Letter to the Editor
Swine Flu and Pakistan: A call for national influenza immunization policy
Gripe porcina y Pakistán; una llamada a una política nacional de vacunación contra la gripe
T.H. Mallhi
, Y.H. Khan
Corresponding author
Department of Clinical Pharmacy, College of Pharmacy, Jouf University, King Khaled Road, Sakaka, Kingdom of Saudi Arabia
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Mallhi, Y.H. Khan" "autores" => array:2 [ 0 => array:4 [ "nombre" => "T.H." "apellidos" => "Mallhi" "email" => array:1 [ 0 => "tauqeer.hussain.mallhi@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Y.H." "apellidos" => "Khan" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Clinical Pharmacy, College of Pharmacy, Jouf University, King Khaled Road, Sakaka, Kingdom of Saudi Arabia" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Gripe porcina y Pakistán; una llamada a una política nacional de vacunación contra la gripe" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Influenza causes considerable morbidity and mortality worldwide and represents a public health problem with significant socio-economic implications. A core strategy for controlling influenza is annual seasonal influenza vaccination, recommended in high risk groups (individuals with specific chronic medical conditions, pregnant women, children, adults over 65 years old, and health care workers).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In recent years, swine flu has created an immense pandemonium among population and healthcare professionals of Pakistan. The first case of swine flu in Pakistan was reported in 2009 followed by the regular incident cases till date, which peaks in January to February and tapers in March every year. Swine flu is associated with considerable mortality worldwide. It is estimated that human deaths due to swine flu might be much more as the disease is under-reported and not diagnosed in many instances.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Swine flu has claimed 5 lives in 2014, 16 in 2015 and recently 38 lives in 2018 in Pakistan.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> There is no specific treatment for influenza and vaccine shots may reduce the risks of infection or at least reduce the severity of illness. Despite compelling evidence of the value of vaccines in preventing disease and disability, and in saving the lives of millions of children every year, vaccine hesitancy has become a growing focus of attention and concern. Vaccine hesitancy refers to a delay in acceptance or refusal of vaccination despite availability of vaccination services.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">World Health Organization (WHO) has forecasted that swine flu pandemic is creeping to all continents of the world and may associate with quadruple burden of morbidity, mortality and healthcare costs. In this context, WHO launched Global Action Plan for Influenza Vaccines (GAP) in 2006, aiming to increase vaccination rate globally. The 2012 WHO position paper on influenza vaccines encourages that countries should consider implementing influenza vaccine programs according to the national resource capacities. Currently, 194 member states of all WHO regions have National Influenza Immunization Policy (NIIP). In recent years, reporting of immunization policies to WHO has increased to 59% indicating the increased NIIP development all over the world.</p><p id="par0020" class="elsevierStylePara elsevierViewall">WHO recommends annual vaccination of high-risk groups to prevent complications of influenza virus infection, however this report demonstrates that many countries do not yet have NIIPs. Countries without influenza immunization policies tend to have fewer resources, use fewer new or under-utilized vaccines, and have weaker routine immunization systems.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Despite regular pattern of prevalent flu cases and high mortality associated with swine flu, Pakistan is one of the countries lacking NIIP. Pakistan has launched Expanded program on Immunization (EPI) in 1978 by which children are immunized against tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, measles, hepatitis B, haemophilus influenza type b (Hib) and pneumococcal infections. EPI is limited to children and public sectors, and does not cover adult population of the country. After 40 years of program launch, mortality rate associated with vaccine preventable diseases is still high. It is pertinent to mention that about two million children die every year from vaccine preventable diseases; and more than 90,000 children suffered from paralytic Polio that could have been prevented by administration of two drops of oral Polio vaccine.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Such enormous burden of vaccine preventable diseases might be attributed to the weak routine immunization system, as indicated by WHO in its position paper.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Unstable immunization program might be a possible that Pakistan lacks NIIP. However, national and international threats of flu spillover, and current healthcare burden of flu associated deaths in Pakistan cannot be disregarded in the context of weak immunization program. Though flu vaccines are available in the country but its accessibility is accompanied by several limitations. Currently approved vaccine costs 600 Pakistani rupees (US<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5–6$), which is comparatively higher than average daily wages (3.5–4.5 US$) for unskilled workers. Moreover, these vaccines are not available in all pharmacies and remain short during the peak season of the year. In addition, vaccine hesitancy in parents and healthcare professionals, and limited knowledge of flu shots in general community are some other contributing factors of very low flu immunization rates in Pakistan.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> In current circumstances, there is a dire need of NIIP, either as a separate entity or in conjunction with existing EPI. WHO recommends that countries initiating or expanding influenza immunization programs should prioritize pregnant women, while other risk groups are not ranked by priority.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Considering the resource limited capacity in Pakistan, Government can initiate targeted NIIP for pregnant women in first phase and may extend the policy in concordance with WHO's GAP. Another important suggestion for this immunization program is to incorporate diagnostic facilities for flu. The diagnostic test of flu costs around 7000 Pakistani rupees (60–65 US$) and therefore recommended for severely ill patients or to those who can afford. We believe that financial barrier in flu diagnosis increase the unrecognized cases in the country and inclusion of diagnostic facilities in NIIP will provide real time epidemiological data for effective control measures. We suggest that the Government of Pakistan should focus on NIIP to curb influenza virus in coordination and closer integration of health departments. Moreover, collaboration with intergovernmental organizations, implementation and monitoring of policies for effective surveillance, fostering of collaboration among infectious disease researchers, informative campaigns that target the general public, provision of accessible and affordable vaccines will not only assist the development and implementation of NIIP but will also strengthen the existing EPI in Pakistan.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Organization WH. Vaccines against influenza WHO position paper—November 2012. 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