Pakistan's expanded programme on immunization: an overview in the context of polio eradication and strategies for improving coverage

The Enterics for Global Health (EFGH) Shigella Surveillance Study in Pakistan

Background

The Enterics for Global Health (EFGH) Shigella surveillance study is a longitudinal multicountry study that aims to estimate incidence rates and document consequences of Shigella diarrhea within 7 countries in Africa, Asia, and Latin America. In addition to a high incidence of childhood diarrhea, Pakistan is facing a problem of antimicrobial resistance in urban and peri-urban areas of Karachi.

Methods

In Pakistan, EFGH will be conducted in Karachi, which is one of the metropolitan cities bordering the Arabian Sea and has a diverse population of 1.6 million according to the 2017 population census. The study aims to enroll 1400 children aged 6-35 months over 2 years (2022-2024) from 6 health care facilities (Abbasi Shaheed Hospital, Khidmat-e-Alam Medical Centre, Sindh Government Hospital Korangi 5, Sindh Government Hospital Ibrahim Hyderi, Ali Akbar Shah VPT Center, and Bhains Colony VPT Center) situated in Nazimabad and Bin-Qasim town. Moreover, population enumeration and health care utilization surveys from a defined catchment area of health facilities will be conducted to estimate the Shigella diarrhea incidence rates.

Conclusions

The study will provide critical data to policy-makers about the burden of Shigella and antimicrobial resistance, which is essential for planning Shigella vaccine trials.

How to eradicate polio in Pakistan: Insights from community health workers

Pakistan, along with Afghanistan, is one of two countries where wild poliovirus is still endemic. Frontline workers (FLWs) are the staff most intimately familiar with both implementation challenges and community context. Harnessing their expertise may be a way to improve the community-polio program interface, which has been a persistent and shifting challenge in polio-endemic areas of both countries. From 2020-2022, we engaged frontline workers in 18 Super High-Risk Union Councils (SHRUCs) in Pakistan through a Human-Centered Design ideas competition. In that competition, teams of polio FLWs identified the most significant barriers they faced in conducting their work, and suggested solutions to those problems-a window into the issues the program faces by the people who know it best. The suggestions of FLWs on how to eradicate polio fell into four main categories. First, there were suggestions to tackle community fatigue by reducing touchpoints, particularly visits solely for data collection. Second, there were calls to improve Primary Health Care in SHRUCs, as a way of addressing community frustrations over an intense focus on just one disease in the context of numerous acute needs. Third, there were suggested ways to increase community engagement through locally relevant channels. Finally, many workers suggested improvements to Human Resources processes and workplace dynamics. Across these ideas, one repeated concept is the need for balance between the intensity of polio activities required for eradication and the provision of other government services, including health services. FLWs engaged the process deeply, providing well thought out problem statements and ideas for change. It is our view that there is no one more qualified to speak to the issues on the ground than FLWs. There are critical insights available if we listen to people who are instrumental to the success of health programs, but not commonly involved with creating policy.

Factors Associated with Vaccine Refusal (Polio and Routine Immunization) in High-Risk Areas of Pakistan: A Matched Case-Control Study

BACKGROUND

Pakistan has subpar childhood immunization rates and immunization activities have faced several challenges over the past years. We evaluated the social-behavioral and cultural barriers and risk factors for refusal of polio, Routine Immunization (RI), or both in high-risk areas of poliovirus circulation.

METHODS

A matched case-control study was conducted from April to July 2017 in eight super high-risk Union Councils of five towns in Karachi, Pakistan. A total of 3 groups, each with 250 cases, including refusals for the Oral Polio Vaccine (OPV) in campaigns (national immunization days and supplementary immunization activities), RI, and both, were matched with 500 controls and identified using surveillance records. Sociodemographic characteristics, household information, and immunization history were assessed. Study outcomes included social-behavioral and cultural barriers and reasons for vaccine refusal. Data were analyzed in STATA using conditional logistic regression.

RESULTS

RI refusal was associated with illiteracy and fear of the vaccine's adverse effects, while OPV refusals were linked to the mother's decision authority and the assumption that the OPV caused infertility. Conversely, higher socioeconomic status (SES) and knowledge of and willingness to vaccinate with Inactivated Polio Vaccine (IPV) were inversely associated with RI; and lower SES, walking to the vaccination point, knowledge of IPV, and an understanding of contracting polio were inversely associated with OPV refusals, with the latter two also inversely associated with complete vaccine refusal.

CONCLUSION

Education, knowledge and understanding of vaccines, and socioeconomic determinants influenced OPV and RI refusals among children. Effective interventions are needed to address knowledge gaps and misconceptions among parents.

Differential coverage for vaccines in the expanded program on immunization (EPI) among children in rural Pakistan

BACKGROUND

Pakistan has a well-established Expanded Program on Immunization (EPI) however vaccine-preventable diseases still account for high infant and child mortality rates. This study describes the differential vaccine coverage and determinants of vaccine uptake in rural Pakistan.

METHODS

From October 2014 to September 2018, we enrolled children younger than 2 years of age from the Matiari Demographic Surveillance System in Sindh, Pakistan. Socio-demographic and vaccination history were collected from all participants. Vaccine coverage rates and timeliness were reported. Socio-demographic variables for missed and untimely vaccination were studied in multivariable logistic regression.

RESULTS

Of the 3140 enrolled children, 48.4 % received all EPI recommended vaccines. Only 21.2 % of these were age appropriate. Around 45.4 % of the children were partially vaccinated, and 6.2 % were unvaccinated. Highest coverage was seen for the first dose of pentavalent (72.8 %), 10-valent Pneumococcal Conjugate Vaccine (PCV10) (70.4 %) and Oral Polio Vaccine (OPV) (69.2 %) and the lowest coverage was for measles (29.3 %) and rotavirus (1.8 %) vaccines. Primary caretakers and wage earners with a higher level of education were protective against missed and untimely vaccination. Enrollment in the 2nd, 3rd and 4th study year was negatively associated with being unvaccinated whereas distance from a major road was positively associated with non-adherence to schedule.

CONCLUSION

Vaccine coverage was low among children in Matiari, Pakistan, and majority received delayed doses. Parents' education status and year of study enrollment was protective against vaccine dropout and delayed vaccination whereas geographical distance from a major road was a predictor. Vaccine promotion and outreach efforts may have had a beneficial impact on vaccine coverage and timeliness.

An Epidemic of Pediatric HIV From Reuse of Infusion Equipment in Pakistan

BACKGROUND

From April to June 2019, a total of 909 new HIV infections were identified in Larkana, Pakistan; 86% was children younger than 15 years. To identify the possible transmission links in this outbreak, a case-control study was conducted in June 2019.

METHODS

For cases, we selected a systematic random sample of 100 HIV-positive children from the screening list. We chose 2 age-matched and sex-matched controls from the neighborhood of each HIV-positive case. All selected children were tested using the World Health Organization-approved rapid diagnosis test algorithm. We interviewed the parents of each selected child about previous exposures to parenteral treatment and compared exposures of case and control children using conditional logistic regression.

RESULTS

The ages of the selected children ranged from 1 month to 10 years. More than 90% of both HIV+ and HIV- children had received outpatient health care from MBBS-qualified private physicians. Eighty-three percent of HIV+ children versus 46% of HIV- children had received health care from one private physician [adjusted odds ratio (aOR) = 29, 95% confidence interval (95% CI): 10 to 79]. Intravenous infusions during the last outpatient visit were reported by 29% of case versus 7% of controls (aOR 57, 95% CI: 2.9 to >1000), whereas no case children and 17% of control children had received only intramuscular injections (aOR 0, 95% CI: 0 to 41). Among cases, 94% had been given infusions through a drip set compared with 85% of control children (aOR = 7.7, 95% CI: 2.3 to 26). Infusions had been administered with reused IV drip sets in 70% of cases compared with 8% of controls (aOR = 197, 95% CI: 16 to 2400).

DISCUSSION

Private physicians reusing intravenous drip sets to treat outpatients seen in private practice were responsible for this HIV epidemic. Mapping and regulation of private practitioners were suggested.

Unveiling and addressing implementation barriers to routine immunization in the peri-urban slums of Karachi, Pakistan: a mixed-methods study

BACKGROUND

Great disparities in immunization coverage exist in Pakistan between urban and rural areas. However, coverage estimates for large peri-urban slums in Sindh are largely unknown and implementation challenges remain unexplored. This study explores key supply- and demand-side immunization barriers in peri-urban slums, as well as strategies to address them. It also assesses immunization coverage in the target slums.

METHODS

Conducted in four peri-urban slums in Karachi, this mixed-methods study consists of a baseline cross-sectional coverage survey of a representative sample of 840 caregivers of children aged 12-23 months, and 155 in-depth interviews (IDIs) through purposive sampling of respondents (caregivers, community influencers and immunization staff). After identifying the barriers, a further six IDIs were then conducted with immunization policy-makers and policy influencers to determine strategies to address these barriers, resulting in the development of an original validated implementation framework for immunization in peri-urban slums. A thematic analysis approach was applied to qualitative data.

RESULTS

The survey revealed 49% of children were fully vaccinated, 43% were partially vaccinated and 8% were unvaccinated. Demand-side immunization barriers included household barriers, lack of knowledge and awareness, misconceptions and fears regarding vaccines and social and religious barriers. Supply-side barriers included underperformance of staff, inefficient utilization of funds, unreliable immunization and household data and interference of polio campaigns with immunization. The implementation framework's policy recommendations to address these barriers include: (1) improved human resource management; (2) staff training on counselling; (3) re-allocation of funds towards incentives, outreach, salaries and infrastructure; (4) a digital platform integrating birth registry and vaccination tracking systems for monitoring and reporting by frontline staff; (5) use of digital platform for immunization targets and generating dose reminders; and (6) mutual sharing of resources and data between the immunization, Lady Health Worker and polio programmes for improved coverage.

CONCLUSIONS

The implementation framework is underpinned by the study of uncharted immunization barriers in complex peri-urban slums, and can be used by implementers in Pakistan and other developing countries to improve immunization programmes in limited-resource settings, with possible application at a larger scale. In particular, a digital platform integrating vaccination tracking and birth registry data can be expanded for nationwide use.

Genetic Epidemiology Reveals 3 Chronic Reservoir Areas With Recurrent Population Mobility Challenging Poliovirus Eradication in Pakistan

BACKGROUND

Pakistan is among 3 countries endemic for wild poliovirus type 1 (WPV1) circulation that are still struggling for eradication of poliomyelitis. Active clinical and environmental surveillance with meticulous laboratory investigations provide insights into poliovirus transmission patterns and genomic diversity to inform decisions for strategic operations required to achieve eradication.

METHODS

We analyzed epidemiological and virological data to comprehend the current epidemiological status of WPV1 in Pakistan during 2015-2017. Stool specimens of patients with acute flaccid paralysis (AFP) and sewage samples collected from 60 environmental sites were tested. Viral culturing, intratypic differentiation by real-time polymerase chain reaction, and nucleic acid sequencing of the VP1 region of the poliovirus genome to determine genetic relatedness among WPV1 strains were applied.

RESULTS

Poliovirus isolates were grouped into 11 distinct clusters, which had ≥95% nucleotide homology in the VP1 coding region. Most of the poliovirus burden was shared by 3 major reservoirs: Karachi, Peshawar, and Quetta block (64.2% in 2015, 75.4% in 2016, and 76.7% in 2017).

CONCLUSIONS

Environmental surveillance reveals importations and pockets of unimmunized children that dictate intensive target mop-up campaigns to contain poliovirus transmission. A decrease in the number of orphan isolates reflects effective combination of AFP and environmental surveillance in Pakistan. The genetic data reflect sustained transmission within reservoir areas, further expanded by periodic importations to areas of high immunity reflected by immediate termination of imported viruses. Improved immunization coverage with high-quality surveillance is vital for global certification of polio eradication.

Quantifying movement patterns and vaccination status of high risk mobile populations in Pakistan and Afghanistan to inform poliovirus risk and vaccination strategy

BACKGROUND

Stopping serotype 1 wild poliovirus transmission in Pakistan and Afghanistan requires ensuring all children <5 years of age are repeatedly vaccinated, including the large proportion living in mobile groups. Vaccinating children living in high-risk mobile populations (HRMPs) remains a priority for the polio programme.

METHODS

In 2017-2018, group-level censuses were conducted in 43 districts of Pakistan, gathering information for all HRMP children <5 years of age residing in settlements. Demographic and mobility information was collected, including HRMP type, ethnicity, language, mode of transportation and movement patterns. Vaccination status was recorded for the most recent polio campaign. Proportion of HRMP children by demographic factors and mode of transportation was determined and the magnitude of movement was quantified based on the origin, previous and next locations. Magnitude of cross-border movement with Afghanistan was evaluated, as was primary crossing point. Vaccination status was evaluated for each district by demographic and mode of transportation information.

RESULTS

In total, 188,130 HRMP children <5 years of age were assessed. The predominant HRMP type, ethnic group, language and mode of transport was Afghan refugees (27%), Pashtun (69%), Pashto (69%) and bus (52%). Overall, 84% of children originated outside of their current district, including 29% from Afghanistan. Previous and next locations, were reported outside of current location by 34% and 77% of children. Afghanistan was previous and next location for 5% and 11% of children, with 5.5% and 3% of children crossing the Afghanistan border in the past 6-months and next 3-months. Primary crossing route was Torkham (79%). Overall vaccination coverage was 98% (IQR: 96%-99%) and consistently >90% across HRMP type, ethnic group, language and mobility means.

CONCLUSION

Large numbers of HRMPs were found across Pakistan, with substantial links throughout the country and with Afghanistan. While vaccination coverage of HRMPs was high, ensuring these populations are consistently vaccinated remains a priority.

Visibility and Analytics Network (VAN) approach to improve immunization supply chain and management performance system in Pakistan

Background

Pakistan has been experiencing several immunization related challenges. The supply chain management information system (MIS) is considered an important component of immunization services as it can improve visibility in key areas such as vaccine shortages or wastage. This study assessed the effectiveness of the Visibility and Analytics Network (VAN) approach in improving vaccine supply and availability of stocks by comparing the situation in intervention and non-intervention districts in Sindh province of Pakistan.

Methods

We utilized a quantitative and qualitative approach to collect data to assess the VAN approach in two districts of Sindh province in Pakistan. The data were collected between August and October 2017. VAN is a systematic monitoring system which measures the performance of vaccine supply chain management based on a set of indicators. We assessed storage facilities of the Expanded Programme on Immunization (EPI) in Sindh and interviewed personnel involved using a pre-tested data collection tool. We also conducted in depth interviews with senior management to assess performance of VAN, adoption mechanism and needs to scale up the VAN approach.

Results

We assessed 52 EPI facilities of Sindh province government. In the intervention district 83.3% managers were using MIS data for decision making related to vaccine supplies whereas in the non- intervention district no MIS based data were available. Ninety percent of stores were maintaining a stock registry and 100% supplies matched with requisitions in the intervention district compared to 40% and 35% in the non-intervention district for the same variables. Vaccine wastage was high in the non- intervention district (BCG 46.7% vs 33.9; OPV 13.5% vs 9.5%; pneumococcal 11.4% vs 7.4%). In-depth interview findings suggested that the VAN approach provided data guided monitoring in Pakistan for the first time. The approach also enabled district managers to make timely decisions.

Conclusion

The VAN approach improves vaccine supply chain management. It should be scaled up and implemented at national or sub national especially in countries struggling with vaccine supply chain management.

Understanding the accountability issues of the immunization workforce for the Expanded Program on Immunization (EPI) in Balochistan: An exploratory study

Background

Among all provinces of Pakistan, immunization coverage is poorest in Balochistan. There is no provincial immunization policy for Balochistan including a lack of human resource management policy. Maladministration and lack of accountability leading to health workforce demotivation and poor performance can be a crucial reason behind an inefficient and ineffective immunization program in Balochistan. The objective of this study was to better understand the accountability issues of EPI workforce at provincial and district level leading to poor program performance and to identify governance strategies for management of inefficiency, demotivation and absenteeism.

Methods

An exploratory qualitative study was carried out to explore issues related to human resource (HR) accountability within immunization program of Balochistan for developing strategies to improve performance of the program. Five districts were selected using purposive sampling based on the comparative poor and good routine immunization coverages and Human Development Index (HDI). Interviews were conducted with EPI Staff and District Health Officers (DHOs) in each district including provincial EPI Staff. A semi-structured and open-ended questionnaire was used. Thematic analysis was used to analyze the qualitative data.

Results

Major barriers to HR accountability included lack of a written HR policy, proper service structure including promotions and benefits and understanding of accurate job description coupled with inadequate HR development budget and activities. Most important demotivating factors were inadequate number of vaccinators, deficient budget with delayed wage and salary disbursements resulting in poor immunization coverage and a lack of appreciation/feedback from senior management for the frontline workers. Key challenge for vaccinators was poor community orientation and mobilization. Although, the participants proposed some solutions based on their perspective, none were elaborate or precise.

Conclusions

Adaptation of National Immunization Policy tailored to the provincial context and proper implementation is much needed. Review of current allocations of vaccinators and need based relocation along with recruitment of new vaccinators with clear job description and terms of reference is desirable. Review of current incentive structure is required. Finally, trust building between community and the vaccination program and social mobilization about the benefits of vaccinations through community influential is vital.

"Does Pakistan still have polio cases?": Exploring discussions on polio and polio vaccine in online news comments in Pakistan

INTRODUCTION

Polio, which is caused by poliovirus, is a contagious, potentially crippling, and deadly disease. Pakistan is one of the countries in which polio is still endemic in the 21st century. In 2019, 146 polio cases were reported across the country with some resulting in deaths. Following the spread of rumors insinuating that children were falling sick after receiving an anti-polio vaccine, a mob attacked and set fire to a small hospital in the Peshawar district in April 2019. The present study investigates readers' discussions that emerged from Dawn's online readers' comments on polio-related news stories in Pakistan.

METHODS

Using thematic analysis, we analyzed (N = 2216) comments made by readers in the polio-related news stories published on Dawn.com from January 1, 2012, to March 1, 2020.

RESULTS

Seven major themes emerged from the analysis of the comments: 1) reasons for and challenges resulting in the failure to eradicate polio; 2) proposed solutions and policy changes to eradicate polio; 3) misinformation; 4) criticism, frustration, and shame; 5) comparison of Pakistan to other countries; 6) the internet as a public sphere; 7) suffering, empathy, and appreciation. Overall, our findings suggested that commenters are knowledgeable about polio vaccines and consider polio a serious threat to public health in Pakistan.

CONCLUSION

Our study not only validated previous study findings such as reasons, challenges, and issues related to polio vaccination, but also found new challenges in online news sites concerning misinformation on polio and polio vaccination in Pakistan.

Covering the last mile for vaccination: Feasibility and acceptability of traditional birth attendant-based referral system in hard-to-reach areas in rural Pakistan

Background

Pakistan has a decent network of community-based workers including lady health workers (LHWs) and vaccinators. However, a major section of the population is not covered by LHWs/vaccinators, labeled here as hard-to-reach (HTR) areas, where immunization coverage is also considerably low. This study explored the feasibility of engagement of traditional birth attendants (TBAs) to improve EPI vaccination coverage in HTR areas in rural Sindh, Pakistan.

Methods

This implementation research was conducted in two sub-districts of Sukkur (a district in Sindh Province). In an HTR selected intervention arm, TBAs were trained for vaccination and monetary incentives were provided to counsel and refer mothers for vaccination. While LHWs covered areas in the adjacent sub-district were provided with refresher training for vaccination only without any monetary incentive, and were considered as control arm. Considering the inherent differences in intervention and comparison group (HTR intervention area being worse regarding infrastructure and access), between groups and within group change in knowledge of TBA/LHWs and vaccination coverage was assessed before and after the intervention. Furthermore, focus group discussions were conducted with vaccinators, TBAs and LHWs and in-depth interviews with supervisors of vaccinators.

Results

TBAs and LHWs' vaccine related knowledge increased significantly after training (pretest vs post test score: 10.5 to 15.4). The BCG coverage improved 74.1% (percentage change) in TBA arm. While completion of vaccination (ie, Penta-3 coverage) increased by 147% from baseline following the intervention. The TBAs, LHWs, vaccinators and their supervisors all welcomed the initiative and considered it as a feasible option.

Conclusions

Involvement of TBAs' to form a referral system has potential to improve vaccine coverage and completion in HTR areas in Pakistan. The system is acceptable to the population and implementation is feasible due to availability of TBAs. However, in order to sustain the initiative minimal incentive need to be provided to TBAs to improve the vaccination coverage. Compared to establishing the infrastructure in HTR the intervention seems less costly however, it requires formal cost-effective or cost-benefit analysis.

Polio Amidst COVID-19 in Pakistan: What are the Efforts Being Made and Challenges at Hand?

Poliomyelitis, a crippling viral disease, has been affecting many children in Pakistan despite the numerous efforts that have been taken to curb its spread. The COVID-19 pandemic has halted mass polio vaccination campaigns globally, including Pakistan, resulting in a resurgence of new cases. Pakistan managed to flatten the COVID-19 curve from July to October that made three immunization drives possible, but the COVID-19 cases are on the rise again which can again complicate the polio situation in the country if left unmonitored. The efforts of Pakistan have been effective with no significant rise in polio cases in 2020 as compared with 2019. We discuss the numerous challenges faced by the polio eradication program in Pakistan. To help eliminate polio, Pakistan needs to enhance its efforts in the struggle against polio with the same zeal and stringency used to flatten the curve of COVID-19 in these challenging times.

Spatiotemporal clustering analysis of Expanded Program on Immunization (EPI) vaccination coverage in Pakistan

Universal vaccination coverage is still far from desired targets in many global regions including Pakistan, despite the success stories and its scientifically proven benefits. EPI Pakistan vaccination coverage data 2012–2016, at district level was collected from Federal EPI Pakistan. District-wise population data were collected from Pakistan Bureau of Statistics. Descriptive statistics and sequence plots were performed in SPSS 13.0. Purely spatial scanning analysis was done in SaTScan 9.4.4 using discrete Poisson model for detection of low vaccination coverage clusters. Geographical information system (GIS) was used to display spatial patterns and clusters of low vaccination coverage districts in Pakistan. Average annual EPI vaccination coverage in each study year were; 70.98 in 2012, 69.39% in 2013, 66.74% in 2014, 61.47% in 2015, and 67.01% in 2016, respectively. Cumulative average national vaccination rate (2012–2016) for all types of EPI vaccines was 60.60%. Average national vaccination rate for BCG, OPV3, pentavalent3 and measles1 was 67.12%, 58.53%, 58.47%, and 58.29%, respectively. Spatial cluster analysis demonstrated that most of low coverage districts for BCG, OPV3 and pentavalent3 were from FATA and KPK; while measles1 low coverage districts belonged to Balochistan. Future research should probe factors involved in low vaccination coverage in high risk districts.

Why Have Immunization Efforts in Pakistan Failed to Achieve Global Standards of Vaccination Uptake and Infectious Disease Control?

Immunization is one of the most successful public health initiatives in recent times. It is, therefore, worrying to learn the level of under-vaccination in Pakistan. Diseases that have been successfully eliminated through the aid of vaccination in other countries have not been eliminated in Pakistan. The reasons for this vary and show the uniqueness of the economic, healthcare and environmental landscape of Pakistan, through which public health programmes need to be implemented. The “Expanded Programme of Immunization” (EPI) is the main programme through which routine immunization is provided to the public. Within Pakistan, it has encountered many problems since its inception. This includes logistical obstacles, inefficient health worker attitudes, parental and female awareness, and education, the influence of religious community leaders and the complications that accompany conflict. When compared to globally standardised targets for immunization, Pakistan is trailing behind. Not achieving these targets is worrying from both a global perspective and within the national healthcare landscape of Pakistan. Research is necessary to bring together findings on the failings of routine immunization and polio campaigns; there are many intersecting factors that global health bodies and the Department of Health in Pakistan must address in order to relieve the burden of vaccine-preventable diseases (VPDs).

System within systems: challenges and opportunities for the Expanded Programme on Immunisation in Pakistan

Background

Pakistan has one of the highest infant and child mortality rates in the world, half of these occurring due to vaccine-preventable diseases. The country started its Expanded Programme on immunisation (EPI) in 1978. However, the programme’s performance is often questioned, as the Immunisation rates have been chronically low and on-time vaccination unsatisfactory. We explored the programme’s insights about its structural and implementation arrangements within the larger governance system, and the ensuing challenges as well as opportunities.

Methods

We carried out a qualitative case study comprised of semi-structured, in-depth interviews with 34 purposively selected key informants from various tiers of immunisation policy and programme implementation. The interviews revolved around WHO’s six building blocks of a health system, their interactions with EPI counterparts, and with the outer ecological factors. Interviews were transcribed and content analysed for emergent themes.

Results

The EPI faces several challenges in delivering routine immunisation (RI) to children, including lack of clarity on whether to provide vaccination through fixed centres or mobile teams, scarcity of human resource at various levels, lack of accurate population data, on-ground logistic issues, lack of a separate budget line for EPI, global pressure for polio, less priority to prevention by the policy, security risks for community-based activities, and community misconceptions about vaccines.

Conclusions

The fulcrum for most of the challenges lies where EPI service delivery interacts with components of the broader health system. The activities for polio eradication have had implications for RI. Socio-political issues from the national and global environment also impact this system. The interplay of these factors, while posing challenges to effective implementation of RI, also brings opportunities for improvement. Collective effort from local, national and global stakeholders is required for improving the immunisation status of Pakistani children, global health security and the sustainable development goals.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0452-z) contains supplementary material, which is available to authorized users.

What is causing high polio vaccine dropout among Pakistani children?

OBJECTIVES

Although the antipolio drive is undertaken across Pakistan, there are still children who have not received any oral polio vaccine or are unable to complete recommended doses of polio vaccine. This study aims at empirically analyzing the associated factors with the no oral polio vaccination (OPV) and OPV dropout groups of children in Pakistan.

STUDY DESIGN

This is a cross-sectional study.

METHODS

Data were obtained from the three waves of Pakistan Demographic and Health Survey of children aged between 12 and 23 months (1990-1991: n = 1214; 2006-2007: n = 1522; 2012-2013: n = 2074). Children who received no OPV and those who drop out of polio vaccination (OPV1-OPV3) were considered as outcome variables. The bivariate relationship of outcome variable with each socio-economic, demographic, and spatial variable is estimated with a P-value of <0.01. For both no OPV and OPV dropout children, we used logistic regression analysis separately.

RESULTS

The percentage of children aged 12-23 months who dropped out of OPV1-OPV3 vaccination was about 76% in the year 1990-1991; 21% in 2006-2007, and 17.5% in 2012-2013 at the national level. Among all indicators, provinces, rural versus urban residence, the mother's age at marriage, the child's birth place (home versus hospital), parental education, and household wealth status are significant predictors of no OPV and/or OPV dropout in Pakistan. Among provinces, Balochistan, Khyber Pakhtunkhwa (KPK), and Sindh are the lagging provinces.

CONCLUSION

Improving the socio-economic status of women helps decrease the chance of polio dropout and thus improves service delivery and program implementation.

Differential achievements in childhood immunization across geographical regions of Pakistan: analysis of wealth-related inequality

BACKGROUND

Childhood immunization is one of the most cost-effective interventions for child health. Still, many children are not able to receive completed immunization status. Wealth - related inequality in immunization is considered a major reason for equitable coverage of immunization in Pakistan. Therefore, we examine wealth-related inequality in completed childhood immunization and to assess achievement indices across geographical regions in Pakistan.

METHODS

The analysis was based on a nationally representative demographic and health survey (DHS) of Pakistan, conducted in 2012-13. We examined completed childhood (12-23 months) immunization in the various regions of the country and we used concentration, extended concentration and achievement indices to demonstrate inequality across geographical regions in Pakistan.

RESULTS

Inequality in completed childhood immunization was seen in Pakistan with concentration index (CI) of 0.181 (95% CI: 0.164-0.209). Regions with high average of complete immunization showed lower inequality except for Sindh. Despite having better average immunization coverage in Kyber Pakhtunkhwa, the relative change of 128% in concentration index (CI) from C2 (standard CI) to C5 (when poorer quantile received highest weights) shows this to be also the most inequitable regions. Four parameters of inequality aversion (v = 2, 3, 4 & 5) demonstrated that 'dis - achievement' in completed immunization is densely concentrated among the poorer regions. Balochistan, Sindh and Gilgit Baltistan exhibited broader inequality gaps (93.75%, 83.35%, and 54.93%, respectively) at higher aversion parameter.

CONCLUSIONS

As hypothesized, achievement index uncovers 'penalized' immunization coverage amongst the poorest population. Thus any policy that stringently focuses on improving average immunization rate without any strategy to deal with inequality will only improve immunization rate within wealthier groups. Based on these results, it is advisable to public health policy makers to use both aspect of information: average and degree of inequality in immunization coverage.

Experiences and Lessons From Polio Eradication Applied to Immunization in 10 Focus Countries of the Polio Endgame Strategic Plan

Nine polio areas of expertise were applied to broader immunization and mother, newborn and child health goals in ten focus countries of the Polio Eradication Endgame Strategic Plan: policy & strategy development, planning, management and oversight (accountability framework), implementation & service delivery, monitoring, communications & community engagement, disease surveillance & data analysis, technical quality & capacity building, and partnerships. Although coverage improvements depend on multiple factors and increased coverage cannot be attributed to the use of polio assets alone, 6 out of the 10 focus countries improved coverage in three doses of diphtheria tetanus pertussis containing vaccine between 2013 and 2015. Government leadership, evidence-based programming, country-driven comprehensive operational annual plans, community partnership and strong accountability systems are critical for all programs and polio eradication has illustrated these can be leveraged to increase immunization coverage and equity and enhance global health security in the focus countries.

Intention to accept pertussis vaccine among pregnant women in Karachi, Pakistan

BACKGROUND

Maternal immunization against pertussis is a potential strategy to protect young infants from severe disease. We assessed factors associated with intention to accept pertussis vaccination among pregnant women in Karachi, Pakistan.

METHODS

We conducted a cross-sectional survey between May and August 2013 in pregnant women who visited healthcare centers in urban slums of Karachi city. Women completed a survey examining socio-demographic factors, vaccination history, knowledge on pertussis disease, perception of vaccine recommendation sources, and potential influences on vaccine decision-making.

RESULTS

Of the 283 participants, 259 (92%) provided their intention to either accept or decline pertussis vaccination. Eighty-three percent women were willing to accept the pertussis vaccine if offered during pregnancy. About half (53%) of the participants had ever heard of pertussis disease. Perceptions of pertussis vaccine efficacy, safety, and disease susceptibility were strongly associated with intention to accept pertussis vaccine (p<0.01). Healthcare providers, Ministry of Health, and mass media were considered as highly reliable sources of vaccine recommendation and associated with intention to accept antenatal pertussis vaccination (p<0.001). Healthcare provider recommendation was a common reason cited by respondents for pregnant women to accept antenatal pertussis vaccination (p=0.0005). However, opinion of primary decision-makers in the family (husbands and in-laws) was a crucial reason cited by respondents for pregnant women to reject pertussis vaccination in pregnancy (p=0.003).

CONCLUSION

Antenatal pertussis vaccination initiatives in South Asia should strongly consider inclusion of family members, healthcare providers, national health ministries, and mass media to help implement new vaccination programs.

Risk factors and short-term projections for serotype-1 poliomyelitis incidence in Pakistan: A spatiotemporal analysis

BACKGROUND

Pakistan currently provides a substantial challenge to global polio eradication, having contributed to 73% of reported poliomyelitis in 2015 and 54% in 2016. A better understanding of the risk factors and movement patterns that contribute to poliovirus transmission across Pakistan would support evidence-based planning for mass vaccination campaigns.

METHODS AND FINDINGS

We fit mixed-effects logistic regression models to routine surveillance data recording the presence of poliomyelitis associated with wild-type 1 poliovirus in districts of Pakistan over 6-month intervals between 2010 to 2016. To accurately capture the force of infection (FOI) between districts, we compared 6 models of population movement (adjacency, gravity, radiation, radiation based on population density, radiation based on travel times, and mobile-phone based). We used the best-fitting model (based on the Akaike Information Criterion [AIC]) to produce 6-month forecasts of poliomyelitis incidence. The odds of observing poliomyelitis decreased with improved routine or supplementary (campaign) immunisation coverage (multivariable odds ratio [OR] = 0.75, 95% confidence interval [CI] 0.67-0.84; and OR = 0.75, 95% CI 0.66-0.85, respectively, for each 10% increase in coverage) and increased with a higher rate of reporting non-polio acute flaccid paralysis (AFP) (OR = 1.13, 95% CI 1.02-1.26 for a 1-unit increase in non-polio AFP per 100,000 persons aged <15 years). Estimated movement of poliovirus-infected individuals was associated with the incidence of poliomyelitis, with the radiation model of movement providing the best fit to the data. Six-month forecasts of poliomyelitis incidence by district for 2013-2016 showed good predictive ability (area under the curve range: 0.76-0.98). However, although the best-fitting movement model (radiation) was a significant determinant of poliomyelitis incidence, it did not improve the predictive ability of the multivariable model. Overall, in Pakistan the risk of polio cases was predicted to reduce between July-December 2016 and January-June 2017. The accuracy of the model may be limited by the small number of AFP cases in some districts.

CONCLUSIONS

Spatiotemporal variation in immunization performance and population movement patterns are important determinants of historical poliomyelitis incidence in Pakistan; however, movement dynamics were less influential in predicting future cases, at a time when the polio map is shrinking. Results from the regression models we present are being used to help plan vaccination campaigns and transit vaccination strategies in Pakistan.

Eradicating polio in Pakistan: an analysis of the challenges and solutions to this security and health issue

Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988 the global incidence of poliomyelitis has fallen by nearly 99 %. From a situation where wild type poliovirus was endemic in 125 countries across five continents, transmission is now limited to regions of just three countries – Pakistan, Afghanistan and Nigeria. A sharp increase in Pakistan’s poliomyelitis cases in 2014 prompted the International Health Regulations Emergency Committee to declare the situation a ‘public health emergency of international concern’. Global polio eradication hinges on Pakistan’s ability to address the religious, political and socioeconomic barriers to immunisation; including discrepancies in vaccine coverage, a poor health infrastructure, and conflict in polio-endemic regions of the country. This analysis provides an overview of the GPEI, focusing on the historical and contemporary challenges facing Pakistan’s polio eradication programme and the impact of conflict and insecurity, and sheds light on strategies to combat vaccine hesitancy, engage local communities and build on recent progress towards polio eradication in Pakistan.

Infectious Diseases and Livelihoods

Agriculture has been the most common form of livelihood for rural communities in developing countries for centuries. Apart from providing a livelihood, rural communities find food and nutrients necessary for their survival and well-being from their farms. Agriculture also brings risks to health through infectious diseases. Poor health leads to reduction in productivity, where individuals are not able to carry out their livelihoods due to ill health. This could lead to reduction in income through excess expenditure on treatments, thereby inhibiting economic development of the affected communities. Infectious diseases have both direct and indirect impact on livelihoods. The direct impact includes poor health and loss of lives, which leads to partial and complete loss of livelihoods. Indirectly, infectious diseases lead to loss of income through poor performance of livelihoods as well as diversion of resources that could have been used to improve livelihood to seek medical treatment. Due to the effects of disease, individuals become marginalized, socially affecting their businesses and ways of earning a livelihood.

A Cross-Sectional Survey of Healthcare Workers on the Knowledge and Attitudes towards Polio Vaccination in Pakistan

INTRODUCTION

Pakistan accounts for 85.2% of the total polio cases reported worldwide. Healthcare workers (HCWs) are an integral part of immunization campaigns and source of education for the general public. This study aimed to assess the knowledge and attitudes towards polio vaccination among HCWs providing immunisation and education to general public in Quetta and Peshawar divisions of Pakistan.

METHODS

A cross-sectional survey of 490 HCWs was conducted in two major referral public teaching hospitals of Quetta and Peshawar divisions. During February to April, 2015, a random sample of 490 HCWs was invited to participate in this study. Knowledge and attitudes were assessed by using self-administered, anonymous and pretested questionnaire. Descriptive and logistic regression analyses were used to express the results.

RESULTS

A total of 468 participants responded to the questionnaire, giving a response rate of 95.5%. Overall, participants demonstrated good knowledge and positive attitudes towards polio vaccination. The mean knowledge score of HCWs about polio was 13.42 ± 2.39 (based on 18 knowledge questions) while the mean attitude score was 28.75 ± 5.5 (based on 9 attitudes statements). Knowledge gaps were identified about the incubation period of poliovirus (19.5%), management issues (31.9%), use of polio vaccine in mild illnesses (34.7%) and the consequences of the polio virus (36.9%). The majority of participants agreed that all children should be vaccinated for polio (95.1%), while reservations were noted about the need of a booster (38.9%), and sterility issues associated with polio vaccines (43.6%). Internet (n = 167, 37%) and Posters (n = 158, 35%) were the main sources used by HCWs to educate themselves about polio.

CONCLUSION

Participants in this study had good knowledge and positive attitudes towards polio vaccination. Although the data are indicative of gaps in the knowledge of HCWs, the findings may not be generalized to other hospitals in Pakistan.

The re-emergency and persistence of vaccine preventable diseases

The introduction of vaccination worldwide dramatically reduced the incidence of pathogenic bacterial and viral diseases. Despite the highly successful vaccination strategies, the number of cases among vaccine preventable diseases has increased in the last decade and several of those diseases are still endemic in different countries. Here we discuss some epidemiological aspects and possible arguments that may explain why ancient diseases such as, measles, polio, pertussis, diphtheria and tuberculosis are still with us.

Vaccine-preventable diseases in humanitarian emergencies among refugee and internally-displaced populations

Humanitarian emergencies may result in breakdown of regular health services including routine vaccination programs. Displaced populations including refugees and internally displaced persons are particularly susceptible to outbreaks of communicable diseases such as vaccine-preventable diseases (VPDs). Common VPDs encountered in humanitarian emergencies include measles, polio, and depending on geographical location, meningococcal meningitis, yellow fever, hepatitis A, and cholera. We conducted a review of 50 published articles from 2000 to 2015 concerning VPDs in humanitarian emergencies. This article provides an update on the available literature regarding vaccinations among this highly vulnerable population and describes the unique challenges of VPDs during humanitarian emergencies. Humanitarian emergencies place affected populations at risk for elevated morbidity and mortality from VPDs due to creation or exacerbation of factors associated with disease transmission such as mass population movements, overcrowding, malnutrition, and poor water and sanitation conditions. Vaccination is one of the most basic and critical health interventions for protecting vulnerable populations during emergencies. Growing insecurity, as seen in the increasing number of targeted attacks on health workers in recent years, as well as destruction of cold chain and infrastructure for transportation of supplies, are creating new challenges in provision of life saving vaccines in conflict settings. Population displacement can also threaten global VPD eradication and elimination efforts. While highly effective vaccines and guidelines to combat VPDs are available, the trend of increasing number of humanitarian emergencies globally poses new and emerging challenges in providing vaccination among displaced populations.