As the global community marks World Polio Day on October 24, the nuclear-armed nation faces a staggering 39 cases so far this year, compared to six in 2023 and 20 the year before.
Going door to door to vaccinate children 5 years old and younger against the poliovirus is a perilous task in Pakistan.
Fozia Kalwar became a vaccinator three years ago. A resident of Pakistan's southern Sindh province, the 35-year-old widow took the part-time job because she needed the money.
Kalwar makes less than $50 for a week of grueling work during vaccination drives. It is not nearly enough to feed her four children. And the reward is small, she said, for a job that comes with serious security risks.
"I feel very scared, but then I wonder how I will feed my children if I don't work," Kalwar told VOA.
She works in a dangerous part of Sindh, where armed bandits rob people in broad daylight.
Still, it was the report of a sexual assault on a fellow polio worker last month that deeply disturbed her, she said. The victim, who lived a few streets away from Kalwar, was allegedly gang-raped by three men while in the field.
Attacks on polio workers in Pakistan are largely limited to Khyber Pakhtunkhwa province. Militants in the northern province often target polio teams, accusing them of partaking in a "Western conspiracy" to render children infertile through the vaccine. They also claim the vaccine has pork-based ingredients that are forbidden for Muslims to consume.
This year in Khyber Pakhtunkhwa, at least two vaccinators were killed and four wounded, while seven policemen providing security to polio teams died and 30 suffered injuries in four attacks.
However, news of the alleged sexual assault in Sindh shocked many.
After the incident, Kalwar said, many people in her area suggested shutting down the polio program.
"They said, 'It is saving our children, but what about our women?'" Kalwar told VOA.
Lack of trust
Despite years of expensive awareness campaigns, many Pakistanis believe anti-vaccine propaganda and refuse the oral vaccine for their children.
Lack of trust in the health care system drives others to shut the door on vaccinators.
In posh areas where there are educated people with more awareness, they don't trust us much. They are very sensitive about their kids. They refuse the vaccine more often for their children. Even if they vaccinate their kids later, for us, the child is counted among refusals.Iza Bibi, Supervisor for Community Health Workers
Sindh, Pakistan's southern and second most populated province, detected 12 polio cases this year, behind Balochistan, where 20 cases emerged.
Karachi is home to eight districts considered high-risk for the spread of the poliovirus. Experts blame overpopulation, poor hygiene and migration from across the country to the economic hub.
Health officials say the challenging demographic landscape of Karachi complicates eradicating polio in the province.
Sindh fared worse this year in case tally than Khyber Pakhtunkhwa in the north, which shares a long, busy border with Afghanistan.
Pakistan and Afghanistan are the only countries still grappling with the naturally occurring wild poliovirus. Afghanistan has detected 18 cases this year.
Future outlook
"Given the widespread virus presence and its intensity of circulation, more cases are expected to emerge alongside environmental detections during the next couple of months," a program document explains.
A nation of over 240 million people, Pakistan is gearing to launch a countrywide polio campaign from October 28. The drive will target 45 million children.
According to Pakistan's polio eradication program, cases of the paralytic disease may rise.
There is also some good news. The variants of the virus present in Pakistan have dropped from 11 in 2019 to two in 2024, according to the official report.
"This decline underscores the impact of targeted vaccination efforts and enhanced surveillance," the document said.
"We should not be demoralized by the rising case numbers. We must keep up our efforts," said Bibi. The 21-year-old was among three health workers chosen from across Pakistan to meet Bill Gates in June. The co-chair of the Bill & Melinda Gates Foundation visited Pakistan to discuss polio, among other issues, with top officials.
Working in Sindh near Jacobabad, one of the hottest cities on the planet in the summer, Kalwar has a strategy to make sure no child misses the vaccine in the upcoming drive.
"In our areas, we now keep a register with every child's name in it so that no one is left out," she said. "When we visit, we ask about each child by name."
VOANews/ SD