Artículo Original
Assessment of immunization status and barriers to
vaccination among the university students of Pakistan
Evaluación del estado de inmunización y las
barreras a la vacunación entre los estudiantes universitarios de Pakistán
Abdul
Majeed1 ORCID: https://orcid.org/0000-0002-6711-0832
Iltaf Hussain1 ORCID: https://orcid.org/0000-0003-0556-0181
Imran Imran2 ORCID: https://orcid.org/0000-0003-1337-8574
Waseem Ashraf2 ORCID: https://orcid.org/0000-0003-2295-6049
Anees Ur Rehman1 ORCID: https://orcid.org/0000-0002-6502-8464
Ali Ahsan1 ORCID:
https://orcid.org/0000-0002-0324-871X
Sarfraz Hamid1 ORCID: https://orcid.org/0000-0002-6676-501X
Fiaz Hussain1 ORCID: https://orcid.org/0000-0003-3962-1974
Talha Abdullah1 ORCID:
https://orcid.org/0000-0002-5374-0139
Muhammad Fawad Rasool1* ORCID: https://orcid.org/0000-0002-8607-8583
1 Bahauddin
Zakariya University, Department of Pharmacy Practice, Faculty of Pharmacy, Multan,
Pakistan.
2 Bahauddin
Zakariya University, Department of Pharmacology, Faculty of Pharmacy, Multan,
Pakistan.
Autor para correspondencia: fawadrasool@bzu.edu.pk
ABSTRACT
A cross-sectional study was conducted to determine the vaccination
status and barriers to vaccination among the university students by utilizing a
simple random sampling technique in the largest public sector university of
Southern Punjab, Pakistan. The participants comprised 380 university students.
Data was collected by a self-designed questionnaire. Statistical Package for
Social Sciences (SPSS) was used for data analysis. Chi-square Test and Fischer
Exact test were applied to assess the impact of demographics on vaccination
status, and barriers to vaccination. Out of 380 participants, 328 (86.31%) were males and 52 (13.68) females.
The immunization status of university students against various diseases was
variable: 97.10% (n=369) were vaccinated against poliomyelitis, 58.68% (n=223) against BCG,
44.21% (n=168) against hepatitis B, 49.21% (n=187) against diphtheria,
pertussis and tetanus and 55.26% (n=210) against measles vaccine. The barriers
to vaccination were unwillingness 15.0% (n=57), inaccessibility 17.10% (n=65),
financial issues 4.47 % (n=17) and unawareness 63.42% (n=241). Moreover, 31%
(n=118) of the participants considered that the use of vaccines is unsafe. The
vaccination status of the university students in Southern Punjab, Pakistan is
alarming as most of the students were unvaccinated. The unawareness and perception of the
unsafety of vaccines were the biggest barriers to vaccination.
Keywords:
vaccination; immunization; students.
RESUMEN
Se realizó un estudio transversal para determinar
el estado de vacunación y las barreras a la vacunación entre los estudiantes
universitarios, mediante la utilización de una técnica de muestreo aleatorio
simple, en la universidad más grande del sector público del sur de Punjab,
Pakistán. Los participantes fueron 380 estudiantes universitarios. Los datos se
recopilaron mediante un cuestionario de diseño propio. Se utilizó el Paquete
Estadístico para Ciencias Sociales (SPSS) para el análisis de datos. Se
aplicaron la prueba de chi-cuadrado y la prueba exacta de Fischer para evaluar
el impacto de la demografía en el estado de vacunación y las barreras para la
vacunación. De 380 participantes, 328 (86,31%) fueron hombres y 52 (13,68%)
mujeres. El estado de inmunización de los estudiantes universitarios frente a diversas
enfermedades fue variable: 97,10% (n = 369) fueron vacunados contra
poliomielitis, 58,68% (n = 223) contra BCG, 44,21% (n = 168) contra hepatitis
B, 49,21% (n = 187) contra la difteria, tos ferina y tétanos y 55,26% (n = 210)
contra la vacuna contra el sarampión. Las barreras para la vacunación fueron la
falta de voluntad 15,0% (n = 57); la inaccesibilidad 17,10% (n = 65); los
problemas económicos 4,47% (n = 17) y el desconocimiento 63,42% (n = 241).
Además, el 31% (n = 118) de los participantes consideró que el uso de vacunas
no es seguro. El estado de vacunación de los estudiantes universitarios en el
sur de Punjab, Pakistán, es alarmante ya que la mayoría de los estudiantes no
estaban vacunados. El desconocimiento y la percepción de la inseguridad de las
vacunas fueron las mayores barreras para la vacunación.
Palabras clave: vacunación; inmunización; estudiantes.
Recibido: 4 de mayo del 2021
Aceptado: 15 de julio de 2021
Introduction
The induction of an immune response to infectious diseases via
vaccination was the major contribution of Jenner and Pasteur to public health.(1)
Vaccines are a small amount of a weakened or killed virus or bacteria or bits
of lab-made protein that imitate the virus to prevent infection by that same
virus or bacteria.(2) The vaccine stimulates the production of
antibodies against the specific disease, which is termed immunization.
Moreover, vaccination has reduced morbidity and mortality due to childhood
infectious diseases.(3)
To control and eradicate infectious diseases, various immunization
programs have been initiated globally. The Global Vaccine Action Plan (GVAP)
was endorsed by the 194 member states of the World Health Assembly in May 2012.
GVAP is a framework to prevent millions of deaths by 2020 through more
equitable access to existing vaccines for people in all communities.(4)
The United Nations Children's Fund (UNICEF) also started an immunization
program to cope with infectious diseases. In 2019, UNICEF reached almost half
of the world’s children with life-saving vaccines. According to UNICEF
statistics, 2.5 billion children have been vaccinated since 2000. Moreover, the
number of children paralyzed by polio has fallen by more than 99% at the end of
2019.(5)
Pakistan is a developing country with a population of 220 million. Its
estimated yearly growth rate is 2% and the infant mortality rate is 57.2 deaths
per 1,000 lives births.(6) In 1978, the Expanded Programme on
Immunization (EPI) was initiated in Pakistan for immunization coverage against poliomyelitis,
tuberculosis (TB), measles, diphtheria, pertussis and tetanus (DPT). Also, the
current immunization schedules contain vaccines against hepatitis B (HBV),
diarrhea, Hib pneumonia, and meningitis.(7) The total estimated
coverage in Pakistan for a fully immunized child varies between 65%-88% with
considerable variation between provinces. The coverage also varies by the
antigen, being the highest for BCG, DPT, and pentavalent vaccines including
DPT, and HBV. The schedule administration time for the BCG vaccine’s first,
second, third, and fourth dose is at birth, six, ten, and fourteen weeks,
respectively. While for pentavalent vaccine doses are scheduled at six, ten,
and fourteen weeks after birth.(8) In terms of coverage, Pakistan is
lagging as compared to regional countries such as Bangladesh and Sri Lanka.
Pakistan is third among the countries with the most unvaccinated children.(9)
The common reasons for lack of immunization are inadequate health
infrastructure, un-accessibility, lack of awareness and education, and lack of
serious policy implementation. Moreover, the lack of motivation of EPI staff,
lack of accountability and lack of private sector involvement are the major
barriers that lead to poor vaccination coverage.(10)
The Pakistan Polio Eradication Program has been fighting to end the
crippling poliovirus from the country since 1994. This program is driven by up
to 260,000 polio vaccinators, quality data collection and analysis,
state-of-the-art laboratories, epidemiologists, and public health experts of
Pakistan and the world.(11) This program is currently implementing
the National Emergency Action Plan (NEAP) for Polio Eradication 2020. As per
the NEAP 2020, the program is committed to stopping wild poliovirus type 1
(WPV1) and vaccine-derived poliovirus type 2 (VDPV2) transmission in Pakistan.
This country is still fighting against this virus, as in 2020, 84 WPV and 83
cVDPV2 polio cases were reported.(12)
It has been seen that vaccination coverage is better among the educated
population as compared to uneducated/illiterate and religious groups.(13)
But still, most of the educated strata show an anti-vaccinating attitude
concerning fear of vaccine side-effects and need for more information about the
risk of vaccination and the belief that they are not at risk. In Pakistan,
various studies have been conducted on vaccination status and barriers among
children, parents, and the general population as focus groups.(14,15) The
student's strata have remained less touched and have not been studied in
detail.
In Pakistan, the immunization rate is not up to the mark, only about 2/3rd
of children get complete vaccination coverage. Many fatal diseases are
preventable if EPI is made accessible for all. In 2013, around 14 thousand
cases of measles were reported that resulted in 306 deaths. While, in 2019, 53
new polio cases were documented, a higher number than in the past 3 years.(9)
Keeping these facts in mind, the current study was conducted to determine
the vaccination status and barriers to vaccination among University students of
Southern Punjab, Pakistan.
Material and Methods
Study design, setting and
duration
The quantitative-cross-sectional study design was used for the current
study that was conducted in Bahauddin Zakariya University (BZU), Multan and was
completed between 10th February and 5th of March, 2020.
Study population and
sampling technique
The study population consisted of students that enrolled in BZU.
Currently, there are thirty thousand enrolled students in BZU, the public sector
university that enrolls students from all over Pakistan (open merit and
reserved seats) and foreign including Nepal, Indonesia, Yemen, and Palestine
under foreign seats. The sample size was 380, calculated by Raosoft® sample
size calculator. A simple random sampling method was used for this study. The
international students were excluded from the study as they were less in
number.
Study instrument validation
and data collection
The initial draft of the questionnaire was prepared after a literature review.(14,15)
This draft was then sent to the profession from medical background to assess
the relativity and simplicity. To check the internal consistency, a pilot study
was conducted on 32 participants. The Statistical Package for Social Science
(SPSS) v25 (IBM Corp., Armonk, NY, USA) was
used and a Cronbach alpha value of 0.71 was obtained which indicates valid
internal consistency. The final draft of the questionnaire was comprised of
data related to demographics, history of childhood infection, vaccination
status, and barriers to vaccination.
The questionnaires were distributed among the students, through simple
random sampling, along with attached informed consent. The knowledge and
vaccination status responses were collected on a “yes” and “no” basis. The
signed informed consent was collected from each participant.
Ethical consideration
The current study was conducted following the Declaration of Helsinki.
The study was reviewed and approved by the ethical committee of the Department
of Pharmacy Practice, Faculty of Pharmacy BZU, Multan, Pakistan (Reference No:
Acad/PRAC/18-22/26). Throughout the study, participants' confidentiality was
maintained and ensured.
Data analysis
For statistical analysis, SPSS v25 was used. The categorical variable
was presented as frequency and percentage. To assess the difference in
demographic variable Chi-square test was used and if the cell counted less than
5, the Fisher exact test was utilized.
Results
A total of 380
participants were recruited in the study, amongst which 97.9% of participants
were fell in the age range of 18-25 years. Most participants were male (86.3%),
and the majority of the participants were enrolled in undergraduate programs
(86%). More than half of the participants were from rural areas (58.2%).
Regarding monthly income status, most of the participants were fell in the
lower middle class (36.8%) followed by the high middle class (25%) and lower
class (22.1%). The demographic data of respondents is
given below in Table 1.
Table 1. Demographic
characteristics of the participants.
|
|
|
Frequency |
Percentage |
|
Age |
18-25 |
370 |
97.9 |
|
|
>25 |
8 |
2.1 |
|
Gender |
Male |
328 |
86.3 |
|
|
Female |
52 |
13.7 |
|
Department/Faculty |
Pharmaceutical sciences |
147 |
38.7 |
|
|
Biological sciences |
127 |
33.4 |
|
|
Social sciences |
83 |
21.8 |
|
|
Management sciences |
23 |
6.1 |
|
Program |
Undergraduate |
326 |
86.0 |
|
|
Postgraduate |
53 |
14.0 |
|
Social Status |
Urban |
221 |
58.2 |
|
|
Rural |
159 |
41.8 |
|
Monthly Income Status |
Lower Class (PKR
4000-20,000) |
84 |
22.1 |
|
|
Lower Middle Class (PKR
21,000-40,000) |
140 |
36.8 |
|
|
Middle High Class (PKR
41,000-60,000) |
95 |
25.0 |
|
|
High Class (PKR
>60,000) |
61 |
16.1 |
In this
study, 23.9% of the participants had a history of childhood infections like
polio, measles, etc. Regarding vaccination
status, the majority of the participants were immunized against polio (97.1%),
TB (58.7%), hepatitis (44.2%), DPT (49.2%), and measles (55.3%). The barriers to vaccination were
unwillingness (15.0%), inaccessibility (17.10%), financial issues (4.47%), and
unawareness (63.42%). Moreover, 31% of the participants considered that the
vaccine is unsafe. The detail of knowledge about immunization, the history of
infectious disease, and barriers are given in Table 2.
Table 2. Responses of the
participants to the history, vaccination status, and barriers to vaccinations.
|
|
Frequency |
Percentage |
|
|
History |
|
|
|
|
Do you have any past
family history of polio, diphtheria, measles, tetanus, T.B, or any other
childhood infectious disease, etc.? |
Yes |
91 |
23.9 |
|
|
No |
289 |
76.1 |
|
Vaccination status |
|
|
|
|
Have you been vaccinated
with the Polio vaccine? |
Yes |
369 |
97.1 |
|
|
No |
11 |
2.9 |
|
Have you been vaccinated
with BCG (a vaccine against TB)? (You can look for the scar mark on your
right forearm (deltoid muscle). |
Yes |
223 |
58.7 |
|
|
No |
157 |
41.3 |
|
Have you been vaccinated
with the hepatitis B vaccine? |
Yes |
168 |
44.2 |
|
|
No |
212 |
55.8 |
|
Have you been vaccinated
with DPT (diphtheria, pertussis and tetanus vaccine? |
Yes |
187 |
49.2 |
|
|
No |
193 |
50.8 |
|
Have you been vaccinated
with the measles vaccine? |
Yes |
210 |
55.3 |
|
|
No |
170 |
44.7 |
|
Barriers to vaccination |
|
|
|
|
Which of the following do
you consider for being Unvaccinated? |
Unawareness |
241 |
63.4 |
|
|
Unwillingness |
57 |
15.0 |
|
|
Un-accessibility |
65 |
17.1 |
|
|
Financial issues |
17 |
4.5 |
|
Do you consider that
vaccine is un-safe |
Disagree |
212 |
55.8 |
|
|
Undecided |
50 |
13.2 |
|
|
Agree |
118 |
31.0 |
Regarding knowledge about vaccination, a significant difference was seen
across the program as undergraduates had more knowledge as compared to
postgraduate (p = 0.04). The rural participants were more immunized against TB
(p = 0.006) and DPT (p = 0.001) in comparison with urban participants. The
association of demographics with knowledge about vaccination, history of
infection, and vaccination status can be seen in Table 3 and Table 4.
Table 3. Impact of demographics (independent
variables) on knowledge and vaccination status (dependent variables).
Table 4. Impact of demographics (independent
variables) on knowledge and vaccination status (dependent variables).
|
|
Monthly Income Status |
|
Age |
|
|||||
|
|
Lower class |
Lower middle class |
High middle class |
High class |
|
18-25 |
>25 |
|
|
|
History |
N (%) |
N (%) |
N (%) |
N (%) |
p |
N (%) |
N (%) |
p |
|
|
History of infectious disease (polio, measles etc) |
Yes |
26 (31.0) |
32 (22.9) |
21 (22.1) |
12 (19.7) |
0.37 |
26 (31.0) |
32 (22.9) |
0.57 |
|
|
No |
58 (69.0) |
108 (77.1) |
74 (77.9) |
49 (80.3) |
|
58 (69.0) |
108 (77.1) |
|
|
Vaccination status |
|
|
|
|
|
|
|
|
|
|
Have you been vaccinated with the polio vaccine? |
Yes |
80 (95.2) |
134 (95.7) |
95 (100.0) |
60 (98.4) |
0.15 |
80 (95.2) |
134 (95.7) |
0.93 |
|
|
No |
4 (4.8) |
6 (4.3) |
0 (0.0) |
1 (1.6) |
|
4 (4.8) |
6 (4.3) |
|
|
Have you been vaccinated with BCG |
Yes |
46 (54.8) |
78 (55.7) |
59 (62.1) |
40 (65.6) |
0.44 |
46 (54.8) |
78 (55.7) |
0.64 |
|
|
No |
38 (45.2) |
62 (44.3) |
36 (37.9) |
21 (34.4) |
|
38 (45.2) |
62 (44.3) |
|
|
Have you been vaccinated with the hepatitis B
vaccine? |
Yes |
37 (44.0) |
59 (42.1) |
45 (47.4) |
27 (44.3) |
0.89 |
37 (44.0) |
59 (42.1) |
0.94 |
|
|
No |
47 (56.0) |
81 (57.9) |
50 (52.6) |
34 (55.7) |
|
47 (56.0) |
81 (57.9) |
|
|
Have you been vaccinated with DPT |
Yes |
38 (45.2) |
62 (44.3) |
49 (51.6) |
38 (62.3) |
0.09 |
38 (45.2) |
62 (44.3) |
0.36 |
|
|
No |
46 (54.8) |
78 (55.7) |
46 (48.4) |
23 (37.7) |
|
46 (54.8) |
78 (55.7) |
|
|
Have you been vaccinated with the measles vaccine? |
Yes |
45 (53.6) |
60 (42.9) |
61 (64.2) |
44 (72.1) |
0.001 |
45 (53.6) |
60 (42.9) |
0.63 |
|
|
No |
39 (46.4) |
80 (57.1) |
34 (35.8) |
17 (27.9) |
|
39 (46.4) |
80 (57.1) |
|
In the study was seen that unawareness, un-accessibility, and financial
issues were the common barriers in lower-class and middle lower-class of the
participants (p = 0.03). Moreover, the unsafety of the vaccine was considered
as a barrier by the middle lower-class in the current study (p = 0.02). The
association of barriers with demographics can be seen in Table 5.
Table 5. Impact of demographics (independent variables) on barriers to
vaccination (dependent variables).
|
|
|
Which of the following do
you consider for being unvaccinated? |
|
Do you consider that
vaccine is unsafe? |
|
|||||
|
|
unawareness |
unwillingness |
un-accessibility |
financial issues |
|
Yes |
Undecided |
No |
|
|
|
|
N (%) |
N (%) |
N (%) |
N (%) |
p |
N (%) |
N (%) |
N (%) |
p |
|
|
Gender |
Male |
206 (85.5) |
46 (80.7) |
59 (90.8) |
17 (100.0) |
0.14 |
184 (86.8) |
42 (84.0) |
102 (86.3) |
0.96 |
|
|
Female |
35 (14.5) |
11 (19.3) |
6(9.2) |
0 (0.0) |
|
28 (13.2) |
8 (16.0) |
16 (13.7) |
|
|
Program |
Undergraduate |
206 (85.8) |
50 (87.7) |
55(84.6) |
15 (88.2) |
0.95 |
176 (83.0) |
46 (92.0) |
104 (89.1) |
0.27 |
|
Postgraduate |
34 (14.2) |
7 (12.3) |
10(15.4) |
2 (11.8) |
|
36 (17.0) |
4 (8.0) |
13 (10.9) |
|
|
|
Social Status |
Urban |
144 (59.8) |
38 (66.7) |
28(43.3) |
11 (64.7) |
0.04 |
120 (56.6) |
29 (58.0) |
72 (56.9) |
0.11 |
|
Rural |
97 (40.2) |
19 (33.3) |
37(56.9) |
6 (35.3) |
|
92 (43.4) |
21 (42.0) |
46 (43.1) |
|
|
|
Monthly Income Status |
Lower Class |
55 (22.8) |
13 (22.8) |
8(12.3) |
8 (47.1) |
0.03 |
44 (20.8) |
12 (24.0) |
28 (24.5) |
0.024 |
|
|
Lower Middle Class |
93 (38.6) |
15 (26.3) |
26(40.0) |
6 (35.3) |
|
80 (37.7) |
17 (34.0) |
43 (40.2) |
|
|
|
Middle High Class |
61 (25.3) |
14 (24.6) |
18(27.7) |
2 (11.8) |
|
58 (27.4) |
10 (20.0) |
27 (23.5) |
|
|
|
High Class |
32 (13.3) |
15 (26.3) |
13(20.0) |
1 (5.9) |
|
30 (14.2) |
11 (22.0) |
20 (11.8) |
|
|
Age |
18-25 |
237 (98.8) |
55 (98.2) |
65(100.0) |
17 (100.0) |
0.74 |
209 (99.1) |
49 (100.0) |
116 (98.0) |
0.69 |
|
|
>25 |
3 (1.3) |
1 (1.8) |
0(0.0) |
0 (0.0) |
|
2 (0.9) |
0 (0.0) |
2 (2.0) |
|
Discussion
The current study was conducted to assess the vaccination status and
barriers to vaccination among university students. It was seen that more than
half of the participants were un-immunized against hepatitis, DPT, and almost
half of the participants were being unvaccinated for TB and measles. Moreover,
unawareness, un-accessibility, financial issues and wrong perception about
vaccines were the most prominent reported barriers in the current study.
Pakistan is still fighting against polio as the majority population
shows anti-vaccinated behavior mainly due to unawareness and misconceptions
about vaccination. The WHO, UNICEF and other concerned bodies contribute major
efforts to eradicate infectious diseases like polio, measles, etc.(16) As
reported by the WHO most of the countries are polio-free but Pakistan is still
fighting against this infectious disease (6) It was seen in the
current study that almost half of the participants were not vaccinated for the
vaccine-controlled infectious disease. But the polio-vaccination status was
high as compared to other listed vaccines in the current study, which is mainly
contributed to the efforts of Pakistani’s health regulatory authorities that
try to make Pakistan polio-free in collaboration with WHO. However, the
frequency of vaccinated participants in the current study was lower than the
reported study from Karachi(17) and Lahore.(6) This low
vaccinated profile highlighted that an intensive and compulsory vaccination
program should be started to increase the coverage of the recommended vaccines.
It is well established that religious extremism and terrorist activities
are mainly contributed to the anti-vaccinated behavior in Pakistan and
neighboring countries.(14,20) Also, in the current study, it has
been observed that unawareness and the perception about vaccine un-safety were
the major reasons for being unvaccinated.(16) In Pakistan, the
majority of the population is in favor that vaccination cause immodesty and it
is a ploy against the Muslim world, which is the major reported myth about
vaccination. Therefore, it is a need of time to initiate focused awareness programs
regarding vaccination by using social, print, and electronic media. The
university administration can increase the acceptability of vaccines among the
students by highlighting their benefits with on-campus-focused educational
activities. Moreover, it is recommended that focused policies should be
designed and implemented to address the religious barriers to vaccination. It
is imperative to teach the importance of vaccination in schools. Public
confidence in vaccination is important to maintain vaccination coverage rates
and preventing outbreaks of vaccine-preventable diseases. Some parents
may be hesitant to vaccinate their children; this issue can be addressed by
implementing parent/guardian specific educational interventions at community
levels.
Higher socioeconomic status and education level positively influence the
immunization rate, as confirmed in other studies.(20,21)
Consistently, it has been observed in the current study that the lower-middle
class participants considered vaccine safety as a barrier to vaccination. A cross-sectional study from Pakistan showed
that the participants who fell in the monthly income range of 5,000-10,000
(PKR) were significantly associated with non-immunization.(20) Moreover,
the urban participants reported unawareness as a major barrier to
non-immunization. This study was consistent with the previous report.(22)
Limitation
The current study is subjected to various limitations. Firstly, the
recall bias may affect the participant's responses regarding vaccination
status. Secondly, the participants of the current study were literate,
therefore it cannot be generalized to the illiterate population.
Conclusions
The coverage of polio vaccination was good but there
is low vaccination coverage of BCG, DPT, HBV and measles vaccine among
students. Unawareness was
the most common cause of poor vaccination status. Moreover, the prevalence of
myths among the university students about the un-safety of vaccination is
alarming, as they are educated strata of the general population. Therefore, the
concerning authorities and policymakers should devise strategic and focused
policies like awareness programs in education sectors including schools,
colleges and universities, door to door awareness campaigns in areas where the
population shows anti-vaccinated behaviors due to unawareness to increase the
vaccination coverage. Also, a compulsory vaccination program should be started
and supported by the regulatory authorities.
References
1. Gross CP,
Sepkowitz KA. The myth of the medical breakthrough: smallpox, vaccination, and
Jenner reconsidered. Int J Infect Dis. 1998; 3(1):54-60. doi:
https://10.1016/S1201-9712(98)900960.
2. Plotkin SL,
Plotkin SA. A short history of vaccination. In: Plotkin SA, Orenstein WA, eds.
Vaccines. Philadelphia: WB Saunders; 2004.p.1-15.
3. Pulendran B,
Ahmed R. Immunological mechanisms of vaccination. Nat Immunol. 2011; 12(6):509-17.
doi: https://10.1038/ni.2039.
4. Aaby P, Bukh J, Lisse IM, Smits AJ. Measles
vaccination and reduction in child mortality: a community study from
Guinea-Bissau. J Infect. 1984; 8(1):13-21. doi:
https://10.1016/s0163-4453(84)93192-x.
5. World Health
Organization. The Global Vaccine Action plan (GVAP). 2019. Geneva: World Health
Organization; 2019. Available at: https://www.who.int/immunization/sage/meetings/2019/october/5_GVAP_2019_Regional_reports_YB.PDF. (Consulted in December 06 2020).
6. United
Nations Children's Fund (UNICEF). Immunization program 2019. New York: UNICEF;
2019. (Consulted on December 06 2020). Available at: https://www.unicef.org/immunization.
7. Worldometer.
[homepage on the Internet]. Pakistan Population (Live). 2020. Available from: https://www.worldometers.info/world-population/pakistan-population/. (Consulted on December 06 2020).
8. World Health Organization. Expanded Programme on
immunization, Pakistan. Washington DC: World Health Organization; 2020.
Available at: http://www.emro.who.int/pak/programmes/expanded-programme-on-immunization.html.
(Consulted on December 06 2020).
9. Kabir M,
Afzal MS. Epidemiology of polio virus infection in Pakistan and possible risk
factors for its transmission. Asian Pac J Trop Med. 2016;9(11):1044-7. doi: https://10.1016/j.apjtm.2016.09.006.
10. end polio
pakistan: Pakistan Polio Eradication Programme. [homepage on the Internet].
Polio Cases in Provinces 2021. Islamabad: Government of Pakistan; 2021.
Available at: https://www.endpolio.com.pk/polioin-pakistan/polio-cases-in-provinces. (Consulted on April 25 2021).
11. Kanwal S,
Kanwal S, Kousar A, Basit A. Coverage of Tetanus Toxoid and Rubella Vaccination
Among Female Students of Qamc and Iub, Bahawalpur. Indo Amer J Pharma Sci. 2018; 5(5):3499-514. doi: https://10.5281/zenodo.1243148.
12. Riaz A,
Husain S, Yousafzai MT, Nisar I, Shaheen F, Mahesar W, et al. Reasons for
non-vaccination and incomplete vaccinations among children in Pakistan.
Vaccine. 2018; 36(35):5288-93. doi:
https://10.1016/j.vaccine.2018.07.024.
13. William
G.C. Sampling Techniques. New York: John Wiley & Sons;1977.
14. Cvjetkovic SJ, Jeremic VL, Tiosavljevic DV.
Knowledge and attitudes toward vaccination: A survey of Serbian students. J
Infect Public Health. 2017; 10(5):649-56.
doi:https://10.1016/j.jiph.2017.05.008.
15. Khan MT,
Zaheer S, Shafique K. Maternal education, empowerment, economic status and
child polio vaccination uptake in Pakistan: a population based cross sectional
study. BMJ open. 2017;7(3):e013853. doi: https://10.1136/bmjopen-2016-
013853.
16. Kazi AM, Ahsan N, Khan
A, Jamal S, Kalimuddin H, Ghulamhussain N, et al. Personalized text messages
and automated calls for improving vaccine coverage among children in Pakistan:
Protocol for a community-based cluster randomized clinical trial. JMIR Res
Protoc. 2019;8(5):e12851. doi: https://10.2196/12851.
17. Siddiqi N, Khan A, Nisar N, Siddiqi A.
Assessment of EPI (expanded program of immunization) vaccine coverage in a
peri-urban area. J Pak Med Assoc. 2007; 57(8):391-5.
18. Shafiq Y, Khowaja AR,
Yousafzai MT, Ali SA, Zaidi A, Saleem AF. Knowledge, attitudes and practices
related to tetanus toxoid vaccination in women of childbearing age: A
cross-sectional study in peri-urban settlements of Karachi, Pakistan. J Infect
Prev. 2017; 18(5):232-41. doi: https://10.1177/1757177416689722.
19. Riaz A,
Husain S, Yousafzai MT, Nisar I, Shaheen F, Mahesar W, Dal SM, Omer SB, Zaidi
S, Ali A. Reasons for non-vaccination and incomplete vaccinations among
children in Pakistan. Vaccine. 2018; 36(35):5288-93. doi: https://10.1016/j.jiph.2016.11.021.
20. Antai D.
Inequitable childhood immunization uptake in Nigeria: A multilevel analysis of
individual and contextual determinants. BMC Infect Dis.2009;9:181. doi: https://10.1186/1471-2334-9-181.
21. Abdulraheem IS, Onajole AT, Jimoh AA,
Oladipo AR. Reasons for incomplete vaccination and factors for missed
opportunities among rural Nigerian children. J Public Health Epidemiol.
2011;3(4):194-203.
22. Naeem M, Imtiaz A, Hussain H, Hidayat S.
Barriers in immunization of children under two years of age in Mohmand Agency,
Federally Administered Tribal Area, Pakistan. J Saidu Med Coll.
2018;8(2):75-82. Available at: https://jsmc.pk/index.php/jsmc/issue/archive.
Conflict of interest
The authors declare no conflict of interest.
Author´s
contribution
Abdul Majeed participated in conceptualization,
statistical analysis, investigation,
data curation, writing and original draft
preparation, writing-review and editing.
Iltaf Hussain participated in conceptualization,
methodology, statistical analysis, data
curation, writing and original draft
preparation, writing-review and editing.
Imran Imran participated in statistical analysis, investigation, data curation, writing and original draft preparation, writing-review and
editing.
Waseem Ashraf participated in methodology, investigation, data
curation, writing and original draft
preparation, writing-review and editing.
Anees Ur Rehman participated in investigation, writing and original draft preparation, writing-review and
editing.
Ali Ahsan participated in conceptualization, writing
and original draft preparation, writing-review and editing.
Sarfraz Hamid participated in conceptualization,
investigation, writing and original draft preparation, writing-review and
editing.
Fiaz Hussain participated in conceptualization,
methodology, statistical
analysis, investigation, writing and original
draft preparation, writing-review and editing.
Talha Abdullah participated in methodology.
Muhammad Fawad Rasool participated in
conceptualization, methodology, statistical analysis, writing-review and editing, supervision.
All authors commented on the previous version of
the manuscript and read and approved the final manuscript.
* Ph.D , Department of Pharmacy Practice, Faculty of
Pharmacy, Bahauddin Zakariya University, Multan, Pakistan.