The EPI in Pakistan was initiated as a pilot project in 1976 and was launched at federal level in 1978 but was only established nation-wide by 1981, prior to the introduction of intensified activities in 1982. The programme currently targets seven vaccine preventable diseases i.e. poliomyelitis, tetanus, including neonatal tetanus, diphtheria, Pertussis, measles and childhood forms of tuberculosis and introduction of Hepatitis B immunization under one year of age children. Without effective immunization, it is estimated that 100,00 deaths due to measles, 70,000 cases of neonatal tetanus and 20,000 paralytic cases of poliomyelitis would occur in Pakistan each year.
The morbidity and mortality of the vaccines preventable diseases are significantly reduced due to very effectively and efficiently implementation of the immunization programme all over the country.
Vaccines scheduled; routine immunization services:
Immunization services are provided annually for approximately 5.1 million children. The routine immunization schedule targets one dose of BCG, 3 doses OPV and DPT vaccines and one dose of measles vaccine in the first year of life. At birth dose of OPV is scheduled if there is health staff contact with the infant before it reaches 6 weeks age. Annually, 5.8 million pregnant women are targeted to receive 2 doses of tetanus toxoid (TT).
Additional EPI strategies
Beginning in 1994, the EPI developed additional strategies aimed at the eradication of poliomyelitis from Pakistan by the end of 2005 and the elimination of neonatal tetanus as a public health problem.
The strategies aimed at polio eradication include National Immunization Days (NIDs) initiated in 1994 and enhanced surveillance for cases of acute flaccid paralysis (AFP), starting in 1995. Additional house-to-house immunization and cross border immunization campaigns, coordinated with neighboring countries, have been conducted since 1998.
Campaigns to immunize all women of child–bearing age living in areas where infants are at high risk of contracting neonatal tetanus, have been successfully conducted in 65 districts of the country. It is planned to conduct these campaigns nation-wide in the course of years 2003-2005.
A supplementary dose of Vitamin A was given to all children aged 6-59 months receiving OPV during the second round of the NIDs conducted in 1999. This policy was continued during the sub-national NIDs (SNIDs) conducted in 2000 and it is intended to be continued during one round of all OPV campaigns until 2003, after which a supplementary dose is scheduled to be given at the same time as measles immunization.
EPI Service delivery
EPI provides immunization throughout the country from fixed centers, outreach clinics and through mobile teams. Currently, there are 2,649 fixed centers, 4,564 outreach teams and 82 mobile teams. Non-government organizations (NGOs) and a limited number of private practitioners provide immunization in some areas and make a significant contribution in urban areas.
To date, immunization has been provided through a mainly “vertical” programme, based on two “EPI vaccinators” located in each Union Council. Their performance is monitored by supervisory vaccinators (DSVs) based at the district level. More senior supervision is provided by supervisory medical officers and the District Health Officer (DHO). In some provinces, but not yet nationally, responsibility for EPI has been delegated to the medical officers in charge of the primary health care facility.
During recent years, limited responsibility to deliver immunization has been extended to include other primary health care personnel, including paramedics and Lady Health Visitors (LHVs). In approximately 30% of Pakistan, where the National Programme for Primary Health Care has been fully implemented, Lady Health Workers (LHWs) are now providing support to EPI through community mobilization, assisting vaccinators during immunization sessions, in Sindh, and other parts of the country during specific campaigns, in administering TT to women of child-bearing age.
Management of the EPI
Responsibility for EPI funding and management is vested in the National and Provincial governments, with the Federal EPI cell and the Provincial EPI cells representing their respective Ministries of Health.
The government has always accepted immunization as a critical element in promoting child health and accepts EPI as a priority element in its schedule of preventive health services. Pakistan is committed to meeting the internationally agreed targets for immunization and disease reduction. This commitment has created much pressure on the federal and provincial EPI cells, on the district and at the union level to achieve expected targets.
Responsibilities for the federal and provincial EPI cells are:
Federal EPI/CDD
- planning, policy making and strategy development
- purchase of syringes, vaccines, logistic needs: supply to provinces
- providing technical guidance and support to provinces
- coordination with international agencies
- monitoring, evaluation and reporting of national data
- coordination of training needs
- provision of mid-level management training
- national activities for social mobilization
Provincial level:
Through the Provincial General Director of Health implementation and administration of EPI at the provincial and district levels, including planning and management of:
- distribution of vaccines, syringes and logistic needs
- supervision of EPI delivery
- monitoring, evaluation, reporting of data from the provincial and
district levels
- training of all EPI workers, other than for mid-level managers
- providing allowances for personnel
- management of transport, repair and POL, cold chain repair
Objectives:
To increase coverage with the full series of EPI vaccines to 80% Nationally and in all
provinces by 2005 and to 90% in all provinces by 2010.
To achieve polio eradication by December 2005. If, realistically, both internal factors
and persisting wild poliovirus in Neighboring countries makes achievement of this
objective impossible, three consequent objectives will be developed:
- to have in place by the end of year 2005, a sufficiently strong system for achieving polio eradication, that it will, inevitably be achieved shortly afterwards,
- to record less than 100 confirmed cases in 2003 and
- to achieve polio eradication in 2001
To achieve elimination of neonatal tetanus nationally and in all districts by 2005.
To reduce the burden of measles to 80% of the pre-vaccine incidence through increasing
routine immunization.
To increase the safety of injections used for all EPI vaccines through converting to the
use of auto disable syringes for all injections by 2002.
To deliver Vitamin A supplementation, as appropriate with supplementary polio
immunization campaigns in 2000-2002 and with routine services from 2003.
To introduce hepatitis B vaccine into the routine schedules of immunization for infants by
mid 2001 and achieve 80% coverage by 2003.
Special Project:
Polio eradication initiative:
Routines Immunization program along with Supplemental Immunization Activities (SIAs) have been the main strategy for stopping poliovirus transmission in Pakistan. With low routine immunization coverage and high growth rate (second in the world), closely spaced vaccination campaigns are major interventions for Polio Eradication. National Immunization Days (NIDs), two rounds of NIDs per year, one month apart with fixed site strategy, started in 1994 up to 1997- 98. The year 1998-1999 was an important landmark when the strategy of house-to-house vaccination was adopted. Since 1994, 37 rounds of NIDs and Sub –National Immunization (SNIDs) have been conducted, 14 through fixed site strategy and 23 through house-to-house vaccine delivery. Major milestones in the development of immunization campaigns are addition of a catch-up strategy for children not reporting to fixed sites in 1998; vitamin A supplementation initiated during NIDs in 1999; shift to house-to-house vaccination strategy and synchronization of campaign dates in Pakistan and Afghanistan, targeted vaccination campaigns in high-risk districts in 2001 and post-campaign monitoring through third parties during 2002.
As a result of the intensified campaigns there is sharp decline in the number of wild polio isolates, from 1803 in 1994, to 324 in 1999, to 199 cases in 2000, to 119 in 2001, to 90 in 2002 and so far 54 cases in 2003 as shown below. The following graph depicts the progress in polio eradication leading to decline in number of wild polio cases since 1994.
In addition to the drop in wild polio cases there is simultaneous drop in the number of districts infected. The widely spread virus infecting 76 districts in the country in 1999 has been localized to 39 districts in 2001, to 28 districts in 2002 and 27 districts in 2003. More over there are twenty-seven (27) districts without a polio case since 1997; thirty-six (36) districts since 1998 and fifty (50) since 1999. Seventy-five (75) districts have not reported a polio case for more than a year. Eradication of poliomyelitis from the country is within reach now.
This confidence in reaching the goal is based on the high quality AFP (acute flaccid paralysis) surveillance system in Pakistan. AFP surveillance in Pakistan has reached the global Certification standards for Polio Eradication. In fact, surveillance system is providing clear epidemiological picture of poliovirus and driving the program decisions. Key surveillance indicators are shown below.
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Program activities and achievements were presented to Technical Advisory Group (TAG), in their meeting held in Geneva (8-10 May 2002), for review and recommendation for the coming months. TAG was impressed by the progress made by Pakistan evidenced by suppression of early seasonal rise in cases during 2001, increasing geographical localization of virus circulation, achieving globally accepted standard of Surveillance system in place and backed up by WHO accredited regional Poliovirus lab in Pakistan.
Significant progress in PE from Pakistan has been possible only through great commitment and active collaboration of Polio Partners that include WHO, UNICEF, Rotary International, DFID, JICA, CDC Atlanta, USAID, IFRCS/PRCS and UNHCR. Government of Pakistan appreciates their technical and financial support for the program. After devolution of power, District Governments have emerged as lead polio partner at the operational levels and very rapid improvements have been observed in districts they are taking lead role. Hyderabad and Peshawar districts are examples to quote but there are many others, as well. There is long list of polio partners at the local levels in NGO/Private sector and many volunteers. Adequate reception of communities to vaccination campaigns has been a huge advantage to the program.
Achievements:
Since 1998, largely reflecting strengthened management at the federal level and in some provinces, marked progress has been made. The key elements in this progress are;
- major success has been achieved in conducting NIDs and extensive house-to-house immunization campaigns. Consequently the incidence of polio caused by wild polioviruses appears to be at a historic low, with a probability that transmission of wild virus will be stopped within 24 months
- AFP surveillance is well established, with good case detection, specimens form a high percentage of cases being submitted to virological investigation and with excellent coordinated laboratory support
- NNT campaigns have been conducted in 65 high-risk districts of the country.
- effective working groups (task forces) and Inter-agency Coordinating Committees (ICC) have been established at the federal and provincial levels
- preparations for provincial 5 year planning has started and, in most provinces, micro-planning to created district level plans.
- planning is advanced to conduct a nation-wide survey of the status and needs for the cold chain and logistics
- hepatitis B vaccine has been added in the routine EPI immunization from August, 2001
- A study for haemophilus influenza B burden has been conducted this fiscal year.
- The national coverage survey in January 1999, reflecting immunization performance 12 months previously, showed that only 49% of children aged 12-23 months were fully immunized, i.e. had received all scheduled vaccines in their first year of life.
- Although social mobilization techniques have been very effectively used in enabling NIDs and other campaigns delivering OPV, these have not yet been developed as a key element of improving routine immunization performance.