Independent Monitoring Broad (IMB) in its new report said that polio cases and positive environmental samples have increased 117 % in 2023-24 in Pakistan. IMB recommended GPEI should constitute a commission of experts (possibly the same as those who conducted the switch review) to carry out an in-depth analysis of the reasons that the Polio Programme in Pakistan has not yet interrupted transmission of wild poliovirus. IMB works on behalf of Global Polio Eradication Initiative (GPEI) which provides independent assessments of the polio program in world In its recent report IMB has long been concerned about the risks to polio eradication posed by the process of changing governments in Pakistan. IMB says that previously political transitions have had a negative impact on the Polio Programme. The report cites the caretaker arrangements were dysfunctional for continuity in the control of polio in Pakistan. Attempts were made to revise the programme management and to change funding flows. There was conflict with the head of the emergency operations center it says. It states the poor maintenance of the polio gains that had been made in Pakistan in the pre-election period was a key factor in triggering the wild poliovirus resurgence during 2024. Showing its grave concerns that Pakistan Polio Programme did not stop wild poliovirus from circulating again in the historical reservoirs. Polio cases and large numbers of environmental positive samples have affected all of these reservoirs it added. Report said historical core reservoirs of the Quetta Block, Khyber Pakhtunkhwa and Karachi that serve as “engines of transmission”, were reinfected. In early June 2024, Quetta City did indeed see the return of the wild poliovirus when the first case of paralytic polio in four years was detected in a two-year-old child, who quickly died of the disease it says. IMB officials claimed that according to their sources close to the frontline say that the Quetta case was missed by two officials conducting surveillance before being reported. If this is true, then it is a serious weakness of vigilance that is unacceptable for this stage of the eradication endeavor At the time of the mid-term review, the only polio-endemic zone in Pakistan was in seven south districts of Khyber Pakhtunkhwa. Here, it had a stubborn hold. The IMB considered that failing to interrupt transmission in this area was probably the greatest risk to achieving Goal One of the strategy, even by the end of 2024. Report further said operating environment in south KP is still complex and threatening. A remarkable 200 plus boycotts of the polio vaccination programme, with diverse sources of grievance and demands, had been running at the beginning of 2023, report said. It is disturbing to realize that violence, insecurity and boycotts are still as prevalent in the KP as they were in 2023. Since the IMB’s mid-term review, 15 policemen have died while trying to ensure safe, effective delivery of the Polio Programme. Despite the intense focus of the Polio Programme, and the skilled and intensive work of the provincial Chief Secretary, the IMB has not yet seen the tide beginning to turn towards interrupting transmission in KP, nor a critical mass of transformative solutions building towards this goal in this polio endemic zone of Pakistan. Wild poliovirus circulation has been unbroken in Pakistan and Afghanistan, with two recent major waves Unfortunately, the other genetic cluster of the wild poliovirus, YB3A, has increased in Pakistan during 2024 and has begun circulating in the historical reservoirs that, at the time of the mid-term review, had been clear of wild poliovirus for some time reads the report. The extensive spread of the YB3A genetic cluster of the wild poliovirus is disappointing. This is the poliovirus that was in the east region of Afghanistan, and that started being detected sporadically in early 2023 in Peshawar, in Punjab province and in Lahore. However, initially, it did not re-establish itself. The virus would apparently disappear and reappear after a month or two. In KP, the security situation is causing the Polio Programme to have to “slice” its campaigns: do a little bit here, a little bit there, so there is no large or intensive vaccination round. As a consequence, the poliovirus always escapes. In Peshawar, poliovirus has been present for 16 months now, in spite of the quality of operations. The IMB declares there are many orphan viruses there that are not fully explained. Peshawar now has a daily influx of an estimated 7,000 children under five years of age due to the repatriation programme. Punjab will always have importations of infection because of Pashtun communities moving from Kabul to Lahore, but it has good essential immunization. In Quetta Block, in areas like Killa Abdullah and Chaman, the Polio Programme is not able to do full vaccination rounds. It is a complex environment because of migration, lack of health facilities and very, very low essential immunization coverage Karachi has always posed a big polio challenge. It has long been a hub for mobile populations, and is now described as having “phenomenal” numbers of people going into and out of it. Some campaigns in Karachi are missing large numbers of children so that a big immunity gap has developed. Karachi East is particularly challenging. The number of zero-dose or unvaccinated children in Karachi East is also extremely high. It is not clear why this is happening because there have been extensive activities by polio partners to improve essential immunization. Looking at polio in Pakistan in the round, parts of south KP, even parts of central Pakistan, but most glaringly, Killa Abdullah and Chaman, are those places where the basic Polio Programme has never really reached a level that could be called strong. For example, two years ago, Pakistan did a sero-survey. Killa Abdullah and Chaman had 60% protection against wild poliovirus type 1, despite all the campaigns that have been done there Coming afresh to an adverse situation, with poliovirus surging back into the seemingly cleared historical polio reservoirs, the new government polio team in Pakistan diagnosed the cause as: “complacency everywhere”. The IMB claims that high pressure to finish the job had meant that frontline teams and their supervisors were terrified of transmitting bad news up the line. The consequence of this was fake finger marking, false data returns, hiding children, chronic rates of missed households, and insufficient escalation of action to deal with clear vaccine refusals. In Pakistan recently, the external pressure and direct urging of the leadership to succeed, has produced a climate of fear at the frontline. One IMB source deep in the field, speaking only on condition of anonymity, said: “I would rather drink poison than tell the Chief Secretary that we have been persistently missing children. There is a risk of a type 2 vaccine-derived poliovirus outbreak in Pakistan, if immunity against that virus type is not improved. There have been sero-surveys of all three types of poliovirus across 25 very high-risk districts. Over 11,000 samples were taken of different age groups under five years old. For the type 2 poliovirus, the seropositivity was lowest (around 30% in some places). So, unless this issue is fixed quickly, there will soon be an outbreak in Pakistan. A management culture of fear leads to evasive and collusive behavior such as fake finger marking, falsification of data returns, and fixing quality metrics. Poliovirus circulation will never be stopped if this is happening. Fear, instilled in the frontline workforce and in communities, puts the poliovirus in a very comfortable position. It can carry on with its mission to paralyze and kill as many children as possible. A cultural shift and removal of rigid hierarchies and autocratic management styles are vital if the Polio Programme in Pakistan is to progress. IMB recommended GPEI should constitute a commission of experts (possibly the same as those who conducted the switch review) to carry out an in-depth analysis of the reasons that the Polio Programme in Pakistan has not yet interrupted transmission of wild poliovirus. This should be conducted as quickly as feasible. In the meantime, the new polio team in Pakistan should carry on with their work to strengthen the programme. There should be no sense of “wait and see”. There should be no delay or diminution of commitment and innovation. In addition, there must be the most rigorous monitoring of the programme performance in real time, with rapid course corrections as soon as plans are going off track The Pakistan provincial chief secretaries should remove the conditions for the propagation of fear at any level in their polio programmes. They should encourage and welcome bad news as a sign of an open, learning, non-hierarchical team structure, it ended.