Understanding the Reasons for Refusal of Polio Vaccine by Families in Quetta Block, Pakistan

"Misconceptions about the vaccine are the main driving force behind vaccine refusals in the study setting. Efficient strategies are required to address misconceptions in this red zone of poliovirus transmission in Balochistan."

Eradication of polio has yet to be achieved in countries like Pakistan, where a surge in number of polio cases was reported in 2019 (146 cases, compared to 12 in 2018). A major reason given for this regression was the increase in vaccine refusals by parents and caretakers. In light of the fact that vaccine refusal is complicated and must be understood in its social, cultural, religious, and epidemiological contexts, this paper attempts to explain why Pakistan has been experiencing high caseloads despite achieving record success in vaccine coverage and political and community engagement.

The study was conducted using data acquired from the 2 polio vaccination campaigns that were conducted in the Quetta Block, Baluchistan province, Pakistan in 2019. The total sample was 754,945 children aged 0-5 years residing in Quetta Block, covering 2 campaigns: the campaign for April [national immunisation day (NID)] and the campaign of June [subnational immunisation day (SNID)]. NID is a mass immunisation campaigns conducted door to door, across the country, to provide polio vaccine to every child under the age of 5 years, whereas SNID is conducted only in those areas with high numbers of positive cases to ensure proper immunisation. The healthcare workers recorded the reasons for refusals during the campaigns using a standardised tool (tally sheet) designed by the World Health Organization (WHO).

Refusal rates were almost 8.6% for the polio campaign of April and 8.1% for June 2019. The total number of refusals was 62,009. Overall, the most prevalent reason for refusal was misconception about vaccines, reported by 34,943 (56.4%) individuals. Other factors were: religion 10,110 (16.3%), children sleeping 7,734 (12.5%), child was sick 4,443 (7.2%), repeated campaigns (fatigue) 3,174 (5.1%), demand for compensation 1,510 (2.4%) and other reasons 96 (0.2%).

In reflecting on the study's findings about misinformation, the researchers point to previous analyses that have highlighted suspicion of health workers linked to the discovery of Osama bin Laden's residence in Pakistan. It was alleged that one of the doctors administering the polio vaccination door to door used this activity as a camouflage to access bin Laden's residence. Research shows that this rumour has impacted polio vaccination severely. However, the exact impact of these rumours has still not been extensively studied.

With regard to the data on religious-based refusal, the researchers discuss the government of Pakistan's establishment in November 2015 of the Islamic Advisory Group on Polio Eradication (IAG). As part of this group, clerics help raise community awareness about the benefits of polio vaccine and affirm that vaccination does not conflict with the teachings of Islam. The IAG has held multiple sessions with healthcare providers to discuss every aspect of polio vaccination and NIDs/SNIDs and has developed literature on polio vaccination based on the Quran and Hadith - promoting it via electronic and print media to help counter negative religious beliefs about polio vaccine. As reported here, these efforts have "had a positive impact on the polio campaigns and helped decrease the rate of refusals. However, efforts need to continue....[S]ustained efforts by the IAG can result in significant decline of vaccine refusals due to religious beliefs."

In the context of recent efforts to boost the COVID-19 vaccine acceptance rates, "[a]s a significant step towards promoting vaccines and mitigating misinformation around vaccines, the Government of Pakistan collaborated with UNICEF [United Nations Children's Fund] to track vaccine uptake trends through social media analysis and research surveys. This action allowed the government to design content (flyers, social media posts, mainstream media news, advertisements) that address the rumours and underlying fear among the public. The Ministry of Health expanded the polio vaccination helpline in the country to include COVID 19 and allow easy public access to vaccines and information about them."

The researchers conclude that, contrary to popular belief that religion contributes most to vaccine hesitancy in Pakistan's polio context, "this study confirms that misconceptions are of far greater significance. Targeted efforts to address existing and emerging reasons for refusal must be made to improve the community's acceptance and perception of the polio vaccine." Examples like the ones shared in this paper hold promise to support these aims, according to the researchers, who "reiterate that the Quetta Block represents a high-risk area and can compromise national eradication efforts if not addressed immediately."