Pakistan is a large country and an important one in the immunisation world. With 7.8 million children born every year in the country, more than one-third fail to get fully vaccinated by their first birthday. And with Covid-19 shadowing our healthcare policymaking, along with the lockdowns and continuous travel disruptions, experts foresee disease outbreaks and further damage when it comes to high child mortality and low immunisation coverage rates.

"We are seeing a mini epidemic of measles in Karachi, polio cases are on the rise, and TB is killing more people than Covid-19. All these infections are preventable and we have vaccines available in Pakistan to combat them," says Dr D S Akram, a paediatrician heading HELP, a non-governmental organisation working on immunisation and child health.

"Diseases with higher transmissibility like measles and polio pose a much higher risk to hit back strongly. Associated morbidity and mortality from these can further intensify the burden on our health system in the current scenario of Covid-19," says a concerned Dr Rana Muhammad Safdar, National Coordinator for the Expanded Programme of Immunisation.

"This makes it vital for both parents and the immunisation programmes to ensure continuity while observing all social distancing measures recommended by authorities as the risks evolve," he says.

Dr Safdar feels it is extremely important that parents do not default during Covid-19 and ensure essential immunisation of children.

Essential or routine childhood immunisation is a set of inoculations, given from birth to the age of 15 months. Completing the schedule protects children under 23 months from 10 diseases that are preventable through vaccines, such as tuberculosis, polio, diphtheria, pertussis (whooping cough), tetanus, haemophilus influenza type B, hepatitis B, diarrhoea, pneumonia, and measles.

Although the entire course is provided for free by the government’s EPI with support from international donors and technical partners, like Gavi, the Vaccines Alliance, WHO and Unicef, children in Pakistan continue to die from these illnesses.

World Health Organisation places Pakistan among the 10 countries that account for almost two-thirds of the world’s unimmunised children.

According to Pakistan Demographic Health Survey 2017-2018 (PDHS), Pakistan’s routine immunisation coverage stands at a dismal 66%. There are substantial coverage and equity challenges with geographic and economic differences between and within regions as well as between provinces. With Punjab taking the lead at 80%, Khyber Pakhtunkhwa (KP), Sindh and Balochistan are behind at 55%, 49% and 29% respectively.

Impact of lockdowns, competing priorities

Faced with serious shortages and potential stocking issues of vaccines due to the global market situation, the immunisation programme is expecting serious delays in vaccine supply on account of global lockdowns and disruption in vaccine production.

Furthermore, the situation has complicated even more with the air space closure in Pakistan. Due to domestic blockage of flight operations, transport and supply of vaccines for Sindh, Balochistan and their further distribution to district and sub-districts is becoming difficult.

"Due to competing priorities of Covid-19 in Ministry of National Health Services, Regulation and Coordination (NHSR&C) and the Ministry of Finance, the federal EPI is struggling to place orders with Unicef for vaccines against pneumococcal, rotavirus, pneumonia and diarrhoea, the latter two being among the deadliest diseases for children," informs Dr Safdar.

On the other hand, delay is also expected in the supply of pentavalent vaccine on account of the global lockdown which has led to a disruption in its manufacturing.

Dr Hari Banskota of Unicef feels it's extremely important that parents continue to vaccinate children as "we have a large pool of unimmunised or under immunised children and this will increase the burden of disease and will add to the cohort of children who are not vaccinated".

Foreseeing a dip in an already low demand for essential immunisation, the federal Expanded Programme on Immunisation, is consulting technical partners to develop guidelines for the purpose for dissemination to the Provinces and Federating Areas, Dr Safdar informed.

Projected shortage in medical supplies

Aside from the vaccines, severe shortage in medical supplies such as syringes etc is also expected in the near future.

For example, China, a major supplier of medical goods, such as auto disable syringes to the EPI, has already informed Pakistan that there may be exceptional delays as currently the country's medical device manufactures have diverted their production to face masks and other relevant products in the response against COVID-19.

This is challenging particularly at a time when the country is not only facing the Covid-19 outbreak, but other infections continue to persist as well.

In light of this situation, "it is imperative that our routine immunisation activities continue to go on at a furious pace", says Dr Akram.

"Any child with a concomitant infection will be more seriously ill if the Covid-19 infection is superadded," she adds.

Coverage for measles and polio

Moreover, the measles season is also upon us and our routine coverage for this disease is not sufficient to provide herd immunity. Many children are still being admitted to hospitals and losing their lives due to complications resulting from measles.

"We cannot afford to face additional outbreaks of vaccine-preventable diseases," says Dr Safdar.

Data shared by Unicef Pakistan shows that we may be heading towards a measles outbreak. It shows that "suspected reported cases of measles in 2019 were around 9,000". It also referred to "the first quarter of 2020 in which the suspected cases of measles (as reported via surveillance during the Polio Eradication Initiative) have reached the figure of 5,000".

In this landscape, if routine vaccination activities are reduced, we may see much higher morbidity and mortality in children due to measles.

Dr Akram says that with infections covered under the EPI on the rise, Covid-19 may become worse despite observing social distancing.

She adds that another challenge already surfacing is the disruption in polio vaccination drives and anticipates that the situation will 'get worse' with no campaigns planned for the next two months on account of 'social distancing'. With the disruption, we can simultaneously see active cases of polio being reported every week.

As health workers are diverted to support the response to Covid-19, shortage of vaccination workers carrying out routine immunisation will worsen an already weak immunisation system in Pakistan.

Children most vulnerable

According to Dr Tariq Bhutta, Chairperson National Immunisation Technical Advisory Groups (Nitag), during any calamity, children are the most vulnerable group. Their immunity falls and if their nutrition is compromised then they are liable to fall prey to other infections.

While global statistics show that death from Covid-19 is inclined more towards the elderly and the fragile, Dr Bhutta says it is important that we do not get complacent and continue to take every measure to protect our children.

Routine immunisation, which is the right of every child in Pakistan, must continue. During epidemics, it is extremely important that children are protected from diseases that can be prevented by vaccines.

Lockdowns in all provinces, closed OPDs, and the public observing physical distancing will result in parents deferring on their children's routine immunisation schedules.

According to an analysis by Gavi, the Vaccine Alliance, at least 13.5 million people in the world are expected to miss out on routine vaccinations due to postponement of campaigns and interruptions, with millions more likely to follow.

While the alliance is urgently providing support to countries for Covid-19 response, its CEO, Dr Seth Berkley has stressed that the "legacy of Covid-19 must not include the global resurgence of other killers like measles and polio".