Polio in Afghanistan: The Current Situation amid COVID-19

Abstract

Polio is a deadly viral disease that has been paralyzing many children in Afghanistan. Despite fundamental efforts, primarily vaccination, to reduce the number of cases in Afghanistan, there are still many children who are deprived of the vaccine every year. Afghanistan is one of the two remaining countries endemic for polio, and the country has undergone various challenges that have hampered the eradication of this disease. The underlying challenges include inaccessibility of unsecured areas, illiteracy, refusal, and, most recently, COVID-19. The country is in the midst of a battle against COVID-19, and polio has almost entirely been neglected. Sadly, polio cases are increasing in the country, particularly in polio-free provinces. After an initial lockdown, many businesses have been allowed to resume, but the mass polio vaccination campaign has not restarted. New cases of polio will surge if endemic regions remain unvaccinated or inaccessible. To curb the further spread of polio, Afghanistan needs to resume nationwide house-to-house vaccination as restrictions due to COVID-19 are loosened.

Full text

Am. J. Trop. Med. Hyg., 103(4), 2020, pp. 1367–1369
doi:10.4269/ajtmh.20-1010
Copyright © 2020 by The American Society of Tropical Medicine and Hygiene
Perspective Piece
Polio in Afghanistan: The Current Situation amid COVID-19
Attaullah Ahmadi,
1
* Mohammad Yasir Essar,
1
Xu Lin,
2
Yusuff Adebayo Adebisi,
3
and Don Eliseo Lucero-Prisno III
4,5
1
Kabul University of Medical Sciences, Kabul, Afghanistan;
2
Department of Thoracic Surgery, The First Affiliated Hospital, College of Medicine,
Zhejiang University, Hangzhou, People’s Republic of China;
3
Faculty of Pharmacy, University of Ibadan, Ibadan, Nigeria;
4
Department of Global
Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom;
5
Faculty of Management and Development
Studies, University of the Philippines (Open University), Los Banos, Philippines
Abstract. Polio is a deadly viral disease that has been paralyzing many children in Afghanistan. Despite fundamental
efforts, primarily vaccination, to reduce the number of cases in Afghanistan, there are still many children who are deprived
of the vaccine every year. Afghanistan is one of the two remaining countries endemic for polio, and the country has
undergone various challenges that have hampered the eradication of this disease. The underlying challenges include
inaccessibility of unsecured areas, illiteracy, refusal, and, most recently, COVID-19. The country is in the midst of a battle
against COVID-19, and polio has almost entirely been neglected. Sadly, polio cases are increasing in the country,
particularly in polio-free provinces. After an initial lockdown, many businesses have been allowed to resume, but the mass
polio vaccination campaign has not restarted. New cases of polio will surge if endemic regions remain unvaccinated or
inaccessible. To curb the further spread of polio, Afghanistan needs to resume nationwide house-to-house vaccination as
restrictions due to COVID-19 are loosened.
INTRODUCTION
Polio (poliomyelitis) is caused by a highly contagious virus
that attacks the nervous system and can lead to paralysis and
death. The virus infects unimmunized children through in-
gestion of contaminated water and food, and it spreads back
to the environment through their feces. Interestingly, 90% of
infected individuals do not exhibit any symptoms and remain
undetected yet are carriers of the virus, which can spread to
others. Thus, mass immunity is required to avoid polio out-
breaks.
1
This goal can only be fulfilled through mass polio
vaccination campaigns, which have proven to be very effec-
tive, resulting in a > 99% decrease in the total number of
worldwide cases, from an estimated 350,000 in 1988 to 33
reported in 2018.
2
Moreover, the number of endemic countries
has decreased from 125 in 1988
2
to two—Afghanistan and
Pakistan—in 2020.
1
The Global Polio Eradication Initiative (GPEI) is a public–
private partnership comprising six organizations—the WHO,
the U.S. CDC, UNICEF, Rotary International, the Bill & Melinda
Gates Foundation, and the Global Alliance for Vaccines and
Immunizations. The GPEI implements the program, aiming to
eradicate polio from the world. The GPEI decided to halt polio
vaccination until the second half of 2020 in a move to use polio
resources in the fight against COVID-19 and to prevent its
spread among the vaccinators.
3
Subsequently, there are con-
cerns that new polio cases will soar and that the disease will
enter polio-free regions, as happened in Nigeria in 2003, when
vaccination cessation resulted in spread to 16 previously polio-
free countries, including Angola, Chad, and the Democratic
Republic of Congo.
4
According to the WHO, if polio is not
eradicated in Afghanistan and Pakistan, it could spread across
the world, with 200,000 new cases every year, within 10 years.
2
New cases of polio have considerably decreased in
Afghanistan. The disease does not exist in 96% of the country.
However, the country still records a considerable number of
new cases every year. From 1997 to 2013, the annual number
of confirmed cases fluctuated between 4 in 2004 and 80 in
2011 (Figure 1).
5,6
In 2018, 21 confirmed cases of polio were
recorded. Despite the launching of door-to-door vaccination
programs in 2019, total confirmed cases reached 29 in that
year. In 2020, 34 confirmed cases have been reported as of
August 1, 2020.
6
EFFORTS
Even as house-to-house immunization campaigns were
paused, the work of polio workers continued in some parts of
the country. Under UNICEF supervision, polio social mobi-
lizers ran the Immunization Communication Network, pro-
viding mother and child health referral services and assisting
families to follow up their children’s health records. These
mobilizers are from the community. Thus, they know the
families well and can trace their immunization routines. Since
the start of the pandemic in the country, the polio mobilizers
have facilitated tracking the routine immunization schedules
of more than 37,000 children in eastern and southern regions
of Afghanistan and have provided them with referral vouchers
to go to vaccination centers. Polio mobilizers are also cau-
tioning people about the COVID-19 outbreak and how infection
can be prevented through basic public health measures.
7
Several complementary approaches have been implemented
to mitigate polio risks. One is to raise awareness regarding the
importance of immunization through regional and local media
and influential religious leaders. UNICEF coordinates other
related services regarding health, water, sanitation, and nu-
trition to accompany immunization services. It coordinates
with Pakistan to place vaccination centers along borders be-
tween the two countries to vaccinate moving populations.
7
CHALLENGES
Polio has been challenging the fragile healthcare system of
Afghanistan for a long time. The country has been constantly
fighting to fully eliminate polio, but the threads of problems
have made it complicated.
* Address correspondence to Attaullah Ahmadi, Kabul University of
Medical Sciences, Ata Turk Avenue, Kabul, Afghanistan 1004. E-mail:
attaullah.ahmadi@gmail.com
1367

At least 95% of children younger than 5 years should be
vaccinated to eradicate the virus.
8
However, the ongoing
conflict in the country has been changing the trajectory of
polio elimination. With prolonged insecurity, the program is
not implemented fully, and many children younger than 5
years are missing vaccinations, primarily in insecure prov-
inces.
9
More than 840,000 children missed vaccination op-
portunities in 2018 in six provinces, mainly in inaccessible
southern and eastern regions.
10
According to the United Na-
tions Assistance Mission in Afghanistan, of the 29 cases re-
ported in 2019, 23 were in inaccessible regions.
11
In addition,
in some cases, GPEI health workers have been targeted and
killed while on assignment.
12
Although a peace deal between
the United States and the Taliban has brought some level of
hope for appropriate health services for Afghans, including
polio vaccination, an intense battle between anti-government
and pro-government forces remains in progress.
Illiteracy, misinformation, and parental refusal are other
barriers to polio eradication. Almost 600,000 Afghan children
miss vaccination because of the refusal of their parents be-
cause of mistrust and the belief that it is prohibited in Islam.
13
Some people think it is a Western conspiracy aiming to ster-
ilize Muslim children.
14
Besides that, huge population move-
ment across the 2,700-km border between Afghanistan and
Pakistan hinders vaccination efforts.
13
Following GPEI’s recommendation to pause door-to-door
polio vaccination, the biggest challenge in the battle against
polio was in Afghanistan. National immunization days aim to
cover around 10 million children against polio,
7
and 10 na-
tionwide polio vaccination programs are usually conducted
every year. However, in 2020, only two programs were con-
ducted before the outbreak of COVID-19 in the country.
14
In
addition, vaccine stocks ran precariously low as supply chains
were disrupted by travel bans. Many health facilities where
children were normally vaccinated were closed. The current
pandemic is reigniting troubles in some of the fragile places
where access to basic h ealth and hygiene is limited.
7
COVID-19
has contributed in pushing polio beyond its endemic regions
of the south and southeast, and now, it threatens everyone
throughout the country. Polio cases have recently emerged in
three provinces, Balkh, Herat, and Badakhshan, which had not
reported any cases in the past 5 years.
14
On May 21, 2020, the
government of Afghanistan ratified an initial plan for loosening
restrictions and allowing some businesses, including money
exchange markets and shops, to reopen.
15
However, this plan
did not include restarting nationwide polio vaccination, and as
of August 1, 2020, the program remains suspended.
CONCLUSION
The fight against polio, which has been waged in Afghani-
stan for a long time, has played a substantial role in controlling
the disease. There are still insecure places in the country which
present new cases every year. With COVID-19 dominating pri-
orities, the country’s existing health facilities and resources have
been reallocated to the fight against the pandemic, resulting in an
increase in polio cases, particularly in previously polio-free
provinces. New cases of polio will surge if endemic regions re-
main unvaccinated or inaccessible. For Afghanistan to curb the
further spread of polio, it needs to resume nationwide vaccination
within the policy of gradual relaxation of pandemic restrictions,
rather than shifting all resources to COVID-19.
Received August 13, 2020. Accepted for publication August 21, 2020.
Published online August 27, 2020.
Acknowledgment: Publication charges for this article were waived due
to the ongoing pandemic of COVID-19.
Authors’addresses: Attaullah Ahmadi and Mohammad Yasir Essar,
Kabul University of Medical Sciences, Kabul, Afghanistan, E-mails:
attaullah.ahmadi@gmail.com and yasir.essar@gmail.com. Xu Lin,
Department of Thoracic Surgery, The First Affiliated Hospital, College
of Medicine, Zhejiang University, Hangzhou, People’s Republic of
China, E-mail: linxu_001@zju.edu.cn. Yusuff Adebayo Adebisi, Fac-
ulty of Pharmacy, University of Ibadan, Ibadan, Nigeria, E-mail:
adebisiyusuff23@yahoo.com. Don Eliseo Lucero-Prisno III, Department
of Global Health and Development, London School of Hygiene and
Tropical Medicine, London, United Kingdom, and Faculty of Man-
agement and Development Studies, University of the Philippines
(Open University), Laguna, Philippines, E-mail: doneliseo.prisno@
upou.edu.ph.
This is an open-access article distributed under the terms of the
Creative Commons Attribution (CC-BY) License, which permits un-
restricted use, distribution, and reproduction in any medium, provided
the original author and source are credited.
REFERENCES
1. GPEI, 2020. Polio +Prevention. Available at: http://polioeradication.
org/polio-today/polio-prevention/. Accessed July 1, 2020.
FIGURE 1. Wild polio cases in Afghanistan. Numbers for 2020 are through August 1, 2020. Source: Global Polio Eradication Initiative. Wild polio
cases in Afghanistan. Cases per year are shown.
1368 AHMADI AND OTHERS

2. World Health Organization, 2019. Poliomyelitis. Available at:
https://www.who.int/news-room/fact-sheets/detail/poliomyelitis.
Accessed July 1, 2020.
3. Roberts L, 2020. ‘We Have No Choice’. Pandemic Forces Polio
Eradication Group to Halt Campaigns. Available at: https://
www.sciencemag.org/news/2020/04/we-have-no-choice-
pandemic-forces-polio-eradication-group-halt-campaigns/.
Accessed June 30, 2020.
4. Chang A, Chavez E, Hameed S, Lamb R, Mixon K, 2012. Eradi-
cating Polio in Afghanistan and Pakistan. Available at: https://
reliefweb.int/sites/reliefweb.int/files/resources/120810_Chang_
EradicatingPolio_Web.pdf. Accessed June 30, 2020.
5. Simpson D et al., 2014. Polio eradication initiative in Afghanistan,
1997–2013. J Infect Dis Nov 210: S162–S172.
6. GPEI, 2020. Afghanistan. Available at: http://polioeradication.org/
where-we-work/afghanistan/. Accessed August 1, 2020.
7. UNICEF, 2020. Polio Eradication: Reaching Every Child in
Afghanistan with Polio Vacci nes. Available at: https://www.
unicef.org/afghanistan/polio-eradication. Accessed July 5,
2020.
8. Akinwotu E, 2020. Polio Campaign in Africa Put on Hold during
Coronavirus. Available at: https://amp.theguardian.com/global-
development/2020/apr/29/polio-campaign-in-africa-put-on-
hold-during-coronavirus. Accessed June 30, 2020.
9. CDC, 2018. Progress toward poliomyelitis eradication –Afghanistan,
January 2017–May 2018. Morb Mortal Wkly Rep 67: 833–
837.
10. World Health Organization, 2018. Afghanistan Polio Eradication Ini-
tiative. Available at: http://www.emro.who.int/afg/programmes/
polio-eradication-initiative.html. Accessed June 30, 2020.
11. UNAMA, 2020. Afghanistan Annual Report on Protection of Civilian in
Armed Conflict: 2019. Available at: https://unama.unmissions.org/
sites/default/files/afghanistan_protection_of_civilians_annual_
report_2019_-_22_february.pdf. Accessed June 12, 2020.
12. RFERL, 2016. Three Polio Workers Killed in Eastern Afghanistan.
Available at: https://www.rferl.org/amp/polio-workers-killed-
afghanistan/27537282.html#aoh=15933509982693&referrer=
https%3A%2F%2Fwww.google.com&amp_tf=From%20%
251%24s. Accessed June 30, 2020.
13. Yusufzai A, 2019. Efforts to eradicate polio virus in Pakistan and
Afghanistan. Lancet Child Adolesc Health 4: 17. Available at:
https://doi.org/10.1016/S2352-4642(19)30382-7.
14. AFP, 2020. New Polio Cases in Afghanistan as Coronavirus Halts
Immunization. Available at: https://medicalxpress.com/news/
2020-06-polio-cases-afghanistan-coronavirus-halts.html.
Accessed June 30, 2020.
15. Office of the President of Afghanistan, 2020. Gradual Relaxation
of the Restrictions. Available at: https://president.gov.af/da/?
p=25128. Accessed June 30, 2020.
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