Living on the fringes of one of the most affluent areas of Pakistan’s mega city Karachi, 39-years-old Nazeeran Bibi’s four children are not adequately vaccinated. "I got my first daughter vaccinated up to the age of six months. My second daughter has never been vaccinated. It never dawned on me that it is something important, till the school started asking for the ‘B Form’ for admission, and to get the B Form, the vaccination card is important," says this resident of Qayyumabad.

Like millions of mothers of Pakistan, it did not seem worth it to her to get her children vaccinated as that would make them temporarily sick. "Bacha beemaar ho jata hai; bukhaar charh jaata hai teekay se (The child becomes sick and develops a fever after vaccination)."

However, illiteracy is not the only factor that holds back Pakistani mothers from getting their children vaccinated. A lack of awareness about the importance of Routine Immunization (RI), and an absence of sensitisation regarding facts that dispel myths, seem to be present across the board. Across the road, there are children in upper tier homes in Karachi that have also not been vaccinated, or have not received follow-ups.

Marvi Junaid, a teacher, is an urban mother who, in her own words, is "confused" about vaccination. "I was stopped from getting my sons vaccinated after the initial shots; my husband studied it in detail and was convinced that this could be detrimental to the child’s immunity, and felt it was more of a money-making scheme," says Marvi. She feels that religious notions also have a role in discouraging people against vaccination. "Even in the upper strata, people believe vaccinations adversely affect children. Once you sense that there is a possible harm of a medicine, you can’t help but stay away from it. I think we need more awareness so that we can make informed decisions."

Mothers remain the central piece of this jigsaw puzzle, and convincing them of the benefits of immunisation seems to be one of the key factors. Dr Asad Ali, Associate Professor of Paediatric Infectious Diseases at the Aga Khan University, with a research focus on vaccine-preventable infectious diseases and malnutrition, says that the role of mothers in this regard is critically important. "Research shows that many a times, mothers are discouraged by the common side effect of short-time fever and local injection site discomfort after the vaccination of their baby. So they do not complete the series and also don’t get other children vaccinated. What they do not realise is that these transient side effects are a small price to pay for the critical protection their baby will get by receiving the full course of vaccines," he says.

Immunisation of children under the age of one-year against major vaccine-preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, hepatitis B, Haemophilus influenza type B [Hib], poliomyelitis, and measles) is one of the most cost-effective means of reducing infant and child morbidity and mortality. The government of Pakistan initiated the Expanded Program on Immunization (EPI) three decades ago to save Pakistani children from these diseases. All vaccines in the RI schedule are provided free of cost in all public health facilities in Pakistan. Even then, the children are not given the coverage they deserve.

The Pakistan Demographic and Health Survey 2012-2013 sheds important light on some facts regarding the state of RI in Pakistan. Gender preference is seen even in RI. Boys are more likely than girls to be fully immunised -- 56 per cent versus 52 per cent. Children’s birth order varies inversely with immunisation coverage -- as birth order increases, immunisation coverage generally decreases. 64 per cent of first-born children have been fully immunised, in contrast to 39 per cent of children of birth order six and above.

"When I first became a mom, vaccination was a given; we diligently set reminders for our daughter’s appointments. It seemed as natural as buying diapers. Within the next three years, and with the transition from new mom to an experienced one, I began to read into everything from how the body has a natural mechanism for fighting fever to how to send more probiotics naturally to the gut. With the virals on the rise and doctors liberally prescribing steroids even for a blocked nose, I began to feel that there was too much of unnatural intervention," says Nida Raza, a working mother of two and a resident of Karachi, who became lax regarding vaccination of her second child. "The anti-vaccination rhetoric on the internet and around didn’t help much and somehow my trust flew out of the window. I have been reading it and discussing it and yet I’m not convinced anymore; I’m confused about its benefits and authenticity."

Urban-rural differences in immunisation coverage are clear. 66 per cent of children residing in urban areas are more likely to be fully immunised, compared to 48 per cent in rural areas, according to PDHS. There are wide differences in coverage by region. Islamabad has the highest percentage of children who are fully immunised (74 per cent), followed by Punjab (66 per cent) and Khyber-Pakhtunkhwa (53 per cent); immunisation coverage remains lowest in Sindh (29 per cent) and Balochistan (16 per cent), as per PDHS findings.

However, the latter two provinces are seeing a thrust in the efforts for reaching out to children who are not vaccinated. For Sindh, fresh research shows that the numbers of covered children are rising, thanks to efforts of EPI Sindh, yet much remains to be done, and unimmunised children continue to pose a challenge.

EPI Sindh’s Project Director Dr Agha Ashfaq, recently giving an overview of the programme to members of the media, said coverage of RI in Sindh has increased to 45 per cent. In view of the loss of lives of children because of Diarrhea, the Rotavirus vaccine is also being included in the RI in Sindh. Success in Sindh is being seen, for example no stock outs of vaccines were reported in 2015-16 in the province.

Vaccine Logistics Management Information System (VLMIS) is being set up in all districts of Sindh. Polio Eradication Initiative (PEI) and Sindh EPI are working in collaboration. Increased mapping of urban slums is being done. There is also newfound emphasis on the monitoring, evaluation and accountability framework. However, more emphasis is needed in raising awareness among parents, especially mothers, because eventually the decision to get one’s child vaccinated or not remains pre-dominantly with them.

Measles remains one of the key indicators of immunisation programmes in any country. Some 20 million infants missed their measles shots world over in 2015, and an estimated 134,000 children died from the disease. Half of the unvaccinated infants and 75 per cent of the measles deaths are in six countries; Pakistan is one of them. "The frequent outbreaks of measles in our country are a clear reminder that should convince parents about the need for vaccines for their children," says Dr. Ali.

"Mothers in Tharparkar are very cooperative when it comes to their children’s health but they need to be convinced. We have not reached out enough to create awareness among the mothers," says Dr. Aziz Kunbhar, former District Health Officer in Tharparkar.

Dr. Ali adds that awareness needs to be raised among parents that vaccination is a right of their children. "Even if vaccinators are not coming to your house, parents must take their children to local governmental vaccination centers."