To understand how COVID-19 has affected routine immunizations in countries, we reviewed publicly available reports and documentation to-date. This review was not intended to be systematic, but rather should be viewed as a pragmatic search and synthesis of public information. Most of the data focused on individual country reports or data synthesized from global vaccine partners (e.g., WHO, UNICEF, Gavi, the Vaccine Alliance, and the Sabin Vaccine Institute) on the challenges and emerging strategies for routine immunization delivery during a pandemic.^1-4 No single public source appears to have collated data across routine vaccines and across countries for the latest trends on childhood vaccination.

It is also worth noting that the broader impacts of COVID-19 on routine immunization services, along with the level of success of country efforts to maintain critical vaccination services, may not be wholly known until months or even years after the present crisis. We have sought to bring together what has been reported thus far and, as more data are collected, analyzed, and disseminated, we may better understand how routine vaccination was conducted during COVID-19.

Global insights and patterns

The COVID-19 pandemic has substantially affected routine immunization services, not only disrupting individual drivers of vaccine utilization – facility readiness, community access, and intent to vaccinate⁵ – but also disrupting the interaction of these drivers to support timely vaccine delivery from local to global levels. For instance, amid escalating travel restrictions and fewer available flights, UNICEF reported a 70-80 percent reduction in planned vaccine shipments between the weeks of March 22 and May 1.⁶ UNICEF also warned of the potential for widespread stockouts, particularly for 26 countries with very limited transport options; of these countries, at least five had measles outbreaks in 2019 and many more are considered at risk.⁶ In late March, WHO recommended delaying previously planned immunization campaigns in areas without active measles and/or polio outbreaks,⁷ considering the risks of exposing healthcare workers and community members to SARS-CoV-2 as greater than the risks from temporary postponements. As such, between March and April 2020, 27 countries reported suspending measles immunization campaigns, and 38 postponed their mass polio vaccination initiatives.¹ As health systems faced surging cases, many administrators followed early WHO guidance to address concerns about capacity and viral exposure: “minimize non-urgent facility-based care whilst tackling the pandemic.”⁸ Health facilities instituted more limited operations or closed altogether during peak transmission periods, while healthcare workers were rapidly dispatched elsewhere to assist with COVID-19 response.^1,2,9,10 In tandem, widespread “lockdowns” markedly reduced if or how people left their homes,¹ and reports indicate that at least some parents in the United States and United Kingdom are postponing or cancelling clinic visits due to concerns about virus exposure.^10–12

On their own, each of these disruptions could negatively affect some aspects of routine immunization services and utilization. Together, they are poised to halt or even reverse the immense progress achieved in vaccine delivery over the past decade. As of May 2020, based on data collected by WHO, UNICEF, Gavi, and the Sabin Vaccine Institute, at least 68 of 129 surveyed countries were experiencing substantially interrupted immunization services, and an estimated 80 million children under the age of 1 could be affected by these disruptions.¹ Further, this collaboration reported that “at least 24 million people in 21 Gavi-supported lower-income countries are at risk of missing out on vaccines against polio, measles, typhoid, yellow fever, cholera, rotavirus, HPV, meningitis A and rubella due to postponed campaigns and introductions of new vaccines.”¹

These concerning statistics follow one of the worst years in global measles outbreaks in recent times,^13,14 and July’s WHO/UNICEF report estimates that 20 million children remained un- or under-vaccinated in 2019.¹⁵

Scaling up coverage of childhood vaccines across low- and middle-income countries is heralded as a massive success story;^16,17 however, maintaining such gains seems increasingly tenuous amid COVID-19’s upheaval of routine immunization services. In South Africa, for instance, coverage of two measles vaccine doses fell to 55 percent in April 2020 amid the country’s lockdowns – a massive decline compared with 77 percent in April 2019.¹⁸ In Karachi, Pakistan, data from its Electronic Immunization Registry showed more than a 50 percent decline in daily immunization visits during lockdown.9 Nigeria’s Ministry of Health has found that numerous health service indicators, including vaccine doses delivered, are currently lower than the same period in 2019.¹⁹ Such examples represent only a portion of the overarching theme surfacing during the COVID-19 pandemic: disruption of routine vaccine delivery has been widespread, and rapidly developing strategies to provide missed doses and close widening gaps in coverage is crucial.

What are Exemplar countries doing to mitigate these challenges? Example from Nepal
(Research Partner: Dr. Sameer Dixit, Center for Molecular Dynamics Nepal)^20,21

Our local research partner in Nepal met with Dr. Jhalak Gautam, who is the Child Health and Immunization Chief at the Family Welfare Division (FWD) within the Ministry of Health and Population (MoPH), to discuss how the COVID-19 pandemic is affecting service delivery. They specifically covered how the pandemic and measures taken in response to the pandemic have impacted immunization services – and how Nepal has sought to address any negative ramifications.^20,21 Below is a summary of their discussion:

Regarding the impact of COVID, the COVID lockdown since March has hindered service provision. For example, the number of immunization service centers operating decreased from around 16,000 nationwide to around 8,000. In addition, many hospital services, including the outpatient department, have regularly shut down due to cases among health professionals. The effects of these disruptions can be seen in a recent study of nine hospitals throughout Nepal’s seven provinces. These hospitals have seen a 50 percent increase in stillbirths since the mid-March lockdown, from 14 deaths per 1,000 live births at the beginning of the year, to 21 at the end of May. Over this same time period, neonatal mortality in these hospitals increased by over 200 percent, from 13 deaths per 1,000 live births in early January to 40 by the end of May.²²

With regards to Nepal’s efforts to minimize disruption to immunizations, the Ministry of Health and Population (MoHP) directed the Family Welfare Division (FWD) to maintain routine immunization services. One example of this is was the resumption of a measles-rubella campaign in June² (in accordance with WHO guidelines to prevent infection and protect health workers), which aims to reach 3 million children between the ages of 9 months and 5 years, and which is tracking to have coverage of above 95 percent.²⁰ In addition, the FWD has worked to introduce the rotavirus vaccine into its routine immunization schedule, even though the country was still in lockdown during July.²³ This was achieved in part by coordinating with GAVI to charter aircraft to deliver vaccines and other consumables. Moreover, to address some of the effects of the early disruptions to immunizations, the FWD controlled a measles outbreak in four of Nepal’s 77 districts, including Kathmandu, and subsequently monitored measles and other seasonal vaccine-preventable diseases, including tetanus and encephalitis. They accomplished this by deploying MoHP personnel to conduct outbreak response immunization (ORI) at affected sites around the country. Overall, Nepal has prioritized immunization, and in conjunction with appropriate measures to prevent infection, has been largely able to resume near-normal operations of immunization services as of July.²⁴

Nepal’s keys to success with prioritizing immunization include national leadership, local government ownership, community demand, and dedicated health workers. Regarding national leadership, the government supported uninterrupted immunization services and has prioritized immunization over many other health and non-health services. At the local level, while there were some challenges after Nepal transitioned from a centralized government to a federal, seven-province structure in 2018, local mayors have taken ownership in ensuring smooth implementation of immunization practices in their areas. This is further supported by community demand for vaccines, as Nepali parents and guardians have shown up in large numbers to immunization centers that were open and able to vaccinate their children. Finally, reports of health worker dedication highlight their invaluable role in delivering vaccines, for example there is a community nurse in northern Nepal who travels 2-3 hours between settlements to vaccinate children.³

This work by the FWD and MoHP to maintain immunizations in the face of adversity is crucial, and has accordingly been praised during a meeting of the Immunization Technical Advisory Group.²⁵ Nepal is currently being researched as an Exemplar country in immunization practices over the period from 2000 to 2015, and COVID-19 does not appear to have affected its focus on this important health service.

What are other countries doing to mitigate disruptions to routine vaccination?

Based on information collated to-date, five common themes emerged across countries that have sought to continue routine vaccination services amid the COVID-19 pandemic and/or recently resumed immunization programming. We view these findings as preliminary, especially as their longer-term effects have yet to be fully studied. Nonetheless, we hope that they can provide a starting point from which greater understanding on what works – and what might not – can grow.

Theme 1: Prioritizing continued immunization services at the national level. According to WHO and other child vaccination partners, many countries have developed and implemented nationally coordinated vaccination strategies to ensure uninterrupted service delivery during COVID-19.^4,26 Reported examples to-date include funding transportation to enable outreach activities in Uganda;1 conducting virtual campaigns with the President and Minister of Health via social media in Paraguay;²⁷ and conducting routine immunization at fixed sites with physical distancing in Laos (even as the country was under nationwide lockdown).¹

WHO/UNICEF indicate that countries have also sought to leverage community health platforms through which outreach-based vaccination services were already well-established. For instance, according to WHO, Cambodia dispatched mobile teams of health workers who had already regularly worked in communities prioritized for outreach services. These trusted teams of health workers simultaneously provided COVID-19 guidance and continued routine vaccination services via outreach programming.²

Theme 2: Identifying alternative locations and infrastructure for providing routine vaccination, beyond health clinics. With a focus on influenza vaccination efforts in April, the Pan American Health Organization (PAHO) reported on several approaches used in the Americas:²⁷ Brazil set up vaccination posts at empty schools closed due to COVID-19; Bolivia dispatched “immunization brigades” to nursing homes and jails to reach at-risk individuals; El Salvador provided vaccination stations at banks; and several countries conducted either drive-through or at-home vaccination services.

Theme 3: Instituting infection prevention controls and physical distancing measures at all vaccine delivery locations. Based on WHO reports, Sri Lankan health clinics extended hours of operation and limited the number of children to one per hour for immunization services to reduce viral exposure.² PAHO reported that Paraguay set up tents outside of health centers to separate individuals who were seeking vaccination services from potential COVID-19 cases.²⁷ In Italy, according to WHO/UNICEF, clinics assigned time slots for vaccination and required physical distancing in waiting rooms.¹

Theme 4: Conducting catch-up vaccination campaigns as soon as SARS-CoV-2 transmission risks can be appropriately mitigated. WHO/UNICEF report that several countries are now conducting “catch-up” mass vaccination campaigns, either because they were previously postponed or to deliberately reach locations with the largest disruptions in service delivery. Pakistan resumed polio vaccination campaigns in high-risk districts, with Aljazeera.com reporting that the country aimed to vaccinate over 800,000 children door-to-door starting in July. Aljazeera also reported Pakistan’s polio vaccine workers were being provided with personal protective equipment (PPE) and had been trained in contact-less vaccine administration.²⁸ Per UN agencies and Gavi, Syria conducted a WHO/UNICEF-supported five-day immunization campaign in June, during which over 8,000 health workers vaccinated at least 210,000 children.^2,3

Theme 5: Setting up systems to track missed doses among patients in areas with the largest disruptions. According to correspondence from The Lancet Global Health,⁹ a pre-existing vaccine registry could prove vital to bringing vaccine services closer to pre-lockdown levels in Karachi, Pakistan. The city’s Electronic Immunization Registry (EIR) – a mobile-based application for tracking child vaccination status – has enrolled more than 2.9 million children since October 2017 and provides detailed data on child vaccination status.⁹ While lockdown measures in Karachi were associated with striking declines in vaccine services (e.g., 88.6 percent reduction in outreach immunization doses administered), authors reported that coverage rates have steadily increased to about 27 percent of baseline levels. Part of this recovery could be related to the EIR’s functionality, which can be used to send embedded text messages to inform caregivers of service resumption and refer them to less crowded health facilities.⁹

References

1. UNICEF. At least 80 million children under one at risk of diseases such as diphtheria, measles and polio as COVID-19 disrupts routine vaccination efforts, warn Gavi, WHO and UNICEF. 2020; published online May 22. https://www.unicef.org/press-releases/least-80-million-children-under-one-risk-diseases-such-diphtheria-measles-and-polio (accessed Aug 3, 2020).
2. World Health Organization (WHO). How WHO is supporting ongoing vaccination efforts during the COVID-19 pandemic. 2020; published online July 14. https://www.who.int/news-room/feature-stories/detail/how-who-is-supporting-ongoing-vaccination-efforts-during-the-covid-19-pandemic (accessed Aug 4, 2020).
3. Gavi, the Vaccine Alliance. Delivering life-saving vaccines during the COVID-19 pandemic. 2020; published online July 23. https://www.gavi.org/vaccineswork/delivering-life-saving-vaccines-during-covid-19-pandemic (accessed Aug 7, 2020).
4. World Health Organization (WHO). Special feature: immunization and COVID-19. WHO. http://www.who.int/immunization/monitoring_surveillance/immunization-and-covid-19/en/ (accessed Aug 4, 2020).
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6. UNICEF. Geneva Palais briefing note on the impact of COVID-19 mitigation measures on vaccine supply and logistics. 2020; published online May 1. https://www.unicef.org/press-releases/geneva-palais-briefing-note-impact-covid-19-mitigation-measures-vaccine-supply-and (accessed Aug 3, 2020).
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8. World Health Organization (WHO). COVID-19 significantly impacts health services for noncommunicable diseases. https://www.who.int/news-room/detail/01-06-2020-covid-19-significantly-impacts-health-services-for-noncommunicable-diseases (accessed Aug 6, 2020).
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21. Personal interview with Dr. Jhalak Gautam. 2020; published online July.
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28. Gadzo M. Pakistan resumes polio vaccinations after coronavirus hiatus. https://www.aljazeera.com/news/2020/07/pakistan-resumes-polio-vaccinations-coronavirus-hiatus-200720071328769.html (accessed Aug 4, 2020).