CG REPORT 2: The Impact of Interruptions in Childhood Vaccination
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Vaccines are highly effective for preventing a range of childhood infections. However, there have been concerns about the decrease in childhood vaccinations in 2020, with the WHO and UNICEF warning of an ‘alarming decline’ due to the COVID-19 pandemic.
By analysing 35 published studies and 10 reports by national or international agencies, we found reductions in diphtheria tetanus pertussis, BCG, measles and polio vaccine uptake, as well as a range of other vaccines regularly given to children. Reductions in many settings were reversed once restrictions were lifted. However, not all settings reported a return to complete normality.
Smaller declines were seen in younger children than older children. In addition, children born to women who could not read and write were more likely to be incompletely immunised. Barriers to access and maintaining public transport infrastructure impacted uptake of childhood vaccinations as well.
The evidence in this review shows that obstacles to the delivery of vaccination services during the COVID-19 pandemic drove down immunisation rates, especially in disadvantaged people and poorer countries.
- Bangladesh – 20-25% of child immunisation services were canceled April-May 2020
- India – greater than 50% drop in vaccination rates April to September 2020
- Indonesia – 42% of services reported disruptions to vaccination programs
- South Korea – vaccination rate for children aged 4-6 dropped by 1.4 to 1.9%
- Japan – COVID-19 resulted in decreases in the vaccination rate for Haemophilus influenza type b in <5-year-olds from approximately 97% each in 2013 and 2019 to 87% and 73% in 2020 for primary and booster doses, respectively
- 13 countries experienced declines in the monthly average number of vaccine doses
- Saudi Arabia – electronic health records reported drops in vaccination visits of 50%, 72% and 68% in March, April, and May 2020 compared with the same months in 2017 to 2019
- Germany – weekly survey data from roughly 1,000 participants in Germany reported on 14 April 2020 that 31 of 73 scheduled childhood vaccinations were cancelled within the previous six weeks (84%) because of the pandemic.
- Scotland – stable attendance rates
- Spain – vaccination coverage declined by 5-60%, depending on the type of vaccine
- Portugal – 21.6% of planned vaccinations were missed
- Italy – 34% of survey respondents indicated that they had skipped vaccine appointments due to provider closures or fear of the SARS-CoV-2 virus
- Three million fewer doses of non-influenza vaccines were ordered from 6 January to 19 April 2020, compared with the previous year
- In New York City, decreases up to 96% could be seen in vaccine uptake for children aged 2 to 18 years
- Blue Cross Blue Shield, which insures 1 in 3 Americans, reported a drop of up to 26% in MMR, DTP & polio vaccines between January and Sept 2020
Latin America and the Caribbean
- Difficulties caused by public transport limitations, confinement and physical distance policies, along with fear of COVID, led to a decrease in demand for vaccination services in half of the 38 countries that reported information to the Pan American Health Organization (PAHO) in June 2020
By Vaccination Type
- BCG administration significantly decreased in Rwanda, Pakistan, and Ethiopia
- DTP reductions noted in Rwanda, Guinea, Nigeria, Ghana, Angola, Gabon, South Sudan, Pakistan, and Senegal
- Measles campaigns were suspended in 27 countries, with specific reductions noted in Italy, Ethiopia, USA, England, Senegal, and the Netherlands
- Polio vaccination campaigns were largely suspended until the second half of 2020; countries experiences vaccine-derived poliovirus outbreaks in Africa include Angola, Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Côte d’Ivoire, the Democratic Republic of the Congo, Ethiopia, Ghana, Mali, Niger, Nigeria, Togo and Zambia
COVID-19 pandemic measures caused significant disruption to childhood vaccination services and uptake. In future pandemics, and for the remainder of the current one, policymakers must ensure access to vaccination services and provide catch-up programs to maintain high levels of immunisation, especially in those most vulnerable to childhood diseases in order to avoid further inequalities.
Quality of Evidence
We did not formally assess the quality of the included studies. However, clinical audit and service evaluation remain valuable for analysing and targeting improvements in healthcare. Publication bias will favour those studies that highlight disruptions and account for excess reporting of falls in vaccination levels. However, alongside the studies, the reviews by international bodies highlight consistent drops in vaccination uptakes during the restrictive phases of the pandemic. Studies that report no falls in vaccination are essential; they highlight strategies that can overcome disruptions during restrictions, and crucially after they have been lifted. Reports of vaccine coverage may not be 100% accurate, particularly during upheavals such as in a pandemic. We rated the quality of the evidence as moderate: the true effect is likely to be close to what is reported.