From their own perspective - constraints in the Polio Eradication Initiative: perceptions of health workers and managers in a district of Pakistan's Punjab province

Eradicating polio in Pakistan: a systematic review of programs and policies

Introduction: Established in 1994, Pakistan's polio program demonstrated early success. However, despite over 120 supplementary immunization activities in the last decade, polio eradication efforts in Pakistan have been unable to achieve their objective of halting polio transmission. Variable governance, and inconsistent leadership and accountability have hindered the success of the polio program and the quality of the campaigns. Insecurity and terrorism has interrupted polio activities, and community fears and misbeliefs about polio vaccinations continue to persist.Areas covered: The article consists of a systematic review of the barriers and facilitators associated with the delivery of polio eradication activities in Pakistan. We also provide a comprehensive review of the policy and programmatic decisions made by the Pakistan Polio Programme since 1994. Searches were conducted on Embase and Medline databases and 25 gray literature sources.Expert opinion: Polio eradication efforts must be integrated with other preventive health services, particularly immunization services. Addressing the underlying causes of polio refusals including underdevelopment and social exclusion will help counteract resistance to polio vaccination. Achieving polio eradication will require building health systems that provide comprehensive community-centered care, and improving governance and systems of accountability.

Exploring Factors Influencing Immunization Utilization in Nigeria-A Mixed Methods Study

Background: In 2005, Nigeria adopted the Reach Every Ward strategy to improve vaccination coverage for children, 0-23 months. By 2015, Ogun state had full coverage in 12 of its 20 local government areas but eight had pockets of unimmunized children, with the highest burden (37%) in Remo-North. This study aimed to identify factors in Remo-North influencing the use of immunization services, in order to inform intervention approaches to tackle barriers to immunization utilization. Methods: We carried out a cross-sectional study using mixed methods including a survey of caregivers of 215 children, 25 semi-structured interviews with stakeholders involved in immunization service delivery and 16 focus group discussions with community men and women (n = 98). Two wards (Ilara and Ipara) were purposively chosen for the study. Data was analyzed using the SAGE Working Group Vaccine Hesitancy model. Results: Only 56 children (32.6%) of the 172 children over 9 months of age had immunization cards available for inspection. Of these, 23 (59.6%) were fully immunized, noticeably higher in Ipara than Ilara. However, when immunization status was assessed by card and recall, 84.9% of the children were assessed as fully immunized. Caregivers in the more rural Ilara had less knowledge of vaccine schedules. The importance of all doses was recognized more by Ipara respondents (95.5%) than in Ilara (75.3%) (p < 0.05). Community links to immunization and household decision-making patterns influenced immunization use in both wards. Migrants and those living in hard-to-reach areas were disadvantaged in both wards. Health service factors like absence of delivery services, shortage of health workers, unavailability of vaccines at scheduled times, and indirect costs of immunization contributed to low utilization. Conclusion: Immunization utilization was influenced by interlinked community and health services issues. Intervention approaches should ensure that communities' priorities are addressed, actors at both levels involved and strategies are adjusted to suit contexts.

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.

Health system barriers and levers in implementation of the Expanded Program on Immunization (EPI) in Pakistan: an evidence informed situation analysis

Background

In Pakistan, immunization coverage has been quite low since the program’s inception, and the 2012–2013 population-based survey recorded it at 54%. Much has been written about the issues, challenges, and constraints in the implementation of Pakistan’s immunization program. However, there is a need to better understand the health system barriers as well as levers that influence progress. This review aims to bridge the information gaps on system-level barriers that currently impede the optimal delivery and uptake of immunization services to the children of Pakistan through the Expanded Program on Immunization (EPI).

Methods

We conducted a comprehensive literature review, using PubMed and Google Scholar to find peer-reviewed literature, and also reviewed EPI-related international and national reports. Additionally, we consulted government reports, surveys, and publications on the health system. Employing the basic tenets of WHO’s health systems framework for health system strengthening, and a socio-ecological model, this study cataloged the service delivery and the demand side perspective on various pillars of Pakistan’s immunization program.

Results

Themes generated from the literature review included financing, governance, service delivery, human resources, information systems, and supplies and vaccines. Findings suggest that certain areas in the larger health system need to be improved for a more coordinated implementation of EPI in Pakistan. Moreover, it is imperative to understand community behaviors and perceptions as well as demand side issues in order to achieve the desired results.

Conclusion

For better immunization coverage and ultimately a reduction in child mortality due to preventable diseases, EPI operations and performance must be improved. Further systematic implementation research could help to develop an even finer understanding of the system-wide bottlenecks encumbering the coverage and efficiency of the program.

Eradication and Current Status of Poliomyelitis in Pakistan: Ground Realities

Pakistan is among the last three countries along with Afghanistan and Nigeria, where polio virus is still endemic. More or less, with some fluctuations, numbers of reported cases in the past few years have shown a rising trend. Year 2014 pushed the country into the deep sea of difficulties, as number of cases rose to red alert level of 328. Security situation has adversely affected the whole immunization coverage campaign. In a country where 40 polio vaccinators have been killed since 2012, such a big number of cases is not a surprising outcome. Worse perception of parents about polio vaccine as in Karachi and FATA, the high risk zones, makes 100% coverage a dream. Minor and perhaps delayed payments to polio workers make them frustrated, resulting in decline of trained manpower for vaccination. Strong implementation of policies is required and those found guilty of attack on polio workers need to be punished. Targeted community awareness programme, strong surveillance network, and involvement of influential religious entities can help to root out polio disease from country. Present review is aimed at analyzing all barriers on the road to success in eradication of polio from Pakistan.

Reasons for non-vaccination in pediatric patients visiting tertiary care centers in a polio-prone country

Background

The Expanded Program on Immunization (EPI) was initiated by World Health Organization (WHO) in 1974 in order to save children from life threatening, disabling vaccine-preventable diseases (VPDs). In Pakistan, this program was launched in 1978 with the main objectives of eradicating polio by 2012, eliminating measles and neonatal tetanus by 2015, and minimizing the incidence of other VPDs. However, despite the efforts of government and WHO, this program has not received the amount of success that was desired. Hence, the objectives of this study were to elucidate the main reasons behind not achieving the full immunization coverage in Pakistan, the awareness of children’s attendant about the importance of vaccination, their attitudes, thoughts and fears regarding childhood immunization, and the major hurdles faced in pursuit of getting their children vaccinated.

Methods

This was an observational, cross-sectional, questionnaire-based study conducted during a one year period from 4th January, 2012 to 6th January, 2013 at the pediatric outpatient clinics of Civil Hospital (CHK) and National Institute of Child Health (NICH). We attempted to interview all the parents who could be approached during the period of the study. Thus, convenience sampling was employed. The parents were approached in the clinics and interviewed after seeking informed, written consent. Those patients who were not accompanied by either of their parents were excluded from the study. The study instrument comprised of three sections. The first section consisted was concerned with the demographics of the patient and the parents. The second section dealt with the reasons for complete vaccination or under-vaccination. The last section aimed to assess the knowledge, attitudes and beliefs of the respondents.

Results

Out of 1044 patients, only 713(68.3%) were fully vaccinated, 239(22.9%) were partially vaccinated while 92(8.8%) had never been vaccinated. The vaccination status showed statistically significant association with ethnicity, income, residence, number of children and paternal occupation (p < 0.05 for all). The most common provocative factor for vaccination compliance was mass media (61.9%). The most common primary reason for non-vaccination was lack of knowledge (18.1%), whereas the most common secondary reason for non-vaccination was religious taboos (31.4%). Majority of the respondents demonstrated poor knowledge of EPI schedules or VPDs. However, most believed that there was a need for more active government/NGO involvement in this area.

Conclusion

The most common primary reason for non-vaccination, i.e. lack of knowledge, and the most common secondary reason, i.e. religious taboos, imply that there is dire need to promote awareness among the masses in collaboration with NGOs, and major religious and social organizations.

Hurdles to the global antipolio campaign in Pakistan: an outline of the current status and future prospects to achieve a polio free world

The Global Polio Eradication Initiative to eradicate polio completely by the year 2000 has been successful, except for three endemic and some non-endemic countries. Pakistan, one of the three endemic polio reservoirs, is posing a serious threat to the success of the initiative. Currently, the expanded programme on immunisation has been geared to win the race over polio virus in Pakistan. After the remarkable decrease in polio cases from 198 in 2011 to only 58 in 2012, Pakistan seemed to be at the verge of success. However, hurdles continue to retard the campaign. The war against terrorism, misconceptions about polio vaccine, religious misinterpretations, frustration among vaccinators, lack of awareness, social considerations, natural calamities, inaccessibility, and inefficient vaccines and so on are continually rupturing the foundations of the worldwide initiative in the country. Weak health management is found at the hub of majority of the challenges. Stricter policies, well managed and supervised plans and strategic actions, risk analysis and enhanced communication may help giving the final punch to polio virus in the country. Analysis suggested that there is some literature available on the challenges to polio elimination, yet there is not a single publication up to date that considers all the possible hurdles in a single manuscript. This paper sorts out the breaches that hamper the goal of eliminating polio from Pakistan. We have evaluated all the possible barriers and explained them with a perspective that will help develop area specific strategies against polio virus and thus eradicate polio virus from the world.

Parental awareness and coverage of mass measles vaccination drive 2011: cross-sectional survey in the metropolitan city of Karachi, Pakistan

High measles incidence and frequent epidemics are reported in Pakistan, given the low coverage for measles vaccine. This study evaluated coverage of mass measles campaign 2011 and estimated parental awareness and determinants for low/no coverage. Household survey was conducted 4 months after the measles campaign in Karachi, Pakistan. Parents of children younger than 5 years were administered structured questionnaire about their knowledge and participation in measles campaign. Of 1020 eligible households, only 282 (28%) parents knew about measles supplementary immunization activity, mainly from public announcements (49%). Of these, 174 (62%) children received measles vaccine, whereas, 108 (38%) parents refused measles vaccine. Overall, only 17% children received measles vaccine during this campaign. Low maternal education, not having received DPT/Pentavalent-3 vaccine, and routine vaccination from public Expanded Program on Immunization facility were significant determinants for low coverage. Measles vaccine coverage in Karachi remains low, and sporadic outbreaks of measles every 2 to 3 years are expected unless population coverage can be rapidly increased.