ovid-19 proved a game-changer for vaccine acceptance in Pakistan. During the last four years, Pakistan witnessed an 11 percent increase in the routine immunisation of children under the age of five. Refusals (by parents) are coming down, and now even hesitant parents are getting their children vaccinated against vaccine-preventable diseases in Pakistan, says Dr Palitha Mahipala, the World Health Organisation’s country representative in Pakistan.

Despite the increase in the immunisation rate, which was 66 percent in 2018 but climbed to 77 percent in 2022 and further increased this year, around 611,000 children remained un-immunised in Pakistan last year. WHO and UNICEF data show that Pakistan is in the 8^th spot for zero-dose children, i.e. who did not receive even a single dose of vaccine last year.

But the WHO and the UNICEF, as well as Pakistani officials, believe that despite challenges, Pakistan is among the countries where acceptance for vaccination is growing. However, there are still pockets in the country, both in the former Tribal Areas and major cities, where parents are refusing to get their children vaccinated.

“People in the southern Khyber Pakhtunkhwa, especially in North Waziristan, are sceptical of the teams going door to door for vaccination. Propaganda against polio teams is one of the major factors behind parents refusing polio vaccine drops and routine immunisation, if it is done at doorsteps, as people are not comfortable at seeing vaccination teams knocking at their doors,” says Dr Akram Shah, a former head of the federal expanded programme on immunisation (EPI).

Dr Shah claims that although acceptance of routine immunisation has increased over the years in Pakistan, including former Tribal Areas of the country, people are still sceptical. He believes that acceptance can be further enhanced by engaging the community elders, designing the campaigns according to their suggestions and resolving the issues they raise.

Another immunisation expert and former head of EPI and National Emergency Operation Centre (NEOC) for Polio Eradication, Dr Rana Safdar, also believes vaccine hesitancy is at its lowest in Pakistan.

“After Covid-19 disruptions in the health service delivery, Pakistan started its battle against vaccine-preventable diseases afresh in July 2020. A key determinant of success was leadership, as Zafar Mirza placed both the EPI and polio eradication programme under one command. When the first Covid cases were reported in February 2020, I was also entrusted to lead Covid-19 surveillance and response at the NCOC. So, we had all resources readily available under a single command. On the one hand, we responded to Covid-19 successfully; on the other hand, we convened a special session on immunisation when all CMs, CSc, health ministers and secretaries were connected,” Dr Rana Safdar, who headed Polio, EPI and Covid-19 response, claims.

But there are still so many challenges in vaccinating children that the Sindh government was compelled to bring legislation to make refusal a punishable crime.

He says being a field epidemiologist and using his specialisation in health metrics and evaluation, he presented modelling projecting cases with several vaccine preventable diseases, including measles, diphtheria and polio. “Immediately afterwards, a consensus decision was taken to resume routine immunisation service delivery as well as door-to-door polio campaigns from July 2020. Using full government ownership and support from stakeholders beyond health as well, an intensified outreach vaccination campaign was started covering all EPI antigens. Polio campaigns quality simultaneously improved. We were able to build a strong immunity wall that brought us that close to polio eradication in 2021 with only one case,” he says.

Dr Safdar says immunisation rates could be improved further by improving service delivery and reaching out to people who cannot afford to take their children to the vaccination centres. “There are many people who cannot take their children to vaccination centres due to poverty and logistical issues. We need to reach out to such families to protect the lives of innocent children,” he adds.

But there are still so many challenges in vaccinating children that the Sindh government has been compelled to bring legislation to make refusal a punishable crime.

“The Sindh cabinet last week approved a bill, which, upon enactment, would make refusing immunisation against vaccine-preventable diseases a punishable offence in the province. Under the draft law, the parents or guardians of children or unprotected persons are responsible for bringing them to vaccination centres in time to be duly vaccinated. If the local authority finds that an unprotected person or parents or guardians have violated provisions of the law, they will be delivered a notice,” an official of the Health Department says.

If the parents or guardians still do not comply with the law, the local authority shall report them to a first-class magistrate for punishment under the law, the Health Department official says, quoting from the draft law. He says that the cabinet has approved the bill and referred it to the provincial assembly.

He says they were compelled to introduce the legislation after dozens of children died due to measles, diphtheria and tetanus, all vaccine-preventable diseases. He added that several children were battling for life in hospitals due to infectious diseases, which could easily be prevented through vaccination.

According to the latest WHO data, in addition to 611,000 zero-dose children in Pakistan, around 1.2 million children were not immunised against measles throughout Pakistan in 2022, resulting in dozens of deaths due to contagious diseases across Pakistan.

According to the data, India leads with the number of zero-dose children – 2.7 million got no vaccine in 2022 – followed by Nigeria with 2.2 million un-immunised children. Indonesia and Ethiopia had 1.1 million un-immunised children each, Philippines had 1 million, DR Congo 734,000, Brazil 710,000, Angola 553,000 and Myanmar 492,000.

Nigeria had the highest number of children who did not have the measles vaccine (3.1 million), followed by India (2.5 million), DR Congo (1.7 million), Indonesia and Pakistan (1.2 million each), Philippines (1 million), Angola (824,000), Brazil (737,000) and the United Republic of Tanzania (536,000).

The writer is an investigative reporter, currently covering health, science, environment and water issues for The News International