Pakistan leads the world in the tragic toll of neonatal, infant, and child mortality; the highest rate of first day deaths and stillbirths — future of promises snuffed out before they even begin. As of 2022, statistics reveal that 57 out of every 1,000 livebirths end in the child’s death indicating that Pakistan stands at the precipice of a healthcare crisis, where diseases claim the lives of children with alarming frequency. What’s worse is that the vast majority of these losses are preventable, succumbing to diseases that could have been stopped in their tracks by simple vaccinations.

Against the backdrop of such a grim reality, World Immunisation Week, celebrated from April 24 to April 30, is a global initiative that stands as a powerful reminder of the lifesaving role of vaccines in safeguarding our most vulnerable and shaping a healthier world for generations to come.

In Pakistan, as in every corner of the globe, understanding immunisation schedules, dispelling misconceptions, and fostering collective action are key to ensuring the success of immunisation efforts. However, perhaps the most pivotal strategy in our arsenal lies in confronting head-on the missed opportunities of vaccination (MOV). This, we believe, is the game changer —the silver bullet — that can transform our aspirations into realities, ensuring that no child is left behind, that no precious life is robbed of the shield of immunity they deserve.

What are missed opportunities for vaccination (MOV) and when do they occur?

MOV encompasses any interaction with healthcare services involving a child eligible for immunisation — meaning they are either unvaccinated or partially vaccinated for their age and lack any contraindication to immunisation — but fail to receive it by the end of that interaction. This missed opportunity can occur during scheduled vaccination visits, preventive services, routine check-ups like growth monitoring and nutrition assessments, as well as visits related to an illness. It can even happen during visits to healthcare facilities while accompanying a sick relative or family member.

Why worry about MOV?

Each MOV poses a dual threat to both personal and community health by increasing the likelihood of vaccine-preventable diseases. In countries like Pakistan, where achieving the target of optimal immunisation coverage is already a challenge, addressing and mitigating these missed chances could substantially enhance child health metrics, including growth, development, and reducing mortality rates among children under five years old.

Why do MOV occur at all?

MOV occur due to a myriad of factors, involving the child, caregiver, and the healthcare system and provider. These encompass instances such as illness coinciding with scheduled immunisation appointments and social disparities, where children from disadvantaged backgrounds face hurdles due to financial limitations or restricted access to healthcare services.

Caregiver-related causes include inadequate education, diminished belief in susceptibility to diseases, apprehensions regarding vaccine side effects, propagation of myths and misconceptions, distrust in the healthcare system, cultural constraints based on gender, and a lack of prioritisation for immunisation, at times exacerbated by the misplacement of vaccination cards.

Provider-related issues encompass insufficient training, staffing shortages, and constrained vaccination schedules or hours, resulting in missed vaccination opportunities. Programmatic policies, such as appointment-only visits, lengthy waiting periods in crowded facilities, designated immunisation days, daily limits on immunisations, and logistical obstacles like transportation issues, also contribute to the problem.

Furthermore, despite well-structured immunisation processes, external challenges such as regional conflicts, natural calamities, population migration, and political influences exert adverse effects on vaccine coverage and utilisation.

Where does this occur?

In the wake of the 2022 floods, a joint survey by the World Bank and Aga Khan University unearthed stark regional divides in immunisation coverage. While the aftermath of the floods undoubtedly contributed to infrastructure loss and the disappearance of immunisation records, numerous other factors loom large in this narrative.

As highlighted earlier, rural and peri-urban regions, grappling with lower literacy rates and limited healthcare accessibility, face an uphill battle in locating and reaching remote immunisation facilities. Consequently, these areas harbour a disproportionate number of children with zero vaccine doses, in stark contrast to urban counterparts blessed with robust health infrastructure and ample healthcare knowledge dissemination.

The emergence of pockets of zero dose children in these marginalised areas underscores an urgent call for resource mobilisation. It’s clear that bridging these disparities demands a concerted effort to bolster healthcare accessibility and education, ensuring that no child is left vulnerable to the ravages of preventable diseases.

It’s time to turn the tide — combat MOVs through action

To truly enhance child health indicators, we must first confront the various obstacles standing in our way. It begins with a simple yet crucial step: identifying zero dose children at every healthcare encounter and meticulously documenting their status. But the key to transformative change lies in the creation of a synchronised database linked to the country’s National Database and Registration Authority, Nadra — which could be the linchpin of our surveillance and detection efforts against missed opportunities for vaccination.

Automated individualised information tools such as text message-based reminders have long been heralded as powerful tools for disseminating public service messages. Leveraging this technology, we can revolutionise immunisation outreach by providing timely, personalised information to each child registered in the database. These automated reminders would guide caregivers and parents to the nearest healthcare facility or immunisation centre, with detailed directions and scheduling information.

However, our efforts must not stop there. In areas with internet connectivity, we must empower caregivers with the knowledge to locate nearby immunisation centres independently. By equipping them with the tools to navigate local GPS or web mapping systems, we remove yet another barrier to access, ensuring that no child is left behind in the quest for better health.

On the national scale, the Lady Health Workers (LHW) programme has shown to be a cost-effective approach and has received extensive community support. Expansion of this programme would not only help reinforce trust with vaccinators and improve immunisation coverage but would also serve to increase access to health education. Many rural or underserved areas lack adequate health information, and this expansion would empower communities to make informed health choices, fostering a positive cultural shift in immunisation practices.

Moreover, enhancing disease surveillance systems and establishing a national database would streamline case reporting, communication, and disaster response. This database would pinpoint areas most affected by vaccine preventable diseases and identify high-risk clusters, enabling targeted interventions and redirect focus towards strategies to address MOV.

Furthermore, refining the national immunisation plan would enhance the country’s ability to recognise and overcome immunisation challenges promptly and effectively.

In the context of MOV, the theme of World Immunisation Week this year is particularly important for Pakistan, as it resonates deeply with the challenges and opportunities we face in the realm of immunisation. It is a reminder that immunisation programmes, while complex, are entirely within our reach if we harness the collective power of the government, healthcare professionals, researchers, the community and technology.

A child needs only five visits during the first year and one visit during the second year of his/her life to complete the vaccination with six visits against 12 dreadful diseases. With unyielding dedication and community support, this milestone in healthcare is not merely attainable; it’s a testament to our collective commitment to the well-being of our children and society as a whole.

Header image: A health worker marks the finger of a child after administering polio vaccine drops during a door-to-door campaign in Lahore on July 20, 2020. — AFP/File