Routine Immunization Coverage Trends Before, During, and After the COVID-19 Pandemic: A Retrospective Ecological Analysis of Administrative Surveillance Data from Khyber Pakhtunkhwa, Pakistan
DOI:
https://doi.org/10.52206/jsmc.2026.16.3.1474Abstract
Background: Maintaining routine health services during public health emergencies is essential for health system resilience. The COVID-19 pandemic disrupted immunization services worldwide, increasing concerns about declining vaccine coverage, zero-dose children, and resurgence of vaccine-preventable diseases. Evidence from Pakistan using administrative surveillance data remains limited.
Objective: To describe temporal changes in routine immunization coverage among children aged under 24 months across pre-COVID-19, intra-COVID-19, and post-COVID-19 periods in Khyber Pakhtunkhwa, Pakistan.
Methodology: A retrospective descriptive ecological study was conducted using aggregated secondary data from the Expanded Programme on Immunization Management Information System. Immunization records from all 28 reporting districts of Khyber Pakhtunkhwa from January 2019 to April 2022 were analyzed across three periods: pre-COVID-19, January 2019–February 2020; intra-COVID-19, March 2020–September 2021; and post-COVID-19, October 2021–April 2022.
Results: Routine immunization coverage indicators demonstrated variation across the study periods. The proxy indicator for fully immunized children increased from 74% during the pre-COVID-19 period to 88% during the post-COVID-19 period, while the proportion of zero-dose children declined from 16% to 4%. Coverage for the major vaccine antigens also increased during the post-pandemic period, although BCG coverage exceeded 100%, reflecting administrative denominator limitations and programmatic factors rather than true population coverage.
Conclusion: Routine immunization indicators derived from administrative surveillance data demonstrated improved programmatic coverage during the post-COVID-19 period in Khyber Pakhtunkhwa. These findings describe temporal patterns in routine immunization service delivery within a provincial immunization programme during and after the COVID-19 pandemic and provide evidence that may inform immunization programme planning and health system preparedness for future public health emergencies. The results should be interpreted in the context of aggregated administrative data and do not imply causal relationships between programme interventions and observed coverage changes.
Keywords: Administrative Data, COVID-19, Ecological Study, Expanded Programme on Immunization, Health Systems, Khyber Pakhtunkhwa, Pakistan, Routine Immunization.
References
Mohammad S, Apatu E, Kapiriri L, Alvarez E. A comparative analysis of COVID-19 physical distancing policies in South Africa and Uganda. PLOS Glob Public Health. 2024;4(7):e0003170. https://doi.org/10.1371/journal.pgph.0003170
Rana S, Shah R, Ahmed S, Mothabbir G. Post-disruption catch-up of child immunisation and health-care services in Bangladesh. Lancet Infect Dis. 2021;21(7):913. https://doi.org/10.1016/S1473-3099(21)00148-1
Iqbal M, Zahidie A, Jumani Y, Asif S, Shahid B. Responding to the COVID-19 pandemic in a resource-constrained country: the case of Pakistan. J Ayub Med Coll Abbottabad. 2021;33(Suppl 1)(4).
Jain R, Chopra A, Falézan C, Patel M, Dupas P. COVID-19 related immunization disruptions in Rajasthan, India: a retrospective observational study. Vaccine. 2021;39(31):4343-4350. https://doi.org/10.1016/j.vaccine.2021.06.022
Toor J, Li X, Jit M, Trotter CL, Echeverria-Londono S, Hartner AM, et al. COVID-19 impact on routine immunisations for vaccine-preventable diseases: projecting the effect of different routes to recovery. Vaccine. 2022;40(31):4142-4149. https://doi.org/10.1016/j.vaccine.2022.05.074
Middeldorp M, van Lier A, van der Maas N, Veldhuijzen I, Freudenburg W, van Sorge NM, et al. Short-term impact of the COVID-19 pandemic on incidence of vaccine-preventable diseases and participation in routine infant vaccinations in the Netherlands in the period March-September 2020. Vaccine. 2021;39(7):1039-1043. https://doi.org/10.1016/j.vaccine.2020.12.080
Wang Z, Qu G. Qualitative comparative analysis of policies implemented by 26 European countries during the 2020 great lockdown. Front Public Health. 2024;12:1396013. https://doi.org/10.3389/fpubh.2024.1396013
Ji C, Piché-Renaud PP, Apajee J, Stephenson E, Forte M, Friedman JN, et al. Impact of the COVID-19 pandemic on routine immunization coverage in children under 2 years old in Ontario, Canada: a retrospective cohort study. Vaccine. 2022;40(12):1790-1798. https://doi.org/10.1016/j.vaccine.2022.02.008
Alves JG, Figueiroa JN, Urquia ML. Impact of COVID-19 on immunization of Brazilian infants. Int J Infect Dis. 2021;107:252-253. https://doi.org/10.1016/j.ijid.2021.04.089
Osei I, Sarwar G, Hossain I, Sonko K, Ceesay L, Baldeh B, et al. Attendance and vaccination at immunization clinics in rural Gambia before and during the COVID-19 pandemic. Vaccine. 2022;40(44):6367-6373. https://doi.org/10.1016/j.vaccine.2022.09.031
Shapiro GK, Gottfredson N, Leask J, Wiley K, Ganter-Restrepo FE, Jones SP, et al. COVID-19 and missed or delayed vaccination in 26 middle- and high-income countries: an observational survey. Vaccine. 2022;40(6):945-952. https://doi.org/10.1016/j.vaccine.2021.12.041
Chelo D, Nguefack F, Enyama D, Nansseu R, Feudjo Tefoueyet G, Mbassi Awa HD, et al. Impact and projections of the COVID-19 epidemic on attendance and routine vaccinations at a pediatric referral hospital in Cameroon. Arch Pediatr. 2021;28(6):441-450. https://doi.org/10.1016/j.arcped.2021.05.006
Abbas K, Procter SR, van Zandvoort K, Clark A, Funk S, Mengistu T, et al. Routine childhood immunisation during the COVID-19 pandemic in Africa: a benefit-risk analysis of health benefits versus excess risk of SARS-CoV-2 infection. Lancet Glob Health. 2020;8(10). https://doi.org/10.1016/S2214-109X(20)30308-9
Sharma M, Singh SK, Sharma L, Dwivedi MK, Agarwal D, Gupta GK, et al. Magnitude and causes of routine immunization disruptions during COVID-19 pandemic in developing countries. J Family Med Prim Care. 2021;10(11):3991-3997. https://doi.org/10.4103/jfmpc.jfmpc_1102_21
Muthuri RNDK, Senkubuge F, Hongoro C. Determinants of motivation among healthcare workers in the East African Community between 2009-2019: a systematic review. Healthcare (Basel). 2020;8(2):164. https://doi.org/10.3390/healthcare8020164
Wazir MA, Goujon A. Assessing the 2017 census of Pakistan using demographic analysis: a sub-national perspective. VID Working Paper. 2019;(6):1-44. https://doi.org/10.1553/0x003cb42c
Malik AA, Ahmed N, Shafiq M, Elharake JA, James E, Nyhan K, et al. Behavioral interventions for vaccination uptake: a systematic review and meta-analysis. Health Policy. 2023;137:104894. https://doi.org/10.1016/j.healthpol.2023.104894
Harris RC, Chen Y, Côte P, Ardillon A, Nievera MC, Ong-Lim A, et al. Impact of COVID-19 on routine immunisation in South-East Asia and Western Pacific: disruptions and solutions. Lancet Reg Health West Pac. 2021;10:100140. https://doi.org/10.1016/j.lanwpc.2021.100140
Qazi U, Malik S, Raza UA, Saad M, Zeeshan MF, Anwar S. Compliance to timely vaccination in an Expanded Program on Immunization center of Pakistan. Vaccine. 2019;37(32):4618-4622. https://doi.org/10.1016/j.vaccine.2018.01.044
Rahman SU, Haq FU, Imran M, Shah A, Bibi N, Khurshid R, et al. Impact of the COVID-19 lockdown on routine vaccination in Pakistan: a hospital-based study. Hum Vaccin Immunother. 2021;17(12):4934-4940. https://doi.org/10.1080/21645515.2021.1979380
Sim JY, Chung JH, Oh JY, Yi JE, Lee YH, Choi SW, et al. Global measles outbreaks. Jugan Geongang Gwa Jilbyeong. 2024;17(34):1432-1448. https://doi.org/10.56786/PHWR.2024.17.34.2
Nawaz A, Saeed A, Rahman S, Haider N. Hematological and biochemical assessment of children infected with measles virus: 2022 outbreak in Pakistan. Proc Pak Acad Sci B Life Environ Sci. 2023;60(S):55-63. https://doi.org/10.53560/PPASB(60-sp1)791
Crankson S, Pokhrel S, Anokye N. Effectiveness of Ghana’s COVID-19 policy responses and lessons learnt for the future: a multi-methods evaluation. medRxiv. 2024:2024.09.16.24313785. https://doi.org/10.1101/2024.09.16.24313785
Limaye RJ, Singh P, Fesshaye B, Karron RA. Lessons learned from COVID-19 vaccine acceptance among pregnant and lactating women from two districts in Kenya to inform demand generation efforts for future maternal RSV vaccines. BMC Pregnancy Childbirth. 2024;24(1):221. https://doi.org/10.1186/s12884-024-06425-y
Ugwu GO, Odii A, Bisi-Onyemaechi A, Ezema GU, Okeke C, Uzochukwu B, et al. Digital technology tool for routine immunization: lessons learned from Open Data Kit intervention and way forward. Niger J Clin Pract. 2023;26:65. https://doi.org/10.4103/njcp.njcp_561_22
Additional Files
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 The authors retain the copyrights. Authors are permitted and encouraged to post their work online (e.g. in institutional repositories or on their website), as it can lead to productive exchanges, as well as greater citation of published work.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Readers may “Share-copy and redistribute the material in any medium or format” and “Adapt-remix, transform, and build upon the material”. The readers must give appropriate credit to the source of the material and indicate if changes were made to the material. Readers may not use the material for commercial purpose. The readers may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.
