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Centre for Global Child Health

A New Approach to the Polio End Game: SickKids’ researchers contribute to first-ever cluster randomized vaccination trial in a conflict setting

Research in conflict-affected areas of Pakistan demonstrates value of community-based interventions to eradicate polio

The threat of polio in conflict-affected areas of Pakistan can be reduced through a package of community-based strategies integrating maternal child health services and routine immunizations, according to a new study published in The Lancet Global Health.

The study conducted by researchers at the SickKids Centre for Global Child Health, the Aga Khan University, the Peshawar Medical College and the London School of Hygiene and Tropical Medicine tested a range of interventions in 387 insecure areas of the country in Bajaur, Karachi and Kashmore where children are especially vulnerable to contracting polio: a disease that has been eradicated in all countries except for Pakistan, Afghanistan and Nigeria.

“Since the eradication of polio is a national and global imperative, we worked closely with the World Health Organization, UNICEF, the Bill and Melinda Gates Foundation, as well as federal and provincial governments to generate evidence that can help achieve the objectives of the National Emergency Plan and the WHO’s Polio Eradication Initiative,” said the senior author of the study, Dr. Zulfiqar A. Bhutta, Co-Director of SickKids Centre for Global Child Health and founding director of AKU’s Centre of Excellence in Women and Child Health. “Importantly, the study’s findings also contribute to targets related to vaccine coverage and immunization against communicable diseases under Goal 3 of the Sustainable Development Goals.”

During the study, researchers identified a range of problems leading to new cases of polio being reported in the country every year. These challenges included children not being present at home during immunization drives, healthcare workers being denied access to particular areas or being unable to cover all homes in an area, distrust of vaccination activity among the population, and fatigue caused by recurrent polio-focused immunization drives.

Researchers were able to expand coverage of the polio vaccine in insecure areas by deploying a wide range of approaches. These interventions included the introduction of pictorial health awareness campaigns, community mobilization and engagement through local volunteers, and the running of holistic health camps after national immunization drives that addressed the unmet need for mother and child health services in these areas.

These steps enabled low cost, accurate health information as well as vaccinations to be provided to over 50,000 families, helped address the problem of children being missed in national drives and alleviated the potential hesitancy of those refusing polio vaccines delivered through frequent door to door immunization campaigns. Furthermore, by focusing each intervention in a distinct cluster, researchers were able to assess the effectiveness of each approach and to recommend which measures would help meet global and country polio eradication targets most effectively.

Community mobilizers from the area were trained to deliver accurate information about immunization to parents and local healthcare providers. Focused sessions were also held with community leaders, religious figures, teachers and other prominent officials at the union council level.

The study also disproved a view that providing an anti-polio injection, the inactivated poliovirus vaccine (IPV), alongside polio drops, the oral poliovirus vaccine (OPV), would result in opposition from the community. Researchers noted that data showed that eight out of ten families agreed to their child receiving the IPV when it was delivered as part of a comprehensive health package that provided vital hygiene, nutrition and antenatal services to mothers and children.

“Our package of interventions enabled us to boost coverage of the oral polio vaccine by 8.5 per cent in areas where there was previously fierce opposition to immunization campaigns. Our steps to organize temporary health camps providing broad-based health services ensured that we reached two-thirds of targeted children and families and helped us to provide booster injections to ensure that every child stayed on track with the four-dose schedule needed to eradicate polio,” says Bhutta.

Previous research by Bhutta’s team, which was published in Vaccine in 2016, demonstrated that the use of booster doses of the IPV enhanced immunity in children and contributed to the eventual introduction of IPV in Pakistan’s routine immunization program in late 2015. This study also generated evidence that strengthened the case made by the WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) for booster doses of IPV to be made a part of Routine Immunization programs around the world.

The study Community engagement and integrated health and polio immunisation campaigns in conflict-affected areas of Pakistan: a cluster randomised controlled trial was funded by the Bill and Melinda Gates Foundation and was completed over a period of four years of planning and execution.