Professor Imran Nisar has spent more than thirteen years working at the intersection of epidemiology and paediatrics, an unusual vantage point from which to watch a country’s vaccine landscape evolve.
As Associate Professor (Research) and Vice Chair (Research) in the Department of Paediatrics and Child Health at Aga Khan University, his research has ranged across vaccine epidemiology, childhood pneumonia and early childhood development, work aimed squarely at generating the kind of evidence that low- and middle-income countries need to improve health outcomes.
Through his role in the Maternal Immunisation Readiness Network in Africa and Asia (MIRNA), he now helps steer Pakistan’s contribution to a question with continent-wide implications: is the country ready to introduce a maternal vaccine against respiratory syncytial virus (RSV)?
His answer, laid out with the precision of a researcher who has spent a career translating data into policy, is layered rather than simple. Pakistan has proof of principle already sitting inside its own immunisation history. What it lacks is the financing architecture, and in places the system integration, to build on that foundation.
Professor Nisar begins with an example that requires no persuasion, because Pakistan has already lived through it. “Maternal immunisation decreases the burden of neonatal morbidity and mortality,” he said. “For example, with the maternal tetanus vaccine, we have seen near elimination of tetanus cases in many parts of the world, including some provinces in Pakistan as well.”
That precedent, tetanus toxoid delivered to pregnant women, offers proof that maternal vaccination can work at scale in Pakistan’s health system. RSV, he argued, represents the next frontier of that same logic. “The new generation maternal vaccines like RSV have further potential to decrease respiratory illness in the first few months of life in newborns, through passive immunisation when given during pregnancy.”
Professor Nisar walked through the underlying biology in plain terms, and it is worth quoting at length because it explains why timing matters so much. “The way these vaccines work is that you vaccinate the mother during pregnancy, the mother produces adequate antibodies which are then passed on to the fetus, and then the newborn is protected for the first six months of life.”
That six-month window is not arbitrary. It corresponds precisely to the period when infants face the greatest danger from respiratory illness. “This is the period where they are most vulnerable, and respiratory infections are one of the leading causes of death,” he said. “Along with childhood vaccination, they can form a continuum of protection, beginning from the pregnancy period up to the first six months of life, where the child is more vulnerable.”
He sketched what that continuum could look like in practice, pairing a maternal RSV vaccine with existing childhood immunisation. “A combination of maternal and childhood vaccine, for example RSV vaccine given in the pregnancy period and pneumococcal vaccine given in the childhood infant period, provides overall protection against pneumonia and respiratory infections.”
Set against that promise, however, is a gap in what Pakistan’s Expanded Programme on Immunisation currently offers pregnant women. “There aren’t many maternal vaccines part of the EPI programme currently,” Professor Nisar said. “It’s only diphtheria and tetanus, which is given during the antenatal period. There was a COVID vaccine which was given during the pandemic times. Besides that, there are recommendations for other vaccines like influenza, but those are not part of the immunisation programmes.”
The consequence, he noted, is limited reach. “So the coverage is really low.”
In terms of introduction of a new maternal vaccine into the country’s EPI programme, Professor Nisar said that the biggest challenge at the moment was the financing part.
He situated that challenge within a shifting global funding landscape that is squeezing immunisation budgets across the region. “With the changing landscape of the Gavi financing mechanisms, where countries have faced significant budgetary cuts, introduction of any new vaccine is becoming a big challenge, because countries are at the moment trying to sustain their existing programmes.”
Public confidence, particularly around anything administered during pregnancy, carries its own weight. “There are aspects related to the safety and acceptance of the vaccine, especially when something is given during pregnancy. Is it safe for the unborn child or not? These are also some of the greatest aspects in relation to the introduction of a new vaccine.”
What MIRNA is actually building
Professor Nisar’s account of the consortium’s methodology reads almost like a checklist for how a country moves from uncertainty to an evidence-based decision. It starts with disease burden. “The way the MIRNA consortium is structured is that it’s trying to generate evidence, first of all, in terms of what is the overall burden of these infections in these priority countries. For example, what is the burden of RSV, how many hospitalisations does it cause, how many children die from RSV in the first six months of life.”
That burden data then feeds directly into a projection of impact. “That can then be translated to: if you have a highly effective vaccine, which we have, and scale it up to a good coverage, and multiply it by the effectiveness of the vaccine, how many hospitalisations and mortality can you prevent.”
From there, the analysis turns financial. “Then you can bring in the cost element of it, like what would be the potential cost of the introduction of the vaccine, and then also what would be the potential cost saved in terms of the illnesses averted or hospitalisations prevented.”
Health system readiness forms the next strand of MIRNA’s work, examining whether Pakistan’s facilities and platforms could actually deliver the vaccine once approved. “The other aspect we are looking at is health systems readiness. Are our health systems, the hospitals, ready for the introduction of a new maternal vaccine? Are the antenatal care systems and the EPI systems integrated with each other?”
Finally, the consortium turns to the people the vaccine is meant to protect. “Looking at it from the demand perspective as well, would a new maternal vaccine be acceptable to pregnant women, and what would be the factors that would be driving the acceptance of these vaccines?”
From evidence to decision
Every strand of that work, Professor Nisar explained, is designed to converge on a single outcome: giving Pakistan’s decision-makers something concrete to act on. “Eventually translating these into policy briefs, through which the stakeholders and policymakers can make informed decisions, based on both the burden perspective as well as the financial perspective.”
It is a methodical, unglamorous case, built from hospitalisation counts, cost projections and system audits rather than appeals to urgency alone. But for a researcher whose career has been defined by turning epidemiological data into practical health policy, that may be precisely the point.
Pakistan already has one maternal vaccine success story in tetanus. Whether RSV becomes the next chapter in that continuum of protection, in Professor Nisar’s telling, now rests less on scientific doubt than on financing and system readiness catching up with what the evidence already shows.