Correspondence e36classic Kawasaki disease. Two of these six patients (patients 7 and 8) had sufficient criteria for typical Kawasaki disease. None of these six children showed evidence of myocardial dysfunction, although pericardial effusion was observed in 3 of 6 children.Coronary artery dilatation was seen in five (62•5%) patients. A z-score of more than 2•5 in the left anterior descending or right coronary artery was reported in three and 2•0-2•5 in two patients (mean 2•94, SD ± 0•97, 95%CI 1•7 -4•16, SE ± 0•44, median 2•6, range +2•06 to +4•27, spread range +2•2). Both children with shocklike pre sentation had coronary artery involve ment, but two patients who fulfilled the Kawasaki disease criteria showed healthy coronary arteries. All children except one (7 of 8, 87•5%) received intra venous immuno globulin (2 g/kg body weight) within the first 2 days of their stay. Three patients received thera peutic anticoagulation (enoxaparin) on the basis of the high risk of thrombo embolism and amount of D-dimers. With the exception of the one death discussed already, the other seven children have been discharged home.Other children with PIMS-TS reported in the literature have presented with acute heart failure and features of acute myocarditis. 3,5,7 This feature has a special notability in our country, because viral myocarditis is a common presentation all year long, and there would be background cases with dilated cardiomyopathy or myocarditis. All children presenting with acute myocarditis in the study period were screened for exposure to SARS-CoV-2 and underwent COVID-19 antibody testing. Only one of six patients admitted with myocarditis during the study period tested positive for COVID-19 antibodies. This child, however, did not show evidence of raised inflammatory markers and is not included in the series.Our data, although restricted by numbers, show some differences For data on COVID-19 cases in Pakistan see www.covid.gov.pk

BackgroundThis study is based on EPI (Expanded Program on Immunization) immunization surveys and surveillance of polio, its challenges in immunization and the way forward to overcome these challenges.MethodsSeveral Government documents, survey reports and unpublished program documents were studied and online search was made to find information on EPI Pakistan. SPSS 16 and Microsoft Excel 2007 were used for the statistical analysis.ResultsImmunization against polio is higher in urban areas as compared to rural areas. Marked variation in vaccination has been observed in different provinces of Pakistan in the last decade. Secondly 10-20% of the children who have received their first dose of trivalent polio vaccine were deprived of their 2nd and 3rd dose because of poor performance of EPI and Lack of information about immunization.ConclusionIn spite of numerous successes, such as the addition of new vaccines and raising immunization to over 100% in some areas, EPI is still struggling to reach its polio eradication goals. Inadequate service delivery, lack of information about immunization and limited number of vaccinators were found to be the key reason for poor performance of immunization and for large number of cases reported each year due to the deficiency of second and third booster dose.

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