Daily Times

This weekend, Pakistan joins the international community in celebrating World Immunisation Week 2021 (April 24-30) under the theme: Vaccines bring us closer. Promoting vaccinations to protect people of all ages against disease is as urgent as ever since it is imperative that routine jabs doses are not missed amidst the scramble for COVID-19 shots. Pakistan needs to contribute significantly to this effort while keeping in mind that the National TB (Tuberculosis) Control Programme (NTP) Expanded Programme on ImmunizationImmunisation (EPI) and the Lady Health Workers Programme (LHWP) have the capacity to complement endeavours towards the attainment of Universal Health Coverage by 2030.

Childhood immunisation saves millions of lives every year and is, without doubt, the most cost-effective health intervention. It also forms part of a multifaceted public health response to the emergence of pandemics such as COVID-19. The eradication of smallpox in 1979 was ad been termed the greatest medical miracle of modern times. The widespread implementation of the Expanded Programme on Immunisation (EPI) in the mid-1970s led to remarkable achievements in the global control of childhood TB, measles, polio, tetanus, diphtheria, and pertussis. While polio has almost been eradicated and measles appears another potential target for elimination — recent additions of pneumococcal conjugate and rotavirus vaccines will lead to a further decline in childhood mortality. Development of vaccines against more complex infections like malaria, tuberculosis and HIV has been challenging, although some progress has been made with preventive and therapeutic cancer vaccines such as HPV and BCG. Future targets include diabetes, hypertension, and Alzheimer’s disease.

Pakistan reaffirmed its commitment to fight childhood illness by establishing the EPI in 1978 and is striving for significant reductions in infant mortality by 2030. The programme is, however, struggling to reach its targets. Pakistan, along with Afghanistan, is one of two remaining polio-endemic countries. Although as of this month, only 1 case of wild poliovirus (WPV) has been detected. Pakistan reported 84 cases in 2020 under the shadow of the COVID-19 pandemic.

Childhood immunisation saves millions of lives every year and is, without doubt, the most cost-effective health intervention. It also forms part of a multifaceted public health response to the emergence of pandemics such as COVID-19

One recurring challenge is sub-optimal routine immunisation coverage. Although sSignificant efforts have, however, been made by the federal and provincial governments and their partners: notably, GAVI the Vaccines Alliance (which includes an annual indigenous investment of close to PKR 36.5 billion dependent on the procurement of vaccines. Based on the Pakistan Demographic and Health Survey (PDHS) 2017–2018, Pakistan has an estimated EPIP coverage of 66 percent in terms of fully immunised children. The PDHS also found that 4 percent of children age 12-23 months had never been vaccinated. Furthermore, vast EPI disparities exist among the provinces: Punjab has 80 percent immunisation, Khyber Pakhtunkhwa 55 percent, Sindh 49 percent and Balochistan just 29 percent of fully immunizedimmunised children..

The WHO provides strategic technical support to the EPI programme, including developing comprehensive multiyear plans (cMYPs) and periodic surveys, while the United Nations Children’s Fund (UNICEF) helps in vaccine procurement, advocacy and social mobilisation. GAVI, since 2000, has disbursed grants close to US$2 billion to support immunisation services, vaccine procurement and health system strengthening.

In Pakistan, most children under the age of 5 die from neonatal tetanus, pneumonia, diarrhoea, measles, injuries, and malaria; all of which are linked to poverty, (mainly maternal) illiteracy, lack of awareness of child healthcare, inadequate provision of health services, malnutrition, poor hygiene, lack of indigenous vaccine production, low motivation in vaccinators, unsafe water and lack of sanitation warranting inter-sectoral action. Immunisation coverage is usually lowest among the poorest population groups. To get around socioeconomic inequalities in child vaccination, we must educate expectant mothers to avail antenatal care visits.

We must also contend with the persistently low demand for immunisation services, especially during the global pandemic. The implementation of various most vaccination programmess haveves routinely been met with widespread scepticism, with the poor being clueless or else deeply misinformed. By contrast, the rich and educated classes often regard such health initiatives as the work of organised corporate mafias.

Here, I must mention the political co-opting of outreach health campaigns, as witnessed in the 2011 Abbottabad incident that has since transformed the humane act of immunising children into a life threatening one. According to a conservative estimate, at least 100 health workers (female and male) as well as their security guards have been killed in Pakistan since 2012. However, instead of conceding defeat, we must redouble efforts to bring about attitudinal changes while addressing social determinants of health.

At the grassroots level, we need to better understand community behaviours, perceptions and demand-side issues, while providing an enhanced role for LHWs. We must also recognise that provincial immunisation rates mask disparities among districts, or even within the same districts, with urban and more easily accessible areas given preference.

Non-interruption of indigenous wild poliovirus transmission in Pakistan has been a matter of great national and international concern. Lack of awareness, false interpretation of religious doctrines, political agendas in conflict zones, lack of proper access to immunisation facilities and poor governance bear collective responsibility for polio failing to be eradicated in the Afghanistan-Pakistan epidemiological bloc that has remained a conflict-affected and security-compromised belt for over four decades. Those who reject polio immunisation belong to low-income and ethnically diverse communities as well as high-income families. All appear prompted by unfounded fears of sterility or autism as well as generally being sceptical ism about the efficiency of immunisation programmes. Weak public services, such as poor sanitation and lack of clean water, leading to diarrheal deaths, have also affected polio control efforts.

In 1994, Pakistan observed its first National Immunisation Days, a one-day mass polio campaign common across the developing world. Since then, we have seen VVIPs administering polio drops to young children; Aseefa Bhutto being the first. For more than a decade, the highest-ranking provincial and district officers have thrown their entire organisational force behind polio eradication, without the desired outcomes being achieved. Edicts of religious scholars from diverse schools of thought have also not had the requisite impact.

Policymakers need to broaden the scope of EPI by including more vaccines; particularly the Human Papillomavirus (HPV) vaccine, prioritised by the WHO and endorsed by the 73rd World Health Assembly (WHA) in 2020. The strategy calls for 90 percent of adolescent girls to be fully vaccinated with the HPV vaccine by 15 years of age. In Pakistan, nearly 20 women are diagnosed with cervical cancer every day, although this figure may be severely under-reported due to lack of access to specialist health facilities and adequate monitoring procedures. This means that 6,000 news cases of cervical cancer are diagnosed annually in Pakistan, making it the third learning cancer among women of all ages. Pakistan needs to incorporate HPV vaccine in its comprehensive multi-year plan for immunisation, to contribute to women’s health, while regarding it as an investment in the future.

In short, we, as a country, both policymakers and citizens alike, need to realise that ‘we have many promises to keep and miles to go before we sleep!

The writer is a senior public health specialist of Pakistan and can be reached at gnkaziumkc@gmail.com