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Health workers identify motivators for OPV refusal in Pakistan
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Health workers reported that parents in regions of Pakistan where polio is still endemic refuse oral polio vaccines for their children due to misconceptions related to vaccination efforts, according to recent research in Vaccine.
“Refusal of the oral polio vaccine (OPV) by the general public exemplifies the difficulties faced in multiple endemic areas, including Pakistan and Nigeria,” Tahir Mehmood Khan, PhD, of the school of pharmacy at Monash University in Malaysia, and colleagues wrote. “In Pakistan, fanatics have succeeded in a propaganda campaign against the polio vaccination by spreading false messages such as that the polio vaccination will make children sterile, contains pig blood, and is not good for children.”
Khan and colleagues explored the challenges health workers faced while attempting vaccination campaigns in Pakistan by conducting focus groups with those who participated in OPV campaigns in polio “red zones.” During these sessions, the researchers explored health workers’ opinions related to factors that influence parental OPV hesitancy and refusal. Workers who conducted OPV campaign efforts in the Pakistani cities of Bannu, Kohat, Hangoo and Peshawar were approached by researchers for study participation. Four focus group discussions were held with 42 health workers from January 2015 to March 2015. Discussions centered on three topics: challenges faced by workers, parental barriers to vaccination and aftereffects of OPV.
The researchers found that the most common reasons given for parental refusal included the belief that OPV is haram, or forbidden by Islamic law; that OPV contains pig’s blood or monkey blood, and that OPV efforts are secretly being conducted to sterilize their children. Furthermore, health workers reported that many parents had strong beliefs in conspiracies related to OPV campaigns, including that the CIA is spying on them through the guise of vaccination.
The researchers said attitudes toward vaccination began to erode after an incident involving the United States in 2011, during which the CIA attempted to obtain DNA samples from children under the pretense of hepatitis B vaccinations, as part of the hunt for Osama bin Laden.
“[The Abbottabad incident] potentially led to an erosion of public trust in immunization,” Khan and colleagues wrote. “It has fueled OPV refusal, making it very difficult to attain millennium development global public health goals and also hindering the achievement of the national milestone of adding Pakistan to the list of polio-free nations.”
Health care workers also reported harsh public attitude and bad behavior toward them as security concerns. These concerns included the threat of attacks on polio teams and the overall threat of terrorist activity in the region. Workers from the Bannu and Peshawar regions, however, did not report any behavioral concerns.
Khan and colleagues suggest improving logistics and facilities for health workers conducting OPV campaigns in Pakistan’s red zones. They also emphasized a need for improved education about the purpose and benefits of vaccines, which could be spearheaded by religious leaders in order to illicit community trust. The researchers warned that without improvements, OPV-refusal may lead to refusal of other essential vaccinations.
“It is important to fine-tune a flexible and acceptable communication strategy to implement the vaccination program in the tribal and rural areas of Khyber Pakhtoon Khawa,” they wrote. “It is the job of the stakeholders to devise methods and campaigns by taking into account the local perceptions and values and by ensuring community participation.” – by David Costill
Disclosure: The researchers report no relevant financial disclosures.Perspective
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Walter A. Orenstein, MD
Vaccines don’t save lives. Vaccinations save lives. And there is no more greater achievement of vaccination than to eradicate a disease. Thus far, smallpox has been the only human disease ever eradicated. But we are close to having a second disease eradicated, polio. In 1988, when the world resolved to eradicate polio, there were an estimated 350,000 persons paralyzed by polioviruses, and 125 countries were considered endemic. In 2015, only 74 cases were detected, and only two countries, Pakistan and Afghanistan, were considered endemic for polioviruses.
One of the three poliovirus serotypes, type 2, was certified as eradicated in 2015, with the last naturally occurring case due to this serotype detected in India in 1999. As of April 13, only 10 cases have been detected compared with 22 cases during the same period in 2015. And 2015 was a record low year, only 74 cases compared with 359 cases reported in 2014. Further, all cases since 2013 were serotype 1. Serotype 3 cases have not been detected since November 2012 in Nigeria and thus, this second serotype may also have been eradicated.
Success in eradication to date is leading to an unprecedented effort, removal of trivalent oral polio vaccines (tOPV) containing all three serotypes in 155 countries that continue to use OPV with replacement by bivalent vaccine containing only types 1 and 3. All of this is taking place during a 2-week period at the end of April. Eventually, with certification of eradication of all three serotypes, all OPV will be stopped.
But polio cannot be eradicated if there are populations of susceptible people in places where the virus continues to circulate, who remain unvaccinated, and hence allow the virus to continue to be transmitted. A recent study, published in Vaccine, investigates the experiences of health workers (HWs) charged with delivering vaccine in critical areas of Pakistan and the obstacles they face in achieving the levels of vaccination needed to interrupt polio transmission. Failure to vaccinate was associated with parental distrust of government workers, beliefs in conspiracy theories about potential harms of vaccines, thinking that polio vaccines being delivered are not good quality, and thoughts that vaccinators are spies for the United States. Finally, there is insecurity in conflict-plagued regions of Pakistan.
The Global Polio Eradication Initiative (GPEI) is aware of these issues and is taking concrete actions to counter the identified problems. This includes working with Islamic religious leaders from national down to local levels to address religious misperceptions to both decrease vaccine refusal and increase vaccine demand. Since 2013, there has been a decrease of more than 60% in the number of families refusing vaccine (personal communication, Zubair Mufti, MBBS, WHO). The fact that there has been so much improvement in the number of cases of polio reported in Pakistan between when the study was conducted and the first few months of 2016, suggests that these efforts are having impact. It is critical to finish the job of eradication since abandonment of the effort would likely result in a resurgence of polio with tens of thousands of cases of paralysis occurring.
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