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A sense of despondency, perhaps even desperation, has been encountered in official Pakistan health circles as 192 cases of polio were reported in 2011, according to the Global Polio Eradication Initiative, despite the launch of a National Emergency Action Plan for Polio Eradication at the start of the year.
The plan was launched after 144 cases were recorded in 2010 - the highest in any nation in the world. The president announced at the time that the purpose was to make the nation "polio free".
The initiative, however, has not been successful, with more incidents of polio reported, and a complete failure to match the success of neighboring countries such as India, which this month completed its first 12-month period without a single case of polio, says a report by IRIN, the UN information unit.
The national coordinator of the prime minister's Polio Eradication and Monitoring Cell, Altaf Bosan, told from Islamabad that while the program was an "extensive and elaborate one", the poor figures showing up were a result of "refusals by households" to have children vaccinated, mainly due to a lack of awareness.
Chairing a meeting in November on polio eradication, as it became clear that the figures for 2011 would be higher than for 2010, the prime minister said officials failing to deliver should be "sacked rather than transferred".
But there has been emerging evidence that the problem of eradicating polio may be more complex than simply a matter of "refusals" or administrative laxity.
Chairperson and Professor of Paediatrics and Child Health at the Aga Khan University Hospital (AKUH) in Karachi Anita Zaidi told: "Malnutrition among children in our country is a significant factor in the problems with the anti-polio campaign."
She said data from India and some data "that had not yet been published but had been shared with the WHO [World Health Organization]" from Pakistan showed that the immune response to polio vaccinations was about four percent lower in malnourished children than in nourished ones.
"With some 40 percent of our children undernourished, this means a large number may not be responding adequately," she said.
According to official figures, Pakistan has 25 million children under five.
Zaidi, who is an expert in infectious diseases, also said the problem was aggravated due to poorly run campaigns which meant all children did not get all doses of the polio vaccine. "When only four or five doses are received rather than the full seven, there is a greater chance of a lack of response, especially among poorly nourished children."
She said there was a need to improve campaign quality and also focus on routine vaccination campaigns as a whole, protecting children against various preventable diseases, rather than focusing exclusively on offering vaccination against polio.
"Because of the concentration on polio, the routine vaccination levels have really slipped and this affects children very badly," she said. "The polio drops must be administered as part of the full immunization plan," she said.
Jehanzeb Khan, health secretary in Punjab Province, where eight cases of the virus were detected this year, told IRIN: "Experts are looking at the possibility that a poor immune response caused by malnutrition may be a factor in the cases." He said polio had occurred among children who had received multiple vaccine doses.
The problem of vaccines not working due to widespread malnutrition has been taken up by medical professionals studying the polio epidemic in Pakistan. At a seminar at AKUH in Karachi, widely reported in the media pediatric specialists discussed the problem in depth, with Zulfiqar Ali Bhutta, chief of the Division of Women and Child Health at AKUH, stating that the finding that 24 percent of polio cases reported in the country till November 2011 occurred among vaccinated children needed to be investigated further.
"Malnutrition, Vitamin A deficiency, and diarrhea in children, could be the reasons why the vaccines were ineffective. It is twice as likely that the polio vaccine does not convert in malnourished children," Bhutta said.
Malnutrition has been identified as a major problem among children, notably in Sindh Province, but also exists elsewhere in the country.
Baseer Achakzai, the national nutrition focal person at the National Institute Health in Islamabad, told IRIN a recent survey conducted by the Ministry for Health in collaboration with AKUH had found 60 percent of the population was food insecure. "Yes, food insecurity and malnutrition are growing. Poverty is certainly a factor but there has also been a failure to put adequate policies in place," Achakzai said.
The impact of widespread malnutrition on the problems Pakistan is facing with its polio campaign are only now beginning to be discussed.
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