The more real you get, the more unreal everything else is. The same has been the case for polio eradication in Pakistan — which remains a distant dream. In 2017, we had eight polio cases in the country, which increased to nine positives cases in 2018. Early 2019 has been even worse with four positive cases until now. On February 15, Punjab which has been polio-free for the last two years witnessed a confirmed polio case. The worsening situation of poliomyelitis transmission in Pakistan is currently the greatest threat to the achievement of the Global Polio Eradication Initiative launched by WHO. It must be noted that Pakistan and Afghanistan are the only countries that still suffer from the active wild poliovirus transmission. So, it has marred the image of both states in the comity of nations. Both considered virus reservoirs which could spread the disease to polio-free countries in the region. While attending my MSc Lecture at the University of London, someone pointed out to me that the polio strain from the Syrian outbreak originated from Pakistan. Similarly, there was a polio outbreak in Egypt, whose strain also originated from this “land of pure”. So, keeping in view the current poliovirus prevalence, Pakistan may face international isolation if it fails to wipe out the virus once and for all. Now, let us understand Polio disease, its transmission, GPEI objectives, ground level causes of polio prevalence in Pakistan and the strategies to eradicate it by following successful polio eradication models from neighbouring countries. Polio (also known as poliomyelitis) is a highly contagious disease caused by a virus that attacks the nervous system. Children younger than five years old are more likely to contact the virus than any other group. It is transmitted through the oral-fecal route and the areas which have poor hygiene and sanitation conditions are at high risk of transmission. Air Droplets can also transmit the virus through sneezing and coughing the virus out; overcrowded people living in IDP camps are at high risk of transmission. Polio by poliovirus wild types 1-3. With wild type 2 eradicated globally in 1999, and wild type 3 not detected since 2012, the current polio cases are suspected of being due to wild type 1 (WPV1). Most polio cases are mild or asymptomatic, with only a small proportion leading to potentially fatal AFP, making polio detection by symptoms alone is difficult. Globally, many countries, organisations and individuals have been fighting the disease, and their goal is to eradicate polio worldwide. The GPEI team consists of 50 million partners involving 200 countries with 20 million volunteers vaccinating over 2.5 billion children by spending over $14 billion in international investment. There are two endemic countries and few outbreak countries. Polio cannot be cured but can be prevented through immunisation with oral and injectable polio vaccine. With a full dose of vaccination, polio is almost always prevented. High levels of vaccination coverage in a community (90 percent) are needed to interrupt polio transmission and prevent outbreaks. However, unfortunately, Pakistan has the least extended program of immunisation coverage, which is below 57 percent. Moreover, due to inadequate WASH measures, wild poliovirus circulates frequently, and environmental samples from sewage stands positive for poliovirus presence. Additionally, oral polio vaccines require an optimal temperature of 2-8 degree centigrade, but the temperature of most areas in Pakistan rises to 35-48 degree centigrade. This rise in temperature disrupts vaccine cold chain management that in turn reduces vaccine efficacy. Vaccine suppliers have been able to maintain the cold chain from national headquarters to divisional headquarters and districts, but when it reaches the tehsil level, it reduces its efficacy due to constant electric outage and low equipment provision for the cold chain. Apart from this, surveillance in an essential tool in diagnosing disease and finding high-risk areas but unfortunately we do not have qualified surveillance officers who work in local villages and at the union council level to eradicate the disease. The surveillance system is up to the mark in cities while at the village levels it is dismal. DG WHO, Mr Tedros Ghebreyesus had said that missing children and refusal by parents were significant challenges to the eradication of poliovirus from the country. This refusal is due to the religious dogmatism of a handful of clerics who consider polio vaccines an anti-Muslim conspiracy. It was widely believed in FATA and KP that this vaccine is sterilising Muslim children. Lastly, owing to the low wages given to healthcare professionals, many short-term employees quit their jobs and WHO teams have to recruit new employees and train them from scratch. The recent polio outbreak in Punjab has been a significant concern for the Pakistani government These were some of the problems faced from the macro to the micro level and must be addressed by the major stakeholders to ensure polio eradication from the world as poliovirus anywhere is a global threat. Similarly, the recent outbreak in Punjab after two years has been a significant concern for the Pakistani government and at this critical time, the following measures should be taken. Keeping in view the above-mentioned problems, low vaccine coverage is the prime cause of polio prevalence. So, it is necessary to vaccinate every single child. For that, we have to strengthen the surveillance system, ensure vaccine supply and access, establish a healthcare workforce to control the outbreak and ensure complete coverage of vaccines to the susceptible population. For strengthening the surveillance system, we should collect demographic data, maintain vaccine records, improve surveillance of Acute Flaccid Paralysis cases and send their stool samples for diagnostics. Also, in order to establish workforce its necessary to address healthcare workforce shortage and to train healthcare workers for achieving long terms goals. Similarly, for ensuring vaccine supply, we must import medicine supplies including vaccines and maintain cold chain management for vaccine efficacy. Secondly, as polio is a viral disease and it spreads through the faecal-oral route, it is necessary to improve water hygiene and sanitation. We should strengthen infrastructure development, water disposal mechanisms and provide people with clean drinking water. In addition to these general solutions, some additional immediate measures need to be taken in a polio outbreak case in all parts of the country. Vaccination coverage, including supplementary immunisation activities and routine immunization of the affected and its surrounding areas. Locating and vaccinating vulnerable populations like refugees, IDPs because they regularly migrate from one place to another. Lastly, proper monitoring and evaluation are pertinent in measuring the success of polio campaigns. The writer is a Chevening Scholar with an MSc Global Health in London School of Hygiene and Tropical Medicine Published in Daily Times, March 13th 2019.