Global IssuesPAKISTAN: Vaccinators Get a Shot in the Arm
The questions came like something from a medical student’s exam: What is routine immunisation? When should a vaccine be destroyed? What is the best temperature for storing a vaccine? At which angle should the needle be held while administering a pentavalent vaccine? And which five diseases does a pentavalent vaccine prevent?
All these and hundreds more were thrown at a group of vaccinators at a three-day training held by the government-run Expanded Programme on Immunisation (EPI). It was part of a nationwide exercise to improve the skills of the country’s army of vaccinators - full-time employees of the Health Ministry whose job is to make sure Pakistan’s 15 million children below five years old are inoculated against disease.
Dr Faisal Mansoor, one of the trainers and a former EPI deputy manager, said a majority of the vaccinators had a mere cursory and layman’s knowledge of the vaccines. The minimum requirement for qualifying as a vaccinator is to have passed Grade 10, with biology as a subject.
'We know that 60 percent of parents get their information about routine immunisation from these vaccinators. So if their knowledge is suspect, they will pass on wrong information to parents, and that can be very dangerous,' said Mansoor.
Routine childhood immunisation is a set of scheduled inoculations, free of cost, given from birth to 11 months to protect the child from diseases like diphtheria, pertussis (whooping cough), measles, pneumonia, tetanus, meningitis, polio, tuberculosis, and hepatitis B. Booster doses are later required for some vaccines.
According to the United Nations Children’s Fund (UNICEF), one in ten children in Pakistan die before reaching the age of five, a majority of them due to diarrhoea, pneumonia or vaccine-preventable diseases.
Poverty, low rates of female literacy, poor environmental hygiene and living conditions, as well as lack of accountability and poor governance within the EPI, are some of the reasons children don’t get immunised, said experts at the National Vaccination Seminar early this month.
'This is the first such intensive training in almost 15 years,' said Hameedullah Khan, spokesperson for the Civil Society Human and Institutional Development Programme (CHIP), the non-government organisation that designed the manual and assisted EPI in organising trainings for at least 2,500 vaccinators.
'It covers information about each and every aspect of vaccine, from the components from which it is made, to its administration; from its manufacture to injecting it and even the side effects and reaction that babies may face, record keeping, and how to calculate and maintain a register for defaulters,' Khan added.
The training also included a session on enhancing interpersonal skills. 'In Pakistan, a vaccinator can play a very important role in coercing and cajoling parents to get their children vaccinated,' said Mehreen Jawed, a consultant who discussed the attitudinal aspects of the job. 'However, if the vaccinator is not happy at the workplace, he wouldn’t give a hoot if the children have been immunised.'
Jawed apparently hit a raw nerve, since the vaccinators have been complaining about not getting wages on time and missing out on benefits or incentives. The vaccinators get anywhere from 7,000 to 18,000 rupees (80 to 200 dollars) a month, depending on the number of years they have been employed.
Some, like Khurram Shahzad, have been on contract for six years. 'I get 7,000 rupees and my work schedule varies. About 15 days in a month I work in the field, which can last for as much as nine hours. At other times I can be at a centre and work from 9am to 2 pm.'
Some of the trainees talked about less than ideal workplaces. 'We may have the ice-lined refrigerator (ILR) in our offices, but what is the use if there is no electricity for over 15 hours at a time?' asked one of the participants.
'But even where there is electricity, it is fluctuating and the voltage regulator has been taken home by your superior; how do we take care of the vaccines?' asked another.
The discussions highlighted the disconnect between reality and the textbook necessities of a vaccination programme. Crucial to an immunisation drive is a cold chain, an uninterrupted series of storage and distribution mechanisms to keep the vaccine at a safe temperature.
While a cold chain must protect vaccines from heat and sunlight, in winter, when temperatures can dip below zero, the vaccines must be prevented from freezing. If they do, they lose their efficacy and need to be destroyed.
The optimum temperatures to store vaccines are between 2 to 8 degrees centigrade. The vaccines also have to be administered by the recommended routes. Pentavalent vaccines are given intramuscular, with the needle kept at a 90-degree angle to the skin. As its name suggests, the pentavalent vaccine protects against five diseases: haemophilus influenza type B, diphtheria, pertussis, tetanus and hepatitis B.
Pakistan is currently among the eight countries that account for almost two-thirds of the world’s unimmunised children, according to the Global Alliance for Vaccines and Immunisation (GAVI), which funded the training.
With 9,000 vaccinators across Pakistan, the Health Ministry said it is able to cover 96 percent of its target population for measles, 99 percent for pentavalent, and 99 percent for oral polio vaccine. The coverage for BCG vaccine against child tuberculosis is reported to be 100 percent.
Dr Zulfikar A. Bhutta, head of the paediatrics department at the Aga Khan University Medical Centre, said government statistics 'should be taken with a pinch of salt.'
'There is a world of difference between what the government reports and what the coverage data are,' he said. 'From a recent survey done in Karachi by the Aga Khan University, for measles alone, the coverage is shown to be not more than 60 percent. So you can draw your own conclusions.'
© Inter Press Service (2011) — All Rights ReservedOriginal source: Inter Press Service