Background on FATA [Federally Administered Tribal Areas], Pakistan's Polio refusal cases:

Since the commencement of house-to-house NIDs [national immunisation days] in our country and particularly in FATA, the incidence of OPV [oral polio vaccine] refusal cases has been increased campaign-to-campaign. The WHO [World Health Organization] has recruited several CCSPs [Community Campaign Support Persons], DHCSOs [District Health Communication Support Officers] and prominent religious leaders in Mohmand Agency, but the chronic problem of refusal cases in Polio NIDs has not been resolved yet.

AIMS:

 

  • The major purpose of this paper is to conduct social and scientific research to find out the ways and means of detection and resolving the OPV refusal cases at UC [union council] and District level in Mohmand Agency as well as all over the country and especially in FATA.
  • To ensure the 100% vaccination target of OPV.

OBJECTIVES:

  • Maximum decrease in OPV refusal cases.
  • To eradicate Polio.
  •  To socially mobilize the Tribal Community about the OPV and routine EPI [Expanded Programme on Immunization] Program.
  • To establish a Research and Analysis Wing for social research of EPI Program at District Level.

Discussion:

During Polio NIDs the following types of OPV refusal cases has been observed.

1.      Religious.

2.      Demand.

3.      Political.

4.      Personal.

5.      Silent.

6.      Ill Child.

7.      No reason.

Each of the above mentioned types of refusal cases has been explained as given below in detail.

1.  Religious Refusal Cases:

Due to lack of sufficient formal and religious education, the illiterate Tribal parents hesitate to vaccinate their <5 years children against Polio.  They wish to consult the Pesh-Imam (Community Religious Leader) either to vaccinate their children or not.

On the other side, the religious leader knows nothing about the OPV; that’s why he advises his innocent and illiterate followers to refuse to vaccinate their children against Polio (OPV).

Remedies:

  • The WHO Surveillance Officers/DSOs [District Support Officers] at each District / Agency level in FATA should register all the Pesh-Imans / Religious Leaders in their respective District/Agency.
  • The SOs [Support Officers] / DSOs should communicate / consult the Pesh-Imans (Community Religious Leaders) at their door steps. There must be workshops at UC [Union Council] level to educate the Pesh-Imams about the OPV/AFP and Polio Eradication Program.
  •  Booklets or published material about the AFP [Acute Flaccid Paralysis] disease and surveillance in the Pashto Language must be provided to the religious leaders at UC level all over the Mohmand Agency.

2.  Demand-Based Refusal Cases:

a.       As we know that all the citizens of a country have some expectations from their governments, FATA is the most backward area of Pakistan. Some of the Tribal population refused to vaccinate their children against Polio and demanded primary schools, water supply schemes, and jobs etc.

b.      Demand-based refusal due to social injustice:

The public refuses the OPV because the government Local Agency Political Administration committed an injustice and social inequality to a family or tribe, and, consequently, the family or tribe refuses to vaccinate their children against Polio.

For example:

                    i.            Arrest of a tribal man by the (Local Agency Political Administration) without any reason.

                  ii.            The tribal also refuses the OPV when the Political Administration snatch/arrest a vehicle and its tribal driver without committing any violation against the law.

Remedy:

The government of Pakistan should address all the problems faced by the Tribal Community of Mohmand Agency, regarding basic facilities of life.

3.  Political Refusal Cases:

Different people have different political thoughts about certain political issues in a society. Due to lack of proper education and sufficient medical sense, the illiterate and innocent Tribal of Mohmand Agency thought that the OPV had been produced and sent by the USA [United States of America] to Pakistan. [According to some parents of under-5-years children,] parents in FATA refused to vaccinate their children against Polio because [they believed] the President of USA and his allies are killing the innocent Muslim in Iraq, Afghanistan, Palestine, Pakistan, and other parts of the Muslim World; on the other hand, they send OPV for the Muslim children to save them from Polio. This contradiction has created a wrong concept in the minds of Tribal community that there is something wrong behind the OPV.

Remedy:

The Agency Surgeons/DSOs and SOs should communicate and mobilize the tribal community at UC level to understand that the OPV has not been produced by the USA and her allies. The people should be informed that the OPV has been produced by the Muslim countries like Malaysia and Indonesia and Pakistan. The OPV has also been checked and approved by WHO. The USA does not send the OPV to Pakistan.

4.  Personal Refusal Cases:

There are two major types of Personal refusal cases i.e. (a) Personal favor and disfavor. (b) Personal knowledge.

a)   Personal favor and disfavor refusal cases.

Some people refuse to vaccinate their children due to their personal favor and disfavor. For example, Mr. Pazir was a team member of Area Manzari Cheena Mohmand Agency; most of the people of the village Manzari Cheena refused to vaccinate their children through him because he was not acceptable to the people/parents.

Remedy:

Local neutral and morally sound social workers must be selected in OPV teams. The social workers must have good IPC [interpersonal communication] skills.

b)  Personal knowledge refusal cases

The Tribal of Mohmand Agency being illiterate and lacking knowledge about EPI/Routine Immunization & Polio NIDs refuses to vaccinate their children against Polio.

Remedy:

There must be well-established and regular Routine Immunization at EPI Centers all over the FATA. The health education and outreach immunization program must be established at each UC level.

5.  Silent Refusal Cases:

Due to lack of Micro Census data about the <5 years children at UC level in Mohmand Agency as well as all over the FATA, the unwilling parents hide/conceal their children from the OPV teams at their door steps.

Secondly, the parents do not want to disturb their children from sound sleep for easily available, free OPV when OPV teams knock on their door because such parents have no knowledge about the importance of OPV/Polio disease.

Remedies:

a)      Micro Census data must be collected at the house-to-house level about the OPV target children in each UC/Area. It will help the OPV teams to know about the exact number of <5 years children in a house; hence, the parents could never hide/conceal the exact number of children.

b)      The nearest government health facility should keep a valid record of the newborn children in their respective catchment areas.

6.  Ill Child Refusal cases:

It has been observed in winter that the parents do not vaccinate their children in Polio NIDs in Mohmand Agency because the parents say that their children are ill due to fever, common cold and diarrhea, etc., and the OPV is cold and will increase the severity of the disease.

Remedies:

a)      Strong social mobilization at house-to-house level in each Area/UC.

b)      The social workers should advise the parents to take their ill children to the nearest health facility; they also should educate the parents that the OPV has no side effects  to the ill children.

7.  No Reason Refusal Cases:

Some tribal refuses to OPV without any reason; if they are asked about the possible reason of refuse, there answer is silence or they close the door.

Remedy:

Active social mobilization at house-to-house level in each Area/UC.

Conclusion/Recommendations:

  • Strong, effective and regular social mobilization through a well-established Routine Immunization network at the UC level.
  • The DHT [district health team], DSO/SO should take a keen interest to convince the refusal cases at the UC level prior to the upcoming Polio NIDs.
  • There must be an Active Networking System for AFP Surveillance and a Research & Analysis Wing for social and scientific issues regarding Polio NIDs /AFP cases.

By Syed Feroz Shah