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This post is part of the #ProtectingKids story roundup. Read all the stories here.

Lakki Marwat, Khyber Pakhtunkhwa, Pakistan

From birth to 15 months, 6 visits to the Immunization Center your child will be protected from 9 vaccine preventable diseases. Repeat after me and memorize these numbers as you did your tables in school.

As some 20 heads nod in agreement, I realized many women and girls sitting in this veranda may never have gone to school. This was an awareness session with community women of Lakki Marwat. The district in Pakistan's northwestern province of Khyber Pakhtunkhwa has a dismally low immunization coverage.

Although it was an all women session, many women had not taken off their burqa (the one which are more popularly known as the shuttlecock burqa which covers them head to toe with just a net near the face to let them see and perhaps breathe a little) for fear that a male glance may fall on them.

Although, I had heard a lot about Lakki Marwat, this was my first visit ever to the place. Khyber Pakhtunkhwa is a conservative province, but Lakki Marwat is by far the most conservative of all the districts.

I was conducting an awareness session with the community women in Lakki. I wanted to speak to young mothers and even mothers in law and tell them the value of vaccination, how it can save their children from diseases and, best of all, it cost them nothing for that. I was also very curious to find out, despite all the benefits, what prevented them from getting their children vaccinated and what could be done to improve the coverage.

I was amazed at the level of excitement and interest. They were all ears, listening in rapt silence. Giving me utmost respect and importance, they raised their hands and patiently awaited their turn if they had a query.

Pakistan is a large country with high child mortality and low immunization coverage. More than 1,000 children under five die each day. Just over half of Pakistani children are fully vaccinated against all nine diseases included in the EPI, with tremendous variation between provinces (Source: 2012-2013 PDHS). It is an important country in the immunization world, and among the last two still fighting the polio virus.

There are severe provincial disparities and marked variations in immunization coverage in provinces and districts, and by gender. A survey conducted to analyze the causes and barriers of routine immunization in three districts of Khyber Pakhtunkhwa (which included Lakki Marwat) by Japan International Cooperation Agency (JICA) late last year indicated an unfortunate 78 percent illiteracy rate amongst women in Lakki district. Knowledge of mothers that children require immunization six times was only 12 percent.

In a comparison on gender differences of children (12-23 months) who had missed routine immunization, that of girls in that area turned out to be 64 percent as compared to boys.

There are several demand and supply side challenges for this low and fragmented progress. Public awareness of benefits is low and local authorities don’t view immunization as a priority. The gap in immunization knowledge among the community impedes them from actively seeking immunization services.

But despite systemic weaknesses, the province is taking impressive steps to not only improve but improve equitable immunization coverage. Lakki Marwat will be amongst the three priority districts in which the provincial government will be working on social mobilization in 2016.

One thing was evident – this was not a place frequented by visitors from other towns, let alone women. I recalled when, during our discussion, the Khyber Pakhtunkhwa EPI Program Manager had, in a sort of challenging cum daring tone, suggested Lakki for the advocacy session with community, if I was really serious in doing a meaningful session. However, while confirming the date and venue, the District EPI Coordinator of Lakki had clearly said I should return home by evening alluding to the place not being safe for women to stay the night.

Knowingly leaving this last piece of information from any conversation I had with my family on my impending visit to Lakki, I did, however, return the same night travelling a good 13 hours on the road. In retrospect, it was one journey I found to be far more satisfying than many others I have taken in my quest to spread the knowledge about the value of vaccinating children against childhood diseases.

Huma Khawar is an IVAC consultant who works on immunization advocacy with stakeholders on the ground in Pakistan.

By Huma Khawar, freelance journalist and consultant for Vaccine Implementation Technical Advisory Consortium (VITAC).

This article was originally published on the VaccinesWork blog and is cross-posted here with permission.

Girl with vaccine card

A little girl with her vaccination card. Photo: Gavi/Doune Porter

Doctors from across Pakistan gathered in Islamabad last Thursday to fight a disease that’s threatening children across the country. This time it wasn’t polio they were working against, but pneumonia, which kills as many as 71,000 children every year in Pakistan.

The event, held to mark World Pneumonia Day, aimed to empower key influencers to better advocate to stop pneumonia and discuss challenges to its prevention. It took place at the Children’s Hospital, Pakistan Institute of Medical Sciences (PIMS), which itself sees many cases of the disease with a daily turnover of over 500 children in its outpatient department from in and around Islamabad.

WPD Seminar Event

The entrance to the seminar. Photo: Huma Khawar.

The pneumococcal vaccine was rolled out in Pakistan in 2012 as part of the routine immunization schedule, when it had already helped children in many other countries avoid pneumonia. It is also proving effective in Pakistan, as Dr. Asad Ali, from Aga Khan University Karachi, demonstrated by sharing preliminary findings from the vaccine impact assessment in Sindh. He explained that even one dose of pneumococcal vaccine is highly effective against the main germs that cause pneumonia (pneumococcus and Hib).

However, pneumonia is still one of the major killers of children under five years old in Pakistan.  A major reason is limited routine immunization coverage – a little more than 50% of children are covered by a basic set of vaccines nationally, and the numbers of children immunized has even been declining in Balochistan. As a result, pneumococcal vaccine faces challenges reaching children across the whole country through this system, and so its population-level effects cannot yet be expected to be significant.

Doctors estimated that this underperformance is fuelled by caregivers’ lack of awareness. Too few parents know that the vaccine is necessary for child health, free-of-cost and available at immunization centers nationally. Yet improving vaccine coverage is crucial, as once infected, access to treatment options for infants remain limited especially in Pakistan’s rural, impoverished regions. Dr. Syed Saqlain Ahmad Gillani, National Immunization Program Manager, concluded the session by voicing support for a public-private health sector partnership to increase routine immunization coverage in the country.

Presentation at Pakistan Event

One presentation from the day. Photo: Huma Khawar.

Facing such a challenge, medical professionals are not the only ones who need to advocate for vaccination against pneumonia. Following the conclusion of the main session, an advocacy session tailored for teachers and headmistresses of public schools was initiated during which they were informed of the need to prevent pneumonia through other proven, low-cost techniques such as immunization, sound hygienic practices and balanced diets for infants and exclusive breast feeding for six months, ensuring good nutrition.

The teachers also shared various risk factors which make children more prone to pneumonia. Poor parental healthcare seeking was one: when children with severe pneumonia often undergo of trial and error at the field levels, before they actually reach the health facility for the right treatment in time.

Exposure to indoor smoke, which in rural Pakistan is an issue for more than 60% of families, is also damaging beyond imagination. There, an average household size is seven, which makes overcrowding (i.e the number of people sharing same room where children sleep) is another important factor contributing to pneumonia.

The teachers agreed that, more than ever before, we know how to protect and prevent children from catching pneumonia, and how to treat those suffering with this illness. They returned home to spread the message. 

By Lois Privor-Dumm and Huma Khawar.

This article was originally published on Vaccineswork and is cross-posted here with permission.

PolioIPVPakistan3

Photo: UNICEF/PAK 2015/Asad Zaidi

In Nigeria and around the world, citizens, governments, doctors, and parents are fighting polio – and they’re winning. After nearly 30 years of polio eradication efforts, the end is in sight. In 1988, the year the World Health Assembly (WHA) resolved to eradicate polio, there were an estimated 350,000 polio cases globally; last year there were only 359, and this year cases so far are down by 75%.Misbau Lawan Didi leads a club he wants to eliminate. As president of the Polio Survivors Association, he is committed to not only end polio in Nigeria but to eradicate it from the planet. “We are determined,” he says, “to ensure that our members are no more.”

Polio has eluded us for decades. There have been plenty of starts and stops and lots of excitement about the polio eradication effort.

So what makes this time different?

Communities around the world are mobilizing, and momentum is building. Last month, one of the remaining three endemic countries, Nigeria, passed the one year mark without a single case of wild poliovirus. Once the final samples are tested and cleared, the World Health Organization should even be able to declare Nigeria a non-endemic country. Many thought it wouldn’t be done.  

Now, Pakistan is embarking on one important step in its fight against polio and implementing the endgame strategy with introduction of the inactivated polio vaccine (IPV) across the country. It will take determination and sustained effort to ensure that it can be done – and with a decentralized health system, years of war, and continued threats against health workers, it will be no easy feat.

Step by step, progress is being made. We are on the brink of an unprecedented accomplishment. Yet, public health experts warn “the last mile” will be the hardest. Ending transmission of the virus in every country will take a focused effort and the use of every available tool against the disease. The Polio Eradication and Endgame Strategic Plan was developed to provide countries with a roadmap to help navigate this challenge. The plan calls on countries to make three important changes to their immunization efforts: 1) to introduce one dose of (IPV) into routine immunization schedules, 2) to strengthen routine immunization, and 3) to eventually withdraw oral polio vaccine (OPV).

The first phase of this plan, the introduction of IPV, is well underway. While there was initial concern over an accelerated timeline, communities and governments around the world have risen to the challenge. The introduction of IPV will be one of the fastest rollouts in history. Out of 126 oral polio vaccine (OPV) only using countries, 30 have now introduced. Today, on August 20th, Pakistan launches its nationwide rollout, which is no small feat. The significance of this rollout is monumental.  

PolioIPVPakistan2

Photo: UNICEF/PAK 2015/Waseem Niaz

Introducing a new vaccine involves hundreds of technical and logistic details. There are budget considerations, procurement, storage and transport of vaccines, training of health workers, and communication with parents. Countries need to assess their systems and strengthen necessary components. In Nigeria, for example, communicating with the public was particularly important as skepticism about the polio vaccine halted past efforts. When Nigeria introduced the new polio vaccine in February of this year, community and religious leaders were active in the outreach to parents. In markets and in mosques, the public was told about the importance of immunization and using the IPV vaccine in the battle against polio. In February, when Nigeria became the first polio endemic country to introduce the vaccine, it was widely accepted by parents.

We are down to the last three polio endemic countries – Nigeria, Pakistan and Afghanistan – and now there is even greater hope.  Last year, there were no new members of Nigeria’s Polio Survivors Association as the country did not have any cases of the disease. Work in Nigeria is far from over, but the effort is paying off: two more years without a reported case and Nigeria can be certified as polio free.

The same can be true in Pakistan and the other countries where communities are hard at work to protect their children and eradicate this virus. This time it really can be different. Pakistan, is your time now?

Lois Privor-Dumm is the Director of Policy Advocacy & Communication at IVAC at the Johns Hopkins Bloomberg School of Public Health. Huma Khawar is a freelance journalist and consultant based in Islamabad who works with stakeholders on the ground in Pakistan to advocate for new vaccines through the Vaccine Implementation Technical Advisory Consortium (VITAC), a project of the Gavi Alliance.

With the help of a long list of partners and supporters, IVAC has developed a portfolio of advocacy materials supporting IPV introduction, which can be found here. Inquiries can be directed to Lois Privor-Dumm at lprivor1@jhu.edu.

This post is part of the #ProtectingKids blog series. Read the whole series here.PATH2015_BlogSeries

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Huma Khawar

Huma Khawar is a freelance journalist and IVAC advocacy and communications consultant working in close coordination with the Expanded Programme on Immunization (EPI) in Pakistan.

By: Huma Khawar

“I don’t have any children of my own, but after 12 years as a lady health worker (LHW) all the children here in my village are my own children,” she explains as we sit together in a small village 150 kilometers outside Pakistan’s capitol of Islamabad. Rukhsana is a young woman in her early thirties with a distinct mission and a packed schedule. She is one of over 100,000 LHWs that go door-to-door every day to educate families – particularly women of child-bearing age – on health topics such as pregnancy, nutrition, hygiene, family planning, and immunization.

In Pakistan, LHWs play an integral role in providing essential health services to communities, especially in rural areas that are difficult to reach. According to local medical experts, the households visited by LHW have 15% more fully-immunized children than households that are outside the LHW catchment area. This is an important outcome as Pakistan is one of three countries that contributes nearly half of the 21.8 million children worldwide that did not receive routine immunization services and where outbreaks of childhood vaccine-preventable diseases, such as measles, are common.

Rukhsana recently earned her official certification as a LHW. She regularly leads immunization sessions, where she vaccinates children and provides basic health care. “When the vaccinator announces their arrival in an area every month, I go door-to-door to bring out children that are due for their shots. I encourage the remaining children to go to the nearest health center so they do not delay their immunization,” Rukhsana reports. “But still, some families hide their children or say that they are visiting relatives in adjoining villages,” she shares openly. These ploys do not deter Rukhsana, who accepts the challenge and is determined to improve the well-being of women and children in her own village.

Pakistan_LHW

She does admit, however, that misconceptions about vaccines are pervasive. “Some parents argue that the injection gives their children fever. I tell them these are common side effects that can be treated with 1-2 doses of pain killers. I give them paracetamol,” Rukhsana shares. She feels that arguments, refusals, and misconceptions can be countered with education and appropriate interventions.

Rukhsana distinguishes herself as a LHW because she establishes excellent rapport with community members. She often pleads with elders who are reluctant to vaccinate their children. “I make sure that all children in my villages are vaccinated,” she states proudly.

Rukhsana reaches 15-20 households each day. This year, Pakistan will provide specialized training for 14,000 LHWs on vaccine administration. It is no doubt that LHWs form the backbone of basic health care for this country and will be instrumental in administering vaccines that are a foundation for protection throughout a child’s life. Vaccines help children grow to reach their full potential.

With her shawl covering her gentle frame, leaving only her eyes to be seen by those she encounters, and a black bag of basic medicines resting comfortably on her shoulder, Rokhsana walks out of her home today, ready to tackle her first visit for the day, feeling ever confident to meet with all the families on her list.

Huma Khawar is based in Pakistan and works for the International Vaccine Access Center (IVAC) at the Johns Hopkins Bloomberg School of Public Health. Support for this project was provided by Gavi, The Vaccine Alliance, for the Vaccine Implementation Technical Assistance Consortium (VITAC). The views expressed by the author does not necessarily reflect the views of Gavi and/or VITAC partners.

This post originally appeared on the VaccinesWork blog and is cross-posted here with permission.

By Huma Khawar

In 2012, Pakistan was the first South Asian country to introduce the pneumococcal vaccine with Gavi support. Provided free of charge to children under the age of five, the vaccine protects against a major cause of pneumonia, a disease that is a major killer of children worldwide. But in order for any vaccine programme to be successful, information and support are essential. And where do many people get their information? The media.

Pakistan Media Session

The question and answer session in action. Photo: Huma Khawar

Dr Taimoor Shah, Deputy Director Khyber Pakhtunkhaw province’s Expanded Programme on Immunization (EPI), knows this well. On World Pneumonia Day last November, he took the opportunity to gather a room full of journalists of all backgrounds at the Press Club in Peshawar, to talk specifically about the pneumococcal vaccine and to answer their questions. 

The result was a discussion that sounded more like a medical classroom than a group of reporters. How many vaccines are included in a child’s immunisation programme? What are the diseases that can be prevented through immunisation? How expensive is the pneumonia injection? It was difficult to decide whether to feel surprise at the lack of awareness among the media about vaccine preventable diseases or to be happy at the eagerness and genuine interest expressed in the reasons for Pakistan’s high rates of child mortality.  

The session was both informal and interactive. Journalists from different organisations suggested ways to educate people on vaccination and eradication of fatal diseases through media messages. They concluded that it was the common duty of parents, government health institutions, media and civil society to take steps for overcoming health issues through vaccination and timely treatment. 

One journalist confessed that although he knew all about how and when to give the different vaccinations, he didn’t know the importance of each. ”It will be easier, he said, to convince mothers on the importance of getting their babies immunised.”  

The session also gave the health journalists an opportunity to express their own opinions and share insights. They talked openly about how, over the years, with so much money and emphasis directed towards polio eradication, routine immunisation had taken a backseat.    

By the end of the session, some 30 plus media personnel had learned much more about vaccines and routine immunisation. One digital reporter admitted that this type of question and answer sessions was essential as a vast majority of journalists have limited knowledge of vaccines and their potential. 

“A lot of mothers get their information from newspapers. Media should be up to date. If their knowledge is suspect, they will pass on wrong information to parents. This can be very dangerous,” he said.

And in a country where each year one in twelve children born die before reaching the age of five, many of them due to vaccine-preventable diseases, spreading this newfound knowledge can only be a good thing. 

media event in Pakistan card

Photo: Humar Khawar

Huma Khawar is a freelance journalist and IVAC communications consultant who works in Pakistan.