International Journal of Community Medicine and Public Health Varughese CS et al. Int J Community Med Public Health. 2020 Jul;7(7):2867-2869 http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040
DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20203029
Commentary
Routine immunization services in the light of COVID-19 pandemic
Chinnu Sara Varughese, Anuradha Kunal Shah*
Department of Community Medicine, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India Received: 09 May 2020 Revised: 17 June 2020 Accepted: 18 June 2020 *Correspondence: Dr. Anuradha Kunal Shah, E-mail: anuradha.moha@gmail.com Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
World immunisation week is observed every year in the last week of 24th April to 30th April. Many parts of the world are still reeling under the threats of vaccine- preventable diseases (VPDs) and the importance of vaccination cannot be understated even in times of any other crisis. Worldwide, millions of children are saved from the grip of infectious diseases like polio and measles, and annually, around 2 to 3 million deaths are being averted.1 Routine immunization services, mass vaccination campaigns, catch up, and mop up sessions through outreach activities form part of the vaccine delivery strategies.
On January 30, WHO declared COVID-19 as public health emergency of international concern, followed by the declaration of the pandemic on March 11. Lockdown measures commenced worldwide since then. Immunization and other routine essential services have been suspended globally by the current COVID-19 pandemic. The need to follow social distancing and the fear among the public of contracting infection, have decreased the utilization of immunization services at the health centers. Procurement of vaccines has become limited due to restrictions in transport and trade. Besides, health care workers are either re-routed to COVID-19 duties or overburdened along with providing routine essential services. This has a tremendous impact on the healthcare system, especially in resource-poor countries.2,3 Several countries have suspended measles campaigns leaving around 117 million children unvaccinated for measles vaccines in over 37 countries, and millions more as other countries follow suit.4 Countries like the Democratic Republic of Congo and the
Central African Republic are currently having an episode of measles outbreak. This added to the prevalence of malnutrition of children and the contagiousness of the disease will lead to grave consequences. There will be a surge in mortality rates. Global polio eradication initiative has suspended its mass campaigns.5 Polio endemic countries like Pakistan and Afghanistan that are trying to fight this disease will be the worst hit.
Lessons from the past have shown that immunization of children is necessary for the smooth functioning of healthcare systems too or they will be overwhelmed with consequences later. For instance, in the WHO European region in 2018, 520,000 children did not receive the measles vaccine due to a lax in vaccination. A year later, around 100,000 people were affected by measles, thus exposing the immunity gap in the region leading to a costly affair for the health systems.6 The global vaccine action plan was endorsed to work through the decade of 2011-2020 for achieving universal access to immunization.7
Despite the efforts to achieve targets, WHO immunization data shows that in 2018, 19.4 million infants had not received the basic vaccines.8 With the immunity gap yet to be covered around the globe, India is no different with 26 million births every year. The need for a steady and organized vaccine delivery mechanism is paramount for saving millions of lives from infectious diseases and sustaining the health care system.9
Even the Ebola outbreak in 2014-15 had more deaths due to infectious diseases like malaria, TB, HIV/AIDS than deaths caused by Ebola itself.10 This gives an important lesson. The emergence of Covid-19 and the furor in
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Varughese CS et al. Int J Community Med Public Health. 2020 Jul;7(7):2867-2869
curbing this virus should not result in the outbreak of other vaccine-preventable diseases. WHO has released a set of guiding principles on 26th March 2020 for immunization activities during the pandemic. The recommendations include temporary suspension of mass vaccination campaigns and considering routine immunization services and VPD surveillance after careful risk-benefit analysis by the authorities in the respective regions.11 This applies across all age groups and subpopulations like pregnant women and the elderly. WHO’s strategic advisory group of experts on Immunization, on March 30th also recommended the continuation of routine immunization services wherever possible, despite the cessation of vaccination campaigns.5
India, on commencing the lockdown period, has been providing only essential and emergency ‘non-COVID’ services. Various print media reports are suggesting that healthcare workers are no longer doing community visits or routine immunization drives. Anganwadis and sub- centers have been shut down. The community themselves are boycotting the same. Even TT doses for pregnant mothers are being put on hold.12 Intensified Mission Indradhanush 2.0 was started in October 2019 by the Indian government to achieve targeted vaccine coverage by March 2020. None of this is going to be met, thus hindering the already lagging vaccine coverage, especially in underperforming states like UP and Bihar.13 Even the urban slums in cities like Mumbai have many unregistered children in healthcare centers and their parents are unaware of the importance of vaccination. Healthcare workers cannot afford to conduct outreach activities in these areas currently. Resistance or even violence from the community could happen and worse, the workers themselves could be conduits of COVID-19 infection, which could spread like wildfire in the densely populated slums. Advocating routine immunization during this period is due to the assumption that vaccinating children for viral diseases like measles, rubella, hepatitis B, varicella, polio may protect them against COVID-19, as it prevents the virus from invading lung cells by producing cross-reactivity. 14
WAY FORWARD
The delay in reaching targets set by programs, should not deter rather motivate in continuing the routine immunization services to prevent the emergence of VPDs. The following strategies have been recommended:
• Conducting risk-benefit analysis of each district based on the spread of Covid-19, the strength of the health care system, availability of trained health care workers periodically. • Mass immunization camps can be done post the lifting of lockdown in areas where a resurgence of VPDs is predicted. • The availability of trained health care workers and their safety should be ensured by the public health authorities.
• Zero dose vaccines to be given mandatorily in all institutional births. • Catch-up vaccination sessions can be initiated as soon as conditions are favorable. • Immunization sessions should be conducted based on fixed appointments to prevent overcrowding with just one accompanying person. • Parents should be educated to visit the nearest immunization centers and avoid visiting hospitals if they/any member of the family is showing symptoms of COVID-19 infection. • Personal protective equipment should be made available and used by all healthcare workers even during outreach sessions. Other preventive measures like social distancing, hand hygiene, regular disinfection of health centers should be followed. • Multiple sessions catering to a smaller number of beneficiaries can be conducted and necessary funds and logistics should be provided in this regard to them. • The existing vacancies in the health system should be filled up and if required fresh appointments can be made on a contract basis to increase workforce capacity. • Health education activities regarding the importance of vaccination should be continued and can be clubbed with health promotion activities related to COVID-19.
To conclude, appropriate conduct of routine immunization services is necessary to decrease mortality and morbidity due to VPDs. Prevention of infectious diseases with special focus on COVID-19 is to be undertaken, to keep up to the theme of immunization this year, i.e. protected together #VaccinesWork.
REFERENCES
1. WHO. Immunization. Available at: https://www. who.int/topics/immunization/en/. Accessed on 09 May 2020. 2. Nelson R. COVID-19 disrupts vaccine delivery. Lancet Infect Dis. 2020;20(5):546. 3. Lessons in preparing to distribute COVID-19 vaccine, Gavi, the Vaccine Alliance. Available at: https://www.gavi.org/vaccineswork/lessons- preparing-distribute-covid-19-vaccine. Accessed on 09 May 2020. 4. WHO. More than 117 million children at risk of missing out on measles vaccines, as COVID-19 surges. World Health Organisation. 2020 Available at: https://www.who.int/immunization/diseases/ measles/statement_missing_measles_vaccines_covi d-19/en/. Accessed on 09 May 2020. 5. COVID-19: massive impact on lower-income countries threatens more disease outbreaks. Gavi, the Vaccine Alliance. 2020. Available at: https://www.gavi.org/news/media-room/covid-19- massive-impact-lower-income-countries-threatens- more-disease-outbreaks. Accessed on 09 May 2020.
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6. WHO/Europe. European Immunization Week 2020 - WHO/UNICEF joint statement – Maintaining routine immunization services vital during the COVID-19 pandemic. 2020. Available at: http://www.euro.who.int/en/media-centre/events/ events/2020/04/european-immunization-week- 2020/statements/whounicef-joint-statement-main- taining-routine-immunization-services-vital-during- the-covid-19-pandemic.Accessed on 09 May 2020. 7. WHO. Decade of Vaccines. Global Vaccine Action Plan 2011-2020. 2020. Available at: https://www. who.int/immunization/global_vaccine_action_plan/ DoV_GVAP_2012_2020/en/. Accessed on 09 May 2020. 8. WHO. Global Vaccine Action Plan. Available at: https://www.who.int/immunization/global_vaccine_ action_plan/en/. Accessed on 09 May 2020. 9. Newborn and child health. UNICEF India. Available at: https://www.unicef.org/india/what-we-do/new born-and-child-health. Accessed on 09 May 2020. 10. Parpia AS, Ndeffo-Mbah ML, Wenzel NS, Galvani AP. Effects of response to 2014-2015 ebola outbreak on deaths from malaria, HIV/AIDS, and tuberculosis, West Africa. Emerg Infect Dis. 2016;22(3):433-41. 11. World Health Organization. Guiding principles for immunization activities during the COVID-19
pandemic. 2020. Available at: http://www.jogh.org/ documents/issue201802/jogh-08-020601.htm. Accessed on 09 May 2020. 12. Ray D. Lockdown halts routine immunization programmes for kids. Ranchi News - Times of India. The Times Of India. 2020. Available at: https://timesofindia.indiatimes.com/city/ranchi/lock down-halts-routine-immunization-programmes-for- kids/articleshow/75035671.cms. Accessed on 09 May 2020. 13. India’s Vaccination Mission Narrows Focus To Meet March 2020 Target. India Spend. 2020 Available at: https://www.indiaspend.com/indias- vaccination-mission-narrows-focus-to-meet-march- 2020-target/. Accessed on 09 May 2020. 14. Salman S, Salem ML. Routine childhood immunization may protect against COVID-19. Vol. 140, Medical Hypotheses. Churchill Livingstone; 2020: 109689
Cite this article as: Varughese CS, Shah AK. Routine immunization services in the light of COVID-19 pandemic. Int J Community Med Public Health 2020;7:2867-9.
International Journal of Community Medicine and Public Health | July 2020 | Vol 7 | Issue 7 Page 2869