Adolescent girls' recommendations for the design of a human papillomavirus vaccination program in Sindh, Pakistan: a qualitative study.

PURPOSE: Vaccination of adolescent girls against human papillomavirus (HPV) significantly reduces the incidence of cervical cancer. HPV vaccines are available in Pakistan but plans to develop HPV vaccination program are at a nascent stage. We conducted a formative study to explore adolescent girls' knowledge and perspectives on HPV and cervical cancer and collect their recommendations for implementing an HPV vaccination program in their community. METHODS: Using qualitative exploratory study design, we conducted four focus group discussions (FGDs) with 12 adolescent girls per group in District West, Karachi. We recruited unmarried girls aged 16-19 years from schools and community settings between May-December 2020. Data analysis was done using NVivo. RESULTS: Overall, participants displayed a positive attitude toward HPV vaccine. However, they were unfamiliar with basic concepts related to female reproductive health. Female relatives were indicated as girls' preferred point of contact for discussions on HPV and cervical cancer, but fathers were portrayed as decision-making authority on vaccination. Participants indicated vaccine hesitancy among parents may affect HPV vaccination uptake. Girls suggested individual household visits and community-based camps as strategies for successful implementation of HPV vaccination program. A solid foundation of trust between girls' families, program managers, and other stakeholders emerged as a key asset for the program's success. CONCLUSION: Adolescent girls' suggestions of informing key decision-makers in the family (particularly fathers) of the benefits of HPV vaccination, establishing trust with vaccine providers, and increasing accessibility of vaccinations should be explored for successful implementation of an HPV vaccination program in Pakistan.

Using a low-cost, real-time electronic immunization registry in Pakistan to demonstrate utility of data for immunization programs and evidence-based decision making to achieve SDG-3: Insights from analysis of Big Data on vaccines.

BACKGROUND: Despite the proliferation of digital interventions such as Electronic Immunization Registries (EIR), currently, there is little evidence regarding the use of EIR data to improve immunization outcomes in resource-constrained settings. To achieve the Sustainable Development Goal (SDG) of ensuring healthy lives and well-being for all ages, particularly for newborns and children under the age of 5 (goal 3b), it is essential to generate and use quality data for evidence-based decision making to overcome barriers inherent in immunization systems. In Pakistan, only 66 % of children receive all basic vaccinations, and in Sindh province, the number is even lower at 49 %. In 2012, IRD developed and piloted Zindagi Mehfooz (Safe Life; ZM) ElR, an Android-based platform that records and analyses individual-level child data in real-time. In 2017 in collaboration with Expanded Programme for Immunization (EPI) Sindh, ZM was scaled-up across the entire Sindh province and is currently being used by 2521 government vaccinators in 1539 basic health facilities, serving >48 million population. OBJECTIVE: The study aims to demonstrate how big immunization data from the ZM-EIR is being leveraged in Sindh, Pakistan for actionable decision making via three use cases (a) improving performance management of vaccinators to increase geographical coverage, (b) quantifying the impact of provincial accelerated outreach activities, and (c) examining the impact of the COVID-19 pandemic on routine immunization coverage to help devise a tailored approach for future efforts. METHODS: From October 2017 to April 2020, more than 2.9 million children and 0.9 million women have been enrolled, and more than 22 million immunization events have been recorded in the ZM-EIR. We extracted de-identified data from ZM-EIR for January 1, 2019 - April 20, 2020, period. Given the needs of each use case, monthly and daily indicators on vaccinator performance (attendance and compliance), daily immunization visits, and the number of antigens administered were calculated. Geo-coordinate data of antigen administration was extracted and displayed on geographic maps using QGIS. All generated reports were shared at fixed frequency with various stakeholders, such as partners at EPI-Sindh, for utilization in decision making and informing policy. RESULT: Our use-cases demonstrate the use of EIR data for data-driven decision making. From January - December 2019, the monthly monitoring of program indicators helped increase the vaccinator attendance from 44% to 88%, while an 85 % increase in geographical coverage was observed in a polio-endemic super high-risk union council (SHRUC) in Karachi. The analysis of daily average antigens administered during accelerated outreach efforts (AOE) as compared to routine activities showed an increase in average daily Pentavalent-3, Measles-1, and Measles-2 vaccines administered by 103%, 154%, and 180% respectively. These findings helped decide to continue the accelerated effort in high-risk areas (compared to the entire province) rather than discontinuing the activity due to high costs. During COVID-19 lockdown, the daily average number of child immunizations reduced from 16,649 to 4335 per day, a decline of 74% compared to 6 months preceding COVID-19 lockdown. ZM-EIR data is currently helping to shape the planning and implementation of critical strategies to mitigate the impact of the COVID-19 pandemic. CONCLUSION: The big data for vaccines generated through EIRs is a powerful tool to monitor immunization work-force and ensure chronically missed communities are identified and covered through targeted strategies. Geospatial data availability and analysis is changing the way EPI review meetings occur with stakeholders, taking data-driven decisions for better planning and resource allocation. In the fight against COVID-19 pandemic, as governments gradually begin to shift from containing the outbreak to strategizing a plan for sustaining the essential health services, the countries that will emerge most successful are likely the ones who can best use technology and real-time data for targeted efforts.

Impact of COVID-19 pandemic response on uptake of routine immunizations in Sindh, Pakistan: An analysis of provincial electronic immunization registry data.

BACKGROUND: COVID-19 pandemic has affected routine immunization globally. Impact will likely be higher in low and middle-income countries with limited healthcare resources and fragile health systems. We quantified the impact, spatial heterogeneity, and determinants for childhood immunizations of 48 million population affected in the Sindh province of Pakistan. METHODS: We extracted individual immunization records from real-time provincial Electronic Immunization Registry from September 23, 2019, to July 11, 2020. Comparing baseline (6 months preceding the lockdown) and the COVID-19 lockdown period, we analyzed the impact on daily immunization coverage rate for each antigen by geographical area. We used multivariable logistic regression to explore the predictors associated with immunizations during the lockdown. RESULTS: There was a 52.5% decline in the daily average total number of vaccinations administered during lockdown compared to baseline. The highest decline was seen for Bacille Cal-mette Guérin (BCG) (40.6% (958/2360) immunization at fixed sites. Around 8438 children/day were missing immunization during the lockdown. Enrollments declined furthest in rural districts, urban sub-districts with large slums, and polio-endemic super high-risk sub-districts. Pentavalent-3 (penta-3) immunization rates were higher in infants born in hospitals (RR: 1.09; 95% CI: 1.04-1.15) and those with mothers having higher education (RR: 1.19-1.50; 95% CI: 1.13-1.65). Likelihood of penta-3 immunization was reduced by 5% for each week of delayed enrollment into the immunization program. CONCLUSION: One out of every two children in Sindh province has missed their routine vaccinations during the provincial COVID-19 lockdown. The pool of un-immunized children is expanding during lockdown, leaving them susceptible to vaccine-preventable diseases. There is a need for tailored interventions to promote immunization visits and safe service delivery. Higher maternal education, facility-based births, and early enrollment into the immunization program continue to show a positive association with immunization uptake, even during a challenging lockdown.