation regarding issues with vaccination storage and cold chain maintenance.&nbsp;&nbsp; 
&nbsp;

<h5>Revision Of Security Operations And Section 144 For The Criminal Procedure Invoked - 2012&nbsp;</h5>

After multiple attacks on the polio health workers, security operations were intensified. Additionally, a criminal code was invoked and through the implementation of this rule, it became a criminal offence if a parent refused to vaccinate his or her child against poliovirus, and any action could be taken against such parents<a href="#accordion">[3]</a>.

&nbsp;

During 2012, 58 cases of wild poliovirus were reported and in 2013, 98 cases of wild poliovirus were detected and they were all due to type 1 strain of the wild poliovirus. Out of the total 151 cases, 123 cases were reported in the Federally Administered Tribal Areas (FATA) due to resistance by militant groups<a href="#accordion">[7]</a>.&nbsp; 
&nbsp;

<h5>Polio Communication Approach Shifted As An Islamic Responsibility - 2013</h5>

In light of the controversies surrounding the oral polio vaccine, it was imperative to include Islamic scholars and members of Shariah council to educate the masses about the vaccine being completely permissible in the religion. It was done in 2013 with the unanimous agreement of the GoP and UNICEF. Maulana Sami ul Haq, an eminent Muslim leader, issued an Islamic ruling (fatwa) stressing on parents to get their children immunized against poliovirus<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<h5>Emergency Operations Center (EOC) - 2014</h5>

The Emergency Operation Center was launched in 2014 at Federal and Provincial level. These centers were backed by the Polio Eradication Committee and they are responsible for managing the polio activities in their region<a href="#accordion">[3]</a>.&nbsp;

&nbsp;

In 2014, polio cases climbed to 306, the highest they have ever been since 2000<a href="#accordion">[5]</a>. However, due to constant efforts against the polio virus the number of cases dropped to 53 in 2015 and further declined to 20 cases in 2016<a href="#accordion">[8]</a>.&nbsp;&nbsp; 
&nbsp;

<h5>International Ulema Conference On Polio Eradication - 2014</h5>

The International Ulema Conference on Polio Eradication was held in 2014 and it was chaired by Islamic scholars from Saudi Arabia, Egypt, and Pakistan. In the conference, a fatwa was issued saying that it is permissible to get polio vaccine, and that it contains no harmful or forbidden (haram) ingredient<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<h5>Revision Of The National EPI Policy And Induction Of Injectable Polio Vaccine (IPV) - 2015</h5>

In 2015, the National EPI policy was revised and it highlighted the commitment of the GoP to deliver safe and effective vaccinations against the vaccine-preventable diseases. Furthermore, injectable polio vaccine (IPV) was added to the schedule of the routine immunization<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<h5>National Immunization&nbsp;Support Project - 2016</h5>

The National Immunization Support Project was launched in 2016 to get funds for the polio eradication campaigns, and to ensure equitable coverage against vaccine preventable diseases that include polio. This project aimed for a polio-free Pakistan by 2018<a href="#accordion">[3]</a>.&nbsp;

&nbsp;

A historic low of 8 cases was reported in 2017, after which the cases surged back. In 2018, 12 cases were reported; in 2019, the figures escalated to 147 before dropping to 84 in 2020<a href="#accordion">[9]</a>.&nbsp; 
&nbsp;

<h5>Polio Endgame Strategy - 2019-2023</h5>

The aim of the Endgame Strategy is to eradicate polio globally and most importantly in the polio endemic regions. This plan further aims to develop strong immunization centers to interrupt and break the chain of polio transmission.&nbsp;

&nbsp;

At provincial level, many polio eradication campaigns were held at Khyber Pakhtunkhwa and FATA region in 2014 and 2015, under the PTI government, to ensure that vaccine is dispensed in areas previously inaccessible due to security issues.&nbsp;

&nbsp;

On 27th January 2022, Pakistan achieved a historic milestone with no cases of polio being reported for a year. Unfortunately, an outbreak occurred soon afterwards in April 2022 and 11 cases were reported<a href="#accordion">[5]</a>. 
&nbsp;

Pakistan has fought bravely with the deadly poliovirus, and has been able to achieve 90% national coverage through its immunization&nbsp;efforts. Complete eradication of wild-polio type 2 and type 3 was achieved in 1997 and 2012 respectively, and only type 1 wild polio-virus remains endemic in the region. The immunization&nbsp;programs have been hindered by various political and environmental factors, but that has not stopped the GoP from making efforts against poliovirus. And health workers have worked diligently to make polio programs successful. Currently, Pakistan has 339,521 trained and hardworking polio workers that are the backbone of the polio eradication program<a href="#accordion">[2]</a>.

<ul>
	<li>Pakistan and Afghanistan are the only two countries still struggling to eradicate wild-type 1 poliovirus.&nbsp;</li>
	<li>Pakistan initiated its polio eradication program in 1994 with the support of WHO, UNICEF, and other international organizations.&nbsp;</li>
	<li>Pakistan faced challenges during the polio eradication campaigns, but the mission remains unaffected and the campaign continues to regularly&nbsp;immunize&nbsp;children.&nbsp;</li>
	<li>Pakistan&#39;s polio cases have dropped by more than 90% as compared to the pre-eradication era.&nbsp;</li>
	<li>Multiple programs have been launched at national, provincial, and district level to ensure mass immunisation&nbsp;against the poliovirus, and to make the country polio-free.&nbsp;</li>
</ul>

[1] What is Polio? - CDC.

[2] "What Is Polio?." End Polio.

[3] Ataullahjan A, Ahsan H, Soofi S, Habib MA, Bhutta ZA. Eradicating polio in Pakistan: a systematic review of programs and policies. Expert Rev Vaccines. 2021;20(6):661-678. doi:10.1080/14760584.2021.1915139

[4] Polio | UNICEF Pakistan.

[5] Polio in Pakistan - Wikipedia.

[6] The Importance of Surveillance for Polio Eradication." 14 Oct. 2016.

[7] Alexander JP Jr, Zubair M, Khan M, Abid N, Durry E. Progress and peril: poliomyelitis eradication efforts in Pakistan, 1994-2013. J Infect Dis. 2014;210 Suppl 1(Suppl 1):S152-S161. doi:10.1093/infdis/jiu450