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

"Overall, the literature points to female education and awareness on this public health as imperative for the performance of the EPI to be improved and to achieve global targets of vaccine coverage."

Since its inception in 1978, Pakistan's Expanded Programme of Immunization (EPI) has encountered many problems, as evidenced by estimates of children aged 1-2 years who receive all routine immunisations falling well below targets (only between 59% and 73%, with uptake varying throughout the country). The purpose of this literature review is to assess why immunisation efforts in Pakistan have failed to achieve global standards of public health, and to make recommendations as to how to overcome the challenges.

The EPI was set up by the World Health Organization (WHO) as a global initiative, in many developing countries, in order to address vaccine-preventable diseases (VPDs). Different national logistics affect how EPI is applied; the WHO acknowledges this and implements the EPI to be as country-specific as possible. There are over 6,000 "fixed" centres of immunisation running within Pakistan, with 1 million mobile outreach services providing similar facilities for harder-to-reach areas. In addition, over 10,000 vaccine personnel, including Lady Health Workers (LHWs) and paramedics, provide vaccines to patients. The local vaccinators are not directly supervised by national EPI managers.

The 3 main goals of the EPI in the contemporary context are the elimination of polio, measles, and neonatal tetanus. Immunisation coverage in Pakistan has seen a unique trajectory in the past few decades. As reported here, "disparities in data do bring to light problems with data collection and accuracy of numbers." However, the advent of the Zindagi Mehfooz (Safe Life; ZM) Digital Immunization Registry in Pakistan, which is an Android phone-based system, allows vaccinators to digitally enrol and track the immunisation status of their district. Automated SMS (text message)-based systems, which ask questions such as "Did the vaccinator visit your house?", can also track vaccine uptake. However, further research is needed to determine if these digital data are sufficiently representative of the true values of vaccine coverage.

One thing that seems clear is that higher rates of vaccination are found in urban areas. As more than 70% of Pakistan's 164 million people live in rural areas, a large fraction of the population of Pakistan are not benefiting from vaccinations. Vaccinators coming to people's houses is one viable option, one that has played a major role in the fight to eradicate polio. Even within fixed centres in which the EPI is being rolled out, immunisation services are often open only once or twice a week.

Related to this issue of availability is the fact that the majority of health services are financed via the private sector, according to sources cited here. "As a result, setting up immunization programmes that require different methods of access for the public have proved difficult. For example, it is of the opinion of many experts that the Department of Health in Pakistan did not actively take part in 'pre-campaign activities' such as meetings, training of health workers, involvement of crucial staff such as Lady Health Workers and citing 'a general lack of interest from DHMT (District Health Management Team)'.....This attitude of disinterest and unaccountability via the public health sector of Pakistan is indicative of the general structure of Pakistan's healthcare system, in which public health-funded activities have never been given priority....The consequences of this mean that the integration of an essentially public health-based programme has been less than satisfactory."

The EPI in Pakistan "also suffers from a severe shortage of human resources at the operational and also management level. The staff in provinces are both under-skilled and the ratio of EPI vaccinators to public is too low - with some areas having as few as 1 or 2 EPI staff members..." LHWs, who (as of 2013) are government employees, are considered by some to be key in assisting with this dearth of personnel. Their training includes a 6-month course, which is viewed by the Pakistani government as secondary to their important position within the community as trusted health workers, who can enter homes and converse openly and equally with families. It is estimated that each LHW serves around 1,000 people. They help civil society organisations (CSOs) in the social mobilisation of the community and have set up vaccination camps and vaccination points, which have reduced vaccine refusals.

There have been some initiatives that have developed to try tackle the failings of the EPI, with varying levels of success. For example, vaccination cards are a "good proxy within Pakistan that have developed in order to provide information and history of vaccination to families....Schemes in other countries have shown that having an effective means of reporting for themselves of vaccination helped a great deal in adherence to vaccination programmes....The efficacy of vaccination cards has been called into question by some research, however." The authors are also critical of short-term measures such as National Immunization Days (NIDs), which they say "increase vaccine uptake for only one day and make an impact on polio uptake mostly. This initiative cannot address the issues of failure to take children for the second and third dose vaccinations."

Communication-related concerns are paramount, considering that "Parents lack of knowledge on the benefits of vaccination and especially the benefits of repeat vaccination, which is also a major concern for the state of immunization within Pakistan." Specifically, attention needs to be paid to findings (in papers cited here) on the importance of the female head of the household on the decision to vaccinate. "Lack of targeting towards mothers on the education of vaccination has meant that a key demographic that is integral to vaccination coverage has gone unnoticed. As the decision makers on this issue, their level of knowledge on how their children can benefit from vaccination could help improve rates of routine immunization."

Thus, "the challenge for immunization service providers is to offer parents balanced and comprehensive information about both the risks and benefits of immunization during counselling sessions....One such intervention was simple but proved statistically effective. Three 'pictorial messages' were given to families by community-based health workers already in place within the healthcare system. When compared with a group that was given only the routine public health advice on vaccines by LHWs, it was found that rates of immunization increased in the intervention group....The study was conducted within a community that had low literacy and high child mortality, and therefore the outcomes show that simple education-based intervention can work in this repeatable model as the context is similar in many communities in Pakistan....LHWs are a system of community health workers already in place that can be utilised in order to implement these educational programmes."

Furthermore, parental trust is an important factor that influences vaccination efforts. "Within low conflict areas of Pakistan which include Sindh, KP [Khyber Pakhtunkhwa] and Punjab, it was found that 61% of parents trust vaccinators. However, in high conflict areas which includes FATA [Federally Administered Tribal Areas], this number was much lower at 28%. This lack of trust extends to further attitudes which put vaccination in jeopardy, such as the view or rumour that vaccination causes sterilisation amongst boys and girls." Along the lines of misinformation: "research has shown that the adverse effects of vaccination in Pakistan are reported more frequently than the positive outcomes, which helps to contribute to parent's unwillingness to take their children for vaccination....Education on the importance of vaccination and re-education to overcome this misinformation is vital in order to make parents bring their children to EPI centres and increase vaccine coverage..."

On a related note, the assessment here is that cultural resistance is "one of the main factors that separates Pakistan and has been a unique reason as to why immunization programmes have failed to reach international targets." In the past, religious clerics in communities have stopped people from taking up the polio vaccine by calling it a Western ploy to sterilise Muslim children and put an end to Islamic progeny. Religious influence takes a further serious turn when the Taliban's influence is considered. They have implemented the blocking of polio immunisation campaigns in FATA (one of the main polio reservoirs in Pakistan), which meant a further 200,000 children were unable to be vaccinated. "From this, we can see a direct cause of under vaccination, due to the feeling of mistrust toward vaccinations and programs. This became an important talking point in the effort to reach vaccination targets."

The literature review also looks at "aid clustering and the polio problem", noting that the polio status of Pakistan (one of the 2 remaining endemic countries) is "an international concern, one that overshadows the health profile of the country greatly....There are two parallel initiatives going on in Pakistan - one for routine immunization and one for polio immunization. As a result, these two often become competing activities at the local context. Thus, 'polio fatigue' has ensued, in which immunization workers feel that resources and focus are not adequately given to routine immunization as a result."

In conclusion, some fundamental issues in Pakistan halt the progression of vaccination services. According to the authors, it is the responsibility of both global health actors and the government of Pakistan to overcome these issues by addressing the obstacles discussed here. For instance, one approach to cultural resistance proposed here is to engage religious leaders in the EPI programmes so they can support the public and vaccine providers in the most personal context within the community - hopefully helping to alleviate the problem of poor community uptake of vaccinations.