Immunization in Pakistan: Misinformation, Frontline Fatigue, and the Fight for Every Shot

Every year Pakistan’s EPI workers set out on a mission that should be straightforward: vaccinate children to protect them from deadly diseases. But what should be a routine public health measure often turns into a battle—against misinformation, mistrust, and terrain both physical and social.

Pakistan’s immunization landscape is shaped largely by the Expanded Programme

on Immunization (EPI), a global initiative launched by the World Health Organization to combat vaccine-preventable diseases (VPDs) in developing countries. While it operates in collaboration with national governments, WHO, UNICEF, pharmaceutical companies, and other global partners, its implementation is far from uniform. EPI programs are designed to be country-specific—tailored to local infrastructure and healthcare systems.

In Pakistan, EPI is the backbone of vaccination efforts, offering protection against childhood diseases like measles, rubella, polio and diphtheria amongst many others. Yet, while urban areas show higher coverage, over 70% of the population lives in rural regions where access is limited and immunization gaps remain.

This blog goes beyond statistics—it takes a look at the daily struggles of vaccinators and healthcare workers, the resistance they face, and the deeper reasons behind vaccine hesitancy, from misinformation and fear, to the silence around those risking everything to protect public health.

Equity in access is a major concern. While urban areas see relatively better coverage, a large portion of Pakistan’s population-over 70%- lives in rural, hard to reach areas. Slums, marginalised and nomadic groups are often overlooked due to poor micro-level planning and inaccurate data regarding the target populations. Immunization planning relies on having up-to-date, localized population numbers, but the lack of regular micro-censuses results in significant blind spots.

A core dilemma is whether vaccines should be delivered through fixed sites or mobile outreach. Years of door to door polio campaigns has enhanced the expectations of communities to believe that all vaccines will arrive at their doorstep. However sustaining such outreach is not just costly but also unrealistic in the long run.

The health workforce, too, remains stretched thin. Pakistan’s 7000 or so fixed EPI centers are often under-resourced, with an uneven distribution of vaccinators, particularly female ones who are crucial in conservative areas. Most of these vaccinators receive a single round of training at the time of induction with no follow-up or refresher trainings, resulting in gaps in knowledge, motivation and accountability check.

picture courtesy: pakistan polio eradication programme

These operational challenges are compounded by data issues. The absence of accurate population estimates leads to poor planning and resource misallocation.

In some areas, vaccines expire and are discarded due to a lack of demand; in others, children are left unvaccinated simply because they were never counted in the first place.

Even when national census data exists, the need for continuous, small-scale updates remains critical.

Vaccine supply and cold chain systems also falter in many districts. While stock levels may appear sufficient at the federal or provincial level, frequent stock-outs—sometimes lasting months—still occur at the lower tiers. These are often caused by budget constraints, especially when it comes to fuel, vehicle maintenance, or backup power systems needed to keep vaccines cold and safe.

Misinformation and mistrust continue to be major barriers. In several regions, vaccine refusal is tied to deep-seated religious narratives. Some clerics have promoted dangerous myths—labelling vaccines as a Western conspiracy to sterilize Muslim children. These beliefs, though debunked, have become deeply engrained in certain communities, making blanket awareness campaigns ineffective. Communication strategies must be tailored to specific local realities if they are to succeed.

Parental education is another crucial factor. Many families simply don’t understand the benefits of vaccines—especially repeated doses. In one Karachi study, 37.5% of families who refused the tetanus toxoid vaccine did so because they believed it offered “no reported benefit.” Health literacy remains low, and access to clear, trustworthy information about vaccine-preventable diseases is still a luxury for many.

Then there’s the issue of fragmented governance. While Routine Immunization (RI) and Polio Eradication share the same resources and staff they are administratively separate. Polio efforts are backed by international donors and operate through their own system—the Emergency Operations Center (EOC)—with separate funding, reporting, and oversight. Meanwhile, routine immunization is left to fight for space within the regular provincial health budgets. This split means routine services often get less attention, fewer resources, and not nearly the same push from political or administrative leaders.

Lastly, frontline workers not only face logistical hurdles but also dire security threats. In many conflict affected areas, vaccinators risk their lives amid extremist resistance. The leading cause of under-vaccination specifically pertaining to polio are security threats, parental refusals and misconceptions about vaccine safety.

picture courtesy: VOA

Pakistan’s immunization challenges don’t just stem from vaccine shortages but from deep-rooted issues, ranging from systemic inefficiencies to societal resistance, combining to form an extremely tough and challenging landscape for Pakistan’s immunization program.

It is in the peeling of these layers that we might be able to find real and sustainable solutions for the country.

The way forward lies in strengthening frontline workers through regular training and support, improving localized data for better planning, and ensuring a separate, protected budget for immunization. Expanding the reach of the Lady Health Worker program, engaging trusted community and religious leaders, and integrating polio and routine immunization efforts can collectively build trust and coverage.

The road ahead is not easy but can be navigated- with the right focus, intention and coordination. Pakistan can transform its potential into protection––for every child, in every corner of the country!

picture courtesy: shot@life

---

For further reading and references, see the list below:

• Butt, M., et al. (2020). Why Have Immunization Efforts in Pakistan Failed to Achieve Global Standards of Vaccination Uptake and Infectious Disease Control? Risk Management and Healthcare Policy.

• Haq, Z., Shaikh, B.T., Tran, N., Hafeez, A., & Ghaffar, A. (2019). System within systems: challenges and opportunities for the Expanded Programme on Immunisation in Pakistan. Health Research Policy and Systems, 17(1), 51.

• John Snow, Inc. (JSI). (2019). Situational Analysis: Understanding Barriers and Challenges for Addressing Inequity of Urban Immunization Services in Karachi, Pakistan.

• Naveed, Z., Saeed, A., Kakar, A., Khalid, F., Alnaji, N., & Kumar, G. (2021). Understanding the Accountability Issues of the Immunization Workforce for the Expanded Program on Immunization (EPI) in Balochistan: An Exploratory Study. Journal of Global Health, 11, 06001.

• Yazdani, A. T., Muhammad, A., Nisar, M. I., Khan, U., & Shafiq, Y. (2021). Unveiling and Addressing Implementation Barriers to Routine Immunization in the Peri-Urban Slums of Karachi, Pakistan: A Mixed-Methods Study. Health Research Policy and Systems, 19(Suppl 2), 55.

• Zarzeczny, A., & Kahar, P. (2024). Vaccine Trends in Pakistan: A Review of Immunization Challenges and Setbacks Prompted by Inadequate Disaster Management. Florida Gulf Coast University. Published March 1, 2024.

• Cover Photo: The Express Tribune: News Lab