Immunization in the time of COVID-19 and beyond
The COVID-19 pandemic is changing the landscape for immunization and other primary health care services across the world, including in low- and middle-income countries. While the World Health Organization has issued clear guidance that immunization is an essential service that countries must continue to prevent the resurgence of killer diseases (e.g., measles, polio, pneumonia, whooping cough), damage from COVID-19 is widespread, particularly in lower-income countries that have weak health infrastructures. Major constraints include:
- Transportation disruptions: Vaccine distribution has been interrupted because of fewer flights from manufacturing sites to national warehouses and in-country transport constraints to clinics. Without vaccines, there’s no vaccination.
- Service interruptions: Community-based outreach services, a mainstay for providing immunization to remote populations, have been suspended in many countries.
- Reduced health worker availability: Health workers are diverted to pandemic response tasks and are also concerned for their own safety. Insufficient supplies of personal protective equipment, practical barriers to critical measures like frequent handwashing, and limited transport to places of work have led to impaired services.
- Low service utilization: Community turnout for immunization has also fallen as caregivers are instructed to stay home and are concerned about going to health centers for preventive services.
Before COVID-19, immunization had greater reach than other health interventions, although global vaccination coverage for DTP3 had stalled at 86% for a decade. Of the 19.4 million children who were unprotected from vaccine-preventable diseases (VPDs) in 2018, two-thirds were completely unvaccinated and one-third was incompletely vaccinated. Poor children suffer disproportionately: Demographic and Health Surveys show that DTP3 vaccination coverage among the wealthiest children in Nigeria is 230% higher than it is among the poorest; 78% higher in Pakistan; and 74% higher in Ethiopia.
Under the current circumstances, the global immunization community faces at least two daunting challenges.
- In the immediate-term, we must adapt approaches to limit pandemic-induced disruptions to avert the resurgence of VPDs at a time when health systems are least able to respond to them.
- We must prepare for the post-pandemic phase, including increasing equity to reach the most vulnerable and improving service quality to attain complete vaccination. In fact, the ultimate public health benefit of a COVID-19 vaccine depends on it. Any vaccine, whether new or already in use, is only as effective as the system that provides it.
Unusual times call for unusual actions that have the potential to improve health services over the long term.
In the rush for urgent, coordinated efforts by WHO, Unicef, Gavi and other partners to limit the damage of COVID-19 on immunization by providing clear guidance and flexible support, we must also lay the groundwork for what will come later. Despite uncertainties about the pandemic’s course, we know some actions that should be taken now.
- Actively monitor immunization where and when service disruptions are occurring. Such information is essential to identify vulnerable areas, take immediate action as possible, and plan ahead both for catch-up campaigns and for rebuilding routine immunization services that reach missed communities.
- Strengthen the management of the immunization supply chain. Real-time sharing of vaccine stock levels through WhatsApp and other online platforms is needed to reduce over- and under-stocking and prevent stockouts at clinics. Close coordination between supply chain managers and immunization program personnel is also essential for identifying and vaccinating people who have been missed.
- Build adaptive management capacity, particularly at sub-national levels for immunization and other services. Regional, district, and facility managers must be capable of applying new information to make technically sound decisions in rapidly-evolving situations. They need to know which questions to ask, when to ask them, where to get answers, how to adapt them, and how to problem-solve in their own context.
- Strengthen proactive communication and partnerships with communities to maintain demand for and trust in immunization. Strong relationships between health personnel and local influential non-health actors (community, political, and religious leaders) that result in a common voice are essential to building resilient communities that maintain trust in health services and withstand rumors and disruptions.
- Encourage innovation to improve the quality of service delivery. Unusual times call for unusual actions that have the potential to improve health services over the long term. The practice of physical distancing could improve patient flow; setting up individual vaccination appointments could increase service satisfaction and completion of the vaccination schedule. Many solutions are likely to come from health workers but will require an environment that encourages and supports innovation among lower level staff.
- Start preparing now for the introduction of a COVID-19 vaccine. While COVID-19 vaccines must be safe and effective, they should also be compatible with the health system. For these vaccine products to be used as intended, early attention is needed to address the attributes that affect immunization service delivery, including required storage temperatures, product presentation, doses per vial, and mode of administration.
While the challenges from COVID-19 are tremendous, we have the knowledge and the responsibility to address them and must actively learn from successes and missteps.
We must apply scientific evidence and strategic programmatic interventions to limit COVID-19 damage while protecting children from vaccine-preventable diseases now and in the future.
Learn more about how we are working with governments around the world to strengthen their COVID-19 response.
Written by Rebecca Fields, Senior Technical Advisor for Immunization