Third-Party Verification Immunization Coverage Survey round two (TPVICS R-II) survey report

This is the first of two reports on a nationally representative district-level vaccination coverage survey conducted in Pakistan in 2022. Immunization is considered a cost-effective intervention and is fundamental to public health programs' efforts to avert vaccine-preventable diseases (VPDs) and associated mortality. The Expanded Program on Immunization (EPI), since its launch in Pakistan in 1976 and following its revival in 1996, has been delivering extensively to reduce the burden of VPDs in the country. To augment further, Pakistan started its National Immunization Support Project (NISP) in 2016 to coordinate efforts for immunization and reducing VPDs. This project liaises with development partners to help coordinate fund distribution and monitors the progress of immunization efforts. NISP includes ten Disbursement Linked Indicators (DLIs), which are the benchmark for progress monitoring of the project and trigger disbursement from the co-financing partners (the World Bank, the United States Agency for International Development (USAID), Gavi the Vaccine Alliance and the Bill and Melinda Gates Foundation). To get more granular information on vaccine coverage, and to provide an independent assessment to validate the immunization coverage data reported by provinces, the Third-Party Verification of Immunization Coverage Survey (TPVICS) was conceived. TPVICS assessed the progress reported by provincial EPI programs in years 3 and 5 of the NISP on four out of ten DLIs. The Aga Khan University, with the support of EPI Pakistan, carried out two rounds of the TPVICS. The first round was conducted in Pakistan between September 2020 and February 2021 and assessed the progress of the agreed DLIs for year 3 of NISP [ ]. The second round of the survey was meant to assess the progress of the DLIs as of NISP year 5. This round of the survey was conducted from April 2022 to August 2022 in the four provinces (Punjab, Sindh, Khyber Pakhtunkhawa (KP), and Balochistan), and in the federal regions of Khyber Pakhtunkhwa Newly Merged Districts (KP-NMDs), Azad Jammu and Kashmir (AJK), Gilgit Baltistan (GB), and district Islamabad. This report presents the findings of the second round of TPVICS for the provinces and the federal regions. TPVICS employed a stratified cluster sampling approach, designed to yield a sample representative at the district level. This round of the survey covered 8,786 clusters and 106,732 households (HHs) from the provinces and regions of Pakistan. Altogether, a total of 108,089 children born between April 2020 and August 2021 were enrolled in the survey. At the time of data collection, all children were between the ages of 12 and 23 months. At the national level excluding AJK and GB, the survey found that 77% [CI: 76.2 —77.8] of the children aged 12-23 months were fully immunized. For TPVICS, a child was considered fully immunized if they had completed all of their immunizations until Measles dose 1 (given at 9 months of age) as per the EPI schedule with the exception of the Rotavirus, Hep-B given at birth, TCV, and IPV2 vaccines. Vaccination of these antigens is not required for a child to be considered fully immunized in this survey. Around 84.4% [CI: 83.8 -85.1] children in the target age group were immunized with Penta 3 antigen and 78.5% [CI: 77.8 — 79.3] of mothers/caregivers presented immunization cards of their children to the surveyors. One of the key survey indicators, DLI1, assessed full immunization coverage among children aged between 12-23 months in the project provinces. Under NISP, the target for Full Immunization Coverage (FIC) in year 5 was 80% for Sindh, Punjab and KP, and 50% for Balochistan. DLI targets do not cover the federal regions of KP-NMDs, AJK, GB and Islamabad. The survey confirmed that Punjab successfully achieved the DLI1 target, whereas Sindh, Balochistan and KP did not achieve their provincial targets. In Punjab 88.9% [CI: 87.9 - 89.7] of the children aged 12-23 months were fully immunized. In Sindh 69.0 % [CI: 67.6 - 70.3], KP 60.5% [CI: 58.4 — 62.6], and in Balochistan 37.6% [CI: 35.3 — 39.9] of the targeted children were fully immunized. In the federal regions, KP-NMDs 41.9% [CI: 38.5 - 45.4], AJK 90.2% [CI: 89.1 - 91.3], GB 70.5% [CI: 66.1 — 74.6], and Islamabad 79.3% [CI: 74.2 — 83.6] of children were fully immunized. Despite these findings, the achievement of FIC varied widely for different vaccines in different provinces. The second indicator covered by the survey is DLI3, which tracks the percentage of districts in each province reporting at least 80% coverage of Penta3 immunization among children aged between 12-23 months. The provincial targets of DLI3 in NISP year 5 were 80% for Sindh and Punjab, 35% for Balochistan, and 60% for KP. TPVICS findings showed that only Punjab achieved its provincial target. Sindh, KP and Balochistan did not meet their respective targets for DLI3. In Punjab, all 36 districts reported at least 80% coverage of Penat3 immunization, while 41.4% districts (12 out of 29 ) in Sindh, 24% (6 out of 25) in KP, and 18.2% (6 out of 33) in Balochistan reported at least 80% coverage of Penat3 immunization among targeted children. Regionally, all districts in AJK, nine districts in GB, one district in KP-NMD and the sole district in Islamabad recorded at least 80% Penta3 coverage. The third indicator covered by TPVICS is DLI8 which tracks vaccination card availability in families with children under two years in each project province. NISP set the DLI8 target for year 4 only and the provinces were assessed in NISP year 5 against the set target. The provincial targets under DLI8 were 50% for Punjab, 60% for Sindh, 55% for KP, and 30% for Balochistan. TPVICS found that all four provinces successfully met the DLI8 targets in NISP year 5. At the time of survey team visits to households, vaccination cards were available for 85.8% [CI: 84.9 - 86.8] of enrolled children in Punjab, 71.2% [CI: 69.5 - 72.8] in Sindh, 70.8% [CI: 69.1 — 72.4] in KP, and 36.2% [CI: 33.7 — 38.8] in Balochistan. Regionally, KP-NMD had 71.9% [CI: 67.6 — 75.8], MK 79.5% [CI: 78.0 - 80.9], GB 65.7% [CI: 62.8 — 68.5] and Islamabad had 73.7% [CI: 67.6 —79.0] cards available at the time of the survey. The fourth indicator covered by TPVICS is DLI10, which tracks FIC among children aged 12 to 23 months in ten urban cities of the country. Similar to DLI8, NISP set the DL10 target for year 4 only and the provinces were assessed in NISP year 5 against the set target. The provincial targets under DLI10 were 69.3% for Sindh, 46.2% for Balochistan, 84.0% for Punjab, and 83.6% for KP. The survey results reflected that Sindh and Balochistan successfully surpassed the target DLI, whereas Punjab and KP did not achieve their provincial targets in year 5 (FICs for urban cities of Sindh were 71.5% [CI: 69.4 - 73.4]; Balochistan 54.4% [CI: 45.5 — 63.0]; Punjab 80.9% [CI: 77.7 - 83.8], and KP 73.6% [CI: 65.7 — 80.1]). The survey revealed differences in DLI target achievement across provinces. The DLI1 and DLI3 targets in NISP year 5 were only achieved by Punjab. For DLI8, all four provinces met their respective targets. For DL10, only Sindh and Balochistan met the target. However, the provinces have tremendously improved immunization coverage under the DLIs in NISP year 5, compared to the baseline coverage estimates that were set by the National EPI and its partners supporting the NISP at the time when the NISP was about to begin. Section C of the report discusses the DLI-wise progress for individual province in detail. The performance of provinces and regions on DLI targets is encouraging given that immunization services in the country were interrupted by the Covid-19 pandemic. It is important to note that the children enrolled in this round of the survey were born during the pandemic, i.e. between May 2020 to August 2021, which made it difficult for the EPI teams to reach them for timely vaccination. Other pandemic-related factors, including parent/caregiver fears and negative rumors about vaccinating children during the peak period of Covid-19 transmission, were major impediments to essential immunization in the country during this time period.