Social determinants of low uptake of childhood vaccination in high-risk squatter settlements in Karachi, Pakistan - A step towards addressing vaccine inequity in urban slums.

Background: Routine vaccination has remained historically low in major urban pockets of Pakistan, and now lags behind rural vaccination rates. Grossly insufficient publicly funded primary healthcare infrastructure, heterogeneous mix of providers and multi-ethnicity of populations pose challenges in the delivery of essential health services. This paper ascertains factors associated with uptake of routine childhood vaccination, using Pentavalent-3 vaccine, as a proxy indicator for completion of age-appropriate vaccines in urban slums of Karachi, at high risk of Polio and vaccine preventable disease outbreaks. Methods: Data was drawn from baseline assessment of an urban immunization delivery pilot project in urban slums of Karachi, Pakistan. The study sample comprised of 2,097 households with children aged 4-12 months, sampled through a cross-sectional cluster survey, applying a structured questionnaire. Multivariable logistic regression was used to determine the association between Penta-3 vaccination, as the outcome variable, and predictor variables including socio-demographic characteristics and healthcare access factors. Results: The findings showed that the likelihood of being immunized with Penta-3 was higher for non-Pashtun ethnicity [adjusted odds ratio (aOR) 1.69; 95% CI 1.33-2.14], children of educated mothers, secondary or higher [aOR 2.95, 95% CI 2.34-3.71], and those whose fathers were formally employed (aOR 1.53; 95% CI 1.19-1.97). No association was seen by gender of child [aOR 0.89; 95% CI 0.73-1.08], and place of new born delivery [aOR 1.01; 95% CI 0.83-1.24]. Conclusion: Pockets of critically low under-vaccinations within the urban slums of Karachi are associated with Pashtun ethnicity, distance to the vaccination centre, lack of mothers' education and lack of stable family income as in the case of unemployed and daily wage-earning fathers. Recognition of these factors is required in designing contextually appropriate strategies to address vaccine inequity in urban settings.

Intussusception risk following oral monovalent rotavirus vaccination in 3 Asian countries: A self-control case series evaluation.

Rotavirus vaccines have substantially decreased rotavirus hospitalizations in countries where they have been implemented. In some high- and middle-income countries, a low-level of increased risk of intussusception, a type of acute bowel obstruction, has been detected following rotavirus vaccination. However, no increased risk of intussusception was found in India, South Africa, or a network of 7 other African countries. We assessed the association between a 2-dose monovalent rotavirus vaccine (Rotarix) and intussusception in 3 early-adopter low-income Asian countries -- Afghanistan, Myanmar, and Pakistan. Children <12 months of age admitted to a sentinel surveillance hospital with Brighton level 1 intussusception were eligible for enrollment. We collected information about each child's vaccination status and used the self-controlled case series method to calculate the relative incidence of intussusception 1-7 days, 8-21 days, and 1-21 days following each dose of vaccine and derived confidence intervals with bootstrapping. Of the 585 children meeting the analytic criteria, the median age at intussusception symptom onset was 24 weeks (IQR: 19-29). Overall, 494 (84 %) children received the first Rotarix dose and 398 (68 %) received the second dose. There was no increased intussusception risk during any of the risk periods following the first (1-7 days: 1.01 (95 %CI: 0.39, 2.60); 8-21 days: 1.37 (95 %CI: 0.81, 2.32); 1-21 days: 1.28 (95 %CI: 0.78, 2.11)) or second (1-7 days: 0.81 (95 %CI: 0.42, 1.54); 8-21 days: 0.77 (95 %CI: 0.53, 1.16); 1-21 days: 0.78 (95 %CI: 0.53, 1.16)) rotavirus vaccine dose. Our findings are consistent with other data showing no increased intussusception risk with rotavirus vaccination in low-income countries and add to the growing body of evidence demonstrating safety of rotavirus vaccines.

Situational analysis of antimicrobial stewardship program (ASP) among public and private sector tertiary care hospitals in Karachi, Pakistan: A qualitative case study.

Objective: To assess the current status of implementation of the Antimicrobial Stewardship Program (ASP) across Tertiary Care Hospitals in Karachi, Pakistan. Design: Exploratory qualitative case study. Setting: Public and private tertiary care hospitals in Karachi, Pakistan. Participants and Methods: The study data were collected from 3 public and 4 private tertiary care hospitals. Twenty-eight in-depth interviews were conducted from the Chief Executive Officer, Chief Medical Officer, Medical Superintendent, and departmental heads of internal medicine, general surgery, and pediatric, respectively. Purposive sampling was done to include higher and middle managers, whereas the infectious diseases consultant, infectious diseases/clinical pharmacist, and clinical microbiologist were interviewed through snowball sampling methodology. Analysis was done using NVivo. Data were source-triangulated within and among the study setting and study participants. Results: We found that more than two-thirds (n = 5, 71%) of tertiary care hospitals in Karachi do not have a structured ASP which includes major public sector hospitals (n = 3, 43%) and half of the private sector hospitals (n = 4, 29%). The study results led to four broad themes, (1) ASP structure, (2) ASP interventions, (3) hospital medical record-keeping system, and (4) structured way for analyzing and reporting mechanism of data related to the ASP. At H1 and H2, there was a consistency in ASP structure and interventions, whereas paucity seen among remaining tertiary care hospitals. Conclusion: There is an alarming need for ASP in the public and private sector hospitals in Karachi. This study can inform future stakeholders regarding ASP and strategies for structural change at hospitals.

Public sector rehabilitation services for physical disabilities in tertiary care hospitals of Karachi, Pakistan: A qualitative study.

BACKGROUND: Around the globe there are 2.4 billion people in need of rehabilitation. Disability and rehabilitation have not gained much importance in the public health arena, possibly due to limited research and awareness regarding the significance of rehabilitation. This study aimed to provide an in-depth understanding of the barriers and facilitators to the provision and utilization of rehabilitation services in public sector tertiary care hospitals of Karachi, Pakistan. METHODOLOGY: This qualitative exploratory study was conducted from August to September 2015 in two tertiary care hospitals of Karachi. The criterion for hospital selection included the availability of functional rehabilitation services. Twenty-four key informant interviews were conducted with health professionals, including doctors, physiotherapists, occupational therapists, prosthetists, orthotists, as well as patients and caregivers. Qualitative content analysis was performed using a consensual qualitative research approach. Responses from key informant interviews were coded into free nodes and then categorized into themes. RESULTS: Two themes emerged from the data: constraints to the provision of rehabilitation services, and barriers to the utilization of rehabilitation services. Basic infrastructure was available at both study sites; however, a lack of structured guidelines for referring patients to these services, a lack of information-sharing and guidance to the patients, and a limited supply of equipment (treatment modalities) hampered the provision of services. The barriers to rehabilitation services included cost pertaining to transport, environmental barriers, lack of support from the employer, and strain on and lack of support from caregivers. CONCLUSION: Rehabilitation services require attention and investment in research and allocation of funds to strengthen the service delivery system. Hospitals, alongside the department of health, need to develop a strategic plan to set future directions and standards of available rehabilitation services.

Administration of sinopharm Covid-19 vaccine in cancer patients.

For prevention against SARS-CoV-2, various vaccines have been approved globally including Pfizer, Sinopharam, Moderna, Johnson & Johnson etc which have proved quite effective. To evaluate the immunization and safety of Sinopharm vaccine in cancer patients. A prospective study was conducted in the Oncology Department of Nishtar Medical Hospital, Multan from March 2021- September 2021. A total of 150 cancer patients undergoing treatment were included in the study. All the patients were administered 0.5 ml Sinopharm vaccine with 28 day difference between the two doses. A two-month follow-up was done to test the immunization using ELISA kits. Among all the patients, 16 patients (10.7%) had a history of COVID-19 before the administration of the vaccine. At the time of vaccination, 23.3% of patients were seropositive. After the vaccination, 130 patients (86.7%) developed immunity against the infection. 30.6% of participants developed a fever and 20.9% had fatigue. Other side effects were also observed including pain, redness, swelling, itching, chills, anorexia, nausea, vomiting, myalgia and diarrhea. Sinopharm vaccine is effective and safe for patients with malignancies especially in patients receiving radiaton therapy but still recommended for older patients and patients receiving chemotherapy.

Barriers and facilitators to exclusive breastfeeding in rural Pakistan: a qualitative exploratory study.

BACKGROUND: Exclusive breastfeeding (EBF) of children until six months of age is considered one of the most critical interventions in tackling childhood undernutrition. EBF rates are suboptimal in Pakistan, particularly in rural areas where child undernutrition is most prevalent. This study aimed to explore barriers to EBF in a rural context of Pakistan. METHODS: The study was conducted in the rural district Matiari of Sindh, Pakistan, during Jan-March 2020. We used a qualitative exploratory study design and conducted 36 focus group discussions (FGDs). Participants were purposively selected mothers who had not practiced EBF during their previous childbirth, their spouses and mothers-in-law, and lady health workers (LHWs) serving in the study catchment. FGDs were audio-recorded, transcribed, and translated into English from the local language and analysed using thematic content analysis. RESULTS: Barriers to EBF included low awareness and cultural practices of prelacteal feeds, insufficient breast milk production, undernutrition of mothers, mothers' occupation as fieldworkers, less birth spacing, low awareness about the correct technique of breastfeeding, maternal and child ailments, abnormal breasts, and influence of in-laws to start top-up feeds. Several facilitators were identified: family support, appropriate maternal diet, maternal awareness, and support in the neighborhood. CONCLUSION: Barriers to EBF are multifaceted in rural areas, and interventions aiming to improve adherence to EBFshould be multipronged. Awareness-raising alone might not be sufficient, and other interventions should be designed to address the barriers of maternal malnutrition, insufficient milk production, and socio-cultural practices. In addition, safe alternatives to breast milk may be necessary if breastfeeding is truly not feasible. Lack of breast milk substitutes is particularly challenging for poor rural women who cannot afford infant formula milk.

An epidemiological, strategic and response analysis of the COVID-19 pandemic in South Asia: a population-based observational study.

INTRODUCTION: South Asia has had a dynamic response to the ongoing COVID-19 pandemic. The overall burden and response have remained comparable across highly-burdened countries within the South Asian Region. METHODOLOGY: Using a population-based observational design, all eight South Asian countries were analyzed using a step-wise approach. Data were obtained from government websites and publicly-available repositories for population dynamics and key variables. RESULTS: South Asian countries have a younger average age of their population. Inequitable distribution of resources centered in urban metropolitan cities within South Asia is present. Certain densely populated regions in these countries have better testing and healthcare facilities that correlate with lower COVID-19 incidence per million populations. Trends of urban-rural disparities are unclear given the lack of clear reporting of the gaps within these regions. COVID-19 vaccination lag has become apparent in South Asian countries, with the expected time to complete the campaign being unfeasible as the COVID-19 pandemic progresses. CONCLUSION: With a redesigning of governance policies on preventing the rise of COVID-19 promptly, the relief on the healthcare system and healthcare workers will allow for adequate time to roll out vaccination campaigns with equitable distribution. Capacity expansion of public health within the Region is required to ensure a robust healthcare response to the ongoing pandemic and future infectious disease outbreaks.

A Novel Knowledge Distillation-Based Feature Selection for the Classification of ADHD.

Attention Deficit Hyperactivity Disorder (ADHD) is a brain disorder with characteristics such as lack of concentration, excessive fidgeting, outbursts of emotions, lack of patience, difficulty in organizing tasks, increased forgetfulness, and interrupting conversation, and it is affecting millions of people worldwide. There is, until now, not a gold standard test using which an ADHD expert can differentiate between an individual with ADHD and a healthy subject, making accurate diagnosis of ADHD a challenging task. We are proposing a Knowledge Distillation-based approach to search for discriminating features between the ADHD and healthy subjects. Learned embeddings from a large neural network, trained on the functional connectivity features, were fed to one hidden layer Autoencoder for reproduction of the embeddings using the same connectivity features. Finally, a forward feature selection algorithm was used to select a combination of most discriminating features between the ADHD and the Healthy Controls. We achieved promising classification results for each of the five individual sites. A combined accuracy of 81% in KKI, 60% Peking, 56% in NYU, 64% NI, and 56% OHSU and individual site wise accuracy of 72% in KKI, 60% Peking, 73% in NYU, 70% NI, and 71% OHSU were obtained using our extracted features. Our results also outperformed state-of-the-art methods in literature which validates the efficacy of our proposed approach.

Feasibility, usability and acceptability of paediatric lung ultrasound among healthcare providers and caregivers for the diagnosis of childhood pneumonia in resource-constrained settings: a qualitative study.

OBJECTIVES: Paediatric pneumonia burden and mortality are highest in low-income and middle-income countries (LMIC). Paediatric lung ultrasound (LUS) has emerged as a promising diagnostic tool for pneumonia in LMIC. Despite a growing evidence base for LUS use in paediatric pneumonia diagnosis, little is known about its potential for successful implementation in LMIC. Our objectives were to evaluate the feasibility, usability and acceptability of LUS in the diagnosis of paediatric pneumonia. DESIGN: Prospective qualitative study using semistructured interviews SETTING: Two referral hospitals in Mozambique and Pakistan PARTICIPANTS: A total of 21 healthcare providers (HCPs) and 20 caregivers were enrolled. RESULTS: HCPs highlighted themes of limited resource availability for the feasibility of LUS implementation, including perceived high cost of equipment, maintenance demands, time constraints and limited trained staff. HCPs emphasised the importance of policymaker support and caregiver acceptance for long-term success. HCP perspectives of usability highlighted ease of use and integration into existing workflow. HCPs and caregivers had positive attitudes towards LUS with few exceptions. Both HCPs and caregivers emphasised the potential for rapid, improved diagnosis of paediatric respiratory conditions using LUS. CONCLUSIONS: This was the first study to evaluate HCP and caregiver perspectives of paediatric LUS through qualitative analysis. Critical components impacting feasibility, usability and acceptability of LUS for paediatric pneumonia diagnosis in LMIC were identified for initial deployment. Future research should explore LUS sustainability, with a particular focus on quality control, device maintenance and functionality and adoption of the new technology within the health system. This study highlights the need to engage both users and recipients of new technology early in order to adapt future interventions to the local context for successful implementation. TRIAL REGISTRATION NUMBER: NCT03187067.

A Three-Stage Teacher, Student Neural Networks and Sequential Feed Forward Selection-Based Feature Selection Approach for the Classification of Autism Spectrum Disorder.

Autism disorder, generally known as Autism Spectrum Disorder (ASD) is a brain disorder characterized by lack of communication skills, social aloofness and repetitions in the actions in the patients, which is affecting millions of the people across the globe. Accurate identification of autistic patients is considered a challenging task in the domain of brain disorder science. To address this problem, we have proposed a three-stage feature selection approach for the classification of ASD on the preprocessed Autism Brain Imaging Data Exchange (ABIDE) rs-fMRI Dataset. In the first stage, a large neural network which we call a "Teacher " was trained on the correlation-based connectivity matrix to learn the latent representation of the input. In the second stage an autoencoder which we call a "Student" autoencoder was given the task to learn those trained "Teacher" embeddings using the connectivity matrix input. Lastly, an SFFS-based algorithm was employed to select the subset of most discriminating features between the autistic and healthy controls. On the combined site data across 17 sites, we achieved the maximum 10-fold accuracy of 82% and for the individual site-wise data, based on 5-fold accuracy, our results outperformed other state of the art methods in 13 out of the total 17 site-wise comparisons.

Operability, Usefulness, and Task-Technology Fit of an mHealth App for Delivering Primary Health Care Services by Community Health Workers in Underserved Areas of Pakistan and Afghanistan: Qualitative Study.

BACKGROUND: The recent proliferation of digital health technology in low- and middle-income countries has made it possible for community health workers (CHWs) to use mobile health (mHealth) to perform tasks such as data collection and training. Although most studies focus on the prospect of digital apps to motivate and connect CHW, only a few have captured end-user experiences with mobile-based apps. We examined the experience of frontline health workers with a move towards digitalized real-time data to record maternal and childcare services in remote areas of Afghanistan and Pakistan. OBJECTIVE: Our study aimed to explore CHW perceptions on the operability of the mHealth app in a community setting, usefulness of the app in the delivery of assigned maternal and childcare functions, and the task-technology fit with monitoring information systems. METHODS: The Hayat app, designed to digitalize and facilitate electronic record keeping, was evaluated to be embedded into mainstream health systems. The app had 2 components: smartphone app for data entry and web dashboard for visualization of the maternal, newborn, and child health reports. Using a qualitative exploratory study design, we conducted a total of 8 focus group discussions with purposively selected lady health workers (LHWs) and CHWs in 3 districts of Pakistan and 3 hamlets of Afghanistan, respectively. Focus group discussions were conducted in the local language, audio recorded, and converted into expanded notes for thematic analysis. RESULTS: Although a majority of LHWs used the app with ease, some initially faced difficulties in operating it and requested a longer duration of training. Contrary to LHWs, the CHWs were able to use the app without difficulty, as they were using it only to register clients. Overall, use of the mHealth app in both countries resulted in a positive impact on health education sessions, easier communication with parents or clients, tracking of routine immunization defaulters and follow-ups, improved data validity, easily accessible vaccination schedules, and faster registration. In addition to building up their image in the community and personal development, the improved reporting and monitoring mechanisms also set the stage for the LHWs to get recognized for their hard work. CHWs in Afghanistan also reported the app provided immediate access to information when requested by their supervisor. Although the Hayat app eliminates the need to carry multiple registers and helps in recalling client information at the touch of a button, technical issues around connectivity and data inputting tabs were highlighted by the participants. CONCLUSIONS: The digitization of records not only provided CHWs support in their daily routine but also strengthened monitoring mechanisms and improved motivation. We recommend conducting end user experience studies before embedding apps into mainstream health systems as high acceptability does not always result in high uptake of digital technology.

Low vaccination in rural Sindh, Pakistan: A case of refusal, ignorance or access?

INTRODUCTION: Pakistan is suffering from low routine childhood immunization (RI) coverage, meriting a systematic examination of community acceptance and barriers towards vaccination with a view to inform responsive strategies. We examine community perspectives on RI for children 0-23 months of age, unveiling community beliefs, health systems barriers and willingness to actively seek immunization services. METHODS: A qualitative study was conducted in the rural under-resourced district of Tando Muhammad Khan of Pakistan's Sindh province. 12 focus group discussions were conducted to probe immunization perceptions and experience: 6 with female caregivers of children <2 years and 6 with Lady Health workers (LHWs). An adapted Health Access Livelihood Framework guided data collection, qualitative data were thematically coded using inductive analysis and findings were triangulated across caregivers and LHWs. RESULTS: Caregivers were either indifferent to vaccination or had an unmet need to know more, with few reporting outright refusals to vaccinate. Caregiver beliefs were characterized by a lack of awareness and a confusion of RI with Polio and a fear of side effects. Religious beliefs were not major considerations. Second, health systems issues of hurried and infrequent vaccination encounters, driven by LHWs' poor capability to handle the vaccine counter-narrative, interrupted vaccine delivery to villages. These challenges were exacerbated by interruptions due to the Polio campaigns. Third, time and public transport constrained access to the Extended Program on Immunization centers. However, female caregivers usually took decisions on vaccination without recourse to male household members, with child's health viewed to be the main concern. CONCLUSIONS: An ineffective vaccination narrative, low LHW capability and prioritization of RI, intermittent outreach vaccination encounters, and overshadowing of RI activities by Polio campaigns limit the uptake of childhood RI services. We contend that critical attention is required for post-immunization messaging, client-centric services, positive immunization experiences and the availability of vaccination encounters.

DeepFMRI: End-to-end deep learning for functional connectivity and classification of ADHD using fMRI.

BACKGROUND: Resting state fMRI has emerged as a popular neuroimaging method for automated recognition and classification of brain disorders. Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common brain disorders affecting young children, yet its underlying mechanism is not completely understood and its diagnosis is mainly dependent on behaviour analysis. NEW METHOD: In this paper, we propose an end-to-end deep learning architecture to diagnose ADHD. Our aim is to (1) automatically classify a subject as ADHD or healthy control, and (2) demonstrate the importance of functional connectivity to increase classification accuracy and provide interpretable results. The proposed method, called DeepFMRI, is comprised of three sequential networks, namely (1) a feature extractor, (2) a functional connectivity network, and (3) a classification network. The model takes fMRI pre-processed time-series signals as input and outputs a diagnosis, and is trained end-to-end using back-propagation. RESULTS: Experimental results on the publicly available ADHD-200 dataset demonstrate that this innovative method outperforms previous state-of-the-art. Different imaging sites contributed the data to the ADHD-200 dataset. For the New York University imaging site, our proposed method was able to achieve classification accuracy of 73.1% (specificity 91.6%, sensitivity 65.5%). COMPARISON WITH EXISTING METHODS: In this work, we propose a novel end-to-end deep learning method incorporating functional connectivity for the classification of ADHD. To the best of our knowledge, this has not been explored by existing studies. CONCLUSIONS: The results suggest that the proposed end-to-end deep learning architecture achieves better performance as compared to the other state-of-the-art methods. The findings suggest that the frontal lobe contains the most discriminative power towards the classification of ADHD.

Applying a governance barometer to vaccine delivery systems: Lessons from a rural district of Pakistan.

INTRODUCTION: Weak vaccine delivery systems in countries off-track for routine immunization targets, need in-depth evidence on system level barriers to be critically resourced and monitored. We applied a Balanced Score Card (BSC) approach in a rural underserved district of Pakistan to (i) identify critical areas needing support in the government vaccine delivery system; and (ii) for benchmarking improvements in the vaccine delivery system. METHODOLOGY: BSC was developed drawing on desk review, government consultations and field testing. 45 immunization indicators were finalized across 8 domains: human resource; vaccine supply; safe vaccination practice; cold chain maintenance; outreach preparedness; records & supervision; verifiable vaccination volume; and client communication. Data were collected through health facility assessments, client exit interviews and household vaccination assessment. A composite score was calculated for each domain and banded into unsatisfactory, borderline and satisfactory categories. 5 lowest ranking domains were targeted for 2 years of health systems strengthening (HSS) interventions. Post-intervention assessment tracked progress. RESULTS: The district obtained a cumulative score of 51% (unsatisfactory) at pre-intervention and improved to 82% (satisfactory) at post-intervention. At pre-intervention, 4 domains scored satisfactory and 4 scored unsatisfactory. Unsatisfactory scores were received for: outreach preparedness; records & supervision; verifiable vaccination volume; and client communication. Post intervention 6 of 8 domains scored satisfactory and 2 moved from unsatisfactory to borderline. Highest percentage point (pp) improvements were seen in outreach preparedness (53 pp, p = 0.01), EPI supervision (52 pp, p = 0.01) and verified vaccination volume (46 pp, p = 0.02). 3 domains that were not intervened through HSS interventions had minimal change in scoring - cold chain maintenance (6 pp), safe vaccination practice (12 pp) and vaccine supply (11 pp). CONCLUSION: BSC served to prioritize interventions towards critical unmet needs for vaccine delivery in the district health system and particularly helped to improve outreach preparedness, EPI supervision and verified vaccination volume.

Development and Validation of Parental Vaccine Attitudes Scale for Use in Low-income Setting.

BACKGROUND: This study aimed to develop a tool and assess its validity to measure childhood vaccine related attitudes among parents in a low-income setting. METHODS: We developed a vaccine attitudes scale (VAS) composed of 14 Likert items each with 5 responses ranging from strongly agree to strongly disagree (sum of scores range 14-70). The tool was administered to 901 parents with children 4-12 months of age during a vaccine coverage survey in Sindh, Pakistan. We performed factor analysis with eigenvalues >0.3 for sufficient factor loading and calculated Cronbach alpha for reliability. RESULTS: The mean ± SD score on VAS was 48 ± 3 and Cronbach alpha was 0.61. Factor analysis identified that VAS measured 2 different domains related to the childhood vaccine related attitudes; (1) 10 items related to vaccine perceptions and concerns (mean 40 ± 5.5; Cronbach alpha 0.95) and (2) 4 items related to vaccine preventable disease salience and community benefit (mean 7 ± 3; Cronbach alpha 0.97). The odds of children being unimmunized was 5 times higher among parents who scored high (13-20) as compared with low (<13) on the subscale related to disease salience and community benefit (odds ratio 5.2; 95% CI: 3.6-7.6). The odds of children being unimmunized was 1.5 times higher among parents scoring high (40-50) as compared with low (<40) on subscale related to vaccine perception/concerns (odds ratio 1.5; 95% CI: 1.1-2.2). CONCLUSION: The 4-item scale assessing parental attitudes toward vaccine preventable disease salience and community benefit is sufficiently reliable and can predict vaccine acceptance among parents in low income setting.

Correction to: Nasopharyngeal carriage of Streptococcus pneumoniae in children under 5 years of age before introduction of pneumococcal vaccine (PCV10) in urban and rural districts in Pakistan.

ᅟ.

Health systems changes after decentralisation: progress, challenges and dynamics in Pakistan.

Decentralisation is widely practised but its scrutiny tends to focus on structural and authority changes or outcomes. Politics and process of devolution implementation needs to be better understood to evaluate how national governments use the enhanced decision space for bringing improvements in the health system and the underlying challenges faced. We use the example of Pakistan's radical, politically driven provincial devolution to analyse how national structures use decentralisation opportunities for improved health planning, spending and carrying out transformations to the health system. Our narrative draws on secondary data sources from the PRIMASYS study, supplemented with policy roundtable notes from Pakistan. Our analysis shows that in decentralised Pakistan, health became prioritised for increased government resources and achieved good budgetary use, major strides were made contextualised sector-wide health planning and legislations, and a proliferation seen in governance measures to improve and regulate healthcare delivery. Despite a disadvantaged and abrupt start to devolution, high ownership by politicians and bureaucracy in provincial governments led to resourcing, planning and innovations. However, effective translation remained impeded by weak institutional capacity, feeble federal-provincial coordination and vulnerability to interference by local elites. Building on this illustrative example, we propose (1) political management of decentralisation for effective national coordination, sustaining stable leadership and protecting from political interfere by local elites; (2) investment in stewardship capacity in the devolved structures as well as the central ministry to deliver on new roles.

Effectiveness of 10-valent pneumococcal conjugate vaccine against vaccine-type invasive pneumococcal disease in Pakistan.

OBJECTIVE: To assess the effectiveness of 10-valent pneumococcal conjugate vaccine (PCV10) against invasive pneumococcal disease (IPD) due to vaccine serotypes of Streptococcus pneumoniae post introduction of the vaccine into the routine immunization program in Pakistan. METHODS: A matched case-control study was conducted at 16 hospitals in Sindh Province, Pakistan. Children aged <5years (eligible to receive PCV10) who presented with radiographically confirmed pneumonia and/or meningitis were enrolled as cases. PCR for the lytA gene was conducted on blood (for radiographic pneumonia) and cerebrospinal fluid (for meningitis) samples to detect S. pneumoniae. The proportion of IPD due to vaccine serotypes (including vaccine-related serogroups) was determined through serial multiplex PCR. For each case, at least five controls were enrolled from children hospitalized at the same institution, matched for age, district, and season. RESULTS: Of 92 IPD patients enrolled during July 2013 to March 2017, 24 (26.0%) had disease caused by vaccine serotypes. Most case (87.5% of 24) and control (66.4% of 134) children had not received any PCV10 doses. The estimated effectiveness of PCV10 against vaccine-type IPD was 72.7% (95% confidence interval (CI) -7.2% to 92.6%) with at least one dose, 78.8% (95% CI -11.9% to 96.0%) for at least two doses, and 81.9% (95% CI -55.7% to 97.9%) for all three doses of vaccine. CONCLUSIONS: The vaccine effectiveness point estimates for PCV10 were high and increased with increasing number of doses. However, vaccine effectiveness estimates did not reach statistical significance, possibly due to low power. The findings indicate the likely impact of vaccine in reducing the burden of vaccine-type IPD if vaccine uptake can be improved.

Nasopharyngeal carriage of Streptococcus pneumoniae in children under 5 years of age before introduction of pneumococcal vaccine (PCV10) in urban and rural districts in Pakistan.

BACKGROUND: Benefits of pneumococcal conjugate vaccine programs have been linked to the vaccine's ability to disrupt nasopharyngeal carriage and transmission. The 10-valent pneumococcal vaccine (PCV10) was included in the Expanded Program on Immunization (EPI) in Sindh, Pakistan in February 2013. This study was carried out immediately before PCV10 introduction to establish baseline pneumococcal carriage and prevalent serotypes in young children and to determine if carriage differed in urban and rural communities. METHODS: Nasopharyngeal specimens were collected from a random sample of children 3-11 and 12-59 months of age in an urban community (Karachi) and children 3-11 months of age in a rural community (Matiari). Samples were processed in a research laboratory in Karachi. Samples were transported in STGG media, enriched in Todd Hewitt broth, rabbit serum and yeast extract, cultured on 5% sheep blood agar, and serotyped using the CDC standardized sequential multiplex PCR assay. Serotypes were categorized into PCV10-type and non-vaccine types. RESULTS: We enrolled 670 children. Pneumococci were detected in 73.6% and 79.5 % of children in the infant group in Karachi and Matiari, respectively, and 78.2% of children 12 to 59 months of age in Karachi. In infants, 38.9% and 33.5% of those carrying pneumococci in Karachi and Matiari, respectively, had PCV10 types. In the older age group in Karachi, the proportion was 30.7%, not significantly different from infants. The most common serotypes were 6A, 23F, 19A, 6B and 19F. CONCLUSION: We found that about 3 of 4 children carried pneumococci, and this figure did not vary with age group or urban or rural residence. Planned annual surveys in the same communities will inform change in carriage of PCV10 serotype pneumococci after the introduction and uptake of PCV10 in these communities.

Reasons for non-vaccination and incomplete vaccinations among children in Pakistan.

BACKGROUND: Global immunization efforts have received a boost through the introduction of several new vaccines. These efforts however, are threatened by sub-optimal vaccine coverage, particularly in countries with large birth cohorts. Pakistan has one of the largest birth cohorts in the world, where coverage of routine vaccination remains persistently inadequate. We undertook this study to ascertain reasons for non-vaccination or incomplete vaccination of children less than two years in 8 districts of southern Pakistan. METHODS: A cross-sectional survey using WHO recommended rapid coverage assessment technique was conducted in 2014. Using probability proportional to size method, we sampled 8400 households with eligible children (aged 4-12 months). Using a structured questionnaire, mothers or other primary caregivers were interviewed to determine vaccination status of an index child. In case of non-vaccination or incomplete vaccination, respondents were asked for reasons leading to low/no vaccine uptake. RESULTS: Based on both vaccination record and recall, only 30.8% of children were fully vaccinated, 46% had an incomplete vaccination status while 23%were non-vaccinated. The most frequently reported reasons for non-vaccination included: mothers/caregivers being unaware of the need for vaccination (35.3%), a fear of side effects (23%), mother/caregiver being too busy (16.6%), distance from vaccination centers (13.8%), and non-availability of either vaccinators or vaccines at vaccination centers (10.7%). Reasons identified for incomplete vaccination were similar, with caregivers being unaware of the need for subsequent doses (27.3%), non-availability of vaccinators or vaccines (17.7%), mother/caregiver being too busy (14.8%), fear of side effects (11.2%), and postponement for another time (8.7%). CONCLUSION: Various factors result in non-compliance with vaccination schedules and vaccine refusal within the surveyed communities, ranging from lack of knowledge to non-availability of supplies at vaccination centers. These barriers are best addressed through multi-pronged strategies addressing supply gaps, increasing community awareness and enhancing demand for routine vaccination services.