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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.
Am. J. Trop. Med. Hyg., 103(4), 2020, pp. 13671369
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 Afliated Hospital, College of Medicine,
Zhejiang University, Hangzhou, Peoples 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 fullled 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 twoAfghanistan and
Pakistanin 2020.
1
The Global Polio Eradication Initiative (GPEI) is a public
private partnership comprising six organizationsthe 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 ght 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 conrmed cases uctuated between 4 in 2004 and 80 in
2011 (Figure 1).
5,6
In 2018, 21 conrmed cases of polio were
recorded. Despite the launching of door-to-door vaccination
programs in 2019, total conrmed cases reached 29 in that
year. In 2020, 34 conrmed 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 childrens 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 inuential 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
ghting 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
conict 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 GPEIs 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 ratied 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 ght 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 countrys existing health facilities and resources have
been reallocated to the ght 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.
Authorsaddresses: 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 Afliated Hospital, College
of Medicine, Zhejiang University, Hangzhou, Peoples 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.
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1368 AHMADI AND OTHERS
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POLIO AMID COVID-19 IN AFGHANISTAN 1369
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Abstract Objective: The present study aimed to assess the attitude and perception of Kabul city’s residents toward COVID-19 vaccines hesitancy and acceptance. Methods: Applying a cross-sectional study design, the data was collected from 665 participants in Kabul city using a predesigned validated questionnaire. For statistical analysis, Spearman correlation, chi-square, and logistic regression techniques were used. Results: Although the vaccine availability was limited for the public during the survey period, 70.5% of the participants were willing to receive COVID-19 vaccines. Meanwhile, 49.2% participants were concerned about the COVID-19 vaccines side effects. The presence of positive COVID-19 cases among family members and friends (OR: 2.7), presence of fears during COVID-19 pandemic (OR: 4.4) and beliefs that vaccine has important and vital role in people’s protection against COVID-19 (OR: 5.3), increase the likelihood of vaccine acceptance among the participants. On the other hand, participant’s mistrust of the safety of COVID-19 vaccines (OR: 0.21) and disbelief on ministry of public health “MoPH” advice about COVID-19 vaccine safety and efficiency (OR: 0.27) decrease the odds of COVID-19 vaccine acceptance among the respondents. In addition, a strong correlation was found between vaccine attitude and vaccine acceptance scales (Spearman ρ=0.52, p<0.001). Conclusion: Although majority of the participants were willing to receive the COVID-19 vaccines, due to high level of participant’s concerns about COVID-19 vaccines-related side effects, a great proportion of the respondents were hesitate to receive the COVID-19 vaccines. Accordingly, public awareness about COVID-19 vaccines must be increased to counteract incorrect and misleading propaganda about vaccination and immunization.
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Polio, or poliomyelitis, is a disabling and life-threatening disease caused by three poliovirus (PV) serotypes. The virus spreads from person to person and can infect a person’s spinal cord, causing paralysis. In 1988, when the WHO registered 350,000 cases of poliomyelitis in the world and 70,000 which occurred in Africa alone, global poliomyelitis eradication was proposed by the World Health Organization to its member States. On 25 August 2020, while the world was waging war against the Coronavirus pandemic, a historic milestone was reached: Africa was officially declared polio-free. It is an important result obtained thanks to an intensive large-scale vaccination campaign. The road was far from smooth, nevertheless, according to the WHO, a great effort needs to be made in order to facilitate access to vaccination and to promote its implementation in those countries where coverage is low and vaccine hesitancy is high because the risk of the spread of poliomyelitis is still relevant. Eradication of the virus in Africa provides us with an excellent opportunity to commemorate the many scientists who contributed to achieving this epoch-making goal: first of all, Jonas Salk, who developed a killed-virus vaccine in 1952, and, especially, Albert Sabin, who in 1961 launched programs of mass immunisation with his oral vaccine against poliomyelitis.
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Afghanistan, Pakistan, and Nigeria remain the only countries where transmission of endemic wild poliovirus type 1 (WPV1) continues (1). This report describes polio eradication activities, progress, and challenges to eradication in Afghanistan during January 2017-May 2018 and updates previous reports (2, 3). Fourteen WPV1 cases were confirmed in Afghanistan in 2017, compared with 13 in 2016; during January-May 2018, eight WPV1 cases were reported, twice the number reported during January-May 2017. To supplement surveillance for acute flaccid paralysis (AFP) and laboratory testing of stool samples, environmental surveillance (testing of sewage samples) was initiated in 2013 and includes 20 sites, 15 of which have detected WPV1 circulation. The number of polio-affected districts increased from six in 2016 to 14 in 2017 (including WPV1 cases and positive environmental samples). Access to children for supplementary immunization activities (SIAs) (mass campaigns targeting children aged <5 years with oral poliovirus vaccine [OPV], regardless of vaccination history), which improved during 2016 to early 2018, worsened in May 2018 in security-challenged areas of the southern and eastern regions. To achieve WPV1 eradication, measures to maintain and regain access for SIAs in security-challenged areas, strengthen oversight of SIAs in accessible areas to reduce the number of missed children, and coordinate with authorities in Pakistan to track and vaccinate mobile populations at high risk in their shared transit corridors must continue.
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Background: This article reviews the epidemiology of polio, acute flaccid paralysis (AFP) surveillance, and the implementation of supplemental immunization activities (SIAs) in Afghanistan from 1997 thru 2013. Methods: Published reports and unpublished national data on polio cases, AFP surveillance, and SIAs were analyzed. Recommendations from independent advisory groups and Afghan government informed the conclusions. Results: From 1997 thru 2013, the annual number of confirmed polio cases fluctuated from a low of 4 in 2004 to a high of 80 in 2011. Wild poliovirus types 2 and 3 were last reported in 1997 and 2010, respectively. Circulating vaccine-derived poliovirus type 2 emerged in 2009. AFP surveillance quality in children aged <15 years improved over time, achieving rates>8 per 100,000 population. Since 2001, at least 6 SIAs have been conducted annually. Conclusions: Afghanistan has made progress moving closer to eliminating polio. The program struggles to reach all children because of management and accountability problems in the field, inaccessible populations, and inadequate social mobilization. Consequently, too many children are missed during SIAs. Afghanistan adopted a national emergency action plan in 2012 to address these issues, but national elimination will require consistent and complete implementation of proven strategies.
Eradicating Polio in Afghanistan and Pakistan
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Polio Campaign in Africa Put on Hold during Coronavirus
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