- Email: [email protected]
Barriers and strategies to improve influenza vaccination in Pakistan
G Model JIPH-686; No. of Pages 3
ARTICLE IN PRESS Journal of Infection and Public Health xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Infection and Public Health journal homepage: http://www.elsevier.com/locate/jiph
Barriers and strategies to improve influenza vaccination in Pakistan Muhammad Junaid Farrukh a , Long Chiau Ming b,c , Syed Tabish Razi Zaidi c , Tahir Mehmood Khan d,∗ a
Faculty of Pharmaceutical Sciences, UCSI University, Cheras, Kuala Lumpur, Malaysia Vector-Borne Diseases Research Group (VERDI), Pharmaceutical and Life Sciences CoRe, Universiti Teknologi MARA, Shah Alam, Selangor, Malaysia Unit for Medication Outcomes Research and Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia d School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia b c
a r t i c l e
i n f o
Article history: Received 29 August 2016 Received in revised form 15 November 2016 Accepted 18 November 2016 Keywords: Vaccine Refusal Flu shot Immunization Traditional norms Availability
a b s t r a c t Influenza vaccination is strongly recommended by World Health Organisation on a yearly basis. The rate of immunization in Pakistan is suboptimal. High cost, traditional norms, customs and low levels of education in Pakistan are preventing people from getting vaccinated. It is timely to include influenza vaccination in the expanded programme on immunization (EPI), which is a disease prevention programme aiming to eradicate preventable diseases through subsidized or free immunization. The Ministry of National Health Services, Regulation and Coordination, Government of Pakistan should launch a national influenza vaccine policy in view of this current situation and oversee its implementation. Healthcare professionals should promote influenza vaccination and focus on high risk groups such as the elderly, pregnant women and children. Convincing and educating family members regarding immunization of pregnant women and follow-up with parents regarding a second influenza shot for their children will further improve vaccination rates in Pakistan. © 2017 The Authors. Published by Elsevier Limited. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction Influenza is an infectious viral disease that affects the lungs, throat and nose [1]. In 2009, the first influenza pandemic of the 21st century occurred. Three main types of influenza were responsible for this pandemic, namely influenza A, B and C [2]. Globally, 5–10% of adults and 20–30% of children are affected by influenza annually. Annual epidemics of this disease results in about 3–5 million cases of serious illness and approximately 500,000 cases of death are reported [3]. Pakistan is the world’s 6th most populous country and 36% of its population lives in cities [4]. Up to 2008, the level of influenza was low – at about 21% – but it showed a significant rise in 2009 up to 27% due to the presence of new influenza A subtype i.e A (H1N1)pdm09. It was first detected in Pakistan in a student who had returned from the United States in 2009. The virus started to spread in the country in early October and its prevalent activity became maximum by the end of the year [4]. Influenza recognition rate was at 18% by 2010 but its activity became high (35%) in
∗ Corresponding author at: School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor 47500, Malaysia. Fax: +60 355146364. E-mail address: [email protected] (T.M. Khan).
December that year. In 2011, Influenza positivity rose again, and reached a high of 27% [5].
Influenza circulation pattern in Pakistan Between 2008 and 2011, several samples were checked for influenza in different regions of the country. The highest percentage (about 53%) was found in Federal capital territory, which was followed by Punjab (24%). Sindh, Khyber Pakhtunkhwa (KPK) and Baluchistan showed lower prevalence which was about 13%, 8% and 2% respectively [6]. Although these parameters are often correlated, percentage is a poor indicator of influenza season incidence. The two main measures of incidence (incidence rate and incidence risk) often are not available in literature [7]. From November 2008 to March 2010, seasonal influenza virus continued to circulate, with a peak in December 2011 [8]. The influenza season of 2015–2016 was mild in comparison to the previous three influenza seasons due to vaccines which were well-matched to the dominant strains in transmission [9]. Since November 2015, 28 deaths have been reported in Pakistan secondary to infection by A(H1N1)pdm09 virus [10]. It must be noted that the figure only represents laboratory-confirmed decedents rather than the actual influenza-associated mortality in Pakistan. The National Institute of Health Pakistan tested a total of 300 samples from across the
http://dx.doi.org/10.1016/j.jiph.2016.11.021 1876-0341/© 2017 The Authors. Published by Elsevier Limited. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).
Please cite this article in press as: Farrukh MJ, et al. Barriers and strategies to improve influenza vaccination in Pakistan. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.11.021
G Model JIPH-686; No. of Pages 3
ARTICLE IN PRESS M.J. Farrukh et al. / Journal of Infection and Public Health xxx (2017) xxx–xxx
2
country for this virus in January 2016. Among them, 110 samples gave positive results. From Punjab, 15 deaths have been recorded and KPK and Islamabad recorded one each [10]. To date, there is no official influenza vaccine policy in Pakistan. The expanded programme on immunization (EPI), established in 1976, included vaccination for six health threats to the Pakistani population: tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis and measles. It is estimated that 1000 deaths in less than 5 year children will occur daily in Pakistan if EPI is discontinued. The effectiveness of EPI lies in the extended targeted groups, including older children, adolescents and adults that would be treated thus eliminating the chance for cross infection [11]. As per World Health Organization (WHO) guidelines, high risk groups should be vaccinated against influenza. These include healthcare professionals and those who have close contact with patients as well as hospitalized patients or those who are at increased risk such as geriatric patients, pregnant women and children. Individuals with comorbidities are also at risk [5]. Influenza vaccination is strongly recommended on a yearly basis and symptoms can be made milder by using antiviral agents [12]. Influenza is more dangerous to children as their immune systems are not yet fully developed so they are at risk of developing flu-related complications. Each year, in Pakistan, about 20,000 children are hospitalized for flu-related complications and during the 2009 influenza epidemic, children aged between 5–14 years were found more likely to be infected compared to adults [13]. Children aged 6 months and older are also at greater risk. Influenza vaccination should be given to children in this age group even if they are otherwise healthy [14]. Two doses of influenza vaccine are needed for children aged between 6 months to 8 years. The first dose activates the immune system, while the second dose provides immune protection. The second dose should be administered 28 days after the first dose [14]. The Ministry of National Health Services, Regulation and Coordination, Government of Pakistan, has taken specific steps to control influenza It has introduced a laboratory-based influenza surveillance network, ensured the availability of influenza vaccine, and is working closely with WHO for the provision of influenza vaccine [15]. Simple procedures such as self-isolation, good hand hygiene and cough manners can reduce transmission and protect others. Early management and post-exposure prophylaxis will reduce the chances of complications caused by this virus [10]. According to a meta-analysis, treatment with neuraminidase inhibitor is associated with reduction in mortality risk which increases by each passing day therefore starting treatment earlier is crucial to contain the mortality risk [16].
Challenges Along with the challenges of managing influenza, public understanding of influenza and decision-making for vaccination are important issues to discuss in the Pakistani setting. According to a recent cross-sectional survey of 283 unvaccinated pregnant women respondents who visited health centers in Karachi, 87% reported willingness to get vaccinated against influenza if offered [17]. In addition, in countries like Pakistan, women unfortunately were found not to have complete authority over their decisions whether or not to go for an influenza shot. In many cases, these women require the consent of their husbands and in-laws [17]. However, the case for vaccination is persuasive – in rural areas where women received influenza vaccination during pregnancy, the incidence of influenza was reduced by up to 70% [18]. Children are considered a high risk group for influenza infection, yet only 59–73% of them are fully immunized in Pakistan. A randomized control trial was done on mothers residing in low-income communities of Karachi to check the impact of educational intervention on infant
immunization completion rates. It was found that vaccine completion rates were improved by 39% [19]. Moreover, along with public willingness to receive the influenza shot, it is important that health care workers are also vaccinated against influenza. The percentage of healthcare professionals who have been vaccinated is quite low in Pakistan. It has been observed in a recent study among healthcare professionals done in Peshawar to investigate knowledge, awareness and attitude towards influenza vaccination. Entire sample (n = 165) believed that getting an influenza shot is not mandatory for them and, moreover, the policy for them to be vaccinated is not implemented by their institutions [20]. Being healthcare professionals, they have greater responsibility towards the community and should set a good example by getting themselves vaccinated. Hospital authorities should make it mandatory for all their staff to get vaccinated. In the northern areas of Pakistan, where the level of education is low and women are striving for their rights, levels of immunization are low. According to a cross-sectional study done in Peshawar, unmarried women are not encouraged to get vaccinated due to fear of injection and risk of side effects [21]. Promotional and educational programmes should be conducted for the general public to increase awareness, especially in northern areas of Pakistan where traditional norms, customs and low levels of education are preventing married and unmarried women from getting vaccinated. Children and women who are at greater risk of infection by influenza virus should be vaccinated. Healthcare teams, including female health workers, should be sent to homes to educate family members regarding this. Different strategies such as conducting awareness programmes and seminars regarding vaccinations are needed to enhance public knowledge and overall results [20]. In implementing an influenza vaccination programme for pregnant women, authorities should strongly consider educating the family members who are the key decision-makers [17]. With respect ® to the affordability of influenza vaccine, (Fluarix ) by GSK costs around 600 Pakistani rupees (US = 5.75$) [22]. This is not affordable in comparison to the minimum daily wage for unskilled workers which is about 333.3–400 Pakistani rupees (US $ = 3.13–3.75) [23]. The Health Minister of Punjab in Pakistan has ensured availability of adequate influenza vaccination in public hospitals. However, nothing has been done regarding reducing the cost of treatment [24], which could be another barrier preventing people from getting vaccinated. Conclusion In spite of the published guidelines from the Health Ministry of Pakistan and adequate availability of vaccines, the rate of immunization in the country is still suboptimal. Apart from availability of vaccines, it is high time that the influenza vaccine be included into the EPI schedule or at least be subsidized so that it is affordable for the general public. Healthcare professionals should promote influenza vaccination and focus on high risk groups such as the elderly, pregnant women and children. Moreover, convincing and educating family members regarding immunization of pregnant women and follow-up with parents regarding the second influenza shot for their children will further improve influenza vaccination rates in Pakistan. Conflict of interest None. Funding No source of funding was received for this study.
Please cite this article in press as: Farrukh MJ, et al. Barriers and strategies to improve influenza vaccination in Pakistan. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.11.021
G Model JIPH-686; No. of Pages 3
ARTICLE IN PRESS M.J. Farrukh et al. / Journal of Infection and Public Health xxx (2017) xxx–xxx
Contributors LMC, STRZ and TMK conceived the concept, MJF wrote the initial draft. TMK, STRZ and LMC finalized the manuscript. All authors contributed toward revising the paper and agree to be accountable for all aspects of the work. References [1] Centers for Disease Control and Prevention. Key facts about influenza (flu); 2016. Available from: http://www.cdc.gov/flu/keyfacts.htm. [Accessed 14 November 2016]. [2] Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases; 2016. Available from: http://www.cdc.gov/ vaccines/pubs/pinkbook/flu.html. [3] World Health Organisation. Influenza fact sheet; 2016. Available from: http:// www.who.int/mediacentre/factsheets/fs211/en/. [Accessed 14 November 2016]. [4] Aamir UB, Badar N, Mehmood MR, et al. Molecular epidemiology of influenza A (H1N1) pdm09 viruses from Pakistan in 2009–2010. PLoS One 2012;7(8):e41866. [5] World Health Organisation global influenza surveillance; 2016. Available from: http://www.who.int/influenza/surveillance monitoring/updates/2016 01 11 update GIP surveillance/en/. [Accessed 14 November 2016]. [6] Badar N, Aamir UB, Mehmood MR, et al. Influenza virus surveillance in Pakistan during 2008–2011. PLoS One 2013;8(11):e79959. [7] Measures of disease frequency and disease burden; 2016. Available from: http://www.healthknowledge.org.uk/e-learning/epidemiology/practitioners/ measures-disease-frequency-burden. [Accessed 14 November 2016]. [8] Hampson AW. Epidemiological data on influenza in Asian countries. Vaccine 1999;17:S19–23. [9] Mild flu season credited to well-matched influenza vaccine, less severe predominant strain; 2016. Available from: http://www.pharmacytimes.com/ resource-centers/flu/mild-flu-season-credited-to-well-matched-influenzavaccine-less-severe-predominant-strain#sthash.qZyWgCl6.dpuf. [Accessed 14 November 2016]. [10] No swine flu outbreak in the region, Ministry of Health & WHO belatedly clarify. The news 2016; 2016. Available from: http://www.thenews.com.pk/ print/92406-No-swine-flu-outbreak-in-the-regionMinistry-of-Health-WHObelatedly-clarify. [Accessed 14 November 2016]\. [11] Minister of State for National Health Services, Regulations & Coordination. The expanded program on immunization (EPI), Pakistan; 2016. Available from: http://epi.gov.pk/?page id=139. [Accessed 14 November 2016].
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[12] European Centre for Disease Prevention and Control. A(H1N1)pdm09 dominant influenza strain in Europe: mid-season risk assessment; 2016. Available from: http://ecdc.europa.eu/en/press/news/ layouts/forms/News DispForm. aspx?List=8db7286c-fe2d-476c-9133-18ff4cb1b568&ID=1354#sthash. c6pJTJHh.dpuf. [Accessed 14 November 2016]. [13] Story C. When the flu turns deadly; 2016. Available from: http://www. healthline.com/health/cold-flu/deadly-flu#2. [Accessed 14 November 2016]. [14] Centers for Disease Control and Prevention. Children, the flu, and the flu vaccine; 2016. Available from: http://www.cdc.gov/flu/protect/children.htm. [Accessed 14 November 2016]. [15] Minister of State for National Health Services, Regulations & Coordination. Saira Afzal Tarar addressing the media on the issue of H1N1 influenza; 2016. Available from: http://nhsrc.gov.pk/news details.php?news id=181. [Accessed 14 November 2016]. [16] Muthuri SG, Venkatesan S, Myles PR, et al. Effectiveness of neuraminidase inhibitors in reducing mortality in patients admitted to hospital with influenza A H1N1pdm09 virus infection: a meta-analysis of individual participant data. Lancet Respir Med 2014;2(5):395–404. [17] Khan AA, Varan AK, Esteves-Jaramillo A, et al. Influenza vaccine acceptance among pregnant women in urban slum areas, Karachi, Pakistan. Vaccine 2015;33(39):5103–9. [18] Lutz R. Flu shot during pregnancy can help reduce infant illness risk; 2016. Available from: http://www.pharmacytimes.com/resource-centers/ flu/flu-shot-during-pregnancy-can-help-reduce-infant-illness-risk#sthash. EO4dmmZs.dpuf. [Accessed 14 November 2016]. [19] Owais A, Hanif B, Siddiqui AR, Agha A, Zaidi AK. Does improving maternal knowledge of vaccines impact infant immunization rates? A communitybased randomized-controlled trial in Karachi, Pakistan. BMC Public Health 2011;11(1):1. [20] Khan TM, Khan AU, Ali I, Wu DB. Knowledge, attitude and awareness among healthcare professionals about influenza vaccination in Peshawar, Pakistan. Vaccine 2016;34(11):1393–8. [21] Afridi NK, Hatcher J, Mahmud S, Nanan D. Coverage and factors associated with tetanus toxoid vaccination status among females of reproductive age in Peshawar. J Coll Phys Surg Pak 2005;15(July (7)):391–5. [22] SEHAT. Fluarix Inj 1PFSx0.5; 2016. Available from: https://sehat.com.pk/ products/Fluarix-Inj-1PFSx0.5ml.html. [Accessed 14 November 2016]. [23] Department of Labour and Employment (Pakistan). Comparative wages in selected countries; 2016. Available from: http://www.nwpc.dole.gov.ph/ pages/statistics/stat comparative.html. [Accessed 14 November 2016]. [24] Govt will ensure availability of H1N1 medicines across Punjab: Rafique; 2016. Available from: http://www.pakistantoday.com.pk/2016/01/24/city/lahore/ govt-will-ensure-availability-of-h1n1-medicines-across-punjab-rafique/. [Accessed 14 November 2016].
Please cite this article in press as: Farrukh MJ, et al. Barriers and strategies to improve influenza vaccination in Pakistan. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.11.021
ARTICLE IN PRESS Journal of Infection and Public Health xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Infection and Public Health journal homepage: http://www.elsevier.com/locate/jiph
Barriers and strategies to improve influenza vaccination in Pakistan Muhammad Junaid Farrukh a , Long Chiau Ming b,c , Syed Tabish Razi Zaidi c , Tahir Mehmood Khan d,∗ a
Faculty of Pharmaceutical Sciences, UCSI University, Cheras, Kuala Lumpur, Malaysia Vector-Borne Diseases Research Group (VERDI), Pharmaceutical and Life Sciences CoRe, Universiti Teknologi MARA, Shah Alam, Selangor, Malaysia Unit for Medication Outcomes Research and Education (UMORE), Pharmacy, School of Medicine, University of Tasmania, Hobart, Australia d School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia b c
a r t i c l e
i n f o
Article history: Received 29 August 2016 Received in revised form 15 November 2016 Accepted 18 November 2016 Keywords: Vaccine Refusal Flu shot Immunization Traditional norms Availability
a b s t r a c t Influenza vaccination is strongly recommended by World Health Organisation on a yearly basis. The rate of immunization in Pakistan is suboptimal. High cost, traditional norms, customs and low levels of education in Pakistan are preventing people from getting vaccinated. It is timely to include influenza vaccination in the expanded programme on immunization (EPI), which is a disease prevention programme aiming to eradicate preventable diseases through subsidized or free immunization. The Ministry of National Health Services, Regulation and Coordination, Government of Pakistan should launch a national influenza vaccine policy in view of this current situation and oversee its implementation. Healthcare professionals should promote influenza vaccination and focus on high risk groups such as the elderly, pregnant women and children. Convincing and educating family members regarding immunization of pregnant women and follow-up with parents regarding a second influenza shot for their children will further improve vaccination rates in Pakistan. © 2017 The Authors. Published by Elsevier Limited. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction Influenza is an infectious viral disease that affects the lungs, throat and nose [1]. In 2009, the first influenza pandemic of the 21st century occurred. Three main types of influenza were responsible for this pandemic, namely influenza A, B and C [2]. Globally, 5–10% of adults and 20–30% of children are affected by influenza annually. Annual epidemics of this disease results in about 3–5 million cases of serious illness and approximately 500,000 cases of death are reported [3]. Pakistan is the world’s 6th most populous country and 36% of its population lives in cities [4]. Up to 2008, the level of influenza was low – at about 21% – but it showed a significant rise in 2009 up to 27% due to the presence of new influenza A subtype i.e A (H1N1)pdm09. It was first detected in Pakistan in a student who had returned from the United States in 2009. The virus started to spread in the country in early October and its prevalent activity became maximum by the end of the year [4]. Influenza recognition rate was at 18% by 2010 but its activity became high (35%) in
∗ Corresponding author at: School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor 47500, Malaysia. Fax: +60 355146364. E-mail address: [email protected] (T.M. Khan).
December that year. In 2011, Influenza positivity rose again, and reached a high of 27% [5].
Influenza circulation pattern in Pakistan Between 2008 and 2011, several samples were checked for influenza in different regions of the country. The highest percentage (about 53%) was found in Federal capital territory, which was followed by Punjab (24%). Sindh, Khyber Pakhtunkhwa (KPK) and Baluchistan showed lower prevalence which was about 13%, 8% and 2% respectively [6]. Although these parameters are often correlated, percentage is a poor indicator of influenza season incidence. The two main measures of incidence (incidence rate and incidence risk) often are not available in literature [7]. From November 2008 to March 2010, seasonal influenza virus continued to circulate, with a peak in December 2011 [8]. The influenza season of 2015–2016 was mild in comparison to the previous three influenza seasons due to vaccines which were well-matched to the dominant strains in transmission [9]. Since November 2015, 28 deaths have been reported in Pakistan secondary to infection by A(H1N1)pdm09 virus [10]. It must be noted that the figure only represents laboratory-confirmed decedents rather than the actual influenza-associated mortality in Pakistan. The National Institute of Health Pakistan tested a total of 300 samples from across the
http://dx.doi.org/10.1016/j.jiph.2016.11.021 1876-0341/© 2017 The Authors. Published by Elsevier Limited. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).
Please cite this article in press as: Farrukh MJ, et al. Barriers and strategies to improve influenza vaccination in Pakistan. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.11.021
G Model JIPH-686; No. of Pages 3
ARTICLE IN PRESS M.J. Farrukh et al. / Journal of Infection and Public Health xxx (2017) xxx–xxx
2
country for this virus in January 2016. Among them, 110 samples gave positive results. From Punjab, 15 deaths have been recorded and KPK and Islamabad recorded one each [10]. To date, there is no official influenza vaccine policy in Pakistan. The expanded programme on immunization (EPI), established in 1976, included vaccination for six health threats to the Pakistani population: tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis and measles. It is estimated that 1000 deaths in less than 5 year children will occur daily in Pakistan if EPI is discontinued. The effectiveness of EPI lies in the extended targeted groups, including older children, adolescents and adults that would be treated thus eliminating the chance for cross infection [11]. As per World Health Organization (WHO) guidelines, high risk groups should be vaccinated against influenza. These include healthcare professionals and those who have close contact with patients as well as hospitalized patients or those who are at increased risk such as geriatric patients, pregnant women and children. Individuals with comorbidities are also at risk [5]. Influenza vaccination is strongly recommended on a yearly basis and symptoms can be made milder by using antiviral agents [12]. Influenza is more dangerous to children as their immune systems are not yet fully developed so they are at risk of developing flu-related complications. Each year, in Pakistan, about 20,000 children are hospitalized for flu-related complications and during the 2009 influenza epidemic, children aged between 5–14 years were found more likely to be infected compared to adults [13]. Children aged 6 months and older are also at greater risk. Influenza vaccination should be given to children in this age group even if they are otherwise healthy [14]. Two doses of influenza vaccine are needed for children aged between 6 months to 8 years. The first dose activates the immune system, while the second dose provides immune protection. The second dose should be administered 28 days after the first dose [14]. The Ministry of National Health Services, Regulation and Coordination, Government of Pakistan, has taken specific steps to control influenza It has introduced a laboratory-based influenza surveillance network, ensured the availability of influenza vaccine, and is working closely with WHO for the provision of influenza vaccine [15]. Simple procedures such as self-isolation, good hand hygiene and cough manners can reduce transmission and protect others. Early management and post-exposure prophylaxis will reduce the chances of complications caused by this virus [10]. According to a meta-analysis, treatment with neuraminidase inhibitor is associated with reduction in mortality risk which increases by each passing day therefore starting treatment earlier is crucial to contain the mortality risk [16].
Challenges Along with the challenges of managing influenza, public understanding of influenza and decision-making for vaccination are important issues to discuss in the Pakistani setting. According to a recent cross-sectional survey of 283 unvaccinated pregnant women respondents who visited health centers in Karachi, 87% reported willingness to get vaccinated against influenza if offered [17]. In addition, in countries like Pakistan, women unfortunately were found not to have complete authority over their decisions whether or not to go for an influenza shot. In many cases, these women require the consent of their husbands and in-laws [17]. However, the case for vaccination is persuasive – in rural areas where women received influenza vaccination during pregnancy, the incidence of influenza was reduced by up to 70% [18]. Children are considered a high risk group for influenza infection, yet only 59–73% of them are fully immunized in Pakistan. A randomized control trial was done on mothers residing in low-income communities of Karachi to check the impact of educational intervention on infant
immunization completion rates. It was found that vaccine completion rates were improved by 39% [19]. Moreover, along with public willingness to receive the influenza shot, it is important that health care workers are also vaccinated against influenza. The percentage of healthcare professionals who have been vaccinated is quite low in Pakistan. It has been observed in a recent study among healthcare professionals done in Peshawar to investigate knowledge, awareness and attitude towards influenza vaccination. Entire sample (n = 165) believed that getting an influenza shot is not mandatory for them and, moreover, the policy for them to be vaccinated is not implemented by their institutions [20]. Being healthcare professionals, they have greater responsibility towards the community and should set a good example by getting themselves vaccinated. Hospital authorities should make it mandatory for all their staff to get vaccinated. In the northern areas of Pakistan, where the level of education is low and women are striving for their rights, levels of immunization are low. According to a cross-sectional study done in Peshawar, unmarried women are not encouraged to get vaccinated due to fear of injection and risk of side effects [21]. Promotional and educational programmes should be conducted for the general public to increase awareness, especially in northern areas of Pakistan where traditional norms, customs and low levels of education are preventing married and unmarried women from getting vaccinated. Children and women who are at greater risk of infection by influenza virus should be vaccinated. Healthcare teams, including female health workers, should be sent to homes to educate family members regarding this. Different strategies such as conducting awareness programmes and seminars regarding vaccinations are needed to enhance public knowledge and overall results [20]. In implementing an influenza vaccination programme for pregnant women, authorities should strongly consider educating the family members who are the key decision-makers [17]. With respect ® to the affordability of influenza vaccine, (Fluarix ) by GSK costs around 600 Pakistani rupees (US = 5.75$) [22]. This is not affordable in comparison to the minimum daily wage for unskilled workers which is about 333.3–400 Pakistani rupees (US $ = 3.13–3.75) [23]. The Health Minister of Punjab in Pakistan has ensured availability of adequate influenza vaccination in public hospitals. However, nothing has been done regarding reducing the cost of treatment [24], which could be another barrier preventing people from getting vaccinated. Conclusion In spite of the published guidelines from the Health Ministry of Pakistan and adequate availability of vaccines, the rate of immunization in the country is still suboptimal. Apart from availability of vaccines, it is high time that the influenza vaccine be included into the EPI schedule or at least be subsidized so that it is affordable for the general public. Healthcare professionals should promote influenza vaccination and focus on high risk groups such as the elderly, pregnant women and children. Moreover, convincing and educating family members regarding immunization of pregnant women and follow-up with parents regarding the second influenza shot for their children will further improve influenza vaccination rates in Pakistan. Conflict of interest None. Funding No source of funding was received for this study.
Please cite this article in press as: Farrukh MJ, et al. Barriers and strategies to improve influenza vaccination in Pakistan. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.11.021
G Model JIPH-686; No. of Pages 3
ARTICLE IN PRESS M.J. Farrukh et al. / Journal of Infection and Public Health xxx (2017) xxx–xxx
Contributors LMC, STRZ and TMK conceived the concept, MJF wrote the initial draft. TMK, STRZ and LMC finalized the manuscript. All authors contributed toward revising the paper and agree to be accountable for all aspects of the work. References [1] Centers for Disease Control and Prevention. Key facts about influenza (flu); 2016. Available from: http://www.cdc.gov/flu/keyfacts.htm. [Accessed 14 November 2016]. [2] Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases; 2016. Available from: http://www.cdc.gov/ vaccines/pubs/pinkbook/flu.html. [3] World Health Organisation. Influenza fact sheet; 2016. Available from: http:// www.who.int/mediacentre/factsheets/fs211/en/. [Accessed 14 November 2016]. [4] Aamir UB, Badar N, Mehmood MR, et al. Molecular epidemiology of influenza A (H1N1) pdm09 viruses from Pakistan in 2009–2010. PLoS One 2012;7(8):e41866. [5] World Health Organisation global influenza surveillance; 2016. Available from: http://www.who.int/influenza/surveillance monitoring/updates/2016 01 11 update GIP surveillance/en/. [Accessed 14 November 2016]. [6] Badar N, Aamir UB, Mehmood MR, et al. Influenza virus surveillance in Pakistan during 2008–2011. PLoS One 2013;8(11):e79959. [7] Measures of disease frequency and disease burden; 2016. Available from: http://www.healthknowledge.org.uk/e-learning/epidemiology/practitioners/ measures-disease-frequency-burden. [Accessed 14 November 2016]. [8] Hampson AW. Epidemiological data on influenza in Asian countries. Vaccine 1999;17:S19–23. [9] Mild flu season credited to well-matched influenza vaccine, less severe predominant strain; 2016. Available from: http://www.pharmacytimes.com/ resource-centers/flu/mild-flu-season-credited-to-well-matched-influenzavaccine-less-severe-predominant-strain#sthash.qZyWgCl6.dpuf. [Accessed 14 November 2016]. [10] No swine flu outbreak in the region, Ministry of Health & WHO belatedly clarify. The news 2016; 2016. Available from: http://www.thenews.com.pk/ print/92406-No-swine-flu-outbreak-in-the-regionMinistry-of-Health-WHObelatedly-clarify. [Accessed 14 November 2016]\. [11] Minister of State for National Health Services, Regulations & Coordination. The expanded program on immunization (EPI), Pakistan; 2016. Available from: http://epi.gov.pk/?page id=139. [Accessed 14 November 2016].
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Please cite this article in press as: Farrukh MJ, et al. Barriers and strategies to improve influenza vaccination in Pakistan. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.11.021