Preparing for future Shigella vaccine introduction in Pakistan: a multi-stakeholder qualitative study of policy readiness and implementation

Background

Shigella remains an important cause of childhood diarrhoeal disease and a growing contributor to antimicrobial resistance in low- and middle-income countries (LMICs). Several Shigella vaccines are in development, yet little is known about community and stakeholder perspectives regarding the introduction of future Shigella vaccines in Pakistan. We explored perceptions related to diarrhoeal disease, vaccine acceptance, and health system readiness to inform the future introduction of a Shigella vaccine.

Methods

We conducted a qualitative study in Karachi, Pakistan, between August 2024 and March 2025. Data collection comprised six focus group discussions (FGDs) with caregivers of children under five years of age, and 16 in-depth interviews (IDis) with key stakeholders including healthcare providers, Expanded Programme on Immunization (EPI) officials, policymakers, technical experts, school administrators, and community and religious leaders. Semi-structured interview guides informed by the Health Belief Model. Audio-recorded interviews were transcribed verbatim, translated into English, and analyzed thematically using both deductive approaches and inductive approaches.

Results

Four interconnected themes emerged from the data: perceptions of diarrhoeal disease and Shigella; factors shaping acceptance of a future Shigella vaccine; evidence and health-system readiness for vaccine introduction; and vaccine attributes, adoption, and sustainability. Although childhood diarrhoeal disease was widely recognized, awareness of Shigella as a specific pathogen was limited. Participants expressed conditional acceptance of a future Shigella vaccine, influenced by trust, perceived safety, and recommendations from healthcare providers and community leaders.

Stakeholders emphasized the need for stronger local evidence on disease burden and cost effectiveness to support vaccine prioritization, while identifying Pakistan’s existing immunization infrastructure as a strength for implementation. Some participants favoured combination vaccines to reduce injections and simplify vaccine delivery, while others emphasized that vaccination should complement continued improvements in water, sanitation, and hygiene.

Conclusion

Knowledge of Shigella and its vaccine was limited, but stakeholders supported future vaccine introduction if informed by local evidence, policy commitment, and program integration.

What is already known on this topic

Shigella remains a leading cause of childhood diarrhoeal disease and antimicrobial resistance in low and middle-income countries, and several vaccine candidates are in advanced stages of development. However, little is known about stakeholder perspectives, policy readiness, and health-system preparedness for the introduction of a future Shigella vaccine in Pakistan.

What this study adds

This study provides the first multi-stakeholder qualitative assessment of perceptions of a future Shigella vaccine in Pakistan. While awareness of Shigella was limited, stakeholders considered vaccine introduction feasible within the existing immunization programme, provided that stronger locally generated evidence, sustained policy commitment, and early implementation planning support decision-making.

How this study might affect research, practice or policy

The findings highlight the need to complement epidemiological evidence with early stakeholder engagement and implementation planning before vaccine introduction. Strengthening surveillance, generating nationally relevant evidence, and leveraging Pakistan’s established Expanded Programme on Immunization (EPI) and trusted community networks may facilitate successful introduction of a future Shigella vaccine.