KARACHI: Polio, measles, diphtheria, hepatitis B, tuberculosis – these are some of the diseases that continue to plague Pakistan on a large scale.

Although health officials managed to halt a measles outbreak in Sindh early this year (but still too late to save over 200 lives), they’re now fighting the same epidemic in Punjab. According to National Institute of Child Health Director Dr. Jamal Raza, these outbreaks will keep recurring until routine immunisation coverage is not increased among Pakistan’s five million under-five children.

While the Expanded Programme on Immunisation (EPI) has introduced new vaccines with the help of the Global Alliance for Vaccines and Immunisation (GAVI alliance), "The disease burden will not come down by the mere introduction of newer vaccines if the coverage continues to remain low," emphasised Dr Iqbal Memon, who heads the Pakistan Paediatric Association.

According to Memon, the immunisation coverage in Pakistan currently lies anywhere between 20 to 50 per cent across the country, although the WHO puts it close to 65 per cent.

Dr Quamrul Hasan, the medical officer for routine immunisation at the WHO, adds that the key reasons for low coverage include "Inadequate service due to a small number of health centres and irregular or non-existent outreach vaccination services, poor, inefficient health management, lack of political ownership, absolutely no accountability at all levels and lack of awareness about immunisation among parents".

Acknowleding that a lack of awareness amongst parents is a major impediment, Dr Raza said, "Whenever we ask the parents if their child has been given vaccination against childhood diseases, the most common response is: 'Yes, my child was given oral drops, not once but several times', " referring to the anti-polio vaccine.

He adds that when they are then told that the polio drops are not going to protect their child from measles, pneumonia, whooping cough and so on, they then say that no one came knocking at their door for that.

"They want everything at their door step," an exasperated Dr Mazhar Khamisani, heading the EPI programme in Sindh, told Dawn.com. "It is not possible to do that. The children will have to be brought to the centre to get vaccinated. We cannot vaccinate them in their homes, it is not logistically possible." Some vaccines, like the BCG and for measles, have to be opened when there are a large number of children, because once open it has to be used up and the leftover discarded within six hours, he said.

The EPI provides free of cost vaccines from birth to 15 months to protect against diseases like diphtheria, pertussis (whooping cough), measles, tetanus, meningitis, polio, tuberculosis, and hepatitis B.

"They want everything at their door step," an exasperated Dr Mazhar Khamisani, heading the EPI programme in Sindh, told Dawn.com. "It is not possible to do that. The children will have to be brought to the centre to get vaccinated. We cannot vaccinate them in their homes, it is not logistically possible."

He was quick to add that devolution played a significant hand in compromising Pakistan’s health sector. "It compounded the problem because the national immunisation programme was handed over to provinces, which were not geared to take on such a huge responsibility."

Last year Pakistan became the first country in South Asia to introduce a free pneumonia vaccine, to immunise five million children against the deadly disease annually. This new initiative is part of the state’s routine child immunisation programme. Yet, today, 20 and 15 percent of Pakistan's under-five children die of pneumonia and diarrhoea annually.

The outbreak of children's diseases every few months, like measles that killed over 200 children in the last three months of 2012, and which has again cropped up in Punjab, is a clear reflection of "bad governance" that has marred the government-run immunisation programme.

"We never contained the measles outbreak and even today the 50 to 70 children we have at the NICH is just the tip of the iceberg," Dr. Raza said. He fears the condition is even worse in interior Sindh. He estimated that even in Karachi, there are hundreds who do not come to NICH but are treated by private doctors or quacks. He is worried this may lead to the spread of pneumonia, diphtheria and whooping cough as well.

"The underlying factor for the high mortality rate of the victims of these diseases is the high malnourishment prevalent in the children," Dr. Raza added. Malnutrition is perhaps the leading cause of pneumonia. According to the last Pakistan Demographic and Health Survey (PDHS) for 2006-7, 38 per cent of children below five years of age are underweight.

Malnutrition, low birth weight, and non-exclusive breastfeeding, make the children more susceptible to pneumococcal diseases.  

With infant and under-five mortality rates of 78 and 94 per 1,000 children respectively, the country is unlikely to complete the staggering and critical task of inoculating enough children to be able to achieve the fourth Millennium Development Goal, of reducing under-five mortality by two-thirds by 2015.

For this, said Dr. Memon, "It is essential, the parents are somehow made aware of the consequences of not vaccinating their children."

At the same time, he said, the government needs to atone for the confidence that parents have lost in the state run immunisation programme. "I know there are still some logistical problems as  well as rude and indifferent behaviour of vaccinators and power outages to account for, but the EPI has turned over a new leaf and now vaccines and vaccinators both are present at most centres, unlike in the past," he told Dawn.com.

He recommended opening more EPI centres in the clinics of private GPs for increasing outreach. "They can charge for their service but at least more children will profit from getting immunised."

"We are trying to help the government in increasing (immunisation) coverage so that it reaches the poor, otherwise it may result in wastage, pilferage and selling the vaccine in the open market," said Dr. Raza.

Khamisani said they had recommended that a child's birth certificate should be given only after the baby has been vaccinated for a year. At the same time, during school admissions, it should be made mandatory that parents produce a vaccination card too.

World Immunisation Week takes place from April 24 to April 30.