Resurgent Measles in Pakistan: A 5-Year Analysis of Vaccination Gaps, Surveillance Challenges, and Urban-Rural Disparities in Khyber Pakhtunkhwa

Measles remains a substantial public health concern in low and middle-income countries. Objectives: This study aimed to provide a comprehensive analysis of measles surveillance data from Khyber Pakhtunkhwa (KP) province in Pakistan from 2020 to 2024, examining epidemiological trends, vaccination coverage, and the effectiveness of the surveillance system. Methods: This retrospective descriptive study conducted a thorough surveillance analysis using several data sources, including weekly vaccine-preventable disease (VPD) reports, zero reports, and standardized case investigation forms provided to the EPI monitoring information system (EPI-MIS). For statistical analysis, Stata 17.0 and R 4.2.1 software programs were used. Results: 82% of cases comprised unvaccinated children (zero-dose) aged 6-59 months, suggesting severe gaps in regular vaccination. Laboratory testing verified 5,550 (39%) measles cases, whereas 6,398 (44%) were rejected, with a non-measles/non-rubella discard rate of 19.4/100,000, indicating a better differential diagnosis. The surveillance system achieved high performance indicators, with 97% district reporting completeness and 87% timeliness. However, case investigation adequacy decreased to 65% in 2024 (p<0.001), especially in low-compliance districts like North Waziristan and Peshawar. Urban centers administered fewer booster doses (Peshawar: 0) than rural areas (Charsadda: 21,155 doses; p<0.001). While specimen collection matched WHO standards (88%), South Waziristan's low rates indicated regional diagnostic shortcomings. Conclusions: The study concluded the critical need for tailored vaccination programs in high-risk areas, improved real-time surveillance, and health system improvement in KP to achieve measles control.