Achieving the End Game: Employing "Vaccine Diplomacy" to Eradicate Polio in Pakistan

In addition to security issues, other challenges, including false beliefs about vaccines and distrust of healthcare workers, play a role in the continued persistence of polio in Pakistan. Assessing the local and international policy environment and its impact on polio eradication in Pakistan, this paper identifies a set of concrete public health, international development, and diplomatic and policy recommendations that can act synergistically under the umbrella of health and vaccine diplomacy to finally put an end to polio.

The paper begins by examining the characteristics of polio in Pakistan, which (along with Afghanistan) remains an endemic reservoir of wild polio virus (WPV). As reported here, based on official data shared by the Pakistani government, more than 40% of the 116 WPV cases that occurred during 2014 were a result of vaccination refusal by families. Most polio cases occurred in Federally Administered Tribal Areas, or FATA (an area neighbouring Khyber Pakhtunkhwa, or KPA) and in the Baluchistan border area with Afghanistan. Combined political instability, security hazards, lower literacy levels, and local religious beliefs are among the challenges associated with eradicating this infectious disease in an area sensitive to social and politically-related risk factors.

In 2016-2017, the Pakistani Ministry of Health, Regulations and Coordination, the National Provincial and FATA Emergency Operations Centers, and donors and technical partners jointly developed the National Emergency Action Plan (NEAP). The Plan's strategic objectives are to eradicate WPV transmission and sustain disease interruption via open communication and multi-stakeholder cooperation. However, efforts to implement the NEAP have been impeded by factors such as persisting distrust among communities living along the border between Afghanistan and Pakistan, where some people believe that a polio vaccine could make them sterile; this distrust has also spread to other provinces like Baluchistan (Quetta).

Social determinants of health have contributed to the risk of polio's spread in FATA, in particular, as discussed in the paper. Efforts to address these social determinants of health are ongoing. A 2012 study of 2-parent households found that the father's decisions, especially in the rural communities, impacted vaccination coverage decisions in the family. These findings indicate that improved education and targeted health promotion and interventions could improve vaccination coverage and prevention of other treatable diseases.

"Vaccine diplomacy" is described here as a branch of global health diplomacy that promotes the use and delivery of vaccines to achieve larger global health goals and shared foreign policy objectives. The paper argues for a holistic approach that involves coordinating multiple areas of leadership, advocacy, policy, and global governance, including around specific areas of:

1. Increasing national access to and ensuring the safety of the vaccine supply chain;
2. Improving water and sanitation in affected areas;
3. Enhancing environmental surveillance;
4. Mobilising community and religious leaders;
5. Assisting internally displaced persons (IDPs); and
6. Conducting effective vaccine health promotion and communication activities.

Table 1 in the paper offers in-depth information regarding these specific recommendations, their primary challenges in the context of polio eradication, and potential solutions. Examples:

• With regard to #4, above, the Imam and other religious leaders can help educate their communities that immunising children and adults will eradicate polio. These leaders may be more persuasive and effective champions by practicing informal and grassroots vaccine diplomacy than national politicians or health staff due to the familiarity with culture and customs specific to affected areas of Pakistan that remain reservoirs for polio transmission. Fatwas (religious decisions) supporting polio vaccination and delivery of messages direct to the FATA and other border communities can also enhance community engagement, secure buy-in, and increase vaccination participation to ensure better compliance with polio eradication programmes.
• With regard to #6, above, people in border areas communicate more frequently through mobile phones compared to traditional mass media forms such as television broadcasts. In response, mobile applications using m-health (mobile health) interventions have been deployed to help polio eradication teams increase their vaccination coverage in affected areas. In Pakistan in 2010, for example, mobile SMS-based service enabled parents to report missed cases of polio vaccine coverage.

Among other approaches discussed in the paper are stakeholder mechanisms to promote vaccine diplomacy in Pakistan and in the broader region, which have included efforts to ensure inter-country coordination between Pakistan and Afghanistan. For instance, on September 21 2016, the Common Reservoirs Coordination Meeting included senior representatives from organisations that make up the Global Polio Eradication Initiative (GPEI) and senior representatives from each country coming together to discuss disease outbreaks in the Pakistan and Afghanistan border areas. They emphasised the critical need for stable relationships between the governments to contain disease spread. Health reporters stressed how improved bilateral notification and information reporting have enhanced polio surveillance, although issues surrounding delayed cross-border notifications still needed to be addressed.

As an example of opportunities for increased military engagement in polio operations, the Pakistan Armed Forces can help improve polio vaccination coverage by training soldiers in polio vaccination techniques to be used during military operations in affected areas.

In conclusion, the paper suggests that "Pakistan's Polio Eradication Program requires continuous monitoring and surveillance in highly at-risk populations, policy action that is responsive to polio surveillance, and effective communication around the importance of polio vaccination as core interventions. Additionally,...there is a need for sustainable informative technology to deliver treatment, effective health communication and interventions, motivated religious leaders to engage with communities impacted, political commitment for funding and resource commitment, border stability to contain cross-border disease spread, and sustained global efforts to ensure adequate polio eradication funding."