My brother was visiting and told me that the polio vaccinators had come and that they were immunising the children in front of the mosque. I asked him to help me take my two children. If he hadn’t been there, I wouldn’t have known about the campaign and my children wouldn’t have been vaccinated…
My husband wasn’t in the mosque when they announced it. He was in the fields working. … This is very difficult for me… if my brother hadn’t been there, I wouldn’t have been able to get my children vaccinated. It’s difficult for a woman to take her children to a place where many people are gathered. I myself would’ve been ashamed to have gone…. I prefer door-to-door vaccination. I know that if men are not at home to take the children to be vaccinated, some women will never get their children vaccinated [if it means having to take them to] the mosque.
These are the words of Gul Sima, who has two children under the age of five, in Marja district in Helmand, a province which historically has had a high incidence of polio, an infectious disease that can lead to the permanent paralysis of parts of the body, and primarily affects children.[1] She is one of ten Afghans we spoke to in November and December 2024, as the polio vaccination campaigns resumed following the ten-week-long break, from 13 August to 28 October.[2]
Most of our interviewees, like Gul Sima, come from the southern provinces. Some, but not all, had heard about the vaccination; Gul Sima was not alone in having heard about it only informally, by chance. Some fathers described losing a day’s work to take their children for vaccination – others had to work and leave their children unprotected. Almost all the interviewees had experienced some level of difficulty or inconvenience and said vaccination on the doorstep would have made life easier and vaccination more feasible. Before hearing from these parents, this report opens with an overview of the polio situation in Afghanistan since 2001 and a recap of last year’s breaks in immunisation.
A brief look at polio in Afghanistan since 2001
It has been compulsory for children in Afghanistan to be vaccinated since 1978 when routine immunisation against polio was launched, under the name, the Mass Immunisation Programme. Since then, the number of polio cases in Afghanistan has decreased from the thousands in the 1980s to the hundreds in the 1990s to only handful each year in the 2000s.[3]
The lower number of positive polio cases since 2001 is the result of an increase in immunisation coverage. For example, while only around 25 per cent of children in 2000 received the third (and final) dose of polio vaccine, by 2023 that percentage had risen to around 68 per cent.[4]
However, there were years when the progress came to a standstill, or went backwards. For example, in 2014, the year when most foreign troops left Afghanistan and a presidential election was held, the number of children immunised dropped to 50 per cent. Both events led to a general deterioration of security and consequently less access for vaccinators.
Likewise, in the years preceding both 2011 and 2020, when a hike in cases, to 80 and 56 respectively, was recorded (see Graph 1 below), gaps in vaccination were caused by intensified fighting, a general lack of oversight of polio vaccination in the country as well as localised bans on door-to-door vaccination by the then Taleban insurgents.[5] In 2020, there were no vaccination campaigns from March to June due to the Covid pandemic, while a year earlier, the more stringently imposed Taleban ban on house-to-house vaccination, announced in May 2018, led to no vaccination campaigns the following year from April to July.
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In general, since 2001, the poliovirus has most often been detected in the southern region and, to a lesser extent, in other parts of country.[6] In the south, the polio endemic is generally concentrated in Kandahar and Helmand and neighbouring provinces.[7] In 2011, for example, out of 80 cases, 62 were recorded in southern Afghanistan. Likewise, in 2020, out of 56 cases, 38 were recorded in the southern region (16 from Helmand, 14 from Kandahar, 4 from Uruzgan, 3 from Zabul and 1 from Nimroz province). In 2024, too, out of 25 positive cases, 21 were recorded in the southern provinces — 14 cases in Kandahar and seven in Helmand.[8]
The latest gap in the immunisation campaign
Usually, every month, a polio immunisation campaign takes place somewhere in Afghanistan, either at the national or sub-national level (targeting specific regions). Each lasts between three and five days. Additionally, smaller targeted campaigns – called ‘campaign responses’ – are also carried out regularly. The monthly campaigns target millions of children under five across all the districts of Afghanistan.[9] The two tables below show an annual overview for 2023 and 2024 of the type of polio campaigns carried out, the number of children vaccinated in each monthly campaign and the number of positive polio cases registered in each month. The two gaps in vaccination can be seen in the 2024 data.
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Table by AAN.
There was a huge break. I’ve [also] been hearing from news since around last two months that the door-to-door vaccination was banned by the Emirate. I was really unhappy, and I was thinking that we won’t have polio drops for our children at all and that the Emirate will ban it for good. Thank God, it’s been resumed.
– Sayed Muhammad, father of three (all under five years of age) from Kajaki district in Helmand
Between 13 August and 28 October 2024, no Afghan child under five was immunised against polio after the Islamic Emirate of Afghanistan (IEA), in the words of a health official speaking to The Guardian in mid-September, “temporarily suspended” the campaign. The official said immunisation had been suspended because of “issues with the modality of implementation,” listing them as security concerns and the involvement of women in administering vaccines. Radio Free Europe in their mid-September report quoted a polio worker in the eastern province of Nangrahar, who said the polio-immunisation campaign in the region was suspended because local Taleban officials were “demanding tax from aid organizations.”
As little was said about the suspension by the authorities publicly, the reasons for it remain uncertain. However, it was evident when vaccination resumed that door-to-door vaccinations had been banned, so presumably it was concern over this method of delivery that had made the authorities hesitate over letting the campaigns go ahead. They were now allowing vaccinations but parents would have to take their children to a temporary polio vaccination centre, such as a mosque.
The way vaccines are delivered has long been a point of contention for the Taleban. During the insurgency, they banned door-to-door vaccinations in areas under their control because of the fear that the vaccinators might be spies (see the AAN reports in footnote 8 for more on this). The health official who spoke to The Guardian said this was still a fear: “‘One of the reasons for banning door-to-door campaigns was security. The south, especially Kandahar, is where the Taliban leaders live, and they are concerned the campaigns could reveal their locations to foreign threats.’”
However, where concerns were expressed by officials they centred rather on public morality, with a local health worker telling The Guardian of the government’s dislike of female vaccinators going door-to-door. This has been hinted at in other statements, for example, as reported by BBC Pashto on 23 September. The BBC quoted the head of the polio vaccination campaign in the Ministry of Public Health, Dr Abdul Qudus Baryalai, as saying door-to-door campaigns had been banned by Supreme Leader Mullah Hibatullah Akhundzada after it was requested by Kandahar’s Ulema Council and representatives of Helmand, Kandahar and Uruzgan provinces, at the “demand of the people of the region.” Baryalai said the Ulema Council’s concern, shared with Mullah Hibatullah, was that “when volunteers knock on their doors, men may not be home.” As will be seen below, this was not what we heard from parents interviewed for this report.
The ban is making health experts anxious because of the inherent benefits to children of door-to-door immunisation campaigns. Vaccinators going from house to house can reach new-borns, children who are sleeping or sick and visiting children. They can reach the children of parents who cannot leave the house: as will be seen, this is often the case for women who cannot leave home unaccompanied by a man, but parents might also be disabled or sick and unable to take their children, or not have transport, so cannot easily get to a far-away vaccination centre. Fathers might be away, or working. Moreover, facing a vaccinator on the doorstep makes it easier for parents to say ‘yes’ to getting their children protected, in contrast to having to actively choose to take them to a centre.
What do parents say?
We wanted to hear from parents about their experiences of polio immunisation since the late summer/early autumn pause and the country-wide ban on door-to-door delivery.[10] We conducted two rounds of interviews with ten parents, in total, who came from 5 of the 16 provinces where vaccination campaigns took place in October and December. We interviewed seven parents who had children under five – two from Kandahar, two from Helmand and one from each Uruzgan, Zabul and Kunduz provinces – just after the IEA resumed the polio vaccination on 28 October 2024.[11] Additionally, after the completion of the second polio vaccination campaign that started on 25 November 2024,[12] we interviewed three additional parents – one each from Kunduz, Kabul, and Zabul provinces. We also reinterviewed a parent from Kandahar who had missed immunising his children during the October campaign. The short questionnaire was a mix of open and close-ended questions.[13]
All our interviewees eventually got their children vaccinated – eight during the October campaign and two during the November campaign. Most had not heard about the campaign before it began. Some found out about it by chance, including Nur Muhammad, the father of two under-fives from Aino Mina in Kandahar province of the October campaign.
We didn’t hear any announcement and the vaccinator didn’t come to our house either. A few months previously, they’d come to our house and vaccinated our children. It isn’t difficult for us to take our children to the mosque or any other centre where vaccination is taking place. We’re an extended family and thank God, we have four cars between us. But if we aren’t aware of the campaign taking place, that’s a problem.
We interviewed him a second time, after the November campaign. Again, he had not heard about it, but this time, he found out by chance and in time.
They aren’t putting a lot of effort to make us aware of the campaigns. We were lucky – one of my friends called me on the fourth day of the campaign and asked if we’d got our children vaccinated. He knew they’d missed out in October. As soon as I heard, I took my children to the hospital in our area and got them vaccinated.
Similarly, Aziz Khan, the father of two under five-years from Kabul province also got to hear about the second vaccination campaign in November 2024 in a haphazard way:
I got vaccinated my children last week. I couldn’t get them vaccinated in the [October] campaign because we didn’t know it was happening. There wasn’t even an announcement in the mosque. I did hear about the latest campaign. I told my brother to find out where it was and take my children to be vaccinated. He searched for the vaccinators and when he found them, they asked him if they could use our house as a polio immunisation centre. They said people hardly ever give them their houses to use as a centre even for only an hour. My brother gave his permission. This way, we got vaccinated our children, as well.
Rahmatullah, the father of three children under-fives from Dasht-e Archi district in Kunduz, told us he did know about the November campaign – it was announced every day in his local mosque. However, he decided his children would miss out on their November vaccinations because he was working and he’d got them vaccinated during in October (three doses of polio vaccine are necessary, so this decision may be detrimental to his children). “I didn’t take my children for vaccination,” he said, “because I’d recently found a job of digging a well. I go early to a village about three kilometres away from our house. I couldn’t lose that work.”
Similar dilemmas faced Muhammad Omar from Shah Joy district, Zabul province, in November: he was busy ploughing his land when that campaign took place. However, the father of three under-fives also objected to where the November vaccinations were taking place:
I got my children vaccinated around 40 days ago [in October]. I didn’t get them vaccinated in the recent campaign [November]. Last time, it was good. It was in the mosque and my wife took our children there. This time, our mosque’s mullah and some elders had decided the mosque shouldn’t be used as a centre for vaccination and selected two other places instead. [O]ne of the centres was very far away. I was working on my land and I’d rented a tractor for ploughing, I was busy with sowing the wheat. My wife didn’t take our children to the centre because she’s a woman. We traditionally don’t allow our women to go out, especially to far-off places.
The second centre was near to our house … maybe five minutes from us, but we didn’t take our children there because it was the house of a man with whom I have differences [a kind of enmity]. I told my wife not to take the children to his house for immunisation.
Another parent, Bibi Aisha, who has four children, three under five, from Arghestan district in Kandahar, told us her husband had to take a day off work so they could take their children for vaccination:
My husband’s working in a pomegranate orchard. He goes there at 6 ‘o clock in the morning, every day. On that day, he didn’t go to his work because he had to go with me to get our three children vaccinated. They’re all under five years old. My husband would never allow me to go on my own to the mosque for vaccination because there are many men in the mosque. He tells me not to take the children for vaccination unless he’s with me. He’s telling me that the children won’t die, but please don’t go alone to the mosque. It’s our tradition. Women don’t go anywhere without being accompanied by a man.
Public information campaigns and clear announcements that campaigns were starting locally appear to have been only haphazardly undertaken. That further reduced the ability of parents to take up opportunities to get their children vaccinated. With door-to-door vaccinations, announcing the start of a campaign is useful, but if parents have to take their children to a centre, it is vital. Several of our parents were critical of the absence of public information. A few had a more positive experience, for example, Sayed Muhammad, father of three under-fives from Kajaki district in Helmand:
I heard about [the October campaign] on the radio and also from the vaccinators over the loudspeakers in our village. We took our children to the mosque and they were immunised there. The mosque isn’t very near to our house. I used to live in our village in the past, but two years ago, I built a new house near my fields, I prefer to live near to my agriculture land…
However, he recalled with regret the convenience of the old door-to-door campaigns:
[The current way of doing things] is very difficult for me. If I’m not at home, my wife can’t take our children for vaccination. My wife is sick. She can’t take the children to the mosque. I prefer door-to-door vaccination. It used to be very easy for us. I don’t think anybody prefers mosque-to-mosque vaccination.
Hassan Khan, father of three (two under five) from Shah Joy district in Zabul province heard about the campaign when it was announced in the mosque.
I wasn’t at home, but my elder son had heard the announcement and took his two infant brothers to the mosque for vaccination. My brother is actually a vaccinator, himself, and was out in another village, vaccinating children. Yet, his two children weren’t immunised against polio because his wife didn’t want to take them to the mosque. Some women don’t go to the mosque for vaccination – they are either not allowed by their husbands or they themselves feel shy. I’ve heard of other children as well in our village that have remained without being vaccination.
Dost Muhammad, father of six (three under five) from Dasht-e Archi, Kunduz, said a campaigner had come to his mosque early in the morning and told all the men to bring their children to the mosque to be vaccinated, which he had done. Mullah Obaidullah Jan, father of eight, with three children under five from Chahar Chino district in Uruzgan, said he had himself announced to the people in his mosque that vaccination would be taking place. However, he said his elder children had had to bring their younger siblings because he was busy welcoming people to the mosque.
All our interviewees said that in their localities, the vaccinators, both past and present, were male. Aziz Khan, the father of two under-fives from Kabul province, was the only one with a different experience: in Kabul city, he said, “the mobilisers were female, but vaccinators were male.” Yet, the programme to deploy women to deliver the vaccine among other duties has expanded since a 2020 pilot project in three provinces. These are the ‘female vaccination mobilisers’, women from the local community who, despite not having the medical training to administer intravenous vaccines, can administer polio drops, be the first-line advocates for polio eradication and deliver health education more generally to other women. In 2024, the programme covered 20 out of Afghanistan’s 34 provinces, with more than 600 workers; these reports by WHO’s Global Polio Eradication Initiative and UNICEF mention female vaccination mobilisers in Nangrahar, Helmand and Khost.
The theory behind the project is that women can more easily reach women: one mobiliser in Khost, Rezia, said to UNICEF that changing people’s minds is the first and biggest step toward getting more children vaccinated, and women are critical players: “I’m respected in the community. … I’m a mother, a grandmother – women listen to me. I can persuade the older women, and they want their daughters to have services they didn’t have. It trickles down.” UNICEF quoted the female vaccination mobilisers as saying that having mothers’ questions answered straightforwardly, by a trusted neighbour, has contributed significantly to changing attitudes toward vaccination in the districts where they work.
Regardless of who delivers the vaccinations, all our interviewees said they preferred door-to-door campaigns because they are convenient, save time and do not require additional logistics. That included the mullah from Uruzgan who said he preferred them because his elder children had had to bring the smaller ones to the mosque. In areas where women generally cannot go alone to the mosque or other centre and need a man to be at home to take the children, the end of door-to-door campaigns will, inevitably, mean fewer children vaccinated, as Nur Muhammad, father of two under-fives from Aino Mina in Kandahar province summed up:
We do indeed prefer door-to-door vaccination. If we’re aware of the campaign then [taking the children to a centre] isn’t a problem for us personally. But for families who only have one man in the family and he’s working, it’s difficult for women to take their children to the mosque or to a polio centre. Many people don’t allow their women to take the children out of the home – and that includes us.
What do the experts say?
It not only parents who prefer the door-to-door campaigns. Experts told AAN the two vaccination gaps in 2024 had caused some damage, but far worse had been the harm done by the ban on door-to-door campaigns. A former UNICEF communication manager told AAN that, in previous years, door-to-door campaigns had been able to reach almost 100 per cent of under-fives. “The mosque-to-mosque modality isn’t successful because people don’t bring their children to the mosque. The reason is tradition – women will not bring their children to the mosque if the men are not at home [to accompany them].” The contrast with the current delivery method, he said, was stark: “The teams could barely reach 60 per cent of children through the mosque-to-mosque approach in previous years. A successful campaign is when you vaccinate at least 95 per cent of children.”
This same conclusion was reached by a vaccinator in Nad Ali district in Helmand province who told AAN that in the November 2024 campaign, his team reached only between 700 and 750 children out of the 1,200 they would normally reach via the door-to-door campaign (less than two-thirds). He said people were not bringing their children to the mosque or village centre because the men might be busy at work and women could not go outside unaccompanied.[14]
The denial of the positive polio cases by the IEA Ministry of Public Health has added to the problem. It seems to be a bizarre exercise in semantics: the ministry’s claim that there is no record of positive polio cases in Afghanistan is based on the fact that, currently, samples are sent for examination to a laboratory in Pakistan. It seems that the ministry is spinning the narrative by denying the positive cases as a ploy to try to get funds to set up a laboratory in Afghanistan, according to several AAN sources, who wish to remain unnamed. However, that denial does not help parents protect their children from the spread of the poliovirus.
Afghanistan and Pakistan are the last two remaining countries in the world where polio is endemic, despite a great deal of resources and attention. Their eradication efforts are interlinked and the two countries are dependent on each other’s success in eliminating polio – or held back by the other’s failings. Pakistan has also seen an increase in positive cases last year; 72 cases had been recorded in 2024, an enormous increase from only 6 in 2023, according to WHO data. The epidemiological evidence suggests that the role of population movement is one of the key factors for poliovirus transmission across Afghanistan. The number of positive polio cases in Pakistan plays an important role in the virus spread through population movement across the border. This is why the intermittent breaks in vaccination, the ad-hoc shifts in approach, as well as unnecessary politicising of the issue, for example, the question of the laboratory location, does not help protect children. However, these particular problems have only existed since 2001 in Afghanistan.
In the past, access to children might always be limited by fighting and lack of security. Today, it is the government’s attitude towards women that is limiting the outreach of vaccinators, together with cultural restraints on women’s autonomy and movement. While the vaccination campaigns will, hopefully, be regular throughout 2025, unless door-to-door campaigns are resumed, it seems inevitable that many Afghan children will be left unprotected from the poliovirus.
Edited by Kate Clark and Rachel Reed
↑1 | Polio, short for poliomyelitis, is an infectious disease that is caused and transmitted by a virus called the poliovirus. Poliovirus only infects humans. It is very contagious and spreads through person-to-person contact. The virus is most often spread by the faecal-oral route, that is, if food or water is contaminated with faecal matter, it enters through the mouth and multiplies in the intestine. Infected individuals shed poliovirus into the environment for several weeks, where it can spread rapidly through a community, especially in areas of poor sanitation. One of the severe symptoms of polio in childhood is paralysis and the disease is therefore also known as ‘infantile paralysis’. |
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↑2 | This was the second break in vaccination in 2024. The first, twelve-week-long break lasted from 1 February to 29 April. |
↑3 | For a more detailed historical analysis on the number of polio cases, see AAN’s report ‘One Land, Two Rules (5): The polio vaccination gap’ from 2019. The publicly available historical data on positive paralytic polio cases in Afghanistan shows that the number of cases dropped from almost 2,000 in the mid-1980s to a handful in the early 2000s; see the ‘Our World in Data’ by Oxford University. |
↑4 | See this World Health Organisation’s immunisation dashboard for an overview of the coverage as a percentage. |
↑5 | The Taleban attitude towards polio vaccinators varied over time and geography, as described in the AAN report in Footnote 3. |
↑6 | In the eastern region, the epidemic is part of what is called the ‘northern corridor transmission zone’, extending from Nangrahar, Kunar and Nuristan into Khyber Pakhtunkhwa, including what were formerly the Federally Administrated Tribal Areas in Pakistan (FATA). The one case in Kapisa since 2001 would probably be placed at the westernmost end of this corridor. There have been fewer positive polio cases further north, for example, in Kunduz and Balkh provinces. Herat province in the west of the country had also seen a few positive polio cases, as has Farah, which neighbours both Herat and Helmand. |
↑7 | AAN’s ‘One Land, Two Rules (5): The polio vaccination gap’, quoting WHO data, described cases in the south as concentrated in Kandahar, but with ‘spillover transmission’ into Helmand and Uruzgan. |
↑8 | See also these two in-depth AAN reports about polio in Kandahar: ‘Why does the Incidence of Polio Vary? A comparative study of two districts of Kandahar (Part 1)’ and Helmand: ‘Why does the Incidence of Polio Vary? A comparative study of two districts in Helmand (Part 2)’. |
↑9 | There are also special immunisation campaigns targeting older children (from 5 to 12 years of age), an example of which can be found in this 2023 WHO annual polio vaccination newsletter. |
↑10 | In the southern provinces of Kandahar and Helmand the door-to-door campaign have been banned for some time. |
↑11 | 16 of 34 Afghanistan’s provinces were targeted for the immunisation campaign that started on 28 October 2024: Helmand, Kandahar, Urozgan, Zabul, Nimruz, Farah, Kabul, Baghlan, Kunduz, Takhar, Khost, Paktika, Nangrahar, Laghman, Kunar and Nuristan. |
↑12 | The second campaign after the ban was carried in ten provinces: Kabul, Nangrahar, Laghman, Kunar, Nuristan, Kandahar, Helmand, Zabul, Uruzgan and Kunduz. |
↑13 | The polio questionnaire:
When did you vaccinate your children last? (Yesterday, Last week, Several months ago) How did you hear about the polio campaign in your village? Was there any break in the vaccination campaigns in your village? For how long? In the past, did the vaccinators come to your house or you took your child/children to the mosque/centre? How far is the mosque/centre where vaccination takes place from your house? How difficult was this for you, to take your children for vaccination? Which one do you prefer: door-to-door vaccine or mosque-to-mosque? Are the vaccinators male or female? What were they in the past? |
↑14 | A polio volunteer in Kabul told AAN that mullahs did not allow them to carry out vaccinations in the mosque in one area of Kabul. He said the mullah is the son of a community elder who is against polio vaccination and had banned the use of the mosque as a polio centre. |