Elsevier

Public Health

Volume 164, November 2018, Pages 16-25
Public Health

Original Research
What is causing high polio vaccine dropout among Pakistani children?

https://doi.org/10.1016/j.puhe.2018.07.008Get rights and content

Highlights

  • In almost three decades, there is about 58 percentage point reduction in polio dropout across Pakistan.

  • Rural Pakistani child is highly likely to be dropout of polio vaccination relative to his/her urban counterparts.

  • Significant likelihood of increase in never-vaccinated children in Baluchistan, KPK, and Sindh during 2012–13 is alarming.

  • Children of female-headed household are less likely to be dropouts.

Abstract

Objectives

Although the antipolio drive is undertaken across Pakistan, there are still children who have not received any oral polio vaccine or are unable to complete recommended doses of polio vaccine. This study aims at empirically analyzing the associated factors with the no oral polio vaccination (OPV) and OPV dropout groups of children in Pakistan.

Study design

This is a cross-sectional study.

Methods

Data were obtained from the three waves of Pakistan Demographic and Health Survey of children aged between 12 and 23 months (1990–1991: n = 1214; 2006–2007: n = 1522; 2012–2013: n = 2074). Children who received no OPV and those who drop out of polio vaccination (OPV1–OPV3) were considered as outcome variables. The bivariate relationship of outcome variable with each socio-economic, demographic, and spatial variable is estimated with a P-value of <0.01. For both no OPV and OPV dropout children, we used logistic regression analysis separately.

Results

The percentage of children aged 12–23 months who dropped out of OPV1–OPV3 vaccination was about 76% in the year 1990–1991; 21% in 2006–2007, and 17.5% in 2012–2013 at the national level. Among all indicators, provinces, rural versus urban residence, the mother's age at marriage, the child's birth place (home versus hospital), parental education, and household wealth status are significant predictors of no OPV and/or OPV dropout in Pakistan. Among provinces, Balochistan, Khyber Pakhtunkhwa (KPK), and Sindh are the lagging provinces.

Conclusion

Improving the socio-economic status of women helps decrease the chance of polio dropout and thus improves service delivery and program implementation.

Introduction

There is a dearth of empirical studies that trace the children with no oral polio vaccination (OPV) and OPV dropout in Pakistan. Poliomyelitis is a disease that creates disability and thus compromises the full potential of human beings. Immunization saves millions of lives across the globe; thus, sustainable development goals (SDGs-3) put emphasis on immunizing children and providing them with better opportunities in life from the very beginning, thus ensuring healthy lives and well-being for everyone (children and adults, regardless of their gender) across the life span. In Pakistan, the Expanded Program on Immunization1, 2, 3 was launched in 1978 with the main objectives of eradicating polio by 2012, eliminating measles and neonatal tetanus by 2015, and minimizing the incidence of other vaccine-preventable diseases.4 Later, vaccines against hepatitis B (2002) and hemophilic influenza type B (2008) were also added with support from the government and development partners.3, 5 About 19.5 million children who are unable to receive routine lifesaving vaccinations remained worldwide.6 Almost 60% of these unvaccinated children of age less than 5 years live in 10 developing countries, including Pakistan.6 Across Pakistan, the vaccination percentage of children increased from 85% in August 2016 to 92% in May 2017.7, 8, 9, 10, 11 Furthermore, there is a remarkable achievement in terms of reducing the incidence of polio cases to 20 in the year 2016 as against 144 in the year 2010.6, 12, 13

Pakistan represents more than 85% of the global wild poliovirus caseload,9, 14, 15 thus becoming the last region (besides Afghanistan and Nigeria) on the planet to have wild poliovirus.12 For the first time in the 21st century, the annual reported cases of polio in Pakistan exceeded 300 in the year 2014.9 Pakistan poses a major hurdle toward achieving global polio eradication because of unvaccinated pockets; dropouts from vaccination and positive environmental samples continue to persist.16, 17 Suspected threats to the population of northern frontier territories and antipeace activists had created a life-threatening environment in the country because of the war on terror. It has demotivated parents to let their children get vaccinated against polio because of insecurity and negative local propaganda about adverse effects of vaccination.18 These activities have made the Federally Administered Tribal Areas (FATA) and their attached areas a prominent polio reservoir in Pakistan.19 Besides these tribal areas, the polio campaign has been severely affected in the Balochistan region. To maintain peace, an antiterrorist military operation ‘Zarb-e-Azb (2014–2015)’ had created a peaceful sociopolitical environment, especially in the Khyber Pakhtunkhwa region and frontier tribal areas of Pakistan.20 It has retrieved and built confidence in affected families to support the polio vaccination campaign. Supported by all these propeace initiatives, the Government of Pakistan is motivated to make polio campaigns a successful program in all areas of the country. According to independent monitoring, in Pakistan, from September 2016 to May 2017, nine high-quality Supplementary Immunization Activities were conducted by Pakistan Polio Eradication Initiative. Across Pakistan, during the same time, the vaccination percentage of children increased from 85% in August 2016 to 92% in May 2017. There is a remarkable achievement in terms of reducing the incidence of polio cases in Pakistan from 2010 to 2016 (144 polio cases vs 20 reported cases in Pakistan, respectively).2, 6, 12

Therefore, there is a need to examine empirically the evidence-based risk factors of no OPV and OPV dropout across Pakistan. Thus, this study aims to examine the factors associated with never-vaccinated children (no OPV) and OPV dropouts (missed any one dose of OPV) among children aged 12–23 months using three waves of Demographic and Health Survey data of Pakistan (1990–1991, 2006–2007, and 2012–2013).

Section snippets

Data

This study uses data from three waves of the nationally representative Pakistan Demographic and Health Survey (PDHS) conducted in 1990–1991, 2006–2007, and 2012–2013 for the analysis of polio dropout incidences and of those children (aged 12–23 months) who were never vaccinated against polio. Information on the vaccination status of children (12–23) months old was taken from ‘Women's Questionnaire’ either through mother recall or through the vaccination card. The first round of PDHS was

Results

The vaccination coverage among children aged 12–23 months in the three rounds of PDHS (1990–1991, 2006–2007, and 2012–2013) by their region and the type of place of residence at the national level is presented in Table 1. For the children of age 12–23 months, the dropout rate of OPV1–OPV3 vaccination in the year 1990–1991 was about 76% (about 77% rural versus 74% urban); for the year 2006–2007, the dropout rate was 21% at the national level (18.5% rural versus 29% urban); and for 2012–2013, the

Discussion

Pakistan remains as one of the three hotspots of polio in the world. There are children still across the country who never received polio vaccination and/or who were dropped out to not have the full dose of vaccination. Therefore, this study aims to identify the factors that contribute toward the polio dropout and no OPV of children aged 12–23 months across Pakistan using the three waves of PDHS. There is a decline of about 58% points in OPV dropout over a period of almost two decades and

Acknowledgments

Faisal Abbas is thankful to Alexander von Humboldt Foundation for providing fellowship.

Ethical approval

None sought. There was no need for ethical clearance as the PDHS data are a publicly available data set.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing interests

The authors declare no conflict of interest.

Authorship statement

W.I. designed the study, developed tables, and interpreted the initial results; S.A.J. designed the model specifications and econometric

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