Immunisation and infant mortality in Pakistan *.

Khan, Zubeda

Our children are our future and if we want them to grow up healthy and strong, we have to protect them from the six dreadful diseases through immunisation which attack them in early childhood. This can be achieved by giving the children one dose of BCG vaccine against tuberculosis and zero dose of Polio at birth [Government of Pakistan (1989)], three doses of DPT vaccine for prevention of diphtheria, whooping cough and tetanus. Three doses of polio vaccine and one dose of measles vaccine should be given before their first birthday. Since the mother is the agent through which a child can receive the vaccinations, it is important that mothers are made aware of the different kinds of immunisation for the children and the times in the child's age at which it should be given.

This can only be done successfully, if the ministry of health launches a full-scale publicity programme. For this purpose, the services of local influential persons, for example the Imams of mosques and school teachers should be sought. Social workers and volunteers should also be included in the publicity programme. An extensive advertising campaign through display of posters about the six preventable diseases shown at all prominent public places, at the hospitals and the health centres should be done. Pamphlets should be handed out in the public, and even supplied on every door step. Public awareness can be increased through radio and television.

In Pakistan health facilities are available to about 55 percent of the population. Most of these health and Maternal and Child Health (MCH) services are concentrated in urban areas, while the rural population has access to Rural Health Centres, Basic Health Units and Family Welfare Centres in addition to Traditional Birth Attendants (TBA) and Hakims [Grant (1992)]. Subsidiary health centres and subcentres of Primary Health Centres are Health Institutes meant for the most vital functions of health schemes in the rural areas of the country. There is a considerable unmet felt need for curative, preventive and promotive health services among the rural population of Pakistan. Some of the main reasons why the health-care delivery system in our villages has not been able to reach those in need are the inaccessibility of services to the majority, especially women and children, who cannot avail them due to transport problems. There is also nonavailability of certain health services, including an inadequate supply of medicines. Also there is a dearth of social acceptability and non-participation of the community in the health delivery system. The indifferent attitude of doctors and paramedical staff has further 'discouraged the villagers from optimally utilising the health-care services provided by the health centres. The location of the health centres is another important factor for its under-utilisation, as villages located away from Primary Health Centres cannot receive the services.

Much of the high child mortality among poorly educated mothers reflect their inadequate hygiene practices and their lack of connections with modern medical care systems. Approximately 60 percent of infant deaths occurred during the neonatal period each year, and over 45 percent of neonatal mortality occurred within the 1st three days after birth [Government of Pakistan (1992)]. One of the priorities of the Government is to provide medical care during pregnancy and at the time of delivery, both of which are essential for infant and child survival and safe motherhood. They were also requested to receive an injection tetanus toxoid (TT) during pregnancy to prevent infant deaths. Over 75 percent of all deaths in the neonatal period occurred mostly due to prematurity, complications of child birth, tetanus and respiratory track infection [Government of Pakistan (1986)].

The major causes of sickness and death of children in Pakistan are infectious diseases, many of which are preventable by immunisation. Poliomyelities is the single major cause of lameness in children under 5 years of age. A large number of cases of diphtheria, tetanus, measles, typhoid fever, poliomyelitis are reported annually. It should be aimed to achieve 100 percent coverage of pregnant women with two doses of TT and at least 85 percent of infants in the whole of Pakistan with the six preventable diseases under this programme [Government of Pakistan (1990-91)].

The Expanded Programme on Immunisation (EPI) has been a major component of the accelerated Health Programme which was initiated in 1982. The Government of Pakistan had been committed to the goal of universal child immunisation by the year 1990. The last EPI review was conducted in Feb-Mar 1988. During the last three years tremendous efforts have been made by the Government of Pakistan to increase the expanded programme on immunisation coverage to higher levels (Table 1).

Now there was an obvious need for a field EPI evaluation survey in order to provide the coverage results needed for universal child immunisation. At the request of the Government of Pakistan, WHO and UNICEF agreed to organise a nationwide EPI review from 13-30 January, 1991 by an international team consisting of 7 international members (6 from WHO and 1 from UNICEF), 36 National Members supported by the Federal EPI Cell of National Institute of Health, Islamabad [Government of Pakistan (1991)].

The objective of this review was to evaluate the immunisation coverage of children 12-23 months of age including, in particular, the immunisation status before their first birthday, together with the assessment of dropout rates and reasons for incomplete immunisation.

Second, to evaluate the Tetanus Toxoid (TT) immunisation coverage of mothers of infants (0-11) months of age.

Third, to review all aspects of EPI management at various levels.

The immunisation coverage survey included the collection of information regarding immunisation based on availability of an immunisation card and mother's history of children less than age 12-23 months for EPI antigens and greater mother of infants 0-11 months for the neonatal tetanus protection in each urban and rural clusters. For the purpose of the survey 240 clusters were randomly selected by provinces and with urban/rural areas. Throughout the survey a total of 8651 households were visited in all the clusters selected. Information on the immunisation status was collected from 1968 children 12-23 months of age and from 1965 mothers of infants 0-11 months of age from all the selected areas. The immunisation coverage results and the neonatal tetanus protection of infants results obtained by the survey are shown in the attached Table 2 to Table 6.

CONCLUDING REMARKS

The high coverage rate achieved in Punjab, North West Frontier Province and Azad Jammu and Kashmir needs to be maintained. Furthermore, there is still room for improvement especially in TT coverage of mothers. The two lagging provinces, namely Sindh and Balochistan need special attention, particularly the latter. In all circumstances, greater emphasis should be put on reaching children in their first year of life. The programme should be regularised along with other health facility activities. Mobile activities being very costly, these should be undertaken as a follow-up to defaulters and for neglected areas.

The main objective of the EPI Programme is to reduce child morbidity and mortality from the six diseases namely poliomyelitis, diphtheria, prenatal tetanus, pertussis, Measles and Tuberculosis. The EPI aim was to reduce children's mortality from these diseases by 90 percent by the year 1990, and in fact infant mortality has been reduced from 106.4 per 1000 live births in 1984-1985 [Government of Pakistan (1986)] to about 100.9 in 1990-1991 [Govenment of Pakistan (1992)].

REFERENCES

Grant, James P. (1992) The State of the World's Children. New York: Oxford University Press.

Pakistan, Government of (1986) Pakistan Contraceptive Prevalence Survey 1984-1985. Islamabad: Pakisatn Population Welfare Division, Ministry of Planning and Development.

Pakistan, Government of (1990-91) Annual Report of the Director General Health. Islamabad: Ministry of Health.

Pakistan, Government of (1991) EPI Programme Review in Pakistan, A Joint Review of the Government of Pakistan/WHO/UNICEF: 13-30.

Pakistan, Government of (1992) Pakistan Demographic and Health Survery, 1990-1991. Islamabad: National Insuitute of Population Studies.

Punjab, Government of (1989) Immunization in Children. Pakistan Pediatric Association.

* Owing to unavoidable circumstances, the discussant's comments on this paper have not been received.

Zubeda Khan is Senior Research Demographer at the Pakistan Institute of Development Economics, Islamabad.

Table 1
Expanded Programme of Immunisation (EPI) Data Regarding Expanded
Programme of Immunisation in Pakistan from 1977 to 1990

Vaccine/Dose 1977-87 1988 1989 1990

BCG 26926336 4236292 4065712 4673505
POLIO
I 29876289 4768641 4883074 5478595
II 23591143 3768332 3899832 4278840
III 17212591 3169281 3510834 4018122
BOOSTER 5706872 1138662 992455 1025439

DPT
I 15925776 3755887 4018140 4551616
II 13310467 3277074 3603269 4070464
III 11725039 3114883 3493929 3695488
BOOSTER 2669949 950015 923077 980183

D.T.
I 10916177 557489 33221 278729
II 9304014 497301 292073 228097
BOOSTER 2891465 193188 67658 39165

TETANUS TOXOID
I 6718926 2938030 4421663 5191841
II 3705743 2079442 3113490 3670422
BOOSTER 106682 133130 259572 1042951

MEASLES 13393559 3171508 3534952 4392782

Source: Government of Pakistan (1990-1991).

Table 2
Results of Immunisation Coverage Survey by Antigen and Dose
According to Card Plus History for Children 12-23
Months Age Group, Pakistan, January, 1991

 No. of BCG
Province Area Children (%)

Punjab Urban 211 96.7
 Rural 212 100.00

Sindh Urban 212 94.8
 Rural 211 96.2

N.W.F.P Urban 215 98.1
 Rural 212 99.1

Balochistan Urban /
 Rural 215 83.7

A.J.K. Urban /
 Rural 210 99.0

Country Wide 97.5

 DPT (%)
Province Area 1 2 3

Punjab Urban 100.00 100.00 99.10
 Rural 100.00 100.00 100.00

Sindh Urban 99.1 97.2 92.5
 Rural 95.7 91.7 86.7

N.W.F.P Urban 98.1 98.1 98.1
 Rural 99.1 99.1 99.1

Balochistan Urban /
 Rural 86.5 79.5 67.4

A.J.K. Urban /
 Rural 99.5 98.6 97.1

Country Wide 98.5 97.4 95.6

 OPV (%)
Province Area 1 2 3

Punjab Urban 100.00 100.00 99.10
 Rural 100.00 100.00 100.00

Sindh Urban 99.1 97.2 92.5
 Rural 95.7 91.7 86.7

N.W.F.P Urban 98.1 98.1 98.1
 Rural 99.1 99.1 99.1

Balochistan Urban /
 Rural 86.5 79.5 67.4

A.J.K. Urban /
 Rural 99.5 98.6 97.1

Country Wide 98.5 97.4 95.6

 Measles Immunity Status
Province Area (%) Not Partial Full

Punjab Urban 99.1 0 1.4 98.6
 Rural 100.00 0 0 100.00

Sindh Urban 93.9 0.9 11.8 87.3
 Rural 93.9 4.3 17.0 78.7

N.W.F.P Urban 98.1 1.4 0.9 97.7
 Rural 99.1 0.9 0.0 99.1

Balochistan Urban /
 Rural 74.4 10.7 29.8 59.5

A.J.K. Urban /
 Rural 97.1 0.5 11.4 88.1

Country Wide 97.0 1.3 5.2 93.5

Source: Government of Pakistan (1991).

Table 3
Coverage Mothers of Children 0-11 Months Age Group
by TT According to Card Plus History,
Pakistan, January, 1991
 Tetanus Toxoid
 Percentage
 No. of
Province Area Mothers 1st Dose 2nd Dose

Punjab Urban 213 97.7 97.7
 Rural 211 99.5 96.7

Sindh Urban 211 85.3 79.3
 Rural 212 72.0 61.8

N.W.F.P. Urban 214 97.2 95.3
 Rural 211 97.2 95.3

Balochistan Urban/
 Rural 213 36.2 30.0
A.J.K. Urban/
 Rural 210 95.2 93.3

 Tetanus Toxoid Percentage

Province Area 3rd Dose 4th Dose 5th Dose

Punjab Urban 20.2 8.0 2.8
 Rural 12.8 1.9 0

Sindh Urban 1.4 0.5 0
 Rural 0.5 0 0

N.W.F.P. Urban 27.1 6.1 1.4
 Rural 34.1 1.9 0.5

Balochistan Urban/
 Rural 6.1 0.9 0.5

A.J.K. Urban/
 Rural 24.3 4.3 0.5

Source: Government of Pakistan (1991).

Table 4
Source of Immunisation for Children 12-23 Months
Age Group, Pakistan, January y, 1991

 Source of Immunisation (%)

 Out
 Health Reach/
Province Area Hospital Centre Mobile Private
 Team

Punjab Urban 13.3 14.7 71.0 --
 Rural 2.4 0.5 97.1 --

Sindh Urban 35.3 21.9 36.3 6.5
 Rural 4.9 6.4 76.4 12.3

N.W.F.P Urban 27.0 31.9 41.1 --
 Rural 15.2 8.6 76.2 --

Balochistan Urban/
 Rural 6.7 10.5 82.8 --

A. J. K. Urban/
 Rural 1.0 42.1 56.9 --

Source: Government of Pakistan (1991).

Table 5
Source of Tetanus Toxoid Immunisation for Mother
of Children 0-11 Months Age Group, Pakistan, January, 1991

 Source of Immunisation (%)

 Out
 Reach/
 Health Mobile
Province Area Hospital Centre Team Private

Punjab Urban 22.1 17.8 56.3 2.8
 Rural 4.8 1.4 93.8 --

Sindh Urban 36.1 24.4 30.6 8.9
 Rural 5.3 15.1 65.1 14.5

N.W.F.P Urban 36.5 28.4 32.2 2.9
 Rural 24.4 4.9 70.7 --

Balochistan Urban/
 Rural 9.1 24.7 64.9 1.3

A. J. K. Urban/
 Rural -- 45.0 55.0 --

Source: Government of Pakistan (1991).

Table 6
Reason for Immunisation Failure among Non and Partially
Immunised Children 12-23 Months Age Group

Reason Number %

Unaware of Need for Immunisation 20 10.3
Unaware of Need for Subsequent Visits 29 15.0
Fear of Side Effects 6 3.1
Others 9 4.6

Subtotal: Lack of Information 64 33.0

Postponed until another Time 5 2.6
No Faith in Immunisation 3 1.5

Subtotal: Lack of Motivation 8 4.1

Place of Immunisation Too Far 1 0.5
Time of Immunisaton Inconvenient 3 1.5
Vaccinator Absent 50 25.8
Mother too Busy 12 6.2
Family Problems 11 5.7
Child Ill not Brought 10 5.2
Child Ill Brought but not Immunised 3 1.5
Others 32 16.5

Subtotal: Obstacles 122 62.9

Total 194 100.0

Source: Government of Pakistan (1991).