Polio Exporter: Pakistan Slapped With Travel Restrictions

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Pakistani Sonya Javed, 20, right, holds her son Shahzeb, 1, to receive a polio vaccine by a health worker at her home in Islamabad, Pakistan. (AP/Muhammed Muheisen)

Strains of the polio virus found throughout the world have been traced back to Pakistan, so it was only a matter of time before the country’s travelers would face travel restrictions.

Naeem Sadiq, a Karachi-based businessman, was set to travel to London, Vancouver and Baltimore, last week to visit his children, but then he heard about possible travel restrictions to be imposed on Pakistanis.

With just two days before he was scheduled to leave, he rushed to find out from various hospitals, government health departments and other authorities how he could be administered polio drops and where he could obtain a certificate saying he did so that would be accepted by immigration officers abroad.

Sadiq told MintPress News of two ways to get the drops and the certificate. One can either obtain these items at an airport kiosk, just prior to departure, “which is risky, as there are long lines and you can miss your flight,” he said, or go straight to the dispensary in the airport. “I did the latter,” he said.

On May 5, the World Health Organization declared the spread of polio an “international public health emergency” requiring an “international response” after it was reported that the virus had been found in 10 countries worldwide so far this year.

“[T]he international spread of polio to date in 2014 constitutes an ‘extraordinary event’ and a public health risk to other States for which a coordinated international response is essential,” the WHO said in a statement.

“If unchecked, this situation could result in failure to eradicate globally one of the world’s most serious vaccine preventable diseases.”

Progress, regression

Despite a 25-year global polio vaccination drive funded largely by foreign donors, Pakistan remains among the three countries in which the virus remains endemic and rife. (The other two are Nigeria and Afghanistan.)

Pakistan had been making good progress in fighting polio: 58 cases were reported in 2012, compared to 198 in 2011.

But then last year, 92 cases were reported. Afghanistan and Nigeria reported 13 and 53 cases, respectively, but in Pakistan, the number of affected children not only doubled — it was more than the other two countries combined. Since January this year, 61 new cases have been recorded.

Pakistan also has the distinction of exporting the virus to other countries. In October, polio was confirmed in 13 of 22 Syrian children who became paralyzed in Deir al-Zor province, marking the country’s first polio infections in 14 years, and the origin of the virus was traced to a strain found in Pakistan.

In 2011, a strain of polio — wild poliovirus type 1, or WPV1 — isolated in China’s Xinjiang region was also traced back to Pakistan. This outbreak affected 10 young children and resulted in two deaths. For China, which has had no endemic cases of polio since 1994, this presented a serious cause for concern.

In December 2012, a strain of the virus from Pakistan was detected in the sewage of Cairo, and in April 2013, a strain in Israel, the West Bank and Gaza Strip was found to have originated in Pakistan.

 Exporting polio

With their country’s reputation for spreading the virus growing ever worse, many speculated that it was inevitable for Pakistanis to be slapped with travel restrictions.

“It was sadly imminent with the rise in polio cases,” Sherry Rehman, former ambassador of Pakistan to the United States, told MintPress. “It will put travelers from Pakistan under unprecedented health protocols.”

The directive to restrict Pakistani travel can not go into effect until after Pakistan receives the required vaccines, though. To date, the vaccines have been procured only for children, so there is not currently enough to meet adult demand. The government was given a 15-day window to procure enough polio vaccines to meet this new demand.

“We just get vaccines for children, but the WHO directive is to vaccinate anyone and everyone leaving the country,” said Dr. Mazhar Khamisani, who heads the Extended Program on Immunization in Pakistan’s Sindh province.

Khamisani estimates that the Sindh province would need 150,000 polio vials for the next six months, noting that each vial contains 20 doses.

Conceding that the government will need some time to work out the specifics of how to put the recommendations into action, Dr. Ni’ma Abid, the acting WHO representative in Pakistan and an epidemiologist, said the WHO would “support the government in doing so.”

According to figures from the Extended Program on Immunization, over 50,000 people leave Sindh province via various modes of transportation each week. Sindh province likely handles the highest volume of travelers in the country, as it is home to Karachi’s Jinnah International Airport.

While the restrictions will keep the immunization program and various provincial health departments on their toes for the next six months, many in Pakistan see the travel restriction as an affront.

“I don’t know if as a nation we are even registering the continuing shame we are being subjected to. It is now taken rather as a given, which is scary. This development has been one of the utmost humiliation and its consequences can be disastrous in many different kinds of ways and long term, unless we can eradicate polio and are able to convince the world of that,” urban planner Farhan Anwar told MintPress.

Vaccination blocks and possible solutions

Abid, of the WHO, stressed that polio will continue to spread because there “are pockets of children who aren’t being reached with polio vaccine.”

While the geographic distribution of wild poliovirus is shrinking globally, he said, it is increasingly confined to areas with severe security constraints that curtail communities’ access to vaccines.

“The transmission of polio in areas without active vaccination taking place, such as parts of northwestern Pakistan, has particularly increased the risk of international spread,” the WHO representative said.

Many place the blame for this problem on the militants in the Federally Administered Tribal Agencies, or FATA. This region has seven administrative districts, known as agencies, bordering Afghanistan and is a stronghold of militant groups who demand that Pakistan enforce Shariah, or Islamic law.

“No polio campaigns have been conducted in North Waziristan and South Waziristan agencies in FATA due to the ban on vaccination by local elements since June 2012, and, as a result, the virus has spread in 2013 and 2014,” Abid explained.

Of the 61 reported cases this year, 47 are from FATA, including 41 reported in North Waziristan, he explained.

Further, due to military operations in areas like the Khyber Agency in FATA, vaccination campaigns have not been able to access these areas.

“I do feel valuable time has been lost, and in the conflation of terrorist dialogue with tolerance for extremist discourse that we see, space for polio programs and vaccinators has definitely gone down,” former Ambassador Rehman said, referring to the peace dialogue — which is currently at a standstill — between the government and the Pakistani Taliban. “Only a year back, Pakistan was much closer to the target zero.”

Cases of polio have been reported in the cities of Karachi and in Peshawar. The WHO has declared the latter (in the Khyber Pakhtunkhwa province) as the “largest reservoir of endemic polio virus in the world”. Abid puts this to “inconsistent campaign quality,” which has resulted in sub-optimal vaccination coverage and, thus, low immunity against polio.

“When you add to this the high rate of population movement to and from polio infected areas, you can understand why it has resulted in the reintroduction of the virus to areas which were previously polio free,” he said.

He also noted that the anti-polio campaigns have been affected by threats to frontline polio workers. In the past two years alone, over 30 polio vaccinators have been killed.

At the same time, government officials have never shied away from shifting part of the blame on the episode of Dr. Shakil Afridi — an event that has made Pakistanis wary of anyone offering vaccines.

A physician from FATA’s Khyber Agency, Afridi carried out a fake door-to-door hepatitis B vaccination drive led by the CIA to confirm the presence of Osama bin Laden in his Abbottabad home. Afridi was arrested shortly after the May 2, 2011, U.S. raid that killed the head of al-Qaida.

“Shakeel Afridi was certainly responsible for exaggerating fears about polio vaccines and the motives behind it,” Rehman said, adding, “The problem was clearly an existing one.”

She further explained:

“His role inflamed anger against already endangered vaccinators in the tribal frontlines, but it did not create the resistance to vaccination among some, nor can it wash away governance deficits in the coverage of the program. As Pakistanis, we do have to take responsibility for what governments can deliver in terms of vaccines and health care awareness. Sometimes the blame is placed only on external actors — which have now done egregious damage, too. [This] takes away from the dispassion needed to take realistic stock of a real challenge on the ground. Remedies can only flow from government action.”

Dr. Zulfiqar Bhutta is Pakistan’s leading pediatrician and founding director of the Center of Excellence in Women and Child Health at Karachi’s Aga Khan University. He believes the travel restrictions could be a boon, “if it has the impact people predict it might,” but he remains skeptical.

Speaking to MintPress from London, he said of the government’s decision to set up polio drop kiosks at airports and other public spaces, “It could also divert resources — human, material and vaccine — to a whole new set of activities, thereby diverting from eradication efforts where they are needed.”

He pointed to the yellow fever vaccination requirement for travel to and from several countries. To date, this requirement has not eradicated the disease in these countries.

Asked what he would do if he were tasked with eradicating polio from Pakistan, Bhutta said he would focus more on “winning hearts and minds of communities around child health and integrating polio with routine immunizations.”

He would also “promote better targeted campaigns with mother, neonatal and child health interventions and set up better quality data and accountability system.”

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