Introduction: Child stunting remains a public health concern. It is characterized as poor cognitive and physical development in children due to inadequate nutrition during the first 1000 days of life. Across south Asia, Pakistan has the second-highest prevalence of stunting. This study assessed the most recent nationally representative data, the National Nutrition Survey (NNS) 2018, to identify the stunting prevalence and determinants among Pakistani children under five. Methods: The NNS 2018, a cross-sectional household-level survey, was used to conduct a secondary analysis. Data on malnutrition, dietary practices, and food insecurity were used to identify the prevalence of stunting among children under five years in terms of demographic, socioeconomic, and geographic characteristics. The prevalence of stunting was calculated using the World Health Organization (WHO) height for age z-score references. Univariate and multivariable logistic regressions were conducted to identify the factors associated with child stunting. Results: The analysis showed that out of 52,602 children under five, 40.0% were found to be stunted. Male children living in rural areas were more susceptible to stunting. Furthermore, stunting was more prevalent among children whose mothers had no education, were between 20 and 34, and were employed. In the multivariable logistic regression, male children (AOR = 1.08, 95% CI [1.04–1.14], p < 0.001) from rural areas (AOR = 1.07, 95% CI [1.01–1.14], p = 0.014), with the presence of diarrhea in the last two weeks (AOR = 1.15, 95% CI [1.06–1.25], p < 0.001) and mothers who had no education (AOR = 1.57, 95% CI [1.42–1.73], p < 0.001) or lower levels of education (primary: AOR = 1.35, 95% CI [1.21–1.51], p < 0.001; middle: AOR = 1.29, 95% CI [1.15–1.45], p < 0.001), had higher odds of stunting. Younger children aged < 6 months (AOR = 0.53, 95% CI [0.48–0.58], p < 0.001) and 6–23 months (AOR = 0.89, 95% CI [0.84–0.94], p < 0.001), with mothers aged 35–49 years (AOR = 0.78, 95% CI [0.66–0.92], p = 0.003), had lower odds of stunting. At the household level, the odds of child stunting were higher in lower-income households (AOR = 1.64, 95% CI [1.46–1.83], p < 0.001) with ≥ 7 members (AOR = 1.09, 95% CI [1.04–1.15], p < 0.001), with no access to improved sanitation facilities (AOR = 1.14, 95% CI [1.06–1.22], p < 0.001) and experiencing severe food insecurity (AOR = 1.07, 95% CI [1.01–1.14], p = 0.02). Conclusion: Child stunting in Pakistan is strongly associated with various factors, including gender, age, diarrhea, residence, maternal age and education, household size, food and wealth status, and access to sanitation. To address this, interventions must be introduced to make locally available food and nutritious supplements more affordable, improve access to safe water and sanitation, and promote female education for long-term reductions in stunting rates.

Background: Immunization is one of the most successful public health interventions available, saving millions of lives from death and disability each year. Therefore, improving immunization coverage is a high priority for the Government of Pakistan and essential to progress toward universal health coverage. This survey reports the national and provincial/regional coverage and determinants of fully, partially, and not-vaccinated children 12–23 months of age, antigen-wise coverage, percentage of home-based vaccination records (HBR) retention, and reasons for nonretention; dropout, timeliness, and prevalence of missed opportunities for simultaneous vaccination (MOSV). Methods: The survey was a descriptive cross-sectional national household survey carried out across Pakistan. The survey included 110,790 children 12–23 months old and their caregivers. A World Health Organization (WHO)—Expanded Program on Immunization (EPI) Survey questionnaire was adapted to collect information. Data were analyzed using the WHO Vaccination Coverage Quality Indicators (VCQI) software and Stata version 17. Results: Nationally excluding Azad Jammu and Kashmir (AJK) and Gilgit Baltistan (GB), the coverage of fully vaccinated children was 76.5%. The likelihood of being fully vaccinated was higher among children of educated parents who belonged to higher wealth quintiles and resided in any province/region other than Balochistan. The main reasons for unimmunization were no faith in immunization, rumors about vaccines, and distance to the facility. About two-thirds (66.2%) of the children had their HBR available, and the main reasons for not having a card were never visiting a health facility and having no awareness about the importance of a card. Dropout was discernible for later doses of vaccines compared with earlier ones. Higher proportions of children received the last doses late by more than two months. Of the 218,002 vaccination visits documented on HBR in the provinces, MOSVs occurred in 17.6% of the visits. Conclusion: The immunization coverage rates provide a direction to strategize the progress to improve the vaccination rates in Pakistan. The country needs to outline the immediate and long-term actions to combat vaccine-preventable diseases, such as escalating integrated immunization campaigns and outreach activities, provision of mobility support, and deploying behavioral interventions as a cross-cutting strategy to improve awareness and reduce misconceptions.

The current polio epidemiology in Pakistan poses a unique challenge for global eradication as the country is affected by ongoing endemic poliovirus transmission. Across the country, 40 union councils (UCs) which serve as core reservoirs for poliovirus with continuous incidences of polio cases are categorized as super-high-risk union councils (SHRUCs). A cross-sectional survey was conducted in 39 SHRUCs using a two-stage stratified cluster sampling technique. 6,976 children aged 12-23 months were covered. A structured questionnaire was used for data collection. Data were analyzed using STATA version 17. Based on both vaccination records and recall, 48.3% of children were fully-, 35.4 % were partially-, and 16.3% were non-vaccinated in the SHRUC districts. A child is considered fully vaccinated when h/she completed vaccination for BCG, OPV0, OPV 1-3, Penta 1-3, PCV 1-3, IPV, and MCV1. Vaccination cards were seen for over half of the children in the SHRUC districts of Khyber Pakhtunkhwa (KP) and the majority of the SHRUC districts in Sindh, except for the SHRUC district of Malir the districts of Balochistan. Results for polio vacancies show that 60.9% of children from the SHRUC districts were vaccinated with at least three doses of OPV and one dose of IPV, while 20.4% were vaccinated with any OPV doses or IPV and 18.7% of children did not receive any polio vaccines. The dropout rate between vaccine visits was higher than the WHO-recommended cutoff point of 10% for all vaccine doses in the SHRUC districts. The likelihood of being fully vaccinated was higher among the children of educated parents. Full vaccination was found significant among the children of any SHRUC districts compared to district Killa Abdullah. Context-specific strategies with more focus on community engagement and targeted mobilization, along with robust monitoring mechanisms, would help address the underlying challenges of under-immunization in the SHRUCs.

Diarrhoeal diseases are the second leading cause of morbidity and mortality in children under five, accounting for an estimated 370 000 deaths in 2019 worldwide [1]. Most childhood diarrhoeal cases and the associated morbidity and mortality occur in low- and middle-income countries (LMICs). Children in these nations experience, on average, three diarrhoeal episodes every year [1], […]

Background: Immunization saves millions of lives, and globally, vaccines have significantly contributed to reducing mortality and morbidity due to more than 20 life-threatening illnesses. However, there are considerable disparities in vaccination coverage among countries and within populations. This study evaluates the reduction in disparities in vaccination coverage across various socio-economic groups by adopting an integrated community-engagement approach combined with maternal and child health services through mobile health camps. Methods: This secondary analysis is based on a community-based demonstration project conducted between 2014 and 2016 across 146 union councils in polio high-risk districts of Sindh, Khyber Pakhtunkhwa (KP) and Baluchistan in Pakistan. The intervention involved structured community engagement and mobile health camps providing routine immunization alongside maternal and child health services. Data were collected through cross-sectional independent surveys using the WHO two-stage cluster technique at the baseline and the endline, covering over 120,000 children under 5 years old. Four key outcome indicators were analyzed: fully vaccinated children, under-immunized children, unvaccinated children, and polio zero-dose children for equity in vaccine uptake. Results: The proportion of fully vaccinated children increased in the lowest wealth quintile from 28.5% (26.7%, 30.3%) at the baseline to 51.6% (49.5%, 53.8%) at the endline. In comparison, the increase in the richest quantities was 16.2% (14.0%, 18.4%) from the baseline 56.4% (54.6%, 58.2%) to the endline 72.7% (71.1%, 74.2%). Under-vaccination dropped by 10.2% (95% CI: −11.4%, −9.1%), with the poorest quintile showing an 11.8% reduction. The gap between the highest and lowest wealth quintiles in full immunization narrowed by 6.9%, from 27.9% to 21.0% at the baseline and the endline, respectively. The prevalence of zero-dose children significantly decreased across all quintiles, with the highest reduction observed in the lowest quintile of −11.3% (−13.6%, −9.1%). The difference between the highest and lowest wealth quintiles reduced from 6.2% to 3.8%. A significant reduction in polio zero-dose children was achieved, as 13.5% (95% CI: −14.8%, −12.2%), from 29.2% (95% CI: 28.0%, 30.3%) to 15.6% (14.8%, 16.5%). Conclusions: This study shows that integrating community engagement with maternal and child health services through health camps can significantly enhance immunization coverage and reduce wealth-based disparities in high-risk, hard-to-reach areas. The approach improved coverage for zero-dose and fully vaccinated children, suggesting a potential for scaling in regions with access issues, conflict, and vaccine hesitancy.

Background: The current polio epidemiology in Pakistan poses a unique challenge for global eradication, with polio transmission dynamics influenced by regional variations in immunity and disparities in immunization coverage. This study assesses the immunity level for all three poliovirus types among children aged 6–11 months in polio high-risk regions of Pakistan. Methods: Four consecutive rounds of cross-sectional serological surveys were conducted in polio high-risk areas of Pakistan between November 2016 and October 2023. Twelve high-risk areas were covered in the first three rounds of the survey, while 44 high-risk areas were covered in the fourth round. 25 clusters from each geographical stratum were selected utilizing probability proportional to size. Results: Across the four rounds of the survey, 32,907 children aged 6–11 months from 2084 clusters and 32,371 households were covered. Comparative analysis across the survey rounds showed that seroprevalence of poliovirus type 1 was high in provinces (>95%), albeit consistently lower in Balochistan (going down to 89.7% in Round 4). Type 2 seroprevalence was significantly lower and more heterogeneous, from 34.6% in Sindh to 83.4% in Punjab, with sharp declines by round 4, particularly in Balochistan (40.4%). Type 3 seroprevalence was overall high (>94% in Punjab, Sindh, and KPK) but dropped in the last round, while Balochistan exhibited continually lower immunity (81.1%). Conclusions: The findings reflect the variations in population immunity to poliovirus in the country, with notable fluctuations over the years. The gaps in type 2 immunity over time and consistently lowest in Balochistan highlight the need for continued monitoring of immunity levels and adaptable vaccination strategies.