Immunisation: are we doing it the right way?

Rani, a five-year old girl, resident of Thatta Sindh, had been suffering from fever for the past three days with malaise, sore throat and swelling of neck. Her mother got extremely worried when Rani was unable to breathe properly. Her father took her to the nearby medical centre where after initial examination, the doctor saw a dirty white membrane on her tonsil. The doctor advised her father to take her to Karachi as it can be something serious. Some tests were conducted, and the father was informed that the child is having diphtheria which has involved her heart as well. It was extremely shocking for Rani’s parents to know that their dear child is in a life-threatening condition.

Considering the case mentioned above, it is a common tragedy that preventable infectious diseases are still haunting and impacting tremendously on quality and well-being of the people of Pakistan. Although routine immunisation is offered conveniently even in the remote areas. For just not taking routine DPT shots, this beautiful young child’s health and life expectancy was compromised. Her father felt extreme depression and desperation as it was his decision not to get his child immunised because of the negative propaganda against immunisation that he received and believed.

The global perspective, in 1974, building on the successful eradication of small pox by vaccination, created an impetus and sustained drive to eradicate other infectious diseases. Global immunisation programmes developed with the consideration that spread of disease is a matter that is beyond simple country boundaries, and multilateral mechanisms are required to eradicate more diseases.

Pakistan adopted a comprehensive programme known as Expanded Program of Immunization (EPI) in the year 1978 with the basic menu of six diseases including diphtheria, pertussis, tetanus, polio, measles and tuberculosis. Currently as per the Federal Directorate of Immunization in Pakistan, for children from newborn to 15 months, a package of vaccination to prevent 12 diseases is being administered.

For the past few years, the world has witnessed extreme viral based pandemics with overwhelming and shattering spread of Covid-19 that has been termed as the “mother of all epidemics” for this century. This epidemic resulted in enormous expansion of vaccination drives with huge allocation of financial resources including fast track launching of vaccine production under the cover of the controversial emergency use authorisation (EUA) given by the World Health Organization (WHO). According to the WHO Covid-related information dashboard, there have been 1,580,631 confirmed cases of Covid-19, with 30,656 deaths reported to WHO. As of May 6, 2023, a total of 338,642,674 vaccine doses have been administered in Pakistan.

Globally vaccinations drives have further been subjected to criticism because of the way the Covid-19 vaccination regime was implemented throughout the world. The urgency of rolling out the vaccine raised eyebrows of many including critics like the Member of British Parliament Andrew Bridgen. He has been leading debates in the British parliament regarding the potential harms that emergency use experimental mRNA Covid-19 vaccines can cause. Though manufacturers of vaccines have tried to clarify points raised by many critiques but still there are lot of questions in the mind of the researchers, academia, clinicians and public that are yet to be answered satisfactorily.

In Pakistan few critical misconceptions that are even taken as facts by some quarters of our population resulted in the cases like Rani. Mostly these are about the misconception of these vaccines as contraceptive mechanisms to reduce the population growth. Also, the spread of conspiracy theories that may restrict the acceptance of vaccines among general masses.

Further issues that have arisen are often linked with the manufacturing, distribution and administration of vaccines in Pakistan’s context are improper storage, concerns about maintenance of the cold chain, training and skills of the vaccinators, compliance of standard operating procedures (SOPs), improper data entry and compromised record keeping (Health Management Information System) and lack of documentation pertaining to adverse events (AE) and serious adverse events (SAE) etc.

A key lesson about immunisation is that the Covid-19 experience has created the impression that if a country does not have the required infrastructure with systems and processes to roll out vaccination drives independently then that country is extremely vulnerable and dependent on outside help and can be further subjected to the whims of developed countries, global pharmaceutical giants and multilateral institutions in a negative manner. Furthermore, people of Pakistan witnessed a unique social scenario of elite vaccination because of two types of perceived quality of vaccines and the associated international travel related requirements during that period.

Now the key matter is: what should be the suggested way forward for Pakistan. First, there is a dire need to build indigenous capacity in Pakistan for clinical research and development of vaccines that are more relevant to the local demographics and needs. An integrated infrastructure for storage and supply chain for vaccines addressing the cold chain and distribution based on quality parameters. Specific training and enhancement of existing and new staff working in this field are required. A robust and integrated health management information system needs to be streamlined for monitoring and decision making. It goes without saying that now the vaccination drives dealing with the epidemics need to be considered as of strategic importance at policy level for countries and Pakistan should do the same eventually leading towards mitigation of cases like that of innocent Rani.

Published in The Express Tribune, June 27^th, 2023.

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