Pakistan’s success at managing the coronavirus pandemic – with relatively low rates of severe disease and death – and distrust of government-led and foreign-funded public health initiatives has driven vaccine hesitancy, which could put the country’s fragile gains against Coronavirus pandemic at risk, say experts and officials.
Since the pandemic began, Pakistan, a country of 220 million people, has registered more than 586,000 cases of the virus, with 13,128 deaths, as per government data.
Its current case-fatality rate of 2.2 percent is comparable to countries such as France and Canada – and is slightly higher than the United States – but is extremely low when its very low rate of testing is accounted for.
Pakistan conducts 0.18 tests per 1,000 people, compared with 4.62 per 1,000 in France or 2.76 per 1,000 in the US, as per government data.
In February, the country opened up vaccinations for hundreds of thousands of front-line healthcare workers across the country, with the arrival of more than 500,000 doses of the Chinese Sinopharm vaccine donated by the Chinese government.
Almost immediately, however, the campaign hit a snag.
“Even in the healthcare community, people thought that taking the vaccine might be harmful,” says a senior health official involved in vaccination efforts in Sindh province, which saw some of the worst of Pakistan’s Coronavirus pandemic.
The official spoke on condition of anonymity.
While thousands of healthcare workers registered themselves for the vaccine, initial rates of vaccination were slow, with doctors saying they were concerned about possible side-effects or reactions to the vaccine.
In the first two weeks after vaccinations began, only 32,582 front-line healthcare workers in Sindh, out of an eligible 78,000, had gotten their first jab of the vaccine, as per government data. In other provinces, the situation was even worse.
“Initially, people did not get vaccinated and a lot of people were concerned about reactions [and side-effects],” says Dr Ahmed Zeb, a physician in the northwestern city of Peshawar, which saw hospital intensive care units overflowing in June, during Pakistan’s first peak of coronavirus cases.
Dr Faisal Sultan, Pakistan’s health minister, says the hesitancy has been driven by healthcare workers “over-analysing the data”.
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“That is a hazard in today’s world, with a number of vaccines available and people looking at all the pros and cons and analysing efficacies, and sometimes losing sight of the fact that for the individual the most important number to remember is the protection against severe Coronavirus pandemic,” he told Al Jazeera.
“And all the licenced vaccines protect against severe disease in the 90 percent [range].”
So far, a month after vaccinations began, Pakistan has only administered 197,000 doses of the vaccine, or 0.9 vaccinations per 100 members of the population, putting it almost dead last in countries where vaccination data is available, according to the Our World In Data dataset.
Moreover, as the vaccination programme moves towards getting senior citizens their jabs, the lack of public buy-in is clear.
Only 240,000 out of an estimated eight million citizens over the age of 65, or three percent, have so far registered to receive the vaccine in the next phase, according to government data.
Why the hesitancy?
So what is driving this hesitancy and could low rates of vaccination drive a later resurgence of the Coronavirus pandemic?
Dr Faisal Mahmood, head of the infectious diseases department at the Karachi-based Aga Khan University Hospital, says there are “many reasons” for the hesitancy but one stands out.
“In a small survey I did, the most common reason [is] concerns regarding safety,” he says. “There is an inherent fear in some to get the vaccine, in some fuelled by distrust of the data, or perhaps due to ‘news’ received from social media.”
Pakistan is currently administering doses of the Chinese Sinopharm vaccine, with 14.6 million doses of the Oxford-AstraZeneca vaccine due to arrive in two batches in March and between April and May through the global COVAX initiative.
The country has also approved the use of the Russian Sputnik V vaccine.
All three vaccines have passed peer-reviewed phase III clinical trials and are in use in at least 10 countries collectively, according to medical journal The Lancet.
“We always have vaccine hesitancy in Pakistan,” says Dr Wajiha Javed, the head of public health at the multinational pharmaceutical company Getz Pharma’s Pakistan division.
“People don’t understand scientific data, if it gets in the hands of people who are not educated enough to understand it [in the media and elsewhere].”
Dr Javed said that qualified doctors in her own company had refused to take the vaccine “because they don’t have good information”.
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Rumours of the vaccine’s safety were not helped by the provincial health minister in Punjab province, the country’s largest, saying during a press conference that citizens took the vaccine “at their own risk”.
By the end of February, levels of vaccine uptake by healthcare workers were so low that Sindh’s health minister ordered all government healthcare workers to take the vaccine or face disciplinary action, with similar orders given by directors at main government hospitals.
According to the country’s health ministry, meanwhile, there has not been a single case of serious side-effects from the vaccine reported in Pakistan since vaccinations began.
The concerns around safety alone, however, may not be enough to fully explain the hesitancy, says Maha Rehman, a data analytics specialist and member of faculty at the Lahore-based LUMS University.
“Efficacy data alone is not enough to [understand the] scepticism around the vaccine rollout,” she says. “The overall level of trust in the health service provider is critical.”
Pakistan consistently ranks low on global healthcare indicators such as access to healthcare and child mortality.
It is one of two countries in the world where polio remains endemic and faces a number of other health challenges.
“People don’t really trust the government,” says Rehman.
“They don’t trust what vaccine they will get, will it be a trial, will it be a placebo? […] There needs to be an active policy shift that everything is being done very, very transparently.”
Health Minister Sultan says that concern may not be relevant, pointing out that vaccines have been developed by international companies and are being administered worldwide.
“At the end of the day, people do know that the vaccines have not been made in a backroom by anyone, they have been made by leading entities in advanced countries who used their technological muscle [and] invest[ed] billions of dollars,” he says.