Dear editor,
In a recent manuscript entitled” The negative impact of the COVID-19 Pandemic on immunization and the positive impact on Polio eradication in Pakistan and Afghanistan“,1 we described the looming threat of poliovirus outbreak in Pakistan and Afghanistan due to the disruption in immunization imposed by COVID-19 Pandemic. The concerns raised by the authors are proved correct as shown by the ongoing poliovirus outbreak in Pakistan and Afghanistan. In this paper, we would like to discuss the impact of the COVID-19 Pandemic on derailing the fight against polio in Pakistan and Afghanistan.
The global polio eradication initiative was established in 1988 when the wild poliovirus was endemic in 125 countries. Due to the tremendous efforts of the global polio eradication initiative, the number of polio cases has decreased by more than 99%, from 350,000 cases in 1988 to 118 cases in 2017. Immunizations have saved billions of lives and prevented countless illnesses and disabilities across the globe.2
Before the emergence of COVID-19, polio was considered one of the most challenging infectious diseases of global public health concern.
Pakistan and Afghanistan are the last two countries in the world where the wild poliovirus is still endemic as 100% (67.5% in Pakistan,32.5% in Afghanistan) of polio cases were reported in these two countries in the last five years.3
Unfortunately, eight wild poliovirus cases were reported from the North Waziristan area of Khyber Pakhtunkhwa (KPK) province of Pakistan. First wild polio case was reported on April 22 , 2022, and eighth polio case was reported on 6th June,2022. The southern part of KPK province bordering Afghanistan had been marked as the area at high risk after the identification of two wild polioviruses in the environmental samples in the last quarter of 2021 from D.I Khan and Bannu Districts.4 Similarly, one case of wild poliovirus was reported in a 24-Month-old female child in Afghanistan in February 2022 in the Dila District of Paktika province5 which is 126 km from the Waziristan area of Pakistan Fig 1 . We fear that more children from the same area may be affected as the virus circulate in the upcoming peak season.
Fig. 1.
Wild poliovirus outbreak in the border area of Pakistan and Afghanistan in 2022.
In 2021, the number of wild poliovirus-1 (WPV1) cases reported was only five (4 in Afghanistan and one in Pakistan), the lowest level in history. Before the COVID-19 pandemic, the polio cases rose from only 12 and 21 polio cases reported in 2018 to 147 and 29 cases in 2019 in Pakistan and Afghanistan, respectively. During the year 2020, the number of polio cases decreased in Pakistan and increased in Afghanistan. Details of reported polio cases in Pakistan and Afghanistan from 2017 to 2022 are presented in Table 1 .
Table 1.
Reported wild poliovirus cases in Pakistan and Afghanistan 2017–2022.
| Year |
Pakistan n (%) |
Afghanistan n (%) |
Total n (%) |
|---|---|---|---|
| 2017 | 8 (3.1) | 14 (11.2) | 22 (5.7) |
| 2018 | 12 (4.6) | 21 (16.8) | 33 (8.5) |
| 2019 | 147 (56.5) | 29 (23.2) | 176 (45.7) |
| 2020 | 84 (32.3) | 56 (44.8) | 140 (36.3) |
| 2021 | 1 (0.38) | 4 (3.2) | 5 (1.3) |
| 2022 | 8 (3.1) | 1 (0.8) | 9 (2.3) |
| Total | 260 (67.53) | 125 (32.47) | 385 (100) |
The latest wild polio cases in Pakistan and Afghanistan have raised to 11 global number of polio infections in 2022, including one in Malawi and one in Mozambique. Malawi has detected a case of wild polio in a 3-year-old child in Lilongwe District and the virus was genetically linked to the poliovirus circulated in Sindh province of Pakistan [6]. The resurgence of polio is a tragedy for the infected children and their families. It is very unfortunate for Pakistan, Afghanistan, and polio eradication efforts all over the world. With only five cases in 2021 in both countries, it was considered that the program is on track to have the lowest toll of polio cases in a decade. This temporary decline in polio cases was assumed to be due to the attribution of efficient awareness of vaccination among the general population. However, the scientific community was very surprised regarding the decline in polio cases in 2021 as the COVID-19 pandemic disrupted life-saving immunization services worldwide, particularly in developing countries including Pakistan and Afghanistan. Due to the disruption in immunization other vaccine-preventable diseases such as Measles showed an unpresidential upsurge and as result, more than 28,125 and 35,000 measles cases were reported in Pakistan and Afghanistan in 2021. COVID-19 pandemic had left more than 40 million children unimmunized in Pakistan [7] and 23 million children in Afghanistan [8].
The border area between Pakistan and Afghanistan from where recent nine wild polio cases were identified has already been considered a high-risk area for polio for the last many years [9] due to a variety of obstacles including security issues, hard to reach area, killing of polio workers, displaced population, low immunization coverage, vaccine hesitancy, vaccine refusal, lack of education and cross border movement of unimmunized population.
Suspension of the door-to-door polio vaccination owing to the COVID-19 pandemic in Pakistan and Afghanistan may not affect immediately but it might potentially result in future polio outbreaks and the international spread of the virus. The persistence and resurgence of polio in Pakistan and Afghanistan have been a warning call for intensifying efforts for polio eradication. Low immunization coverage, disruption in immunization in both countries along with Taliban control in Afghanistan threaten to reverse the tremendous achievements in polio eradication.
The government of Pakistan and Afghanistan along with the international health organizations should actively implement urgent immunization activities along with active surveillance in high-risk areas which will help eradicate polio from the world. Failure to eradicate polio now could result in a resurgence of infection, with as many as 200,000 to 300,000 new cases worldwide every year.
Declaration Competing Interest
The authors declare no competing interests.
References
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