The History and Current Killings of Polio Vaccinators in Pakistan: A Need for Targeted Surveillance Strategy

Poliomyelitis has been eliminated from all countries of the world except Pakistan and Afghanistan. One of the major reasons is the stigmas associated with the polio vaccine that has been repetitively discussed in literature, and governments of both the countries are already making serious efforts to control this public health challenge, but till this moment, the state officials have not introduced any surveillance strategy for the security of polio workers in National Emergency Action Plan (NEAP) for Polio Eradication. This report highlights the issue of targeted killing and terrorism attacks on polio vaccinators in Pakistan and also devises a surveillance strategy to provide security to polio workers at immediate possible because the current chaos in Afghanistan will ultimately lead to more terrorist attacks on polio vaccinators.


• • The killing of polio workers in Pakistan and
Afghanistan is an issue of grave concern. • • There is a lack of awareness of the dangers of polio, and false religious beliefs are quite common in northern areas of Pakistan, especially in cities near the Pakistan-Afghan border. • • More than 200 polio team workers have lost their lives while working on polio campaigns.
Poliomyelitis is a viral infection transmitted via the oral-fecal route and targets the motor nervous system. This can lead to paralysis and is sometimes fatal. The killing of polio workers in Pakistan and Afghanistan is an issue of grave concern. There is a lack of awareness of the dangers of polio, and false religious beliefs are quite common in northern areas of Pakistan, especially in cities near the Pakistan-Afghan border. A majority of the population is not familiar with the consequences and transmission dynamics of polio virus. 1 Another population study from Peshawar, Pakistan, reported that 79% of participants were not willing to vaccinate their children as they believe that vaccine was composed of ingredients that are prohibited in their religion. 2 Pakistan is still endemic for polio because of a long history of attacks on polio workers. The increasing terrorist attacks on polio vaccinators have made its elimination increasingly difficult. During the last decade, security personnel and police accompanying polio workers have also become victims of terrorism attacks. Some local resources have confirmed 70 deaths of polio workers in Khyber Pakhtunkhwa (KPK) province, since 2012.
The year 2021 started with a further shooting incident on polio teams and with parents refusing to vaccinate their children in Karak City of KPK province of Pakistan. Karak is a hotspot of poliovirus because the cases reported from there in 2020. This hostile attitude toward polio vaccinators and misconceptions about religion and polio vaccine may turn out to be a major public health challenge of the century because the rest of the world had been declared polio free and Pakistan may become a source of its transmission to other parts of the world. Although Pakistan has outlined effective strategies under the National Emergency Action Plan to address current challenges, unfortunately, this plan does not include any policy and strategic priority for the safety of polio workers.
According to published reports, most of the attacks on polio workers were committed by The Taliban and the 2021 crisis in Afghanistan and the Taliban's take over will  probably lead to more targeted killings of polio vaccine teams. Therefore, it is very necessary for Pakistan to establish and implement an effective surveillance strategy that must address polio eradication along with the safety of polio workers. More than 200 polio team workers have lost their lives while working on polio campaigns, including female workers, male workers, police, and security personnel and a large number of casualties have also been reported. In January 2016, 16 polio workers died in a suicide attack in Quetta while 6 female polio workers were shot and died in the same city. A further source reported 68 deaths all across Pakistan from December 2012 to January 2014. In addition to this, multiple cases of verbal and physical abuse have also been reported in Karachi and KPK province and 11 teachers involved in polio campaigns were also abducted from Khyber agency (Figure 1).
In Table 1, we collected data related to polio workers' killings from different media sources and observed the highest number of killings in different cities of KPK province, specifically the towns located near the Pakistan-Afghan border. Karachi and Quetta are also potential hotspots of terrorism attacks on polio workers. We also noticed that most of the victims of terrorist attacks were females, reflecting the composition of the polio teams. These statistics and figures may not represent the actual count because large number of cases go unreported due to unavailability of media sources and correspondents in remote and underprivileged parts of the country. Maximum number of killings occurred during 2012 to 2016, and the Taliban claimed responsibility for most of the attacks, and current political chaos in Afghanistan indicates terrorism and insecurity will be a persistent challenge. The absence of any proper strategic plan of security of polio worker in "National Emergency Action Plan (NEAP) for Polio Eradication 2020" will lead Pakistan to a failing trajectory. This study highlights the gap in National Emergency Action Plan (NEAP) for Polio Eradication 2020 and also proposes surveillance strategy to control the risk of terrorism attacks on polio teams that are highly probable to occur in the near future following Taliban's takeover in Afghanistan during the second half of the year 2021 ( Figure 2).

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval
Ethical approval was not needed because the study did not involve any human and animal subjects.